rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
6989,"NEBRASKA CITY CARE AND REHABILITATION CENTER, LLC",285109,1420 NORTH 10TH STREET,NEBRASKA CITY,NE,68410,2014-12-11,248,D,0,1,9RWM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -LICENSURE REFERENCE NUMBER: NAC 12-006.09D5b Based on observation, record review and staff interview; the facility failed to provide individualized activities for two residents (Resident 55 and 53). The facility identified a census of 50 residents. Findings are: A. A records review of the care plan dated 6/17/2013 for Resident 55 revealed Resident 55 was admitted on [DATE] for the following diagnoses- Unspecified after Cataract, Urinary Frequency, Acute pain due to trauma, [MEDICAL CONDITION], Dementia condition classified elsewhere without behavioral disturbance, swelling of limb, unspecified [MEDICAL CONDITIONS], Obstructive chronic [MEDICAL CONDITION] with exacerbation, other vitamin B 12 deficiency [MEDICAL CONDITION], unspecified essential hypertension, unspecified vitamin D deficiency. A records review of the Resident 55's MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning) dated 09/15/2014, revealed the facility assessed the following about the resident: Resident 55 has a BIMS (Brief Interview for Mental Status) score of 00, (BIMS is used to determine a resident's cognitive understanding. A BIMS score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment.) Resident 55 is assessed as having Inattention and Disorganized Thinking. Preferences for Customary Routine and Activities has the following marked: Reading books, newspapers or magazines, listening to music, Being around animals such as pets, Keeping up with the news, Doing things with groups of people, Participating in favorite activities, Spending time outdoors, Participating in religious activities or practices. Total dependence in bed mobility and transfers. Mobility is by wheelchair A records review of Recreation Services assessment dated [DATE] Resident 55, revealed Resident 55's activity preferences are- Independent, 1:1, with friends and family, small groups, out of room, outside, outings, with no time preferences noted. A records review of the care plan dated 6/17/2013 for Resident 55 revealed: I have a short attention span exhibited by: Wandering in and out of activities. Because of cognitive loss I need cuing with simple directions to stay on task. The goal identified for Resident 55 was to participate in short activities when offered. Interventions identified on the care plan were reading the newspaper, music programs, socials and games, going outside when the weather is nice, invite me to Catholic Services or ask Father to stop by and see me. A record review of the Activity Logs for the months of October, (MONTH) and (MONTH) revealed that there was no church activity, 1:1, reading, current events or outings documented. On the following dates and times, Resident 55 was observed to be in Resident ' s 55 wheel chair doing no activities in various locations of the ACU (Alzheimer Care Unit): 12/03/2014 2:03 PM, 12/04/2014 10:27 AM, 12/08/2014 11:21 AM and 12/08/2014 3:13 PM An interview on 12/08/2014 at 12:32 PM with AA (Activity Assistant) B revealed the following: AA B states that AA B didn't do the activity assessment, but does do the calendar. So the residents will do the parachute, fishing game, crafts-every other week. But AA B does not run the activity, the NAs (Nursing Assistants) or nurses run it. AA B states that AA B is not very involved with things back there unless it's a craft, then AA B will set it up and/or provide the example. An interview on 12/08/2014 at 2:02 PM with SW (Social Worker) C, revealed the following: Since there has been no ACU director for a time and no one has been dealing with residents' activities. SW C agrees that TV is not an appropriate activity for Resident 55 due to short attention span. SW C confirmed that the care plan is not individualized to Resident 55. B. Record review of an Admission Record dated 12/02/2014 revealed Resident 53 was admitted to the facility on [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Physician Fax sheet dated 10/31/2014 with facility request for Resident 53 be placed in the Alzheimer's unit due to wandering behaviors with physician response of OK. Record review of Recreation Services assessment dated [DATE] revealed that Resident 53 provided information that Resident 53 is blind, hearing intact, and had clear speech. Resident 53 was alert, cooperative and activity interest were: games/cards, puzzles/trivia, computer/video games, exercise/sports, television/movies, music, reading, writing, pets, and outdoor activities and outings. The Recreation Services Assessment also revealed Resident 53 sometimes liked discussion groups. Record review of (MONTH) 2014 Activity Calendar with highlighted activities that Resident 53 attended to include: - Snack and Chat with Staff on (MONTH) 3rd at 14th at 3 PM. - Snack and Chat with Staff on (MONTH) 18th, 19th, and 24th at 10 AM. - Snack and Chat with Staff refused by Resident 53 on (MONTH) 8th, 12th, and 17th. Record review of (MONTH) 2014 Activity calendar on 12/4/2014 with no documentation of activities attended for Resident 53. Review of (MONTH) 2014 Activity Calendar for Alzheimer's Unit included Snack and Chat with Staff schedule for 10 AM and 3 PM Monday through Friday every week through (MONTH) and Hot Chocolate and Coffee with Staff scheduled at 10 AM and Movie/Games or Picture Bingo at 3 PM for Saturdays and Sundays for the month. Observation on 12/04/201 at 9:50 AM, 11:49 AM, and 1:55 PM revealed resident lying in bed with eyes closed with no activities being provided. Observation on 12/04/2014 at 2:31 PM revealed Resident 53 sitting at the side of the bed, stands, and walk toward the door, walks into the hallway telling a nurse walking by that Resident 53 has to go to the bathroom. Licensed Practical Nurse (LPN) assisted Resident 53 to the bathroom and stay in the bathroom with Resident 53 until Resident 53 is finished. At 2:48 PM Resident 53 was encouraged by LPN to walk to the dining room to eat something and Resident 53 agreed he/she would eat something. LPN served chocolate milk and juice to Resident 53 and LPN leaves dining room with no activity being provided to Resident 53. Observation on 12/08/2014 at 10:36 AM revealed Resident 53 sitting on edge of the bed with no activities being provided. Observation on 12/08/2014 1st 3:07 PM revealed Resident 53 in room [ROOM NUMBER] bathroom stating, I got turned around. Resident 53 was redirected back to his/her room by the Alzheimer's Care Unit (ACU) Director. Observation on 12/09/2014 at 10:38 AM revealed Resident 53 sitting on the edge of the bed with no activities being provided. Observation on 12/09/2014 at 2:43 PM to 3:05 PM revealed Resident 53 in the bathroom with the Hospice Aide sitting on Resident 53's bed. At 3:05 PM Resident 53 came out of the bathroom and laid down in bed and closed Resident 53's eyes. Interview with Social Service Director on 12/08/2014 at 2:18 PM confirms that the Activity Log for Resident 53 for (MONTH) 2014 is blank and would indicated that Resident 53 had not attended activities in the month of (MONTH) as of today's date. Interview with Director of Nursing and ACU Director on 12/09/2014 at 1:40 PM confirmed that the activity calendar does not meet the individualized needs for Resident 53.",2018-07-01
1426,LIFE CARE CENTER OF OMAHA,285137,6032 VILLE DE SANTE DRIVE,OMAHA,NE,68104,2017-01-11,431,E,0,1,N57P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC ,[DATE] 12E Based on observation, interview and record review; the facility failed to ensure that medications were kept secure in the medication storage room on the South nurses unit, and failed to ensure that outdated medications and unlabeled medications were not available for resident use. The facility identified a census 85. Findings are: [NAME] An observation on [DATE] 07:55 AM the medication storage room door was propped open with a full garbage bag, with no nursing staff present in the area. A housekeeper appeared shortly after the observation of the door was made and entered the open area. This observation revealed that medications were present on the counter. The medications included: Carvedilol 12.5 mg - a drug used to treat heart failure and hypertension Atrovastatin Calcium 10 a drug used as a lipid-lowering agent and for prevention of events associated with cardiovascular disease Eliqus 2.5 mg a drug used to inhibit blood clotting and reduce the risk of heart attack and blood clots. Levothyroxine 25 mcg. a drug used to increase thyroid levels Protonix 40 mg a drug used to treat various gastric disorders such as ulcers Diltiazem 24 hour 300 mg a drug used to treat hypertension and chest pain, and treat irregular heart rhythm Alprazolam 0.25 mg a drug that is a Controlled substance used to treat anxiety Januvia 100 mg a drug used to treat diabetes and control blood sugar levels Carvedilol 12.5 mg a drug used to treat high blood pressure and heart failure Namenda 14 mg a drug used to treat memory loss Lasix 20 mg a drug used treat heart failure and decrease swelling Escitalopram 20 mg a drug used to treat depression and anxiety Alprazolam 0.5 mg a drug that is a Controlled substance used to treat anxiety Metromidazole 500 mg a drug used to treat infections Levocetirizine 5 mg a drug uses to treat allergies [REDACTED]. ADON K confirmed that nursing staff are to be present when the door is open. ADON K confirmed the housekeeping staff did have access to the medication storage room unsupervised and did have access to the drugs listed above. Record review of the facility Medication Storage and Security in the Facility Policy revised ,[DATE] revealed : 2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized are allowed access to medications. Medications rooms, carts, and medication supplies are locked or attended by persons with authorized access. 175 NAC ,[DATE] 12E B) Findings are: Observation on [DATE] 7:25 AM revealed that a stock medication, present on the medication cart for the 400 hall on the North wing, had Geri-Lanta Antacid ( used to treat stomach discomforts such as heartburn) that had the expiration date of [DATE]. Interview with Licensed Practical Nurse B on [DATE] 7:25 AM confirmed that the medication had expired on ,[DATE] and should have been disposed of. Record review of the facility policy titled Expiration Dates, dated [DATE] revealed that : Drugs, including those in the medication carts, are to be checked monthly for expiration date by nursing personnel. If the drug is outdated, it must be disposed of as per state and federal laws. 175 NAC ,[DATE] 12E C. Findings are: Observation on [DATE] at 7:25 AM revealed that there were 3 resident specific [NAME]fen DM/AF ,[DATE]mg/5cc bottles of liquid (cough medication) that had been prescribed by the physician in (MONTH) of (YEAR). The pharmacy provided a label that required the open date to be placed on the label. There was no open date present on the label or on the bottles. Interview with LPN B on [DATE] at 7:25 AM confirmed that the medication pharmacy label did have area for date opened to be placed on the 3 bottles, and no where on the bottles was there a date opened. Interview with ADON K on [DATE] at 07:55 AM Confirmed that a date open should be placed on any medication when the pharmacy label requests the date open.",2020-09-01
1407,LIFE CARE CENTER OF ELKHORN,285134,20275 HOPPER STREET,ELKHORN,NE,68022,2016-11-07,431,F,0,1,6P3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC ,[DATE].12E1 Based on observation, record review and interview; the facility failed to ensure that medications were maintained at the required temperatures, failed to ensure outdated medications were not available for resident use, and failed to ensure medications were dated when they were opened. This had the potential to affect all the residents that reside in the facility. The facility census was 95. Findings are: Record review of the facility policy for Medication Administration revised ,[DATE] revealed that medications that require refrigeration should be stored at temperature of 36 to 46 degree Fahrenheit (F). Medications that are out dated, contaminated or deteriorated are immediately removed from stock. Medications that are multi-dose are to be labeled with a date open date, this date provides expiration date of medication, based on manufacturer recommendations outlined in the table in this policy. [NAME] Observation on [DATE] at 8:10 AM revealed that the temperature control record on the south medication storage refrigerator had temperatures below the recommended storage temperature for medication. Record review of the Temperature Log revealed that the log has Required Temperature ,[DATE] degree F posted on the top of the log, it also states Notify Maintenance Immediately if Variation of Temperature. The temperatures readings were 30 degrees on ,[DATE] ,[DATE], Temperatures read 32 degrees on ,[DATE]/,,[DATE],,[DATE],,[DATE], ,[DATE] of (YEAR). The temperature log revealed no temperatures were logged on the temperature log for the following dates ,[DATE],,[DATE], ,[DATE],,[DATE],,[DATE],,[DATE], ,[DATE], ,[DATE] ,[DATE], ,[DATE],,[DATE], ,[DATE],,[DATE],,[DATE] of (YEAR). Medications present in this refrigerator included insulin and albuterol (for respiratory treatments). Observation on [DATE] at 8:30 AM of the North medication refrigerator revealed that the facility had not documented the temperature of the medication refrigerator for the month of (MONTH) or (MONTH) of (YEAR). Medications present in this refrigerator included Aplisol 10 test vial (tuberculin), Pneumoccal (pneumonia) vaccine,Prevnar 13 (pneumonia vaccine) for stock, Insulins, Vancomycin (antibiotic) and Promethazine Hydrochloride suppositories (Antiemetic therapy). Interview with Licensed Practical Nurse (LPN) B on [DATE] at 8:30 AM confirmed that the temperatures of the medication storage refrigerators failed to ensure that medications were maintained at the required temperatures. B Observation on [DATE] at 8:10 AM revealed that Preperation H ointment( ointment for rectal use) had expired on [DATE] and was opened for resident use on [DATE]. Observation on [DATE] at 8:30 AM revealed the 4 vials of Pneumococcal vaccine for facility wide use had expired in (MONTH) of (YEAR). Interview with LPN B on [DATE] confirmed that the Preperation H was outdated on [DATE] and had been dated as opened for use [DATE]. LPN B confirmed that the Pneumococcal vaccine had expired in (MONTH) of (YEAR) and that the facility failed to ensure outdated medications were not available for resident use. C. Observation on [DATE] at 8:00 AM revealed that medication of nasal spray was open, there was a sticker on the side for a date to be written on for date open, there was no date written on the tag. Medication of Albuterol Sulfate had a tag on the side for date open, there was no date written on the tag. Interview with LPN B on [DATE] at 8:00 AM confirmed that the nasal spray and the albuterol container should have a date written as to when the medication was opened. LPN B confirmed that upon opening the date is placed on the container so that the expiration begins on the date that it was opened, and that most expire 30 days after opening.",2020-09-01
4487,AZRIA HEALTH AT MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2016-05-17,279,D,0,1,Z8DT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.04C3a(5) Based on record review and interview, the facility staff failed to develop a comprehensive care plan related to the care and use of an Intravenous (IV) device for Resident 6 and to address bathing refusals for Resident 42. Facility census was 134. Findings Are: Physician order [REDACTED]. The order also said to place a Peripherally Inserted Central Catheter ( PICC) line (a catheter placed into a vein and extends to the heart). Record Review revealed that the PICC line was placed in Resident 6's left arm by a contracted agency on 5-2-16. Record review revealed that the comprehensive care plan was updated on 5/2/16 to include the infection and the intervention of the antibiotic IV medication. The comprehensive care plan did not contain care needed for the PICC line. Interview with Registered Nurse (RN) B on 5/16/16 at 3:30 PM confirmed that no comprehensive plan of care was developed for Resident 6's PICC line. B. Interview on 5/16/16 at 4:58 PM with Nursing Assistant (NA) C revealed that Resident 42 often refused a bed bath. NA C revealed that when Resident 42 would refuse a bath, most staff would mark it as refused. NA C stated if encouraged Resident 42 would then permit bathing. Interview with NA D on 5/17/16 at 8:16 AM revealed that Resident 42 would need encouragement to have any hygiene care performed, that you would have to talk the resident into it. NA D revealed that a pillow case was to be placed under the abdominal folds and breasts, after drying, but the resident didn't like it very much and would refuse it. Record review of Resident 42's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 4/9/16 revealed a Brief Interview for Mental Status (BIMS) score of 10 ( 8 to 12 is moderately impaired). Resident 42 required extensive extensive assist of one person for personal hygiene and bathing. Record Review of the form titled Resident Bathing Type by Day Chart for the month of (MONTH) revealed that Resident 42 received 3 bed baths for the month of (MONTH) (4/3/16, 4/10/16 and 4/17/16). Record Review of the Plan of Care for Resident 42 revealed that the facility identified that Resident 42 was non-compliant with bathing. A goal was developed that Resident 42 would comply with medical/nursing treatments of bathing. The plan care did not have interventions or approaches for staff to follow to achieve this goal.",2020-04-01
11641,MAPLE CREST CARE CENTER,285149,2824 NORTH 66TH AVENUE,OMAHA,NE,68104,2011-11-08,157,D,1,0,MU3W12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to notify resident's physician of critical lab value for 1 (Resident 2) of 14 sampled residents. The facility had a total census of 124 residents. Findings are: A. Resident 2 was admitted to the facility on [DATE] according to Admission Record. Hospital Discharge Summary dated 9/30/11 listed [DIAGNOSES REDACTED]. A review of Resident 2's Care Plan revealed a focus area dated 10/23/11 related Resident 2's pressure ulcer-left ischeal buttock, right hip and history of [MEDICAL CONDITION] in left elbow. Resident 2's Care Plan listed the following intervention ""Obtain and monitor lab/diagnostic work with regards to IV medications as ordered. Report results to MD (Medical Doctor)-infectious disease, and to the Pharm D (Doctor of pharmacy) who preps (Resident 2's) IV (intravenous) meds; ensure that new orders are followed per Pharm D orders. A review of Resident 2's 10/11 MAR (Medication Administration Record) revealed a physician's orders [REDACTED]. A review of laboratory results dated [DATE] for Resident 2 revealed a [MEDICATION NAME] Trough of 17.2 which was identified as a critical result. The reference range for the [MEDICATION NAME] Trough was listed as 5-10 micrograms/milliliter. Documentation on the laboratory results report stated results were called to VNA (Visiting Nurses Association) and directions received to continue same dose of [MEDICATION NAME]. Case Communication Report from facility pharmacy dated 10/17/11 stated the following: ""Spoke with (RN F) RN/Maplecrest. Dose given at 0900 this am, trough drawn around 0800. Trough result=17.2. Will plan to continue same dose unless we hear otherwise from MD (Medical Doctor). They do not have any more doses. Will send enough to get through next Mondays labs."" In interviews on 11/8/11 at 10:40 AM and 12:10 PM, RN (Registered Nurse) Unit Manager E reported [MEDICATION NAME] trough lab reports are faxed to the VNA's pharmacist and pharmacist confers with resident's physician. RN Unit Manager E reported it is facility policy that critical lab values be called to the resident's physician. RN Unit Manager E confirmed there was no evidence to show Resident 2's physician was notified of Resident 2's critical [MEDICATION NAME] Trough level. Facility policy titled ""Lab and Diagnostic Test Results-Clinical Protocol"" revised October 2010 stated the following: ""High or toxic drug levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician.""",2015-03-01
10739,MT CARMEL HOME- KEENS MEMORIAL,285216,412 WEST 18TH STREET,KEARNEY,NE,68847,2012-11-20,157,D,1,0,PO3011,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.04C3a6 Based on interview and record review the facility failed to notify the physician of a resident having an open area. The facility had a census of 74 and a complaint investigation sample of 6. This failure affected Resident 01.Findings are:According to the undated ADMISSION & DISCHARGE SUMMARY Resident 01 was admitted to the facility on [DATE]. The following [DIAGNOSES REDACTED]. Review of a 10/25/12 ACCIDENT/INCIDENT REPORT revealed that a nursing assistant reported to the charge nurse that Resident 01 had an open area on the left side of the middle abdomen at 7:00 PM. The nurse assessed the area to be a 1 centimeter round open area that was draining. Review of the 10/26/12 NURSES NOTES confirmed that the open area was red and warm to touch. The nurse documented cleansing the area and applying a dressing at 7:15 PM on 10/26/12. Review of the NURSE'S NOTES dated 10/27/12 at 9:30 AM revealed that the nurse noted the abdominal open area to be reddened and the dressing was changed. Review of the NURSE ' S NOTES confirmed that the physician was notified of the open area on 10/27/12 at 2:00 PM (43 hours after the staff first documented the open area). The physician prescribed Keflex 500 miligrams twice daily to treat the open area. Interview on 11/20/12 at 2:20 PM with the DON (Directror Of Nursing) revealed that the expectation was for the nurse to report the open area to the doctor as soon as the nurse became aware of it or the very next morning at the latest. The physican should have been consulted for a treatment plan as soon as possible. The DON reported that the physician notification in the situation with the open area on Resident 01 was tardy.,2015-11-01
4416,"SCHUYLER CARE AND REHABILITATION CENTER, LLC",285110,2023 COLFAX STREET,SCHUYLER,NE,68661,2018-07-18,604,D,0,1,NXEG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.05 (8) Based on observation, record review and interview; the facility failed to use a restraint for the least time possible; failed to provide monitoring and evaluation for continued use of a physical restraint; and failed to develop and implement interventions for the restraint for 1 resident (Resident 3) Census was 28 and sample size was 13. Interview on 7/12/18 at 08:07 AM with Resident 3 revealed that the resident was reluctant to get up related to the alarm going off. Resident 3 stated, If I get up the alarm goes off. Observation on 7/12/18 at 08:07 AM of revealed a safety alarm on the bed of Resident 3. Interview on 7/16/18 at 10:09 AM with the Director of Nurses (DON) confirmed that the resident had 2 falls on 12/30/17. The DON confirmed that the alarm was a restraint if the resident felt that they were unable to get up related to the alarm going off. Interview with a staff member on 07/16/18 at 10:10 AM revelaed that the resident was thinking the resident could walk and tried to maneuver out of bed. The resident was bed ridden. Record review of Resident 3's MDS (Minimum Data Set) revealed the resident was at risk for falls related to new environment balance problems. The resident had 2 falls on 12/30/17. Intervention initiated on12/30/17 was a Bed alarm. The MDS dated ,[DATE] and 7/2018 revealed no falls since last assessment. The nurses note dated 7/5/2018 by the Intradisciplinary Care Plan Team revealed; no recent falls, refuses floot mat, and refuses the bed in the low position.",2020-07-01
11784,MAPLE CREST CARE CENTER,285149,2824 NORTH 66TH AVENUE,OMAHA,NE,68104,2011-09-12,309,D,1,0,MU3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09 Based on record review and interviews, the facility failed to assess effectiveness of pain management for 1 (Resident 9) of 10 sampled residents. The facility had a total census of 124 residents. Findings are: Resident 9 was admitted to the facility on [DATE] according to admission record. Resident 9's 8/29/11 history and physical included a [DIAGNOSES REDACTED]. Occurrence Report for Resident 9 dated 8/28/11 at 11:15 PM stated ""Dr. White' called; noted res outside of room in hallway laying flat on (gender) back."" The Occurrence Report stated Resident 9 complained of right hip pain. A review of physician orders [REDACTED]. Radiology Report dated 8/29/11 for Resident 9 stated Resident had an acute right [MEDICAL CONDITION]. A review of physician's orders [REDACTED]. A review of Resident 9's MAR (Medication Administration Record) revealed physician orders [REDACTED]. According to back side of 8/11 MAR, Resident 9 was administered Tylenol 650 mg orally for complaint of right hip pain at 3 AM on 8/29/11. The section of Resident 9's MAR for results or response was not completed. Nurse's Notes dated 8/28/11 at 5 AM stated the following: ""Still sore and hurts."" In an interview on 9/8/11 at 7:45 AM, RN D reported not wanting to sedate the resident. A review of Nurse's Notes and Resident 9's MAR indicated [REDACTED]. Nurse's Note dated 8/28/11 at 12:39 PM stated Resident 9 received pain medication from ambulance crew prior to departing the facility for transport to hospital. In an interview on 9/12/11 between 11:45-11:55 AM, the DON reported expecting residents pain be reevaluated to see if another pain medication is needed and to contact the resident's physician if needed.",2015-01-01
12349,"LANCASTER REHABILITATION CENTER, LLC",285275,1001 SOUTH STREET,LINCOLN,NE,68502,2011-01-19,279,D,1,1,VFG211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09C Based on observation of residents, interview with staff and record review; the facility failed to develop comprehensive care plan goals and interventions regarding 1) the provision of oxygen therapy for 1 resident (Resident 110); 2) [MEDICAL TREATMENT] care and services for 1 resident (Resident 143); 3) hospice services for 1 resident (Resident 258); and 4) regarding pain management for 1 residents (Residents 98). Findings are: A. Review of the Comprehensive Care Plan for Resident 258 on 01/19/2011 revealed; -Identified Hospice service initiated: 11/13/2010 for ""end stage heart"" with plan to invite Resident, family and hospice to all care plan reviews; spiritual support will be provided by personal pastor and St. Elizabeth chaplain. Interview and observation of Resident 258 on 01/18/2011 in resident room revealed: -A medication was provided on a regular basis and that there was medication to take at other times. The pain did increase at times it depended on what activity the resident was or had been doing; -The resident was currently taking an antibiotic for a ""cough"" and had a respiratory illness. Interview with the Nursing Station 2 Manager on 01/19/2011 revealed: -Hospice service was initiated on 11/15/2010; -No Hospice contract or individualized Plan of Care for Hospice Service could be located in the medical records or provided by the staff. - A Hospice Nurse visited on 01/08/2011 to discuss medication therapy for pain control for routine administrations and which medications should be given on a as needed basis, use of other medications for congestive heart and kidney failure. Other alternative treatments (non-pharmacological) were were ordered that included: topical creams for muscle pain, heat and massage. Plan included assessment for hydration. This information is found in the Progress notes for physician/nurse communications with orders; -Review of the current care plan for Resident 258 with the Nurse Manager did not reveal an Initial Plan of Care coordinated with Hospice for the care and treatment for [REDACTED]. B. Review of the Resident Admission Record and MARS (medication administration records) for Resident 98 on 01/18/2011 revealed: -[DIAGNOSES REDACTED]. Review of the Annual MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for car planning), 09/20/2010 evaluates pain for Resident 98: -""pain is less then daily and mild intensity, non-specific sites"". Had scheduled pain medication at bedtime and pain medication ordered for ""as needed"" every 4-6 hours. Interview with the Station 1 Nurse Manger on 01/19/2011 at Station 1 revealed: -Non-pharmacological interventions are not used with routine administration of pain medications. The use of routine medications given for pain are not identified in the care plan. Non-pharmacological interventions used for pain management are not cited in the care plan either but would be documented in the notes when provided with ""as needed"" medications. Review of the current individualized Care Plan for Resident 98 on 01/18/2011 revealed: There is no INITIAL entry to identify pain/pain management, the use of medications, individualized alternative interventions or measurable goals. C. Review of the CARE PLAN for Resident 110 01/19/2011 with Nurse Manager, Station One revealed: Care Plan had entry for: 12/06/2010 [DIAGNOSES REDACTED]. -Approaches for use include ""O2 (oxygen) at 2L (liter)/minute at night. Review of the MDS 2.0 review coded ""2"" for an annual review with a reference date of 08/12/2010 for Resident : -Required oxygen therapy. Review of PHYSICIAN ORDERS/MEDICATION REVIEW for 60 day recertification dated 04/17/10 revealed: ""Professional Med Admin Record: O2 to keep SAO2 88% prn (as necessary)"". Review of the MARS (Medication Administration Records) for December, 2010 revealed: -1/29/2010 O2 to keep SAO2 88%PRN (as necessary); --04/23/2010 O2 at NOC (night) via N/C (nasal cannula) to keep SAO2 90%; -08/17/2010 SAO2 at NOC. Review of the Medication Administration Record [REDACTED] -December, 2010 did not reveal recordings of oxygen levels or assessments for day hours/activities; -January, 2011 did not reveal recordings of oxygen levels recorded for day hours/activities. Review of the Physician Orders and 60 day Medication Review/Recert and faxed communication for Physician Orders, 12/14/2010, do not meet the facility policy/procedure for orders and instructions for the use of oxygen therapy; -Review of the facility policy and procedure expectations for OXYGEN THERAPY revealed: -""Oxygen order will include: *Length of time oxygen is to be used; *Titrate oxygen to keep SAO2 above 88%; *Mode (mask, cannula); *Liter Flow; *Portable oxygen tank for mobility; *[DIAGNOSES REDACTED]. *Oxygen must be at a minimum of five (5) liters per minute when using a mask. Directions for provision of oxygen therapy were incomplete and without measurable interventions and goals within the Plan of Care for Resident 110. Based on observation, interview and record review; the facility failed to develop comprehensive care plan goals and interventions regarding 1) the provision of oxygen therapy for 1 resident (Resident 110); 2) [MEDICAL TREATMENT] care and services for 1 resident (Resident 143); 3) hospice services for 1 resident (Resident 258); and 4 regarding pain management for 2 residents (Residents 98 and 81). C) Record review of Resident's 143's Minimum Data Set ( A federally mandated comprehensive assessment tool used for care planning) dated 11/6/10; revealed a [DIAGNOSES REDACTED]. Record review of the History and Physical dated 2/17/10; revealed Resident 143 has [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Interview with Registered Nurse (RN) M at 4:04PM on 1/18/10; revealed that the nursing staff monitor with full body assessment for 24 hours when returned to center from the [MEDICAL TREATMENT] treatments. Received [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. The facility takes this resident to and from for [MEDICAL TREATMENT] treatments. Interview with Resident 143 at 2:30 on 1/18/11; revealed that this resident goes to [MEDICAL TREATMENT] treatments at another facility three times a week and this facility provides the transportation. Record review of Plan of Care with target date of 2/24/11; revealed no documentation of [MEDICAL TREATMENT] problem with no specific goal and/or approaches. This resident received [MEDICAL TREATMENT] on Monday, Wednesday, and Friday of each week. No documentation in plan of care of nursing performing a 24 hour assessment or other assessment interventions. Interview with RN M on Unit 4 at 3:00PM on 1/18/11; revealed that Residents 143's plan of care was worded that this resident received [MEDICAL TREATMENT] on Monday, Wednesday, and Friday with no individual problems, goals, or approaches done.",2014-08-01
1958,WILBER CARE CENTER,285172,611 NORTH MAIN,WILBER,NE,68465,2018-08-30,655,D,0,1,FIS811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09C1a Based on record review and interview, the facility failed to ensure that the base line care plan was accurate for Resident 36. Facility sample size was 24. The facility census was 48. Record review revealed that the resident was admitted on with 5/17/18 complicated urinary tract infection. The Baseline Care Plan did not address the UTI (Urinary Tract Infection) or risk of UTI. Record review of Medication Administration Record [REDACTED]. Record review of Care plan Baseline had not addressed the UTI or the risk of UTI. On 08/28/18 at 02:04 PM, interview with DON (Director of Nurses) confirmed that the admitting [DIAGNOSES REDACTED].",2020-09-01
4346,"BCP MILFORD, LLC",285132,1100 WEST 1ST STREET,MILFORD,NE,68405,2017-04-24,318,D,0,1,3QPH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09D4 Based on observations, record review and interview, the facility failed to provide range of motion and application of splint device to prevent further decline in range of motion for 1 (Resident 23) of 3 sampled residents. The facility had a total census of 45 residents. Findings are: Resident 23 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations on 4/18/17 at 10:38 AM revealed Resident 23's hand was contracted into a fist with no splint device in place. Observations on 4/20/17 at 10:04 AM revealed Resident 23's left hand was contracted in to a fist with no splint device in place. A review of MDS (Minimum Data Set; a comprehensive assessment used for care planning) dated 4/15/17 revealed Resident 23 had functional limitation of range of motion on both sides of upper and lower extremities. A review of Resident 23's Care Plan revealed a problem dated 2/17/12 related to activities of daily living. Resident 23 was noted to have contractures to all extremities, trunk and neck. Approaches for this problem included receiving range of motion during dressing and other daily cares by nursing staff; encourage resident to consider splints for hands to prevent further contractures, nursing staff unable to provide range of motion to lower extremities due to contractures of extension, and praise resident when participates in exercise or range of motion. A review of Occupational Therapy Discharge Summary dated 8/29/16 indicated that Resident 23 met goal of increasing right shoulder flexion and extension all joints/all planes. Discharge summary identified Resident 23 had reached maximum potential was being referred to restorative nursing program/functional maintenance program. Occupational Therapy Note dated 8/29/16 stated Resident 23 requesting something to open hand up. Resident 23 was given choices and selected palm contracture guard device. A review of Restorative Nursing Care Record for 10/2016 revealed Resident 23 received range of motion to upper extremities 27 times in 10/2016. Monthly restorative review and note dated 10/31/17 stated goals were met and restorative would be discontinued. A review of Restorative Screening and Assessment revealed notation dated 1/31/17 that Resident 23 had no change in activities of daily living. In interviews on 4/23/17 at 10:57 AM and 12:15 PM Nurse Aide A reported staff assist resident with dressing but do not provide range of motion. Nurse Aide A did not recall seeing a splint device for Resident 23. In an interview on 4/24/17 at 12:07 PM Occupational Therapist B reported that that a palm guard was order for Resident 23. Occupational Therapist B reported showing nursing staff how to use but did not follow up after that. Occupational Therapist B confirmed a resident with contractures would benefit from ongoing range of motion. In an interview on 4/24/17 at 9:56 AM, the Director of Nursing reported residents are placed on restorative based on needs including an increase in need for assistance with activities of daily living or falls. When a resident is taken off depends on how they are doing. The Director of Nursing reported range of motion for Resident 23 would be provided with dressing.",2020-08-01
10825,DOUGLAS COUNTY HEALTH CENTER,285019,4102 WOOLWORTH AVENUE,OMAHA,NE,68105,2012-10-09,309,D,1,0,48UM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09D5 Based on observations, interviews, and record review; the facility failed to ensure a medical evaluation was completed for adverse behaviors for 1 (Resident 1) of 4 sampled residents. The facility had a total census of 240 residents. Findings are: Resident 1 was admitted to the facility on [DATE] according to Resident 1's care plan. Admission history and physical dated 8/20/12 listed a [DIAGNOSES REDACTED]. A review of Nurse's Notes for Resident 1 dated 9/22/12 revealed Resident 1 was observed standing over Resident 3 touching Resident 3 on buttocks and pubic region. According to the facility investigation summary dated 9/25/12, Resident 3 was fully clothed. According to the facility investigation completed 9/26/12, the following interventions were put in place in response to the incident: -Both residents were placed on 15 minute checks; -Care plans were reviewed and Resident 1's care plan was up dated; -Geriatric Psychiatric service was notified. The facility investigative report stated both residents were followed by the Geriatric Psychiatric Service. A review of the facility investigative summary dated 9/26/12 revealed Resident 1 was observed to take a hold of Resident 2's hand while Resident 2 was walking with family member. Resident 1 stated Resident 1 would marry either one of them and pulled Resident 1's penis out of pants with other hand and shook it. According to the facility investigation completed 9/28/12, the following interventions were put in place in response to the incident: -Resident 1 was continued on 15 minute checks -On 9/26/12, Resident 1 was moved to a room closer to the nurses' station and away from Resident 2's room. -Geriatric Psychiatric Services was notified of the incident. The facility investigative report stated both residents were followed by the Geriatric Psychiatric Service. -Staff were to use 1:1 supervision intermittently to help calm resident behaviors. Observations on 10/3/12 at 8:13 AM revealed Resident 1 was being assisted out of bed in room [ROOM NUMBER]. In an interview at 8:16 AM on 10/3/12, LPN (Licensed Practical Nurse) A reported Resident 1 was moved to room [ROOM NUMBER] after Resident 1 was discovered standing over roommate making comments. Nurses' Notes for Resident 1 dated 10/2/12 at 11:45 stated Resident 1 was discovered standing over roommate stating Look at that lady, Isn't she pretty, I'm gonna get me some of that. Resident 1 was holding Resident 1's penis in Resident's 1 hand. Resident 1 was removed from the room. A review of Resident 1 medical record did not reveal any documentation which indicated Resident 1 had been seen by Geriatric Psychiatric Services although a fax was sent to Geriatric Psychiatric Services on 9/22/12 regarding the incident on 9/22/12. Nurses' Notes dated 9/25/12 stated Resident 1's primary physician was notified of incident on 9/22/12 and an order was received for a referral to Geriatric Psychiatric Services. A fax was sent to Geriatric Psychiatric Services on 9/25/12 at 10: 30 AM requesting a consult for Resident 1. A review of Resident 1's medical record revealed a fax was sent to Geriatric Psychiatric Services on 9/25/12 regarding incident involving Resident 1 on 9/25/12. A review of physicians' communication sheet for Resident 1 revealed incident on 9/25/12 was documented on this report. Entry was not signed by Resident 1's primary physician indicating that it had been reviewed. A review of Resident 1's physician progress notes [REDACTED]. In an interview on 10/3/12 at 1:43 PM, RN (Registered Nurse) B and RN C confirmed there was no evidence Resident 1's primary physician had been notified of incident on 9/25/12 or had seen Resident 1 since incident on 9/22/12. RN B and RN C also confirmed Resident 1 had not been seen by Geriatric Psychiatric Services. In an interview on 10/3/12 at 2:49 PM, RN B reported Resident 1 had been placed on one-to-one supervision.",2015-10-01
12386,GOLDEN LIVINGCENTER - GRAND ISLAND PARK PLACE,285105,610 NORTH DARR AVENUE,GRAND ISLAND,NE,68803,2010-09-23,248,D,1,1,E49Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09D5b The facility failed to ensure that an ongoing program of meaningful activities was developed and provided for 2 residents (Residents 57 and 62). The facility census was 56 residents. The sample size was 26 residents. Findings are: A. A review of Resident 57's Initial Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 4/3/2008 revealed that Resident 57 was born on 5/9/1959; had previously resided at a MR/DD (Mental [MEDICAL CONDITION]/Developmentally Disabled) facility prior to admission to the nursing home; and had a customary routine that included being involved in group activities. Activity preferences at that time included: crafts/art; exercise/sports; music; reading; spiritual activities; and television. A review of Resident 57's most recent Annual MDS Assessment was completed on 5/6/2010. At that time, Resident 57's activity interests were documented as crafts/art; exercise/sports; music; reading; spiritual activities; and television. A review of Resident 57's CARE PLAN (5/30/2010) revealed that Resident 57 had been identified as responding well to ""being outdoors and playing catch with a ball...able to kick a ball with instructions,,,responds well to in room activities...can give high five and able to hold hands"". Interventions included: being seated near the activity leader or volunteer for assistance and using sensory materials during 1:1 visits. A review of Resident 57's RECREATION PARTICIPATION RECORDS revealed the following: - June 2010 - Resident 57 participated in ""music"" activities on 6 out of 30 days during the month; and participated in ""Fit & Fun"" on 1 day during the month. - July 2010 - Resident 57 participated in ""movies"" one day during the month; ""music"" activities 3 days during the month; ""sensory/relaxing"" activities 5 days during the month; ""entertainment"" once during the month; went outdoors twice during the month; had 2 documented 1:1 visits during the month; and watched/listened to television/radio 26 days during the month. - August 2010 - Resident 57 participated in one 1:1 visit during the month; and - September 1 - 22, 2010 - Resident 57 participated in ""entertainment"" activities once; ""Fit & Fun"" three times; 1:1 visits five times; and watched/listened to television/radio on 22 days during the month. A review of Resident 57's ACTIVITY DOCUMENTATION TOOL FOR IN ROOM USE revealed that the resident's ""Activities of Choice"" were documented on top of the form as: Music; outdoors - rides in wheelchair; hand massages; sound; spas; soft conversation; reading bible passages; also noted was to open the window curtains in room during the day. There were multiple documented entries regarding Resident 57 being ""in the wheelchair watching television"" or ""listening to music"". There were no documented entries regarding hand massages; wheelchair rides outdoors; using the sound machine; or reading the bible passages to the resident. NOTE: Observation of residents' room revealed no direct outside window in Resident 57's cubicle section within the room. A review of Resident 57's LIFE ACTIVITY PREFERENCES completed upon admission to the facility 4/2008; revealed that Resident 57's interests included: switches/vibrations; aquatics; tambourines; dancing; tactile exploration; auditory stimuli; and visual stimulation. A review of Resident 57's ANNUAL RECREATION assessment dated [DATE]; revealed that the resident had low vision/[MEDICAL CONDITION] issues; was able to sit in events for audio stimulus and enjoyed Fit & Fun; sound stimulus; reading out loud; pet visits; wheeling outdoors; holiday celebrations; music stimulus; and was able to hold and pass objects back and forth with 1:1 assistance Observations of Resident 57 included: - 9/20/2010 10:20AM - Resident observed sitting in wheelchair in room. Aquatic box sitting on dresser to the left of the resident. Television not on/music not playing. - 9/20/2010 2:10PM - Resident sitting in wheelchair in room. Aquatic box on dresser turned on. Television set playing Hawaiian music/videos. - 9/20/2010 4:30PM - Resident sitting in wheelchair. Residents' wheelchair is close to the wall between the television and the bed. The resident has one sock on one foot and the other foot is bare with a sock observed lying on the floor beside the wheelchair. The resident was observed making ""bucking"" movements in the wheelchair and yawning. The television was on playing Hawaiian music/videos. - 9/21/2010 9:38AM - Resident observed sitting in wheelchair facing television. Television channel on the Animal Planet station. The resident was moving about in the wheelchair in a ""thrashing"" motion. No noises being made, just moving back and forth. The Aquatic box on the dresser was turned on, but the resident was unable to see it from where the residents' wheelchair was placed. B. A review of Resident 62's Initial Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 4/3/2008 revealed that Resident 62 was born on 11/29/1959; had previously resided at a MR/DD (Mental [MEDICAL CONDITION]/Developmentally Disabled) facility prior to admission to the nursing home; and had a customary routine that included being involved in group activities. Activity preferences at that time included: cards/games; exercise/sports; music; reading; trips, wheeling outdoors; and television. At that time, Resident 62 was involved in activities 'some' of the time (1/3 to 2/3's of the time). A review of Resident 62's most recent full MDS Assessment was completed on 2/28/2010. At that time, Resident 62's activity interests were documented as being music; reading ; television and talking. A review of Resident 62's CARE PLAN (3/4/2010) revealed that Resident 62 was identified as having a ""poor response"" to others due to [DIAGNOSES REDACTED]. Interventions included: being provided with 1:1 activities; a trial of sensory stimulating activities such as massaging hands and 1:1's. A review of Resident 62's RECREATION PARTICIPATION RECORDS revealed the following: - July 2010 - Resident 62 participated in music once; participated in special events once; participated in sensory/relaxation activities once; participated in entertainment once; participated in ""window view"" on 26 days out of the month; participated in watching television/radio on 26 days out of the month; went outdoors on 3 occasions; and participated in 1:1's on 3 occasions. - August 2010 - Resident 62 participated in one Fit & Fun group during the month and one 1:1 visit during the month; and - September 1 - 22, 2010 - Resident 62 participated in five 1:1's during the month and watched television/radio on 22 days during the month. Observations of Resident 62 included: - 9/20/2010 3:00PM - Resident observed sitting in tilt in space wheelchair in residents room after being brought back into room by Activity director. Per interview, the Activity Director had just taken Resident 57 outside in the wheelchair for a ride around the building. - 9/20/2010 4:30PM Resident sitting in wheelchair in room. No television or music playing. Window curtains open. - 9/21/2010 9:42AM Resident observed sitting in wheelchair in room, facing out the window. Curtains open and light on in room. No music or television on. 9/22/2010 - 2:20PM Resident observed lying in bed on back. No TV, lights or music on. Resident eyes closed. No movements noted. Bed in low position. The residents' call light was in reach. 9/22/2010 - 2:20PM Resident observed lying in bed on back. No TV, lights or music on. Resident eyes closed. No movements noted. Bed in low position. The residents' call light was in reach. A review of Resident 62's ACTIVITY DOCUMENTATION TOOL FOR IN ROOM USE revealed that the resident's ""Activities of Choice"" were documented on top of the form as: Music; outdoors; rides in wheelchair; hand massages; sound machine; spas; soft conversation; reading Bible passages; and open the window curtains in room during the day. There were multiple entries with the resident documented as being up in the chair; music on; curtains open; being down in bed; looking outside; listening to music. There were no documented activities of being outdoors; reading Bible passages; hand massages or sound machine/spas. 9/22/2010 - 3:30pm Interview with the facility Activity Director revealed that nursing staff is responsible to complete ACTIVITY DOCUMENTATION TOOL FOR IN ROOM USE. Those are the activities that nursing staff provide for the residents. The Activity director confirmed that the residents weren't being taken out of their rooms very often and so now is slowly trying to do that for them. The activity director didn't know why they weren't taken out of the room for a facility birthday party stating that ""staff aren't used to taking Resident 57 and Resident 62 out of the room"". Interview with the Corporate Clinical Director on 9/22/2010 at 4:10PM revealed that the facility had not developed a quality assurance plan addressing the individualized activity issues for Resident 57 and Resident 62.",2014-07-01
11666,GOOD SAMARITAN SOCIETY - MILLARD,285098,12856 DEAUVILLE DRIVE,OMAHA,NE,68137,2011-10-20,323,D,1,0,HIJ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09D7 Based on observations, interviews, and record review, the facility failed to place Secure Guard bracelet (elopement prevention device) on resident in accordance with manufacturer's instructions for 1 (Resident 5) of 13 sampled and 2 non-sampled residents, failed to monitor function of Secure Guard bracelet on a daily basis in accordance with manufacturer's instructions and facility policy for 1 (Resident 4) of 13 sampled and 2 non sampled residents, and facility to implement assessed interventions to prevent falls for 1 (Resident 2) of 13 sampled and d2 non-sampled residents. The facility had a total census of 102 residents. Findings are: A. Resident 5 was admitted to the facility on [DATE] according to face sheet. Resident 5's Cumulative [DIAGNOSES REDACTED]. Resident 5's Care Plan included a problem dated 7/7/11 related to being at risk for elopement. The following Plans and Approaches were listed for Resident 5: -Take a picture of resident and keep in Medication Administration Record -Label all clothing with name -Secure guard transmitter to left wrist check placement each shift and functioning every day expiration May 2014 -Provide appropriate activities 1:1 if wandering -Notify family, medical doctor and Director of Nursing, Administrator of any elopement -Discuss possible move to a dementia unit with family. A Secure Guard transmitter/bracelet emits a radio frequency which triggers an alarm and/or locks the door when a resident wearing the bracelet approaches a monitored exit door. Incident Report dated 7/9/11 stated Resident 5 was found standing in front of the front door. The facility investigative report stated Resident 5 "". . . exited out of front door of the building and was standing in front of the door."" The investigative report stated "". . .if resident had arm that had secure guard attached was raised more than 6 inches from the door handle the secure guard system did not function. Staff placed an additional secure guard bracelet on (Resident 5's) ankle, contacted family. Maintenance has had secure guard out to re-evaluate the secure guard system and maintenance on the system was completed."" A review of undated investigative report regarding Resident 5 revealed the following: ""On 7/17/2011 the above mentioned resident had exited the activity room door. Staff were alarmed by the alarm from (Resident 5's) secure guard bracelets and responded when staff arrived (Resident 5) was back in the activity room (Resident 5) stated ""it was too hot out there."" When visualized on the camera the time on the camera showed that (Resident 5) was outside the threshold of the door for 35 seconds and then came back in. Recently we had secure guard out to the building to upgrade our status of their devices at our front entrance. At this time we also have the secure guard devices working on the activity door."" physician's orders [REDACTED]. In an interview on 10/19/11 at 10:09 AM, Staff Development Nurse F clarified doors equipped with Secure Guard lock when a resident wearing a Secure Guard bracelet approach the door in addition to an alarm sounding at the nurse's station. Observations at 10:46 AM on 10/19/11 revealed Resident 5 had Secure Guard bracelet on left wrist. Observations between 3:31-3:45 PM on 10/19/11 revealed Resident 5 had Secure Guard bracelet on left wrist. A check of functioning by Nurse G revealed Secure Guard bracelet on Resident 5's left wrist was functioning correctly. In an interview at 4:07 PM on 10/19/11, the DON (Director of Nursing) reported the range around the front door that would activate the Secure Guard system to lock the front door had been increased after Resident 5 eloped. The DON reported the second bracelet on Resident 5's ankle had been removed at that time. The exit doors equipped with the Secure Guard system were tested with a functioning Secure Guard bracelet beginning at 4:25 PM on 10/19/11. Observations revealed the locking system was not activated on the 200 unit courtyard door when the Secure Guard bracelet was held approximately 5 feet off the floor. The Secure Guard on the 200 unit courtyard door and the activity door was located near the floor. A review of Secure Care Products, Inc. Strap Instructions revised 8/24/04 stated ""To ensure proper operation of the Transmitter, it must be in an upright or vertical position on the ankle."" B. Resident 4 was admitted to the facility on [DATE] according to Face Sheet and discharged from the facility on 9/30/11 according to Discharge Summary. Resident 4 had a [DIAGNOSES REDACTED]. A review of facility investigative report dated 9/9/11 revealed the following: ""on 9/3/11 about 4:30 pm, (Resident 4) was outside by the driveway about 15 ft from the front door in (Resident 4's) w/c (wheelchair). A staff member that was leaving brought (Resident 4) inside. (Resident 4) stated (Resident 4) wanted to leave, wanted to go home, didn't want to stay here. (Resident 4) calmed (Resident 4) and placed a secure band on (Resident 4's) w/c."" The facility investigative report dated 9/9/11 stated the following later in the report: ""On 9/6/11 about 4:00 pm, (Resident 4) again went out the front door. The secure guard did not alarm or lock the door. A visitor informed a staff that (Resident 4) was outside by the front door, and staff bought (Resident 4) in. (Resident 4) secure guard was not working and was replaced by a new one. Both secure guards were checked prior to them being placed on (Resident 4's) w/c. Upon further investigation, it is felt the first one may not have been at full strength. It worked with the tester, but apparently was not strong enough to lock the door."" Interdisciplinary Progress Notes for Resident 4 dated 9/4/11 stated ""Wanderguard in place on chair."" Interdisciplinary Progress Notes dated 9/5/11 for Resident 4 did not address checking Resident 4's Secure Guard bracelet for either functioning or placement. A review of Resident 4's Treatment Administration Record revealed checking Secure Guard for placement was first initialed as completed on the 3 PM-11 PM shift on 9/6/11 and checking Secure Guard for functioning was first initialed as completed on the 7 AM-3 PM shift on 9/10/11. In an interview on 10/20/11 at 2:10 PM, the DON confirmed there was no documentation that the functioning of Resident 4's Secure Guard bracelet had been checked on 9/5/11. Secure Care Products, Inc. manual revised 8/24/04 stated the following: ""A documented test of each ankle transmitter at the facility must be made each day."" A review of facility Policy & Procedure regarding bed, chair and door alarms revised 10/08 revealed wandering bracelets are to be checked daily to see if alarm sounds. Record review of a Face Sheet dated 8/29/2011 revealed Resident 2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Falls Data Collection Tool sheet dated 10/07/2011 revealed Resident 2 scored a 23. According to the information on the Falls Data Collection Tool sheet, a score of 12 or higher equals high risk. record review of Resident 2's Comprehensive Care Plan (CCP) dated 8/29/2011 revealed Resident 2 had ""decreased mobility"" and had a history of [REDACTED]. The interventions identified in the CCP included using a pressure relief alarm to the bed and wheelchair. Observations on 10/19/2011 at 9:47 AM and 10:28 AM revealed Resident 2 was seated in a wheelchair without a pressure relieving alarm. Observation on 10/20/2011 at 8:00 AM revealed Resident 2 was in the dining room for breakfast. Resident 2 did not have a pressure Relieving alarm in place. A interview with Licensed Practical Nurse (LPN) E was conducted on 10/20/2011 at 8:02 AM, During the interview, LPN E confirmed Resident 2 did not have a pressure relieving alarm in place. A follow up interview with LPN E was conducted on 10/20/2011 at 8:07 AM. during the interview, LPN E confirmed Resident 2 was to have the alarm on at all times.",2015-02-01
11631,MAPLE CREST CARE CENTER,285149,2824 NORTH 66TH AVENUE,OMAHA,NE,68104,2011-09-12,323,G,1,0,MU3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09D7 Based on record review, observations, and interviews, the facility failed to implement care planned fall alarm interventions to prevent falls for 1 (Resident 9) of 10 sampled residents. The facility had a total census of 124 residents. Findings are: Resident 9 was admitted to the facility on [DATE] according to admission record. Resident 9's 8/29/11 history and physical included a [DIAGNOSES REDACTED]. Resident 9's care plan included a problem dated 7/12/11 of potential risk for falls. Interventions listed included use of a bed alarm when in bed. Occurrence Report for Resident 9 dated 8/28/11 at 11:15 PM stated ""Dr. White' called; noted res outside of room in hallway laying flat on (gender) back."" On occurrence checklist alarm and alarm activated were both checked no. In an interview on 9/8/11 at 7:45 AM, RN D reported Resident 9's bed alarm was on Resident 9's bed and not attached to Resident 9 when Resident 9 was found on floor in hallway. Radiology Report dated 8/29/11 for Resident 9 stated Resident had an acute right hip fracture. A review of acute care plan dated 8/29/11 for Resident 9 revealed Resident 9 was to have bed and chair alarms and floor mats down when in bed. Observations of Resident 9 in wheelchair in room at 7:45 AM on 9/8/11, in wheelchair in dining room at 8:05 AM and in wheelchair in resident lounge at 9 AM revealed Resident 9's chair alarm was not hooked up. In an interview on 9/12/11 at 11:45 AM, the DON (Director of Nursing) confirmed Resident 9 was to have sit stand alarm in place.",2015-03-01
6152,BEAVER CITY MANOR,285269,"P O BOX 70, 905 FLOYD STREET",BEAVER CITY,NE,68926,2016-02-11,431,D,0,1,Q2NL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.12E4 Based on observation, record review and interviews; the facility failed to ensure a discontinued medication was not available for resident use for Resident 10. The facility census was 21. Findings are: Observation of the medication administration by LPN (Licensed Practical Nurse)-G for Resident 10 on 02/09/2016 at 7:01 AM revealed LPN-G took a tube of Triamcinolone Cream 0.1% (a steroid cream used to treat skin inflammation) from the medication cart drawer. Interview with LPN-G on 02/09/2016 at 7:01 AM revealed Resident 10 had been receiving the Triamcinolone Cream 0.1% routinely and was currently receiving it quite regularly on a PRN (as needed) basis. Observation on 02/09/2016 at 7:02 AM revealed LPN-G reviewed the electronic MAR (medication administration record) and then said that the Triamcinolone Cream 0.1% had been discontinued and there was not a PRN order. LPN-G placed the medication back into the medication cart drawer. Record review revealed the medication had been ordered on [DATE] and was to be given for 2 weeks. Observation of the medication cart storage on 2/11/2016 at 5:05 PM revealed Resident 10's discontinued Triamcinolone Cream 0.1% was in the medication cart drawer. Interview with LPN-H on 2/11/2016 at 5:06 PM confirmed that the Triamcinolone Cream 0.1% order was discontinued and there was no PRN order. LPN-H confirmed the discontinued medication was still in the medication cart and available for Resident 10's use. Interview with DON (Director of Nursing) and NHA (Nursing Home Administrator) on 2/11/2016 at 5:30 PM revealed that their expectations were that all discontinued medications would be removed by the nurse from the medication/treatment cart at the time the order was received.",2019-06-01
11681,LIFE CARE CENTER OF OMAHA,285137,6032 VILLE DE SANTE DRIVE,OMAHA,NE,68104,2011-10-17,411,D,1,0,6KY011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.14 Based record review and interview, the facility failed to arrange routine dental services for 2 (Residents 3 and 5) of 9 sampled and 3 non-sampled residents. The facility had a total census of 104 residents. Findings are: A. Resident 5 was admitted to the facility on [DATE] according to the Face Sheet. According to Diagnosis/History, Resident 5 has a [DIAGNOSES REDACTED]. A review of Resident 5's medical record did not reveal any evidence of Resident 5 being provided or refusing routine dental services. In an interview at 10/17/11 on 11:25 AM, Social Worker A reported there was no documentation of Resident 5 being seen by a dentist since admission to the facility. In an interview on 10/17/11 at 11:34 AM, Resident 5 confirmed Resident 5 had not seen a dentist since admission to the facility. Undated facility policy stated the following: ""Residents are provided with routine and emergency dental care when needed."" Interviews with Social Worker A and Social Worker E at 10/17/11 at 10:07 AM revealed dental services are offered to residents and family members at a meeting held within 72 hours of admission. They reported the facility did not have a mechanism for tracking resident dental visits. B. Record review of a Face sheet dated 9/23/2011 revealed Resident 3 re-admitted to the facility on [DATE]. Record review of a Oral Assessment Form dated 6/24/2011 revealed the assessment did not identify Resident 3 with missing teeth. The sections of the assessment form identified as upper and lower had an area to be marked if the resident had missing teeth. These sections of the assessment were left blank. Record review of Oral Assessment Form dated 9/13/2011 revealed Resident 3 was assessed to have missing teeth to both, the upper and lower sections. An interview on 10/17/2011 at 10:15 AM was conducted with the Social Service Director (SSD). During the interview, the SSD was asked if Resident 3 had been seen by the Dentist, the SSD stated ""no"". Record review of a undated policy for dental services revealed he following: -Residents are assessed for oral health status and needs ninety (90) days after admission or fourteen (14) days after by a qualified dental professional.",2015-02-01
1425,LIFE CARE CENTER OF OMAHA,285137,6032 VILLE DE SANTE DRIVE,OMAHA,NE,68104,2017-01-11,325,D,0,1,N57P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12.006.09D Based on interview, record review, and observation; the facility failed to evaluate the diet needs and provide the correct diet for one of one resident reviewed (Resident 141) related to [MEDICAL CONDITION] requiring [MEDICAL TREATMENT] and Diabetes. The facility census was 85. Findings are: Record review of Resident 141 medical record, revealed that Resident 141 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 141's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated 11/16/2016 revealed that, Resident 141's cognitive status score was 15 out of 15. Interview with Resident 141 revealed that with the [DIAGNOSES REDACTED]. Resident 141 revealed that prior education, to the diet that should be followed, was received, and that the diet being provided makes it difficult to follow the restrictions that Resident 141 had followed at the hospital and at home. Resident 141 revealed that it included limiting foods high in potassium, sugar, carbohydrates and phosphorus. Resident 141 revealed that family had provided food items, to maintain the diet restrictions. Record review of Resident 141's Physician order [REDACTED]. Record review of Resident 141 ' 2 Physician order [REDACTED]. Potassium is a nutrient that is critical to the function of nerve and muscle cells, including those in your heart. Your blood potassium level is normally 3.6 to 5.2 millimoles per liter (mmol/L).(* mayoclinic) and required 15 grams of [MEDICATION NAME] in 60 ml of [MEDICATION NAME] by mouth on Sunday (12/4/16) evening and to recheck potassium level on 12/5/16. ([MEDICATION NAME]/[MEDICATION NAME] drug to remove the potassium from the system by way of the gastric system). Record review of lab values, for Resident 141, from the [MEDICAL TREATMENT] center, performed on 11/28/16 revealed that Resident 141's Potassium was 6.4 mmol/L. Record review of Resident 141's Lab performed on 12/5/16 revealed a Potassium of 4.9 mmol/L. Record review of Resident 141's Nutrition Data Collection assessment dated [DATE] , Section 1, included a list of Resident 141's current [DIAGNOSES REDACTED]. Record revealed resident was on a Regular diet with regular condiments, with a supplement of a snack at bedtime. Section 2 revealed Resident 141's labs. Section 3 listed that Resident 141's energy needs of calories to be 1575 to 1875 calories per day, Protein needs of 69-88 grams per day, and fluid needs of 1575-1875 milliliters (ml) per day. A summary found in section 3 revealed that Resident 141's height was 60 inches, and had a current body weight of 250 pounds. Resident 141 was eating an average of 65% of meals on a regular diet with diet condiments. Resident 141's medications and labs were reviewed and that Resident 141 went to [MEDICAL TREATMENT] three times a week. Resident 141 had some weight loss, that may have been expected with [MEDICAL TREATMENT]. Resident 141 had a higher protein need related to [MEDICAL TREATMENT], and recommended to add 30 ml of prosource (a drink with protein) daily. Record review of a Progress note from Dietary on 11/14/16 revealed that Resident 141 ' s weight was stable, and oral intake was adequate. Recommendation was to continue with the same diet. Record review of Resident 141's comprehensive plan of care, dated 9/21/16, revealed that, Resident 141 had been at risk for complications, associated with [MEDICAL CONDITION] (high blood sugars) or [DIAGNOSES REDACTED] (low blood sugars), related to the [DIAGNOSES REDACTED]. Resident 141's goal was that hyperglycemic/hypoglycemic episodes would be minimized with medications and nutritional interventions, as ordered, through next review date of 12/21/16. Approaches to achieve this goal were listed as follows: Administer insulin as ordered. Observe for signs and symptoms of unstable blood sugar levels. Observe intake of meals and offer substitutes, supplements or alternative choices as needed. Perform blood sugars as order with sliding scale and long acting insulin as ordered. Report to physician signs or symptoms of unstable blood sugars. Record review of Resident 141's comprehensive plan of care, dated 9/21/16, revealed that Resident 141 had a nutritional risk related to the [DIAGNOSES REDACTED]. The goal set, for Resident 141, had been that there would not be a significant weight loss through next review, with the target dates of 12/21/16 and 3/2017. Approaches to achieve this goal were listed as follows: Diet per Physician order. Weights per Physician order. Offer meal substitutes as desired. Continue to monitor and encourage food intake at meals and as needed. Supplements per Physician order. Interview with Registered Nurse (RN) L, from the [MEDICAL TREATMENT] center that Resident 141 attended three times a week, on 01/10/2017 at 10:38 AM revealed that, the [MEDICAL TREATMENT] center's plan of care recommended a Renal diet. (*a diet prescribed in [MEDICAL CONDITION] and designed to control intake of protein, potassium, sodium, phosphorus, and fluids, depending on individual conditions) Interview with the Registered Dietitian (RD) M, from the [MEDICAL TREATMENT] center that Resident 141 attended three times a week, on 01/10/2017 at 1:09 PM revealed that, Resident 141 had been working with this RD, since (MONTH) of (YEAR). RD M revealed that Resident 141 was to be on a Renal diet and had increased protein needs. RD M revealed that Resident 141 demonstrated knowledge of a renal diet and that education was provided to Resident 141 regarding increasing protein was needed, and what items to choose. RD M stated that the [MEDICAL TREATMENT] center was not aware that Resident 141 was on a regular diet with regular condiments. Record review of a fax of Resident 141's [MEDICAL TREATMENT] Kardex, date of print, 1/10/17, was received from the [MEDICAL TREATMENT] center. The Kardex confirmed that Resident 141's Nephrologist ordered . dated 7//15/16, had specific of Protein 126gm/day, Sodium 2500mg/day, Phosphorus 1260 mg/day Potassium 2500 mg/day. Resident 141's fluids would be limited to 1200cc in a 24 hour period. The Nephrologist order was for a Renal Diet. Resident 141's was to also have had Carbohydrate controlled diet related to the Diabetes, and that these were established daily needs based on Average body weight of 105 kg, it had also included a plan to promote gradual weight loss. Record review of RD M's Physician Patient Notes for Resident 141, received 1/10/17 revealed Nutritional Status concerns as follows: Resident 141 had low [MEDICATION NAME], that began on the date of 11/3/16, [MEDICATION NAME] target goal was greater than or equal to 4.0 and the goal was not met. RD M's note listed the contributing factors and interventions to include Resident 141's diet, appetite, and pain, with education provided to resident. Resident 141 had a High Potassium, that began on the date of 11.30/16, the goal of the Potassium level for Resident 141 was 3.5-5.5 and the goal was not met. RD M's note revealed that Resident 141 had stated that there had been increase in consuming excess amount of fruits and vegetables, revealed that the diet at the facility, had included cling peaches and cottage cheese at some meals. RD M and Resident 141 discussed portion size and educated patient on diet. Resident 141 previously had potassium in target range. Resident 141 had Low [MEDICATION NAME], that began on the date of 12/07/16. The goal a target >=4.0 for Resident 141 was not met. RD M's note listed contributing factors as appetite with no change, education was provided to resident. Comments section revealed that Resident 141 was working on getting increased protein foods at the facility. Resident 141 requiring 5 hours of [MEDICAL TREATMENT]. Weight loss is desired. Resident 141 had a Elevated Phosphorus on 12/06/16. Resident 141's goal Phosphorus was 3.0-5.5,and goal was not met. Contributing factors and interventions were, RD M, evaluated Resident 141 ' s appetite, Resident 141 has had presence of gastrointestinal symptoms and nutrition related changes. [MEDICATION NAME] binders ([MEDICATION NAME] binders are medications used to reduce the absorption of [MEDICATION NAME] and taken with meals and snacks), reviewed by RD M with Resident 141. Resident having limited mobility and is on pain medication and managing bowels with medications, RD M would continue to follow. Interview with facility RD on 01/10/16 at 2:30 PM revealed that she had not reviewed Resident 141's record due to being new to the facility during survey. Facility RD did provide a copy of the facility Liberal Renal Diet, a diet moderately restricting sodium, potassium, and phosphorus and is extended on the facility menu. Food is prepared without additional salt. This diet does include Protein choices for the Resident, as well as lists of foods that are low, medium and high in Potassium and Phosphorous. Interview on 01/10/2017 at 9:55AM with Assistant Director Of Nursing (ADON) K confirmed that Resident 141 was on a regular diet, and confirmed that Resident 141 has had problems with elevated potassium. ADON K confirmed that Resident 141's plan of care does reveal that a consult with a Dietitian was to be as needed, for nutritional support, related to [MEDICAL CONDITION]. ADON K confirmed that when Resident 141's potassium was elevated, the facility Dietitian had not reviewed Resident 141's diet. Interview on 01/10/2017 at 11:55 AM Interview with facility Director of Nursing (DON) confirmed that a resident that required [MEDICAL TREATMENT] does have special dietary needs. The DON confirmed that Resident 141's diet was not communicated with the [MEDICAL TREATMENT] center and that the facility had not consulted with the [MEDICAL TREATMENT] Center's Dietitian to meet Resident 141's deitary needs.",2020-09-01
9545,GOOD SAMARITAN SOCIETY - SUPERIOR,285187,1710 IDAHO STREET,SUPERIOR,NE,68978,2013-01-31,278,D,0,1,OXQ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC Licensure Reference Number: 12-006.09B Based on record review and interviews, the facility failed to accurately code MDS (Minimum Data Set, a federally mandated comprehensive tool utilized to develop resident care plans) for one sampled resident (Resident 40). Facility census was 63. Findings are: Record review of an MDS revealed the most recent assessment of ADL (Activities of Daily Living) Assistance as Limited assistance, staff provide guided maneuvering of limbs or other non-weight bearing assistance. The previous assessment as Independent and no assistance. Record review of Care Plan dated 12/26/12 revealed that resident had a problem identified as Self Care Deficit r/t (related to) Diabetes, [MEDICATION NAME] Degeneration, Diabetic [MEDICAL CONDITION], Arthritis, and was either independent or supervised with ADL's, needs limited assist with bathing. Further record review revealed that interventions were identified as the resident was independent with AM cares and dressing, may need occasional supervision and/or set-up assistance and was independent with PM cares and undressing, may need occasional supervision and/or set-up assistance. Interview on 1/31/13 with MA (Medication Aide) - I at 9:15 AM revealed that resident had not had any decline in ADL's, and was independent in dressing. Interview with MDS Coordinator at 9:30 AM on 1/31/13 confirmed that the resident had not had any significant changes or declines. Further interview revealed that the MDS Coordinator did see the MDS was incorrectly coded.",2016-07-01
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
1970,WILBER CARE CENTER,285172,611 NORTH MAIN,WILBER,NE,68465,2019-12-17,759,D,0,1,Q3K311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 759 LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review and interview the facility failed to ensure a medication rate of less than 5%. The medication error rate was 7.69% resulting from 2 errors of 26 opportunities. The facility census was 48. Findings are: [NAME] An observation on 12/16/19 at 12:05PM of medication administration by LPN (Licensed Practical Nurse B for Resident 41. The [MEDICATION NAME] 25mcg(micrograms), Aspirin 325mg(milligrams), Vitamin D3 1000 units, and [MEDICATION NAME] 5mg were crushed and added to pudding. [MEDICATION NAME] 125mg Sprinkles 2 capsules were opened with gloved hands and added to the pudding. The medication was administered while Resident 41 was eating the noon meal. Record review of Resident 41's physician orders [REDACTED].>[MEDICATION NAME] tablet; 25 mcg; amount: 25 mcg; oral Once a Day at 09:30. [MEDICATION NAME] tablet, delayed release (DR/EC); 125 mg; amount: 2 caps; oral Three Times A Day 10:00AM, 4:00PM, and 8:00PM. [MEDICATION NAME] chloride tablet; 5 mg; amount: 5 mg; oral Twice A Day 10:00 - 1PM 7:00 - 9:00PM. Aspirin (OTC) tablet; 325 mg; amount: 325 mg; oral Once A Day 10:00 - 1:00PM [MEDICATION NAME] (vitamin D3) (OTC) capsule; 1,000 unit; amount: 1,000 unit; oral Once A Day 10:00 - 1:00PM. An interview on 12/17/19 12:49 PM with DON (Director of Nurses) confirmed; the [MEDICATION NAME] should be given on an empty stomach. B. An observation on 12/16/19 at 12:27PM of medication administration by MA (Medication Aide) C for Resident 21. [MEDICATION NAME] 1 tsp (teaspoon) was added to 5.5 ounces of Cranberry Juice and mixed. Record review of Resident 21's physician order [REDACTED].>An interview on 12/17/19 12:49 PM with the DON confirmed; that the [MEDICATION NAME] for Resident 21 had not been given per the physician order.",2020-09-01
11599,MID-NEBRASKA LUTHERAN HOME,285213,109 NORTH 2ND STREET,NEWMAN GROVE,NE,68758,2011-07-13,309,D,0,1,J4GR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ;LICENSURE REFERENCE NUMBER 175 NAC 12-006-09 Based on observations, record review and staff interviews, the facility failed to provide interventions to meet the individualized needs of Resident 24 with wheelchair positioning. Resident 24 was observed sitting in the wheelchair with head, neck and shoulders slumped forward. Facility census was 30. Findings are: Review of Resident 24 ' s Minimum Date Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/13/11 identified [DIAGNOSES REDACTED]. This MDS reflected Resident 24 required extensive assist with bed mobility, transfers, ambulation, dressing, toileting, personal hygiene and eating. The resident was also identified as having functional limitations to bilateral upper and lower extremities. Review of the Comprehensive Care Plan dated 6/13/11 indicated Resident 24 required assistance with all cares. The care plan indicated Resident 24 "" cries to return to bed soon after the resident is gotten up in the chair. "" Nursing approaches included placing resident in the wheelchair for meals and to get resident up only a short time before meals, then to return the resident to bed as quickly as possible after the meal. Resident 24 was observed sitting in a wheelchair in the dining room on 7/7/11 at 7:33 AM, 7/11/11 at 8:10 AM and 12:00 PM, 7/12/11 at 7:20 AM and 1:06 PM, and 7/13/11 at 8:15 AM with head, neck and shoulders slumped forward. No interventions were used to assist the resident to maintain an upright posture or to prevent the resident from slumping forward. During an interview 7/7/11 from 8:15 AM to 8:20 AM in the dining room NA-D (Nursing Assistant D) was observed feeding Resident 24 and stated "" different positioning would probably help, we haven ' t tried anything that I know of. "" During interview on 7/11/11 from 3:20 PM to 3:30 PM with RN-C (Registered Nurse C) and Director of Nursing (DON), the DON verified Resident 24 had poor positioning when sitting in current wheelchair and no interventions were in place to improve positioning. RN-C stated "" I think Occupational Therapy (OT) put Resident 24 in current wheelchair, but I looked through the resident ' s medical record and could not find any documentation. "" DON verified no documentation was available regarding previous evaluation of Resident 24 ' s sitting posture in current wheelchair. Review of Resident 24 ' s physician's order [REDACTED]. Review of Therapy Treatment Progress Notes dated 7/13/11 revealed OT assessment of wheelchair positioning. "" Chair is too large for resident in all directions. Kyphosis (a curving of the spine that causes a bowing or rounding of the back, which leads to a hunchback or slouching posture) and slumped posture with chin almost touching abdomen. Currently sits in chair approximately 6 hours a day. Nursing reports starting to have difficulty with swallowing due to rounded posture. OT has made contact with a wheelchair vendor for assessment of seating system and to make appropriate changes to improve posture and bring resident into a more upright position. "" Interview with the OT on 7/13/11 from 10:00 AM to 10:40 AM, verified a previous evaluation had not been performed.",2015-04-01
3924,HILLCREST COUNTRY ESTATES-COTTAGES,285293,6082 GRAND LODGE AVENUE,PAPILLION,NE,68133,2018-07-18,770,D,1,1,NCIW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 175 NAC 12-006.09 Based on interview and record review, the facility failed to obtain physician order to discontinue previously ordered lab for 1 (Resident 78) of 1 sampled residents. The facility had a total census of 46 residents. Findings are: Resident 78 was admitted to the facility on [DATE] and discharged on [DATE] according to Face Sheet. A review of Care Plan Report for Resident 78 revealed a [DIAGNOSES REDACTED]. A review of Resident 78's physician orders revealed an order for [REDACTED].>A review of Clinical Notes dated 6/7/18 revealed Resident 78's physician had discontinued order for urinalysis. A review of Resident 78's physician orders revealed an order dated 6/13/18 to change Foley catheter and bag. A urinalysis and culture and sensitivity was to be obtained from the new bag. A review of Resident 78's Clinical Notes dated 6/13/18 at 7 PM revealed no clean Foley bag could be found after calling several cottages. A message was left with Director of Nursing that a new bag needed to be obtained and a specimen sent in the morning. A review of Resident 78's physician orders did not reveal any orders to discontinue the order for the urinalysis on 6/6/18 or 6/13/18. In an interview on 7/17/18 at 9:46 AM, Physician B verified that orders for urinalysis on 6/6/18 had been discontinued due to Resident 78 not showing signs or symptoms of a urinary tract infection and the urinalysis on 6/13/18 had been discontinued due to moving up Resident 78's appointment with the urologist. In an interview 7/17/18 at 11:33 AM, Regional Director of Clinical Services confirmed there was no physician order to discontinue orders for urinalysis on 6/6/18 or 6/13/18.",2020-09-01
4424,"SCHUYLER CARE AND REHABILITATION CENTER, LLC",285110,2023 COLFAX STREET,SCHUYLER,NE,68661,2018-07-18,880,E,1,1,NXEG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 175 NAC 12.006.17 175 NAC 12.006.17B 175 NAC 12.006.17D Infection Prevention and Control Based on observations, record review, and interview; the facility failed to ensure interventions were in place to prevent cross contamination related to resident care supplies being stored together affecting 4 residents; and related to not doing hand hygiene to prevent cross contamination for 2 residents. This had the potential to affect Resident 22, 24, 1, 23, 11 and 18. Sample size was 13. Facility census was 28. Observation on 07/16/18 at 03:09 PM revealed Perineal Care was provided to Resident 22 by NA A and B (Nurse Aides). It was noted that no hand washing was done upon entry to the room. Both nurse aides donned gloves and gathered the supplies. Nurse Aide B had done perineal-care to the front with a wet wipe then retrieved the trash bin and set it next to the bed and continued the perineal care without change of gloves nor hand sanitization. Perineal-care was done to the buttocks and anal area. Nurse aide B changed gloves without hand sanitization and applied cream to the buttocks bilateral. Nurse aide A applied cream to the front perineal area. Gloves removed by Nurse Aide B and put in the trash can, the liner was removed and Nurse Aide B left the room. Nurse Aide A removed gloves and put them in the trash, entered hall way where Nurse Aide A then touched other residents without evidence of hand sanitization. Interview on 07/17/18 at 02:41PM with the Assistant Director of Nursing revealed that there were no competencies for Nurse Aide [NAME] Record review on 07/17/18 at 02:41 PM revealed Perineal Care Policy and Perineal-care Audit that the staff was to gather the supplies prior to the start of the care, after washing the resident, gloves were to be removed and hand hygiene performed. The audit read that the staff were to clean up the work area, dispose of soiled linen in the trash bag, remove gloves and perform hand hygiene before leaving the room. B. Observation on 07/12/18 at 03:10 PM with Registered Nurse C (RN) revealed that RN C completed hand washing prior to hooking up the [MEDICATION NAME] for 7 seconds Record review of the facility's hand washing policy revealed that hand washing should be 20 seconds. C. Room observation on 7/12/18 at 2:09 PM revealed no individual names on towel bars in bathrooms of Residents 1, 23, 11, and 18. Room observation on 7/18/18 at 8:20 AM revealed no individual names on towel bars in bathrooms of Residents 1, 23, 11, and 18. Interview with the Administrator on 07/18/18 at 09:04 AM confirmed that that the towel bars weren't marked in the bathroom of resident rooms and this could possibly put residents at risk for infection.",2020-07-01
4069,HILLCREST MILLARD,285302,13225 WESTWOOD LANE,OMAHA,NE,68144,2019-09-25,725,E,1,0,EL7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 725 Licensure reference 12-006.04C Based on observations, interviews, and record reviews, the facility failed to ensure sufficient numbers of nursing staff to provide bathing assistance to 3 (Residents 8, 9, 10 and 14) of 6 current sampled residents, failed to answer call lights in a timely manner for 3 (Resident 8, 11, and 14) of 6 current sampled residents and in 3 of 5 confidential interviews residents reported concerns about staffing and ability to get call light answered. The facility had a total census of 65 residents. Findings are: [NAME] In confidential interviews conducted on 9/23/19 between 11 AM-2 PM and on 9/25/19 between 10:55-11:29 AM, 3 of 5 sampled residents reported concerns related to staffing and ability to get call lights answered. Comments included the following: -weekend staffing is a nightmare -resident reported waiting for an hour for assistance then getting self ready for bed -not uncommon to wait 20 minutes to get call lights answered -resident reported taking self to bathroom when was non-weight bearing -delay in answering call lights B. A review of Device Monitoring Records revealed the following: -Resident 14 had 25 call lights on for greater than 15 minutes out of 128 between 9/14/19-9/25/19 with one call light on for 62 minutes and 15 seconds -Resident 8 had 26 call lights on for greater than 15 minutes out of 96 between 9/13/19-9/23/19 with one call light on for 65 minutes and 58 seconds -Resident 11 had 17 call lights on for greater than 15 minutes out of 171 between 9/13/19-9/25/19 with one call light on for 47 minutes and 23 seconds In an interview on 9/24/19 at 2:38 PM, the Director of Nursing reported the goal is to have call lights answered within 15 minutes. In an interview on 9/23/19 at 3:15 PM, the Administrator reported that the facility has working on improving call light times by changing the escalation of call lights to nurse and management pagers, encouraging nurses to answer pages and implementing angel rounds in which administrative staff are given 6-8 rooms to round on each day to check with residents about needs. C. Resident 14 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations on 9/25/19 at 10:57 AM revealed Resident 14 had long whiskers on face. In an interview on 9/25/19 at 10:57 AM, Resident 14 reported having a shower the day before for the first time since admission but would have liked one sooner. Resident 14 reported Resident 14 would like to shave but did not have a razor. A review of Resident 14's Nurse Tech Care Plan revealed Resident 14 required 1 assist for transfer and walking. Resident 14's Nurse Tech Care Plan listed Resident 14 has preferring evening showers. In an interview on 9/25/19 at 11:29 AM, Nurse Manager A reported that staff should have asked Resident 14 if Resident 14 wanted to shave when getting a shower. In an interviews on 9/25/19 at 2:47 PM and 3:16 PM, the Director of Nursing reported no documentation could be found of Resident 14 getting a bath or shower. D. Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 8's Nurse Tech Care Plan revealed Resident 8 required 1 assist for transfers. Resident 8 bath preferences were listed as Monday and Friday morning. A review of Resident 8's bathing report revealed no documented baths between 9/11/19 and 9/23/19, a total of 12 days. In an interview on 9/25/19 at 3:17 PM, the Director of Nursing reported no other documentation of Resident 8 having a bath/shower since 9/11/19 had been located. E. Resident 9 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. In an interview on 9/23/19 at 12:30 PM, Resident 9 reported that sometimes it would take a couple of days to get a bath after asking. A review of Resident 9's Nurse Tech Care Plan revealed bath preference of evening on Sunday and Wednesday. A review of Resident 9's bathing reported revealed no documented baths between 8/31/19 and 9/13/19, a total of 13 days. In an interview on 9/25/19 at 3:17 PM, the Director of Nursing did not have evidence of additional baths being provided to Resident 9. F. In an interview on 9/24/19 10:16 AM, Nurse Aide B verified that resident baths are not getting done. In an interview on 9/24/19 on 2:38 PM, the Director of Nursing reported that there was a problem with the bath scheduling in the computer and the facility is working on getting it corrected. [NAME] In an interview on 9/24/19 at 2:38 PM, the Director of Nursing reported staffing has been a challenge with staff calling in and not coming in.",2020-09-01
5310,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-01-23,225,D,1,0,5YZX12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Record review and interview the facility failed to complete a thorough investigation for 1 of 3 residents reviewed (Resident 4) related to an allegation of neglect. The facility census was 96 Findings are: Review of Resident 4 Admission Record dated 8/25/2016 revealed Resident 4 had the following Diagnosis: [REDACTED]. The facility investigation states the resident had an apneic(absence of breathing) episode on 11/1/2016 and staff were able to suction Resident 4's [MEDICAL CONDITION] and remove the obstruction and send Resident 4 to the hospital for further treatment. Review of the facility investigation revealed on 11/3/2016 the complainant voiced concerns regarding the need for Resident 4 to have been suctioned more often prior to Resident 4's hospitalization . Review of the facility investigation revealed a summary of the event that resulted in Resident 4 being transfered to the hospital on [DATE], however, did not address the care of Resident 4's [MEDICAL CONDITION] prior to the event. Review of Resident 4's progress note dated 11/1/2016 revealed no documentation of Resident 4's condition prior to or during the event requiring transfer to the hospital. Review of Resident 4s Treatment Administration Record (TAR) dated for (MONTH) (YEAR) revealed no suctioning or [MEDICAL CONDITION] site care was completed on the following dates: - 10/8/16 - 10/9/16 - 10/13/16 - 10/15/16 - 10/19/16 - 10/20/16 - 10/23/16 - 10/24/16 - 10/29/16 Interview with the Administrator revealed the Treatment Administration Record (TAR) had not been looked at during the investigation to determine if suctioning was completed as ordered and that should have been reviewed to determine the outcome of the concern voiced by the complainant.",2020-01-01
1386,LIFE CARE CENTER OF ELKHORN,285134,20275 HOPPER STREET,ELKHORN,NE,68022,2018-05-17,609,D,1,0,69JP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Record review and interview, the facility failed to report a fall resulting in a significant injury for 1 of 3 residents reviewed (Resident 1) to the state agency within 2 hours. The facility census was 95. Findings Are: [NAME] Review of Resident 1's progress notes revealed Resident 1 fell on [DATE] at 10:00 PM. Resident 1 did not initially complain of pain however, on 4/29/2018 Resident 1 did report increased pain. Review of Resident 1 progress notes revealed Resident 1 complained of leg pain and an x-ray was completed. The results of the x-ray was called to the facility at 9:00 PM indicating a fractured femur. Review of the facility VOI (Verification of Investigation) dated 5/3/3018 revealed the state agency was notified of the fall resulting in a significant injury on 4/30/2018 at 6:45 AM. Review of the facility policy dated 2/2018 titled Protection of Residents: Reducing the Threat of Abuse and Neglect revealed all events resulting in serious bodily injury are to be reported to the state agency within 2 hours. Interview with the VP Vice President) of clinical services revealed a report was called within 2 hours of the time the facility is aware of a significant injury.",2020-09-01
1086,EMERALD NURSING & REHAB LAKEVIEW,285106,1405 WEST HWY 34,GRAND ISLAND,NE,68801,2018-05-07,625,D,1,1,QN7C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility staff failed to issue notice of bed hold for 3 of 3 sampled residents's legal representative when Resident 22, Resident 33, and Resident 49 were transferred to the hospital. The facility identified a census of 55 at the time of survey. Findings are: [NAME] Review of Resident 22's Discharge Tracking and Entry records revealed Resident 22 was hospitalized [DATE] to 9/17/2017; 9/29/2017 to 10/2/2017; 10/6/2017 to 10/24/2017; 11/18/2017 to 11/21/2017; and 1/12/2018 to 1/13/2018. Record review of Resident 22's admission and discharge records revealed no documentation Resident 22's legal representative was given written notice of the facility's bed hold policy at the time Resident 22 was transferred from the facility to the hospital. Interview with the AC (Admission Coordinator) on 5/07/18 at 3:51 PM confirmed there was no documentation Resident 22's legal representative had been issued notice of the facility bed hold policy when Resident 22 was transferred to the hospital. The AC confirmed the bed hold notices had not been issued. 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 to the facility and/or when a resident leaves for hospitalization , observation or therapeutic leave. Before the resident may be transferred to a hospital or for a therapeutic leave, the facility is required to provide the facility's bed hold policy to the resident or legal representative. B. Review of the Progress Notes for Resident 33 dated 1/10/17 revealed the resident was a direct admission from a Physician Office visit to the hospital. The documentation was absent about notifying the family of the bed hold by the nursing staff. The family being notified of the admission to the hospital was absent. Review of Residents Census Tab (list changes in the residents admission status) revealed that on 1/10/18 Resident 33 was sent to hospital. C. Review of Resident 49's MDS's dated 10/16/17 and 2/16/18 revealed a discharge MDS with return anticipated for both dates. There were two (2) hospitalization s. Review of Progress Note dated 10/16/17 revealed Resident 49 was a direct admission to the hospital from a Physician Office visit. Attempts were made to contact the family. Documentation was absent about the bed hold policy education. Review of Progress Note dated 10/18/17 revealed the family was notified but the documentation was absent about the bed hold policy education. Review of Progress Noted dated 2/16/18 revealed Resident 49 was a direct admission to the hospital from a Physician Office visit. The family was notified but the documentation was absent about the bed hold policy education. Review of Residents Census Tab (list changes in the residents admission status) revealed that on 10/16/17 and 2/16/18 Resident 49 was sent to hospital. Interview on 05/07/18 at 01:49 PM with BOM (Business Office Manager) revealed that the Bed Hold Policy and letters are not being given with every discharge or transfer to hospital.",2020-09-01
1986,FLORENCE HOME,285173,7915 NORTH 30TH STREET,OMAHA,NE,68112,2017-12-06,578,E,1,1,CVPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure the wishes for CPR (Cardiopulmonary Resuscitation) for 4 residents (Resident 13, 60, 32, 72) of 25 residents sampled were communicated to the nursing staff. The facility staff identified the facility census at 68. The findings are: [NAME] An interview conducted on [DATE] at 12:18 with Licensed Practical Nurse (LPN) A revealed that if a resident was unexpectedly found to not be breathing or without a heartbeat, the nursing staff would check their report sheets if they had one or for a blue dot on the spine of the resident's chart to see if the resident was to receive CPR. The residents that were supposed to receive CPR would have a blue dot on the spine of their chart. LPN A reported they would also look for a blue dot on the door, but that the dots on the door were not always up to date. Resident 72 was the only resident that had received CPR in the past 3 months and the resident expired after arriving to the hospital. A review of Resident 72's Face Sheet dated [DATE] revealed that the resident was admitted to the facility on [DATE] and that the resident was listed as no for resuscitate. A review of Resident 72's Resuscitate Policy form dated [DATE] revealed that Resident 72 had elected to not receive CPR if found to be without a heartbeat. A review of Resident 72's nurse's note dated [DATE] revealed that the resident was found without a pulse and not breathing and that CPR was started and maintained until the ambulance squad arrived and took the resident to the hospital. At the hospital, the resident was declared deceased . An interview conducted on [DATE] at 2:12 PM with the Social Services Director (SSD) revealed that the process for communicating CPR wishes was the responsibility of Admissions on admission or Social Services if the resident chose to change their CPR status after admission. The SSD reported that in (MONTH) (YEAR), the Social Services and Admissions department staff went through 100% of the residents charts to ensure each resident's CPR elections were accurately reflected on the chart, name plate, and Face Sheet. The SSD reported that there was not much of a chance that the blue dot sticker would fall off the charts as the stickers are on the resident's name label that is inside a plastic holder. An interview conducted on [DATE] at 2:27 PM with LPN B revealed that when Resident 72 was found without a heartbeat, their Face Sheet said they were a full code and that the old Resuscitate policy indicating resident was to receive CPR was in the chart. LPN B reported that new staff were trained in new hire orientation that blue dots signified the resident was to receive CPR. LPN B reported that Social Services had gone through the entire building in (MONTH) making sure each resident's CPR elections were correct on the chart, name plate, and Face Sheet. A review of the facility's CPR Guideline dated ,[DATE] revealed the following: CPR, when indicated, will be performed on those residents who have yes checked on the Resuscitate Policy in their chart. A blue dot will be placed on the name plate outside of the resident's room, a blue dot will be placed on the outside of their chart B. A review of Resident 13's Face Sheet dated [DATE] revealed that the resident was admitted to the facility on [DATE] and that the resident was listed as yes for resuscitate. A review of Resident 13's Resuscitate Policy form dated [DATE] revealed that Resident 13 had elected to receive CPR if found without a heartbeat. An observation conducted on [DATE] at 10:18 AM revealed that Resident 13's chart did not have a blue dot on the spine which would make nursing staff think the resident was not to receive CPR. An interview conducted on [DATE] at 3:03 PM with Registered Nurse G confirmed that Resident 13's chart did not have a blue dot on the spine. C. A review of Resident 32's Face Sheet dated [DATE] revealed that the resident was admitted to the facility on [DATE] and that the resident was listed as yes for resuscitate. A review of Resident 32's Resuscitate Policy form dated [DATE] revealed that Resident 32 had elected to receive CPR if found without a heartbeat. An observation conducted on [DATE] at 10:20 AM revealed that Resident 32's chart did not have a blue dot on the spine. An interview conducted on [DATE] at 2:53 PM with LPN C revealed that Resident 32's chart did not have a blue dot on the spine which would make nursing staff think the resident was not to receive CPR. D. A review of Resident 60's Face Sheet dated [DATE] revealed that the resident was admitted to the facility on [DATE] and that the resident was listed as no for resuscitate. A review of Resident 60's Resuscitate Policy form dated [DATE] revealed that Resident 60 had elected to not receive CPR if found without a heartbeat. An observation conducted on [DATE] at 10:59 PM revealed a blue dot on the resident's name plate. An interview conducted on [DATE] at 2:53 PM with LPN C revealed that Resident 60's name plate was marked with a blue dot which would make nursing think the resident was to receive CPR.",2020-09-01
2373,GOOD SAMARITAN SOCIETY - BEATRICE,285203,401 S 22ND STREET,BEATRICE,NE,68310,2017-09-13,323,D,1,1,9PTJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to investigate ongoing falls for 1 of 3 residents reviewed for Accidents (Resident #94) in order to determine if identified interventions were implemented and/or effective and to develop new interventions to prevent recurrence. Findings are: Resident #94 was deceased and not available for interview or observation. According to the [DATE] Summary of Skilled Services admission note, Resident #94 was admitted to the facility due to a history of falls, required two staff assistance with transfers and required a lot of assistance pulling himself into an upright position. The Care Conference note, dated [DATE], revealed the resident's spouse indicated that (resident) had a lot of falls at home as the resident did not use the walker. The Falls Tool, dated [DATE], identified the resident was at low risk for falls. The Physical Device and Restraint Assessment, dated [DATE], indicated an assist grab bar on the bed would be appropriate as it would make the resident able to repo(sition) and sit up by self. Review of Nursing Progress Notes between the resident's admission on [DATE] and death on [DATE] revealed he experienced 19 falls. Review of the Fall Scene Huddle Worksheets and Investigation forms, completed after each fall, revealed staff documented sometimes conflicting information, or lacked the details necessary to assess the cause of each fall and to develop new interventions to prevent recurrence. In addition, the facility failed to identify potential trends related to the grab bar as a risk factor for injury with falls. For example: According to a nurse progress note, dated [DATE] 0133, residents call light was on, staff went to answer his light, staff turned on the light and saw him lying on the floor with his head between the hand rail and bed. staff removed the hand rail and bed . Review of the Fall Scene Huddle Worksheet, dated [DATE], indicated the resident fell at 12:35 a.m. This form also identified the resident last had contact with a staff member at 11:30 p.m. about an hour prior to the fall. The form also indicated the resident was last toileted at 12:30 a.m. There was no clarification to this contradictory information. The Investigation indicated the resident, was rolling over and was too close to edge of bed and he couldn't stop and kept rolling. There was no indication the call light was on, as identified in the progress note. Neither the Fall Scene Huddle Worksheet or Investigation were signed by the staff member who completed them, making follow-up difficult. Neither of these forms identified the resident was caught between the grab bar and the bed. There was no follow up by the facility regarding this discrepancy, and the resident continued to have the grab bar on his bed. The [DATE] 0137 progress note indicated the resident was, found upper body still in bed, lower body on fall mat next to bed. The Fall Scene Huddle Worksheet included a hand drawn picture that made it appear as though the grab bar was potentially involved. There was no follow up by staff to determine if that was the case, or whether the grab bar could be a risk factor given the resident's upper body remaining in the bed after a fall. The [DATE] 2359 progress note identified the, Resident rolled out of bed. Lower half of body on fall mat. Neck area caught on grab bar. Resident face red in color. Lowered grab bar to free neck area . No injuries noted. After this incident, the facility re-assessed the grab bar and removed it from the resident's bed. Additional falls, without the grab bar as a potential factor, also lacked specific, consistent details in order to prevent recurrence. The [DATE] Fall Scene Huddle Worksheet indicated the resident fell in the bathroom attempting to self-transfer. When asked to identify the time the resident was last toileted (information that could be used to determine if the resident received the care he required, was having urgency or frequent voiding, or required any new interventions), staff documented, at time of incident. In addition, the form was not signed or dated by the staff member who completed it making follow-up difficult. The [DATE] Fall Scene Huddle Worksheet was not signed or dated by the staff member who completed it. It did not provide responses to the questions of what staff member last had contact with the resident prior to the fall, or when that had occurred. It did not identify when the resident was last toileted. The Investigation identified the resident was in bed, reaching for the call light and slid out of bed. The intervention to prevent recurrence was, make sure call light is within reach. The investigation did not identify where the call light was when the resident fell . This information would be useful to determine if staff had met the resident's needs prior to the fall or whether an alternative call light might be useful. The [DATE] Fall Scene Huddle Worksheet indicated the resident fell at 9:00 a.m. It also identified the resident was last provided care, 2 hours prior to the fall when he was toileted. The same worksheet also noted the resident was last toileted at 5:30 a.m. (3 1/2 hours prior to the fall). This conflicting information was not clarified on the worksheet, preventing the facility from determining if he had been provided care as care planned or needed more frequent toileting. The [DATE] Fall Scene Huddle Worksheet indicated the resident was last seen by staff 8 minutes prior to his fall at 6:43 p.m. The intervention to prevent recurrence was, Staff to monitor every 2 hours. There was no indication how this would prevent recurrence when the resident was frequently found to have fallen less than 30 minutes after being seen by staff, and in the case of this fall, less than 10 minutes after staff observed him. In an interview on [DATE] at 4:29 p.m., Staff A, Administrator, stated she did not recall anything about the [DATE] incident involving the grab bar. She stated the Fall Scene Huddle Worksheet should always be signed by the staff member who completed it. She stated she expected the progress note and the Fall investigations to match, and if there was contradictory information it would be addressed when the Administrator, Director of Nursing, and Social Worker reviewed (and signed) the Investigation forms. She was unable to explain why this, and other discrepancies had not been identified by the facility. In an interview on [DATE] at 9:24 a.m., Unit Manager, Staff D, reviewed the above-mentioned fall investigations. She stated for the [DATE] fall, the investigatory forms should be complete and detailed. She stated the time the resident was last toileted should be identified and that the staff member who completed the form should sign it. She stated staff review the fall investigations, however, don't always see those things. For the [DATE] fall, she stated the location of the call light should have been included, otherwise we can't tell what was happening. She also stated the last time he was cared for or seen should be included. She stated the information in the [DATE] fall was inconsistent, for the [DATE] she could not tell if the grab bar was included in the fall, and that the intervention to check every two hours after the [DATE] fall was not appropriate given the circumstances of the falls.",2020-09-01
1347,HILLCREST HEALTH & REHAB,285133,1702 HILLCREST DRIVE,BELLEVUE,NE,68005,2017-08-02,156,D,1,1,YKIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide a cost listing of what Medicaid would and would not cover upon admission. This effected 2 residents (Resident 161 and 285 ). The facility census was 110. Findings are: [NAME] Record review of Resident 161's Face Sheet, dated 7/27/17, revealed that, Resident 161 was admitted to the facility on [DATE]. Record review of Resident 161's Census History, dated 7/27/17, revealed that Resident 161 became Medicaid eligible on 5/1/2016 . Interview on 7/26/17 at 3: 40 PM with Resident 161's family revealed that staff did not provide a list of services and items that would and would not be charged for when Resident 161 became eligible for Medicaid. Interview with the facility business office, Staff Member I, on 7/27/17 at 3:10 PM confirmed that there was not a form provided to Resident 161's family upon eligibility for Medicare. Interview with the facility Administrator on 7/27/17 at 3:11 PM confirmed that the facility did not provide information to Resident 161's family regarding Medicaid coverage and charges. B. Record review of Resident 285's Face Sheet, dated 7/27/17, revealed that, Resident 161 was admitted to the facility on [DATE]. Record review of Resident 161's Census History, dated 7/27/17, revealed that Resident 161 became Medicaid eligible on 7/22/16. Interview on 7/26/17 at 2:45 PM with Resident 285's family revealed that staff did not provide a list of services and items that would and would not be charged for when became eligible for Medicaid. Interview with the facility business office, Staff Member I, on 7/27/17 at 3:10 PM confirmed that there was not a form provided to Resident 285's family upon eligibility for Medicare. Interview with the facility Administrator on 7/27/17 at 3:11 PM confirmed that the facility did not provide information to Resident 285's family regarding Medicaid coverage and charges.",2020-09-01
3416,WESTFIELD QUALITY CARE OF AURORA,285263,"PO BOX 166, 1313 1ST STREET",AURORA,NE,68818,2019-11-13,712,D,1,0,P0CC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility staff failed to ensure Resident 2 was seen by their physician/medical provider or physician delegate (physician delegate: physician assistant, nurse practitioner, or clinical nurse specialist) every 60 days. This affected 1 of 3 sampled residents. The facility identified a census of 64 at the time of survey. Findings are: Review of Resident 2's Admission Record revealed an admission date of [DATE]. Review of Resident 2's Clinical Health Records revealed Resident 2 was seen by a physician/medical provider on 6/5/19, 6/18/19, 6/24/19, and 8/26/2019. Resident 2 was seen by an optometrist/ophthalmologist (eye doctor) on 10/9/2019. There was no documentation Resident 2 had been seen by their physician/medical provider since (MONTH) 26, 2019. Review of Resident 2's Progress Notes revealed no documentation Resident 2 had been seen by their physician/medical provider since (MONTH) 26, 2019. Interview with the BOM (Business Office Manager) on 11/13/2019 at 2:45 PM revealed that some residents only wanted to be seen by their physician annually. The residents and/or responsible parties were to sign a Physician Visit Form which indicated they only wanted to see their physician/medical provider annually. The BOM confirmed Resident 2's appointment in (MONTH) was an eye Dr. appointment, not with their physician/medical provider. Requested documentation that Resident 2 refused to be seen by their physician/medical provider every 60 days. Review of Resident 2's medical record revealed no documentation Resident 2 or their responsible party had declined to see their physician/medical provider every 60 days. Interview with the BOM on 11/14/2019 at 3:35 PM confirmed they could not find Resident 2's Physician Visit Form which would have indicated Resident 2's preference of when they wanted to see their medical provider. Review of the facility policy Physician Visits and Physician Delegation dated (YEAR) revealed the following: It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. The Physician should see resident within 30 days of initial admission to the facility. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by State Law.",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
3421,WESTFIELD QUALITY CARE OF AURORA,285263,"PO BOX 166, 1313 1ST STREET",AURORA,NE,68818,2019-11-13,842,D,1,0,P0CC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review; the facility failed to ensure meal intakes were documented. This affected 2 of 3 sampled residents (Residents 3 and 4). The facility identified a census of 64 at the time of survey. Findings are: Resident 3 [NAME] Review of Amount Eaten by Resident 3 revealed that Resident 3 had 2 meals on 10//17/19; 2 meals on 10/24/19 and 2 meals on 10/29/19 there was no documentation of refusals for a meal. Review of PN (Progress Notes) for Resident 3 revealed: PN dated: 10/18/19 at 8:46 PM Resident very upset about supper. States resident was tired of sitting in the dining room for long periods of time waiting for residents food. States staff don't feed resident in a timely manner. States that resident can't transfer by self anymore to bed or bathroom and that upsets resident. Tried to comfort and talk with resident regarding the meals. Informed resident that meals are rotated with who staff serve first and that do to staffing. 400 hall and those that need assistance need to come first. Resident 4 B. Review of Amount eaten by Resident 4 revealed that Resident 4 had 2 meals recorded on 11/7/19; 1 meal on 11/8/19; 2 meals on 11/9/19; and 2 meals on 11/10/19 there was only one documentation of a meal not received for Resident 4. Review of PN ( Progress Notes) for Resident 4 revealed there was no documentation stating resident refused meals. There was a documentation of the following. PN dated: 11/7/19 at 9:13 PM Resident did not receive room tray at supper do to staff error. Spouse went outside of facility and bought resident supper. Dietary and staff educated on this and the responsibilities of room trays. Dietary states resident was on a long term list for room trays and staff are aware of that. An interview on 11/13/19 at 11:10 AM with LPN-A (Licensed Practical Nurse) revealed the Charge Nurse documents in the progress notes if the resident refused a meal. Also the staff can document that the Resident refused the meal. The only time Resident 4 goes out of the facility was for a physician's appointment. Review of a Concern/Compliment Form filed by Resident 4 revealed after an investigation was completed that staff were aware Resident 4 did not go into the dining room. There was no documentation on the grievance to indicate Resident 4 was taken a room tray or if Resident 4 refused. Review of the notes from the staff meeting held on 11/7/19 at 1:00 PM & 2:15 PM, prior to the Concern/Compliment Form being filed for Resident 4, revealed *Room tray changes/pick up trays in timely manner. We can work as a team on this. Open for suggestions to make this go [MEDICATION NAME] with an undated hand written note -staff decided to chart own room trays on their assigned halls. An interview on 11/13/19 at 5:32 PM with the DON (Director of Nursing) the dietary staff charts the meal if the resident is in the dining room. Nursing documents the room tray when the trays are picked up by staff. The dietary staff also keep track of what the intake was on the Room Tray slips. The staff are aware that documentation is done. The previous dietary staff were to document the room trays. The staff were informed that when a resident refuses anything the charge nurse needs to be informed and the charge nurses are told to document any refusal. Review of the documentation of the Room Trays revealed documentation for the reason for the room tray such as Never out, Just being mean, was out but got taken back to room, never comes out, doesn't want to, hand leftovers for noon, sick, and out with family. There was no documentation on the meals consumed on (MONTH) 9, 2019 and (MONTH) 10, 2019.",2020-09-01
4052,HILLCREST FIRETHORN,285300,8601 FIRETHORN LANE,LINCOLN,NE,68520,2018-06-14,698,D,1,0,U8OO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation and record review the facility: 1) failed to assess residents before and after [MEDICAL TREATMENT] treatments, 2) failed to ensure orders were in place for [MEDICAL TREATMENT] care related to the infusion site, 3) failed to give medications as ordered to ensure absorption of the medications occurred prior to [MEDICAL TREATMENT], and 4) failed to coordinate care with the [MEDICAL TREATMENT] Provider for the continuation of care related to the residents [MEDICAL TREATMENT] needs. This had the potential to affect 2 residents (Resident 46 and 41) out of 2 sampled residents. The facility census was 30. Findings are: An observation on 6/13/18 at 8:33 AM of Resident 41 revealed the resident eating breakfast in the resident's room. The Resident reported had not received any of scheduled morning medications. Blood Glucose level had not been checked this am, and that the assessment was usually completed late. Yesterday's lunch time check was completed at 2:00 PM. The Resident had already been to therapy, and went on to report that the scheduled dressing change had not been completed, and planned on leaving the facility for [MEDICAL TREATMENT] about 10:00 AM. A review of the Medication Administration Record [REDACTED]. The medications were scheduled to be given 6:00-9:30 AM and the documentation did not indicate they had been administered as of 9:30 AM on 6/13/18. Further review of MAR for Resident 41, revealed [MEDICATION NAME] is ordered 800mg Tablet 3 times daily with meals, was held on 5/23/18 at noon and 5/24/18 morning and noon dose. The signed physician orders [REDACTED]. The order for [MEDICATION NAME] was on the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The dose on (MONTH) 12, at 9:14 AM and 2:16 PM was documented not available. Per Nursing Drug Handbook (YEAR), [MEDICATION NAME] is a polymeric [MEDICATION NAME] binder and is to be given with meals. The drug may bind with other medication and decrease bioavailability. Recommendation is to give other drugs 1 hour before or 3 hours after this medication. Patient teaching; 1) Instruct patient to take with meals and to adhere to diet 2) inform patient to take whole do not chew or crush the medication, 3) tell patient to take other drugs 2 hours before or 4 hours after the medication. Per article Phosphorus Binders ([MEDICATION NAME] Binders) and the [MEDICAL TREATMENT] Diet www.davita. Com, Phosphorus binder [MEDICATION NAME] soaks up [MEDICATION NAME] like a sponge and it is then excreted in the stool. This medication is taken 5-10 minutes prior to meals or immediately after meals. An interview on 6/13/18 at 9:43 AM, with Resident 41, revealed the resident's scheduled medications were offered at 8:45 AM, after the Resident had eaten breakfast. The Resident reported declining to take the medications as they were offered to close to the scheduled [MEDICAL TREATMENT] and they would be flushed out. An interview on 6/13/18 at 9:48 AM, with Licensed Practical Nurse (LPN)-E revealed the LPN had visited with the APRN (Advanced Practice Registered Nurse) who was in the building, and had any of Resident 41's medication ordered for once daily could be safely rescheduled for 4:00 PM, or whenever the Resident returned from [MEDICAL TREATMENT]. The LPN reported/confirmed Resident 41 did not receive the medication [MEDICATION NAME] or [MEDICATION NAME], and did not have Blood sugar/glucose checked before the morning meal, as ordered. The LPN continued to anticipate being able to complete the ordered wound care prior to the Guest leaving for [MEDICAL TREATMENT] this morning. An observation on 6/13/18 at 10:15 AM was conducted of wound care/dressing change to Resident 41's foot by LPN-E revealed the LPN , wrapped the Resident's foot and lower leg, reapplied a pressure relieving boot. The Resident's foot was positioned on foot pedal of wheel chair (w/c), then immediately transported per w/c out of the room to transportation staff who had been waiting to take Resident 41 out for [MEDICAL TREATMENT]. No further assessments were completed prior to Resident 41 leaving the facility. Review of the MAR/TAR (medication/treatment administration record) and Care Plan, printed 6/12/18, revealed no documentation related to resident assessments recommended to be completed prior to and after receiving [MEDICAL TREATMENT]. The documentation indicated Resident 41 did not receive medications as ordered on a routine basis. Interview with the Medical Director (MD) and Acting Director of Clinical Services (DCS) on 6/14/18 at 2:34 PM, confirmed Resident 41's disease processes had not all been fully addressed. The Medical Director reported that Resident 41 was knowledgeable and wanted to be in control of the disease process, wanted to change the timing of a medication, and take the medication once a day on [MEDICAL TREATMENT] days, rather than the three times daily as ordered by the Resident's Liver Specialist. The MD revealed the MD made the requested changes to take the medication 1 time daily on [MEDICAL TREATMENT] days, and take two times daily on other days of the week. Staff are working with Resident 41 on the timing of the resident's medications. When asked if Resident 41's Kidney and Liver Specialists had been consulted with related to the changes, the MD reported (gender) had not personally consulted with the Specialty MDs. B. On (MONTH) 14, (YEAR) an observation at 1:00 PM revealed Resident 46 was not in room, and the corporate nurse revealed that Resident 46 was at [MEDICAL TREATMENT]. On (MONTH) 14, (YEAR), a record review of physician's orders [REDACTED]. On (MONTH) 14, (YEAR), a record review of Care Plan date range 4/1/2018-6/14/2018 revealed Resident 46 received [MEDICAL TREATMENT] 3 times a week on Tues, Thurs, and Sat. Observe fistula (a surgically made passage between a vein and an artery, which allows connecting to the [MEDICAL TREATMENT] machine) site in the evening after [MEDICAL TREATMENT]. Monitor for Bruit/Thrill (A bruit is a sound associated with blood flow in the fistula. Although usually heard with the stethoscope, such sounds may occasionally also be felt as a thrill) daily. On (MONTH) 14, (YEAR) a record review of Clinical Notes Report and Resident Vital Sign Report with date range of 5/14/18-6/14/18 revealed on Tuesday 5/22/18 at 2:49 am that Resident 46 woke up with nausea and vomiting, given 7-up. No vital signs or assessment were done. On Saturday 5/26/18 no assessment was done. Saturday 6/2/18 no vital signs were done, on Sat 6/9 no assessment on [MEDICAL TREATMENT] and on Tues 6/12 no vital signs were done. On (MONTH) 14, (YEAR) an observation at 3:30 PM revealed Resident 46 was back in room from [MEDICAL TREATMENT]. No fistula was seen, Resident 46 did have a dressing on right upper chest. On (MONTH) 14, (YEAR) at 3:30 PM and interview with corporate nurse revealed Resident 46 does not have a fistula, Resident 46 had a PICC ( A peripherally inserted central catheter or PICC is a thin, soft, flexible tube - an intravenous (IV) line).",2020-09-01
3656,RIDGEWOOD REHABILITATION & CARE CENTER,285279,624 PINEWOOD AVENUE,SEWARD,NE,68434,2018-06-05,744,D,1,1,RVGM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation, and record review; the facility failed to ensure that psychosocial needs were met for residents with dementia. This failure had the potential to affect one resident, Resident 32. The facility census was 73. Findings are An interview on 5/30/18 at 11:00 AM with Resident 32's Family Member revealed Resident 32 had recently been moved out of a room in the Facility's SCU (Special Care Unit) for Memory Care, into a room within the general population of the facility. The Family Member reported the dependent resident had resided in the SCU since being admitted to the facility, and had been included in all of the scheduled social and recreational activities offered while residing in the SCU. The Family Member went on to report since being moved, Resident 32 spent an increased amount of time alone in the resident's room; and it seemed as if the staff assigned to the current living area did not know the resident, so therefore the staff were unable to anticipate Resident 32's care needs. A review of an undated Care Plan (CP) for Resident 32 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the CP revealed a CP Focus initiated on 4/20/17 and revised on 1/6/18 that indicated the resident experienced cognitive impairment due to [DIAGNOSES REDACTED]. Resident 32 had a history of [REDACTED]. Resident 32 triggered for a high elopement risk however IDT (interdisciplinary team) reviewed and did not feel the resident was at risk at this time. Interventions included Resident to reside in secure memory support unit, which was initiated on 4/20/17 and had not been revised. On 06/04/18 at 10:35 AM, an interview with the DON (Director of Nursing) revealed the facility was unable to locate documentation related to the decision to relocate Resident 32 from the Memory Care Unit into the General Population. The DON reported knowledge that the team felt the resident no longer fit into the Social Model for the Memory Care Unit related to a continued decline in condition. They talked to Resident 32's family to receive the ok and the resident was moved the next day. A review of a facility document titled FAMILY MEMORY SUPPORT HIGHLIGHTS, dated 2/2017, revealed the memory support philosophy was to provide a secure, structured, and calm environment where residents with dementia can be engaged in meaningful social activities. The Memory Care Household door was shut/secured to promote safety, smaller environment with less noise and less people walking in and out, to minimize the feeling of confusion and fear. The household was designed to be a supportive living environment for residents with dementia and was not a behavioral health unit. Meaningful activities, approach, and communication were the best ways to manage these issues. Discussions regarding admission/discharge/transfer would involve the resident and/or designee, the interdisciplinary team; and would at minimum occur within care plan meetings and/or special meetings requested by the resident and/or designee. The interdisciplinary team would identify if there were care needs that surpass the goals of the memory support household and would be better served outside of the specialized environment. Goals of the facility included: to be a resource and support for families with loved ones with dementia, and to provide consistency in memory support caregivers who have received additional training to effectively provide care for residents with dementia. A review of Progress Notes for Resident 32 revealed a note dated 9/6/17 indicating notification of room change was given to the resident's Responsible Party. The notes did not indicate a reason for the move or a change of condition/decline for Resident 32.",2020-09-01
1644,MAPLE CREST HEALTH CENTER,285149,2824 NORTH 66TH AVENUE,OMAHA,NE,68104,2018-12-18,609,D,1,1,864P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to ensure investigation of possible abuse were submitted to state survey agency within 5 working days for 2 (Residents 70 and 441) of 8 sampled residents. The facility had a total census of 138. Findings are: [NAME] Resident 441 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Adult of Protective Service reported dated 11/16/18 revealed a facility self-report regarding Resident 441's hair being cut. The report stated that Resident 441's family had not wanted Resident 441's haircut. A review of facility State Reportable Log investigations did not include report regarding Resident 441's hair being cut. In an interview on 12/13/18 at 1:30 PM, Social Worker A confirmed an investigation of Resident 441's hair being cut being cut was not submitted to the state agency. A review of facility policy titled Abuse Investigations revised (MONTH) 2006 revealed results of all investigations and reports shall be faxed or emailed to the state survey and certification agency within 5 days of notification of allegations. B. Record Review of Progress Notes dated 11/21/2018 for Resident 70 revealed: a call was placed to the state agency to report a fracture to the right 4th finger that showed on the x-ray after Resident 70 presented with a cyst to the knuckle. The nurse practitioner asked for a re-read of the x-ray and it was determined that it was not a fracture, but results of Uric Acid eating at the resident's joint. DON placed another call to the state agency to update with the current findings. Interview conducted on 12/17/2018 at 04:00 PM with the DON confirmed the call was placed to the state agency, but an investigation had not been completed or reported to the state agency within the 5 working days.",2020-09-01
4747,"SORENSEN CARE AND REHABILITATION CENTER, LLC",285107,4809 REDMAN AVENUE,OMAHA,NE,68104,2017-06-15,280,D,1,1,F9RW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to ensure the responsible party was involved in the care planning process for 1 resident (Resident 87) of 3 residents sampled. The facility staff identified the census at 68. The findings are: An review of Resident 87's Admission Record dated 6/15/17 revealed the resident was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. A review of Resident 87's most recent Minimum Date Set (MDS: A federally mandated comprehensive assessment tool used for care planning) their Brief Interview for Mental Status (BIMS) score was 5 out of 15 indicating severe cognitive impairment. An interview conducted on 6/12/17 at 4:32 PM with Resident 87's responsible party revealed that the responsible party had not been notified of care plan meetings and had not been included in the care planning process for Resident 87. A review of Resident 87's progress notes since admission revealed no documentation regarding a care plan meeting or that the responsible party was notified of a care plan meeting. An interview conducted on 6/14/17 at 3:29 PM with the Social Services Director revealed that they documented care plan meetings in the progress notes on the computer, but would look for other documentation. A review of an untitled form used to document care plan meetings, supplied by the Social Services Director, dated 4-20-17 revealed the care plan meeting was attended by social services and activities representatives only. The area to document if a letter was sent to the responsible party was left blank. The area to document if a letter was given to the resident was left blank.",2020-03-01
1159,PRESTIGE CARE CENTER OF NEBRASKA CITY,285109,1420 NORTH 10TH STREET,NEBRASKA CITY,NE,68410,2017-05-02,323,E,1,1,4KPH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to monitor interventions when a resident was identified at risk of elopement and failed to implement interventions to prevent future elopements for 3 of 3 Residents (Residents 44, 51, and 68). The facility census was 43. Findings are: [NAME] Review of resident census revealed Resident 68 was admitted on [DATE] and discharged on [DATE]. Review of the resident's care plan revealed a care plan for elopement related to anger at placement in living center. Intervention included that the resident wore a wanderguard bracelet (A device used to alert staff if a residents wearing one is too close to the doors). Staff were to check for placement and functioning every shift and as needed and change every 90 days and as needed. Review of the facility investigation revealed Resident 68 left the faciity on [DATE] without the staff knowledge and Resident 68 did have a wanderguard in place. Although Resident 68 did not score as an elopement risk on the assessment. Resident 68 did have poor safety awareness. Review of a Social Service Note dated 11/25/2016 at 4:57 PM revealed a Nursing Assistant (NA) noticed that the resident was outside of the facility. The NA came in to ask the staff if the resident was to be outside. The Charge nurse stated that Resident 68 was not. When asked what resident was doing, the resident stated that the alarms did not sound. Review of progress note dated 10/24/2016 at 5:08 PM revealed Resident 68 did have a wanderguard on at that time. Interview on 4/20/2017 at 3:30 PM with the administrator revealed the wanderguard checks were documented on the TAR (Treatment Administration Record). Resident 68 did have a wanderguard on at the time of leaving the facility and it did not sound the alarm. Review of the TAR dated for (MONTH) (YEAR) revealed no documentation of wanderguard checks for Resident 68. 04/25/2017 12:04:52 PM, interview with Health DON (Director of Nursing) revealed no documentation on the TAR dated for (MONTH) (YEAR) prior to or after the elopement to indicate if the wanderguard was checked for functioning. B . Review of Resident 51's MDS dated 11//25/2017 revealed a cognitive score of 7/15, indicating poor cognitive function. Review of a Nursing Note dated 12/4/2016 at 10:06 AM revealed Resident 51 was observed in the courtyard of the memory support unit ambulating across the grounds in a direction away from the back of the building. Resident 51 exited the building unsupervised. Review of Nursing Note dated 12/6/2016 revealed that, at 9:15 PM, Resident 51 went out the snack room door. Resident 51 stated the resident was going to the gas station. Review of care plan dated 11/8/2016 revealed Resident 51 was to have a wanderguard in place. Review of Resident 51's TAR for (MONTH) (YEAR) revealed no documentation of monitoring the functioning of the wanderguard. Review of Resident 51's TAR dated 12/2016 revealed Resident 51's wanderguard was not being monitored prior to Resident 51's elopement. C. Record review of an Elopement Risk assessment dated [DATE] revealed Resident 44 had scored a 21. According to the information, a score of 10 or higher identified a resident was at risk for elopement. Record review of Resident 44's Comprehensive Care Plan dated 1-03-2017 revealed a wanderguard ( device placed on Resident 44 that would sound an alarm if the resident were too close to an exit door) that was to be checked for placement and function every shift. Record review of Resident 44's Medication Administration Record (MAR) and TAR for (MONTH) (YEAR) revealed the wandergaurd was not identified on either document that staff were monitoring the device. On 5-01-2017 at 1:35 PM, an interview was conducted with the DON. During the interview, Resident 44's MAR and TAR for (MONTH) (YEAR) were review. The DON confirmed that Resident 44's wanderguard had not been monitored and should have been.",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
4070,HILLCREST MILLARD,285302,13225 WESTWOOD LANE,OMAHA,NE,68144,2019-09-25,761,D,1,0,EL7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review the facility failed to ensure the medication cart was locked and supervised, the facility failed to ensure medications were not left at bedside for Resident 7, the facility failed to ensure that nebulizer treatment was given for Resident 11. The facility census was 63 Findings: 09/24/19 record review of Medication Policy-Medications are documented as administered after the medication Aide/nurse has assured the guest consumed the medication- During administration of medications, the medication cart/medications cabinet will be kept closed and locked when out of sight of the medication team member. No medications can be left on top of Medication cart or medications cabinet in rooms without team member that is administering medications within sight of the medications. [NAME] Observation during Medication Pass on 09/24/19 at 7:50AM with RN E, revealed medication for Resident 7 was in medication cup on bedside table. Interview with Resident 7 revealed that she had not taken her medications left at bedside last night, she had forgotten. Interview with RN11 passing medications agreed that medication should not have been left at bedside. Record Review of MAR (Medication Administration Record) for Resident 7 for 09/23/19 revealed medications were charted as taken. B. 09/24/19 7:55AM Observation during Medication Pass with RN E, revealed breathing treatment (nebulizer) contained liquid in the container for Resident 11 Interview with Resident 11 revealed that he had not taken his breathing treatment last night and was wondering if he could take it now. Interview with RN [NAME] agreed that the treatment should have been observed as having been completed Record Review of Resident 11 MAR (medication administration Record) IPRAT-ALBUT 0.5-3mg/3ml inhale 1 vial via nebulizer 4 times /day. C .09/24/19 10:15AM Observation , Medication cart was sitting in doorway of room [ROOM NUMBER], medication pack with medication was laying on top of cart and medication drawer of cart was not locked and was unattended by authorized staff. 09/24/19 10:20 AM Interview with Nurse E, who returned to the unlocked medication cart, agreed that nurse [NAME] should not have walked away from unlocked cart and that medications should not have been left unattended on top of cart. 09/24/19 8:15AM Interview DON (director of Nursing) confirmed that the medication policy does state that medications should not have been left in resident 7,and resident 11 room for them to take unattended. And that medications should not be charted that were not observed being taken by resident.",2020-09-01
2175,LEGACY GARDEN REHABILITATION & LIVING CENTER,285186,200 VALLEY VIEW DRIVE,PENDER,NE,68047,2018-10-04,880,F,1,1,JIFC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review; the facility staff failed to perform hand hygiene for care/treatment of [REDACTED]. The facility census was 34. Findings are: Observation on 10/04/18 at 1:10 PM during wound care observation for Resident 5 revealed two NA's (Nurse Aides F and G) came in to assist with the procedure. NA G did not use hand sanitizer nor did hand washing prior to application of gloves before care for Resident 5. Record review of Infection Control policy dated 01/2018 revealed staff members were to use either antimicrobial soap and water or alcohol based hand rub before performing resident care procedures. Record review of the facility's Hand Hygiene Policy dated 01/2018 revealed staff members were to use either antimicrobial soap and water or alcohol based hand rub between resident contact.",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
5520,"SORENSEN CARE AND REHABILITATION CENTER, LLC",285107,4809 REDMAN AVENUE,OMAHA,NE,68104,2016-11-14,155,D,1,0,7EEE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview; the facility failed to ensure that an Advanced Directive (information about the residents wishes for end of life care) had been formulated for Resident 4 and Resident 3. Sample size was two. The census was 66. Findings are: [NAME] Record review of the facility Policy and Procedure for Advance Directives dated [DATE] revealed that the resident had a right to execute or refuse to execute an advance directive which stipulates how the decisions regarding his/her medical care will be made. The procedure revealed that prior to or upon admission, family members, and or legal representatives were informed and provided written materials governing their legal rights pertaining to medical decisions upon admission to the facility. These rights included the right to formulate an advanced medical directives such as a living will, Power of attorney for Health Care, Do not resuscitate or health care surrogate. The procedure identifies that prior to or upon admission to the facility, the admissions Coordinator or Social Services Designee ascertains the presence of any existing advance directives and a copy is placed under the advance directive tab in the medical record. Prior to or on admission, the Social services designee will provide written information to the resident/legal representative concerning right to make decisions regarding medical care including the right to accept /refuse medical /surgical treatment and the right to formulate advance directives. Record review of Resident 4's Face Sheet dated [DATE] revealed that Resident 4 had been admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 4's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) dated [DATE] and quarterly MDS dated [DATE] revealed that Resident 4 had a cognitive score of ,[DATE] which indicated that Resident 4 was independent with cognitive decision making. Interview on [DATE] at 10:10 AM with Resident 4 revealed that the facility staff had not talked to Resident 4 regarding Advance Directive wishes or what was to be done if (gender) heart stopped. Resident 4 indicated that Resident 4 did not wish to have anything done and no pushing on the chest or anything. Record review of Resident 4's medical record showed no Advance Directive information or Cardiopulmonary Resuscitation status (CPR, a basic emergency method of lifesaving) present in chart. Resident 4's physician orders contained no information about Advance Directives or CPR orders. Record review of Resident 4's Care Plan dated [DATE] and updated [DATE] contained no indications of Advance Directives or CPR status. Interview on [DATE] at 11:14 AM with the Administrator confirmed there was no designation of code status in Resident 4's medical record. Interview on [DATE] at 11:20 PM with SW confirmed that there was no CPR status or Advanced Directive information present in Resident 4's chart. B. Review of the face sheet for Resident 3 revealed that the resident admitted to the facility on [DATE]. Review of Resident 3's entire medical record revealed no cardiopulmonary resuscitation (CPR) wishes were designated in the medical record. Review of Resident 3's care plan dated [DATE] revealed no designation of Residents 3's CPR status. Review of the Quarterly Nursing Assessment for Resident 3 dated [DATE], revealed that Resident 3 was alert and oriented with no memory problems and was independent in decision making. An interview with Resident 3 on [DATE] at 10 AM revealed that the facility had never asked Resident 3 about CPR wishes. Resident 3 revealed that Resident 3 would like to have CPR done and kept alive until (gender) children could arrive then they should pull the plug. An interview with the social worker on [DATE] at 10:55 am confirmed that their was no evidence that the facility had evaluated Resident 3's CPR wishes and they should have and confirmed there was no CPR status present in Resident 4's chart.",2019-11-01
5857,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2016-08-10,441,D,1,0,142711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview; the facility staff failed to wash hands and changes gloves to prevent potential cross contamination during the provision of personal cares for 2 residents (Resident 1 and 3). The facility staff identified a census of 164. Findings are: A. Record review of an undated Resident Face Sheet revealed Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 8-05-2016 revealed the facility staff assessed the following about the resident: -Short and long term memory problem with severely impaired cognition. -Required total assistance with bed mobility, transfers, locomotion, dressing, eating, personal hygiene. -Required extensive assistance with toilet use. -Always incontinent of bowel and bladder. -Had indicators of pain or possible pain with possible pain observed 3 to 4 times out of 5 days. -Other [DIAGNOSES REDACTED]. Observation on 8-09-2016 at 7:56 AM of personal care revealed Nursing Assistant (NA) E and NA G washed hands and donned gloves. Resident 1 was observed to have a splinting device to the right leg. NA E and NA G unfastened the adult briefs Resident 1 was wearing. NA G, using a white washcloth wiped the resident's groin folds revealing brown stains on the wash cloth. NA G without changing gloves and hand washing, obtained another wash cloth and wiped down the vaginal area. Resident 1 was then positioned onto the left laying position. NA G without changing the soiled gloves cleansed in between each buttock. NA G without changing the soiled gloves obtained a clean adult brief and placed it onto Resident 1. An interview with NA G was conducted on 8-09-2016 at 10:13 AM. During the interview, NA G confirmed the soiled gloves had not been changed and should have been. B. Record review of Resident 3's MDS signed as completed on 6-04-2016 revealed the facility staff assessed the following about Resident 3: -Short and long term memory impairments. -Required extensive assistance with transfers,eating, toilet use and personal hygiene. -Required limited assistance with bed mobility and walking in the corridor and had fall in the facility. Record review of Resident 3's Comprehensive Care Plan (CCP) dated 7-08-2015 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review of Resident 3's CCP revealed an updated problem area that identified Resident 3 at risk for falls and injury due to impaired cognition, and use of an antidepressant medication. The goal was Resident 3 would be free from falls and injuries. A new intervention to prevent falls dated 5-21-2016 was that Resident 3 was to have a fall mat in place. Observation on 8-10-2016 at 7:02 AM revealed Nursing Assistant (NA) J assisted Resident 3 into the bathroom, assisted with pulling down Resident 3's pants and sat Resident 3 onto the toilet. Once Resident 3 completed using the toilet, NA J cued Resident 3 into an upright position. NA J obtained toilet paper and wiped Resident 3's buttocks. NA J then obtained a wet wash cloth cleansed Resident 3 buttocks. Without changing the soiled gloves, NA J obtained a clean washcloth and cleansed Resident 3's penis and groin area. NA J without changing the soiled gloves, obtained a clean, dry towel and dried off Resident 3. An interview on 8-10-2016 at 7:26 AM was conducted with NA J. During the interview, NA J confirmed the soiled gloves had not been changed and should have been. Record review of the facility Handwashing Policy and procedure dated 12-2009 revealed the following: -Purpose: - To provide guidelines to employees for proper and appropriate hand washing techniques that will aid in the prevention of the transmission of infections. -When to wash hands: -After handling any contaminated items, linens, soiled diapers, garbage, etc.",2019-08-01
3403,WESTFIELD QUALITY CARE OF AURORA,285263,"PO BOX 166, 1313 1ST STREET",AURORA,NE,68818,2019-05-14,695,D,1,0,V7OX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interviews, the facility failed to obtain an order for [REDACTED]. Findings are: Record review of Resident 36's Admission Record dated 5-7-19 revealed date of admission 7-9-18 with [DIAGNOSES REDACTED]. Review of Resident 36's admission MDS dated [DATE] revealed the resident used oxygen while 'not' a resident and 'while' a resident. The MDS also revealed the resident had a [DIAGNOSES REDACTED]. Observation on 5/06/19 at 10:00 AM of Resident 36's room revealed the oxygen concentrator turned on but the tubing was no where near the resident who was on the opposite side of the bed. Inteview with NA-F (Nurse Aide) revealed the resident only wore oxygen when in bed at night time. Record review on 5/06/19 at 10:26 AM of undated Physician orders [REDACTED]. Review of (MONTH) and (MONTH) TARS/MARS (treatment / medication administration records) revealed absence of an order for [REDACTED]. Review of current order summary report dated (MONTH) 7, 2019 revealed absence of an oxygen order for Resident 36. Interview on 5/07/19 at 4:30 PM with LPN-G (Licensed Practical Nurse) revealed the Oxygen orders were not documented on the TAR or MAR. LPN-G confirmed when a resident had an order for [REDACTED]. LPN-G reviewed Resident 36's medical record and confirmed the absence of an oxygen order but confirmed the resident had used oxygen per nasal cannula via concentrator at night time only since admission last July. Interview on 5-7-109 at 4:33 PM with RN-H (Registered Nurse) reviewed the medical record of Resident 36 and confirmed the resident had been on oxygen and the facility the resident transferred from and the transfer papers revealed the resident was to be on oxygen 1-5 liters per nasal cannula at bedtime. RN-H confirmed after reviewing the facility's admission orders [REDACTED]. Review of Resident 36's admission orders [REDACTED]",2020-09-01
5409,"SORENSEN CARE AND REHABILITATION CENTER, LLC",285107,4809 REDMAN AVENUE,OMAHA,NE,68104,2017-01-25,323,D,1,0,TUGY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interviews; the facility failed to ensure residents were transferred in a safe manner for 1 of 3 residents reviewed (Resident 2). The facility census was 86. Review of Resident 2 ' s medical [DIAGNOSES REDACTED]. Review of Resident 2 ' s progress notes dated 10/31/2016 revealed Resident 2 fell on [DATE] while being transferred to the toilet. Review of Resident 2 ' s care plan dated 10/31/2016 revealed a new intervention stated that staff were to transfer Resident 2 with the sit to stand lift (a mechanical device to assist resident to stand) at all times. Interview on 1/25/2017 at 2:10 PM with NA-B revealed that Resident 2 only needed a little assistance to transfer. Observation on 1/25/2017 at 2:15 PM revealed Nursing Assistant (NA)-A and NA-B entered Resident 2 ' s room to transfer Resident 2 to the toilet. NA-A pushed Resident 2 into the bathroom in the wheelchair. While standing behind Resident 2 without a gait belt (a device used to assist in stabilizing resident) or using a sit to stand lift. NA-A leaned over the back of the wheelchair, instructed Resident 2 to hold on to safety bars and to pivot onto the toilet. Interview on 1/25/2017 at 2:25 PM with the Director of Nursing (DON) revealed Resident 2 is only to be transferred with the sit to stand lift with all straps secured. DON confirmed transferring Resident 2 without the use of the sit to stand lift was not a safe transfer.",2020-01-01
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
3321,BLUE VALLEY LUTHERAN NURSING HOME,285259,"P O BOX 166, 220 PARK AVENUE",HEBRON,NE,68370,2017-08-08,314,D,1,0,2H1K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record reviews, and interviews; the facility failed to initiate preventative pressure ulcer interventions on 2 (Resident 100 and 112) out of 4 residents sampled. Resident census was 46. Findings are: A Review of Resident 112's undated face sheet revealed an admitted 11 18 12. Review of the undated [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) for Resident 112 dated 5 18 17 revealed the resident had moderately impaired cognition. The resident required extensive assist of 2 staff with transfers, dressing, and toileting. The resident required extensive assist of 1 staff for locomotion and eating. Interview on 08 07 17 at 11:00 AM with the Administrator revealed Resident 112 had facility acquired pressure ulcers on the resident's toes caused by the resident's shoes. Review of the PN (Progress Notes) dated 07 10 17 revealed the resident went to the Physician's clinic to be seen for the open/reddened sores on the 2nd and 3rd toes. The resident returned with new orders to treat the pressure ulcers. Review of Resident 112's Careplan revealed absence of any pressure ulcer interventions . Review of the last annual MDS dated 09 10 16 CAA's (Care Area Assessment) revealed the risk for pressure ulcers was triggered. Review of the CAA worksheet revealed the decision was to care plan the risk for pressure ulcers and therefore put interventions into place to help prevent pressure ulcers. Review of Resident 112's Kardex revealed absence of any documentation that the resident had pressure ulcers or any pressure ulcer interventions . Interview on 08 07 17 at 3:50 with the DS (Dietary Supervisor) revealed the DS was not aware Resident 112 had any pressure ulcers or was at risk for pressure ulcers. The DS revealed when a resident initially had a pressure ulcer, the DS would be informed then the DS would notify the RD (Registered Dietician) who was contracted for the facility. B Review of Resident 100's undated face sheet revealed an admitted 02 15 17. Review of the undated [DIAGNOSES REDACTED]. congested heart failure, [MEDICAL CONDITION], abnormal weight loss, [DIAGNOSES REDACTED] of the skin of the nose. Review of the admission MDS for Resident 100 revealed a BIMS Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 13 which indicated Resident 100 had no cognition impairment. The resident required limited assist of 1 staff with bed mobility and extensive assist of 1 staff with transfers, personal hygiene, bathing, dressing, walking, locomotion, and toileting. The resident did not admit with a pressure ulcer. Review of the CAA's revealed the risk for pressure ulcers was triggered. Review of the CAA worksheet revealed the decision was to care plan the risk for pressure ulcers . Review of Resident 100's Care plan revealed the absence of the resident being at risk for pressure ulcers and the absence of pressure ulcer interventions. Interview on 08 08 17 at 3:05 PM with the MDS Nurse confirmed there were no pressure ulcer interventions documented. Interview on 08 08 17 at 11:10 AM with the family revealed on 07 11 17 the resident was transferred from the facility to the hospital. The admitting hospital informed the family the resident had a stage 2 pressure ulcer on the resident's coccyx area. Interview on 08 08 17 at 3:00 PM with the DON (Director of Nursing) confirmed the facility did not do a skin assessment on the resident before the resident was transferred to the hospital. The DON revealed besides the pressure reducing mattress which every resident in the facility had, no other pressure ulcer interventions were initiated.",2020-09-01
5754,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2016-09-20,441,E,1,0,TD4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations and interviews, the facility failed to ensure that 1) the whirlpool chair in the 300 wing bathing room (which was used for routine bathing for 13 residents) and the whirlpool chair in the Special Care Unit bathing room (which was used for routine bathing for 36 residents) were cleaned and free of a buildup of whitish gray material on the metal surfaces which created a rough surface that had the potential to harbor bacteria, 2) towel bars used in semiprivate bathrooms were labeled so that the residents or staff could identify which hand towels and washcloths belonged to which resident for 10 sampled residents (Residents 107 and 91 in room [ROOM NUMBER], 104 and 162 in room [ROOM NUMBER], 77 and 13 in room [ROOM NUMBER], 76 and 28 in room [ROOM NUMBER] and 121 and 132 in room [ROOM NUMBER]), 3) bathroom call light strings with a buildup of brownish, black and gray colored material were replaced for four sampled residents (Residents 30 and 7 in room [ROOM NUMBER] and 104 and 162 in room [ROOM NUMBER]), 4) bathroom light pull strings with a buildup of brownish, black and gray colored material were replaced for four sampled residents (Residents 2 and 45 room [ROOM NUMBER] and 125 and 66 in room [ROOM NUMBER]), 5) torn vinyl covered calf pads were replaced for one sampled resident (Resident 54), 5) four plastic gallon containers of distilled water were not stored on the floor in the 300 wing medication room and 6) hand washing was performed after removing disposable gloves during cares and before continuing with other tasks for two sampled residents (Residents 88 and 52) to reduce the risk of cross contamination. The facility census was 114. Findings are: Licensure Reference Number 175 NAC 12-006.17B A. Observations of the 300 wing bathing room and the SCU (Special Care Unit) bathing room on 9/12/16 at 11:30 AM, during the environment tour with the Administrator, Maintenance Director and Housekeeping Supervisor, revealed that the whirlpool bathing chairs had a buildup of debris and whitish, gray colored material resembling hard water stains on the metal surfaces. Interview on 9/14/16 at 7:45 AM with RN (Registered Nurse) - A, Infection Control Nurse, confirmed that the whirlpool bathing chairs needed to be cleaned to reduce the risk of cross contamination. RN - A confirmed that 13 residents utilized the whirlpool on the 300 wing and 36 residents used the whirlpool on the SCU. B. Observations of resident rooms on the 400 wing and the 500 wing 9/7/16 from 9:30 AM through 10:30 AM revealed shared bathroom towel bars were not labeled with the resident ' s name or bed number to ensure that the residents or staff members could identify which washcloths and hand towels belonged to which resident. The bathroom towel bars were not labeled for Residents 107 and 91 in room [ROOM NUMBER], Residents 104 and 162 in room [ROOM NUMBER], Residents 77 and 13 in room [ROOM NUMBER], Residents 76 and 28 in room [ROOM NUMBER] and Residents 121 and 132 in room [ROOM NUMBER]. Interview on 9/14/16 at 7:45 AM with RN - A, Infection Control Nurse, confirmed that the bathroom towel bars should be labeled with the resident's name or bed number to reduce the risk of cross contamination by using another resident's linens. C. Observations of resident rooms on the 200 wing, 400 wing and the 500 wing on 9/7/16 from 9:30 AM through 10:30 AM revealed bathroom call light strings soiled with brownish black and gray colored material utilized by four sampled residents (Residents 30 and 7 in room [ROOM NUMBER] and Residents 104 and 162 in room [ROOM NUMBER]). Further observations revealed bathroom light strings soiled with brownish black, and gray colored material for four sampled residents (Residents 2 and 45 in room [ROOM NUMBER] and Residents 125 and 66 in room [ROOM NUMBER]). Interview on 9/14/16 at 7:45 AM with RN - A, Infection Control Nurse, confirmed that the bathroom call light and light strings needed to be replaced when soiled to reduce the risk for cross contamination. D. Observations on 9/8/16 at 7:10 AM and 11:00 AM and on 9/12/16 at 11:40 AM revealed Resident 54 seated in the wheelchair in the hallway. Further observations revealed that the vinyl covered wheelchair calf pads had multiple tears and worn edges which exposed the material underneath. Interview on 9/14/16 at 8:00 AM with RN - A confirmed that the calf pads needed to be replaced as they were no longer cleanable. E. Observations of the 300 wing medication room on 9/8/16 at 2:30 PM revealed four plastic gallon containers of distilled water, one opened and about half full, on the floor. Interview on 9/8/16 at 2:30 PM with LPN (Licensed Practical Nurse) - B, Charge Nurse, confirmed that the containers should not be stored on the floor to reduce the risk of cross contamination. Licensure Reference Number 175 NAC 12-006.17D F. Observations on 9/8/16 at 7:00 AM revealed LPN - C, Charge Nurse, donned disposable gloves and checked Resident 88's blood sugar. Further observations revealed LPN - C removed the gloves, placed the glucometer (machine used to measure blood sugar) on the medication cart, documented the blood sugar on the computer and continued with further tasks without hand washing. Observations on 9/8/16 at 8:10 AM revealed RN - D, Charge Nurse, prepared medications for Resident 52, donned disposable gloves, administered the medications, removed the gloves, returned to the medication cart, signed off the medications on the computer and continued to prepare medications for the next resident without hand washing. Interview on 9/14/16 at 2:00 PM with RN - A, Infection Control Nurse, confirmed that the nurses were to wash their hands when disposable gloves were removed and before continuing with other tasks to reduce the risk of cross contamination.",2019-09-01
6387,"NORTH PLATTE CARE CENTER, LLC",285165,2900 WEST E STREET,NORTH PLATTE,NE,69101,2016-03-02,367,E,1,0,BM4911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews and record reviews; the facility failed to ensure that evening snacks were offered to four sampled insulin dependent diabetic residents (Resident 1, 6, 8 and 9). The facility census was 47. Findings are: A. Observations on 3/1/16 at 7:30 PM and 8:10 PM revealed MA (Medication Aide) - B passed snacks to several residents. Interview on 3/1/16 at 8:15 PM with MA - B revealed that snacks were offered to residents but there was no list of residents who needed a snack because they were diabetic. Further interview revealed there was no documentation of which residents were offered or accepted the snacks. B. Review of Resident 1's Routine Medications, dated (MONTH) (YEAR), revealed that the resident had a [DIAGNOSES REDACTED]. Further review revealed no documentation that the resident received an evening snack. Interview with the resident's family member on 3/1/16 at 7:45 PM revealed that the resident did not always receive a bedtime snack. C. Review of Resident 6's Routine Medications, dated (MONTH) (YEAR), revealed that the resident had a [DIAGNOSES REDACTED]. Further review revealed no documentation that the resident received an evening snack. Interview with the resident on 3/2/16 at 9:15 AM revealed that evening snacks were not always offered. D. Review of Resident 8's Routine Medications, dated (MONTH) (YEAR), revealed that the resident had a [DIAGNOSES REDACTED]. Further review revealed no documentation that the resident received an evening snack. Interview with the resident on 3/2/16 at 9:30 AM revealed that was not always offered an evening snack. E. Review of Resident 9's Routine Medications, dated (MONTH) (YEAR), revealed that the resident had a [DIAGNOSES REDACTED]. Further review revealed no documentation that the resident received an evening snack. Interview on 3/2/16 at 3:30 PM with the DON (Director of Nursing) confirmed that there was no documentation that evening snacks were offered to diabetic residents every night. Further interview confirmed that the evening snacks should be offered every evening and should be documented on the Routine Medications forms to reduce the risk for low blood sugar levels during the night or in the morning.",2019-03-01
2165,LEGACY GARDEN REHABILITATION & LIVING CENTER,285186,200 VALLEY VIEW DRIVE,PENDER,NE,68047,2017-07-20,329,D,1,1,E93U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, and record reviews; the facility failed to implement non pharmacological interventions prior to administering a [MEDICAL CONDITION] medication for 2 residents (Residents 28 and 7) of the 5 residents sampled. The facility staff identified the resident census at 31. [NAME] Review of Resident 7's undated Face Sheet revealed that Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 7's Medication Administration Record [REDACTED]. A review of Resident 7's Progress Note dated [DATE] at 2:11 AM revealed Resident 7 was confused with rambling speech and was yelling out for their deceased spouse; resident was given [MEDICATION NAME] 1mg and [MEDICATION NAME] 1mg as needed. No non-pharmacological interventions were documented in the progress note. Resident 7 was documented as having rested quietly after the [MEDICATION NAME] and [MEDICATION NAME] was given. A review of Resident 7's [MEDICAL CONDITION] Drug Use Care Plan dated [DATE] revealed a goal for the resident to be prescribed the lowest effective dose of medications. The approaches included to have staff attempt to redirect the resident with non-medication interventions and to monitor and document mood and behaviors. An interview conducted on [DATE] at 3:09 PM with the Director Of Nursing (DON) confirmed that Resident 7 received on [DATE] [MEDICATION NAME] 1mg as scheduled at 8:00 PM, [MEDICATION NAME] 1mg as needed at 8:29 PM, and [MEDICATION NAME] 1mg as needed at 8:29 PM. The DON confirmed there was no non-pharmacological interventions documented as completed prior to the administration of the as needed [MEDICATION NAME] and [MEDICATION NAME]. The DON reported that the resident had been having behaviors of acting out aggressively towards staff and that numerous staff had refused to take care of the resident. The DON reported that Resident 7's family wanted the resident to remain in the facility and that the only way to do so was to medicate the resident to the point the resident did not have any behaviors. The DON reported that the facility staff had not evaluated the resident for pain prior to starting the scheduled [MEDICATION NAME]. B. A review of Resident 28's undated Face Sheet revealed that Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 28's (MONTH) (YEAR) MAR indicated [REDACTED]. A review of Resident 28's Behavior Administration History dated [DATE] to [DATE] revealed no behaviors were documented on [DATE]. A review of Resident 28's Progress Noted revealed no documentation regarding behaviors on [DATE]. A review of Resident 28's Behavior Analysis dated [DATE] to [DATE] revealed there were no behaviors documented on [DATE]. A review of Resident 28's [MEDICAL CONDITION] Drug Use Care Plan dated [DATE] revealed approaches to attempt non-pharmacological interventions and objectively document the resident's mood and behavior. An interview conducted on [DATE] at 3:03 PM with the DON revealed that there are no behaviors documented on [DATE] indicating the need for the [MEDICATION NAME] and there are no non-pharmacological interventions documented prior to the [MEDICATION NAME] being given. The DON reported that the behaviors and non-pharmacological interventions should have documented. A review of the facility's Psychoactive Drug Monitoring policy dates [DATE] revealed the following Legacy Garden Policy: Every effort is made to ensure that residents receiving these medications obtain the maximum benefit with the minimum of untoward effects. Policy Guidelines: 7. Behavioral monitoring charts or a similar mechanism are used to document the resident's need for and response to drug therapy.",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
2490,PIONEER MANOR NURSING HOME,285212,"P O BOX 310, 318 N 3RD STREET",HAY SPRINGS,NE,69347,2019-02-13,689,G,1,0,U39J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interview; the facility failed to ensure that 1) interventions were in place to prevent an elopement and resulting injuries from the facility for one current sampled resident (Resident 4) with multiple attempts to leave the facility unattended, 2) identify causal factors to reduce the risk for further injuries related to skin injuries for one current sampled resident (Resident 2) and falls for two current sampled residents (Residents 7 and 8) and one closed record (Resident 6). The facility census was 51 with nine current sampled residents and one closed record reviewed. Findings are: Licensure Reference Number 175 NAC 12-006.097 [NAME] Review of the Resident Face Sheet, printed 2/11/19, revealed that Resident 4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, printed 2/12/19, revealed that the resident was a higher risk for elopement related to confusion and frequent wandering. Approaches, dated 1/31/19, included wanderguard device in place on the wheelchair, charge nurse will check functioning of the device two times a day and replace as needed. Further review revealed that the resident had moderate impaired cognition and was not able to make good decisions, had impaired vision and communication, significant memory loss and poor judgement regarding safety with transfers and required assistance for transfers. Review of the Resident Progress Notes revealed the following including: - 12/16/18 at 7:50 PM Resident opened the door at the end of the west hall and set the alarm off, did not exit; 9:32 PM Resident continued exit seeking between 7:40 PM and 8:30 PM, activity caused alarms to sound repeatedly and redirection was not successful; - 12/19/18 at at 2:48 PM Resident opened the west door in the main dining room and attempted to go outside, redirected to the assistance dining room; 6:28 PM Resident exit seeking throughout the day, wanderguard alarm alerted at this time, found resident attempting to exit from the west wing door and the resident was stopped before exiting the building; 6:38 PM assisted the resident from the west door, tried to exit, resident was disoriented and confused; - 12/22/18 at 2:19 AM Resident self ambulated into the hallway at 1:30 AM; 10:47 PM Resident ambulated in the hallway without the wheelchair with a very unsteady gait; - 12/24/18 at 5:40 PM Resident attempted to elope out of the west wing door, opened the door and was stopped before going out; - 12/31/18 at 1:13 AM Resident's behaviors are more resistive and aggressive as well as increased exit seeking; - 1/6/19 at 12:15 AM at 11:50 PM The resident was up walking with roommate's walker in the hallways; - 1/24/19 at 8:15 PM Resident exited out of the front door, wanderguard in place under the wheelchair; - 1/26/19 at 6:06 PM Resident wandering throughout the facility into restricted areas, sets off alarms often today; - 1/27/19 at 11:40 AM Resident pushed east hall door open, staff intervened before resident could elope; - 2/1/19 at 1:45 PM Resident followed family member out the front door, alarm sounded and staff assisted the resident back into the facility; - 2/7/19 at 4:15 AM Resident ambulated independently in room and the halls; - 2/8/19 at 1:04 AM During shift change, just before dinner, staff heard banging on the window outside the assistance dining room, the nurse ran outside to discover the resident on knees in the snow, a wheelchair was immediately rushed outside where two staff assisted the resident into the chair and brought the resident inside. The resident's pants were covered with snow and bare hands were red and cold. The resident walked outside and the wheelchair was left inside, the wanderguard was attached to the wheelchair. The resident's temperature was initially 92.5, oxygen saturation were difficult to obtain reading 75 - 80% to hands and 89 - 90% on great toe. At 7:10 PM, the resident's temperature was 96.3, then 97.9 and oxygen saturations were 84- 85% on room air, lung sounds coarse. Oxygen was applied at 4-5 liters per minute and oxygen saturation came up to 90%. 2:59 AM Resident very restless and agitated, refused oral pain medication, very confused and difficult to redirect, right hand swollen, all fingers and thumb. The resident was coughing up thick green phlegm. - 2/8/19 at 5:26 AM Large yellow blisters on right fingers; 1:57 PM Resident had a harsh wet cough; 9:00 PM Resident restless, rubbed the blisters and opened two of the blisters, noted tears from the resident's eyes; - 2/9/19 at 6:23 PM Resident complained of back and rib pain, pain medication administered, agitated and unable to redirect, wandered into other resident's rooms and yelled; - 2/10/19 at 3:05 AM Skin assessment included large bruise to the left shoulder and right posterior shoulder to the elbow, large bruise to the left hip area, multiple intact and ruptured blisters to both hands and multiple fingers. Observations on 2/12/19 at 4:10 PM revealed the resident seated in the wheelchair banging on the east hallway exit door. LPN (Licensed Practical Nurse) - C responded and redirected the resident away from the exit door. Interview with the Administrator on 2/13/19 at 10:00 AM confirmed that interventions were not in place to manage the resident's ongoing attempts for elopement and to prevent elopements from the facility. Reference: Taber's Cyclopedic Medical Dictionary, Edition 20, Copyright 2005 Body temperature varies with the time of day and the site of measurement. Oral temperature is usually 97.5 degrees to 99.5 degrees F (Fahrenheit). Hypothermia is a body temperature below 95 degrees F, can be life threatening and is due to exposure to wet and cold conditions. Fundamentals of Nursing, Potter-Perry, 6th Edition Oxygen Saturation normal range is 95% - 99%. Licensure Reference Number 175 NAC 12-006.09D7b (1) (3) B. Review of the Resident Progress Notes for Resident 2 revealed that on 12/24/18 at 4:28 PM staff noted a faded yellow bruise under the resident's right great toe. The resident was unable to state how the bruise was obtained. Further review revealed no documentation that potential causal factors were identified. Review of the Abuse, Neglect or Misappropriation report, dated 12/24/18, revealed that the resident had a bruise to the right great toe and after interviewing the resident and staff, the origin of the injury was still unknown. Review of the Care Plan, printed 2/12/19, revealed that the resident required assistance of two staff to transfer with a pivot disc, had impaired vision and was alert with fair recall. Further review revealed no care plan to address the injury or changes in care to prevent further injuries. C. Review of the Abuse, Neglect or Misappropriation report, dated 11/27/18, revealed that on 11/26/18, Resident 7 was found on the floor in another resident room. Further review revealed no documentation of potential causal factors related to the fall. Review of the Resident Progress Notes, dated 11/26/18, revealed that at 10:30 AM, staff alerted the nurse that the resident was sitting on the floor in another resident's room. The resident sustained [REDACTED]. (centimeters), a skin tear to back of the right hand which measured 1 cm. and both areas had large amount of bruising around them. The resident also had a large bruise and raised area at the right cheek. The resident complained of increased right hip and leg pain and was sent to the hospital for evaluation. The resident returned to the facility with no new orders. Review of the Care Plan, goal date 5/2/19, revealed that the resident had cognitive loss, dementia, impaired vision, conversations were disorganized, unrelated or delusional and required limited assistance with activities of daily living. D. Review of the Resident Progress Notes for Resident 8 revealed the following including: - 2/2/19 at 8:00 AM Resident was on the floor in the room by the recliner; 10:30 AM Resident was on the floor in front of the recliner; - 2/4/19 at 9:25 PM Resident was found sitting on the floor in room; - 2/9/19 at 8:35 PM Resident fell by the nurses station, attempted to self transfer from the chair to the wheelchair with the breaks off. Further review revealed no documentation of potential causal factors related to the falls. Review of the Care Plan, printed 2/12/19, revealed that the resident had a fall on 2/9/29 due to self transferring, a fall on 2/4/19, was no longer to ambulate independently, had cognitive loss and dementia, memory was impaired and unable to make proper decisions or make self understood, often resisted cares, had impaired vision and hearing and required assistance with activities of daily living and transfers. E. Review of the Resident Progress Notes for Resident 6 revealed the following including: - 11/25/18 at 12:20 AM Resident was found laying on the floor in room with head leaning on the wall; - 12/9/18 at 4:45 PM Resident was found on the floor by the bed; - 12/12/18 at 5:45 AM Resident was found on the floor in the assist dining room. Further review revealed no documentation of causal factors related to the falls. Review of the Care Plan, printed 2/11/19, revealed that the resident required supervision with ambulation and activities of daily living and cognition was severely impaired and was not able to make good decisions. Interview with the Administrator on 2/13/19 at 10:15 AM confirmed that causal factors, related to injuries and falls, needed to be determined so that care plan interventions could be reevaluated and changed to reduce the risk for further injuries or falls.",2020-09-01
6688,SUNRISE COUNTRY MANOR,285232,"PO BOX A, 610 224TH STREET",MILFORD,NE,68405,2015-11-09,279,D,1,1,HZ1311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews: the facility failed to: 1) identify and develop interventions to address one sampled resident's (Resident 32) assistance with activities of daily living (ADL's); and 2) identify and develop interventions to address one samples resident's (Resident 16) non-pressure related skin condition. Facility census was 72. Finding are: A. Interview with LPN (Licensed Practical Nurse)-N on 11/4/15 at 9:35 AM revealed Resident 32 had been declining in the ability to complete ADL's for several months. Observations of Resident 32 at 10:05 AM revealed two staff members LPN-N and MA (Medication Aide)-A transferring the resident using a hoyer lift to transfer resident from recliner to bed. Record review of Resident 32's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care planning) assessments revealed a significant change in Resident 32's functional status. The MDS revealed Resident 32 required extensive assist for bed mobility, transfer, dressing, toilet use and personal hygiene. Record review of Resident 32's Care Plan printed on 11/2/15 with goal dates through 1/28/16 revealed there were no problems, goals or approaches developed or identified on the care plan to address the resident's assistance needed to complete ADL's. Interview with the Director of Nursing on 11/9/15 at 3:25 PM revealed the care plan did not address the ADL's and there should have been changes made at the time when the resident had the significant change in condition. B. Observations of Resident 16 throughout the survey revealed bruises on bilateral forearms. Record review of Resident 16's Care Plan printed on 10/22/15 with goal dates through 1/21/16 revealed there was no mention of bruising on Resident 16's care plan. Interview with the Director of Nursing on 11/9/15 at 3:20 PM revealed the care plan contained no mention of the resident's bruising. Resident 16 had received [MEDICAL CONDITION] Therapy and would have been strapped to the table to prevent movement, which could have caused the brusing it could have happened at that time.",2018-11-01
4816,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2017-04-19,323,D,1,1,HWP011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to 1) change fall interventions after a fall to reduce the risk of recurrent falls for one closed sampled resident (Resident 5) and 2) ensure that a portable oxygen cylinder was secured to reduce the risk of accidents for one sampled resident (Resident 13). The facility census was 24 with eight current sampled residents and five closed records reviewed. Findings are: Licensure Reference Number 175 NAC 12-006.09D7b [NAME] Review of the Admission Record, printed 4/18/17, revealed that Resident 5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility Investigation Report, dated 2/22/17, revealed that on 2/22/17 the resident was found on the floor in room after attempting to reach a brief package off the dresser. The immediate measures put into place to protect the resident was request staff assistance as needed .Further review revealed that the resident sustained [REDACTED]. Review of the care plan, target date 6/1/17, revealed that the resident was at risk for falls related to dizziness, history of multiple falls and impaired balance and mobility. Interventions included assistance of two staff members for transfers, bed alarm and chair alarm, and place call light and personal belongings within reach. Further review revealed no changes in interventions after the fall on 2/22/17 to reduce the risk for further falls. Interview with the Administrator on 4/19/17 at 10:15 AM confirmed that fall interventions were not changed after the fall on 2/22/17 to reduce the risk for further falls. Licensure Reference Number 175 NAC 12-006.09D1a B. Observations of Resident 5's room on 4/17/17 at 11:30 AM and at 2:15 PM revealed an unsecured portable oxygen tank leaning against the wall. Interview with the Director of Nursing on 4/17/17 at 2:15 PM confirmed that the portable oxygen tank was not secured and needed to be secured to reduce the risk of accidents.",2020-03-01
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
2614,WAUNETA CARE AND THERAPY CENTER,285220,"PO BOX 520, 427 LEGION STREET",WAUNETA,NE,69045,2017-07-20,323,E,1,1,3Q2711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to ensure that 1) interventions were in place to reduce the risk for falls for one sampled resident (Resident 34) and 2) chemicals were secured to reduce the risk for accidental exposure and injury for nine residents identified as confused and wandered in the facility (Residents 14, 17, 20, 26, 22 13, 21, 34 and 28). The facility census was 31 with 11 current sampled residents. Findings are: Licensure Reference Number 175 NAC 12-006.09D7b [NAME] Review of Resident 34's Departmental Notes, dated 2/5/17, revealed that at 4:20 PM, the resident was heard hollering and was found sitting on the floor. The resident stated was in my closet and my shoe slipped and I lost my balance abd (sic) fell to my right and hit my right arm. Review of the Care Plan, goal date 3/2/17, revealed a problem that the resident had a history of [REDACTED]. Approaches included Ensure that (resident) has and wears properly - fitting non-skid soled shoes for ambulation, Removed unsafe slippers and replace with closed heel slippers. and Give (resident) verbal reminders not to ambulate or transfer without assistance. Interview with the Director of Nursing on 7/19/17 at 2:20 PM confirmed that the resident was at risk for falls. Further interview confirmed that the care plan interventions were not in place to reduce the risk for falls as the resident was not wearing safe shoes at the time of the fall and did not call for assistance to transfer or ambulate. Licensure Reference Number 175 NAC 12-006.09D7a [NAME] Observations on 7/17/17 at 6:50 PM, during the initial tour of the facility, revealed an unlocked oxygen storage room across from the nurses station and resident lounge area. Further observations revealed a can of Lynx disinfectant spray on the counter. Several residents were in the hallways and in the lounge area. Interview with LPN (Licensed Practical Nurse ) - A on 7/17/17 at 6:50 PM confirmed that the chemicals were to be kept in locked cupboards to reduce the risk of accidental exposure and injuries for confused and wandering residents. LPN - A identified nine residents who were confused and wandered in the facility (Residents 14, 17, 20, 26, 22 13, 21, 34 and 28). Reference: Material Safety Data Sheet for Lynx Surface Disinfectant Spray Emergency Overview . Primary Route of Entry: Skin contact, inhalation . EYES: Causes severe irritation, experienced as discomfort or pain, excess blinking and tear production, which redness and swelling of the conjunctiva. SKIN: Brief contact may cause slight irritation. Prolonged contact may cause more severe irritation with pain, local redness and swelling. INHALATION: High vapor/aerosol concentrations (>1000ppm (parts per million)) are irritating to the respiratory tract. INGESTION: (MONTH) cause headache, dizziness, un-coordination, nausea, vomiting, diarrhea and general weakness.",2020-09-01
5745,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2016-09-20,323,E,1,0,TD4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to ensure that 1) interventions were in place to reduce the risk of recurrent falls for one sampled resident (Resident 132), 2) ensure potentially hazardous chemicals were secured to reduce the risk of accidental exposure and injury for two residents identified as confused and wandering in the unit (Residents 67 and 159), 3) footrests were utilized when transporting residents in wheelchairs to support the resident's feet and to reduce the risk for injuries for three sampled residents (Residents 132, 4, and 97), 4) one staff member did not transport two residents seated in wheelchairs in the hallway at the same time (Residents 7 and 124), 5) a safety assessment was completed for grab bars on the bed which contained gaps large enough for potential entrapment of limbs for one sampled resident (Resident 132) and 6) oxygen concentrators were turned off when not in use or when residents were out of the room to reduce the risk for fires for four sampled residents (Residents 2, 12, 68 and 86). The facility census was 114. Findings are: Licensure Reference Number 175 NAC 12-006.09D7 A. Review of the Admission Record, printed 9/8/16, revealed that Resident 132 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, with a goal date of 11/20/16, revealed that the resident was confused with impaired cognition, had poor vision, was incontinent of bowel and bladder and was at risk for falls related to history of falls and wandering behaviors. Further review revealed that the resident fell on [DATE], 8/16/16, 8/22/16, and 8/23/16. Interventions included encourage resident to use call light for help, frequent checks, non slip footwear, encourage and remind to toilet frequently, toileting after supper, keep resident close while in the wheelchair and keep environment fee of clutter and well lit. Review of the Progress Notes revealed the following including: - 8/16/16 at 12:33 PM, Resident slipped on the floor, hit head and sustained an open area to the right forehead, hematoma to the right forehead, skin tear to the right elbow, open area to the right hand; - 8/17/16 at 9:25 PM, Resident was found sitting on the floor between the bed and the wall. Skin tear to right elbow; - 8/18/16 at 1:05 PM, Resident tried to walk in the hallway independently. Staff reminded of the need to have staff walk with the resident; - 8/22/16 at 5:53 AM, Resident found lying on the floor at the foot of the bed and in front of the wheelchair, skin tear to right elbow. 9:23 PM, Resident observed on the floor on knees, transferred self to chair and lowered self to the floor. No new injuries observed. Resident was transferred to the emergency room for evaluation due to multiple falls in the last week; - 8/23/16 at 7:30 PM, Resident found sitting on the floor next to bed and in front of the wheelchair. The floor was noted to be wet; - 8/25/16 at 9:50 AM, Resident tried to walk the hallway without assistance. Staff reminded resident to have staff walk with the resident; - 8/28/16 at 3:33 AM, Resident self transferred to the bathroom. Educated resident to utilize call light for transfers; - 9/3/16 at 10:37 AM, Resident was confused and forgetful. Got up and walked in hallway. Discouraged to walk alone and to call for help but does it anyway; - 9/11/16 at 2:53 PM, Resident observed trying to help another resident out of a recliner; - 9/12/16 at 3:25 AM, Resident was found on the floor in room, sitting in the doorway of the bathroom. Small elevated area at the posterior left ear with an abrasion; - 9/12/16 at 9:35 AM, Resident tried to walk independently several times. Staff redirected multiple times and resident continued to get out of the wheelchair without assistance; - 9/13/16 at 4:00 PM, Resident got up and ambulated without assistance; - 9/14/16 at 3:15 AM, Resident continued to self transfer and ambulate without assistance. Educated to have staff assist with transfers and to use wheelchair. Observations on 9/12/16 at 7:20 AM revealed the resident ambulated independently in the dining room and the hallways and, at 2:00 PM, ambulated independently in room. Further observations revealed healing bruising on right forehead and multiple skin tears at various stages of healing on arms and legs. Observations on 9/15/16 at 1:55 PM revealed the resident ambulated independently in room and bathroom. Observations on 9/19/16 at 4:20 PM revealed the resident ambulated independently in the hallways and the front lobby area. Interview with the DON (Director of Nursing) on 9/19/16 at 3:30 PM confirmed that the resident was a high risk for falls with injuries and current interventions were not effective to ensure that the the resident does not ambulate without staff assist. Interview with LPN (Licensed Practical Nurse) - E, Charge Nurse, confirmed that the care plan interventions were not effective as the resident continued to get up and walk independently and will not use the call light to ask for assistance. Licensure Reference Number 175 NAC 12-006.09D7a B. Observations on 9/6/16 at 1:30 PM, during the initial tour of the facility, revealed an unlocked and unattended shower room by Room 225 with an opened container of Classic Whirlpool Disinfectant Cleaner on the floor by the shower chair. Interview on 9/6/16 at 1:30 PM with LPN - O, Charge Nurse, confirmed that the shower door was to be locked. Further interview revealed that Resident 67 and Resident 159, residents on the unit, were confused and wandered in the hallways and were at risk for accidental exposure to the disinfectant. Interview on 9/6/16 at 3:45 PM with the Administrator confirmed that the whirlpool disinfectant was to be kept locked up to reduce the risk of accidental exposure to residents. Observations on 9/8/16 at 11:00 AM revealed the shower room on the 200 wing next to Room 225 unlocked and unattended with the whirlpool disinfectant unsecured on the floor by the shower chair. Interview on 9/8/16 at 11:10 AM with RN (Registered Nurse) - A, Charge Nurse, confirmed that the shower room was to be kept locked to reduce the risk of accidental exposure for confused and wandering residents. Review of the Material Safety Data Sheet for Classic Whirlpool Disinfectant Cleaner revealed that potential health hazards included eye irritation, can be harmful if swallowed or if spray mist is inhaled, redness, irritation or burning sensation to skin. C. Observations on 9/7/16 at 3:20 PM revealed Resident 132 seated in the wheelchair without footrests propelled in the hallways by spouse. Observations on 9/8/16 at 7:30 AM revealed NA (Nursing Assistant) - P transported Resident 4 in the wheelchair in the hallway with no footrests. D. Observations on 9/8/16 at 11:30 AM revealed NA - Q pushed Resident 7 in the wheelchair and pulled Resident 124 in the wheelchair in the hallway at the same time. E. Observations of Resident 132's room on 9/7/16 at 12:20 PM revealed a grab bar on each side of the bed with gaps within the grab bars large enough for potential entrapment of limbs. Observations of the grab bars on 9/19/16 at 11:30 AM revealed gaps including the following: -13 inches from the headboard to the grab bar; - horizontal gap of 13 inches by 3 inches; - vertical gaps 24 inches by 3.5 inches and 18.5 inches by 4.5 inches. Interview on 9/19/16 at 11:30 AM with NA (Nursing Assistant) F, Unit Coordinator, confirmed that the resident used the grab bars for bed mobility. Further interview confirmed that the gaps within the grab bars posed a risk for entrapment of the resident's limbs and no safety assessment was completed to ensure the safe use of the grab bars. F. Observations of Resident 2's room on 9/7/16 at 3:20 PM revealed the oxygen concentrator on while the resident was out of the room with the oxygen cannula placed on top of the concentrator next to the privacy curtain. G. Observation on 9/19/16 at 10:00 AM of Resident 97 pushed through the hallway on a bath chair with no foot rests in place. Interview on 9/20/16 at 4:00 PM with the Administrator and the (Director of Nursing) DON verified that Resident 97 should not have been pushed through the hallway in a shower chair without footrests for safety issues. H. Observation on 9/7/16 at 9:30 AM of Resident 12's oxygen concentrator left running and tubing hanging draped over the chair while the resident was at breakfast. Observation on 9/19/16 at 9:30 AM of Resident 12's oxygen concentrator left running and laying on the bed in the residents room while the resident was at breakfast. I. Observation on 9/7/16 at 9:30 AM of the oxygen concentrator running in the room of Resident 68 and laying over the concentrator. Further observation revealed that Resident 68 was out of the room at breakfast with a portable oxygen tank. Observation on 9/12/16 at 9:45 AM of Resident 68's oxygen concentrator running in the room and the tubing draped over the concentrator while the resident was at breakfast. Interview with (Nursing Assistant) NA - CC on 9/19/16 at 9:50 AM revealed that some of the residents remove their own oxygen and turn off their concentrators prior to leaving their rooms. Occasionally the residents forget and leave the concentrators running. Further interview verified that Resident 12 and 68 had left the concentrator running while they were at breakfast. Continued interview confirmed that it was not safe to leave the concentrators running in the rooms and the oxygen concentrators were shut off by NA - CC. Interview on 9/20/16 at 4:10 PM with the Administrator and the DON confirmed that it was not safe to have oxygen concentrators running in the rooms of Residents' 12 and 68 while the residents were at breakfast.",2019-09-01
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
5742,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2016-09-20,309,D,1,0,TD4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to ensure that 1) ongoing aggressive behaviors were managed to reduce the risk of physical altercations with other residents for two sampled residents (Resident 131 and 104) and 2) interventions were in place prevent skin injuries for one sampled resident (Resident 13) identified at high risk for skin injuries and ensure weekly skin assessments were completed which included measurements of skin tears to ensure healing without complications. The facility census was 114. Findings are: Licensure Reference Number 175 NAC 12-006.09D A. Review of Resident 131's Care Plan, goal date 6/30/16, revealed that the resident had [DIAGNOSES REDACTED]. Further review revealed that the resident had behaviors including crying, cursing, trying to help other residents, wandering in and out of other resident's rooms and waking them up and agitated and combative with attempts to redirect the behaviors. Interventions included medications as ordered, avoid upsetting situations or people and attempt interventions before behaviors begin such as one on one time with staff. Review of theBehavior Detail Report revealed the following including: - 6/1/16 at 9:36 AM, resident wandered in other resident's rooms and refused medications, interventions ineffective; - 9:37 AM, resident screamed at staff, interventions ineffective; - 9:45 AM, resident hit staff, cursed, screamed at staff, scratched staff, shoved staff, undressed in public, rejected cares, rejected medications, wandered in the halls; - 10:18 AM, resident hit, shoved, scratched staff, undressed in public; - 12:32 PM, resident had physical behaviors directed towards others; - 1:07 PM, resident wandered in hall, screamed at staff and others; - 3:35 PM and 8:55 PM, resident wandered in hall, redirection not effective. Review of the Progress Notes, revealed the following including: - 6/1/16 at 12:50 PM, resident was noted by staff to be holding another resident up against the wall, squeezing and pushing the resident's left arm with hands; - 6/2/16 at 5:35 AM, resident wandering in hallway and other resident's room, crying and laughing at times, medication given for anxiety with no effect, exit seeking, removing clothing in the hallway; 7:39 AM, standing on bed trying to get out out the window, redirection interventions unsuccessful; 1:41 PM, resident slapped another resident in the back of the head while the resident was seated in a wheelchair assisted by staff in the hallway; - 6/3/16 at 10:41 AM, resident was yelling at another resident in Spanish, reached out and pulled the resident back as the resident was walking away; 6:59 PM, resident observed hitting another resident on the arm. B. Review of Resident 104's Care Plan, goal date 9/13/16, revealed that the resident had [DIAGNOSES REDACTED]. Interventions included watch for nonverbal cues, pacing, increased fighting and signs of pain, encourage activities, offer snacks and beverages and help with toileting. Review of Resident 104's Progress Notes revealed the following including: - 1/17/16 at 10:03 AM, Resident was very agitated, chasing after staff with lower half of body undressed, hollering and shoving staff, tight grip on staff's hands, threw drink offered, screaming and grunting; 3:28 PM, Resident agitated, yelling and grabbing at other residents, as needed anti anxiety medication and snack administered and resident became calm; - 2/2/16 at 9:08 AM, Resident was observed pushing another resident (Resident 123) from behind to the floor; - 2/10/16 at 7:13 AM, Resident was agitated and restless this morning with morning cares, pacing the halls, circled another resident's chair in the living room and sat down and kicked the resident in the leg. Interview on 9/20/16 at 7:15 AM with LPN (Licensed Practical Nurse) - E, Charge Nurse, confirmed that behavior management interventions were not always effective to manage ongoing aggressive behaviors towards other residents or staff. Licensure Reference Number 175 NAC 12-006.09D2c C. Review of Resident 13's Care Plan, goal date 12/13/16, revealed that the resident required extensive assistance with activities of daily living, used a mechanical lift for transfers, used a wheelchair for locomotion and was on a blood thinner medication. Interventions included gerigloves (soft gloves utilized to protect the resident's fragile skin) to be put on resident by staff. Review of the Progress Notes, dated 9/1/16 at 2:02 PM, revealed that, at 7:50 AM, the resident had skin tears on the right arm which measured 5 x 1 cm. (centimeter). The skin tear was cleansed and dressings were applied for protection. There was no documentation that the gerigloves were in place when the skin tear was identified. Review of the Weekly Skin Review, dated 9/1/16, revealed that the resident had a skin tear which measured 5 x 1cm. Review of the Weekly Skin Review, dated 9/8/16, revealed that the resident had a skin tear at the right forearm, right elbow and the left forearm with no signs and symptoms of infection. There were no measurements recorded for these skin tears. Review of the Weekly Skin Review, dated 9/15/16, revealed that the resident had a skin tear at the right forearm which was cleaned and a dressing applied. There were no measurements of the skin tear. Observations on 9/8/16 at 2:30 PM revealed the resident seated in the wheelchair in room. Further observation revealed a geriglove on the left arm but not on the right arm. Observations on 9/19/16 at 1:45 PM revealed the resident resting in bed. LPN (Licensed Practical Nurse) - E and LPN - N, removed the dressing at the resident's right arm and measured the skin tear as 4.5 cm . X 3 cm. There was no geriglove observed on the resident's right arm. Interview on 9/19/16 at 1:45 PM with LPN - E confirmed that the weekly skin assessments did not include measurements of the skin tears to ensure healing without complications. Interview with the DON (Director of Nursing) on 9/19/16 at 3:30 PM confirmed that the resident was at risk for skin tears and gerigloves were to be worn to protect the resident's skin.",2019-09-01
5717,NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER,285271,2100 CIRCLE DRIVE,SCOTTSBLUFF,NE,69361,2016-10-03,425,E,1,0,SRLF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews the facility failed to: 1) ensure that ordered medications were available for three sampled residents (Residents 8, 10, 14); 2) prevent medication omission errors involving three sampled residents (Residents 12, 13, and 14); 3) question an ordered medication provided for one sampled resident (Resident 8) which was listed among resident allergies [REDACTED]. residents (Residents 2, 8, 9, 10, 12, 13, and 14). Sample size was 12 current residents. Facility census was 51. Findings are: Licensure Reference Number: 175 NAC 12-006.12 A. Record review of Resident 8's Medications Administration History form for (MONTH) of (YEAR) revealed the following medication omissions: -an order for [REDACTED]. -a scheduled dose of Losartan, ordered to be administered at bedtime was not administered on 9/28/16 due to the medication being unavailable from the pharmacy. -Scheduled doses for the resident's Omeprazole ordered for administration twice daily were not administered on 9/22/16 at 8 p.m. and 9/23/16 at 6 a.m. due to the medication being unavailable from the pharmacy. Record review of Resident 10's Medications Administration History form for (MONTH) of (YEAR) revealed the following omission on 8/11/16 for Tramadol (pain medication) which was ordered on [DATE]. The comment for why the medication was not administered read: Drug Item unavailable. Record review of Resident 14's Medications Administration History form for (MONTH) of (YEAR) revealed an order for [REDACTED]. Licensure Reference Number: 175 NAC 12-006.12A B. Record reviews of Resident facility medication error reports revealed the following errors were investigated: - Error occurring on 8/23/16 revealed Resident 12's ordered medications for: Omeprazole, Simethicone, Levothyroxine, Hydrochlorothiazide, Losartin, and Nifadipine scheduled for 8 a.m. doses were omitted and not given. - Error occurring on 8/23/16 revealed Resident 13's ordered medications for Metoprolol and Namenda were omitted and not given to the resident as scheduled for 8 a.m. doses. - Error occurring on 8/20/16 revealed Resident 14's ordered medication for Coreg, ordered twice daily was omitted and not given the resident during the scheduled 5 p.m. dose. C. Record review of Resident 8's Physician Order Report for 9/3/16 through 10/3/16 revealed a list of resident allergies [REDACTED]. Record review of Resident 8's Medications Administration History form for (MONTH) of (YEAR) revealed Resident 8 was administered the Morphine Concentrate solution on 9/27; 9/28; 9/29; and 9/30/16. D. Observation on 9/29/16 at 6:30 a.m. revealed LPN (Licensed Practical Nurse)-H administering medications for Resident 2. During the observation, LPN-H prepared and administered a dose of Pepcid to the resident. LPN-H stated that the time was incorrectly inputted into the computerized medical record for administration at 8 a.m. and that the time needed to be changed so the resident would receive the medication prior to meals as the manufacturer directs. Record review of Resident 2's Medications Administration History for 9/1/16 through 9/28/16 revealed an order for [REDACTED].>Second interview with LPN-H on 9/29/16 at 1:20 p.m. confirmed the order was taken on 9/24/16 and incorrectly entered to administer at 8 a.m. which was after the resident's usual breakfast time. LPN-H confirmed the order was not changed until today 9/29/16, five days after the order was received. E. Record reviews of facility Medications Administration History forms revealed the following documentation regarding ordered medication doses not being administered to residents: Resident 2's (MONTH) (YEAR) administration forms revealed: - Resident 2's aspirin dose scheduled daily at bedtime was not given due to the resident sleeping. -Resident 2's Restasis scheduled twice daily was not administered in the evening on 8/1/16 due to the resident sleeping. and on 8/23/16 the morning dose was not administered due to the resident being at activities. Resident 9's (MONTH) (YEAR) administration record forms revealed: - an ordered dose for Combigan eye drops with instructions for twice a day dosing was not administered on 9/19/16 for the scheduled 9 p.m. dose due to the eye drops not in the box couldn't find. Resident 12's (MONTH) (YEAR) administration record forms revealed: - an ordered dose for Aspirin with orders to administer the medication daily at 7 a.m. was not administered to the resident until 12:03 p.m. on 8/23/16. - an ordered dose of Miralax scheduled daily at 8 a.m. was not administered to the resident until 12:07 p.m. on 8/23/16 - an ordered dose of Refresh eye drops scheduled daily at 8 a.m. was not administered until 12:07 p.m. on 8/23/16. Resident 14's (MONTH) (YEAR) administration record forms revealed: - an ordered dose for a daily vitamin scheduled to be administered at bedtime was omitted and not administered to the resident on 8/23/16 due to the resident being asleep. F. Record reviews of facility Medications Administration History forms revealed the following: Review of Resident 2's administration records for (MONTH) and (MONTH) of (YEAR) revealed 20 instances where medications were documented late (after the scheduled time with one hour leeway before and after scheduled times) in (MONTH) and 19 instances where medications were documented late in September. Review of Resident 9's administration records for (MONTH) and (MONTH) of (YEAR) revealed 11 instances where medications were documented late in (MONTH) and 9 instances where medications were documented late in September. Review of Resident 10's administration records for (MONTH) (YEAR) 11 instances where medications were documented late in August. Review of Resident 12's administration records for (MONTH) (YEAR) 41 instances where medications were documented late in August. Review of Resident 13's administration records for (MONTH) (YEAR) 29 instances where medications were documented late in August. Review of Resident 23's administration records for (MONTH) (YEAR) 11 instances where medications were documented late in August. Record review of the facility policy for Administering Medications revised (MONTH) of 2012 revealed policy directions for staff to: The individual administering the medication must initial the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones. Interview was conducted with the facility Administrator, Director of Nursing, Nurse Consultants, and Corporate Chief Executive Officer on 10/3/16 beginning at 11:45 a.m. During the interview the findings from this review along with document reviews of sampled resident Medication Administration Histories. The Administrator, Director of Nursing, and Nurse Consultants verified documentation that medications were unavailable for residents 8, 10, and 14; medication errors omitting resident scheduled medications were investigated and confirmed for Residents 12, 13, 14; Time of administration was incorrectly entered into Resident 2's computerized medical record; documentation of omissions of medications occurred for Residents 2, 9, 12, and 14; and the staff were failing to document medications as soon as they were administered according to facility policy and current standards of practice for medication administration for Residents 2, 8, 9, 10, 12, 13, and 14.",2019-10-01
5302,BLUE VALLEY LUTHERAN CARE HOME,2.8e+280,"P O BOX 166, 755 SOUTH 3RD STREET",HEBRON,NE,68370,2019-01-02,604,E,1,0,JR9H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews, the facility failed to ensure 3 (Resident 12, 100, and 23) out of 3 residents were free from physical restraints and the restraints that were being used, were used to treat medical symptoms. The facility census was 30. Findings are: [NAME] Observation of Resident 12 on 1-2-18 at 10:10 [NAME]M. revealed the resident was sitting in the wheelchair with a locked laptray, seatbelt, and wrist restraints on both wrists that prevented the resident from lifting either arm up off of the lap tray. Observations of the residents hands revealed both fingers/hands were contracted into a fist like shape. The lap tray was absent of any activity or food/drink items for the resident. Record review of Resident 12's Face Sheet dated 1-2-19 revealed the date of admission as 6-2-14 and [DIAGNOSES REDACTED]. Review of the Annual MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-12-18 revealed no restraints. Interview on 1-2-19 at 2:55 PM with NA-B (Nurse Aide) revealed Resident 12 was admitted with the seatbelt, laptray, and wrist restraints. NA-B revealed the resident had the laptray, the seatbelt, and the wrist restraints applied whenever up in the wheelchair. NA-B confirmed the resident was unable to remove the seatbelt, the laptray or the wrist restraints. NA-B confirmed the staff do not remove the restraints once applied unless they are transferring the resident back to bed. The resident was fed via a feeding tube into the stomach so did not need the hands to eat. Interview on 1-2-19 at 3:00 PM with LPN-A (Licensed Practical Nurse) revealed the resident was not able to remove the lap tray or the seatbelt. LPN-A revealed sometimes the resident by shear force may break free of the wrist restraints but was not able to remove them in the same manner they were applied. LPN-A confirmed the laptray, seatbelt, and wrist restraints were applied every time the resident was placed in the wheelchair and removed when transferred back to bed. LPN-A revealed the purpose of the wrist restraints were to prevent the resident from flailing the arms and cause injury to self and other residents from the spastic muscle movements the resident had. Review of the Annual Restorative Therapy Summary dated 12-13-18 revealed the wheelchair was equipped with a tray which included wrists/forearm straps to assist in positioning the bilateral upper extremities to prevent injuries from the residents unpredictable extremity movements. On 9-19-18 a representative from an Occupation Therapy Company and fitted the resident for a better-fitted seating and positioning system and modifications to the lap tray. Review of the notes revealed absence of what the medications were or why. Record review of the resident's Physician orders revealed absence of an order to apply and identify the medical symptoms for the the seatbelt, laptray, and wrist restraints. Record review revealed absence of documentation related to: -The seatbelt, laptray, and wrist restraints being used were the least restraints to be used on Resident 12, used for the least amount of time, and other interventions attempted to treat the medical symptom were ineffective. -The legal representative was informed of the potential risks and benefits of all options under consideration including using the restraint, not using a restraint, and alternatives to restraint use. -The resident could demonstrate to staff the ability to 'intentionally' remove the device in the same manner that the staff applied it. -The type of specific direct monitoring and supervision provided during the use of the seatbelt, laptray, and wrist restraints including documentation of the monitoring by the staff. -The on going re-evaluation to show the need for the laptray, seatbelt, and wrist restraints and how it was effective in treating the medical symptom it was being used for. B. Observation on 1-2-19 at 10:15 AM of Resident 100 sitting in the wheelchair with a locked lap tray on in the hallway near the nurses' desk. The lap tray was absent of any activity or food/drink items on the tray for the resident. Resident also had a locked seatbelt on around the waist. Record review of Resident 100's Face sheet dated 1/2/19 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident 100's MDS dated [DATE] revealed the resident did not use restraints. The BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) revealed the resident was severely cognitively impaired. Interview on 1-2-19 at 2:55 PM with NA-B revealed Resident 100 was deaf and blind and a high fall risk. Whenever the resident was up in the wheelchair, the staff applied the seatbelt and the laptray on the resident or the resident would slide right out of the chair. NA-B revealed a few times new staff were not aware to apply the seatbelt and laptray and the resident right away started scooting self down in the chair. NA-B revealed the resident was not able to remove the seatbelt of the laptray independently. Interview on 1-2-19 at 3:05 PM with LPN-A revealed Resident 100 was not able to remove the lap tray or the seatbelt independently. LPN-A revealed both the seatbelt and the laptray were on anytime the resident was up in the wheelchair for positioning to prevent the resident from sliding out of the wheelchair. Record review of the resident's Physician orders revealed absence of an order to apply and identify the medical symptoms for the the seatbelt and laptray restraints. Record review revealed absence of documentation related to: -The seatbelt and laptray being used were the least restraints to be used on Resident 100, used for the least amount of time, and other interventions attempted to treat the medical symptom were ineffective. -The legal representative was informed of the potential risks and benefits of all options under consideration including using the restraint, not using a restraint, and alternatives to restraint use. -The resident could demonstrate to staff the ability to 'intentionally' remove the device in the same manner that the staff applied it. -The type of specific direct monitoring and supervision provided during the use of the seatbelt and laptray restraints including documentation of the monitoring by the staff. -The on going re-evaluation to show the need for the laptray and seatbelt restraints and how it was effective in treating the medical symptom it was being used for. C. Observation on 1-2-19 at 10:30 AM revealed Resident 23 sitting in a merrywalker (framed walker/chair combination assistive device) in the hallway with the strap intact between the resident legs and the bar secured in front of the resident to prevent the resident from exiting the merrywalker device. Review of Resident 23's Face Sheet dated 12-24-18 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of annual MDS dated [DATE] revealed restraints used daily. Review of the CAA worksheet with this MDS revealed restraints were triggered with the following documentation: This triggered due to the need for a merry walker. (Resident 23) used the merry walker for mobility within the facility. This allowed the resident freedom of movement while decreasing the risk of falls. However, the resident was not able to open the front bar and transfer at will. Due to this the merry walker must be considered both an enabler and a restraint. Record review of the resident's Physician orders revealed absence of an order to use the merrywalker and identify the medical symptoms for the restraint. Record review revealed absence of documentation related to: -The merrywalker restraint used was the least restraint to be used on Resident 23, used for the least amount of time, and other interventions attempted to treat the medical symptom were ineffective. -The resident could demonstrate to staff the ability to 'intentionally' remove the device in the same manner that the staff applied it. -The type of specific direct monitoring and supervision provided during the use of the merrywalker restraint including documentation of the monitoring by the staff. Review of the facility policy titled Use of Restraints revised (MONTH) 2011 revealed if the resident cannot remove a device in the same manner in which the staff applied it given the resident's physical condition, and the device restricts the residents' typical ability to change position or place, that device is considered a restraint. Examples of devices listed were arm restrains, trays that the resident could not remove. The policy also revealed prior to placing a resident in restraints, there shall be a pre-restraint 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. Safety guidelines shall be implemented and documented while a resident is in restraints and shall not cause physical injury to the resident. To ensure the least possible discomfort to the resident a resident will be observed at leased every 30 minutes by nursing personnel and an account of the resident condition shall be recorded in the medical record. The opportunity for motion and exercise would be provided for a period of not less than 10 minutes during each 2 hours in which restraints were employed. Resident must be repositioned every 2 hours on all shifts. Residents/family shall be informed about the potential risks and benefits of all options under consideration, including the use of restrains, not using restraints, and the alternative to restraint use. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reeducation, less restrictive methods of restraints, or total restraint elimination. Documentation regarding the use of restraints shall include observation, range of motion, and repositioning flow sheets. Interview on 1-2-19 at 1:15 PM with the (ADM) Administrator confirmed none of the documentation had been completed on the residents with restraints. The ADM also confirmed the facility had reviewed their current restraint policy and were going to start 3 new assessment forms, a physical restraint assessment, a physical evaluation worksheet and a physical restraint consent form. The Administrator confirmed none of the 3 forms had been started on any resident yet after they were cited for F604 'Right to be Free from Physical Restraints' on 12-4-18 at their annual survey.",2020-02-01
4298,OGLALA SIOUX LAKOTA NURSING HOME,2.8e+301,"7835 ELDERS DRIVE, STATE HIGHWAY 87",RUSHVILLE,NE,69360,2017-11-16,309,D,1,1,XK2J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews, the facility failed to ensure staff monitored one sampled resident's (Resident 30) [MEDICAL TREATMENT] port on a daily basis. Resident 30 was the only current resident receiving [MEDICAL TREATMENT] services. 14 Residents were sampled. Facility census was 29. Findings are: Record review of Resident 30's Admission Record printed on 11/14/17 revealed the resident was admitted to the facility on [DATE]. Among the resident's medical [DIAGNOSES REDACTED]. Observation of Resident 30 on 11/14/17 at 1:39 p.m. revealed the resident had a shunt to the left forearm. Interview with Resident 30 on 11/14/17 at 1:39 p.m. revealed the facility assisted transporting the resident to a [MEDICAL TREATMENT] center for treatment three times a week. Record review of Resident 30's Care Plan revealed a Focus problem revised on 11/13/17 which identified a problem of at risk for complications related to [MEDICAL TREATMENT] for the [DIAGNOSES REDACTED]. Among interventions to address the problem included directions to check the resident's shunt site daily and as needed for symptoms of infection, pain, or bleeding. Record review of Resident 30's medical record including treatment sheets, medication sheets, and progress notes revealed there was no documentation that the staff were monitoring the shunt daily for signs of bleeding or infection. Interview with the DON (Director of Nursing) on 11/16/17 at 10:27 a.m. confirmed the staff were not recording daily assessments of Resident 30's shunt site condition.",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
4299,OGLALA SIOUX LAKOTA NURSING HOME,2.8e+301,"7835 ELDERS DRIVE, STATE HIGHWAY 87",RUSHVILLE,NE,69360,2017-11-16,323,D,1,1,XK2J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews, the facility failed to: 1) ensure oxygen concentrators were turned off when not in use and unattended for one sampled resident (Resident (Resident 2). This failure could potentially oxygenate the room resulting in increased fire hazard; and 2) identify causal factors and develop strategies to prevent re-occurrence of falling for one sampled resident (Resident 12) after a fall occurred. Sample size was 14 residents. Facility census was 29. Findings are: Licensure Reference Number: 175 NAC 12-006.09D7 [NAME] Record review of Resident 2's Admission Record printed on 11/14/17 revealed the resident was admitted to the facility on [DATE] and had medical [DIAGNOSES REDACTED]. Record review of Resident 2's Admission MDS (Minimum Data Set, a federally mandated comprehensive tool utilized to develop resident care plans) completed on 9/26/17 revealed the resident received Oxygen therapy. Observation on 11/15/17 at 9 a.m.; 10 a.m.; 11:00 a.m.; and 12 noon revealed Resident 12's oxygen concentrator was running set on two liters while the resident was out of the room and the room was unattended to. Another observation with the DON (Director of Nursing) on 11/15/17 at 12:15 p.m. revealed Resident 12's concentrator was left on and unattended. Interview with the DON during the observation on 11/15/17 at 12:15 p.m. confirmed Resident 12's oxygen concentrator was left on while unattended in the room. Licensure Reference Number: 175 NAC 12-006.09D7b B. Record review of Resident 12's Admission Record printed on 11/14/17 revealed the resident was admitted to the facility on [DATE] and had a medical [DIAGNOSES REDACTED]. Record review of Resident 12's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) revealed revealed a Significant Change in Status MDS was completed for the resident on 8/18/17. The MDS recorded the resident's cognition had declined from a score of 6 to 3 on a scale where score of 0-7 suggests severe memory impairments. The MDS also recorded the resident did not walk and was assisted by two staff for extensive assistance with transfers. The MDS identified the resident had not fallen in the previous 90 days. Record review of Resident 12's Progress Notes revealed an entry on 10/12/17 at 8:10 a.m. recording a Nurse Aide reported finding the resident on the floor in front of the bathroom and the resident was bleeding. The charge nurse, LPN (Licensed Practical Nurse)-C assessed the resident and provided a cool washcloth to the forehead while the staff assisted the resident into a wheelchair. The resident was assessed with [REDACTED]. The charge nurse cleansed the areas and applied a Telfa pad. The resident was sent to the ER (emergency room ). A note recorded at 11:06 a.m. on 10/12/17 recorded the resident returned from the ER with 10 staples to the forehead. There was nothing in the progress notes between 10/12/17 and 10/25/17 identifying causal factors related to the resident's fall or any changes in staff interventions to prevent re-occurrence of the fall. Progress Notes entry on 10/25/17 at 11:33 a.m. revealed the resident was found on floor in room with the wheelchair behind the resident. Resident was lying on side, pressure applied to the forehead and the resident was transferred to the ER for evaluation. The resident returned at 4:42 p.m. with no new medical treatment while at the ER. Record review of a facility investigation of the incident involving Resident 12, dated 10/16/17 revealed the resident fell on [DATE] after trying to take self to the bathroom. With regard to measures put in place to prevent reoccurrence of the fall, the facility recorded they would provide re-education to Resident to use (the resident's) call button. There was nothing recorded in the investigation identifying precipitating factors or cause of the resident attempting to get up unassisted, nor intervention changes to prevent the resident from falling again. Interview with the DON (Director of Nursing) on 11/16/17 at 10:34 a.m. revealed prior to Resident 12 falling on 10/12/17, the resident used a urinal and didn't like the urinal. At the time of the fall, the DON stated the resident experienced a UTI (Urinary Tract Infection) with increased confusion causing the resident to attempt transferring self to the bathroom instead of using the call light. The DON confirmed there was no evidence the facility identified factors leading to the resident's fall, the possible causes of the resident attempting to get up unassisted, or identifying interventions to prevent re-occurrence. The DON confirmed a resident with confusion would not recall reminders to use a call button.",2020-09-01
4820,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2017-04-19,425,E,1,1,HWP011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews, the facility failed to: 1) obtain medications for administration as ordered for one sampled resident (Resident 26); and 2) ensure medication labels were compared to instructions on resident Medication Administration Records a minimum of three times per nursing standards of practice for medications administered to eight current residents (Residents 43, 15, 41, 10, 8, 21, 28, and 3). Sample included fifteen current residents and five closed records. Facility census was 24. Findings are: [NAME] Licensure Reference Number: 175 NAC 12-006.12A Record review of Resident 26's Admission Record printed on 4/18/17 revealed the resident was admitted to the facility initially on 12/2/2014. Among the medical diagnoes listed on the document were: Hypertension, Chronic Kidney Disease, and Chronic Obstructive Pulmonary Disease. Record review of Resident 26's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) records revealed the following: - The resident was discharged from the facility to a hospital setting on 3/1/17 and returned on 3/7/17. - The resident was discharged from the facility to a hospital setting on 3/13/17 and returned on 3/14/17. - The resident was discharged to another nursing facility on 3/31/17. Closed medical record review of Resident 26's medical physician orders [REDACTED]. The instructions read for the resident to take two tablets at 7 a.m.; and one tablet at 11 a.m.; 2 p.m.; and 6 p.m. Record review of Resident 26's Medication Administration Record [REDACTED]. Record review of Resident 26's Progress Notes (including Nurses Notes) revealed on 3/14/17 at 12:15 p.m. the resident was readmitted to the facility. Further review of the notes revealed an entry on 3/14/17 at 5:42 p.m. recording the resident's Lasix was not administered to the resident in the evening due to Product unavailable, pharmacy notified. Record review of Resident 26's Order Summary Report signed by the physician for orders ranging between 3/1/17 and 3/31/17 revealed a physician's orders [REDACTED]. Record review of Resident 26's Medication Administration Record [REDACTED]. Record review of Resident 26's Progress Notes revealed an entry on 3/15/17 at 6:47 a.m. recording the Singulair was not given due to being ordered on its way from pharmacy. An entry on 3/16/17 at 7:56 a.m. recorded the Singulair was not administered due to: medication on its way ordered coming by pharmacy. Interview with the Administrator on 4/19/17 at 11:00 a.m. confirmed that Resident 26 was in and out of the hospital in (MONTH) of (YEAR) and was experiencing issues with fluid retention. The Administrator confirmed the resident was re-admitted to the facility on [DATE] at 12:15 a.m. with orders for Lasix administration with the next doses due at 2:00 p.m. and 6 p.m. The Administrator verified the Medication Administration Record [REDACTED]. Reference Licensure Number 175 NAC 12-006.10A2 B. Observations on 4/18/17 at 7:10 AM to 11:30 AM of (Licensed Practical Nurse) LPN - B administer medications to 6 sampled residents (Resident 43, 15, 41, 10, 8, and 28). During the observation, the med packets for each resident were placed on the top of the medication cart and the LPN looked at the (Electronic Medical Record) Order summary for (MONTH) (YEAR) and then grabbed the packets quickly and popped the pills into medication cups and placed the medication packets back into the medication cart and then administered the medications to the 5 sampled residents. Interview on 4/18/17 at 3:00 PM with the Interim (Director of Nursing) DON confirmed that 3 complete medication checks should be done prior to administering medications to residents per standards of nursing medication administration practice. Further observation verified that the 3 checks had not been done by the LPN - B as there were medication labeling discrepancies noted later. Continued interview verified if the checks would have been completed there would not have been discrepancies from the original orders, to the Order Summary, to the administration of residents medications. Interview on 4/18/19 at 3:30 PM with the Interim Administrator verified that prior to administering medications to residents the medications should be checked 3 times to ensure that the correct medications are administered to residents. Potter/Perry Reference: Fundamentals of Nursing Potter/Perry, 6th Edition, Copyright @ 2005, Mosby, Inc. Standards are those actions that ensure safe nursing practice .When medications are first ordered, the nurse compares the medication recording form or computer orders with the prescribe's written orders. when administering medications, the nurse compares the label of the medication container with the medication form. The nurse does this 3 times: (1) before removing the container from the drawer or shelf, (2) as the amount of medication ordered is removed from the container, and (3) before returning the container to storage .",2020-03-01
5714,NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER,285271,2100 CIRCLE DRIVE,SCOTTSBLUFF,NE,69361,2016-10-03,323,D,1,0,SRLF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews; the facility failed to: 1) Transfer a cognitively impaired resident with balance impairments with the use of a gait belt as identified in the resident's care plan; 2) Assess the need for and safety for the use of a grab bar device attached to the resident's bed; and 3) Investigate all potential causes for a bruise of unknown origin. All of these failures affected one sampled resident (Resident 2). Sample size included four current residents. Facility census was 51. Findings are: Licensure Reference Number: 175 NAC 12-006.09D7a A. Record review of Resident 2's Resident Face Sheet printed on 9/28/16 revealed the resident was admitted to the facility on [DATE] with the latest return recorded 5/23/16. Among the resident's medical [DIAGNOSES REDACTED]. Record review of Resident 2's Quarterly review MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) completed on 7/18/16 revealed the following: - The resident's BIMS (Brief Interview of Mental Status, a test to assess resident memory capabilities) scored a 6 (0-7=severe cognitive impairment) - The resident's ability to transfer between surfaces and walk were recorded as: Extensive Assist (Resident involved in activity, staff provide weight-bearing support). - The resident's ability to move on and off the unit was recorded as: Limited Assist (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance). - The resident's ability to balance while moving from seat to standing, walking, and turning around while walking was assessed as: Not steady, only able to stabilize with staff assistance. Record review of Resident 2's Care Plan with Goal Target Dates through 10/17/2016 revealed the resident had a problem identified as falls due to a history of falling, poor judgment and reasoning, and decline in cognition. An additional problem regarding ADL (Activities of Daily Living) functionality revealed the resident leaned to the right when sitting and needed extensive assistance with toileting, ambulation in the room and hall with use of a walker. Approaches to the problem directed staff to: Walk to dine with a gait belt and assistance of one and walker and Use gait belt 1 assist and 4 wheeled walker for all toileting, use gait belt and hand held assistance for all other transfers. Interview with Resident 2's family members on 9/28/16 at 11:20 a.m. revealed the family had concerns regarding facility staff utilizing the gait belt during resident transfers. The family reported having installed a video camera in the room so family could monitor the resident throughout the day and reported on several occasions having observed staff performing transfers of the resident without using a gait belt. The family had documented times specifically observing improper transfers and described on 9/10/16 they observed a nurse aide transferring the resident from the chair by pulling on both hands from the armpit area of the resident's right arm. Observation on 9/29/16 at 1:15 p.m. revealed NA (Nurse Aide)-C assisting Resident 2 from the bathroom. The resident was in a wheelchair and when asked by NA-C, the resident stated preference to lie down in bed. NA-C positioned the wheelchair next to the bed and transferred the resident from the wheelchair to the bed by guiding the resident, holding on to the resident's right arm. A gait belt was not used during the transfer. Second interview with Resident 2's family members on 10/2/16 at 5:00 p.m. revealed the family had been monitoring the video camera earlier this morning and observed staff transferring the resident to the resident's chair at 5:26 a.m. The family stated staff had not utilized a gait belt during the transfer. Interview with the Administrator, Director of Nursing, and facility Nurse Consultants on 10/3/16 beginning at 11:45 a.m. confirmed Resident 2's family had expressed concerns about observing transfers of the resident without the gait belt use. The Administrator, Director of Nursing, and facility Nurse Consultants confirmed the facility required staff to utilize gait belts during transfers with residents experiencing balance problems or requiring assistance/dependence with transfers between surfaces. B. Observations of Resident 2 during initial tour of the facility on 9/28/16 at 11:20 a.m. revealed Resident 2's bed had a metal grab bar device attached to the right side of the bed which was positioned against the resident's room wall. Interview with NA-C and NA-D on 9/29/16 at 7:20 a.m. revealed the two staff members provided daily cares for the resident on the day shift. Both NA-C and NA-D stated the resident required assistance from the staff with positioning in bed and with transfers. When questioned about the grab bar attached to the bed, both NA-C and NA-D stated the resident does not use the device for positioning and to their knowledge did not ever see the resident hang on to or use the bed cane. Record review of Resident 2's chart revealed their were no assessments pertaining to the resident's need for the grab bar and whether or not the device had been deemed safe for the resident's use. Record review of Resident 2's Care Plan with Goal Target Dates through 10/17/2016 revealed the grab bar device was not included in the resident's care plan. Interview with Resident 2's family members on 10/2/16 at 5:00 p.m. discussed the grab bar device on the resident's bed. The family members confirmed from their observations that the resident had never used the device while in bed and they were unaware of the reason for the device being attached to the bed. Interview with NA-E on 10/2/16 at 6:50 p.m. revealed NA-E worked with Resident 2 and assisted with direct cares on the evening shift. NA-E was not certain why the resident's bed had a grab bar and stated not having observed the resident utilizing the device during time in bed. Interview with the Director of Nursing and facility Nurse Consultants on 10/3/16 beginning at 11:45 a.m. confirmed there were no assessments in Resident 2's medical record to determine the need for a metal grab bar device attached to the bed or whether or not the device would be safe for the resident. Licensure Reference Number: 175 NAC 12-006.09D7b (1) C. Record review of a facility Verification of Investigation form for an event occurring on 9/7/16 at 5:30 a.m. revealed Resident 2 was taken for a bath and noted to have a purple bruise measuring 17 x 4 cm (centimeters). The resident was assessed and noted to be taking Plavix and aspirin daily (medications that may cause bleeding/bruising). The investigation included an interview with the resident who was unsure how the bruise was obtained. The summary and outcome of the investigation concluded the resident was observed by staff member to be pushing arm against table while pushing drinks into place. The measures put in place to prevent re-occurrence were to educate staff to position resident's drinks where resident prefers them. Further review of the facility's investigation revealed a photo of the injury which extended from the resident's elbow to above the wrist on the anterior portion of the resident's right arm. Interview with Resident 2's family members on 9/28/16 at 11:20 a. m. revealed the family had concerns related to the facility findings of how the bruise occurred. The family stated having observed the bruise which was located on the resident's top side of the right arm extending from the elbow to the resident's wrist. The family questioned if this came from pushing items on the dining room table concluding the resident would have had to have done so with the right arm inverted and the resident's top of the hand in touch with the table. The family stated that they were not satisfied the facility had ruled out other possible causes for the injury. They believed that for the resident to have obtained a bruise on the anterior portion of the arm by pushing objects on the table, the injury would have been on the posterior side of the arm rather than the anterior. The family provided a photo of the injury (the same one from the facility investigation) confirming the location of the bruise was on the anterior right arm extending from the elbow to the wrist. The family also stated they wondered if the injury may have occurred during transfers as they had observed several occasions where staff members were not utilizing gait belts as directed on the resident's care plan. Observation of Resident 2's right arm on 9/28/16 at 11:45 a.m. revealed the resident's bruising had healed. Observations of Resident 2's care during the survey revealed the following: - 9/28/16 at 12:14 p.m. NA-F assisted the resident into the bathroom and to the dining room. The resident was observed using a wheeled walker. The doorways into the bathroom and out of the resident's room were observed in which the spacing was tight. - 9/29/16 at 10:30 a.m. the resident was observed sitting in a wheelchair in a lounge area attending a Bible group study. Observation revealed the resident sitting with the anterior portion of the resident's right arm in the resident's lap and in contact with the resident's wheelchair arm. - 9/29/16 at 1:15 p.m. the resident was observed being assisted by NA-A. The observation revealed the resident in the wheelchair coming out of the bathroom being pushed by NA-A. The doorway to the bathroom accommodated the wheelchair width but left about two inches leeway on either side. Further observation of the resident's transfer at this time revealed NA-A failed to use a gait belt during the transfer and held onto the resident's right forearm during the transfer from the wheelchair to the bed. - Meal observations of the resident during the breakfast and noon meals on 9/29/16 and supper meal on 10/2/16 revealed the resident was fidgeting at times by folding, refolding the napkin and would push glasses and silverware away from the edges of the table. The observations did not reveal the resident pushing with the anterior side of the arm on the table, but the posterior side was in contact. In addition, the resident's dining chair was observed with wooden arm rests in which the resident's anterior portion of the arms rested on while staff fed the resident. - Observations of the resident's bed throughout the survey beginning with an initial tour observation on 9/28/16 at 11:40 a.m. through 10/3/16 revealed a metal grab bar attached to the right side of the resident's bed. Interview with the facility Administrator, Director of Nursing, and facility Nurse Consultants on 10/3/16 beginning at 11:45 a.m. confirmed Resident 2 obtained a bruise injury discovered by staff on 9/7/16 during bathing. Interviews with staff members revealed no one had discovered the bruise or concluded how the resident may have obtained the bruise until the resident's bath. Interviews with staff had not concluded how the resident obtained the injury except one staff member reported observing the resident pushing glasses away from the table during dining. The Administrator and Director of Nursing stated that based on the observation of pushing glasses on the table, the facility concluded this was the likely cause. During the interview the Director of Nursing and Administrator verified having received concerns of the resident's family that the resident was not consistently transferred with the use of a gait belt. They also confirmed the resident had a metal grab bar on the right side of the bed which had not been assessed for safety use. The Administrator and Director of Nursing stated they had not considered improper transfers, doorway clearances, wheelchair and dining room arm rests, or the grab bar as potential causes for the injury during their investigation.",2019-10-01
6670,GRAND ISLAND PARK PLACE CARE AND REHABILITATION CE,285105,610 NORTH DARR AVENUE,GRAND ISLAND,NE,68803,2015-11-19,431,D,1,0,67D811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure that one residents (Resident 8) Wound Vac (wound healing through negative pressure wound therapy) was at the prescribed level as ordered by the physician. The facility census was 54. Findings are: Review of Resident 8's Wound Clinic Visit on 10/23/15 revealed: -The resident was finished with the antibiotic. -The resident had more edema in left foot. The resident kept feet up except when eating. -The resident's Wound Vac pressure was increased to 150 mmHg (millimeters of mercury) continuously with a black sponge. The sponge was to be changed three times weekly. -The wounds were to be washed with soap and water at each dressing change. Review of Resident 8's Wound Clinic Visit dated 10/29/15 revealed: -The left foot was more swollen around the ankle. -There was an increase in serosanguinous drainage (blood and serum part of the blood leaving the body from a new wound) from a wound under the dressings. -The resident was having more pain and had medication adjustment for pain. -The resident's Wound Vac pressure remained at 150 mmHg continuously with a black sponge. -The sponge was to be changed three times weekly. -The wounds were to be washed with soap and water at each dressing change. -The resident was to remain at non-weight bearing on both feet.-The resident was to elevate both legs as much as possible. Review of Resident 8's (MONTH) (YEAR) TAR (Treatment Administration Record) revealed: -The resident's Wound Vac order on 10/23/15 for an increase in pressure from 125 to 150 mmHg was not updated. The order still read Wound Vac at 125 mm on both feet to be changed on Monday, Wednesday, and Friday to continuous suction. -The residents Wound Vac dressing change was not completed on 11/4/15. Review of Resident 8's (MONTH) (YEAR) TAR revealed: -The resident had an order for [REDACTED]. -The resident's Wound Vac order on 10/23/15 for an increase in pressure from 125 to 150 mmHg was not updated. -The residents Wound Vac dressing changes were not completed on 10/19/15, 10/21/15, 10/23/15, and 10/28/15. Interview with the DON (Director of Nursing) on 11/30/15 at 2:30 pm the facility had discovered the change in the resident's Wound Vac pressure and clarified the order with the physician.",2018-11-01
3944,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,712,D,1,1,OLWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure 2 (Resident 14 and 15) out of 4 residents Physician visits were completed at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. The census was 34. Findings are. [NAME] Review of Resident 14's undated Face Sheet revealed the resident was admitted on [DATE]. Review of Resident 14's Physician's PN (Progress Notes) revealed the resident had an initial Physician visit on 12-02-16. The Physician PN revealed the next 30 day Physician visit was not until 02-28-17 which was 60 days later and not the 30 days later as required. Review of Resident 15's undated Face Sheet revealed the resident was admitted on [DATE]. Review of Resident 15's Physician's PN revealed the resident had an initial Physician visit on 12-14-16. The Physician PN revealed the next 30 day Physician visit was 01-12-17. The 3rd 30 day Physician visit was absent from the medical record. Interview on 03/20/18 at 04:13 PM with MA-D (Medication Aide), who was the[NAME] Clerk, confirmed the Progress Notes were absent for the 2nd 30 day Physician visit for Resident 14 and for the 3rd 30 day Physician visit for Resident 15. B. Review of Resident 15's 60 day Physician visits revealed the resident received a 60 day visit from the Primary Care Physician in April, (MONTH) and (MONTH) (YEAR) then another visit was not documented until (MONTH) (YEAR). Interview on 03/20/18 at 04:13 PM with MA-D revealed the MA-D could not find any documentation of a 60 day Physician visit which occurred between (MONTH) (YEAR) and (MONTH) (YEAR).",2020-09-01
4933,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2018-06-12,757,D,1,1,ELDP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure 2 residents (Resident 31 and 1) were free from the use of unnecessary medications as medications were given without indication for use and not in accordance with physician's orders [REDACTED]. Findings are: [NAME] Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/7/18 revealed [DIAGNOSES REDACTED]. Review of Resident 1's Medication Administration Record [REDACTED]. Further review revealed orders dated 9/28/17 for Tylenol 650 mg every 6 hours as needed for mild pain with pain rated as 1-4 on a pain scale. Review of the 5/2018 MAR indicated [REDACTED] -5/12/18 at 8:35 for pain level of 3; -5/14/18 at 7:00 PM for pain level of 4; -5/15/18 at 8:30 AM for pain level of 4; -5/18/18 at 1:44 AM for pain level of 4; -5/21/18 at 9:22 PM for pain level of 4; -5/22/18 at 11:59 PM for pain level of 4; -5/26/18 at 9:39 PM for pain level of 3; and -5/27/18 at 5:41 AM for pain level of 3. Review of the 6/2018 MAR indicated [REDACTED]. Documentation indicated the following: -6/6/18 at 8:01 AM for pain level of 3; -6/7/18 at 9:17 AM for pain level of 2; -6/8/18 at 7:24 PM for pain level of 4; -6/10/18 at 7:05 PM for pain level of 4; -6/11/18 at 8:06 AM for pain level of 4; and -6/12/18 at 7:01 AM for pain level of 3. B. Review of Resident 1's MAR indicated [REDACTED] -[MEDICATION NAME] (medication used to treat anxiety) 1 mg every 8 hours PRN for anxiety (order date 1/2/18); and -[MEDICATION NAME] 1 mg every 6 hours PRN for restlessness related to anxiety disorder (order date 5/15/18). Further review of Resident 1's MAR indicated [REDACTED] -Resident 1 received [MEDICATION NAME] 1 mg on 5/12/18 at 5:03 PM and again at 8:36 PM (3 hours and 30 minutes between doses); -No [MEDICATION NAME] was given on 5/27/18 and an order was obtained for [MEDICATION NAME] 10 mg IM (intramuscular) every 4 hours PRN for agitation/aggression/confrontation/anxiety; and -[MEDICATION NAME] 10 MG IM was given on 5/27/18 at 6:13 PM. C. Interview with the Director of Nurses (DON) on 6/12/18 at 9:00 AM confirmed Resident 1's [MEDICATION NAME] was not given as indicated and ordered for pain and [MEDICATION NAME] was given without an indication for use. D. Review of Resident 31's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. Review of Resident 31's MARs dated 4/2018, 5/2018 and 6/2018 revealed an order dated 7/12/16 for [MEDICATION NAME] 0.5 mg via [DEVICE] (gastrostomy tube, a tube inserted through the abdomen that delivers nutrients directly to the stomach) every 1 hour as needed for [MEDICAL CONDITION] activity. Review of the 4/2018 MAR indicated [REDACTED] -4/1/18 at 2:12 AM; -4/7/18 at 10:31 PM; -4/15/18 at 3:05 AM; -4/17/18 at 11:31 PM; -4/18/18 at 2:02 AM and at 9:26 PM; -4/19/18 at 12:14 AM; -4/21/18 at 2:30 AM; -4/29/18 at 1:06 AM and at 3:02 AM; and -4/30/18 at 1:31 AM and at 3:33 AM. Review of Resident 31's MAR indicated [REDACTED] -5/3/18 at 6:47 PM; -5/17/18 at 11:58 PM; -5/18/18 at 2:46 PM; -5/27/18 at 10:00 PM; and -5/28/18 at 3:10 AM. Review of Resident 31's MAR indicated [REDACTED] -6/9/18 at 5:57 PM; and -6/10/18 at 8:54 PM. During an interview on 6/12/18 at 9:31 AM the DON confirmed Resident 31 was given the [MEDICATION NAME] when the staff felt the resident was restless or was moaning and not for [MEDICAL CONDITION] activity as the practitioner's order for the medication indicated.",2020-03-01
5465,GOOD SAMARITAN SOCIETY - WOOD RIVER,285198,1401 EAST STREET,WOOD RIVER,NE,68883,2017-03-22,334,E,1,1,HUVK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure 5 of 59 residents (Residents 82, 78, 61, 85 and 71) were offered the pneumococcal vaccinations as required. The facility census was 58. Findings are: [NAME] Review of Resident 82's electronic medical record revealed Resident 82 was admitted on [DATE] and had no documented evidence of being offered the pneumococcal vaccination. 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 2/8/17 revealed Resident 82's pneumococcal vaccination was not up to date and was not offered. B. Review of Resident 78's electronic medical record revealed Resident 78 was admitted on [DATE] and had no documented evidence of being offered the pnuemococcal vaccination. Review of Resident 78's MDS dated [DATE] revealed Resident 78's pneumococcal vaccination was not up to date. C. Review of Resident 61's electronic medical record revealed Resident 61 was admitted on [DATE] and had no documented evidence of being offered the pnuemococcal vaccination. Review of Resident 61's MDS dated [DATE] revealed Resident 61's pneumococcal vaccination was not up to date. D. Review of Resident 85's electronic medical record revealed Resident 85 was admitted on [DATE] and had no documented evidence of being offered the pnuemococcal vaccination. Review of Resident 85's MDS dated [DATE] revealed Resident 85's pneumococcal vaccination was not up to date and had not been offered. E. Review of Resident 71's electronic medical record revealed Resident 71 was admitted on [DATE] and had no documented evidence of being offered the pnuemococcal vaccination. Review of Resident 71's MDS dated [DATE] revealed Resident 71's pneumococcal vaccination was not up to date and had not been offered. Interview with the Assistant Director of Nursing (ADON) on 03/20/2017 at 4:39 PM revealed documentation could be found to indicate any of the above residents had been offered the pneumococcal vaccination as required. Review of the facility's policy for Immunizations for Residents revised 11/16 revealed, Upon admission, each resident and/or resident representative will receive the Vaccination Information Statements for influenza and pneumococcal vaccines. The policy continues to direct staff to assess the resident's current immunization status for pneumococcal vaccination and receive a physician's orders [REDACTED].",2020-01-01
6383,"FULLERTON CARE AND REHABILITATION CENTER, LLC",285115,"PO BOX 648, 202 NORTH ESTHER",FULLERTON,NE,68638,2016-03-10,247,E,1,0,UFFQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure Resident's Responsible Parties were notified prior to transferring residents into different rooms within the facility. This violation had the potential to affect four residents (Residents 2, 6, 8, and 11). The facility census was 70. Findings are: A review of a facility Policy/Document # SS-705 titled Transfers and Discharges with a review date of 2/26/2015 revealed the Social Services Director (SSD) would ensure systems were implemented to provide written notification to the resident and family prior to transfer. A review of the Notice of Transfer or Discharge forms for sampled residents revealed the following: -Resident 2 was moved from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on 6/26/15 and from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on 7/6/15; -Resident 6 was moved from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on 11/25/15; -Resident 8 was moved from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on 7/6/15, and from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-1 on 3/3/16; -Resident 11 was moved from room [ROOM NUMBER]-1 to room [ROOM NUMBER]-2 on 9/22/15, from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-1 on 10/22/15, and from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on 2/12/16. Further review of the forms revealed the Resident's Legal Representatives were notified by mail on the actual date of the moves and not before the moves. An interview on 3/9/16 at 2:45 PM with Social Services Assistant (SSA)-J confirmed the sampled Resident's Legal Representatives were not notified prior to the day of the resident moves. The SSA reported written notification of the resident moves were mailed out on the day of the actual transfers.",2019-03-01
5331,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-01-31,285,D,1,0,BKZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that a new Pre-Admission Screening and Resident Review (PASRR) was performed, according to the requirements for 1 resident (Resident 81) out of 1 sampled resident . The facility census was 69. Findings are: Record review of the facility policy titled, Pre-Admission Screening for MR/MI, dated 02/15, revealed that the facility would verify that all residents were screened prior to admission to determine whether they have a mental illness (MI) or mental [MEDICAL CONDITION]/developmental disability (MR/DD) [DIAGNOSES REDACTED]. A Level II screen was done to assist the facility in determining the types of services required to care for the resident. Record review of Resident 81's Admission Record, dated 1/30/17 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Record review of Resident 81's PASRR revealed a review date of 8/7/14 for admission to a receiving nursing facility on 4/12/14 that was not this facility. Interview with Social Service Director (SSD) on 1/30/17 at 2:57 PM revealed that Resident 81 did not have a PASRR performed upon admission to this facility. The SSD confirmed that the only PASRR present for Resident 81's record was the one provided by the transferring facility dated 8/7/14. Interview with the facility Administrator on 01/30/2017 at 3:02 PM confirmed that the facility failed to request a PASRR upon admission to the facility.",2020-01-01
4415,"SCHUYLER CARE AND REHABILITATION CENTER, LLC",285110,2023 COLFAX STREET,SCHUYLER,NE,68661,2017-06-20,205,B,1,0,KY7C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure the bed hold policy was provided to residents or resident representative prior to the resident leaving the building for therapeutic leave or hospitalization . This failure had the potential to effect three sampled residents (Residents 3, 5, and 6). The facility census was 31 at the time of survey. Findings are [NAME] A review of the Census Tab in Resident 3's medical record, printed on 6/20/17, revealed the resident had one Therapeutic Leave and three Hospital Leaves from the facility from 10/29/16 thru 5/26/17. Further review of Resident 3's record revealed no documented evidence indicating the resident received information related to the facility's Bed Hold Policy, at the time of admission or with any of the resident's temporary leaves from the facility. An interview on 6/20/17 at 9:20 AM with the Social Services Director (SSD) revealed the facility's bed hold policy is gone over and signed upon admission, notification is not given at the time of hospitalization or other forms of tempore leaves from the facility. The SSD reported inability to locate a Bed Hold Policy and Notification form for Resident 3. B. An interview on 6/15/17 at 5:30 AM with Registered Nurse (RN)-A, revealed Resident 5 was out of the building on Bed Hold status related to being hosptalized on [DATE]. Review of an Investigation Report dated 6/18/17, revealed Resident 5 fell in the resident's room on 6/13/17. The fall caused the resident to be hospitalized and placed on Bed Hold status at the facility. A review of Resident 5's records revealed an undated BED HOLD POLICY AND NOTIFICATION form containing the resident's signature. Review of the Facility's form, revised 3/25/16, revealed each resident/legal representative will be informed 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. Resident 5's record did not contain evidence indicating the Bed Hold Policy was reviewed with the resident prior to being sent to the hospital on [DATE]. An interview on 6/20/17 at 9:20 AM with the SSD, confirmed the facility's bed hold policy was not reviewed with Resident 5 prior to the resident's hospitalization . C. An interview on 6/15/17 at 5:30 AM with RN-A revealed Resident 6 was out of the building on bed hold status following hospitalization on [DATE]. A review of physician's orders [REDACTED]. A review of MDS (a mandatory comprehensive assessment tool used for care planning) information for Resident 6 revealed assessments were in place for Entry into the facility, dated 2/10/17; and an assessment for Discharge with return anticipated, dated 6/10/17. A review of Resident 6's records revealed a BED HOLD POLICY AND NOTIFICATION form dated 2/10/17, which contained the signature of the Resident Representative. Further review of the Facility's form, revised 3/25/16, revealed each resident/legal representative will be informed 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. Resident 6's record did not contain evidence indicating the Bed Hold Policy was reviewed with the Resident's Representative prior to or with notification of the resident's hospitalization on [DATE]. An interview on 6/20/17 at 9:20 AM with the SSD, confirmed the facility's bed hold policy was not reviewed with Resident 6's Representative prior to or with notification of the resident's hospitalization .",2020-07-01
1764,PLUM CREEK CARE CENTER,285159,1505 NORTH ADAMS STREET,LEXINGTON,NE,68850,2018-05-02,578,D,1,0,GG8Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure the wishes for CPR (Cardiopulmonary Resuscitation) for 2 (Residents 1 and 6) out of 5 sampled residents were communicated to the nursing staff. The facility census was 36. Findings are: [NAME] Review of the nursing progress notes identified that Resident 1 was admitted to the facility for skilled care services on [DATE]. Interview on [DATE] at 1:10 PM with the MDS (Minimal Data Set) Coordinator revealed that they were unable to locate the advanced directive in the resident's medical record. Interview on [DATE] at 3:00 PM with LPN (Licensed Practical Nurse)-A revealed that Resident 1 had fallen in their room on [DATE] and became combative. LPN-A stated that the physician wanted the resident to be transferred to the hospital. LPN-A stated that there was no advanced directive in their medical record, so LPN-A had to call the resident's spouse to find out what the resident's wishes were in case something would happen to the resident. After the call, LPN-A stated that they went to the resident's room and resident became unresponsive, so LPN-A started CPR per the spouse's wishes. When the paramedics arrived, they continued the CPR on the resident during the transfer to the hospital. Resident passed away later that night. Interview on [DATE] at 3:00 PM revealed that the ADM (Administrator) had found the advanced directive for Resident 1. The form revealed that the resident had marked DNR (Do Not Resuscitate) on the form on [DATE]. The form was sent to the primary care physician who had signed the form on [DATE] and returned it to the facility. The ADM confirmed that there was no copy of the advanced directive in the resident's chart at the time of the incident on [DATE]. B. Review of the facility's list of new admissions for the past 3 months identified that Resident 6 was admitted to the facility on [DATE] and discharged on [DATE]. Interview on [DATE] at 1:10 PM with the MDS Coordinator revealed that the facility did not have a copy of the resident's advance directive in the resident's medical record. MDS Coordinator stated that usually if the primary care physician is in town, then the facility hand delivered the advance directive for their signature. If the physician was out of town, then the form is faxed to the physician for the signature. However, the MDS Coordinator stated that they had no copy of Resident 6's advance directive wishes. Interview on [DATE] at 3:00 PM with the ADM confirmed that the facility did not have a copy of the advance directive for Resident 6.",2020-09-01
5581,"BROKEN BOW CARE AND REHABILITATION CENTER, LLC",285120,224 EAST SOUTH E STREET,BROKEN BOW,NE,68822,2018-05-17,645,D,1,1,1IGA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to have 1 resident (Resident 23) referred for a level 2 PASARR (Preadmission Screening and Resident Review) evaluation and determination prior to admission or within 30 days after admission based off of the resident's current medical [DIAGNOSES REDACTED]. The sample of residents used was 2. The facility census was 30. Findings are: [NAME] Review of Resident 23's undated Face Sheet revealed date of admission 3-22-18. The Face Sheet revealed [DIAGNOSES REDACTED]. Review of Resident 23's PASARR dated 4-7-14 revealed the resident had no serious MI (mental illness) or ID (intellectual disability). The resident did have anxiety and was on the medication [MEDICATION NAME] (an antianxiety medication). The PASARR revealed the resident did not need a level 2. Interview on 5-16-18 at 8:54 AM with the SSD (Social Service Director) revealed the resident transferred to their facility on 3-22-18 from another facility Alzheimer's unit. The SSD reviewed the resident's current medical diagnoses, medications, and behaviors and confirmed the resident should have had a review for a potential level 2 services. B. Review of Resident 21's undated Face Sheet revealed date of admission 1-17-18. The Face Sheet revealed [DIAGNOSES REDACTED]. Review on 5-15-18 at 9:04 AM of Resident 21's PASARR dated 1-17-18 revealed the resident was to be evaluated for a level 2 PASARR, however the level 2 PASARR was not in the medical record. Interview on 5-15-18 at 10:51 AM with SSD revealed the PASARR for Resident 21 was done but probably did not get filed in the chart. Interview on 5-15-18 at 2:57 PM with the SSD confirmed the facility did not have the level 2 results for Resident 21 and the SSD had to contact the State Designated Authority to obtain it. The SSD revealed the SSD called the State Designated Authority to confirm the results documented on the form which read the level 2 was halted and meant Resident 21 did not qualify for level 2 services so the evaluation was stopped back in (MONTH) (YEAR). The SSD confirmed the facility had not been aware of the PASARR results until today, 5-15-18. Review of the level 2 determination and evaluation on the PASARR for Resident 21 revealed halted and had a fax stamp dated 5-15-18 at 11:35 AM on the form.",2019-11-01
3954,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,838,E,1,1,OLWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to have an accurate facility assessment to care for the residents with pressure ulcers as competencies were not completed for licensed nursing staff showing the licensed nursing staff were competent to provide care and treatment for [REDACTED]. Findings are: Review of the Facility Assessment Tool completed by the ADM (Administrator) identified that the facility could provide care and treatment for [REDACTED]. Review of the facility's education and in service books identified that there were no competencies completed for the licensed nursing staff that were providing the care and treatment for [REDACTED]. The only competency that was found for pressure ulcer care was for a registered nurse in 2006. Interview on 3/20/18 at 8:24 AM with the DON (Director of Nursing) confirmed that any competencies for the licensed nursing staff would be in the education binder. The DON further stated that the DON was not aware that any of the licensed nursing staff had been competency trained on the care and treatment for [REDACTED]. Interview on 3/20/18 at 5:01 PM with the ADM (Administrator) confirmed that the Facility Assessment Tool identified that the facility would be able to care and treat residents with pressure ulcers. The ADM also confirmed that the facility did not have completed competencies documented for the licensed nursing staff to care and treat residents with pressure ulcers.",2020-09-01
3719,GOOD SAMARITAN SOCIETY - GRAND ISLAND VILLAGE,285285,4061 TIMBERLINE STREET & 4055 TIMBERLINE STREET,GRAND ISLAND,NE,68803,2019-02-19,646,D,1,0,XNDC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to notify the Physician of one resident (Resident 100) out of one resident sampled, change of condition. The facility census was 61. Findings are: Record review of Resident 100's Admission Record dated 2-14-19 revealed [DIAGNOSES REDACTED]. Review of Resident 100's MDS dated [DATE] revealed a BIMS of 14 which indicated the resident had no cognitive impairment. The resident required limited assistance of one staff with bed mobility, transfers, walking, locomotion, and toileting. Record review of Resident 100's PN dated 1-23-19 at 1:53 AM revealed the resident ambulated with the walker and the walker started to collapse. The resident used the resident's right hand to attempt to prevent a fall. The nurse assessed the resident and discovered the right ring finger had a slight amount of bleeding and the right middle finger had some swelling. The fingers were cleansed and wrapped with gauze and coban. The resident was assisted back into bed. The resident was adamant with refusal to go do the ER (emergency room ) to have the fingers examined during the night. PN on 1-23-19 at 7:43 AM revealed the resident's right hand was assessed and the middle finger appeared rotated at a 30-45 degree angle and bent away from body. The nurse called the on-call Physician and orders were received to send the resident to the ER to be evaluated. Record review of the Incident Report for Resident 100 dated 1-23-19 revealed the third finger assessed to be limp and possibly broken. Report was given to the oncoming shift to follow-up on the injury. Review of the Incident Report revealed absence of documentation of the Physician notified of the resident change of condition based on the nurse assessment on 1-23-19 at 1:53 AM. Review of the Hospital Physician order [REDACTED]. Interview on 2-19-19 at 3:30 PM with the DON (Director of Nursing) confirmed the Physician should have been notified 1-23-19 immediately after the night nurse assessed Resident 100's right hand fingers at 1:53 AM and the assessment revealed suspected fracture, even though the resident had refused to seek treatment during the middle of the night.",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
3839,OLD MILL REHABILITATION (OMAHA TCU),285289,1131 PAPILLION PARKWAY,OMAHA,NE,68154,2018-05-07,625,D,1,0,PUW011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide bed hold policy to 1 (Resident 1) of 1 sampled residents on transfer to the hospital. The facility had a total census of 41 residents. Findings are: Resident 1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Progress note dated 2/12/18 at 10:03 PM reported that Resident 1 was voiding small amount with complaint of burning and pain in kidney and bladder and Resident 1 was being transported to the hospital for evaluation. Progress note dated 2/13/18 at 7:58 AM noted that Resident 1 was admitted to the hospital and was not discharging for a while. In an interview on 5/7/18 at 8:19 AM, Social Worker G reported families are contacted when a residents is sent to the hospital. If a resident is not expected back to the facility in a couple of days, the family is asked if they can pick up the resident's personal items or if they want the facility to pack them up. Families are requested to pick up the resident's personal items in a couple of days. In an interview on 5/10/18 at 8:45 AM, the Administrator reported that residents are given information on the bed hold policy on admission. No information is given at the time that a resident is sent to the hospital regarding bed hold. A review of Admission Packet revised 1/2018 revealed the following bed hold policy: If a patient requires a hospital stay overnight, we do not hold any beds at Old Mill Rehabilitation. A new referral will need to be sent to our facility for review to see if we can meet the patient's needs. If we hold or reserve a vacant bed for you at your request and the charges for the bed are not paid by insurance or any third-party payor, you are responsible for paying our daily charges for the bed for each day we hold or reserve the bed for you. This will need to be approved and arranged with our facility administrator.",2020-09-01
3945,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,726,F,1,1,OLWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide competencies for the nursing staff to care for the residents with pressure ulcers. This affected 4 sampled residents with pressure ulcers and the facility census was 34. Review of the Facility Assessment Tool completed by the ADM (Administrator) identified that the facility could provide care and treatment for [REDACTED]. Review of the facility's education and in service books identified that there were no competencies completed for the licensed nursing staff that were providing the care and treatment for [REDACTED]. The only competency that was found for pressure ulcer care was for a registered nurse in 2006. Interview on 3/20/18 at 8:24 AM with the DON (Director of Nursing) confirmed that any competencies for the licensed nursing staff would be in the education binder. The DON further stated that she was not aware that any of the licensed nursing staff had been competency trained on the care and treatment for [REDACTED].",2020-09-01
5580,"BROKEN BOW CARE AND REHABILITATION CENTER, LLC",285120,224 EAST SOUTH E STREET,BROKEN BOW,NE,68822,2018-05-17,644,D,1,1,1IGA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to reflect 1 resident's (Resident 26) level 2 PASARR (Preadmission Screening and Resident Review) status on the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) out of 1 resident sampled. The facility census was 30. Findings are: Review of Resident 26's Face Sheet dated 2-13-18 revealed the resident's date of admission 10-13-17. The Face Sheet revealed the resident's [DIAGNOSES REDACTED]. Review of Resident 26's admission MDS dated [DATE] revealed the resident did not have a level 2 PASARR. Review of the Resident 26's admission PASARR dated 10-13-17 revealed a level 2 with the final determination results of the resident met the minimum criteria for nursing home admission and required the following services: ongoing medication review by a psychiatrist, ongoing med review by a medical doctor, and therapy by an OT/PT (Occupational Therapist/Physical Therapist). Interview on 5-16-18 at 8:08 AM with the SSD (Social Service Director) confirmed the resident had a level 2 PASARR and the admission MDS did not reflect the resident's current PASARR status and another MDS had not been done to update it.",2019-11-01
1348,HILLCREST HEALTH & REHAB,285133,1702 HILLCREST DRIVE,BELLEVUE,NE,68005,2017-08-02,225,D,1,0,YKIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report a significant injury for Resident 3 to the state agency within the regulatory timeframe and failed to submit a completed investigation for Resident 2 to the state agency within 5 days. The facility census was 110 . Findings are: [NAME] Review of the facility report dated 5/5/2017 for Resident 3 revealed Resident 3 sustained a fall and was sent to the hospital emergency room . Resident 3 returned to the facility at 11:55 PM on 4/29/2017 with a [DIAGNOSES REDACTED]. Review of the facility report revealed a call was placed to the state agency at 2:00 PM on 4/30/2017. Review of the facility undated policy titled Reporting Allegations of Abuse/Neglect/Exploitation revealed the facility was to notify the appropriate agencies immediately: In the case of serious bodily injury, no later than 2 hours after discovery. Interview on 5/17/2017 at 11:30 AM with the Director of Nursing (DON ) revealed the incident with injury was not reported to the state agency within 2 hours. B. Review of the facility report dated 4/30/2017 for Resident 2 revealed Resident 2 sustained a head injury and was admitted to the hospital on [DATE]. Review of the facility report revealed a facsimile (fax) report dated 4/30/2017 at 3:13 PM with a result of NO ANS (Answer). Interview on 5/17/2017 at 11:20 AM with the DON revealed the report should have been resubmitted to the state agency due to the initial report not arriving. The DON stated no other confirmation reports could be found. Review of the undated facility policy titled Reporting Allegations of Abuse/Neglect/Exploitation revealed the facility should follow up with government agency to confirm the report was received and to report the results of the investigation when a final report as required by the state agency.",2020-09-01
2286,GOOD SAMARITAN SOCIETY - OSCEOLA,285193,600 CENTER DRIVE,OSCEOLA,NE,68651,2017-08-03,225,D,1,1,X4SG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report allegations of abuse. This had the potential to effect 2 of 3 residents sampled, Residents 27 and 25. Investigation: [NAME] Record review of a grievance dated 7/11/17 revealed that Resident 27 alleged that NA (Nursing Assistant) A was rough tossing things all over the place and left resident on the toilet for over 30 minutes. Record review of the MDS (Minimum Data Set, a tool for implementing standardized assessment and for facilitating care management in nursing homes) dated 6/21/17 revealed a BMS (Brief Interview for Mental Status, the level of cognitive ability among nursing home residents) of 10 (08-12 indicates moderately impaired). On 08/03/2017 at 1:06 PM, an interview with the DON (Director of Nursing) revealed, this was not reported to the state authority because, on re-interview, the resident denied the staff did anything wrong. Record review of reportable incidents provided by the facility revealed no documentation of this allegation of abuse being reported to the state authority. B. Record review of a grievance dated 9/21/16 revealed that on 9/19/16 Resident 25 alleged that gender got slapped, while rubbing left cheek. Record review of a grievance dated 9/22/16 revealed that on 9/17/16 Resident 25 alleged that a girl slapped me, while putting gender's hand to left cheek. Record review of the MDS dated [DATE] revealed a BIMs of 4 (00-07 indicates severe impairment). On 08/03/2017 at 1:10 PM, an interview with the DON reveled that, on re-interview, the resident's story kept changing and no determination could be made so this allegation of abuse was not reported to the state authority. Record review of investigation of the allegation of abuse revealed that upon receiving the allegation, all female Hispanic aides had been suspended pending investigation. An investigation was completed with no findings of abuse. Further review revealed there was no documentation that this allegation of abuse was reported to the state authority. C. Record review of the facility Abuse and neglect policy dated 2/2013 revealed, alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse will be reported immediately to the administrator and to other officials in accordance with state law.",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
2684,HERITAGE OF EMERSON,285222,607 NEBRASKA STREET,EMERSON,NE,68733,2018-12-03,610,D,1,0,BWYO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to submit an investigation to the State Agency within 5 working days after 1 resident (Resident 50) had a fall with injury requiring medical treatment. The sample size was 4 and the facility census was 31. Findings are: [NAME] Review of the facility policy titled Abuse and Neglect Prevention Standard (revision date 3/2017) included the following: -Any accident that resulted in serious resident injury should be reviewed for potential abuse/neglect and also must be reported to the proper agency; and -After conducting an internal investigation, a report of all investigation results must be reported to the state within five working days. B. Review of Progress Notes dated 11/11/18 at 7:20 AM revealed Resident 50 was observed sitting on the floor in front of the room door and bathroom. The resident sustained [REDACTED]. Documentation further indicated the laceration was 6 centimeters in length and required staples. The resident was to remain overnight at the hospital for observation. Review of facility investigations of potential abuse/neglect for 11/2018 revealed an investigation was not submitted to the State Agency regarding Resident 50's fall with injury on 11/11/18. Interview with the Administrator on 12/3/18 at 11:35 AM confirmed an investigation regarding Resident 50's fall with injury was not submitted to the State Agency as required.",2020-09-01
4934,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2018-06-12,758,D,1,1,ELDP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to: 1) ensure there was an indication for the use of PRN (as needed) [MEDICATION NAME] (an antipsychotic drug used to alter certain chemicals in the brain to effect changes in behavior, mood and emotions); and 2) ensure PRN [MEDICATION NAME] was not prescribed for more than 14 days without an evaluation by the Healthcare Practitioner (HCP) and without a new written order for the PRN [MEDICATION NAME]. This involved 1 resident (Resident 1). The sample size was 22 and the facility census was 39. Findings are: Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/7/18 revealed [DIAGNOSES REDACTED]. The MDS further indicated the following regarding Resident 1: -short term and long term memory problems; -displayed no adverse behavioral symptoms; -received antipsychotic medication daily in the past 7 days; and -received 1 antianxiety medication and 1 opioid (a drug derived from [MEDICATION NAME] and used to alleviate pain) medication in the past 7 days. Review of Resident 1's Medication Administration Record [REDACTED]. Review of Progress Notes dated 5/27/18 at 2:31 PM revealed Resident 1 had slept very little through the night and during the day hours. The resident .appears anxious at times pacing and wandering. Staff have attempted one on one, change in location/environment, snacks and coloring. Documentation further indicated the resident was currently socializing with staff and cueing was provided to assist the resident to participate in an activity. The resident was redirected early that morning from entering other resident rooms. Review of Progress Notes dated 5/27/18 at 5:10 PM revealed Resident 1 .is wandering and restless and has been confrontational with staff and other residents today was reported by the dayshift staff. Documentation indicated the resident had several instances in the last 30 days of being aggressive and agitated with staff and .Staff has offered many interventions daily and PRN medications for anxiety and pain with little or no improvement. Documentation further indicated the .on call provider would be contacted for .direction with resident concerning increased agitation, behaviors and lack of sleep. Review of Progress Notes dated 5/27/18 at 5:23 PM revealed the on call provider (not the resident's psychiatric Health Care Practitioner) was contacted and an order was received for Resident 1 to receive 10 mg of [MEDICATION NAME] (an antipsychotic medication) by intramuscular injection (IM) every 4 hours PRN for aggression, agitation, restlessness, and other behaviors. Documentation further indicated the resident was wandering from the living area, dining room area and stopped occasionally at the door while sometimes carrying a duffle bag. Review of Resident 1's MAR indicated [REDACTED]. Review of Resident 1's Progress Notes dated 6/5/18 at 9:32 PM revealed the resident was evaluated by the psychiatric Health Care Practitioner (HCP) that day and there were no new orders. Review of the Geriatric Psych (psychiatric) Form (a progress report by the psychiatric HCP) dated 6/5/18 revealed no evidence the psychiatric HCP was aware Resident 1 had received PRN [MEDICATION NAME] on 5/27/18. No orders were given for a new prescription for PRN [MEDICATION NAME]. Review of Resident 1's MAR indicated [REDACTED]. Review of Resident 1's Progress Notes dated 6/8/18 at 10:36 PM documented the .Resident was wandering into rooms behind staff and was reluctant to take direction. The resident was seen in the nurses' station unattended and was then taken to the resident's room to prepare for bed. The resident was given an injection for restlessness and agitation. Review of Resident 1's MAR indicated [REDACTED]. There was no evidence the HCP evaluated the resident or the need for the PRN [MEDICATION NAME]. A new prescription for PRN [MEDICATION NAME] was not obtained. Interview with the Director of Nurses on 6/12/18 at 9:00 AM confirmed Resident 1 received PRN [MEDICATION NAME] on 2 occasions and the order for the PRN [MEDICATION NAME] had not been re-evaluated by the HCP.",2020-03-01
6616,OMAHA NURSING AND REHABILITATION CENTER,285240,4835 SOUTH 49TH STREET,OMAHA,NE,68117,2015-12-07,309,D,1,0,JX0E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview; the facility staff failed to evaluate respiratory status for 1 resident (Resident 1). The facility staff identified a census of 60. Findings are: Record review of an Admission Record sheet printed on 12-07-2015 revealed Resident 1 was admitted to the facility with the [DIAGNOSES REDACTED]. Record review of an Order Summary Report sheet printed on 12-07-2015 revealed Resident 1 was to have nothing by mouth (NPO). Record review of a Fax sheet noted on 9-02-2015 revealed the facility staff had notified Resident 1's physician that Resident 1 was observed drinking water and reported did not know (gender) was NPO. According to the information on the fax sheet, Resident 1 reported eating and drinking when goes out with a family member. Resident 1's physician gave an order to . try thicken liquids PO (by mouth). Record review of Resident 1's medical record revealed there was not an ongoing evaluation of Resident 1's respiratory status for the trail of the thicken liquids. An interview was conducted with the facility Director of Nursing (DON). During the interview review of the Fax sheet notes on 9-02-2015 was reviewed. When asked how often Resident 1's respiratory status should be evaluated, the DON reported every shift. The DON confirmed during the interview Resident 1's respiratory status had not been monitored every shift and should have been.",2018-12-01
5938,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2016-07-26,225,D,1,0,10VG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to complete an investigation to determine the causal factors of an injury of unknown origin for Residents 1 and Resident 3. The facility census was 163. Findings are: A. Review of Resident 1's Care plan dated 7/8/2016 revealed Resident 1 has a [DIAGNOSES REDACTED]. Review of the Nurses Notes dated 7/4/2016 for Resident 1 revealed Resident 1 complained of pain in the left leg with no traumatic event identified. Review of the Nurses Notes dated 7/6/2016 revealed Resident 1 was admitted to the hospital with [REDACTED]. Review of the facility investigation revealed Resident 1 had not experienced a recent fall and Resident 1 could not explain how the injury occurred. The facility did not interview the staff working with Resident 1 from other shifts except the shift the pain was found on. Interview on 7/25/2016 at 3:55 PM with the Director of Nursing (DON) revealed that the only staff that were interviewed were the staff that was working at the time the injury was found. No interviews were done with the staff assigned to Resident 1 on prior shifts to determine how the injury occurred. Interview on 7/25/2016 at 4:00 PM with the DON revealed the investigation should have included the staff from the previous shift and the health care practitioner to attempt to determine the causal factors of the injury. B. Record review of a Incident/Accident Report sheet dated 4-11-2016 revealed Resident 3 was evaluated as having a bruise to the right inner leg. Record review of a Resident's Statement sheet dated 4-11-2016 revealed the resident did not know how the bruise happened. Record review of a Injuries of Unknown Source Investigation sheet dated 4-11-2016 revealed the bruise to the right inner thigh measured 14 centimeters (cm) by 5 cm and purple in color. Record review of Resident 3's medical record revealed there was not evidence that the facility staff had conducted interviews with facility staff on prior shifts in an attempt to determine when and how the bruise occurred. An interview was conducted with the DON on 7-25-2016 at 3:42 PM. During the interview, the DON confirmed that staff on other shifts had not been interviewed. The DON confirmed during the interview the investigation into the injury of unknown source was not completed.",2019-07-01
1381,LIFE CARE CENTER OF ELKHORN,285134,20275 HOPPER STREET,ELKHORN,NE,68022,2018-02-27,758,D,1,1,YXZR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to complete behavior monitoring for continued use of [MEDICAL CONDITION] medications for 2 residents (Residents 4 and 82) of 5 residents sampled. The facility staff identified the census at 101. The findings are: [NAME] A review of Resident 4's undated Face Sheet revealed that the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Resident 4's Medication Administration Record [REDACTED]. The resident received the medication on 2-18-18. A review of Resident 4's MAR for (MONTH) (YEAR) revealed the resident received [MEDICATION NAME] (an anti-anxiety medication) on an as needed basis for anxiety. The resident received the medication on 1-1-18, 1-11-18, 1-12-18, 1-15-18, 1-19-18, 1-24-18, 1-26-18, and 1-27-18. A review of Resident 4's Behavior/Intervention Monthly Flow Record for (MONTH) (YEAR) revealed the resident was documented as having no behavior episodes the entire month. A review of Resident 4's Behavior/Intervention Monthly Flow Record for (MONTH) (YEAR) revealed the resident's behaviors were no longer documented after 2-8-18. An interview conducted on 2-22-18 at 1:25 PM with Medication Assistant (MA) [NAME] revealed that the process for giving an as needed anti-anxiety medication was that the MA would notify the charge nurse that the resident had requested a medication or that the resident was having behaviors and the non-pharmacological interventions were not effective. The medication would be given by the MA at the direction of the charge nurse. The MA would document on the MAR indicated [REDACTED]. The charge nurse would document on the Behavior/Intervention Monthly Flow Record for that shift what the behaviors were and what was done for the resident to alleviate the behaviors. B. Record review of a Policy and Procedure for Psychopharmacological (medications used to manage behaviors) Medications dated 8/23/17 revealed the following: - That each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: without adequate monitoring. - The facility would establish an ongoing process of assessing the resident's behavior indicators, monitoring for adverse consequences, response and efficacy of psychopharmacological medications. - Accurate and thorough assessment of the resident's behavior indicators are fundamental in determining the appropriate utilization of psychopharmacological medications. - Documentation will be noted in the resident's medical record and will include but not be limited to: type of behaviors, new or worsening behaviors, times observed and frequency, interventions provided and resident's response to intervention. Record review of Resident 82's Comprehensive Care Plan (CCP) dated 1/27/18 identified that Resident 82 used [MEDICAL CONDITION] medication (medications used to manage behaviors), an antidepressant and an anti-anxiety medication related to [DIAGNOSES REDACTED]. Resident 82's behavior care plan identified the following behavior problems: physically abusive, socially inappropriate, and sexually inappropriate and resists cares. Target behaviors were identified as: restless, combative, socially inappropriate and sexually inappropriate. Interventions included: Observe behavior episodes, attempt to determine underlying cause and monitor for effectiveness of [MEDICAL CONDITION] drugs. Record review of Resident 82's Physician orders [REDACTED]. Record review of Resident 82's Behavior Intervention Monthly Flow Records dated (MONTH) and (MONTH) (YEAR) revealed target behaviors of combative and fidgety. The Behavior Flow Records did not identify any other target behaviors as were identified in Resident 82's CCP. Review of the (MONTH) and (MONTH) Behavior Flow Records for Resident 82 revealed that behavior monitoring was documented sporadically throughout the month. There were many blank spots on the flow record. Interview on 2/27/18 at 9:48 AM with the Director of Nursing (DON) confirmed that Resident 82's Behavior /Intervention Monthly Flow Sheets were not filled out correctly and there was only sporadic documentation of the monitoring of Resident 82's behaviors. The DON confirmed that not all of Resident 82's target behaviors had been identified on the monthly flow records.",2020-09-01
3844,OLD MILL REHABILITATION (OMAHA TCU),285289,1131 PAPILLION PARKWAY,OMAHA,NE,68154,2017-07-20,225,E,1,1,ZXDC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to ensure all significant injuries and allegations of abuse were reported to the State Agency and investigated for 4 residents. (Residents 93, 240, 250). The facility census was 43. [NAME] Review of the facility abuse reporting policy includes material dated 8/20/2012 indicating an injury that is significant for the resident requires reporting to the state agency. Review of Resident 93's progress notes revealed Resident 93 fell on [DATE] and received a laceration requiring 7 staples in the emergency room . Review of Resident 93's progress notes on 7/16/2017 revealed Resident 93 required Extensive assist of 1 staff to ambulate to the bathroom. Review of Resident 93's progress notes dated 2/17/2017 at 2:00 AM revealed resident 93 had a change of ADL status and required Extensive assist of 2 staff to ambulate to the bathroom. Interview on 07/19/2017 at 10:27 AM with the Administrator and Director of Nursing (DON) revealed the significant injury on[NAME]O'Hara was not called to the state agency. B. Review of the facility policy titled Reporting Abuse to the Facility Management dated (MONTH) 2009 revealed verbal abuse is defined as any use of oral language that willfully includes disparaging and derogatory terms to residents or their families. Record review revealed on 6/21/2017 Resident 250 filed a concern form with the Social Worker stating a staff member was rude, derogatory and mocking Resident 250. Interview on 7/19/2017 at 10:30 AM with the DON revealed Resident 250's concern was not identified as abuse or called into the state agency as an allegation of abuse. Interview on 7/19/2017 at 10:35 AM with the Administrator revealed the staff member was not suspended and a thorough investigation was not completed. C. Review of the facility policy titled Reporting Abuse to Facility Management dated (MONTH) 2009 revealed mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Record review revealed on 6/23/2017 the facility received a letter from Resident 240's family in which they alleged a staff member was confrontational regarding why the family and resident would not allow a male caregiver and that since Resident 240 had made that decision Resident 240 would have to wait for assistance with toileting or let the male caregiver assist. The family stated this was inappropriate. Interview on 7/19/2017 at 10:31 AM with the DON and the Administrator revealed this was not identified as abuse and was not called to the state agency.",2020-09-01
1100,EMERALD NURSING & REHAB LAKEVIEW,285106,1405 WEST HWY 34,GRAND ISLAND,NE,68801,2019-05-29,625,D,1,0,X6N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to notify the residents' legal representative of the bed hold policy for transfer to the hospital for 1 of 4 sampled residents (Resident 4). The facility census was 69. Findings Are: Review of Resident 4's Admission status revealed an admission date of [DATE] Review of Resident 4's medical [DIAGNOSES REDACTED]. Review of MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 3/6/19 revealed for Section C: Cognitive Patterns C0100 Should Brief Interview for Mental Status be conducted the answer was coded as No (Resident is rarely/never understood) C1000. Cognitive Skills for Daily Decision Making was coded as 3. Severely impaired. Review of MDS dated [DATE] a Significant Change in status MDS revealed for Section C: Cognitive Patterns C0100 Should Brief Interview for Mental Status be conducted the answer was coded as No (Resident is rarely/never understood) C1000. Cognitive Skills for Daily Decision Making was coded as 3. Severely impaired. Review of Resident 4's bed hold letter revealed that resident's name was signed on form dated 2/4/19 and then again on 5/9/19. Both letters are written with Residents name present and the Facility representative Signature. There is no documentation that the POA (Power of Attorney) was informed of the bed hold notification or who the copy of the notification letter was sent to. Review of Resident 4's Progress Notes revealed no documentation that a copy of the Bed Hold Policy had been sent to Resident 4's legal representative. Interview on 5/29/19 at 11:44 AM with DON (Director of Nursing) revealed, there is a bed hold letter sent with the resident to the hospital and copies are kept, along with the Ombudsman monthly notifications in a calendar book. Interview on 5/29/19 at 11:55 AM with ADM (Administrator) revealed that the POA (Power of Attorney) or legal representative has never been notified in writing that someone has gone to the hospital and what the rate of private pay will be. We complete the bed hold letter and send it to the hospital with the resident. We make a copy and place it in the bed hold book. Review of the Bed Hold Policy dated 05-17 revealed: The Policy: PR[NAME]EDURE FOR BED HOLD NOTIFICATION PURPOSE: The facility shall inform and provide in writing to the resident and/or the resident's representative the facility's bed hold and return to the facility policy at the time of transfer or leave of absence specifying the duration of the bed hold policy. PR[NAME]EDURE 1. The nurse will obtain the Bed Hold Policy and Return to Facility notice and provide the notice to the resident and their representative at the time of transfer or leave of absence. 2. The nurse will ensure that a copy of the notice accompanies the resident as the resident leaves the facility. 3. The nurse will inform the resident representative, on the telephone if necessary about the bed hold and return to facility policy and ask how best to provide a copy of the notice to the representative. a. The nurse will inform the representative that the notice accompanied the resident at the time the resident left the facility. b. The nurse will document the provision of the Bed Hold Policy and Return to Facility notice to the resident and information given to the representative in the resident's record.",2020-09-01
3919,HILLCREST COUNTRY ESTATES-COTTAGES,285293,6082 GRAND LODGE AVENUE,PAPILLION,NE,68133,2017-05-04,428,E,1,1,POAF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, and interview the pharmacy failed to identify irregularities of medication and notify the facility staff and physician of irregularities for 3 residents (55, 27, and 29) of 5 sampled. The facility census was 46. Findings are: [NAME] Record review of Resident 55's electronic medical record revealed that Resident 55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of Activities of Daily Living (ADL's), on 5/3/17 at 11:44 AM revealed that Resident 55 had multiple prescription creams present in the room for use. Record review of Resident 55's physician orders [REDACTED]. 1) Desoximetasone 0.25% apply topically two times daily as needed for rash . 2) Hydrocortisone 2.5% apply topically to back, as needed for itching.3) Mometasone Furoate 0.1% apply topically to affected areas daily as needed. 4) Triamcinolone 0/1% ointment apply to affected area's 2 to 3 times daily as needed. 5) Risamine ointment apply to buttocks twice daily. Record review of Resident 55's Monthly Pharmacy review, dated 12/2/16, revealed a request for a clinical rationale for Desoximetasone 0.25% cream, Clobetasol Propionate cream, and Mometasone Furoate cream. Record review of Resident 55's Monthly Pharmacy reviews dated 1/6/17, 2/6/17, 3/3/17 and 4/3/17 reveal no follow up on the request for clinical rationale for the above listed creams. ` Interview with Resident 55's pharmacy revealed that all the creams were the same medication but in different strengths. The Pharmacist confirmed that Resident 55 did have unnecessary medications, evidenced by the multiple creams that provide the same treatment at different strengths. B. Record review of Resident 27's physician orders [REDACTED]. Record review of Resident 27's Medication Administration Records for January, February, March, (MONTH) and (MONTH) revealed that Resident 27 had not been administered the Fluconazole in the past 5 months. Record review of Resident 27's Weekly Skin Assessments for the past (MONTH) and (MONTH) revealed no areas of concern under breast, and the Nystatin powder continued to be applied every shift and was not discontinued. Record review Resident 27's Monthly Pharmacy Reviews revealed no irregularities noted. Interview with facility administrator on 5/4/17 17 at 2:09 PM confirmed that pharmacy had not alerted the facility to the medication irregularities for Resident 27. C. Record review of Resident 99's physician orders [REDACTED]. Miconazole Nitrate 2% cream (Miconazole is used to treat skin infections such as athlete's foot, jock itch, ringworm, and other fungal skin infections) , orders for Monostat cream (used to treat yeast infections) , and Clotrimazole (used to treat skin infections such as athlete's foot, jock itch, ringworm, and other fungal skin infections) . Record review of Resident 99's Medication Administration Records for January, February, March, (MONTH) and (MONTH) revealed that these medications have not been used in the past 5 months. Record review of Resident 99's weekly skin assessments for the months of March, (MONTH) and May, have no documentation of skin issues that would require this medication. Record review of Resident 99's Pharmacy reviews revealed no irregularities noted. Interview with facility administrator on 5/4/17 17 at 2:09 PM confirmed that pharmacy had not alerted the facility to the medication irregularities for Resident 27.",2020-09-01
5790,WAYNE COUNTRYVIEW CARE AND REHABILITATION,285135,811 EAST 14TH STREET,WAYNE,NE,68787,2016-09-14,309,D,1,0,IB0Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation and interview; the facility failed to develop interventions to prevent the reoccurrence of skin breakdown and to complete cares per practitioner's orders related to the application of ted hose (compression devices worn to assist with swelling) for Resident 4. In addition, the facility failed to provide assessment and cares to promote healing of a wound for Resident 1. The sample size was 5 and the facility census was 37. Licensure Reference Number: 175 NAC 12-006.09D2c Findings are: A. Review of facility Policy and Procedure entitled Skin and Wound Monitoring and Management Care Guidelines (revised 1/2016) revealed the following: -At the time of admission or readmission to the facility, a licensed nurse was to complete a comprehensive assessment to identify risk factors related to the potential development of skin breakdown. -A comprehensive plan of care should be developed using the assessment with individualized interventions developed to meet the resident's needs. -Wounds identified after admission should be assessed and evaluated on a weekly basis by a licensed nurse. -The assessment should include but not be limited to; measurement and a description of the wound location, the nature of the wound, characteristics of the wound and any signs and/or symptoms of infection or complications of the wound. Review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 6/28/16 revealed the resident required extensive staff assistance with transfers, personal hygiene, bed mobility and toileting. The assessment further revealed the resident had [DIAGNOSES REDACTED]. The resident was identified as having Moisture Associated Skin Damage (MASD- the general term to describe inflammation, or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat or wound drainage) with interventions for a pressure reduction device to the resident's chair and bed. Review of Resident 1's current Care Plan dated 1/7/16 revealed the resident was at risk for impaired skin integrity related to history of fragile skin, [MEDICAL CONDITION] (infection of the skin) and [MEDICAL CONDITION] (swelling). The following interventions were identified: -Monitor and document the location, size and treatment of [REDACTED]. -Educate resident and family of causative factors and interventions to prevent skin injury. -Report abnormalities, failure to heal, signs of infection or maceration to the physician. Review of Resident 1's Treatment Administration Record (TAR) revealed an order dated 4/19/16 for [MEDICATION NAME] dressing (absorbent, semi-permeable and waterproof dressing used for treatment of [REDACTED]. Review of Weekly Skin Assessment and Evaluation of the MASD to Resident 1's coccyx revealed the following: -4/19/16 Slough (stringy mass that may or may not be attached to surrounding tissue. Slough can range in color and thickness) noted to the wound bed and area measured 0.7 centimeters (cm) by 0.5 cm. -4/26/16 Area was covered with a [MEDICATION NAME] dressing. Measurements were unchanged. -5/3/16 Area measured 0.8 cm by 0.4 cm by 0.1 cm. Review of Resident 1's medical record revealed no evidence the resident's physician was notified the resident's wound had increased in size or that any new interventions were developed to prevent further decline of the wound. Review of Weekly Skin Assessment and Evaluation of the MASD to Resident 1's coccyx revealed the following: -5/17/16 Dressing in place to the wound and staff continued to monitor. (No measurement of the wound was documented with the assessment). -5/24/16 Wound now measured 0.9 cm by 0.4 cm by 0.1 cm. -5/31/16 Assessment and measurement of the wound was unchanged. -6/14/16 Assessment revealed no change in the size, shape or measurement of the wound. Review of Resident 1's medical record revealed no evidence the resident's physician was notified when the resident's wound had increased in size on 5/24/16 or that any new interventions were developed to promote healing of the resident's wound. Review of Weekly Skin Assessment and Evaluation of the MASD to Resident 1's coccyx revealed the following: -6/28/16 Area measured 0.6 cm by 0.4 cm by 0.2 cm. No further assessment was documented. -7/13/16 Assessment revealed the area remained unchanged in size and depth. -7/26/16 Area measured 0.3 cm by 0.1 cm. No further assessment was documented. Weekly Skin Assessments were completed of the MASD to the resident's coccyx on 8/2/16 and on 8/9/16. The assessments indicated the area remained unchanged. No measurements were documented with the assessments and the assessments did not identify any characteristics of the resident's wound or if the wound had any signs of infection. Review of Resident 1's medical record revealed no further assessments of the MASD to the resident's coccyx. During an observation on 9/13/16 from 10:33 AM to 10:55 AM, Nursing Assistant (NA-H) provided Resident 1 with perineal hygiene. A [MEDICATION NAME] dressing was observed to cover the resident's coccyx area. During an interview on 9/13/16 from 12:55 PM to 1:15 PM, NA-H indicated the resident had a sore to the coccyx area and the area was to be covered with a dressing at all times to protect it. NA-H was unaware of what the wound looked like as staff had never seen the area without a dressing. During an interview on 9/14/16 from 2:00 PM to 2:15 PM, the Administrator verified the resident's physician should have been notified for a potential change in treatment when the resident's wound increased in size. The Administrator further identified a licensed nurse should have assessed the area to Resident 1's coccyx and documented the assessment weekly until the area was healed. The Administrator indicated assessments had not been completed due to concerns with staffing levels. B. Observation of Resident 4's wound treatment with LPN (Licensed Practical Nurse)-F on 9/14/16 at 10:21 AM revealed the resident had a scabbed abrasion to the left Achilles (area to the back of the heel approximately 2 to 3 inches above the base of the foot). Resident 4's feet were bare inside of black slip on dress shoes. Review of Resident 4's Medical Record revealed the following: -Weekly Skin Assessment and Evaluation dated 5/16/16 indicated a scabbed area to the back of the resident's heel. The charting did not identify which heel. -Weekly Skin Assessment and Evaluation dated 6/6/16 indicated an abrasion to both left and right Achilles. -Weekly Skin Ulcer Non-Pressure assessment dated [DATE] indicated the area to the right Achilles was a previous abrasion that re-opened. -Weekly Skin Assessment and Evaluation dated 7/4/16 indicated abrasions had resolved. -Weekly Skin Ulcer Non-Pressure assessment dated [DATE] indicated the resident had an open area measuring 1.5 cm by 1 cm to the back of the left heel. -Weekly Skin Assessment and Evaluation dated 9/12/16 indicated a superficial abrasion/scab remained to the resident's left heel. Review of Resident 4's undated Care Plan revealed no evidence to indicate causal factors were assessed or addressed to prevent skin breakdown. Interview with Resident 4 on 9/14/16 at 10:25 AM revealed the scabbed abrasion was likely from the shoes rubbing. Further interview revealed the resident had been wearing the same shoes for a year and previously had trouble with skin breakdown caused from the same shoes that were currently being worn. Interview with LPN-F on 9/14/16 at 10:40 AM confirmed Resident 4 had open areas on the Achilles areas in the past that had healed, and now had developed a new area. LPN-F felt the open areas were caused by the resident's shoes rubbing or by the way the resident removed the shoes. Further interview confirmed interventions had not been put in place to prevent re-occurrence of skin breakdown. Licensure Reference Number: 175 NAC 12-006.09 C. Review of Resident 4's Order Summary Report (signed physician's orders [REDACTED]. Observation of Resident 4 on 9/14/16 at 10:20 AM revealed the resident was not wearing ted hose and had [MEDICAL CONDITION] to both feet. Interview with LPN-F on 9/14/16 at 1:35 PM confirmed Resident 4 had an order to wear ted hose daily, but did not have them on as ordered. LPN-F described Resident 4's [MEDICAL CONDITION] to both feet as 3 plus (+) [MEDICAL CONDITION] (Pitting [MEDICAL CONDITION] leaves an indentation in the [MEDICAL CONDITION] area when pressure is applied. Pitting [MEDICAL CONDITION] is scored from 1+ to 4+ with 4+ being the most [MEDICAL CONDITION]).",2019-09-01
5486,GOOD SAMARITAN SOCIETY - WOOD RIVER,285198,1401 EAST STREET,WOOD RIVER,NE,68883,2018-05-22,849,D,1,0,NLW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation and interview; the facility failed to ensure Hospice representatives were involved as part of the interdisciplinary group to update, follow and provide hospice comprehensive care plan recommendations to reflect current information and care needs for terminally ill residents. This failure had the potential to effect 2 of 4 sampled residents (Resident 10 and 23.) Facility census was 39. [NAME] Record review on 5/24/18 at 9:00 AM revealed that Resident 10 was admitted to hospice on 12/8/17. The care plan meeting was on 1/3/18 and the Hospice representative had not attended the meeting. No documentation on a follow up meeting with hospice team to create the comprehensive hospice care plan. Record review of Resident 10's Hospice care plan with the initiation date of 5/21/15. The correct Hospice admitted was 12/8/17. The care plan was not updated or revised until 2/22/18. The care plan meeting date was 1/3/18. Record review on 5/24/18 at 11:00 AM revealed the focused person centered comprehensive care plan for hospice addressed the following for Resident 10: Resident seen 4 times per month for extra companionship. Social Worker will visit 1 time a month for support of resident and family. Facility to work with nursing staff to provide maximum comfort for the resident by review date. Hospice RN (Registered Nurse) will visit 1 time a week and Hospice nurse aide will visit 2 times a week. Pastoral services will visit 2 times a month. Resident will be comfortable physically, spiritually, and emotionally and receive spiritual support and prayer from visits. There were no documented notes in the facility documentation of follow through with visits. Record review on 5/21/18 at 2:01 Care plan revealed Focus: The resident had a terminal [DIAGNOSES REDACTED]. Goal: resident's comfort will be maintained through the review date initiated on 4/17/18 target date 5/30/18. Intervention 1. Work with Aseracare to provide maximum comfort for the resident. RN 3 times per week, nurse aide 3 times per week 1 time per month, pastor to evaluate on 4/17/18 of need for visits. 2. Environmental: Aseracare to provide pressure reducing mattress for resident to be used for maximum comfort. B. Record review on 5/24/18 at 1:52 PM for Resident 23 revealed hospice start of care date as 4/13/18. Aseracare was not in attendance of the scheduled care plan meeting on 4/27/18 and there was no follow up documentation on a care plan meeting with Hospice to maintain a collaborative development of the comprehensive care plan. An Interview on 5/22/18 at 4:00PM, with the Corporate Nurse Consultant confirmed that the Corporate Nurse Consultant was unable to locate documentation on hospice and that the Consultant had to call the hospice company to requestthe records. The records were not located at the facility and the records had to be retrieved from the Hospice Company. C. Review of facility policy with a revised date of 3/17, revealed that a coordinated plan of care shall be jointly developed by the rehab skilled care location and hospice. Hospice participation in the care plan conference and input from the hospice representative is required. The plan of care must include directives for managing pain and other symptoms associated with hospice care and must be revised and updated to reflect the current clinical psychosocial and spiritual condition.",2020-01-01
3804,MITCHELL CARE CENTER,285287,1723 23RD STREET,MITCHELL,NE,69357,2018-06-19,758,D,1,0,57D211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interview, the facility failed to ensure PRN (as needed) anti-psychotic (tranquilizing medications used to control hallucinations, delusions, and behavioral aggression) medications were not extended beyond the required 14-day limitation without evaluation by a medical practitioner and documented rationale for extending the PRN for two sampled residents (Residents 2 and 6). Sample size was 3 current residents receiving anti-psychotic medications. Facility census was 49. Findings are: [NAME] Record review of Resident 2's Admission Record printed on 6/19/18 revealed the resident was admitted to the facility on [DATE] and had a medical [DIAGNOSES REDACTED]. Record review of Resident 2's Medication Review Report dated 6/4/18 signed by the resident's physician revealed the resident had orders for [MEDICATION NAME] Solution (an anti-psychotic medication) with instructions to administer 2 milligrams of the medication either by intramuscular injection or by mouth every 12 hours as needed for severe agitation. The report recorded the medication start date was 4/05/2018. Record review of Resident 2's Medication Administration Records for May, and (MONTH) of (YEAR) revealed the resident continued to have active orders for [MEDICATION NAME] 2 milligrams every 12 hours as needed. The resident was administered the medication 10 times by mouth and twice by injection in (MONTH) and was not administered the medication anytime in June. Record review of Resident 2's medical record charting and electronic chart revealed there was no re-evaluation of the use of PRN [MEDICATION NAME] beyond 14 days by the practitioner nor was there any documentation by the practitioner of a rationale to continue the PRN [MEDICATION NAME] beyond the required 14 day limit. B. Record review of Resident 6's Admission Record printed on 6/19/18 revealed the resident was admitted to the facility on [DATE]. Among the resident's [DIAGNOSES REDACTED]. Record review of Resident 6's Progress Notes revealed an entry on 5/14/18 at 3:20 p.m. which read: Received orders to d/c (discontinue) [MEDICATION NAME] and start [MEDICATION NAME] (an anti-psychotic medication) 2.5 mg (milligrams) po (by mouth) bid (twice daily) prn for [MEDICAL CONDITION]. Record review of Resident 6's medical practitioner documentation revealed the following: - A Palliative Medicine progress note was documented by a Nurse Practitioner on 5/15/18. The Practitioner documented the plan included: [MEDICATION NAME] 2.5 mg po bid. Continue prn. There was no documentation including recommendations for the duration of the PRN use. - A physician's orders [REDACTED]. There was no change written in the resident's use of [MEDICAL CONDITION] medication and nothing documented regarding recommendations for the duration of the PRN use. Record review of Resident 6's Medication Administration Record [REDACTED]. Record review of Resident 6's medical record charting and electronic chart revealed Resident 6 was ordered PRN [MEDICATION NAME] on 5/15/18 with no recommended duration of use. There was no documentation of a re-evaluation of the PRN order beyond the 14 day requirement, nor any documentation of a rationale to extend the PRN medication beyond 14 days by the resident's medical practitioners. Interview with LPN (Licensed Practical Nurse)-A, the facility's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) Coordinator, on 6/19/18 at 2:35 p.m. verified Residents 2 and 6 had been ordered PRN anti-psychotic medications in which the orders extended beyond the required 14 day limit without re-evaluation by a practitioner or documented rationale to extend the medication orders.",2020-09-01
5463,GOOD SAMARITAN SOCIETY - WOOD RIVER,285198,1401 EAST STREET,WOOD RIVER,NE,68883,2017-03-22,329,D,1,1,HUVK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews the facility failed to trial GDR's (gradual dose reductions) and/or document the rationale or need to continue the use of psychoactive (medications used to treat depression and or other psychiatric symptoms) for 2 residents (Resident 6 and 47) out of the 5 sampled residents. The facility census was 59. Findings are: A Review of the undated census sheet for Resident 6 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1-17-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 3 which indicated Resident 6 had severe cognition impairment. Review of Resident 6's current Physician orders [REDACTED]. [MEDICATION NAME] 100mg (milligram) daily for depression [MEDICATION NAME] 5mg bid (twice a day) for dementia with behaviors ABH ([MEDICATION NAME]: an antianxiety medication, [MEDICATION NAME]: an [MEDICATION NAME]: an antipsychotic) gel TID (three times a day) and PRN (as needed) for agitation Review of Resident 6 medical record revealed no documentation of 6 month reviews of the resident's [MEDICAL CONDITION] medications and attempts to reduce the medications. No documentation was also found from the Physician documenting the clinical rationale why not to attempt a GDR. B) Review of the undated census sheet for Resident 47 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-28-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 3 which indicated Resident 47 had severe cognition impairment. Review of Resident 47's current Physician orders [REDACTED]. [MEDICATION NAME] 50mg TID for anxiety/agitation [MEDICATION NAME] 0.5 mg every 2 hours PRN for agitation Review of Resident 6 medical record revealed no documentation of 6 month reviews of the resident's [MEDICAL CONDITION] medications and attempts to reduce the medications. No documentation was also found from the Physician documenting the clinical rationale why not to attempt a GDR. Interview on 3-15-17 at 3:26 PM with the RP (Registered Pharmacist) revealed the pharmacy contract did not include for their company to review and recommend GDR's on the residents at this facility. The RP revealed the DON (Director of Nursing) and the MD (Medical Director) would complete monitor the psychoactive medications of all the residents and conduct the GDR's. Interview on 3-20-17 at 11:44 AM with the DON revealed the DON was aware the RP did not do the GDR's. The DON revealed the former Administrator set up the process for the DON to meet monthly with the MD and review residents on psychoactive medications. The MD would make recommendations and those recommendation would be sent to the resident's primary Physicians requesting orders. The DON revealed a reduction in psychoactive medications was not requested routinely every 6 months. The DON also confirmed there was not documentation from the Physician documenting the clinical rationale why not to attempt a GDR. The DON revealed the DON and MD reviewing [MEDICAL CONDITION] medications was only being done on residents who were not under the medical care of the APRN from [NAME] Lanning Memorial Hospital Behavioral Unit. The DON revealed those residents medications did not require to be reviewed.",2020-01-01
5511,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2016-12-22,309,D,1,0,B6C911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to assess and treat a laceration in a manner to promote healing for one resident out of the 4 sampled residents. The facility census was 105. Findings are: Review of the undated [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 11-30-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 100 had no cognitive impairment. Resident 100 required limited assistance of one staff with bed mobility, transfers, dressing, and toileting. Review of the Incident Report dated 11-30-16 revealed Resident 100 was found on the floor at 1:40 PM with an injury of an 8 x 5 cm (centimeter) skin tear on the left lower leg on the front side. The nurse cleansed the wound and applied skin prep (a liquid film-forming dressing applied to the skin which prepared the skin for adhesives) to the skin that surrounded the wound. Next the nurse applied steri-strips (thin adhesive strips used to close open wounds) to the wound and wrapped the leg in a dry dressing. The Physician was notified of the resident's fall and of the skin tear to the leg. Review of the Physician orders [REDACTED]. Review of the (MONTH) and (MONTH) (YEAR) TAR (Treatment Administration Record) revealed no nursing orders to monitor or treat the skin tear on the left lower leg. Review of the Nursing Notes revealed no assessment of the skin tear wound to the left lower leg. Interview on 12-22-16 at 3:42 PM with the Facility Nursing (UM) Unit Manager on the unit Resident 100 resided on revealed the UM had not observed the skin tear to the resident's leg. The UM spoke to the nurse who initially assessed the wound and was informed the wound was a large skin tear. The UM revealed the UM had been informed that, for the top portion of the skin tear, the nurse was able to roll the skin back over the wound and steri-strip the area. For the lower portion of the skin tear wound, the skin was missing and therefore the nurse was not able to steri-strip that portion of the wound together. Interview on 12-22-16 at 2:35 PM with Nurse-A revealed Resident 100 was seen on 12-14-16 by the resident's PCP (Primary Care Physician) at the Physician's clinic. The nurse revealed the physician had assessed the wound to the left lower leg as a large gapping full thick untreated laceration. The Physician informed the resident and resident's spouse that the wound should have had sutures initially after injury and that it was not a skin tear. Review of the PCP clinic notes dated 12-14-16 revealed the Physician was notified on 11-30-16 by the facility that Resident 100 had received a skin tear to the left lower leg. As the area was not suturable, the facility would dress the wound. On 12-14-16, the wound was assessed as a large full thickness laceration which remained opened and was draining serum constantly. Interview on 12-22-16 at 4:11 PM with the Resident 100's spouse revealed the spouse had observed the wound on the left lower leg after the incident had occurred and had felt the wound was large and required sutures. The spouse denied the resident having had reinjured or bumped the left lower leg since the resident had left the faciity on [DATE] up through the time the resident saw the physician on 12-14-16.",2019-11-01
2499,PIONEER MANOR NURSING HOME,285212,"P O BOX 310, 318 N 3RD STREET",HAY SPRINGS,NE,69347,2018-08-07,726,G,1,0,9WZ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to ensure a newly hired nursing employee (Nurse Aide-A) received orientation competency demonstrations in safely transferring residents while providing direct care/transfers. The failure resulted in an improper transfer of one sampled resident (Resident 1) which resulted in a major injury requiring medical attention. Sample size was 3 current residents. Facility census was 51. Findings are: Record review of a facility investigative report entitled Fall with major injury dated 7/23/18 revealed the facility investigated an incident which occurred on 7/18/18 involving Resident 1. The report indicated non-residents involved in the incident included NA (Nurse Aide)-[NAME] The report revealed that during a transfer between surfaces Resident 1's leg seemed to break during mid transfer and the resident transported to the hospital for potential broken leg. Record review of a Hospital History and Physical dated 7/18/18 revealed the resident was seen in the emergency room after arriving via rescue unit. The resident had fallen with bruising and swelling of the left lower leg. The x-ray findings recorded on the document indicated the resident sustained [REDACTED]. Record review of Resident 1's Care Plan History report revealed a problem dated 6/6/18 indicated the resident had been lowered to the floor in the bathroom and the approach to prevent serious injury was updated on 6/6/18 directing staff to transfer the resident with 2 staff members assisting. Record review of the facility's Nursing Schedule documents between 5/27/18 and 6/23/18 revealed NA-A was working evening shifts as an orientee during scheduled days during this time frame. Record review of NA-A's employee records revealed no documentation of the resident's competency testing from orientation or indicating the employee had demonstrated competency in safely transferring residents. Interview with the Administrator on 8/7/18 at 11:45 a.m. confirmed that on 7/18/18 NA-A transferred Resident 1 without the assistance of another staff member and the resident lost balance during the transfer and fell . The Administrator verified NA-A had transferred from dietary to nursing and was employed as an orientee in nursing between 5/27/18 and 6/23/18 but that there was no record the employee had demonstrated competency as a direct care staff member or competency in safely transferring residents.",2020-09-01
6643,MITCHELL CARE CENTER,285287,1723 23RD STREET,MITCHELL,NE,69357,2015-12-21,514,D,1,0,BM5D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to: 1) record late entry information in the medical record; record events related to wound care and an emergency room visit; and record accurate wound assessments for one sampled resident (Resident 2); and 2) record the administration of a narcotic topical medication in the resident's medical record for one sampled resident (Resident 1). Facility census was 47. Findings are: Licensure Reference Number: 175 NAC 12-006.16A A. Record review of Resident 2's Admission Record printed on 12/21/15 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 2's Progress Notes revealed the following entries: - 10/23/15 at 8:14 p.m.- the entry was recorded as a Late Entry documented the Resident taken to ER (emergency room ) via private vehicle . The entry failed to record the actual date and time the resident was taken to the ER. - 10/23/15 at 11:20 p.m.- the entry was recorded as a Late Entry documented Resident back from ER . The entry failed to record the actual date and time the resident returned from the ER. - 10/24/15 at 10:18 a.m.- the entry was recorded as a Late Entry documented the resident's condition. The entry failed to record the actual date and time of the assessed condition. - 10/27/15 at 1:23 p.m.- the entry was recorded as a Late Entry documented the resident's condition. The entry failed to record the actual date and time of the assessed condition. - 10/28/15 at 8:13 p.m.- the entry recorded an assessment of the resident's forehead and a notation the physician office had not responded to the facility about removal of staples from the wound. The entry failed to record the actual date and time of the assessment. Source: The American Health Information Management Association LTC (Long-Term Care) Health Information Practice & Documentation Guidelines Version 1.0 (MONTH) 2001. - 5.3.2.1 Making a Late Entry. When a pertinent entry was missed or not written in a timely manner, a late entry should be used to record the information in the medical record . Identify or refer to the date and incident for which late entry is written . Licensure Reference Number: 175 NAC 12-006.16B (1) Record review of Resident 2's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessments revealed Resident 2 was discharged to an other location on 12/3/15 and re-entered the facility from an other location on 12/4/15. Record review of Resident 2's Progress Notes revealed the following documentation: - 12/3/15 at 9:55 p.m. the staff recorded the resident had fallen and developed a laceration. An on-call physician provided orders for the facility to transport the resident to the emergency room for evaluation and treatment. There were no further entries or late entry notes regarding when the resident was transported to the emergency room or returned. Record review of Resident 2's medical record revealed the following: - Physician Telephone Orders form dated 10/29/15 revealed an order was received on 10/29/15 for the staff to remove (wound) staples today. - Review of Progress Notes revealed an entry dated 10/29/15 at 12:46 a.m. revealed Staples intact. An entry on 10/30/15 at 1:44 p.m. recorded Resident's laceration to forehead now has steri stripes (sic for strips) that are intact . -There were no entries on 10/29/15 or 10/30/15 recording when the forehead staples were removed or the condition of the wound and resident's response to the procedure at the time of their removal. Record review of the resident's Treatment Administration Record for (MONTH) of (YEAR) revealed no documentation of the date or time the resident's forehead staples were removed. Licensure Reference Number 175 NAC 12-006.16B (2) Record review of Resident 2's Progress Notes revealed the following discrepancies in describing the resident's wound and treatment following a laceration from a fall on 10/22/15: -10/23/15 at 3:44 p.m. the entry recorded the resident Sutures remain clean, dry, and intact. - 10/23/15 at 3:51 p.m. the entry recorded the resident was seen in theER on [DATE], orders received . to take out staples . in 7-14 days. -10/23/15 at 11:20 p.m. a Late Entry recorded the resident returned from the emergency room with 6 staples to laceration on forehead . - 10/24/15 at 10:18 a.m. a Late Entry recorded the resident had 7 stapes are intact on 5 cm (centimeter) laceration . - 10/25/15 at 3:12 p.m. the entry recorded all seven staples are intact with edges approximated measures 7 cm in length . - 10/28/15 at 3:25 a.m. the entry recorded . Staples x6 remain intact to forehead . Interview with the Director of Nursing (DON) and the Administrator on 12/21/15 at 3:30 p.m. verified that Resident 2's Progress Notes contained Late Entry documentation on 10/23; 10/24; 10/27; and 10/28/15. The DON and Administrator confirmed these late entries had not recorded the actual date and time of the events documented as late entries. The DON and Administrator verified Resident 2 sustained a fall and was transported to the emergency roiagnom on [DATE] and there was no documentation pertaining to when the resident was transported and no assessment and record of the resident's return and condition following the emergency room visit. The DON and Administrator verified an order was received and staples removed from Resident 2's forehead and confirmed there was no documentation describing the procedure or identifying when the procedure was done. The DON and Administrator verified discrepancies in the description of Resident 2's forehead wound and treatment confirming that entries differed as to the number of staples, whether sutures or staples were in place, and the measurements of the resident's wound. Licensure Reference Number 175 NAC 12-006.16B(1) B. Review of the facility reports to State Agency dated 12/2/15 revealed a completed investigation in regards to misappropriation of a [MEDICATION NAME] on Resident 1. Further review revealed that a new patch was placed on the resident on 11/25/15. Review of the Medication Administration Record [REDACTED]. Review of the facility Narcotic Patch Change Sheet dated as starting 10/24/15 revealed an entry of 11/25/15 with the placement of a new patch on the left upper shoulder for Resident 1. Interview with LPN - C on 11/25/15 at 10:00 AM verified that the Narcotic Patch Change Sheet did reveal that Resident 1 had a [MEDICATION NAME] placement to the left upper shoulder on 11/25/15. Further interview verified that the resident's MAR indicated [REDACTED]. Interview with the Administrator on 12/21/15 at 3:30 PM verified that Resident 1 did have a [MEDICATION NAME] missing that had been replaced on 11/25/15. Further interview verified that the [MEDICATION NAME] had been checked out on the Narcotic Patch Change Sheet on 11/25/15. Continued interview confirmed that the MAR for Resident 1 had not been completed to include the [MEDICATION NAME] administered on 11/25/15.",2018-12-01
2580,AZRIA HEALTH MIDTOWN,285218,910 SOUTH 40TH STREET,OMAHA,NE,68105,2019-05-06,609,D,1,0,7FUR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > F609 Based on record review and interview, the facility failed to submit results of investigation to state survey agency within 5 working days for 1 (Resident 1) of 2 sampled residents with a significant injury. The facility had a total census of 53 residents. Findings are: Resident 1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of facility investigation dated 4/10/19 revealed Resident 1 had an x-ray of the patella during a follow up orthopedic appointment on 4/3/19. The x-ray showed Resident 1's patella had been re-fractured. Facility investigation could not determine cause for re-fracture of Resident 1's patella but may have been related to fall on 3/29/19. The facility investigation report did not include a confirmation of delivery receipt indicating that report had been sent to survey agency. In interviews on 5/6/19 at 10:10 AM and 10:25 AM, the Administrator reported the report was sent by email and no confirmation receipt had been received. The Administrator identified that the survey agency email address had been miss spelled which resulted in report not being sent.",2020-09-01
1649,MAPLE CREST HEALTH CENTER,285149,2824 NORTH 66TH AVENUE,OMAHA,NE,68104,2018-12-18,689,E,1,1,864P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > F689 Based on observations, record reviews and interviews, the facility failed to ensure chemicals were secured for 5 sampled residents (Residents 78, 87, 98, 441, and 442) of 28 total residents residing in the Memory Care Unit that are self-mobile. The facility had 34 residents residing in the memory unit and a total census of 138 residents. Findings are: Observations on 12/13/18 at 7:10 AM in Memory Care Unit dining room revealed a spray bottle of Sani-T-10 plus in unlocked under the sink cabinet. Dining room was open for residents of the memory care unit. Observations on 12/13/18 at 1:05 PM revealed of spray bottle Sani-T-10 plus in unlocked in under the sink cabinet. Dining room was open for residents of the memory care unit. In an interview on 12/13/18 at 1:05 PM, Licensed Practical Nurse B confirmed spray bottle of Sani-T-10 plus should not be in unlocked under the sink cabinet. A review of Safety Data Sheet revealed Sani-T-10 Plus revealed chemical is harmful if swallowed and causes severe [MEDICAL CONDITION] serious damage. A review of list of self-ambulatory residents who resided in the memory care unit revealed the following sampled residents were self-ambulatory: Residents 78, 87, 98, 441, and 442.",2020-09-01
4826,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2017-10-04,155,G,1,0,VJ5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Federal Tag F155 Based on record review and interviews, the facility failed to follow the resident's advance directives to perform CPR (Cardiopulmonary Resuscitation). This affected one sampled resident (Resident 4). Facility census was 17. Findings are: Review of the Nursing Progress Note, dated [DATE], for Resident 4; identified that on [DATE] at 7:39 PM, MA(Medication Aide)-B called the LPN (Licensed Practical Nurse)-D to Resident 4's room. The resident was non-responsive and the resident's breath was short and pursed, and the nail bed was cyanotic. LPN-D went to the nurse's station and called 911. While on the phone with 911, MA-B called LPN-D back to the resident's room. When LPN-D went back to the room, the resident's body went limp and non-responsive. LPN-D was holding the resident in the bed with LPN-D's legs so that the resident would not fall out of the bed. The paramedics arrived and transferred the resident to the gurney for transport to the hospital. The paramedics left with the resident at approximately 8:20 PM. The resident's physician called the facility and asked for the signed advanced directive and LPN-D was unable to locate one in the resident's chart. At 11:10 PM, a hospital employee called the facility to inform them that the resident was transferred to another medical center in Colorado. Review of the facility document, titled Admit/Discharge To/From Report, identified that Resident 4 passed away on (MONTH) 22, (YEAR). Review of the facility policy, titled Cardiopulmonary Resuscitation (CPR) - Basic Life Support, dated ,[DATE], stated that Unless a decision not to initiate CPR has previously been made by the resident/patient, CPR will be initiated for any resident/patient who experiences a cardiopulmonary arrest while in the facility. If a decision (code status) has not been established and documented, CPR will be initiated. Interview on [DATE] at 2:25 PM with RN (Registered Nurse)-A revealed that if a resident was found to be unresponsive and it was unknown as to what the resident's code status was, then the expectation was that the licensed nurse would assess the resident for respirations and a pulse rate, then initiate the CPR process while other staff call 911, the Administrator and the Director of Nursing. Interview with the DON (Director of Nursing) on [DATE] at 12:30 PM, revealed that LPN-D called the DON after 911 was called but before the ambulance had arrived at the facility. LPN-D informed the DON that they were unable to locate Resident 4's advance directive in the chart. The DON stated that the day charge nurse had sent off the resident's advance directive to the physician's clinic to be signed off by the resident's physician but did not make a copy of the advanced directive to be kept in the chart until the signed copy was returned to the facility. After the incident with the resident, the DON confirmed that the signed copy of the advance directive was sent back to the facility and it was determined that the resident was listed as a full code. Interview with MA-B on [DATE] at 2:09 PM, identified that LPN-D and MA-B were the only two nursing staff working the evening shift together when resident's call light went off. LPN-D went into the resident's room, came out and told MA-B, who was walking by the room, that the resident was in some distress. LPN-D stated that LPN-D did not know what the protocol was. Both MA-B and LPN-D went into the resident's room and saw that the resident was starting to code, so MA-B told LPN-D to call 911. LPN-D returned to the room and said that 911 was on the phone but didn't know what to tell them. LPN-D stayed with the resident while MA-B got on the phone with 911. While on the phone with 911, the resident's chart was pulled and staff was unable to find the code status for the resident. MA-B hung up the phone when sirens were heard outside of the building. MA-B did not see LPN-D assess the resident for pulse rate, respirations and did not initiate any CPR. Once the ambulance arrived, and the resident was transferred to the gurney, then the EMT's (Emergency Medical Technician's) initiated CPR on the resident. MA-B thought it was about 5 to 6 minutes from the time 911 was called and when the ambulance arrived. Interview with LPN-D on [DATE] at 4:37 PM identified that on [DATE] at approximately 7:30 PM, Resident 4 complained of tightness in the chest, so LPN-D started oxygen on the resident. Then, MA-B came into the room and LPN-D told MA-B that the resident was in distress. While in the room, the resident started to code, so LPN-D went to the nurse's station to call 911 while MA-B stayed with resident. LPN-D stated that LPN-D went back into the room while MA-B finished the call with 911. When asked if LPN-D started CPR on the resident, LPN-D stated that LPN-D did not because the biggest priority was keeping the resident from falling out of bed. LPN-D stated that it was only minutes before the ambulance arrived and took the resident. LPN-D stated that LPN-D did not assess the resident for respirations or a pulse, but did put on oxygen and turned it up. LPN-D said that LPN-D was unable to find the code status on resident. LPN-D stated that they did not initiate the CPR process on Resident 4.",2020-03-01
2898,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2019-04-22,689,G,1,1,BJ6K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSE REFERENCE NUMBER 175 NAC 12-006 09D7 Based on observation, interview and record review the facility failed to ensure Resident 14 was supervised during smoking. This had the potential to affect one resident (Resident 14). The facility census was 60. Findings are: [NAME] On 04/9/19 at 9:30 AM an observation of Resident 14 in wheel chair (w/c) outside, on the northeast side of the facility. One staff person had walked out with Resident 14 and walked around the building after lighting Resident 14's cigarette. Resident 14 sat in w/c on porch area for a while and then wheeled self, in a motorized w/c, down the driveway past the building, out of eyesight of the staff member and returned up driveway a short time later. Resident 14 did not have on a smoking apron. Resident 14 keeps cigarette in mouth the entire time of smoking as Resident 14 is unable to use hands to hold cigarette. When Resident 14 was finished with the cigarette, staff remove the cigarette. On 4/9/19 at 2:15 PM an observation of Resident 14, who was outside, on the northeast side of the facility with a different staff person, staff lit Resident 14's cigarette. Resident 14 in w/c, went down the driveway out of eyesight of staff, and returned. Resident 14 did not have a smoking apron on at this time. On 4/10/19 at 8:40 PM an observation of Resident 14 outside, on the northeast side of the facility, in w/c with a lit cigarette in mouth and no staff were around. Resident 14 said there was no staff member outside at this time. There was not a smoking apron on Resident 14. On 4/10/19 at 10:30 am a record review of the facility's smoking policy revealed residents admitted before [DATE] (YEAR) will be attempted to accommodate the practices of those residents, on an interim basis. The facility will permit supervised smoking in one designated area at designated times. In addition the facility will offer smoking alternatives, cessation programs and education. The facility expects to complete its campus wide conversion to tobacco free by (MONTH) 1, (YEAR). On and after this date, smoking will not be permitted at any time or in any location on the property. 1) The policy continues that Keystone does not allow smoking of any kind within the Facility. A designated smoking area is located along the concrete walkway at the northwesterly point of the Facility ground, and is at least 20 feet away from the building. 2) The designated smoking area shall be under the periodic observation of facility personnel or responsible adults. 3) Residents wishing to smoke must be physically able to smoke without the assistance of staff, as assessed on admission and thereafter. Residents who cannot physically smoke may call on volunteers to provide smoking assistance during the scheduled smoking times. Residents wishing to smoke must have a smoking assessment to determine safety. Such assessment will be kept in the resident's chart. 4) Cigarettes will be lit by staff. 5) The Facility reserves the right to immediately confiscate smoking materials and rescind individual smoking privileges in the interests of of resident or staff safety. If a resident is non-compliant with the smoking policy, he/she will be given a thirty (30) day notice of discharge in accordance with applicable State and Federal regulations on the grounds that his/her presence creates a threat to the safety of other individuals in the facility. On 4/10/19 at 10:40 am a record review of Resident 14 Smoking evaluation dated, 3/4/19, revealed resident is unable to hold a cigarette on own, is unable to light cigarette. Holds cigarette in mouth until the cigarette is done and then requires assist to put it out. On 04/10/19 at 11:25 AM an interview with the ADM revealed that supervised smoking was when a staff person had the resident within eyesight at all times. The ADM confirmed that the smoking area was on the northwest side of the building and Resident 14 was smoking on the northeast side of the building. The ADM also confirmed Resident 14 was an unsafe smoker as resident is unable to hold the cigarette with hands or put the cigarette out when finished. On 4/10/19 at 6:30 pm an interview with the ADM confirmed the smoking policy had stated no one was to smoke on grounds after (MONTH) 1, (YEAR) and that Resident 14 was smoking on facility grounds.",2020-09-01
3270,COMMUNITY MEMORIAL HEALTH CENTER,285257,"P O BOX 340, 1015 F STREET",BURWELL,NE,68823,2017-07-25,223,E,1,1,DLQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on observations, record review and interview; the facility failed to ensure residents were protected from potential abuse. This involved 4 residents (Residents 1, 67, 56 and 62). The sample size was 29 and the facility census was 49. Findings are: [NAME] Review of the facility Policy and Procedure related to Suspected or Actual Abuse (undated) included the following: -The purpose of the policy was to maintain the rights of all residents to be free from abuse, neglect and mistreatment and to provide a mechanism for prompt identification, reporting and investigation of any allegation and/or reasonable suspicion of abuse or a complaint of abuse by a resident; -Verbal abuse was defined as any use of oral, written or gestured language that willfully included disparaging and derogatory terms. Examples of verbal abuse included threats of harm, saying things to frighten a resident or conversation that would make the resident uncomfortable; -Physical abuse was defined as hitting, slapping, punching and kicking; and -During the abuse investigation, residents were to be protected as appropriate, including but not limited to: separation and/or redirection of residents, instituting visual checks/monitors as appropriate and taking action to manage and monitor the behavior of a resident against whom there was a verified charge of abuse. B. Review of Incident/Accident Form dated 6/16/17 revealed on 6/13/17 at 6:30 PM, Resident 1 threatened Resident 67 while the residents were in the dining room. Documentation indicated Resident 1 had told Resident 67 if you touch my pudding again, I will break your fingers. Resident 1 was removed from the dining room and was taken to the resident's room. Further review of the form revealed the area of the form in which staff were to document comments and/or steps taken to prevent reoccurrence had been left blank. Review of Resident 1's current Care Plan dated 6/2/17 revealed the resident had a history of [REDACTED]. An update to the Care Plan (undated) indicated Resident 1 was to remain at current dining table due to most staff oversight in dining room. The Care Plan indicated the resident's current table placement was next to the medication cart and that staff were seated at the table during meals to assist other residents with eating. Observations on 7/18/17 of the main dining room revealed the following. -12:00 PM, Resident 1 was seated in a wheelchair and was positioned at a table in the dining room. A medication cart was located next to the resident's table, but no staff was utilizing the medication cart. -12:05 PM, Resident 67 was assisted into the dining room and was placed in a chair immediately to the left of Resident 1's wheelchair. -12:05 PM to 12:20 PM, no staff were available in the dining room to provide the residents with supervision and to prevent a potential resident to resident altercation. Observations on 7/19/17 of the main dining room revealed the following: -8:20 AM, Resident 1 and 67 were seated at their dining table next to each other. No staff were available to provide the residents with ongoing supervision. -12:11 PM, facility staff were in and out of the dining room assisting residents to the noon meal. Resident 67 and Resident 1 were seated next to each other at their table. No staff were seated at their table or available next to the medication cart to provide supervision and monitoring. During an interview on 7/24/17 at 10:00 AM, Licensed Practical Nurse (LPN)-E confirmed the following: -Residents 1 and 67 had a resident to resident altercation in the dining room on 6/13/17; -Resident 1 had a history of [REDACTED]. -Resident 67 was not offered a choice as to a different seating arrangement in the dining room; and -Staff had been instructed to remain in the dining room at all times when the residents were in the dining room. Observation on 7/25/17 revealed at 1:00 PM, Residents 1 and 67 remained in the dining room seated next to each other. No other residents remained at the resident's table and no staff were available to provide supervision and monitoring of the residents. C. Review of an Incident/Accident form dated 7/11/17 revealed on 7/11/17 at 6:45 AM, Resident 56 was seated in a recliner in the Special Care Unit (secured area used to protect and better meet dementia residents' needs and to address behaviors associated with dementia) dining room. Resident 62 approached Resident 56 with fists rolled and Resident 62 stated, Do you want to fight? Resident 56 did not respond and Resident 62 then kicked Resident 56's right foot. The residents were immediately separated and Resident 62 was taken outside to the enclosed courtyard. Further review of the form revealed the resident's placement in the dining room for meals was changed so that the residents would be separated. In addition, unit staff were provided with education to monitor the residents closely to prevent further altercations. Review of Resident 62's current Care Plan dated 4/21/17 revealed an intervention to intervene when the resident is shadow boxing' and to redirect the resident to either go outside or to the resident's room. There is no documentation on the resident's plan of care regarding the need to keep the resident separated from Resident 56. During an observation on 7/24/17 from 11:00 AM to 11:15 AM, Resident 62 was seated in a chair outside in the Special Care Unit's enclosed courtyard. Resident 56 self-propelled a wheelchair outside to the courtyard and positioned the wheelchair directly to the right of Resident 62. No staff was available in the courtyard to provide supervision and monitoring of the residents. During an interview on 7/24/17 from 11:30 AM to 11:45 AM, Nurse Aide (NA)-J confirmed Resident 56 and 62 were to be kept separated and were to be visually supervised in order to prevent additional resident to resident altercations.",2020-09-01
5542,"WAUSA CARE AND REHABILITATION CENTER, LLC",285111,703 SOUTH VIVIAN,WAUSA,NE,68786,2017-05-02,223,E,1,1,MTYD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on observations, record review and interviews; the facility failed to ensure residents were protected from potential abuse. This involved 2 (Residents 20 and 24) out of 25 sampled residents. The facility census was 15. Findings are: [NAME] Review of the facility Abuse Prohibition and Prevention Program policy (revised 9/7/16) included the following: -The purpose of the policy was to maintain the rights of all residents to be free from abuse, neglect and mistreatment and to provide a mechanism for prompt identification, reporting and investigation of any allegation and/or reasonable suspicion of abuse or a complaint of abuse by a resident; -Verbal abuse was defined as any use of oral, written or gestured language that willfully included disparaging and derogatory terms. Examples of verbal abuse included threats of harm, saying things to frighten a resident or conversation that would make the resident uncomfortable; -Physical abuse was defined as hitting, slapping, pinching and kicking; and -During the abuse investigation, residents were to be protected as appropriate, including but not limited to: separation and/or redirection of residents, instituting visual checks/monitors as appropriate and taking action to manage and monitor the behavior of a resident against whom there was a verified charge of abuse. -Appropriate steps were to be taken in an effort to prevent reoccurrence of any incidences and the steps should be documented. B. Review of a facility investigation revealed on 1/30/17 at 12:00 PM, Resident 24 was leaving the dining room with a walker as Resident 20 was headed to the dining room in a wheelchair. The residents both had room placement on the East corridor and needed to pass through the same doorway. Resident 24 verbally threatened Resident 20 telling Resident 20 move over or I will hit ya. Due to placement of a laundry cart and a linen cart in the corridor, Resident 20 was unable to reposition wheelchair and Resident 24 proceeded to bump the resident's walker into Resident 20's wheelchair. Documentation indicated the residents were separated and the plan to prevent a reoccurrence included moving both of these carts away from the doorway on the East corridor and putting up a sign on the corridor wall to remind staff about proper placement of the carts. Resident 20 was offered different room placement but the resident declined. Review of a facility investigation dated 4/17/17 at 5:30 PM, revealed Resident 20 was self-propelling the resident's wheelchair in the East corridor and stopped in front of Resident 24's room entrance. Resident 24 told Resident 20 to get your ass out of the way or I will run over the top of you. Further review of the investigation revealed the residents were immediately separated and staff provided Resident 20 with re-education regarding provocation of Resident 24. The report indicated Resident 20 had been offered room placement on a different corridor but the resident had refuse. Documentation revealed no evidence that additional interventions were developed to prevent reoccurrence. C. Review of Resident 24's current Care Plan with revision date 4/17/17 revealed the resident had a history of [REDACTED]. The following interventions were identified: -Do not seat the resident around people who may disturb the resident. -Help the resident to avoid situations or people who are upsetting to the resident. -Keep resident in a calm environment. -Laundry/linen carts to be moved from the doorway of the East corridor. -Signage to be placed on wall of East corridor by the doorway to remind staff not to place carts in this area. On 4/25/17 from 8:00 AM until 12:00 PM (4 hours), a facility linen cart and a 3 compartment laundry cart were observed positioned next to the doorway of the East corridor. In addition, there was no evidence of a sign on the wall of the East corridor to identify where the carts were to be placed. Observations on 5/1/17 from 9:30 AM to 1:00 PM (3 1/2 hours) revealed a 3 compartment laundry cart was again positioned next to the doorway of the East corridor and there was no evidence of a sign on the wall of the corridor to indicate where the cart should be located. Interview with the Administrator and the Director of Nursing (DON) on 5/1/17 from 2:00 PM to 2:21 PM revealed the following: -Resident 24 had a history of [REDACTED]. -The laundry cart and the linen cart were to be placed at the opposite end of the East corridor or in an empty resident room on the corridor so that placement of the carts did not block or limit the doorway of the corridor. -The sign which had been posted on the wall of the East corridor to remind staff about where to position the carts was missing. -Resident 20 had been offered a room on a different corridor but had refused to move. -The staff were concerned that moving Resident 24 to a different room would trigger additional behaviors. -No new interventions had been developed after the second resident to resident altercation between Resident 20 and 24 on 4/17/17 to prevent potential reoccurrence. D. Interview with Registered Nurse-B on 5/2/17 at 9:29 AM revealed Resident 20 had a history of [REDACTED]. Resident 20 would park the wheelchair in front of Resident 24's room door. Review of Resident 20's undated Care Plan revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. Further review of Resident 20's Care Plan confirmed the resident had a history of [REDACTED]. doorway to provoke Resident 24. Resident 20 had an altercation with Resident 24 on 1/31/17. The goal was for Resident 20 to avoid provoking other residents and for Resident 20 to not park the wheelchair in the way of Resident 24's door. Interventions included: - The linen and laundry carts were moved from inside the hallway so Resident 20 could move to the side of the hallway and allow other residents through. - Resident 20 was offered to change rooms but refused. - A sign was placed on the wall just inside the East corridor to remind staff to not place the linen cart there. On 4/17/17 the Care Plan goal was listed as not met as Resident 20 continued to stop in front of Resident 24's door. There was no evidence to indicate new interventions had been put in place to prevent a potential reoccurrence.",2019-11-01
2136,COLONIAL MANOR OF RANDOLPH,285183,"P O BOX 67, 811 SOUTH MAIN STREET",RANDOLPH,NE,68771,2018-08-28,725,E,1,1,BSGP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSE REFERENCE NUMBER 175 NAC 12-006.04C Based on observations, record review and interview, the facility failed to ensure sufficient numbers of nursing staff were available to: 1) answer call lights in a timely manner for Residents 29, 23 and 4; and 2) provide assistance with activities of daily living (ADL) for 3 (Residents 3, 19 and 25) of 3 sampled residents with ADL needs. In addition, 3 of 8 confidential resident interviews voiced concerns that there was not enough nursing staff available to meet their needs. The total sample size was 19 and the facility census was 29. Findings are: [NAME] 3 confidential resident interviews conducted between 8/22/18 at 1:28 PM and 8/23/18 at 7:36 AM voiced concerns that there was not enough nursing staff available to meet their needs as call lights were not answered in a timely manner. Comments included the following: -It can take 20 to 30 minutes for the call light to get answered; and -It has taken up to an hour to get the call light answered. B. Observations of call light response times on 8/27/18 revealed Resident 29's call light was on at 7:23 AM. The call light remained on and at 7:35 AM, Licensed Practical Nurse (LPN)-C used a pager to notify other staff members that Resident 29's call light needed to be answered. Resident 29's call light was observed to be on until 7:42 AM (19 minutes). Review of facility call light reports (computer generated report of call light use and response) for 8/27/18 revealed Resident 29's call light was activated that day at 7:19 AM and was not answered until 7:42 AM (22 minutes). Further review of facility call light reports for 8/27/18 revealed the following: -Resident 23's call light was activated at 6:12 AM and not answered until 6:31 AM (18 minutes); and -Resident 4's call light was activated at 5:26 PM and was not answered until 5:59 PM (32 minutes). Interview with Resident 29 on 8/28/18 at 7:47 AM confirmed the resident's call light had been on for quite a while the morning of 8/27/18. Interview with the Director of Nurses (DON) on 8/28/18 at 2:15 PM revealed the expectation was for call lights to be answered in 15 minutes. C. Review of Resident 3's current Care Plan (undated) included the following: -Independent with the use of the toilet; -Remind to change clothes when they are wet. Resident often refuses to change clothes. Offer to assist; and -Uses urinal when possible to avoid getting the floor wet. Uses the urinal at night and needs assistance with emptying the urinal. Resident 3 was observed on 8/23/18 at 9:20 AM to be seated on the side of the bed wearing a gray shirt which was stained and soiled with dried food. A strong urine odor was noted in the room. Urine odors were noted in Resident 3's room on 8/27/18 at 8:30 AM, 8:45 AM, 9:00 AM and 9:20 AM. Observations on 8/27/18 from 10:15 AM until 2:25 PM revealed the following: -10:15 AM-Resident 3 was observed lying in bed and a urinal was hanging from an open drawer on the bedside dresser. The urinal was not covered and there was urine in the urinal. A urine odor was noted in the room; -12:28 PM-An uncovered urinal containing urine was hanging from an open drawer on the bedside dresser in Resident 3's room. A urine odor was noted in the room; and -2:25 PM-Resident 3 was lying in bed and an uncovered urinal containing urine was hanging from an open drawer on the bedside dresser. A urine odor was noted in the room. Observations on 8/28/18 from 7:55 AM until 10:14 AM revealed the following: -At 7:55 AM, 8:25 AM and 9:06 AM- An uncovered urinal containing urine was hanging from an open drawer on the bedside dresser in Resident 3's room. A urine odor was noted in the room; and -At 9:35 AM and 10:14 AM-Resident 3 was lying in bed and an uncovered urinal containing urine was hanging from an open drawer on the bedside dresser. A urine odor was noted in the room. Interview with Nursing Assistant (NA)-A on 8/28/18 at 10:15 AM revealed Resident 3 was independent with toileting, had urine incontinence and was able to change clothing independently. NA-A confirmed there was a urine odor in the resident's room and it was possibly from the resident's clothing as the resident did not like to change clothes very often. NA-A was aware Resident 3's urinal was to be emptied by staff when needed. Interview with Registered Nurse (RN)-G on 8/28/18 at 10:25 AM confirmed there was a urine odor in Resident 3's room. RN-G indicated Resident 3 did not like to change clothes and suspected the resident only changed clothes on bath days. D. Review of Resident 19's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool utilized to develop resident care plans) dated 7/20/18 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was totally dependent with bathing. During interview on 8/23/18 at 07:21 AM, Resident 19 indicated the resident was to receive a shower every 2-3 days. The resident further indicated an inability to remember the last time the resident received a shower. Review of a Point of Care Audit Report (electronic record of baths provided daily) from 7/1/18 through 8/27/18 revealed showers were provided on 7/8/18, 7/11/18, 7/13/18, 7/16/18 and 7/21/18 (a total of 5 out of the 9 total showers that were to be provided). No shower was provided again until 8/7/18 (17 days later). Resident 19 received a bath on 8/9/18, 8/15/18, 8/17/18 and then on 8/24/18 (a total of 5 out of the total 7 the resident was supposed to have been provided). During interview on 8/28/18 at 12:44 PM, the Bath Aide (BA)-J verified Resident 19's was to receive a shower or a bath at least twice a week. BA-J confirmed the resident had not been receiving a bath or shower every 2-3 day as BA-J had been ill and would try to make up for missed baths/showers but was not always able to fit everyone into the schedule. E. Review of Resident 25's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/3/18 included the following: -was admitted [DATE] with [DIAGNOSES REDACTED]. -was cognitively intact; -required extensive, 2 person physical assistance with bed mobility, transfers and toilet use; -required extensive, 1 person physical assistance with dressing and personal hygiene; and -was always incontinent of bowel and bladder. Review of Resident 25's Care Plan dated 1/24/16 revealed the resident had bowel and bladder incontinence related to physical limitations, impaired mobility, and activity intolerance. Nursing interventions included the following: -during the night, wants to be assisted with incontinent care and perineal hygiene at 2:00 AM and 6:00 AM; -wears an incontinent brief; -check as required for incontinence; -provide perineal hygiene and change clothing as needed after incontinence episodes; and -monitor for signs and symptoms of urinary tract infections [MEDICAL CONDITION]. During interview on 8/22/18 at 11:05 AM, Resident 25 verified having bowel and bladder incontinence and wearing an incontinent brief. The resident further indicated a preference not to use the toilet or commode, expected staff to provide incontinent care every 2 hours, and verified this was not always provided. During observations on 8/27/18 from 7:09 AM until 7:19 AM, Licensed Practical Nurse (LPN)-B provided incontinence care while Resident 25 was lying in bed, and the following was observed: -the bedding was pulled back from the resident and a strong odor of urine was noted; and -the incontinent brief was removed and observed to be heavy with urine as it was disposed of in the trash receptacle. During interview on 8/27/18 at 7:35 AM, LPN-B indicated the resident's incontinent brief was usually not as wet as it was that morning, and verified being unsure when the resident was last provided incontinent care. During interviews with Resident 25, the following was revealed related to incontinence care: -8/27/18 at 8:22 AM - did not recall that staff provided incontinent care during the night, and verified the incontinent briefs were frequently very wet in the morning; and -8/28/18 at 7:00 AM - once transferred to the recliner in the morning, staff did not check for incontinence again until 2:00 PM.",2020-09-01
1263,ARBOR CARE CENTERS-TEKAMAH LLC,285118,823 M STREET,TEKAMAH,NE,68061,2019-07-11,690,D,1,1,U22Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSE REFERENCE NUMBER 175 NAC 12-006.09D3(1) The facility failed to develop a Bowel and Bladder(B&B) training program to address incontinence and failed to provide perineal care(Perineal Care involves cleaning the private areas of a patient) in a manner to prevent a potential for cross contamination for Resident 5, and failed to provide cleansing of suprapubic catheter (suprapubic catheter (SPC) a device that's inserted into the bladder to drain urine if one can't urinate, a SPC is inserted a couple of inches below the navel, or belly button, directly into the bladder, just above the pubic bone) for one resident, (Resident 24). This had the potential to affect 2 residents out of 3 sampled residents. The facility census was 32. Findings are: On 7/9/19 a record review of bowel and bladder record data collection tool dated 3/29/19-3/31/19 revealed Resident 5 has occasional periods of incontinence. On 7/9/19 a record review of Bowel and Bladder Program Screener' dated 3/29/19 revealed Resident 5 was a candidate for a schedule B&B training program. On 7/9/19 a record review of the MDS dated [DATE] revealed Resident 5 is occasionally incontinent of bladder and frequently incontinent of bowel and no B&B toileting program. On 07/11/19 at 12:05 PM an interview with RN A mds/care plan coordinator confirmed Resident 5 did not have a B&B training program and that Resident 5 should have a B&B training program. An observation on 07/10/19 at 11:10 AM of pericare revealed Nurse Aid (NA) B washing hands, donning gloves, and then assisting Resident 5 into the bathroom, where Resident 5 stood and NA B pulled down pants and brief, and wiped down the inner legs and across the scrotum with a peri wipe, NA B tossed the wipe and got 2 more out of container, had the resident turn slightly so NA B could wipe the resident's bottom, NA B wiped Resident 5's bottom two times without turning the cloth to a clean area. NA B then assisted Resident 5 in pulling up the brief and pants, helped adjust clothes and removed gloves. On 7/10/19 at 10:45 AM an observation of perineal care revealed NA B donning gloves. NA B assisted with pulling down Resident 24 pants and brief. NA B took two wipes from the container and wiped down the inside of Resident 24's right leg three times without turning the cloth, and then to the left side, with a new wipe, wiping down three times without turning the wipe, got a clean wipe and wiped the perineum twice without turning the cloth. NA B got a new cloth, had the resident turn to side and wiped bottom three times without turning the cloth. NA B removed the old brief and put on a new brief and had resident turn to back and fastened the brief and assisted in pulling up pants. without removing gloves. On 07/11/19 at 03:04 PM a review of Perineal Care Policy dated march 2019 revealed staff are to use different areas of the washcloth for each stroke or use separate disposable wet wipes for each stroke. If changing brief or dressing/undressing resident, apply new gloves before proceeding with those items. 07/11/19 09:49 AM An interview with the DON confirmed staff should use a different area of the washcloth or a new wet wipe for each stroke and that gloves should be changed before adjusting clothes. On 7/10/19 at 10:50 AM an observation of cath care revealed NA C washed hands and donned gloves, NA C took an alcohol swab and opened it and wiped around the suprapubic catheter one time for Resident 24, then assisted with his brief and pants being pulled up. 07/11/19 03:03 PM a record review of policy and procedure for Urinary Catheter Care dated (MONTH) 2019, revealed staff are to cleanse around the insertion site with a circular motion, change the position of the wipe with each cleansing stroke, use a clean perineal wipe to cleanse the catheter from insertion site to approximately four inches outward. 07/11/19 09:49 AM An interview with the DON confirmed that peri wipes should be used with catheter care and the catheter should be cleansed from the opening of the skin down about 4 inches.",2020-09-01
2601,SOUTHLAKE VILLAGE REHABILITATION & CARE CENTER,285219,9401 ANDERMATT DRIVE,LINCOLN,NE,68526,2017-07-06,323,D,1,0,7YLU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record reviews and interviews, the facility failed to protect residents from injury by not initiating interventions based on all of the possible root causal factors of an injury for one resident (Resident 300) out of the 3 residents sampled. The facility census was 101. Findings are: Review of the Face Sheet dated 6-13-17 for Resident 300 revealed an admission date of [DATE]. Review of the surgical report dated 6-7-17 revealed the resident's [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 6-2-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 300 had no cognition problems. Resident 300's balance while moving from seated to standing position, moving on and off the toilet, and surface to surface transfers was assessed as not steady and only able to stabilize with staff assistance. Review of the Progress Notes dated 6-25-17 revealed Resident 300 complained of pain in the right axilla (armpit) area which began on the evening 6-24-17. Notification was sent to the PCP (Primary Care Physician). Pain medications were given to the resident PRN (as needed) but the resident continued to complain of pain. On 6-27-17 the resident was seen by the PCP and diagnosed with [REDACTED]. Interview on 7-6-17 at 12:41 PM with Resident 300 revealed the resident had been living at home until a fall that caused a fractured hip which required surgery and rehabilitation at the Nursing Home. The resident revealed about a week ago on the weekend, two staff transferred the resident during the evening and injured the right shoulder. Resident 300 revealed the resident knew it happened at the exact moment because there was sudden sharp pain in her right axilla area. The resident revealed the gait belt (a belt worn around the waist of the patient used by a caregiver to aide in transferring a resident from one positions such as sitting to a standing or assist in walking to help prevent falls) slipped from the waist and went up under the breast/armpit area during the transfer. Review of the facility Investigation report dated 6-29-17 revealed Resident 300 initially complained of pain to 2 nurse aides on the day shift on 6-25-17 and revealed the pain started on the evening of 6-24-17. The resident was seen by the PCP (Primary Care Physician) who diagnosed the resident with a right pectoral muscle tear. The PCP revealed the muscle tear could have been caused by a number of ways which included turning in the bed wrong, pulling something, or being transferred incorrectly. The resident already had a degenerate shoulder and was on blood thinners. The PCP felt it would not take much to cause the injury. The PCP wrote the orders to hold the blood thinner medications a few days, apply ice to the injured area, and have PT (Physical Therapy) continue with therapy of ROM (range of motion and strengthening to the right shoulder). These were the only interventions documented in the facility report. Review of the Incident Investigation/Interdisciplinary Team Review Meeting form dated 6-27-17 revealed Resident 300 had a bruise to the right axilla/side/breast area that measured 18 cm (centimeters) x 16 cm. The PCP was made aware of the bruise and the root cause was indefinite with root cause. The documentation revealed a discussion was held to determine if the gait belt could have caused the bruise. The PCP felt it may had been multiple factors and not one single event. Interview on 7-6-17 at 2:20 PM with the DON (Director of Nursing) revealed the facility investigation into the root cause of the injury revealed no one incident caused the muscle tear but was a combination of the degenerative shoulder, an increase in the resident use of the accessory muscle related to transferring with a post-op surgical hip, and a possible incorrect placement of the gait belt during a transfer. The DON confirmed the interventions were the orders the PCP directed and the DON educated 2 nurse aides from day shift. The DON revealed the DON did not document the education provided to the 2 nurse aides. The DON revealed the 2 nurse aides educated were chosen to be educated because the resident had changed the story and said the incident happened during the day shift, not the evening shift. The DON revealed no other staff had been educated either on the resident's unit or campus wide on proper use of the gait belt after the incident because the DON had observed a couple of the staff use of the gait belt on a few residents and their technique was appropriate. The DON confirmed there was no documentation of this investigation and the results of it.",2020-09-01
3641,NYE LEGACY HEALTH & REHABILITATION CENTER,285278,3210 N CLARKSON,FREMONT,NE,68025,2019-06-19,880,D,1,0,6KP511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSE REFERENCE NUMBER 175 NAC 12-006.17 Based on observation, interview and record review the facility failed to ensure staff followed infection control guidelines during hand hygiene and wound cleansing for one resident (Resident 101) out of 3 sampled residents. The facility census was 98. Findings are: On 6/19/19 at 10:00 AM an observation of Licensed Practical Nurse (LPN) A doing wound care on Resident 101 revealed LPN A donned clean gloves and removed the old dressings. LPN A went to the bathroom sink and washed her hands for 5 seconds, put on clean gloves and cleansed the wounds. LPN A squirted Normal Saline onto the first wound, holding a folded gauze at the bottom of the wound, and then wiped the wound with the same gauze. LPN A then wiped around the wound with the same piece of gauze and then wiped across the same wound with the same gauze. LPN A discarded the gauze and continued cleansing the 3 wounds on Resident 101's leg with the same practice, using one gauze to cleanse the wound, the area around the wound and across the wound. LPN A changed her gloves and cleansed the two wounds on Resident 101's left leg, using normal saline and one piece of gauze for each wound, repeating, wiping the wound, wiping the area around the wound and wiping the wound again without changing the surface of the gauze being used. LPN A finished the wound care, gathered supplies to put away and went to the bathroom sink to wash hands for 10 seconds. On 6/19/19 at 10:15 AM an interview with LPN A revealed hand hygiene was to be performed for 15 seconds. On 6/19/19 at 10:20 AM an observation of LPN A doing a treatment on Resident 106, LPN A gathered supplies and went into the bathroom to do hand hygiene. LPN A washed her hands for 10 seconds, donned gloves and went to bedside to perform the treatment for [REDACTED]. LPN-A washed hands for 10 seconds. On 6/19/19 a record review of Handwashing/Hand Hygiene policy and procedure dated (MONTH) 2012 revealed employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water. On 6/19/19 a record review of Dressings, Dry/Clean policy and procedure dated (MONTH) 2010 revealed Cleanse the wound. If using gauze, use a clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward). On 6/19/19 at 3:31 PM an interview with the Director of Nursing (DON) confirmed hand hygiene should be done for 15 seconds and that a clean gauze should be used each time the wound was wiped.",2020-09-01
1180,PRESTIGE CARE CENTER OF NEBRASKA CITY,285109,1420 NORTH 10TH STREET,NEBRASKA CITY,NE,68410,2019-10-02,880,D,1,1,057T11,"**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 staff failed to ensure proper hand hygiene during pressure ulcer treatment for [REDACTED]. Findings are: Interview with the Resident on 09/26/19 08:48 AM revealed he had a pressure ulcer about the size of a nickel on his bottom. Observation of wound care to the Resident's buttocks on 10-2-19 at 0815 AM reveals RN G and two aides (CNA H and CNA I) in the room with resident. The Resident was prepped with brief undone, RN G came to the room from the hallway with 4x4's and a dressing (4x4 bordered dressing) marked with date and initials. RN G stated that she had washed her hands prior to entering the room. RN G donned gloves, cleaned area with 2 different 4x4's saturated with an unknown substance, (unwitnessed), after cleaning the area and drying, she then changed gloves with no hand sanitizer or hand washing and applied a new dressing. She then proceeded to take old dressing and used supplies out of the room (not in a bag), wrapped in paper towels. On 10/02/19 at 9:51 AM an interview with the DON states that staff should change gloves after the staff handle soiled material, wash hands, and apply new gloves. Record Review of the facility policy titled Clinical Management Handwashing reveals routine handwashing should be accomplished before and after contact with wounds, whether surgical, traumatic or associated invasive devices.",2020-09-01
3093,CHRISTIAN HOMES HEALTH CARE CENTER,285246,1923 WEST 4TH AVENUE,HOLDREGE,NE,68949,2019-10-03,761,D,1,1,HLI311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSED REFERENCE NUMBER 175 NAC 12.006.12E7 and 12.006.10 Based on observation, record review, and interviews, the facility failed to ensure the labels on the medications matched the Physician orders [REDACTED]. The facility census was 72. Findings are: [NAME] Observation on 10-2-19 at 8:24 AM of medication administration to Resident 9 by MA-B (Medication Aide) revealed the medication package read Vitamin D3 1000 IU (international units) x 2 (2 tablets) every day, which MA-B administered to Resident 9. Record review on 10-2-19 at 10:25 AM of Resident 9's (MONTH) 2019 MAR (Medication Administration Record) revealed Vitamin D3 2000 IU po (orally) daily. Record Review on 10-2-19 at 10:32 AM of the Resident 9's Physician order [REDACTED]. Interview on 10-2-19 at 4:30 PM with the DON (Director of Nursing) confirmed the order for the Vitamin D3 revealed to give 2000 IU and the MAR indicated [REDACTED]. The DON confirmed the facility used Medication Aides to administer medications to the residents. B. Observation on 10-2-19 at 8:15 AM revealed MA-B administered to Resident 59 [MEDICATION NAME] 2.5 mg (milligram) (a diuretic medication used to treat fluid retention), [MEDICATION NAME] 40 mg (a diuretic medication used to treat fluid retention), and [MEDICATION NAME] 25 mg (a diuretic medication used to treat fluid retention) all given at the same time. Review of the Physician orders [REDACTED]. Requested from the DON and the Administrator a report or print out from the MAR indicated [REDACTED]. Interview on 10/03/19 at 3:06 PM with HIM (Health Information Management) revealed the facility was unable to print a report but HIM was able to show me the requested information on the computer. HIM brought up on the computer the documentation which revealed for Resident 59 on 10-2-19 given at 8:24 AM was the [MEDICATION NAME], Zarolxolyn, and [MEDICATION NAME]. On 9-30-19 given at 8:15 AM was the [MEDICATION NAME], and [MEDICATION NAME]. HIM confirmed the 3 medications were documented as being given at the same time per documentation on both days. Interview on 10-2-19 at 4:30 PM with the DON confirmed the Zarolyxn should have been given 1 hour prior to the [MEDICATION NAME] and [MEDICATION NAME].",2020-09-01
5131,SOUTHLAKE VILLAGE REHABILITATION & CARE CENTER,285219,9401 ANDERMATT DRIVE,LINCOLN,NE,68526,2017-02-15,312,D,1,0,O8PQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE NUMBER 175 NAC ,[DATE].09D1c Based on record reviews, and interviews, the facility failed to ensure 1 dependent resident requiring ADL (Activities of Daily Living) assistance had call lights answered as quickly as the resident (Resident 235) requested of the 3 sampled residents. The facility census was 114. Findings are: Review of the Face Sheet dated [DATE] for Resident 235 revealed an admission date of [DATE]. Review of the face sheet dated [DATE] had the [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated [DATE] revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 235 had no cognitive impairment. Resident 235 required extensive assistance of one staff for bed mobility, toileting, and dressing. The resident required limited assistance of one staff for transfers, locomotion on and off the unit, and personal hygiene. Resident 235 required supervision with set up help only for eating. The resident was not observed ambulating during the assessment period. Resident 235 had no falls and was on hospice. Review of the Call Light report provided by the ADM (Administrator) for Resident 235 on the date of [DATE] revealed the resident's bathroom call light turned on at 12:35 PM and was turned off at 1:14 PM. The report revealed on [DATE] at 5:02 PM the resident's bathroom call light turned on and was turned off at 5:13 PM. Review of the Progress Notes dated [DATE] revealed Resident 235 was observed lying on the bathroom floor at 1:13 PM with blood present on the floor. The resident was transferred to the emergency room for laceration repair on the scalp. Review of the Progress Notes dated [DATE] revealed Resident 235 was heard yelling from the resident's room and found lying on the floor. While moving the resident to transfer, the resident became unresponsive and stopped breathing and expired. Interview on [DATE] at 3:42 PM with the ADM revealed an investigation had not been completed to explain the failure to respond to the call lights.",2020-02-01
2576,MT CARMEL HOME- KEENS MEMORIAL,285216,412 WEST 18TH STREET,KEARNEY,NE,68845,2018-12-31,677,E,1,0,U5OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE NUMBER 175 NAC 12-006.09D1c Based on record reviews, and interviews, the facility failed to ensure 5 dependent residents requiring ADL (Activities of Daily Living) assistance had call lights answered in a timely manner. Findings are: [NAME] Interview on 12-31-18 at 12:30 PM with Resident 200 revealed sometimes it took the staff a long while to answer the call lights. Review of Resident 200's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-6-18 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 12 which indicated a moderate impairment of cognition. Resident 200 required extensive assist of 2 staff with bed mobility, transfers, and toileting. Review of Resident 200's call light report for the month of (MONTH) (YEAR) revealed 38 call lights over 10 minutes (with 5 of those lights being in the 30 plus minutes, 1 at 48 minutes, 2 at 62 minutes, and 1 at 90 minutes). B. Observation on 12-31-18 at 3:20 PM in Resident 301's room revealed resident was in bed awake and the call light was on the floor on top of the fall mat beside the bed. Review of Resident 301's MDS dated [DATE] revealed a BIMS score of 4 which indicated severe cognitive impairment. Resident 301 was totally dependent on staff for transfers. Review of the facility Grievance Log revealed on 5-14-18 the family complained about the Resident 301's call light not being with in reach of the resident. C. Interview on 12-31-18 at 3:00 PM of Resident 208 revealed the resident often has had to wait 30 minutes or more to have the call light answered by staff. At times it even up to an hour. Review of Resident 208's MDS dated [DATE] revealed the resident required extensive assist with 2 staff for bed mobility and toileting. The resident was totally dependent on staff for transfers. The BIMS was 15 which indicated the resident had no cognitive impairment. Review of Resident 208's call light report for the month of (MONTH) (YEAR) revealed 37 call lights over 10 minutes. Of the 37 call lights, 4 of them were over 40 minutes and 6 of them in the 30 minute range. D. Observation on 12-31-18 at 2:40 PM of Resident 303 revealed the resident sitting in a leisure chair in the resident's room without the call light in reach. The call light was on the floor beside the chair. Interview on 12-31-18 at 2:50 PM with Resident 303 revealed there are times the resident has to wait a long time for someone to answer the call lights, even up to 1 hour. Review of Resident 303's MDS dated [DATE] revealed a BIMS of 15 which indicated no cognitive impairment. Resident 303 required extensive assist of staff for transfer, bed mobility, and toileting. Interview on 12-31-18 at 3:20 PM with NA-A revealed the facility expectation is to answer call lights within 15 minutes of the call light turning on. Review of the call light report provided by the ADM for (MONTH) 1-31st, (YEAR) revealed 66 call lights over 10 minutes. Of these 66 call lights 7 were in the 30 minute range, 4 in the 40 minute range, 3 in the 50 minute range, 2 in the 60 minute range, and 1 was 75 minutes long. Interview on 12-31-18 at 5:10 PM with the Administrator confirmed the residents were expected to have their call lights within reach at all times. Administrator also confirmed the long call lights were unacceptable.",2020-09-01
1574,"BCP BLUE HILL, LLC",285144,414 NORTH WILLSON,BLUE HILL,NE,68930,2019-06-12,689,G,1,0,HI9911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE NUMBER 175 NAC 12-006.09D7 Based on observations, record review and interviews, the facility failed to ensure one resident (Resident 1) out of 3 sampled residents did not receive [MEDICAL CONDITION] hot liquids. The facility census was 32. Findings are: Record review of Resident 1's Admission Record dated 6-12-19 revealed date of admission of 3-5-18 and [DIAGNOSES REDACTED]. Review of Resident 1's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4-21-19 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 9 which indicated Resident 1's cognition was moderately impaired. The resident had impairment in range in motion to one side of the body. Resident 1 required extensive assistance of 2 staff with bed mobility, dressing, and toileting. The resident was dependent on 2 staff for transfers and locomotion. Resident 1 required supervision of 1 staff with eating. The resident was on insulin, antipsychotic and antidepressant medications. Review of the admission/transfer/discharge/ form provided by the facility revealed the resident had been transferred to the hospital on 5-28-19 and was not in the facility during the time of the investigation. Review of PN (Progress Notes) dated 4-28-19 for Resident 1 revealed the resident had been very anxious during the evening shift which carried on into the night shift. At 2:45 AM on 4-29-19 the resident banged on the trashcan wanting to get up for the day and have a cup of coffee. The staff dressed the resident and sat the resident in the resident's wheelchair in the living room with a table to Resident 1's right side and placed the Styrofoam coffee cup with a lid on the table. The staff were not in the same room with the resident but heard the resident holler out ouch. The staff found the resident with the coffee cup tipped over and spilled coffee on the resident's pants. The resident was assessed and first aide administered. The skin assessment revealed a light pink area that blanched to the left thigh measured at 4 x 4 cm (centimeters), 2 red areas to right thigh that blanched and measured at 4 x 4.2 cm and below this area measured a 2nd site at 5 x 2.5 cm red area. Review of Skin and Wound Evaluation form for the right thigh burn wound on 4-30-19 at 7:12 AM revealed a 4.6 x 3.8 cm in size wound which appears as a reddened band of tissue with ruptured blisters within peeling edges - no signs or symptoms of infection. Doctor notified of open wounds, requested treatment orders on 4/30/19 - will follow-up. Currently cleansing and covering with [MEDICATION NAME] dressing to protect from clothing and resident scratching as witnessed with bathing. On Skin and Wound Evaluation form dated 5-16-19 revealed the right thigh burn wound measured 2.6 x 3.7 cm and the burn had darkened area of slough (dead tissue) cover. Treatment consisted of a Vaseline gauze covered with foam dressing. The facility had a contracted Wound Nurse come to the facility and assess the wound on 5-13-19. Review of the Wound Care Nurse documentation dated 5-14-19 revealed Resident 1 had a full thickness burn to the right thigh measured 3 x 6 cm with undetermined depth and serosanguinous drainage. The wound bed was 50% red/pink in color and 50% black tissue firmly adherent, hard eschar (dead tissue). Resident assessed for wound pain to have moderate pain as indicated with a furrowed brow, pursed lips, and holding breath. Recommendations were given for daily dressing changes. Review of the SOM (State Operational Manual) revealed the definition of a Third-degree burn was damage that penetrated the entire thickness of the skin and permanently destroyed tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first-and second-[MEDICAL CONDITION] third-degree burns, and dry leathery skin. The skin may appear charred or have patches that were white, brown, or black in color. Review of the facility investigation report of the burn for Resident 1 revealed on 4-29-19 at approximately 2:45 AM Resident 1 was assisted out of bed and into the wheelchair and taken to the living room at the resident's request. The resident had been agitated and had requested a cup of coffee. The NA (Nurse Aide) provided the resident with a cup of coffee in a paper cup with a lid. The staff left the resident to continue their work answering call lights and resident cares. When the staff returned to the nurse's station, they heard the resident calling out to them and observed the resident had spilled the coffee onto the front of the resident's pants. Record review of the SOM revealed Time and Temperature for a liquid to be at 155 degrees F it would only take 1 second to cause a 3rd degree burn; 148 degrees F would take 2 seconds and at 140 degrees F would take 5 seconds for a 3rd degree burn.[MEDICAL CONDITION] occur even at liquid temperatures below these listed, depending on an individual's condition and length of exposure. Review of Resident 1's medical record revealed absence of a hot liquid risk assessment. Inteview on 6-12-19 at 2:00 PM with the DON (Director of Nursing) confirmed the facility had not performed a hot liquid assessment on Resident 1 prior to the coffee burn incident or after the incident of the coffee burn. Review of Resident 1's undated Careplan revealed absence of having identified the resident at being at risk for hot liquids. The Careplan also was absent any interventions to prevent hot [MEDICAL CONDITION] lids on the resident's coffee cups prior to the incident of the coffee burn. The Careplan had an intervention dated 4-29-19 to use a bedside tray table when the resident wants to drink coffee outside of meal times and coffee/hot liquids must be served in a cup with a lid dated 4-29-19.",2020-09-01
3932,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,550,D,1,1,OLWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 12-006.05(21); 12-006.05(20) Based on observations, record review and interview; the facility failed to serve 4 (Residents 23, 30, 32, and 16) out of 4 sampled residents who were on a pureed diet, the same menu as those residents who were not on a pureed diet; and failed to ensure the resident's dignity by posting personal information about resident care in the resident room for Resident 24. The sample size was 5 and the facility census was 34. Findings are: [NAME] Observation of the noon meal service on 3/13/18 at 12:30 PM identified that Residents 16, 23, 30 and 32 were served a pureed diet that consisted of pulled pork, mashed potatoes and gravy, cauliflower and peaches. The residents that didn't have a pureed diet were served the pulled pork, sweet potatoes, cauliflower and peaches. The menu board posted outside the dining room identified the noon meal service to be pulled pork, sweet potatoes, cauliflower and peaches. A review of the dietary menu from the kitchen staff for 3/13/18 identified the meal to be pulled pork, sweet potatoes, cauliflower and peaches. Review of the facility's Food Consistency for Tuesday, (MONTH) 13th report, identified that Residents 16, 23, 30 and 32 received a pureed diet. Interview on 3/15/18 at 10:00 AM with the DM (Dietary Manager)-H and RD (Registered Dietician)-P revealed that all of the residents should have received the sweet potatoes, even Residents 16, 23, 30 and 32, who had a pureed diet. DM-H and RD-P stated the cook did not follow the menu that was posted. RD-P confirmed that the residents with the pureed diet should have been served pureed sweet potatoes and not mashed potatoes and gravy. B. Record review of Resident 24's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1/31/18 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 11 which indicated Resident 24's cognition was moderately impaired. Observation on 03/13/18 at 10:57 AM revealed a sign was posted on the outside of the closet door in Resdient 24's room and the sign stated that a heel protector was to be on the right foot at all times. Crossed out on the sign, but still able to be read, was the statement no TED ([MEDICAL CONDITION]-Embolic-Deterrent) hose to the right leg. Interview with the SSD (Social Services Director) on 03/19/18 at 12:10 PM revealed that since the resident resided in a private room the SSD did not think the sign was a concern.",2020-09-01
1867,"NORTH PLATTE CARE CENTER, LLC",285165,2900 WEST E STREET,NORTH PLATTE,NE,69101,2017-08-29,226,D,1,0,NP8D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.02(8) Based on record review and interviews, the facility staff failed to report an injury of unknown origin within 24 hours for 1 of 3 sampled residents (Resident 3) and failed to report an allegation of neglect for 1 of 5 sampled staff members. The facility identified a census of 49 at the time of survey. Findings are: [NAME] Review of NA (Nurse Aide)-G's personnel file revealed a hire date of 10/28/2014. NA-G's personnel file revealed documentation that 2 residents and 2 staff members had made allegations on 2/14/2017, 2/16/2017, and 2/17/2017 that NA-G had refused to answer call lights and assist residents with cares. Review of NA-G's personnel file revealed documentation that NA-G was terminated from employment from the facility on 2/24/2017 due to insubordination, unsatisfactory performance, and resident care standards. Review of NA-G's personnel file revealed no documentation the allegations of neglect made by the residents and staff were reported to the state agency. Interview with the DON (Director of Nursing) on 8/29/2017 at 2:48 PM confirmed the allegations made against NA-G prompted an investigation by the facility for neglect and should have been reported to the State Agency. Review of the facility policy Abuse Prevention Program & Reporting Policy revised 4/2017 revealed the following: Notify the appropriate State agency(s) immediately by fax or telephone after identification of alleged/suspected incident. Initiate process according to State-specified regulations. Neglect means any knowing or intentional act or omission on the part of a caregiver to provide essential services or the failure or a vulnerable adult, due to physical or mental impairments, to perform self-care or obtain essential services to such an extent that there is actual physical injury to a vulnerable adult or imminent danger of the vulnerable adult suffering physical injury or death. Report must be made within 2 hours: if the suspected criminal activity resulted in significant/serious bodily injury, it must be reported immediately, but no later than 2 hours after the suspicion of criminal activity is formed. Report must be made within 24 hours: if the suspected criminal activity does not result in serious bodily injury, it must be reported within 24 hours of forming the suspicion. Educate staff; they are required to immediately report concerns, incidents, and grievances, allegations of abuse, neglect, exploitation and/or misappropriation. B. Review of facility investigation form dated 12/01/2016, identified that Resident 3 complained of right knee pain on 11/25/2016 at 7:46 PM. Resident was taken to the ER (emergency room ) by the resident's family for x-rays on 11/25/2016. Resident 3 returned to the facility. The hospital faxed paperwork that stated that the resident was okay and could bear weight as tolerated. The facilty received a call from the hospital at 9:00 AM on 11/26/2016 that stated that there was an override on the x-ray and that the resident had a crack on the right knee. On 11/28/2016, resident saw an orthopedic physician and was diagnosed with [REDACTED]. The administrator called APS (Adult Protective Services) on 11/29/2016 at 4:10 PM and reported the fractured right leg injury. Interview with the Director of Nursing on 8/29/2017 at 3:10 PM confirmed that the facility was informed of the injury on 11/26/2016 and that it was not reported until 11/29/2016. DON understood that the injury should have been reported to APS within 24 hours from the notification of the injury.",2020-09-01
2875,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2018-01-02,725,F,1,1,51KH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.04 C Based on observations, record review, and interviews; the facility failed to provide sufficient staffing levels to provide Activity of Daily Living services, nutritional intake, prevention of pressure ulcer development, bowel elimination and accident prevention, with the potential to affect all residents residing in the facility. The facility census was 66. Findings are: Record review of the Facility assessment dated [DATE] revealed: The purpose of the assessment is to determine what resources are necessary, to care for residents completely, during both day to day operation and emergencies. The assessment will help make sure decisions about direct care staff needs, as well as our capabilities to provide services to the residents in the facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. Overview of the Assessment: 1. Resident profile including numbers, diseases/conditions, physical and cognitive disabilities, and acuity, and ethnic/cultural/religious factors that impact care. 2. Services and care offered based on resident needs. 3. Facility resources needed to provide competent care for residents, including staff, staffing plan, staff training/educations and competencies, education and training, physical environment and building needs, and other resources, including agreements with third parties, health information technology resources and systems, and a facility-based and community-based risk assessment. Assistance with Activities of Daily Living (ADL) : The following is the Facility Assessment of ADL's, those that are independent, require assistance of one or two staff and those dependent on staff for ADL's. Independent Assist of 1-2 staff Dependent on staff Bathing: 0 44 22 Dressing: 7 57 2 Transfer 12 51 3 Eating 47 17 2 Tilting 5 58 3 Mobility 2 38 39 The facility Nursing Services Staffing Plan revealed the following Director of Nursing (DON): one full time on days. Assistant Director of Nursing (ADON): one full time days MDS Nurse : one full time days Nursing Assistant (NA) Staffing Coordinator: Part time days RN's/ LPN's 6 am 6 PM: 2 RN's LPN's 6 AM - 2 PM -2 RN/LPN 10 PM- 6 AM-: 1 NA's 6 AM to 2 PM : 7 NA's 2 PM to 10 PM : 5 NA's 10 PM O 6 AM: 4 Based on the facility wide assessment of the resident population, and types of staff, the facility has identified the following needed competencies, based on high risk, high volume and problem prone service areas: B. Nursing Assistants 1. NA skills competency 2. Incontinent Perineal Care 3. Catheter Care 4. Transfers/Gait Belts/ Mechanical lifts 5. Vital signs C. Licensed Nurses: 1. Skills competency 2. Medication Administration 3. Injections/safer sharps 4. Glucometers 5. Dressing Changes 10. Change in condition assessment and intervention Observations during the survey process starting on 12/20/17 and ending 1/2/18, it was observed that residents had not received cares in the following area's resulting in deficient practice: * ADL's * Feeding Assistance * Repositioning * Prevention of Pressure Ulcers * Prevention of accidents * Bowel and Bladder elimination * Safe Dining Record review revealed that Staff competencies had not been performed to ensure safe transfers with use of gait belt. Observations during the survey process starting on 12/20/17 and ending 1/2/18 revealed management and corporate management staff were utilized to perform NA's duties. Observations of Resident 39 on 12/20/17 from 8:30 AM to 11:00 AM revealed that Resident 39 was in the room, in the bed, in a hospital gown. Resident 39 was observed every 15 minutes during this time with no cares provided. Observation at 11:01 AM revealed resident had odor of bowel movement. Observation of Resident 39 from 11:00 AM to 12:45 PM resident remained in room in bed in hospital gown. Observation of resident every 15 minutes during this time did not reveal Resident 39 being provided any cares, meals, or hygiene. Interview with staff revealed the following: 12/21/17 at 1: 15 NA J and NA R revealed that there was not enough staff to have someone in the dining room during meal time, therefore they had to leave resident's in the dining room unsupervised. 12/20/17- 1/26/17 Observed RN U to perform the NA duty of observing in the dining area during meals. Observation on 1/26/17 at 12:45 PM no staff present in the dining room, resident remain in dining room. Interview with MDS RN confirmed that other duties pulled from the dining duty that was being covered, d/t not enough NA's to observe dining room and provide care to other residents at that time. Interview on 12/27/17 at 3: 37 PM with the facility DON and ADON confirmed that the facility was using agency acquired staff to supplement their staffing. The ADON confirmed that NA competencies had not been completed to include Gait belt training. The facility was found to be deficient in multiple areas of regulatory compliance after the tasks of the standard annual survey was completed. Please refer to the tag citations for specific detailed findings that the facility failed to have the resources needed to provide competent care for residents, including staff, staffing plan, staff training/educations and competencies, education and training. * F 675 The facility failed to implement a bowel care regimen to prevent impaction for Resident 36. * F 676 The facility failed to ensure dentures were available for use and failed to ensure Resident 51 was assisted with dressing. * F 677 The facility failed to provide assistance with morning cares and meals for Resident 39. * F 680 The facility failed to have a activity director that meets the required qualifications. This has the potential to affect all residents in the facility. * F 684 The facility failed to ensure the coordination of care for Hospice Resident, Resident 36. * F 686 The facility failed to identify pressure ulcers, and failed to implement interventions to prevent development/redevelopment of pressure ulcers for Resident 160, 36, 51 and 3. *F 688 The facility failed to implement a specific restorative program for Resident 3. * F 689 The facility failed to implement interventions to prevent falls for Resident 38, failed to provide supervision during smoking for Resident 3, failed to utilize gait belt in a manner to prevent potential accidents for Residents 12, 21, and failed to observe patient in the dining area risking potential choking for Resident 19,32, 56. * F 690 The facility failed to ensure that Resident s were free of indwelling catheters for Resident 23, and 49. * F 692 The facility failed to assist Resident 36 with nutritional intake. * F 726 The facility failed to provide training for gait belt use and specialized equipment to maintain Range of Motion. *F 758 The facility failed to monitor behaviors for use of [MEDICAL CONDITION] medications use for Resident 52 and 160. * F 759 The facility failed to maintain a medication error rate less than 5% the medication error rate was 7.69%. * F 760 The facility failed to ensure Resident 23 was free of a significant medication error. * F 801 The facility failed to have a qualified dietary manager, this had the potential to affect all residents.",2020-09-01
6686,SUNRISE COUNTRY MANOR,285232,"PO BOX A, 610 224TH STREET",MILFORD,NE,68405,2015-11-09,223,E,1,1,HZ1311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.05 (9) Based on interview and record review, the facility failed to ensure that interventions were in place to prevent physical altercations between residents as follows: 1). (Resident 92 and 59) two altercations; 2). (Residents 92 and 36) three altercations and; 3) (Resident 11 and 46) one altercations. The facility census was 72. Findings are: A. Review of Resident 92's Admission History and Physical revealed the following Diagnoses: [REDACTED]. Review of Resident 92's Care Plan dated 8/7/14 revealed that the resident had deteriorating cognitive functioning secondary to dementia. The resident had hallucinations and delusions. The resident yelled out and was resistive with cares. The resident was physically aggressive with staff. The resident's goal was to cause no physical harm to self or others. An intervention was added on 11/2/14 that the resident reached out and grabbed another resident's wrist when the resident came up to the resident at the nurse's station. The resident was to be within arm's reach of staff at all times and not in walkway where other residents can walk or propel themselves through. Review of Resident 92's IDPN (Interdisciplinary Progress Notes) revealed: -On 11/19/14 at 7 am, the resident was awake yelling out and was seated in a wheelchair at the nurses' station. -On 11/19/14 at 4 pm, the resident was awake alert and yelling out. The resident was seated by the nurses cart and frequently grabbed at staff. The resident was redirected not to hit or grab. -On 11/21/14 at 5 pm, the resident was yelling out. The resident reached out and grabbed out at staff. -On 11/22/14 at 4 am, the resident was given an enema and the resident beat the wall the remainder of the shift. -On 11/22/14 at 11:45 am, Resident 92 grabbed Resident 59 as the resident walked by. Resident 59 picked up the resident's walker hit Resident 92 on the resident's hand twice. Review of Resident 92's IDPN (Interdisciplinary Progress Notes) revealed: -On 1/25/15 at 5:51 am, the resident was making sexual comments towards staff members and was not easily directed. The resident had yelled on and off during the night. -On 1/25/15 at 5:30 pm, Resident 92 was in a w/c (wheel chair) in the main lobby and the resident grabbed Resident 59. Resident 59 grabbed the resident walker and hit Resident 92 five times. Resident 92 was not injured. The nurses immediately placed Resident 92 at the nurse's station. Review of the facility Procedure for Abuse Prevention dated as revised (MONTH) 2009 revealed that staff were to identify, correct, and to intervene in situations where abuse or neglect by analyzing for compatible roommates, staff training and supervision of residents, and assessment and care planning with interventions that were updated and succeeded and failed. Interview on 11/4/15 at 3 pm with the ADON (Assistant Director of Nursing) revealed that Resident 92 reached out and grabbed Resident 59 when Resident 59 was walking by. Resident 92 did not single Resident 59 out. Resident 92 was to be seated at the Nurses Station right by the charts and not in the main lobby area where the resident would have access to grab other residents. B. Review of Resident 36's History and Physical dated 3/4/15 revealed the following Diagnoses: [REDACTED]. Review of Resident 36's IDPN revealed that, on 8/31/14 at 2:45 pm, Resident 92 was found lying in Resident 36's bed. Resident 92 was sidelying and hanging onto of Resident 36's left leg and wrist. Review of the 8/31/15 Resident to Resident investigation revealed that Resident 36 sustained one red area on the resident's left leg measuring 4.5 cm (centimeters) by 3 cm and a red area on the resident's left wrist measuring 2 cm by 1 cm. The injury did not require medical attention. Resident 36 was transferred to another room for protection. Resident 92 was assisted back to bed. The final report determined that Resident 92 should be in a private room. Resident 92 was placed in the resident's wheelchair and taken to the main lobby where staff could closely monitor the resident. Interview with the SSD (Social Service Director) on 11/9/15 at 3:30 pm revealed that it was determined by the management team that Resident 36 could return to room with Resident 92 since Resident 92 was non-ambulatory after the incident on 8/31/14. Review of Resident 92's IDPN revealed that, on 2/5/15 at 3 pm, the resident walked out of the resident's room and sat down in the hallway. Review of Resident 92's Physician Fax Cover Sheet revealed: -On 1/23/15 the hospice nurses reported that behaviors were escalating. The resident was on [MEDICATION NAME] 2 mg (milligrams) per 1 ml (milliliter) every 4 hours. The nurse recommended to increase the [MEDICATION NAME] to 3 ml or 6 mg every 4 hours for the resident's behaviors. The resident was seen by the physician and ordered [MEDICATION NAME] 6 mg every 4 hours. -On 1/28/15 the resident attempted to stand from the wheelchair and fell . -On 2/14/15 the resident was observed laying on the floor underneath Resident 36's bed. Review of Resident 36's IDPN revealed: -On 3/22/15 the resident was observed in bed laughing. Resident 92 was in the resident's bed hugging Resident 36. The resident did not have any injury. -On 3/29/15 at 2 am, Resident 92 was observed on top of Resident 36. Resident 36 had scratches on the resident's forehead with four open superficial areas. There was a scratch below Resident 36's left eye and upper lip. -Resident 36 was moved to another room for protection. Review of the facility resident to resident report dated 3/22/15 revealed that Resident 92 was found in Resident 36's bed unclothed hugging Resident 36. Resident 92 had previously been found on Resident 36's side of the room before. Resident 92 had behavior of repositioning self near Resident 36's bed. Resident 92 was put on 15 minute checks for the remainder of the night shift. An alarm was placed on Resident 92's bed. There were no available rooms to move either residents to. Conclusion was that Resident 92 was very difficult to place with any roommates due to constant yelling. Resident 36 was nonverbal. Staff were looking into medication changes for Resident 92. The conclusion was this was an isolated incident. Interview with the DON (Director of Nursing) on 11/4/15 at 3:45 pm revealed that Resident 92 did not have a roommate for the remainder of the resident's stay after the resident to resident interaction on 3/29/15 with Resident 36. The Resident 92's behaviors were difficult to manage. Review of the facility's Abuse Prohibition Investigation Protocol reviewed (MONTH) 2009 revealed that residents were to be protected from harm during an abuse investigation. Occurrences were to be analyzed to determine what changes were needed to prevent further occurrences. C. Review of Resident 11's History and Physical dated 10/10/15 revealed the following Diagnoses: [REDACTED]. Review of Resident 11's Care plan dated as reviewed on 10/29/15 revealed that the resident reached out and grab others at times. The resident was physically aggressive towards staff during cares. The resident was affectionate in nature and did not know the difference between appropriate and inappropriate touch. The resident could go very quickly from gentle to aggressive touch. The resident's goal was to not cause physical harm to self or other residents. The resident was to be within an arm's length away from staff and within eyeshot of the staff. Review of Physician Fax Cover Sheet dated 7/22/15 revealed Resident 11 grabbed Resident 46 in the hallway. Resident 46 hit the resident in the back of the resident head. Resident 11 grabbed Resident 46 and then Resident 46 hit the resident on the arm. There was no injury to either resident. Interview with the ADON on 11/4/15 at 10 AM revealed that Resident 11 grabbed out at staff and residents that would come close. Resident 46 would take the resident grabbing at the resident as a personal insult and would respond by hitting. The resident had angry outbursts anything could set the resident off.",2018-11-01
2357,GOOD SAMARITAN SOCIETY - RAVENNA,285202,411 WEST GENOA,RAVENNA,NE,68869,2017-11-28,641,D,1,0,VQ0X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure that 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.) was accurately coded to reflect the resident's ADL (activities of daily living) status for toilet use. This affected Resident 2. The facility census was 39. Findings are: Review of the MDS, dated [DATE], for Resident 2; identified that the resident required extensive assistance with one person physical assist for toilet use. Review of the comprehensive care plan, revised date 10/10/2017, for Resident 2; identified that the resident required 2 person assist with a high back sling with the total lift for toilet use. Interview with the DON ( Director of Nursing) on 11/28/2017 at 10:30 AM revealed that the MDS for Resident 2 was incorrectly coded for toilet use. The DON confirmed that the resident required a 2 person assist with the full lift for toileting.",2020-09-01
3646,RIDGEWOOD REHABILITATION & CARE CENTER,285279,624 PINEWOOD AVENUE,SEWARD,NE,68434,2017-05-04,278,D,1,1,RJ9E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.09B Based on record review and interviews, the facility failed to ensure the MDS (Minimum Data Set) reflected the current status and care provided for Resident 11 and 84. Sample size was 39. Facility census was 68. Findings are: [NAME] Review of the admission orders [REDACTED]. Review of the Admission 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 1/20/2017 did not identify Resident 84 with metastatic [MEDICAL CONDITION]. Interview with the Assistant Director of Nursing on 5/03/2017 at 4:00PM confirmed [MEDICAL CONDITION] should have been identified as an active [DIAGNOSES REDACTED]. B. Review of the Quarterly MDS dated [DATE] for Resident 11 identified that the resident needed supervision with set up assistance with eating. Review of the Comprehensive Care Plan dated 3/13/2017 for Resident 11 identified the resident as independent with eating after set up assistance. Interview on 5/04/2017 at 11:30AM with Resident 11 revealed that the nursing staff placed the lap tray on the Resident while in the bed, took off the clear plastic wrap covering the dishes and took off the paper from the straws, then they left the room. Resident 11 stated that the nursing staff did not stay in the room while the Resident ate nor did the nursing staff encouraged the resident to eat. When the Resident was finished with the meal, the Resident turned on the call light to have the room tray removed from the room. Interview with NA-B on 5/04/2017 at 11:28AM confirmed that NA-B provided set up assistance only for Resident 11 when they took the room tray to Resident 11's room. NA-B stated that the nursing staff placed the meal tray on Resident 11's lap table, took off the clear plastic wrap that covered the dishes and the paper from the straws for the drinks, then left the room. NA-B confirmed that the nursing staff did not provide encouragement to the Resident to eat the meal and Resident 11 would use the call light when finished with the meal. Review of the Nursing Progress Notes dated 3/04/07 - 3/10/2017 identified Resident 11 as independent with eating with set up assistance. Interview on 5/04/2017 at 8:00AM with the Assistant Director of Nursing (ADON) confirmed that Resident 11's Comprehensive Care Plan was documented as independent with eating but the MDS was documented as superivision with eating. ADON also confirmed that the Nursing Progress Notes from 3/04/2017 - 3/10/2017 indicated the Resident as independent with eating.",2020-09-01
1888,"PREMIER ESTATES OF KENESAW, LLC",285166,"P O BOX 10, 100 WEST ELM AVENUE",KENESAW,NE,68956,2018-02-22,637,D,1,0,VY6911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.09B1(2) Based on record review and interviews, the facility failed to complete a significant change Minimum Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) for 1 (Resident 10) who was admitted to hospice services. The sample size was 3 and the facility census was 46. Findings are: Interview on 2/21/2018 at 1:30 PM with NA B identified that Resident 10 was receiving hospice services. Review of a hospice progress note on 12/15/18 at 5:37 PM revealed that Resident 10 was admitted to hospice care for late effects of Cerebral Vascular Disease with resulting [MEDICAL CONDITION]. Review of a hospice provider document identified that Resident 10 was admitted to hospice. Review of the facility MDS schedule for Resident 10 did not identify that a significant change MDS was completed for the resident when they were admitted to hospice care. Interview on 2/22/18 at 11:15 AM with RN A confirmed that a significant change MDS was not completed within the required time frame for Resident 10 when they were admitted to hospice care. RN A acknowledged that a significant change MDS should have been completed when the resident was admitted to hospice care within the required 14 days.",2020-09-01
6173,RIDGEWOOD REHABILITATION & CARE CENTER,285279,624 PINEWOOD AVENUE,SEWARD,NE,68434,2016-06-20,280,D,1,0,G6RN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.09C1c Based on observation, interview, and record review, the facility failed to review and revise three residents' (Residents 1, 3, and 5) Comprehensive Care Plan interventions to assist in preventing fall reoccurrence. The facility census was 75. Findings are: A. Review of Resident 1's History and Physical dated 4/12/16 revealed that the resident had both shoulders with dislocations and the shoulders were frozen. The resident also had compression fractures of the spine. The resident had bilateral pes planus (flat footed) with some tibial (large bone in lower leg) tendonitis (inflammation in tendon). Review of Resident 1's Fall Risk assessment dated [DATE] revealed that the resident had a total risk score of 16. A total risk score of 10 or more indicated a high risk for falls. Review of Resident 1 MDS dated [DATE] revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 15/15 (cognitively intact). The resident required extensive assistance of two assistance with bed mobility, transfers, dressing, and toilet use. The resident required total staff assist with personal hygiene and wheelchair locomotion in and out of the resident's room. The resident was non ambulatory. The resident required physical assistance with transferring from one surface to another surface safely. The resident was impaired with one sided upper body range of motion. Review of Resident 1's Comprehensive Care Plan dated 4/25/16 revealed that the resident had a history of [REDACTED]. The resident took medications for high blood pressure. The resident had a goal to not receive injuries from a fall. The resident required 2 staff assistance with bed mobility and transfers. The resident required assistance with wheelchair mobility. The resident's care plan was updated on 6/16/16 with the following information: the resident was able to s/p (self propel) and the resident had pressure reducing mattress and wheelchair cushion. Additional information was added on 6/20/16 that included: poor trunk control and limited range of motion in the resident's upper extremities. Review of Resident 1's Acute Care Plan dated 6/13/16 stated that the resident had actual skin impairment on the resident's forehead. The goal was to heal existing area. Interventions included: medication and treatments as ordered per the physician, weekly skin assessments, and monitor for signs and symptoms of infections, monitor for pain, and therapy screen as needed. The Care Plan was not revised to include the resident's sutures were to be taken out in 8 days and to ensure immunization status in regards to tetanus. Review of Resident 1's Fall Scene Investigation and Report revealed at first the resident was involved in an unwitnessed fall with a laceration on the resident's forehead that required transfer to the hospital for sutures on 6/12/16 at 7:30 PM. The immediate intervention was to re-teach the resident to use the call light and to wait for staff assistance. After additional investigation it was determined that the resident was being assisted by facility staff when the resident fell . The resident did not have foot pedals on the resident's wheelchair to assist with locomotion. Review of the Comprehensive Care Plan did not reveal that the resident was immediately educated to use the call light and wait for help or for staff to use the resident's foot pedals when assisting the resident in the wheelchair. Interview with the DON (Director of Nursing) on 6/16/16 at 3:15 AM revealed at first the investigation looked like the resident was self propelling self into the bathroom and fell unwitnessed. After additional interviews were conducted it was determined that staff was present in the room as was assisting the resident. The DON acknowledged on this dated that the Comprehensive Care Plan had not been updated from the fall to educate the resident immediate intervention. The DON stated the investigation was not completed. B. Review of Resident 3's emergency room Report on 5/21/16 revealed that the resident fell and had the [DIAGNOSES REDACTED]. Review of Resident 3's 6/11/16 MDS revealed that the resident had a 14 day BIMS score of 11 (moderate cognitive loss). The resident had an altered level of consciousness. The resident had a total mood score of 11 (moderate depression). The resident required two staff assistance for bed mobility, and dressing. The resident required total assistance of two staff members with transferring and toilet use. The resident required total assistance with wheelchair mobility. The resident was non ambulatory, had impaired balance, and impairment on one side of upper and lower range of motion. The resident received physical and occupational therapies. Review of Resident 3's Fall Risk assessment dated [DATE] revealed that the resident had a fall risk score of 14 (high risk). On 5/25/16 the resident's fall risk score was elevated to 22 (high risk). Review of Resident 3's Fall Scene Investigation and Report dated revealed that the resident fell on [DATE] at 8:30 PM, when the resident attempted to self-transfer in bathroom. The fall was unwitnessed, but a staff member was in the resident's room. The resident told staff that the resident thought the resident was able to walk self from toilet to bed. The resident's assistive device was in use. The immediate initial intervention was to stay with the resident while on the toilet. The medical review revealed that the resident had a [DIAGNOSES REDACTED]. Review of the IDPN (Interdisciplinary Progress Notes) dated 5/25/16 at 4:30 PM revealed that the resident had returned to the facility. Review of Resident 3's Comprehensive Care Plan dated 12/10/15 sent to State Agency on 5/27/16 revealed that no new interventions were put in place to prevent further falls. The resident ambulated with front wheeled walker and gait belt, ambulated in room, and used a wheelchair with assist with locomotion outside of room. The resident's bed and chair alarm was discontinued on 5/21/16. No other safety interventions were added. The resident transferred with 1 assist, gait belt, and front wheeled assist. Review of Resident 3's Current Care Plan identified by the facility dated 12/10/16 had an addition added left hip and wrist fracture on 6/14/16. On 5/21/15 an intervention was added to stay with resident while on toilet, even if just in the room to prevent self transferring without the alarm present. An intervention added on 4/1/0/16 Put recliner controls in side pocket on recline when not in use that was discontinued on 5/31/16. On 5/27/16 new interventions included: total body lift with 2 staff members, wheelchair with assistance for mobility. Interview with RN (Registered Nurse) A on 6/16/16 at 10:15 AM revealed that the resident's goal to stay with the resident was initial changed due to the resident not wanting staff while on the toilet. It was acceptable for staff to be in the resident's room and not bathroom. Interview with the DON on 6/16/16 at 3:15 PM stated that Resident 3 had staff with the resident while using the toilet since the resident used the mechanical lift. The DON was unable to explain the difference in the Comprehensive Care Plans. C. On 6/16/16 at 10:38 am, review of admission data sheet for Resident 5 revealed admitted to facility on 4/15/16 for fracture of foot. Further medical record review: - A nursing note entry of Resident 5 revealed: fall on 6/4/16 a Saturday at 1:30 pm, attempted to sit on edge of bed and sat on a manilla envelope and slipped off bed and on way down heard a cracking noise and felt pain in low back of a 9 out of 10. Tylenol (pain medication) given to resident. - A Physician notification via fax on 6/4/16 of fall with back pain, was not noted by any physician until 6/6/16 with a note of send to the ER (emergency room ) per Resident 5's primary physician. A second entry noted on this same facsimile document stated phone call to set up appointment with physician tomorrow on 6/7/16. - Comprehensive Care Plan stating Fall risk, history of fall, poor safety awareness. Review of approaches listed under fall concern stated none at this time. - Observation of Resident 5 seated on edge of bed on 6/15/16 at 12:49 pm noted bedspread for resident was hanging to the floor on the corridor view side of bed and only covering two inches of mattress on the back side of the bed (indicating as the resident was seated on bed the bedspread would shift forever with the residents weight and movement). Papers were strewn on the bed and also two papers were on the floor to the residents right side. -After the fall on 6/4/16, the facility had not implemented in additional safety interventions as of 6/15/16. Resident 5 remained at risk for additional falls/sliding off the bed as no assessment for causal factors or environmental changes needed had been completed. -Interview with Charge Nurse Y on 6/16/16 at 10:38 am revealed just today (12 days after fall with compression fracture injury) I added a triangle top metal grab bar to the side of the bed to help Resident 5 get up.",2019-06-01
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
1766,PLUM CREEK CARE CENTER,285159,1505 NORTH ADAMS STREET,LEXINGTON,NE,68850,2018-05-02,657,D,1,0,GG8Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.09C1c Based on record review and interviews, the facility failed to revise the comprehensive care plan for 2 (Residents 1 and 5) out 5 sampled residents for advanced directives. The facility census was 36. Findings are: Review of the facility's new admissions for the past 3 months identified that Resident 1 was admitted to the facility on [DATE]. Review of the comprehensive care plan for Resident 1 did not identify what the advanced directive wishes were for Resident 1. Review of the facility's new admissions for the past 3 months identified that Resident 5 was admitted on [DATE]. Review of the comprehensive care plan for Resident 5 did not identify what the advanced directive wished were for Resident 5. Interview on 5/02/18 at 1:10 PM with the MDS (Minimal Data Set) Coordinator revealed that the advanced directives for Resident 1 and 5 were not included on the resident's comprehensive care plan. MDS Coordinator confirmed that the advanced directives should have been included on the resident's care plan. Review of the facility document titled, Advance Directives, with a revised date 11/2016; identified that The resident's/guardian's and/or family's decision will be entered into the individual care plan and be reviewed as per individual care plan policy and procedure. Interview on 5/02/18 at 3:00 PM with the ADM (Administrator) confirmed that the advanced directives for Resident 1 and 5 were not on their care plan and should have been.",2020-09-01
6668,GRAND ISLAND PARK PLACE CARE AND REHABILITATION CE,285105,610 NORTH DARR AVENUE,GRAND ISLAND,NE,68803,2015-11-19,309,G,1,0,67D811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.09D2c Based on observation, interview, and record review the facility failed to ensure that one resident (Resident 8) received wound care to promote the healing of the resident's wounds. The facility census was 54. Findings are: Interview with Resident 8 revealed that the facility staff had not done the Wound V.A.C. (wound healing through negative pressure wound therapy) dressing changes as ordered by the resident's physician. The resident stated that the dressing change was to occur three times weekly. The resident stated that staff stated that they did not know how to care for the resident's Wound Vac, the resident was too complex, staff were too busy, it was too late in the day to do the residents Wound Vac dressing change, or there was not enough staff to change the Wound Vac dressing. The resident stated that, by not getting the dressing changes, this had caused the resident to have to go through additional debridement (medical removal of dead, damaged or infected tissue to improve healing potential for healthy tissue) and hospitalization for a wound infection since the resident's admission to the facility (MONTH) (YEAR). Review of Resident 8's Order Review Report Dated 9/14/15 revealed that the resident had a [DIAGNOSES REDACTED]. The resident's order to treat the [MEDICAL CONDITION] and abscess on the lateral malleolus (outer ankle) and left lateral foot ulcer with a Wound Vac at 125 mm / Hg (millimeters of mercury) coat pressure one time a day every Monday, Wednesday and Friday through 9/5/15. On 9/5/15 the Wound Vac order was to be changed to once daily on Tuesday, Thursday, and Saturday related to [MEDICAL CONDITION] and abscess of the foot. Review of Resident 8's Consultant/ Clinic Referral dated 8/4/15 Follow up visit revealed that the resident had a [MEDICAL CONDITION], osteo[DIAGNOSES REDACTED] (bone infection) and multiple drug resistant bacteria. The resident had an extensive left foot diabetic foot wound infection and required six weeks of antibiotics on 8/14/15. The orders included to finish intravenous [MEDICATION NAME] (antibiotic) and Meropenem (antibiotic) to end on 8/14/15. On 8/15/15 the resident started [MEDICATION NAME] (oral antibiotic) 100 mg (milligrams) twice daily for two weeks. The physician ordered laboratory tests. Review on 8/14/15 from the Wound Clinic Visit documentation revealed: -Wash all wounds with soap and water at dressing changes. -Wound Vac 125 mmHg continuous with a black sponge to left lateral foot and left lateral foot distal three times a week. -[MEDICAL CONDITION] wear to both lower legs base of toes to below knees. Do not have Vac tubing underneath. Run the Vac tubing through a hole in the [MEDICAL CONDITION] wear. -The resident was non-weight bearing to the resident's left foot except for the left heel for pivot transfers. Review of Resident 8's Wound Clinic Visit on 10/23/15 documentation revealed: -The resident was finished with the antibiotic. -The resident had more [MEDICAL CONDITION] in left foot. The resident kept feet up except when eating. -The resident's Wound Vac pressure was increased to 150 mmHg continuously with a black sponge. The sponge was to be changed three times weekly. -The wounds were to be washed with soap and water at each dressing change. Review of Resident 8's Wound Clinic Visit documentation dated 10/29/15 revealed: -The left foot was more swollen around the ankle. -There was an increase in serosanguinous drainage (blood and serum part of the blood leaving the body from a new wound) under the dressings. -The resident was having more pain and had medication adjustment for pain. -The resident's Wound Vac pressure remained at 150 mm Hg continuously with a black sponge. The sponge was to be changed three times weekly. -The wounds were to be washed with soap and water at each dressing change. -The resident was to remain at non-weight bearing on both feet.-The resident was to elevate both legs as much as possible. Review of Resident 8's (MONTH) (YEAR) TAR (Treatment Administration Record) revealed: -The resident's Wound Vac order on 10/23/15 for an increase in pressure from 125 to 150 mmHg was not updated. The order still read Wound Vac at 125 mm on both feet to be changed on Monday Wednesday and Friday to continuous suction. -The residents Wound Vac dressing change was not completed on 11/4/15. Review of Resident 8's (MONTH) (YEAR) TAR revealed: -The resident had an order for [REDACTED]. -The resident's Wound Vac order on 10/23/15 for an increase in pressure from 125 to 150 mmHg was not updated. -The residents Wound Vac dressing changes were not completed on 10/19/15, 10/21/15, 10/23/15, and 10/28/15. -The resident received intravenous [MEDICATION NAME] (antibacterial medication) 600 mg twice daily for [MEDICAL CONDITION] and non-pressure ulcer for 14 days. -The resident was hosptalized on [DATE]. Review of Resident 8's (MONTH) (YEAR) TAR revealed: -There was an order to change the resident's Wound Vac dressing three times weekly on Tuesday Thursday and Saturday with an order date of 9/5/15. -The Wound Vac dressing was changed three times weekly and the wound was to be washed with soap and water before reapplying the new dressing. The washing of the wound was set for Monday, Tuesday, Wednesday, Friday, and Saturday. -The resident did not receive treatment on 9/1/15, 9/3/15, 9/5/15, 9/8/15, 9/10/15, 9/12/15, and 9/24/15. -The resident was hospitalized [DATE]- 9/30/15. Review of Resident 8's (MONTH) (YEAR) TAR revealed: -The resident had an order for [REDACTED]. -The resident did not receive the Wound Vac dressing change on 8/10/15, 8/17/15, 8/19/15, 8/21/15, 8/24/15, 8/26/15, 8/28/15, and 8/31/15. -the resident completed the dose of intravenous Meropenem and [MEDICATION NAME] to treat the resident's [MEDICAL CONDITION] and abscess of the resident's foot. Review of Resident 8's (MONTH) (YEAR) TAR revealed: -The resident had an order for [REDACTED]. The Wound Vac was on hold from 7/1/15 through 7/10/15. -The resident's Wound Vac dressing was not changed on 7/20/15 and 7/24/15. -The resident completed a 14 day cycle of [MEDICATION NAME] 100 mg twice daily for the resident's [MEDICAL CONDITION] and abscess of foot except toes which was ordered on [DATE]. -The resident received different courses of [MEDICATION NAME] throughout the month for [MEDICAL CONDITION] and abscesses. Review of Resident 8's Progress Notes revealed: -There were no progress notes on 10/23/15 regarding the resident's visit to the Wound Clinic and order change of the Wound Vac pressure. -On 10/30/15 at 10:29 am it stated that the resident went to see the wound doctor. The nurse stated that the wound was swollen purple and soft around the heel area where it was debrided on the left foot. The resident's orders stated to return to the clinic in three weeks and continue with the same treatments. -On 11/12/15 at 3:05 pm there was a late entry that stated that the Wound Vac was on at 125 mmHg with serosanguinous drainage. The resident was complaining of pain. Interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing) on 11/19/15 at 3 pm were unaware that Resident 8's treatments were not being done.",2018-11-01
6593,UTICA COMMUNITY CARE CENTER,285161,1350 CENTENNIAL AVENUE,UTICA,NE,68456,2015-12-08,309,D,1,0,UTS911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.09D2c Based on observation, interview, and record review; the facility failed to ensure that two residents (Residents 1 and 4) wounds were assessed and interventions were in place to promote the healing of the resident's wounds. The facility census was 35. Findings are: A. Review of Resident 1's History and Physical dated 7/15/15 revealed that the resident had a [DIAGNOSES REDACTED]. Review of Resident 1's Care Plan revealed that the resident was at risk for pressure ulcers related to impaired mobility related to [MEDICAL CONDITION] (paralysis below the waist). The resident recently healed left and right heel ulcers and on 11/21/15 developed a right buttock open area. Interventions included: chair pad to reduce pressure, encourage the resident to reposition routinely, elevate heels in bed, heel protectors on at all times except may remove for cares, encourage the resident to allow staff to do cares on rounds. The Incident Report dated 10/28/15 stated that Resident 1's blister on the right heel was the resulted from [MEDICAL CONDITION] and refusal to remove TED hose and shoes and to lay down. The resident was to wear heel protectors instead of shoes and encouraged to lay down instead of sitting up in the resident's wheelchair. The heel was to be monitored daily for healing progress, signs of infections. Review of Physician Fax dated 11/5/15 from Dietary Manager to Physician revealed that Resident 1 had pressure ulcers to heels and asked the physician for permission to add extra protein at meals. The physician approved. Review of Physician Fax dated 11/12/15 the resident was refusing the high protein snack for wound healing. The resident stated that it was pointless and wanted it discontinued. Review of Physician Fax dated 11/9/15 the dietitian requested a daily multivitamin with minerals and a high protein morning snack. The physician approved. Review of Resident 1's Right Heel Daily Wound Record revealed that on 11/25/15 the area was a scabbed over dry blister 2 cm (centimeters) by 1 and 1/2 cm in size. The right heel was resolved on 11/30/15. Review of Resident 1's Left heel blister Daily Wound Record was resolved on 11/25/15. Review of Resident 1's Physician Fax dated 11/21/15 revealed that the resident had an area on the resident's right buttock that was 1.4 inches in length and 2 cm in width. The skin was intact but discolored a purple color. The resident stated that it was a bedsore from not being taken care of and staying in bed. On 11/23/15 the physician ordered [MEDICATION NAME] (a foam dressing used for pressure or diabetic ulcers can be cut to fit area) to area every day. Review of Resident 1's Initial Wound Evaluation dated 11/21/15 revealed that the resident had a deep tissue injury (pressure ulcer with injury to tissues under the skin dangerous lesion with rapid potential for rapid deterioration). The wound was not open and was 1.4 inches long and 2 cm in width with no depth. The wound was purple in color. The resident did not have pain. The current treatment was to monitor twice daily until healed. Review of Resident 1's Daily Wound Assessment for the Week of (MONTH) 20, (YEAR) revealed that [MEDICATION NAME] to area was added and to change as needed. On 11/21/15 an open area to the right buttocks was 3.4 cm in length and 1.8 cm in width superficial. The wound base was beefy red with a defined wound edge. The wound was not painful and there was no drainage or odor. The wound was checked again on 11/25/15, 11/27/15, 11/30/15, 12/1/15, 12/5/15, and 12/6/16. On 11/30/15, 12/1/15, and 12/6/15 the entry stated [MEDICATION NAME] intact. The other dates did not indicate the size of the wound. Review of Resident 1's Treatment Sheet dated (MONTH) (YEAR) revealed: -The order for [MEDICATION NAME] to area on right buttock daily until healed started on 11/24/15. -The [MEDICATION NAME] was documented as done on 11/24/15 and 11/25/15. -On 11/21/15 the monitoring of the purple area on the right buttock changed from twice daily to weekly on Saturday. The resident's wound was not documented as done on 11/27/15. Review of Resident 1's Treatment Sheet dated (MONTH) (YEAR) revealed: -Measure purple area to right buttock weekly on Saturday. -It was initialed that the resident's wound was measured but it was not documented. -[MEDICATION NAME] to area on right buttock daily until healed. -Resident may wear gripper socks when up for dignity. Interview with RN (Registered Nurse) A on 11/24/15 at 5:05 AM revealed that Resident 1 had a pressure ulcer (localized injury to skin and/ or underlying tissue over a bony prominence) on the resident's ischial tuberosity (weight bearing point in the sitting position of the pelvis). The resident's treatment was a DuoDerm dressing (DuoDerm dressing indicated for full-thickness wounds, pressure ulcers staged 2- IV, superficial wounds, partial thickness burns, and donor sites). The RN stated that at times the resident would stay up in the resident's wheelchair and not lie down if the staff the resident liked was not working. The resident would allow the night shift to empty the resident's catheter one time during the night. The resident would not allow staff to turn the resident. Observation of Resident 1 on 11/24/15 at 5:59 AM the resident was lying in bed with pillows to support arms and legs. The resident stated as comfortable as can be. The resident had an air mattress on the resident's bed Observation of Resident 1 on 12/8/15 at 12:10 PM revealed that the resident was up in the resident's electric wheelchair eating lunch the resident had a cushion in the wheelchair feet were on the foot rest. The resident's feet were [MEDICAL CONDITION] (swollen). The resident was wearing gripper socks. Interview with Resident 1 on 12/8/15 at 12:34 PM revealed that the resident stated the resident had a wound on the resident's right buttock. The resident stated that was in bed all day yesterday and it was hard to receive cares and to eat. The resident stated that the resident did not want some staff providing care for the resident and did not know what they were doing. The resident stated laid on the resident's right side and it was done a certain way with pillows a certain way. The staff use a mechanical lift to get the resident in and out of bed. The resident stated he was paralyzed from the waist down and had partial use of the resident's hands. Observation of Resident 1's cares on 12/8/15 at 1:15 PM revealed: -The resident refused to allow his wound on his buttock to be viewed. -NA (Nurse Aide) J and NA L transferred the resident to bed. The resident was wearing gripper socks. -NA J removed the resident's TED (elastic hose to prevent swelling) and reapplied the resident's gripper socks. The resident's heels had dry flakey skin. Left heel had a pinpoint scab. -The NAs positioned the resident on the right side with pillows until the resident was comfortable. Interview with Resident 1 on 12/8/15 at 1:30 PM stated that the resident was comfortable and refused for LPN (Licensed Practical Nurse) C to come to the resident's room to change the resident's dressing. Review of the facility Skin and Wound Management Program Overview dated 3/10/15 revealed that whenever a new wound was identified a licensed nurse would completed the Initial Wound Review Form. The staging of pressure ulcers was to be performed by a RN or a LPN wound certified. If the wound was identified as a pressure ulcer, the wound would be documented with staging on the Initial Wound Review. The licensed nurse would initiate the New Wound Quality Improvement Checklist to be used as a guideline to ensure the resident received the services needed. All wounds were to be monitored daily with documentation on the Daily Wound Review. Weekly Wound Progress Review would include location and staging of pressure ulcer, size measurement of greatest length width and depth, presence, location and extent of undermining, or tunneling, appearance of the wound bed, drainage, pain, and surrounding tissue . Interview with the DON (Director of Nursing) on 12/8/15 at 4:18 PM stated that Resident 1 did not have a deep tissue injury on the resident's right buttocks. The DON remembered getting phone call about that and remembered looking at the wound. It looked more like a bruise than a deep tissue injury there was never any depth. The DON acknowledged that Resident 1's wounds were not monitored according to the facility's policy and procedures. The DON stated that there was no particular wound nurse that all nurses were responsible for assessing wounds. B. Interview with the DON on 12/8/15 at 12:15 PM revealed that Resident 4 had a DuoDerm on the resident as protection only. The resident went to the Wound Clinic for treatment of [REDACTED]. Review of Resident 4 Daily Wound Assessment to the left ischium stated on 12/7/15 that there was a 0.8 cm by 1 cm abrasion area on the left ischium. DuoDerm was applied for protection. On 12/7/15 [MEDICATION NAME] was applied. Review of Resident 4's 12/6/15 Physician Fax revealed that the DuoDerm to the resident's bottom sticks to the resident's skin and had been causing abrasions. an order for [REDACTED]. Review of Resident 4's (MONTH) Treatment Sheet revealed that the [MEDICATION NAME] was implemented on 12/7/15. Observation of Resident 4 on 12/8/15 at 12:55 PM revealed that the resident was seated in the resident's recliner with feet elevated on a pillow. Observation of Resident 4's cares on 12/8/15 at 2:30 PM revealed: -NA L and NA M assisted the resident from the resident's recliner to commode with a mechanical lift. -The resident was seated on a Roho cushion (special cushion to prevent pressure) in the resident's recliner. - The resident was raised in the lift for cares and on the resident's left buttock the resident had a large area approximately 4 cm in length by 3 cm in width of peeling skin with a .5 cm x .5 cm superficial open area. -NA L applied A and D ointment to the wound area on the resident's buttock. -The resident was positioned in bed on the resident's back with legs elevated to relieve [MEDICAL CONDITION]. The resident's head of the bed was elevated. -The resident had an Encompass air mattress on the bed. Observations of Resident 4's left buttock on 12/8/15 at 4:30 PM revealed that there was some remaining adhesive material that peeled off leaving an abraised appearance of a wound. The pealed area of former observation on 12/8/15 was now open with approximately 6 superficial areas with a red wound bed. Interview with the DON on 12/8/15 at 4:30 PM stated that the facility was out of [MEDICATION NAME] and it was scheduled to arrive the next day. The dressing was soiled in the morning and had to be removed.",2018-12-01
5987,GOOD SAMARITAN SOCIETY - BLOOMFIELD,285156,"P O BOX 307, 300 NORTH SECOND ST",BLOOMFIELD,NE,68718,2016-07-18,315,D,1,0,363M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.09D3 (6) Based on observation, record review and interview; the facility failed to provide treatment and services for an indwelling urinary catheter (tube inserted into the bladder to drain urine) to prevent urinary tract infections for 1 resident (Resident 4). The facility census was 31. Findings are: A. Review of facility policy titled Catheter Care with revision date of 11/13 revealed the following: -Cleanse the urinary meatus in female residents from front to back and then cleanse for four inches down the catheter tubing. -Make sure the urinary collection drainage bag and tubing remain below the level of the catheter and bladder. B. Review of Resident 4's Minimum Data Set (MDS-a federally mandated comprehensive tool used for care plans) dated 6/8/16 revealed the resident had short and long term memory loss with severely impaired decision making skills. No behaviors were identified. The resident required extensive staff assistance with activities of daily living which included; transfers, toileting and personal hygiene. The assessment indicated Resident 4 was frequently involuntary of bowel and had an indwelling urinary catheter. Review of Resident 6's physician orders [REDACTED]. Review of Resident 4's Care Plan revised 6/9/16 revealed the resident had an indwelling urinary catheter with frequent infections. Interventions included changing the catheter every 2 weeks, keeping the catheter drainage bag below the level of the resident's bladder, encouraging fluids and providing catheter care every shift. During observation of care for Resident 4 on 7/18/16 from 2:43 PM to 3:00 PM, Nurse Aide (NA)-A removed the resident's disposable incontinent brief. Resident 4 was involuntary of a small amount of soft feces (stool). NA-A provided Resident 4 with perineal hygiene, positioned the resident on the left side and proceeded to cleanse feces from the resident's rectal area. Without removing soiled gloves, NA-A opened an alcohol swab and cleansed around the urinary catheter insertion site. The resident's urinary catheter drainage bag was observed hanging from the bedframe on the left side of the resident's bed. Still without removing soiled gloves, NA-A pulled at the urinary catheter tubing until the drainage bag was free from the bedframe and placed the drainage bag near the edge of the bed. The drainage bag was positioned directly on top of the bed linens which allowed urine to drain back into the bladder from the catheter tubing. NA-A removed soiled gloves, washed hands and donned clean gloves before draining 200 cubic centimeters (cc) of dark yellow urine from the urinary catheter collection bag. NA-A did not offer Resident 4 any fluids before leaving the resident's room. During an interview on 7/18/16 from 3:10 PM to 3:15 PM, NA-A verified direct care staff had been trained to remove soiled gloves and to use hand sanitizer or to wash hands after completion of perineal hygiene and incontinence cares. In addition, staff were not to pull on the urinary catheter drainage tubing or to position the urinary catheter drainage bag above the level of the resident's bladder as this increased the risk for infections. During an interview on 7/18/16 at 3:30 PM, the Director of Nursing (DON) confirmed the resident was treated for [REDACTED]. In addition, Resident 4 was to be offered fluids frequently and NA-A should have offered the resident a drink after completion of cares.",2019-07-01
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
6174,RIDGEWOOD REHABILITATION & CARE CENTER,285279,624 PINEWOOD AVENUE,SEWARD,NE,68434,2016-06-20,323,D,1,0,G6RN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.09D7 (b) Based on observation, interviews, and record review, the facility failed to ensure that interventions were implemented and causal factors were identified to prevent potential falls for 2 residents (Residents 3 and 5) that were identified at high risk for falls. The facility census was 75. Findings are: A. Review of Resident 3's emergency room Report on 5/21/16 revealed that the resident fell and had the [DIAGNOSES REDACTED]. Review of Resident 3's 6/11/16 MDS revealed that the resident had a 14 day BIMS score of 11 (moderate cognitive loss). The resident had an altered level of consciousness. The resident had a total mood score of 11 (moderate depression). The resident required two staff assistance for bed mobility, and dressing. The resident required total assistance of two staff members with transferring and toilet use. The resident required total assistance with wheelchair mobility. The resident was non ambulatory, had impaired balance, and impairment on one side of upper and lower range of motion. The resident received physical and occupational therapies. Review of Resident 3's Fall Risk assessment dated [DATE] revealed that the resident had a fall risk score of 14 (high risk). On 5/25/16 the resident's fall risk score was elevated to 22 (high risk). Review of Resident 3's Fall Scene Investigation and Report dated revealed that the resident fell on [DATE] at 8:30 PM, when the resident attempted to self-transfer in bathroom. The fall was unwitnessed, but a staff member was in the resident's room. The resident told staff that the resident thought the resident was able to walk self from toilet to bed. The resident's assistive device was in use. The immediate initial intervention was to stay with the resident while on the toilet. The medical review revealed that the resident had a [DIAGNOSES REDACTED]. Review of Resident 3's Current Care Plan identified by the facility dated 12/10/16 had an addition added left hip and wrist fracture on 6/14/16. On 5/21/15 an intervention was added to stay with resident while on toilet, even if just in the room to prevent self transferring without the alarm present. An intervention added on 4/1/0/16 Put recliner controls in side pocket on recline when not in use that was discontinued on 5/31/16. On 5/27/16 new interventions included: total body lift with 2 staff members, wheelchair with assistance for mobility. Observation on 6/20/16 at 10:20 AM revealed that the resident was seated in the resident's recliner on a cushion with the resident's feet on the floor. The resident's body and head was leaning to the right side at an approximately 30-40 degree angle. There were no nursing staff in the resident's hallway only housekeeping and laundry staff that went past the resident's doorway. Interview with RN (Registered Nurse) A on 6/20/16 at 10:30 AM revealed that the resident was not positioned in a way to prevent falls. B. On 6/16/16 at 10:38 am, review of admission data sheet for Resident 5 revealed admitted to facility on 4/15/16 for fracture of foot. Further medical record review: - A nursing note entry of Resident 5 revealed: fall on 6/4/16 a Saturday at 1:30 pm, attempted to sit on edge of bed and sat on a manilla envelope and slipped off bed and on way down heard a cracking noise and felt pain in low back of a 9 out of 10. Tylenol (pain medication) given to resident. - A Physician notification via fax on 6/4/16 of fall with back pain, was not noted by any physician until 6/6/16 with a note of send to the ER (emergency room ) per Resident 5's primary physician. A second entry noted on this same facsimile document stated phone call to set up appointment with physician tomorrow on 6/7/16. - Comprehensive Care Plan stating Fall risk, history of fall, poor safety awareness. Review of approaches listed under fall concern stated none at this time. - Observation of Resident 5 seated on edge of bed on 6/15/16 at 12:49 pm noted bedspread for resident was hanging to the floor on the corridor view side of bed and only covering two inches of mattress on the back side of the bed (indicating as the resident was seated on bed the bedspread would shift forever with the residents weight and movement). Papers were strewn on the bed and also two papers were on the floor to the residents right side. -After the fall on 6/4/16, the facility had not implemented in additional safety interventions as of 6/15/16. Resident 5 remained at risk for additional falls/sliding off the bed as no assessment for causal factors or environmental changes needed had been completed. -Interview with Charge Nurse Y on 6/16/16 at 10:38 am revealed just today (12 days after fall with compression fracture injury) I added a triangle top metal grab bar to the side of the bed to help Resident 5 get up.",2019-06-01
3742,GOOD SAMARITAN SOCIETY - GRAND ISLAND VILLAGE,285285,4061 TIMBERLINE STREET & 4055 TIMBERLINE STREET,GRAND ISLAND,NE,68803,2018-07-03,689,D,1,0,00V911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.09D7 and 12-006.09D7b Based on observations, record review and interviews, the facility failed to provide sufficient staff to prevent a resident elopement for Resident 1 and to establish and implement a system for monitoring and assessing residents at risk for elopement for Residents 2 and 3. The sample size was 3 and the facility census was 60. Findings are: [NAME] Review of a nursing progress note on 6/29/18 at 4:37 PM stated that Resident was not able to be found in their room or common areas. Started building and grounds search. Wheelchair found in parking lot. Staff member stated their car was missing. 911 was called and information was given to them. Policy for elopement was followed from the time noted they were missing. Review of the state agency report on 6/29/18 at 5:17 PM revealed that the DON (Director of Nursing) stated that the facility was conducting a fire drill exercise at the time of the Resident 1's elopement. Review of the facility document titled Fire Report, dated 6/29/18, identified that the fire drill was conducted at 2:40 PM, however, during an interview with the ADM (Administrator) on 7/03/18 at 1:00 PM revealed that the review of the security camera footage identified that the fire drill was conducted at 3:29 PM and Resident 1 went out the door at 3:39 PM and got into the facility staff's car at 3:41 PM. The facility was not aware that the resident left the building until 4:37 PM per documentation in the nursing progress notes. Review of the facility policy titled Fire Drills/Reports did not address how the staff were to monitor the exit doors when the fire alarm goes off. Interview on 7/03/18 at 10:30 AM with the ADM confirmed that the facility policy did not identify how the facility monitored the residents, who have been identified as at risk for elopement, from going out the exit doors during a fire drill, when the magnetic locks disengaged when the fire alarm was activated. B. Observation on 7/3/18 at 10:40 AM of Resident 2 revealed the resident sitting at the snack bar in the unit dining room coloring in an adult coloring book. Resident 2 was alert and confused. A chair alarm was noted on the back of the wheelchair and a wander guard bracelet was present on Resident 2's right ankle. Review of the MDS (Minimum Data Set, a federally mandated assessment tool used in care planning) dated 5/15/18 revealed a BIMS (Brief Interview for Mental Status, a brief snapshot of how a person is functioning cognitively at the moment) score of 8 which indicates moderately cognitive impairment. Cognitively intact (no impairment) is a score of 13-15. Review of Census status sheet revealed an admission date of [DATE]. Review of undated [DIAGNOSES REDACTED]. Review of a Progress Note dated 5/29/18 revealed, Resident was caught outside by activities director wheeling self-down the side walk just outside the unit. Review of Progress Note dated 6/12/18 Resident 2 informed staff that Resident 2 wanted to slit Resident 2's throat. Review of Progress Note dated 6/12/18 revealed Resident 2 was being sent to a behavioral unit for evaluation and treatment. Review of Progress Note dated 6/26/18 revealed Resident 2 returned to facility with new orders. Review of Assessments in Point Click Care revealed no assessments for elopement or wandering risk. Review of the Elopement Policy revealed guidelines for assessing and identifying those residents at risk for elopement. When Wander guard was placed rehabilitation and nursing are to check wander alert bracelet daily according to this policy. Exit door alarms are to be checked weekly to determine if they are in working order. There was an Elopement Checklist Worksheet form attached to the Policy. Review of the Treatment Administration Record (TAR) dated for the months of May, (MONTH) and (MONTH) there was no documentation of the wander guard checks and/or placement of the wander guard. On 7/3/18 at 10:30 AM an interview with the ADM (Administrator) revealed that the exit doors were not being monitored during the fire drill on 6/29/18. Review of the Fire Policy revealed there were no guidelines for monitoring exit doors when they are unsecured during fire drills or other times such as inclement weather. On 7/3/18 at 11:25 AM an interview with LPN A(Licensed Practical Nurse) revealed that visualization of the wander guard bracelet was how the bracelets were checked. The check was to make sure the bracelet was on and that it's intact. The function of the bracelet is not conducted. The checks were not documented but they are done daily. LPN A was not aware of a wander guard tester for the bracelets or the exit door. Confirmation was received that the test is visual only. The door and bracelet can be checked when the resident gets close to the door. There was also no order for the bracelet so it's not located on the treatment TAR. On 7/3/18 at 11:55 AM an interview with the DON (Director Of Nursing) and ADON (Assistant Director Of Nursing) revealed there was no log to track placement of wander guard bracelets. All wander guard bracelets are replaced at the same time because they were all stamped with the same expiration date. The wander guard bracelets are good for [AGE] years. How often the wander guard bracelets were to be checked is listed on each residents Care Plan. When the wander guard bracelet is checked was documented under the Task Tab in Point Click Care. Review of the undated Care Plan for Resident 2 revealed the resident had a potential for elopement and a wander guard bracelet was in place. There were no interventions in place to state how often the wander guard bracelet was to be checked or how it was to be checked. Review of Task listed under the Task Tab in Point Click Care revealed no task listing for checking or documenting the wander guard bracelets. An interview on 7/3/18 at 1:15 PM with MA B (Medication Aide) revealed that when the fire alarm sounds and the location is in this unit the residents are moved to the family room. One staff person stays with those residents at all times and the other staff person removes the other residents. This staff person was unaware of any new changes in the fire drill policy, however; the staff person was not at work for 3 to 4 days. An interview on 7/3/18 at 1:31 PM with MA C revealed when there is a fire alarm sounding the fire location is checked by looking at the fire panel. If the fire is on that unit the residents are removed to the family room and someone stays with the residents. The new change to the fire policy was that there will be staff assigned to monitor exit doors until they are secured. An interview on 7/3/18 at 1:45 PM with MA D revealed when there is a fire alarm the location is determined by looking at the fire panel. Residents closest to the fire are removed to the family room past the fire doors. The new change in the last 3 or 4 days was a staff person will be assigned to each exit door until the doors are secured. Observation on 7/3/18 at 3:09 PM revealed a dining room door on the south west side of the building that had sensor alarms in place by the door on the floor. When staff were interview, MA D, about this it was revealed that Physical therapy staff had used the door and it was difficult to turn the alarm off. Staff were informed that the key pad is not functioning correctly. An interview on 7/3/18 at 3:12 PM with the ADM revealed that the sensor alarms were added as an additional precaution and that the west door is locked and secured. On 7/3/18 at 3:17 PM an interview with the DON revealed that the Elopement Worksheet Checklist is not being completed on any residents at risk for elopement or who had previous elopements. C. Review of the nursing progress note on 6/07/18 at 5:20 PM identified that Resident 3 was found by the DON's (Director of Nursing) office in their wheelchair. The resident was redirected back to the Cottonwood dining room and a wanderguard bracelet was placed on the resident. Review of the resident's comprehensive care plan revealed that the resident had the potential for elopement related to dementia and exhibited wandering behavior. The intervention included a wanderguard was used to alert staff to resident's movement and to assist staff in monitoring movement. Review of the TAR for (MONTH) and (MONTH) (YEAR) for Resident 3 revealed that the testing of the wanderguard bracelet was not placed on the TAR. Interview on 7/03/18 at 11:15 AM with LPN-E stated that the staff check the wanderguard bracelets with a tester and document the results on the resident's TAR. LPN-E was not aware that Resident 3 had a wanderguard bracelet on, therefore was not checking to see if the bracelet was working. LPN-E looked on the resident's TAR and confirmed that the checking of the bracelet was not on the TAR. LPN-E stated that the person who placed the wanderguard on the resident should have put the testing of the bracelet on the resident's TAR. LPN-E confirmed that the wanderguard was placed on the resident on 6/07/18 per the progress note and was put on the resident's care plan, but stated that he was not told that the resident had a wanderguard put on them. Interview on 7/03/18 at 11:45 AM with the DON revealed that the DON stated that they told LPN-E that morning that Resident 3 had a wanderguard bracelet on. The DON stated that the placement of the wanderguard should be on the care plan with the frequency as to how often it is checked. The DON also stated that checking of the wanderguard bracelets should be on the TAR or it may have been put on the task section of Point Click Care for the aides to check. Review of the task section of Point Click Care did not identify that the checking of the wanderguard bracelets for Resident 3 was added, therefore, was not being completed. Interview on 7/03/18 at 12:15 PM with LPN-E revealed that the DON did not tell LPN-E that Resident 3 had a wanderguard bracelet on and LPN-E confirmed that the testing of the wanderguard bracelet was not in the task section of Point Click Care. Interview with the DON on 7/03/18 at 11:45AM stated that she told the LPN that the resident had a wanderguard this morning. DON stated that the wanderguard should be on the care plan and the frequency as to how often it is checked. DON also stated that the checking of the wanderguard should be on the TAR or it may be in the task section for the aides to check. Review of those two areas did not identigy that the wanderguard was checked.",2020-09-01
2219,GOOD SAMARITAN SOCIETY - ST JOHNS,285189,3410 CENTRAL AVENUE,KEARNEY,NE,68847,2018-04-16,689,D,1,1,KX9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.09D7b Based on observation, record review and interviews; the facility failed to protect residents from an accident with an injury. This affected 2 (Resident 26 & 20) out 2 sampled residents. The facility census was 46. Findings are: [NAME] Review of Nursing Progress Note on 10/1/2017 at 2:49 AM for Resident 26, revealed that Resident was found on the floor while staff during rounds. The resident was assessed for injuries and pain but denied any pain. The resident stated that the resident was trying to get their clothes so the resident could get dressed for church. Review of the care plan history for Resident 26 identified that the facility initiated a sensor pad to the resident's bed on 10/03/17 as a fall intervention. However, the sensor pad intervention was taken off the care plan on 11/21/17 with fall mat at bedside added to the care plan. The fall mat was already a fall intervention since 9/05/17, so the facility did not add a new fall intervention to replace the sensor pad intervention on 11/21/17. Review of the Nursing Progress Note on 1/23/2018 at 3:45 AM for Resident 26 stated that the resident had an unwitnessed fall in their room. The resident fell out of bed. Head and upper chest not on gray floor mat. Laceration above right eye (was wearing glasses-glasses were pressed against this laceration). Goose eye to right posterior head. Skin tear x2 to right lower arm and x1 to right medial hand. Neuro checks normal for resident. ROM (range of motion) unchanged. Denies pain/ discomfort. Ice applied to head injuries. [MEDICATION NAME] and coban applied to skin tears. Resident placed on 15 minute checks for 72 hours r/t (related to) intervention. Review of the Nursing Progress Note on 1/23/2018 at 5:44 PM stated Resident returns from ER (emergency room ). diagnosed : 1. fall 2. Head Injury 3. Skin Tear. Visit included Basic medical screen examination and CT (computed tomography). Other: Tissue Adhesive. Make an appt (appointment) to see primary care physician in 3-5days. Interview on 04/10/18 at 9:37 AM with the ADM (Administrator) revealed that the sensor pad was placed on the bed on 10/03/17, resolved on 11/21/17. The intervention for the fall mat at bedside was added to care plan on 11/21/18. Also, for the fall on 1/23/18, the intervention was for 15 minute checks for 72 hours. The physician was not contacted until 1/29/18 to make changes to the resident's medications. Interview on 04/10/18 at 9:39 AM with MDS-C (MDS Coordinator) MDS (Minimal Data Set: a federally mandated comprehensive assessment tool used for care planning) revealed that the fall mat was added to the care plan on 9/4/17 and that the intervention was not resolved, so the adding of the fall mat on 11/21/17 was not a new intervention. MDS-C confirmed that that the fall mat intervention was not a new intervention and also confirmed that there was 3 days after the 15 minute checks for 72 hours until the physician was contacted for medication changes. Interview on 04/10/18 at 9:56 AM with the ADM confirmed that the fall mat at bedside was not a new fall intervention on 11/21/17. ADM agreed that the fall mat was already in place and was not resolved from the care plan. ADM stated I must have missed that on the care plan when we added the intervention on 11/21/17. B. Review of MDS (Minimal Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 2/6/18 revealed BIMS (Brief Interview For Mental Status, assessment used to test cognitive function) revealed a score of 15. A score of 15 would indicated a person is intact cognitively. Review of Care Plan with a start date as 3/29/18 revealed that a fall mat on the floor by the edge of the bed was added on 2/20/18 after a fall. Observation on 04/11/18 at 07:17 AM witnessed Resident 20 lying in bed the over the bed table sitting by the edge of the bed on the gray fall prevention floor mat. The over the bed table was locked into place. Interview on 04/11/18 at 7:25 AM with MDS-C revealed that fall interventions were put into place by the Administrator and any safety issues or concerns need to be addressed by the Administrator. MDS Coordinator did remove the over the bed table from the fall mat after asking Resident 20 if it would be ok. Interview on 04/11/18 at 08:03 AM DON (Interim DON) when discussing the over the bed table on the gray floor mat it was confirmed the over the bed table should be left off the floor mat due to safety issues.",2020-09-01
6691,SUNRISE COUNTRY MANOR,285232,"PO BOX A, 610 224TH STREET",MILFORD,NE,68405,2015-11-09,425,D,1,1,HZ1311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.12 Based on interview and record review, the facility failed to obtain 4 medications for one resident (Resident 46) over a two day period to treat the resident's seizures and psychiatric condition. The facility census was 72. Findings are: Review of Resident 46's History and Physical dated 2/13/15 revealed [DIAGNOSES REDACTED]. Review of Resident 46's annual MDS (Minimum Data Set: a federally mandated comprehensive care planning tool used for care planning) dated 7/14/15 revealed that the resident had a Brief Interview for Mental Status score of 11 (moderately impaired). The resident displayed thoughts of disorganized thinking daily. The resident had delusions and was independent with the resident's activities of daily living. The resident received antipsychotic medications to treat the resident's psychosis, anxiety, and traumatic brain disorder. Review of Resident 46's (MONTH) (YEAR) Medication Administration Record [REDACTED] -Zyprexa (antipsychotic medication) 20 mg (milligram) was ordered at bedtime. The Zyprexa 20 mg dose was not available on 10/18/15 and 10/19/15. -Lamactil (mood/ seizure medication) 20 mg was ordered at bedtime for mood. The Lamactil was not available on 10/18/15 and 10/19/15 for the bedtime dose. -Dilantin (treats seizures) 200 mg twice daily was not available for both doses on 10/19/15. -Simvastatin (treats high cholesterol) 20 mg at bed time was not able for administration on 10/18/15 and 10/19/15 as ordered. The medication was not available. -Gabapentin 600 mg ordered four times daily was only given three times on 10/19/15 because the medications was not available. Review of the Physician order [REDACTED]. Interview with the DON (Director of Nursing) on 11/12/15 at 10 am revealed that staff were to use the medications available in the emergency medication box when medication was not available from their contracted pharmacy. The facility had a backup pharmacy located in town for emergencies. The DON stated that they could get medications from anywhere if notified from staff when medications were not available.",2018-11-01
6356,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2016-03-10,425,D,1,0,L3TD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.12 Based on observation, interview, and record review; the facility failed to administer one resident's (Resident 2) topical medication according to the physician's orders [REDACTED]. Findings are: Observation of Resident 2's dressing change on 3/10/16 at 9:40 AM revealed: -RN E had to peel back the lower one third portion of the residents Lidoderm patch (lidocaine pain patch) to remove the drain dressing. Another Lidoderm patch was located below the drain dressing. The patch was dated as applied on 3/10/16 and contained the initials of the staff that applied the patch. -The RN replaced the dressing and situated the Lidoderm patch back on the resident. -The resident stated to the nurse that was the resident liked it. Interview of Resident 2 on 3/10/16 at 9:45 AM revealed that the resident had occasional abdominal pain rated at a one. Review of Resident 2's Clinical Referral dated 3/1/16 revealed an order for [REDACTED]. Interview with RN E on 3/10/16 at 1:15 PM revealed that the RN acknowledged that the Lidoderm topical patch should not have been applied over the drain dressing, even if the resident liked it there, since the resident would not get the full dose of the medication.",2019-03-01
3960,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,919,F,1,1,OLWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-007.04G Based on observation, record review and interview; the facility failed to ensure that the residents' call light system was functioning. This had the potential to affect all of the residents that reside at the facility. The facility census was 34. Findings are: Tour of the room occupied by Resident 4 on 3/13/18 at 3:13 PM identified that at 3:13 PM, the resident's call light was pushed. At 3:53 PM, NA-R (Nurse Aide) was asked if the call light for Resident 4 showed up on their pager to be answered. NA-R stated that the call light for Resident 4 was not identified, but that room [ROOM NUMBER] and Sunshine Circle #1 was going off. NA-R went to Resident 4's call light and pulled the box from the wall bracket and looked on the back of the call light and the box was identified as Sunshine Circle #1. NA-R took the call light box to RN-C (Registered Nurse) who stated that the nursing staff was wondering where the call light was going off and they checked all of the call lights in the Sunshine Circle area, and none of them were going off. The nursing staff could not find the correct call light box for Resident 4, so NA-R took the call light box from the other bracket in the resident's room and placed it on the bracket next to Resident 4's bed. Resident 4 did not have a roommate. Interview on 3/13/18 at 4:15 PM with Charge Nurse, RN-C, identified that the facility did not have a system in place to ensure that the residents had the correct call lights. RN-C stated that all of the call lights will be checked to ensure that all of the residents have their correct call lights. Interview on 3/13/18 at 4:30 PM with the Administrator confirmed that the facility did not have a process in place to ensure that all of the residents had their correct call lights and that the nursing staff would be checking all of the call lights to ensure the correct call lights were assigned to the correct residents. Interview on 3/13/18 at 4:45 PM with RN-C revealed that the nursing staff did not locate the call light box for Resident 4, so a new call light box was programmed and assigned to Resident 4. RN-C confirmed that there were a couple of call lights boxes that were not with the assigned residents, but that the nursing staff had corrected the problem.",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
6337,BIRCHWOOD MANOR,285247,1120 WALNUT ST,NORTH BEND,NE,68649,2018-08-15,600,D,1,0,IJZK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE LUMBER 175 NAC 12-006.05(9) Based on observations, record reviews, and interviews, the facility failed to protect residents from other residents (Resident 201) with adverse behaviors. This affected one out of 3 sampled. The census was 50. Findings are: Review of Resident 201's PN's (Progress Notes) dated 6-28-18 revealed Resident 201 physically hit another resident. The staff intervened and the two residents were separated immediately. No injury resulted to the victim resident. The documentation was absent documentation of an intervention to prevent it from re-occurring. Review of Resident 201's Face Sheet dated 7-19-18 revealed [DIAGNOSES REDACTED]. Interview on 8-13-18 at 11:42 PM with NA-A (Nurse Aide) revealed Resident 201 had repetitive behaviors of verbally yelling at other residents and occasionally hitting them. NA-A was not aware of any injury to any of the residents. NA-A revealed the only intervention the Nurse Aide was aware of to calm the resident was one the resident self-initiated and it was to place a cloth over the resident's head. Interview on 8-15-18 at 11:04 AM with NA-B revealed Resident 201 required 1 staff stand by assist with ADL (Activity of Daily Living) cares such as setting out the clothes and provide a lot of cueing for the resident who then would perform the tasks independently. NA-B revealed you had to work slowly with the resident or it would upset the resident and then Resident 201 would become verbally and physically aggressive with staff. NA-B revealed Resident 201 had been observed calling other residents [***] several times but this was Resident 201's behavior. NA-B was aware Resident 201 had hit another resident. Interview on 8-15-18 at 1:00 PM with RN-A (Registered Nurse) revealed Resident 201 had behaviors of verbally yelling and hitting other residents but it had improved recently. When the resident had hit other residents in the past, the facility practice was to immediately intervene and separate the residents. The victim resident was assessed for any injury but if there was none, there was no further action taken. A long term intervention was not developed and the problem was not placed on the careplan of Resident 201. Review of Resident 201's careplan on 8-14-18 at 4:30 PM revealed absence of documentation of the resident's verbal and physical behaviors towards other residents and any interventions to protect the residents. Interview on 8-15-18 at 2:30 PM with the MDS-C (Minimum Data Set Coordinator) confirmed Resident 201's careplan did not address the resident's verbal or physical behaviors. Interview on 8-15-18 at 3:00 pm was held with the ADM (Administrator) and the DON (Director of Nursing), SWD (Social Work Designee) and MDS-C all in attendance. Interview with the ADM revealed the practice at the facility had been when a resident to resident altercation had occurred, the residents were immediately separated and the victim resident was assessed. If there was no injury, no further interventions were initiated for the perpetrator to prevent the incident from re-occurring.",2019-04-01
5460,GOOD SAMARITAN SOCIETY - WOOD RIVER,285198,1401 EAST STREET,WOOD RIVER,NE,68883,2017-03-22,309,D,1,1,HUVK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE LUMBER 175 NAC 12-006.09D5 Based on observations, record reviews, and interviews, the facility failed to protect residents from other residents with adverse behaviors on the SCU (Special Care Unit). This affected 3 residents (Resident 63, 36, 6) out of the 3 sampled. The facility census on the SCU was 18. Findings are: A Review of the undated census sheet for Resident 63 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-20-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 3 which indicated Resident 63 was severely cognitively impaired. The resident exhibited physical behaviors directed toward others 1-3 days and verbal behaviors directed toward others 1-3 days. Resident 63 rejected cares 1-3 days. The resident required supervision with setup help only with ambulation and limited assist of one staff with ADL's (activities of daily living). Observation in the SCU DR (Dining Room) on 3-22-17 at 8:42 AM revealed Resident 36 sat at the activity table in the DR and Resident 63 sat in the brown recliner behind 36. Resident 63 made a verbal derogatory remark to Resident 36 which was heard by Staff X who sat at another DR table charting. Staff X continued to chart on the computer, and without turning to face the resident, Staff X instructed Resident 63 that what was said was not nice and to stop saying it. Resident 63 did not verbally respond but stared at Staff X. Within less than 1 minute, Resident 63 stood up and walked over to Resident 36 and placed Resident 63's right hand on Resident 36's left shoulder. Resident 36 slapped Resident 63's hand and the resident turned around to Staff X and used a crying voice said (gender) slapped me, ouch, (gender) slapped me. Staff X went over to Resident 63 and looked at her hand. Staff X called the SW (Social Worker) about the situation who arrived on the SCU and investigated. At 09:00 AM the AD (Activity Director) arrived to the SCU and started the 09:00 AM activity. Resident 63 sat at the table and Resident 36 pulled a chair and sat right next to Resident 63. Staff X and other staff who were aware of the incident were in the DR. The activity was music and Resident 36 pounded on the table to the music. Resident 63 glared at Resident 36. At 3-22-17 at 9:10 AM interview with AD revealed none of the other staff had informed the AD about the incident between the 2 residents which occurred 30 minutes prior. Interview on 3-22-17 at 9:28 AM with Staff M revealed Staff M did not have a way to look up what the residents' interests or interventions were to be used to decrease behaviors were on individualized residents. Interview on 3-22-17 at 1:44 PM with Staff X revealed Staff X had not been shown how to use the Careplan feature in the computer and did not know Staff X should or could look at the careplan for the residents on the SCU. Interview on 3-22-17 at 12:26 PM with the SW revealed the new intervention was entered into Resident 36's care plan to monitor other residents proximity to Resident 36 as the resident did not like (gender) personal space invaded. Resident 36 will initiate contact with others if the resident wanted it. The SW confirmed the nurse aides do not have access to the Careplans. The SW revealed the new interventions are communicated through a notebook called the 'Communication' book kept at the nurse's desk which was used for report. SW confirmed the communication book was not a permanent part of the resident chart and was only communicated in report for a few days. The staff who float into the SCU, new staff, or past interventions therefore were not kept and the facility did not have a process to communicate all careplanned behavioral interventions for the residents to the staff on the SCU. B) Review of the undated census sheet for Resident 36 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 2-15-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 10 which indicated Resident 36 had moderately impaired cognition. The resident exhibited no behaviors during the MDS assessment period. Resident 36 required supervision to limited assist of one staff with ambulation and ADL's. Review of Progress Notes dated 10-21-16 revealed at 09:45 AM Resident 36 and Resident 6 became angered with one another and began slapping each other's hands. They were separated by 2 NA's (Nurse Aide) on duty. The other resident had said something to Resident 36 which angered Resident 36 and caused the resident to instigate the slapping of hands. Review of the facility investigation revealed the intervention for the incident of 10-21-16 was to put a coffee/end table in between the 2 recliner chairs that Resident 36 and Resident 6 frequent in the SCU. Review of Resident 36's Careplan revealed staff were to put an a side table in between the recliner that Resident 36 frequents and the recliner that Resident 6 frequents as to provide a barrier for any escalated interactions. The dated listed on the intervention was 10-27-16. Observation on 3-22-17 at 08:42 AM revealed a row of recliners in the solarium and there was an end table between the wall and one recliner, not between 2 chairs as per careplanned. Interview on 3-22-17 at 8:45 AM with Staff X revealed the two chairs the residents sat in but was unaware there was to be an end table in between them. C) Review of the undated census sheet for Resident 6 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1-17-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 3 which indicated Resident 6 was severely cognitively impaired. The resident was independently ambulatory and required extensive assistance of 1 staff with ADL's. Review of APS (Adult Protective Service) report revealed the facility's DON (Director of Nursing) called in a resident to resident altercation between Resident 6 and Resident 36 on 11-1-16. Review of Resident 6's Progress Notes revealed absence of documentation of the incident. Review of Resident 6's Careplan revealed absence of new interventions dated around the date of 11-1-16. Review of the facilities investigation revealed absence of an investigation for 11-1-16 for Resident 6 and 36. Interview with the SW revealed the SW was not aware of the incident. The SW revealed during the time of (MONTH) (YEAR) the facility had an RN ( Registered Nurse) by the name of the caller who was an RN whose office was in the SCU and most likely the RN called in the incident then forgot to document or report it to anyone. The RN was no longer employed with the facility.",2020-01-01
2438,WAKEFIELD HEALTH CARE CENTER,285209,306 ASH STREET,WAKEFIELD,NE,68784,2019-01-16,689,J,1,0,QW7C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER ,[DATE].09D7 Based on observations, record reviews and interviews, the facility failed to: 1) ensure interventions were in place for the prevention of elopement (when a resident leaves the premises or a safe area without authorization and/or supervision) for Residents 1, 3, 8 and 9; and 2) develop interventions for the prevention of elopement for Resident 2. The sample size was 9 and the facility census was 22. Findings are: [NAME] Review of the facility policy titled Wander Guard monitoring system dated ,[DATE] revealed the facility utilized an elopement prevention system known as Wander Guard (a bracelet/signaling device is worn by the resident and sounds an alarm if the resident comes within a certain distance of the door). The policy included the following: -Nursing staff were to determine at the time of admission, which residents were at risk for wandering. A wandering risk assessment was to be performed on the day of admission; -Residents determined to be at high risk to wander (scoring 8 or above on the wandering assessment) would have a signaling device applied to their dominant wrist. Due to certain conditions alternate placement of the signaling device might be necessary; -The 90 day signaling device would be checked daily to ensure it was functioning; and -Problems with the Wander Guard signaling devices would be immediately reported to the Director of Nursing (DON and the Administrator and the Care Plan would be updated to reflect additional safeguards. B. Interview with Licensed Practical Nurse (LPN)-A on [DATE] at 4:40 PM revealed 6 residents currently residing in the facility wore Wander Guards. LPN-A indicated the following: -Resident 1's Wander Guard was not functioning; -Resident 1's Wander Guard could not be replaced as there were no additional Wander Guard bracelets available in the facility. C. Review of Resident 1's Wandering Risk assessment dated [DATE] revealed the following regarding Resident 1: -forgetful/short attention span; -experiencing feelings of anger/fear of abandonment; -known wanderer/history of wandering; and -the wandering risk score was 9 which indicated the resident was at moderate risk for wandering. Review of Resident 1's current Care Plan dated [DATE] revealed the resident was at risk to wander and a goal was developed that the resident would not wander away from the facility unattended. Interventions included the following: -anticipate and meet basic daily needs in an effort to deter exit seeking; -if exit seeking/wandering occurs try using distraction to get resident to return/remain in facility; -monitor Wander Guard signaling device placement and battery function daily; and -Wander Guard signaling device on at all times and replaced every 90 days and as needed. Review of Resident 1's Medication Administration Record (MAR) dated ,[DATE] revealed an order to change the Wander Guard signaling device every 90 days. Documentation indicated the Wander Guard signaling device was changed on [DATE]. Review of Resident 1's MAR dated ,[DATE] revealed the Wander Guard signaling device was due to be changed on [DATE]. Documentation on [DATE] indicated the Wander Guard was not replaced and a 9 (refer to progress notes) was documented on the MAR. Review of Resident 1's Progress Notes dated [DATE] revealed no progress notes regarding the Wander Guard Signaling device. Interview with LPN-A on [DATE] at 4:40 PM revealed LPN-A was not aware if additional interventions had been developed for the prevention of elopement by Resident 1 other than watching the resident more closely. Interview with the DON on [DATE] at 6:45 PM confirmed Resident 1's Wander Guard signaling device had not been changed as required on [DATE] due to unavailability of additional devices. The DON confirmed additional interventions for the prevention of elopement had not been developed for Resident 1. At 7:00 PM on [DATE] LPN-A was observed to test the functioning of Resident 1's Wander Guard signaling device. The device was functioning at this time. Interview with LPN-A at 7:00 PM on [DATE] confirmed Resident 1's Wander Guard signaling device was expired and the device needed to be replaced every 90 days to assure reliability. D. Review of Resident 3's MAR dated ,[DATE] revealed an order to change the Wander Guard signaling device every 90 days. Documentation indicated the Wander Guard signaling device was changed on [DATE]. Review of Resident 3's Wandering Risk Assessment completed [DATE] included the following regarding Resident 3: -forgetful/short attention span; -disturbed by environmental noise levels, recent medication change; -known wanderer/history of wandering; and -the wandering risk score was 8 which indicated the resident was at moderate risk for wandering. Review of Resident 3's current Care Plan dated [DATE] revealed the resident was at risk for wandering. Interventions included the following: -anticipate and meet basic daily needs in an effort to deter exit seeking; -if exit seeking/wandering occurs try using distraction to get resident to return/remain in facility; -monitor Wander Guard signaling device placement and battery function daily. It is kept on wheelchair so the resident cannot remove it; and -Wander Guard signaling device on at all times (on the wheelchair) and replaced every 90 days and as needed. Review of Resident 3's MAR dated ,[DATE] revealed the Wander Guard signaling device was due to be changed on [DATE]. Documentation on [DATE] indicated the Wander Guard was not replaced and a 5 (which meant hold) was documented on the MAR. Further review of the MAR from [DATE] through [DATE] revealed no evidence the Wander Guard was replaced. Review of Resident 3's MAR dated ,[DATE] and ,[DATE] revealed the Wander guard signaling device was checked every evening to ensure it was functioning. A 9 was documented on the MAR on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] (which meant to refer to progress notes). Review of Resident 3's Progress Notes from [DATE] through [DATE] revealed no documentation regarding the functioning of the Wander Guard signaling device. Review of Resident 3's MAR dated [DATE] through [DATE] revealed no evidence the Wander Guard signaling device was replaced (the last replacement was [DATE] which was over 90 days). Interview with the DON on [DATE] at 6:45 PM confirmed Resident 3's Wander Guard signaling device was not changed on [DATE]. The DON confirmed additional interventions were not developed for the prevention of elopement. At 7:09 PM on [DATE], Licensed Practical Nurse (LPN)-A tested the battery of Resident 3's Wander Guard signaling device and noted the device was not functioning. Interview with LPN-A at 7:09 PM on [DATE] confirmed Resident 3's Wander Guard signaling device would not be replaced as there were no devices available. E. Interview with the Administrator on [DATE] at 6:05 PM and 7:30 PM revealed additional Wander Guard signaling devices were ordered by facility staff on [DATE]. The Administrator indicated there had been a discrepancy with the billing from the supplier of the Wander Guard signaling devices and after this was resolved the supplier was paid on [DATE]. The Administrator reported the Wander Guard signaling devices were supposed to arrive on [DATE] but as of [DATE] the devices had not arrived. The Administrator reported being unaware that any of the Wander Guard signaling devices currently in use were not functioning. F. The immediate jeopardy identified on [DATE] was abated to a D level on [DATE] at 8:00 PM when: -15 minutes checks were implemented and documented beginning at 6:00 PM for Resident 1 and at 6:30 PM for Resident 3 on [DATE]; -motion sensors were placed by the doorways to Resident 1 and Resident 3's rooms to alert staff when the resident's exited their rooms; -daily checks of all Wander Guard signaling devices would continue; and -15 minutes checks and room door motion sensors would be implemented if the daily Wander Guard checks determined additional signaling devices were not functioning. [NAME] Review of a Wandering Risk assessment dated [DATE] revealed Resident 2 was admitted to the facility that day. Documentation further indicated the following regarding Resident 2: -forgetful/short attention span; -recent experiences included admission with the last month, transfer from one unit to another and surgery; -ambulates with 1 assist; -[MEDICAL CONDITION]; -Taking antidepressants; and -the wandering risk score was 7 which indicated the resident was at moderate risk for wandering. Review of Resident 2's Interim Admission Care Plan dated [DATE] indicated a goal that the resident will not wander from facility unattended. Further review of the Interim Admission Care plan revealed there were no interventions related to this goal. Review of the current Care Plan dated [DATE] revealed no evidence the resident's moderate risk of wandering was addressed and there were no interventions developed for the prevention of wandering and/or elopement. Observation at 6:35 PM on [DATE] revealed a handwritten note taped to the desk at the Nurses Station which indicated Resident 2 needed a Wander Guard when the supplies arrived. Interview with the DON on [DATE] at 7:30 PM revealed Resident 2 was currently not considered an elopement risk as the resident required assistance with transfers and mobility. The DON confirmed there was no documentation related to this assessment. Review of Resident 2's Progress Notes dated [DATE] at 1:39 PM revealed the resident scored at a moderate risk to wander. Documentation further indicated the resident was unable to ambulate without assistance, had an unsteady gait and therefore a Wander Guard was not to be placed at this time. There was no evidence additional interventions for the prevention of elopement were developed. Review of Resident 2's Progress Notes dated [DATE] at 5:59 PM included the following: -the resident was last seen in the room at 4:30 PM; -at 5:05 PM staff reported the resident was not in the room and the resident could not be located in the facility; -at 5:25 PM staff located the resident outside within the immediate block and at a house on the southwest corner. The resident was assisted back into the facility; and -the buttock area of the resident's pants was noted to be wet and muddy. The resident sustained [REDACTED]. H. Interview with the Administrator on [DATE] at 9:00 AM revealed the Wander Guard policy was revised and residents who were determined to be at moderate risk and high risk for wandering/elopement would have a Wander Guard. The Administrator reported additional Wander Guard signaling devices were delivered to the facility on [DATE] and were placed on Residents 1, 2 and 3. The Administrator reported there were 3 additional Wander Guards available for resident use and the plan was to keep some Wander Guards in stock. I. Review of the revised policy Wander Guard monitoring system dated [DATE] revealed .Residents determined to be at a moderate or high risk to wander will have a signaling device applied to their dominant wrist. [NAME] Interview with the DON and Registered Nurse (RN)-E on [DATE] at 9:47 AM revealed the following regarding the Wandering Risk Assessments: -Residents with a score of ,[DATE] were low risk for wandering/elopement; -Residents with a score of 5 or above were at moderate risk for wandering/elopement; and -Residents with a score of 11 were at high risk for wandering/elopement. K. Review of Resident 8's Wandering Risk assessment dated [DATE] revealed the resident's wandering risk score was 5 which indicated the resident was at moderate risk for wandering. Review of Resident 8's current Care Plan dated [DATE] revealed no interventions to address the resident's moderate risk for wandering/elopement. Observations of Resident 8 on [DATE] at 8:25 AM revealed the resident was not wearing a Wander Guard although the resident was identified at moderate risk for wandering/elopement. L. Review of Resident 9's Wandering Risk assessment dated [DATE] revealed the resident's wandering risk score was 7 which indicated the resident was at moderate risk for wandering. Review of Resident 9's current Care Plan (undated) revealed no interventions to address the resident's moderate risk for wandering/elopement. Observations of Resident 9 on [DATE] at 9:30 AM revealed the resident was not wearing a Wander Guard although the resident was identified at moderate risk for wandering/elopement. M. Interview with the DON and RN-E on [DATE] at 9:47 AM confirmed Resident 8 and 9 were not wearing Wander Guards and alternate interventions for the prevention of elopement had not been developed. The DON and RN-E further indicated the current Wandering Risk Assessments were most likely not accurate regarding the resident's risk for wandering/elopement. N. The immediate jeopardy identified on [DATE] was abated to a D level on [DATE] at 3:15 PM when: -The Wandering Risk Assessment form was revised to more accurately assess each resident's risk of wandering/elopement; -All residents of the facility were reassessed using the revised Wandering Risk Assessment form; -Care Plans for all residents identified at risk for wandering/elopement were revised and interventions for the prevention of elopement were developed and implemented; -All Wander Guards in use were functioning properly and additional Wander Guard signaling devices were available for use; -A plan was developed to routinely audit Care Plans and ensure interventions for the prevention of wandering/elopement were implemented; and -Provision of staff education regarding wandering assessments, implementing Care Plan interventions and monitoring to ensure interventions were in place for prevention of wandering/elopement.",2020-09-01
4271,HILLCREST SHADOW LAKE,2.8e+300,1507 E GOLD COAST ROAD,PAPILLION,NE,68046,2017-08-14,279,D,1,1,728T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 12-006.04C3a(5) Based on record review and interviews, the facility failed to develop a vision care plan for (Residents 7 and 14), 2 of 21 sampled. The facility census was 102. [NAME] Resident 7's face sheet revealed that, Resident 7 was admitted to the facility on [DATE]. The face sheet revealed that Resident 7 had the [DIAGNOSES REDACTED]. It causes damage to the macula, a small spot near the center of the retina and the part of the eye needed for sharp, central vision, which lets us see objects that are straight ahead). Record review of Resident 7's MDS (Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated 6/20/17, revealed that Resident 7's vision was moderately impaired (limited vision; not able to see newspaper headlines but can identify objects and did not have corrective lenses. Record review of Resident 7's Comprehensive Plan of Care (CPC) ( A Plan of Care Developed by a facility to direct care in achieving and marinating optimal status of health, functional ability and quality of life), failed to reveal the resident's diminished eye site, and failed to provide care givers with individualized interventions to assist the resident in maintaining functional ability with vision loss. Interview with the facility MDS Coordinator on 8/10/17 at 12:04 PM confirmed that Resident 7 did have vision loss. Interview with the facility MDS Coordinator confirmed that the resident did not have corrective lenses. The facility MDS Coordinator confirmed that the facility failed to develop a CPC to meet Resident 7's needs of vision loss. B. A review of Resident 14's Face Sheet revealed Resident 14 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of Resident 14's MDS dated [DATE] revealed that the resident had impaired vision with no corrective lenses. A review of Resident 14's Care Area Assessment (tool linked to the MDS used for care planning) revealed that the resident had [MEDICATION NAME] Degeneration due to Diabetes which caused limited vision and that the care plan would be developed with interventions to meet the resident's needs. A review of Resident 14's Care Plan dated 9/7/17 revealed a problem statement of Vision/Dental/Hearing that did not have an explanation of Resident 14's vision needs and did not have any interventions or measurable goals that addressed the resident's vision. An interview conducted on 8/10/17 at 12:04 PM with the MDS Coordinator revealed the following regarding Resident 14: -Had [MEDICATION NAME] Degeneration with limited vision. -Did not have corrective lenses and was able to read very large print, but not regular print or that is large print books. -Was seeing an ophthalmologist yearly until (YEAR) when their family declined further vision services due to no further treatment options available. -Visual function and interventions were not reflected on the care plan.",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
4914,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2018-04-03,602,E,1,0,F6ND11,"**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 to ensure 3 (Residents 2, 3 and 4) of 8 sampled residents were protected from misappropriation. The facility census was 35. Findings are: [NAME] Review of the facility's Abuse and Prohibition Policy (undated) revealed the following: -The facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state law. -The facility will report such allegations to the state, in accordance with state regulations. -The facility will protect residents from harm during investigations. B. Review of Resident's 2's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for Care Planning) dated 2/2/18 revealed the resident was cognitively intact. The assessment identified [DIAGNOSES REDACTED]. A pain interview conducted with the resident identified the resident had occasional pain which the resident rated at a 7 out of 10 on the pain level scale (scale of 1-10 used to rate an individual's pain. A score of 0 indicates no pain and a score of 10 is pain so severe it could cause the person to lose consciousness). Review of Resident 2's Medication Administration Record [REDACTED]. Further review revealed the resident received the medication a total of 23 times. 19 of the 23 times the resident was documented as receiving the pain medication, the medication was administered by Licensed Practical Nurse (LPN)-[NAME] Review of Resident 2's MAR indicated [REDACTED]. Both of these doses were administered by LPN-[NAME] During an interview on 4/3/18 at 2:30 PM, Resident 2 identified a history of pain. Resident 2 confirmed an order for [REDACTED]. Furthermore the resident could not remember the last time the resident's pain had been severe enough for the resident to take the [MEDICATION NAME]. C. Review of Resident 3's MDS dated [DATE] revealed the resident's cognition was severely impaired. The resident had [DIAGNOSES REDACTED]. A pain interview was conducted and the resident identified occasional pain which the resident rated as a 6 out of 10 on the pain scale. Review of Resident 3's MAR indicated [REDACTED]. Further review revealed the resident received a dose of the [MEDICATION NAME] 29 times and on each of these occasions the medication was administered by LPN-[NAME] A staff assessment of the resident's pain was completed 4 times a day and the assessment was also documented on the resident's MAR. On 16 out of the 29 times the resident received the [MEDICATION NAME], the staff documented a score of 0 for the resident's pain level, indicating the resident was having no pain. Review of Resident 3's MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. During an interview on 4/3/18 from 8:40 AM to 8:55 AM, Resident 3's spouse indicated the resident did have pain back in (MONTH) but has not had pain since around that time. Resident 3's spouse identified visiting the resident on a daily basis. The spouse further identified the staff had questioned them on 4/1/18 to determine if the resident had asked for and received any pain medication and verified the resident had not complained of pain or received any pain medication. D. Review of Resident 4's MDS dated [DATE] revealed the resident's cognition was severely impaired. The resident had [DIAGNOSES REDACTED]. The resident was identified as having a scheduled pain medication regimen and as receiving non-medication interventions for pain. Review of Resident 4's MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of Resident 4's Controlled Medication Utilization Record (form used to document administration of narcotic medication and to maintain an inventory of the amount of medication remaining) for the [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg 1 tablet 4 times a day revealed on 4/2/18 there was a count of 24 tablets remaining. Further review revealed at 8:50 AM, LPN-A documented the administration of 1 tablet of the [MEDICATION NAME]-[MEDICATION NAME] with a remaining count of 23 tablets. At 12:03 PM, Registered Nurse (RN)-B documented the administration of a second dose of the [MEDICATION NAME]-[MEDICATION NAME], however there were only 21 tablets remaining. A notation printed below RN-B's documentation identified the following recounted when nurse took noon dose and noted count from the AM nurse was off by 1 pill. E. During an interview on 4/3/18 from 1:00 PM to 1:30 PM, the Administrator and the Director of Nursing (DON) confirmed the following: -DON began employment at the facility 1/2018. -DON had been approached by members of the nursing staff from the time the DON had started working at the facility regarding suspicions that LPN-A was misappropriating narcotic medications from the residents. -DON had been monitoring LPN-A, and identified inconsistencies regarding administration of narcotic medications, but was unable to find concrete evidence that LPN-A had misappropriated the medications. -LPN-A denied taking narcotic medications when interviewed by the DON. -4/1/18 Medication Aide (MA)-I was scheduled from 6:00 AM to 6:00 PM to pass medications. LPN-A was called to come into work the morning of 4/1/18 due to a call in by a Nurse Aide. LPN-A demanded to be placed on the medication pass but RN-B, who was scheduled as the Charge Nurse, told LPN-A the staff needed assist with answering call lights and providing cares for the residents. MA-I went to break and during that time, LPN-A documented the administration of as needed narcotic pain medication for Resident 2 and 3. MA-I was concerned, as MA-I had assessed both residents and both denied the presence of pain. MA-I then interviewed Resident 2 and Resident 3's spouse and both denied the residents had asked for or received any pain medications from LPN-A on 4/1/18. - LPN-A was scheduled to pass medications 4/2/18 and was suspended during the LPN's shift. 4/2/18 LPN-A was suspended regarding standards of practice (administering pain medications when residents did not have pain) and insubordination (arguing with the Charge Nurse regarding assignments on 4/1/18 when LPN was called in to work). -the DON and the Administrator were unaware the Controlled Medication Utilization Record for Resident 4 was found to be incorrect after LPN-A left the facility.",2020-03-01
5185,IMPERIAL MANOR NURSING HOME,285252,"P O BOX 757, 933 GRANT STREET",IMPERIAL,NE,69033,2017-02-15,282,E,1,0,BN3V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 12-006.09C Based on observation, interview, and record review; the facility staff failed to follow care plan interventions to prevent falls and potential injury for 3 of 3 sampled residents. This affected Residents 60, 61, and 62. The facility identified a census of 36 at the time of survey. Findings are: [NAME] Review of Resident 61's Annual MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 9/3/2016 revealed an admission date of [DATE]. Resident 61 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated Resident 61 had severe cognitive impairment and Resident 61 required limited assistance from 1 staff person for transfers and ambulation. Resident 61 also had 1 fall with injury since admission. Review of Resident 61's care plan dated 12/6/16 revealed that Resident 61 fell [DATE] and fractured their arm. Fall interventions included the following: give resident verbal reminders not to ambulate or transfer without assistance. Assess resident's need for assistive/supportive device. Instruct resident on appropriate use of assistive/supportive device. Observation of Resident 61 on 2/15/17 at 4:20 PM revealed Resident 61 stood up out of the loveseat in the hall by the nurses' station and walked down the hall to their room without asking for assistance from staff or using an assistive device. Interview with Resident 61 on 2/15/17 at 4:25 PM that Resident 61 did not recall the facility staff educating them about fall interventions and Resident 61 was unaware of what they needed to do so they did not fall. Resident 61 revealed they could go on my own without assistance or an assistive device. B. Review of Resident 62's Annual MDS dated [DATE] revealed an admission date of [DATE]. Resident 62 had a BIMS score of 13 which indicated Resident 61 was cognitively intact. Resident 62 required extensive assistance from 1 staff person for transfers and ambulation and Resident 62 had a history of [REDACTED]. Review of Resident 62's care plan dated 12/15/2016 revealed Resident 62 fell on [DATE] and fractured their ribs. Fall interventions included the following: pressure alarm to bed, power wheelchair and recliner. Give resident verbal reminders not to ambulate or transfer without assistance. Assess residents need for assistive/supportive device. Instruct resident on appropriate use of assistive/supportive device. Observation of Resident 62 on 2/15/17 at 11:49 am revealed Resident 62 was sitting in the recliner in their room. No alarm device was observed to be in use. Observation of Resident 62 on 2/15/17 at 4:06 PM revealed Resident 62 attempted to self-transfer out of the power wheelchair. No alarm device was observed to be in use. Interview with Resident 62 at this time revealed they had not called staff for assistance. C. Review of Resident 60's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 60 had a BIMS score of 00 which indicated severe cognitive impairment. Resident 60 required extensive assistance from 1 staff person for transfer and ambulation and had 1 fall with injury since the last assessment. Review of Resident 60's care plan dated 1/6/17 revealed Resident 60 fell [DATE]. Fall interventions included the following: Mat on floor at bedside. Check every 1 hour for safety. Pad alarm to bed at bedtime. Pull tabs in wheelchair during day. Give resident verbal reminders not to ambulate or transfer without assistance. Observation of Resident 60 on 2/15/17 at 4:01 PM revealed Resident 60 resting in bed. The fall mat was folded up and propped up on the foot board. Observation of Resident 60 on 2/15/17 at 5:00 PM revealed Resident 60 was resting in bed. The fall mat was folded up and propped up on the foot board. Interview with the DON (Director of Nursing) at that time revealed the fall mat should have been placed on the floor by Resident 60's bed and not propped up on the foot board. The DON also confirmed that the staff were to follow the residents' care plan. Review of the facility's Accident and Fall Prevention policy dated 4/1/15 revealed that the facility would provide an environment that remained as free of accident hazards as possible and that each resident would received adequate supervision and assistive devices to prevent accidents.",2020-02-01
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
3566,PLAINVIEW MANOR,285273,"P O BOX 219, 101 HARPER STREET",PLAINVIEW,NE,68769,2018-03-28,656,E,1,1,ZOJ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 12-006.09C Based on record review, observation and interview; the facility failed to develop and/or implement care plan interventions for: 1) the prevention of hot liquid spills for Resident 29; 2) the prevention of falls for Residents 8 and 82; and 3) to address the individualized medical needs of Resident 2. The total sample size was 20 and the facility census was 32. Findings are: [NAME] Review of Resident 29's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/13/18 indicated the resident had severely impaired cognition and required supervision with eating. Review of Resident 29's current Care Plan dated 3/15/18 revealed the resident had cognitive impairment and required set-up assistance with eating. The goal was for the resident to eat independently or with set-up assistance during the review period, and there were no interventions developed related to eating. Review of Nursing Progress Notes dated 1/9/18 at 11:48 AM revealed Resident 29 was in the dining room and had spilled hot cocoa in lap. The resident's right upper inner thigh was observed to be light red, and no blisters were noted. The resident complained of some discomfort to the site. There was no evidence the resident's Care Plan was reviewed following the burn incident, or that interventions were developed to prevent further hot liquid spills. During interview on 3/28/18 at 8:45 AM, the Director of Nursing (DON) verified interventions for the prevention of hot liquid spills should be addressed on Care Plan. B. Review of Resident 8's current undated Care Plan revealed: - The resident was at risk for falls and fall related injuries; - On 3/7/18, the resident fell from the resident's wheelchair; - On 3/8/18, the resident fell from the resident's wheelchair; and - On 3/9/18, a Velcro seat belt was added to the resident's wheelchair as an intervention to prevent potential ongoing falls. The Velcro seat belt was to be checked every 2 hours while the resident was in the wheelchair and this was to be documented. Review of a physician's orders [REDACTED]. Review of Resident 8's Medication Administration Record [REDACTED]. On 3/27/18 at 9:06 AM Resident 8 was observed to self-propel the resident's wheelchair throughout the facility. The Velcro seat belt was attached loosely, seated on the resident's lap approximately 4 to 5 inches below the resident's abdomen. Interview with Nursing Assistant-H on 3/27/18 at 9:28 AM confirmed the Velcro seat belt was to prevent Resident 8 from falling out of the wheelchair. Interview with the DON on 3/27/18 at 10:22 AM confirmed Resident 8's Velcro seat belt was checked weekly for safety and not every 2 hours as identified on the Care Plan and physician's orders [REDACTED].>C. Interview with Registered Nurse-F revealed residents that took blood pressure medications had their vital signs (including blood pressure and pulse) checked weekly. Review of Resident 2's Pulse Summary revealed: - On 2/14/18, the resident's pulse was 46 (with a normal range of 60 to 100); - On 3/7/18, (21 days later) the resident's pulse was 60; and - On 3/21/18, (14 days later) the resident's pulse was 58. Review of the facility's Weekly Vital Signs documentation dated 2/21/18 and 2/28/18 revealed Resident 2 refused to have the resident's vital signs checked (there was no documenting to indicate the vital signs were attempted on a later date, until the next weekly check). Review of a physician's Progress Note dated 11/28/17 revealed the following: - Resident 8 was seen for a follow up related to Dementia and Hypertension; - Resident 8 took multiple blood pressure medications; - Resident 8 had a history of [REDACTED]. - Resident 8 needed multiple blood pressure medications due to the resident's difficult to treat hypertension. The resident continued all blood pressure medications to prevent a potential reoccurrence of hypertensive [MEDICAL CONDITION]. Interview with the DON on 3/27/18 at 10:19 AM revealed Resident 2 was on comfort cares and had previously seen a cardiologist regarding the resident's hypertension and use of multiple anti-hypertensive medications. Further review confirmed the resident was scheduled for weekly vital signs but the resident often refused and went weeks between vital sign checks. Review of Resident 2's current undated Care Plan confirmed the resident was on comfort cares with an intervention to maintain the resident's status at highest level possible, unless clinically unavoidable. Further review revealed the Care Plan was not developed to include the resident's use of multiple anti-hypertensive medications and did not include what monitoring/follow up was needed regarding the frequency of vital signs and follow up on abnormal vital signs. D. Review of Resident 82's Care Plan dated 7/2/17 revealed [DIAGNOSES REDACTED]. The Care Plan identified the resident was at risk for falls and interventions included the use of a TABS alarm (A pull-string is attached to the resident's garment and sounds an alarm when the resident attempts to rise out of a chair or bed) at all times. Review of a facility investigation of potential abuse/neglect dated 8/11/17 revealed on 8/10/17 at 3:25 PM, Resident 82 was assisted into the dining room by Nursing Assistant (NA)-I. NA-I failed to put on the TABS alarm and the resident subsequently stood up and fell . Interview with the Administrator on 3/27/18 at 2:00 PM confirmed Resident 82's Care Plan was not implemented as the TABs alarm was not in place on 8/10/17 when the resident fell in the dining room.",2020-09-01
5788,HILLCREST HEALTH & REHAB,285133,1702 HILLCREST DRIVE,BELLEVUE,NE,68005,2016-09-29,323,D,1,0,QWZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 12-006.09D7 Based on observation, record review and interview; the facility staff failed to implement assessed interventions to prevent falls for 2 (Resident 5 and 8) of 3 residents. The facility staff identified a census of 101. Findings are: A. Record review of a Face Sheet dated 9-20-2016 revealed Resident 5 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 5's Comprehensive Care Plan (CCP) dated 9-01-2016 revealed Resident 5 had a fall. The goal for Resident 5 was to have reduced risk for falling and the interventions listed on the CCP included Increase lighting, bed in lowest position, keep bathroom door open, shoes on when up and remind the resident to ask for help. Observation on 9-29-2016 at 8:36 AM revealed Resident 5 was in bed asleep. The bed was positioned at waist level and not in the low position. Observation on 9-29-2016 at 9:40 AM revealed Resident 5 was in bed awake. The bed was positioned at waist level and not in the low position. Observation on 9-29-2016 at 4:45 PM revealed Resident 5's was in bed and the bed was at waist level. An interview was conducted Registered Nurse (RN) E on 9-29-2016 at 4:55 PM. During the interview, RN D was able to lower Resident 5's bed into the lowest position. RN E confirmed Resident 5's bed was not in the lowest position. B. Record review of Resident 8's CCP printed on 9-28-2016 revealed Resident 8 was risk for falls. Resident 8's CCP also identified Resident 8 had falls on 7-06-2016, 8-01-2016 and 9-24-2016. The goal for Resident 8 was to be able to ambulate and transfer without fall related injuries and would have the a reduced risk for fall. The interventions on Resident 8's CCP included footwear to fit properly, respond promptly to calls for assistance to use the bathroom, keep items in reach and bed in lowest position when in bed. Observation on 9-29-2016 at 3:45 PM revealed Resident 8 was in bed receiving a treatment for [REDACTED]. Resident 8's bed was at the waist level. PT F completed the treatment and left Resident 8's room. Resident 8's bed remained at waist level. Observation on 9-29-2016 at 4:45 PM revealed Resident 8's bed in at the waist level. An interview was conducted with Registered Nurse (RN) D on 9-29-2016 at 4:45 PM. RN D confirmed Resident 8's bed was not in the lowest position. RN D adjusted Resident 8's bed into the lowest position at the time of the interview.",2019-09-01
3567,PLAINVIEW MANOR,285273,"P O BOX 219, 101 HARPER STREET",PLAINVIEW,NE,68769,2018-03-28,689,E,1,1,ZOJ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 12-006.09D7 Based on observations, record review and interview; the facility failed to implement interventions to prevent ongoing falls for Residents 8 and 82, and to prevent hot liquid spills for Resident 29. The total sample size was 20 and the facility census was 32. Findings are: [NAME] Review of Resident 29's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/13/18 indicated the resident had severely impaired cognition and required supervision with eating. Review of Resident 29's current Care Plan dated 3/15/18 revealed the resident had cognitive impairment and required set-up assistance with eating. The goal was for the resident to eat independently or with set-up assistance during the review period, and there were no interventions developed related to eating. Review of Nursing Progress Notes dated 1/9/18 at 11:48 AM revealed Resident 29 was in the dining room and had spilled hot cocoa in lap. The resident's right upper inner thigh was observed to be light red, and no blisters were noted. The resident complained of some discomfort to the site. The area was cleansed with a cool wet cloth and was to be monitored until resolved. Review of Nursing Progress Notes revealed the following related to the burn area on Resident 29's upper right thigh: -1/9/18 at 11:14 PM - very lightly red in color. Denies any pain or discomfort; -1/10/18 at 11:31 AM - no redness noted from hot cocoa spill on leg yesterday. No complaints of discomfort to area; and -1/17/18 at 4:45 PM - red area to right upper thigh resolved. There was no evidence in the medical record that the burn incident was investigated for causal factors, that the resident was assessed for safety related to hot liquid spills, or that interventions were developed to prevent further incidents. During observation on 3/26/18 at 7:48 AM, Resident 29 was seated at the dining room table with head down and eyes closed. There was a coffee cup half full of creamed coffee and/or cocoa positioned on the table directly in front of the resident. There was no protective equipment observed, and the resident was holding a terry cloth clothing protector in hands. During interview on 3/27/18 at 9:05 AM, the Director of Nursing (DON) indicated Resident 29 was independent in eating and drinking, and verified the resident was not assessed for safety related to hot liquid spills. During observation on 3/27/18 at 9:38 AM, hot water poured directly from the spigot on the dispenser in the dining room measured 167 degrees, and the hot coffee from the same dispenser measured 168 degrees. During interview on 3/27/18 at 9:40 AM, the facility Administrator verified hot liquid temperatures were not monitored prior to serving, and residents were not assessed for safety related to hot liquid spills. B. Review of Resident 8's current undated Care Plan revealed: - The resident was at risk for falls and fall related injuries; - On 3/7/18, the resident fell from the resident's wheelchair; - On 3/8/18, the resident fell from the resident's wheelchair; and - On 3/9/18, a Velcro seat belt was added to the resident's wheelchair as an intervention to prevent potential ongoing falls. The Velcro seat belt was to be checked every 2 hours while the resident was in the wheelchair and this was to be documented. Review of a physician's orders [REDACTED]. Review of Resident 8's Medication Administration Record [REDACTED]. On 3/27/18 at 9:06 AM Resident 8 was observed to self-propel the resident's wheelchair throughout the facility. The Velcro seat belt was attached loosely, seated on the resident's lap approximately 4 to 5 inches below the resident's abdomen. Interview with Nursing Assistant-H on 3/27/18 at 9:28 AM confirmed the Velcro seat belt was to prevent Resident 8 from falling out of the wheelchair. Interview with the DON on 3/27/18 at 10:22 AM confirmed Resident 8's Velcro seat belt was checked weekly for safety and not every 2 hours as identified on the Care Plan and physician's orders [REDACTED].> C. Review of Resident 82's Care Plan dated 7/2/17 revealed [DIAGNOSES REDACTED]. The Care Plan identified the resident was at risk for falls and interventions included the use of a TABS alarm (A pull-string is attached to the resident's garment and sounds an alarm when the resident attempts to rise out of a chair or bed) at all times. Review of a facility investigation of potential abuse/neglect dated 8/11/17 revealed on 8/10/17 at 3:25 PM, Resident 82 was assisted into the dining room by Nursing Assistant (NA)-I. NA-I failed to put on the TABS alarm and the resident subsequently stood up and fell . Interview with the Administrator on 3/27/18 at 2:00 PM confirmed Resident 82's TABS alarm was not in place on 8/10/17, as indicated by the Care Plan, and when the resident fell in the dining room.",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
5519,GRAND ISLAND PARK OPERATIONS LLC,285105,610 NORTH DARR AVENUE,GRAND ISLAND,NE,68803,2016-11-29,322,G,1,0,UQK311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 ,[DATE].09D6(1) Based on record reviews and interviews, the facility failed to ensure the HOB (head of bed) was elevated when indicated for Resident 100 with an EN (enteral nutrition-delivery of nutrients through a feeding tube directly into the stomach or colon). The facility also failed to ensure the feeding tube was flushed with water to remove formula residue prior to medications being administered for one resident (Resident 308) out of 2 residents sampled. The facility census was 59. Findings are: [NAME] Review of the undated face sheet for Resident 100 revealed an admission date of [DATE] and the resident ' s death date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated [DATE] revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 11 which indicated Resident 100 had moderately impaired cognition. Resident 100 exhibited no behaviors. The resident required extensive assist of two staff with bed mobility, transfers, toileting and personal hygiene. The resident required extensive assist of one staff for dressing and was totally dependent on one staff for eating. Resident 100 did not walk. Resident 100 received enteral nutrition. [NAME]S.P.E.N. (American Society for [MEDICATION NAME] and Enteral Nutrition) published (MONTH) 4, (YEAR) ASPEN Safe Practices for Enteral Nutrition Therapy revealed an essential step in EN administration to prevent aspiration was to maintain the HOB (head of bed) to at least 30 degree or upright in a chair, unless contraindicated. Review of the Progress Notes for Resident 100 on [DATE] at 1:06 PM (late entry for [DATE] at 06:15 AM) revealed LPN-A (Licensed Practical Nurse) entered the room of Resident 100 to disconnect the resident's EN. At 06:20 AM, LPN-A heard the resident coughing and returned to the room and the resident had vomited and was SOB (short of breath). The nurse elevated the HOB a little more and the resident reported to the nurse the difficulty in breathing the resident had. Vital signs were 99.9 axillary-Pulse was 80, Respirations were32 and blood pressure was,[DATE]. Resident 100 ' s oxygen saturation was 79% on 3 liters of oxygen. The nurse increased the oxygen to 4 liters and gave the resident the medication [MEDICATION NAME] in attempt to help alleviate the SOB. Another dose of [MEDICATION NAME] was given as LPN-A documented the resident had vomited the first dose administered. At 07:55 AM the resident had expired. Interview on [DATE] at 4:00 PM with the DON (Director of Nursing) revealed the investigation into Resident 100 ' s death revealed LPN-A found Resident 100 with the HOB not elevated when LPN-A had entered the resident's room at 6:15 am on [DATE]. LPN-A had immediately elevated the HOB and it was then that the resident started to vomit. The investigation did reveal the last time the staff visualized the resident with the HOB elevated was at 5:30 AM on [DATE]. The staff revealed the resident did elevate and lower the HOB independently. The DON revealed the DON or Care Plan team was not aware of the resident changing the HOB position, but the staff on the units had been aware prior to [DATE] and had informed the administration. The DON confirmed no interventions were put into place to prevent the resident from positioning the HOB flat while receiving EN. Interview on [DATE] at 3:24 PM with NA-F (Nurse Aide) revealed when cares are done to the residents with EN, the residents ' beds were placed into a near flat position by the nurse aides. Review of Resident 100 ' s careplan revealed no interventions about how to prevent the resident from repositioning the HOB by themselves. Interview on [DATE] at 11:00 AM with RN-G revealed Resident 100 had a remote at the HOB which resident had access to control the HOB positioning Interview on [DATE] at 4:00 PM with the DON confirmed the DON was not aware the staff were putting the residents with EN beds flat while performing cares. B. Review of the facility policy Enteral Tubes dated [DATE] revealed when medications were administered, first verify tube placement then flush the tube with at least 30 cc (cubic centimeters of water before medications were administered. Observation on [DATE] at 09:20 AM revealed RN-G administered medications to Resident 308 via enteral tube. RN-G verified placement of the enteral tube followed immediately by adding the crushed medications into the enteral tube without first flushing with water to remove the formula residue from the tube. Interview with the DON revealed the expectation was to flush enteral tubes with water before medications were administered.",2019-11-01
3894,LITZENBERG MEMORIAL COUNTY HOSPITAL,285292,1715 26TH STREET,CENTRAL CITY,NE,68826,2018-02-05,686,G,1,1,B5KI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 12-006.09D2a Based on observation, record review, and interview; the facility failed to prevent one stage 3 pressure ulcer (Full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss.) on the left buttock and one stage 2 (Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). Presents as a shiny or dry shallow ulcer without slough or bruising ulcer.) on the right buttock of Resident 12. The census was 27. Findings are: Review of Resident 12's undated [DIAGNOSES REDACTED]. Review of Resident 12's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-6-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 12 which indicated Resident 12's cognition was moderately impaired. Resident 12 required extensive assistance of 2 staff with bed mobility and toileting and of 1 staff for personal hygiene and dressing. The resident did not walk and required limited assistance of one staff for locomotion on and off the unit. Resident 12 was identified as at risk for developing pressure ulcers and had two stage 3 pressure ulcers. Review of Resident 12's admission MDS dated [DATE] CAA (Care Area Assessment) revealed pressure ulcer was triggered to be careplanned. However, the documentation revealed the resident's actual problem was a venous stasis ulcer (wounds that are occur due to improper circulation). Review of Resident 12's admission Braden assessment dated [DATE] revealed a score of 16. A score of 18 or below according to the directions on the form indicated the resident was at risk for developing a pressure sore. On 11-16-17 a Braden Assessment was completed with a score result of 14. Review of the Wound Data Collection form dated 11-20-17 for Resident 12 revealed the initial data of the left buttock wound described as 2.5 x 2 cm (centimeter) area with 3 open areas with yellow tissue and open areas measured 0.8 x 0.7 cm; 0.5 x 0.4 cm; and 0.2 x 0.2 cm. The wound bed was described as 100% slough (tissue that is yellow or white in appearance and adheres to the ulcer bed in strings or thick clumps or is mucinous) with minimum amount of drainage. Review of the Wound RN (Registered Nurse) assessment dated [DATE] revealed the left buttock wound was assessed to be a stage 3 pressure ulcer. Review of the Wound Data Collection form dated 2-5-18 for Resident 12 revealed the left buttuck wound measured at 1 x 1.2 x 0.1 cm. Review of the Wound Data Collection form dated 1-22-18 revealed the right buttock had a wound which measured 05. x 0.2 x 0.1 cm Review of the Wound RN assessment dated [DATE] revealed the wound on the right buttock was a stage 2 pressure ulcer. Review of the Wound Data Collection form dated 2-5-18 revealed the right buttock pressure ulcer measured 0.1 x 0.1 x 0.1 cm Observation on 02-01-18 at 7:34 AM of LPN-E (Licensed Practical Nurse) performing the wound care to the two pressure ulcers on Resident 12's right and left buttocks. Left buttock pressure ulcer was approximately 1 cm round in size open with white rounded smooth edges with pink granulated tissue without any drainage. Right buttock pressure ulcer was approximately 0.5 cm round in size open with white rounded smooth edges with pink granulated tissue without any drainage. Resident 12 denied any pain when the left buttock pressure ulcer was treated but complained of pain with treatment of [REDACTED]. Interview on 02-15-18 at 12:54 PM with Resident 12 revealed most of the time the pressure sores do not hurt but occasionally the right buttock pressure sore does cause pain. Observation on 01-29-18 at 10:42 AM of Resident 12's bed revealed no air mattress or air overlay on the bed to help relieve pressure to the buttock pressure wounds when the resident was laying down. Observation on 01-29-18 at 10:42 AM revealed a cushion in the resident's wheelchair but the resident's bed was absent of an air mattress or air overlay to help reduce pressure when the resident laid in bed on (gender) buttocks. Review of the undated Physician orders [REDACTED]. Review of Resident 12's careplan revealed a plan of care was not revised and entered onto the careplan regarding the stage 3 pressure ulcer on the left buttock until 12-05-17. The interventions listed were 1) needs pressure relieving foam/gel cushion in wheelchair 2) treatment per Physician order [REDACTED]. Interview on 02-01-18 at 2:03 PM with the MDS Coordinator revealed on admission resident had venous stasis ulcers on legs, wounds on toes, and did not have pressure ulcers. The facility did not address the resident sitting on a personal pillow in the resident's wheelchair until the resident developed the first pressure ulcer on the left buttock. Then they worked with the resident to have the resident sit on a professinal pressure relieving cushion but it took time as the resident was noncompliant at first. The resident now was fully complaint but recently developed the 2nd pressure ulcer on the right buttock. The MDS Coordinator confirmed the absence of documentation on the careplan or the Kardex (tool used to communicate to the nurse aides for resident cares) about other interventions to relieve pressure to the buttocks such as encouraging the resident to lay down during the day or trialing an air mattress on the bed. Interview on 02-05-18 with the DON (Director of Nursing) revealed the DON reviewed the chart and also could not find any documentation where any other interventions were initiated to help prevent the development of the pressure ulcers from ever starting when first identified upon admission as at risk for developing pressure ulcers.",2020-09-01
5946,GRAND ISLAND PARK OPERATIONS LLC,285105,610 NORTH DARR AVENUE,GRAND ISLAND,NE,68803,2016-07-06,441,D,1,0,HDGT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 12-006.17B Based on observation, record reviews, and interviews; the facility failed to prevent potential cross-contamination from Resident 311 with positive[DIAGNOSES REDACTED]icile entercolitis (inflammation of the digestive tract) to other residents by failing to follow isolation procedures. The facility census was 55. Findings are: Review of Resident 311's Face Sheet, dated 7-5-16, revealed the resident was admitted to the facility on [DATE] with the most recent hospital stay of 6-15-16 to 6-21-16. The face sheet listed the [DIAGNOSES REDACTED]. Interview on 7-5-16 at 4:05 PM revealed Resident 311 required a sit to stand lift with one assist for transfers and one assist with dressing, toileting, bed mobility, and personal hygiene. The resident was independent with eating and locomotion once in the wheelchair. Review of the Admission Physician orders dated 6-21-16 revealed Resident 311 returned from the hospital on IV (intravenous) [MEDICATION NAME] (an antibiotic) medication for MRSA in the stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) ulcer to the right buttock. Review of a Lab (Laboratory) sheet dated 6-23-16 for a stool specimen for Resident 311 revealed[DIAGNOSES REDACTED] was detected. Review of the Consultation/Clinic Referral form dated 6-28-16 revealed Resident 311 was seen by the physician for a follow-up from the hospitalization dismissal of 6-21-16. The form revealed the resident was positive for[DIAGNOSES REDACTED] on 6-23-16 and started on the medication [MEDICATION NAME] (an antiprotocoal) on 6-27-16. Review of a Physician Communication fax dated 6-28-16 revealed Resident 311 had an elevated temperature and the physician started a new medication of [MEDICATION NAME] 250 mg (milligrams) orally QID (four times a day) for 10 days for[DIAGNOSES REDACTED]icile enteritis. Review of the CDC (Centers for Disease Control and Prevention) recommended for residents with[DIAGNOSES REDACTED] infection in LTC (Long Term Care) Contact Precautions should be used. Listed recommendations were to place the resident in a private room if available, to wear gloves when entering the resident's room and during patient cares, to perform hand hygiene after removal of the gloves, to wear gowns when entering patient room and during patient care, to wash hands only with soap and water and do not use alcohol based sanitizers, and dedicate or perform cleaning of any shared medical equipment. Environment cleaning should use sources of hypochlorite (household chlorine bleach) over disinfectants. Review of the facility policy titled Clostridium Difficile revealed residents would be placed on Contact Precautions for the duration of the illness. Healthcare workers and visitors would don gloves and gowns when entering the room for the resident with[DIAGNOSES REDACTED]. Observation on 7-5-16 at 3:40 PM of Resident 311's room revealed no isolation cart outside the room and no sign on the door or walls informing visitors to report to the nurses' station before entering the room. Observation on 7-5-16 at 2:45 PM of the resident in bed receiving physical therapy from the PT (Physical Therapist). The PT leaned over touching the bed linen while raising the resident's leg. The PT did not have a gown or gloves on. Interview on 7-5-15 at 3:46 PM with RN-A (Registered Nurse), the charge nurse for Resident 311, revealed Resident 311 was on the oral [MEDICATION NAME] for the infected wound and denied any other infectious process. Interview on 7-5-16 at 4:05 PM with the AM-B (Account Manager who was also the Department Manager of Housekeeping) revealed that, when a resident required isolation or special cleaning precautions, the information was communicated during Stand-Up meeting which was held every morning with department managers. AM-B communicated the information to the housekeeping staff immediately after the meetings. AM-B revealed there usually was a cart outside the resident's room but there always was a sign on the resident's door which told visitors to report to the nurses' station before entering the room. AM-B revealed currently there was only 1 resident in isolation or with any type of special cleaning precautions and the resident lived on another unit. Interview on 7-5-16 at 5:30 PM with the ADON (Assistant Director of Nursing) revealed the ADON was not aware the resident had[DIAGNOSES REDACTED]icile while at the facility. After review of the labs and the physician orders, the ADON confirmed Resident 311 should have been in Contact Precautions.",2019-07-01
1509,AZRIA HEALTH ASHLAND,285140,1700 FURNAS STREET,ASHLAND,NE,68003,2019-04-16,686,D,1,1,19PP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 12-006.D2b Based on observation, record review, and interviews, the facility failed to ensure pressure ulcer treatment was followed per Physician orders [REDACTED]. The census was 69. Findings are: Review of Resident 68's Admission Record dated 4-15-19 revealed a date of admission of 7-23-18 with [DIAGNOSES REDACTED]. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling) to the sacral region. Resident 68's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 3-29-19 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. The resident did require supervision with bed mobility and locomotion. Resident 68 was independent with transfers, personal hygiene, and eating. The resident had a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (piece of dead tissue) may be present. Often includes undermining and tunneling) and a MASD (moisture associated skin damage wound). Review of the undated Physician orders [REDACTED]. Cover the wound with an ABD (highly absorbent pad) pad BID (twice a day) and PRN (as needed) soiling. The order was initiated on 4/8/2019. Observation on 4-10-19 at 9:25 AM of the sacral wound revealed the sacral wound approximate size was 5 x 3 x 0.3 cm (centimeter) with the inferior edge having an undermined edge and the superior edge with white macerated skin above the wound. Observation on 4-10-19 at 9:25 AM of LPN-E (Licensed Practical Nurse) perform the wound treatments to the left and right ischium and sacrum. The wound treatment was also supervised by the DON (Director of Nursing). LPN-E performed the treatment to all 3 wounds and applied the [MEDICATION NAME] followed by the Calcium Alginate and covered the wounds with ABD pads. However, LPN-E did not apply the moisture barrier around any of the wounds. Interview on 04/16/19 at 01:24 PM with the ADON (Assistant Director of Nursing) revealed the facility/unit was to use Dimethicone for the moisture barrier for Resident 68 and the ADON confirmed per the Physician order [REDACTED]. Interview on 4-16-19 at 8:54 AM with the DON confirmed the top edge of the sacral wound appeared macerated. The DON confirmed LPN-E did not apply the moisture barrier when the wound treatment was performed on 4-10-19 at 9:25 AM as ordered.",2020-09-01
6092,LIFE CARE CENTER OF OMAHA,285137,6032 VILLE DE SANTE DRIVE,OMAHA,NE,68104,2016-06-28,328,G,1,0,M9KH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAACP 12-006.09 Db Based on record review, observation, and interview; the facility failed to evaluate and ensure functioning of respiratory equipment for one resident (Resident 1). The facility census was 104 Findings are: A review of Resident 1's face sheet revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's physician orders [REDACTED]. A review of a list of interviewable residents in the facility provided by the Director of Nursing on 6-28-16 at 4 PM revealed Resident 1 was interviewable. An interview conducted on 6-28-16 at 4:20 PM with Resident 1 revealed that prior to Resident 1's hospitalization on [DATE], Resident 1 was to wear a [MEDICAL CONDITION] while sleeping. Resident 1 stated that the [MEDICAL CONDITION] machine had been broken for weeks. Resident 1 reported that multiple staff were made aware that it was broken, however the staff just kept saying the company that owned the [MEDICAL CONDITION] would have to come out and fix it but no one ever came. Resident 1 stated the settings were not correct on the [MEDICAL CONDITION] and it would shoot out a very high pressure of air and then it would just turn off and stay off. Resident 1 stated that upon return to the facility after the hospitalization Resident 1 received a new [MEDICAL CONDITION] and Resident 1 has had no problems with the new [MEDICAL CONDITION] machine. Review of Resident 1's Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed Resident 1 was to have the [MEDICAL CONDITION] on at bedtime and off in the AM. The documentation showed that the [MEDICAL CONDITION] was not put on Resident 1 from (MONTH) 19 th to (MONTH) 1st, with documentation on the back of the TAR that stated the [MEDICAL CONDITION] did not work. Review of Resident 1's TAR for (MONTH) (YEAR) revealed Resident 1 was to have the [MEDICAL CONDITION] on at bedtime. The documentation showed that the [MEDICAL CONDITION] was not put on Resident 1 from (MONTH) 1st to (MONTH) 21st and the documentation on the back of the TAR stated the [MEDICAL CONDITION] did not work. A review of Resident 1's progress notes revealed that on 4-21-16 the resident was short of breath. The physician was contacted and Resident 1 was ordered to be sent to the hospital for evaluation. Review of Resident 1's hospital physician note dated 4-21-16 stated Resident 1 presented to the hospital with acute chronic [MEDICAL CONDITION] with hypercapnia (excessive carbon [MEDICATION NAME] (CO2) in the blood from difficulty breathing) and respiratory acidosis (a condition when the lungs cant remove all the CO2 in the lungs and becomes acidic). The physician note stated that Resident 1 was above baseline pCO2 (lab value showing the amount of CO2 in the blood) which was consistent with Resident 1's symptomology. Resident 1 was to be transferred to the ICU (Intensive Care Unit) for [MEDICAL CONDITION] (a machine to help with breathing while sleeping), etiology likely multifactoral with noncompliance with [MEDICAL CONDITION] as it was apparently broken. Review of Resident 1's progress notes dated 4-27-16 revealed that Resident 1 was readmitted to the facility from the hospital. An interview with the Administrator on 6-28-16 at 5:15 PM revealed that the Administrator spoke with the company that owned Resident 1's [MEDICAL CONDITION] machine and they reported they had been out to check the mask and tubing but had never checked Resident 1's machine or turned it on to see if it was functioning and did not recall staff informing them that Resident 1's [MEDICAL CONDITION] was not functioning. An interview conducted on 6-28-16 at 5:40 PM with Medication Aide (MA) A revealed that MA A had worked with Resident 1 many times in the evening. MA A stated that Resident 1's [MEDICAL CONDITION] machine was not working right prior to the resident's hospitalization in the end of April, (YEAR). MA A stated that the [MEDICAL CONDITION] machine was putting out too much pressure and Resident 1 reported the resident couldn't breathe with the [MEDICAL CONDITION] machine on and it would sometimes just turn off. MA A revealed that MA A had reported it once to one of the nurses, but could not remember whom or when. An interview on 6-28-16 at 5:51 PM with the Director of Nursing (DON) revealed that the DON was never made aware the Resident 1's [MEDICAL CONDITION] was not functioning until the day that Resident 1 was sent to the hospital. The DON revealed that if a MA or any other staff knew that Resident 1's [MEDICAL CONDITION] was not functioning the staff should have notified the nurse and the nurse should inform the DON and get someone to come out and look at the machine.",2019-06-01
2439,WAKEFIELD HEALTH CARE CENTER,285209,306 ASH STREET,WAKEFIELD,NE,68784,2019-01-16,835,J,1,0,QW7C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].02 Based on observations, record review and interview, the Administration failed to ensure effective management of facility resources to: 1) ensure the safety of 6 residents who were identified at risk for elopement (when a resident leaves the premises or a safe area without authorization and/or supervision) and utilized Wander Guards (a bracelet/signaling device is worn by the resident and sounds an alarm if the resident comes within a certain distance of the door); and 2) failure to maintain an effective plan of action to prevent resident elopement with Resident 2 subsequently eloping from the facility on [DATE]. The sample size was 9 and the facility census was 22. Findings are: Review of deficient practice identified during the survey revealed the following: -F 689. [NAME] On [DATE] Wander Guard signaling devices for 2 residents (Residents 1 and 3) were expired and Resident 3's Wander Guard signaling device was not functioning when tested . There were no additional replacement Wander Guard signaling devices available in the facility. Additional interventions for the prevention of elopement were not developed. B. Facility interventions developed [DATE] for the prevention of resident elopements were ineffective as Resident 2 eloped from the facility on [DATE]. Resident 2 was identified at moderate risk for elopement, however interventions for the prevention of elopement were not developed prior to the resident eloping from the facility on [DATE]. C. Failure to ensure a safe environment for residents identified at risk for wandering was cited during the annual survey on [DATE]. The facility plan of correction indicated a Wander Guard monitoring device was installed at the entrance of the east hallway to the Assisted Living portion of the building. While this device was observed in place during the complaint survey, the alarm would not be activated if the Wander Guard signaling device worn by the resident was not functioning.",2020-09-01
3405,WESTFIELD QUALITY CARE OF AURORA,285263,"PO BOX 166, 1313 1ST STREET",AURORA,NE,68818,2019-05-14,726,F,1,1,V7OX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].04 Based on observation, interview, and record review; the facility failed to have staff present or readily available who were certified to act in an emergency such as choking during resident dining. This had the potential to affect the 15 residents who resided and ate their meals in the facility SU (Secure Unit-a locked unit designed to protect residents with cognitive impairment and/or wandering from leaving the facility unattended). The facility also failed to ensure nursing personnel were knowledgeable and had demonstrated competency and skills set to perform care of residents with Wound VAC therapy (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) for 2 ( Resident 33 and 46)out of 2 residents and wound dressings related to infection control practices for 3 (Resident out of 33, 36, adn 48) out of 3 residents sampled. The facility identified a census of 57 at the time of survey. Findings are: [NAME] Observation of the SU dining room on [DATE] at 12:52 PM and 12:54 PM revealed Resident 15 was eating. No staff or other residents were present. Observation of the SU dining room on [DATE] at 12:06 PM revealed NA-O (Nurse Aide), NA-J, MA-P (Medication Aide) were in the dining room. Residents were observed eating food. No nurse was present. Observation of the SU dining room on [DATE] at 12:16 PM revealed no nurse was in the dining room. NA-O, NA-J and MA-P were in the dining room. The following residents were observed in the dining room eating: Resident 22, Resident 3, Resident 2, Resident 63, Resident 1, Resident 16, Resident 60, Resident 31, Resident 15, Resident 39, Resident 27, and Resident 41. Observation of the SU dining room on [DATE] at 12:40 PM revealed no nurse was present in the dining room. NA-O, NA-J, and MA-P were in the dining room. Residents were eating. Observation of the SU dining room on [DATE] at 12:59 PM revealed there were residents still eating. No nurse was present. MA-P was present in the dining room. Interview with NA-O who was working in the SU on [DATE] at 10:43 AM revealed they were not trained or certified in emergency procedures including CPR or the [MEDICATION NAME] maneuver. NA-O revealed that if a resident started choking during a meal NA-O would have to leave the SU and go find a nurse. NA-O revealed the nurse will occasionally come back to the SU and check on the residents but there was no nurse routinely present during meal times. Interview with NA-J who was working on the SU on [DATE] at 10:43 AM revealed they were not trained or certified in emergency procedures including CPR or the [MEDICATION NAME] maneuver. NA-J revealed that if a resident was choking during a meal NA-J would have to go find a nurse. NA-J revealed the nurse was not available by phone; the staff had to physically go find a nurse. Interview with MA-P on [DATE] at 12:11 PM revealed they were not trained in emergency procedures such as CPR or the [MEDICATION NAME] maneuver. Review of the list received from the DM (Dietary Manager) of residents receiving mechanically altered diets (pureed or ground food to ease chewing and swallowing) and potentially at a higher risk for choking included Resident 2, Resident 63, Resident 22, Resident 60, Residnt 31, and Residnet 16. Interview with RN-H (Registered Nurse) on [DATE] at 12:42 PM revealed the NA and MA staff were not trained on how to perform the [MEDICATION NAME] Maneuver. The NAs and MAs were educated on what choking was and looked like and they were advised to go seek a charge nurse to perform the [MEDICATION NAME] maneuver. B. Observations during this annual survey of 3 different residents (Resident 33,36, and 48) wound care revealed violations of infection control, see F tag 880 for details. The facility had two residents (Resident 33 and 46) with a Wound VAC receiving active treatments. Interview on [DATE] at 9:50 AM with RN-A (Registered Nurse) revealed RN-A had not been competency checked since employment started at this facility and since facility started receiving residents with [DEVICE]. Interview on [DATE] at 12:42 PM with the Infection Control (IC) Nurse revealed the annual competencies that had been completed were hand hygiene, handling of soiled linen, removing of personal protective equipment, perineal care, and glucometer disinfection for Medication Aides only. The IC nurse confirmed the facility did not have any competencies completed or planned for the nurses related to wound dressings, infection control, or [DEVICE]. The IC nurse revealed when the facility admitted the resident with a wound VAC, the facility contracted with a company who provided education and trained 3 facility staff who then turned around and trained the rest of the facility staff. The IC nurse confirmed there was absence of documentation of when the facility nurses were trained and confirmed competency's completed on the nurses.",2020-09-01
2951,RIDGECREST REHABILITATION CENTER,285239,3110 SCOTT CIRCLE,OMAHA,NE,68112,2018-01-23,839,F,1,0,L1D311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].04 Based on record review and interview; the facility failed to ensure 1( Licensed Practical Nurse (LPN) G) of 14 nursing licenses reviewed was not expired and failed to ensure 9 of 13 Nursing Assistants (NA) were qualified to work in the facility Memory Support Unit (MSU). The facility staff identified a census of 60. Findings are: [NAME] Record review of LPN G's employee file revealed LPN G's current nursing license would expire on [DATE]. Further review of LPN G's employee file revealed there was no evidence LPN G had reviewed the license to practice as a nurse. On [DATE] at 9:45 AM an interview was conducted with the facility Nurse Consultant (NC). During the interview on [DATE] at 10:25 AM the facility NC reported LPN G's licensed had expired on [DATE] and confirmed LPN G had continued to work in all areas of the facility as a nurse. B. Record review of a facility staff in-service sheet dated [DATE] that included a staff Sign-In Sheet, revealed multiple topics were discussed including tips for successful communication at all stages of [MEDICAL CONDITION]. Further review of the staff Sign-in Sheet dated [DATE] revealed NA B, NA E, NA F, NA O, NA P, NA Q, NA R, NA S and NA T had not signed in for the in-service. Record review of the nursing schedule as worked for the MSU from [DATE] to [DATE] revealed NA B, NA E, NA F, NA O, NA P, NA Q, NA R, NA S and NA T had worked in the MSU. On [DATE] at 8:40 AM an interview with the facility Administrator was conducted via phone. During the interview the Administrator confirmed the 9 staff had worked in the unit and did not have the in-service training completed.",2020-09-01
3503,BEAVER CITY MANOR,285269,"P O BOX 70, 905 FLOYD STREET",BEAVER CITY,NE,68926,2017-07-10,226,D,1,0,OB1711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].04A3b Based on interview and record review, the facility failed to follow their policy for screening employees for a history of abuse and for ensuring nursing staff were licensed for 1 of 5 staff reviewed (Nurse Aide B). The facility identified a census of 19 at the time of survey. Findings are: [NAME] Record review of NA-B's (Nurse Aide) personnel file revealed a hire date of [DATE]. NA-B's APS/CPS (Adult Protective Services/Child Protective Services) Central Registry check had not been processed due to missing information. The facility had been requested to correct and resubmit the application so the registry checks could be completed. Interview with the facility Administrator on [DATE] at 1:58 PM revealed the facility had not corrected and resubmitted the application for the APS/CPS registry checks. The Administrator confirmed the APS/CPS registry check had not been completed and it was to have been completed before now. The facility Administrator confirmed that NA-B had been working in the facility and providing direct resident care since they were hired and they were currently employed by the facility. Review of the nursing staff schedule for March, April, May, June, and (MONTH) (YEAR) revealed NA-B had been working in the facility since (MONTH) 10. (YEAR) and was currently employed by the facility. B. Review of LPN-A's (Licensed Practical Nurse) personnel file revealed a hire date of [DATE]. LPN-A had a Temporary Nebraska Practical Nurse license that expired [DATE]. Interview with the facility Administrator on [DATE] at 11:40 AM confirmed LPN-A was not currently licensed to practice in Nebraska. Review of the nursing staff schedule for (MONTH) (YEAR) revealed LPN-A had been scheduled to work at 6 PM (MONTH) 2 to 6 AM (MONTH) 3rd and 6 PM (MONTH) 4th to 6 AM (MONTH) 5. No other licensed nursing staff were scheduled to work during those shifts. Interview with the DON on [DATE] at 11:50 AM confirmed LPN-A had worked as charge nurse on those shifts and they should not have as their temporary nursing license had expired and they were not currently licensed to work in the State of Nebraska. Interview with the facility Administrator on [DATE] at 1:12 PM confirmed that LPN-A should not have been working with an expired license. Interview with the facility Administrator and DON (Director of Nursing) on [DATE] at 2:22 PM confirmed that NA-B had been providing direct resident care to all of the residents in the facility and the LPN-A had been responsible for all of the residents' care while they had been working unlicensed. Review of the facility policy Abuse and Neglect Prevention dated [DATE] revealed the following: All potential employees will be screened for history of abuse, neglect or mistreating residents .child abuse and adult abuse background checks will be completed per State of Nebraska policy. Licenses and certifications will be checked for all nurses.",2020-09-01
3504,BEAVER CITY MANOR,285269,"P O BOX 70, 905 FLOYD STREET",BEAVER CITY,NE,68926,2017-07-10,353,F,1,0,OB1711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].04C3 Based on interview and record review, the facility failed to ensure a licensed nurse was on duty every shift. This had the potential to affect all of the residents residing in the facility. The facility staff identified a census of 19 at the time of survey. Findings are: Review of LPN-A's (Licensed Practical Nurse) personnel file revealed a hire date of [DATE]. LPN-A had a Temporary Nebraska Practical Nurse license that expired [DATE]. Interview with the facility Administrator on [DATE] at 11:40 AM confirmed LPN-A was not currently licensed to practice in Nebraska. Review of the nursing staff schedule for (MONTH) (YEAR) revealed LPN-A had been scheduled to work at 6 PM (MONTH) 2 to 6 AM (MONTH) 3rd and 6 PM (MONTH) 4th to 6 AM (MONTH) 5. No other licensed nursing staff were scheduled to work during those shifts. Interview with the DON on [DATE] at 11:50 AM confirmed LPN-A had worked as charge nurse on those shifts and they should not have as their temporary nursing license was expired and they were not currently licensed in the State of Nebraska. Interview with the facility Administrator on [DATE] at 1:12 PM confirmed that LPN-A should not have been working with an expired license. Interview with the facility Administrator and DON (Director of Nursing) on [DATE] at 2:22 PM confirmed that LPN-A had been responsible for all of the residents' care while they had been working unlicensed. Review of the facility policy Abuse and Neglect Prevention dated [DATE] revealed the following: Licenses and certifications will be checked for all nurses.",2020-09-01
2218,GOOD SAMARITAN SOCIETY - ST JOHNS,285189,3410 CENTRAL AVENUE,KEARNEY,NE,68847,2018-04-16,684,D,1,1,KX9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09 Based on record review and interviews, the facility failed to ensure an assessment was completed on one resident's (Resident 100) incision that became infected and the facility proceeded to remove the staples from the incision which caused the wound condition to decline and the resident to be hospitalized . The sample size was one and the facility census was 46. Findings are: Review of PN (Progress Notes) dated [DATE] for Resident 100 revealed resident was admitted to the facility on [DATE] for Medicare A services related to a recent hip surgery, pain control, and Therapy services. The resident was alert with some mild confusion. The resident's hip incision went from the right knee to the hip with staples intact and an ABD (Army Battle Dressing) to cover the incision. The pain was controlled with routine narcotic medications. PN dated [DATE] revealed the resident was alert with some confusion. The incision to the right hip had staples and the dressing was changed because the dressing was partially saturated with serious (clear colored) drainage. No signs or symptoms of infection was observed. Review of the Wound RN Assessment form dated [DATE] of the right hip incision wound revealed staples were intact to the right lateral thigh incision. There was some pinkness on the skin surrounding the lower portion of the incision. Review of the Wound Data Collection form dated [DATE] of the right incision wound revealed the incision was 38 cm (centimeters) long with the skin pink and intact and the resident had mild pain. An Infection Noted dated [DATE] revealed the facility received the blood draw lab results of a BMP (Basic Metabolic Panel) and CBC (Complete Blood Count) and faxed the results to the resident's Physician office. Staff from the Physician's clinic were updated on the yellow drainage from the right hip surgical site and also the right lower leg had 2+ [MEDICAL CONDITION] (excess of watery fluid in the tissue) with seepage of drainage from the right lower leg also. PN dated [DATE] revealed large surgical site to right upper hip and down the leg had moderate amount of yellow drainage on the ABD pad when the RN (Registered Nurse) Skin Nurse changed the dressing. The RN observed 2+ [MEDICAL CONDITION] to lower legs bilaterally. The RN notified the Physician's clinic on the [MEDICAL CONDITION] with seepage of drainage to the right lower leg. PN dated [DATE] revealed incision to the right hip surgical wound had a small amount of red drainage noted to the distal end of the wound and the dressing was changed. During the assessment, the resident complained of ,[DATE] out of 10 pain to the back and right hip. The resident revealed the pain was poorly controlled and refused to work with Therapy that day. PN dated Friday, [DATE] revealed Resident 100 rated the pain at an 8 out of 10. The incision to the right hip had the staples intact but there was moderate amount yellow/red drainage on the dressing so it was removed and a new dressing applied. The resident had ,[DATE]+ [MEDICAL CONDITION] to the lower legs bilaterally. The resident was scheduled to see Resident 100's primary Physician on Monday, [DATE]. PN dated [DATE] revealed the dressing to the right leg/hip was soiled with blood. The dressing was changed. PN dated Sunday, [DATE] revealed the staples were removed from the incision to the hip. After the staples were removed, the resident was sat up on the side of the bed to dangle the feet and the bottom 8 inches of the incision dehisced (ruptured, broke open). The Physician was notified and sent to the ER (emergency room ). Interview on [DATE] at 3:15 PM with the Primary Physician's nurse confirmed the Physician did not feel the Physician was kept updated on the decline of the right hip incision status after [DATE] notification. The Physician's nurse revealed if the Physician would have been notified on the day of [DATE] and informed of the condition of the incision, the Physician wound have ordered the staples to have not been taken out. Review of Perry, Potter, and Ostendorf 8th Edition revealed Removing Staples The health care provider and /or nurse judge whether to remove all staples if any sign of the incision line separation was evident during the process of staple removal. It was not uncommon to remove every other staple initially, removing the rest of the staples several days to a week later. Before removal, assess healing ridge and skin integrity of suture line for uniform closure of wound edges, normal color, and absence of drainage. These signs and symptoms indicate adequate wound healing for support of internal structures without continued need for the staples. A Clinical Decision Point: If wound edges were separated or signs of infection were present, the wound had not healed properly. Notify the health care provider because the staples may need to remain in place and /or other wound care initiated. Review of the Admission Note from the KRMC (Kearney Regional Medical Center) dated [DATE] revealed Resident 100 was admitted on the afternoon of [DATE] with a dehisced right hip incision wound. The Admission Note revealed the resident had the staples were removed but with the increased swelling over the past several days, the wound dehisced on the distal portion of the right lateral thigh. The resident was admitted to KRMC for wound dehiscence, [MEDICAL CONDITION] and possible [MEDICAL CONDITION] and wound infection. The assessment of the wound revealed the skin to the incision was reddened and warm around the incision site. The wound was open at the distal end and draining serosanguinous fluid (pink in color). The resident had 3+ [MEDICAL CONDITION] in the feet bilateral which extended into the thighs and dependent [MEDICAL CONDITION] noted in the buttocks and groin. Interview on [DATE] at 8:35 AM with the DON (Director of Nursing) confirmed the expectation of a nurse to remove staples would be to assess the wound first and if any doubt of the wound having signs or symptoms of infection, call the Physician. Phone interview with the family on [DATE] at 3:47 PM revealed the resident was transferred from the facility to theER on [DATE] and then admitted to the hospital for the right hip incision wound infection. The family refused to have the resident return to the facility so chose to discharge to home with Home Health Care services of a Wound Nurse on [DATE]. The resident's condition continued to decline and on [DATE] the resident was sent back to the ER and expired on [DATE] from a cardiac event caused by septic shock.",2020-09-01
3939,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,657,E,1,1,OLWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09C1b Based on observation, interview and record review, the facility staff failed to review and revise Resident 18's care plan to include interventions to address a sleep disorder including monitoring for adverse medication side effects of the medications the resident was receiving; failed to revise Resident 35's care plan to reflect the resident's status when the resident was admitted on to hospice services; failed to revise the care plan to reflect the current status for Residents 4 and 17; failed to revise the care plan to reflect Resident 24's pressure ulcer care; and failed to implement interventions after Resident 34 fell . This affected 6 of 17 residents whose care plans were reviewed. The facility identified a census of 34 at the time of survey. [NAME] Review of Resident 18's Physician's Progress Notes dated [DATE] revealed Resident 18 was having issues with terminal [MEDICAL CONDITION]. The provider documented Resident 18 was taking [MEDICATION NAME] (an antianxiety medication) at bedtime and receiving [MEDICATION NAME] (an antidepressant also used for treating pain) for chronic pain. The provider documented Resident 18 went to bed about ,[DATE] PM and woke up about 2 in the morning and could not go back to sleep. The provider added 25 mg (milligrams) of [MEDICATION NAME] (an antidepressant used for sleep disorders) at bedtime to see if this helps with this. Review of Resident 18's Physician order [REDACTED]. Review of Resident 18's care plan dated [DATE] revealed no documentation of interventions to address the [MEDICAL CONDITION] problem or monitoring for adverse side effects of the medications Resident 18 was receiving. Interview with LPN-G (Licensed Practical Nurse) on [DATE] at 10:08 AM revealed there was no documentation of interventions to manage Resident 18's sleep disorder including monitoring for adverse medication side effects on Resident 18's care plan. B. Review of Resident 35's undated Face Sheet revealed the resident was admitted on [DATE] to the facility and expired on [DATE]. The Face Sheet also revealed the [DIAGNOSES REDACTED]. Review of the PN (Progress Notes) dated [DATE] revealed the resident was admitted to Hospice services on [DATE]. New orders were received to discontinue the IV (intravenous) fluids and other medication changes related to the resident starting hospice services. Review of Resident 35's Careplan revealed absence of documentation regarding the resident on Hospice services and the change in the interventions related to Hospice. Interview on [DATE] at 12:04 PM with the SSD (Social Service Director) confirmed Resident 35's Careplan was not updated with the Hospice services. C. Review of the nursing progress note dated [DATE] at 3:50 PM for Resident 4; revealed a fax was received from the primary care physician to start [MEDICATION NAME] nebulizer 2.5mg ,[DATE] vial BID (twice a day) X 5 days and [MEDICATION NAME] 500mg TID (three times a day) X 7 days and may crush the appropriate medications and administer together, all at one time, in applesauce/liquid of resident's choice for URI (Upper Respiratory Infection). Review of the nursing progress note dated [DATE] at 12:35 AM for Resident 4; revealed that the resident refused to have their vital signs taken and continued on antibiotic for URI with no adverse reaction noted. Review of the comprehensive care plan for Resident 4 did not identify that the resident was started on an antibiotic and a nebulizer treatment on [DATE] for URI . Interview on [DATE] at 8:22 AM with LPN -G; identified that the URI was not on the care plan nor was the treatment of [REDACTED]. D. Review of the nursing progress note for Resident 23, identified that on [DATE] at 4:20 PM, Resident exiting out front door. When asked where he/she (gender) was going? Resident states I'm looking for my son, I think that's him coming in. Resident's son here at this time visiting in lobby. Review of the nursing progress note for Resident 23, identified that on [DATE] at 6:40 PM, Resident crying and looking for daughter. Review of the nursing progress note for Resident 23, identified that on [DATE] at 4:23 PM, Resident repeating to go home and see their family. Finally taken outside to show them how cold it was and that resident needed to stay inside. When returned, continues to ask to go home to their family. Review of the nursing progress note for Resident 23, identified that on [DATE] at 4:42 PM, Staff makes general observation of increased confusion as the resident now believes he/she (gender) does not live here and wants to go home. Tries to call their family often off of their phone list in their room. Has increased wandering as they feel they need to look for their family to take them home. Review of the nursing progress note for Resident 23, identified that on [DATE] at 7:04 PM Resident has wondered aimlessly through facility all day. Review of the resident's comprehensive care plan identified that the resident was able to self propel with feet and hands throughout the halls. Review of the Wander Data Collection Tool dated [DATE] identified that the resident was at a significant risk of getting to a potentially dangerous place (stairs, outside the facility). Review of the Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated [DATE] identified that the resident had a history of [REDACTED]. Interview on [DATE] at 11:58 AM with the SSD (Social Services Director) confirmed that the elopement risk was not identified on the resident's care plan. SSD stated that they were told by previous Director of Nursing that they didn't need to have a separate care plan problem as long as the wander risk assessment was completed. The SSD confirmed that the resident's elopement risk should have been identified on the care plan. E. Record of Resident 24's Pressure Ulcer Weekly Physician Notification forms dated [DATE] revealed a stage 3 pressure ulcer on the left calf, a stage 4 pressure ulcer on the right lateral calf, and an unstageable pressure ulcer on the heel. Observation on [DATE] at 1:30 PM revealed a stage 3 pressure ulcer on the resident's left calf, a stage 4 pressure ulcer right lateral calf, and a stage 3 pressure ulcer on the right heel during the dressing change performed by LPN-G (Licensed Practical Nurse). Record review of Resident 24's care plan revealed the resident had one pressure ulcer to the right calf and a history of a pressure ulcer to the right heel. The care plan was absent of documentation of the pressure ulcer to the left calf and the pressure ulcer to the right heel. The interventions listed on the care plan revealed the resident had a wound vac treatment to right calf pressure ulcer. Record review of a turn sheet dated [DATE] to [DATE] for Resident 24 revealed the resident was on a turning program. The care plan revealed lack of documentation of the resident being on a turning program. Interview on [DATE] at 09:12 AM with NA-E (Nurse Aide) indicated that the resident was to be turned every 2 hours. Interview with LPN-G on [DATE] at 10:01 AM revealed the resident had been seen by a Physician on [DATE] and TheraSkin (a human skin from a cadaver which promotes wound healing) had been applied to all 3 pressure ulcers and was the current treatment for [REDACTED]. F. Review of Resdient 34's MDS (minimum data set, a federally mandated assessment used for care planning) dated [DATE] revealed Resident 34's BIMS (brief interview for mental status, screening tool used in nursing homes to assess cognition) was 05 which indicated severe cognitive impairment. Review of a Progress Note date [DATE] revealed Resident 34 had a fall in the dining room by sliding from the wheelchair. Review of the FALLS TRACKING LOG dated (MONTH) (YEAR) revealed Root Cause of fall was the resident self-propeled Resident 24's wheelchair and did not lock the brakes on the wheelchair at times. Wheelchair cushion was overinflated causing resident to slide forward. Intervention was Air deflated from wheelchair cushion for better positioning. OT (Occupational Therapy) consult for wheelchair positioning. Review of Resident 34's Care Plan on [DATE] revealed none of the interventions listed on the FALLS TRACKING LO[NAME] Care Plan was not updated to include new interventions to prevent further falls from wheelchair.",2020-09-01
3319,BLUE VALLEY LUTHERAN NURSING HOME,285259,"P O BOX 166, 220 PARK AVENUE",HEBRON,NE,68370,2018-03-21,657,D,1,0,Y8IU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09C1c Based on interview and record review, the facility staff failed to review and revise Resident 1's care plan after a fall to prevent further falls and injury. Sample size was 4. The facility identified a census of 42 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 [DATE] revealed an admission date of [DATE]. Resident 1 had a BIMS (Brief Interview for Mental Status) score of 1 which indicated Resident 1 had severe cognitive impairment. Resident 1 required assistance from staff for transfers and had a fall since the prior assessment. Review of Resident 1's fall scale assessment dated [DATE] revealed Resident 1 was at a high risk for falling. Review of Resident 1's Progress Notes dated [DATE] revealed Resident 1 fell . Review of Resident 1's Care Plan dated [DATE] revealed no documentation Resident 1's care plan had been revised and updated with a new intervention to prevent further falls and injury after Resident 1 fell on [DATE]. Review of Resident 1's Progress Notes dated [DATE] revealed Resident 1 was found on the floor in the bathroom. Resident 1 was transferred to the hospital with complaints and signs of right hip/leg pain. Resident 1 was then transferred to another hospital after examination revealed Resident 1 had a fractured right hip. Review of Resident 1's ED (Emergency Department) Note dated [DATE] revealed Resident 1 had a [DIAGNOSES REDACTED]. Review of Resident 1's Progress Notes dated [DATE] revealed Resident 1 died at the hospital. Interview with RN-A (Registered Nurse) on [DATE] at 1:00 PM confirmed Resident 1's care plan had not been updated after the fall on [DATE] and an intervention should have been put into place to prevent further falls and injury. Review of the facility policy Assessment and Recognition reviewed [DATE] revealed the following: the staff and/or physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.",2020-09-01
5523,"SORENSEN CARE AND REHABILITATION CENTER, LLC",285107,4809 REDMAN AVENUE,OMAHA,NE,68104,2016-11-14,328,E,1,0,7EEE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09D6 Based on observation, record review and interviews; the facility failed to ensure the necessary equipment for Cardiopulmonary Resuscitation was accessible for use per the facility policy for 2 of 2 crash carts reviewed. Findings are: An observation on [DATE] at 8:15 AM of the crash carton on the East side revealed the crash cart (a cart with supplies for staff to use when there is an emergent cardiopulmonary event) was missing an Ambu bag (a self-inflating bag used in cardiopulmonary resuscitation). No inventory sheet was observed on the cart. An observation on [DATE] at 8:17 AM of the crash cart on the West side revealed a missing Ambu bag, oxygen tank and backboard. Record review of the crash cart inventory and equipment maintenance log for the West crash cart for (YEAR) revealed no inventory had been checked after (MONTH) (YEAR). An interview with the Director of Nursing (DON) on [DATE] at 11 AM revealed that crash carts were to be checked at least monthly and after a Cardiopulmonary event for the inventory of items. The DON revealed the Supply Manager was responsible for ensuring the inventory was accurate on the crash carts. An interview with the Supply Manager on [DATE] at 11:15 AM revealed that the crash carts were to be restocked monthly and after a cart was used. The Supply Manager revealed that after the cart was used the nursing staff were to let the supply staff know what was taken and they would go restock the cart however this didn't always get done, as they didn't always have time. The Supply Manager revealed staff had used the crash cart the other day and the Supply Manager did not find out about it until today ([DATE]) and so the cart just now was restocked. Review of the facility policy on CPR-Basic Life Support with a creation date of ,[DATE] revealed: Procedure: 1. The equipment needed to provide CPR is maintained in an area readily accessible by the staff. The emergency equipment may include, but is not limited to, the following: -Disposable one-way valve mask -Backboard -Disposable gloves -Blood pressure cuff -Stethoscope -Portable oxygen and set-up -Portable suctioning equipment -Ambu bag",2019-11-01
5076,"NORFOLK CARE AND REHABILITATION CENTER, LLC",285101,1900 VICKI LANE,NORFOLK,NE,68701,2018-10-11,689,G,1,0,XE5H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09D7a Based on interview and record review, the facility failed to ensure Resident 1 was free from accident hazards related to the use of 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) and failed to determine causal factors and develop interventions to prevent falls for Resident 2. The sample size was 3 and the facility census was 35. Findings are: [NAME] Review of the undated Bestcare [MI]L.C Owner's Manual revealed the mechanical sit-to-stand lift had an emergency lowering mechanism to assist if a resident was left suspended mid-air. The emergency lowering device was located at the top of the [MEDICATION NAME] shaft. The device consists of a plastic collar ring that should be turned clock-wise continually until the resident has been lowered. B. Review of Resident 1's current undated Care Plan revealed the resident was at risk for falls related to the need for extensive assistance with activities of daily living and transferring. Review of an Accident/Unusual Occurrence Report with an incident date of [DATE] revealed Physical Therapist Assistant (PTA)-G was transferring Resident 1 with a sit-to-stand lift when the battery to the lift died . The resident was stuck in the high position in the sit-to-stand lift. PTA-G along with an Occupational Therapist manually assisted Resident 1 out of the sit-to-stand lift sling. During the manual assist the resident's right arm became hyperextended. Further review revealed the resident received an X-ray on [DATE] which showed a fracture to the right humerus. Interview with the Social Services Director on [DATE] at 10:05 AM revealed a video was shown online through YouTube to educate the staff following the sit-to-stand incident on [DATE]. Review of the Lift Training sign in sheet revealed staff members completed the training between [DATE] and [DATE]. Further review revealed not all nursing and therapy staff had completed the training. Review of the YouTube video titled Beststand Assist Lift Series revealed the educational video shown did not mention the emergency lowering mechanism or what to do if the lift malfunctioned. Interview with PTA-G on [DATE] at 9:50 AM revealed the facility had not completed any formal sit-to-stand lift training with PTA-G prior to PTA-G using the sit-to-stand lift with Resident 1. PTA-G stated nursing staff had shown PTA-G how to use the sit-to-stand lift but had not shown PTA-G what to do if the battery died /lift malfunctioned. PTA-G stated after the incident on [DATE] the facility showed a short video on how to use the sit-to-stand lift. PTA-G stated the video did not explain what to do if the battery died /lift malfunctioned. PTA-G remained unaware of how to lower a resident in the sit-to-stand lift if this were to happen again, but stated PTA-G would not use the sit-to-stand lift again, unless further training was provided. Interview with Licensed Practical Nurse (LPN)-B on [DATE] at 10:20 AM, revealed LPN-B was unaware of how to get a resident out of the sit-to-stand lift if the battery died with the resident mid-air. Interview with Registered Nurse (RN)-F on [DATE] at 11:35 AM, revealed RN-F was unsure of how to get a resident out of the sit-to-stand lift if the battery died with a resident mid-air. Interview with the Director of Nursing (DON) on [DATE] at 11:35 AM confirmed more training needed to be completed on the emergency lowering function on the sit-to-stand lift. C. Review of Resident 2's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated [DATE] indicated the following: -[DIAGNOSES REDACTED]. -severe cognitive impairment; -extensive assistance with bed mobility, transfers, ambulation in the corridor and toilet use; -limited assistance with ambulation in the room; -not steady and only able to stabilize with human assistance when moving from seated to standing position, when walking, when turning around and facing the opposite direction while walking, when moving on and off the toilet, and during surface-to-surface transfers (between bed and chair or wheelchair); and -had 2 falls without injury since the last assessment. Review of Resident 2's current Care Plan with a target date of [DATE] revealed the resident was at risk for falls related to cognitive impairment, weakness, and a history of falling on [DATE], [DATE], [DATE], and [DATE] as a result of self-transfer attempts. Nursing interventions included the following: -be sure the call light is within reach and encourage to use it for assistance; -assure wearing appropriate footwear when ambulating or mobilizing in wheelchair; and -gripper strips (attached to the surface of flooring to provide a rough, non-skid surface for fall prevention) added to the floor by the bed. Review of Progress Notes dated [DATE] at 10:22 AM revealed Resident 2 was found in room on knees next to the bed. The resident reported trying to move from the bed to the wheelchair without staff assistance. Review of the POS [REDACTED]. Causal factors related to the fall were not determined, and there were no new interventions developed to prevent further falls. Review of a Post Fall Analysis/Plan dated [DATE] at 3:15 PM indicated Resident 2 lost balance, slipped and slid out of bed while attempting to self-transfer. Documentation indicated the resident had impaired safety awareness and judgment. Causal factors related to the fall were not determined, and there was a recommendation to start resident on toileting program (a toileting schedule based on the resident's individual toileting trends and needs) to prevent further falls. During interviews on [DATE] the following was revealed: -from 10:56 AM until 1:15 PM, Medication Aide (MA)-A and MA-D verified Resident 2 was not on a toileting program but was routinely offered the toilet every 2 hours as was standard for all residents; -at 1:20 PM, the DON verified the toileting program had not been developed yet and was just initiated on this date (3 days following the fall); and -at 1:25 PM, the Administrator verified causal factors were not promptly determined and new interventions for the prevention of falls were not established and implemented.",2020-02-01
2096,HILLCREST CARE CENTER,285178,702 CEDAR AVENUE,LAUREL,NE,68745,2019-03-25,689,D,1,1,F0S011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09D7b (1) (3) Based on observation, record review and interview; the facility failed to protect Resident 1 from ongoing skin tears and bruising, and Resident 15 from falls. The sample size was 5 and the total facility census was 27. Findings are: [NAME] Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated [DATE] revealed the resident's cognition was severely impaired with [DIAGNOSES REDACTED]. The assessment indicated the resident required extensive staff assistance with transfers, bed mobility, dressing, toileting and personal hygiene. Review of a Nursing Progress Note dated [DATE] at 11:11 PM revealed the resident was ambulated from the bathroom and back to the resident's bed. When the resident was assisted to sit on the side of the bed, the resident started to slide and was then lowered to the floor. The resident had been holding onto a walker and the walker hit the resident's forearm causing a large skin tear (16 centimeters (cm) x (by) 2 cm) to the left arm. Further review of the resident's medical record revealed [REDACTED]. Review of a Nursing Progress Note dated [DATE] at 10:16 PM revealed the resident had a 6 cm x 4 cm skin tear to the right lower leg with a 10 cm x 12 cm bruise and a 6 cm x 9 cm bruise to the resident's left lower leg. An intervention was identified to place padded leggings on the resident's lower legs to prevent further injury. Further review of the resident's medical record revealed [REDACTED]. Review of a Nursing Progress Note dated [DATE] at 5:00 PM revealed Resident 1 had been resting on the resident's bed. Staff entered the resident's room and a large amount of blood was observed to the resident's bed linens and to the padded legging on the resident's left lower leg. The legging was removed and revealed a laceration which measured 5.6 cm x 0.3 cm to the resident's left outer leg. The resident was transferred to the emergency room and received 10 sutures to the wound. review of the resident's medical record revealed [REDACTED]. Review of a Nursing Progress Note dated [DATE] at 3:18 PM revealed a late entry for [DATE] at 2:00 PM which identified the resident was found to have a dark purple bruise to the top of the resident's left hand which extended into the 3rd and 4th fingers and measured 7 cm x 6 cm. When interviewed, the resident was unable to identify how the bruising had occurred. There was no evidence in the resident's medical record to indicate further investigation was conducted to determine the cause of the bruising or that interventions were revised and/or developed to protect the resident from further bruising. Review of a Nursing Progress Note dated [DATE] at 1:54 PM revealed during the resident's weekly skin assessment, the resident was observed to have a dark purple bruise which measured 10 cm by 8 cm to the resident's left lower leg. review of the resident's medical record revealed [REDACTED]. Review of Resident 1's current Care Plan with revision date of [DATE] revealed the resident was at risk for skin concerns related to urinary incontinence, and the need for staff assistance with activities of daily living. The following interventions were identified: -apply Cavelon (skin protectant cream with a water proof barrier) to coccyx/buttocks weekly; -pressure relief mattress to bed; -staff to use extreme caution when assisting to change the resident's disposable urinary incontinence brief; -monitor for skin irritations and/or reddened areas; and -weekly skin assessment by a nurse. Review of a Nursing Progress Note dated [DATE] at 9:37 AM revealed during the resident's weekly skin assessment, the resident was found to have a 10 cm x 8 cm dark purple bruise to the left lower leg and a 17 cm x 10 cm bruise to the right lower leg. In addition, the resident had a 5 cm x 7 cm bruise to the left elbow and bruising to the resident's bilateral groin areas. Further review of the resident's medical record revealed [REDACTED]. Review of a Nursing Progress Note dated [DATE] at 8:30 PM revealed the resident was transferred with the use of a mechanical lift (assistive device that allows residents to be transferred between a bed and a chair using hydraulic power) into the bathroom. The resident's right elbow was bumped on the doorframe causing a 1.8 cm skin tear. There was no evidence a new intervention was developed to prevent further injury to the resident during transfers with the mechanical lift. Review of a Weekly Skin assessment dated [DATE] at 4:15 PM revealed the resident was found with a 4 cm skin tear to the left lower leg, an 11 cm x 27 cm bruise to the left shin area, a 0.4 cm x 0.6 cm bruise to the top of the left foot second toe, a 10 cm x 9 cm bruise to the right lower leg and a 5 cm x 3 cm bruise to the top of the right foot. In addition, the assessment indicated the resident had several bruises to bilateral arms. A new intervention was developed for a more form fitted leg protector to be placed on both of the resident's lower legs. review of the resident's medical record revealed [REDACTED]. During an interview on [DATE] at 7:37 AM, the Administrator verified from [DATE] through [DATE], Resident 1 had multiple injuries including skin tears, lacerations and bruises. Despite these injuries, investigations were not completed to determine potential causal factors for Resident 1's injuries. Furthermore, the only additional intervention developed to prevent ongoing injuries was the use of a more form fitting leg protector to the resident's bilateral lower legs. B. Review of the MDS dated [DATE] included the following related to Resident 15: -admitted [DATE] with [DIAGNOSES REDACTED]. -cognitively intact; -required extensive 1 person physical assistance with transfers, ambulation and toilet use; -was unsteady and only able to stabilize with human assistance during transfers and walking; -occasionally incontinent of bladder; and -had a history of [REDACTED]. Review of the current Care Plan dated [DATE] and edited [DATE] indicated Resident 15 was at risk for falls, and nursing interventions included the following: -1 assist with ambulation and transfers with wheeled walker; -encourage use of environmental devices such as hand grips and hand rails; -non-skid grips under recliner, in front of recliner and at bedside; -encourage to keep wheeled walker near at all times; and -assure wearing stable footwear for any ambulation/transfer attempts. Shoes are footwear of choice. Encourage not to go without shoes. Review of Nursing Progress Notes revealed the following related to Resident 15: -[DATE] at 9:48 AM - Assisting to get out of bed and ambulate to the bathroom. Went to sit into the recliner after toileting, lost balance and sat on the arm of the recliner. Staff nearby and steadied (the resident). Cautioned to ask for staff assistance with ambulation to the dining room for breakfast; -[DATE] at 12:45 PM - Walking out to dinner with a staff member as remains unsteady at times. Approximately half way between the resident's room and the dining room, became unsteady again and needed a wheelchair to complete the transfer to the dining room; and -[DATE] at 1:45 PM - Resident had an unwitnessed fall in room this morning. Stated was wanting to go to the bathroom, got out of bed, started walking with walker and lost balance, tried to break the fall and ended up on the floor. Stated put left arm out to try to stop the fall and has some pain in the shoulder/neck area. Review of the Follow-up Fall Investigation Report dated [DATE] indicated the following related to Resident 15's fall: -occurred at 7:45 AM while attempting to go to the bathroom; -no assistive devices were involved and the walker was nearby; -the call light was within reach and was activated by the resident; -the resident was wearing slipper socks at the time of the fall; and -the intervention implemented to prevent reoccurrence of falls was wear shoes during waking hours. The following was observed on [DATE] from 7:21 AM until 7:23 AM: -Resident 15 was standing in the doorway to room in night clothes, barefoot, and supporting self with wheeled walker. The resident's call light was activated. Resident 15 asked for help and stated I've had my light on since quarter to seven; -Licensed Practical Nurse (LPN)-D arrived to work, entered the office located on the same hallway, removed coat and approached Resident 15's room; -Resident 15 indicated need to go to the bathroom, and LPN-D assisted the resident into the room and closed the entry door; and -Medication Aide (MA)-F entered the hallway and answered Resident 15's call light which was still activated, then left the area when LPN-D offered to complete the resident's care. Review of the current Care Plan that was edited [DATE] revealed the intervention to encourage the resident not to go without shoes had a start date of [DATE]. There was no evidence to indicate a new intervention for the prevention of falls was developed following Resident 15's fall on [DATE].",2020-09-01
4267,GENOA COMMUNITY HOSPITAL/LTC,2.8e+272,"P O BOX 310, 606/706 EWING AVENUE",GENOA,NE,68640,2017-12-14,726,E,1,1,ZW3J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].10A3 Based on record review and interview, the facility failed to ensure Medication Aides (MAs) had an active license when administering medications for 1 Medication Aide (MA-H). The sample size was 16 and the facility census was 29. Findings are: Review of MA-H's Certification of Nebraska Licensure form indicated MA-H's Medication Aide license expired on [DATE] and a new license was not issued until [DATE]. Review of Resident 24's Medication Administration Record [REDACTED]. Review of Resident 24's MAR indicated [REDACTED]. During an interview with the Director of Nursing (DON) on [DATE] from 1:25 PM to 1:44 PM, the DON confirmed MA-H passed medications without an active Medication Aide license.",2020-09-01
3897,LITZENBERG MEMORIAL COUNTY HOSPITAL,285292,1715 26TH STREET,CENTRAL CITY,NE,68826,2018-02-05,770,E,1,1,B5KI11,"**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 3 residents (Resident 14, 2 and 3) out of 3 residents sampled. The census was 27. Findings are: Observation on [DATE] at 10:14 AM of the Nurse Medication / Treatment cart revealed 2 Assure Platinum glucose strip bottles ( test strips used to monitor residents' blood sugar) were absent of a date when the bottles were opened. Interview on [DATE] at 10:14 AM with LPN-E (Licensed Practical Nurse) confirmed the 2 bottles were not dated and both had been opened and being used on 3 residents (Resident 14, 2, and 3). Review of the instructions on the bottles and the package insert of the Assure Platinum glucose strips revealed the bottle must be dated when opened and the strips expired in 3 months of the date they were opened.",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
2929,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2018-07-02,791,D,1,0,EO8U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12- Based on record review and interview; the facility staff failed to provide dental services for 1 (Resident 107) of 3 sampled residents. The facility staff identified a census of 54. Findings are: Record review of Resident 107's Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) dated 5-8-2018 revealed the facility staff identified the following about Resident 107: -Required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. Observation on 7-02-2018 at 1:35 PM of oral care revealed Nursing Assistant (NA) J obtained a tooth brush and applied tooth past and cued Resident 107 to brush teeth. Further observation revealed Resident 107's gums started to bleed. Resident 107 completed brushing the teeth and rinsed the mouth with mouth wash provided by NA [NAME] Record review of a Dental Hygienist assessment dated [DATE] revealed staff were to remind Resident 107 to brush the teeth with a soft toothbrush 2 times a day. Review of Resident 107's medical record revealed there was not evidence Resident had a annual evaluation of dental needs. On 7-02-2018 at 3:10 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed Resident 107 had not been provided a annual dental examine.",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
3720,GOOD SAMARITAN SOCIETY - GRAND ISLAND VILLAGE,285285,4061 TIMBERLINE STREET & 4055 TIMBERLINE STREET,GRAND ISLAND,NE,68803,2019-02-19,689,D,1,0,XNDC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006. 9D7a Based on record reviews and interviews, the facility failed to ensure interventions were implemented to prevent injuries after falls for one resident (Resident 200) out of 3 residents sampled. The census was 61. Findings are: Review of Resident 200's Admission Record dated 2-19-19 revealed date of admission 12-3-14 and [DIAGNOSES REDACTED]. coli) as the cause of diseases classified elsewhere, amnesia, and disorientation. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-4-18 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 2 which indicated Resident 200 had severe cognitive impairment. The resident required extensive assist of one staff with bed mobility, transfers, walking, and toileting. Review of Resident 200's PN (Progress Notes) dated 1-16-19 revealed the resident had been found on the floor in the resident's room. Resident assessed and blood pressure was low at 97/63 and the resident had low oxygen saturation at 70%. The Physician was notified and the resident was transferred to the ER (emergency room ) to be evaluated and was admitted . PN revealed absence of a new intervention. Review of Incident Report dated 1-16-19 revealed the resident's alarm sounded which alerted the staff to the resident's room and found the resident on the floor. The report was absent of new interventions to prevent another fall. Review of the Hospital Discharge Summary dated 1-18-19 for Resident 200 revealed the resident was hospitalized with [MEDICAL CONDITION] (low oxygen in the blood), low blood pressure, and change in mentatiion. The report revealed a CT of the head and cervical spine and X-rays of the pelvis were performed to rule out fractures and all were negative. The resident was diagnosed with [REDACTED]. Review of Resident 200's undated Careplan revealed the facility had addressed the resident's risk for falls and listed the 1-16-19 fall by the recliner and the resident had been admitted to the hospital with [REDACTED]. However, the Careplan was absent of a new or revised intervention to prevent future falls. Interview on 2-19-19 at 12:53 PM with the DON (Director of Nursing) revealed the IDT (Interdisciplinary Team) reviewed the fall and felt it was related more to [MEDICAL CONDITION] medications versus the UTI so therefore had done some medication changes. The DON denied documentation of these changes on the Careplan. The DON also denied any specific training/re-education provided to the specific staff who care for Resident 200 on proper peri-cares to prevent the potential of future UTI's from E-coli, the cause of the hospitalization .",2020-09-01
1868,"NORTH PLATTE CARE CENTER, LLC",285165,2900 WEST E STREET,NORTH PLATTE,NE,69101,2017-08-29,332,D,1,0,NP8D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.01D Based on observation, interview, and record review; the facility failed to maintain a medication administration error rate below 5%. This affected 2 of 25 opportunities of medication administration for Residents 5 and 6, resulting in a medication error rate of 8%. The facility identified a census of 49 at the time of survey. Findings are: [NAME] Observation of medication administration by MA (Medication Aide)-B revealed MA-B administered Humalog (insulin [MEDICATION NAME]-a rapid onset insulin used to manage blood sugar levels) to Resident 5 on 8/29/2017 at 11:37 AM. There was no food or juice observed in Resident 5's room and MA-B did not offer any food or juice to resident 5. Observation of Resident 5 on 8/29/2017 at 12:12 PM revealed Resident 5 was sitting in the dining room at the table with a glass of water. No food or juice was present. Observation of Resident 5 on 8/29/2017 at 12:16 PM revealed Resident 5 was in the dining room receiving their meal. Resident 5 did not have any other food or juice on the dining room table prior to receiving their meal. Interview with Resident 5 on 8/29/2017 at 2:27 PM revealed they did not receive anything to eat or drink after receiving their insulin at 11:37 AM prior to receiving their meal at 12:16 PM, which was 39 minutes. Review of Resident 5's Humalog order dated 8/10/2016 revealed it was to be given at lunch time. B. Observation of medication administration by MA-B for Resident 6 on 8/29/2017 at 12:15 PM revealed MA-B crushed a [MEDICATION NAME] (a medication used to increase gastro-intestinal motility) and [MEDICATION NAME] with [MEDICATION NAME] (an opioid [MEDICATION NAME]/pain medication), mixed them together with applesauce, and gave them to Resident 6. Resident 6 was sitting at the dining room table and had food in front of them and there was evidence Resident 6 had already started eating (food on their face). Review of Resident 6's order for [MEDICATION NAME] dated 7/19/2016 revealed it was to be given before meals related [MEDICAL CONDITION](gastro-[MEDICAL CONDITION] reflux disorder). Review of the Nursing (YEAR) Drug Handbook revealed that insulin [MEDICATION NAME] should be given within 15 minutes before the meal and [MEDICATION NAME] was to be given 30 minutes before the meal when used for GERD. Interview with the DON (Director of Nursing) on 8/29/2017 at 2:28 PM revealed Resident 5 should have received food within 15 minutes of the rapid-acting insulin and the [MEDICATION NAME] should have been given 30 minutes before the meal and not given with other medication and food. Review of the facility policy Medication Administration dated 01/13 revealed the following: Purpose: to administer the following according to the principle of medication administration, including the right medication, to the right resident/patient, at the right time, and in the right dose and route. Procedure: Verify physician's orders for medication to be administered. Verify/clarify orders as needed prior to administration.",2020-09-01
3090,CHRISTIAN HOMES HEALTH CARE CENTER,285246,1923 WEST 4TH AVENUE,HOLDREGE,NE,68949,2018-09-11,609,D,1,0,G5HQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on interview and record review, the facility failed to report a fall with significant injury to the State Agency within the required time frame. This affected 1 of 4 sampled residents (Resident 3). The facility identified a census of 74 at the time of survey. Findings are: Review of Resident 3'S admission MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 8/23/2018 revealed Resident 3 was admitted to the facility on [DATE]. Resident 3 required assistance from staff for transfers, walking, and locomotion and had a history of [REDACTED]. Review of Resident 3's Nurses' Notes dated 8/19/2018 revealed Resident 3 was found on the floor in front of the bathroom door at 1:00 PM. Resident 3 had a 10 cm (centimeter) by 2 cm abrasion to the right lateral side. At 6:20 PM Resident 3 was having right sided chest wall pain with movement and increased dyspnea (shortness of breath) and requested an x-ray of the right lateral rib area. At 7:45 PM Resident 3 went to the hospital for the x-ray and returned at 10:05 PM. Review of Resident 3's X-ray Report dated 8/19/2018 revealed the following IMPRESSION: 1. Positive for fracture. 2. Multiple acute-appearing, lower lateral right sided rib fractures center on the proximal (closest) 9th and 10th ribs. Review of Resident 3's Nurses' Notes revealed no documentation Resident 3's fall and rib fractures were reported to the State Agency. Interview with the facility Administrator on 9/11/2018 at 1:45 PM revealed the facility staff did not report Resident 3's fall with rib fractures to the State Agency. Interview with Resident 3 on 9/11/2018 at 2:04 PM confirmed Resident 3 had fallen and suffered broken ribs. Review of the facility Abuse Policy and Procedures revised (MONTH) (YEAR) revealed the following: The Elder Justice Act requirements are included in the Quick Decision Trees: reasonable suspicion of a crime, with a physical injury-you are personally required by law to report it to (the State Agency) within 2 hours. Report of the investigation is due within 5 working days from the allegation.",2020-09-01
4915,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2018-04-03,609,E,1,0,F6ND11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on interview and record review, the facility failed to report an allegation of potential misappropriation to the state agency within the required time frame for 3 (Residents 2, 3 and 4) of 8 sampled residents. The facility identified a census of 35. Findings are: [NAME] Review of the facility's Abuse and Prohibition Policy (undated) revealed the facility was to report allegations of misappropriation to the state, in accordance with state regulations. B. Review of Resident 2's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for Care Planning) dated 2/2/18 revealed the resident was cognitively intact. The assessment identified [DIAGNOSES REDACTED]. Review of Resident 2's Medication Administration Record [REDACTED]. Further review revealed the resident had received the [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg on 4/1/18 at 9:15 AM and on 4/2/18 at 9:36 AM. Both of these doses were administered by Licensed Practical Nurse (LPN)-[NAME] During an interview on 4/3/18 at 2:30 PM, Resident 2 identified a history of pain. Resident 2 confirmed an order for [REDACTED]. Furthermore the resident could not remember the last time the resident's pain had been severe enough for the resident to take the [MEDICATION NAME]. C. Review of Resident 3's MDS dated [DATE] revealed the resident's cognition was severely impaired. The resident had [DIAGNOSES REDACTED]. Review of Resident 3's MAR indicated [REDACTED]. Further review of Resident 3's MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. A score of 0 indicates no pain and a score of 10 is pain so severe it could cause the person to lose consciousness) indicating the resident had no pain. During an interview on 4/3/18 from 8:40 AM to 8:55 AM, Resident 3's spouse indicated the resident did have pain back in (MONTH) but has not had pain since around that time. Resident 3's spouse identified visiting the resident on a daily basis. The spouse further identified the staff had questioned them on 4/1/18 to determine if the resident had asked for and received any pain medication and verified the resident had not complained of pain or received any pain medication. D. Review of Resident 4's MDS dated [DATE] revealed the resident's cognition was severely impaired. The resident had [DIAGNOSES REDACTED]. Review of Resident 4's MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of Resident 4's Controlled Medication Utilization Record (form used to document administration of narcotic medication and to maintain an inventory of the amount of medication remaining) for the [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg 1 tablet 4 times a day revealed on 4/2/18 there was a count of 24 tablets remaining. Further review revealed at 8:50 AM, LPN-A documented the administration of 1 tablet of the [MEDICATION NAME]-[MEDICATION NAME] with a remaining count of 23 tablets. At 12:03 PM, Registered Nurse (RN)-B documented the administration of a second dose of the [MEDICATION NAME]-[MEDICATION NAME], however there were only 21 tablets remaining. A notation printed below RN-B's documentation identified the following recounted when nurse took noon dose and noted count from the AM nurse was off by 1 pill. E. Interview with the facility Administrator and the Director of Nursing on 4/3/18 from 1:00 PM to 1:30 PM verified there was no documentation the potential misappropriation of narcotic medications for Residents 2, 3 and 4 had been reported to the state agency.",2020-03-01
2313,"CALLAWAY GOOD LIFE CENTER, INC",285200,"PO BOX 250, 600 WEST KIMBALL STREET",CALLAWAY,NE,68825,2017-08-01,225,D,1,0,G79911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on interview and record review, the facility staff failed to report a fall with significant injury to the state agency within the required time frame. This affected 1 of 3 sampled residents (Resident 1). The facility identified a census of 27 at the time of survey. Findings are: Review of Resident 1's annual MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 4/11/2017 revealed Resident 1 was admitted to the facility on [DATE]. Resident 1 had a BIMS (Brief Interview for Mental Status) score of 4 which indicated Resident 4 had severe cognitive impairment. Resident 1 required extensive assistance from one staff person for bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, and toilet use. Review of Resident 1's progress notes dated 7/16/2017 revealed Resident 1 was found on the floor in their room at 4:24 AM. Resident 1 complained of left arm pain, had skin tears on the back of the left hand and the left elbow, and a hematoma (swollen bruise) on the left temple. At 9:37 AM on 7/16/2017, Resident 1 complained of left shoulder pain so bad they could hardly move it. Resident 1 continued to complain of left arm and/or shoulder pain on 7/16 , 7/17, 7/18, 7/19, and 7/20/2017. Review of Resident 1's Fax Communication to Physician dated 7/16/2017 revealed Resident 1 was found on the floor and complained of shoulder pain and had limited range of motion. Review of Resident 1's departmental notes dated 7/18/2017 revealed documentation that Resident 1 went to see the medical provider with the facility requesting that Resident 1's left shoulder be x-rayed. Review of Resident 1's Clinic Referral Form dated 7/18/2017 revealed documentation that Resident 1 complained of left shoulder pain and the medical provider had Resident 1's left arm X-rayed. Review of Resident 1's X-Ray report dated 7/18/2017 revealed Resident 1 had a fractured left shoulder. Review of Resident 1's progress notes revealed Resident 1's fall with significant injury (fractured left shoulder) was reported to the State agency on 7/20/2017, 4 days after Resident 1 fell , and 2 days after Resident 1's x-ray revealed Resident 1's fractured left shoulder. There was no documentation the fall with significant injury was reported to the state agency within the required time frame. Interview with the facility Administrator on 8/1/2017 at 2:07 PM revealed Resident 1's fall with significant injury was reported to the state agency on 7/20/2017, 4 days after the fall with injury. The Administrator confirmed Resident 1's fall with significant injury was not reported to the state agency within the required time frame and should have been. Review of the facility policy Abuse Investigation and Reporting dated 2001 revealed the following policy statement: all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. A significant injury was to be reported to the state agency within 2 hours.",2020-09-01
2349,GOOD SAMARITAN SOCIETY - RAVENNA,285202,411 WEST GENOA,RAVENNA,NE,68869,2018-05-31,609,D,1,0,JHDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on interview and record review, the facility staff failed to report a significant injury of unknown origin to the State Agency within the required time frame for Resident 1. This affected 1 of 2 sampled residents. The facility identified a census of 31 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 4/24/2018 revealed an admission date of [DATE]. Review of Resident 1's Progress Notes dated 5/15/2018 revealed Resident 1 was found on the floor in their room and had a head injury that required Resident 1 be transferred to the emergency room for stitches to the forehead. Review of the Fax report revealed documentation the facility report of the investigation of Resident 1's significant injury was submitted to the State Agency on 5/30/2018, 11 working days after the incident occurred. Review of the facility Fallen or Injured Resident Clinical Skill Checklist dated (YEAR) revealed the following: report to the state regulatory agency as appropriate. Review of the Individual Injury reporting requirements for the State Agency identified by the DON (Director of Nursing) as the facility reporting requirements revealed the internal investigation was due within 5 working days from the allegation. Inteview with the DON on 5/31/2018 at 11:39 AM revealed the written investigation of Resident 1's significant injury was not reported to the State Agency within the required time frame.",2020-09-01
2355,GOOD SAMARITAN SOCIETY - RAVENNA,285202,411 WEST GENOA,RAVENNA,NE,68869,2017-10-30,226,D,1,0,7T6F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on interview and record review, the facility staff failed to submit a written report regarding a fall with significant injury for 1 of 3 sampled residents (Resident 1) within the required time frame. The facility identified a census of 38 at the time 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 tool used to develop a resident's care plan) dated 9/20/2017 revealed Resident 1 had a BIMS (Brief Interview for Mental Status) score of 4 which indicated severe cognitive impairment. Resident 1 required limited assistance from 1 staff person for bed mobility, transfer, locomotion on the unit, dressing, and toilet use. Resident 1 had 1 fall with no injury since admission/entry or reentry or the prior assessment. Review of Resident 1's Progress Notes dated 10/4/2017 revealed Resident 1 fell and was transferred to the hospital. Review of Resident 1's ER Progress Note Narrative dated 10/5/2017 revealed Resident 1 had a fractured pelvis and that Resident 1 had fallen on 10/4/2017. Review of Resident 1's Progress Notes revealed no documentation the written report of investigation of the fall with significant injury was submitted to the state agency within the required time. Interview with the DON (Director of Nursing) on 10/30/2017 at 4:15 PM confirmed Resident 1 fell and suffered a fractured pelvis on 10/4/2017. The DON confirmed there was no documentation the written investigation was submitted to the state agency within the required time frame. Review of the facility policy Abuse and Neglect revised 11/16 revealed the results of all investigations will be reported to the state survey and certification agency within five working days of the incident.",2020-09-01
2652,AZRIA HEALTH BROADWELL,285221,800 STOEGER DRIVE,GRAND ISLAND,NE,68803,2019-06-06,609,D,1,1,IQ3V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on interview and record review; the facility failed to report an incident with an allegation of abuse and neglect to the state agency within the required time frame. This affected 2 of 3 (Resident 21 and Resident 212) sampled residents. The facility identified a census of 62 at the time of survey. Findings are: [NAME] Review of Resident 21's quarterly 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 21 was rarely/never understood. Resident 21 required extensive assistance of 2 staff for transfer and bed mobility. Review of Resident 21's Progress Notes dated 5/31/2019 at 6:40 AM Resident 21 was laying on their back with Hoyer lift laying on its side. Resident 21 was still hooked up to the lift. NA et bath aide stated they were transferring Resident 21 to the bath chair and the lift kept falling towards the bath aide, then it just tipped over and the NA and bath aide were unable to stop it from tipping. Interview with Resident 21's family member on 6/03/19 at 2:01 PM revealed the facility staff tipped the lift over and Resident 21 was in it. Resident 21 was landed on the floor. Resident 21's family member expressed concern that Resident 21 may have been injured as Resident 21 was non-verbal and was unable to report injury. Review of Resident 21's Incident Report Form dated 5/31/2019 revealed the bath aide and a nurse aide were using the full lift to transfer Resident 21 to the bath chair. The lift tipped over with Resident 21 in the lift sling onto the floor. There was no documentation the incident was reported to the state agency. The facility had to re-educate the staff on the use of the lift, check the lift and bed for proper function and monitor Resident 21 for 1 week for pain/bruising. Interview with the facility Administrator on 6/05/19 at 12:29 PM revealed they did not report the incident with Resident 21 being tipped over in the lift. They did have to educate and retrain the staff. Review of the facility policy Abuse, Neglect, and Exploitation Prohibition and Prevention Program dated 9/1/2018 revealed the following: Neglect is the failure of the community (facility), it's employees, or service provider to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may be intentional (such as withholding or omitting care) or unintentional (e.g., the caregiver should have known that care was needed, but it was not provided). All covered individuals including mandated reporters, employees, and LTC communities, have an obligation to report all allegations of abuse, neglect, or exploitation to the appropriate state authorities including the State Certification Agency and all other agencies, as required, immediately, but no later than 24 hours after the allegation or occurrence. A report of the investigation is provided to the appropriate state agency within five working days of the incident, unless otherwise indicated by state law or regulation. Per the Elder Justice Act, the Community will need to report to the U.S. Department of health and Human Services and locally identified law enforcement agency any reasonable suspicion of a crime against a resident of other individual receiving care in the community. If there is reasonable suspicion of a crime, and serious bodily injury has occurred, a report is made immediately, but no later than two hours after the suspicion is formed, if there is reasonable suspicion of a crime without bodily injury, a report is made no later than 24 hours after the suspicion is formed. B. Review of PN (Progress Notes) for Resident 212 revealed that the resident attended [MEDICAL TREATMENT] routinely after the abuse allegstion was reported by the facility. PN dated: 12/8/2018 12:06 AM Resident's daughter came and picked resident up and resident discharged . Paperwork signed. All of his items have been collected and removed. PN dated: 12/7/2018 4:12 PM With daughter to [MEDICAL TREATMENT] at 9:30 am. Returned by daughter at 3:15pm. PN dated: 12/5/2018 4:26 PM To [MEDICAL TREATMENT] per daughter, no problems or concerns. PN dated: 12/3/2018 3:23 PM Returned from [MEDICAL TREATMENT]. No new orders. PN dated: 11/30/2018 3:02 PM Returned from [MEDICAL TREATMENT], no new orders. PN dated: 11/25/2018 11:00 PM Resident returns to facility with daughter after outing. Marilyn left him here with staff member and left. Staff got him ready for bed and put him to bed. PN dated: 11/23/2018 3:44 PM Resident transported to and from [MEDICAL TREATMENT] by his daughter. Returned at 3 PM. No new orders. PN dated: 11/21/2018 02:27 PM To [MEDICAL TREATMENT] per daughter, no concerns. PN dated: 11/19/2018 4:40 PM Returned from [MEDICAL TREATMENT]. No new orders. PN 11/16/2018 6:36 PM Had [MEDICAL TREATMENT] today. No new orders. PN dated: 11/16/2018 1:59 PM Psychosocial Note Text: Nursing Communication reminded: No visits may take place in the room due to continued complaints voiced by other residents involving infringing on their rights and privacy. Daughter will Report to Nursing Station when daughter arrives. Resident 212 will be brought to daughter in a common area for all visits. (Public sitting areas, Dining Room, Fireside Room) If Resident 212 does not wish to go an appointment, it is residents right to refuse. Daughter cannot go into resident's room. This includes to dress resident or to make resident go. If daughter arrives after Resident 212 is asleep, if resident chooses to get up and meet with daughter, staff will take resident to meet with daughter in a designated area. If daughter chooses to be uncooperative with these guidelines, then staff will be notified not to allow daughter into the building after the facility has been locked for the evening. If daughter becomes disruptive and refuses to leave when asked, Law Enforcement will be contacted to escort daughter out of the building. PN dated: 11/12/2018 10:51 COMMUNICATION - with Family/NOK/POA (Next of Kin/Power of Attorney) Note Text: At approximately 9:45AM Staff reported that daughter was in Resident 212's room, dressing resident while resident was still in bed. Today is [MEDICAL TREATMENT] and resident had communicated to staff earlier that resident did not want to go. Administrator and SS (Social Service) went to visit with daughter who was still in resident's room and stated daughter did not have the phone (which has a translation app) with daughter. Daughter had been given notice in writing (Spanish) that daughter could not be in residents room nor could daughter force resident to attend medical appointments. (See documentation 11/2/18) When CNA/Med-Aid (Certified Nursing Assistant/Medication-Aid) staff attempted to ask resident if resident wanted to go to [MEDICAL TREATMENT], daughter would interrupt and step between them shaking daughter's finger at staff. Two times however Resident 212 was adamant resident did not want to go when asked, Dialisis, si? Resident replied, No! No Dialisis! Daughter was informed if daughter took Resident 212 out of the building, APS (Adult Protective service) would have to be contacted. Daughter stated daughter needed father to be well so they could move to Florida, and [MEDICAL TREATMENT] will make resident well. Daughter was informed Resident 212 cannot be forced to go to appointments against his will. This was communicated through ADON's (Assistant Director of Nursing) Cell Phone with Translator App. (Application) Daughter then refused to sign the check-out book but eventually agreed when informed daughter must sign to take resident out of the building. Contacted [MEDICAL TREATMENT] and spoke with Nurse. Informed Nurse of current situation and that Daughter was leaving the building with Resident 212, who may or may not be cooperative once they arrive. APS (Adult Protective Services) notified at 10:00 AM PN dated: 11/5/2018 08:45 COMMUNICATION - with Resident Note Text: Quarterly Assessment-BIMS:9 (increased from 7), Mood:2. Triggered for feeling more tired however states only on [MEDICAL TREATMENT] days and decreased appetite which resident states has been just so-so, agreeing resident still enjoys coffee, chocolate ice cream and strawberry yogurt. Resident is not on any med's for mental health and denies feeling anxious or depressed. Resident enjoys being social with other residents and staff. There are times resident will refuse to attend [MEDICAL TREATMENT] or other medical appointments at times. The importance of [MEDICAL TREATMENT] has been disused with resident by social worker, family, medical staff. Hospice has been brought up with resident, but resident is not interested at this time. Resident feels there are times resident will go, and times resident chooses not to, and does not wish to discuss further. Daughter is very involved. At times however daughter requires redirection/reminders to ensure daughter was being mindful of others, which the Ombudsman has been contacted for additional input. Resident 212 is from Cuba and states resident does not enjoy the change of colder seasons. Resident's room has many personal belongings and is homelike. Resident enjoys being independent with choices. Resident's religious preference is Catholic which is very importation to resident. Overall resident was stable and content this quarter. Discharge plan is Long Term Care and is reviewed annually; however daughter has stated daughter was still working to move resident to Florida with daughter once all the arrangements are in place. No other questions/concerns. Continue with current plan of care. PN dated: 11/2/2018 3:51 PM: Returned from [MEDICAL TREATMENT]. No new orders. PN dated: 11/2/2018 10:25 AM COMMUNICATION - with Family/NOK/POA Note Text: Daughter was in the building and was requested to the front office by an interpreter. Meeting started with Daughter, Administrator, Social Services and Interpreter. Interpreter and Daughter were provided updated information in Spanish. Requested Daughter to please read and then if daughter had questions we could further discuss and clarify. After reading, Daughter stated daughter was going to see an attorney and walked out of the room. Updated points provided to Daughter during the meeting: Guidelines on Daughter's visits per Facility and State Ombudsman Office 11/1/2018 No visits may take place in the room due to continued complaints voiced by other residents involving infringing on their rights and privacy. Daughter will Report to Nursing Station when daughter arrives. Resident 212 will be brought to Daughter in a common area for all visits. (Public sitting areas, Dining Room, Fireside Room) If Resident 212 does not wish to go an appointment, it is resident's right to refuse. Daughter cannot go into resident's room. This includes to dress resident or to make resident go. If Daughter arrives after Resident 212 is asleep, if resident chooses to get up and meet with daughter, staff will take resident to meet with daughter in a designated area. If daughter chooses to be uncooperative with these guidelines, then staff will be notified not to allow daughter into the building after the facility has been locked for the evening. If daughter becomes disruptive and refuses to leave when asked, Law Enforcement will be contacted to escort daughter out of the building. Review of Resident 212's Care Plan revealed a risk for dehydration related to End Stage [MEDICAL CONDITION] with hemodilysis 3 times a week. Communication with Resident was documented on the residents Care Plan. Resident does not wish to cooperate with staff (at facility & [MEDICAL TREATMENT]) to go/participate/leave appointments. Had discussion with Resident 212 if resident wants to continue [MEDICAL TREATMENT]? Resident 212 states resident would continue to go, denied hitting staff, and feels resident should be able to sleep and rest when resident wants and when resident agrees to go, not to have to stay so long at [MEDICAL TREATMENT]. Education given on why resident needs to attend, why the long length of time there, etc. Resident voiced understanding. Review of the Investigation Report for Resident 212 dated 11/12/18 revealed documentation of the original report called into APS (Adult Protective Services) there was no documentation of an investigation report submitted within the required 5 (Five) working days. Review of the Abuse, Neglect, and Exploitation Prohibition and Prevention Program revealed on Page 2. Abuse was defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. Mandated Reporter is usually any person who has assumed full or intermittent responsibility for the care or custody of an elder or dependent adult, whether or not (s) he receives compensation. Policy Guidelines list in D. Prompt, through investigations are conducted in response to complaints or allegations of abuse, neglect, and/or exploitation, and all proper and required notifications are made to the proper individuals and authorities according to applicable state and federal regulations. E. Administrator is responsible for the oversight and implementation of the Abuse, Neglect, and Exploitation Prohibition and Prevention Program. Interview on 6/6/19 1:51 PM with the ADM (Administrator) revealed that there was no investigation completed of the abuse allegation so there will be no documentation of one being done.",2020-09-01
2747,BROOKEFIELD PARK,285226,1405 HERITAGE DRIVE,ST PAUL,NE,68873,2019-09-24,609,D,1,1,2YDQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on interview and record review; the facility failed to send in the written report of an investigation to the state agency regarding an incident with Resident 165 within the required time frame. This affected 1 of 3 reported incidences. The facility identified a census of 65 at the time of survey. Findings are: Review of Resident 165's Progress Notes revealed an admission date of [DATE] at 2:45 PM. On 10/31/018 at 6:51 PM, Resident 165 had a choking episode at which time Resident 165 became dusky and lethargic (sleepy/sluggish). Resident 165 remained in the facility. On 11/1/2018 at 5:20 AM Resident 165 was found in their bed without signs of life. Interview with the facility Administrator on 9/24/19 at 10:40 AM revealed they had reported the incident per phone call to the state agency. The administrator confirmed they had not sent in the written report of their investigation. Review of the facility policy Abuse and Neglect Prevention Standard revised 3/2017 revealed the following: After conducting an internal investigation, you must submit a report of all investigation results to the state within five working days.",2020-09-01
6608,GOOD SAMARITAN SOCIETY - ST LUKE'S VILLAGE,285192,2201 EAST 32ND STREET,KEARNEY,NE,68847,2015-12-21,225,D,1,0,NJ5Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on interviews and record review, the facility staff failed to report an injury of unknown origin for Resident 4 to the state agency within 24 hours of becoming aware of the injury. The facility census was 46 at the time of survey. Findings are: Review of Resident 4's Admission MDS (Minimum Data Set-a comprehensive resident assessment tool) revealed an admission date of [DATE]. Review of Resident 4's Physical Therapy Plan of Care dated 11/18/2015 revealed [DIAGNOSES REDACTED]. Interview with Resident 4's child on 12/21/2015 at 1:59 PM revealed that on 12/4/2015 the resident's child noticed Resident 4 had a large area of bruising on the left side of Resident 4's body that extended from the armpit to 2-3 inches above the knee on both front and back that circled around from mid chest to mid back. Resident 4's child reported that the bruising was not there the morning prior when the child had been present when Resident 4 was examined by the physician the morning of 12/3/2015. Resident 4's child reported that Resident 4 returned to the facility from the physician's visit on 12/3/2015 at approximately 11:30 AM and was admitted to the hospital on [DATE]. Resident 4's child reported seeing the bruising on Resident 4's body immediately after Resident 4 was admitted to the hospital. Resident 4's child reported that Resident 4 was unable to explain how the bruising had occurred. Resident 4's child revealed reporting the bruising to the facility DNS (Director Of Nursing) on 12/4/2015. Review of Resident 4's progress notes dated 11/18/2015 to 12/5/2015 revealed no documentation of the bruising on Resident 4's body. Interview with the DNS on 12/21/2015 at 3:28 PM revealed the DNS became aware of the bruising on Resident 4's body on 12/4/2015 when Resident 4's child visited the facility and reported the bruising on Resident 4's body to the DNS. The DNS reported going to the hospital to see Resident 4 and indicated Resident 4 did have bruising on the left side of the body. The DNS reported talking to the facility staff and they thought the bruising could have been from the sling on the sit to stand lift (a mechanical lift used to assist residents from a sitting to a standing position) however, this was unwitnessed. Interview with the facility Administrator on 12/21/2015 at 3:50 PM revealed the bruising on Resident 4's body was not new and the bruising was consistent with an injury Resident 4 had prior to admission to the facility. Interview with the DNS on 12/21/2015 at 3:50 PM revealed the bruising on Resident 4's body was consistent with an injury Resident 4 received prior to admission to the facility. The facility Administrator and DNS were asked to provide documentation that the bruising on Resident 4's body was present prior to 12/4/2015. Interview with the facility Administrator on 12/21/2015 at 4:35 PM revealed there was no documentation in Resident 4's medical record that bruising was present prior to 12/4/2015. The Administrator confirmed the bruising was consistent with an injury of unknown origin and should have been reported to APS within 24 hours after the facility staff was made aware of the bruising on Resident 4's body on 12/4/2015. Review of the facility Policy Abuse and Neglect revised 9/2013 revealed the following: -Alleged or suspected violations involving any mistreatment, neglect or abuse including injuries of unknown origin will be reported immediately to the center administrator and to other officials in accordance with state law, including the state survey and certification agency. -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. -An injury should be classified as an injury of unknown source when both of the following conditions are met: 1. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and 2. The injury is suspicious because of the extent of the injury . Review of the facility Procedure Abuse and Neglect revised 8/2015 revealed the following: -Notification procedures: Notify the location administrator immediately of any incidents of resident abuse, misappropriation of resident property, alleged or suspected abuse and injury of unknown origin, neglect, financial exploitation or involuntary seclusion. Immediately, in this procedure, means as soon as possible after discovery of the incident, and ought not to exceed the end of the shift, in the absence of a shorter state time frame requirement. -If the event that caused the suspicion results in serious bodily injury, the individual will report the suspicion immediately, but no later that two hours after forming the suspicion, or does not result in serious bodily injury, the individual will report the suspicion no later than 24 hours after forming the suspicion. -Notify the designated agency in accordance with state law, including the state survey and certification agency. You may need to notify more than one agency to fulfill federal and state regulations.",2018-12-01
1801,PLUM CREEK CARE CENTER,285159,1505 NORTH ADAMS STREET,LEXINGTON,NE,68850,2018-12-18,609,D,1,1,P4JF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on interviews and record reviews; the facility staff failed to report an allegation of staff neglect to the state agency within the required time frame for 1 of 3 sampled residents (Resident 22). The facility identified a census of 37 at the time of survey. Findings are: Review of Resident 22's Annual MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 10/24/2018 revealed an admission date of [DATE]. Resident 22 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated Resident 22 had no cognitive impairment. Resident 22 required extensive assistance from 2 staff persons for bed mobility, transfer, dressing, toilet use, and personal hygiene. Interview with Resident 22 on 12/11/18 at 2:06 PM revealed the facility staff were helping Resident 22 transfer from the bath chair to bed with the mechanical full body lift and the staff did not have a hold of Resident 22 and Resident 22 ended up on the floor. Resident 22 reported they pulled a muscle in their right leg as a result. Review of Resident 22's Care Plan dated 10/26/2018 revealed Resident 22 was to be assisted with transfers using the full body lift with assistance of 2 staff persons. Review of the facility report Fall-Witnessed dated 11/28/2018 confirmed Resident 22 slid out of the toileting sling onto the floor while staff were transferring Resident 22 with the full body lift. There was no documentation on the report that the facility staff notified the state agency of the incident. Review of Resident 22's Progress Notes revealed no documentation the facility staff reported the incident to the state agency. Interview with the DON on 12/13/18 at 3:06 PM revealed the facility completed an investigation into the incident on 11/28/18 involving Resident 22 and the full body lift; and the facility completed competency training with the 2 staff members who were working with Resident 22 when Resident 22 slipped out of the lift sling. The DON revealed both of the staff who were working with Resident 22 on 11/28/18 were agency staff and had not received training on the operation of a full lift. Interview with the DON (Director of Nursing) on 12/18/18 at 9:20 AM confirmed the facility did not call the incident on 11/28/18, with the full lift on when Resident 22 slipped out of the lift sling to the state agency. During further interview, the DON confirmed the incident should have been reported to the state agency. Review of the facility policy Abuse Prevention Plan revised (MONTH) (YEAR) revealed the following: All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the state survey agency and adult protective services where state law provides for jurisdiction in long-term care facilities in accordance with state law through established procedure. The facility will take all necessary corrective actions depending on the results of the investigation and complete and send a final investigative report to the state agency within 5 business days. 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. Neglect of goods or services may occur when staff are aware, or should be aware, of residents' care needs, based on assessment and care planning, but are unable to meet the identified needs due to other circumstances, such as lack of training to perform an interventions (e.g. suctioning, transfers, use of equipment), lack of sufficient staffing to be able to provide the services, lack of supplies, or staff lack of knowledge of the needs of the resident. Examples include, but not limited to: not providing sufficient, qualified, competent staff to meet residents' needs, not providing orientation and training to staff, not provide supervision and/or monitoring of the delivery and implementation of care and/or environment. Alleged violation: situation or occurrence that is observed or reported but not yet investigated and if verified, could be noncompliance with the federal requirements. All health care workers/staff, regardless of place of employment, that provide services in a facility are mandated reporters and must report any known or suspected type of abuse, neglect, misappropriation of funds, exploitation or involuntary seclusion. Staff includes employees, the medical director, consultants, contractors and volunteers. This also includes caregivers who provide care and services to residents on behalf of the facility.",2020-09-01
2653,AZRIA HEALTH BROADWELL,285221,800 STOEGER DRIVE,GRAND ISLAND,NE,68803,2019-06-06,610,D,1,1,IQ3V11,"**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 protect 1 of 3 sampled residents from potential abuse (Resident 212). The facility identified a census of 62 at the time of survey. Findings Are: Review of Resident 212's Significant Change MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 9/24/18 revealed Section C: Cognitive Patterns: BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) of 7 which indicates severe cognitive impairment; Section [NAME] behaviors for rejection of care occurred 1 to 3 days in the last 7 days; Section F: Preferences: Resident answered very important for the question: How important is it to you to have your family or a close friend involved in discussion about your care? Section O Special treatment/Rehab OX; Received [MEDICAL TREATMENT] Review of Resident 212's Quarterly MDS dated [DATE] revealed Section C: Cognitive Patterns: BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) of 7 which indicates severe cognitive impairment; Section [NAME] behaviors for rejection of care occurred 1 to 3 days in the last 7 days; Section F: Preferences: Resident answered very important for the question: How important is it to you to have your family or a close friend involved in discussion about your care? Section O Special treatment/Rehab OX; Received [MEDICAL TREATMENT] Review of PN (Progress Notes) for Resident 212 revealed the following entries and that Resident 212 left with the daughter on [MEDICAL TREATMENT] days and returned with the daughter. PN dated: 12/8/2018 12:06 AM Resident's daughter came and picked resident up and resident discharged . Paperwork signed. All of his items have been collected and removed. PN dated: 12/7/2018 4:12 PM With daughter to [MEDICAL TREATMENT] at 9:30 am. Returned by daughter at 3:15pm. PN dated: 12/5/2018 4:26 PM To [MEDICAL TREATMENT] per daughter, no problems or concerns. PN dated: 12/3/2018 3:23 PM Returned from [MEDICAL TREATMENT]. No new orders. PN dated: 11/30/2018 3:02 PM Returned from [MEDICAL TREATMENT], no new orders. PN dated: 11/25/2018 11:00 PM Resident returns to facility with daughter after outing. Marilyn left him here with staff member and left. Staff got him ready for bed and put him to bed. PN dated: 11/23/2018 3:44 PM Resident transported to and from [MEDICAL TREATMENT] by his daughter. Returned at 3 PM. No new orders. PN dated: 11/21/2018 02:27 PM To [MEDICAL TREATMENT] per daughter, no concerns. PN dated: 11/19/2018 4:40 PM Returned from [MEDICAL TREATMENT]. No new orders. PN 11/16/2018 6:36 PM Had [MEDICAL TREATMENT] today. No new orders. PN dated: 11/16/2018 1:59 PM Psychosocial Note Text: Nursing Communication reminded: No visits may take place in the room due to continued complaints voiced by other residents involving infringing on their rights and privacy. Daughter will Report to Nursing Station when daughter arrives. Resident 212 will be brought to daughter in a common area for all visits. (Public sitting areas, Dining Room, Fireside Room) If Resident 212 does not wish to go an appointment, it is residents right to refuse. Daughter cannot go into resident's room. This includes to dress resident or to make resident go. If daughter arrives after Resident 212 is asleep, if resident chooses to get up and meet with daughter, staff will take resident to meet with daughter in a designated area. If daughter chooses to be uncooperative with these guidelines, then staff will be notified not to allow daughter into the building after the facility has been locked for the evening. If daughter becomes disruptive and refuses to leave when asked, Law Enforcement will be contacted to escort daughter out of the building. PN dated: 11/14/2018 1:41 PM To [MEDICAL TREATMENT] per daughter with no problems. PN dated: 11/12/2018 4:21 PM Daughter returned resident from [MEDICAL TREATMENT] at 4:05 PM. No new orders. PN dated: 11/12/2018 10:55 AM Discharge Summary Note Text: Called Admissions in Florida. Left message with Administrator if any additional information was needed or if the facility can meet Resident 212's needs. Asked if Administrator could please call with an update. PN dated: 11/12/2018 10:51 COMMUNICATION - with Family/NOK/POA (Next of Kin/Power of Attorney) Note Text: At approximately 9:45AM Staff reported that daughter was in Resident 212's room, dressing resident while resident was still in bed. Today is [MEDICAL TREATMENT] and resident had communicated to staff earlier that resident did not want to go. Administrator and SS (Social Service) went to visit with daughter who was still in resident's room and stated daughter did not have the phone (which has a translation app) with daughter. Daughter had been given notice in writing (Spanish) that daughter could not be in residents room nor could daughter force resident to attend medical appointments. (See documentation 11/2/18) When CNA/Med-Aid (Certified Nursing Assistant/Medication-Aid) staff attempted to ask resident if resident wanted to go to [MEDICAL TREATMENT], daughter would interrupt and step between them shaking daughter's finger at staff. Two times however Resident 212 was adamant resident did not want to go when asked, Dialisis, si? Resident replied, No! No Dialisis! Daughter was informed if daughter took Resident 212 out of the building, APS (Adult Protective service) would have to be contacted. Daughter stated daughter needed father to be well so they could move to Florida, and [MEDICAL TREATMENT] will make resident well. Daughter was informed Resident 212 cannot be forced to go to appointments against his will. This was communicated through ADON's (Assistant Director of Nursing) Cell Phone with Translator App. (Application) Daughter then refused to sign the check-out book but eventually agreed when informed daughter must sign to take resident out of the building. Contacted [MEDICAL TREATMENT] and spoke with Nurse. Informed Nurse of current situation and that Daughter was leaving the building with Resident 212, who may or may not be cooperative once they arrive. APS (Adult Protective Services) notified at 10:00 AM PN dated: 11/9/2018 3:37 PM To [MEDICAL TREATMENT] this date and returned at 3:00 PM. No new orders PN dated: 11/8/2018 1:25 PM Daughter requested Social Services re-fax to facility in Florida to Admissions. Included copy of Resident 212's Driver's License which daughter supplied. PN dated: 11/7/2018 3:22 PM Returned from [MEDICAL TREATMENT]. No new orders. PN dated: 11/5/2018 08:45 COMMUNICATION - with Resident Note Text: Quarterly Assessment-BIMS:9 (increased from 7), Mood:2. Triggered for feeling more tired however states only on [MEDICAL TREATMENT] days and decreased appetite which resident states has been just so-so, agreeing resident still enjoys coffee, chocolate ice cream and strawberry yogurt. Resident is not on any med's for mental health and denies feeling anxious or depressed. Resident enjoys being social with other residents and staff. There are times resident will refuse to attend [MEDICAL TREATMENT] or other medical appointments at times. The importance of [MEDICAL TREATMENT] has been disused with resident by social worker, family, medical staff. Hospice has been brought up with resident, but resident is not interested at this time. Resident feels there are times resident will go, and times resident chooses not to, and does not wish to discuss further. Daughter is very involved. At times however daughter requires redirection/reminders to ensure daughter is being mindful of others, which the Ombudsman has been contacted for additional input. Resident 212 is from Cuba and states resident does not enjoy the change of colder seasons. Resident's room has many personal belongings and is homelike. Resident enjoys being independent with choices. Resident's religious preference is Catholic which is very importation to resident. Overall resident is stable and content this quarter. Discharge plan is Long Term Care and is reviewed annually; however daughter has stated daughter is still working to move resident to Florida with daughter once all the arrangements are in place. No other questions/concerns. Continue with current plan of care. PN dated: 11/2/2018 3:51 PM: Returned from [MEDICAL TREATMENT]. No new orders. PN dated: 11/2/2018 10:25 AM COMMUNICATION - with Family/NOK/POA Note Text: Daughter was in the building and was requested to the front office by an interpreter. Meeting started with Daughter, Administrator, Social Services and Interpreter. Interpreter and Daughter were provided updated information in Spanish. Requested Daughter to please read and then if daughter had questions we could further discuss and clarify. After reading, Daughter stated daughter was going to see an attorney and walked out of the room. Updated points provided to Daughter during the meeting: Guidelines on Daughter's visits per Facility and State Ombudsman Office 11/1/2018 No visits may take place in the room due to continued complaints voiced by other residents involving infringing on their rights and privacy. Daughter will Report to Nursing Station when daughter arrives. Resident 212 will be brought to Daughter in a common area for all visits. (Public sitting areas, Dining Room, Fireside Room) If Resident 212 does not wish to go an appointment, it is resident's right to refuse. Daughter cannot go into resident's room. This includes to dress resident or to make resident go. If Daughter arrives after Resident 212 is asleep, if resident chooses to get up and meet with daughter, staff will take resident to meet with daughter in a designated area. If daughter chooses to be uncooperative with these guidelines, then staff will be notified not to allow daughter into the building after the facility has been locked for the evening. If daughter becomes disruptive and refuses to leave when asked, Law Enforcement will be contacted to escort daughter out of the building. Review of Resident 212's Care Plan revealed a risk for dehydration related to End Stage [MEDICAL CONDITION] with hemodilysis 3 times a week. Communication with Resident was documented on the residents Care Plan. Resident does not wish to cooperate with staff (at facility & [MEDICAL TREATMENT]) to go/participate/leave appointments. Had discussion with Resident 212 if resident wants to continue [MEDICAL TREATMENT]? Resident 212 states resident would continue to go, denied hitting staff, and feels resident should be able to sleep and rest when resident wants and when resident agrees to go, not to have to stay so long at [MEDICAL TREATMENT]. Education given on why resident needs to attend, why the long length of time there, etc. Resident voiced understanding. Review of the Investigation Report for Resident 212 dated 11/12/18 revealed documentation of the original report called into APS (Adult Protective Services) there was no documentation of an investigation report submitted within the required 5 (Five) working days. Review of the Abuse, Neglect, and Exploitation Prohibition and Prevention Program revealed on Page 2. Abuse was defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. Mandated Reporter is usually any person who has assumed full or intermittent responsibility for the care or custody of an elder or dependent adult, whether or not (s) he receives compensation. Policy Guidelines list in D. Prompt, through investigations are conducted in response to complaints or allegations of abuse, neglect, and/or exploitation, and all proper and required notifications are made to the proper individuals and authorities according to applicable state and federal regulations. E. Administrator is responsible for the oversight and implementation of the Abuse, Neglect, and Exploitation Prohibition and Prevention Program. Interview on 6/6/19 1:51 PM with the ADM (Administrator) revealed that there was no investigation completed of the abuse allegation so there will be no documentation of one being done.",2020-09-01
5069,"NORFOLK CARE AND REHABILITATION CENTER, LLC",285101,1900 VICKI LANE,NORFOLK,NE,68701,2018-03-08,609,D,1,1,2SKI11,"**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 notify the State Agency of an adverse event which involved 2 (Resident 159 and 160) of 24 sampled residents. The facility census was 52. Findings are: [NAME] Review of a facility's Abuse, Neglect. Exploitation, Mistreatment and Misappropriation of Resident Property Policy dated 5/17 revealed the following: -The Nursing Home Administrator or designee will make an initial (immediate or within 24 hours) report pf abuse/neglect to the State Agency. A follow up investigation will be submitted to the State Agency with in 5 working days. -Neglect is defined as a failure of the facility, it's employees or service providers to provide services that are necessary to avoid physical harm, pain, mental anguish or emotional distress. B. Review of Resident 159's Admission Nursing assessment dated [DATE] revealed the resident was admitted at 10:00 AM from the hospital. The resident's admitting [DIAGNOSES REDACTED]. An Elopement Risk Assessment was completed 4/18/17 at 11:15 AM and identified a score of 7. The assessment indicated a score of 10 or higher meant the resident was at risk for elopement. Review of Resident 159's Nursing Progress Notes dated 4/18/17 revealed the following: -12:00 PM the resident was admitted from the hospital at 10:00 AM with weakness and dehydration. The resident's spouse was to be admitted to the facility as well. Resident 159's family were at the facility to assist with the admission process and indicated Resident 159 had a split personality. -4:05 PM the resident was agitated and wanted to check out of the facility with spouse and to go home. The resident and spouse attempted to get out various exits of the building. The staff tried to redirect the resident and placed a wanderguard (a bracelet worn by the resident and sounds an alarm if the resident comes within a certain distance of the door) on the resident and the spouse. Resident 159 was able to stretch out the band, take off the bracelet and then threw it at the staff. -4:50 PM the resident was very agitated, yelled at staff and verbally threatened the staff. The resident's family was notified of the resident's behaviors and was asked to return to the facility. -5:05 PM the resident pushed staff out of the way and exited the facility with the spouse, through the front entrance. The resident remained very agitated and staff were unable to redirect the resident to return to the facility. The resident exited the facility parking lot and crossed the street to an adjacent parking lot. Resident 159 made the comment I am going to throw myself out into traffic. The facility called the police to assist with maintaining the resident's safety. Resident 159's family arrived at the facility and attempted to redirect the resident and spouse but were unsuccessful. Resident 159 again made a statement the resident was going to go out into the traffic and took a step toward the street. -5:22 PM four police officers arrived at the facility. Resident 159's family asked to have the resident's placed in Emergency Protective Custody (EPC-part of the mental health commitment act which permits law enforcement to take into custody a mentally ill dangerous person who is likely to do harm to himself or herself or others). -6:07 PM the resident and spouse were taken by ambulance to the hospital for a psychiatric evaluation. C. Review of Resident 160's Admission Nursing Assessment revealed the resident was admitted from home on 4/18/17 at 3:00 PM with a [DIAGNOSES REDACTED]. The assessment indicated the resident was independent with transfers and required staff supervision with ambulation. The resident was cooperative and pleasant and cognition was moderately impaired. Review of an Elopement Risk Assessment completed 4/18/17 at 3:47 PM revealed the resident had a score of 12. The assessment identified a score of 10 or greater indicated the resident was at risk for elopement. Review of Resident 160's Nursing Progress Notes dated 4/18/17 revealed the following: -4:05 PM the resident was attempting to exit the facility and made comments about going home with spouse. A wanderguard was placed on the resident and staff attempted to redirect. -4:05 PM the resident's family were called and asked to return to the facility to assist with the resident's behaviors. -5:05 PM the resident's spouse pushed staff out of the way and exited the front door with Resident 160. Resident 160's family arrived and attempted to redirect the resident back into the facility without success. The police department was notified and Resident 160 and spouse left the facility parking lot and crossed to an adjacent parking lot. -5:22 PM the resident's family requested to have Resident 160 and spouse taken into Emergency Protective Custody. -6:07 PM the resident was taken with spouse per ambulance to the hospital for a psychiatric evaluation. D. Interview with the Director of Nursing (DON) on 3/6/18 at 2:14 PM revealed Resident 159 and Resident 160 were both admitted on [DATE]. Resident 160 had a [DIAGNOSES REDACTED]. Resident 159 became ill, was weak and dehydrated requiring hospitalization . After Resident 159 was discharged for m the hospital, the residents were admitted to the facility to receive therapy with a potential discharge back home. Initially both residents were in favor of the admission but as the day progressed the residents became agitated. The residents were confused about admission and demanded to go home. Wanderguard bracelets were placed on both residents and staff attempted to redirect the residents, but the residents physically pushed staff away and exited from the front door with staff at their side. Facility staff and family were unable to get the residents to return to the facility and per family request the residents were taken into emergency protective custody and sent to the hospital for psychiatric evaluation. The DON confirmed the facility did not report the incident to the State Agency and even though the facility completed an investigation, the investigation was not sent to the State Agency. -",2020-02-01
6509,"OMAHA METRO CARE AND REHABILITATION CENTER, LLC",285097,5505 GROVER STREET,OMAHA,NE,68106,2016-01-19,225,D,1,0,GIIR11,"**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 submit investigations to the required state agency within 5 working days of an allegation of potential neglect for 2 residents (Resident 1 and 4). The facility staff identified a census of 86. Findings are: A. Record review of Resident 1's Comprehensive Care Plan (CCP) printed on 12-23-2015 revealed Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further review of Resident 1's CCP revealed Resident 1 was tube feed and required 1 to 2 person assistance with cares. Record review of a Verification of Investigation (VOI) report dated 12-19-15 revealed Resident 1 was .found between (gender) recliner and bed. According to the VOI dated 12-19-15 Resident 1's left knee had swelling from above the left knee to just below the left knee. Resident 1 complained of pain with any movement to the left knee. Resident 1's physician was notified and Resident 1 was sent to the hospital for an evaluation. Additional information in the VOI dated 12-19-15 revealed Resident 1 had sustained a fracture to the left leg. Record review of Resident 1's record revealed there was not any evidence the facility had submitted their investigation into the required state agency within 5 working days. An interview was conducted on 1-14-16 at 7:15 AM with the Director of Nursing (DON). During the interview, the DON confirmed the investigation had not been submitted to the state within 5 working days. B. Record review of a Clinical Health Status (CHS) sheet dated 9-21-2015 revealed Resident 4 readmitted to the facility with the [DIAGNOSES REDACTED]. Record review of a VIO dated 8-16-15 revealed Resident 4 had been found by the facility staff on the sidewalk outside of the building. According to the information on the VOI dated 8-16-15, Resident 4 was attempting to go to another city. Further review of the VOI dated 8-16-15 revealed the facility did implement interventions to prevent elopement. Record review of Resident 4's record revealed there was not evidence the facility staff had submitted their investigation to the required state agency. An interview was conducted on 1-14-16 at 10:43 AM with the DON. During the interview the DON confirmed the investigation had not been submitted to the state agency within 5 working days. Record review of the facility abuse and neglect protocols faxed on 1-19-2016 revealed the decision tree on investigating and reporting allegations of abuse/neglect revealed the facility investigation reporting was due to the state agency .within 5 working days.",2019-01-01
3281,COMMUNITY MEMORIAL HEALTH CENTER,285257,"P O BOX 340, 1015 F STREET",BURWELL,NE,68823,2018-09-25,609,D,1,1,E7OB11,"**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 and investigate an incident of potential neglect after Resident 15 developed significant bruising. The sample size was 3 and the facility census was 50. Findings are: [NAME] Review of the facility Policy and Procedure related to Suspected or Actual Abuse dated 3/13/15 revealed; individual injuries which were significant for the resident or the explanation of the injury created a reason to suspect abuse/neglect occurred were to be reported to the Administration and State Agency. In addition, steps would be taken to protect the individual and an internal investigation would be conducted. B. Review of Resident 15's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 7/13/18 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was cognitively intact and required 2 staff to provide extensive assistance with transfers. Review of Progress Notes dated 8/6/18 at 1:16 AM revealed Resident 15 was found to have bruising on the right rib area which measured 3 by 2 centimeters (cm) and bruising on the right side of the abdomen which measured 9 cm by 7 cm. Review of Progress Notes dated 8/7/18 at 6:25 AM revealed Resident 15 had continued bruising of the right breast and abdomen. Documentation further included the following: -the right side of the resident's right breast was covered with a purple colored bruise; -the resident was alert and oriented, did not report how the bruises were obtained but denied abuse; -the resident acknowledged having delicate skin and the resident was taking aspirin; and - .Suspect area to be occurring with application/removal of clothing such as bra or gait belt. There was no evidence Resident 15's bruising was reported to the facility Administration nor was there evidence interventions were developed in an attempt to prevent further bruising. Review of a Non-Pressure Skin Condition Report dated 8/8/18 revealed Resident 15 had bruising covering the right breast/rib area which measured 15 cm by 23 cm (an increase in size). Review of Progress Notes dated 8/8/18 at 4:27 PM revealed Resident 15's gait belt was being modified with lambs wool (soft padding) for use with transfers. Review of a Non-Pressure Skin Condition Report dated 8/15/18 revealed Resident 15's bruised area measured 18 cm by 26 cm (an increase in size). Review of a Non-Pressure Skin Condition Report dated 8/16/18 revealed Resident 15's bruised area measured 43 cm by 45 cm and Bruising now from waist to right elbow. Rib area to past nipple on (right) breast. Review of a Timeline from 7/23/18 through 9/20/18 provided by the Director of Nurses (DON) revealed on 8/16/18 Resident 15 reported the bruising occurred days ago when the resident lost balance and staff caught the resident. Review of a record of counseling/education provided to Nursing Assistant (NA)-P on 8/16/18 revealed NA-P had previously transferred Resident 15 with 1 assist (instead of with 2 assistants). There was no evidence Resident 15's bruising and incident of potential neglect was reported to the State Agency and a thorough investigation was not completed. Interview with the Administrator and DON on 9/25/18 at 6:40 AM confirmed Resident 15's bruising was not reported to the State Agency and an investigation was not completed promptly.",2020-09-01
2950,RIDGECREST REHABILITATION CENTER,285239,3110 SCOTT CIRCLE,OMAHA,NE,68112,2018-01-23,835,H,1,0,L1D311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observation, record review and interview; the facility administrative staff failed to ensure the facility resources were effectively utilized to maintain or improve the physical, psychosocial and mental well-being of the facility residents. This deficient practice had the potential to affect all residents in the building. The facility staff identified a census of 60. Findings are: Review of the following information revealed the following: -F692. The facility staff failed to identify and implement interventions to prevent weight loss. This practice affected 4 of 4 residents that were reviewed for the survey. The facility staff had identified Residents 22 and 24 had weight loss and identified interventions to prevent further weight loss. Observations during the survey revealed those interventions were not carried out for Resident 22 and 24. Resident 20's care plan indicated Resident 20 was to receive large portions and Resident 20 did not during the survey, in addition, Resident 20 had significant weight loss and the loss was not evaluated. Resident 25 had weight loss without interventions and lost a significant amount of weight. -F686. The facility staff failed to identify, evaluate casual factors and implement interventions for the development of a pressure ulcer for 1 (Resident 20) of 1 residents. Resident 20 had a history of [REDACTED]. Observations during the survey revealed Resident 20 developed a pressure ulcer. The facility staff had not identified the pressure ulcer, had not evaluated casual factors or implemented interventions. -F 744. The facility failed to have specific activities for residents with Dementia who reside in a Memory Support Unit, and failed to have specific guidelines on how activity services would be provided and what staff members would be responsible for the activities on the MSU. Observations during the survey revealed individualized activities that were resident centered was not provided to 4 (Resident 21, 22, 23 and 24) of 4 residents reviewed. Observations during the survey revealed residents were not provided activities, facility staff did not engage residents and failed to have qualified staff in the MSU. Review of the Facility Assessment revealed there was criteria for admission and discharge from the Memory Support Unit, however, there was not information of how resident centered services would be provided to those residents with the [DIAGNOSES REDACTED]. -F606. The facility failed to ensure reference checks were completed on 4 of 6 employee files reviewed. The facility had a Policy and Procedure for competing background checks. During the survey an interview with the facility Human resources personal was conducted that revealed reference checks should have been completed. -F880. The facility failed to ensure gloves were worn when removing soiled meal items from the table for Resident 22. Review of Resident 22's CCP revealed management had identified Resident 22 liked to clear the table after meals and that Resident 22 was to wear gloves and wash hands. -F730. Ongoing Nursing Assistant education. Review of 34 nurse aide employee files revealed 24 nurse aide employees did not have the required 12 hours per year of continuing training. -F550. During observation 4 (Resident 20, 21, 22 and 25) dignity was not maintained. On 1-23-2018 at 10:35 AM an interview was conducted with the facility Administrator. During the interview, the administrator confirmed cited deficiencies were not identified as a problem in the facility.",2020-09-01
6423,LYONS LIVING CENTER,285301,1035 DIAMOND STREET,LYONS,NE,68038,2018-05-10,835,K,1,0,2CLY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observations, record review and interview, the administration failed to ensure the facility resources were utilized in a manner to ensure provision of care and services for residents. This deficient practice provided the potential to affect all residents of the facility. The sample size was 14 and the facility census was 23. Findings are: The facility was found to be deficient in multiple areas of regulatory compliance which required an extended partial survey related to substandard quality of care. The following issues related to systems failure and/or failure to follow standards of care resulted in patterns of, or widespread failure in the facility and included the following citations: -F 600. The facility failed to protect residents from residents with adverse behaviors. This affected all residents (Residents 1, 2, and 10) who were residing on the Memory Support Unit (MSU-an enclosed wing or hallway which specializes in care of residents with dementia or [MEDICAL CONDITION]). Resident 1 displayed sexually inappropriate behaviors toward Resident 2 on 3/19/18. There was no evidence interventions were developed or implemented to protect Resident 2 from sexual abuse by Resident 1. Documentation revealed Resident 1 attempted sexual contact with Resident 2 on 4/21/18. New interventions were to have 2 staff working in the MSU at all times and for staff to provide and document every 15 minute checks of the resident. Observations during the survey revealed there were not 2 staff working in the MSU at all times. In addition, Resident 1 displayed threatening behaviors towards Resident 10 on 5/2/18. There were no interventions to prevent altercations between Resident 1 and Resident 10. -F 609. The facility failed to report, investigate and submit an investigation to the State Agency, regarding potential sexual abuse involving Resident 1 and Resident 2 which occurred on 3/19/18. The facility had a policy which indicated all altercations would be reported and investigated with the results of the investigation submitted to the State Agency within 5 working days of the alleged incident. The Provisional Administrator confirmed the incident had not been reported or investigated. -F 689. The facility failed to protect residents from potential accident hazards. Smoking safety assessments were not completed for Residents 3, 6 and 7 who were allowed to smoke. There was no evidence the residents were assessed to determine capability to smoke in a safe manner. Observations conducted during the survey revealed facility protocols related to safe smoking were not followed. Residents 3 and 4 were not assessed for risk of wandering and/or interventions were not implemented to prevent elopement (leaving the facility unattended and without staff knowledge). There was no evidence Resident 7's use of a motorized wheelchair was addressed in the current Care Plan, or that nursing interventions related to safety and the prevention of accidents and injury were implemented. Interview with the Occupational Therapist verified Resident 7 had incidents of running into other residents and/or items during transfers in the motorized wheelchair. The environment was not maintained in a manner to prevent potential accidents as windows in residents' rooms were not secured to prevent elopement, hazardous chemicals were observed unsecured and unattended in the Laundry Room and on the Housekeeping Cart, the Boiler Room was left unlocked and unattended, and the Maintenance tool storage utility cart was observed unattended and unsecured in a resident room. The Provisional Administrator confirmed during interview that the windows in the facility were supposed to be secured so they would open no more that 2 to 4 inches and would not allow access to the outside of the building. The Provisional Administrator further verified the Boiler Room was to be locked when unattended, the utility cart of tools was to be locked up when not in use, and the Laundry Room was supposed to be locked when the room was unattended. -F 725. The facility failed to ensure sufficient numbers of staff were available to monitor the MSU in order to protect Resident 2 and Resident 10 from Resident 1 who displayed adverse sexual and threatening behaviors. The facility developed interventions to have 2 staff working in the MSU at all times and for staff to provide and document every 15 minute checks of the resident. Observations during the survey, record review and interview confirmed there were not 2 staff working in the MSU at all times. In addition the facility failed to provide assistance with activities of daily living for Residents 1, 2, 4 and 6 which was related to insufficient numbers of staff. -F 677. The facility failed to provide bathing assistance for Residents 1 and 2, feeding and bathing assistance for Resident 4 and transfer assistance for Resident 6. F 656-The facility failed to ensure individualized Care Plans were developed to address Residents 6 and 3's smoking needs, Resident 4's elopement (leaving the facility unattended and without staff knowledge) risk and Resident 1's adverse behaviors. F 761. The facility failed to ensure Medication Administration Records matched current MEDICATION ORDERS FOR [REDACTED]. -F 607. The facility failed to complete criminal background, Nurse Aide (NA) registry, Adult Protective Services/Child Protective Services (APS/CPS), sex offender registry and reference checks as a condition of employment for 4 of 8 employees. Interview with the Provisional Administrator confirmed employee files were incomplete. -F 839. The facility failed to ensure 2 professional staff were licensed in accordance with applicable State laws. 1 Registered Nurse (RN) and 1 Licensed Practical Nurse (LPN) were not licensed in the state where they resided. The Provisional Administrator confirmed both staff were currently employed by the facility but was not aware of the requirement for RN's and LPN's to be licensed in the state where they resided. -F 842. The facility failed to ensure medical records contained completed information regarding Smoking Safety Screens for Residents 7, 3, and 6, Nursing Admission Assessments for Residents 4 and 6 and Elopement (leaving the facility unattended and without staff knowledge) Risk Assessments for Resident 3. Interviews with the Director of Nurses and/or Provisional Administrator confirmed these assessments had not been completed. -F 947. The facility failed to provide staff training which included dementia management training. This had the potential to affect Residents 1, 2 and 10 who resided in the locked Memory Support Unit (an enclosed wing or hallway which specializes in care of residents with dementia or [MEDICAL CONDITION]). -F 732. The facility failed to post the daily nurse staffing information as required which prevented families, residents and visitors from having access to information regarding the census and numbers of direct care staff providing care in the facility.",2019-03-01
5605,GOOD SHEPHERD LUTHERAN HOME,285148,2242 WRIGHT STREET,BLAIR,NE,68008,2016-12-19,225,D,1,0,JMDD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on record review and interviews, the facility failed to ensure allegations of abuse were reported to the State Agency and failed to ensure protection during an investigation for 1 (Resident 5) of 2 residents reviewed. The facility census was 80. Findings are: Review of the facility policy, Abuse/Neglect/Misappropriate of Property with a revision date of 12/2016 revealed: Purpose: The resident has the right to be free from verbal, sexual, physical, and mental abuse. It is the facilities responsibility to protect the resident from any form of abuse. Definitions: Physical Abuse includes but is not limited to, hitting, slapping, pinching, kicking, etc. Identification/Protection: It is the facilities responsibility to protect the resident and identify abuse. All allegations of abuse must be reported to the facility Administrator. The facility staff will ensure that the resident is protected throughout the investigation. Reporting/Response: Administrative staff will notify Adult Protective Services, or local law enforcement immediately, or within 2 hours after the report has been made. Review of Resident 5's face sheet revealed that the resident admitted to the facility on [DATE]. Review of Resident 5's Brief Interview for Mental Status (BIMS=an assessment to determine cognitive status) on 11-23-16 revealed a score of 15/15 which meant the resident was cognitively intact. On 12-19-16 at 11:15 AM observation revealed that Resident 5 approached the Social Worker, (SW) and angrily asked if the SW was going to do anything about Resident 5's roommate or Resident 5 was leaving. On 12-19-16 at 11:30 AM the Administrator revealed that Resident 5 had alleged that Resident 5's roommate had struck the resident over the weekend and the facility was just starting the investigation and administration had just been informed. Review of Resident 5's Progress Notes revealed an entry on 12-17-16 by Licensed Practical Nurse (LPN) B that stated at 3:30 PM Resident 5 had a skin tear to the right forearm measuring 2 cm (centimeters) x 1.5 cm. Resident 5 stated Resident 5 obtained the skin tear from roommate when the roommate was getting up from bed and bumping Resident 5's table. Resident 5 stated the roommate swung at the resident causing the skin tear. Unable to get any further details from Resident 5 as to what the resident was hit with or if the table bumped Resident 5's arm causing the skin tear. The Primary care physician was faxed. An interview conducted on 12-19-16 at 12 PM with LPN B revealed that on 12-17-16 LPN B had spotted the skin tear to Resident 5's arm and Resident 5 told LPN B that the roommate was bumping Resident 5's bedside table and Resident 5 was trying to hold it steady and then the roommate swung at Resident 5 and Resident 5 got a skin tear. LPN B revealed (gender) was unable to determine exactly how Resident 5 got the skin tear. LPN B confirmed that Resident 5 did say the roommate swung at the resident. LPN B revealed that LPN B did not notify administration of incident, however Resident 5 told them today about the incident. An interview on 12-19-16 at 1:15 PM with Resident 5 revealed that the resident was hit by the roommate on 12-17-16 when the roommate swung at Resident 5 causing a skin tear to Resident 5's right forearm. Resident 5 then held up (gender) right forearm and pointed at a bandage with some blood observed to be seeping through. Resident 5 revealed that the roommate was pushing Resident 5's bedside table over and Resident 5 was pushing against it on the other side and then the roommate swung at Resident 5. Resident 5 revealed that (gender) told the nurse on duty when it happened, and then today Resident 5 went and talked to the Social Worker. Resident 5 stated that after the incident on 12-17-16 the roommate and Resident 5 both stayed in the same room and confirmed that they were not separated by staff. An interview on 12-19-16 at 1:30 PM with the Administrator (ADM) confirmed that Resident 5 had alleged that the roommate had swung at Resident 5 and it should have been reported immediately to the Administrator or the social worker and the two residents should have been separated to protect Resident 5.",2019-11-01
2272,GOOD SAMARITAN SOCIETY - ST LUKE'S VILLAGE,285192,2201 EAST 32ND STREET,KEARNEY,NE,68847,2018-06-19,609,D,1,0,8O6H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on record reviews and interviews, the facility failed to report to the State Authorities within 24 hours 1 verbal abuse allegation for Resident 47 and 1 fall with a fracture for Resident 11. This affected 2 out of 3 sampled facility investigations reviewed. The facility census was 51. Findings are: [NAME] Review of the facility investigation report of Resident 11's fall with a fracture on 2-19-18 revealed the resident was found on the floor on 2-19-18. The resident complained of pain to the left hip and groin so was sent to the emergency room for an evaluation. The initial telephone report the facility received from the hospital revealed the resident did not have a fracture and would return to the facility that night. However, while in the emergency room the resident had a hypoxic (lack of oxygen to a region of the body) event and was admitted to the hospital. It was during the hospitalization the Physician discovered the resident had a fracture. Resident 11 returned on 2-22-18 with a new 2 mm (millimeter) non-displaced left acetabular fracture and new orders for toe touch weight bearing on the left leg and PT/OT orders (Physical Therapy / Occupational Therapy). The facility reported the fall with fracture incident to APS (Adult Protective Services) on 2-27-18. Review of the Hospital Transfer paper for Resident 11 dated 2-22-18 revealed a [DIAGNOSES REDACTED]. Review of PN (Progress Notes) dated 2-22-18 at 3:50 PM revealed the resident returned from the hospital and was toe touch weight bearing and to receive Physical Therapy. Review of PT (Physical Therapy) Evaluation and Plan of Treatment Notes dated and signed by the Physical Therapist on 2-22-18 at 4:26 PM revealed the reason for the referral was the resident had been admitted to the hospital on 2-20-18 after suffering a fall with a minimally nondisplaced acetabular fracture. Review of PN dated 2-25-18 the Summary of Skilled Services revealed the resident had a fall on 2-20-18 and resulted with a new left acetabulum fracture. Interview on 6-18-18 at 4:01 PM with the DON (Director of Nursing) confirmed the resident returned on 2-22-18 with a new [DIAGNOSES REDACTED]. The DON revealed Administration was notified on 2-27-18 and it was then reported to the APS (Adult Protective Services). B. Review of the facility investigation report of verbal abuse from a staff person to Resident 47 revealed the alleged incident occurred on 3-12-18 during the night shift. NA-G (Nurse Aide) was a witness but did not report the incident to anyone until 3-17-18 on the night shift to a charge nurse, LPN-H (Licensed Practical Nurse). LPN-H did not report the alleged verbal abuse to the Administration until 3-18-18 on the night shift when LPN-H saw the Social Service person working that evening. The Social Service called the Administration on 3-18-18 and the alleged verbal abuse was reported to the State Agencies on 3-19-18 at 1:00 PM. Interview on 06/18/18 at 04:03 PM with the HR (Human Resource) staff confirmed the incident of alleged verbal abuse had not been reported immediately to the Administration as required by the staff.",2020-09-01
4399,"NORTH PLATTE CARE CENTER, LLC",285165,2900 WEST E STREET,NORTH PLATTE,NE,69101,2017-04-25,223,D,1,0,TDQ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on interview and record review, the facility failed to ensure residents were protected from potential verbal. This had the potential to affect 2 of 3 sampled residents (Residents 1 and 2). The facility census was 49 residents. Findings are: Review of the facility investigation of an allegation of verbal abuse on 4/5/17 at 6:00 PM. Revealed RN-C (Registered Nurse) stated I am not going to listen to your bullshit. Interview with RN-A on 4/25/2017 at 3:15 PM revealed verbal abuse was witnessed on 2 different incidents. One incident was with a wheelchair resident (Resident 1) said something to RN-C, which I did not hear. RN-C stated (he/she) was not going to listen to that bull[***]and told the aide to remove the resident from the area. Resident 1 was in the foyer and had just came from the evening meal. The Resident had a habit of making inappropriate comments. The other incident involved Resident 2 when RN-C told the resident shut up wasn't going to listen to help me, help me for another 12 hours tonight. RN-A revealed RN-C worked the whole shift Interview with NA-B (Nurse Aide) on 4/25/2017 at 3:30 PM revealed Resident 2 said help me, help me and RN-C stated I am not going to listen to our bull[***]for the next 12 hours, shut up. Also heard RN-C scream at another resident to get the hell out of here now. NA-B revealed RN-C worked the whole shift. Review of RN-C Time Card Report revealed RN-C worked 4/5/17 from 5:53 PM until 9:54 PM and 10:41 PM to 6:31 AM. A total of 11:75 hours. Continued review revealed RN-C worked on 4/7/17 from 5:00 AM to 6:54 AM. A total of 2 hours. Review of the Facility form entitled Risk Management Abse Prevention Program and Reporting Policy dated 4/17 revealed in the case of a direct caregiver being suspented of allegedly abusing a resident, the Administrator (in the absence the Director of Nursing, Asisstant Director of Nursing, Charge Nurse) must imediately relieve the individual of their duties without pay (suspended) until the investigation is complete.",2020-08-01
4336,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-04-13,225,D,1,0,Y94911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on interview and record review, the facility staff failed to report an allegation of abuse to the State Agency within the required time frame for Resident 1. This affected 1 of 3 sampled residents. The facility identified a census of 77 at the time of survey. Findings are: Review of Resident 1's Face Sheet revealed an admission date of [DATE]. Interview with Resident 1 on 4/13/2017 at 1:10 PM revealed that Resident 1 had made an allegation of abuse against a facility staff member and had reported it to the facility. Record review of the facility investigation into the allegation of abuse by Resident 1 revealed no documentation the allegation was reported to the State Agency within the required time frame. Interview with the facility administrator on 4/13/2017 at 9:47 AM confirmed the allegation of abuse had not been reported to the State Agency within the required time frame. Interview with the DON (Director of Nursing) on 4/13/2017 at 1:33 PM confirmed the allegation of abuse had not been reported to the State Agency within the required time frame. Review of the facility policy Freedom from Abuse, Neglect and Exploitation dated 1/2017 revealed the following: For allegations of abuse, report to APS (Adult Protective Services) within 2 hours.",2020-08-01
3783,GREELEY CARE HOME,285286,201 E O'CONNOR AVENUE,GREELEY,NE,68842,2019-08-13,609,D,1,1,R2ED11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on interview and record review; the facility failed to submit a written report of an investigation regarding a Resident to Resident incident between Resident 6 and Resident 21 within the required time frame of 5 working days. This affected 1 of 4 investigations reported to the state agency. The facility identified a census of 21 at the time of survey. Findings are: Review of Resident 6's Entry Tracking Record revealed an admission date of [DATE]. Interview with Resident 6 on 8/08/19 at 9:21 AM revealed they had a confrontation with Resident 21 about 2 weeks ago. Resident 6 felt that Resident 21 had mistreated them and had Resident 21 blamed them for things they had not done. Resident 6 stated they had reported the incident to the SSD (Social Service Director). Review of Resident 6's Grievance Form dated 7/2/2019 revealed the incident between Resident 6 and Resident 21 had occurred on 6/26/2019 and was reported to the SSD on 7/2/2019. Resident 6 reported that Resident 21 had hit Resident 6 and had made some gestures and mumbled some comments to Resident 6. There was documentation the incident had been called in to the state agency but there was no documentation the written report of the investigation had been submitted to the state agency within the required time frame of 5 working days after the incident. Interview with the facility Administrator on 08/12/19 at 2:09 PM revealed they did not send a written report of their investigation of the incident between Resident 6 and Resident 21 to the state agency. They called it in and did the investigation, but failed to submit the written investigation within the required time frame. Review of the facility policy Abuse, Neglect, and Exploitation Policy dated 8/1/2013 revealed the following: After conducting an internal investigation, you must submit a report of all investigation results to the state. B. Record review of Resident 21's Admission Face Sheet revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of the facility investigation of an altercation between Resident 6 and Resident 21 revealed the state agency was notified; however, there was no documentation the written report of the investigation was submitted to the state agency within the required 5 working day time frame. Interview on 08/12/19 at 3:30 PM with the ADM (Administrator) revealed there was an investigation of the incident between Resident 21 and Resident 6. The ADM confirmed that the written report of the investigation that communicated the nursing home investigation and findings to the state agency was not submitted within the required 5 working day time frame. Interview on 08/12/19 at 3:32 PM with BOM/NA (Business Office Manager/Nursing Assistant) confirmed that the investigation was completed; however, it was not submitted to the state agency within the required time frame.",2020-09-01
2500,PIONEER MANOR NURSING HOME,285212,"P O BOX 310, 318 N 3RD STREET",HAY SPRINGS,NE,69347,2017-09-07,225,F,1,0,KXTW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on observation, interview and record review; the facility failed to protect residents, failed to investigate, and failed to report an allegation of abuse to the state agency within the required time for Resident 1. This had the potential to affect all of the facility residents. The facility identified a census of 49 at the time of survey. Findings are: Review of Resident 1's Face Sheet revealed Resident 1 was admitted to the facility on [DATE]. Interview with Resident 1 on 8/31/2017 at 2:00 PM revealed Resident 1 felt NA-B (Nurse Aide) had been rough while dressing Resident 1 and had called Resident 1 a derogatory name, retard. Observation of NA-B on 8/31/2017 at 1:09 PM revealed NA-B was in the facility dining room caring for residents. Interview with the facility Administrator on 8/31/2017 at 1:24 PM revealed Resident 1's family member had reported to the facility charge nurse on 8/27/2017 that NA-B had been rough with Resident 1 and had called Resident 1 a derogatory name. Interview with LPN (Licensed Practical Nurse)-A on 8/31/1027 at 2:07 PM revealed they had received a call from Resident 1's family member on 8/27/2017 between 1 and 2 PM that NA-B had been rough with Resident 1 and had called Resident 1 a derogatory name. LPN-A stated they had sent NA-B to another hall to care for other residents and reported the incident to the facility Administrator on 8/28/2017. LPN-A revealed they did not report the allegations to the State Agency. Review of NA-B's Payroll Detail for 8/27/2017 to 8/31/2017 revealed NA-B continued to work on 8/27, 8/28, 8/30 and 8/31 after the allegations that NA-B was rough with Resident 1 and had called Resident 1 a derogatory name. Interview with the facility Administrator on 8/31/2017 at 2:44 PM revealed that the allegations of NA-B being rough with Resident 1 and calling Resident 1 a derogatory name should have been investigated as potential abuse and/or neglect. The Administrator revealed that LPN-A should not have allowed NA-B to care for other residents, LPN-A should have notified the administrator immediately, and should have reported the allegations to the State Agency. The Administrator confirmed the allegations were not reported to the State Agency and NA-B continued to work. The Administrator further revealed there was no documentation the allegations had been investigated. Interview with the facility administrator on 8/31/2017 at 3:53 PM confirmed NA-B had been taking care of all of the facility residents except for Resident 1 since the allegations of being rough and name calling had been received on 8/27/2017. Review of the Nursing Schedule for (MONTH) and (MONTH) (YEAR) revealed NA-B was scheduled to work including after the allegations of NA-B being rough with and calling Resident 1 a derogatory name had been received on 8/27/2017. NA-B was scheduled to work on 8/27, 8/28, 8/30, and 8/31/2017. Review of the facility policy Abuse/Neglect/Misappropriation Reporting Requirements dated 1/1/2017 revealed the following: Policy: The purpose of this policy is to ensure reporting requirements are being met in the situation of any allegation involving abuse of a resident by anyone. Compliance guidelines: The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, are reported immediately to the administrator of the facility and to other officials in accordance with State law. Process: When a circumstance occurs that meets any of the definitions below the staff person should immediately contact Administrator. What you should know about reporting: If you suspect abuse, neglect or misappropriation/exploitation, immediately take action to ensure the safety of the resident. Inform your supervisor about the incident as soon as possible. An Abuse/Neglect Related Reportable Incident: There is reason to suspect or believe abuse has occurred or an allegation has been made, or conditions are present that could result in abuse/neglect: take steps to protect individual, Notify Administration, Begin internal investigation. Immediately repot to Adult and Child Abuse and Neglect Hotline.",2020-09-01
6510,"OMAHA METRO CARE AND REHABILITATION CENTER, LLC",285097,5505 GROVER STREET,OMAHA,NE,68106,2016-01-19,323,D,1,0,GIIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on observation, record review and interview; the facility staff failed to implement interventions to prevent falls for 1 resident (Resident 1) and failed to implement an identified intervention to prevent elopement for 1 resident (Resident 3). The facility staff identified a census of 86. Findings are: A. Record review of Resident 1's Comprehensive Care Plan (CCP) printed on 12-23-2015 revealed Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further review of Resident 1's CCP revealed Resident 1 was at risk for falls and/or injuries. The goal for Resident 1 was to remain free of fall related injuries. Interventions listed on Resident 1's CCP included Bed in a low position, Enabler bars for assistance with repositioning and to ensure fall precautions were in place. Record review of a Verification of Investigation (VOI) dated 8-21-15 revealed Resident 1 had slid out of the wheelchair. The intervention implemented was for staff not to leave Resident 1 in a wheelchair while alone in (gender) room. Observation on 1-13-15 at 2:30 PM revealed resident 1 was seated in a wheelchair in (gender) room without staff with Resident 1. Observation on 1-14-16 At 10:27 with the Director of Nursing (DON) revealed Resident 1 was in bed and the Resident 1's bed was not in the low position. The DON confirmed Resident 1's bed was not in the low position. Observation with Registered Nurse (RN) A on 1-19-16 at 6:37 AM revealed Resident 1 was in bed and Resident 1's bed was positioned at waist high level. RN A confirmed Resident 1's bed was not in the low position and should have been. B. Record review of a Risk for Elopement evaluation dated 11-26-15 revealed Resident 3 was at risk to elope from the facility. Record review of a VOI dated 1-5-16 revealed a visitor to the facility had let Resident 1 out of the facility and reset the alarm that were sounding when Resident 1 went through the door. According to the information in the VOI dated 1-5-16, the visitor thought Resident 1 was a visitor. The VOI also identified the visitor was educated. Other interventions identified on the VOI to prevent Resident 1 from eloping was to place a sign at the door for families/visitors not to let people out or to reset alarms. Observation with the facility Administrator on 1-14-16 at 11:34 AM revealed the sign posted at the doors informed visitor/families not to let residents out. The Administrator confirmed the sign did not inform visitors or families not to reset alarms.",2019-01-01
1018,PRESTIGE CARE CENTER OF PLATTSMOUTH,285104,602 SOUTH 18TH STREET,PLATTSMOUTH,NE,68048,2018-02-27,607,D,1,0,W9MF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on observation, record review and interview; the facility staff failed to investigate bruising for 1(Resident 21) of 5 residents. The facility staff identified a census of 78. Findings are: Record review of Resident 21's Comprehensive Care Plan (CCP) dated 1-10-2018 revealed Resident 21 admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further review of Resident 21's CCP revealed Resident 21 was at risk for bruising related to taking [MEDICATION NAME] medication. The interventions included staff were to inspect skin for bruising/unusual bleeding daily during cares. Record review of Resident 21's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 1-05-2018 revealed Resident 21's Brief Interview for Mental Status (BIMS) was a 12. According to the MDS Manuel, a score of 8 to 12 indicated moderately impaired cognition. Observation on 2-21-2018 at 10:48 AM revealed Resident 21 had a bruise to the back of the left hand that measured approximately 3.0 centimeters (cm) and was dark purple in color and the back of the right hand had a bruise that measured approximately 2.0 cm and was purplish in color. Resident 21 stated they are rough with me. Nursing Assistant (NA) A was in the room with Resident 21 preparing to assist Resident 21 with toileting needs. NA A stated oh, you're kidding. Review of Resident 21's record revealed there was not evidence the facility staff had investigated the cause of the bruising. On 2-21-2018 at 4:35 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported not knowing why Resident 21 had bruising.",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
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
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
6133,AZRIA HEALTH MIDTOWN,285218,910 SOUTH 40TH STREET,OMAHA,NE,68105,2016-06-13,225,D,1,0,NEIH11,"**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 follow facility policy to submit a completed investigation related to allegations of abuse for Residents 1 and 2. The facility census was 59. Findings are: A. Review of the facility policy OPS331-NE Abuse Prohibition with a revision date of 05/01/16 revealed: 9. Report findings of all completed investigations within five working days to Health Facility Investigations. 10. The following information must be submitted along with the completed investigation report form: - current care plan related to behaviors/behavior management, - nursing notes, - social services notes, and - medical notes if seen by a medical practitioner. B. Review of Resident 2's face sheet revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of an investigation submitted to Health Facility Investigations dated 5-20-16 for Resident 2 revealed Resident 2 alleged on 5-18-16 that a white, heavyset male with glasses and short hair touched Resident 2. The investigation revealed that Resident 2 stated that Resident 2 could point out the person. There was no documentation if this was completed. Three other residents were interviewed and felt safe. No staff fitting the description worked with Resident 2 on 5-18-16. Attached to the investigation was Resident 2's face sheet. The investigation report included no interviews with Resident 2, staff or other residents, nor the residents care plan or nurses notes. Review of the Adult Protective Services (APS) report dated 5/18/16 revealed that the staff were going to see about getting a Psychiatric evaluation for Resident 2 and have 2 staff members with Resident 2 for all cares. This was not found on the investigation submitted to Health Facility Investigations from the facility. Interview with the social worker on 6/13/16 at 11:15 am confirmed the investigation summary and the face sheet were the only items submitted to Health Facility Investigations. The social worker stated that the interview with Resident 2 did not get submitted with the investigation nor the interview with other residents or staff on duty. Nor was Resident 2's care plan or nurses notes submitted. The social worker confirmed the investigation submitted was not complete. Exit conference with the Administrator on 6/13/16 at 1:15 PM revealed the Administrator confirmed the investigation that was submitted to Health Facility Investigations for Resident 2 was not complete. C. Review of the facility investigations revealed Resident 1 reportedly had a verbal altercation with a staff member and an investigation was completed. There was no documentation in the facility investigation folder of the facility submitting the investigation to the state agency in 5 working days. Interview on 6/13/16 at 10:45 AM with the Social Services Director revealed that the facility had no way to verify that the report was sent to the state agency in 5 working days. Interview on 6/13/16 at 1:00 PM revealed the Administrator was in agreement there was no documentation that the report was sent to the state agency located in the file.",2019-06-01
4872,ARBOR CARE CENTERS-NELIGH LLC,285124,"PO BOX 66, 1100 NORTH T STREET",NELIGH,NE,68756,2017-03-02,225,D,1,0,042P11,"**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 an incident of potential abuse/neglect involving 1 resident (Resident 1) who fell and sustained a significant injury. The sample size was 9 and the facility census was 44. Findings are: Review of the facility policy titled Nursing Facility Abuse/Neglect/Misappropriation Reporting Requirements dated 8/20/12 revealed the following: -Physical injury was defined as damage to bodily tissue caused by non-therapeutic conduct, including, but not limited to fractures, bruises, lacerations, internal injuries or dislocations including but not limited to physical pain, illness or impairment of physical function; -Alleged violations involving mistreatment, neglect or abuse were to be reported to the administrator of the facility and to other officials in accordance with State law. Review of a Verification of Investigation form regarding Resident 1 dated 2/3/17 revealed the following: -Resident 1 was seated in a wheelchair at the dining room table at 6:20 PM; -At 6:30 PM the resident was found lying on the floor and sustained a 4 centimeter (cm) circular hematoma (an abnormal collection of blood outside the blood vessels and most commonly caused by injury to the wall of a blood vessel) on the left part of the forehead; -The resident stated yes when asked if the resident had a headache; -The resident's responsible family member, physician and hospice service were notified of the fall; -The resident's responsible family member and physician declined transfer to the hospital for further evaluation; and -The State Agency was not notified of the fall with injury. Review of Resident 1's Progress Notes dated 2/4/17 at 6:33 PM documented the resident continued to have vital signs (temperature, pulse, respiratory rate and blood pressure) and crani checks (assessment used to determine potential head or [MEDICAL CONDITION]) completed due to the fall. Interview with the Director of Nurses on 3/2/17 at 1:13 PM confirmed Resident 1's fall with injury was not reported to the State Agency.",2020-03-01
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
2404,COUNTRYSIDE HOME,285207,703 NORTH MAIN STREET,MADISON,NE,68748,2017-07-17,225,E,1,1,UNB311,"**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 the incidence of a fall for Resident 80, and to submit investigations to the State agency within 5 working days for resident to resident abuse allegations between Residents 62 and 40, Residents 62 and 14, and Residents 66 and 79. Total sample size was 29 and the facility census was 68. Findings are: [NAME] Review of the undated facility policy and procedure titled Abuse/Elopement/Neglect/Misappropriation Reporting indicated the following: -any allegation of abuse, neglect, or elopement that results in resident injury must be reported; -if in doubt, report immediately to the Administrator or his/her designee; and -the Charge Nurse, Administrator, or Director of Nursing (DON) will notify APS (Adult Protective Services) within hours. B. Review of Resident 80's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/18/17 revealed the resident was admitted to the facility on [DATE] with a history of falling and a current [DIAGNOSES REDACTED]. Review of Resident 80's Nursing Progress Notes dated 4/16/17 at 11:43 PM revealed the following: -at 6:15 PM, was found lying on the floor next to the bed with legs out in front; -the left leg was rotated inward, with the foot nearly touching the floor, and the right leg was rotated outward; -was transferred to the emergency room (ER); and -at 10:00 PM, returned to the facility. Review of the Emergency Department Record dated 4/16/17 indicated x-rays were completed of Resident 80's left foot and left hip with pelvis. The x-rays indicated left hip and left foot contusions (bruising) as a result of the fall. During interview on 7/13/17 at 2:25 PM, the Social Services Director (SSD) verified Resident 80's fall and treatment at the ER was not reported to the State agency. During interview on 7/17/17 at 7:35 AM, the DON verified Resident 80's fall and subsequent injuries were not investigated as to causal factors. C. Review of an Abuse Investigation Report Form dated 9/10/16 revealed Resident 40 reported having a coughing spell during the night and Resident 62 (the roommate) threw a glass of water in may (sic) face. Documentation indicated the allegation was reported to APS on 9/1/16 at 1:59 PM. The results of the investigation showed no evidence to support Resident 40's allegation. During interviews, the SSD verified the following: -7/13/17 at 2:25 PM, APS was notified of the incident on 9/11/16, and not 9/1/16 as indicated on the Abuse Investigation Report Form; and -7/17/17 at 6:59 AM, the completed investigation related to the incident involving Residents 40 and 62 was not submitted to the State agency. D. Review of Abuse Investigation Report Forms and Transaction Reports (verification of the date and time a facsimile (fax) was sent) revealed the following: -5/6/17 at 10:15 AM, APS was notified of a resident to resident abuse allegation between Residents 14 and 62, and the completed investigation was faxed to the State agency on 5/15/17 at 10:22 AM (6 working days since the allegation occurred); and -6/13/17 at 11:00 AM, APS was notified of a resident to resident abuse allegation between Residents 66 and 79, and the completed investigation was faxed to the State agency on 6/21/17 at 9:50 AM (6 working days since the allegation occurred). During interview on 7/13/17 at 2:25 PM, the SSD verified abuse investigations were to be submitted to the State agency within 5 working days of when the abuse allegation occurred.",2020-09-01
6607,ALPINE VILLAGE RETIREMENT CENTER,285190,706 JAMES STREET,VERDIGRE,NE,68783,2015-12-28,225,D,1,0,FEDO11,"**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/or investigate a potential allegation of abuse and/or neglect for 1 resident (Resident 2). The facility census was 41. Findings are: A. Review of the facility Abuse Reporting and Investigation policy (revision date 2/11/12) included the following: -In all cases of alleged abuse/neglect the facility was to intervene in the situation, report the situation to the proper authorities, investigate the allegation and prevent abuse/neglect while the investigation was in process. -The abuse reporting procedure was to be initiated when an accident with significant injury occurred and resulted in the resident needing immediate medical attention. B. Review of Nursing Progress Noted dated 10/7/15 at 10:55 AM revealed Resident 2 had been seated on a couch next to the Nurse's Station. Documentation indicated Resident 2 stood up unassisted and was heard by staff shuffling feet and then falling. The resident sustained [REDACTED]. Review of Nursing Progress Note dated 10/7/15 at 11:40 AM revealed Resident 2 was seen at the physician clinic and received 6 sutures to the laceration above the resident's left eye. Review of the facility investigations of potential abuse/neglect from 7/8/15 through 12/28/15 revealed no report had been filed with the State Agency regarding Resident 2's fall on 10/7/15 which resulted in the need for immediate medical attention. There was no evidence to indicate an investigation had been completed or submitted to the State Agency. Interview with the Administrator on 12/28/15 at 12:00 PM confirmed Resident 2's fall with injury on 10/7/15 was not reported to the State Agency and an investigation had not been completed.",2018-12-01
5801,COMMUNITY PRIDE CARE CENTER,285208,901 SOUTH 4TH STREET,BATTLE CREEK,NE,68715,2016-09-08,225,E,1,0,CN7211,"**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/or investigate potential allegations of abuse/neglect for 2 of 7 current residents reviewed (Residents 1 and 4) and for 2 closed resident records (Resident 9 and 10). The facility census was 43. Findings are: A. Review of the facility Abuse, Neglect and Misappropriation of Property Policy (undated) included the following: -Abuse means any knowing, intentional, or negligent act or omission on the part of any person which results in physical, sexual, verbal or mental abuse, unreasonable confinement, cruel punishment, exploitation, or denial of essential care, treatment or service to a resident; -Mental abuse includes but is not limited to humiliation, harassment, threat of punishment or deprivation; -Reports of suspected and/or alleged abuse/neglect will be promptly reported to the Administrator and the Director of Nursing; -The Administrator or designee will notify Adult Protective Services (APS) immediately; -A reasonable suspicion of crime without serious physical injury will be reported to local law enforcement within 24 hours of forming the suspicion; -An internal investigation will be conducted and the results of the investigation will be submitted to the State Agency within 5 working days. B. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/15/16 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had moderate cognitive impairment, evidence of an acute change in mental status and displayed fluctuating psychomotor [MEDICAL CONDITION] (unusually decreased level of activity such as sluggishness, staring into space, staying in 1 position and/or moving very slowly). Interview with the Director of Nurses (DON) on 9/8/16 at 9:14 AM confirmed Resident 1 required extensive assistance with activities of daily living. The DON indicated a visitor attempted to take the resident out of the facility the other night. The Charge Nurse stopped the resident from leaving due to the resident's health care needs and notified facility administration. The DON indicated a family member of the resident notified law enforcement of the situation and the local law enforcement came to the facility to escort the visitor out of the building. The DON confirmed the situation was not reported to APS. Interview with the Administrator and Social Services Director (SSD) on 9/8/16 at 11:34 AM confirmed the situation involving a visitor attempting to take Resident 1 out of the facility without authorization was not reported to APS and an investigation was not completed or submitted to the State Agency. C. Review of Resident 4's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had moderate cognitive impairment. Interview with the Administrator and SSD on 9/8/16 at 11:42 AM revealed the facility received a call on 5/6/16 from a family member of Resident 4. The family member reported Resident 4's spouse commented about bringing a gun into the facility. The family member reported the gun would be removed from the spouse's possession and indicated it was a type of pellet gun. The facility was immediately placed on lockdown until 5/7/16 when the family member reported the pellet gun had been removed from the spouse's possession. Further interview with the Administrator and SSD confirmed the incident was not reported to APS. The Administrator indicated the actions taken by the facility to remedy the situation were reported to the State Agency on 5/10/16 and local law enforcement was notified on 5/10/16 (4 days later). D. Review of the Policy Statement for Filing Grievances/Complaints (undated) revealed any grievance that contained an allegation of abuse or neglect was to be reported immediately to the Administrator and/or DON. A report was to be made to APS within 24 hours of the allegation and any grievance that contained an allegation of abuse would follow the abuse prevention policies and procedures. E. Review of a Grievance Report dated 4/17/16 revealed Resident 10 voiced a complaint that staff gave instructions to not use the call light unless the resident really had to use the bathroom. The resident reported being afraid to use the call light for fear of getting into trouble. There was no evidence to indicate Resident 10's complaint was reported to APS and an investigation was not completed. F. Review of a Grievance Report dated 3/14/16 revealed Resident 9 voiced a complaint on 3/14/16 that a staff member was rough and voiced complaints of back pain. Further interview with the resident on 3/15/16 by Licensed Practical Nurse I revealed the resident's shoulders were pulled on while being repositioning which caused the resident's back to hurt. Documentation further indicated .Determined there was no abuse issue. There was no evidence Resident 9's complaint of rough treatment during repositioning was reported to APS and an investigation was not completed by the facility. G. Interview with the Administrator and SSD on 9/8/16 from 11:42 AM until 12:05 PM confirmed the allegations of potential abuse/neglect regarding Resident 9 and Resident 10 had not been reported to APS and investigations had not been completed.",2019-09-01
5322,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-01-03,225,D,1,0,R6LS11,"**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 complete a thorough investigation, report to the state agency within the require time frame and failed to submit the results of that investigation to the required state agency within 5 working days for 1 (Resident 6) of 4 residents. The facility staff identified a census of 88. Findings are: Record review of a Admission Record sheet dated 12-21-2016 revealed Resident 6 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. PBA occurs secondary to a neurologic disease or [MEDICAL CONDITION]), and Dementia with agitation. Record review of a Grievance Form dated 11-10-2016 revealed Resident 6 had reported the day and night nurse .cause me trouble. The day nurse said that I make (gender's) day bad. The nurse grabs my arm and causes arm to hurt. The night nurse isn't here now, but they hollered at me and teasing me. Night nurse doesn't always change my brief. Will tell them it's (brief's) wet but they tell me it's not wet and they don't change me, they just shut my door and go on. Further review of the back page of the Grievance Form dated 11-10-2016 revealed an undated and unsigned entry that had identified an unknown staff followed up with the resident. According to the hand written information, the resident was not afraid of any staff, and reported (gender) had not been swore at. Resident 6 also had concerns about length of time call lights were answered and to wipe Resident 6's table mates mouth when needed. On 12-29-2016 at 3:34 PM an interview was conducted with the Director of Nursing (DON). During the interview, Resident 6's grievance form dated 11-10-2016 was reviewed. The DON confirmed the grievance had indicators of potential abuse and a thorough investigation should have been completed but was not. The DON further confirmed a report had not been made to the state agency.",2020-01-01
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
5328,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-01-31,225,D,1,0,BKZI11,"**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 conduct a complete investigation for allegations of abuse for Resident 32 and failed to submit a written investigation to the required State Agency within 5 working days for Resident 60. This affected 2 of 11 sampled residents reviewed. The facility census was 69. Findings are: [NAME] Record review of resident 32's face sheet revealed Resident 32 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of a facility investigation completed on 10-18-16 revealed that on 10-12-16 a family member of another resident in the facility reported that Licensed Practical Nurse (LPN) M forcefully assisted Resident 32 into the wheelchair (WC). The investigation revealed that Resident 32 was unable to be interviewed due to the level of cognitive impairment and Dementia. LPN M was interviewed and reported Resident 32 was very strong and at the time of the incident LPN M was able to carefully assist Resident 32 back into the wc with some verbal cueing and assistance with a gait belt. The investigation did not contain any interviews from other staff working, nor from other residents the nurse worked with. An interview conducted on 01/30/2017 at 1 PM with the Assistant Director of Nursing (ADON) revealed that the ADON did do the investigation and no other residents or staff were interviewed related to this abuse allegation and confirmed that only the nurse alleged of abuse, LPN M, was interviewed. An interview was conducted on 01/30/2017 at 1:42 PM with the Social Worker and confirmed this was not a complete investigation and agreed that other staff and residents should have been interviewed regarding the allegation. Findings are: B) The closed record review of Resident 60's electronic medical record revealed that Resident 60 was admitted to the facility on [DATE] and discharged on [DATE]. Record review of Resident 60's progress note dated 11/2/16 revealed that Resident 60 had exited a door by the facility Chapel. The Care Plan Coordinator, and the Administrator, had responded to the alarm and had found Resident 60 ambulating down the walkway. Resident 60 was returned to the building. Resident 60 had not been identified as an elopement risk prior to this event. The facility actions were that they placed a wander guard to resident's right arm and initiated elopement precautions, and had notified Resident 60's family and physician. Record review of the facility investigation revealed that, the facility did perform an initial report to the appropriate agency in a timely manner. The incident had occurred on 11/2/16 at 4:02 PM and the state agency was notified on 11/2/16 at 4:25 PM of the incident. Interview with the facility Director of Nursing (DON) on /30/17 at 3:18 PM revealed that the facility did have documentation that they had submitted on 11/8/17 the completed investigation of the incident. Upon review, of the document that had been provided, by the DON there had been a transmission report that showed it had failed to be sent. The transmission report revealed that an error had occurred and that the transmission had not been sent to the state agency. The DON confirmed that the transmission report did reveal that an error had occurred and that the facility had not attempted to re-send the data. The DON confirmed that, therefore the facility failed to submit the investigation within the 5 working days.",2020-01-01
2248,ELMS HEALTH CARE CENTER,285191,"P O BOX 628, 410 BALL PARK ROAD",PONCA,NE,68770,2019-01-24,609,E,1,1,E2LJ11,"**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 immediately report to the State Agency, complete investigations, and submit the results of the investigations within 5 working days regarding potential incidents of abuse/neglect for 3 (Residents 3, 8 and 241) of 7 sampled residents. The facility census was 38. Findings are: [NAME] Review of the facility Abuse and Neglect Policy (undated) included the following: -Neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness; -All alleged violations and substantiated incidents were to be reported to the State agency as required; -Abuse/Neglect related reportable incidents were to be investigated; and -Results of the investigation were to be submitted to the State agency within 5 working days. B. Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/8/19 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7 (with a score from 0-7 indicating severe cognitive impairment). Review of Resident 3's Progress Notes revealed the following: - On 11/16/18 at 9:37 PM, after the 1:30 PM smoke break the resident became upset and wanted to go back to the resident's room. Resident 3 was seated close to Resident 13 and did not want to be that close to Resident 13. Resident 3 began to yell and swung at Resident 13. Resident 3 hit Resident 13 on the shoulder and in the back of the head. Resident 13 became very confused, upset, and angry. Staff separated the 2 residents. - On 1/9/19 at 8:47 PM, the resident was physically aggressive towards other residents. The resident pushed the resident's fingers into another resident's arm at the table and told the resident's tablemates to ''shut up'' or ''[***] off''. During an interview with the Director of Nursing (DON) on 1/23/19 at 10:40 AM, the DON confirmed an investigation was not completed and the events were not reported to the State Agency. C. Review of an Adult Protective Services (APS) Intake Worksheet dated 6/6/18 revealed the facility reported Resident 8 fell while out of the facility on 6/5/18. Documentation further indicated the resident sustained [REDACTED]. The resident was sent to the emergency room for evaluation on 6/6/18. Review of facility investigations of potential abuse/neglect from 6/5/18 through 1/23/19 revealed no evidence an investigation was completed and submitted to the State agency regarding Resident 8's fall with injury on 6/5/18. Interview with the DON on 1/23/19 at 2:30 PM confirmed Resident 8's fall with injury on 6/5/18 was not reported to the State agency until 6/6/18. The DON further confirmed an investigation was not completed or submitted to the State agency as required. D. Review of an APS Intake Worksheet dated 6/29/18 revealed the facility reported Resident 241 sustained an injury during a confrontation with staff. The resident was swinging arms at staff and hit the patio grill, resulting in a skin tear. Review of the facility investigations of potential abuse/neglect from 6/5/18 through 1/23/19 revealed no evidence an investigation was completed and submitted to the State agency regarding Resident 241's confrontation and injury on 6/29/18. During interview on 1/23/19 at 12:54 PM, the DON confirmed an investigation of Resident 241's injury was not completed or submitted to the State agency as required.",2020-09-01
3718,GOOD SAMARITAN SOCIETY - GRAND ISLAND VILLAGE,285285,4061 TIMBERLINE STREET & 4055 TIMBERLINE STREET,GRAND ISLAND,NE,68803,2019-02-19,609,D,1,0,XNDC11,"**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 report to APS (Adult Protective Services) a resident fall with potential fracture (Resident 200) which required x-rays, a resident (Resident 200) fall which required evaluation in the ER and hospitalization , and failed to report to APS a fall with fracture (Resident 100) within the 2 hour required time frame. This was out of 3 residents sampled. The facility census was 61. Findings are: [NAME] Record review of Resident 200's Admission Record dated 2-19-19 revealed the [DIAGNOSES REDACTED]. 1. Review of Resident 200's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-4-18 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 2 which indicated the resident was severely cognitively impaired. Resident 200 required extensive assist of one staff person for bed mobility, transfers, walking, locomotion, and toileting. Record review of Resident 200's PN (Progress Notes) dated 12/5/2018 revealed the resident was found on the floor in the resident's room. A head to toe assessment was completed that revealed no injuries and the resident denied pain at the time of the fall. PN dated 12/6/18 revealed the resident had bruising and swelling to the left wrist and the staff documented they felt it was from the fall on the day prior on 12/5/18. An assessment was completed of the wrist which revealed the range of motion was good but the resident did complain of a little pain. The Physician was notified and orders were received to evaluate the left wrist with an x-ray. PN dated 12/7/2018 revealed Mobilex was at the facility and the X-ray completed of the left wrist. Interview on 2/19/19 at 3:30 PM with the DON (Director of Nursing) revealed the x-ray of Resident 200's left wrist had revealed no fracture. The DON confirmed Resident 200's fall on 12-5-18 with possible [MEDICAL CONDITION] wrist had not been called into APS. 2. Review of Resident 200's PN dated 1-16-19 revealed the resident had been found on the floor in the resident's room. Resident assessed and blood pressure was low at 97/63 and the resident had low oxygen saturation at 70%. The Physician was notified and the resident was transferred to the ER (emergency room ) to be evaluated and was admitted . Review of the Hospital Discharge Summary dated 1-18-19 for Resident 200 revealed the resident was hospitalized with [MEDICAL CONDITION] (low oxygen in the blood), low blood pressure, and change in mentatiion. The report revealed a CT of the head and cervical spine and X-rays of the pelvis were performed to rule out fractures and all were negative. The resident was diagnosed with [REDACTED]. Review of the facility investigation records revealed the facility did not report the fall resulting in evaluation at the ER and hospitalization to the APS. B. Record review of Resident 100's Admission Record dated 2-14-19 revealed [DIAGNOSES REDACTED]. Review of Resident 100's MDS dated [DATE] revealed a BIMS of 14 which indicated the resident had no cognitive impairment. The resident required limited assistance of one staff with bed mobility, transfers, walking, locomotion, and toileting. Record review of Resident 100's PN dated 1-23-19 at 1:53 AM revealed the resident ambulated with the walker and the walker started to collapse. The resident used the resident's right hand to attempt to prevent a fall. The nurse assessed the resident and the right hand and the ring finger had a slight amount of bleeding and the middle finger had some swelling. The fingers were cleansed and wrapped with gauze and coban. The resident was assisted back into bed. The resident was adamant with refusal to go do the ER (emergency room ) to have the fingers examined during the night. PN on 1-23-19 at 7:43 AM revealed the resident's right hand was assessed and the middle finger appeared rotated at a 30-45 degree angle and bent away from body. The nurse called the on-call Physician and orders were received to send the resident to the ER to be evaluated. Record review of the Incident report for Resident 100 dated 1-23-19 revealed the third finger assessed to be limp and possibly broken. Report was given to the oncoming shift to follow-up on the injury. Review of the Hospital Physician order [REDACTED]. Review of the APS report revealed the incident was called to APS on 1-23-19 at 3:02 PM and not within the two hours of a suspected fracture. Interview on 2-19-19 at 3:30 PM with the DON confirmed the Administration was not notified by the staff of the fall with potential injury to the fingers on 1-23-19 until the next morning instead of immediately during the night when the fracture was suspected. The DON also revealed the DON was aware the resident went to the ER at 7:43 AM on the morning of 1-23-19 and the DON confirmed the APS was not notified until 3 PM that afternoon.",2020-09-01
2892,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2019-04-22,609,D,1,1,BJ6K11,"**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 staff failed to report an allegation of abuse within 2 hours for 1 (Resident 309) and failed to report a significant injury within 2 hours to the required State Agency for one resident (Resident 49). This affected two out of 6 residents sampled . The facility staff identified a census of 60. Findings are: Review of a undated investigation revealed Nursing Assistant (NA) O reported to the DON of witnessing another staff member being verbally abusive last night to a resident in the facility. On 4-04-2019 at 1:30 PM the facility Director of nursing (DON) reported there was an allegation of abuse that occurred on 4-03-2019 on the night shift. The DON further confirmed the allegation of abuse had not been reported to the required State Agency within the required 2 hour time fram. On 04/08/19 at 07:06 AM the DON reported that Resident 49 had a fall over the weekend, had an x-ray which showed no fractures, was taken to theER on [DATE] and a fracture was identified. DON confirmed that it was not reported within the 2 hours. Record review of the Nursing Note dated 4/6/2019 11:20 revealed that Resident 49 was found on floor in activity room laying on back. Record review of Nursing Note dated 4/6/2019 at14:41 revealed that Resident 49 was now limping on left side. Call out to MD for x-ray. Record Review of Nursing Note dated 4/6/2019 at 17:37 revealed X-ray results received and negative for fracture. Record Review of Nursing Note dated 4/7/2019 at 17:29 revealed that Resident 49 was in wheelchair most of day. Resident 49 got out of bed and ambulating in hallway with pronounced limp. Resident 49's legs were uneven and left hip pronounced. Resident 49 was transported to the emergency room . Record Review of Nursing Note dated 4/7/2019 18:39 revealed that Resident 49 returned from emergency room with family with a [DIAGNOSES REDACTED]. 4/11/2019 Review of Policy and Procedure for reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment dated 11/28/2017 revealed for the facility to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately but: Not later than 2 hours after the allegation is made if the events cause the allegation involves abuse or results inn serious bodily injury.",2020-09-01
6426,LYONS LIVING CENTER,285301,1035 DIAMOND STREET,LYONS,NE,68038,2018-05-10,947,E,1,0,2CLY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04 Based on record review and interview, the facility failed to provide staff training which included dementia management training. This had the potential to affect the 3 residents (Residents 1, 2 and 10) who resided in the locked Memory Support Unit (an enclosed wing or hallway which specializes in care of residents with dementia or [MEDICAL CONDITION]). The sample size was 14 and the facility census was 23. Findings are: A. Observations on 5/7/18 at 8:40 AM revealed the facility had a locked MSU where Residents 1, 2 and 10 resided. There was no evidence to indicate the facility had policies and procedures which addressed care of residents in a MSU. B. Review of the following employee files revealed no evidence that additional dementia management training was provided to address the needs of residents in the MSU: -Nursing Assistants (NA)-B, H, I, O and P; -Licensed Practical Nurse (LPN)-A; and -Registered Nurses (RN)-F and K. C. A confidential interview with a NA on 5/7/18 at 1:30 PM indicated the NA was assigned at times to work in the MSU. The NA confirmed no additional training had been provided for care of residents in the MSU. D. Interview with the Consultant Administrator and the Provisional Administrator on 5/10/18 at 1:43 PM confirmed there were no written policies and procedures for the MSU. The Consultant Administrator and the Provisional Administrator indicated in-service education was provided on 4/27/18 to address resident behaviors. E. Review of the facility in-service/training record dated 4/27/18, which included a staff sign-in record, revealed topics discussed were Elopement, Behaviors, Workplace Safety. Further review of the staff sign-in record revealed LPN-A, NA-M and NA-N had not signed in for the in-service education. F. Review of Nurse Staff Postings and/or Daily Assignment Sheets (nursing staff schedule which specifies assigned work areas) from 4/28/18 to 5/7/18 revealed the following: -LPN-A was assigned as charge nurse on 4/28/18, 4/29/18, 5/4/18 and 5/7/18; -NA-M was assigned to work in the MSU on 4/29/18, 5/6/18 and 5/7/18; and -NA-N was assigned to work in the MSU on 5/4/18.",2019-03-01
5792,WAYNE COUNTRYVIEW CARE AND REHABILITATION,285135,811 EAST 14TH STREET,WAYNE,NE,68787,2016-09-14,353,E,1,0,IB0Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04 C Based record review and interviews, the facility failed to provide nursing staff to meet resident's needs related to provision of baths in accordance with bath schedules for Residents 1, 2, 3, and 4 who required assistance with bathing. The sample size was 5 and the facility census was 37. Findings are: A. Review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 6/28/16 revealed the resident required extensive staff assistance of 2 persons with bathing. Review of the Bathing Schedule (not dated) revealed Resident 1 was to receive baths 2 times weekly on Tuesdays and on Fridays. Review of Bath Documentation for 6/1/16 through 9/13/16 revealed Resident 1 received a bath on 7/26/16 and not again until 8/2/16 (7 days), on 8/17/16 and not again until 8/27/16 (10 days) and the resident did not receive another bath until 9/6/16 (10 days later). B. Review of Resident 2's MDS dated [DATE] revealed the resident required extensive staff assistance of 1 person with bathing. Review of the Bathing Schedule (not dated) revealed Resident 1 was to receive baths 2 times weekly on Tuesdays and on Fridays. Review of Bath Documentation for 6/2016 through 9/13/16 revealed Resident 2 received a bath on 7/15/16 and not again until 8/9/16 (25 days), on 8/15/16 and not again until 8/26/16 (11 days) and resident 2 did not receive a bath again until 9/13/16 (18 days later). C. During an interview on 9/13/16 from 2:00 PM to 2:10 PM the Director of Nursing (DON) verified residents were not always receiving baths according to their individual preferences and their bathing schedule due to staffing concerns. D. Review of Resident 4's MDS dated [DATE] revealed the resident required extensive staff assistance of 1 person with bathing. Review of the Bathing Schedule (not dated) revealed Resident 4 was to receive baths 2 times weekly on Mondays and on Thursdays. Review of Bath Documentation for 6/1/16 through 9/13/16 revealed Resident 4 received a bath on 7/18/16 and not again until 7/28/16 (10 days), and on 8/1/16 and not again until 8/10/16 (9 days). During an interview on 9/14/16 at 10:25 AM, Resident 4 confirmed baths were not given 2 times weekly as scheduled. E. Review of Resident 3's MDS dated [DATE] revealed the resident required extensive staff assistance of 1 person with bathing. Review of the Bathing Schedule (not dated) revealed Resident 3 was to receive baths 2 times weekly on Mondays and on Thursdays. Review of Bath Documentation for 6/1/16 through 9/13/16 revealed Resident 3 received a bath on 7/11/16 and not again until 7/18/16 (7 days), on 7/21/16 and not again until 8/1/16 (11 days), on 8/1/16 and not again until 8/10/16 (9 days), on 8/10/16 and not again until 8/17/16 (7 days), and on 8/17/16 and not again until 9/5/16 (19 days).",2019-09-01
5549,"WAUSA CARE AND REHABILITATION CENTER, LLC",285111,703 SOUTH VIVIAN,WAUSA,NE,68786,2018-03-14,741,E,1,0,1GWJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04 C Based record review and interviews, the facility failed to provide nursing staff to meet resident's needs related to provision of baths in accordance with bath schedules for Residents 2, 3, and 4 who required assistance with bathing. The sample size was 6 and the facility census was 19. Findings are: [NAME] Review of Resident 2's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 12/15/17 revealed the resident required extensive staff assistance with bathing. Review of Bath Documentation for 12/29/16 through 3/14/18 revealed Resident 2 received a bath on 1/6/18 and not again until 1/16/18 (10 days). Resident 2 did not receive a bath again until 1/27/18 (11 days). Resident 2 received a bath on 2/3/18 and not again until 2/13/18 (10 days), on 2/20/18 and not again until 2/27/18 (7 days). Resident 2 received a bath on 3/6/18 and as of 3/14/18 (7 days) the resident had still not received another bath. B. Review of Resident 3's MDS dated [DATE] revealed the resident required extensive staff assistance with bathing. Review of Bath Documentation for 12/29/17 through 3/14/18 revealed Resident 3 received a bath on 2/12/18 and not again until 2/19/18 (7 days), on 2/22/18 and not again until 3/5/18 (11 days). C. Review of Resident 4's MDS dated [DATE] revealed the resident required extensive staff assistance with bathing. Review of Resident 4's current Care Plan dated 2/27/18 revealed the resident had limited mobility and range of motion and required extensive staff assistance with bathing. The Care Plan further identified the resident was to receive 2 baths each week. Review of Bath Documentation for 12/29/17 through 3/14/18 revealed Resident 4 received a bath on 1/19/17 and not again until 1/26/18 (7 days). Resident 4 did not receive a bath again until 2/2/18 (7 days). Resident 4 received a bath on 2/9/18 and not again until 2/14/18 (5 days), on 2/19/18 and not again until 2/27/18 (8 days). D. During an interview on 3/14/18 from 2:00 PM to 2:10 PM, the Interim Administrator verified residents were not always receiving baths according to their individual preferences and their bathing schedule due to staffing concerns.",2019-11-01
3936,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,607,F,1,1,OLWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 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 1 of 5 employees (HA(Housekeeping Aide)-M) for abuse prior to employment. This had the potential to affect all 34 residents in the facility. The facility identified a census of 34 at the time of survey. Findings are: Interview with Resident 30's family member on 3/13/18 at 3:44 PM revealed a concern about the lack of policy and procedure for how the facility handled potential allegations of abuse. Review of the personnel files for 5 newly hired employees identified that the facility failed to complete a Nurse Aide Registry verification for adverse findings for HA-M. Interview on 3/20/18 at 10:00 AM with the BOM (Business Office Manager) revealed that the personnel file for HA-M did not contain the Nurse Aide Registry verification. The BOM confirmed that the verification should have been in the personnel file. Review of the facility policy Abuse & Neglect (YEAR) revealed the following: *The facility must not employ individuals who have had a finding entered in the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [REDACTED].",2020-09-01
2893,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2019-04-22,610,D,1,0,BJ6K12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3d Based on record reviews and interviews the facility failed to thoroughly investigate an elopement for 1 (Resident 43) of 1 sampled residents. The facility staff identified a census of 50. The findings are: Review of the Policy and Procedure for Elopement dated 6/2019 revealed it is the facility policy to provide a safe environment for all residents. The facility will properly assess residents and plan their care to prevent accidents related to wandering behavior of elopement. Elopement is defined as slipping away secretly, running away, leaving without accompaniment or knowledge of staff. Review of Resident 43's medical record revealed an admitted d of 10/30/2018 with [DIAGNOSES REDACTED]. Review of Resident 43's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 5/24/2019 revealed a BIMS (Brief Interview for Mental Status) score of 8 which indicates moderately impaired. Review of the current physician orders [REDACTED]. Review of the Treatment Administration Record for (MONTH) 2019 revealed documentation of check placement and functioning of wander guard every shift with an order date of 11/21/2018. Review of the incident report for elopement dated 5/22/2019 revealed the BOM (Business Office Manager) called the DCS (Director of Clinical Services) office and reported Resident 43 was in the hallway outside of her office. Review of facility investigation dated 5/22/2019 revealed that Resident 43 was seen by the BOM in the assisted living area as Resident 43 was headed to the BOM office to get money to buy cigarettes. The staff were not aware of where Resident 43 was. Immediate action taken was facility staff completed a search of the building, completed the elopement protocol and Resident 43 was assisted back to the Garden Level of the facility. Interview conducted with SSD (Social Service Director) on 6/13/2019 at 07:45 AM revealed the incident that occurred on 5/22/2019 with Resident 43 was determined not to be an elopement. SSD stated that Resident 43 had a plan. SSD reported that Resident 43 did not have a wander guard until after the elopement occurred. SSD further reported Resident 43's BIMS to be a 15 and SSD educated Resident 43 on smoking policy and the policies on leaving the facility. Interview with CMA (Certified Medication Aide) A on 6/13/2019 at 08:20 AM revealed that when a resident with a wander guard goes out of the door or gets on the elevator an alarm goes off. CMA A stated the day that Resident 43 had eloped the alarm did not go off and maintenance was notified. Interview with RN (Registered Nurse) B on 6/13/2019 at 08:22 AM revealed that RN B was here on the day that Resident 43 eloped. RN B was unaware if the alarm went off or not but was involved in the elopement protocol and Resident 43 was found safe and sound. Interview with DCS on 6/13/2019 at 09:30 AM revealed that DCS did not consider the incident an elopement because it was in the same building. DCS revealed that the alarm did not sound that day because DCS believes that someone put the code in because Resident 43 was going to the Business Office for money. DCS confirmed that the wander guard alarming was not a part of the investigation and the BIMS was incorrect on the investigation.",2020-09-01
3841,OLD MILL REHABILITATION (OMAHA TCU),285289,1131 PAPILLION PARKWAY,OMAHA,NE,68154,2018-05-07,726,D,1,0,PUW011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04B Based on interview and record review; the facility failed to ensure staff had been educated on management of Insulin pump use and low blood glucose for 1 of 1 (Resident 1) residents sampled. The facility census was 41. Findings are: [NAME] A review of Resident 1's plan of care revealed Resident 1 had a [DIAGNOSES REDACTED]. B. An interview with Registered Nurse (RN) D on 5/10/2018 at 9:52 am; RN D stated that RN D had been trained in the monitoring of blood glucose, administering insulin via syringe and insulin pen. RN D then stated that RN D had not received training in the management of an insulin pump. C. An interview with Registered Nurse [NAME] on 5/10/2018 at 9:52 am; RN [NAME] stated that RN [NAME] had been trained in the monitoring of blood glucose, administering insulin via syringe and insulin pen. RN [NAME] then stated that RN [NAME] had not received training in the management of an insulin pump. D. An interview with Registered Nurse F on 5/10/2018 at 10:00 am; RN F stated that RN F had been trained in the monitoring of blood glucose, administering insulin via syringe and insulin pen. RN F then stated that RN F had not received formal training in the management of an insulin pump. RN F stated that in the past, prior to a Resident being admitted with an insulin pump there had been briefing related to that Residents specific pump. E. A review of facility policy on undated Insulin Administration revealed management of an insulin pump was not included. F. In an interview on 5/10/18 at 9:58 AM, the Director of Nursing confirmed that the facility had not provided any training on use of an insulin pump.",2020-09-01
2231,GOOD SAMARITAN SOCIETY - ST JOHNS,285189,3410 CENTRAL AVENUE,KEARNEY,NE,68847,2019-09-04,725,E,1,1,HPB011,"**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 staff failed to ensure the facility had enough staff to ensure residents received assistance with bathing weekly. This affected 5 of 5 residents evaluated for bathing during the survey process (Residents 14, 19, 38, 8, and 28). The facility identified a census of 37 at the time of survey. Findings are: [NAME] Record review of Admission Record dated 9-4-19 for Resident 14 had admission date of [DATE] to the facility with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 7-4-19 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 9 which indicated the resident was cognitively impaired. The resident required 1 staff with physical help in part of bathing. Review of Resident 14's CarePlan revealed the resident required 1 assist with bathing. Record review on 9/03/19 at 11:17 AM of the facility bath schedule provided by the DON (Director of Nursing) revealed Resident 8 was scheduled for one bath a week. Review of bathing documentation from P[NAME] (Point of Care) provided by the DON on 9-3-19 at 12:22 PM revealed from (MONTH) 2019 to (MONTH) 3, 2019 revealed the resident received weekly baths in (MONTH) and (MONTH) 2019 and revealed: 3/1 w/p 3/15 w/p 14 days without a bath. 3/21 w/p 4/4 w/p 14 days without a bath. 4/12 bed bath 11 days without a bath. 4/17 tub 4/23 tub 5/3 w/p 5/10 w/p 5/20 bed bath 5/23 bed bath 5/31 w/p 6/19 w/p The month of (MONTH) only 1 bath. This caused Resident #14 to go 19 days without a bath then go 25 more days without a bath in the middle of summer. 7/14 w/p 7/19 w/p 7 30 w/p 11 days without a bath. 8/12 w/p 13 days without a bath. 819 w/p 8/30 w/p 11 days without a bath. B. Review of the Admission Record dated 9-4-19 for Resident 19 revealed had admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident 19's MDS dated [DATE] revealed a BIMS of 15 and the the resident did not receive a bath Record review on 9/03/19 at 11:17 AM of the facility bath schedule provided by the DON revealed Resident 8 was scheduled for one bath a week on Fridays. Review of bathing documentation from P[NAME] provided by the DON on 9-3-19 at 12:22 PM revealed from (MONTH) 2019 to (MONTH) 3 the resident received: 1/4 shower 1/11 shower 1/14 resident refused 1/18 shower 1/28 shower 2/8 shower 11 days without a bath. 2/12 tub 2/15 shower 2/21 shower 3/1 shower 3/13 shower 12 days without a bath. 3/23 shower 10 days without a bath. 4/3 shower 4/24 shower The month of (MONTH) only 2 baths. 5/10 shower 523 tub The month of (MONTH) only 2 baths. 6/3 shower 6/15 shower The month of (MONTH) only 2 baths. 7/1 shower 7/30 shower The month of (MONTH) only 2 baths (29 nine days apart). 8/13 shower 8/23 shower The month of (MONTH) only 2 baths. C. Review of Resident 38's Admission Record dated 9-3-19 revealed date of admission of 6-20-19 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed a BIMS score of 10 which indicated moderate cognitive impairment with behaviors of delusions, wandering, and other behaviors not directed toward others in 1-3 days. The resident was frequently incontinent of bowels and bladder. Bathing did not occur during the 7 day assessment period. Record review on 9/03/19 at 11:17 AM of the facility bath schedule provided by the DON revealed Resident 8 was scheduled for one bath a week on Thursdays. Review of bathing documentation from P[NAME] provided by the DON on 9-3-19 at 12:22 PM revealed from (MONTH) 20, 2019 to 9-3-19 the resident received 3 baths since admission on 7/13, 7/22 and 8/13. The resident was offered and refused 8 times per documentation by the bath aide. Review of the documentation in the PN (Progress Notes) from (MONTH) to (MONTH) revealed absence of documentation by the nurses of the resident's behavior of refusing baths and the nurse's attempt with other interventions to have the resident baths or at least a bed bath given. Review of Resident 38's CarePlan dated 6-20-19 revealed the resident preferred to receive a shower daily. Interview on 9/03/19 at 12:55 PM with NA-G (Nurse Aide) revealed NA-G was scheduled to perform baths 4 days a week but lately had been pulled to work on the units quite often because of not enough staff. NA-G revealed today,9-3-19 NA-G was scheduled to give baths but was pulled because of a call-in so was working on the floor. On the days NA-G was scheduled to perform baths, NA-G would try to do extra baths to help get those that were missed caught up. NA-G revealed when a resident refuses a bath, NA-G documented it in P[NAME] to show it was refused, but NA-G would go back later in the same day and re-approach the resident and if refused again, NA-G would document the refusal again. If the resident would continue to refuse, NA-G would give a bath to a resident from the next day and report the refusals to the charge nurses. Review of Resident 38's P[NAME] documentation of the bathing revealed on 7/18 a refusal at 7:53 AM and at 9:08 AM and again on 8/23 two refusals on the same day at 11:44 AM and at 1:48 PM. Reviewed Bathing p/p dated 10/17 revealed absence of how many times a week a resident should receive a bath. Interview on 9/03/19 at 12:13 PM with the DON revealed every resident was scheduled for 1 bath a week due to that was all the facility could manage to provide because of their staffing. Currently the facility had 1 BA (Bath Aide) hired and there were about 4-5 other Nurse Aides that were trained to perform baths on the BA's day off or when baths were needed to be done on the evening shift or weekend. The DON revealed the DON had hired two more new staff to be bath aides. The DON revealed the DON had been aware there had been a problem with baths over the past year because of shortage of staffing and the DON had been working on it. The BA was scheduled 4 days a week but at times would get pulled to the floor due to staffing needs. When this happened staff were instructed to do bed baths but the DON did not realize for quite a while the staff were giving the bed baths to the residents for their 1 bath a week and then not documenting it as a bath. The DON revealed next intervention was every week on Thursdays the DON did an audit of the documentation of baths to see which resident did not have a bath documented and then those resident were scheduled for Friday and the weekend to get a bath. The DON revealed for residents requesting more than one bath a week had been told if they wanted more than 1 bath a week right now, it would have to be a bed bath due to staffing. Right now there was only one resident who received more than one bath a week and it was not Resident 38. The DON reviewed Resident 38's CarePlan and confirmed the CarePlan revealed the resident requested to have a shower daily but the DON revealed because of the staffing this request was not possible at this time and confirmed Resident 38 was scheduled one bath per week. D. Interview on 8-29-19 at 10:49 AM with the Resident 8 revealed the resident had not always received a bath weekly in the past year. The resident kept track of the days the resident received baths and shared this information. The resident revealed a bed bath is not the same as a tub bath or a shower, it is better than nothing but you don't feel as clean. Record review on 9/03/19 at 11:17 AM of the facility bath schedule provided by the DON revealed Resident 8 was scheduled for one bath a week on Fridays. Review of Resident 8's Care Plan dated 6-21-19 revealed the resident preferred 2 baths per week. Interview on 9/03/19 at 12:13 PM with the DON revealed since (MONTH) the facility has assisted the resident to have 2 baths a week by having one bath as a shower and the 2nd bath is a bed bath. The bed bath is given by the evening nurse aides but the nurses document it on the treatment record after they ensure it was done. Review of bathing documentation from P[NAME] provided by the DON on 9-3-19 at 12:22 PM revealed from (MONTH) 2019 to current revealed the resident got a weekly bath in (MONTH) 2019. However in (MONTH) baths received on 2/5, 2/9, and 2/20 which was 11 days in between baths. In (MONTH) baths received on 3/1, 3/13 a twelve day span without a bath, 3/23 a ten day span without a bath. In (MONTH) a bath was given on 4/3 a twelve day span without a bath, 4/22 nineteen days without a bath. In (MONTH) the resident started receiving a 2nd bath a week of a bed bath every Monday and then a shower was scheduled every Friday. Review of the showers revealed the resident received a shower on 5/3, eleven days without a bath. The resident received on 5/10 a bed bath instead of a shower, 5/23 thirteen days without a bath but total of 20 days without being in a tub or shower because the resident had only a bed bath during that time frame. On 6/4, twelve days since last tub bath/shower, 6/15 eleven days since last tub bath/shower ,6/28 thirteen days since last tub bath/shower. In the month of (MONTH) 7/14 sixteen days since last tub bath/shower, 7/30 sixteen days since last tub bath/shower, 8/9, 8/19 fifteen days since last tub bath/shower. Documentation on TAR (treatment administration record) revealed a bed bath was given every Monday at bedtime weekly from (MONTH) 13 to [DATE] except (MONTH) 22 was blank. Documentation between both forms revealed the resident did not get a tub bath/shower or a bed bath between (MONTH) 15 and (MONTH) 29 which was 2 weeks. E. Interview with Resident 28 during the Resident Council meeting on 9/03/19 at 3:00 PM revealed the facility was understaffed in the bath department. Resident 28 revealed the facility did not allow somebody to be there to staff the baths. Resident 28 revealed they maybe got a bath once a week but they sometimes went more than 2 weeks without a bath. Resident 28 revealed the facility did not allow a staff person to fill the bath aide job. Resident 28 revealed there was supposed to be a staff person designated to do baths but they got pulled to the floor (reassigned from doing baths to performing direct care in the resident care areas) because the facility did not have enough staff. Resident 28 revealed if the facility needed a job to be done there had to be someone to do it. Review of Resident 28's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 7/26/2019 revealed an admission date of [DATE]. Resident 28 had a BIMS (Brief Interview for Mental Status Score) of 15 which indicated Resident 28 was cognitively intact. Resident 28 required limited assistance of 1 staff person for bathing. Review of Resident 28's Care Plan dated 12/30/2016 revealed Resident 28 preferred 2 baths per week. Resident 28 required 1 staff assist with bathing. Review of Resident 28's Follow Up Question Report dated 8/1/2018 to 9/3/2019 revealed documentation Resident 28 received a bath on: 9/7/18, 9/21/18 (14 days with no bath); 11/14/18 11/23/18 (9 days with no bath); 12/20/18 1/4/19 (15 days with no bath); 2/4/19 2/15/19 (11 days with no bath); 2/26 (11 days with no bath); 3/12 (14 days with no bath); 3/23 (11 days with no bath); 4/3 (11 days with no bath); 4/12 (9 days with no bath); 4/22 (10 days with no bath); 5/3 (11 days with no bath); 5/16 6/3 (18 days with no bath); 6/15 (12 days with no bath); 6/21 7/11 (20 days with no bath); 7/19 (8 days with no bath); 7/30 (11 days with no bath); 8/9 (10 days with no bath). Interview with the DON (Director of Nursing) on 9/03/19 at 4:30 PM revealed the residents were to receive at least 1 bath a week. The DON confirmed Resident 28 was not receiving at least 1 bath a week. Review of Resident 28's MDS schedule revealed Resident 28 not been out of the facility. Interview with the DON on 9/03/19 at 5:46 PM revealed they did not find any documentation Resident 28 had refused any baths and the DON confirmed Resident 28 had not out of the facility. The DON revealed ensuring the residents received their baths had been an issue. Review of the facility policy Bathing revised 10/17 revealed no documentation of how often residents were to receive a bath. Review of the untitled document identified by the DON as the bath schedule revealed Resident 28 was on the schedule to receive a bath on Fridays. Interview with the DON on 9/04/19 at 8:37 AM confirmed the bath aide did get removed from the bathing task to work in the other resident care areas.",2020-09-01
1787,PLUM CREEK CARE CENTER,285159,1505 NORTH ADAMS STREET,LEXINGTON,NE,68850,2019-11-14,725,F,1,0,4F4Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observation, interview, and record review; the facility failed to ensure there was enough staff to respond to resident calls for assistance, provide assistance with ADLs (Activities of Daily Living) and failed to ensure staff were trained to use the lifts. This had the potential to affect all of the facility residents. The facility identified a census of 38 at the time of survey. Findings are: A. Interview with Resident 4 on 11/14/2019 at 12:44 PM revealed the facility did not have enough staff. Resident 4 revealed they had to wait quite a while for help. Resident 4 revealed a couple of times Resident 4 had to wait 2 hours for help while Resident 4 was on the toilet. B. Interview with Resident 2 on 11/14/2019 at 1:20 PM revealed the facility did not have enough staff. Resident 2 revealed call light response times were 45 minutes to an hour. Resident 2 revealed they would be on their call light 45 minutes and one resident yelled out the door for help and the aide answered them first because they were yelling. I don't think that's right. C. Interview with Resident 1 on 11/14/2019 at 1:49 PM revealed the staff used the STS (Sit to Stand-a lift used to assist residents into a standing position) lift to transfer them. Resident 1 revealed sometimes 1 staff person used the lift and sometimes 2 staff used the lift. Interview with NA-A (Nurse Aide) on 11/14/2019 at 1:32 PM revealed they worked for agency staffing. NA-A revealed this was their 3rd week working in the facility and that they had been an aide for 8 years. NA-A revealed this facility was by far the shortest staffed facility they went to. NA-A revealed the resident they were helping now wanted to go to the bathroom [ROOM NUMBER] minutes ago. NA-A revealed there were supposed to be 4 aides on staff and there are only 3 and one of them was 16 so they couldn't use the lift. NA-A revealed they have witnessed staff using the lifts by themselves. NA-A revealed the bath house aide had been using the lifts all day by themselves. NA-A revealed they usually worked evenings and evening staffing was so much worse. NA-A revealed there were only 3 aides on in the evenings. Interview with the DON (Director of Nursing) on 11/14/2019 at 2:53 PM revealed 2 staff were required for every lift. The DON revealed they had an in-service. Agency staff were supposed to get the information they needed to care for the residents from the Kardex on POC (Point of Care in the EHR-electronic health record). They also got report from the charge nurses. The nurses were supposed to use the information sheets to convey information to the agency staff. Interview with the DON on 11/14/2019 at 3:51 PM revealed the staff were trained upon orientation-it was on the orientation check list. Agency staff had a checklist when they came on. The DON revealed they did not keep the documentation that agency staff were trained on the lifts. The other staff were to tell them they were supposed to use 2 staff with the lifts. Requested the lift training records for the agency staff from the DON and these were not received. Interview with MA-E (Medication Aide) on 11/14/2019 at 3:55 PM revealed the direct care staff were not properly trained to care for the residents or use the lifts; they just got thrown into it. Both lifts were supposed to be used with 2 staff. Sometimes they didn't use 2 staff because there was not enough help. A lot depended on who the nurse was-the nurse would give them a run-down of how things went but that was not always the case. Interview with Anonymous on 11/14/2019 at 4:44 PM revealed the facility was short staffed. The facility had 2 aides on most of the time to care for all of the facility residents. Anonymous revealed every night they always saw a different aide working which was not good for continuity of care. Review of the undated Certified Nursing Assistant job description revealed the following: Answers residents' call bells promptly and courteously. Lifts, moves, and transports residents, using proper body mechanics or lifting devices for accident prevention. D. On 11/14/19 at 11:10 AM an observation of Resident 1 was resident sitting in the room in wheelchair with no attempts made by the resident to reposition self. An interview on 11/14/19 at 11:45 AM with RN-D (Registered Nurse) revealed that the staffing was good today because of surveyors being in the building. Adult Protective Services had been in the building several times because of neglect due to complaints about staffing. Staff try to do their best but call lights can be 1 to 2 hours or longer before they are answered. The agency staff are put on the floor right away with no orientation as to what needs to be done for each resident. Due to lack of staffing the staff are forced to transfer residents with lifts which require 2 persons for transfers. An interview on 11/14/19 at 12:10 PM with Resident 1 revealed that Resident 1 had to wait 20 minutes or longer for staff to answer the call light to go to lie down in bed between meals or to go to bed at night. An interview on 11/14/19 at 12:50 PM with NA-B (Nurse Aide) revealed there are not enough staff to take care of the residents basic needs. Residents' have to wait over an hour to be taken to the bathroom. On 11/10/19 one staff person was on the floor to take care of all 38 residents because the other staff didn't show up. Staff are informed to let other staff, like the office staff, know help was needed. The NA's are usually informed the people in the office will help us but they are busy right now. The help never shows up. An interview on 11/14/19 at 2:30 PM with NA-E (Nurse Aide) revealed that there was not enough staff to take care of the residents' in the way they deserve. It isn't fair to the residents to cut corners such as transferring them without enough staff to help. All lifts are to be 2 person transfers but one person is having to do it because of staff shortage and making the resident sit for 1 hour, 2 hours or longer to go to the bathroom. Review of the call light log for Resident 1 room [ROOM NUMBER] revealed the following: 10/18/19 at 12:39 AM bathroom call light 26 minutes 50 seconds 10/18/19 at 6:19 PM bathroom call light 25 minutes 22 seconds 10/19/19 at 7:25 AM bathroom call light 34 minutes 26 seconds 10/19/19 at 11:48 AM bathroom call light 15 minutes 3 seconds 10/19/19 at 5:39 PM bathroom call light 28 minutes 26 seconds 10/19/19 at 7:50 PM bathroom call light 54 minutes 57 seconds 10/20/19 at 11:20 PM bathroom call light 26 minutes 43 seconds 10/20/19 at 6:40 PM bathroom call light 44 minutes 14 seconds 10/20/19 at 9:22 PM bathroom call light 31 minutes 50 seconds 10/28/19 at 7:04 PM bed call light 30 minutes 43 seconds 10/30/19 at 5:15 PM bed call light 35 minutes 9 seconds 11/1/19 at 7:07 AM bed call light 34 minutes 24 seconds 11/1/19 at 8:15 AM bed call light 22 minutes 16 seconds 11/1/19 at 10:56 AM Bed call light 39 minutes 43 seconds 11/1/19 at 8:35 PM bed call light 55 minutes 28 seconds 11/2/19 at 8:57 PM bed call light 60 minutes 54 seconds 11/9/19 at 7:46 AM bed call light 50 minutes 17 seconds 11/10/19 at 2:54 PM bed call light 56 minutes 12 seconds 11/13/19 at 3:23 PM bed call light 23 minutes 51 seconds E. An interview with surveyor # Resident 2 had to wait for 45 minutes to an hour to have staff answer the call light. Review of the call light for Resident 2 room [ROOM NUMBER] revealed the following: 10/15/19 at 8:33 PM bed call light 15 minutes 3 seconds 10/17/19 at 8:26 PM bathroom call light 50 minutes 14 seconds 10/18/19 at 3:32 PM bed call light 25 minutes 47 seconds 10/19/19 at 8:44 AM bed call light 48 minutes 31 seconds 10/20/19 at 6:49 PM bed call light 37 minutes 54 seconds 10/21/19 at 6:40 PM bed call light 33 minutes 26 seconds 10/22/19 at 12:57 PM bed call light 32 minutes 20 seconds 10/23/19 at 8:50 PM bathroom call light 39 minutes 1 second 10/25/19 at 5:59 AM bed call light 23 minutes 4 seconds 10/25/19 at 6:56 AM bed call light 38 minutes 55 seconds 10/26/19 at 6:34 PM bed call light 54 minutes 20 seconds 10/27/19 at 4:49 AM bed call light 56 minutes 55 seconds 10/27/19 at 5:57 AM bathroom call light 65 minutes 22 seconds 10/28/19 at 5:08 AM bed call light 28 minutes 44 seconds 10/29/19 at 8:13 PM bed call light 58 minutes 31 seconds 10/30/19 at 5:44 AM bathroom call light 109 minutes 58 seconds 10/31/19 at 8:28 PM bed call light 37 minutes 38 seconds 11/1/19 at 7:20 PM bed call light 70 minutes 35 seconds 11/2/19 at 6:29 PM 51 bed call light 51 minutes 48 seconds 11/3/19 at 4:41 AM bed call light 51 minutes 55 seconds 11/4/19 at 7:45 PM bathroom call light 70 minutes 4 seconds 11/5/19 at 5:31 PM bed call light 41 minutes 41 seconds 11/6/19 at 6:17 PM bed call light 71 minutes 22 seconds 11/6/19 at 12:45 PM bed call light 54 minutes 8 seconds 11/7/19 at 7:54 AM bed call light 42 minutes 30 seconds 11/8/19 at 4:37 AM bed call light 58 minutes 47 seconds 11/9/19 at 7:03 AM bed call light 48 minutes 30 seconds 11/10/19 at 10:16 AM bed call light 34 minutes 11 seconds 11/10/19 at 7:44 PM bed call light 61 minutes 22 seconds 11/11/19 at 7:18 PM bed call light 29 minutes 4 seconds 11/13/19 at 4:54 AM bed call light 35 minutes 21 seconds 11/13/19 at 7:54 AM bed call light 33 minutes 19 seconds 11/13/19 at 12:38 PM bed call light 32 minutes 51 seconds F. An interview on 11/14/19 at 1:48 PM with Resident 4 revealed that staff are not always good about repositioning the resident. Resident 4 stated that resident has not been able to move self or reposition in the bed. There are not enough staff to assist the resident. Review of the call light log for Resident 4 room [ROOM NUMBER] revealed the following: 10/21/19 at 1:03 PM bathroom call light 21 minutes 9 seconds 10/28/19 at 8:14 AM bathroom call light 15 minutes 17 seconds 10/26/19 at 4:06 PM bathroom call light 29 minutes 33 seconds 10/24/19 at 10:10 PM bathroom call light 17 minutes 56 seconds 10/24/19 at 7:59 PM bathroom call light 14 minutes 25 seconds 10/23/19 at 7:54 AM bathroom call light 55 minutes 6 seconds 11/4/19 at 4:39 PM bathroom call light 43 minutes 39 seconds 11/8/19 at 1:15 PM bathroom call light 59 minutes 50 seconds 11/9/19 at 1:16 PM bathroom call light 16 minutes 46 seconds 11/9/19 at 1:16 PM bathroom call light 68 minutes 57 seconds Review of the Nursing Assignment sheets revealed on 11/10/19 the other staff scheduled to work the day shift did not show up and did not call. There were hand written notes with names added with no date listed as to when the notes were placed on the sheets. It was observed on the Assignment Sheet that the day shift works with one NA or half of the shift covered to work the 100, 200, and 400 halls. There was one staff to cover the 400 hall with the other staff person for the 100,200, and 400 halls. If the facility uses 2 staff to cover all the hallways and it's a policy that 2 staff must be used for all lift transfers (sit to stand and full body) who is watching the floors and answering call lights. The Working Schedule was asked for at 9:00 AM and it was presented to this surveyor at 3:00 PM. There were handwritten changes made to the schedule with no dates or initials as to when or by whom the changes were made. Review of the Answering the Call Light Policy revealed, The purpose of this is to respond to the residents' request and needs. On General Guidelines #9: Answer the residents' call as soon as possible. On Procedures #4: Do what the resident asks of you, if you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfil the residents' request, ask the nurse supervisor for assistance.",2020-09-01
4938,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2018-11-29,725,F,1,0,SHK811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observation, interview, and record review; the facility failed to provide sufficient nurse staffing levels to ensure safe medication administration practices. This had the potential to affect all residents. The facility census was 32. 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 the resident had an active [DIAGNOSES REDACTED]. On 11/29/18 at 7:50 AM, Registered Nurse (RN)-G administered [MEDICATION NAME] (a medication used to treat high blood pressure) 12.5 milligrams (mg) to Resident 4. Review of Resident 4's Physician order [REDACTED].>Review of Resident 4's Medication Administration Record [REDACTED]. During an interview with RN-G on 11/29/18 at 7:50 AM, RN-G confirmed Resident 4 had received [MEDICATION NAME] 12.5mg. B. Review of Resident 1's MDS dated [DATE] revealed the resident had an active [DIAGNOSES REDACTED]. Review of Resident 1's MAR indicated [REDACTED]. The [MEDICATION NAME]was to be held if the resident's blood sugar was less than 80. Further review of Resident 1's MAR indicated [REDACTED]. Interview with RN-E on 11/29/18 at 10:40 AM confirmed the [MEDICATION NAME]should have been held on 11/5/18, 11/7/18, 11/9/18, and 11/20/18. C. Review of the facility Medication Error Incidents log revealed from 10/2018 through 11/2018 there were 20 documented medication errors. During an interview with RN-G on 11/28/18 at 1:55 PM, RN-G felt the high number of medication errors was due to poor time management by a nurse. Review of the Resident Council Meeting Minutes dated 10/8/18 revealed residents voiced concerns that their medications were not being given on time. Review of the undated form titled [MEDICATION NAME] Estates of West Point Facility Assessment revealed the form did not address how many nursing staff members were needed to safely care for the residents based on the residents' needs. During an interview with the Administrator on 11/29/18 at 1:20 PM, the Administrator confirmed the Facility Assessment did not address the amount of nursing staff needed to safely care for the residents.",2020-03-01
3417,WESTFIELD QUALITY CARE OF AURORA,285263,"PO BOX 166, 1313 1ST STREET",AURORA,NE,68818,2019-11-13,725,F,1,0,P0CC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observation, interview, and record review; the facility staff failed to ensure there was sufficient staff to care for the residents. This had the potential to affect all of the facility residents. The facility identified a census of 64 at the time of survey. Findings are: [NAME] Interview with MA-B (Medication Aide) on 11/13/2019 at 9:48 AM revealed they were administering medications for 2 halls. MA-B revealed the facility had 4 halls/units. MA-B revealed they were way behind on their med pass and they were administering medication that were to have been administered before or with breakfast, which was at 8:00 AM. Observation of MA-B on 11/13/2019 at 9:58 AM revealed they administered medications to Resident 10. Observation of MA-B on 11/13/2019 at 10:11 revealed they administered medications to Resident 8. Observation of MA-B on 11/13/2019 at 10:19 AM revealed they administered medications to Resident 9. Review of Resident 8's, Resident 9's and Resident 10's MAR (Medication Administration Record) for (MONTH) 13, 2019 revealed the medications MA-B had administered were scheduled at 7:00 AM, 7:30 AM, and 8:00 AM which indicated MA-B's medication pass was 2 to 3 hours late. Interview with MA-B on 11/13/2019 at 10:24 AM revealed the facility was short of help today. There was supposed to be 1 NA (Nurse Aide) and 1 MA on each hall. The locked unit was supposed to have 1 MA and 2 N[NAME] They usually have a MA for each cart. There were 4 halls/units in the facility. Because they were short of help, MA-B had to do pass medications on 2 units or from 2 carts and it made their med pass late. B. Interview with anonymous on 11/13/2019 at 12:56 PM revealed the facility did not have enough staff and residents had to wait over an hour for their calls for assistance to be answered. Anonymous revealed they had witnessed residents getting up on their own without assistance placing them at risk for falls and injury because their calls for assistance were not answered. C. Interview with anonymous on 11/13/2019 at 3:10 PM revealed the facility did not have enough staff to respond to resident calls for assistance. Anonymous revealed some residents had to wait 2 hours for assistance. Anonymous also revealed there had been a lot of staff turnover. C. An interview on 11/13/19 at 9:50 AM with Resident 2 revealed that he had waited for more than an hour many times to go to the bathroom or return to bed. It didn't matter what shift it was. Review of Call light log for Resident 2 room [ROOM NUMBER] revealed: 11/6/19 at 5:44 PM bed call light of 40 minutes 8 seconds; 11/8/19 at 4:54 PM bed call light of 450 minutes 52 seconds; 11/8/19 at 1:25 PM bathroom call light of 46 minutes 15 seconds; 11/9/19 at 2:18 AM bed call light of 155 minutes 10 seconds; 11/8/19 at 10:37 PM bed call light of 191 minutes 48 seconds; 11/8/19 at 6:52 PM bathroom call light of 429 minutes 49 seconds; 11/9/19 at 8:07 PM bathroom call light of 31 minutes 57 seconds; 11/10/19 at 12:34 PM bathroom call light for 355 minutes 8 seconds; 11/12/19 at 2:08 PM bathroom call light of 272 minutes 36 seconds; and 11/12 at 10:45 PM bathroom call light of 151 minutes 52 seconds. D. An interview on 11/13/19 at 10:20 AM with Resident 3 stated he had waited almost 2 hours to get the call light answered and it was really bad at night. Review of Call light logs for Resident 3 room [ROOM NUMBER] revealed revealed the following call light; 10/14/19 at 8:38 PM bathroom call light of 28 minutes 50 seconds; 10/14/19 bed at 2:13 PM for 428 minutes 27 seconds; 10/15/19 bed call light at 6:21 AM for 29 minutes 36 seconds; 10/16/19 at 12:39 AM 45 minutes 51 seconds; 10/17/19 at 3:57 AM bed call light for 122 minutes 28 seconds; 10/19/19 at 10:10 AM bed call light for 29 minutes 13 seconds; 10/19/19 at 2:49 PM bathroom call light for 469 minutes 28 seconds; 10/20/19 at 5:59 AM bed call light for 97 minutes 23 seconds; 10/20/19 at 9:47 PM bed call light for 252 minutes 23 seconds; 10/23/19 at 3:55 AM bed call light for 456 minutes 51 seconds; 11/11/19 at 8:44 AM bathroom call light 131 minutes 28 seconds; and 11/13/19 bed call light at 5:47 AM for 403 minutes 8 seconds. E. An interview on 11/13/19 at 10:40 AM with Resident 4 regarding call light stated that he has waited a long time sometimes for hours to get up and it is really bad on the weekends. Review of the Call light times for Resident 4 room [ROOM NUMBER] revealed call light times of 10/15/19 for the bathroom of 39 minutes 42 seconds at 10:00 AM ; Call light on 10/16/19 at 5:12 PM for 15 minutes 46 seconds; Call light time for the bed on 10/16/19 for 11 minutes 29 seconds at 11:29 AM; on 10/17/19 14 minutes and 7 seconds for bed at 7:06 PM; on 10/20/19 at 11:33 AM bed call light for 12 minutes and 22 seconds; on 10/20/19 at 3:26 PM bed call light for 50 minutes 25 seconds; 10/21/19 at 9:59 PM for 69 minutes and 14 seconds; 10/22/19 at 10:30 PM for 33 minutes 8 seconds from the bathroom; 10/27/19 bathroom call light of 235 minutes 55 seconds; 11/4/19 bathroom call light at 11:53 AM for 22 minutes 55 seconds; 11/6/19 bed call light for 113 minutes 51 seconds at 7:50 PM; 11/8/19 bed call light at 10:36 PM for 171 minutes 27 seconds; 11/8/19 bed call light for 415 minutes 54 seconds; 11/10/19 bed call light at 12:31 PM for 195 minutes 12 seconds; and 11/10/19 bed call light at 4:35 AM for 414 minutes 15 seconds. An interview on 11/13/19 at 11:30 AM with LPN-A (Licensed Practical Nurse) revealed call light times continue to be long. Staff try their best to answer the call lights. An interview on 11/13/19 at 5:50 PM with the ADM (Administrator) revealed that when call light logs are reviewed the average response time was what was analyzed because of the number of call light activations and not the length of the call light. The facility informs staff to answer the call light as soon as they can. Review of the call light policy: Call Lights: Accessibility and Timely Response states the purpose of this policy was to assure the facility was adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. The policy goes over an explanation of the system and that all staff member who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. The policy does not give an expectation or guidelines to how soon the call light should be answered. There was no definition of what an appropriate timely response was for the staff to follow.",2020-09-01
6420,LYONS LIVING CENTER,285301,1035 DIAMOND STREET,LYONS,NE,68038,2018-05-10,725,E,1,0,2CLY11,"**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 ensure sufficient numbers of staff were available to: 1) monitor the Memory Support Unit (MSU-an enclosed wing or hallway which specializes in care of residents with dementia or [MEDICAL CONDITION]) in order to protect Resident 2 and Resident 10 from Resident 1 who displayed adverse sexual and threatening behaviors; 2) provide bathing assistance for Residents 1 and 2; and 3) provide transfer assistance for Resident 6. The sample size was 14 and the facility census was 23. Findings are: A. Review of Resident 1's Nursing Progress Notes dated 3/19/18 at 3:00 AM revealed the resident was found in the resident's room with Resident 2. Resident 2 was seated on the side of the bed and Resident 1 was on knees, in an inappropriate position between Resident 2's legs. Both residents were covered with a blanket. The residents were immediately separated and the Director of Nurses was notified of the incident. Review of Time Card Report for Improve Care Management (record of staff on duty) dated 3/19/18 revealed there were 3 staff on duty during the night of 3/19/18 at the time of the incident between Resident 1 and Resident 2 at 3:00 AM. Staff were 1 Licensed Practical Nurse (LPN)-Q and 2 Nursing Assistants (NA)-P and NA-R. B. Review of a facility investigation dated 4/26/18 revealed on 4/21/18 at 11:58 AM, staff entered a vacant room on the MSU and found Resident 1 and Resident 2 with their pants down and perineal areas fully exposed. Resident 1 was holding Resident 2 in a bent over position and Resident 2's torso was on the bed. Resident 1 was attempting to have anal sex with Resident 2. Resident 2 appeared frightened and Resident 1 was resistive when staff attempted to remove the resident from the situation. Review of the Nurse Staff Posting (a list of staff on duty) dated 4/21/18 (Saturday) revealed 4 staff (LPN-A, NA-O, NA-S and Agency NA-T) were on duty at the time of the incident between Resident 1 and Resident 2 on 4/21/18 at 11:58 AM. Agency NA-T was the 1 staff person assigned to work in the MSU that day. C. Review of staff documentation related to 15 minute checks of the residents on the MSU revealed at 9:30 AM on 5/2/18, Resident 1 drew back a fist and threatened to punch Resident 10. At 11:00 AM on the same day, Resident 1 came down the hallway toward Resident 10 with fists drawn. Review of the Daily Assignment Sheet (a list of staff on duty including assigned work areas) dated 5/2/18 revealed 1 staff (NA-O) was assigned to work on the MSU on 5/2/18. D. Observations of the MSU on 5/7/18 from 9:00 AM to 12:30 PM revealed the following: -9:07 AM Resident 1 was lying on the resident's bed with eyes closed. Resident 10 entered the resident's room and stood next to Resident 1's bed. -9:11 AM NA-B entered Resident 1's room and led Resident 10 away from Resident 1's bed. NA-B assisted Resident 10 to the bathroom in Resident 10's room. NA-B closed the door to Resident 10's room while assisting the resident with toileting. NA-B was unable to visualize Resident 1 and Resident 2 and no other staff was available on the unit. -9:11 AM Resident 2 ambulated out of the dining room and into Resident 1's room and closed the door. -9:11 AM to 9:22 AM Resident 1 and Resident 2 remained in the room with the door closed. NA-B remained in Resident 10's room with the door closed. -9:22 AM NA-B exited Resident 10's room and looked in the dining room and then in the corridor for Resident 2. NA-B opened the door to Resident 1's room and assisted Resident 2 out of the room. NA-B closed Resident 1's room door. NA-B led Resident 2 to the Living Room area and placed a movie on the television for Resident 2 to watch. -9:22 AM Resident 10 entered Resident 1's room and closed the room door. -9:25 AM Resident 10 opened the door to Resident 1's room but remained in the doorway of the room. Resident 10 glanced up and down the corridor, re-entered Resident 1's room and again closed the room door. NA-B remained in the Living Room with Resident 2. No other staff was available on the Memory Support Unit to monitor the residents. -9:29 AM, NA-B approached Resident 10's room and when unable to locate Resident 10, opened the closed door to Resident 1's room. Resident 10 was again assisted out of Resident 1's room and was taken into the Living Room to watch a movie with Resident 2. -9:30 AM to 12:30 PM NA-B was the only staff member working on the Memory Support Unit. E. During an interview on 5/7/18 from 1:30 PM to 2:00 PM, NA-B identified the following: -when Resident 1 was re-admitted on [DATE] the MSU was to be staffed with 2 NAs. However, the facility is short staffed and after the first couple of days, there has never been more than 1 NA at a time scheduled on the unit; -staff are to complete and document every 15 minute checks on Resident 1, Resident 2 and Resident 10. These are the only residents on the unit; -staff have been instructed to keep Resident 2 and Resident 10 out of Resident 1's room. However, both residents try repeatedly each day to gain access and it takes up the whole day just redirecting the residents; -Resident 2 requires 1-2 staff for an every 2 hour check and change schedule for incontinence; -Resident 10 requires cues and assistance every 2 hours for toileting and incontinence cares; and -when assisting Resident 2 or Resident 10 with cares, there is no one available to monitor the remaining residents to assure no abuse. F. During an interview on 5/7/18 from 2:00 PM to 2:30 PM the Provisional Administrator confirmed when Resident 1 was readmitted to the MSU the facility was to ensure 2 staff were scheduled at all times. Staff were to conduct and document every 15 minute checks on the residents. Even with use of several Staffing Agencies the facility has been unable to schedule 2 staff at all times for the unit as not enough staff available. G. Review of Resident 1's Bathing Documentation from 2/27/18 through 5/6/18 revealed 2 baths weekly were not provided as evidenced by the following: -No bath was provided from 2/27/18 until 3/8/18 (9 days); -No bath was provided from 3/8/18 until 3/15/18 (1 week); -No bath was provided from 3/15/18 until 3/27/18 (12 days); -No bath was provided from 3/27/18 until 4/16/18 (20 days); and -No bath was provided from 4/16/18 until 5/3/18 (17 days). During an interview on 5/10/16 at 8:30 AM, Bath Aide (BA)-C confirmed the residents on the MSU were to be offered 2 baths each week. However, residents did not receive baths as scheduled due to ongoing concerns with staffing. H. Review of Resident 2's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/7/18 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident required extensive assistance with activities of daily living and was totally dependent with bathing. Review of Resident 2's current Care Plan (undated) revealed the resident was scheduled to receive a bath 2 times weekly on Sunday and Wednesday. Review of Resident 2's Bathing Documentation (record of baths given) from 2/7/18 through 5/6/18 revealed 2 baths weekly were not provided as evidenced by the following: -No bath was provided from 2/21/18 until 3/7/18 (2 weeks); -No bath was provided from 3/14/18 until 3/21/18 (1 week); -No bath was provided from 3/28/18 until 4/8/18 (10 days); and -No bath was provided from 4/15/18 until 4/22/18 (1 week). I. Review of Resident 6's current undated Care Plan revealed the resident transferred with the full body lift and 2-3 staff members. Review of a Progress Note dated 3/24/18 at 5:17 AM revealed Resident 6 had been having behaviors since 3:00 AM (2 hours and 17 minutes prior). Further review revealed the resident wanted to get up. The staff member explained to the resident that it was 3:00 AM and the other staff were completing rounds. The resident then put on the call light and informed the nurse that the resident wanted to get up. The resident then continued to pull the call light. There was no evidence to indicate the resident was assisted out of bed. Interview with Registered Nurse-L on 5/10/18 at 9:08 AM revealed the overnight shift was staffed with either 1 Nursing Assistant (NA) and 1 Nurse or 2 NA's and 1 Nurse. Further interview confirmed Resident 6 required 2 staff members and the full body lift for transfers.",2019-03-01
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
4465,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2018-09-25,725,E,1,1,YIK212,"**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 sufficient nursing staff to ensure medications were administered within the required time frames for 2 (Resident 340 and 350) of 7 sampled residents and failed to ensure 1 (Resident 42) of 1 sampled residents was toileted to prevent incontinency. The facility staff identified a census of 58. Findings are: [NAME]Record review of Resident 340's MAR for (MONTH) (YEAR) revealed Resident 340 was to receive [MEDICATION NAME]-[MEDICATION NAME] (anti Parkinson medication) 25/100 milligrams (mg) twice a day in the AM and Lunch and Ropinirole (anti Parkinson medication) 0.25 mg's in the AM, lunch and evening. Observation on 11-13-2018 at 2:07 AM revealed MA B administered the [MEDICATION NAME]-[MEDICATION NAME] and the Ropinirole medications to Resident 340. On 11-13-2018 at 2:16 PM an interview was conducted with MA B. MA B confirmed Resident 340's medications were given late. B. Observation on 11-14-2018 at 9:50 AM with Licensed Practical Nurse (LPN) A revealed Resident 42 was in bed. LPN A explained to Resident 42 the need to observe buttock areas. LPN A unfasten and pulled down Resident 42's adult brief revealed Resident 42 had a strong odor of urine and the adult brief was saturated through onto the bed sheet. LPN A removed the soiled brief, cued Resident 42 to use a walker and assisted Resident 42 into the bathroom. On 11-14-2018 at 9:50 AM an interview was conducted with LPN [NAME] During the interview LPN A confirmed Resident 42's adult brief was saturated through onto the bed sheet and confirmed Resident 42 had a strong odor of urine. LPN A reported staff were busy right now.",2020-06-01
1397,LIFE CARE CENTER OF ELKHORN,285134,20275 HOPPER STREET,ELKHORN,NE,68022,2018-10-11,741,E,1,0,PGI211,"**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 staff failed to ensure sufficient staffing for the provision of medications for 5 (Resident, 2,4,5,6 and 8) of 6 residents reviewed for medication administration. The facility staff identified a census of 99. Findings are: [NAME] Record review of Physician order [REDACTED]. -Xarelto (anticoagulant)10 milligrams (mg), 1 table by mouth daily. -Calcium with Vitamin D (supplement) 500/200 mg, 1 by mouth twice a day. -Fludrocortisone (steroid) 0.1 mg , 1 table by mouth daily. -Senna 8.6 mg, give 2 tabs by mouth daily. -Occuvite (vitamin),1 capsule daily. -[MEDICATION NAME] (anticonvulsant), 300 mg by mouth 2 times a day. Observation on 10-10-2018 at 10:20 AM revealed Registered Nurse (RN) D administered the medications to Resident 4. On 10-10-2018 at 10:30 AM an interview was conducted with RN D. During the interview RN D confirmed Resident 4's medications were late. RN D reported during the interview that it was difficult to get all the medication done on time due to the cares of the residents. B. Observation of a medication administration for Resident 2 on 10/10/2018 at 12:26 revealed RN A completed an accucheck for Resident 2 with results of 257. Review of Resident 2 MAR (Medication Administration Record) revealed that Resident 2 was to receive 10 Units of [MEDICATION NAME] Insulin before meals. Further observation of medication pass revealed that RN A was unable to administer insulin as ordered due to insulin being unavailable for Resident 2. Interview with RN A confirmed that the order was to give Resident 2 10 Units of [MEDICATION NAME] Insulin and the Insulin was unavailable. C. Observation of the Medication administration on 10/10/2018 at 09:30 AM-10:10 AM with Licensed Practical Nurse (LPN) A revealed LPN A administered the following medications to Resident 5: -Stool Softener 100 mg 1 tablet. -Bactrim DS (an antibiotic) 800 mg 1 tab. -[MEDICATION NAME] (a medication for high blood pressure) 12.5 mg 1 tab. -[MEDICATION NAME] (a medicine for digestive health) 1 cap. -[MEDICATION NAME] 325 mg 2 tabs. Review of Resident 5's PO signed on 8-2-2018 revealed the medications were ordered for 8:00 AM. Interview with LPN A on 10/10/2018 at 11:00 AM confirmed Resident 5's medications were ordered for 8:00 AM and were given late. D. Observation of the medication administration on 10/10/2018 at 09:45 AM-10:10 AM with LPN A revealed LPN A administered the following medications to Resident 6: -Fish Oil 1000 mg 2 tabs. -Galantamine (a medication used for Alzheimer's) 24 mg 1 tab. -Refresh Eye drops 1 drop each eye. -Senna (a medication used for constipation) 8.6 mg 3 tabs. -Oxybuytin (a medication used for overactive bladder) 10 mg 1 tab. -[MEDICATION NAME] (a medication used for [MEDICAL CONDITION]) 300 mg 1 tab. -Clearlax (a medication used for constipation) 17 gm 1 capful. Review of Resident 6's PO dated 8-29-2018 revealed the medications were ordered for 8:00 AM. Interview with LPN A on 10/10/2018 at 11:00 AM confirmed Resident 6's medications were ordered for 8:00 AM and were given late. E. Observation on 10-10-2018 at 10:25 AM revealed Resident 8 received the following medications by Certified Medication Assistant (CMA) B: -[MEDICATION NAME] (a medication for diabetes) 5 mg 1 tab. -[MEDICATION NAME] (a medication used for enlarged prostate) 1 tab. -[MEDICATION NAME] (medication used to reduce extra fluid) 10 mg 1 tab. -Eplerenone (medication used for high blood pressure) 25 mg 1 tab. -[MEDICATION NAME] (medication used for irregular heart rate) 200 mg 1 tab. -Carvedilol (medication used to treat heart failure) 12.5 mg 1 tab. -[MEDICATION NAME] (medication used to treat chest pain) 30 mg 1 tab. -Folic Acid 1 mg 1 tab. -Vitamin B 12 1 tab. -Aspirin 81 mg 1 tab. -[MEDICATION NAME] (a stool softener) 100 mg 1 tab. -Iron 325 mg 1 tab. Review of Resident 8's PO dated 9-17-2018 revealed the medications were ordered for 8:00 AM. Interview with CMA B on 10/10/2018 at 10:45 confirmed Resident 8's medications were ordered for 8:00 AM and they were given late. Record review of the Facility Assessment (FA) (a facility tool used to define services and resources for the facility residents) revealed the FA did not define the minimum nursing staff to provide care and services that would have included the administration of medications to the facility residents within the required time frames. Cross reference to F759, F760 and F732",2020-09-01
6233,O'NEILL OPERATIONS LLC,285108,"PO BOX 756, 1102 NORTH HARRISON",O' NEILL,NE,68763,2016-05-04,353,E,1,0,OPK411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observations, record review, and interviews; the facility failed to provide sufficient staff on the Alzheimer's Care Unit (ACU-an enclosed wing or hallway which specializes in care of residents with dementia or [MEDICAL CONDITION]) to provide monitoring and supervision to prevent ongoing falls for Resident 8 and to protect Residents 2, 3, 4 and 10 from other residents with adverse behaviors. Facility census was 69. Findings are: A. Review of Resident 8's Nursing Progress Notes revealed the following: -4/3/16 at 6:36 PM- The resident had been self-propelling the wheelchair out to the dining room and the resident had been leaning forward in the chair. The resident was then found seated on the floor in front of the wheelchair. -4/4/16 at 6:56 AM- The resident attempted to self-transfer from the bed to the wheelchair and fell , hitting head on a trash receptacle at bedside. The note further identified the resident was non-compliant with calling for staff assistance with transfers. 4/5/16 at 3:15 PM- The resident was in the resident's room seated in the wheelchair without foot pedals in place. While self-propelling the wheelchair, the resident got feet too far underneath of the wheelchair and fell forward onto knees. -4/23/16 at 7:10 AM- The resident was found on the floor of the resident's room. The resident indicated the resident had been attempting to dress self. -4/26/16 at 11:00 PM- The resident was seated in the wheelchair in the resident's room and was self-propelling about the room. At 11:15 PM staff heard a loud noise and the resident was found on the floor in front of the wheelchair by the bathroom door. During an interview on 5/3/16 at 5:00 AM, Licensed Practical Nurse (LPN)-A confirmed Resident 10 was at high risk for falls. LPN-A identified the resident was to be visually observed every 15 minutes due to repeated falls related to the resident leaning forward in the wheelchair and the resident's non-compliance with fall prevention interventions. In addition, the resident had received a new wheelchair and the resident was to have foot pedals in place to the chair and a pillow propped on the resident's right side to prevent the resident from leaning forward. LPN-A further identified due to staffing concerns it was difficult to complete the 15 minute checks and to assure fall prevention interventions were in place. During observations of Resident 8 the following were noted: -5/3/16 at 10:00 AM- The resident was seated in a wheelchair in the Family Room of the Alzheimer Care Unit (ACU-an enclosed wing or hallway which specializes in care of residents with dementia or [MEDICAL CONDITION]) playing the keyboard piano. The resident was leaning forward to reach the keyboard and no wheelchair pedals and no pillow were in place to the wheelchair to assure proper positioning to prevent falls. No staff were present in the Family Room -5/3/16 from 10:30 AM to 11:15 AM- The resident remained seated in the wheelchair without benefit of a pillow propped on the right side of the chair and without foot pedals. Resident 10 was self-propelling the chair in the corridor of the ACU. Nursing Assistant (NA)-I walked by the resident in the corridor but did not stop to adjust the resident's positioning in the chair. -5/3/16 at 12:35 PM- The resident was positioned at the Dining Room table on the ACU in a wheelchair. No foot pedals and no pillow were in place to the wheelchair. B. Review of facility investigation dated 1/18/16 revealed at 9:00 PM Resident 4 was ambulating in the Alzheimer's Care Unit corridor and when Resident 4 passed Resident 2, Resident 4 grabbed Resident 2's breast. Resident 2 responded by hitting Resident 4's arm with the back of Resident 2's right hand. The following steps were then taken to protect the residents: -The residents were immediately separated and provided with one to one (1:1) and redirection. -Resident 4 was placed on every 15 minute visual checks. -Medication review by Resident 4's primary physician. Review of facility investigation dated 2/17/16 at 8:00 PM revealed Resident 4 was in the resident's room and in bed. Resident 3 had entered Resident 4's room and had attempted to pull Resident 4 out of bed. Immediate steps taken to protect the residents included the following: -The Resident 3 was removed from Resident 4's room and provided with 1:1. -Staff members to continue completion of dementia training videos. Review of facility investigation dated 4/18/16 at 8:30 PM revealed Resident 4 was ambulating in the ACU corridor when Resident 2 backed a wheelchair into Resident 4. Resident 4 then struck Resident 2 with an open hand and began pulling at Resident 2's hair and shirt in an attempt to remove Resident 2 from the wheelchair. The following steps were then taken to protect the residents: -Residents were immediately separated. -1:1 with both residents to decrease their level of agitation. -Medication review on both residents. -Staff education provided on response to behaviors. -Staffing patterns reviewed and then adjusted to assure consistent staffing on the ACU. Review of facility investigation dated 4/29/16 at 7:45 PM revealed Resident 2 was self-propelling wheelchair in the ACU corridor and passed by Resident 10 who was also in the corridor in a wheelchair. The residents wheelchairs collided and Resident 2 then struck Resident 10 on the left hand and leg with an open hand. Preventative measures put into place by the facility included the following: -Residents were separated immediately by the staff. -Medication review planned for Resident 2 due to agitation. -Staffing review completed. Facility to continue to work on recruitment of new staff and scheduling of the most appropriate staff on the ACU. -Resident 2 to be offered finger foods when agitated to assure agitation not related to hunger due to recent poor intakes. -Resident 10 to be placed in a recliner in the afternoons to prevent behaviors. Observations on 5/3/16 of the ACU revealed the following: -10:00 AM- Residents 2 and 4 were seated in wheelchairs next to each other in the corridor directly outside of the Library Room of the ACU. Resident 4 was seated in a recliner inside of the Library and within direct visualization of Residents 2 and 4. Resident 3 was seated on a sofa directly across the room from Resident 4. No activities were available in the ACU for the residents during this time. -From 10:00 AM to 10:20 AM- No staff were available to provide direct monitoring of the residents in the ACU Library Room and/or the ACU corridor. -From 3:00 PM to 3:30 PM- Resident 4 was seated in a recliner and Resident 3 was seated on a sofa directly across from Resident 4 in the Library Room of the ACU. No activities were offered at this time. No ACU staff were available to provide direct monitoring the residents in the ACU Library Room. During an interview with the ACU Coordinator on 5/3/16 from 7:00 PM to 7:30 PM, the ACU Coordinator confirmed from 1/18/16 through 4/29/16 there had been a total of 5 resident to resident altercations involving Residents 2, 3, 4, and 10. The ACU Coordinator verified Residents 3 and 4 were currently on every 15 minute visual checks due to aggressive behaviors toward other residents. The ACU Coordinator further verified due to staffing concerns it was difficulty to complete the 15 minute visual checks and to provide the residents with activities and redirection to prevent adverse behaviors. C. Interview with the Assistant Director of Nurses (ADON) on 5/4/16 from 12:00 PM to 12:30 PM revealed staffing patterns for the facility were identified on the daily nurse staff posting. The ADON verified there were 13 residents currently residing in the ACU and the direct care staffing pattern for the ACU was: -2 Nurse Aides from 6:00 AM until 2:00 PM -2 Nurse Aides from 2:00 PM until 10:00 PM -1 Nurse Aide from 10:00 PM to 6:00 AM Review of the daily nurse staff postings from 4/1/15 through 5/3/16 revealed there was only 1 NA assigned to work the 6:00 AM until 2:00 PM shift in the ACU on 15 out of 33 days, only 1 NA to work the 2:00 PM to 10:00 PM shift 30 out of 33 days and only 1 NA to work the 10 PM to 6:00 AM shift on 23 out of 33 days. Interview with the ADON on 5/4/16 from 12:00 PM to 12:30 PM confirmed all shifts had not been covered in accordance with the daily nurse staff posting.",2019-05-01
4916,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2018-04-03,725,D,1,0,F6ND11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on record review and interview, the facility failed to provide nursing staff for the provision of baths/showers for Residents 2 and 3. 3 of 3 confidential resident interviews and 1 confidential family interview voiced concerns that there was not enough nursing staff available to meet the resident's needs. The sample size was 8 and the facility census was 35. Findings are: [NAME] 3 of 3 confidential resident interviews and 1 confidential family interview conducted on 4/3/18 from 9:00 AM until 3:00 PM voiced concerns that there was not enough nursing staff available to meet their needs. 2 of the 3 residents commented at times there was only 1 Nurse Aide (NA) on duty and further indicated this has occurred on all shifts. B. Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/9/18 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident required extensive staff assistance with bathing. Review of Resident 3's current Care Plan dated 11/25/17 revealed the resident was totally dependent on staff for assistance with bathing and was to receive a bath 2 times a week. Review of Bathing Documentation (paper record of baths provided daily) and Point of Care Audit Report (electronic record of baths provided daily) from 3/1/18 through 4/3/18 revealed Resident 3 did not receive 2 baths a week. Documentation indicated baths were provided on (MONTH) 5, 14 and the 29th (a total of 3 out of 10 baths that were to have been provided). C. Review of Resident 2's MDS dated [DATE] revealed the resident had no cognitive impairment and was totally dependent with bathing. Review of Resident 2's current Care Plan with revision date 10/20/17 revealed the resident was totally dependent on staff to provide a bath 2-3 times a week. The care plan further identified the resident's preference was to be bathed on Monday, Wednesday and Friday. Review of Bathing Documentation from 3/1/18 through 4/3/18 revealed Resident 2 received a bath/shower on (MONTH) 12th, 19th, 22, and 29 (a total of 4 out of 13 baths that were to have been provided). Interview with Resident 2 on 4/3/18 at 2:30 PM confirmed the resident did not receive 3 bath/showers a week and had to get by with just 1 a week usually. D. Interview with the Director of Nursing (DON) on 4/3/18 revealed the facility staffing pattern from 6:00 AM to 6:00 PM included: 1 Licensed Nurse as Charge Nurse, 1 Medication Aide (MA) or Licensed Nurse passing medications, 2 NA and 1 Bath Aide on Monday through Friday. On Saturday and Sunday the facility operated with 1 Charge Nurse and 1 Licensed Nurse or MA and 2 NA on the day shift as there was not a BA scheduled. The staffing pattern from 6:00 PM to 6:00 AM was 1 Nurse and 2 NA through 10 PM then only 1 NA from 10PM to 6 AM. The DON identified the full time bath aide had walked out without notice in (MONTH) of (YEAR) and the facility continued to struggle with staffing at times.",2020-03-01
4912,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2018-02-05,725,E,1,0,15YY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on record review and interview, the facility failed to provide nursing staff to provide toileting plans/assistance for Residents 7 and 27 and provision of baths/showers for Residents 18 and 34. 3 of 4 confidential resident interviews and 1 confidential family interview voiced concerns that there was not enough nursing staff available to meet the resident's needs. The sample size was 4 and the facility census was 36. Findings are: [NAME] 3 of 4 confidential resident interviews and 1 confidential family interview conducted on 2/5/18 from 10:30 AM until 3:00 PM voiced concerns that there was not enough nursing staff available to meet their needs. 1 resident commented at times there was only 1 Nursing Assistant on duty during the night shift and That is not enough. Another confidential resident interview stated there was not enough staff and the resident had to wait up to 30 minutes at times for staff to take the resident to the bathroom. B. Interview with the Administrator on 2/5/18 revealed the facility staffing pattern from 6:00 AM to 2:00 PM included: 1 Nurse, 2 Nursing Assistants (NA) and 1 Bath Aide on Monday through Friday. On Saturday and Sunday the facility operated with 1 Nurse and 2 NA on the day shift as there was not a BA scheduled. The staffing pattern from 10:00 PM until 6:00 AM was 1 Nurse and 2 N[NAME] C. Review of the Daily Deployment Sheet (nursing schedule) dated 1/25/18 revealed the following: -The BA and 1 NA worked from 6:00 AM to 2:00 PM and 1 NA worked from 6:00 AM to 9:00 AM (which left 5 hours not covered by a NA); -1 Nurse and 1 NA (instead of 2 NA) worked from 10:00 AM until 6:00 AM. D. Review of a list provided by the facility on 2/5/18 which identified the number of residents who required assistance with transfers revealed the following: -3 residents required the use of the sit to stand lift (a mechanical device used to support the resident to a standing position); -9 residents required the use of a full mechanical lift (a lift that totally lifts dependent residents); -3 residents required the assistance of 2 staff members; -4 residents required the assistance of 1 staff member; and -17 residents were independent (19 of 36 residents required assistance with transfers). E. Review of Resident 18's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/8/17 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was totally dependent with bathing. Review of Resident 18's current Care Plan (undated) revealed the resident preferred a bath every day, Monday through Friday (5 days per week), per family request. Review of Bathing Documentation (paper record of baths provided daily) and Point of Care Audit Report (electronic record of baths provided daily) from 1/1/18 through 2/5/18 revealed Resident 18 did not receive 5 baths weekly. Documentation indicated baths were provided on (MONTH) 4, 6, 7, 8, 10, 11, 12, 16, 17, 18, 19, 24, 26, 31, (YEAR) and (MONTH) 1,2 and 5, (YEAR) (a total of 17 out of 26 baths that were to have been provided). Interview with Nursing Assistant (NA)-A on 2/510/18 at 10:50 AM revealed Resident 18 was scheduled to receive 5 baths per week on Monday through Friday. NA-A confirmed Resident 18 did not always receive 5 baths per week due to staffing shortages. F. Review of Resident 34's MDS dated [DATE] revealed the resident had no cognitive impairment and was totally dependent with bathing. Review of Resident 34's current Care Plan (undated) revealed the resident was totally dependent on staff to provide a shower once a week and as necessary. Review of Bathing Documentation from 1/1/18 through 2/5/18 revealed Resident 34 did not receive a bath/shower from 1/18/18 until 2/1/18 (2 weeks). Interview with Resident 34 on 2/5/18 at 3:00 PM confirmed the resident went 2 weeks without a bath/shower recently. [NAME] Review of Resident 7's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 12/28/17 revealed the following: -severe cognitive impairment; -required extensive assistance with toileting; -had no falls since the previous assessment; -was occasionally incontinent of urine; and -a toileting program had not been attempted. Review of Progress Notes dated 12/30/18 at 6:18 PM revealed a staff member witnessed Resident 7 exiting the bathroom independently. The resident's pants were around the resident's ankles and the staff member assisted the resident. Review of Progress Notes from 1/1/18 through 1/10/18 revealed Resident 7 remained non-complaint in waiting for assistance with transferring and toileting as evidenced by the following: -1/1/18 at 4:45 PM- .Not always compliant with wait for assist, takes self to the bathroom; -1/4/18 at 1:21 PM- .has been incontinent of bowel and bladder; -1/6/18 at 2:10 AM- .Reminded to ask for assistance and reoriented to call light. Pt. (patient) self transferred several times this shift .Up several times this evening wandering in halls .Limited assist of 1 with ADL's (activities of daily living) and toileting; and -1/10/18 at 6:38 PM-The resident was not always compliant with waiting for assistance and did not make needs known consistently. Review of a Bladder Incontinence Data Collection/Evaluation dated 1/11/18 revealed Resident 7 had a history of [REDACTED]. Documentation indicated the resident was not consistently able to communicate the urge to urinate and 2 assists were required to transfer the resident to the toilet. There was no evidence Resident 7 was assessed or provided with a toileting program or a scheduled toileting plan. H. Review of Resident 27's current undated Care Plan revealed the resident had bladder incontinence related to confusion and impaired mobility. Interventions include toileting Resident 27 upon waking in the morning, before and after meals, and before bed (approximately 8 times per day). Review of Resident 27's Task documentation dated 1/23/18 through 2/5/18 revealed documentation of the resident's toileting was completed only 1-2 times daily. Interview with Registered Nurse-G on 2/5/18 at 1:30 PM confirmed Resident 27 was on a toileting program and should have been taken to the bathroom upon waking in the morning, before and after meals, and before bed. Interview with NA-B on 2/5/18 at 1:57 PM confirmed Resident 27 was not taken to the bathroom before lunch on 2/5/18. NA-B went on to indicate the resident could be transferred from the bed to the wheelchair by 1 staff member, but needed 2 staff members and the use of the sit to stand lift (a mechanical device used to support the 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 transfer to the bathroom. NA-B stated Resident 27 was not taken to the bathroom before lunch because there was not another staff member available to assist with the sit to stand lift.",2020-03-01
6676,CAREAGE CAMPUS OF CARE,285135,811 EAST 14TH STREET,WAYNE,NE,68787,2015-11-17,353,E,1,0,KXTF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on record review and interview, the facility failed to to provide nursing staff to meet residents' needs related to: 1) 4 of 5 confidential resident interviews voiced concerns regarding lack of staff; 2) lack of bathing in accordance with weekly bath schedules for Residents 3, 6, 7, 1 and 2; and 3) on-going family and/or resident concerns voiced through grievances and/or Resident Council meetings regarding call light response times and failure to provide scheduled baths. Facility census was 41. Findings are: A. Four residents voiced concerns regarding insufficient nursing staff during confidential interviews conducted on 11/17/15 from 9:00 AM until 10:30 AM. Comments included the following: -at times they are exceedingly short and mostly at night; -scheduled for 2 baths a week and getting them almost once a week; and -have to wait a long time for call lights to be answered and to receive medications. B. Review of Bath Schedules (not dated) and Bath Documentation from 10/1/15 through 11/16/15 revealed Residents 3, 6, 7, 1 and 2 were not receiving the scheduled 2 baths weekly, Residents 6 and 7 went 11 days between baths, Resident 1 went 12 days between baths, and Resident 2 went 8 days and 9 days between baths. C. Review of the Grievance Resolution Forms dated 4/7/15 through 11/3/15 revealed the following: -5 residents and/or family members voiced concerns regarding the length of time it took for staff to respond to call lights; and -4 residents and/or family members voiced concerns that baths were not provided as scheduled. D. Review of monthly Resident Council Meeting Minutes revealed the following: -4/10/15 - taking too long to answer call lights; -5/8/15 - left in bathroom [ROOM NUMBER] minutes; -6/15/15 - wait too long to go to bathroom, call light not in reach, and baths not happening as scheduled; -7/10/15 - call light not within reach for 1 resident, and bath issues not resolved; -8/14/15 - call lights on for a long time and baths continue to be a problem; -9/11/15 - call lights on for a long time, 15 to 25 minutes, and baths continue to be a problem; -10/9/15 - call lights not being answered and baths not getting done; and -11/13/15 - bath issues not resolved. E. During interview on 11/17/15 from 1:35 PM until 2:00 PM, the Administrator verified the facility was challenged with providing sufficient nurse staffing.",2018-11-01
1485,"PREMIER ESTATES OF PIERCE, LLC",285139,"P O BOX 189, 515 EAST MAIN STREET",PIERCE,NE,68767,2017-10-11,157,D,1,1,3PT811,"**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 medical practitioner of 1) a change in condition for Resident 1 and 2) blood pressure readings as ordered by the practitioner for Resident 34. The facility identified a census of 31 and 24 residents were sampled. Findings are: [NAME] Review of Resident 34's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/11/17 revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of a Change in Condition facsimile (fax) dated 7/18/17 revealed an order for [REDACTED]. Review of Resident 34's medical record revealed no evidence the blood pressure readings were faxed to the resident's physician. Interview with the Director of Nursing (DON) on 10/10/17 from 3:30 PM to 3:45 PM confirmed Resident 34's physician had not been notified regarding the resident's blood pressure readings. B. Review of the facility policy titled Clinical Change in Condition Management dated 6/2015 indicated daily observations were important to identify and manage a resident experiencing a change in condition. Observations were to include participation in daily routines, physical assessment (such as cardiovascular, respiratory mental status, and neurological), behavior, mobility, comfort level, and response to medications. Further review indicated the physician should be contacted and provided clinical data and information about the resident's condition. Review of Resident 1's Progress Notes revealed the following: - On 5/15/17 at 10:05 AM, the resident was transferred to the hospital; - On 5/19/17 at 2:45 PM, the resident was readmitted to the facility from the hospital; - On 5/19/17 at 5:49 PM, an order was entered for [MEDICATION NAME] (an antibiotic medication) 2 times daily for a total of 4 administrations; - On 5/19/17 at 11:25 PM, the resident was up in a motorized wheelchair until 9:30 PM and was then assisted to bed; - On 5/20/17 at 3:15 AM, the resident requested a [MEDICATION NAME] (a combination of medications which are inhaled to assist with breathing) treatment for [REDACTED]. The resident also voiced prior to going to bed, I just don't feel right and complained of feeling disorientated and confused; - On 5/20/17 at 9:50 AM, the resident requested a [MEDICATION NAME] treatment for [REDACTED]. - On 5/20/17 at 6:28 PM, the resident requested a [MEDICATION NAME] treatment for [REDACTED]. - On 5/20/17 at 10:00 PM, the resident was very warm to touch with a temperature of 104.3 degrees Fahrenheit. The resident's pulse was strong and rapid at 104 beats per minute. The resident was given Tylenol (a medication used to treat pain and/or an elevated temperature). The resident was having difficulty swallowing and complained of a sore throat. The resident was alert and confused and had not been up that shift; - On 5/21/17 at 2:20 AM, a summary was entered which stated at midnight the resident had a temperature of 102.9 (after Tylenol administration) and the resident was restless. At 1:30 AM, the nurse entered the room to find the resident unresponsive, Cardio-Pulmonary Resuscitation was initiated and 911 was called; -There was no evidence to indicate Resident 1's change in condition was identified and no evidence to indicate the physician was notified of the resident's change in condition prior to the resident becoming unresponsive. During an interview on 10/5/17 at 2:12 PM the DON confirmed there was no evidence to indicate Resident 1's physician had been contacted regarding the resident's change in condition prior to the resident becoming unresponsive at 1:30 AM on 5/21/17.",2020-09-01
4269,HILLCREST SHADOW LAKE,2.8e+300,1507 E GOLD COAST ROAD,PAPILLION,NE,68046,2017-08-14,157,D,1,1,728T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a Based on record review and interview; the facility staff failed to notify the physician that medications were not given for 1 (Resident 95) of 5 sampled residents. The facility staff identified a census of 102. Findings are: Record review of a physician's orders [REDACTED]. [MEDICATION NAME] (medication used for hypertension) 6.25 milligrams (mg), twice a day with meals. Moxifloxacin 0.5% (antibiotic) eye drop. [MEDICATION NAME]6 units three times a day. [MEDICATION NAME] (steroid) 1% eye drop four times a day. [MEDICATION NAME] (controls phosphorus blood levels) 800 mg three times a day. Review of Resident 95's Medication Administration Record [REDACTED] [MEDICATION NAME] was not given 2 times. [MEDICATION NAME]was not given 6 times. [MEDICATION NAME] AC 1% Eye Drop not given 2 times. Moxifloxacin 0.5% Eye Drops not given 2 times. [MEDICATION NAME] 800 mg was not given 5 times. Review of the physician's orders [REDACTED]. On 8 10 (YEAR) at 9:20 AM, an interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed there was not an order to hold the medication and further confirmed Resident 95's physician had not been notified of the medications were not given.",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
5684,"PREMIER ESTATES OF KENESAW, LLC",285166,"P O BOX 10, 100 WEST ELM AVENUE",KENESAW,NE,68956,2016-10-05,157,D,1,0,ZLX211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on interviews and record review, the facility failed to notify the resident's physician of a change in condition for 1 resident (Resident 1). This had the potential to affect 1 of 5 sampled residents (Resident 1). The facility census was 46. Findings are: A. Review of Resident 1's face sheet revealed [DIAGNOSES REDACTED]. Review of the facility progress notes, that painted a picture of the resident, revealed Resident 1's physician was not notified of a change in condition as follows: -9/24/16 at 6:56 PM, the resident was pocketing food and took 2 bites in 30 minutes. -9/24/16 at 9:26 PM, the resident was cooperative and pleasant. The foley drained minimal amounts of cloudy yellow urine. The resident was needing more help with ADL's (Activities of daily living) notably weaker, having problems with feeding self and chewing food, and continued to chew food without swallowing. -9/25/16 at 3:24 PM, the resident was confused, speech garbled and unable to form complete sentences. The foley drained amber colored urine. The resident was pocketing food in cheeks and required extensive cues to chew and swallow bites. -9/25/16 at 7:05 PM, the spouse reported resident seemed more confused. -9/25/16, the resident stated smarter than earlier because talked to Mom on the phone. -9/27/16 at 4:32 PM, the resident was confused and lethargic. The foley drained cloudy amber urine with sediment. The resident required 2 assist for transferring and had a poor intake. -9/27/16 3:59 AM, the resident was confused and failed to use the call light. A mechanical lift was used for transfers. The foley drained dark amber and thick sediment urine. - -9/29/16 at 1:30 PM, the foley catheter drained dark/cloudy urine in the bag. The resident required 2 assist with ADL's and transferred with a full lift. -9/30/16 at 8:20 PM, the resident was weaker with increased confusion and delusions. The resident was uncooperative with cares and hit out at staff. The resident spit out medications. -9/30/16 at 8:58 PM resident spit out medications, -10/1/2016 at 8:11 PM, the resident required full lift for transfers. The resident spitting out medication and had a flat affect. The foley drained amber urine. The resident had a appetite poor and would not open mouth. -10/2/16 at 8:45 AM, the resident had a decreased L[NAME] (level of consciousness). The foley drained a small amount of dark cloudy urine. The resident ' s temperature was 100.9. Oxygen saturations on room air was 68% and BP (blood pressure) 89/53. A call was placed to the resident's doctor and the resident was transferred to the hospital at 9:25 AM. Review of the MD'S (Minimum Data Set; a federally mandated comprehensive assessment tool used for care planning) dated 9/16/16, revealed the BIMS (brief interview for mental status) scored 2 out of 15 for cognition (meaning severely cognitively impaired) , bed mobility 3/3 (extensive assist of two persons) , transfer 3/3, locomotion on unit 4/2 (total dependent on one person) , locomotion off unit 4/2, dressing 4/2, eating 3/2 (extensive assist on one person), toilet use 3/3, personal hygiene 4/2, bathing 3/2, catheter, bowel always continent and the resident was at risk for a pressure ulcer. Interview with the DON (Director of Nurses) at 10/5/2016 at 2:31 PM revealed the recommendations were for the staff assessing the resident to document the findings and to notify the doctor when a change in condition occurred. The medical record revealed the resident's doctor was not notified of the change in condition. Review of the facility form entitled Clinical Change in Condition, dated 6/2015 revealed the interdisciplinary team strived to identify and manage all residents that were experiencing a change in condition as follows: -Daily observation and communication was important in identifying changes in a resident that requires further investigation. -Clinical care management included routine assessment, evaluation, response to change in clinical condition and communication with residents /families and/or responsible parties. -Contact the physician and provide clinical data and information about the resident's condition. -Document notification and physician response in the resident medical record. Initiate any new physician orders.",2019-10-01
6015,BEAVER CITY MANOR,285269,"P O BOX 70, 905 FLOYD STREET",BEAVER CITY,NE,68926,2016-07-27,157,E,1,0,VTBH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on interviews and record review, the facility failed to notify the responsible party or the provider when a change in condition occurred with Resident 1 and an injury occurred with Resident 4 . The facility census was 17 at the time of survey. Findings are: A. Review of Resident 1's face sheet revealed an admission date of [DATE] and a discharge date of [DATE]. Confidential interview on 7/27/2016 at 12:40 PM revealed that Resident 1 fell on [DATE] and the responsible party and Resident 1's health care provider were not notified by the facility about the fall or a pressure sore that had developed while Resident 1 was residing in the facility. Review of Resident 1's Departmental Notes dated 4/20/ revealed that Resident 1 slid out of a wheelchair in the dining room at 12:30 PM. There was no documentation that Resident 1's responsible party or health care provider were notified about the fall. Review of Resident 1's Daily Skilled Notes dated 4/23/2016 revealed documentation that Resident 1 had open areas on both buttocks. There was no documentation that Resident 1's health care provider or responsible party were notified about the open areas. B. Review of Resident 4's face sheet revealed an admission date of [DATE]. Review of Resident 4's Departmental Notes dated 5/10/2016 revealed that Resident 4 received a skin tear to the right leg. There was no documentation that Resident 4's health care provider or responsible party were notified about the injury. Review of the facility policy and procedure Notification of change in Resident Status dated 8/9/2007 revealed that it was the policy of the facility to keep families informed of change in resident status and when condition change of a resident was noted, the charge nurse was to complete an assessment and immediately notify the physician. When a condition change was noted during the night shift, and was non-emergent, the day charge nurse was to notify the physician the following morning and the charge nurse was to notify the family or legal representative of all condition changes.",2019-07-01
1054,PRESTIGE CARE CENTER OF PLATTSMOUTH,285104,602 SOUTH 18TH STREET,PLATTSMOUTH,NE,68048,2017-06-07,157,D,1,0,MSQJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on observation, record review and interview; the facility staff failed to notify the physician of skin breakdown for 1 (Resident 3) of 3 residents reviewed and failed to notify the physician of suicidal statements for 1 (Resident 2) of 1 residents reviewed. The facility staff identified a census of 87. Findings are: [NAME] Record review of Resident 3's Comprehensive Care Plan (CCP) printed on 5-18-2017 revealed Resident 3 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of a treatment to Resident 3's buttocks by Registered Nurse (RN) A on 5-11-2017 at 11:00 AM revealed RN A completed the wound care as ordered to Resident buttocks. During the observation of the buttock treatment Resident 3 was observed to have a Band-Aid covering the left knee. The Band-Aid stuck to RN A's elbow as RN A completed the buttocks treatment. Observation of the left knee area revealed an abrasion that measured approximately 3 centimeters roundish. The wound abrasion had a small amount of drainage. Review of Resident 3's medical record revealed there was not evidence the facility staff had informed Resident 3's physician of the wound to Resident 3's left knee. An interview was conducted with RN A on 5-11-2017 at 11:45 AM. During the interview RN A reported that the area to the left knee was new and had not been aware of the wound. RN A reported that Resident 3's physician would need to be notified and further confirmed there was no wound tracking for the wound to the left knee and there should have been monitoring. Review of a Weekly Skin Check sheet dated 5-11-2017 revealed the abrasion had occurred on 5-08-2017. B. Record review of Resident 2's Progress Note (PN) dated 4-05-2017 revealed Resident 2 was over heard talking and saying that Resident 2 would quit taking medications and kill myself. According to the PN dated 4-05-2017 the resident was placed on 15 minute checks. On 5-11-2017 at 11:54 AM an interview was conducted with the facility Director of Nursing (DON). During the interview, the DON confirmed Resident 2's physician had not been notified of the suicidal statements. On 5-11-2017 at 12:15 PM an interview was conducted with the Social service Director (SSD). During the interview the SSD reported that Resident 2's room was checked for items that could be used to self harm. SSD reported that (gender) had discussed with Resident 2 the self harm statements and after evaluating that with Resident 2 felt that Resident 2 was more upset and frustrated over Resident 2's health and home issues. SSD reported not being aware if Resident 2's physician had been notified of the self harm statements. Review of the facility Policy titled Suicide Prevention dated 2-2014 revealed the following information: -#6. Notify Physician and/or Medical Director of the initial assessment including mood, mental status and safety issues, to obtain an order for [REDACTED].>",2020-09-01
2985,OMAHA NURSING AND REHABILITATION CENTER,285240,4835 SOUTH 49TH STREET,OMAHA,NE,68117,2019-01-02,580,D,1,0,UQIO11,"**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 staff failed to notify the physician and responsible party of the development of a pressure ulcer for 1 (Resident 40) and failed to notify the physician of un-available medications for 1 (Resident 37) of 6 residents. The facility staff identified a census of 58. Findings are: [NAME] Record review of Resident 40's Comprehensive Care Plan (CCP) dated 3-15-2018 revealed Resident 40 had a stage 3 (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar (dead tissue) may be visible but does not obscure the depth of tissue loss) to the left heel and an unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). Record review of a LN (Licensed Nurse) Skin Pressure Weekly (LNSPW) sheet dated 12-26-2018 revealed the size of the left heel pressure area measured 2.2 centimeters (cm) by 1.9 cm with a depth of 0.2 cm. Observation on 12-31-2018 at 12:18 PM of the treatment of [REDACTED]. Further observations of the left heel revealed a dark black looking area that was area oblong looking position more on the left heel. Record review of Resident 40's Physical Therapy Treatment Encounter Notes (PTTEN) dated 11-29-2018 revealed Physical Therapist (PT) C identified Resident 40 with a stage 3 pressure on the left medial heel and an unstageable pressure ulcer below the left heel pressure area. Record review of Resident 40's PTTEN dated 12-19-2018 revealed PT C identified Resident 40 with a stage 3 pressure area on the left medial heel and an unstageable pressure ulcer below the left heel pressure area. Record review of Resident 40's PTTEN dated 12-24-2018 revealed PT C identified Resident 40 with a stage 3 pressure area on the left medial heel and an unstageable pressure ulcer below the left heel pressure area. Record review of Resident 40's PTTEN dated 12-26-2018 revealed PT C identified Resident 40 with a stage 3 pressure area on the left medial heel and an unstageable pressure ulcer below the left heel pressure area. On 12-31-2018 at 3:55 PM an interview was conducted with PT C. During the interview review PT C reported Resident 40 had developed additional pressure ulcer to the left heel and confirmed no measurement had been taken of the new pressure ulcer. On 1-02-2019 at 11:21 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed there was not evidence Resident 40's physician and family had been informed of the new pressure ulcer to the left heel. B. Record review of a Admission Record sheet printed on 1-02-2019 revealed Resident 37 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Transition Orders and Information For the Continuation Of Patient Care sheet revealed Resident 37 was discharged to the facility on [DATE] with orders for medications that included [MEDICATION NAME] ( anti-convulsant medication) ER (extended release) 500 milligrams, 1 tablet in the AM and 2 tablets at hour of sleep (HS) and [MEDICATION NAME] (anti-convulsant medication) 150 mg to be taken twice a day. Both medication carried the [DIAGNOSES REDACTED]. Record review of Resident 37's Progress Notes (PN) dated 12-29-2018 revealed medication had not arrived on the evening shift. Further review of Resident 37's PN notes since admission revealed there was not evidence the facility staff had notified Resident 37's physician medications were not available for Resident 37 that included the anticonvulsant medication. Record review of Resident 37's Medication Administration Record [REDACTED]. On 1-02-2019 at 11:04 AM an interview was conducted with the DON. During the interview the DON reported not being aware Resident 37's physician had been notified medications not available for Resident 37 that included the anticonvulsant medication.",2020-09-01
5308,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-01-23,157,D,1,0,5YZX12,"**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 family of a change in condition for 1 (Resident 7) of 3 residents and failed to notify the physician of medication errors for 1 (Resident 1) of 3 sampled residents. The facility staff identified a census of 96. Findings are: [NAME] Record review of Resident 7's progress note dated 8-4-2016 revealed Resident 7's physician had instructed that Resident 7 was to be sent to the emergency room (ER) after [MEDICAL TREATMENT] due to a bowel obstruction. Review of Resident 7's medical record revealed there was not evidence the family was notified of Resident 7 being sent to the ER. Review of Resident 7's progress note dated 8-5-2016 revealed Resident 7 family member had called and was furious that (gender) was not notified . Resident 7 had been sent to ER. On 3-14-2017 at 1:36 PM an interview was conducted with the Medical Records Director (MRD). During the interview the MRD confirmed Resident 7's family member had not been notified of Resident 7 being sent to ER. The MRD confirmed family should have been notified of the transfer. B. Record review of Resident 1's Medication Administration Record [REDACTED]. According to the instruction on the MAR for (MONTH) (YEAR) facility staff were to hold the medication if the heart rate was less than 50 or the systolic (top number of a blood pressure reading) blood pressure (SBP) was equal to or less than 100. Further review of Resident 1's MAR for (MONTH) (YEAR) revealed the following dates and blood pressure readings when the [MEDICATION NAME] was given: -11-4-2016, Blood Pressure (BP),100/59. -11-5-2016, BP, 98/56. -11-6-2016, BP, 100/54. -11-25-2016, BP, 100/56. -11-26-2016, BP, 100/56 - [MEDICATION NAME]. -11-26-2016, BP, 100/56. Record review of Resident 1's MAR for (MONTH) (YEAR) revealed [MEDICATION NAME] was given on the following dates: -12-3-2016, BP, 96/50. -12-25-2016. BP, 96/55. On 3-14-2017 at 11:47 AM an interview was conducted with the Director of Nursing (DON). During the interview, review of Resident 1's MARs for (MONTH) and (MONTH) (YEAR) were reviewed. The DON confirmed Resident 1 should not of received the medication [MEDICATION NAME] on (MONTH) 4,5,6, 25 and 26th. In addition, the DON confirmed Resident 1 should not have received the [MEDICATION NAME] on 12-3-2016 and 12-25-2016. The DON confirmed Resident 1's physician should have been notified of the medication errors.",2020-01-01
2777,SOUTH HAVEN LIVING CENTER,285231,1400 MARK DRIVE,WAHOO,NE,68066,2019-12-05,580,D,1,1,L51P11,"**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 identify a change in skin condition for 1 resident (Resident 47). The facility census was 80. FIndings are: Review of physician orders [REDACTED]. Review of Resident 47's Treatment Administration Records for (MONTH) and (MONTH) 2019 revealed that weekly skin check were documented as being completed on 7/4/19, 7/11/19, 7/18/19, 7/25/19 8/1/19, 8/8/19, 8/15/19, 8/22/19 and 8/29/19. No documentation of results of weekly skin check for Resident 47 was found in electronic health record. Interview on 12/05/19 at 10:05 AM with Director of Nursing confirmed that there is no documentation of results of weekly skin checks done in (MONTH) and (MONTH) 2019 for Resident 47.",2020-09-01
3883,BROOKESTONE ACRES,285291,4715 38TH STREET,COLUMBUS,NE,68601,2019-05-14,580,G,1,0,99CH11,"**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 physician's of a change in condition for 2 ( Resident 1 and 2) of 4 residents reviewed related to falls. Residents 1 and 2 sustained falls with immediately obvious injuries, and the Primary Care Practitioners (PCP) were not notified for treatment recommendations until 2 to 4 hours following the incidents. The facility census was 75. Findings are: [NAME] Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/27/19 revealed the resident had [DIAGNOSES REDACTED]. The resident had severely impaired cognition, and required extensive to total assistance with bed mobility, transfers, toileting and bathing. Review of Resident 1's current Care Plan with target dates of 5/15/19 indicated the resident had a history of [REDACTED]. Nursing interventions included the following: -anticipate and meet resident's needs; -verbal reminders not to ambulate or transfer without assistance; -keep bed beside wall due to right sided deficit; -place items frequently used within easy reach; -environment free of clutter and safety hazards, with adequate lighting, free of glare; and -scoop mattress to define the edges of the bed. Review of Nursing Progress Notes on 5/8/19 revealed the following related to Resident 1: -10:47 AM - Observed on the floor of the whirlpool room following a fall from the whirlpool chair during bathing. Initial Vital Signs (VS) were Temperature (T) 98.0 degrees, Pulse (P) 189, Respirations (R) 28, lying Blood Pressure (BP) 207/146, sitting BP 189/100. Had an abrasion on the front forehead measuring 5.3 cm (centimeters) x (by) 2.0 cm, a bruise on the left elbow 2 cm x 0.9 cm, and a skin tear on the left elbow 2 x 0.6 cm. Neuro checks (an assessment of neurological status including P, R and BP measurements, pupil size and reactivity, and equality of hand grip strength) were initiated; and -3:32 PM - Call placed to physician's office at 2:15 PM to call back to communicate on resident status. No call back at this time. This nurse called physician office again at 2:45 PM. At 3:00 PM the on-call physician gave this nurse verbal orders to send the resident to the emergency room . During interview on 5/8/19 from 12:36 PM until 1:40 PM, the Director of Nursing (DON) verified the first attempt to notify Resident 1's physician of the fall from the whirlpool chair was at 2:15 PM (3 hours and 28 minutes following the incident), and the PCP did not return the call until 3:00 PM. B. Review of Resident 2's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The resident was cognitively intact, required limited assistance with transfers and toileting, and extensive assistance with bed mobility. Review of Resident 2's current Care Plan dated 4/27/19 indicated the resident had a history and/or potential for falls related to impaired gait and balanced, poor safety awareness, and self transfers. Nursing interventions included the following: -anticipate and meet resident's needs; -call light reachable and use encouraged; -verbal reminders not to ambulate or transfer without assistance; -place items frequently used within easy reach; and -provide environment with adequate lighting; free of glare. Review of Nursing Progress Notes dated 5/7/19 revealed the following related to Resident 2: -6:15 PM - Sitting in a chair in the parlor of the 300/400 Wing awaiting the start of an activity. Observed by the activity facilitator to have stooped over and fell to the floor head first. Was reported to be unresponsive for 45 seconds to 1 minute following the fall; -7:30 PM - Event reported to the resident's child and will attempt to get an order to send to ED (Emergency Department); and -8:20 PM - Report of the event called in and given to (hospital) ED. During interview on 5/8/19 from 12:36 PM until 1:40 PM, the DON verified Resident 2's PCP was not notified until 8:20 PM (2 hours and 5 minutes after the incident). The DON indicated notification of the PCP should occur within an hour of the occurrence of an incident and/or change of condition.",2020-09-01
4401,GOOD SAMARITAN SOCIETY - ATKINSON,285177,409 NEELY STREET,ATKINSON,NE,68713,2017-04-19,157,D,1,0,VDBU11,"**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 a need to alter treatment for [REDACTED]. Findings are: [NAME] Review of Resident 2's undated Care Plan revealed a [DIAGNOSES REDACTED]. B. Review of the facility policy titled Notification of Change dated 11/2016 indicated the facility must immediately inform the resident, consult with the resident's physician and notify the resident's representative when there was a need to alter treatment significantly such as a need to discontinue or change an existing form of treatment or to commence a new form of treatment. C. Review of facsimile (fax) sent to Resident 2's physician dated 4/10/17 at 5:30 AM, revealed the resident had a skin tear and hematoma (an abnormal collection of blood outside a blood vessel usually caused by trauma) to the left elbow and a bruise to the left hip as a result of a fall that occurred at 2:15 AM. Steri-strips (adhesive bandage strips used to close small wounds) were placed on the skin tear and it was covered with a [MEDICATION NAME] (a type of foam dressing). The fax was returned by the physician with no new orders provided. D. Review of Resident 2's Progress Note dated 4/10/17 at 3:34 PM revealed a pressure dressing was applied to the left elbow as it continued to bleed. There was no evidence to indicate the physician was notified of the need to change the treatment due to continued bleeding. E. There was no evidence of further monitoring of the area until a Progress Note on 4/11/17 at 4:33 PM indicated after lunch on 4/11/17 the resident's left elbow area continued to bleed. The physician was notified and the resident was subsequently seen by the physician. F. Review of Resident 2's Progress Note dated 4/11/17 at 5:32 PM indicated cutaneous glue (a medical adhesive that joins the edges of a wound together) was used to seal the left elbow skin tear. [NAME] Interview with Registered Nurse (RN)-C on 4/19/17 at 4:15 PM confirmed the resident had continued bleeding to the left elbow area which was associated with its location. RN-C stated it would open up when the resident's elbow bent.",2020-08-01
1216,ARBOR CARE CENTERS-FULLERTON LLC,285115,"PO BOX 648, 202 NORTH ESTHER",FULLERTON,NE,68638,2017-08-28,157,D,1,1,3S2F11,"**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 regarding Resident 52's high and/or low blood sugars. The sample size was 41 and the facility census was 62. Findings are: Review of Resident 52's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/4/17 revealed a [DIAGNOSES REDACTED]. Review of Resident 52's Medication Administration Record [REDACTED] -An accucheck (a blood test used to determine blood sugar levels) was to be completed at 8:00 AM, 10:00 AM, 12:00 noon, 2:00 PM, 6:00 PM, 8:00 PM and 2:00 AM; and -The physician was to be notified if the blood sugar level was below 60 or above 400. Further review of Resident 52's MAR indicated [REDACTED] -488 on 8/1/17 at 2:00 AM; -453 on 8/5/17 at 2:00 AM; -58 on 8/11/17 at 10:00 AM; -50 on 8/12/17 at 8:00 PM; -438 on 8/17/17 at 8:00 PM; and -428 on 8/18/17 at 2:00 AM. Review of Resident 52's medical record revealed no evidence the physician was notified of the blood sugar levels which were below 60 or above 400 on 8/1/17, 8/5/17, 8/11/17, 8/12/17, 8/17/17 and 8/18/17. Interview with the Director of Nurses on 8/24/17 at 11:15 AM confirmed Resident 52's physician should have been notified of all blood sugar levels which were below 60 or above 400.",2020-09-01
1431,LIFE CARE CENTER OF OMAHA,285137,6032 VILLE DE SANTE DRIVE,OMAHA,NE,68104,2018-03-19,580,D,1,1,93SH11,"**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 and responsible party of elevated blood glucose levels for 1 resident (Resident 60) of 4 sampled residents. The facility staff identified a census of 92. Findings are: Record review of Resident 66's Compressive Care Plan (CCP) dated 02/13/2018 revealed the following about the resident: -[MEDICAL CONDITION]/[DIAGNOSES REDACTED] -Risk for complications associated with hyper or [DIAGNOSES REDACTED] due to [DIAGNOSES REDACTED]. -Observe for signs and symptoms (s/s) of unstable blood sugar levels -Report to physician s/s of unstable blood sugar levels Record review of Resident 66's (MONTH) (YEAR) Physician order [REDACTED]. -Monitor for s/s of hypo/[MEDICAL CONDITION] every shift -Call MD (Medical Doctor) for blood sugar less than 60 or greater than 400 Record review of Resident 66's (MONTH) Blood Glucose log revealed Resident 66's blood glucose level results were the following: 3/2/18 at 7:00 am 490, at 11:00 am 428, at 5:00 PM 436 3/3/18 at 7:00 am 493 3/4/18 at 8:00 PM too High to register on monitor 3/7/18 at 7:00 am too high to register on monitor 3/9/18 at 7:00 am 414, at 5:00 PM 415 3/10/18 at 7:00 am 454 3/11/18 at 7:00 am too high to register on monitor 3/12/18 at 8:00 PM too High to register on monitor 3/15/18 at 428, at 5:00 438 3/16/18 at 5:00 PM 438 Interview with the Director of Nursing (DON) on 3/19/2018 at 3:11 PM confirmed that a physician order [REDACTED]. The DON also confirmed that the physician was not notified of the elevated blood glucose levels. Record review of the facility's Policy for Change in a Resident's condition Revised on 03/2010 revealed: -All changes in the resident's condition will be recorded in the resident's medical record. -The attending physician will be notified of any change in the resident's medical condition -Resident's representative will be notified of all changes in condition.",2020-09-01
1031,PRESTIGE CARE CENTER OF PLATTSMOUTH,285104,602 SOUTH 18TH STREET,PLATTSMOUTH,NE,68048,2018-05-21,580,D,1,1,8OXW11,"**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 and responsible party of elevated blood sugar (BS) for 1 (Resident 33) of 3 sampled residents. The facility staff identified a census of 62. Findings are: Record review of Resident 33's quarterly Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 3/15/18 revealed a [DIAGNOSES REDACTED]. Record review of Resident 33's Physician order [REDACTED]. Record review of Resident 33's Medication Administration Record [REDACTED] -4/1/18 at 11:00 am BS 365, at 4:30pm BS 376, at 8:00pm BS 393, -4/2/18 at 11:00 am BS 354, -4/4/18 at 11:00 BS 411, at 8:00pm BS 363, -4/6/18 at 11:00 am BS 409, at 8:00pm BS 379, -4/7/18 at 11:00 am BS 356, -4/9/18 at 4:30pm BS 397, at 8:00pm BS 378, -4/10/18 at 11:00 am BS 438, at 4:30 BS 380, at 8:00pm BS 425, -4/11/18 at 8:00pm BS 433, -4/12/18 at 4:30pm BS 403, at 8:00pm BS 447, -4/13/18 at 11:00 am BS 443, -4/14/18 at 4:30pm BS 351, -4/15/18 at 8:00pm BS 421, -4/17/18 at 11:00 am BS 368, at 4:30 BS 465, at 8:00pm BS 389, -4/18/18 at 11:00 BS 385, at 4:30pm BS 465, at 8:00pm BS 389, -4/19/18 at 7:00 am BS 423, at 11:00 am BS 506, at 8:00pm BS 508, -4/20/18 at 11:00 am BS 442, at 8:00pm BS 576, -4/21/18 at 7:00 am BS 450, at 8:00pm BS 415, -4/22/18 at 11:00 am BS 367, -4/25/18 at 11:00 BS 423, -4/26/18 at 4:30pm BS 390, at 8:00pm BS 378, -4/27/18 at 4:30pm BS 397, at 8:00pm BS 479, -4/28/18 at 8:00pm BS 367, -4/29/18 at 8:00pm BS 415, -4/30/18 at 4:30pm BS 378, at 8:00pm BS 440. -5/1/18 at 11:00 BS 355, at 8:00pm BS 357, -5/2/18 at 11:00 BS 469, at 4:30pm BS 368, at 8:00pm BS 542, -5/3/18 at 4:30pm BS 382, -5/4/18 at 4:30pm BS 374, at 8:00pm BS 369, -5/5/18 at 7:00 am BS 386, at 11:00 BS 485, 4:30pm BS 456, -5/7/18 at 4:30pm BS 357, at 8:00pm BS 460, -5/8/18 at 4:30pm BS 387, at 8:00pm BS 492, -5/10/18 at 4:30pm BS 413, 8:00pm BS 542, -5/11/18 at 11:00 am BS 390, at 4:30pm BS 387, at 8:00pm BS 399, -5/12/18 at 7:00 am BS 355, -5/13/18 at 4:30pm BS 434, -5/15/18 at 4:30pm BS 436, at 8:00pm BS 396. Record review of Resident 33's Medical Record revealed that the Physician had not been informed of the blood sugars that had exceeded 350. Record review of policy, Notification of Changes Policy, date 5/17 states: That changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, and reported to the attending physician or delegate. Interview with the Director of Nursing (DON) on 5/21/18 at 8:35 am; The DON reported that the expectation was that changes in condition were immediately reported to the physician responsible for the resident's care. Parameters were to be set by the Physician in an order, if no parameters were established at the time of admission, the nurse must call the Physician and obtain an order for [REDACTED].",2020-09-01
2940,RIDGECREST REHABILITATION CENTER,285239,3110 SCOTT CIRCLE,OMAHA,NE,68112,2018-01-23,580,D,1,0,L1D311,"**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 and responsible party of weight loss for 2 (Resident 20 and 25) of 4 sampled residents. The facility staff identified a census of 60. Findings are: [NAME] Record review of a Face Sheet dated 8-18-2017 revealed Resident 20 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 20's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) signed as completed on 12-26-17 revealed the facility staff assessed the following about the resident: -Totally dependent for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Record review of a Weight Record Sheet (WRS) provided by the facility revealed Resident 20's weight on 9-13-17 was 268 pounds. Further review of the WRS revealed Resident 20's weight on 11-8-17 was 233.4 pounds, a loss of 34.6 pound weight loss or 11.39% indicating a significant weight loss. Record review of Resident 20's medical record revealed there was no evidence the facility staff had notified Resident 20's physician or responsible party. B. Record review of Resident 25's CCP dated 11-9-2013 revealed Resident 25 had the potential for a nutritional deficit. The goal identified for Resident 25 was to maintain weight. Record review of Resident 25's WRS dated 10-25-17 revealed Resident 25's weight was 170 pounds. Review of Resident 20's WRS dated 12-27-17 revealed a weight of 158 pounds, a loss of 12 pounds or 7.05 percent. Record review of the WRS dated 1-8-18 revealed Resident 25's weight was 149.8, a loss of 20.2 pounds or 11.88% compared to the weight on 10-25-2017. Record review of Resident 25's medical record revealed there was no evidence the facility staff had notified Resident 25's physician or responsible party of the progression of weight loss resulting in a significant weight loss. On 1-23-2017 at 9:35 AM an interview was conducted with the Facility Nurse Consultant (NC). During the interview the NC confirmed Resident 20 and Resident 25's physician and responsible party had not been informed of the weight loss and should have been.",2020-09-01
1395,LIFE CARE CENTER OF ELKHORN,285134,20275 HOPPER STREET,ELKHORN,NE,68022,2018-10-11,580,D,1,0,PGI211,"**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 a blood sugar result as ordered for 1 (Resident 2) of 2 sampled residents. The facility identified a census of 99. Record review of Resident 2 current Physician order [REDACTED]. Record review of Resident 2 Medication Administration Record [REDACTED]. Review of Resident 2's Progress Notes revealed there was no evidence Resident 2's physician had been notified of the blood sugar result of 429. Interview with Licensed Practical Nurse (LPN) B on 10/10/2018 at 04:00 PM confirmed that the physician had not been notified of the blood sugar result and the physician should have been notified on that date.",2020-09-01
1362,LIFE CARE CENTER OF ELKHORN,285134,20275 HOPPER STREET,ELKHORN,NE,68022,2019-02-19,580,D,1,0,2BLY11,"**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 practitioner of a wound area for 1 (Resident 5) of 3 sampled residents. The facility staff identified a census of 105. Findings are: Record review of a Weekly Skin Integrity Data Collection (WSIDC) sheet dated 2-7-19 revealed Resident 5 was evaluated with having a 0.25 centimeter (cm) area to the right heel. Review of Resident 5's medical record revealed there was no evidence the facility staff had notified and request an order for [REDACTED]. Observation on 2-11-19 at 2:28 PM with Licensed Practical Nurse (LPN) F of Resident 5's right heel revealed an open area that measured approximately 0.3 round appearing area to Resident 5's right heel. On 2-11-19 at 4:07 PM a interview was conducted with LPN F. During the interview LPN F reported (gender) was the facility wound nurse. LPN F confirmed Resident 5 had an open area to the right heel and that Resident 5's practitioner had not been notified When asked when should the practitioner be notified, LPN F reported the same day it was identified.",2020-09-01
4433,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-08-31,157,D,1,0,I5FW11,"**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 decline in the condition of a pressure ulcer to the practitioner for 1 (Resident 4) of 4 sampled residents. The facility staff identified a census of 60. Findings are: [NAME] Record review of an Admission Record sheet printed on 8-31-2017 revealed Resident 4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a fax sheet dated 7-15-2017 revealed Resident 4's physician was notified Resident 4 had developed an open area to the left heel that measured 0.9 centimeters (cm) by 0.3 cm and requested a treatment. Record review of Resident 4's Skin Grid for Pressure Skin Impairments (SGPSI) dated 7-15-2017 revealed the measurements of the pressure ulcer was 0.9 cm by 0.3 cm with a depth of less than 0.1 cm. The pressure ulcer had a small amount of drainage with slough (dead tissue). Record review of Resident 4's SGPSI dated 8-2-2017 revealed the pressure ulcer measured 1 cm by 0.6 cm by 0.1 cm, a decline in the condition of the pressure ulcer. No further evaluation of the pressure ulcer was identified on the SGPSI. Review of Resident 4's record revealed there was no evidence Resident 4's practitioner was notified in the decline of the pressure ulcer healing. Record review of Resident 4's SGPSI dated 8-10-2017 revealed the pressure ulcer measured 1.3 cm by 1.5 cm, drainage was identified as scant with red and white slough, indicating a further decline in the condition of the pressure ulcer. On 8-31-2017 at 9:20 AM an interview was conducted with the Director of Nursing (DON). During the interview, review of Resident 4's SGPSI dated from 7-15-2017 through 8-10-2017 was completed. The DON confirmed the pressure ulcer condition had declined on 8 -2-2017 and Resident 4's practitioner was not notified and should have been.",2020-06-01
5852,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2016-08-10,157,D,1,0,142711,"**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 and emergency contact person of suicidal statements for 1 resident (Resident 4). The facility staff identified a census of 164. Findings are: Record review of an undated Resident Face Sheet revealed Resident 4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident Resident 4's Nurse's Notes (NN) dated 7-28-2016 revealed Resident 4 had reported to a facility staff member of wanting to slice and kill (gender) self. Further review of Resident 4's NN dated 7-28-2016 at 2:42 AM revealed there was not evidence Resident 4's Physician or emergency contact had been notified of Resident 4's suicidal statements. An interview was conducted with the Director of Nursing (DON) on 8-09-2016 at 1:28 PM. During the interview when asked if Resident 4's Physician and emergency contact had been informed of the suicidal statement on 7-28-2016 at 2:42 AM, the DON reported the physician or emergency contact had not been notified. Record review of the facility Policy and Procedure for Suicide Precaution dated 10-25-2016 revealed the following: -Nursing will notify the physician to discuss the circumstances and obtain orders to transfer to the hospital. -Emergency contact is to be notified of new orders or hospital admission.",2019-08-01
4876,LIFE CARE CENTER OF OMAHA,285137,6032 VILLE DE SANTE DRIVE,OMAHA,NE,68104,2017-03-29,157,D,1,0,YJ8Z11,"**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 1) of 3 residents sampled. The facility staff identified a census of 77. Findings are: Record review of Resident 1's Physician order [REDACTED]. In addition, Resident 1's physician ordered to be notified if Resident 1's blood sugar results were below 60 or greater than 500. Record review of Resident 1's Progress Note (PN) dated 3-26-2017 revealed Resident 1 was diaphoretic. According to the PN dated 3-26-2017 the facility nurse checked Resident 1's BS level with the glucometer indicating lo. There was no evidence that the physician was notified of the low blood sugar results. Record review of Resident 1's PN dated 3-16-2017 revealed Resident 1 was shaking. According to the information in the PN dated 3-16-2017, the facility nurse was unable to obtain Resident 1's BS level. The PN dated 3-16-2017 contained information that the facility nurse administered [MEDICATION NAME] ( medicine used to treat severe low blood sugar ([DIAGNOSES REDACTED]). There was no evidence Resident 1's physician was notified of Resident 1's condition. Record review of Resident 1's PN dated 3-02-2017 revealed a nursing assistant informed Resident 1's nurse that Resident 1 was not responding right. The facility nurse checked Resident 1's BS levels with the results being Lo. The nurse administered [MEDICATION NAME] and re-checked Resident 1's BS level 15 minutes later with a result of 55. There was no evidence Resident 1's physician was notified of Resident 1's BS being below 60. Record review of Resident 1's PN dated 2-04-2017 revealed Resident 1's BS level was 28. There was not evidence that Resident 1's physician had been notified of the low BS level. On 3-28-2017 at 1:00 PM an interview was conducted with the Director of Nursing (DON). During the interview when asked if a Hi or Lo reading for BS should be reported to the physician, the DON stated yes. Review of Resident 1's PN notes dated 3-26-2017, 3-16-2017, 3-02-2017 and 2-04-2017. The DON confirmed Resident 1's physician was not notified of the low or high BS results for Resident 1.",2020-03-01
6042,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2016-06-09,157,D,1,0,M5U711,"**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 Primary Care Physician of Resident 111's change of condition in respiratory status. The facility census was 118. Findings are: Review of Resident 111's undated Medical [DIAGNOSES REDACTED]. Review of Resident 111's MDS (Minimum data Set, a federally mandated comprehensive assessment tool used for care planning) dated 5-12-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 12 which indicated Resident 111's cognition was moderately impaired. Resident 111 required extensive assistance of two with bed mobility, dressing, toileting, and personal hygiene. Resident 111 required total assistance of two with transfers and was non-ambulatory. Review of Resident 111's Progress Notes dated 5-25-16 at 5:08 AM revealed a communication fax had been sent to the Physician regarding resident's wheezing and requesting a PRN (as needed) inhaler or nebulizer treatment. Review of Progress Notes dated 5-26-16 at 11:01 AM revealed an assessment of Resident 111 included audible wheezes and respirations slightly labored. Review of Progress Notes dated 5-27-16 at 9:28 PM revealed the facility received the first communication back from the Physician in the form of a fax with orders for a PRN ProAir inhaler. Interview on 6-9-16 at 3:47 PM with LPN-B (Licensed Practical Nurse) revealed the process for notifying a Physician was to call and not fax the primary Physician or Physician on call for all resident condition changes and clarification of orders. LPN-B revealed if a message was left for a Physician about a resident's condition, the nurses would call back until the Physician was reached before the end of their shift or if unable to reach the Physician, the nurse would document and communicate to the next shift to have kept trying. Interview on 6-9-16 at 5:15 PM with the DON (Director of Nursing) confirmed Resident 111's condition change and need for PRN medications on 5-25-16 should not have been faxed to the Physician but should have been called to ensure the Physician was notified on 5-25-16 instead of 64 hours later.",2019-06-01
5943,GRAND ISLAND PARK OPERATIONS LLC,285105,610 NORTH DARR AVENUE,GRAND ISLAND,NE,68803,2016-07-06,157,D,1,0,HDGT11,"**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 family, who was the legal representative, of the change of condition related to skin impairment for Resident 100. The facility census was 55. Findings are: Review of Resident 100's Face Sheet dated 6-9-16 revealed the resident was admitted from the hospital on 6-1-16 and discharged from the facility on 6-18-16. [DIAGNOSES REDACTED]. Interview on 7-6-16 at 5:31 PM with Resident 100's family revealed Resident 100 was transferred from the facility to an acute hospital on 6-18-16 because of low oxygen. Upon initial assessment of the resident at the hospital, the doctor discovered the resident had pressure ulcers on both heels and the buttocks at the base of the spine. The skin being black at all 3 areas. The family revealed they had visited daily before the resident was admitted to the hospital and had not been informed of any skin sores. Review of Resident 100's Progress Notes revealed a late entry dated 6-16-16 at 4:00 PM which was entered into the Progress Notes on 6-21-16. The documentation revealed a nurse aide discovered a reddened area to Resident 100's coccyx during the bath. The nurse aide reported it to an LPN (Licensed Practical Nurse) who then assessed the area and discovered the area was blanchable and not open. A full assessment was completed at that time and no other new areas were noted. Review of the Progress Notes from 6-16-16 to 6-18-16 at time of discharge to the acute hospital revealed no documentation about notification to the family of any skin impairment. Review of Resident 100's Care Plan revealed resident was at Risk for Altered Skin Integrity related to a red, blanchable area on the coccyx. The Care Plan did not reveal documentation about notification to family after the finding of the skin impairment on 6-16-16. Interview on 7-5-16 at 6:15 PM with the ADON (Assistant Director of Nursing) confirmed no documentation was in the chart of notification to the family about the skin impairment to the coccyx. The ADON also revealed the ADON was part of the Care Plan team and the team did not notify the family of the skin issue.",2019-07-01
5453,GOOD SAMARITAN SOCIETY - WOOD RIVER,285198,1401 EAST STREET,WOOD RIVER,NE,68883,2017-03-22,157,D,1,1,HUVK11,"**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 legal representative for one resident (Resident 63) out of 3 sampled residents for change in resident condition. The facility census was 59. Findings are: Review of the undated census sheet for Resident 63 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the undated census sheet revealed the resident had a legal guardian. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-20-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 3 which indicated Resident 63's cognition was severely impaired. A) Review of a late entry Progress Notes dated 8-16-16 revealed Resident 63 was hit in the forehead by a plastic glass thrown by another resident which resulted in no injuries. Review of the Incident/Accident report dated 8-16-16 revealed the family was notified for Resident 63. However, the family name documented who was notified was not the name listed on the census sheet as Resident 63's Guardian, but was the Legal Representative of the perpetrator. Interview on 3-20-17 at 11:08 AM with the DON (Director of Nursing) confirmed the documentation to Resident 63's Guardian regarding the incident of 8-16-16 was to the wrong person. B) Review of the Progress Notes dated 8-17-16 revealed Resident 63 was sitting at a table with another resident and the other resident kicked Resident 63 in the left knee which resulted in no injury. The documentation revealed the primary Physician and Social Worker was notified. The documentation revealed absence of the Guardian notification. Interview on 3-20-17 at 11:08 AM with the DON confirmed the documentation in the Progress Notes and the DON's review of the Incident / Accident report of 8-17-16 revealed the Guardian of Resident 63 had not been notified.",2020-01-01
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
1863,"NORTH PLATTE CARE CENTER, LLC",285165,2900 WEST E STREET,NORTH PLATTE,NE,69101,2017-07-20,164,D,1,0,2TNM11,"**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 1's privacy by failing to close the window blinds during assistance with toileting. This affected 1 of 3 sampled residents. The facility identified a census of 52 at the time of survey. Findings are: Review of Resident 1's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 6/29/2017 revealed an admission date of [DATE]. Resident 1 had a BIMS (Brief Interview for Mental Status) score of 13 which indicated Resident 1's cognition was intact and Resident 1 required extensive assistance from 2 staff persons for transfers. Observation of Resident 1 on 7/20/2017 at 1:07 PM revealed the following: PTA (Physical Therapy Assistant), NA-B (Nurse Aide), and NA-C assisted Resident 1 with standing, lowering their pants, and sitting on a commode in Resident 1's room. Resident 1's window blinds were open and cars were visible driving on the street. Resident 1 was sitting on the commode that was visible from the window. Interview with the facility Administrator on 7/20/2017 at 3:20 PM revealed the staff were expected to provide privacy with cares and Resident 1's window blinds should have been closed while staff were assisting Resident 1 with toileting in their room. The Administrator confirmed there were cars driving by on the street visible from Resident 1's room through the window blinds. Review of the facility policy Resident Rights copyright (YEAR) revealed the following: The resident has the right to personal privacy including personal care.",2020-09-01
1084,EMERALD NURSING & REHAB LAKEVIEW,285106,1405 WEST HWY 34,GRAND ISLAND,NE,68801,2018-05-07,583,E,1,1,QN7C11,"**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 protect resident privacy by posting personal care information visible to passers-by, weighing residents in a public area with the result screen visible to passers-by and failing to close the door and window blinds during administration of medications into Resident 22's feeding tube. This affected 3 of 3 sampled residents and had the potential to affect 50 residents in the facility. The facility identified a census of 55 at the time of survey. Findings are: [NAME] Review of Resident 19's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 1/22/2018 revealed Resident 19 had a BIMS (Brief Interview for Mental Status) score of 13 which indicated Resident 19 was cognitively intact. Resident 19 required extensive assistance from 2 staff for toilet use and Resident 19 was frequently incontinent of urine. Observation of Resident 19's room on 5/02/18 at 11:24 AM revealed a sign hanging on the closet door Dr. order to use pink under pads (a product used to manage incontinence) visible from the hallway to potential passers-by. Interview with the facility Administrator on 5/07/18 at 10:55 AM confirmed the sign in Resident 19's room contained personal care information and should not be posted in an area visible to others. B. Observation of the 400 hall on 5/02/18 at 1:25 PM revealed staff weighing unidentified residents on a scale in the hall. The screen displaying the residents' weights was visible to passers-by. Interview with the ADON (Assistant Director of Nursing) on 5/7/18 at 11:01 AM revealed 50 of the 55 residents in the facility were weighed using the scale in the hallway. C. Record review of Resident 22's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 22 had severely impaired cognitive skills for daily decision making and had a feeding tube. Observation of LPN (Licensed Practical Nurse)-E on 5/3/2018 at 12:20 PM revealed LPN-E entered Resident 22's room and did not close the door or the window blinds. LPN-E then proceeded to expose Resident 22's feeding tube and administered medication into it. Resident 22's feeding tube was visible through the window and to passers-by in the hall. Interview with the DON (Director of Nursing) on 5/07/18 at 10:53 AM revealed facility staff were expected to close the door when providing cares. Review of the facility policy Confidential Information dated 6/3/2014 revealed the following: All employees will maintain the confidentiality of resident information in accord with this policy. Description of confidential information: resident data, such as diagnosis, treatment condition, progression or regression.",2020-09-01
1865,"NORTH PLATTE CARE CENTER, LLC",285165,2900 WEST E STREET,NORTH PLATTE,NE,69101,2017-07-20,242,D,1,0,2TNM11,"**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 bathing preference for Resident 1 and Resident 3. This affected 2 of 3 sampled residents. The facility identified a census of 52 at the time of survey. Findings are: [NAME] Review of Resident 1's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 6/29/2017 revealed an admission date of [DATE]. Resident 1 had a BIMS (Brief Interview for Mental Status) score of 13 which indicated Resident 1's cognition was intact. Resident 1 required extensive assistance from 2 staff persons for transfer and extensive assistance from 1 staff person for bathing. Review of Resident 1's bathing documentation for 6/22/2017-7/20/2017 revealed documentation that Resident 1 received a bath on 6/26/2017, 6/29/2017, 7/6/2017 (7 days since last bath) and 7/17/2017 (11 days since last bath). Review of Resident 1's New Admission Bathing Form dated 6/22/2017 revealed Resident 1 had a bathing preference of 2 times per week on Monday and Thursday. Interview with Resident 1's responsible party on 7/20/2017 at 11: 05 AM revealed Resident 1's bathing preference was not being honored. B. Review of Resident 3's Admission MDS dated [DATE] revealed an admission date of [DATE]. Resident 3 had a BIMS score of 10 which indicated Resident 3 had moderately impaired cognition. Resident 3 required extensive assistance from 2 staff persons for transfers and extensive assistance from 1 staff person for bathing. Review of Resident 3's bathing documentation for 5/10/2017 to 7/20/2017 revealed documentation that Resident 3 received a bath on 5/10 (Wednesday), 5/17 (Wednesday-7 days since last bath), 5/31 (Wednesday-7 days since last bath), 6/5 (Monday), 6/7 (Wednesday), 6/14 (Wednesday-7 days since last bath), 7/3 (Monday), 7/10 (Monday-7 days since last bath), 7/12 (Wednesday), and 7/19 (Wednesday-7 days since last bath). Review of Resident 3's undated New Admission Bathing Form revealed Resident 3 had a bathing preference of 2 times per week on Tuesday and Friday. Interview with the DON (Director of Nursing) on 7/20/2017 at 2:04 PM revealed the facility did not have a bathing policy as baths were to be offered according to resident preference.",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
2729,BROOKEFIELD PARK,285226,1405 HERITAGE DRIVE,ST PAUL,NE,68873,2020-01-16,622,D,1,0,4QD611,"**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 notify Resident 169's PR (Personal Representative) of the reason for discharge and failed to document discharge instructions were provided to the PR for Resident 169. This affected 1 of 3 residents discharged from the facility. The facility identified a census of 58 at the time of survey. Findings are: Review of Resident 169's Admission Record revealed an admission date of [DATE]. Review of Resident 169's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 12/6/2019 revealed a BIMS (Brief Interview for Mental Status) score of 7 which indicated severe cognitive impairment. Resident 169 required extensive assistance from staff for bed mobility, transfer, toilet use, locomotion on and off unit, and dressing. Resident 169 was dependent upon staff for bathing and walking in room and corridor did not occur. Review of Resident 169's Comprehensive Care Plan dated 11/26/2019 revealed Resident 169's planned discharge date was 12/27/2019. Review of Resident 169's Progress Notes dated 12/19/2019 revealed (family member) notified SSD that family is planning a discharge to home for resident on 12/27/2019 with Home Health. Review of Resident 169's Progress Notes dated 12/21/2019 revealed Resident 169 went home with family per private vehicle. Review of Resident 169's Nursing Discharge Summary dated 12/21/2019 revealed date and time of discharge 12/21/2019 at 10:53 AM: discharged to home in family car with (family member). Interview with the facility Administrator 1/16/20 at 2:00 PM revealed they did not issue a notice of discharge to Resident 169 including the reason why Resient 169 was being discharged . Record review of Resident 169's Medical Record revealed no documentation Resident 169's discharge instructions had been given to the resident and/or the family and that they understood them. Interview with the SSD on 1/16/2020 at 2:20 PM confirmed they had no documentation of the discharge instructions given to Resident 169's PR. The SSD revealed they thought the nurse went over the instructions with Resident 169's PR but they failed to keep a signed copy. Interview with the SSD on 1/16/2020 at 4:36 PM confirmed they did not have the discharge instructions that the nurse should have gone over with Resident 169's PR.",2020-09-01
1803,PLUM CREEK CARE CENTER,285159,1505 NORTH ADAMS STREET,LEXINGTON,NE,68850,2018-12-18,623,E,1,1,P4JF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (5) Based on interviews and record reviews; the facility failed to notify the Ombudsman of facility initiated discharges for Residents 10, 20 and 86, and did not give 30 days notice of discharge to resident 86. This affected 3 of 3 sampled residents. The facility identified a census of 37 at the time of survey. Findings are: [NAME] Review of Resident 10's SCSA MDS (Significant Change in Status, Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 9/25/2018 revealed an admission date of [DATE]. Interview with Resident 10's family member on 12/12/18 at 9:31 AM revealed Resident 10 had a facility initiated discharge to a psychiatric hospital. The family reported Resident 10 was in the hospital 19 days. Review of Resident 10's MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) discharge and re-entry tracking revealed Resident 10 was transferred to the psychiatric hospital on [DATE] and returned to the facility on [DATE]. Interview with the BOM (Business Office Manager) on 12/18/18 at 1:10 PM revealed the facility, had not notified the Ombudsman when residents were transferred or discharged from the facility including facility initiated discharges. B. Review of MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) list for Resident 20 revealed that a discharge MDS was completed on 7/26/18 and a Entry MDS was completed on 7/27/18. Review of progress notes dated 7/26/2018 revealed Resident 20 was sent to the emergency room and there was no documentation that the POA (Power of Attorney) or Ombudsman was contacted regarding transfer. Review of admission status revealed that Resident 20 was sent to the hospital on [DATE]. Interview 12/18/18 11:02 AM with BOM (Business Office Manager) revealed the facility was not notifying the ombudsman of resident transfers or discharges from the facility. C. Review of Admission Status for Resident 86 on Admission Record and Census revealed an admission date of [DATE] Review of Transfer/Discharge Report dated 11/16/18 and signed by Residents 86's POA (Power of Attorney) revealed no documentation for Chief complaint (reason for transfer). Review of Resident 86's Progress Notes (PN) revealed the following: Progress note for Resident 86 dated: 11/15/2018 stated: Called and spoke POA about concern of resident's elopement and how fast resident was able to leave facility. Family was planning on resident going to another facility on Monday. Told POA, the facilities concerns of how cold the temperature was supposed to be this weekend. The facility had concerns about resident remaining in this facility and the risk of elopement. At this time, the other facility was not able to admit until Monday. Asked POA, if the family could take resident home over the weekend until the other facility can admit resident on Monday. POA said yes the family could. Review of physician orders [REDACTED]. Review of Paper work received from the DON (Director of Nursing), MDS Coordinator, and Social Services revealed no confirmed fax date and time stamp for when information was sent to the other facility. The date Resident 86 went to the other facility was 11/19/18 and the date the information was printed off to fax was 11/21/18. On 12/18/18 at 2:00 PM request was made for information from the DON (Director of Nursing) about Resident 86's discharge, such as the Discharge Summary and a letter of Involuntary/Voluntary Discharge Notification and no paperwork presented. Review of Resident 86's EHR (Electronic Health Record) revealed no Discharge Summary or discharge documentation. Interview on 12/18/18 at 2:48 PM with DON revealed that family was asked to come and take resident home over the weekend due to concerns for their safety. DON stated this was not actually an involuntary discharge because the family did say they would take the resident home when asked. Requested on 12/18/18 at 3:55 PM a copy of this facilities policy on Admission/Transfers/Discharges and no policy was obtained. No letter of Discharge Notification was obtained.",2020-09-01
3669,THE LIGHTHOUSE AT LAKESIDE VILLAGE,285280,17600 ARBOR STREET,OMAHA,NE,68130,2019-09-17,605,D,1,0,49P911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (8) Based on record review and interviews, the facility failed to ensure residents are not being given medication as a means for chemical restraints for 1 of 1 resident reviewed Resident 3. The facility census was 33 . Findings are: Review of Resident 3's MAR indicated [REDACTED]. Review of Resident 3's Medication Administration Record [REDACTED]. Review of Resident 3's MAR indicated [REDACTED]. Review of Resident 3's MAR indicated [REDACTED]. Review of Resident 3's Neurological Flow sheet dated 9/18/2019 at 0030 revealed Resident 3's level of consciousness was documented as Lethargic. Review of Resident 3's MAR for 9/18/2019 revealed at 0033 Resident 3 was given [MEDICATION NAME] with is ordered as needed for agitation or restlessness. Review of the facility policy titled Restraint Free Care dated 2/26/2018 revealed a restraint may not be used for the purpose of discipline or staff convenience. Interview on 9/18/2019 at 9:55 AM with the Director of Nursing confirmed Behavior charting should be completed each time an as needed (PRN) medication is given. The DON revealed staff are giving medication at consistent times which could indicate convenience of staff.",2020-09-01
5319,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-01-10,223,D,1,0,YCVU11,"**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 2 from verbal intimidation and involuntary seclusion. This affected 1 of 8 sampled residents. The facility identified a census of 123 at the time of survey. Findings are: Review of Resident 2's face sheet revealed an admission date of [DATE] and a reentry date 12/30/2016. Review of Resident 2's Significant Change in Status MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 1/6/2017 revealed that Resident 2 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated that Resident 2 was cognitively intact Observation of Resident 2 on 1/10/2017 at 10:20 AM revealed LPN-A (Licensed Practical Nurse) told Resident 2 that they needed to get back to their room, get to bed and get off that butt in the presence of LPN-B at the nurses' station. LPN-A was observed standing over Resident 2, who was in a wheelchair, talking in a harsh tone of voice. Resident 2 was observed attempting to inform LPN-A that their bed needed to be made. Two unidentified residents were also observed at the nurse's station. LPN-B did not intervene to protect Resident 2 from LPN-A as they both continued to stand at the nurses' station as Resident 2 proceeded to go back to their room. Interview with Resident 2 on 1/10/2017 at 10:26 AM revealed that LPN-A talked to them in a harsh manner and Resident 2 described LPN-A as being gruff, bossy, and sassy. Resident 2 reported that the reason they went out to the nurses' station was to get something to eat because they had slept through breakfast. Observation of Resident 2's bed at this time also confirmed that it had been stripped and had no linens on it, so Resident 2 was unable to go to bed, as they had been trying to tell LPN-[NAME] Interview with LPN-B on 1/10/2017 at 11:05 AM revealed that they would consider it abuse if a staff member ordered a resident to get back to their room, get to bed and get off that butt and that residents should not be ordered to do anything. Interview with the DON (Director of Nursing) on 1/10/2017 at 11:14 AM confirmed that staff members were not to order residents to do things, were not to speak to residents with a harsh tone of voice and that these actions would be considered abuse. The DON confirmed that LPN-B should have intervened to protect Resident 2 from LPN-A and should have reported it immediately, which had not occurred. The DON confirmed that LPN-B had the authority to suspend LPN-A and had not done so and the DON confirmed that LPN-A was still on duty caring for residents. Interview with the DON on 1/10/2017 at 12:06 PM revealed the DON took immediate action to protect the residents after being informed of the potential abusive situation. Review of the facility policy Protection from Abuse dated 4/1/2016 revealed that all allegations of abuse will be reported immediately to the administrator or his/her designated representatives and that residents were to be protected from abuse including verbal abuse and involuntary seclusion.",2020-01-01
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
1505,AZRIA HEALTH ASHLAND,285140,1700 FURNAS STREET,ASHLAND,NE,68003,2019-04-16,623,D,1,0,19PP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 Based on record review and interview, the facility failed to provide in writing to the resident's legal representative a 30 day notice in advance of the discharge from the facility for Resident 372 and failed to notify the resident and the residents representative in writing of the reason for the discharge for Resident 62 out of 2 residents sampled for discharge. The facility census was 69. Findings are: Review of Resident 372's Admission Record dated 4-11-19 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident 372's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1-4-18 revealed the resident had disorganized thinking. The resident had not had any behaviors exhibited during the assessment period in January. Resident 372 required supervision of one staff with transfers, walking, toileting and eating. Review of Resident 372' undated Care Plan revealed the discharge plan was initiated on 5-1-17 and was the resident and family wanted Resident 372 to stay in the facility long term. The resident/family was to be included in any discharge plans and kept updated of any changes during the resident's stay. This intervention was last updated 1-23-18. Social Service would visit with the resident and family to keep them updated and the resident would receive assistance for referrals to appropriate community resources as needed. This intervention was last updated 6-9-17. Review of the PN (Progress Notes) of Resident 372 revealed the resident had a history of [REDACTED]. On 3-4-18 the resident exhibited behaviors towards other residents without any injury resulted and toward staff and the facility transferred Resident 372 via an ambulance to a hospital to be evaluated. The resident was evaluated at the hospital and had not been demonstrating any behaviors at that time so the hospital wanted to send the resident back to the facility. Review of the PN dated 3-5-18 at 6:49 PM revealed .SSD (Social Service Department) received a call from a case worker at (Hospital) that they wanted to send resident back to (facility). (Gender) was not showing behaviors at this time and (gender) was regretful'. After this SSD spoke to caseworker insisting that they keep (gender). If they couldn't, I asked (the hospital) to ask the family if one of them can stay in our facility over night, or if (the resident) can stay at one of their homes because we cannot provide 1:1 care. Interview on 4-11-19 at 2:02 PM with SSD-U revealed before the incident of 3-4-18, the facility had not been actively searching for another facility for the resident to live. The facility had been managing the resident's behaviors but lately Resident 372's behaviors had been escalating and after the 3-4-18 incident, the SSD-U felt if they readmitted the resident back to the facility the facility would be putting the other residents at harm and the facility did not have the staff to do 1:1 care with Resident 372 until they could find another placement. SSD-U confirmed a 30 day notice had not been given to the resident or legal representative nor had a written explanation been given explaining the reason for the discharge. Interview on 4-16-19 at 10:02 AM with the DON (Director of Nursing) confirmed up until the incident on 3-4-18 the facility had not been planning on discharging Resident 372 and there had not been any discussions or written information given to the legal representative about needing to discharge the resident. After the incident of 3-4-18 with the 3 other residents, the facility felt at times, the resident required 1:1 attention and the facility did not have the staff to provide this so therefore felt they could not meet the resident's needs. The DON confirmed a 30 day notice had not been given to the resident or legal representative nor had a written explanation been given explaining the reason for the discharge.",2020-09-01
1504,AZRIA HEALTH ASHLAND,285140,1700 FURNAS STREET,ASHLAND,NE,68003,2019-04-16,622,D,1,1,19PP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 Based on record review and interview, the facility failed to provide in writing to the resident's legal representative a 30 day notice in advance of the discharge from the facility for Resident 372 and failed to notify the resident and the residents representative in writing of the reason for the discharge for Resident 62 out of 2 residents sampled for discharge. The facility census was 69. Findings are: Review of Resident 372's Admission Record dated 4-11-19 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident 372's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1-4-18 revealed the resident had disorganized thinking. The resident had not had any behaviors exhibited during the assessment period in January. Resident 372 required supervision of one staff with transfers, walking, toileting and eating. Review of Resident 372' undated Care Plan revealed the discharge plan was initiated on 5-1-17 and was the resident and family wanted Resident 372 to stay in the facility long term. The resident/family was to be included in any discharge plans and kept updated of any changes during the resident's stay. This intervention was last updated 1-23-18. Social Service would visit with the resident and family to keep them updated and the resident would receive assistance for referrals to appropriate community resources as needed. This intervention was last updated 6-9-17. Review of the PN (Progress Notes) of Resident 372 revealed the resident had a history of [REDACTED]. On 3-4-18 the resident exhibited behaviors towards other residents without any injury resulted and toward staff and the facility transferred Resident 372 via an ambulance to a hospital to be evaluated. The resident was evaluated at the hospital and had not been demonstrating any behaviors at that time so the hospital wanted to send the resident back to the facility. Review of the PN dated 3-5-18 at 6:49 PM revealed .SSD (Social Service Department) received a call from a case worker at (Hospital) that they wanted to send resident back to (facility). (Gender) was not showing behaviors at this time and (gender) was regretful'. After this SSD spoke to caseworker insisting that they keep (gender). If they couldn't, I asked (the hospital) to ask the family if one of them can stay in our facility over night, or if (the resident) can stay at one of their homes because we cannot provide 1:1 care. Review of Resident 372's medical record revealed absence of documentation of the legal representative requesting to discharge the resident to another facility. Interview on 4-11-19 at 2:02 PM with SSD-U revealed before the incident of 3-4-18, the facility had not been actively searching for another facility for the resident to live. The facility had been managing the resident's behaviors but lately Resident 372's behaviors had been escalating and after the 3-4-18 incident, the SSD-U felt if they readmitted the resident back to the facility the facility would be putting the other residents at harm and the facility did not have the staff to do 1:1 care with Resident 372 until they could find another placement. SSD-U confirmed a 30 day notice had not been given to the resident or legal representative nor had a written explanation been given explaining the reason for the discharge. SSD-U confirmed the the family had not discussed discharging the resident from the facility prior to 3-4-18 when the facility initiated the discharge. Interview on 4-16-19 at 10:02 AM with the DON (Director of Nursing) confirmed up until the incident on 3-4-18 the facility had not been planning on discharging Resident 372 and there had not been any discussions or written information given to the legal representative about needing to discharge the resident. After the incident of 3-4-18 with the 3 other residents, the facility felt at times, the resident required 1:1 attention and the facility did not have the staff to provide this so therefore felt they could not meet the resident's needs. The DON confirmed a 30 day notice had not been given to the resident or legal representative nor had a written explanation been given explaining the reason for the discharge.",2020-09-01
5648,"LANCASTER REHABILITATION CENTER, LLC",285275,1001 SOUTH STREET,LINCOLN,NE,68502,2016-11-22,176,D,1,0,FLP211,"**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 ensure the safety of one resident (Resident 100) out of 43 residents on the dementia unit to self-administer medications. The facility census was 221. Findings are: Observed on 11-22-16 at 7:12 AM Resident 100 sat in a chair in the solarium of the secured dementia unit with two [MEDICATION NAME] HFA Inhaler units (an aerosol medication used to treat [MEDICATION NAME] of the lungs and open up the airways) in the resident's hands and no staff within sight. Interview on 11-22-16 at 7:20 AM with LPN-A (Licensed Practical Nurse) revealed Resident 100 self-administered the [MEDICATION NAME] HFA inhaler and the resident kept the inhaler in the pants pocket. LPN-A revealed the resident lived on the dementia unit because the resident wandered and hallucinated. Review of Resident 100's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 10-13-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 3 which indicated severely impaired cognition. Resident 100 exhibited the behaviors of hallucinations and delusions. Resident 100 required supervision of 1 staff with bed mobility, transfers, walking, locomotion on the unit, dressing, and toileting. The resident required extensive assistance of 1 with locomotion off the unit. Interview on 11-22-16 at 12:11 PM with the SW-C (Social Work Manager) revealed the process in the facility when a resident requested to self-administer a medication was the Interdisciplinary Team reviewed the request to ensure the resident's cognition level and safety ability. A Physician's order would be obtained, a self-administration assessment would be completed and the resident's ability to self-administer the medication would be placed on the Care Plan. Review of the Physician orders for Resident 100 dated 10-3-16 revealed [MEDICATION NAME] HFA aerosol inhale 2 puffs by mouth every 4 hours as needed for SOB (shortness of breath) or wheezing. The Physician orders did not have an order for [REDACTED]. Review of the care plan revealed no documentation about the resident to self-administer the [MEDICATION NAME] HFA inhaler. Interview on 11-22-16 at 12:06 PM with SW-B (Social Worker) revealed the Care Plan Team was not a part of the decision to allow the resident to self-administer the [MEDICATION NAME] HFA Inhaler. Interview on 11-22-16 at 1:45 PM with the UNM (Unit Nurse Manager) confirmed there was not a Physician order for [REDACTED]. UNM confirmed the decision to allow the resident to self-administer the [MEDICATION NAME] HFA inhaler was not discussed with the Care Plan Team and was decided upon to deter the resident's behaviors.",2019-11-01
5329,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-01-31,241,D,1,0,BKZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(21) Based on observation and interviews, the facility staff failed to ensure residents were treated with respect and dignity while providing cares for one (Resident 14) of three residents reviewed. The facility census was 69. Findings are: Review of Resident 14's face sheet revealed the resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 14's Minimum Data Set (MDS- a federally mandated assessment) completed on 12/26/2016 revealed Resident 14 had a BIMS (Brief Interview of Mental Status assessment) score of 15/15 which meant Resident 14 was cognitively intact. An observation was made on 01/25/17 at 2:17 PM of Nurse Aide (NA) G and NA H providing peri-care to Resident 14. NA H gathered supplies and Resident 14 was lying in bed on back was pillow pulled out from under Resident 14's hips by NA H and G, Resident 14 yelled out in pain, crying. NA G stated that she has not had a break yet today and has never worked with the resident. Resident 14 was assisted to roll on to Resident 14's side, Resident 14 hollered out in pain when rolled and NA H cleansed Resident 14's bottom and removed soiled brief, applied a new brief and Resident 14 was then assisted onto back. Pericare was then provided to the front of the resident. NA H and NA G applied powder in abdominal folds and Resident 14 asked if the staff got the left side. NA G replied yes and rolled eyes and then placed towels under abdominal folds. Resident 14 then told NA G and NA H that Resident 14 had problems getting pillows situated under hips and legs comfortably and staff needed to help lift Resident 14's legs and be sure and not to drop them, as that really hurts. NA H lifted Resident 14's and put pillow under hip and leg and the resident yelled out that it hurt. NA G then lifted Resident 14's left leg to put a pillow under it and Resident 14 yelled ow. Resident 14 then stated that the pillow wasn't under the leg only the hip. NA G stated yes it was, and Resident 14 stated no it was not. NA G then rolled eyes and pulled pillow out from under the resident and NA H stated that NA H would do it. NA G then stated, that NA G needed to take a break and stepped away. NA H then lifted the resident's left leg and put the pillow under it and the resident yelled ow. An interview with Resident 14 conducted on 01/25/2016 at 3:15 PM revealed that Resident 14 stated Resident 14 felt like a burden to staff by seeing staff roll their eyes and hear the comments that the staff needed to go take a break repeatedly. Resident 14 reported that Resident 14 had seen and heard this a lot and it really bothered (gender) the way that staff treated (gender). An interview conducted on 1/25/17 at PM with the Administrator revealed that staff were not to roll their eyes at residents nor tell them that they need to go take a break during cares. The administrator agreed that was not respectful to Resident 14 and should not have been done.",2020-01-01
1430,LIFE CARE CENTER OF OMAHA,285137,6032 VILLE DE SANTE DRIVE,OMAHA,NE,68104,2018-03-19,550,D,1,1,93SH11,"**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 a urine drainage bag was covered to maintain dignity for 1 (Resident 22) of 2 residents. The facility staff identified a census of 92. Findings are: Record review of Resident 22's Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) dated 2-28-2018 revealed Resident 22 had a Brief Interview for Mental Status (BIMS) of 15. According to the MDS Manual a score of 13-15 indicated a person was intact cognitively. The resident had the [DIAGNOSES REDACTED]. Observation on 3-14-2018 at 4:17 PM revealed Resident 22 was in bed and the [MEDICATION NAME] drainage bag was hung on the side of the bed without a cover. Observation on 3-13-2018 at 2:00 PM revealed Resident 22 was up in a wheelchair with a urine collection bag uncovered. On 3-14-2018 at 4:17 PM an interview with Resident 22 was completed. During the interview, Resident 22 reported that (gender) would like to have the drainage collection bag covered. Observation on 3-15-2018 at 4:45 AM revealed Resident 22 was in bed and the urine collection bag was uncovered and exposed to the view of the door. Observation on 3-19-2018 at 9:23 AM revealed Resident 22 was in bed. Resident 22's urine drainage beg was uncovered and exposed to the door view. On 3-19-2018 at 9:23 AM an interview was conducted with Licensed Practical Nurse (LPN) F. During the interview LPN F confirmed Resident 22's urine drainage bag was uncovered and should have been in a dignity bag.",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
2213,GOOD SAMARITAN SOCIETY - ST JOHNS,285189,3410 CENTRAL AVENUE,KEARNEY,NE,68847,2018-04-16,622,D,1,1,KX9U11,"**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 give the regulatory required notice of discharge and provide documentation of the reason for the discharge for Resident 9. Sample size was 16. Facility census was 46. Findings Are: Review of Resident 9's MDS (Minimal Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1/23/18 showed an admission date of [DATE]. Review of MDSs dated 1/23/18, 11/7/18, 8/21/18, 6/6/18, 3/21/17, 1/3/17, and 10/11/16, revealed that the resident had no behaviors physically, verbally or threatening toward others coded on the MDSs. Also noted on each MDS was a BIMS (Brief Interview For Mental Status) of 15. A score of 15 indicated a person was intact cognitively. Review of the Resident 9's Care Plans with start dates of 3/29/18, 1/10/18, and 11/15/17 showed the Care Plans were not revised or updated with new interventions or goals, and no revisions regarding any behaviors with roommates, other residents, or staff. Behaviors addressed on the Care Plan for Resident 9 included noncompliance with physician orders [REDACTED]. Review of Progress Notes from 11/29/17 through 3/26/18 revealed one verbal altercation with Resident 9 and the roommate was witnessed by a NA (Nurse Aide). There was no documentation of Hallucinations in the Progress notes. Review of Progress Notes from 3/9/18 through 3/26/18 revealed documentation of contacts to local nursing homes and ombudsman. There was no documentation of Hallucinations in the Progress notes. Review of Medical [DIAGNOSES REDACTED]. Review of facility Incident Reports for the last six months revealed no resident to resident altercations with Resident #9 and any other resident or staff. Review of a File from the (ADM) Administrator regarding a written report dated 3/21/18 revealed that an incident of an alleged verbal abuse occurred on 3/4/18 at 2:16 PM. On 3/5/18 the SSD (Social Service Director) and ADM were informed of what Resident 9 had said to roommate. The local Ombudsman was contacted A primary care provider note in the medical record dated 3/15/18 revealed, To Whom It (MONTH) Concern, this resident at a nursing home, has had recent increases in verbal abuse and inappropriate behaviors towards multiple roommates and residents at the nursing home. Resident is a potential risk to self and/or others. Resident would most likely be better served in different living circumstance because of these factors. Record review of the discharge form Notification Of Transfer or Discharge-Nebraska revealed the reason for transfer/discharge was the safety of individuals in the facility i-was endangered due to the behavioral status of the resident. The form did not state the facility the resident would be discharging to. Interview on 04/11/18 at 05:28 PM with ADM (Administrator) revealed Resident 9 had no documented Resident to Resident altercations and if there were any it was years ago. The only one recently was with the former roommate and no staff persons. The Administrator agreed there were no revisions on the Care Plan regarding the resident's recent verbal behavior with former roommate and that the MDSs back to 10/11/16 had no coding for behavior on them in the Behavior section. 04/12/18 at 04:55 PM record review of Physician notification of changes in behavior listed in Resident Spaces in Computer system revealed one notification regarding change in Resident 9's behaviors from 4/10/18 through 4/17/17.",2020-09-01
1802,PLUM CREEK CARE CENTER,285159,1505 NORTH ADAMS STREET,LEXINGTON,NE,68850,2018-12-18,622,D,1,1,P4JF11,"**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 ensure that discharge planning was completed for Resident 86. Facility census was 37. Findings are: Review of Admission Status for Resident 86 on Admission Record and Census revealed an admission date of [DATE] Review of Elopement Risk Assessment for Resident 86 dated 10/1/2018 revealed a history of elopement prior to admission, including Resident 86 wandering outside the home, to neighbors and being unable to find the way back home. Review of 72 hour Transitional Care Meeting and Discharge Plan form for Resident 86 dated 10/1/2018 revealed upon admission the Plan #1 on page 1 of 2 Section B Plan stated, Resident plans to stay in this community long term and the Barriers to discharge in #2 on page 1 of 2 revealed, Family unable to keep Resident 86 safe at home due to wandering. Review of Transfer/Discharge Report dated 11/16/18 and signed by Residents 86's daughter revealed no documentation for Chief complaint (reason for transfer). Review of Resident 86's Progress Notes (PN) revealed the following: Progress note for Resident 86 dated 11/6/2018 stated: Administrator and I met with resident's family today in regards to different placement. Due to the residents love of being outdoors and elopement we stated that we feel a locked unit would be more beneficial for resident's well being. Family agreed and stated they would go talk to another facility on 11/7/18. We offered to assist in anything they needed for the transition. Progress note for Resident 86 dated 11/11/2018 stated: Staff from the other facility called today requesting information on resident. Family had been in and toured their facility. Called and talked to POA (Power of Attorney) and POA gave verbal consent to fax information. Progress note for Resident 86 dated: 11/15/2018 stated: Called and spoke w/daughter, POA (Power of Attorney) about today's elopement. Spoke w/daughter about concern of resident's elopement and how fast resident is able to leave facility. Family is planning on resident going to another facility on Monday. Told daughter our concerns of how cold the temperature is supposed to be this weekend. We have concern about resident remaining in our facility and the risk of elopement. At this time, the other facility was not able to admit until Monday. Asked daughter, if they could take resident home over the weekend until the other facility can admit resident on Monday. Daughter said yes they could. They will plan on coming after they are done driving the bus tomorrow afternoon, between 4:30 PM and 5 PM, to get resident. Progress note for Resident 86 dated 11/16/2018 which is the last Progress Noted in Resident 86's EHR (Electronic Health Record) stated: received order for resident to discharge with current medications. Did explain to MD (Medical Director) that resident will be leaving with family today and to admit to the other facility on Monday. PCP (Primary Care Provider) did Ok this. Review of physician orders [REDACTED]. Review of Paper work received from the DON (Director of Nursing), MDS Coordinator, and Social Services revealed no confirmed fax date and time stamp for when information was sent to the other facility. The date Resident 86 went to the other facility was 11/19/18 and the date the information was printed off to fax was 11/21/18. Review of Care Plan revealed a print date of 11/21/18 with a focus for resident being admitted to this facility for staying long term. Resident 86 being an elopement risk was also focused on with an initiation date of 10/4/2018. The Care Plan was not revised and updated to indicate a change in the plan to discharge. On 12/18/18 at 2:00 PM request was made for information from the DON (Director of Nursing) about Resident 86's discharge such as the Discharge Summary and a letter of Involuntary/Voluntary Discharge Notification and no paperwork was presented.",2020-09-01
1280,ARBOR CARE CENTERS-NELIGH LLC,285124,"PO BOX 66, 1100 NORTH T STREET",NELIGH,NE,68756,2019-03-11,604,D,1,1,UV2T11,"**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 assess Resident 85 for use of a potential physical restraint prior to applying a seat belt alarm (a self-release belt secured about the waist that alarms when the clasp is released) to the wheelchair and recliner, and to provide routine monitoring to assure the resident was able to remove the seat belt independently and on command. 2 residents were reviewed for physical restraints, and the total facility census was 36. Findings are: Review of the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/6/18 revealed the following regarding Resident 85: -[DIAGNOSES REDACTED]. -a BIMS (Brief Interview for Mental Status) score of 7 which indicated severe cognitive impairment; -required extensive assistance with bed mobility, transfers, dressing and toilet use; -a history of falls; and -a bed alarm and chair alarm were used daily. Review of the current Care Plan dated 8/5/18 indicated the resident was at risk for falls related to poor safety awareness, generalized weakness, poor balance at times, shuffled gait, impulsiveness and impatience. Nursing interventions included the following: -encourage to ask for assist with transfers; -call light within reach; -provide a well-lit and clutter freed environment; -encourage to ask for assistance when attempting to transfer; -provide appropriate footwear; -seat belt alarm on both wheelchair and recliner; sensor alarm on bed when occupied; and sensor alarm on chair in dining room; and -check ability to self release seat belt upon command every shift and every Friday and document results in the progress notes. Review of Nursing Progress Notes revealed the following: -11/30/18 at 9:30 AM - Heard alarm sounding and observed Resident 85 fall face forward to the floor in the doorway; and -11/30/18 at 11:19 AM - removed the table in the resident's room used to help get up out of the wheelchair, and put a seat belt alarm on the wheelchair instead of a sensor alarm. There was no evidence in the medical record that an assessment for the appropriate use of the seat belt alarm was completed prior to it's use to assure Resident 85 was not physically restrained. Furthermore, there was no evidence the seat belt alarm was routinely monitored to assure Resident 85 was consistently able to release it independently and on command. During interview on 3/11/19 at 8:29 AM, the Director of Nursing (DON) confirmed there were no facility policies/procedures for the assessment of residents prior to the application of seat belt alarms as potential physical restraints, and that routine monitoring of Resident 85's seat belt alarm was not completed.",2020-09-01
6693,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7350 GRACELAND DRIVE,OMAHA,NE,68134,2015-11-10,223,D,1,0,UFAP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(8) Based on records review and interviews; the facility failed to investigate potential sexual abuse for one resident (Resident 2). The facility staff identified a census of 63. Findings are: A. Review of admission record dated 9/20/2015 revealed Resident 2 was admitted on [DATE] with the following Diagnosis: [REDACTED]. Record Review of a physician history and physical (H&P) dated 7/09/2013 revealed that Resident 2 had a previous history of Dementia with both short term and long term memory loss. Under the section of the H & P titled 'exam' was information that Resident 2 was A&O (alert and orientated-Person, Place and Time) X3. Record review of a physician H & P, dated 12/1/2014, revealed in the exam notes section under exam neurological: - Alert and oriented to person but not to place or time. - The mini mental exam -MMSE (Mini-Mental State Examination) score was recorded as 18/30. According to the MMSE testing sheet, a score of 18-23 showed Mild cognitive impairment. - Dementia: testing showed problems with orientation, but was able to go to meals on (gender) own. Did very well with the following instructions. Would require assisted living level of care for adequate nutrition as was dependent on food being provided. Not able to cook in own home. Record Review of Resident 2's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 8/19/2015 revealed Resident's 2 BIMS (Brief Interview for Mental Status) score of 6. According to the MDS Manual, a BIMS score of 00-07 indicates severe impairment. Record Review of the facility's Abuse, Neglect or Misappropriation report, dated 10/29/2015, revealed that, on 10/29/2015, a Nursing Assistant walked into Resident 1's room and found Resident 1 preforming a sex act with Resident 2. Both residents were separated and redirected and their physicians, POAs (Power of Attorney) and families were notified for the incident. Under the section what immediate steps were taken to protect the Resident? it was noted that both were separated and redirected as the staff were unsure if family members were comfortable with this level of intimacy. Record review of Resident 2's chart and EMR (Electronic Medical Record) revealed there were no notes found of an assessment of Resident 2's ability to consent to the sexual actions or investigation of potential sexual abuse. An interview with Resident 2 was conducted on Tuesday, 11/10/2015 at 1:30 PM revealed Resident 2 was not orientated to person or place, just to self. Resident 2 did not recall (gender) date of birth, age, whether or not Resident 2 had a roommate or who else lived in the facility. Resident 2 denied that (gender) was engaged in any sexual actions with anybody at the facility. Resident 2 stated that (gender) did not know anyone at the facility. When asked about Resident 1, Resident 2 stated that (gender) knew Resident 1, but that they were only friends and denied engaging in any sexual actions with Resident 1. An interview with RN A (Registered Nurse A) on 11/10/2015 at 1:49 PM, revealed Resident 2 was A&O (alert and orientated) x1 all the time, but 2-3 days a week x2. When asked if Resident 2 was capable of making an informed consent to engage in sexual relations, RN A stated Resident 2 had good days and bad days, but not 100% of the time. When asked if Resident 1 and Resident 2 should be having sex, RN A confirmed that they should not be having sex based on Resident 2's BIMS Score of 6. When asked if Resident 2 could make those decisions, RN A said No. A telephone interview with Resident 2's POA on 11/10/2015 at 3:16 PM revealed that Resident 2's confusion level ha increased and the POA didn't think that Resident 2 had the cognitive ability to make the decision to have sexual relations. The POA had only seen hand holding and talking and nothing more. POA stated that the POA had never witnessed any public displays of affection such as kissing or hugging. An interview with SSD (Social Services Director) on 11/10/2015 at 2:15 PM confirmed that a BIMS of 6 indicated that a resident was severely cognitively impaired. Further interview confirmed that a resident, with a BIMS Score of 6, couldn't make their own decisions consistently, and that no evaluation of Resident 2's ability to consent to the relationship was performed. SSD further stated that Resident 2 was not consistent in Resident 2 answers to questions.",2018-11-01
4367,"BCP COLUMBUS, LLC",285152,1112 15TH STREET,COLUMBUS,NE,68601,2018-04-10,600,D,1,1,9GM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(9) Based on interview and record review, the facility failed to protect Resident 28 from potential misappropriation of property. The sample size was 18 and the facility census was 36. Findings are: [NAME] Review of the facility Abuse, Neglect, and Exploitation Prohibition and Prevention Program policy with a revision date of 2/9/17 revealed misappropriation of resident property included stealing cash or property. Review of a facility investigation dated 5/15/17 revealed Resident 28 had a missing piggy bank with money in it. Further review revealed during the investigation Nursing Assistant (NA)-E reported that Volunteer-L was seen in Resident 28's room. Further review revealed no evidence to indicate Volunteer-L was interviewed/investigated regarding the missing piggy bank with money in it. Interview with NA-E on 4/5/18 at 1:55 PM revealed Volunteer-L went into resident rooms when the residents were not in them. NA-E confirmed these concerns were voiced during an investigation regarding the missing money and missing piggy bank that belonged to Resident 28. NA-E confirmed the concerns of Volunteer-L going into resident rooms was also reported prior to Resident 28's missing money and piggy bank. Interview with the Social Services Director (SSD) on 4/9/18 at 1:21 PM confirmed Volunteer-L was a volunteer at the facility at the time Resident 28's piggy bank with money in it went missing. The SSD confirmed Volunteer-L was not interviewed following the incident involving Resident 28's missing money and piggy bank (even after Volunteer-L's suspicious behavior was identified in the investigation process). B. Review of the facility Pre-Employment Background Check Process policy dated 4/1/15 revealed a Team Member included all employees as well as volunteers. Further review revealed a criminal search was required and would be conducted for all candidates. Review of the facility Volunteer Program Guidelines dated 1/5/07 revealed a Junior Volunteer was any volunteer less than [AGE] years of age. Further review revealed the following was required for Junior Volunteers: -Junior Volunteers would fill out an application and provide references; -Junior Volunteers would participate in an orientation program prior to their service; -Junior Volunteers would have a signed job description; -Junior Volunteers would have direct supervision while they were in the building; and -Junior Volunteers would sign in and out. Review of the Volunteer Sign-In Sheet revealed no evidence to indicate Volunteer-L signed in or out when volunteering at the facility. Review of the Volunteer Background Check book revealed no evidence to indicate Volunteer-L had a background check completed prior to volunteering at the facility. Interviews with the Activity Director (AD) on 4/5/18 at 11:17 AM and 4/10/18 at 7:29 AM confirmed Volunteer-L was a volunteer under the age of 16. The AD revealed volunteers should have a background check done prior to starting and were to sign in and out when they volunteered. Further interview revealed Volunteer-L's main duty was to read to a resident in the resident's room (where Volunteer-L was not under direct supervision). The AD confirmed Volunteer-L was seen going in and out of residents' rooms when the residents were not in them. The AD was unsure if a background check had been completed for Volunteer-L since the volunteer was under the age of 16.",2020-08-01
2432,COMMUNITY PRIDE CARE CENTER,285208,901 SOUTH 4TH STREET,BATTLE CREEK,NE,68715,2019-08-06,600,E,1,1,LEUQ11,"**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 ensure interventions were in place to protect residents from potential allegations of verbal and/or physical abuse involving 4 (residents 11, 33, 99 and 100) of 5 sampled residents reviewed for abuse. The facility census was 48. Findings are: [NAME] Review of the facility policy titled Abuse, Neglect, and Misappropriation of Resident Property Policy (Undated) included the following related to Definitions of Abuse and Neglect: -Verbal abuse was the use of oral, written or gestured language that willfully included disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability; and -Physical abuse included hitting, slapping, pinching and kicking. It also included controlling behavior through corporal punishment. B. Review of an Alleged Report of Possible Abuse/Neglect dated 12/26/18 revealed an investigation was conducted regarding an allegation that Nurse Aide (NA)-I was rough when providing cares for Resident 99 and had used inappropriate language in front of Resident 33. The following was revealed: -Resident 33 was admitted with [DIAGNOSES REDACTED]. -Resident 99 was admitted with [DIAGNOSES REDACTED]. -12/22/18 NA-J was assisting NA-I with getting Resident 33 ready for bed. Staff were using the Hoyer Lift (a mechanical device that allows residents to be transferred between a bed and a chair using hydraulic power and requires no weight bearing assistance from the resident) to transfer the resident and the lift was malfunctioning and kept dying. NA-J reported every time the lift quit, NA-I would say this mother [***] ing thing. NA-J further reported Resident 33 kept apologizing as the resident felt the malfunction was the resident's fault; -12/23/18 NA-J assisted NA-I with putting Resident 99 to bed. Resident 99 was seated on the side of the bed and NA-I pushed the resident into the bed. NA-J indicated Resident 99 was almost in tears and complained of shoulder pain and NA-J felt NA-I was rough when putting a night gown on the resident. NA-I then told NA-J the resident had been like this the last 3 nights and NA-I was done with this; -12/24/18 (2 days after the incident of verbal abuse by NA-I related to Resident 33 and 1 day after the physical abuse by NA-I related to Resident 99) NA-J reported the above allegations to the Director of Nursing (DON); -12/24/18 at 8:30 AM the DON notified Adult Protective Services of the abuse allegations; -12/24/18 at 9:15 AM, NA-I was suspended pending an investigation; and -12/26/18 NA-I's employment was terminated as the allegations were substantiated. C. Review of the facility Grievance Log revealed on 1/23/19 at 1:00 PM, Resident 100 reported a concern to the Social Service Director (SSD) regarding treatment by Licensed Practical Nurse (LPN)-B. The resident indicated the resident's medications were brought late to the resident's room. When LPN-B brought the medications the resident was on the phone with a friend. LPN-B spoke harshly to the resident and had spoken loudly enough for the resident's friend to overhear the conversation while on the phone with Resident 100. Review of facility investigations from 12/1/18 through 8/1/19 revealed no evidence an investigation was completed regarding the resident's allegation that LPN-B had spoken harshly to the resident or that interventions were put into place to prevent further potential verbal abuse. D. Review of Resident 11's Behavior Progress Notes dated 2/24/19 revealed at 11:27 AM, Resident 11 was coming down the hallway and saw another resident in the way. Resident 11 indicated the other resident was going to have to move. Staff attempted to move the other resident when Resident 11 gave a hard pat to the other resident's left knee to get them out of the way. Staff told Resident 11 this was unnecessary and the resident needed to be more patient. Review of facility investigations from 12/1/18 through 8/1/19 revealed no evidence an investigation was completed regarding the resident to resident altercation with Resident 11 to identify which other resident was involved or that interventions were put into place to prevent further occurrence. Review of the facility Grievance Log revealed on 3/26/19, Resident 11 had voiced a complaint regarding treatment by NA-[NAME] Resident 11 had activated the call light in the resident's room and when NA-A responded, the resident requested assistance with use of the urinal. NA-A wanted the resident to use the bathroom and the resident indicated discomfort with moving and again asked for the urinal. Resident 11 stated NA-A threw the urinal into the resident's lap and then left the resident's room. Review of facility investigations from 12/1/18 through 8/1/19 revealed no evidence an investigation was completed regarding Resident 11's allegation concerning treatment by NA-A or that interventions were put into place to prevent potential further abuse. E. During an interview on 7/31/19 at 2:02 PM, Resident 33 identified NA-I could be pretty mean sometimes. When asked if the resident had reported this, the resident stated everyone knew it. F. Interview with the DON on 8/5/19 at 7:18 AM confirmed the following: -NA-I was scheduled and provided direct resident cares on 12/22/18, 12/23/18 and 12/24/18. NA-J did not report the potential allegation of verbal abuse related to Resident 33 on 12/22/18 or the potential allegation of physical abuse towards Resident 99 which had occurred on 12/23/18 to the DON until 12/24/18; -no education had been provided to NA-J or to the other facility staff regarding the timely reporting of potential allegations of abuse; -the grievances related to Resident 100's concern about how LPN-B spoke to the resident and Resident 11's concern about treatment by NA-A should have been investigated as potential abuse allegations and interventions should have been put into place to assure the residents were protected; and -the DON was never informed a resident to resident altercation had occurred between Resident 11 and another resident. Further interview revealed the DON had determined the other resident involved was Resident 99. No interventions had been put into place to protect Resident 99 or to prevent Resident 11 from involvement of further resident to resident altercations. In addition, no education had been provided to the facility staff to assure timely reporting of potential abuse.",2020-09-01
3069,PARKSIDE MANOR,285245,"P O BOX 350, 607 NORTH MAIN STREET",STUART,NE,68780,2018-11-06,600,E,1,1,YR0C11,"**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 ensure interventions were in place to protect residents from verbal abuse and sexual abuse involving 4 of 6 sampled residents (Residents 13, 15, 17 and 2) reviewed for abuse. The facility census was 21. Findings are: [NAME] Review of the facility policy titled Abuse, Neglect, and Misappropriation of Resident Property, (Undated) included the following related to Definitions of Abuse and Neglect: -Verbal abuse was the use of oral, written or gestured language that willfully included disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability; and -Sexual abuse was non-consensual sexual contact of any type with a resident. The policy further indicated the facility would protect the residents from the alleged offenders. B. Review of Resident 13's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/28/18 revealed the resident was admitted to the facility 9/17/18 with [DIAGNOSES REDACTED]. -was cognitively intact; -experienced delusions (misconceptions or beliefs that were firmly held and contrary to reality); -had physical behavioral symptoms directed toward others (such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually) on 1 to 3 days; -exhibited wandering behaviors on 1 to 3 days; and -required limited assistance with transfers and ambulation with use of a walker. Review of Resident 13's comprehensive Care Plan (not dated) indicated the resident displayed socially inappropriate behavior by touching or exposing self in the company of others, and trying to touch and/or kiss other residents, thinking they were a spouse. Review of Nurses Notes revealed the following related to Resident 13: -9/19/18 at 4:13 PM - thinks another resident (unidentified) is spouse and did kiss (the resident); -9/22/18 at 2:49 PM - noted ambulating into other unidentified resident rooms and needed redirection. Also noted leaning over another resident (unidentified) and rubbing the resident's leg; and -9/24/18 at 9:25 AM - housekeeper reported finding the resident in another unidentified resident's room. There was no evidence these incidents were investigated in an attempt to identify the residents targeted by Resident 13, and to develop interventions to prevent further invasion of their personal space and inappropriate sexual behaviors. Review of a Social Services Note dated 9/27/18 at 11:12 AM revealed staff were trying to keep Resident 13 at least an arms length from a certain (gender) resident (unidentified) that Resident 13 knew previously from home town. Documentation indicated Resident 13 sometimes gets a little too close and the unidentified resident is not cognitive enough to know. Review of Nurses Notes dated 9/30/18 at 10:59 AM revealed that prior to breakfast dietary staff observed Resident 13 fondling Resident 2 in front of the nurses station. Review of an Alleged Report of Possible Abuse/Neglect dated 10/4/18 revealed an investigation of the incident that occurred between Residents 13 and 2 on 9/30/18. The following was revealed: -Resident 2 was admitted with [DIAGNOSES REDACTED]. -At approximately 7:30 AM the Dietary Aide (DA) observed Resident 13 leaning over Resident 2, who was in a wheelchair, with 1 hand under Resident 2's shirt and the other hand in own pants; and -Resident 13 was placed on timed periodic checks every 15 minutes, an alarm was placed on Resident 13's door to alert staff when the resident entered and/or exited the room, supervision and diversional activities were increased, and an appointment for a psychiatric consult was initiated. During interviews the following was revealed: -10/31/18 at 10:54 AM - the Director of Nursing (DON) indicated Resident 2's name was removed from the room door in an attempt to prevent Resident 13 from identifying Resident 2's location and acting inappropriately with Resident 2; and -11/1/18 at 11:00 AM - Registered Nurse (RN)-A verified Resident 13 targeted Resident 2 as spouse as they did know each other previously from their home town. C. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/10/18 revealed [DIAGNOSES REDACTED]. Review of Resident 15's Care Plan (undated) revealed the following: -Becoming more verbal with other residents. Denies making fun of them or being verbal. If resident is being verbal remove from area for a short time; and -Yells at other residents or mimics them when they talk or make a noise. A goal was identified for Resident 15 to stop making fun of other residents when sitting in the living room. Interventions to prevent Resident 15's verbal behaviors included observing the resident when in the living room with other residents and removing the resident from public areas when behavior was disruptive. Review of Nurses Notes revealed Resident 15 was verbally abusive to other unidentified residents as follows: -6/1/18 at 2:26 PM-yelled .shut up, you[***] and shut up every time the resident in another room hollered out; -6/13/18 at 11:13 AM-called another resident an expletive and mimicked other residents calling them names; -7/15/18 at 5:25 PM-yelled at another resident to get out of the way and called the other resident an[***] ; -7/25/18 at 1:01 AM-after supper made unkind and mocking comments to another resident; -7/26/18 at 9:58 AM-yells at another resident to shut the hell up you freak; -8/23/18 at 2:29 PM-stated repeatedly to another resident to shut up you[***] and at meals will call other residents names; -8/27/18 at 4:38 PM-makes rude statements to another resident such as shut the hell up you dummy or be quiet[***] . Resident 15's tablemate refused to sit with Resident 15 at meals due to Resident 15 calling the tablemate names and being mean to the tablemate; -9/1/18 at 12:55 PM-made rude comments at breakfast and lunch to tablemate. Voiced to the tablemate .you have a long ugly face and your (you are) an[***] ; -9/12/18 at 3:06 PM-mocked another resident and called the other resident foul names; and -9/14/18 at 10:53 AM-called another resident a .dumb ass and mocked other residents seated in the living room. There was no evidence Resident 15's incidents of verbal abuse toward other residents were investigated in an attempt to identify the residents targeted by Resident 15. In addition, there was no evidence additional interventions were developed to protect other residents from Resident 15's verbal abuse. Interview with Nursing Assistants (NA)-B and NA-D on 11/5/18 at 9:38 AM confirmed Resident 15 made fun of Resident 17 in particular. NA-B and NA-D reported Resident 15 and Resident 17 do not sit at the same table in the dining room and staff monitor where Resident 15 sits to make sure Resident 15 is not seated in an area where the resident can make fun of other residents.",2020-09-01
2114,BUTTE SENIOR LIVING,285180,210 BROADWAY,BUTTE,NE,68722,2017-07-19,223,D,1,0,PFZV11,"**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 residents from potential neglect during an ongoing investigation of a fall sustained during an unsafe transfer of Resident 1. The sample size was 3 and the facility census was 30. Findings are: Review of the facility policy titled Abuse, Neglect, and Misappropriation of Property Prevention with a revision date of 3/1/09 defined neglect as a failure through inattentiveness, carelessness, seclusion, or omission, without a reasonable justification, to provide timely, consistent, and safe services, treatment, and care to a resident. Further review revealed for protection of the residents, the staff member would be suspended without pay until the investigation was completed. Review of Resident 1's current undated Care Plan revealed the resident was admitted to the facility on [DATE] with flaccid [MEDICAL CONDITION] (paralysis affecting one side of the body) affecting the left side and a right leg [MEDICAL CONDITION]. Further review revealed on 7/7/17 the resident required 2 staff assistance for transfers and positioning. Review of the Resident Incident Report dated 7/7/17 revealed Resident 1 had fallen on 7/7/17 at 9:20 PM. The resident was transferred from the wheelchair into bed by Nursing Assistant (NA) - C. When NA-C turned away from the resident to move the resident's wheelchair, the resident rolled onto the floor. Review of the Investigative Report submitted to the State Agency on 7/12/17 revealed on 7/8/17 (the day after the fall) Resident 1 complained of left hip pain, was transferred to the emergency room , and was diagnosed with [REDACTED]. Interviews with the Administrator on 7/19/17 at 11:45 AM, 12:35 PM, and 3:00 PM confirmed: - Resident 1's fall was a result of the resident being transferred with 1 staff member instead of 2. - Licensed Practical Nurse- F failed to identify the fall as potential neglect. Therefore, NA-C continued to work with the residents through the remainder of NA-C's shift. - NA-C was then suspended on 7/8/17 pending investigation, but had continued to work with the residents the night of 7/7/17 into the morning of 7/8/17. -NA-C was allowed to return to work following a written disciplinary warning and re-education. - Once the investigation was completed, the Administrator determined it was a system breakdown and/or a communication issue, and neglect was not substantiated.",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
1363,LIFE CARE CENTER OF ELKHORN,285134,20275 HOPPER STREET,ELKHORN,NE,68022,2019-02-19,600,L,1,0,2BLY11,"**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 protect residents during an investigation of a sexual assault allegation. The facility failure had the potential to affect all residents residing in the facility. The facility staff identified a census of 105. Findings are: Record review of the facility Policy and Procedure for Protection of Residents: Reducing the Threat of Abuse & Neglect revised on 2-2018 revealed the following information: -Introduction: -To minimize the threat of abuse and/or neglect , nursing homes must incorporate clear cut policy and practices that demonstrate a hardline,zero tolerance approach to resident abuse. -Position Statement and Guidelines: - Residents must not be subjected to abuse by anyone. -It is the policy and practice of this facility that all residents will be protected from all types of abuse,neglect, misappropriation of resident property and exploitation. -Investigation and Protection: -It is the policy of this facility that reports of abuse (abuse, neglect, mistreatment, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. -Procedure: -1. Following identification of alleged abuse, the resident(s)receive prompt medical attention as necessary and the resident(s) are protected during the course of the investigation to prevent recurrence. Staff will respond immediately to protect the alleged victim(s)/others and integrity of the investigation. -3. When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence. Protection will be provided to the alleged victim and other residents, such as room or staffing changes as needed to protect the resident(s) from the alleged perpetrator. Record review of a Resident Transfer Record dated 2-03-2019 revealed Resident 100 was transferred to the hospital related to increased anxiety and difficulty breathing. Record review of a the facility preliminary investigation note dated 2-04-(2019) revealed the facility Director of Nursing (DON) and the facility Administrator were notified on 2-04-2019 at 12:30 PM of an allegation of sexual assault of 1 of the facility Residents (Resident 100) by the facility Advanced Registered Nurse Practitioner (ARNP) who was following up with Resident 100 in the hospital. Further review of the preliminary investigation note dated 2-04-2019 revealed the police were notified and at apprx (approximately) 1:55 PM returned a call to the facility and obtained the information of the allegation of Resident 100 being sexually assaulted. According to the preliminary investigation note dated 2-04-2019 a police officer followed up with a phone call to the facility on [DATE] at 4:27 PM reporting Resident 100 had injuries to the vaginal region and believed something happened at the facility. On 2-06-2019 at 3:18 PM an interview was conducted with the facility Administrator. During the interview when asked how the facility residents were being protected after the allegation of sexual assault for Resident 100, the facility Administrator reported being instructed not to discuss the issue with anyone and had not implemented interventions to protect the facility residents. The facility Administrator further reported the facility staff had not been educated on the allegation of a facility resident being sexually assaulted. On 2-06-2019 at 4:38 PM an interview was conducted with Detective [MI] During the interview,discussion protecting the facility residents and integrity of the investigation was completed. During the interview, Detective L reported the facility staff should be protecting the facility residents. On 2-06-2019 at 1:20 PM an interview was conducted with Registered Nurse (RN) [NAME] During the interview RN A reported not being aware of an allegation abuse or neglect currently in the facility. On 2-06-2019 at 1:25 PM an interview was conducted with Nursing Assistant (NA) B. During the interview NA B reported not aware of an allegation of abuse currently being investigated in the facility. On 2-06-2019 at 1:30 PM an interview was conducted with Housekeeping (HK) C. During the interview HK C reported not being aware of an allegation of abuse currently being investigated in the building. On 2-06-2019 at 1:35 PM an interview was conducted with LPN D. During the interview LPN D reported not being aware of an allegation of abuse currently being investigated in the building. On 2-06-2019 at 1:45 PM an interview was conducted with NA E. During the interview NA [NAME] reported not being aware of an allegation of abuse currently being investigated in the facility. B. Abatement Statement: Based on the information provided on 2-06-2019 to correct the immediacy of the situation, the facility staff provided the following information to protect residents: 1. No males associates may work unsupervised without female associate in resident care area assisting residents. All staff were to review the requirement prior to starting their next shift. 2. All staff must review and sign off as understanding prior to their next shift of the facility Reducing the Threat of Abuse &Neglect Policy and review of this abatement plan with focus to understand sexual abuse, identifying and reporting injuries of unknown origin. 3. The facility charge nurse must document the review of the policy and is accountable to ensure no males associates may work unsupervised without a female associate in resident care areas (non-public). 4. The facility Executive Director shall ensure a log is maintained of the staff member assigned and reviewing . The log will be verified with those staff members clocked into the facility. 5. All staff are to report immediately to the facility Executive Director any concerns following review of this policy and memo and follow the facility Protection of Residents: reducing the threat of Abuse&Neglect Policy. The immediacy had been removed, however, the deficient practice was not totally corrected. Therefore, the severity was lowered to an F level.",2020-09-01
3743,GOOD SAMARITAN SOCIETY - GRAND ISLAND VILLAGE,285285,4061 TIMBERLINE STREET & 4055 TIMBERLINE STREET,GRAND ISLAND,NE,68803,2019-08-26,600,G,1,0,JW1F11,"**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 2 out of 3 residents (Resident 1 and Resident 7) received weekly baths to promote cleanliness and well-being. The facility census was 61. Findings are: [NAME] Review of the Admission Record dated 8-22-19 revealed a date of admission of 12-18-18 and [DIAGNOSES REDACTED]. Interview on 8-22-19 at 9:15 AM with Resident 1 in the resident's room revealed the resident had a bad sore on the the heel of the left foot and on the 5th little toe. The resident had been to the Wound Clinic and the facility nurses' performed treatments to the wounds. The 5th toe became infected and then that thing happened with the bath. The resident went on to explain the facility had missed providing the resident with baths and then when at the Doctor's office, the Physician found maggots inside the heel wound. The resident revealed the Physician explained to the resident during the time frame when the resident did not receive a bath would have been enough time for a fly to have laved eggs on the wound and the eggs hatched into the maggots. The resident revealed the resident had been very satisfied with the care the resident received at the facility prior but when the resident discovered maggots were found in the wound, the resident was very angry and distraught. Review of the Clinic Referral form dated 8-6-19 revealed maggots in left heel wound today. Review of the bathing documentation from P[NAME] (Point of Care: the computer program where the Nurse Aides document) performed by the Bath Aides for the last 3 months of June, July, and (MONTH) 2019, provided by the Administrator, revealed two time frames when Resident 1 did not receive a weekly bath. During (MONTH) 13 to (MONTH) 21 a period of 9 days revealed absence of documentation of Resident 1 receiving any type of bath or shower. During (MONTH) 27 to (MONTH) 8, a period of 13 day (nearly two weeks) revealed absence of documentation of Resident 1 receiving any type of bath or shower. Review of current bath schedule dated 6-9-19 revealed Resident 1 was to receive a bath/shower on Monday's and Friday's every week. Interview on 8-26-19 at 9:40 AM with NA-C (Nurse Aide) confirmed Resident 1 had never refused to take a bath or shower for NA-C whenever offered and NA-C had never heard any of the other staff talk about Resident 1 refusing baths before. Interview on 8-26-19 at 9:44 AM with LPN-B (Licensed Practical Nurse) revealed LPN-B was not aware of Resident 1 ever refusing to take a bath or shower before. LPN-B revealed LPN-B doubted the resident would refused to bathe because the resident always seemed eager to bathe. LPN-B also revealed the resident did not refuse the nurse to perform the dressing changes to the left foot wounds either. LPN-B revealed the resident would ask at times if the dressing change could be done the next day with the bath instead of today because the dressing changes were to be done either every other day or sometimes every 3 day, depended on the wound treatment at the time. LPN-B revealed the nurses would accommodate and take the dressing off prior to the shower so that the wound would be cleansed in the shower. Interview on 8-26-19 at 11:00 AM with the DON (Director of Nursing) confirmed the documentation from the P[NAME] bathing documentation revealed Resident 1 did not have any type of bath/shower for 9 days from (MONTH) 13 to 21 and for 13 days from (MONTH) 27 to (MONTH) 8, 2019. The DON also confirmed that on (MONTH) 6, 2019 the Physician found maggots in Resident 1 left heel wound which was on the 11 day of the resident not having had a bath/shower. The DON revealed the facility did an investigation and was unable to find an answer as to how the resident was found with the maggots in the wound. The DON revealed the DON could not find any other documentation to refute the resident not having had a bath during the times frames. B. Review of bathing documentation completed by the Bath Aides for the last 3 months for Resident 7. The months of June, July, and August, revealed no baths documented from (MONTH) 1, 2019 until a bath was given on (MONTH) 17, 2019. This was 16 days with no bath given. The next bath documented was (MONTH) 1, 2019 and the next bath documented was (MONTH) 19, 2019. This was 17 days with no bath given. Review of MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used in care planning) dated 7/10/19 revealed that resident was able to make self- understood and was able to understand others. For Section G (Functional Status) revealed Resident 7 was totally dependence with one person physical assist for bathing. An interview on 8/26/19 at 11:35 AM with LPN-A (Licensed Practical Nurse) revealed that when a resident refuses a bath there was a documentation made in the progress notes. Review of the bath schedule for Resident 7 for Cedar Creek revealed Resident 7 was to receive a bath on Mondays and Thursdays. Review of Progress Notes for Resident 7 dated 8/1/2019 through 8/26/2019 revealed no documentation of refusals of baths. Review of Physician order [REDACTED].",2020-09-01
2803,SUNRISE COUNTRY MANOR,285232,"PO BOX A, 610 224TH STREET",MILFORD,NE,68405,2017-05-23,166,F,1,0,2FAT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.06A and B Based on record reviews and interviews, the facility failed to assure resolution of residents' complaints for 3 of 3 sampled residents (Residents 100, 200, and 222 ). This practice had the potential to affect all of the residents. The facility census was 74. Findings are: [NAME] Interview on 5-22-17 at 12:00 PM with LPN-A (Licensed Practical Nurse) revealed the facility did not have any grievances between the dates of (MONTH) 1, (YEAR) and (MONTH) 22, (YEAR). B. Interview on 5-23-17 at 8:55 AM with Resident 100 revealed the resident used to use a form called Care and Concern form for any complaints/grievances the resident wanted to report to the facility. The resident stopped using the forms because the facility did not respond back to the resident with a resolution. Now the resident stated the resident would go to the Administrator face to face to report complaints/grievances but still did not receive consistent responses back with resolution to the issues. Review of Resident 100 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) of 15 which indicated the resident had no cognitive impairment. C. Interview on 5-23-17 at 1:55 PM with Resident 200 revealed the resident denied having been informed of a process to follow to report complaints or concerns the resident may have about the facility, other residents, or any issues. Review of Resident 200 MDS dated [DATE] revealed a BIMS of 14 which indicated the resident had no cognitive impairment. D. Interview on 5-23-17 at 2:00 PM with Resident 222 revealed the resident denied having been informed of a process to follow to report any complaints or concerns the resident may have about the facility, other residents, or any issues. The resident revealed the resident had verbally complained one time about an issue and the resident was not satisfied with the answer. Review of Resident 222 MDS dated [DATE] revealed a BIMS of 12 which indicated the resident was moderately impaired with cognition. E. Interview on 5-23-17 at 09:30 AM with the Administrator (ADM ) confirmed the facility had no grievances filed from (MONTH) (YEAR) to (MONTH) 22, (YEAR). The ADM revealed the current Grievance policy was, if an issue was first addressed informally and not resolved to their satisfaction, then the resident/family would fill out the grievance form. The ADM revealed currently, when a resident/family report issues/concerns such as missing laundry item, noise in the hall, complaints about a care not given etc.; the ADM received the complaint verbally and directed it to the appropriate department manager to address. Either the ADM or the department head followed-up with the resident/family. The ADM confirmed a form was not completed and no documentation was completed about the concern or the follow-up. The ADM confirmed that, between the (MONTH) (YEAR) and (MONTH) (YEAR), the facility did have resident/family complaints and had addressed the issues, but did not have any documentation to show the concerns or the follow-up resolutions that was taken to address the concerns.",2020-09-01
1864,"NORTH PLATTE CARE CENTER, LLC",285165,2900 WEST E STREET,NORTH PLATTE,NE,69101,2017-07-20,166,D,1,0,2TNM11,"**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 failed to resolve grievances to Resident 1's responsible party's satisfaction. This affected 1 of 3 sampled residents. The facility identified a census of 52 at the time of survey. Findings are: Review of Resident 1's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 6/29/2017 revealed an admission date of [DATE]. Resident 1 had a BIMS (Brief Interview for Mental Status) score of 13 which indicated Resident 1's cognition was intact. Interview with Resident 1's responsible party on 7/20/2017 at 11: 05 AM revealed the responsible party had notified the facility staff of issues they had with Resident 1's care and they had not received a resolution of the issues from the facility staff. Resident 1's responsible party revealed they had reported specific concerns to the facility staff regarding Resident 1's oxygen, bathing, call light being in reach, toileting issues, and issues with a staff member. Resident 1's responsible party did not feel the facility staff was working with them to resolve the issues and the staff had not followed up with them to see if the issues had been resolved. Interview with the facility Administrator on 7/20/2017 at 12:00 PM confirmed Resident 1's responsible party had reported issues they had with Resident 1's care. Review of Resident 1's Resident Grievance/Concern/Complaint Report dated 6/26/2017 revealed no documentation the facility staff addressed the specific concerns. Resolution of grievance/concern/complaint: is blank and was grievance/concern/complaint resolved? is marked no with explanation: refused to sign. Referred to LTC (Long Term Care) Ombudsman (A LTC Ombudsman is an advocate for the rights and well being of nursing home and assisted-living facility residents). Interview with the SSD (Social Services Director) on 7/20/2017 at 3:36 PM revealed Resident 1's responsible party refused to sign the grievance form because they did not feel the issues were resolved. Interview with the Administrator on 7/20/2017 at 3:36 PM revealed there was no documentation of what the facility did to resolve the specific issues Resident 1's responsible party had expressed concerns about. Review of the facility policy QAPI-Grievance Form dated 03/13 revealed the following: Documentation of Facility Follow-Up: Note the the investigation used to explore and follow-up on the report. Include steps taken to investigate. Identify by checking yes or not if grievance/concern/complaint was resolved. Describe all actions taken to resolve concern.",2020-09-01
6674,CAREAGE CAMPUS OF CARE,285135,811 EAST 14TH STREET,WAYNE,NE,68787,2015-11-17,166,E,1,0,KXTF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.06B Based on record review and interview, the facility failed to resolve grievances regarding call light response times and failure to provide baths according to the weekly schedule. This affected five confidential residents. Facility census was 41. Findings are: A. Review of the Grievance Resolution Forms dated 4/7/15 through 11/3/15 revealed the following: -5 residents and/or family members voiced concerns regarding the length of time it took for staff to respond to call lights; and -4 residents and/or family members voiced concerns that baths were not provided as scheduled. B. Review of monthly Resident Council Meeting Minutes revealed the following: -4/10/15 - taking too long to answer call lights; -5/8/15 - left in bathroom [ROOM NUMBER] minutes; -6/15/15 - wait too long to go to bathroom, call light not in reach, and baths not happening as scheduled; -7/10/15 - call light not within reach for 1 resident, and bath issues not resolved; -8/14/15 - call lights on for a long time and baths continue to be a problem; -9/11/15 - call lights on for a long time, 15 to 25 minutes, and baths continue to be a problem; -10/9/15 - call lights not being answered and baths not getting done; and -11/13/15 - bath issues not resolved. C. During 5 confidential resident interviews conducted on 11/17/15 from 9:00 AM until 10:30 AM, 3 residents voiced concerns regarding the length of time it took for call lights to be answered, and 3 residents voiced concern regarding baths not being provided as scheduled. D. During interview on 11/17/15 from 1:35 PM until 2:00 PM, the Administrator indicated call light audits had not been completed in response to family and resident complaints, nor had there been an attempt to investigate patterns or trends that could contribute to a resolution.",2018-11-01
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
3648,RIDGEWOOD REHABILITATION & CARE CENTER,285279,624 PINEWOOD AVENUE,SEWARD,NE,68434,2018-06-05,635,D,1,1,RVGM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.08A Based on interviews and record review, the facility failed to ensure admission orders [REDACTED]. This had the potential to affect one resident (Resident #66). The facility census was 73. Findings are: Review of the Admission Record revealed Resident #66's original admitted was 03/06/2018. Resident 66's current admitted was 4/11/2018. [DIAGNOSES REDACTED]. Review of an undated Summary of Care Document print stamped on 4/11/18 revealed Resident #66 had an indwelling Foley catheter (a tube inserted into the bladder to drain urine) and a PEG (Percutaneous Endoscopic Gastrostomy) tube (a tube placed into a person's stomach through the abdominal wall to provide a means of feeding when oral intake is not adequate) on admission. Review of Occupational Therapy Plan of Care dated 4/12/15 revealed the resident was assessed for 'recent hospitalization resulting in decline in self-cares and functional transfers. Review of an Order Summary Report dated 04/25/18 revealed an admission date of [DATE]. The report was signed by the physician on 4/25/18 and the start date for orders ranged from 4/11/18 to 4/25/18. Review of the Summary of Care dated 4/11/18 revealed instructions for discharge and discharge orders, however orders were not signed by a physician. Interview with the Administrator on 06/05/18 at 08:05 AM revealed the facility was unable to locate admission orders [REDACTED]. Interview with the Director of Nursing on 06/05/18 at 09:30 AM revealed the facility was unable to locate admission orders [REDACTED].",2020-09-01
3942,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,710,D,1,1,OLWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.08B Based on record review and interview the facility failed to ensure written orders were in place for 1 (Resident 236) out of 4 sampled residents admitted to the facility. Findings Are: Review of Resident 236's paper chart revealed an admission date of [DATE]. No written admission orders [REDACTED]. On 03/21/18 at 08:43 AM Interview with the DON (Director of Nursing) revealed a written policy dated 3/5/2018 PHYSICIAN ORDERS-TRANSCRIBING AND VERIFICATION. In the policy the person receiving the orders sign off the order with signature, date, and time. Licensed professionals note off orders are double checked ([NAME] Clerk and Charge Nurse or Charge Nurse with another professional nurse.) Interview on 03/21/18 at 10:00 AM with the DON regarding admission orders [REDACTED]",2020-09-01
3943,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,711,E,1,1,OLWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.08B(3) Based on record reviews and interview, the facility failed to ensure the Physicians orders were dated by the Physicians for 4 (Residents10, 3, 235, and 33) out of 4 residents sampled. The census was 34. Findings are: [NAME] Review of Resident 10's Physician order [REDACTED]. The form had a space labeled for the Physician's signature, but not a space labeled for the date. Review of the Physician order [REDACTED]. Review of Resident 10's Valley View Senior Village Referral Form dated 10-19-17 by a nurse revealed new orders for the resident for NWB (non-weight bearing) to the RLE (right lower extremity) and RTC (return to clinic) in 4 weeks. Two Physician's signed the form but neither of them had a date along with their signature. The form was absent a space labeled to date the form after the signature. B. Review of Resident 3's Physician Notification form dated 3-15-18 by nursing staff requested the medication [MEDICATION NAME] to be discontinued revealed the Physician signed the form but did not document a date. Review of Resident 3's Valley View Senior Village form without a date on the form and had a typed order of (MONTH) crush appropriate medications and administer together, all at one time, in applesauce/liquid of the resident's choice was signed by a Physician but not dated. Interview on 3-21-18 at 11:52 AM with the ADM (Administrator) confirmed the ADM had just became aware of the situation and the facility will be reviewing all forms. C. Interview with Dietician on 03/21/18 at 09:40 AM revealed that she does not write the orders for the residents', the dietician does send notification to physician for him to write orders for resident. Review of Physician order [REDACTED]. D. Interview with DON (Director of Nursing) on 03/21/18 at 10:05 AM revealed the DON was aware that the Physicians were not dating orders on residents'. Review of Physician order [REDACTED]. and was implemented on resident. Review of Resident chart noted PT 03/12/18 sent notification to physician to review and sign and date order for Therapy under skilled nursing care. On 09/18/17 physician order [REDACTED]. Physician order [REDACTED].",2020-09-01
4406,GOOD SAMARITAN SOCIETY - ATKINSON,285177,409 NEELY STREET,ATKINSON,NE,68713,2017-04-19,502,D,1,0,VDBU11,"**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 laboratory (lab) tests were completed as ordered for Resident 2. The sample size was 13 and the facility census was 46. Findings are: [NAME] Review of Resident 2's undated Care Plan revealed the resident had a [DIAGNOSES REDACTED]. B. Review of Resident 2's physician's orders [REDACTED]. Review of Resident 2's Progress Notes revealed no evidence the CBC was drawn on 3/28/17 (one week from the order on 3/21/17). Review of CBC results dated 4/6/17 revealed Resident 2's hemoglobin was 6.2 (with a reference range of 12.9 to 16.4). C. Review of physician's orders [REDACTED]. -a blood transfusion, -a hemoglobin level drawn the morning after the transfusion, and -a CBC drawn weekly on Wednesdays before 8:00 AM. D. Interview with Registered Nurse-K on 4/19/17 at 1:45 PM confirmed the resident's CBC on Wednesday 4/19/17 wasn't drawn until 1:35 PM (the CBC was ordered to be drawn before 8:00 AM). Interview with the MDS coordinator on 4/19/17 at 4:30 PM confirmed there was no evidence the CBC had been drawn as ordered.",2020-08-01
2315,"CALLAWAY GOOD LIFE CENTER, INC",285200,"PO BOX 250, 600 WEST KIMBALL STREET",CALLAWAY,NE,68825,2017-08-01,309,D,1,0,G79911,"**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 identify a change in condition and obtain prompt medical treatment after a fall with injury for Resident 1. This affected 1 of 3 sampled residents. The facility identified a census of 27 at the time of survey. Findings are: Review of Resident 1's annual MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 4/11/2017 revealed Resident 1 was admitted to the facility on [DATE]. Resident 1 had a BIMS (Brief Interview for Mental Status) score of 4 which indicated Resident 4 had severe cognitive impairment. Resident 1 required extensive assistance from one staff person for bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, and toilet use. Review of Resident 1's progress notes dated 7/16/2017 revealed Resident 1 was found on the floor in their room at 4:24 AM. Resident 1 complained of left arm pain, had skin tears on the back of the left hand and the left elbow, and a hematoma (swollen bruise) on the left temple. At 9:37 AM on 7/16/2017, Resident 1 complained of left shoulder pain so bad they could hardly move it. Resident 1 continued to complain of left arm and/or shoulder pain on 7/16 , 7/17, 7/18, 7/19, and 7/20/2017. Review of Resident 1's Fax Communication to Physician dated 7/16/2017 revealed Resident 1 was found on the floor and complained of shoulder pain and had limited range of motion. Review of Resident 1's departmental notes dated 7/18/2017 revealed documentation that Resident 1 went to see the medical provider with the facility requesting that Resident 1's left shoulder be x-rayed. Review of Resident 1's Clinic Referral Form dated 7/18/2017 revealed documentation that Resident 1 complained of left shoulder pain and the medical provider had Resident 1's left arm X-rayed. Review of Resident 1's X-Ray report dated 7/18/2017 revealed Resident 1 had a fractured left shoulder. Interview with LPN-B (Licensed Practical Nurse) on 8/1/2017 at 1:42 PM revealed Resident 1's medical provider was not notified about Resident 1's continuing left arm and/or shoulder pain until 7/18/2017, 2 days after Resident 1 fell and began complaining of left arm and/or shoulder pain. Interview with the facility Administrator on 8/1/2017 at 2:07 PM confirmed there was no documentation the nursing staff notified Resident 1's provider and obtained medical treatment for [REDACTED]. The Administrator further revealed the facility nursing staff should have obtained evaluation and treatment for [REDACTED]. Interview with the DON (Director of Nursing) on 8/1/2017 at 2:50 PM confirmed there was no documentation the provider was notified that Resident 1 continued to complain of left arm and shoulder pain after Resident 1 fell on [DATE] before an appointment was made on 7/18/2017. Review of the facility policy Acute Condition Changes-Clinical Protocol revised (MONTH) (YEAR) revealed the following: The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response. The nursing staff and physician will discuss possible causes of the condition change based on factors including resident history, current symptoms, medication regimen, and existing test results. If necessary the physician will order diagnostic tests or evaluate the resident directly.",2020-09-01
3320,BLUE VALLEY LUTHERAN NURSING HOME,285259,"P O BOX 166, 220 PARK AVENUE",HEBRON,NE,68370,2018-03-21,684,D,1,0,Y8IU11,"**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 identify a change in condition for Resident 4 which led to a fall. This affected 1 of 4 sampled residents. The facility identified a census of 42 at the time of survey. Findings are: Review of Resident 4's Quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 1/4/2018 revealed an admission date of [DATE]. Review of Resident 4's fall scale dated 1/5/2018 revealed Resident 4 was at a high risk for falling. Review of Resident 4's Progress Notes dated 2/13/2018 revealed Resident 4 was walking without the walker and was very unsteady. Resident 4 was also very confused and forgetful. Review of Resident 4's progress notes dated 2/14/2018 at 9:13 AM revealed Resident 4 was having vomiting and diarrhea. Review of Resident 4's progress notes dated 2/14/2018 at 11:23 PM revealed Resident 4 was found on the floor. Resident 4 had been incontinent of bowel and was unable to explain what happened. Review of Resident 4's Care Plan dated 8/7/2017 revealed no documentation of interventions implemented due to Resident 4's change in condition which placed Resident 4 at risk for falls. Interview with RN-A (Registered Nurse) on 3/21/2018 at 1:00 PM revealed the facility staff were expected to update the resident care plans with interventions to prevent falls. Review of the facility policy Change in a Resident's Condition or Status reviewed 3/21/2018 revealed our facility will discuss and review for changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, cognition, or decline in abilities, etc.)",2020-09-01
1601,AZRIA HEALTH CENTRAL CITY,285147,2720 SOUTH 17TH AVENUE,CENTRAL CITY,NE,68826,2018-03-20,684,D,1,0,R8X411,"**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 initiate and complete neurological assessments for Resident 2 after the resident fell . This affected 1 of 3 sampled residents. The facility identified a census of 55 at the time of survey. Findings are: Review of Resident 2's Annual MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 1/1/2018 revealed Resident 2 was admitted to the facility 1/14/2015 and had a BIMS (Brief Interview for Mental Status) score of 8 which indicated Resident 2 had moderately impaired cognition. Review of Resident 2's Progress Notes revealed documentation that Resident 2 fell and neurological checks were initiated on 12/22/2017 and 11/9/2017. Review of Resident 2's Neurological Assessment Flow Sheet dated 12/22/2017 revealed the neurological assessment was done on 12/22/2017 at 15 minute intervals x 4 and at one 2 hour interval. The assessment interval indicated for the remainder of the assessment time period was incomplete. Review of Resident 2's medical record revealed no documentation the neurological assessment for 11/9/2017 was initiated or completed. Interview with RN-A (Registered Nurse) on 3/20/2018 at 3:55 PM revealed that if a resident had an unwitnessed fall or hit their head an assessment was initiated immediately and neurological checks were completed. Interview with the facility Administrator on 3/20/2018 at 4:01 PM revealed the neurological assessments should have been completed. Interview with the facility DON (Director of Nursing) on 3/20/2018 at 4:24 PM revealed it was their expectation that the neurological assessments be completed. Review of the facility policy Neurological assessment dated [DATE] revealed the following: A neurological assessment provides an evaluation tool for reference when evaluating the resident's neurological status. Recommended frequency of neurological assessment/monitoring of a resident who has sustained a head-injury: Every 15 minutes x 4, then every 2 hours x 3, then every shift x 3.",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
6016,BEAVER CITY MANOR,285269,"P O BOX 70, 905 FLOYD STREET",BEAVER CITY,NE,68926,2016-07-27,309,D,1,0,VTBH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on interviews and record review, the facility failed to assess a change in condition for Resident 1. The facility census was 17 at the time of survey. Findings are: Review of Resident 1's face sheet revealed an admission date of [DATE] and a discharge date of [DATE]. Confidential interview on 7/27/2016 at 12:40 PM revealed that Resident 1 had a broken right leg when Resident 1 was transferred to the hospital from the facility on 4/27/2016. The interview further revealed that Resident 1's condition was not as such when Resident 1 was admitted to the facility on [DATE]. Confidential interview revealed that Resident 1's right leg was broken and had to have been that way for at least 3 days before the facility notified anyone. Review of Resident 1's Departmental Notes dated 4/14/2016 revealed no documentation that Resident 1 had a broken right leg upon admission to the facility. Review of Resident 1's Departmental Notes revealed that Resident 1 slid out of a wheelchair on 4/20/2016. On 4/21/2016, Resident 1 complained of pain of over 10 (severe) in the right leg. Resident was repositioned, food and water offered and resident was encouraged to relax. On 4/27/2016 there was documentation of bruising to Resident 1's right thigh. On 4/27/2016, Resident 1 was transferred to the hospital where it was discovered that Resident 1's right leg was severely broken. There was no documentation that there had been an assessment of Resident 1's right leg after Resident 1 fell on [DATE] or after Resident 1 started to complain of severe right leg pain on 4/21/2016. Review of Resident 1's Daily skilled Nurses Notes revealed no documentation of an assessment to Resident 1's right leg after the fall on 4/20/2016 or after Resident 1 complained of severe right leg pain on 4/21/2016. Resident 1 complained of right leg pain on 4/26/2016, the area was assessed and was very warm to touch, slightly red and had a contusion (raised bruise) in the center of it. The area caused Resident 1 much pain when palpated and it was hard to the touch and moveable. The health care provider was notified of the assessment findings at that time, 6 days after the fall on 4/20/2016 and 5 days after Resident 1 started to complain of right leg pain. Review of Resident 1's Departmental Notes for 4/14/2016 to 4/27/2016 revealed no documentation that Resident 1 had complained of right leg pain before sliding out of the wheelchair on 4/20/2016. Review of the facility policy and procedure Notification of Change in Resident Status dated 8/9/2007 revealed that when a condition change of a resident was noted, the charge nurse was to complete an assessment and immediately notify the physician.",2019-07-01
5022,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2017-02-21,309,D,1,0,3Y2S11,"**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 identify a change in condition for Residents 199, 65, and 42. This affected 3 of 4 sampled residents. The facility identified a census of 81 at the time of survey. Findings are: [NAME] Review of Resident 199's Admission MDS (a comprehensive assessment tool used to develop a resident's care plan) dated 1/7/2017 revealed Resident 199 had an admission date of [DATE]. Resident 199 required extensive assistance from 1 staff person for transfers and toilet use and Resident 199 had a history of [REDACTED]. Review of Resident 199's IDPN (Interdisciplinary Progress Notes) dated 2/5/2017 revealed Resident 199 fell and was sent to the emergency room for treatment of [REDACTED]. There was no documentation of interventions implemented to monitor resident during the change in condition secondary to diarrhea to prevent falls and injury. B. Review of Resident 65's MDS dated [DATE] revealed that Resident 65 was admitted to the facility on [DATE]. Resident 65 was rarely/never understood, required extensive assistance for transfers, and Resident 65 had a history of [REDACTED]. Observation of Resident 65 on 2/21/2017 at 1:50 PM revealed Resident 65 leaning forward in the wheelchair requiring staff members to physically push Resident 65 back into the wheelchair to prevent Resident 65 from falling out of the wheelchair. 2 staff then proceeded to transfer Resident 65 out of the wheelchair into a recliner with a full lift. Review of Resident 65's IDPN dated 2/13/2017 revealed the following: Requires total care for ADLs (Activities of Daily Living). Review of Resident 65's IDPN dated 2/12/2017 revealed the following: Lethargic, decline in ability to transfer which has been noted and addressed with POA (Power of Attorney). Review of Resident 65's care plan dated 2/16/2017 revealed no documentation of Resident 65's current transfer status, no interventions to prevent Resident 65 from falling out of the wheelchair due to leaning forward, and no documentation regarding Resident 65's decline in condition. Interview with the ADON/DON (Assistant Director of Nursing/Director of Nursing) on 2/21/2017 at 3:29 PM confirmed there was no documentation on Resident 65's care plan of Resident 65's current transfer status and no documentation of interventions to prevent Resident 65 from falling out of the wheelchair due to Resident 65 leaning forward. C. Review of Resident 42's Significant Change In Status MDS dated [DATE] revealed an admission date of [DATE]. Resident 42 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated Resident 42 was cognitively intact. Interview with Resident 42 on 2/21/2017 at 4:15 PM revealed that Resident 42 had fallen and broken their arm but the fracture wasn't discovered right away. Review of Resident 42's IDPN dated 1/14/17 revealed that Resident 42 was found on the floor at 11:15 AM. Resident 42's IDPN further revealed documentation that Resident 42 complained of elbow pain on 1/14/2017 and 1/15/2017 with swelling and redness. There was no documentation that Resident 42's provider was notified about the elbow pain, swelling, and redness until 1/16/2017 at 8:10 AM when an appointment was made for Resident 42 to see the medical provider. Review of Resident 42's IDPN dated 1/16/2017 at 1:30 PM revealed Resident 42 had an x-ray at the clinic and was diagnosed with [REDACTED]. Interview with the ADON/DON on 2/21/2017 at 4:59 PM confirmed there was no documentation that Resident 42's medical provider was contacted about Resident 42's change in condition from 1/14/2017 to 1/16/2017.",2020-02-01
1282,ARBOR CARE CENTERS-NELIGH LLC,285124,"PO BOX 66, 1100 NORTH T STREET",NELIGH,NE,68756,2019-03-11,684,D,1,1,UV2T11,"**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 identify bruising and to provide assessment and monitoring to assure healing of bruises for 2 (Residents 21 and 25) of 2 sampled residents. The facility census was 36. [NAME] Review of the facility policy titled Skin Integrity Guideline (undated) revealed the purpose of the policy was to provide a comprehensive approach for monitoring skin conditions and to promote healing. The policy identified all residents were to be assessed for skin breakdown within 24 hours of admission or of readmission. The policy indicated a weekly skin assessment was to be completed by a licensed nurse and any identified areas of skin breakdown monitored with documentation on the weekly skin assessment until the area was resolved and/or healed. B. Review of Resident 21's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/22/19 revealed [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive staff assistance with transfers, bed mobility, dressing and toilet use. The resident was at risk for the development of pressure ulcers and was identified as having Moisture Associated Skin Damage (MASD-skin damage caused by sustained exposure to moisture and not by pressure). Review of Resident 21's current Care Plan with revision dated 2/1/19 revealed the resident was at risk for altered skin integrity as the resident was easily bruised due to routine use of an anticoagulant (medication which inhibits the clotting of the blood with potential side effect of severe bruising). Nursing interventions included the following: -pressure reducing wheelchair and mattress; -weekly skin checks (head to toe assessment). Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and drainage as well as any other changes or observations; and -inspect skin with cares. Report any reddened areas, rashes, bruising or open areas to the charge nurse. Review of a Weekly Skin Check dated 2/13/19 at 11: 48 PM revealed the assessment was completed due to the resident's readmission from the hospital. The assessment identified the resident had bruising to bilateral arms and legs, which varied in color from light purple to dark purple. The assessment indicated the bruising occurred during the resident's hospitalization . Further review revealed no indication an assessment was completed to identify how many bruises the resident actually had, the exact location of each bruise or that the bruises had been measured to assess for healing. Review of a Weekly Skin Check dated 2/18/19 at 1:51 PM revealed the resident continued with bruising to bilateral arms and legs, from light purple to dark purple from hospital. Review of a Weekly Skin Check dated 2/28/19 at 4:19 PM revealed the assessment was completed due to the resident's readmission from the hospital. No bruising was identified with this assessment. During an observation on 3/4/19 at 10:41 AM, Resident 21 was lying in bed in the resident's room. The resident was wearing a loose fitting t-shirt and a large dark purple bruise which measured approximately 8 centimeters (cm) x (by) 8 cm was visible to the resident's right upper chest and breast area. In addition, the resident had several purple bruises visible on the resident's arms, hands and to the top of the resident's feet. The resident indicated the bruising had occurred during a recent hospitalization and that the resident had been taking an anticoagulant medication which was now on hold. Interview with the Director of Nursing (DON) on 3/6/19 at 2:53 PM revealed the nursing staff were to perform a skin assessment on a weekly basis and with any readmissions to the facility. The DON confirmed the resident had 2 recent hospitalization s and there was no evidence the bruising to the resident's chest and breast area had been identified or that a detailed assessment had been completed to identify all of the bruising on the resident's arms, hands, feet and legs. Review of an Incident Report dated 3/6/19 at 3:37 PM revealed the resident had a purple bruise to the right side of the resident's chest which extended down into the breast tissue. The bruise measured 7 cm x 8 cm and the resident denied any complaints of pain. The report indicated the resident identified the bruise occurred with recent hospitalization and with return to the facility the resident's anticoagulant had been placed on hold. Review of a Weekly Skin Check completed 3/6/19 at 3:53 PM revealed in addition to the bruise on the resident's right chest, the resident had bruising on arms, legs and chest which were at various stages of healing. C. Review of the MDS dated [DATE] revealed the following regarding Resident 25: -[DIAGNOSES REDACTED]. -a BIMS (Brief Interview for Mental Status) score of 15 which indicated cognitively intact; -required extensive to total assistance with bed mobility, transfers, eating and toilet use; and -was at risk for the development of pressure ulcers but had no current wounds. Review of the current Care Plan dated 2/25/19 revealed Resident 25 was at risk for pressure ulcers, skin tears, and bruises related to no movement or sensation from the waist down. Nursing interventions included the following: -weekly skin checks (head to toe assessment) with weekly treatment documentation to include measurements of width, length, depth, type of tissue and exudate (drainage) and any other notable changes or observations for each area of skin breakdown; -float heels when in bed and use a padded boot to the left foot when up and slipper sock to the right foot; -inspect skin with cares and report reddened areas, rashes, bruising or open areas to the Charge Nurse; -low air loss mattress (used to reduce pressure) -pressure reducing cushion to wheelchair; and -reposition every 2 to 3 hours when in bed. Review of Nursing Progress Notes revealed the following related to Resident 25: -1/30/19 at 2:25 PM - transferred to the hospital by ambulance with complaints of chest pain radiating to the left arm; -1/31/19 at 2:14 PM - returned to the facility; and -2/1/19 at 1:46 PM - Skin assessment completed and documented. Review of a Weekly Skin Check dated 2/1/19 at 1:07 AM revealed the following: -2x1 light purple bruise in the right antecubital (inside surface of the elbow); -2x2 dark purple bruise on the back of the right hand; -two light purple bruises measuring 3x2 and 1X1 on the right lateral arm; and -2X4 purple bruise across the top of the toes of the right foot that extends down between the toes. Review of an Incident Report dated 2/3/19 at 3:38 PM (3 days after the resident returned from the hospital and 2 days following the most recent skin assessment) indicated bruises to the upper chest area noted by the Medication Aide (MA) that morning when getting Resident 25 dressed. Yellow bruise measured 5cm x 2cm, and larger bruise noted to be yellow with areas of purple measured 13cm x 5.5cm. The resident stated I think that has been there for awhile I'm not sure. Documentation further indicated the resident was recently transferred to the emergency room by rescue unit, stayed overnight at the hospital, and returned to the facility within the last 72 hours. The facility concluded the bruise was consistent with the strap on the gurney that the rescue unit used to transport the resident. There was no evidence of continued monitoring/assessment of the bruises on Resident 25's chest until a Nursing Progress Note dated 2/17/19 at 11:06 AM (14 days after it was first identified) indicated Bruising to chest did resolve without complication. During interview on 3/07/19 at 10:00 AM the DON verified Resident 25's bruises on the chest should have been identified by the nurse who completed the skin assessment on 2/1/19, and/or the Nursing Assistants should have noticed the bruising during cares and reported it to the Charge Nurse. The DON further verified monitoring of bruises should be done on a weekly basis.",2020-09-01
6377,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2016-03-31,281,D,1,0,Z6YJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observation, interviews and record review; the facility failed to ensure that a physician order [REDACTED]. Findings are: Record Review revealed on 3/29/2016 an order from Resident 19's physician for knee immobilizer with all transfers. Observation of a transfer for Resident 19 on 3/31/2016 at 9:50 AM with NA-D (Nursing Assistant) and NA-E revealed Resident 19 transferred from the w/c (wheelchair) to the bed without the use of a knee immobilizer. Interview with the Director of Nursing (DON) on 3/31/2016 at 10:00 AM about the use of a knee immobilizer during the transfer for Resident 19. The DON stated that the DON was looking in Resident 19's closet for the knee immobilizer and was unable to find one, therefore, the resident was transferred from the w/c to the bed without the use of a knee immobilizer. The DON stated since the knee immobilizer was missing, an order would be faxed to the Physician to obtain a new knee immobilizer for Resident 19. Interview with the Physical Therapy Aide on 3/31/2016 at 11:47 AM revealed Resident 19 had a new knee immobilizer that had been obtained from a local Medical Supply Company.",2019-03-01
5323,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-01-03,309,G,1,0,R6LS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observation, record review and interview; the facility staff failed to evaluate and implement interventions to manage pain for 1 (Resident 3) of 1 residents reviewed for pain. The facility staff identified a census of 88. Findings are: Record review of a Admission Record sheet dated 12-12-2016 revealed Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 3's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) signed on 12-13-2016 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) was assessed as a 10. According to the MDS Manuel, a score of 8 to 12 indicate moderately impaired cognition. -Required supervision with bed mobility, transfers, ambulation, eating and toilet use. -Required extensive assistance with dressing and personal hygiene. -No indicators of pain. Record review of an Accidents/Unusual Occurrence sheet revealed Resident 3 fell on [DATE]. Record review of a Radiology Report sheet dated 12-14-2016 revealed Resident was evaluated with having an Acute distal end right clavicle fracture. Record review of Resident 3's progress notes revealed Resident 3 discharged from the facility on 12-22-2016. Record review of a Clinical Health Status sheet dated 12-26-2016 revealed Resident 3 was readmitted to the facility with a fracture to the right hip. Further review of the Resident Assessment sheet revealed that, on a scale of 0 to 10, Resident 3 ' s acceptable level of pain was a 4. Record review of Resident 3's care plan dated 12-28-2016 revealed Resident 3 had pain to the right shoulder and right hip. Interventions identified on the care plan for control of pain included the following: -Assess and establish a level of pain on the numeric assessment tool. -Monitor response on numeric pain scale related to medication and procedures. -Evaluate the need to provide medications prior to a treatment or therapy. -Don't wait for the resident to request pain medication, but offer to the resident at frequency indicated in the physician ' s orders. Observation on 1-03-2017 at 8:14 AM with the Director of Staff Development (DSD) revealed Nursing Assistant (NA) E, NA F and NA G transferring the resident NA [NAME] informed Resident 3 of the process of a transfer from bed to Resident 3's wheelchair. NA [NAME] applied a gait belt to Resident 3 while Resident 3 was in bed. NA [NAME] turned Resident 3 from side to side to apply the gait belt which resulted in Resident 3 moaning and crying out. Resident 3's eyes were clinched shut with a deeply furrowed face. NA E, NA F and NA G them slid Resident 3 to the right edge of the bed. Observations at this time revealed Resident 3 had a deeply furrowed brow, was holding (gender) breath and moaned out loud. The NA's did not stop the transfer and inform the nurse of Resident 3's pain. NA E, NA F and NA G, on the count of three, lifted Resident 3 from the bed into the wheelchair. Observations during the transfer from bed to the wheelchair revealed Resident 3 eye were tightly closed The resident initially held (gender's) breath and moaned out loud. NA E, NA F and NA G then positioned Resident 3 in the wheelchair causing Resident 3's face to turn reddish and the resident again moaned out loud. On 1-03-2017 at 8:24 AM, an interview was conducted with NA E. During the interview when asked if Resident 3 was in pain, NA [NAME] reported Resident 3 was always painful. An interview with Resident 3 was conducted on 1-03-2017 at 8:26. During the interview when Resident 3 was asked to rate pain on a scale of 0 to 10 with 10 being the worst, Resident 3 reported the pain level as being a 9. On 1-03-2017 at 8:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) H. During the interview when asked when the last time Resident 3 had pain medication, LPN reported pain medications was last administered on 1-02-2017 at 9:03 PM. Record review of Resident 3's Medication Administration Record [REDACTED]. An interview was conducted on 1-03-2017 at 8:40 AM with the DSD. During the interview, the DSD confirmed Resident 3 was having pain and should have been pre-medicated. An interview on 1-03-2017 at 2:48 PM was conducted with the Director of Nursing (DON). When asked if the NA's should have stopped the transfer and informed the nurse of Resident 3's pain, the DON stated yes. Record review of the facility policy on Pain Management dated 9-2013 revealed the following information: -Policy: -The facility is committed to reducing physical and psychosocial symptoms associated with pain to assist the resident in achieving their highest practicable level of functioning. -Procedure: -#3. Complete a pain evaluation with increase of pain. -#5. Identify potential causes for the resident's pain. Evaluate alleviating and/or exacerbating factors. -#6. Determine appropriate interventions to manage pain and side effects. Appropriate interventions may include pharmacological as well as non-pharmacological interventions. -#8. Communicate interventions to staff. -#13. Re-assess the resident ' s status as indicated including, but not limited to, level of pain relief, side effect management and effectiveness of interventions.",2020-01-01
2933,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2018-10-18,684,D,1,0,EF0X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observation, record review and interview; the facility staff failed to identify and monitor skin abrasions for 2 (Resident 1 and 2) of 3 sampled residents. The facility staff identified a census of 50. Findings are; [NAME] Record review of Resident 1's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 9-20-2018 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was 11. According to the MDS Manuel, a score of 8 to 12 indicate moderately impaired cognition. -Was very important to choose between a tub bath, shower, bed bath or sponge bath. -Required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. -Direct care and resident believed Resident 1 was capable of increased independence in at least some Activities of Daily Living (ADL). -Occasionally incontinent of bowel and bladder with no trial of a toileting program. - admitted to the facility with 2, stage 2 pressure ulcer (Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister). Observation on 10-17-2018 at 3:30 PM revealed Resident 1 was observed to have a dressing to the left elbow area dated 10-14-2018. Record review of Resident 1's medical record that included physician orders, Treatment Administration Record (TAR) and Comprehensive Care Plan (CCP) revealed there was no evidence the facility staff had identified and were treating a skin impairment. Observation on 10-17-2018 at 3:50 PM with Licensed Practical Nurse (LPN) [NAME] revealed Resident 1 had a dressing covering the left elbow. LPN [NAME] confirmed during the observation the date on the dressing was 10-14-2018. LPN [NAME] reported not being aware of a treatment to the left elbow. LPN [NAME] removed the dressing revealing a nickel sized abrasion. LPN A confirmed the abrasion to the left elbow had not been monitored and further confirmed there was not a treatment ordered for the left elbow. B. Record review of Resident 2's CCP revealed the facility staff had identified Resident 2 was at risk for impaired skin integrity. Observation on 10-18-2018 at 7:42 AM during personal cares revealed Resident 2 had a scab like area to the right shoulder. Record review of Resident 2's medical record that included TARs, physician orders [REDACTED]. On 10-18-2018 at 10:33 AM an interview was conducted with LPN C. During the interview LPN C reported not being aware of the skin breakdown to Resident 2's right shoulder.",2020-09-01
1166,PRESTIGE CARE CENTER OF NEBRASKA CITY,285109,1420 NORTH 10TH STREET,NEBRASKA CITY,NE,68410,2019-07-17,684,D,1,0,TP0511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observation, record review and interview; the facility staff failed to implement a wound treatment as ordered for 1 (Resident 1) of 3 sampled residents and failed to obtain measurements of wounds for 2 (Resident 1 and 3) of 3 sampled residents. The facility staff identified a census of 45. Findings are: [NAME] Record review of a Order Summary Sheet printed on 7-16-2019 revealed Resident 1's practitioner had order a treatment to Resident 1's right foot. The treatment ordered was for staff to apply [MEDICATION NAME] ointment to Resident 1's right foot cover with a [MEDICATION NAME] ( a dressing with a non stick type of covering) and to secure with a kling or kerlix ( cotton type of dressing that usually is in a rolled format). Observation on 7-17-2019 at 8:32 PM with Licensed Practical Nurse (LPN) B revealed LPN B removed a boarder gauze type of dressing (similar to a large Band-Aid). Resident 1 reported to LPN B nurses were using the dressing removed for a while. On 7-17-2019 at at 8:32 AM LPN B confirmed the boarder gauze was not the correct order. B. Record review of Resident 1's Weekly Skin Check (WSC) sheets revealed on 6-07-2019, 6-14-2019, 6-26-2019,7-03-2019 and 7-12-2019 had not measured the size of the wound to Resident 1's right foot. C. Record review of Resident 3's WSC dated 7-12-2019 revealed Resident 3 had a wound to the right foot. Further review of the WSC dated 7-12-2019 revealed there were no measurements of the wound on the right foot. In addition, review of Resident 3's WSC dated 7-05-2019, 6-26-2019, 6-25-2019 and 6-21-2019 did not have the size of the wound to the right foot. On 7-16-2019 at 2:11 Pm an interview was conducted with the Assistant Director of nursing (ADON). During the interview the ADON reported all wounds were to have measurements and confirmed Resident 1 and 3's WSC did not identify the sizes of the wounds. Record review of the facility Prevention and Management of Wounds dated 7-01-2013 revealed the following information: -#12. The Wound Care Coordinator or licensed nurse will document progress of the wound healing weekly. The documentation should include length, width and depth.",2020-09-01
6231,O'NEILL OPERATIONS LLC,285108,"PO BOX 756, 1102 NORTH HARRISON",O' NEILL,NE,68763,2016-05-04,309,E,1,0,OPK411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observations, record review and interviews; the facility failed to provide supervision and monitoring to protect residents from other residents with adverse behaviors. This had the potential to affect 4 residents (Residents 2, 3, 4 and 10) who resided on the Alzheimer's Care Unit (ACU-an enclosed wing or hallway which specializes in care of residents with dementia or [MEDICAL CONDITION]). The facility census was 69. Findings are: A. Review of Resident 2's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/8/16 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had severe cognitive impairment with adverse verbal behaviors, rejection of cares and wandering. Review of facility investigation dated 1/18/16 revealed that at 9:00 PM, Resident 4 was ambulating in the ACU corridor. Resident 4 passed Resident 2 and then grabbed Resident 2's breast. Resident 2 responded by hitting Resident 4's arm with the back of Resident 2's right hand. The following steps were taken to protect the residents: -The residents were immediately separated and provided with one to one (1:1) and redirection. -Resident 4 was placed on every 15 minute visual checks. -Medication review by Resident 4's primary physician. Review of Resident 2's Nursing Progress Notes revealed that, on 3/10/16 at 10:15 AM, the resident was noted to be rubbing legs against another resident's legs. The residents were separated and Resident 2 was instructed not to do this again. Review of Resident 2's current Care Plan (revision date of 3/17/16) revealed the resident had behaviors which included refusing medications, rejection of cares, verbal behaviors and wandering. The Care Plan further identified the resident was restless with attempts to self-transfer at times and the resident liked to touch male residents. The following interventions were identified: -Resident to be placed next to residents who did not annoy the resident. -Staff to help the resident to avoid situations or people which upset the resident. -Offer the resident activities of choice to prevent and/or decrease behaviors; reading, looking at pictures and picture books and playing ball. Review of Resident 2's Nursing Progress Note revealed that, on 4/18/16 at 8:30 PM, the resident was struck by another resident on the ACU. Resident 2's hair was pulled and the other resident attempted to pull Resident 2 out of the wheelchair. Resident 2 was taken to the resident's room for safety and away from the other resident. Review of facility investigation dated 4/18/16 at 8:30 PM revealed Resident 4 was ambulating in the ACU corridor when Resident 2 backed a wheelchair into Resident 4. Resident 4 then struck Resident 2 with an open hand and began pulling at Resident 2's hair and shirt in an attempt to remove Resident 2 from the wheelchair. The following steps were then taken to protect the residents: -Residents were immediately separated. -1:1 with both residents to decrease their level of agitation. -Medication review on both residents. -Staff education provided on response to behaviors. -Staffing patterns reviewed and then adjusted to assure consistent staffing on the ACU. Review of Resident 2's Nursing Progress Notes dated 4/29/16 at 7:45 PM revealed the resident was self-propelling wheelchair in the ACU corridor. The resident passed by another resident who was seated in a wheelchair and the 2 wheelchairs collided. Resident 2 then hit the other resident with an open hand on the other resident's left hand and leg. Review of facility investigation dated 4/29/16 at 7:45 PM revealed Resident 2 was self-propelling wheelchair in the ACU corridor and passed by Resident 10 who was also in the corridor in a wheelchair. The resident's wheelchairs collided and Resident 2 then struck Resident 10 on the left hand and leg with an open hand. Preventative measures put into place by the facility included the following: -Residents were separated immediately by the staff. -Medication review planned for Resident 2 due to agitation. -Staffing review completed. Facility was to continue to work on recruitment of new staff and scheduling the most appropriate staff on the ACU. -Resident 2 was to be offered finger foods when agitated to assure agitation not related to hunger due to recent poor intakes. -Resident 10 to be placed in a recliner in the afternoons to prevent behaviors. B. Review of Resident 4's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further identified the resident had severe cognitive impairment with adverse physical behaviors directed at others, rejection of cares and episodes of wandering. Review of facility investigation dated 1/18/16 revealed that, at 9:00 PM, Resident 4 was ambulating in the ACU corridor when Resident 4 passed Resident 2. Resident 4 grabbed Resident 2's breast. Resident 2 responded by hitting Resident 4's arm with the back of Resident 2's right hand. The following steps were then taken to protect the residents: -The residents were immediately separated and provided with 1:1 and redirection. -Resident 4 was placed on every 15 minute visual checks. -Medication review by Resident 4's primary physician. Review of facility investigation dated 2/17/16 at 8:00 PM revealed Resident 4 was in the resident's room and in bed. Another resident had entered Resident 4's room and was attempting to pull Resident 4 out of bed. Immediate steps taken to protect the residents included the following: -The other resident was removed from Resident 4's room and provided with 1:1. -Staff members to continue completion of dementia training videos. Review of Resident 4's Nursing Progress Note revealed the following: -3/10/16 at 2:22 AM- The resident was up and wandering on the ACU. The resident was going in and out of other resident's rooms and was looking for the resident's spouse. The resident became agitated when staff attempted to redirect the resident out of other resident's rooms. -3/10/16 at 1:45 PM- The resident was in the ACU corridor with another resident. The other resident was rubbing their legs up and down Resident 4's legs. Staff separated the residents but later found Resident 4 in the other resident's room leaning over the resident's bed with their faces in close proximity to each other. Review of Resident 4's current Care Plan with revision date of 3/28/16 revealed the resident had behaviors which included wandering, resistance with cares, touching others sexually and aggressive behaviors toward others secondary to dementia. The following interventions were identified: -15 minute visual checks of the resident due to behaviors. -Staff to help the resident avoid situations and people that are upsetting to the resident. -Offer the resident activities that the resident enjoys as a diversion and to prevent and/or decrease behaviors; praying, playing dominoes and playing ball. Review of Resident 4's Nursing Progress Note revealed on 4/18/16 at 8:30 PM the resident struck another resident on the ACU, pulled the resident's hair and attempted to pull the other resident out of a wheelchair. Review of facility investigation dated 4/18/16 at 8:30 PM revealed Resident 4 was ambulating in the ACU corridor when Resident 2 backed a wheelchair into Resident 4. Resident 4 then struck Resident 2 with an open hand and began pulling at Resident 2's hair and shirt in an attempt to remove Resident 2 from the wheelchair. The following steps were then taken to protect the residents: -Residents were immediately separated. -1:1 with both residents to decrease their level of agitation. -Medication review on both residents. -Staff education provided on response to behaviors. -Staffing patterns reviewed and then adjusted to assure consistent staffing on the ACU. C. Review of Resident 3's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS indicated the resident's cognition was severely impaired and the resident displayed adverse verbal behaviors directed at others with episodes of wandering. Review of Resident 3's current Care Plan (revision date of 2/8/16) revealed the resident had behaviors which included wandering, socially inappropriate and disruptive behaviors, [MEDICAL CONDITION] and verbal and physical behaviors directed at others. Interventions included the following: -Provide the resident with redirection when needed; offer to walk with the resident or assist the resident to the bathroom. -Make sure the resident's hearing aides are in place and operational. -Staff to help the resident avoid staff or situations that are upsetting to the resident. Review of facility investigation dated 2/17/16 at 8:00 PM revealed Resident 3 entered another resident's room and attempted to pull the other resident out of bed. Immediate steps taken to protect the residents included the following: -Resident 3 was removed from the other resident's room and provided with 1:1. -Staff members to continue completion of dementia training videos. -Resident 3's medications were reviewed and a pain assessment was completed. Review of Resident 3's Nursing Progress Notes revealed that, on 3/9/16 at 2:09 PM, another resident attempted to remove a toy from the Library room and Resident 3 yelled at the resident and stated you give that back. Right after lunch, another resident was acting as though the resident was wiping off a table in the Library room and Resident 3 hollered at the resident just stop that. Resident 3 remained on every 15 minute visual checks. D. Review of Resident 10's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS identified the resident had severe cognitive impairment displayed other adverse behaviors not directed at others and episodes of wandering. Review of Resident 10's current Care Plan (revision date of 3/17/16) revealed the resident sometimes had behaviors which consisted of yelling out during cares, [MEDICAL CONDITION], pushing staff away when they attempted to assist with cares, agitation and restlessness. Interventions included the flowing: -Allow the resident to wander in the corridor and redirect from other residents as needed. -Staff to call the resident Grandma as this calmed and soothed the resident. -Staff to offer 1:1 as needed for behaviors. Review of facility investigation dated 4/29/16 at 7:45 PM revealed Resident 2 was self-propelling wheelchair in the ACU corridor and passed by Resident 10 who was also in the corridor in a wheelchair. The resident's wheelchairs collided and Resident 2 then struck Resident 10 on the left hand and leg with an open hand. Preventative measures put into place by the facility included the following: -Residents were separated immediately by the staff. -Medication review planned for Resident 2 due to agitation. -Staffing review completed. Facility to continue to work on recruitment of new staff and scheduling the most appropriate staff on the ACU. -Resident 2 to be offered finger foods when agitated to assure agitation not related to hunger due to recent poor intakes. -Resident 10 to be placed in a recliner in the afternoons to prevent behaviors. E. Observations on 5/3/16 of the ACU revealed the following: -10:00 AM- Residents 2 and 4 were seated in wheelchairs next to each other in the corridor directly outside of the Library Room of the ACU. Resident 4 was seated in a recliner inside of the Library and within direct visualization of Residents 2 and 4. Resident 3 was seated on a sofa directly across the room from Resident 4. -From 10:00 AM to 10:30 AM- No staff were available to provide direct monitoring of the residents in the ACU Library Room and/or the ACU corridor and no activities were available for the residents. -From 3:00 PM to 3:30 PM- Resident 4 was seated in a recliner and Resident 3 was seated on a sofa directly across from Resident 4 in the Library Room of the ACU. No activities were offered at this time. No ACU staff were available to provide direct monitoring the residents in the ACU Library Room. During an interview with the ACU Coordinator on 5/3/16 from 7:00 PM to 7:30 PM, the ACU Coordinator confirmed from 1/18/16 through 4/29/16 there had been a total of 5 resident to resident altercations involving Residents 2, 3, 4, and 10. The ACU Coordinator verified Residents 3 and 4 were currently on every 15 minute visual checks due to aggressive behaviors toward other residents. The ACU Coordinator further verified due to staffing concerns it was difficulty to complete the 15 minute visual checks and to provide the residents with activities and redirection to prevent adverse behaviors.",2019-05-01
4058,HILLCREST MILLARD,285302,13225 WESTWOOD LANE,OMAHA,NE,68144,2019-03-11,684,D,1,0,ZTA511,"**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 notify the physician of a change in status for 1 (Resident 186) of 1 sampled resident. The facility staff identified a census of 53. The findings are: Review of Policy and Procedure for Change in Condition or Status of Guest dated 5/23/17 revealed the nurse manager will notify the guest's attending physician or On-call physician when there has been a significant change in the guest's physical/emotional/mental condition. A significant change in condition is a decline or improvement in the guest's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Review of admission clinical notes dated 1/28/2019 revealed Resident 186 was admitted with a [DIAGNOSES REDACTED]. Review of 5 day Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 2/1/2019 revealed the functional status for Resident 186 was limited assistance for bed mobility, transfers and toileting, and supervision for eating. Review of SBAR (Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication) dated 1/31/2019 at 3:18 PM and signed by Physical Therapy Assistant (PTA) A revealed documentation of a decline in functional status with patient requiring more assistance to stand and sit. Documentation included that patient now requires partial assistance to substantial assistance for all transfers. Significant new leaning to the left with patient needing partial assistance to even sit. SBAR signed and dated the next day 2/1/2019 at 8:40 AM by LPN B and revealed a request for Urinalysis was made. Interview with LPN B on 3/11/19 at 07:20 AM confirmed that there was no documentation of physician notification or request for urinalysis in the record. Interview with DCS (Director of Clinical Services) on 3/7/2019 at 2:30 PM revealed there were no labs drawn while resident was here at the facility and there was no orders for labs. Interview conducted with LPN B at 8:50 AM on 3/11/19 revealed that when an SBAR is completed by therapy it sends a red flag to the nursing staff that is under the to do list on the elctronic record. If the nurse does not check the to do list the SBAR could be missed. Interview conducted with PTA A at 9:00 AM 0n 3/11/2019 confirmed that the SBAR was completed on 1/31/19 for Resident 186 due to a change in condition from the initial therapy assessment and was verbally communicated to the nursing staff along with the SBAR in the electronic record. Review of PTA note dated 1/31/19 revealed that the Nurse was notified verbally of change in status and via SBAR. Review of Progress note dated 2/1/2019 revealed that Resident 186 was transferred to the emergency room per family request and physician. Interview conducted with DCS 3/11/19 at 09:22 AM confirmed that when an SBAR is completed regarding a change in condition the physician should be notified immediately and the physician was not notified of the change in condition for Resident 186 on 1/31/2019.",2020-09-01
2082,GOOD SAMARITAN SOCIETY - ATKINSON,285177,409 NEELY STREET,ATKINSON,NE,68713,2018-11-29,684,D,1,1,1GHE11,"**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 1) ensure that a change of condition was identified and treatment was initiated for Resident 13's fracture; 2) provide ongoing assessment and monitoring of Resident 13's bruise; 3) identify and provide treatment for [REDACTED]. The sample size was 2 and the facility census was 33. Findings are: [NAME] Review of a Change in Condition Evaluation policy and procedure with revision date 5/2016 revealed the following purpose for the policy: -improve communication between nurses and a provider when nursing are monitoring a change in condition; -provide a standard format to collect pertinent clinical data prior to contacting the provider when there is a change in condition; and -standardize shift to shift communication about a resident's change in condition. Further review of the policy identified the following procedures: -staff to review the resident's medical record and to review diagnoses, medications, recent Nursing Progress Notes and any recent Interdisciplinary Notes; and -staff to check with other staff members who have regular contact with the resident to obtain an accurate picture of a change in condition. B. Review of Resident 13's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/6/18 revealed the resident's cognition was severely impaired with [DIAGNOSES REDACTED]. The assessment indicated the resident required total staff assistance with transfers, bed mobility, dressing, toileting and personal hygiene; and the resident had an indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage). Review of Resident 13's current Care Plan with revision date 1/11/18 revealed the resident had potential for skin issues and/or pressure ulcer development related to [DIAGNOSES REDACTED]. The resident was identified as being dependent on staff for all movement and for all cares. In addition, the resident was identified as having an indwelling urinary catheter with a history of urinary tract infections. Interventions included monitoring, recording and reporting to the resident's health care provider any signs and symptoms of urinary tract infections included [REDACTED]. Review of a Nursing Progress Note dated 10/11/18 at 11:00 PM revealed a purple bruise which measured 6 centimeters (cm) by 8 cm was identified on Resident 13's right upper arm. Review of Resident 13's medical record revealed no documentation as to how the bruising to the resident's right upper arm had occurred. Review of a Nursing Progress Note dated 10/16/18 at 2:26 PM revealed it had been passed on with shift report that the resident had a large bruise to the resident's right upper arm. Upon inspection the bruise was identified as measuring 18 cm by 14 cm with a darker bruised area on the underside of the resident's right arm. The upper arm was swollen and the resident had facial grimacing when the arm was moved. An appointment was made for the resident to be examined at the clinic and for an x-ray. Review of the resident's medical record from 10/11/18 when the bruise was first identified as measuring 6 cm by 8 cm until 10/16/18 when the bruise was identified as measuring 18 cm by 14 cm revealed no documentation regarding an assessment or monitoring of the resident's bruise. Review of a Nursing Progress Note dated 10/16/18 at 4:13 PM revealed the x-ray report identified a fracture to the residents' right proximal humerus (long bone of the upper arm between the elbow joint and the shoulder). The resident returned to the facility with an immobilizer to the resident's right shoulder. Review of the resident's Treatment Administration Record (TAR) dated 10/2018 revealed an order dated 6/8/18 to give the resident an extra 200 cubic centimeters (cc) of water once a shift as needed if the resident's urine had increased sediment, odor or was darker in color. Review of a Nursing Progress Note dated 10/29/18 at 1:46 PM revealed the resident was given an extra 200 cc of water due to the color and odor of the resident's urine. Review of a Nursing Progress Note dated 10/30/18 at 3:46 PM revealed the resident's indwelling urinary catheter was changed as the resident's urine was very cloudy with foul odor present. Review of a Nursing Progress Note dated 11/1/18 at 1:31 PM revealed the resident received an extra 200 cc of water due to the color and odor of the resident's urine. Review of a Nursing Progress Note dated 11/2/18 at 2:30 AM revealed the resident's indwelling urinary catheter was again changed as the catheter was leaking and staff were unable to irrigate. After insertion of the new catheter, staff obtained urine return of thick, dark, tan urine followed by cloudy yellow urine with increased odor. Review of the resident's medical record from 10/16/18 through 11/3/18 revealed no documentation regarding the size/measurement of the bruising to the resident's right upper arm. Review of a Skin Observation Report (document used to record weekly skin checks and assessment of any current skin conditions) dated 11/3/18 at 6:00 AM revealed a faint bruise to the front of the resident's right shoulder and a faint purple bruise to the right upper arm. Further review revealed no documentation regarding measurement of the bruising to the resident's right arm. Review of a Nursing Progress Note dated 11/3/18 at 1:57 PM revealed the resident was given an extra 200 cc of water due to the color, odor and increased sediment of the resident's urine. Review of a Nursing Progress Note dated 11/4/18 at 1:41 PM revealed the resident was given an extra 200 cc of water due to the color, odor and increased sediment of the resident's urine. Review of Nursing Progress Notes dated 11/5/18 revealed the following: -9:27 AM the resident was given an extra 200 cc of water due to the color, odor and increased sediment of the resident's urine. -11:13 AM the resident's indwelling urinary catheter was changed due to leaking. Thick mucus sediment is noted immediately upon insertion into the bladder with dark, sediment urine after an hour or so. Review of Nursing Progress Notes dated 11/6/18 revealed the following: -12:30 AM the resident was given an extra 200 cc of water due to the color, odor and increased sediment of the resident's urine. Slime, mucous noted in catheter bag. -2:08 AM the resident's urine remained dark. -5:00 AM the resident was given an additional 200 cc of water as urine remained dark in color. -6:00 AM the resident's urine remained dark, the resident was having bladder spasms and the catheter had leaked a very large amount. Review of a Nursing Progress Note dated 11/7/18 revealed the resident had received an extra 200 cc of water at 12:30 AM and at 5:00 AM due to dark colored urine. Review of a Nursing Progress Note dated 11/8/18 revealed the resident had received an extra 200 cc of water at 12:30 AM and at 5:00 AM due to dark colored urine. Review of a Skin Observation Report dated 11/11/18 at 2:19 PM revealed no documentation as to the size/measurement of Resident 13's bruise but which indicated old yellow bruising remains to right shoulder and forearm. Review of a Skin Observation Report dated 11/16/18 at 1:27 PM revealed scattered areas of light purple bruising to the resident's right upper arm and to the inner aspect of the upper arm. There was no documentation as to the size/measurement of the bruising to the resident's right upper arm. Review of a Skin Observation Report dated 11/25/18 at 1:30 PM revealed the resident continued to have yellow bruises to the front of the resident's right shoulder and upper arm. There was no documentation as to the size/measurement of the bruising to the resident's right upper arm. During an interview on 11/28/18 at 1:56 PM, the Director of Nursing (DON) verified the following: -a bruise to Resident 13's right upper arm was first identified on 10/11/18 and it was assessed to measure 6 cm by 8 cm; -on 10/16/18 the bruise to the resident's right upper arm now measured 18 cm by 14 cm, the upper arm was swollen and the resident had increased pain with any movement. The resident had an x-ray which revealed a fracture to the resident's right proximal humerus. Staff failed to identify the resident's change of condition and to obtain treatment for [REDACTED]. -staff are to complete a Skin Observation Report after completion of the resident's weekly skin assessment and when any new areas of skin breakdown are identified. Any areas of skin breakdown or bruising are to be assessed and measured each week to determine healing or need for a change in treatment. Staff failed to measure the resident's bruising to the right upper arm after the assessment completed on 10/16/18; and -staff failed to identify the resident's change in condition regarding the resident's indwelling urinary catheter and to address a potential urinary tract infection. C. Review of Resident 84's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had severe cognitive impairment, an infection of the foot and [MEDICAL CONDITION]. Review of Resident 84's Medication Review Report revealed physician's orders [REDACTED]. The foam dressing is placed in the wound and sealed with a dressing. The pump provides suction to drain fluids from the wound and promotes healing of the wound). The wound vac was to be changed on 3 times per week. Review of Nursing Progress Notes dated 11/22/18 at 4:00 AM revealed Resident 84's wound vac was making a loud noise and was leaking air. The dressing was removed but there were no dressings available to replace the wound vac. Documentation indicated gauze dressings were applied to the wound in place of the wound vac. Review of Progress Notes dated 11/23/18 at 10:34 AM, 11/24/18 at 1:56 PM and 11/25/18 at 10:20 PM revealed the wound vac was not in use on Resident 84's wound. There was no evidence alternate treatment orders were obtained from Resident 84's physician after the wound vac was removed on 11/22/18. Interview with the DON on 11/28/18 at 10:00 AM confirmed treatment orders were not obtained from Resident 84's physician when the wound vac was not in use from 11/22/18 until 11/26/18.",2020-09-01
6638,COMMUNITY MEMORIAL HEALTH CENTER LTC,285257,"P O BOX 340, 295 NORTH 8TH STREET",BURWELL,NE,68823,2015-12-16,309,D,1,0,ICXF11,"**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 complete laboratory tests to monitor the use of [MEDICATION NAME] (a medication used to thin the blood and used to prevent [MEDICAL CONDITIONS] and blot clots) for Resident 3. The facility census was 52. Findings are: Review of Resident 3's Order Summary Report (list of physician orders) dated 10/13/15 revealed an order dated 6/5/15 for [MEDICATION NAME] 1 milligram (mg) to be given 4 days per week and 2 mg to be given 3 days per week. Review of a laboratory (lab) report dated 6/12/15 revealed a [MEDICATION NAME] Time and International Normalized Ratio (PT/INR are blood tests used to monitor how well the [MEDICATION NAME] is working. The goal of [MEDICATION NAME] therapy is to maintain a balance between preventing clots and causing excessive bleeding and this balance requires careful monitoring) were completed for Resident 3. Documentation on the same lab report dated 6/15/15 revealed an order from the physician to recheck the PT/INR in 1 month. Review of a lab report dated 7/14/15 revealed a PT/INR was completed for Resident 3. Review of Resident 3's Medication Regimen Review completed by the Registered Pharmacist (RP) dated 9/22/15 revealed INR results were needed for 8/2015 and 9/2015. Review of the Resident 3's Medication Regimen Review dated 10/22/15 revealed documentation by the RP which indicated INR results needed to be obtained. Review of Resident 3's medical record revealed no evidence to indicate a PT/INR was completed between 7/15/15 and 11/19/15 (4 months). Review of a facsimile (fax) to the physician dated 11/19/15 revealed the physician was notified Resident 3 had not had a PT/INR completed since 7/2015. The physician gave orders for a PT/INR to be completed monthly. Interview with the Director of Nurses (DON) on 12/16/15 revealed each physician was to order how often the PT/INR was to be checked when a resident was receiving [MEDICATION NAME]. However, if the physician did not indicate how often the PT/INR was to be completed then it was the responsibility of the facility to contact the physician for further PT/INR orders. The DON confirmed a PT/INR had not been completed for Resident 3 between 7/15/15 and 11/19/15.",2018-12-01
2962,RIDGECREST REHABILITATION CENTER,285239,3110 SCOTT CIRCLE,OMAHA,NE,68112,2019-07-30,684,D,1,0,CJZM11,"**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 complete neurochecks after a fall with injury for 2 (Resident 1 and 2) of 4 sampled residents. The facility staff identified a census of 73. Findings are: [NAME] Record review of a Event Report (ER) sheet dated 11-03-2019 revealed Resident 1 had been walking to the bathroom, feel backwards and hit (gender) head on a bed frame. Further review of the ER sheet dated 11-03-2019 revealed the facility staff completed an initial neurological assessment ( neuro checks are used to assess an individuals neurological functions and level of consciousness in order determine whether or not a individual is functioning properly and reacting appropriately to the tests being performing). Review of Resident 1's record revealed there was not evideance the facility had completed ongoing neurochecks for the required time frames. On 7-30-2019 at 12:35 PM an interview was conducted with Nurse Consultant (NC) [NAME] During the interview NC A reported the facility staff were not able to locate the additional neurockecks for Resident 1. B.Record review of Resident 2's Resident Face Sheet revealed Resident 2 had a [DIAGNOSES REDACTED]. Review of Resident 2's care plan revealed Resident 2 was at risk of falls related to cognitive deficits and high risk medications. Review of Resident 2's Progress notes dated 6/12/2019 Resident 2 was sent to the hospital emergency room for evaluation and treatment. Review of Resident 2's Event Report dated 6/12/2019 Resident 2 was wandering in the halls prior to being found on the floor and the fall was unwitnessed. Resident 2 was determined to have swelling and a laceration above the right eye. Review of Neurological checks revealed Neurological checks were completed every 15 minutes for 4 checks with only 1 set of Vital signs completed, No further checks were completed as Resident 2 was out of the facility in the emergency room . Review of Neurological checks revealed Resident 2's vital signs were not taken when Resident 2 returned from the hospital and Neurological checks were resumed. Neurological checks for Resident 2 were resumed every 4 hours for 3 checks with no vital signs taken. Eight hour checks were done only 1 time and then Neurological checks were discontinued. Review of the facility policy titled Neurological assessment dated (MONTH) 2014 nerological assessments should be completed for the following reasons: - physician orders - following an unwitnessed fall - after a fall with a suspected head injury - as indicated by resident condition When assessing neurological status, always include frequent vital signs and complete every 15 min times 4, every 30 minutes times four, every hour times four, every four hours times four, every 8 hours times four. Interview with the Director of Nursing revealed vital signs should have been taken more frequently and complete all Neurological checks for Resident 2.",2020-09-01
5941,STANTON HEALTH CENTER,285102,"P O BOX 407, 301 17TH STREET",STANTON,NE,68779,2016-07-19,309,D,1,0,4OYT11,"**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: 1) assess causal factors and develop interventions to prevent injury for Resident 2 who sustained a wrist injury from an unknown cause and; 2) develop interventions to ensure Resident 3 was protected from adverse behaviors displayed by Resident 4. The facility census was 61. Findings are: A. Review of Progress Notes dated 7/10/16 at 6:55 PM revealed Resident 2's left hand was .inflamed, warm to touch, reddened and painful to touch. Documentation indicated the resident was unable to answer as to when the injury occurred or what happened. Review of Progress Notes dated 7/10/16 at 7:41 PM revealed the resident was transferred to the hospital emergency room for evaluation. Review of Progress Notes dated 7/11/16 at 12:54 AM revealed Resident 2 returned to the facility with the [DIAGNOSES REDACTED]. Review of the X-ray results of Resident 2's left wrist dated 7/11/16 included the following: -Scapholunate dissociation (a significant ligamentous wrist injury which most commonly results from trauma), -[DIAGNOSES REDACTED] (deposit of calcium salts in the cartilage of joints), and -Osteopenia (bone density that is lower than normal). Review of an Injury Investigation Form (undated) revealed Resident 2 was observed with redness, warmth and discoloration of the left wrist on 7/10/16 at 6:55 PM. Documentation indicated 4 staff members were interviewed in an attempt to determine when and how the injury occurred. Staff interviews revealed the following: - 2 staff members did not observe any problems with the resident's left hand/wrist during the day shift on 7/10/16. -1 staff member observed no problems with the resident's left hand on 7/9/16. The resident's left hand was observed to be swollen on 7/10/16 and the staff member reported this to the charge nurse. -1 staff member indicated the resident's left hand was observed to be swollen on 7/9/16. Review of the Accident Report dated 7/12/16 indicated Resident 2's injury was of unknown origin but it was believed that, on 7/6/16, another resident tripped over Resident 2's feet and Resident 2 could have possibly attempted to catch the other resident from falling. Interventions to prevent the accident/incident from reoccurring were identified as Due to unknown origin, staff re-educated on resident's current Care Plan. Changes made to the Care Plan were New focus on resident's wrist injury. Review of Resident 2's current Care Plan (revised 7/10/16) revealed the wrist injury was identified however no interventions were developed in an attempt to prevent additional injuries. Interview with the interim Director of Nurses (DON) on 7/19/16 at 8:00 AM revealed other potential causal factors of Resident 2's wrist injury were not assessed. The DON confirmed additional interventions for the prevention of injury were not developed. B. Review of Resident 4's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/25/16 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had delusions and displayed verbal behavioral symptoms (such as threatening, screaming, cursing) toward others 1 to 3 days per week. Review of Resident 4's MDS dated [DATE] revealed the resident had delusions, displayed physical behavioral symptoms directed toward others (such as hitting, kicking, pushing, scratching, grabbing) and verbal behavioral symptoms directed toward others. These behaviors occurred 1 to 3 days per week. Review of a Resident to Resident Abuse Report revealed on 6/5/16 at 6:30 PM, Residents 4 and 3 were seated in wheelchairs in the dining room. Resident 3 backed up in the wheelchair and bumped into Resident 4 and Resident 4 poked Resident 3 in the back with a fork. Documentation indicated the residents were immediately removed from each other. Steps taken to prevent reoccurrence indicated the residents were Seated at different tables. Review of Resident 4's current Care Plan (undated) revealed the incident which occurred on 6/5/16 was not addressed and additional interventions were not developed to protect Resident 3 from further physical altercations. Interview with the DON on 7/19/16 at 8:00 AM confirmed additional interventions to prevent altercations were not addressed on Resident 4's Care Plan.",2019-07-01
5534,PRESTIGE CARE CENTER OF NEBRASKA CITY,285109,1420 NORTH 10TH STREET,NEBRASKA CITY,NE,68410,2016-11-02,309,D,1,0,0B0V11,"**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 monitor the mouth condition after teeth extraction for 1 (Resident 1) of 1 resident with oral needs. The facility staff identified a census of 44. Findings are; Record review of a Admission Record sheet printed on 5-03-2016 revealed Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a H&P Update/PO Note Progress Record dated 5-18-2016 from the Hospital revealed Resident 1 had 20 teeth removed. Record review of Resident 1's Progress Note (PN) dated 5-18-2016 revealed Resident 1 had returned to the facility after having the 20 teeth removed. According to the PN dated 5-18-2016, Resident 1 was supposed to have 2 teeth removed and all of Resident 1's remaining teeth were removed Further review of Resident 1 medical record revealed there was not evidence the facility staff had been monitoring the condition of Resident 1's mouth after having the 20 teeth removed. An interview was conducted with the Director of nursing (DON) on 11-02-2016 at 2:05 PM. During the interview when asked what the expectation was for the for staff to monitoring Resident 1's mouth after have 20 teeth removed, the DON stated my expectation is monitor (gender) mouth every shift until healed. The DON confirmed staff did not monitor Resident 1 mouth after have (gender) teeth removed.",2019-11-01
3400,WESTFIELD QUALITY CARE OF AURORA,285263,"PO BOX 166, 1313 1ST STREET",AURORA,NE,68818,2019-05-14,684,D,1,1,V7OX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record review and interviews, the facility failed to monitor, assess, and notify the Physician of a change of condition in one resident (Resident 33) related to constipation. The facility census was 57. Findings are: Review of Resident 33's Admission Record dated 5-8-19 revealed the date of admission of 8-24-18 with [DIAGNOSES REDACTED]. Review of Resident 33's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4-8-19 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 11 which indicated the resident's cognition was moderately impaired. The resident required extensive assist of 2 staff with bed mobility, transfers, dressing, and toileting. Resident 33 did not walk and required extensive assist of 1 staff for locomotion, personal hygiene, and eating. The resident had pain but was not on any scheduled pain medication. Resident 33 used PRN (as needed) pain medications and nonpharmalogical interventions for pain control. Interview on 5/06/19 at 11:24 AM with Resident 33 revealed the resident had difficulty with constipation. Review of Resident 33's PN (Progress Notes) from (MONTH) 2019 to (MONTH) 2019 revealed the resident received an opioid pain medication, [MEDICATION NAME]/APAP frequently PRN (as needed) for pain control. According to the Nursing (YEAR) Drug Handbook, constipation was a very common adverse effect from taking the opioid [MEDICATION NAME]/APAP and to treat constipation aggressively. Review of the facility undated Bowel Elimination policy revealed documentation of bowel elimination must be done daily. A report was to be ran on the night shift and the following steps were to be followed on all residents: 1. No BM (bowel movement) in 48 hours, the resident was to be offered bran flakes, prune juice, or both. 2. No BM in 72 hours, the resident was to be offered MOM (Milk of Magnesia, a laxative) orally. 3. If no results within 24 hours (day 4) from the MOM, the resident was to be offered a [MEDICATION NAME] Suppository (a laxative). 4. If no results within 24 hours (day 5) from the suppository, the resident was to be offered a Fleets Enema. 5. If no results from the above after 6 days, the Physician was to be notified for additional orders. Review of the documentation from the 'Bowel Elimination' report for Resident 33 for the past 30 days, (MONTH) 16 to (MONTH) 24, 2019, revealed the resident did not have a BM for 8 days. Interview on 5/13/19 at 6:52 PM with LPN-D (Licensed Practical Nurse) revealed at 4:00 AM every night, a BM list was printed from the 'Bowel Elimination' report for every resident to monitor those residents' who had not had a BM for 2 or more days. As a result of the report the following day shift would follow up as follows: If a resident had not had a BM for 2 days the resident received prune juice and a bran muffin, no BM for 3 days the resident received a PRN oral laxative, no BM for 4 days the resident received either a [MEDICATION NAME] suppository or an enema, and the 5th day if no BM the resident was assessed by the nurse. LPN-D reviewed Resident 33's 'Bowel Elimination' report and confirmed the documentation revealed the resident had not had a BM for 8 days during the time from of 4-16 to 4-24. LPN-D then reviewed the MARS (Medication Administration Records) for (MONTH) 2019 and confirmed absence of documentation for any PRN laxatives, suppository, or enemas given during the time frame of 4-16 to 4-24. LPN-D then reviewed in a notebook which LPN-D revealed was the staff old assignment sheets to try and find documentation of laxatives given or that the resident had a BM during the time frame of 4-16 to 4-24 but LPN-D there was absence of documentation to explain why the constipation was not addressed. Review of the Progress Notes for (MONTH) 16 to (MONTH) 24, 2019 for Resident 33 revealed absence of documentation of a bowel assessment, BM documentation, or laxatives PRN given.",2020-09-01
5332,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-01-31,309,G,1,0,BKZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record review, observations and interviews; the facility failed to ensure residents pain was monitored and treated for [REDACTED]. The facility census was 69. Findings are: [NAME] Review of Resident 14's face sheet revealed the resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 14's Minimum Data Set (MDS- a federally mandated assessment) completed on 12/26/2016 revealed Resident 14 had a BIMS (Brief Interview of Mental Status assessment) score of 15 out of 15 which meant Resident 14 was cognitively intact. The MDS revealed that Resident 14's pain was almost constant and severely impaired Resident 14's ability to sleep and had limited day to day activities. Review of Resident 14's pain assessment dated [DATE] revealed that Resident 14 had generalized and joint pain due to Arthritis, [MEDICAL CONDITION], and Chronic Pain. The assessment further stated that pain increased for Resident 14 during cares and repositioning and past medications that were ineffective were [MEDICATION NAME] (an opioid pain medication) and the current pain interventions were not effective and staff were to reassess interventions. Review of Resident 14's care plan with a revision date of 11/03/2015 revealed that Resident 14 had an Activities of Daily Living Self-care Deficit related to limited mobility, obesity and needed extensive assist of 2 staff with bed mobility, hygiene and toileting. Review of Resident 14's care plan with a revision date of 11/03/2015 also revealed that Resident 14 had pain with interventions of: - administer [MEDICATION NAME] as per orders and give 1/2 hour before treatments or cares - Monitor and report to the nurse any signs or symptoms of pain - Notify physician if interventions were unsuccessful - Resident 14 was able to call for assistance when in pain, voice how much pain the resident was in and what increased pain and alleviated pain. An observation was made on 01/25/17 at 2:17 PM of Nurse Aide (NA) G and NA H providing peri-care to Resident 14. NA H gathered supplies and Resident 14 was lying in bed on back was pillow pulled out from under Resident 14's hips by NA H and G, Resident 14 yelled out in pain, crying. Resident 14 was assisted to roll on to Resident 14's side. Resident 14 hollered out in pain when rolled and NA H cleansed Resident 14's bottom and removed the soiled brief, applied a new brief and Resident 14 was then assisted onto their back. Peri-care was then provided to the front of the resident. NA H and NA G applied powder in abdominal folds and Resident 14 asked if the staff got the left side. NA G replied yes and then placed towels under the resident's abdominal folds. Resident 14 then told NA G and NA H that Resident 14 had problems getting pillows situated under hips and legs comfortably and staff needed to help lift Resident 14's legs and be sure and not to drop them, as that really hurt. NA H lifted Resident 14's leg and put pillow under hip and leg and the resident yelled out that it hurt. NA G then lifted Resident 14's left leg to put a pillow under it and Resident 14 yelled ow. Resident 14 then stated that the pillow wasn't under the leg only the hip. NA G stated yes it was under the leg and Resident 14 stated no it was not. NA G then pulled the pillow out from under the resident and NA H stated that NA H would do it. NA H then lifted the residents left leg and put the pillow under it and the resident yelled ow. Resident 14 requested to have a sheet put on top of the pillow to help with cooling the skin and NA H lifted the leg and put a sheet under the leg and dropped the resident's leg onto the pillow. Resident 14 started yelling out in pain and crying. NA H and G finished covering up Resident 14 and left the room. NA H was observed going past the nurse's station and to the opposite hall and did not stop and talk to the nurse. NA G was observed heading to the break room and not stopping to talk to the nurse. An interview with Resident 14 conducted on 01/25/2016 at 3:15 PM revealed that Resident 14 stated Resident 14 had a lot of problems with pain control in hips and knees due to severe [MEDICAL CONDITION]. Resident 14 revealed that Resident 14's pain was worse when being moved or assisted with cares. Resident 14 revealed that pain medicine was not offered to the resident prior to cares. Review of Resident 14's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no documentation of Resident 14 being given an [MEDICATION NAME] on 01/25/2017. An interview with the Director of Nursing (DON) on 01/30/2017 confirmed that Resident 14 did not get any pain medication on 01/25/2017 prior to cares and confirmed the care plan revealed the resident was to get pain medication prior to cares. The DON also confirmed that NA G and NA H should have stopped cares and notified the nurse of Resident 14's pain during cares. B. Review of Resident 79's face sheet revealed that Resident 79 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 79's Progress notes revealed that on 01/23/2017 the left heel ulcer measured 8.5 cm (centimeters) x 11 cm and the right heel ulcer measured 5.5 cm x 3.6 cm and the resident refused to have staff assess ulcers to Resident 79's bottom. Review of Resident 79's care plan with a revision date of 12/02/2016 revealed Resident 79 had pain with interventions of: - administer routine [MEDICATION NAME] as ordered and use PRN (as needed) medications as Resident 79 needed. - Evaluate the effectiveness of pain interventions every shift and as needed. - Monitor/record pain characteristics every shift and as needed - Notify physician if interventions were unsuccessful - Resident 79 was able to call for assistance when in pain, reposition self, ask for pain medication and voice how much pain Resident 79 was having, what increased pain and what relieved pain. Review of a Pain Evaluation Form for Resident 14 dated 11/05/2016 revealed that Resident 14 had pain in the past 5 days at the pressure ulcer sites and that pain was increased with treatments. An observation was made on 01/25/17 at 11 am of Licensed Practical Nurse (LPN) [NAME] providing wound treatments to Resident 79's bilateral heels. Resident 79 was in Resident 79's room sitting in a wheel chair. LPN [NAME] gathered supplies and washed hands and donned gloves. LPN [NAME] asked Resident 79 to lift up left leg and Resident 79 stated it just hurt too bad to lift them up. LPN [NAME] proceeded to lift legs and cut off wrapped bandages from bilateral feet and legs and placed a towel under both feet. Resident 79 stated that the 'pain was terrible' to feet and was noted to wring hands on the arms of the wheel chair. LPN [NAME] asked Resident 79 what pain level was. Resident 79 replied it was a 9 out of10 (0=no pain, 10=worst possible pain). LPN [NAME] stated that Resident 79 went to the wound clinic yesterday and the pressure ulcer to the left heel was debrided. LPN [NAME] then proceeded to remove gloves, wash hands and don new gloves. Resident 79 stated that the pain was terrible and just goes all the way down the legs to the feet. The left heel was noted to be dripping blood on the towel and the pressure ulcer was noted to be deep and half dollar size. The right heel pressure ulcer was quarter size and open with minimal bloody drainage noted. LPN [NAME] cleansed both heels with sterile water and gauze. Resident 79 was noted to be wringing hands on the wheel chair arms again during cleansing and stated Ow, oh that hurts. LPN [NAME] finished and then washed hands and gloves were changed. LPN [NAME] started to apply a bandage to the left heel and wrapping it with gauze and Resident 79 yelled, Oh God that hurts. Resident 79 asked LPN [NAME] to call the doctor and get something for pain as it had been worse lately. LPN [NAME] replied that LPN [NAME] notified the doctor the other day and would have to see if the doctor responded. LPN [NAME] replied that LPN [NAME] could get Resident 79 a pain pill and Resident 79 said Yes. LPN [NAME] finished wrapping the left foot and leg and then washed hands and changed gloves. LPN [NAME] then applied bandage to right heel and started wrapping with gauze. Resident 79 yelled ow again and LPN [NAME] said LPN [NAME] would get Resident 79 a pain pill. Resident 79 replied, Well get me one already. LPN [NAME] stated LPN [NAME] would. LPN [NAME] then finished wrapping the right foot and leg cleaned up the towels and used gauze and bandage wrappers, washed hands and wheeled Resident 79 out to the nurse's station. Observation made on 01/25/17 at 11:40 AM revealed LPN [NAME] gave Resident 79 an [MEDICATION NAME] 10mg tablet for pain. Resident 79 reported pain was at a 10 out of 10 on the pain scale. LPN [NAME] offered to put on heel protectors to Resident 79's feet and Resident 79 refused and started crying stating that the heel protectors hurt the resident's feet, cost a lot and that Resident 79's feet just hurt so bad. Review of the MAR for (MONTH) (YEAR) for Resident 79 revealed Resident 79 received scheduled long acting [MEDICATION NAME] (opioid pain medicine) tablet 120mg the morning of 01/25/2017 but nothing as needed for pain until after the treatment at 11:40 AM. An interview conducted on 01/30/2017 at 1 PM with the DON revealed that Resident 79 had very sensitive feet and legs and will often complain of pain. The DON agreed that LPN [NAME] should have given Resident 79 some as needed pain medication prior to the wound treatments to help with Resident 79's pain or at least LPN [NAME] should have stopped the treatment and gotten Resident 79 pain medicine when the resident asked for it.",2020-01-01
5944,GRAND ISLAND PARK OPERATIONS LLC,285105,610 NORTH DARR AVENUE,GRAND ISLAND,NE,68803,2016-07-06,309,D,1,0,HDGT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record reviews and interviews, the facility failed to assess Resident 100 for therapeutic diet and fluids based on change of condition. The facility census was 55. Findings are: Review of Resident 100's Face Sheet dated 6-9-16 revealed Resident 100 was readmitted from the hospital on 6-1-16 and discharged from the facility on 6-18-16. [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set - a federally mandated comprehensive assessment tool used for care planning) dated 6-13-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 7 which indicated Resident 100's cognition was severely impaired. Review of the functional status revealed resident required extensive assist of 2 with bed mobility, transfers, dressing, and toileting. The resident required extensive assist of one person with personal hygiene. The nutritional assessment revealed resident had been holding food in resident's mouth and had a weight loss. Review of the Nursing Facility admission orders [REDACTED]. Review of the facility's Physician orders [REDACTED]. Review of the Progress Notes dated 6-1-16 at 8:35 PM revealed Resident 100 was given a glass of milk by a nurse and had trouble swallowing it. The resident was then given thickened water which resident had no trouble swallowing. Review of the Nutritional assessment dated [DATE] completed by the RD (Registered Dietician) revealed a nutrition intervention of regular/mechanical soft diet. There was no documentation of thickened fluids was on the form. Interview on 7-5-16 at 3:30 PM with the RD revealed, that when Resident 100 returned from the hospital, the RD reviewed the hospital transfers papers and discovered a discrepancy regarding resident's diet. The Nursing Facility admission orders [REDACTED]. The RD revealed the RD placed resident on a mechanical soft diet and did a trial by error of food textures and fluid consistency to see what would work best for the resident. The resident had been pocketing food in the mouth when eating and had fluids drool out the sides of the mouth with drinking. The RD revealed the RD was aware of the 6-1-16 Progress Note when the resident was able to swallow the thickened fluid without trouble versus the regular liquid. The RD was unable to provide documentation about trailing thickened liquids except for the one attempt by the nurse. The RD denied having asked the ST (Speech Therapy) for a screening for swallowing issues. The RD revealed a fax was sent to the Physician to clarify the diet order and asked for an ST evaluation but a response was never received. Review of the medical record revealed no fax communication asking for clarification of the diet or an ST evaluation. Interview on 7-5-16 at 6:00 PM with the DON (Director of Nursing) confirmed there was no diet order for the resident from 6-1-16 to 6-18-16. The DON confirmed Resident 100 had been pocketing food and had trouble swallowing fluid since the return from hospital on 6-1-16. This was a new issue since returned from the hospital 6-1-16 for Resident 100. The DON confirmed Nursing did not ask for a ST screening for swallowing difficulties. Interview on 7-5-16 at 4:00 PM with the Director of Rehab revealed Resident 100 had been evaluated and treated by ST during (MONTH) (YEAR) and (MONTH) (YEAR). Both times, the resident was seen for cognitive deficits. The Director of Rehab confirmed ST had not been asked to perform a screening or evaluation for swallowing issues at any time for Resident 100.",2019-07-01
5809,"SUTTON COMMUNITY HOME, INC.",285277,1106 NORTH SAUNDERS,SUTTON,NE,68979,2016-09-13,309,E,1,0,OVZV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record reviews and interviews, the facility failed to assess residents to identify those who may be at risk [MEDICAL CONDITION] hot liquids of the 3 out of the 3 sampled residents (Resident 01, 03, and 09). The census was 26. Findings are: A. Review of Resident 03's face sheet dated 09-13-16 revealed an admission on 04-22-15 with [DIAGNOSES REDACTED]. Review of Resident 03's medical records revealed no assessments were completed to identify if the resident was at risk [MEDICAL CONDITION] hot liquids. Review of Resident 03's Care Plan revealed no documentation of the resident being assessed for risk [MEDICAL CONDITION] hot liquids. B. Review of Resident 01's face sheet dated 09-13-16 revealed an admission on 06-09-15 with [DIAGNOSES REDACTED]. Review of Resident 01's medical records revealed no assessments were completed to identify if the resident was at risk [MEDICAL CONDITION] hot liquids. Review of Resident 01's Care Plan revealed no documentation of the resident being assessed for risk [MEDICAL CONDITION] hot liquids. C. Review of Resident 09's face sheet dated 09-13-16 revealed an admission on 09-25-15 with [DIAGNOSES REDACTED]. Review of Resident 09's medical records revealed no assessments were completed to identify if the resident was at risk [MEDICAL CONDITION] hot liquids. Review of Resident 09's Care Plan revealed no documentation of the resident being assessed for risk [MEDICAL CONDITION] hot liquids. Review of the facility policy Assistance with Meals dated 07-12-15 revealed all hot liquids shall not exceed a temperature of 145 degrees. Review of the policy did not reveal any process to assess residents for a risk [MEDICAL CONDITION] hot liquids. Interview on 09-13-16 at 1:32 PM with the Administrator confirmed the Assistance with Meals policy was the only policy the facility had in place for hot liquids. The Administrator also confirmed the facility did not complete any type of assessments on any residents to identify if they were a risk [MEDICAL CONDITION] hot liquids.",2019-09-01
1784,PLUM CREEK CARE CENTER,285159,1505 NORTH ADAMS STREET,LEXINGTON,NE,68850,2019-11-14,657,D,1,0,4F4Y11,"**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 failed to review and revise 2 of 8 resident care plans with interventions for wandering and to prevent elopement (Resident 5 and Resident 7). The facility identified a census of 38 at the time of survey. Findings are: A. Review of Resident 5's Care Plan revealed an admission date of [DATE]. Review of Resident 5's Progress Notes revealed documentation that Resident 5 left the facility unattended on 7/14/2019 and 6/16/2019. There was documentation in Resident 5's Progress Notes they were Exit Seeking on 6/21/2019; 6/17/19 and 5/27/19 and Wandering on 6/25/19; 6/21/2019; 6/11/19; 6/7/19; 6/4/19; 5/31/19; 5/27/19; 5/24/19; 5/19/19; 5/16/19 and 5/14/19. Review of Resident 5's Elopement Risk assessment dated [DATE] revealed Resident 5 was at risk for elopement. Review of Resident 5's Care Plan dated 2/25/2019 revealed no documentation of interventions for wandering or to prevent elopement. B. Review of Resident 7's Care Plan revealed an admission date of [DATE]. Review of Resident 7's Elopement Risk assessment dated [DATE] revealed the following: Resident attempted elopement on 11/13/2019. Review of Resident 7's Progress Notes dated 11/13/2019 revealed the following: received return fax with order wandergaurd placement as resident wanders around throughout facility. Wander guard (a device used to set off a door alarm to alert staff of resident's attempts to leave the facility unattended) placed on left lower leg. Notified POA (Power of Attorney). On 11/11/2019 there was documentation in Resident 7's Progress Notes: Placed wander guard on right ankle d/t (due to) wandering this evening. Review of Resident 7's Care Plan dated 11/8/2019 revealed no documentation of the wandergaurd or interventions to prevent elopement. Review of the facility policy Care Plan Revisions Upon Status Change Policy dated April 23, 2019 revealed the following: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Interview with the DON (Director of Nursing) on 11/14/2019 at 2:26 PM confirmed there were no elopement interventions on Resident 5's care plan. Interview with the facility Administrator on 11/14/2019 at 2:52 PM revealed the interventions were not documented on the care plans. The administrator revealed the facility staff were expected to update the care plans.",2020-09-01
3414,WESTFIELD QUALITY CARE OF AURORA,285263,"PO BOX 166, 1313 1ST STREET",AURORA,NE,68818,2018-06-12,657,D,1,0,L68U11,"**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 review and revise 2 of 3 sampled residents' care plans to include interventions after falls to prevent further falls and potential injury. This affected Residents 2 and 3. The facility identified a census of 52 at the time of survey. Findings are: [NAME] Review of Resident 2's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 5/23/2018 revealed an admission date of [DATE]. Review of Resident 2's Interdisciplinary Progress Notes dated 6/9/2018 revealed documentation that Resident 2 fell . Review of Resident 2's Care Plan dated 5/29/2018 revealed no documentation Resident 2's care plan was reviewed and revised to include interventions to prevent further falls and potential injury after Resident 2 fell on [DATE]. Interview with the DON (Director of Nursing) on 6/12/2018 at 3:02 PM revealed there was no documentation on Resident 2's care plan of interventions to prevent further falls and potential injury after Resident 2 fell on [DATE]. B. Review of Resident 3's Significant Change in Status MDS dated [DATE] revealed an admission date of [DATE]. Review of Resident 3's Interdisciplinary Progress Notes dated 4/10/2018 revealed documentation that Resident 3 was partially out of bed and a follow up assessment was completed for a fall. Review of Resident 3's Care Plan dated 6/12/2017 revealed no documentation Residents 3's care plan was reviewed and revised to include interventions to further prevent Resident 3 from falling. Interview with the DON on 6/12/2018 at 2:30 PM revealed there was no documentation on Resident 3's care plan of interventions to prevent further falls and potential injury after Resident 3 fell on [DATE]. Interview with NA-A (Nurse Aide) on 6/12/2018 at 2:01 PM revealed they got the information they needed to care for the residents from the residents' care plans. Interview with the DON on 6/12/2018 at 3:25 PM revealed the resident care plans were to be updated quarterly and as needed.",2020-09-01
5333,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-01-31,311,D,1,0,BKZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 D (1) b Based on observation, interview and record review; the facility failed to ensure services and interventions were provided to Resident 63 to maintain functional status related to mobility and eating. This affected 1 of 5 residents sampled. The facility census was 69. Findings are: Record review of Resident 63's electronic medical record revealed the admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 63's MDS (The Long-Term Care Minimum Data Set (MDS): 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) revealed that Resident 63 had a decline in mobility from the Assessment Reference Dates (ARD) of 10/20/16 to the ARD of 11/2/16. The MDS revealed that Resident 63 BIM's (Brief Interview for Mental Status) was unchanged and was a 3 on both records. The MDS revealed that Resident 63's ability to transfer from surface to surface was unchanged and that the resident required extensive assistance of one person. The MDS revealed that Resident 63's ability to walk in room was unchanged and required limited assist of one. The MDS revealed that Resident 63's ability to eat had changed from supervision only with set up to extensive assist of one. The MDS revealed that Resident 63's ability to walk in corridor had changed from supervision with set up only to extensive assist of one Record review of Resident 63's medical record revealed a Therapy Review dated 11/6/16. Resident 63 was not ambulating in the facility as the resident had done over the course of the last two weeks per staff. The Physical Therapy Clinical Narrative revealed that Resident 63 presented with decreased independence in all basic self-care performances ( ADL's) due to decreased coordination, balance, strength and safety. Resident 63 was not ambulating in the facility any longer and was now staying in the wheelchair throughout the day and was having to be rolled to meals. Resident 63 had changed to require maximum assistance to a sit to stand now. Resident attempted to walk with therapy but was unable. Resident 63 was able to walk with the therapist with modified independence on 8/10/16. Resident 63 was performing self-transfers with a safe technique, proper body mechanics and no use of assistive devices and was independent on 10/10/16. Resident 63 had good standing balance and was able to reach standing without assistance without limitations and had the ability to correct balance from any reaching distance. Presently Resident 63 was unable to walk 0 out of10 feet, was dependent with transfers and offered no assistance (dependent 1 person transfer) and was unable to stand unsupported. Resident 63 at this date was unable to stand upright without assist of two. Interview with the Physical Therapist on 01/25/2017 at 1:46 PM revealed that upon the resident's screen last week, the resident had become weaker and had been having an increase in falls. The Physical Therapist revealed that the facility had not had a Restorative Program or a walk to dine program during Resident 63's admission. Record review of Resident 63's Plan of Care revealed the Plan of Care did not have an intervention of the walk to dine program. Interview on 01/30/2017 at 9:16 AM with Nursing Assistant N confirmed that Resident 63 had walked with a walker upon admission in (MONTH) and had been at risk for wandering and elopement. Nursing Assistant N confirmed that there had been a decline in the ability for the resident to do things for self and confirmed that the facility did not have a restorative program at this time. Interview on 01/30/2017 at 9:19 AM with the DON (Director of Nursing) confirmed that Resident 63 did have a decline in the resident's ability to ambulate and required assistance to eat at this time. The DON confirmed that the care plan did not have measures in place to maintain or improve the resident's mobility. The DON confirmed that the facility did not have a Restorative Program or a walk to dine program at this time.",2020-01-01
5336,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-01-31,323,D,1,0,BKZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 D (7) b on observation, record review and interview; the facility failed to ensure interventions were in place to prevent falls for 2 of 4 residents sampled (Resident 55 and63). The facility census was 69. Findings are: Record review of the facility policy, titled Fall Risk Reduction and Management revised 12/2015 revealed the interdisciplinary team worked with the residents and families to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. The components of the falls risk reduction program include implementation of individualized interventions to minimize risk factors for falls and injuries. Record review of Resident 63's Admission Record revealed that Resident 63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 63'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.) with the reference date of 11/2/16 revealed that resident usually is understood and usually understands. Resident 63's Brief Interview for Mental Status (BIMS) revealed the score of 3 of 15. The MDS revealed that Resident 63 required extensive assistance of one person to transfer from surface to surface, limited assist of one to ambulate in room and corridor, extensive assist of one to move between location on and off the unit, and extensive assist of one for toileting. Record review of Resident 63's Comprehensive Plan of Care with a revision date of 12/9/16 revealed that Resident 63 was at risk for falls related to confusion, dementia, poor safety awareness, deconditioning, gait/balance problems, impulsiveness, depression, anxiety, and daily use of psychotropic medication. The Goal that was developed for Resident 63 to be free of falls with injury through the next review. This had a target date of 2/18/17. The interventions to achieve Resident 63's goals were to use anti-roll backs to the wheelchair, keep call light in reach, prompt response to the call light, anticipate the resident's needs, ensure the resident is wearing appropriate footwear such as nonskid socks or shoes, sit to stand alarm in the wheelchair and a pad alarm in bed, and keep items in reach. Observation on 01/25/2017 at 8:57 AM of Resident 63 revealed the resident was in the chapel seated in a wheelchair that had anti tippers. The resident had blue and yellow coloring that covered most of the face, it was darkest at forehead and cheeks. Resident also had blue and yellow coloring that covered the backs of both hands with raised dark dry skin over knuckles of middle and index finger. Resident had a sit to stand alarm hanging on the back part of the wheel chair. The cord was hanging and not connected to the alarm box. Observation on 01/25/2017 at 1:46 PM revealed Resident 63 was in the therapy department. Observation revealed that the sit to stand alarm cord was not connected to the alarm box on the back of the wheelchair. Observation on 01/30/2017 at 9:13 AM revealed Resident 63 was in the wheelchair in the hallway near the television with no alarm present on the back of the wheel chair. Record review of Resident 63's progress notes revealed that on 11/22/2016 at 6:14 PM, Resident 63 was observed on the floor with complaints of general all over pain. Resident 63 was to have stated that had rolled out of bed. Resident 63 was assisted up with two assist and no injuries were noted. Record review of the progress notes revealed that, on 12/16/2016 at 7:49 PM, Resident 63 was found on the floor beside the bed at 4:00 PM, with no new injuries. Record review of the progress notes revealed that on, 12/30/2016 at 4:37 PM Resident 63 was found on the floor beside the bed, that was in a low position, with no new injuries. Record review of the progress notes revealed that, on 1/7/2017 at 7:57 PM, Resident 63 was found on the floor at 5:15 PM in the prone position with the extremities in a normal position. Resident 63 was able to move all extremities without discomfort. Resident 63 was assisted from the floor with 3 staff members and a gait belt. A call was placed to Resident 63's physician with the order received to send Resident 63 to the emergency room for evaluation. Family and Director of Nursing (DON) were notified. Record review of the progress notes revealed that on, 1/7/2017 at 9:45 PM Resident 63 returned from the emergency room . Resident 63 had injuries to the face, left elbow, right index, and middle fingers. Sutures were present to right fingers. Resident 63 had a dressing to the fingers and the left elbow. New orders were received to remove the sutures in 7-10 days and to follow up with physician in 2-4 days. A interview with the Physical Therapist on 01/25/2017 at 1:46 PM, confirmed that the cord was not connected to the alarm box and therefore would not alert staff to resident standing from a sitting position. A interview on 01/30/2017 at 9:19 AM with the DON, where Resident 63 was sitting, confirmed that Resident 63 did not have an alarm on as per the fall plan of care. The DON confirmed that the facility had not provided new interventions upon each of Resident 63's fall and that the facility staff was not following the interventions that were put into place. The DON could not confirm that the alarm had been on the resident when in bed on the dates that the falls occurred from bed. B. Review of Resident 55's face sheet revealed the resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 55's care plan with a revision date of 11-20-16 revealed that Resident 55 was at risk for falls related to unawareness of safety needs, deconditioning, and had suffered an ankle fracture from a fall on 11-20-16. Listed interventions were Resident 55 was to have a dycem pad (a device to prevent sliding) to the recliner. Review of Resident 55's fall investigation dated 11-20-16 revealed Resident 55 had slid from the recliner on 11-19-16 and the new intervention was a dycem pad to the recliner. Resident 55 slid out of the recliner again on 11-20-16 and was later complaining of pain to the foot. An X-ray was completed and Resident 55 was found to have a fractured toe. An observation was made on 01/25/2017 at 1:58 PM of Resident 55 getting up out of the recliner and walking to the bathroom with a walker and no dycem was observed in the recliner. An interview conducted on 01/30/2017 at 10 AM with Licensed Practical Nurse (LPN) I revealed that LPN I was the nurse for Resident 55 and did not know if Resident 55 was to have a dycem pad to the recliner or not. An observation made on 01/30/2017 at 10:30 AM with Nurse Aide (NA) J revealed NA J assisted Resident 55 to stand up out of the recliner and no dycem pad was observed in the recliner. NA J confirmed that there was not a dycem pad to the recliner and that NA J was unaware if Resident 55 was supposed to have a dycem pad to the recliner or not. An interview conducted on 01/30/2017 at 1 PM confirmed that Resident 55 was supposed to have a dycem pad in the recliner after the fall happened on 11-19-16 and that staff should have known the dycem was to be in place to the recliner.",2020-01-01
6392,GOOD SAMARITAN SOCIETY - BEATRICE,285203,401 S 22ND STREET,BEATRICE,NE,68310,2016-03-08,323,D,1,0,G23R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 D7 Based on observation, interview and record review; the facility failed to implement interventions to prevent the potential for accidents/injury for one resident (Resident 1). The facility census was 69. Findings are: Review of Resident 1's care plan, with a print date of 3/7/16, revealed that this resident had [DIAGNOSES REDACTED]. Review of the Physical Therapy (PT) Discharge Summary, dated 2/4/16, revealed that Resident 1 reported right knee pain with ambulation and continued to demonstrated difficulty with balance at the time of PT discharge. Further review of Resident 1's care plan revealed a problem, initiated on 11/5/15, of actual fall related to history of falls, poor balance and unsteady gait. Fall on 11/30/15, 12/3/15 and 1/18/16. The goal for this problem, with a target date of 6/1/16, was for Resident 1 to resume usual activities without further incident by review date. Interventions listed for this problem included: -fall mat on floor (next to bed) -1/18/16 horseshoe pillow while in bed at all times Incident reports and Fall Scene Investigation Reports done on the dates of these falls revealed the following about Resident 1's falls: 11/30/15 Resident was walking with walker and went to flip walker around and used it backwards, lost (gender) balance and fell over hitting (gender) head on fireplace. 12/3/15 Resident was found on floor of room scooting around trying to find kids. 1/18/16 Resident found on floor with legs extended with back to bed. The cause of the fall was found to be turning in bed. The interventions to prevent future falls were to monitor every two hours and use horseshoe pillow while in bed all the time. Nurse note dated 3/7/16 states, Resident is extensive assist with all ADLs (Activities of Daily Living). One assist with gait belt and walker with ambulation On 3/7/16 at 1:17 PM Resident 1 was observed lying in bed on back. The fall mat was observed to be rolled up and on the floor in front of the dresser. No horseshoe pillow was in place. Observation was made on 3/8/16, at 8:50 AM, of Medication Aide-A (MA-A) walking with Resident 1 from the dining room to the common area where the fireplace and TV were located. A gait belt (a device used to transfer people from one position to another or while ambulating people who have problems with balance) was not being used on the resident during ambulation. MA-A was interviewed at 8:52, on 3/8/16, and indicated that sometimes a gait belt was used and sometimes not. MA-A confirmed being the one that got Resident 1 out of bed on this morning and when asked stated that no horseshoe pillow was in place when resident was in bed. The Director of Nursing (DON) was interviewed on 3/8/16 at 10:55 AM. The DON confirmed that fall interventions on the current plan of care for Resident 1 included the use of a floor mat and horseshoe pillow when resident was in bed. The DON confirmed the expectation that, due to Resident 1's fall risk, a gait belt should be used when ambulating with the resident.",2019-03-01
3937,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,641,E,1,1,OLWQ11,"**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 the status of Resident 18, Resident 29, and Resident 30at the time of assessment. This affected 3 of 17 residents whose MDS assessments were reviewed. The facility identified a census of 34 at the time of survey. Findings are: [NAME] Interview with Resident 18 on 3/14/18 at 8:46 AM revealed Resident 18 fell about 6 months ago and was injured. Review of Resident 18's Progress Notes dated 10/10/2017 revealed Resident 18 fell at 7:00 AM and 12:30 PM on 10/10/2017. Resident 18 received injuries including striking their head when they fell at 7:00 AM. Review of Resident 18's quarterly MDS dated [DATE] revealed Resident 18 had no falls since admission/reentry or prior assessment. Interview with LPN (Licensed Practical Nurse)-G on 3/15/18 at 10:40 AM confirmed that the falls should have been coded on Resident 18's quarterly MDS dated [DATE]. B. Interview with Resident 29 on 3/13/18 at 3:26 PM revealed they had an unhealed pressure ulcer. Review of Resident 29's Wound Evaluation Flow Sheet dated 2/12/2018 revealed Resident 29 had a Stage 4 pressure ulcer. Review of Resident 29's annual MDS dated [DATE] revealed Resident 29 had an unhealed Stage 3 pressure ulcer. Interview with LPN-G on 3/19/18 at 1:34 PM revealed Resident 29 had a Stage 4 pressure ulcer that was marked a Stage 3 pressure ulcer on the annual MDS dated [DATE]. LPN-G confirmed the MDS should have reflected Resident 29 had a Stage 4 pressure ulcer. C. Record Review of Resident 30's annual MDS dated [DATE] revealed the resident was on an antipsychotic medication for 7 days during the assessment period. Record review of the [MEDICAL CONDITION] Medication Reduction Form dated 8/31/17 revealed the doctor had discontinued the antipsychotic medication, Risperidal for Resident 30. Interview on 03/19/18 at 2:44 PM with LPN-G confirmed the resident's Risperidal was discontinued and the MDS was coded incorrectly.",2020-09-01
3649,RIDGEWOOD REHABILITATION & CARE CENTER,285279,624 PINEWOOD AVENUE,SEWARD,NE,68434,2018-06-05,636,D,1,1,RVGM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on interviews and record reviews, the facility failed to develop a comprehensive care plan to direct the staff to provide the cares the resident required to meet the resident's activities, indwelling Foley catheter (a tube inserted into the bladder to drain urine) and a PEG (Percutaneous Endoscopic Gastrostomy) tube (a tube placed into a person's stomach through the abdominal wall to provide a means of feeding when oral intake is not adequate) for 1 (Resident # 66). This has the potential to Resident #66. The facility census was 73. Findings are: [NAME] Review of the Baseline Care Plan dated 4/11/18 revealed Resident #66 had no goals for activities. Review of the Care Plan printed on 5/31/18 revealed that Resident #66 will state preferences and 'coordinate between nursing, dietary, life enrichment and family members for snack preferences. Review of an undated Order Summary Report revealed that Resident #66's diet order was nothing by mouth Interview with Staff member A revealed right now Resident 66 was tube fed and didn't have a lot of speech . Review of Resident 66's Admission/Medicare MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4/18/18 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 99 which indicated Resident #66 was unable to complete the tool. Section I revealed current active diagnoses but did not include: [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], altered mental status or facial droop. Observation of cares for Resident #66 on 06/04/18 from 08:28 AM to 08:40 AM by Staff D and Staff [NAME] revealed that staff was nonverbal throughout cares. Staff D and Staff [NAME] used a piece of white paper with YES and NO on it and thumbs up/thumbs down hand signals to communicate with staff. These approaches for care were not listed on the Baseline Care Plan dated 4/11/18 or the Care Plan printed on 5/31/18 Interview with the DON (Director of Nursing) on 06/04/18 at 10:32AM revealed communication approaches were not on the 04/11/18 Baseline Care Plan or the Care Plan printed on 5/31/18. Interview on 5/31/18 at 03:10 PM with Staff C revealed The Life Enrichment goal was for snacks but Resident #66 was NPO (nothing by mouth), so Resident #66's snack was a tube feeding. B. Review of the Speech Therapy Plan of Care dated 4/13/18 revealed severe [MEDICAL CONDITION] (inability to form speech or language) and inability to swallow. Review of an undated Order Summary Report revealed that Resident #66's diet order was nothing by mouth Interview with Staff member A revealed right now Resident was tube fed and didn't have a lot of speech. Review of the Admission/Medicare MDS dated [DATE] revealed a BIMS score of 99 which indicated Resident #66 was unable to complete the tool. Section I revealed current active diagnoses but did not include: [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], altered mental status or facial droop. Review of Order Summary Report revealed orders for continuous enteral feeding (the delivery of a nutritionally complex feed, containing protein, carbohydrate, fat, water, minerals and vitamins) directly into the stomach or intestine dated 4/11/18. Review of Baseline Care Plan dated 4/11/18 revealed heart healthy diet, tube feeding was not selected. Review of Care Plan printed on 5/31/18 revealed interventions for the PEG tube feedings, no goal or interventions for NPO status or care of the PEG tube. Interview with Staff member A revealed right now Resident was tube fed and didn't have a lot of speech. Interview with the DON on 5/31/18 at 09:40 AM revealed that there was no [DIAGNOSES REDACTED].#66's NPO status or care of the PEG Tube. Observation of the tube feeding administration and PEG tube site care for Resident #66 revealed Resident #66 received a bolus tube feeding and cares to the PEG tube site. The resident was nonverbal throughout the procedure. C. Review of Resident 66's Baseline Care Plan dated 4/11/18 revealed: indwelling Foley catheter was not marked. Interview with the DON on 5/31/18 at 09:40 AM revealed that there was no [DIAGNOSES REDACTED].#66's indwelling Foley catheter on the Baseline Care Plan dated 4/11/18 or the Care Plan printed on 5/31/18. Review of the Bladder Assessment Form dated 4/18/18 revealed Resident #66 had an indwelling Foley catheter and was marked that staff would verify there was a specific [DIAGNOSES REDACTED]. Interview on 5/31/18 at 03:10 PM with Staff C revealed I did review and update the baseline care plan and care plan today.",2020-09-01
3394,WESTFIELD QUALITY CARE OF AURORA,285263,"PO BOX 166, 1313 1ST STREET",AURORA,NE,68818,2019-05-14,641,D,1,1,V7OX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on observation, interview, and record review the facility failed to code the MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) to reflect Resident 48's current condition by coding a prosthesis on the MDS when the resident did not have one and failed to code oxygen use on the MDS for Resident 36. This affected 2 of 24 residents whose MDS assessments were reviewed during the survey process. The facility identified a census of 57 at the time of survey. Findings are: [NAME] Review of Resident 48's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Limb prosthesis was used for mobility devices. Observation of Resident 48 on 5/07/19 at 3:54 PM revealed no limb prosthesis was in use. Interview with the DON (Director of Nursing) on 5/08/19 at 2:47 PM revealed Resident 48 did not have a limb prosthesis and they did not know why it was coded on the MDS. Interview with MDS-C on 5/09/19 at 8:28 AM revealed Resident 48 did not have a limb prosthesis and the MDS was coded in error. Interview with the administrator on 5/09/19 at 3:18 PM revealed the facility did not have a policy for coding MDS assessments. The facility staff were to code the MDS per the RAI (Resident Assessment Instrument) manual. B. Record review of Resident 36's Admission Record dated 5-7-19 revealed date of admission 7-9-18 with [DIAGNOSES REDACTED]. Observation on 05/06/19 at 10:00 AM of the resident's room revealed an oxygen concentrator up against the wall between the wall and Resident 36's bed still running with oxygen tubing connected. Interview on 5-6-19 at 10:15 AM with NA-F (Nurse Aide) revealed the resident wore the oxygen when in bed at night time. Interview on 05/07/19 at 4:30 PM with LPN-G (Licensed Practical Nurse) revealed the resident was admitted back in (MONTH) (YEAR) with the oxygen and had been on it ever since but only at night time. Interview on 05/07/19 at 4:33 PM with RN-H (Registered Nurse) revealed RN-H recalled the resident was admitted with the oxygen and wore the oxygen only at night time. RN-H reviewed Resident 36's chart and revealed their was not an order for [REDACTED]. Review of Resident 36's admission MDS dated [DATE] revealed the resident used oxygen while 'not' a resident and 'while' a resident. The MDS also revealed the resident had a [DIAGNOSES REDACTED]. Review of Resident 36's MDS dated [DATE] revealed the resident was not on oxygen 'while' a resident. Interview on 5/09/19 at 11:18 AM with the MDS-C (MDS Coordinator) confirmed the MDS-C was aware the resident wore oxygen at night. MDS-C confirmed the MDS dated [DATE] was coded inaccurately by stating the resident was not on oxygen 'while' a resident.",2020-09-01
5582,"BROKEN BOW CARE AND REHABILITATION CENTER, LLC",285120,224 EAST SOUTH E STREET,BROKEN BOW,NE,68822,2018-05-17,656,E,1,1,1IGA11,"**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 failed to develop a comprehensive interdisciplinary careplan to include one resident's (Resident 14) risk for elopement and one resident's (Resident 12) actual skin impairment of a rash out of 12 residents careplans sampled. The facility census was 30. Findings are: [NAME] Review of Resident 14's undated Face Sheet revealed [DIAGNOSES REDACTED]. Review of Resident 14's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 2-13-18 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 8 which indicated Resident 14's cognition was moderately impaired. The resident was independent with bed mobility, walking in room and hall, and locomotion on and off the unit. Resident 14 required supervision and/or cueing with dressing, toileting, and personal hygiene. Record review of Resident 14's PN (Progress Notes) dated 5-12-18 revealed the resident started pacing the halls at 5 AM with the resident's coat. The resident told the staff the resident was going home. At 7:30 AM the resident attempted to exit the facility through the north side door and again told the staff the resident wanted to go home. Review of ADL (Activity of Daily Living) charting for behaviors revealed Resident 14 wandered on 4-18-18 at 4:41 AM. Review of the Quarterly/Annual/Significant Change Nursing Evaluations form on the Elopement section dated 5-2-18 for Resident 14 revealed an assessment risk score of 11. The form revealed a score of 10 or higher placed a resident at risk for elopement. Review of Resident 14's Careplan revealed absence of documentation for the resident to be at risk of elopement. Interview on 5-16-18 at 3:03 PM with the DON (Director of Nursing) confirmed the careplan did not address elopement. B. Interview on 5-15-18 at 8:33 AM with the DON revealed the facility identified 4 residents with a suspicious rash to possibly be scabies and Resident 12 was one of the 4 residents. The resident had a rash in the groin area and was going to be treated with the medication Ivermectin (oral medication commonly used to treat scabies). Review of Resident 12's Weekly Skin Sheet dated 4-4-18 revealed the resident had a rash to the arms and lotion was applied. Review of PN dated 4-22-18 revealed the resident complained of itching to the lower extremities and was observed to have a red rash on the left knee and between the legs bilaterally. The resident was treated with prn (as needed) oral medication [MEDICATION NAME] (an [MEDICATION NAME]). On 5-1-18 PN the Physician was notified and a routine order was received for routine [MEDICATION NAME] twice a day for itching. Review of the Weekly Skin Sheet dated 5-3-18 revealed the rash had spread to the whole body. On 5-9-18 the Weekly Skin Sheet revealed the rash continued to the body all over, and a request was sent to the Physician for the resident to be seen by a dermatologist. Observation on 5-17-18 at 10:53 AM revealed the resident's skin to have scabbed and open sores and rash on Resident 12's bilateral arms, legs, chest, and abdomen. Interview on 5-17-18 at 10:53 AM with the resident revealed the resident had the rash for a few months. The resident revealed the rash improved, then got worse. Review of the resident's careplan revealed absence of documentation of the rash and any treatment that followed. Interview on 5-17-18 at 11:26 AM with the DON confirmed Resident 12's careplan was absent documentation about the rash or treatment for [REDACTED].",2019-11-01
5670,EMERALD NURSING & REHAB LAKEVIEW,285106,1405 WEST HWY 34,GRAND ISLAND,NE,68801,2016-10-04,278,D,1,0,Z2XH11,"**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 Cognitive Pattern of the MDS (Minimum Data Set, a federally mandated assessment used for care planning purposes) was not completed so therefore did not reflect the current status of 1 (Resident 311) of 3 sampled residents. The facility census was 65. Findings are: Review of Resident 311's face sheet, dated 07-10-15, revealed an admission date of [DATE]. Review of Resident 311's MDS dated [DATE] revealed neither the resident assessment nor the staff assessment of the resident's cognitive status was completed. Interview on 10-04-16 at 2:50 PM with the MDS Coordinator revealed Section C, Cognitive Patterns, of the MDS was not completed on Resident 311.",2019-10-01
5024,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2017-02-22,278,D,1,0,7IYH11,"**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 MDS (minimum data set, a federally mandated assessment used for care planning purposes) did not reflect the current pain status of one resident (Resident 222 ) of the three sampled residents. The facility census was 103. Findings are: Review of the undated Census sheet for Resident 222 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the significant change MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 222 had no cognitive impairment. The PHQ-9 (Patient Health Questionnaire which screens for symptoms of depression and provides a standardized severity score) scored a 6 which indicated the resident had evidence of mild depression. An assessment for pain was completed which revealed Resident 222 was not on any routine pain medications. The resident did take PRN (as needed) pain medication and utilized non-pharmacological pain interventions during the assessment period. The resident complained of pain daily. Review of the MDS date 12-14-16 revealed the resident was not on any routine pain medications and did not utilize any PRN or non-pharmacological pain interventions. Review of the MDS date 9-13-16 revealed the resident was not on any routine pain medications and did not utilize any PRN or non-pharmacological pain intervention. Review of the Physician orders [REDACTED]. Review of the MARs (Medication Administration Record) documentation revealed the resident had received [MEDICATION NAME] daily for pain since (MONTH) (YEAR). Interview on 2-22-17 at 3:15 PM with RN-A (Registered Nurse) confirmed Resident 222 had been on a pain medication since (MONTH) (YEAR) and the MDS data was entered incorrectly for the last 3 MDS's.",2020-02-01
2685,HERITAGE OF EMERSON,285222,607 NEBRASKA STREET,EMERSON,NE,68733,2018-12-03,636,D,1,0,BWYO11,"**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 1 resident's (Resident 8) Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) was accurate regarding falls. The sample size was 4 and the facility census was 31. Findings are: Review of Resident 8's MDS dated [DATE] revealed the resident had a [DIAGNOSES REDACTED]. Review of Resident 8's Progress Notes dated 8/27/18 at 05:53 AM revealed the resident reported going down on 1 knee while attempting to sit in the recliner. The resident reported being able to get back up to sit in the chair. Review of Resident 8's MDS dated [DATE] indicated the resident had no falls since the last assessment (the last assessment was 8/15/18). The MDS failed to identify the resident's fall on 8/27/18. Interview with the Director of Nurses on 12/3/18 at 1:05 PM confirmed Resident 8's MDS dated [DATE] should have identified the resident had 1 fall since the last assessment.",2020-09-01
5579,"BROKEN BOW CARE AND REHABILITATION CENTER, LLC",285120,224 EAST SOUTH E STREET,BROKEN BOW,NE,68822,2018-05-17,641,D,1,1,1IGA11,"**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 (Minimum Data Set, a federally mandated assessment used for care planning purposes) reflected the current status of 1 resident out of 2 residents sampled. This affected Resident 19 for Hospice. The census was 30. Findings are: Review of Resident 19's MDS (Minimum Data Set, a federally mandated assessment used for care planning purposes), dated 4/16/18 revealed in Section J (Health status) for the question, Does the resident have the prognosis of a condition or chronic disease that may result in a life expectancy of less than 6 months? The question was marked as No. Section O for coding of special treatments such as Hospice. The space by Hospice was not marked as to indicate Yes for receiving Hospice Care. Review of Progress Notes dated 4/9/18 through 4/23/18 revealed Hospice service mentioned and that orders were clarified through Hospice services. Review of undated Care Plan with a revision date of 4/9/18 revealed the facility staff would collaborate with hospice while providing cares according to Resident 19's wishes. An interview on 05/15/18 at 5:04 PM with NA-E (Nurse Aide-E) revealed Resident 19 was on Hospice Care. An interview on 05/16/18 at 2:31 PM with RN-A (Registered Nurse-A) confirmed after reviewing the MDS dated [DATE] that the MDS in Section J the prognosis of a condition or chronic disease that may result in a life expectancy of less than 6 months? was marked as No. Then Section O with special treatments such as Hospice was marked No for receiving Hospice Services. RN-A confirmed that the MDS was not coded correctly and both questions should have been answered Yes.",2019-11-01
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
5518,GRAND ISLAND PARK OPERATIONS LLC,285105,610 NORTH DARR AVENUE,GRAND ISLAND,NE,68803,2016-11-29,278,E,1,0,UQK311,"**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 reflect the resident ' s current status on the MDS (Minimum Data Set, a federally mandated assessment used for care planning purposes) for section C-Cognitive Patterns for 2 residents (Resident 216 and 114), on section D- Mood for 1 resident (Resident 114) and on section G for 1 resident (Resident 114) for eating ability out of the 4 residents sampled. The facility census was 59. Findings are: 1) Review of Resident 216's undated face sheet revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of Resident 216's MDS dated [DATE] revealed the resident assessment for section C-Cognitive Patterns was documented the resident was unable to complete the assessment. The staff assessment of the resident's cognitive status was not completed. Interview on 11-29-16 at 1:10 PM with the SW (Social Worker) confirmed the staff assessment of the resident's on section C-Cognitive Patterns of the MDS was not completed on Resident 216 and should have been when the resident was unable to complete the resident assessment. 2) Review of Resident 114's undated face sheet revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of Resident 114's MDS dated [DATE] revealed the section C-Cognitive Patterns and section D-Mood was not completed. Interview on 11-29-16 at 2:01 PM with the SW confirmed the section C-Cognitive Pattern and section D-Mood was not completed. Review of Resident 114's MDS dated [DATE] revealed section G the resident's ability to eat and drink was documented as supervision with setup help only. Interview on 11-29-16 at 3:45 PM with the MDS-C (MDS Coordinator) revealed during the assessment period of the MDS, the resident had been on an enteral tube feedings (delivery of nutrients through a feeding tube directly into the stomach or colon) for 13.5 hours per day along with oral food for pleasure. MDS-C revealed the MDS on section G for eating was incorrect and should have been coded as an extensive assist of one person.",2019-11-01
3891,LITZENBERG MEMORIAL COUNTY HOSPITAL,285292,1715 26TH STREET,CENTRAL CITY,NE,68826,2018-02-05,641,D,1,1,B5KI11,"**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 accurately reflect one resident's (Resident 18) services on Hospice on the MDS (minimum data set, a federally mandated assessment used for care planning purposes) out of one resident sampled. The census was 27. Findings are: Interview on 01-29-18 at 4:03 PM with Resident 18's Family Representative revealed the resident had been on hospice for at least a year and the hospice nurse was excellent about calling the representative weekly with an update status. Interview on 1-31-18 at 9:19 AM with the Hospice RN-B (Registered Nurse) revealed Resident 18 was on hospice for advanced dementia and received RN visits weekly, home health aide visits twice a week, Social Service visits monthly, Chaplain monthly, and a Volunteer twice a month as needed. Review of Resident 18's MDS dated [DATE] revealed the resident was not receiving Hospice services. Interview on 02-01-18 at 8:56 AM with the SSW (Social Service Worker) revealed the resident had been on hospice services during the MDS period and the MDS was coded incorrectly.",2020-09-01
5078,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2017-02-22,282,D,1,0,KLLA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on interview and record review; the faciltiy staff failed to follow care plan interventions to perform weekly skin assessments for 2 of 2 sampled residents (Residents 2 and 4). The facility census was 25 at the time of the complaint investigation. Findings are: [NAME] Review of Resident 4's care plan, with a revised date of 1/21/2017, revealed an entry for weekly skin assessment. Review of Resident 4's assessment sheet revealed the last skin assessment was dated 2/7/2017. Continued review of Resident 4's assessment sheet revealed no documentation of a skin assessment performed on 2/14/2017. Review of Resident 4's progress notes revealed no documentation that a skin assessment was completed on 2/14/2017. B. Review of Resident 2's care plan, with a revised date of 1/21/2017, revealed an entry for weekly skin assessment. Review of Resident 2's assessment sheet revealed the last skin assessment was dated 2/7/2017. Continued review of Resident 4's assessment sheet revealed no documentation of a skin assessment performed on 2/14/2017. Review of Resident 2's progress notes revealed no documentation that a skin assessment was completed on 2/14/2017 and 2/21/2017. Interview with the Director of Nurses on 2/22/2017 at 12:03 PM confirmed the documentation was not in the chart in the progress notes or on the skin assessment sheet of the findings that a skin assessment was completed on 2/14/17 and 2/21/2017. The guidance was for the licensed nurse to complete an assessment weekly and more often if issues. Interview with LPN-A (Licensed Practical Nurse) on 2/22/2017 at 11:38 AM revealed the skin assessments were to be completed weekly with the baths. LPN-A confirmed the documentation of the skin assessment dated [DATE] and 2/21/2017 were not in the medical record for Resident 4 and 2. Review of the facility policy entitled Skin Integrity Guidelines, no date of origin, revealed the facility staff will develop a routine schedule to review residents with wounds or at risk for wounds, on a weekly basis and will document the findings. The Director of Nursing Service or designee will be responsible to implement and monitor the skin integrity program, Wound status was to be monitored on a weekly basis.",2020-02-01
3651,RIDGEWOOD REHABILITATION & CARE CENTER,285279,624 PINEWOOD AVENUE,SEWARD,NE,68434,2018-06-05,656,D,1,1,RVGM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on interviews, observation and record review; the facility failed to develop a comprehensive care plan for 1 resident (Resident #66). This had the potential to affect Resident #66. The facility census was 73. Findings are: [NAME] Review of an Admission Record revealed Resident #66's original admitted was 03/06/2018, another admission date of [DATE]. The resident had diagnosed including: [DIAGNOSES REDACTED]. On 05/29/18 at 02:31 PM observation of Resident #66 in the resident's room and the resident nodded the resident's head yes or no to questions; or signaling thumbs up or thumbs down. On 06/04/18 at 10:32 AM Interview with the DON revealed (Staff A) is the person responsible for Resident #66's activities. On 06/04/18 at 02:30 PM interview with Staff A revealed Resident #66 was tube fed and didn't have a lot of speech. In the mornings Staff A got Resident #66 a dry erase board, have resident trace dots, write residents name, today we went outside to pollinate tomatoes. Resident #66 tries to verbalize and points. I usually go in about 11 am, Resident #66 is tired after therapy, usually 1:1 with resident, resident and spouse attend devotions, and resident usually sleeps in the afternoon. Review of Resident 66's Care Plan printed by and received from the DON on 5/31/18 revealed Stated preferences for customary routine interview that the following daily preferences are very important; having snacks between meals, caring for personal belongings, receiving shower, wife and son involvement in care discussion. Created on:3/7/201, Revision on 4/16/18 . Goal will report in conversations or inquires a satisfaction with care according to expressed preferences. Interventions coordinate between nursing, dietary, life enrichment, and family members for snack preferences while balancing nutritional needs and preferences. Created on: 3/7/201, Revision on 4/16/18. Review of an Order Summary dated 4/25/18 revealed orders for nothing by mouth diet. B. Review of an Admission Record revealed Resident #66's original admitted was 03/06/2018, another admission date of [DATE]. The resident had diagnosed including: [DIAGNOSES REDACTED]. 06/04/18 08:28 AM Observation of AM cares for Resident #66 by Staff D and Staff E. Staff [NAME] knocked on the door of Resident #66's room and stated Good Morning. Resident #66 nodded head. Staff [NAME] showed Resident 66 an 8 x 10 piece of paper with large print of YES NO and asked Are you ready to get up. Resident #66 pointed to yes and nodded. Can we change your brief Resident #66 pointed to yes and nodded. Staff [NAME] brought a warm washcloth and asked the resident to wash face. Resident 66 washed the resident's face with the washcloth. Resident #66 made no verbalizations throughout cares. On 05/31/18 at 09:53 AM interview with the DON revealed that Resident #66 communicated with yes/no nodding, hand gestures, and facial expressions. The DON reviewed Resident 66's Care Plan printed on 5/31/18 and stated there are no communication goals Review of the Speech Therapy Plan of Care Dated 4/13/18 revealed severe [MEDICAL CONDITION] (the inability to comprehend and formulate language). Review of the Admission/Medicare 5 day, MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4/18/1/ revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 99 which indicated Resident # 66 was unable to complete the interview. Section B revealed the resident was rarely or never understood and usually understands others. Review of the Care Plan printed on 5/30/18 revealed: no goals for impairment of communication or sensory and no interventions for communication for Resident #66. Urinary Catheter or UTI C. Review of an Admission Record revealed Resident #66's original admitted was 03/06/2018, another admission date of [DATE]. The resident had diagnosed including: [DIAGNOSES REDACTED]. 06/04/18 08:28 AM Observation of AM cares for Resident #66 by Staff D and Staff [NAME] included emptying urine from the Foley catheter bag and cleansing the peri area/Foley catheter insertion site. Review of the undated Summary of Care Document with a print stamp at the bottom dated 4/11/18, revealed Lines, Tubes and Drains Instructions, PEG, Urinary Catheter, maintain Foley for [MEDICAL CONDITION] Review of the Resident Care Plan printed by the DON on 5/31/18 revealed:; Focus: Urinary Tract Infection date initiated 5/17/18, Goal UTI (Urinary Tract Infection) will resolve none of the 3 interventions mention an indwelling Foley catheter present on admit. Review of the Bladder Assessment Form dated 4/18/18 revealed the resident had an indwelling Foley catheter, it was expected to remain in more than 14 days, and the resident had terminal illness or severe impairments, which made positioning or clothing changes uncomfortable, or which was associated with intractable pain and verify that there is very specific [DIAGNOSES REDACTED]. On 05/31/18 at 03:10 PM interview with Staff C which included a review of Resident 66's Care Plan dated 5/31/18 revealed no [DIAGNOSES REDACTED]. Staff C said the nurse aides had a piece of paper that told them which residents had catheters. There was no specific goal or interventions for the indwelling Foley catheter.",2020-09-01
5004,GOLDEN OURS CONVALESCENT HOME,2.8e+200,902 CENTRAL AVENUE,GRANT,NE,69140,2017-03-16,282,D,1,0,907511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on observation, interview, and record review; the facility staff failed to implement care planned interventions to prevent falls for Resident 1. This affected 1 of 3 sampled residents. The facility identified a census of 29 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 1/9/2017 revealed an admission date of [DATE]. Resident 1 had a BIMS (Brief Interview for Mental Status) score of 5, which indicated Resident 1 had severe cognitive impairment. Resident 1 required assistance from 1 staff person for transfers and had 2 or more falls since the prior assessment. Review of Resident 1's care plan dated 2/26/2017 revealed Resident 1 was to have bed and chair alarms due to Resident 1 being at risk for falls. Observation of cares provided to Resident 1 on 3/16/2017 at 11:19 AM revealed NA-A (Nurse Aide) and NA-B transferred Resident 1 into the wheelchair and NA-A wheeled Resident 1 out of the room. Resident 1's chair alarm was not applied. Interview with the DON (Director of Nursing) on 3/16/2017 at 11:36 AM revealed staff were to follow Resident 1's care plan and the chair alarm should have been applied.",2020-03-01
5674,"BROKEN BOW CARE AND REHABILITATION CENTER, LLC",285120,224 EAST SOUTH E STREET,BROKEN BOW,NE,68822,2016-10-11,282,D,1,0,EZTD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on observation, interviews, and record review; the facility failed to implement care plan interventions regarding the use of a gait belt for transfers for Resident 425 and interventions regarding a pressure ulcer for Resident 402. This affected 2 of 5 sampled residents. The facility identified a census of 32 at the time of complaint investigation. Findings are: A. Review of Resident 402's Quarterly MDS (Minimum Data Set-a comprehensive resident assessment tool used for developing a resident's care plan) dated 9/15/2016 revealed an admission date of [DATE] and that Resident 402 had a Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed; may also present as an intact or open/ruptured blister) pressure ulcer. Interview with the DON (Director of Nursing) on 10/11/2016 at 10:05 AM revealed that Resident 402 had a pressure ulcer on the right lateral foot. Review of Resident 402's pressure ulcer documentation dated 10/3/2016 revealed an area present to the right lateral foot measuring 1.2 cm (centimeters) by 0.8 cm. Interview with the DON on 10/11/2016 at 2:59 PM revealed the pressure ulcer on Resident 402's right lateral foot had not been assessed since 10/3/2016. Review of Resident 402's Order Review Report dated (MONTH) 11, (YEAR) revealed an order for [REDACTED]. Review of Resident 402's Treatment Administration Record for 10/1/2016 to 10/31/2016 revealed no documentation the dressing change had been completed on (MONTH) 2nd or (MONTH) 5th and no documentation the weekly skin review had been completed on Saturday (MONTH) 8th. Interview with the DON on 10/11/2016 at 3:05 PM confirmed there was no documentation the dressing changes or skin assessment had been completed as ordered and there should have been. Review of Resident 402's Care Plan dated 12/19/2013 revealed the following interventions: conduct weekly skin inspection, treatments as ordered, and weekly wound assessment. B. Observation on 10/11/2016 at 10:20 AM revealed NA-A (Nurse Aide) assisted Resident 425 off the bed by taking ahold of the resident's upper arm. The resident performed a pivot transfer to the wheelchair. After the resident was moved to the bathroom NA-A assisted the resident out of the wheelchair by holding on to the resident's upper arm to the toilet. Once the resident was ready to transfer from the toilet to the wheelchair NA-A took ahold of the resident's upper arm while the resident performed a pivot transfer to the wheelchair. Review of Resident 425's care plan, with a revision date of 10/16/2014, revealed a gait belt was to be used with transfers. Interview with the DON (Director of Nurses) on 10/11/2016 at 1:45 PM revealed staff were expected to use the gait belts during transfers. The gait belts were on the care plan.",2019-10-01
5540,"WAUSA CARE AND REHABILITATION CENTER, LLC",285111,703 SOUTH VIVIAN,WAUSA,NE,68786,2016-12-14,282,D,1,0,0XL011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on observation, record review and interview; facility staff failed to transfer Resident 3 using a gait belt (a safety device used to provide support for a resident during transfers or ambulation, and to help prevent falling) in accordance with the Care Plan and as an intervention to prevent falls. 4 resident transfers were observed, and the facility census was 24. Findings are: [NAME] Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/25/16 indicated the resident had [DIAGNOSES REDACTED]. The MDS further indicated the following related to Resident 3: -severe cognitive impairment, -required extensive assistance with bed mobility and transfers, -required supervision to limited assistance with ambulation, and -had problems with balance when moving from a seated to standing position, moving on and off the toilet, and during transfers. Review of Resident 3's Care Plan dated 10/31/16 revealed the resident was at risk for falls. Nursing interventions included the use of a gait belt with transfers. The following observations were made on 12/13/16: -2:55 PM - Registered Nurse (RN)-G assisted Resident 3 to ambulate in the East corridor, and no gait belt was used; and -3:00 PM to 3:08 PM - Nursing Assistant (NA)-E assisted Resident 3 to ambulate to the bathroom and get on and off the toilet, and no gait belt was used. During observation on 12/14/16 at 7:10 AM, NA-C assisted Resident 3 to ambulate from the bath house into the South corridor, and then to sit in the wheelchair. No gait belt was used during the transfers. During interview on 12/14/16 at 12:45 PM, the Director of Nursing and Administrator verified a gait belt should be used during transfers.",2019-11-01
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
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
3892,LITZENBERG MEMORIAL COUNTY HOSPITAL,285292,1715 26TH STREET,CENTRAL CITY,NE,68826,2018-02-05,656,E,1,1,B5KI11,"**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 comprehensive interdisciplinary careplan for Hospice for one resident (Resident 18) out of one resident sampled. The census was 27. Findings are: [NAME] Interview on 01-29-18 at 4:03 PM with Resident 18's Family Representative revealed the resident had been on hospice for at least a year and the hospice nurse was excellent about calling the representative weekly with an update status. Interview on 1-31-18 at 9:19 AM with the Hospice RN-B (Registered Nurse) revealed Resident 18 was on hospice for advanced dementia and received RN visits weekly, home health aide visits twice a week, Social Service visits monthly, Chaplain monthly, and a Volunteer twice a month as needed. Review of Resident 18's careplan revealed absence of documentation that the resident was on hospice. Interview on 02-01-18 at 8:56 AM with the SSW (Social Service Worker) revealed the resident had been on hospice services for quite a while. SS confirmed the careplan was absent of documentation about hospice but that it should have been on the careplan. B. Record review of the Physician orders [REDACTED]. Interview with NA-K (Nursing Assistant) on 1/30/18 at 4:15 pm, revealed the resident had behaviors, such as sundowners. Record Review of Resident #1's Care Plan revealed it was absent of documentation about behaviors. Interview with RN-D on 1/30/18 at 3:00 pm, confirmed that the resident had no documentation of behaviors on the care plan.",2020-09-01
1895,"PREMIER ESTATES OF KENESAW, LLC",285166,"P O BOX 10, 100 WEST ELM AVENUE",KENESAW,NE,68956,2017-06-20,279,D,1,1,QJH211,"**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 comprehensive interdisciplinary careplan to include Resident 14's PASRR (Preadmission Screening and Resident Review) plan of care. This affected one resident (Resident 14) out of one resident sampled. The facility census was 45. Findings are: Review of the undated face sheet for Resident 14 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 5-2-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 11 which indicated the resident's cognition was moderately impaired. The resident required supervision and setup assist with bed mobility, transfers, locomotion and eating. The resident required limited to extensive assist with 1 assist of staff with personal hygiene,dressing and toilet use. Review of Resident 14's medication record revealed the resident had a PASRR level 2 completed in (MONTH) (YEAR) and again 5-10-17. The current PASRR had the recommendations the resident required evaluation for the following services: Ongoing medication review by a Psychiatrist. Ongoing medication review by a Physician Neurological examination to substantiate organicity Vocational evaluation Physical Therapy Visual Evaluation Dental Evaluation Audiological Evaluation Increase in stimulation / environmental enhancements Other: exercise, activity assessment, skills training, talk therapy as needed Review of Resident 14's careplan revealed absence of documentation the resident had a level 2 PASRR and none of the interventions were listed on it. Interview on 6-14-17 at 3:31 PM with SSD (Social Service Designee) confirmed the level 2 PASRR and the recommended services was not on Resident 14's careplan and had not been on the careplan for the PASRR completed in (MONTH) (YEAR) either.",2020-09-01
3913,HILLCREST COUNTRY ESTATES-COTTAGES,285293,6082 GRAND LODGE AVENUE,PAPILLION,NE,68133,2017-05-04,279,E,1,1,POAF11,"**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 comprehensive plan of care for 8 of 28 residents reviewed - Residents 44 and 63 for activities; Resident 24 for adls (Activities of Daily Living); Resident 37 for hospice care; for skin issues for Resident 55, 27 and 99, and Resident 3 for [MEDICAL CONDITION] and for bleeding risk . The facility census was 46. Findings are: [NAME] Review of Resident 63's face sheet revealed Resident 63 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 63's MDS (Minimum Data Set- a federally mandated assessment tool used for care planning) completed on 3/16/2017 revealed the resident triggered for Activities as a Care Area of Concern and it was checked that it would be addressed in the care plan. Review of Resident 63's care plan with an effective date of 3-3-17 revealed no care plan for activities. Interview conducted on 05/03/2017 at 11:57 AM with the Assistant Administrator confirmed that Resident 63 did not have an activity care plan and should have. B. Review of Resident 44's face sheet revealed Resident 44 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 44's MDS, completed on 12-2-16, revealed, in section V, that Resident 44 would have activities care planned. Review of Resident 44's care plan with an effective date of 12-17-14 to present revealed no care plan for activities. Interview conducted on 05/03/2017 at 11:57 AM with the Assistant Administrator confirmed that Resident 44 did not have an activity care plan and should have. C. Review of Resident 24's face sheet revealed that the resident was originally admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 24's MDS completed on 12-2-16 revealed Resident 24 needed assistance with ADL's (Activities of Daily Living) of dressing, transferring, toileting, and bed mobility and triggered as a Care Area to be care planned in Section V. Review of Resident 24's care plan with a start date of 11-10-15 revealed no care plan for ADL's An interview conducted with the Director of Clinical Services on 5-4-17 at 1 PM confirmed there was no ADL care plan for Resident 24 and there should have been. D. Review of Resident 3's Face sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 3's Medication Administration Record [REDACTED] - [MEDICATION NAME] 50 mg (milligram) at bedtime (an antidepressant sometimes used to help [MEDICAL CONDITION]) and - Eliquis 5 mg daily (a blood thinning medication). Review of Resident 3's Psychiatric Note dated 12-16-17 revealed Resident 3 was taking [MEDICATION NAME] for [MEDICAL CONDITION] and was to continue the medication. Review of Resident 3's Care plan with an effective date of 12-30-14 to present revealed no care plan for [MEDICAL CONDITION] with the use of [MEDICATION NAME] and no care plan for bleeding risk with the use of Eliquis. An interview conducted on 5-4-17 at 1: 20 PM with the Administrator confirmed that there was no care plan developed for Resident 3 for [MEDICAL CONDITION] with [MEDICATION NAME] use nor for bleeding risk with the use of Eliquis and there should have been. E. The code of Federal Regulations 483.70 , includes that a communication process, including how the communication will be documented between the Long Term Care (LTC) facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. The code of Federal Regulation 483.70(o) (4) revealed that each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of services furnished by the LTC facility to attain or maintain the residents highest practicable physical, mental and psychosocial well-being, as required at 483.24. Record review revealed that Resident 37 was admitted to hospice services on 2/22/17. Record review of Resident 37's comprehensive plan of care, undated, revealed that Resident 37 was planning to remain at the facility on hospice cares. Interventions were to notify hospice if a change occurred, and to utilize medications if resident appears uncomfortable. Interview with the facility Administrator confirmed that Resident 37's plan of care did not provide information regarding the facility and the hospice rolls in Resident 37's services to attain or maintain the residents highest practicable physical, mental and psychosocial well-being. F. Observation of Resident 55, on 5/3/17 at 11:44 AM, revealed that multiple prescriptions creams were used during bathing by the Medication Aide D. Review of Resident 55's Physician orders [REDACTED]. 1) [MEDICATION NAME] 0.25% apply topically two times daily as needed for rash. The order date was 11/11/2016. 2) [MEDICATION NAME] 2.5%, apply topically to back, as needed for itching. The order date was 2/16/17. 3) Mometasone Furoate 0.1%, apply topically to affected area's daily as needed. The order date was 11/11/16. 4) [MEDICATION NAME] 0/1% ointment, apply to affected area's 2 to 3 times daily as needed. The order date was 11/11/16. 5) Risamine ointment, apply to buttocks twice daily. The order date was 2/17/15. Record review of Resident 55's comprehensive care plan effective 12/9/16 to present, did not reveal related skin issues for the treatments listed above. Interview on 5/3/17 at 2:07 PM, with the facility Registered Nurse (RN) H, confirmed that the comprehensive care plan did not reflect the skin issues areas of which Resident 55's had requested the multiple creams to be applied to. RN H confirmed that the care plan did not reflect dates of new skin issues and new interventions for skin cares when new treatments were initiated. [NAME] Record review of Resident 27's medications revealed that Resident 27 was receiving [MEDICATION NAME] 100,000units/gram powder (antifungal antibiotic), topically under the breasts every day, every shift. The order date of this medication was on (MONTH) 16 of (YEAR). In addition to this order for the powder, Resident 27 was to have Fluconazole (antifungal agents), 150 mg (milligram) tablet, by mouth weekly as needed for yeast infection (Yeast is a fungus). The original order for this medication was 6/12/2013. Record review of Resident 27's comprehensive care plan, undated, did not reflect that resident had any skin concerns or, in past, was at risk for any fungal infections. Interview with RN H on 5/4/17 confirmed that the comprehensive plan of care did not reflect that Resident 27 frequently developed a rash under the breasts and that the facility used the [MEDICATION NAME] for moisture to prevent breakdown of skin under the breasts. RN H confirmed that the care plan should reflect skin issues and treatments. H. Record review of Resident 99's medications revealed that Resident 99 had orders for [MEDICATION NAME] 2% cream ([MEDICATION NAME] is used to treat skin infections such as athlete's foot, jock itch, ringworm, and other fungal skin infections) to be applied as needed , and orders for Monostat cream (used to treat yeast infections) to be applied to peri area/groin folds as needed for yeast infection prn (as needed)., and [MEDICATION NAME] (used to treat skin infections such as athlete's foot, jock itch, ringworm, and other fungal skin infections) 1% to be applied topically on and between the 4th and 5th toes of the right foot twice daily until healed, then an additional week for athlete foot. Record review of Resident 99's comprehensive care plan, undated, did not reflect that resident had any skin concerns. Interview with RN H on 5/4/17 confirmed that the comprehensive plan of care did not reflect that Resident 99, had skin issues requiring treatments. RN H confirmed that the care plan should reflect skin issues and treatments.",2020-09-01
6070,EMERALD NURSING & REHAB LAKEVIEW,285106,1405 WEST HWY 34,GRAND ISLAND,NE,68801,2016-06-08,282,D,1,0,X4IK11,"**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 ensure interventions were being followed from the care plan to protect one resident (Resident 111) from another resident (Resident 108) with potential adverse behaviors. The facility census was 62. Findings are: Review of Resident 108's undated [DIAGNOSES REDACTED]. Review of Resident 108's MDS (Minimum data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4-18-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 10 which indicated Resident 108's cognition was moderately impaired. The assessment of Resident 108's behaviors revealed the resident rejected cares and wandered 1-3 days during the assessment period. Resident 108 required supervision of one staff with bed mobility, walking, and locomotion. Resident 108 required limited assistance of one staff with dressing, eating, toileting, and personal hygiene. Resident 108 required limited assistance of two staff with transfers. Review of Resident 108's care plan revealed interventions dated 5-16-16 to remove resident from other residents that cause anxiety or anger, 1:1 with the resident as needed, and Resident 108 was not to be in the activity room with male Resident 111. Observation of the Activity room on 6-7-16 from 3:28 PM to 3:55 PM revealed the following: At 3:28 PM Resident 108 entered the Activity room and sat on the couch and ate a snack. At 3:29 PM Resident 111 entered the room and sat in a chair directly across from Resident 108. The two residents had a conversation then Resident 108 got up from the couch and approached Resident 111 and handed Resident 111 part of the snack Resident 108 had been eating. Resident 108 returned back to the couch and sat down. At 3:36 PM NA-G (Nurse Aide) stood in the doorway of the Activity room and looked around at the residents, but did not enter the room and intervene between Residents 111 and 108. At 3:38 PM Resident 108 walked directly in front of Resident 111 and exited the Activity room. At 3:41 PM Resident 108 returned to the Activity room and sat on the couch across from Resident 111. At 3:45 PM the DON (Director of Nursing) came into the Activity room to speak with the surveyor and stood between the 2 residents. The DON left the room without separating the residents. At 3:55 PM Resident 111 independently left the Activity room. Interview on 6-7-16 at 3:58 PM with MA-F (Medication Aide) revealed Resident 108 exhibits behaviors of verbal and physical aggression when upset. MA-F revealed a known trigger was Resident 108 would become upset if anyone sat in a particular chair in the Activity room that Resident 108 claimed as (gender) own. MA-F revealed also men tended to be a trigger for Resident 108 and specifically the new admission Resident 112. MA-F denied identifying any other specific male residents caused behaviors in Resident 108 MA-F denied any other known triggers for Resident 108's behaviors. MA-F revealed interventions used for Resident 108 were to tell resident the chair was not the resident's, [MEDICATION NAME] medication, and try and take resident to resident's room. MA-F denied any particular resident being a trigger of behaviors besides the new admit and denied any special interventions for any particular resident. Interview on 6-7-16 at 4:03 PM with NA-G revealed Resident 108 triggers for behaviors were anyone who sat in a particular chair in the Activity room or someone who took items (dirty linens) from resident's room. NA-G revealed the interventions used were nothing. Resident 108 was hard to deal with and became upset with both residents and staff. Resident 108 wanted staff to do things Resident 108 wanted but staff could not always do what Resident 108 wanted. NA-G denied any particular other resident being a trigger of behaviors and denied any special interventions for any particular resident. Interview on 6-8-16 at 10:00 AM with the DON revealed the DON educated the staff of Resident 108's behaviors after the incident between Resident 108 and Resident 111 and reviewed the signature sheet which showed the names of staff the DON educated. The DON did confirm one of the two staff interviewed name was not on the list as being educated.",2019-06-01
2730,BROOKEFIELD PARK,285226,1405 HERITAGE DRIVE,ST PAUL,NE,68873,2020-01-16,655,D,1,0,4QD611,"**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 provide a written summary of Resident 169's baseline care plan to the PR (Personal Representative) and ensure they understood it prior to the completion of the initial comprehensive care plan. This affected 1 of 3 residents admitted to the facility. The facility identified a census of 58 at the time of survey. Findings are: Review of Resident 169's Admission Record revealed an admission date of [DATE]. Review of Resident 169's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 12/6/2019 revealed a BIMS (Brief Interview for Mental Status) score of 7 which indicated severe cognitive impairment. Resident 169 required extensive assistance from staff for bed mobility, transfer, toilet use, locomotion on and off unit, and dressing. Resident 169 was dependent upon staff for bathing and walking in room and corridor did not occur. Interview with Resident 169's PR (personal representative) on 1/16/2020 at 10:50 AM revealed the facility staff had to administer Resident 169 their medications as Resident 169 not able to do this. The PR revealed they found out on 12/4/19 that Resident 169's medication list had [MEDICATION NAME] (a narcotic pain medication) on it and the PR was not aware Resident 169 was still supposed to be taking it; Resident 169 was only supposed to get [MEDICATION NAME] (a type of pain medication). The PR revealed the [MEDICATION NAME] was a medication that was ordered while Resident 169 was in the hospital after an accident prior to being admitted to the facility. The PR revealed the facility staff went ahead and gave the [MEDICATION NAME] to Resident 169. The PR revealed they had no knowledge Resident 169 was still receiving the [MEDICATION NAME] and they understood that it had been discontinued while Resident 169 was still at the hospital. The PR revealed they called the doctor to see if the facility staff should be giving Resident 169 the [MEDICATION NAME] and to make sure it was on the list of medications Resident 169 was supposed to be receiving because the PR questioned that it was making Resident 169 confused. Review of Resident 169's baseline care plan dated 11/25/29 revealed Resident 169 signed it on 12/5/2019. There was no documentation the PR had been given a written summary of the care plan or that it had been reviewed with the PR. Review of Resident 169's Progress Notes dated 12/5/2019 revealed care plan offered to resident and (gender) declined. There was no documentation the baseline care plan was reviewed with the PR or that a copy was offered to them. On 12/2/2019 under Social Services review in Resident 169's Progress Notes it was documented Resident 169 had a BIMS of 7 severely impaired' and that Resident 169 had a power of attorney for health care. On 11/27/19, 11/28/19, 11/2/19, 12/1/19, 12/2/19, 12/3/19, 12/4/19, 12/5/19, 12/6/19, 12/7/19, 12/8/19, 12/13/19, 12/14/19, 12/18/19, and 12/20/19 impaired decision making ability was documented for Resident 169. On 11/26/19, 11/30/19, 12/8/19, 12/11/19, 12/12/19, 12/14/19, 12/15/19, 12/18/19, and 12/20/19, short-term memory impairment was documented for Resident 169. Interview with MDS (Minimum Data Set Coordinator) on 1/16/2020 at 4:12 PM revealed they did not go over the baseline care plan with Resident 169's PR or give them a copy. Review of the facility policy Baseline Care Plan Guidelines dated 8.2019 revealed no documentation of who and when the baseline care plan was to be reviewed with or that a written summary would be provided to the PR. Interview with MDS on 1/16/2020 at 4:20 PM confirmed there was no documentation of the baseline care plan procedure on the policy. MDS confirmed there was no documentation Resident 169's knew about what medications Resident 169 was receiving. Review of the facility Admission Agreement revised 6.2018 revealed the following: Baseline Care Plan. Within 24 hours of your admission, the Facility will develop a baseline care plan. The baseline care plan will include instructions needed to provide you effective person-centered care. The baseline care plan will address, at a minimum, your initial goals based on your admission orders [REDACTED]. The facility will provide you and your representative with summary of the baseline care plan.",2020-09-01
4477,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2019-04-01,655,D,1,0,OJJK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1A Based on record review and interview; the facility staff failed to provide a summary of the Base Line Care Plan (BLCP) to the resident and/or responsible party for 1 (Resident 13) of 4 sampled residents. The facility staff identified a census of 52. Findings are: Record review of a Transfer/Discharge Report sheet printed on 3-25-2019 revealed Resident 13 was admitted to the facility on [DATE]. Record review of Resident 13's 48 Hour Plan of Care sheet dated 10-09-2019, revealed the section identified as Completion Date revealed #3 date to be reviewed with Resident/Representative was not filled in. Review of Resident 13 medical record revealed there was not evidence the facility staff had provided a summary of the base line care plan to the resident/representative. On 4-1-19 9:15 AM a interview was conducted with the Social Service Director (SSD). During the interview when asked if the summary of the BLCP had been provided to Resident 13 or Responsible Party, The SSD stated no.",2020-06-01
3650,RIDGEWOOD REHABILITATION & CARE CENTER,285279,624 PINEWOOD AVENUE,SEWARD,NE,68434,2018-06-05,655,D,1,1,RVGM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1a Based on interviews, observation and record review; the facility failed to develop an initial care plan addressing activities, communication and sensory, nutrition, tube feeding and urinary catheter needs for 1 (Resident #66). This has the potential to affect one Resident (Resident #66). The facility census was 73. Findings are: [NAME] Review of an Admission Record revealed Resident #66's original admitted was 03/06/2018, another admission date of [DATE]. The resident had [DIAGNOSES REDACTED]. Observation on 05/29/18 at 10:26 AM revealed Resident #66 was not in their room. On 05/29/18 at 10:49 AM observation revealed Resident #66 was in the therapy room working with green therapy bands. Resident 66 was following 1:1 directions for therapy. Resident #66 didn't speak, used mostly head nodding and very quiet speech and thumbs up and thumbs down hand signals. Staff F stated Resident #66 was receiving all three therapies; Physical Therapy, Occupational Therapy and Speech Therapy. On 05/29/18 at 02:31 PM observation of Resident #66 in the resident's room and the resident nodded the resident's head yes or no to questions; or signaling thumbs up or thumbs down On 06/04/18 at 10:32 AM interview with the DON revealed that Staff A was the person responsible for Resident #66's activities. On 06/04/18 at 02:30 PM interview with Staff A revealed Resident #66 was tube fed and didn't have a lot of speech. In the mornings Staff A got Resident #66 a dry erase board, have resident trace dots, write residents name, today we went outside to pollinate tomatoes. Resident #66 tries to verbalize and points. I usually go in about 11 am, Resident #66 is tired after therapy, usually 1:1 with resident, resident and spouse attend devotions, and resident usually sleeps in the afternoon. On 05/31/18 at 03:10 PM interview with Staff C , while reviewing Base Line Care Plan dated 4/11/18 stated Social Services is covering the Life Enrichment portions right now; Life enrichment goal was for snacks but Resident #66 is NPO, and resident snack is [MEDICATION NAME] (Resident's tube feeding). Review of 'Baseline Care Plan' Dated 4/11/18 revealed no goals for activities B. Review of an Admission Record revealed Resident #66's original admitted was 03/06/2018, another admission date of [DATE]. The resident had [DIAGNOSES REDACTED]. On 05/29/18 at 02:41 PM observation of Resident #66 was able to nod head yes or no for questions. There were no any communication devices at bedside or posted anywhere in Resident #66's room On 05/31/18 at 09:53 AM interview with the DON revealed Resident #66 communicated mostly yes/no, hand gestures, and facial expressions and that there were no communication or sensory goals on the 'Baseline Care Plan dated 4/11/18 On 05/31/18 at 11:07 AM interview with Staff F on how Resident #66 communicated revealed that the staff said that the resident used yes/no head gestures, and thumbs up and thumbs down. Resident #66 did use a white board and pointed to what the resident needed. I think Speech Therapy put a board in the resident's room. On 06/04/18 at 08:28 AM Observation of AM cares for Resident #66 by Staff D and Staff [NAME] revealed Staff [NAME] knocked on Resident #66' door , stated Good Morning and Resident #66 nodded their head. The staff shoed the resident an 8 x 10 piece of paper with large print YES NO and asked Are you ready to get up. Resident #66 pointed to yes and nodded. Can we change your brief Resident #66 pointed to yes and nodded . Staff [NAME] brought some warm washcloths and asked Resident #66 to wash face. Resident #66 washed face with washcloth. Resident #66 made no verbalizations throughout cares. On 06/04/18 at 08:09 AM interview with Staff G regarding communication for Resident #66 revealed Resident #66 would make eye contact, and had a writing board in room. Staff G revealed that the resident was able to nod yes or no, sometimes Resident #66 said yes or no. The staff use the 'faces scale for pain assessment. Review of a Speech Therapy Plan of Care Dated 4/13/18 revealed severe [MEDICAL CONDITION] (inability to form speech or language) and the inability to swallow. Review of Resident 66's 'Baseline Care Plan' dated 4/11/18 revealed: Communication 1. Can the resident easily communicate with staff? And the response was marked yes 2. Does the resident understand staff? And the response was marked yes. There was no indication Resident #66 was non-verbal, communicated with yes no head nods, thumbs up/thumbs down gestures or used a white board for communication. Review of Resident 66's Baseline Care Plan dated 4/11/18 revealed no goals or approaches for Resident #66's communication needs such as nodding head yes/no, thumbs up/thumbs down signals or the use of a white board to communicate. C. Review of an Admission Record revealed Resident #66's original admitted was 03/06/2018, another admission date of [DATE]. The resident had [DIAGNOSES REDACTED]. On 05/31/18 at 09:49 AM Interview with the DON Resident #66 is NPO On 06/04/18 at 09:40 AM Observation of Staff G performed tube feeding administration and PEG tube site cares. Resident #66 had no verbalizations throughout the tube feeding administration or cleansing of the PEG tube site. Resident #66 nodded head to yes/no questions or gestured thumbs up or thumbs down. Review of Summary of Care Document undated, print stamp at bottom dated 4/11/18, page 50 of 51 revealed Lines, Tubes and Drains Instructions, PEG, Urinary Catheter, maintain Foley for [MEDICAL CONDITION] Review of Speech Therapy Plan of Care Dated 4/13/18 revealed severe [MEDICAL CONDITION] (inability to form speech or language) and the inability to swallow. Record Review in PointClickCare revealed: On 3/6/18 weight was 162.0 and 5/27/18 weight was 170.0 and inability to take oral food/fluid. Review of Order Summary Report dated 4/25/18 revealed nothing by mouth diet dated 4/12/18 and enteral (tube feeding) feed order [MEDICATION NAME] 1.5 tube feeding continuous tube feeding dated 4/11/18 Review of Baseline Care Plan dated 4/11/18 revealed: Eating: support provided marked no set up or physical help from staff. Dietary,Therapy and Social Services: Diet Order listed as Health Heart Diet. TPN or tube feeding- tube feeding is not selected. Dietary Interventions selected eats in dining room. Review of Baseline Care Plan dated 4/11/18 revealed no goals or approaches for Resident #66's NPO status and tube feeding for nutrition. D. Review of an Admission Record revealed Resident #66's original admitted was 03/06/2018, another admission date of [DATE]. The resident had [DIAGNOSES REDACTED]. On 05/31/18 at 09:49 AM Interview with the DON revealed Resident #66 was NPO. On 06/04/18 at 09:40 AM Observation of Staff G performing tube feeding administration and PEG tube site cares revealed Resident #66 had no verbalizations throughout the tube feeding administration or cleansing of the PEG tube site. Resident #66 nodded head to yes/no questions or gestured thumbs up or thumbs down. Review of a Speech Therapy Plan of Care dated 4/13/18 revealed severe [MEDICAL CONDITION] (inability to form speech or language) and the inability to swallow. Record Review in PointClickCare revealed: On 3/6/18 Resident 66's weight was 162.0 and 5/27/18 weight was 170.0 and the resident had an inability to take oral food/fluid. Review of an Order Summary Report dated 4/25/18 revealed nothing by mouth diet dated 4/12/18 and enteral (tube feeding) order for [MEDICATION NAME] 1.5 tube feeding continuous tube feeding dated 4/11/18 Review of Resident 66's Baseline Care Plan dated 4/11/18 revealed: Eating: support provided was marked no set up or physical help from staff. Dietary, Therapy and Social Services: Diet Order listed was Health Heart Diet. TPN or tube feeding- tube feeding is not selected. Dietary Interventions selected eats in dining room. Review of the Baseline Care Plan dated 4/11/18 revealed no goals or approaches for Resident #66's PEG tube feeding or NPO status. E. Review of an Admission Record revealed Resident #66's original admitted was 03/06/2018, another admission date of [DATE]. The resident had [DIAGNOSES REDACTED]. On 06/04/18 at 08:28 AM observation of AM cares for Resident #66 by Staff D and Staff [NAME] included incontinence care, emptying the Foley catheter drainage bag and cleansing the catheter area. Review of the undated Summary of Care Document with a print stamp at the bottom dated 4/11/18, revealed Lines, Tubes and Drains Instructions, PEG, Urinary Catheter, maintain Foley for [MEDICAL CONDITION] Review of Resident 66's Baseline Care Plan dated 4/11/18 revealed: Section C Bowel and Bladder 1. Urinary continence marked 0. Always continent 2. Bowel continence marked 0. Always continent 3. Constipation present marked 0 No 4. Bowel and bladder appliances a, Indwelling catheter (not marked) e. NONE THE ABOVE was selected. Review of the Bladder Assessment Form dated 4/18/18 revealed the resident had an indwelling Foley catheter, it was expected to remain in more than 14 days, and terminal illness or severe impairments, which makes positioning or clothing changes uncomfortable, or which is associated with intractable pain and verify that there is very specific [DIAGNOSES REDACTED]. On 05/31/18 at 03:10 PM interview with Staff C and review of Admission Baseline Care Plan 4/11/18 revealed indwelling Foley catheter was not on the care plan. On 06/04/18 at 08:28 AM observation of AM cares for Resident #66 by Staff D and Staff [NAME] included incontinence care, emptying the Foley catheter drainage bag and cleansing the catheter area. Review of Resident 66's Baseline Care Plan dated 4/11/18 revealed no goals or approaches for Resident #66's PEG tube feeding or NPO status.",2020-09-01
5854,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2016-08-10,280,D,1,0,142711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1a Based on record review and interview, the facility staff failed to review and revise a Comprehensive Care Plan (CCP) related to suicide ideation for 1 resident (Resident 4). The facility staff identified a census of 164. Findings are: Record review of an undated Resident Face Sheet revealed Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident Resident 4's Nurse's Notes (NN) dated 7-28-2016 revealed Resident 4 had reported to a facility staff member of wanting to slice and kill (gender) self. Record review of Resident 4's CCP dated 3-28-2016 revealed there was not any evidence the facility staff had reviewed and revised Resident 4's CCP to include the suicidal ideation and how staff were to provide care when Resident 4 was having suicidal thoughts. On 8-09-2016 at 1:28 PM an interview was conducted with the Director of Nursing (DON). During the interview, review of Resident 4's CCP was completed with the DON. The DON confirmed Resident 4's CCP had not been updated to reflect Resident 4's suicidal ideation and should have been.",2019-08-01
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
3938,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,656,D,1,1,OLWQ11,"**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 develop an individualized and person centered Care Plan to reflect Resident 13's behavior history with baths and also failed to develop interventions to decrease further behaviors. The facility census was 34 . Findings are: Review of Resident 13's undated Care Plan revealed no reference to behaviors during baths and no goals or interventions to aide staff in dealing with bathing issues. The use of an antianxiety medication was not listed on the care plan. The Care Plan did not reflect how the facility would assist in meeting the resident's need of receiving baths. Review of Resident 13's Medications Flow Sheet for (MONTH) revealed Resident 13 was to receive [MEDICATION NAME] (anxiety medication) before baths. The Behavior flow sheet attached to the Medications Flow Sheet revealed that Resident 13 had received [MEDICATION NAME] four (4) times during the month of (MONTH) and no times (0) during March. Interview on 03/20/18 at 08:09 AM with the DON (Director of Nursing) revealed that the resident should be getting [MEDICATION NAME] with every bath due to the order stating give [MEDICATION NAME] for target behavior of resistive to cares, striking out, pinching and hitting with bath 15-30 minutes before bath as needed. The Care Plan was not developed to include interventions regarding bathing behaviors.",2020-09-01
4341,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-04-11,280,D,1,0,T8J411,"**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 revise the care plan for Resident 1 to prevent falls and potential injury. This affected 1 of 3 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 Significant Change in Status MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 3/3/2017 revealed that Resident 1 had a BIMS (Brief Interview for Mental Status) score of 9 which indicated moderate cognitive impairment and Resident 1 required extensive assistance from 1 staff person for transfers and locomotion. Resident 1 also had 2 or more falls with injury since admission/entry, reentry, or prior assessment. Review of Resident 1's Fall by the Week log revealed documentation that Resident 1 fell on [DATE], 3/5/2017, three times on 3/6/2017, and 2 times on 3/7/2017. Review of Resident 1's care plan dated 12/30/2016 revealed no documentation of interventions to prevent further falls and potential injury after Resident 1 fell on [DATE], 3/5/2017, and 3/6/2017. Interview with the DON (Director of Nursing) on 4/11/2017 at 2:50 PM confirmed there was no documentation of interventions to prevent falls and potential injury on Resident 1's care plan after the falls on 3/4/2017, 3/5/2017 and 3/6/2017 and there should have been. Review of the facility policy Falls Management dated 4/2015 revealed the following procedure: Assess and review resident risk factors for falls and injuries upon admission, with a significant change in condition or after a fall. Complete the Fall Risk Assessment within the electronic medical record (EMR). Implement goals and interventions with resident/patient/family for inclusion in the Interdisciplinary Plan of Care (IP[NAME]) based on individual needs. Fall Injury Prevention-Post Fall: Assess the resident/patient and immediately implement appropriate measures to prevent injury. Adjust/add interventions on the Plan of Care-Fall Risk Reduction. Review and revise Interdisciplinary Plan of Care.",2020-08-01
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
2356,GOOD SAMARITAN SOCIETY - RAVENNA,285202,411 WEST GENOA,RAVENNA,NE,68869,2017-10-30,280,D,1,0,7T6F11,"**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 Resident 1's care plan after Resident 1 had documented falls. This affected 1 of 3 sampled residents. The facility identified a census of 38 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 tool used to develop a resident's care plan) dated 9/20/2017 revealed Resident 1 had a BIMS (Brief Interview for Mental Status) score of 4 which indicated severe cognitive impairment. Resident 1 required limited assistance from 1 staff person for bed mobility, transfer, locomotion on the unit, dressing, and toilet use. Resident 1 had 1 fall with no injury since admission/entry or reentry or the prior assessment. Review of Resident 1's fall documentation revealed Resident 1 had falls on 12/23/2016, 12/25/2016, 12/27/2016, 3/21/2017, 4/4/2017, 4/6/2017, 6/22/2017, 9/19/2017, 10/4/2017, 10/11/2017, 10/12/2017, 10/14/2017, twice on 10/15/2017, and 10/18/2017. Review of Resident 1's care plan dated 12/23/2016 revealed no documentation of interventions implemented to prevent further falls after Resident 1 fell on [DATE], 9/19/2017, 10/4/2017, 10/14/2017, 10/15/2017, or 10/18/2017. There was an entry documented on the care plan revision 10/15/2017 but no documentation that a new intervention was implemented. Interview with the DON (Director of Nursing) on 10/30/2017 at 4:37 PM revealed the nurse on duty was supposed to put interventions on the care plan each time Resident 1 fell . The DON confirmed interventions were not documented on Resident 1's care plan and they should have been. Review of the facility policy Comprehensive Care Plan and Care Conferences revised 9/17 revealed care plans must be revised as the resident's needs/status changes.",2020-09-01
2555,MT CARMEL HOME- KEENS MEMORIAL,285216,412 WEST 18TH STREET,KEARNEY,NE,68845,2018-01-17,657,E,1,0,V7FS11,"**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 the care plans for Residents 1, 2, 3, 4, 5, and 6 to prevent further incidents and potential injury after resident to resident altercations. This affected 6 of 6 sampled residents. The facility identified a census of 67 at the time of survey. Findings are: [NAME] Review of Resident 1's Admission Record revealed an admission date of [DATE]. Review of Resident 2's Admission Record revealed an admission date of [DATE]. Review of Resident 1's Progress Notes dated 10/15/2017 revealed Resident 1 was slapped on the right forearm by Resident 2. Review of Resident 1's Care Plan dated 6/17/2017 revealed no documentation that the care plan was reviewed and revised with measures to protect Resident 1 after Resident 2 slapped them. Review of Resident 2's Care Plan dated 12/30/2014 revealed no documentation that the care plan was reviewed and revised with measures to prevent Resident 2 from slapping Resident 1 or any other resident. B. Review of Resident 3's Admission Record revealed an admission date of [DATE]. Review of Resident 4's Admission Record revealed an admission date of [DATE]. Review of Resident 3's Progress Notes dated 10/19/2017 revealed Resident 3 swatted Resident 4 on the nose. Review of Resident 4's Care Plan dated 1/8/2016 revealed no documentation the care plan was reviewed and revised with measures to protect Resident 4 from further physical altercations with Resident 3. Review of Resident 3's Care Plan dated 10/15/2015 revealed no documentation the care plan was reviewed and revised with measures to prevent Resident 3 from further physical altercations with Resident 4 or any other resident. C. Review of Resident 5's Admission Record revealed an admission date of [DATE]. Review of Resident 6's Admission Record revealed an admission date of [DATE]. Review of Resident 5's Progress Notes dated 11/8/2017 revealed Resident 5 smacked Resident 6 on the hand 4 times. Review of Resident 5's Progress Notes dated 11/27/2017 revealed Resident 6 punched Resident 5 on the left arm then Resident 5 punched Resident 6 back on the right arm. Resident 6 then punched Resident 5 again on the left arm. Review of Resident 5's Care Plan dated 1/2/2015 revealed no documentation the care plan was reviewed and revised with measures to prevent Resident 5 from having any other altercations with Resident 6 or any other resident. Review of Resident 6's Care Plan dated 6/28/2017 revealed no revealed no documentation the care plan was reviewed and revised with measures to prevent Resident 6 from having any other altercations with Resident 5 or any other resident. Interview with the DON (Director of Nursing) on 1/17/2018 at 2:06 PM confirmed there was no documentation on the care plans for Residents 1, 2, 3, 4, 5, and 6 of review and revision with measures implemented to prevent further altercations between the residents. The DON confirmed the care plans were to have been reviewed and updated. Interview with NA (Nurse Aide)-A on 1/17/2018 at 2:47 PM revealed they get the information they need to care for the residents from the care plan.",2020-09-01
3398,WESTFIELD QUALITY CARE OF AURORA,285263,"PO BOX 166, 1313 1ST STREET",AURORA,NE,68818,2019-05-14,657,E,1,1,V7OX11,"**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 invite 1 anonymous resident's responsible party to the quarterly care plan meeting, failed to document the use of a bed rail on Resident 16's care plan, failed to document the use of oxygen on Resident 44's care plan, failed to update 3 residents' (Resident 33,36, and 29) careplans related to pressure ulcer interventions, and failed to document a fall intervention on Resident 48's care plan. This affected 7 of 24 residents whose care plans were reviewed during the survey process. The facility identified a census of 57 at the time of survey. Findings are: [NAME] Interview with an anonymous responsible party of an anonymous resident on 5/06/19 at 3:59 PM revealed the facility used to hold quarterly care plan meetings but they had not been invited to a care plan meeting for their resident since (MONTH) of (YEAR). The anonymous family member reported they had told the facility staff to send them the care plan reports so they didn't have to come in when the weather was bad but they had not received any of the care plan reports either. Review of the anonymous resident's care plan revealed no documentation the care plan had been reviewed since (MONTH) of 2019. Interview with the SSA/AC (Social Service Assistant/Activities Coordinator) on 5/13/19 at 1:25 PM confirmed the last care conference the anonymous responsible party had been invited to was in (MONTH) of 2019. Review of the Care Plan Dates and Signatures for the anonymous resident revealed the last care conference was in (MONTH) of 2019. Review of the anonymous resident's MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) schedule revealed their last assessment had been completed in (MONTH) of 2019. Interview with MDS-C on 5/13/19 at 2:19 PM revealed the anonymous resident's care plan was late because the assessment had gotten missed. MDS-C revealed the anonymous resident's assessment and care plan review was due in (MONTH) of 2019 and they had not been completed. B. Observation of Resident 16's room on 5/07/19 at 9:45 AM revealed a 1/4 bed rail was on the bed. Review of Resident 16's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 16 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated severe cognitive impairment. Resident 16 required extensive assistance of 2 staff persons for bed mobility and transfers. Restraints were not used. Review of Resident 16's care plan dated 9/12/2018 revealed no documentation of the use of the bed rail. Interview with the facility Administrator on 05/13/19 07:54 PM confirmed the bed rail should have been documented on Resident 16's care plan. C. Review of Resident 44's SCSA MDS dated [DATE] revealed an admission date of [DATE]. Resident 44 had a BIMS (Brief Interview for Mental Status) score of 4 which indicated severe cognitive impairment. Oxygen was not used while a resident in the facility. Observation of Resident 44 on 5/08/19 at 9:40 AM revealed MA-K (Medication Aide) put oxygen tubing into Resident 44's nose. Oxygen concentrator was on at 2 LPM (Liters Per Minute). Observation of Resident 44 on 5/08/19 at 1:27 PM and 5/9/19 at 8:41 AM revealed Resident 44 had oxygen on at 2 LPM. Interview with RN-A on 5/13/19 at 10:51 AM had an order for [REDACTED]. Review of Resident 44's Order Summary Report dated 2/28/2019 revealed and order to administer oxygen at 2 LPM to Resident 44. Review of Resident 44's care plan dated 1/8/2019 revealed no documentation Resident 44 used oxygen. D. Review of Resident 48's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 48 required extensive assistance of 2 staff persons with bed mobility. Interview with Resident 48 on 5/07/19 at 11:08 AM revealed they had fallen out of bed on 4/19/19 and the facility staff put a horseshoe pillow on their bed they put on there after they fell . Observation of Resident 48 on 5/07/19 at 3:54 PM and 5/8/19 at 9:16 AM revealed Resident 48 was resting in bed and had a horseshoe or U-shaped pillow around them. Review of Resident 48's Progress Notes dated 4/20/2019 revealed Resident 48 was found on the floor. Resident 48 reported to facility staff they had rolled out of bed. Staff placed a U shaped pillow around resident. Review of Resident 48's care plan dated 11/13/2018 revealed no documentation of the U-shaped pillow implemented as an intervention after Resident 48 fell out of bed on 4/20/2019 on the current care plan. Interview with MDS-C on 5/13/19 at 4:34 PM revealed the U-shaped pillow should have been documented on Resident 48's current care plan. Interview with NA-J (Nurse Aide) on 5/08/19 at 10:33 AM revealed they got the information they needed to care for the residents from the care plan. E. Review of Resident 33's Admission Record dated 5-8-19 revealed the date of admission of 8-24-18 with [DIAGNOSES REDACTED]. Review of Resident 33's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4-8-19 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 11 which indicated the resident cognition was moderately impaired. The resident required extensive assist of 2 staff with bed mobility, transfers, dressing, and toileting. Resident 33 did not walk and required extensive assist of 1 staff for locomotion, personal hygiene, and eating. The resident had pain but was not on any scheduled pain medication. Resident 33 used PRN (as needed) pain medications and nonpharmalogical interventions for pain control. The resident had an indwelling catheter. The resident was at risk for pressure ulcers and had 1 current pressure ulcer which was unstageable (Unstageable:Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). Review of the significant change MDS dated [DATE], which was before the resident developed the pressure ulcer, revealed the resident had a BIMS of 15 to indicate cognition was intact. The resident had weight loss and was not on a weight loss regiment and was at risk for pressure ulcer but did not have any current pressure ulcers at the time of the MDS. The resident required extensive assist of 2 staff with bed mobility, transfers, dressing, and toileting. Review of the WPIR (Weekly Pressure Injury Record) form dated 2-18-19 revealed the initial documentation of the stage 2 pressure ulcer (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-sanguineous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising) measured 4.5 x 4.5 x 0.1 cm (centimeter) with sero-sanguineous drainage, no odor, no tunneling, surrounding skin was dark pink in color. The location of the PU (pressure ulcer) was diagramed on a drawing on the right ischium (the ischium forms the lower and back part of the hip bone and is located at the lower portion of the buttock). Interventions listed on the WPIR form were to turn the resident every 2 hours, a pressure relieving cushion (but did not document for the chair or the bed), and treat with [MEDICATION NAME] (a zinc oxide-based barrier that protects against moisture). The Physician and Registered Dietician were notified and resident was identified at significant weight loss. Review of Resident 33's admission Braden Scale dated 8-24-18 revealed a score of 15. (Braden Scale - An assessment tool for Predicating Pressure Sore Risk. The score results indicate:severe risk 9 or less, high risk 10-12, moderate risk 13-14, mild risk 15-18). Review of initial comprehensive Careplan dated 9-7-18 revealed absence of addressing the potential risk of skin impairment at all, including the risk of developing a pressure sore. Review of current Careplan revealed the resident's pressure ulcers were addressed with the focus and intervention initiated on 3-12-19 and revised date of 4-22-19. The interventions listed were to educate the importance of position changes to prevent a pressure ulcer dated 3-12-19; required a pressure relief in both seated surface and sleep surface dated 3-12-19; weekly treatment documentation; resident seen by the wound clinic; the resident to be up in a chair only 1 hour a day; the wound VAC treatment, and nutritional interventions. Absent on the Careplan were the focus and interventions prior to development of the pressure ulcer in (MONTH) 2019. Review of Consulting Physician Observation, Progress Notes, and New Orders form dated 4-5-19 revealed 1) discontinue previous dressing change to right ischium. 2) start saline wet to dry dressing change bid (twice a day) to right ischium until wound VAC (vacuum assisted closure) is available) 3) When VAC is available, start VAC at 125 mmHg (millimeters) continuous, black sponge, change 3 times a week 4) start a low airloss mattress and the resident to be in bed at all times except for 1 hour total combined time for meals only. No more than 1 hour TOTAL. Interview on 5-8-19 at 9:45 AM with RN-A revealed Resident 33's PU was a facility acquired (developed after the resident started living and received care at the nursing home) pressure ulcer to the right ischium. RN-A revealed interventions for the PU were to reposition the resident every 2 hours, bedrest except for 1 hour a day, float the heels, and wear heel boots. RN-A revealed the resident was compliant with the interventions except for nutrition which contributed to the weight loss. Review of the current careplan revealed absence the interventions of the heel boots to prevent PU's to the heels and how the interdisciplinary team was to work together to provide cares physically and psychosocially for the resident on bedrest except for 1 hour a day. Interview on 5/8/19 at 4:20 PM with the DON (Director of Nursing) revealed the DON confirmed the 1 hour the resident was to be up should be an interdisciplinary Care Team planning and this would impact Activities, Psychosocial, Nutritional, Nursing and all disciplines should have addressed it on the careplan. F. Record review of Resident 36's Admission Record dated 5-7-19 revealed date of admission 7-9-18 with [DIAGNOSES REDACTED]. Review of Resident 36's admission MDS dated [DATE] revealed the resident was at risk for developing a pressure ulcer but did not have a pressure ulcer. The admission MDS 7-18-18 revealed at risk for pressure ulcer and did not have any. The MDS dated 3.-29-19 revealed resident had 1 current stage 3 PU. Review of the Braden Score dated 7-10-18 equaled an 11 to place the resident at a high risk for developing pressure ulcers. Review on 05/06/19 at 03:38 PM of the 'Weekly Pressure Injury Record' in Wound book revealed initial documentation of a stage 3 PU located on the left lateral foot (per a drawing on a picture as the documentation of the site was blank) dated 1-8-19 measured 1.7 x 1.0 x 0.5 cm described as 100% eschar of the wound bed. Interventions listed as started on 1-8-19 were an antibiotic because of the redness and warmth of a cellutlits, offload pressure to the site, and [MEDICATION NAME] treatment to the wound. Received on 5/13/19 at 4:32 PM Resident 36's Baseline Careplan which was undated and not titled but confirmed with MDS-C it was the original Baseline CarePlan. The careplan revealed the resident had derma sleeves to arms and legs at all times, heel protectors, special cushion and mattress were blank, and the resident was to be turned every 2 hours. Review of current Careplan revealed a focus to address potential pressure ulcers was developed 1-6-19 which was 2 days prior to the date the resident stage 3 PU was found. The interventions listed were: treatments as ordered and the resident was seen by the Wound Care Nurse. The treatment as of 3-25-19 for the stage 3 PU was listed with revision date of 4-4-19; assess/record/monitor wound healing weekly and PRN as the resident dated 1-6-19; educate the resident, family, and caregivers as to cause of skin breakdown and importance of cares dated 1-6-19; monitor nutritional status, 2 cal supplement was given dated 4-4-19. Absence on the care plan was the resident to wear heel boots or to float the heels. Interview on 5/13/19 at 4:05 PM with the DON revealed the lack of documentation on the TARS was poor documentation but the DON felt the treatments were documented weekly with the weekly assessments. The DON confirmed the DON was not aware of the documentation issue on the TARS. The DON did confirm the pressure ulcer was a facility acquired pressure ulcer. [NAME] Review of Resident 29's Admission Record dated 5-10-19 revealed date of admission 12-10-18 with [DIAGNOSES REDACTED]. Interview on 5/13/19 at 9:41 AM with RN-A revealed Resident 29 had 2 current pressure ulcer's, 1 on the heel and 1 on the buttock and both were facility acquired. Review of Resident 29's MDS dated [DATE] revealed a BIMs score of 8 indicated the resident's cognition was moderately impaired. The resident had 1 unstageable (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) with DTI (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) in evolution pressure ulcer. Review of Braden Scale score completed on admission 12-10-18 equaled 14 to identify the resident at a moderate risk for pressure ulcer risk. Review of the Baseline Careplan revealed skin care needs: resident had a pressure ulcer/skin injury to the posterior right wrist of 0.5 cm length. Resident wore a right wrist brace. Interventions were to cleanse the area and apply a Band-Aid. Review of admission Careplan revealed focus of pressure ulcer risk prevention was addressed on 1-5-19. Interventions listed were to educate on causes of skin breakdown, reasons for frequent repositioning, good nutrition, provide pressure relief both in the seated surface and in the bed, dated 1-5-19. The only revised intervention was 3-6-19 if the resident refused treatment to confer with the resident, careplan team, and family to try and determine why and try alternate methods. The Wound Nurse was to see the resident weekly. PU Site #1: Review of the 'Weekly Pressure Injury Record' initiated 1-15-19 revealed on the right heel an unstageable, dark purple/black measured at 1.8 x 4 cm and a dark red/purple area measured 2.9 x 4 cm pressure ulcer. The most recent documentation revealed of the right heel dated 5-1-19 the pressure ulcer was staged at a stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) measured at 1.8 x 1.4 x 0.2 cm. Observation on 05/09/19 at 09:10 AM revealed LPN-B perform the treatment of [REDACTED]. Observation of the PU revealed an open wound with dark purple/red color without drainage measured 1.5 x 1.5 cm by the nurse. The resident denied any pain at the site. A Braden Scale was also completed on 1-29-19 and scored an 11 which placed the resident at a high risk for pressure ulcers. Site #2: Review of the 'Weekly Pressure Injury Record' initiated on 4-22-19 for a stage 2 pressure ulcer (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-sanguineous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising) measured 0.8 x 0.5 cm with surrounding tissue of wound edges attached, intact documented for location as on the left buttock. On 4-26-19 the stage 2 PU measured 0.7 x 1.0 x 0.1 cm with flat surrounding wound edges of pink in color. On 5-2-19 the left buttock was a stage 2 measured at 1.2 x 1.2 of pale pink wound bed. On 5-8-19 the stage 2 now measured 2.3 x 2.4 x 0.1 with wound bed dark pink red and the wound bed was now flat with irregular edges. The treatment remained the same. 05/09/19 10:32 AM Interview on 5-9-19 at 3:50 PM with the DON confirmed Resident 29's pressure ulcers both were facility acquired. The DON also revealed the DON had instructed the staff to place on the Careplan to float the resident's heels and to apply the heel boots on the resident. The DON confirmed neither were documented on the Careplan. Review of current careplan dated 4-27-19 revealed focus of pressure ulcer risk prevention was addressed on 1-5-19. Interventions listed were to educate on causes of skin breakdown, reasons for frequent repositioning, good nutrition, provide pressure relief both in the seated surface and in the bed, dated 1-5-19. The revised intervention was 3-6-19 if the resident refused treatment to confer with the resident, careplan team, and family to try and determine why and try alternate methods. The Wound Nurse was to see the resident weekly. There was one notation on 4-27-19 which revealed the resident had a pressure ulcer to the right buttock and [MEDICATION NAME] applied, repositioned, encouraged calories, /protein. Will monitor weekly and PRN The area to the right heel was improving unstageable DTI. Continue with current approached, weekly monitoring and to see the Wound Nurse. Careplan was still absent about the heel boots or to float the heels. The careplan did have documented a history of 2 DTI to bilateral heels and a healed coccyx area. Careplan was absent any new interventions to address the deterioration of the stage 2 PU on the right buttock.",2020-09-01
4978,MITCHELL CARE CENTER,285287,1723 23RD STREET,MITCHELL,NE,69357,2017-03-15,280,D,1,0,JTXS11,**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 update Resident 1's care plan to include monitoring to prevent potential injuries to other residents. This affected 1 of 3 sampled residents. The facility identified a census of 45 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 2/24/2017 revealed Resident 1 had an admission date of [DATE]. Resident 1 had a BIMS (Brief Interview for Mental Status) score of 1 which indicated Resident 1 had severe cognitive impairment. Resident 1 required supervision with walking in the room and corridor. Resident 1 had physical behavioral symptoms directed towards other that occurred 1 to 3 days during the 7 day assessment period. Interview with the DON (Director of Nursing) on 3/15/2017 at 11:50 AM revealed staff were to be monitoring Resident 1's whereabouts every 30 minutes as an intervention to protect other residents from Resident 1's behaviors. Review of Resident 1's care plan dated 10/3/2014 revealed no documentation that staff were to monitor Resident 1's whereabouts every 30 minutes. Interview with the DON on 3/15/2017 at 1:39 PM confirmed there was no documentation on Resident 1's care plan to monitor Resident 1's whereabouts every 30 minutes.,2020-03-01
1089,EMERALD NURSING & REHAB LAKEVIEW,285106,1405 WEST HWY 34,GRAND ISLAND,NE,68801,2018-05-07,657,D,1,1,QN7C11,"**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 Resident 18's care plan regarding their refusal of restorative therapy, failed to implement interventions to prevent elopement (leaving the facility unattended) for Resident 112, and failed to revise Resident 13's care plan to reflect awalking program. This affected 3 of 35 residents whose care plans were reviewed. The facility identified a census of 55 at the time of survey. Findings are: [NAME] Review of Resident 18's care plan dated 1/15/2018 revealed Resident 18 was to receive a Restorative Therapy Program for active range of motion, walking, dressing, and grooming 6 times per week. Interview with the DON (Director of Nursing) on 5/07/18 at 4:33 PM revealed Resident 18 did not receive restorative care. Interview with the DON on 5/07/18 at 4:50 PM confirmed Resident 18 was not receiving restorative therapy program and it should not have been on the care plan. Interview with LPN (Licensed Practical Nurse)-E on 5/07/18 at 5:03 PM confirmed Resident 18 was not receiving a restorative therapy program. Interview with the DON on 5/07/18 at 4:57 PM revealed the facility did not have a policy to review and revise the care plan. All of the staff were trained to update the care plan with any changes. Risk management team was meeting once month so they were to be updated then also. The facility had quarterly care plan meetings also when the care plans were updated and gone over with the family. Interview with NA(Nurse Aide)-C on 5/03/18 at 10:46 AM revealed they get the information they need to care for the residents from the residents' care plan. B. Review of MDS dated [DATE] revealed Resident 112 had no wandering behaviors. No behaviors were noted. Section C noted disorganized thinking with unclear or illogical flow of ideas. Review of Physician order [REDACTED]. Review of [DIAGNOSES REDACTED].>Review of undated Physician orders [REDACTED]. Review of Progress Notes dated 2/19/2018 at 02:50 PM revealed the facility staff spoke with Resident 112's family about moving Resident 112 out of the ACU (Alzheimer's Care Unit) to the long term care wing and the family agreed with the move. Review of Progress Note dated 2/25/2018 at 05:52 PM revealed the elopement care plan was initiated after Resident 112 was observed in the parking lot at 01:20 PM. Documentation revealed the family was educated to alert charge nurse if the family was leaving the building and this was not on the Elopement Care Plan. Review of undated Care Plan revealed that no elopement interventions had been initiated until Resident 112 was observed in the parking lot on 2/25/18. C. Review of MDS Quarterly assessment dated [DATE] Functional Status revealed Resident #13 was independent in walking in room, with no staff support; and supervision, with no staff support for walking in the corridor. Review of Resident #13's care plan received 05/03/2018 revealed care plan was not updated for the restorative program and did not include instructions for staff to assist Resident #13 with ambulation in the room, or corridor after the restorative program was complete. Review of Physical Therapy Discharge Summary Dated 01/30/2018, revealed Resident #13 was able to ambulate 200 feet with modified assistance; and discharge ' to facilitate patient maintaining current level of performance and in order to prevent decline, development and instruction in the following RNP (Restorative Nursing Program) has been completed . Review of the Clinical Management Restorative Nursing Policy dated 05/2017 revealed If resident/patient refuses to participate, then care needs will be managed by Nursing and other Clinical staff as indicated. Document the refusal in the resident/patient's medical record. Re-evaluate, at least quarterly, to determine if the resident/patient would benefit from restorative and if they continue to refuse restorative care and Initiate Restorative Program patients requiring documentation of daily participation and/or number of interventions per week. Communicate interventions and goals to staff. Document goals, and interventions in the resident plan of care. and review and revise the Restorative Program Plan based on individual resident/patient needs. Add, modify or delete restorative programs as appropriate. Restorative Nurse to document on Restorative Monthly Review or Discharge Summary. Discharge from a restorative nursing program will occur when the IP[NAME] (Interdisciplinary Plan of Care) team determines the resident/patient meets the following criteria: Restorative Program goals are met and resident/patient is able to maintain their highest practicable level without nursing intervention. Resident/patient is unable to meet goals of restorative program. Individual needs will be managed through ongoing nursing care. Complete Restorative Monthly Review or Discharge summary. Update Resident Plan of Care. Review of care plan received 5/3/2018 initiated 12/04/2017 revealed no restorative nursing goals or interventions; and no walk to dine nursing goals or interventions. Interview on (MONTH) 3 (YEAR) at 1030 AM with Resident #13 stated I have not ambulated since therapy was discontinued and I am not involved in a restorative therapy program and don't attend an exercise class. They used to walk me to meals but they don't do that anymore. Interview on 05/03/18 09:06 AM with ADON (Assistant Director of Nursing) revealed Resident 13 had not been walking with staff in the hallway. Interview on 05/03/18 09:20 AM LPN (Licensed Practical Nurse)-A revealed Resident #13 did not walk to meals. Reviewed Resident 13's Progress Notes dated 3/22/18 revealed Resident 13 had refused a restorative program for ambulation. Interview on 05/07/18 at 04:44 PM with MA (Medication Aide)-G revealed they had not observed Resident #13 walk to the dining room for meals. Review of the facility Walk to dine list, undated, revealed Resident #13 was not listed. On 05/07/18 at 11:30 AM Interview with the MDS Coordinator revealed Resident #13 walked in their room, to go to the bathroom and Resident #13 didn't walk day to day to the dining room. Interview with MA-F on 05/07/18 at 0915 AM revealed, Resident #13 no longer walked outside of their room. Reviewed NA cheat sheet, undated, received 05/07/2018 for Resident #13 revealed no instructions to ambulate Resident #13 in corridor. On 05/07/18 at 04:39 PM Interview with DON Stated The charge nurse is responsible for updating the resident's care plans as changes occur. If it's not updated by the charge nurse, it should be updated with the MDS if it is in the MDS review time frame. Interview on 05/07/18 at 04:44 PM with MA-G revealed Resident #13 did not walk to the dining room for meals.",2020-09-01
4272,HILLCREST SHADOW LAKE,2.8e+300,1507 E GOLD COAST ROAD,PAPILLION,NE,68046,2017-08-14,280,D,1,1,728T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on observation, record review and interview; the facility staff failed to include 1 (Resident 40) of 21 resident in planning care, failed to review and revise Comprehensive Care Plans (CCP) related to not eating breakfast for 1 (Resident 104) and for urinary incontinence for 1 (Resident 7) of 21 sampled residents. The facility staff identified a census of 102. Findings are: [NAME] On 8 07 (YEAR) at 2:12 PM, an interview was conducted with Resident 40. During the interview; when asked if staff included Resident 40 in decisions about medications, therapy or other treatments, Resident 40 stated no. Review of Resident 40's medical record revealed there was no evidence the facility had included Resident 40 in Resident 40's care planning process. An interview on 8 10 (YEAR) at 9:00 AM was conducted with the Director of Nursing (DON). During the interview, the DON confirmed Resident 40 had not been included in the Care Conference meeting with the facility. B. Observation on 8 09 (YEAR) at 8:32 AM revealed Resident 104 had not been served a breakfast meal. On 8 09 (YEAR) at 8:33 AM, an interview was conducted with Certified Medication Assistant (CMA) [NAME] During the interview, CMA G reported Resident 104 did not eat breakfast. CMA G reported Resident 104 had a supplement and took orange juice at breakfast. On 8 10 (YEAR) at 8:53 AM, an interview was conducted with Registered Nurse (RN) H. During the interview, RN H reported Resident 104 did not eat breakfast. Record review of a Resident's Preference sheet printed on 8 10 (YEAR) revealed Resident 104 did not like breakfast. Record review of a Nutritional assessment dated 12 10 15 revealed Resident 104 did not eat breakfast. Record review of Resident 104's CCP dated 2 26 (YEAR) revealed that Resident 104 not wanting breakfast was not identified on Resident 104's CCP. On 8 10 (YEAR) at 2:15 PM, an interview was conducted with the DON. During the interview, the DON confirmed Resident 104's CCP had not been updated to reflect Resident 104 did not want breakfast. B. Resident 7's face sheet dated revealed that Resident 7 was admitted to the facility on [DATE]. The face sheet revealed that Resident 7's the [DIAGNOSES REDACTED]. Record review of Resident 7's MDS (Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated 6/20/17 revealed that Resident 7 was frequently incontinent of urine. Record review of Resident's Bladder assessment dated [DATE] revealed a score of 8. Bladder assessment dated [DATE], revealed that Resident 7 had a total score of 14. The scoring for the facility Bladder Assessment tool was the 0 9 which required bladder tracking, care planning, and for nursing to consider bladder retraining program. The scoring for 10 18 required that the facility perform an individualized care plan. Record review of Resident 7's CPC failed to be updated with individualized plan of care for Resident 7's change in assessment.",2020-09-01
1195,FALLS CITY CARE CENTER,285114,2800 TOWLE STREET,FALLS CITY,NE,68355,2019-04-04,657,D,1,1,9FKE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on observations, record reviews, and interviews, the facility failed to ensure the careplans were updated to include the use of the wheelchair chest positioning device for one resident (Resident 34), failed to include the weight loss for 1 resident (Resident 5), and Restorative for 1 resident (Resident 33) out of 22 residents sampled. The facility census was 57. Findings are: [NAME] Review of the Admission Record for Resident 34 revealed [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 2-4-19 revealed the resident's cognition was severely impaired. Resident 34 required total dependence of two staff with bed mobility, transfers, dressing, personal hygiene, and toileting. The resident did not walk and was on a turning/reposition program. The resident did not have any restraints. Observation on 4-2-19 at 8:02 AM of Resident 34 revealed the resident sitting in a tilt-n-space wheelchair. The resident had a butterfly chest/vest device on that was positioned across the chest and had two straps that went across the shoulders and secured on the back of the wheelchair and two other straps that came down at the bottom of the device and around the body and secured to the back of the wheelchair. Observation on 4-2-19 at 3:56 PM of Resident 34 in bed revealed the resident did not have the butterfly chest/vest device on. Observation on 4/03/19 at 11:04 AM of Resident 34 revealed the resident in the tilt-n-space wheelchair with the butterfly chest/vest device on and secured. Interview on 4/04/19 at 10:28 AM with NA-S (Nurse Aide) revealed the resident used to have a lap belt that was worn across the lap but that was a long time ago. The butterfly chest/vest device worked better to sit the resident up straight and was to be worn whenever up in the wheelchair. Review of Resident 34's Careplan revealed absence of documentation about the butterfly chest/vest device. The Careplan did address the resident's [MEDICAL CONDITION] disorder and as an intervention, while up in wheelchair, the resident was to wear a lap belt used as therapeutic intervention to achieve proper body position/alignment. The lap belt was to be checked every 30 minutes. The intervention was initiated 03/16/2016 and did not have a revision date. Interview on 4/03/19 at 4:27 PM with MDS-R (MDS Coordinator) revealed the butterfly chest/vest device was not a restraint but a positioning device that OT (Occupational Therapy) had ordered for the resident to aid the resident to sit up straight in the wheelchair to maximize respiratory effort. MDS-R revealed Resident 34 used to have a different type of device but in (YEAR) OT re-evaluated the resident and obtained this newer device that went across the chest and fit better. MDS-R confirmed the butterfly chest/vest device was not on the resident's Careplan. B Record review of Resident 33's Care Plan revealed; a focus for Fall Prevention: Resident 33 had a history of [REDACTED]. This was initiated on 09/02/2015. Intervention was a Restorative Nursing Program (a program designed to prevent the decline in mobility) and the specifics for the program would be found in the Tasks (an area of the EMR (Electronic Medical Record) for the NA (Nurse Aide) or RA (Restorative Aide) to document) this was initiated on 09/02/2015. Record review of Tasks revealed; Resident 33 there were no tasks that were related to a Restorative Program. An interview on 04/03/19 at 10:00 AM with the Restorative aide revealed; Resident 33 had not been on a Restorative Program since the staff member had been doing the program. An interview on 04/03/19 at 10:14 AM with the Therapy Director revealed; that Resident 33 had not been on a Restorative Program related to Resident 33's refusal to participate in the program. An interview on 04/03/19 at 02:31PM with MDS (Minimal Data Set (is a standardized federally mandated assessment used to complete a person centered care plan) confirmed Resident 33's care plan had not been update to reflect Resident 33's current condition related to Restorative services. C. Review of Resident 5's Care Plan dated 04/02/19 revealed [DIAGNOSES REDACTED]. Review of Resident 5's quarterly MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 03/15/19 revealed the resident did not have any swallowing disorders or dental problems, and required supervision and set up help only with eating and drinking. Review of Resident 5's weights from the Vital Signs section of the electronic medical record revealed the resident weighed 97 lbs. on 03/20/19. Resident 5 weighed 103 lbs. on 02/20/19, which indicated a 6% weight loss over 1 month. Resident 5 weighed 118 lbs. on 09/22/18, which indicated an 18% weight loss over 6 months. Review of Resident 5's care plan dated 04/02/19 revealed the resident was independent in eating, and the goal was to maintain independence. The resident's interventions included receiving 4 ounce House Supplement (fortified milk) with meals and 4 ounce Resource (nutrition supplement) between meals, a regular soft diet, staff to monitor changes in ability to eat independently, and to be weighed monthly. No specific focus of weight loss was noted on the care plan. Observation on 04/03/19 at 11:59 AM revealed Resident 5 was sitting at the dining room table. Resident 5 had two glasses that were partially full of juice and house supplement. The resident was drinking while waiting for the meal to be served, which consisted of potato wedges and a hamburger. NA-N (Nurse Aide) cut the resident's burger into quarters before serving to Resident 5. The resident ate a small amount of the burger and 3 pieces of potato independently. Resident 5 then picked at the remaining food with the fork, but didn't eat more even when encouraged by NA-N. The resident began folding a napkin and didn't eat anything else. Review of Progress Note by the Nutrition at Risk IDT (Interdisciplinary Team) Committee dated 03/25/19 revealed the physician was notified of continued weight loss on 03/20/19. The cause for weight loss was identified as very poor intake related to confusion and loose stools treated with [MEDICATION NAME] (medication to treat diarrhea) as needed. Interventions identified included providing the resident with fortified milk and Resource supplements to increase calorie and protein intake, staff encouragement, and offering foods the resident liked. Review of the (MONTH) and (MONTH) MAR (medication administration record) revealed the resident received [MEDICATION NAME] to treat loose stools. The resident received [MEDICATION NAME] 8 times in (MONTH) and 0 times in April. Interview on 04/02/19 at 2:06 PM with NA-M and NA-N revealed Resident 5 frequently refused meals for various reasons including the food being too spicy, portion sizes were too big, or not being hungry. NA-N revealed bland alternatives were offered to the resident when Resident 5 refused meals due to spicy foods. NA-N revealed that the resident would typically eat approximately 25% of the meal, but would eat 50-75% if the meal consisted of a favorite food. NA-N revealed the resident could eat and drink independently, but needed encouragement to eat. Interview on 04/03/19 at 4:32 PM with the RD (Registered Dietician) revealed Resident 5 had poor intake related to poor cognition and dementia. The RD confirmed the resident received fortified milk and Resource supplements. The RD revealed Resident 5 was also offered snacks between meals and was prompted to eat by staff. The RD revealed there was difficulty finding foods the resident would eat consistently because the resident's preferences varied based on mood. The RD confirmed there was no specific focus on the care plan for weight loss, and Resident 5 should have been care planned to have staff assistance with meals as the resident required encouragement from staff and was no longer independent.",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
3914,HILLCREST COUNTRY ESTATES-COTTAGES,285293,6082 GRAND LODGE AVENUE,PAPILLION,NE,68133,2017-05-04,280,D,1,1,POAF11,"**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 ensure that the comprehensive care plan was reviewed and revised for Resident 55 related to pressure ulcers. Facility census was 46 . Findings are: Electronic medical record revealed that Resident 55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 55 developed a Stage IV Pressure ulcer to left heel. (Stage IV Pressure ulcer is a full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structure). Record review revealed that Resident 55 had a catheter for urine and an ostomy for bowel. Record review of wound care changes revealed that Resident 55 had required multiple interventions to a deteriorating wound from 2/1/17 to date of survey, 5/3/17. Record review revealed that a wound vac was presently being used on resident. Record review of Resident 55's plan of care for a problem of an unstageable pressure ulcer on left heel showed interventions that included to check for incontinence and to clean and dry skin if wet or soiled. The care plan intervention for the wound vac did not include wound vac settings, frequency of changes, or individualized cares to be provided. Interview on 5/3/17 at 2:07 PM with RN (Registered Nurse) H, confirmed that the care plan for Resident 55 was not initialized and did not reflect the changes in wound care. RN H revealed that resident had been non-compliant with wearing a shoe when was asked not to d/due to developing wound. RN H confirmed that the care plan did not reflect Resident 55 noncompliance with pressure relieving measures. RN H confirmed that Resident 55 did have progression of wound from admission to date.",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
2115,BUTTE SENIOR LIVING,285180,210 BROADWAY,BUTTE,NE,68722,2017-07-19,280,D,1,0,PFZV11,"**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 Resident 3's Care Plan related to interventions to prevent falls. The sample size was 3 and the total facility census was 30. Findings are: [NAME] Review of the MDS (Minimum Data Set: a federally mandate assessment used for care planning purposes) dated 6/7/17 revealed the following related to Resident 3: -had a [DIAGNOSES REDACTED]. -was cognitively intact; -required limited assistance of 2 for transfers and ambulation in the resident's room; -required extensive assistance of 2 for toilet use; -was unsteady and only able to stabilize with staff assistance during transitions and walking; and -had a history of [REDACTED]. Review of Resident 3's Care Plan dated 1/23/17 indicated the resident had limited physical mobility and was at risk for falls. Nursing interventions included the following: -required assistance of 1 for mobility and transfers, and use of a gait belt (a safety device used during transfers and ambulation to help prevent falling); -dycem (an anti-slip material) on seat of wheelchair to prevent sliding; -sign placed on the wall stated (resident) always ring your call light for help you are unable to walk by yourself; -bed in lowest position with fall mat (a mat placed on the floor next to the bed to provide padding in case of a fall from the bed) in place; and -call light within reach. Review of Nursing Progress Notes revealed the following related to Resident 3's history of falls: -3/26/17 at 4:56 AM, found on the floor mat next to the bed following an attempt to go to the bathroom independently; encouraged to use the call light; educated that it is very important to have staff assistance until therapy feels (the resident) can go independently; -5/12/17 at 5:47 AM, fell at 5:30 AM while walking from the bed to the bathroom; knees buckled and staff lowered the resident to the floor; and -6/7/17 at 3:30 AM, went to the bathroom independently, and on the way back attempted to sit on the recliner, slid off and sat onto the floor mat. Review of the Fall Investigation dated 6/7/17 at 3:30 AM revealed Resident 3 activated the call light at 3:10 AM and requested to go to the bathroom. Nursing Assistant (NA)-D informed the resident (gender) was scheduled to go at 3:30 AM according to the bowel/bladder plan. At 3:30 AM, NA-D returned to the resident's room and found the resident on the floor. The resident verbalized going to the bathroom independently. There were no new interventions initiated in an attempt to prevent further falls. Review of Nursing Progress Notes dated 6/22/17 at 5:10 AM indicated Resident 3 was heard kicking the room door and was found on the floor yelling get towels I peed. The resident was incontinent of urine and indicated the fall occurred while going to the bathroom. There was no evidence to indicate the facility assessed causal factors for Resident 3's falls, or reviewed and revised interventions to prevent further falls. During interview on 7/19/17 at 1:42 PM, the Director of Nursing (DON) verified new interventions were not developed for the prevention of further falls by Resident 3.",2020-09-01
4061,HILLCREST MILLARD,285302,13225 WESTWOOD LANE,OMAHA,NE,68144,2019-03-21,657,D,1,0,EZUW11,**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 revise the Comprehensive Care Plan for the current status of skin integrity for 1 (Resident 10) of 3 sampled residents. The facility staff identified a census of 53. The findings are: Review of Resident 10's Medical Record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record Review of Resident 10's Medical Record revealed that Resident 10 was assessed by facility staff on 02/07/2019 to have a Stage 2 Pressure Ulcer (the top layer of skin is broken creating an open sore). Review of the current CCP (Comprehensive Care Plan) dated 2/5/2019 revealed that Resident 10 was at risk for skin issues due to decreased mobility and [DIAGNOSES REDACTED]. The goals included were Resident 10 would have reduced risk for skin breakdown and Resident 10 will have no skin breakdown. The interventions were as follows: 1. Float heels while in bed or recline recliner as needed. 2. Keep head of bed elevated. 3. Encourage footwear when up for protection. 4. Encourage ambulation as tolerated for pressure relief. 5. Pressure reduction mattress. 6. Wheelchair cushion. The Comprehensive Care Plan did not include the current skin status for Resident 10's identified Stage 2 Pressure Ulcer. Review of the Policy and Procedure for Comprehensive Care Planning undated revealed that the assessments of guests are ongoing and care plans are revised as information about the guest and the guest's condition change. Interview conducted with the Director of Clinical Service on 03/21/2019 at 2:39 PM confirmed that the CCP had not been revised to include the Stage 2 Pressure Ulcer for Resident 10.,2020-09-01
5583,"BROKEN BOW CARE AND REHABILITATION CENTER, LLC",285120,224 EAST SOUTH E STREET,BROKEN BOW,NE,68822,2018-05-17,657,E,1,1,1IGA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on record review, observation, and interviews, the facility failed to revise 4 residents' (Resident 5, 11, 19, and 17) Careplans out of 12 residents sampled to reflect their current status. The facility census was 30. Findings are: [NAME] Observation on 5-14-18 at 10:28 AM revealed Resident 11 had a rash with scabbed sores on both arms. Interview on 5-14-18 at 10:28 AM with Resident 11 revealed the rash was over the entire body and the resident had an appointment with the Dermatologist that day. Interview on 5-14-18 at 4:32 PM with the DON revealed Resident 11 just returned from the Dermatology appointment and had orders to treat the rash for scabies and was being placed in transmission based precautions for 24 hours. Review of the Physicians orders revealed an order for [REDACTED]. Observation on 5-15-18 at 2:43 PM revealed the resident had a PPE (personal protective equipment) cart outside the resident's room with a sign on the outside of the door instructing visitors to report to the nurses' station before entering the resident's room. Record review on 5-16-18 at 8:45 AM of Resident 11's careplan revealed the careplan had not been updated to reveal the resident had been placed in transmission based precautions and treated for [REDACTED]. B. Observation on 5-14-18 at 2:45 PM of Resident 5 revealed a rash with scabbed sores on bilateral arms and the resident was scratching at the rash on the arms. Interview on 5-14-18 at 5:22 PM with the DON (Director of Nursing) revealed Resident 5 just recieved orders to treat the rash for scabies and was being placed in transmission based precautions for 24 hours. Review of the Physicians orders revealed an order for [REDACTED]. Observation on 5-15-18 at 2:43 PM revealed the resident had an PPE cart outside the resident's room with a sign on the outside of the door instructing visitors to report to the nurse's station before entering the resident's room. Record review on 5-16-18 at 8:45 AM of Resident 5's careplan revealed the careplan had not been updated to reveal the resident had been placed in transmission based precautions and treated for [REDACTED]. C. Review of MDS (Minimum Data Set, a federally mandated assessment used for care planning purposes) dated 4/16/18 revealed Section H which was Bowel/Bladder function had indwelling catheter (a tube inserted into the bladder that drains urine from your bladder into a bag outside your body) marked as Yes to indicate Resident 19 had a catheter. Section V which is the Care Area of concern was marked to indicate that this was to be placed on the Resident 19's Care Plan. Review of undated Physician order [REDACTED]. Review of Progress Notes dated 4/10/18 revealed Resident 19 returned to the facility with an indwelling Foley catheter. Review of the undated Care Plan with a revision date of 4/9/18 for Hospice Service revealed that the indwelling Foley catheter was not located on the Care Plan. An Interview on 05/15/18 at 5:04 PM with NA-E (Nurse Aide-E) revealed Resident 19 had a catheter and it was drained by the staff. An interview on 05/16/18 at 2:31 PM with RN-A (Registered Nurse-A) confirmed after reviewing the MDS dated [DATE] that the Section H (Bladder and Bowel) had indwelling catheter marked to indicated, Yes the resident had one. RN-A also confirmed that Section V was marked to indicate that the catheter was triggered and needed to be care planned. After review the Care Plan, RN-A validated that the catheter was not listed on the Care Plan.",2019-11-01
5025,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2017-02-22,280,D,1,0,7IYH11,"**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 revise the Care Plan for one resident (Resident 222) out of three sampled residents. The facility census was 103. Findings are: Review of the undated Census sheet for Resident 222 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the Physician orders [REDACTED]. Review of the (MONTH) (YEAR) MARs (Medication Administration Records) revealed Resident 222 had requested and received the [MEDICATION NAME] for complaints of pain at least twice a daily on the days of (MONTH) 1 through 6. Review of the significant change MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 222 had no cognitive impairment. The PHQ-9 (Patient Health Questionnaire which screens for symptoms of depression and provides a standardized severity score) scored a 6 which indicated the resident had evidence of mild depression. An assessment for pain was completed which revealed Resident 222 was not on any routine pain medications. The resident did take PRN (as needed) pain medication and utilized non-pharmacological pain interventions during the assessment period. The resident complained of pain daily. Review of the CAA (Care Area Assessment) on the MDS dated [DATE] revealed pain was triggered and the care plan decision was documented as yes. Review of the Care Plan last revised on 2-16-17 did not address pain. Interview on 2-22-17 at 3:15 PM with RN-A (Registered Nurse) confirmed Resident 222 did have pain and was newly diagnosed with [REDACTED]. The RN confirmed that pain should have been addressed on the Care Plan and that ist was not.",2020-02-01
3893,LITZENBERG MEMORIAL COUNTY HOSPITAL,285292,1715 26TH STREET,CENTRAL CITY,NE,68826,2018-02-05,657,D,1,1,B5KI11,"**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 one resident, Resident 17, to reflect the resident status for an acute UTI (Urinary Tract Infection) out of one resident sampled. The facility census was 27. Findings are: Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-15-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 17's had no cognition impairment. Interview on 1-31-18 at 10:40 AM with MA-C (Medication Aide) revealed the resident had a history of [REDACTED]. MA-C revealed signs and symptoms of a potential UTI with the resident that the Aide would report to the nurse were blood in the urine, an odor, a change in the color of the urine such as a darkening of color, a change in the resident's behaviors, cloudiness, or an elevated temperature. Interview on 01-31-18 at 8:30 AM with RN -D (Registered Nurse) revealed the resident was on a [MEDICATION NAME] antibiotic because of chronic UTI's. The resident just finished with a round of antibiotics for an acute UTI on 01-28-18 but was still having problems. On 01-30-18 a nurse performed a PVR (post void residual: a test to measure the amount of urine in the bladder after toileting) and Resident 17 still had 593 cc of urine. RN-D revealed the staff encouraged fluids and were to discourage caffeine drinks but the resident loved to drink caffeinated soda pop daily. Review of the Physician orders [REDACTED]. The resident was also [MEDICATION NAME](Antibiotic) 125 mg every other day for UTI started on 12-15-17. Review of undated Careplan revealed the focus of the resident had bladder incontinence related to recurrent UTI, urge with continued incontinent episodes despite having the urge to void. The interventions listed were the resident was to use incontinence products and the staff were to monitor and document the signs and symptoms of a UTI. Examples of signs and symptoms were listed on the careplan. Interview on 01-31-18 at 3:48 PM with the MDS Coordinator revealed the careplan should have been updated when the resident received new orders for the antibiotics and other new orders related to the acute UTI.",2020-09-01
2675,AZRIA HEALTH BROADWELL,285221,800 STOEGER DRIVE,GRAND ISLAND,NE,68803,2018-11-14,657,D,1,0,CPVI11,"**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 one resident, Resident 30, to reflect the resident's current status for falls. The facility census was 60. Findings are: Review of admission PN (Progress Notes) dated 10-22-18 for Resident 30 revealed the resident had [MEDICAL CONDITION] with very spastic movements to the lower extremities. A fall mat was put into place and a bed in low position for fall interventions. 10-27-18 Resident skilled observation and assessment revealed the resident was alert and oriented. Resident 30's pain medication was increased and the fall mat was in place with the bed in low position also. 11-4-18 Resident 30 was having increased leg spasms. Review of PN (Progress Notes) dated 11-11-18 revealed Resident 30 was found on the floor next to the bed on the resident's right side with red marks on the resident's skin on the hip from the legs of the over-bed table, to the ribcage from the bed remote cord the resident was laying on and the shoulder which was on the floor. Lack of documentation about a floor mat being in place on the floor at the time of the fall. Review Resident 30's careplan on 11-14-18 at 9:09 AM revealed the resident was at risk for falls initiated 10-23-18. There were 2 interventions both dated 10-23-18, which was the resident's admitted , revealed My caregivers will ensure that I am wearing appropriately fitting foot wear and clothing and obtain a therapy referral as ordered by Physician. Interview on 11-14-18 at 4:04 PM with NA-A (Nurse Aide) revealed NA-A was not aware of any fall interventions to be used with Resident 30 except for the positioning bar on the bed. NA-A denied knowledge to use fall mats. Interview on 11-14-18 at 4:07 PM with NA-B revealed NA-B was not aware of any fall interventions for the resident, including a fall mat. Interview on 11-14-18 at 4:11 PM with MA-C (Medication Aide) revealed MA-C was not aware of any fall interventions for Resident 30 including a fall mat. Interview on 11-14-18 at 1:30 PM with the ADON (Assistant Director of Nursing) revealed as part of the IDT (interdisciplinary team)the ADON was not aware of the resident having had fall mats by the resident's bed. The ADON confirmed Resident 30 did not have fall mats by the bed as a fall intervention on the night of 11-11-18 at the time of the fall out of bed. The ADON revealed the floor nurses' must have initiated the fall mat upon admission because of the resident's severe leg [DIAGNOSES REDACTED] and concern of it causing the resident to fall out of bed. The ADON reviewed the careplan and confirmed the fall from 11-11-18, the PT (Physical Therapy) intervention, and the fall mat was not on the careplan.",2020-09-01
5219,BLUE VALLEY LUTHERAN NURSING HOME,285259,"P O BOX 166, 220 PARK AVENUE",HEBRON,NE,68370,2017-02-08,280,D,1,0,6J8311,"**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 update the careplan for one resident, Resident 214, to reflect the resident's current status related to the declining functional status after hospitalization [DATE] and related to the increased need for assistance after the fractured right arm on 01-21-17. This reflected one resident out of the three residents sampled. The facility census was 47. Findings are: Review of the undated face sheet for Resident 214 revealed a re-admitted from an acute care hospital on 01-19-17. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-16-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 14 that indicated no cognition problems. Resident 214 required extensive assist of 1 staff with bed mobility, transfers, dressing, toileting, and personal hygiene. The resident required limited assist of 2 staff with locomotion and walking. Resident 214 required set up assistance and supervision for eating. Review of the MDS dated [DATE], which was after the fractured arm, revealed a BIMS score of 13. The resident required extensive assist of 2 staff with bed mobility, transfers, dressing, toileting, and personal hygiene. The resident required extensive assist of 1 staff for locomotion and did not walk during the assessment period. Resident 214 required extensive assistance of 1 staff for eating. [NAME] Review of the Progress Notes revealed Resident 214 was hospitalized on [DATE] and returned on 01-19-17. Review of the Thayer County Health Services Discharge Instruction sheet dated 01-19-17 for Resident 214 revealed the discharge [DIAGNOSES REDACTED]. Interview with Staff A on 02-08-17 at 12:15 PM revealed when Resident 214 returned from the hospital on 01-19-17 and before the fall on 01-21-17, the resident was weaker and had intermittent periods of mild confusion. The resident required more assistance with ADL's (activities of daily living) and with transfers and was the reason for the use of the sit to stand lift. The resident had not used a mechanical lift prior to hospitalization of 01-03-17. Review of the Resident's Care Plan dated with revision 02-03-2016 revealed Resident 214 was a limited /extensive assist with 1 staff with bed mobility, transfers, dressing, toilet use and incontinence cares. The Care Plan was absent of any documentation of the use of a mechanical lift for transfers. B. Observation on 02-08-17 at 9:45 AM revealed the Resident 214 sitting in a wheelchair in the dining room at a table with food on a tray in front of the resident. The resident had a cast on the right arm and was being assisted to eat the meal by a staff person. Interview with Staff A on 02-08-17 at 12:15 PM revealed the resident prior to the fractured arm fed self independently. The resident now required staff to assist to eat with utensils to eat food items such as soup, cereal, and vegetables. Review of the resident's Care Plan dated revision date 01-25-17 revealed alteration in nutrition with multiple [DIAGNOSES REDACTED]. The interventions were absent of any new interventions after the fracture and absent regarding the resident required assistance to eat meals whereas the resident did not require assistance prior to the fractured arm. Interview on 02-08-17 at 11:45 AM with the DON (Director of Nursing) confirmed the Care Plan should have been updated on 01-19-17 to reflect the resident's return from hospitalization with change in condition and made changes to the ADL's for the increased need for assistance such as the mechanical lift. The DON confirmed when the resident returned with the fractured arm on 01-21-17 the Care Plan should have been updated to reflect changes with the increased assistance required with ADL's including eating.",2020-02-01
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
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
1806,PLUM CREEK CARE CENTER,285159,1505 NORTH ADAMS STREET,LEXINGTON,NE,68850,2018-12-18,661,D,1,1,P4JF11,"**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 a discharge summary for 1 of 1 sampled residents (Resident 86). Facility census was 37. Findings are: Review of Admission Status for Resident 86 on Admission Record and Census revealed an admission date of [DATE] Review of Transfer/Discharge Report dated 11/16/18 and signed by Residents 86's POA revealed no documentation for Chief complaint (reason for transfer). Review of Resident 86's Progress Notes (PN) revealed the following: Resident 86's Progress Note dated 11/11/2018 revealed: Staff from the other facility called today requesting information on resident. Family had been in and toured their facility. Called and talked to POA (Power of Attorney) and POA gave verbal consent to fax information they requested. Review of Resident 86's EHR (Electronic Health Record) revealed no Discharge Summary or discharge documentation. Interview on 12/18/18 at 2:48 PM with DON revealed: family was asked to come and take resident home over the weekend due to concerns for resident's safety. DON stated this was not actually an involuntary discharge because the POA did say the family would take the resident home when asked. Discharge Summaries were not completed when a resident was discharged from the facility. Requested on 12/18/18 at 3:55 PM a copy of this facilities policy on Admission/Transfers/Discharges and Letter of Discharge Notification were not obtained.",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
3949,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,758,E,1,1,OLWQ11,"**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 pharmacist failed to request a GDR (Gradual Dose Reduction) for [MEDICAL CONDITION] antianxiety medication for Residents 18, 22, 21, and 13; and the facility failed to ensure that there was clinical rationale for the continued use of a PRN (as needed) antipsychotic medication for Resident 4. This affected 5 of 5 residents. The facility identified a census of 34 at the time of survey. Findings are: [NAME] Review of Resident 18's quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 1/24/2018 revealed an admission date of [DATE]. Antianxiety medication was used 7 days of the 7 day look back period. Review of Resident 18's Physician order [REDACTED]. Review of Resident 18's [MEDICAL CONDITION] Medication Reduction form dated 2/12/ revealed no documentation the facility consultant pharmacist requested the GDR for Resident 18's [MEDICATION NAME]. Interview with the SSD (Social Services Director) on 3/14/18 at 2:38 PM revealed the facility consultant pharmacist did not request specific GDRs. The SSD confirmed the [MEDICAL CONDITION] medication reduction form was completed by the provider. The SSD confirmed the [MEDICAL CONDITION] medications were reviewed by the provider on rounds and not requested by the pharmacist. Interview with the DON (Director of Nursing) on 3/14/18 at 2:57 PM revealed the facility consultant pharmacist did not request the GDR on the dose. The facility consultant pharmacist came in and made sure the physicians completed the review that the facility staff had set up for the providers to do. Interview with the SSD on 3/14/18 at 2:59 PM confirmed the consultant pharmacist did not make recommendations for GDRs. B. Review of Resident 22 Physician orders [REDACTED]. Review of Resident 22's MDS revealed the resident had the behavior of wandering daily. Review of Resident 22's Careplan revealed the resident also had behaviors of difficulty focusing or being easily distracted and wandering. Review of the medical record revealed absence of a GDR recommendation from the RP (Registered Pharmacist). Interview on 3-15-18 at 3:03 PM with the SSD revealed the RP did not recommend a GDR from the Physician on the medications. The facility staff initiate a [MEDICAL CONDITION] Medication Reduction form and give it to the Physician to review and complete on the 60 day Physician visits. C. Review of a physician's orders [REDACTED]. Review of the MARs (Medication Administration Record) for January, (MONTH) and (MONTH) (YEAR); identified that that the ABH cream was given on 3/12/18, 2/19/18 and 2/08/18 and not at all in January. The documentation on the MAR indicated [REDACTED]. Review of the nursing progress note, dated 02/08/18 at 2:04 PM identified that at 9:55 AM ABH cream applied topical for anxiety during bath. Review of the nursing progress note, dated 02/19/18 at 2:18 PM, identified that PRN ABH cream given prior to whirlpool. Staff reports not helpful, as resident still yells and tries to hit. Review of the Monthly Drug Regimen Review for (MONTH) (YEAR), identified no recommendations from the pharmacy for a dose reduction for the ABH cream. Review of the [MEDICAL CONDITION] Medication Reduction Form, dated 1/09/18 identified that a dose reduction for the ABH cream was completed by the facility and signed by the physician. The form recommended a dose reduction since the PRN medication had been used once in 4 weeks, however, the physician denied the dose reduction due to Dose reduction likely to impair function, cause increase distressed behavior or psychiatric instability by exacerbating medical or psychiatric disorder. Review of the Monthly Drug Regimen Review for (MONTH) 11, (YEAR), identified that the consulting pharmacist documented that the dose reduction for the ABH cream was denied on 1/09/18. Interview on 3/15/18 at 11:00 AM with the LPN-G confirmed that the nursing staff should have documented the rationale as for giving the PRN ABH cream and that getting a bath is not a clinical rationale. LPN-G also stated that the nursing staff was not giving the PRN medication for each bath and that there was no consistency as to why it was or was not given at bath time. Interview on 03/15/18 at 11:43 AM with the DON (Director of Nursing) identified that the facility did not have a policy on PRN medication administration. The DON also stated that the facility was unaware that they needed to have continued clinical rationale for every 14 days of a PRN antipsychotic medication. D. Review of Resident 21's Physician orders [REDACTED]. Review of Resident 21's record revealed absence of a GDR recommendation from the RP Review of Resident 21's Care plan revealed the resident had behaviors of paranoid and the resident accused the staff of talking about the resident. Interview on 3-15-18 at 3:03 PM with the SSD revealed the RP did not recommend a GDR from the Physician on the medications. The facility nursing staff initiated a [MEDICAL CONDITION] Medication Reduction form and gave it to the Physician to review and complete on the 60 day Physician visits. Interview with DON (Director of Nursing) revealed that the GDR was not being completed by pharmacist. The nurses are filling out the GDR (Gradual Dose Reduction Form) paperwork and then having the Physician sign and date the form. E. Review of MDS (minimum data set, a federally mandated assessment used for care planning) dated 1/17/18 revealed a BIMS (brief interview for mental status, screening tool used in nursing homes to assess cognition) of 3. This indicates severe cognitive impairment. Review of physician orders [REDACTED]. Review of PHYSICIAN ACTION REPORT dated 2/5/2018 revealed the nurses' request a rational for duplicate therapies and no reply was documented. [MEDICATION NAME] (for anxiety) was not mentioned on the list as rationale for continuing to use. [MEDICATION NAME] (for depression) is not mentioned for GDR (Gradual Dose Reduction) trial. Review of Medication Flow sheet revealed that [MEDICATION NAME] had been given four (4) times in (MONTH) and as of (MONTH) 19th had not been given. There is no consistency for documentation of resident's baths or for monitoring of behaviors. Interview on 03/19/18 at 11:35 AM with MA-B (Medication Aide-B) revealed MA-B stated Resident 13 should receive [MEDICATION NAME] anytime she has one of the target behaviors. Interview on 03/19/18 at 12:08 PM with DON revealed Resident 13 should get [MEDICATION NAME] before every bath. DON confirmed if behaviors occur during the bath then it is too late to give the [MEDICATION NAME]. Resident is to receive her bathes on Tuesdays and Fridays.",2020-09-01
5320,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-01-10,282,D,1,0,YCVU11,"**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 staff failed to follow Resident 1's care plan to provide supervision to prevent potential injury. This affected 1 of 8 sampled residents. The facility identified a census of 123 at the time of survey. Findings are: Review of Resident 1's face sheet revealed an admission date of [DATE]. Review of Resident 1's annual MDS (minimum data set-a comprehensive assessment used to develop a resident's care plan) dated 12/2/2016 revealed that Resident 1 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated that Resident 1 was cognitively intact. Resident 1 also required assistance from staff for transfer and toileting. Review of Resident 1's care plan dated 3/17/2016 revealed that Resident 1 was at risk for falls and that staff will remain in resident bedroom while resident is using the restroom. Interview with the DON (Director of Nursing) on 1/10/2017 at 2:50 PM revealed that Resident 1 wore a seat belt while using the restroom for medical reasons; however, the staff were to stay in Resident 1's room while Resident 1 used the restroom. Observation of Resident 1's room on 1/10/2017 at 3:40 PM revealed the restroom call light was on, Resident 1 was in the restroom, and no staff were present in the room. Interview with Resident 1 on 1/10/2017 at 5:25 PM revealed that Resident 1 needed a seat belt because staff did not stay with them while they used the restroom.",2020-01-01
5853,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2016-08-10,278,D,1,0,142711,"**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 identify limited Range Of Motion (ROM) for 1 resident (Resident 1) on a Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning). The facility staff identified a census of 164. Findings are: Record review of an undated Resident Face Sheet revealed Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 8-05-2016 revealed the facility staff assessed the following about the resident: -Short and long term memory problem with severely impaired cognition. -Required total assistance with bed mobility, transfers, locomotion, dressing, eating, personal hygiene. -Required extensive assistance with toilet use. -Always incontinent of bowel and bladder. -Had indicators of pain or possible pain with possible pain observed 3 to 4 times out of 5 days. -Other [DIAGNOSES REDACTED]. Record review of a Radiology Report sheet dated 7-22-2016 revealed Resident 1 sustained a fracture to the right knee. Record review of Resident 1's MDS signed as completed on 8-05-2016 revealed the facility staff had not identified Resident 1 with limited ROM to the lower right extremity. An interview was conducted on 8-10-2016 at 10:36 AM with Registered Nurse (RN) [MI] During the interview, Resident 1's MDS dated as completed on 8-5-2016 was reviewed with RN [MI] RN L confirmed during the interview that coding for functional ROM was not correct and should have identified Resident 1 with limitations.",2019-08-01
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
5766,ARBOR CARE CENTERS-NELIGH LLC,285124,"PO BOX 66, 1100 NORTH T STREET",NELIGH,NE,68756,2016-09-13,309,D,1,0,XBS311,"**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 necessary care and services to Resident 1 related to the management of [MEDICAL CONDITION]. The sample size was 4 and the facility census was 46. Findings are: Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/25/16 indicated the resident was moderately intact related to cognition, and required extensive assistance with activities of daily living. Review of Progress Notes dated 8/18/16 revealed Resident 1 had [DIAGNOSES REDACTED]. Review of Resident 1's Nursing Progress Notes revealed the following: -8/20/16 at 6:05 PM - resident stated feels like (resident) has to go to the bathroom but can't; and -8/20/16 at 6:37 PM - complained of pressure to urinate but cannot and takes Tylenol (a medication used to treat pain) for this. Review of the I&O (Intake and Output) Detail Report revealed the following related to Resident 1's urinary output: -8/20/16 at 10:01 PM - voided 4 times during the shift; -8/21/16 at 6:03 AM - voided 4 times during the shift; -8/21/16 at 9:53 PM - voided 3 times during the shift; -8/22/16 at 4:24 AM - voided 3 times during the shift; -8/22/16 at 1:50 PM - voided 3 times during the shift; -8/22/16 at 9:50 PM - voided 2 times during the shift; -8/23/16 at 6:09 AM - voided 2 times during the shift; -8/23/16 at 2:04 PM - voided 2 times during the shift; -8/23/16 at 8:33 PM - voided 3 times during the shift: -8/24/16 at 5:31 AM - voided 2 times during the shift; and -8/24/16 at 1:51 PM - voided 1 time during the shift. There was no indication the total volume of urine voided by the resident during each shift was monitored. Review of Nursing Progress Notes dated 8/24/16 at 5:42 PM indicated Resident 1 was continent of bladder, and during the afternoon has been voiding in small amounts. Review of the I&O Detail Report revealed the following related to Resident 1's urinary output: -8/24/16 at 10:29 PM - voided 1 time during the shift; -8/25/16 at 6:15 AM - No Output during shift; and -8/25/16 at 1:37 PM - voided 3 times during the shift. There was no indication the total volume of urine voided by the resident during each shift was monitored. Review of Nursing Progress Notes dated 8/25/16 at 6:08 PM indicated Resident 1 complained of voiding very little, and the resident had a history of [REDACTED]. drain urine). Review of a physician's orders [REDACTED]. There was no indication Resident 1's urinary function was further assessed until a Nursing Progress Note dated 8/25/16 at 1:20 AM (7 hours and 12 minutes following the prior assessment and the PCP's catheter order) revealed the following: -staff reported Resident 1 did not void on the 2:00 PM to 10:00 PM shift; -Resident 1 told staff can not pee; -the resident's abdomen was distended; -a catheter was inserted and 700 cc of dark yellow odorous urine was drained from the bladder; and -the catheter was left in place as ordered by the PCP. During interview on 9/13/16 from 12:00 PM until 12:10 PM, the Director of Nursing verified Resident 1's volume of urine output was not monitored until after the urinary catheter was inserted, and that the need for catheter insertion should have been assessed more timely.",2019-09-01
6321,HERITAGE CROSSINGS,285230,501 NORTH 13TH STREET,GENEVA,NE,68361,2016-04-18,309,D,1,0,HX8F11,"**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 treatment by not coordinating care with a specialty physician for one resident (Resident 1) related to [MEDICAL CONDITION] care and vision care. This caused the resident to have vision loss. The facility census was 58. Findings are: Review of Resident 1's care plan dated 1/7/16 revealed the resident required assistance with Activities of Daily Living (ADLs) related to a right [MEDICAL CONDITION] with non weight bearing status .and [MEDICATION NAME] degeneration. Interventions included two person assist for transfers with a mechanical lift. The transfer status changed to one person assist on 2/26/16. Resident 1's family member was interviewed on 4/18/16 at 10:04 AM. The family member said that Resident 1 had been seeing an eye specialist for several years and receiving injections to prevent further vision loss from [MEDICATION NAME] degeneration. The last injections were on 11/25/15 and 12/8/15. On 12/8/15 an appointment was made for 1/19/16. The family member stated that Resident 1 fractured a bone just below the hip and after surgery rehabilitation was ordered and there was to be no weight bearing on that leg. The fracture occurred on 1/1/16 and the facility canceled the eye appointment for 1/19/16 because of the fracture and the weight bearing status. The family member expressed concern to the facility that Resident 1 needed the eye injections to prevent vision loss. Review of the Interdisciplinary Progress Notes (IPNs) for Resident 1 revealed that on 2/19/16 it was noted that Resident 1 was scheduled to see the orthopedic specialist on 2/26/16 and that an appointment with the eye specialist had been rescheduled for 3/21/16. On 3/17/16 the IPN revealed that the 3/21/16 appointment was rescheduled for 4/25/16 and that the resident's family member was informed of this change after the fact. Both of these IPNs were written by Licensed Practical Nurse A (LPN A). On 4/18/16 at 3:49 PM LPN A was asked about conversations which had taken place with Resident 1's eye specialist. LPN A said the conversations about appointment changes took place with the scheduler at the eye specialist clinic. No conversation took place with the eye specialist about the risks to Resident 1's eyesight if not seen for the injections which had been scheduled in (MONTH) and again for 3/21/16. LPN A said the resident was unable to attend the appointment related to her inability to tolerate the van ride. This decision was not based on consultation with the orthopedic specialist but rather on assessment by the facility staff. On 4/19/16 at 4:40 PM the Director of Nursing (DON) was interviewed about care coordination between the orthopedic specialist and the eye specialist to determine Resident 1's care needs related to vision and the healing fracture. The DON confirmed that the orthopedic specialist was not consulted about the resident's ability to physically attend an appointment for her eye injections. There was no coordination to have the two specialists consult with each other about Resident 1's care needs. Review of a clinic report for Eye Surgical Associates dated 3/22/16, revealed Resident 1 was being treated for [REDACTED]. The report also indicated that Resident 1 had fallen and fractured leg right below the hip on 1/1/16. Resident was non weight bearing for 6-8 weeks. Resident 1's family member reported to the eye specialist that the facility called their office and canceled an appointment for 1/19/16 due to Resident 1 being unable to bear weight. The appointment was rescheduled for 3/21/16 which the facility again called and rescheduled to 4/25/16. Loss of vision in the OD (right eye). Under 'Plan' on the clinical report it stated, There has been increased exudation (oozing of fluids as a result of inflammation) in the left eye since last visit as (gender) has gone without treatment since last visit. On 4/18/16 at 1:01 PM an interview was conducted with the eye specialist who stated that Resident 1's eye injections were medically necessary to prevent vision loss. The specialist confirmed that not getting the injections resulted in vision loss for Resident 1.",2019-04-01
5804,MOTHER HULL HOME,285254,125 EAST 23RD STREET,KEARNEY,NE,68847,2016-09-14,309,D,1,0,U65711,"**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 assess the effectiveness of pain medication for 1 of 3 sampled residents (Resident 48). The facility census was 55. Findings are: Interview with Resident 48 on 9/14/16 at 11:45 AM stated the facility staff did not listen to my complaints about pain when I broke my hip. Resident 48 revealed the pain was bad all the time but on 8/16/16 the pain was really bad. My doctor requested I be taken to the hospital for x-rays that revealed a [MEDICAL CONDITION]. Review of the facility form entitled MEDICATIONS ADMINISTRATION HISTORY dated 8/6/16 TO 8/31/2016 revealed the following: -8/7/16 at 8:48 AM reason of PRN (as needed) medication: pain; no effectiveness recorded, -8/7/16 at 3:15 PM reason for PRN medication-pain; no effectiveness recorded, -8/7/16 at 8:42 PM reason for PRN medication-pain; no effectiveness recorded, -8/8/16 at 7:12 AM reason for PRN medication-pain; no effectiveness recorded, -8/8/16 at 8:03 PM reason for PRN medication-pain; no effectiveness recorded, -8/9/16 at 7:02 AM reason for PRN medication-pain; no effectiveness recorded, -8/9/16 at 1:20 PM reason for PRN medication-pain; no effectiveness recorded, -8/9/16 at 4>34 PM reason for PRN medication-pain; no effectiveness recorded, -8/9/16 at 7:33 PM reason for PRN medication-pain; effectivenes recorded as not effective- no further assessment, -8/9/16 at 7:40 PM reason for PRN medication-pain; no effectiveness recorded, -8/9/16 at 12:40 AM PRN result somewhat effective; no further assessment, -8/10/16 at 4:54 AM reason for PRN medication-pain; no effectiveness recorded, -8/10/16 at 8:00 AM PRN result somewhat effective; no further assessment, -8/10/16 at 8:12 AM reason for PRN medication-pain; no effectiveness recorded, -8/10/16 at 5:30 PM reason for PRN medication-pain; no effectiveness recorded, -8/10/16 at 10:11 PM PRN results not effective; no further assessment recorded, -8/11/16 at 1:47 AM reason for PRN medication-pain; no effectiveness recorded, -8/11/16 at 4:59 AM PRN results somewhat effective; no further assessment recorded, -8/11/16 at 5:00 AM reason for PRN medication-pain; no effectiveness recorded, -8/11/16 at 8:40 AM PRN results somewhat effective; no further assessment recorded, -8/11/16 at 8:43 AM reason for PRN medication-pain; no effectiveness recorded, -8/11/16 at 12:27 PM reason for PRN medication-pain; no effectiveness recorded, -8/11/16 at 10:23 PM reason for PRN medication-pain; no effectiveness recorded, -8/12/16 at 6:33 AM reason for PRN medication-pain; no effectiveness recorded, -8/12/16 at 3:01 PM reason for PRN medication-pain; no effectiveness recorded, -8/12/16 at 8:33 PM reason for PRN medication-pain; no effectiveness recorded, -8/12/16 at 11:54 PM reason for PRN medication-pain; no effectiveness recorded, -8/13/16 at 5:17 AM reason for PRN medication-pain; no effectiveness recorded, -8/13/16 at 7:33 AM reason for PRN medication-pain; no effectiveness recorded, -8/13/16 at 11:45 PM reason for PRN medication-pain; no effectiveness recorded, -8/14/16 at 9:57 PM reason for PRN medication-pain; no effectiveness recorded, -8/15/16 at 9:41 PM reason for PRN medication-pain; no effectiveness recorded, -8/16/16 at 3:15 AM reason for PRN medication-pain; no effectiveness recorded, -8/16/16 at 4:30 AM reason for PRN medication-pain; no effectiveness recorded, -8/16/16 at 10:43 AM reason for PRN medication-pain; no effectiveness recorded, Review of Resident 48's nurse progress noted, dated 8/7/16 to 8/16/16, did not address the assessment of the PRN medications administered for pain. Interview with the DON (Director of Nurses ) on 9/14/16 at 2:15 PM revealed the staff did not address the results of the PRN medication given. The expectation was for the staff to assess and record the effectiveness of the PRN medications with in an hour. If the PRN medication was not effective expected the staff to address the situation. Review of the facility form entitled MEDICATION ADMINISTRATION USING MED STRIP PACKAGING, no date of origin, revealed PRN medications will be labeled with a large RED sticker on the outside of the plastic bag that contains the PRN medication pouches.",2019-09-01
5885,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2016-08-04,315,D,1,0,IWFH11,"**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 implement a toileting program for 1 resident (Resident 1). The facility staff identified a census of 89. Findings are: Record review of a Admission Record sheet dated 7-22-2016 revealed Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of a VOI dated 6-12-2016 revealed Resident 1 had fallen onto the floor. According to the VIO dated 6-12-2016 Resident 1 was transferring from a wheelchair to the bedside commode. Record review of a Interdisciplinary Progress Note (IPN) dated 6-14-2016 revealed Resident 1 was found on the floor with a wheelchair partially on top of Resident 1. According to the IPN dated 6-14-2016, Resident 1 was going to the bathroom. Record review of a VOI dated 7-7-2016 revealed Resident 1 had fallen when attempting to go to the bathroom. Record review of Resident 1's medical chart revealed there were not evidence the facility had evaluated Resident 1 for a toileting program. An interview was conducted on 8-4-2016 at 7:30 AM with the Director of Nursing (DON). During the interview, the DON confirmed Resident 1 had not been evaluated for a toileting program. The DON further reported that a toileting program should have been completed and implemented for Resident 1.",2019-08-01
4098,CARL T CURTIS HEALTH EDUCATION CENTER NURSING HOME,28A065,"PO BOX 250, 100 INDIAN HILLS DRIVE",MACY,NE,68039,2017-10-16,329,D,1,1,FXJ411,"**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 behaviors for the use of a antipsychotic medication for 1 (Resident 8) of 5 sampled residents. The facility staff identified a census of 17. Findings are: Record review of Resident 8's Medication Administration Record [REDACTED]. Record review of Resident 8's medical record revealed there was no evidence the facility staff were monitoring specific behaviors related to the use of the [MEDICATION NAME]. On 10-12-2017 at 12:35 PM an interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed there were no specific behaviors that were being monitored for the use of the [MEDICATION NAME] medication.",2020-09-01
4749,"SORENSEN CARE AND REHABILITATION CENTER, LLC",285107,4809 REDMAN AVENUE,OMAHA,NE,68104,2017-06-15,329,D,1,1,F9RW11,"**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 to monitor specific target behaviors for the use of anti-psychotic medications for 3 (Resident 8, 79 and 84) of 5 sampled residents. The facility staff identified a census of 67. Findings are: [NAME] Record review of Resident 8's Medication Administration Record [REDACTED]. According to information on the 6-2017 MARs, the target behaviors to monitor for were hallucinations and paranoia. Record review of Resident 8's Comprehensive Care Plan (CCP) revealed Resident 8 had additional behaviors that included agitation and anxiety during care. Record review of Resident 8's behavior monitoring sheet for (MONTH) (YEAR) revealed the behavior being monitored was depressed/withdrawn. There were not specific behaviors being monitored for the use of the antipsychotic medication. On 6-15-2017 at 9:12 AM an interview was conducted with the Social Services Director (SSD). During the interview,review of Resident 8's (MONTH) (YEAR) behavior monitoring was conducted. The SSD confirmed during the interview there were no specific target behaviors being monitored for the use of the antipsychotic medication. B. Record review of Resident 79's Order Summary Report sheet dated 3-16-2017 revealed Resident 79 had orders for medications that included [MEDICATION NAME] (an antipsychotic medication), 25 mg's twice a day. Record review of Resident 79's Behavior Flow sheet for 6-2017 revealed the behaviors being monitored were depressed and anxiety, there were no specific target behaviors being monitored for the use of the antipsychotic medication. On 6-15-2017 at 9:13 AM an interview was conducted with the Social Services Director (SSD). During the interview review of Resident 79's behavior monitoring was conducted. The SSD confirmed during the interview there were no specific target behaviors being monitored for the use of the antipsychotic medication. C. Record review of an Active Orders sheet dated 6-07-2017 revealed Resident 94's Physician had ordered medications that included [MEDICATION NAME] (an antipsychotic medication) 25(mg) at bed time. Review of Resident 94's medical record revealed there was not evidence the facility staff had identified specific target behaviors Resident 94 exhibited for the use of the [MEDICATION NAME]. On 6-15-2017 at 9:15 AM an interview was conducted with the Social Services Director (SSD). During the interview review of Resident 94's behavior monitoring was conducted. The SSD confirmed during the interview there were no specific target behaviors being monitored for the use of the antipsychotic medication.",2020-03-01
3916,HILLCREST COUNTRY ESTATES-COTTAGES,285293,6082 GRAND LODGE AVENUE,PAPILLION,NE,68133,2017-05-04,329,E,1,1,POAF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review, observations and interviews; the facility failed to evaluate the continued use of psychoactive medications for 1 (Resident 3) of 5 sampled residents related to a medication for [MEDICAL CONDITION] and use of an antipsychotic medication, and failed to evaluate the continued use and need for medicated creams for 3 (Resident 55, 99 and 27) of 3 residents reviewed. The facility census was 46. Findings are: [NAME] Review of Resident 3's Face sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 3's Medication Administration Record [REDACTED] -[MEDICATION NAME] 50 mg (milligram) at bedtime (an antidepressant sometimes used to help [MEDICAL CONDITION]) started on 8/23/16 and -[MEDICATION NAME] 10 mg daily (an antipsychotic medication) started on 2/22/16. Review of Resident 3's Psychiatric Note dated 12-16-17 revealed Resident 3 had no psychotic behaviors noted and had some aggression. but the note state that did not feel it was related to [MEDICAL CONDITION] and more of a personality trait. The staff were ordered to continue with [MEDICATION NAME] for [MEDICAL CONDITION]. Review of progress notes for Resident 3 from (MONTH) (YEAR) to (MONTH) (YEAR) revealed no documented behaviors or difficulty sleeping. Review of Resident 3's Electronic Medical Record (EMR) Progress notes, Physician visit notes, Assessments, and Labs revealed no sleep evaluation or documentation of [MEDICAL CONDITION]. Review of Resident 3's Care plan with an effective date of 12-30-14 to present revealed Resident 3 was on [MEDICATION NAME] for unprovoked aggression due to prosecutorial paranoid delusions with interventions of Cottage Team to review every 2-3 months and as needed for a possible dose reduction. There was no Care plan noted for [MEDICAL CONDITION] or [MEDICATION NAME] usage. Review of Resident 3's EMR Progress notes, Physician orders, Telephone orders, labs, and Assessments revealed no dose reduction attempts for the [MEDICATION NAME] or [MEDICATION NAME]. An interview conducted on 5/4/17 at 9:15 AM with Nurse Aide (NA) [NAME] revealed it was very rare for Resident 3 to have any behaviors and could not recall the last time the resident had behaviors. An interview conducted on 5/4/17 at 9:20 AM with NA J revealed that Resident 3 would sometimes get depressed or sad but not very often and had not had behaviors in a long time. An interview conducted on 5/4/17 at 1:20 PM with the Administrator revealed there was no sleep monitoring for Resident 3. The Administrator confirmed Resident 3 had not had behaviors from (MONTH) to (MONTH) and there was no dose reduction attempts on Resident 3's [MEDICATION NAME] or [MEDICATION NAME] but there should have been. B. Record review of Resident 55's electronic medical record revealed that Resident 55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of Activities of Daily Living (ADL's), on 5/3/17 at 11:44 AM revealed that Resident 55 had multiple prescription creams present in the room for use. Record review of Resident 55's physician orders [REDACTED].: 1) [MEDICATION NAME] 0.25% apply topically two times daily as needed for rash. The order date was 11/11/2016. 2) [MEDICATION NAME] 2.5% apply topically to back as needed for itching. The order date was 2/16/17. 3) Mometasone Furoate 0.1% apply topically to affected areas daily as needed. The order date was 11/11/16. 4) [MEDICATION NAME] 0/1% ointment apply to affected areas 2 to 3 times daily as needed. The order date was 11/11/16. 5) Risamine ointment apply to buttocks twice daily. The order date was 2/17/15 Record review of Resident 55's Monthly Pharmacy review, dated 12/2/16, revealed a request for a clinical rationale for [MEDICATION NAME] 0.25% cream, [MEDICATION NAME] Propionate cream, and Mometasone Furoate cream. Interview with Resident 55's pharmacist revealed that all the creams were the same medication, used for the same purpose, and the difference was they were in different strengths. The Pharmacist confirmed that the orders did not specify where the creams were to be applied. The Pharmacist confirmed that Resident 55 did have unnecessary medications evidenced by the multiple creams that provide the same treatment at different strengths. C. Record review of Resident 27's physician orders [REDACTED]. The order date of this medication was on (MONTH) 16 of (YEAR) Resident 27 was to have Fluconazole (antifungal agents), 150 mg tablet by mouth weekly as needed for yeast infection (Yeast is a fungus). The original order for this medication was 6/12/2013. Record review of Resident 27's Medication Administration Records for January, February, March, (MONTH) and May, revealed that Resident 27, had not been administered the Fluconazole in the past 5 months. Record review of Resident 27's Weekly Skin Assessments for the past 2 months revealed no areas of concern under the breast and the [MEDICATION NAME] powder continued to be applied every shift. Interview on 5/3/17 at 2:07 PM, with the facility Registered Nurse (RN) H confirmed that Resident 27 had been receiving the [MEDICATION NAME] powder under breast for moisture and not for treatment of [REDACTED]. D. Record review of Resident 99's physician orders [REDACTED].)., and [MEDICATION NAME] (used to treat skin infections such as athlete's foot, jock itch, ringworm, and other fungal skin infections) 1%, apply topically on and between the 4th and 5th toe of the right foot twice daily until healed, then an additional week for athlete foot. Record review of Resident 99's Medication Administration Records for January, February, March, (MONTH) and May, revealed that these medications have not been used in the past 5 months. Record review of Resident 99's weekly skin assessments for the months of March, (MONTH) and (MONTH) revealed no documentation of skin issues that would require these medications. Interview on 5/3/17 at 2:07 PM with the facility RN H confirmed that Resident 99 had not used these medications recently and had no skin issues. RN H confirmed that Resident 99 should have had these medications discontinued for non-use.",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
4908,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2018-02-05,677,D,1,0,15YY11,"**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 provide bathing assistance for Residents 18 and 34 who were totally dependent with bathing. The sample size was 4 and the facility census was 36. Findings are: [NAME] Review of Resident 18's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/8/17 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was totally dependent with bathing. Review of Resident 18's current Care Plan (undated) revealed the resident preferred a bath every day, Monday through Friday (5 days per week), per family request. Review of Bathing Documentation (paper record of baths provided daily) and Point of Care Audit Report (electronic record of baths provided daily) from 1/1/18 through 2/5/18 revealed Resident 18 did not receive 5 baths weekly. Documentation indicated baths were provided on (MONTH) 4, 6, 7, 8, 10, 11, 12, 16, 17, 18, 19, 24, 26, 31, (YEAR) and (MONTH) 1,2 and 5, (YEAR) (a total of 17 out of 26 baths that were to have been provided). Interview with Nursing Assistant (NA)-A on 2/510/18 at 10:50 AM revealed Resident 18 was scheduled to receive 5 baths per week on Monday through Friday. NA-A confirmed Resident 18 did not always receive 5 baths per week. B. Review of Resident 34's MDS dated [DATE] revealed the resident had no cognitive impairment and was totally dependent with bathing. Review of Resident 34's current Care Plan (undated) revealed the resident was totally dependent on staff to provide a shower once a week and as necessary. Review of Bathing Documentation from 1/1/18 through 2/5/18 revealed Resident 34 did not receive a bath/shower from 1/18/18 until 2/1/18 (2 weeks). Interview with Resident 34 on 2/5/18 at 3:00 PM confirmed the resident went 2 weeks without a bath/shower recently.",2020-03-01
1866,"NORTH PLATTE CARE CENTER, LLC",285165,2900 WEST E STREET,NORTH PLATTE,NE,69101,2017-07-20,312,D,1,0,2TNM11,"**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 staff failed to provide assistance with bathing for Resident 1. This affected 1 of 3 sampled residents. The facility identified a census of 52 at the time of survey. Findings are: Review of Resident 1's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 6/29/2017 revealed an admission date of [DATE]. Resident 1 had a BIMS (Brief Interview for Mental Status) score of 13 which indicated Resident 1's cognition was intact. Resident 1 required extensive assistance from 2 staff persons for transfers and extensive assistance from 1 staff person for bathing. Review of Resident 1's bathing documentation for 6/22/2017-7/20/2017 revealed documentation that Resident 1 received a bath on 7/6/2017 and 7/17/2017. There was no documentation that Resident 1 received a bath from 7/6/2017 to 7/17/2017, or 11 days without a bath. Interview with Resident 1's responsible party on 7/20/2017 at 11: 05 AM revealed Resident 1 did not receive a bath for 11 days. Interview with the DON (Director of Nursing) on 7/20/2017 at 2:04 PM confirmed that there was no documentation that Resident 1 got a bath from 7/6/2017 to 7/17/2017. The DON revealed that it was the expectation that facility residents receive at least 1 bath a week. The DON revealed the facility did not have a bathing policy as the bathing protocol was based on resident preference.",2020-09-01
6132,MT CARMEL HOME- KEENS MEMORIAL,285216,412 WEST 18TH STREET,KEARNEY,NE,68847,2016-06-14,312,E,1,0,ZEZZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on interviews and record review, the facility staff failed to provide care to residents needing assistance within the designated time frame. This affected Resident 10, 16, 44, and 46. The facility census was 68 at the time of survey. Findings are: A. Review of Resident 16's Admission MDS (Minimum Data Set-a comprehensive resident assessment tool used to develop a resident's care plan) dated 5/31/2016 revealed that Resident 16 required assistance from staff for bed mobility, transfer, locomotion, dressing, eating, toilet use, personal hygiene, and bathing. B. Review of Resident 44's Significant Change in Status MDS dated [DATE] revealed that Resident 44 required assistance from staff for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, and bathing. Interview with Resident 44 on 6/14/2016 at 1:35 PM revealed that Resident 44 sometimes had to wait a long time before the call light was answered and that Resident 44 had toileting accidents while waiting for staff to answer the call light. Interview with the facility Administrator on 6/14/2016 at 4:04 PM revealed that call lights were to be answered within 15-20 minutes. Review of Resident 16's Alarm Event Report for the time period of 6/1/2016 to 6/14/2016 revealed that Resident 16 had the following calls that were more than a 20 minute response time: 6/1/2016 call placed at 7:18 AM; cleared at 7:54 AM, for a total of 36 minutes; 6/4/2016 call placed at 7:58 AM; cleared at 8:23 AM for a total of 25 minutes; 6/6/2016 call placed at 5:54 AM; cleared at 6:22 AM for a total of 28 minutes; 6/6/2016 call placed at 6:41 AM; cleared at 7:05 AM for a total of 24 minutes 6/7/2016 call placed at 6:06 AM; cleared at 6:41 AM for a total of 35 minutes 6/7/2016 call placed at 6:22 PM; cleared at 6:43 PM for a total of 21 minutes 6/11/2016 call placed at 12:17 PM; cleared at 12:48 PM for a total of 31 minutes 6/12/2016 call placed at 12:28 AM; cleared at 12:53 AM for a total of 25 minutes 6/12/2016 call placed at 12:15 PM; cleared at 12:51 PM for a total of 36 minutes 6/12/2016 call placed at 6:22 PM; cleared at 6:44 PM for a total of 22 minutes 6/12/2016 call placed at 8:17 PM; cleared at 8:41 PM for a total of 24 minutes Review of Resident 44's Alarm Event Report for the time period of 6/1/2016 to 6/14/2016 revealed that Resident 44 had the following calls that were more than a 20 minute response time: 6/3/2016 called placed at 11:58 AM; cleared at 12:32 PM for a total of 34 minutes 6/3/2016 called placed at 6:12 PM; cleared at 6:38 PM for a total of 26 minutes 6/4/2016 called placed at 12:03 PM; cleared at 12:31 PM for a total of 28 minutes 6/4/2016 called placed at 6:26 PM; cleared at 6:58 PM for a total of 32 minutes 6/7/2016 called placed at 6:32 AM; cleared at 7:17 AM for a total of 45 minutes 6/7/2016 called placed at 12:16 PM; cleared at 12:42 PM for a total of 26 minutes 6/8/2016 called placed at 12:21 PM; cleared at 12:48 PM for a total of 27 minutes 6/10/2016 called placed at 9:27 PM; cleared at 9:48 PM for a total of 21 minutes 6/12/2016 called placed at 12:21 PM; cleared at 12:57 PM for a total of 36 minutes 6/12/2016 called placed at 4:39 PM; cleared at 5:03 PM for a total of 24 minutes Interview with the facility Administrator on 6/14/2016 at 4:04 PM confirmed that some of the call light response times on the logs were too long. Review of the facility operational guideline call lights approved 3/2012 revealed that each resident would have a call light readily available to them to communicate needs and to provide a sense of security. C. Review of the MDS dated [DATE] revealed required assistance from staff for bed mobility, transfer, locomotion, dressing, eating, toilet use, personal hygiene, and bathing. Review of the facility Alarm Event Report from 6/1/2016 to 6/14/16 for Resident 10 revealed the following: -6/1/16 at 7:24 PM alarm sounded, was cleared at 7:48 PM, a total of 23 minutes later, -6/2/16 at 12:06 PM alarm sounded, was cleared at 12:29 PM, a total of 23 minutes later, -6/2/16 at 12:38 AM alarm sounded, was cleared at 1:04 AM, a total of 25 minutes later, -6/3/16 at 12:56 AM alarm sounded, was cleared at 1:25 AM, a total of 29 minutes later, -6/3/16 at 7:32 PM alarm sounded, was cleared at 7:53 PM, a total of 21 minutes later, -6/6/16 at 12:16 PM alarm sounded, was cleared at 12:46 PM, a total of 30 minutes later, -6/7/16 at 7:04 PM alarm sounded, was cleared at 7:27 PM, a total of 23 minutes later, -6/7/16 at 7:30 AM alarm sounded, was cleared at 7:55 AM, a total of 25 minutes later, -6/7/16 at 9:12 AM alarm sounded, was cleared at 10:04 AM, a total of 51 minutes later, -6/8/16 at 7:52 PM alarm sounded, was cleared at 8:19 PM, a total of 26 minutes later, -6/8/16 at 8:55 PM alarm sounded, was cleared at 9:19 PM, a total of 23 minutes later. Record review of the Facility Alarm Event Report for Resident 46 for the dates of 06/01/2016 to 06/14/2016 revealed a response time of 22 minutes on 6/13/2016 from 9:23 AM to 9:45 AM.",2019-06-01
5512,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2016-12-15,312,D,1,0,NMQL11,"**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 provide bathing per facility requirement for 2 of 3 sampled residents (Residents 2 and 3). The facility identified a census of 59 at the time of survey. Findings are: [NAME] Review of Resident 3's Annual MDS (Minimum Data Set-a comprehensive resident assessment tool used for developing a resident's care plan) dated 6/1/2016 revealed that Resident 3 was admitted to the facility on [DATE] and that Resident 3 required extensive assistance from 1 staff person for bathing. Review of Resident 3's care plan dated 6/11/2015 revealed that Resident 3 required extensive assistance from one staff person for bathing. Interview with Resident 3's family member on 12/15/2016 at 9:35 AM revealed the family was bathing Resident 3 during their weekly visits because Resident 3 had greasy hair and body odor when they visited. Observation of Resident 3 on 12/15/2016 at 9:30 AM revealed Resident 3 had greasy looking hair. Review of Resident 3's bathing documentation for 11/16/2016 to 12/15/2016 days revealed a shower there was no documentation Resident 3 received a bath from 11/16/2016 to 11/26/2016 (10 days) and 11/26/2016 to 12/7/2016 (11 days). There was documentation Resident 3 refused a bath on 11/30/2016 with no documentation the staff offered again after Resident 3 refused. Interview with RN-B, ACU (Alzheimer's Care Unit) Director, on 12/15/2016 at 10:23 AM confirmed that if it the bathing documentation was not listed the resident received a bath or it said not applicable the resident did not receive a bath. Interview with the DON on 12/15/2016 at 10:51 AM revealed that all residents were supposed to receive at least one bath a week and ideally 2. Interview with RN-B and the DON on 12/15/2016 at 2:24 PM confirmed the facility did not have any other bathing documentation. Interview with RN-A, Consultant, on 12/15/2016 at 3:16 PM revealed the facility did not have a policy regarding bathing. B. Review of Resident 2's MDS, dated [DATE], revealed the resident was an extensive assist of one person for bathing. Review of Resident 2's care plan, dated 8/30/16, revealed bathing process weekly. Review of Resident 2's bathing documentation revealed the following: -resident refused a bath the week of 11/16/16 thru 11/18/16, a total of 2 days; -no bath recorded for the week of 11/19/16 thru 11/25/16, a total of 7 days;",2019-11-01
4923,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2018-06-12,677,E,1,1,ELDP11,"**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) bathing assistance for 2 residents (Residents 10 and 31); 2) feeding assistance for Resident 10; 3) toileting assistance and incontinence management for Resident 30; 4) personal care assistance for Resident 1; and 5) repositioning assistance for 2 residents (Residents 10 and 31). The sample size was 22 and the facility census was 39. Findings are: [NAME] Review of Resident 10's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/14/18 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was totally dependent on the staff for assistance with mobility, transfers, eating and bathing. Review of Resident 10's current Care Plan with revision date of 1/30/18 revealed the resident was totally dependent on staff for assistance with bathing, repositioning and with eating. Further review revealed the following identified interventions: -resident was to receive one bath a week by the facility staff (Mondays) and an additional bath each week with Hospice (Thursday); and -staff to provide the resident with assistance to turn/reposition at least every 2 hours or more often if required. Review of Daily Deployment Sheets (paper record of staffing and baths provided daily) and Point of Care Audit Reports (electronic record of baths provided daily) revealed the following: -from 5/1/18 through 5/31/18 the resident received baths on (MONTH) 3, 17, 22, 28 and 31, (YEAR) (a total of 5 out of 9 baths the resident was to have received); and -from 6/1/18 through 6/12/18 the resident received a bath on (MONTH) 7, (YEAR) (a total of 1 bath out of the 3 baths the resident was to have received). During observations on 6/6/18 from 9:12 AM to 12:30 PM (3 hours and 18 minutes) the resident was positioned in a Broda (chair designed to redistribute pressure and provide support with pain relief) wheelchair. The resident was not repositioned throughout this time frame. Observations of Resident 10 on 6/11/18 revealed the following: -8:10 AM Resident 10 was seated in the Broda wheelchair and was assisted out to the Dining Room for breakfast. -8:45 AM the resident remained positioned in the Broda wheelchair and was assisted to the lobby area outside of the Nurse's Station. -9:44 AM the resident remained in the Broda wheelchair and was assisted from the front lobby to the resident's room. Resident 10 was not provided a change in positioning or offered an opportunity to lay down in the resident's bed. -11:45 AM the resident remained in the Broda wheelchair and was positioned at a table in the Dining Room. The resident was served the noon meal which consisted of 3 Nosey Cups (an adaptive drinking cup with a u-shaped cut out on one side which provides space for the nose, allowing the user to tilt the cup for drinking without bending the neck or tilting the resident's head) which contained the resident's liquefied menu items of lasagna roll-ups, green beans, and a brownie. In addition, the resident was served a Butter Pecan flavored Menu Magic cup (frozen dietary supplement with added calories), a Nosey cup containing 206 Juice (high protein, high calorie nutritional supplement) and a disposable plastic cup with 90 milliliters (ml) of Med Pass (nutritional drink with added calories and protein). Nursing Assistant (NA)-B was seated next to the resident. NA-B offered Resident 10 a bite of the Menu Magic cup followed by a drink of the 206 Juice. NA-B then got up and walked away from Resident 10 and out of the Dining Room. -12:10 PM, NA-B returned to the Dining Room and again sat next to Resident 10. NA-B offered the resident another bite of the Menu Magic Cup and when the resident refused the bite, NA-B removed the resident's clothing protector and assisted the resident out of the Dining Room. Resident 10's Broda chair was positioned in the front lobby. Resident 10 had been seated in the Broda chair without being repositioned since 8:10 AM (4 hours). B. Review of Resident 31's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was totally dependent on the staff for assistance with mobility, transfers and bathing. Review of Resident 31's current Care Plan with revision date 2/19/18 revealed the resident required total assistance of 2 staff with all of the resident's activities of daily living. The Care Plan identified the resident was to have 3-5 baths each week. Review of Daily Deployment Sheets and Point of Care Audit Reports revealed the following: -from 5/1/18 through 5/31/18 the resident received baths on (MONTH) 3, 10, 17, 22, 24, 28 and 31, (YEAR) (a total of 7 out of 13 baths the resident was to have received); and -from 6/1/18 through 6/12/18 the resident received a bath on (MONTH) 4 and 7, (YEAR) (a total of 2 out of the 5 baths the resident was to have received). Observations of Resident 31 on 6/5/18 from 11:00 AM to 3:29 PM (4 hours and 29 minutes) revealed the resident was lying in bed. The resident was positioned on the left side with a pillow propped behind the resident's back. Facility staff did not reposition the resident throughout this time. During an observations of Resident 31 on 6/6/18 from 6:50 AM to 9:50 AM (3 hours) the resident was lying in bed on the resident's left side. A pillow had been placed behind the resident's back. The resident was not repositioned throughout this time. Observations of Resident 31 on 6/7/18 from 12:30 PM to 3:30 PM (3 hours) revealed the resident was seated in the tilt-n-space wheelchair (chair which provides alternatives in positioning with tilting or reclining of chair and allows resident to be self-mobile when in an upright position). The resident was not repositioned and the position of the resident's chair was not adjusted throughout this time. During observations on 6/11/18 from 9:00 AM to 1:30 PM (4 and 1/2 hours) the resident was seated in the tilt-n-space wheelchair. The resident was not repositioned and the position of the resident's chair was not adjusted throughout this time. C. During an interview on 6/12/18 from 9:31 AM to 9:55 AM the Director of Nursing (DON) confirmed the following: -Resident 10 was to receive 2 baths a week, one with facility staff and one with Hospice. The resident had not received 2 baths a week due to staffing problems; -Resident 10 was to be repositioned at least every 2 hours due to high potential for skin breakdown; -Resident 10 required total staff assistance with eating and NA-B should have spent more time assisting the resident to eat on 6/11/18 as the resident was a weight loss; -Resident 31 was to have up to 5 baths a week but the facility tried to assure the resident received at least 3 baths. -Resident 31 did not receive the adequate number of baths each week due to staffing issues; and -Resident 31 was to be repositioned at least every 2 hours. D. Review of Resident 30's MDS dated [DATE] included the following: -[DIAGNOSES REDACTED]. -severe cognitive impairment; -extensive assistance with bed mobility, transfers and toilet use; and -frequently incontinent of bowel and bladder. Review of Resident 30's Care Plan dated 5/21/18 indicated bladder and bowel incontinence related to impaired mobility and confusion. Nursing interventions included the following: -encourage fluids during the day to promote prompted voiding responses; -toilet upon waking in the morning, before and after meals, before bed and PRN (as needed); -wears a large disposable brief; and -provide loose fitting, easy to remove clothing. The following observations of Resident 30 were made on 6/7/18: -9:05 AM to 9:22 AM - returned to the room after the breakfast meal, and NA-G and NA-H used the sit-to-stand mechanical lift to transfer the resident to the toilet and back into the wheelchair, then pushed the resident to the lobby area to watch television; -9:23 AM to 10:44 AM - remained out of the room for activities; -10:45 AM to 11:17 AM - returned to room and positioned in front of the television in wheelchair; -11:18 AM - NA-H asked the resident if ready to go to the dining room for the noon meal, then wheeled the resident from the room without offering use of the toilet; -11:19 AM until 1:00 PM - remained in the dining room for the noon meal; -1:01 PM - NA-H returned the resident to room and positioned the wheelchair in front of the television without offering use of the toilet; -1:03 PM until 1:37 PM - wheeled from the room by a visitor and spent time in common areas of the facility; -1:38 PM - wheeled to the dining room for a Bingo activity; and -1:39 PM until 2:48 PM (5 hours and 26 minutes since last toileted) - remained in the dining room at the Bingo activity. E. Review of Resident 1's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated Resident 1 required extensive assistance with dressing, toileting and was totally dependent on staff for provision of personal hygiene. Observations of Resident 1 on 6/5/18 from 1:22 PM until 2:08 PM revealed the following: -1:22 PM-the resident exited the room, walked across the hall and stood in the doorway of Resident 35's room. The resident was wearing not wearing pants and had on a wet disposable incontinent brief and a shirt. Medication Aide (MA)-L redirected Resident 1 back into the resident's own room, closed the door and did not assist Resident 1 to change the disposable incontinent brief or get dressed. -1:38 PM-the resident exited the room wearing only a shirt and a wet disposable incontinent brief. The resident walked down the corridor and into the sitting area by the nurses' station before being redirected back to the room; -2:08 PM-the resident (now fully clothed) wandered through the corridors.",2020-03-01
1694,WISNER CARE CENTER,285151,1105 9TH STREET,WISNER,NE,68791,2017-11-21,312,D,1,1,YOTW11,"**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 eating and toileting assistance for Resident 36 who required assistance with activities of daily living. The facility census was 30 and the sample size was 26. Findings are: Review of Resident 36's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/12/17 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had severe cognitive impairment, required supervision (oversight, encouragement or cueing) with eating and extensive assistance with toileting. Review of Resident 36's current Care Plan dated 10/19/17 revealed the following: -the resident had the potential for unintended weight loss due to not eating enough and refusal of staff assistance. An intervention dated 10/25/17 indicated the resident needed staff to assist with feeding; and -the resident had urine incontinence and interventions were for staff to prompt the resident to use the bathroom, provide scheduled toileting and make sure the resident used the bathroom before and after activities and restorative programs. Observations of the breakfast meal in the main dining room on 11/20/17 from 7:49 AM until 8:34 AM revealed the following: -Resident 36 was seated at the table at 7:49 AM. A bowl of hot cereal was on the table in front of the resident. The resident made no attempt to feed self and no cueing or assistance was provided; -at 7:54 AM, 7:59 AM and 8:03 AM, Resident 36 made no attempt to feed self and no cueing or assistance was provided; -at 8:11 AM (22 minutes later), Registered Nurse (RN)-B administered the resident's medications but provided no eating assistance or cueing/encouragement to feed self; -at 8:18 AM Nursing Assistant (NA)-E sat next to the resident and fed the resident the hot cereal (29 minutes after the resident was first observed). The resident did not refuse the assistance and consumed all of the hot cereal. NA-E then placed a glass containing a milkshake in the resident's hand, encouraged the resident to drink the milkshake and exited the dining room; -from 8:21 AM to 8:25 AM Resident 36 made no attempt to drink the milkshake; -NA-A approached Resident 36 at 8:29 AM and asked if the resident wanted anything else to eat. Resident 36 stated water and NA-A assisted the resident to drink part of a glass of water and sips of the milkshake; -NA-A exited the area at 8:31 AM and Resident 36 made no attempts to feed self; -at 8:34 AM Resident 36 pushed away from the table and Licensed Nurse D wheeled the resident out of the dining room. Observations of Resident 36's morning care on 11/21/17 at 6:50 AM revealed the following: -NA-E and NA-F removed the resident's disposable incontinent brief which was soiled with urine and assisted the resident out of bed and into the bath chair (mobile device used for transport); -The resident was not offered the use of the toilet and was incontinent of urine after seated in the bath chair; - NA-E and NA-F prepared to wheel the resident out of the room to the bath house when the Director of Nurses (DON) intervened and instructed the NA's to ask if the resident wanted to use the toilet first; -NA-E asked the resident about using the toilet and Resident 36 indicated a need to use the toilet; -NA-E and NA-F then proceeded to assist Resident 36 into the bathroom and onto the toilet. Interview with NA-E on 11/21/17 at 9:12 AM confirmed Resident 36 should have been toileted upon arising. Interview with the DON on 11/21/17 at 9:15 AM indicated the expectation was for Resident 36 to be toileted upon arising and before and after meals.",2020-09-01
1293,ARBOR CARE CENTERS-NELIGH LLC,285124,"PO BOX 66, 1100 NORTH T STREET",NELIGH,NE,68756,2017-12-27,677,D,1,1,5PYR11,"**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 and incontinence management for Resident 5 who required assistance with activities of daily living. Facility census was 45 and the sample size was 13. Findings are: Review of Resident 5's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/28/17 revealed [DIAGNOSES REDACTED]. The same assessment indicated the resident's cognition was severely impaired, the resident required extensive staff assistance with toileting, transfers and personal hygiene and indicated the resident was frequently incontinent of bowel and bladder. Review of Resident 5's current Care Plan with revision date of 10/2/17 indicated the resident was dependent on staff for assistance with activities of daily living and identified the resident was to be toileted per toileting schedule (before and after all meals, mid-afternoon, at bedtime and when awake and restless during the night). In addition, the resident was identified as wearing a disposable incontinent brief which staff were to check every 2 hours and to change as needed. Observations of Resident 5 on 12/26/17 revealed the following: -7:06 AM, the resident was seated in a tilt-n-space (wheelchair chair which provides pressure relief and provides alternatives in positioning with tilting or reclining of chair) chair. The resident was assisted out of the resident's room and into the corridor outside of the dining room. -8:05 AM to 9:10 AM, the resident remained in the wheelchair and was positioned at a table in the dining room. -9:15 AM, the Activity Director (AD) assisted the resident out of the dining room and to the resident's room. The resident was not offered an opportunity to use the bathroom and the AD did not lay the resident down to check the resident's disposable incontinent brief. -9:40 AM, the AD assisted the resident from the resident's room to the Chapel area for an activity. -9:40 AM-11:45 AM, the resident remained in the Chapel area seated in the resident's wheelchair. -11:49 AM, without offering the resident the opportunity to use the bathroom and without checking the resident's disposable incontinent brief, Licensed Practical Nurse (LPN)-C assisted the resident out to the dining room for the noon meal. -1:01 PM, LPN-C assisted the resident out of the dining room and back to the resident's room. During an interview on 12/26/17 at 1:50 PM, LPN-C identified Resident 5 had been assisted to use the bathroom when gotten up at 6:30 AM and then was not offered an opportunity to use the bathroom or provided incontinence cares again until 1:30 PM (7 hours later). LPN-C further confirmed when assisted at 1:30 PM the resident was incontinent of both bowel and bladder.",2020-09-01
1716,GOOD SAMARITAN SOCIETY - BLOOMFIELD,285156,"P O BOX 307, 300 NORTH SECOND ST",BLOOMFIELD,NE,68718,2019-08-15,677,E,1,1,8FR211,"**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 timely assistance with evening cares for Resident 9 and bathing assistance for Residents 7 and 26. The sample size was 3 and the facility census was 44. Findings are: [NAME] Review of Resident 9's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 5/25/19 indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assist of 2 staff for bed mobility, transfers, dressing, personal hygiene and toileting and was frequently incontinent of bowel and bladder. During observations on 8/12/19 the following was observed for Resident 9: -6:29 PM the resident's call light was turned on; -6:32 PM the resident's call light was turned off; -6:38 PM the resident's call light was turned on; -6:41 PM the resident's call light was turned off; and -7:01 PM the resident was observed seated in a wheelchair by the entrance of the resident's room. Resident 9's call light was draped across the foot board of the resident's bed. The call light had been secured to the edge of the foot board directly next to the wall. During an interview on 8/12/19 at 7:05 PM, Resident 9 verified the following: -resident wanted to go to bed and had placed the call light on several times in order to get assistance; -the staff had come into the resident's room, asked the resident what was needed and then turned off the call light indicating someone would be back to assist the resident when staff were available; -required extensive staff assistance with all cares and 2 staff were needed to transfer the resident into bed; -a staff member had removed the call light from the resident's wheelchair arm and had placed the call light on the end of the resident's bed; and -the resident was unable to reach the call light from where it was secured on the foot board of the resident's bed. During an interview with the Director of Nursing (DON) on 8/15/19 at 9:08 AM the DON confirmed the following: -Resident 9 required extensive assistance from the staff for the resident's cares; -the resident frequently requested assistance to go to bed directly after the evening meal; and -staff should not have repeatedly turned off the resident's call light until able to provide the resident assistance and the staff should not have removed the resident's call light from reach on the evening shift of 8/12/19. B. Review of Resident 7's MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 (with a score between 13-15 indicating the resident was cognitively intact). Review of a Progress Note dated 3/14/19 at 11:02 AM revealed Resident 7 was unhappy with the bath schedule. Resident 7 requested 2 baths per week. Review of Resident 7's current undated Care Plan confirmed Resident 7 wanted 2 baths per week. Review of Resident 7's Bath Documentation dated 7/18/19 to 8/12/19 revealed the resident received a bath on 7/29/19 and then did not receive another bath until 8/5/19 (7 days later). During an interview on 8/15/19 at 10:17 AM, the DON confirmed Resident 7 had not received a bath between 7/29/19 and 8/5/19. Further interview revealed the facility bath aide had quit and at times the staff member giving baths would have to help with other duties. C. Review of Resident 26's Bathing Charting dated 7/14/2019-08/14/2019 revealed the resident had been receiving 2 whirlpool baths per week. On 8/3/19 Resident 26 was placed on contact precautions and the resident was told there wouldn't be any whirlpool baths while on isolation precautions. The resident could only have a sponge or bed baths. An Interview on 8/13/19 at 10:30 AM with Resident 26 confirmed the resident's last bath was last Friday (8/9/19) and the resident had not received any further sponge bath, bed bath, or whirlpool due to having [DIAGNOSES REDACTED] and being on isolation precautions. Interview on 8/15/19 at 11:00 AM with the DON confirmed Resident 26 had only received a sponge bath on 8/9/19 and there was no bath given on 08/13/19. The DON stated she was going to have residents contact precautions removed and possibly have a whirlpool today.",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
5791,WAYNE COUNTRYVIEW CARE AND REHABILITATION,285135,811 EAST 14TH STREET,WAYNE,NE,68787,2016-09-14,312,E,1,0,IB0Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on record and interview, the facility failed to provide scheduled bathing for Residents 1, 2, 3 and 4 who required assistance with activities of daily living. The sample size was 5 and the facility census was 37. Findings are: A. Review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 6/28/16 revealed the resident required extensive staff assistance of 2 persons with bathing. Review of the Bathing Schedule (not dated) revealed Resident 1 was to receive baths 2 times weekly on Tuesdays and on Fridays. Review of Bath Documentation for 6/1/16 through 9/13/16 revealed Resident 1 received a bath on 7/26/16 and not again until 8/2/16 (7 days), on 8/17/16 and not again until 8/27/16 (10 days) and the resident did not receive another bath until 9/6/16 (10 days later). B. Review of Resident 2's MDS dated [DATE] revealed the resident required extensive staff assistance of 1 person with bathing. Review of the Bathing Schedule (not dated) revealed Resident 1 was to receive baths 2 times weekly on Tuesdays and on Fridays. Review of Bath Documentation for 6/1/16 through 9/13/16 revealed Resident 2 received a bath on 7/15/16 and not again until 8/9/16 (25 days), on 8/15/16 and not again until 8/26/16 (11 days) and resident 2 did not receive a bath again until 9/13/16 (18 days later). C. During an interview on 9/13/16 from 2:00 PM to 2:10 PM, the Director of Nursing (DON) verified residents were not always receiving baths according to their individual preferences and their bathing schedule due to staffing concerns. D. Review of Resident 4's MDS dated [DATE] revealed the resident required extensive staff assistance of 1 person with bathing. Review of the Bathing Schedule (not dated) revealed Resident 4 was to receive baths 2 times weekly on Mondays and on Thursdays. Review of Bath Documentation for 6/1/16 through 9/13/16 revealed Resident 4 received a bath on 7/18/16 and not again until 7/28/16 (10 days), and on 8/1/16 and not again until 8/10/16 (9 days). During an interview on 9/14/16 at 10:25 AM, Resident 4 confirmed baths were not given 2 times weekly as scheduled. E. Review of Resident 3's MDS dated [DATE] revealed the resident required extensive staff assistance of 1 person with bathing. Review of the Bathing Schedule (not dated) revealed Resident 3 was to receive baths 2 times weekly on Mondays and on Thursdays. Review of Bath Documentation for 6/1/16 through 9/13/16 revealed Resident 3 received a bath on 7/11/16 and not again until 7/18/16 (7 days), on 7/21/16 and not again until 8/1/16 (11 days), on 8/1/16 and not again until 8/10/16 (9 days), on 8/10/16 and not again until 8/17/16 (7 days), and on 8/17/16 and not again until 9/5/16 (19 days).",2019-09-01
5675,"BROKEN BOW CARE AND REHABILITATION CENTER, LLC",285120,224 EAST SOUTH E STREET,BROKEN BOW,NE,68822,2016-10-11,312,D,1,0,EZTD11,"**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 provide scheduled bathing for Residents 405 and 425 who required assistance with activities of daily living. This had the potential to affect 2 of 5 sampled residents. The facility census was 36. Findings are: A. Observation of Resident 425 on 10/11/2016 at 10:20 AM revealed the resident was unshaven and the hair had an oily appearance. Interview with NA-A (Nurse Aide) on 10/11/16 at 10:32 AM revealed the resident was shaved on bath days. NA-A checked the bathing schedule and revealed the resident was to receive a bath on Wednesday AM and Friday PM. Interview with MA-B (Medication Aide) on 10/11/2016 at 10:45 AM revealed the baths were to be charted and the open spaces on the bathing checklist would indicate the resident was not shaved. Review of Resident 425's bathing checklist and ADL (activities of daily living) charting revealed the resident had showers on 8/31/16, 9/2/16, 9/7/16, 9/14/16, 9/23/16, 9/28/16, 9/30/16, 10/5/16, 10/8/16. The checklist revealed no documentation of being shaved on 10/5 and 10/8. Review of the MDS (Minimum Data Set; a federally mandated comprehensive assessment tool used for care planning) dated 8/19/2016 revealed the resident had memory issues and was moderately impaired for decision making. The resident needed supervision for cares. For bathing, the resident was an extensive assist of one staff person. B. Observation of Resident 405 on 10/11/16 at 11:09 AM found the resident's hair was combed but had an oily appearance. Review of the MDS, dated [DATE] revealed a cognition scored of 11 out of 15 indicating the resident had moderately impaired cognition. For bathing the resident was independent with supervision. Interview with MA-B on 10/11/2016 at 10:45 AM revealed the baths were to be charted and the open spaces on the bathing checklist would indicate the resident was not bathed. Review of Resident 405's bathing checklist and ADL charting revealed the resident had not been bathed since 10/3/16. Review of the facility bath and weight list revealed Resident 405 was to be bathed on Tuesday evenings and Friday evenings.",2019-10-01
6418,LYONS LIVING CENTER,285301,1035 DIAMOND STREET,LYONS,NE,68038,2018-05-10,677,E,1,0,2CLY11,"**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 provide: 1) bathing assistance for 3 residents (Residents 1, 2 and 4); 2) feeding assistance for Resident 4; and 3) transfer assistance for Resident 6. The sample size was 14 and the facility census was 23. Findings are: A. Review of Resident 2's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/7/18 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident required extensive assistance with activities of daily living and was totally dependent with bathing. Review of Resident 2's current Care Plan (undated) revealed the resident was scheduled to receive a bath 2 times weekly on Sunday and Wednesday. Review of Resident 2's Bathing Documentation (record of baths given) from 2/7/18 through 5/6/18 revealed 2 baths weekly were not provided as evidenced by the following: -No bath was provided from 2/21/18 until 3/7/18 (2 weeks); -No bath was provided from 3/14/18 until 3/21/18 (1 week); -No bath was provided from 3/28/18 until 4/8/18 (10 days); and -No bath was provided from 4/15/18 until 4/22/18 (1 week). B. Review of Resident 1's MDS dated [DATE] revealed the resident's cognition was severely impaired; the resident had a [DIAGNOSES REDACTED]. Review of Resident 1's Bathing Documentation from 2/27/18 through 5/6/18 revealed 2 baths weekly were not provided as evidenced by the following: -No bath was provided from 2/27/18 until 3/8/18 (9 days); -No bath was provided from 3/8/18 until 3/15/18 (1 week); -No bath was provided from 3/15/18 until 3/27/18 (12 days); -No bath was provided from 3/27/18 until 4/16/18 (20 days); and -No bath was provided from 4/16/18 until 5/3/18 (17 days). During an interview on 5/10/16 at 8:30 AM, Bath Aide (BA)-C confirmed the residents on the MSU were to be offered 2 baths each week. However, residents did not receive baths as scheduled due to ongoing concerns with staffing. C. Review of Resident 4's MDS revealed the resident was admitted on [DATE] and required limited assistance with eating. Observation of Resident 4's room on 5/7/18 revealed the following: - At 12:55 PM the resident was seated in a recliner in the resident's room with lunch placed on a bedside table in front of the recliner. The resident ate independently. - At 3:00 PM (2 hours later) the resident was resting in bed. The resident's lunch tray was seated on the floor beside the bedside table. Spilled food was spread across the resident's floor. An area approximately 6 foot by 4 foot was covered with scattered food debris. Interview with RN-L on 5/10/18 at 9:08 AM confirmed Resident 4 ate in the resident's room independently and the nursing staff were responsible for cleaning up the room when the resident was finished eating. Review of Resident 4's Bath Schedule from 4/26/18 through 5/10/18 revealed the following. -No bath was provided from 4/26/18 until 5/3/18 (7 days later); and -No bath was provided from 5/3/18 until 5/10/18 (7 days later). Interview with NA-C (who was also the bath aide) on 5/10/18 at 10:45 AM confirmed resident 4 had received a bath on 4/26/18 and 5/3/18. Further interview confirmed the resident should have received a bath 2 times per week D. Review of Resident 6's current undated Care Plan revealed the resident transferred with the full body lift and 2-3 staff members. Review of a Progress Note dated 3/24/18 at 5:17 AM revealed Resident 6 had been having behaviors since 3:00 AM (2 hours and 17 minutes prior). Further review revealed the resident wanted to get up. The staff member explained to the resident that it was 3:00 AM and the other staff were completing rounds. The resident then put on the call light and informed the nurse that the resident wanted to get up. The resident then continued to pull the call light. There was no evidence to indicate the resident was assisted out of bed. Interview with Registered Nurse-L on 5/10/18 at 9:08 AM revealed the overnight shift was staffed with either 1 Nursing Assistant (NA) and 1 Nurse or 2 NA's and 1 Nurse. Further interview confirmed Resident 6 required 2 staff members and the full body lift for transfers.",2019-03-01
1575,"BCP BLUE HILL, LLC",285144,414 NORTH WILLSON,BLUE HILL,NE,68930,2018-07-24,677,E,1,0,T1I111,"**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 staff failed to provide bathing assistance to 6 of 7 sampled residents who required assistance with bathing (Residents 1, 2, 3, 6, 7, and 8). The facility identified a census of 32 at the time of survey. Findings are: [NAME] Review of Resident 1's bathing documentation revealed Resident 1 received a bath 7/3/18 then did not receive another bath until 7/18/18, which was 15 days between baths. Review of Resident 1's Care Plan dated 7/12/2018 revealed Resident 1 required assistance from staff for bathing. B. Review of Resident 2's bathing documentation revealed Resident 2 received a bath on 7/3/18 then did not receive another bath until 7/19/18, which was 16 days between baths. Review of Resident 2's admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 6/20/2018 revealed Resident 2 required assistance from staff for bathing. C. Review of Resident 7's bathing documentation revealed Resident 7 received a bath on 5/27/28, 6/5/18 (8 days without a bath); 6/14/28 (9 days without a bath); and 6/25/18 (11 days without a bath). Review of Resident 7's admission MDS dated [DATE] revealed Resident 7 required assistance from staff for bathing. Inteview with the DON (Director of Nursing) on 7/24/2018 at 2:23 PM confirmed there was an issue with the residents receiving baths. Interview with the DON on 7/24/2018 at 3:56 PM revealed the facility did not have a policy about how often a resident was to receive a bath. D. Review of the Bath Record for completed baths from (MONTH) to (MONTH) revealed that Resident #3 had to wait 13 and 14 days between baths. Resident #3 had a bath on 5/22/18 then on 6/4/18. Resident #3 then had a bath on 6/12/18 and the next one was on 6/26/18. E. Review of the Bath Record for completed baths from (MONTH) to (MONTH) revealed that Resident #6 waited 12 days before getting a bath. The dates without getting a bath were from 6/1/18 to 6/14/18. F. Review of the Bath Record for completed baths from (MONTH) to (MONTH) revealed that Resident #8 went 11 and 14 days between baths. Resident #8 received a bath on 5/3/18 and then on 5/14/18. The next bath was 5/23/18, which was 8 days between baths. Resident #8 then received baths routinely until the bath of 6/13/18 and waited until the next bath on 6/27/18. On 7/24/18 at 2:20 PM an interview with the DON (Director of Nursing) confirmed that baths were not being completed at a minimum of weekly. The bath aide was being pulled to assist on the units and it was difficult to complete baths.",2020-09-01
4976,CROWELL MEMORIAL HOME,285210,245 SOUTH 22ND STREET,BLAIR,NE,68008,2017-03-02,311,D,1,0,43DC11,"**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 staff failed to implement assessed interventions to prevent a potential decline in Activities of Daily Living (ADL) for 3 (Resident 3,4 and 6) of 3 residents. The facility staff identified a census of 62. Findings are: [NAME] Record review of Resident 3's Minimum Data Set ( Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) signed as completed on 2-27-2017 revealed the facility staff assessed the following about the resident: - Resident 3 scored an 8 on the Brief Interview for Mental Status (BIMS). According to the MDS Manuel, a score of 8 to 12 indicate moderately impaired cognition. -Independent with eating. -Limited assistance with personal hygiene. -Extensive assistance with bed mobility, transfers, locomotion, dressing, and toilet use. Record review of a therapy communication sheet dated 8-24-2016 revealed Resident 3 had had reached the maximum potential with therapy and was identified as being appropriate to transition to a restorative program (RP). According to the therapy communication, Resident 3 was to receive a RP 2 to 3 times a week. According to the RP, Resident 3 was to complete Active Range of motion (AROM) to both lower legs through all of the planes of motion to maintain strength and mobility. Further review of the RP revealed Resident 3 was to transfer with supervision and including standing tolerance and as Resident 3 tolerated. walk with a front wheel walker in a straight line with the wheelchair following as Resident 3 was able to tolerate. Record review of Resident 3's RP attendance log revealed no RP had been completed. Record review of Resident 3's medical chart revealed no evidence the RP had been completed for (MONTH) (YEAR). On 3-02-2017 at 10:30 am an interview was conducted with Restorative Assistant (RA) [NAME] During the interview RA A confirmed Resident 3 had a RP and further confirmed the RP was not competed for (MONTH) (YEAR). On 3-02-2017 at 10:55 AM an interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed the RP had not been completed for Resident 3. B. Record review of Resident 4's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS score was 13. According to the MDS Manuel, a score of 13 to 15 indicates cognitively intact. -Independent with bed mobility, transfers, ambulation, eating and personal hygiene. -Required limited assistance with dressing and toilet use. Record review of a fax sheet dated and signed by Resident 4's physician revealed the facility had notified the physician that Resident 4 had archived the majority of the goals and that Resident 4 was transitioning to a RP to maintain highest level of function and safety. Resident 4's Physician gave orders to start the RP. Record review of Resident 4's medical record that included Resident 4's care plan and RP attendance sheet reveal there was no evidence a RP had been started for Resident 4. An interview was conducted on 3-02-2017 at 9:10 AM with RA [NAME] During the interview, RA A reported not completing a a RP for Resident 4. On 3-02-2017 at 10:55 AM an interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed the RP had not been completed. C. Record review of Resident 6's MDS dated [DATE] revealed the facility staff assessed the following about Resident 6: - BIMS was a 7. According to the MDS Manuel, a score of 0 to 7 indicates severe cognitive impairment. -Independent with eating. -Limited assistance with ambulation. -Extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Record review of an Occupational Therapy (OT) communication sheet dated 9-7-2016 revealed OT identified Resident 6 was appropriate for a RP. According to the OT communication sheet, Resident 6 was to receive the RP 2 to 3 times a week to maintain current functional level. Resident 6's RP was identified as both upper arms with a 1 to 2 pound weight exercises to all planes and ranges of movement. In addition, Resident 6 was to receive a RP for Functional reaching activity standing with 1 upper arm support on a 4 wheel walker. Record review of a Physical Therapy (PT) communication sheet dated 9-7-2016 revealed PT had identified Resident 6 was appropriate for a RP. Further review of the PT communication sheet dated 9-7-2016 revealed Resident 6 was to receive a RP 2 to 3 times a week. Review of Resident 6's (MONTH) (YEAR) ADL Flowsheet revealed Resident 6 did not have the RP completed. An interview was conducted with RA A on 3-02-2017 at 8:58 AM. During the interview RA A confirmed the RP had not been completed for Resident 6. On 3-2-2017 at 10:55 AM an interview was conducted with the DON. During the interview, the DON confirmed the RP had not been completed.",2020-03-01
2228,GOOD SAMARITAN SOCIETY - ST JOHNS,285189,3410 CENTRAL AVENUE,KEARNEY,NE,68847,2019-09-04,677,E,1,1,HPB011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on record reviews and interviews, the facility failed to ensure residents received bathing weekly for 5 residents (Resident 14, 19, 38, 8, and 28) out of 5 of residents reviewed. The facility census was 37. Findings are: [NAME] Record review of Admission Record dated 9-4-19 for Resident 14 had admission date of [DATE] to the facility with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 7-4-19 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 9 which indicated the resident was cognitively impaired. The resident required 1 staff with physical help in part of bathing. Review of Resident 14's CarePlan revealed the resident required 1 assist with bathing. Record review on 9/03/19 at 11:17 AM of the facility bath schedule provided by the DON (Director of Nursing) revealed Resident 8 was scheduled for one bath a week. Review of bathing documentation from P[NAME] (Point of Care) provided by the DON on 9-3-19 at 12:22 PM revealed from (MONTH) 2019 to (MONTH) 3, 2019 revealed the resident received weekly baths in (MONTH) and (MONTH) 2019 and revealed: 3/1 w/p 3/15 w/p 14 days without a bath. 3/21 w/p 4/4 w/p 14 days without a bath. 4/12 bed bath 11 days without a bath. 4/17 tub 4/23 tub 5/3 w/p 5/10 w/p 5/20 bed bath 5/23 bed bath 5/31 w/p 6/19 w/p The month of (MONTH) only 1 bath. This caused Resident #14 to go 19 days without a bath then go 25 more days without a bath in the middle of summer. 7/14 w/p 7/19 w/p 7 30 w/p 11 days without a bath. 8/12 w/p 13 days without a bath. 819 w/p 8/30 w/p 11 days without a bath. B. Review of the Admission Record dated 9-4-19 for Resident 19 revealed had admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident 19's MDS dated [DATE] revealed a BIMS of 15 and the the resident did not receive a bath Record review on 9/03/19 at 11:17 AM of the facility bath schedule provided by the DON revealed Resident 8 was scheduled for one bath a week on Fridays. Review of bathing documentation from P[NAME] provided by the DON on 9-3-19 at 12:22 PM revealed from (MONTH) 2019 to (MONTH) 3 the resident received: 1/4 shower 1/11 shower 1/14 resident refused 1/18 shower 1/28 shower 2/8 shower 11 days without a bath. 2/12 tub 2/15 shower 2/21 shower 3/1 shower 3/13 shower 12 days without a bath. 3/23 shower 10 days without a bath. 4/3 shower 4/24 shower The month of (MONTH) only 2 baths. 5/10 shower 523 tub The month of (MONTH) only 2 baths. 6/3 shower 6/15 shower The month of (MONTH) only 2 baths. 7/1 shower 7/30 shower The month of (MONTH) only 2 baths (29 nine days apart). 8/13 shower 8/23 shower The month of (MONTH) only 2 baths. C. Review of Resident 38's Admission Record dated 9-3-19 revealed date of admission of 6-20-19 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed a BIMS score of 10 which indicated moderate cognitive impairment with behaviors of delusions, wandering, and other behaviors not directed toward others in 1-3 days. The resident was frequently incontinent of bowels and bladder. Bathing did not occur during the 7 day assessment period. Record review on 9/03/19 at 11:17 AM of the facility bath schedule provided by the DON revealed Resident 8 was scheduled for one bath a week on Thursdays. Review of bathing documentation from P[NAME] provided by the DON on 9-3-19 at 12:22 PM revealed from (MONTH) 20, 2019 to 9-3-19 the resident received 3 baths since admission on 7/13, 7/22 and 8/13. The resident was offered and refused 8 times per documentation by the bath aide. Review of the documentation in the PN (Progress Notes) from (MONTH) to (MONTH) revealed absence of documentation by the nurses of the resident's behavior of refusing baths and the nurse's attempt with other interventions to have the resident baths or at least a bed bath given. Review of Resident 38's CarePlan dated 6-20-19 revealed the resident preferred to receive a shower daily. Interview on 9/03/19 at 12:55 PM with NA-G (Nurse Aide) revealed NA-G was scheduled to perform baths 4 days a week but lately had been pulled to work on the units quite often because of not enough staff. NA-G revealed today,9-3-19 NA-G was scheduled to give baths but was pulled because of a call-in so was working on the floor. On the days NA-G was scheduled to perform baths, NA-G would try to do extra baths to help get those that were missed caught up. NA-G revealed when a resident refuses a bath, NA-G documented it in P[NAME] to show it was refused, but NA-G would go back later in the same day and re-approach the resident and if refused again, NA-G would document the refusal again. If the resident would continue to refuse, NA-G would give a bath to a resident from the next day and report the refusals to the charge nurses. Review of Resident 38's P[NAME] documentation of the bathing revealed on 7/18 a refusal at 7:53 AM and at 9:08 AM and again on 8/23 two refusals on the same day at 11:44 AM and at 1:48 PM. Reviewed Bathing p/p dated 10/17 revealed absence of how many times a week a resident should receive a bath. Interview on 9/03/19 at 12:13 PM with the DON revealed every resident was scheduled for 1 bath a week due to that was all the facility could manage to provide because of their staffing. Currently the facility had 1 BA (Bath Aide) hired and there were about 4-5 other Nurse Aides that were trained to perform baths on the BA's day off or when baths were needed to be done on the evening shift or weekend. The DON revealed the DON had hired two more new staff to be bath aides. The DON revealed the DON had been aware there had been a problem with baths over the past year because of shortage of staffing and the DON had been working on it. The BA was scheduled 4 days a week but at times would get pulled to the floor due to staffing needs. When this happened staff were instructed to do bed baths but the DON did not realize for quite a while the staff were giving the bed baths to the residents for their 1 bath a week and then not documenting it as a bath. The DON revealed next intervention was every week on Thursdays the DON did an audit of the documentation of baths to see which resident did not have a bath documented and then those resident were scheduled for Friday and the weekend to get a bath. The DON revealed for residents requesting more than one bath a week had been told if they wanted more than 1 bath a week right now, it would have to be a bed bath due to staffing. Right now there was only one resident who received more than one bath a week and it was not Resident 38. The DON reviewed Resident 38's CarePlan and confirmed the CarePlan revealed the resident requested to have a shower daily but the DON revealed because of the staffing this request was not possible at this time and confirmed Resident 38 was scheduled one bath per week. D. Interview on 8-29-19 at 10:49 AM with the Resident 8 revealed the resident had not always received a bath weekly in the past year. The resident kept track of the days the resident received baths and shared this information. The resident revealed a bed bath is not the same as a tub bath or a shower, it is better than nothing but you don't feel as clean. Record review on 9/03/19 at 11:17 AM of the facility bath schedule provided by the DON revealed Resident 8 was scheduled for one bath a week on Fridays. Review of Resident 8's Care Plan dated 6-21-19 revealed the resident preferred 2 baths per week. Interview on 9/03/19 at 12:13 PM with the DON revealed since (MONTH) the facility has assisted the resident to have 2 baths a week by having one bath as a shower and the 2nd bath is a bed bath. The bed bath is given by the evening nurse aides but the nurses document it on the treatment record after they ensure it was done. Review of bathing documentation from P[NAME] provided by the DON on 9-3-19 at 12:22 PM revealed from (MONTH) 2019 to current revealed the resident got a weekly bath in (MONTH) 2019. However in (MONTH) baths received on 2/5, 2/9, and 2/20 which was 11 days in between baths. In (MONTH) baths received on 3/1, 3/13 a twelve day span without a bath, 3/23 a ten day span without a bath. In (MONTH) a bath was given on 4/3 a twelve day span without a bath, 4/22 nineteen days without a bath. In (MONTH) the resident started receiving a 2nd bath a week of a bed bath every Monday and then a shower was scheduled every Friday. Review of the showers revealed the resident received a shower on 5/3, eleven days without a bath. The resident received on 5/10 a bed bath instead of a shower, 5/23 thirteen days without a bath but total of 20 days without being in a tub or shower because the resident had only a bed bath during that time frame. On 6/4, twelve days since last tub bath/shower, 6/15 eleven days since last tub bath/shower ,6/28 thirteen days since last tub bath/shower. In the month of (MONTH) 7/14 sixteen days since last tub bath/shower, 7/30 sixteen days since last tub bath/shower, 8/9, 8/19 fifteen days since last tub bath/shower. Documentation on TAR (treatment administration record) revealed a bed bath was given every Monday at bedtime weekly from (MONTH) 13 to [DATE] except (MONTH) 22 was blank. Documentation between both forms revealed the resident did not get a tub bath/shower or a bed bath between (MONTH) 15 and (MONTH) 29 which was 2 weeks. E. Interview with Resident 28 during the Resident Council meeting on 9/03/19 at 3:00 PM revealed the facility was understaffed in the bathing department. Resident 28 revealed the facility did not allow somebody to be there to staff the baths. Resident 28 revealed they maybe got a bath once a week but they sometimes went more than 2 weeks without a bath. Resident 28 revealed the facility did not allow a staff person to fill the bath aide job. Resident 28 revealed there was supposed to be a staff person designated to do baths but they got pulled to the floor (reassigned from doing baths to performing direct care in the resident care areas) because the facility did not have enough staff. Resident 28 revealed if the facility needed a job to be done there had to be someone to do it. Review of Resident 28's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 7/26/2019 revealed an admission date of [DATE]. Resident 28 had a BIMS (Brief Interview for Mental Status Score) score of 15 which indicated Resident 28 was cognitively intact. Resident 28 required limited assistance of 1 staff person for bathing. Review of Resident 28's Care Plan dated 12/30/2016 revealed Resident 28 preferred 2 baths per week. Resident 28 required 1 staff assist with bathing. Review of Resident 28's Follow Up Question Report dated 9/1/2018 to 9/3/2019 revealed documentation Resident 28 received a bath on: 9/7/18 9/21/18 (14 days with no bath); 11/14/18 11/23/18 (9 days with no bath); 12/20/18 1/4/19 (15 days with no bath); 2/4/19 2/15/19 (11 days with no bath); 2/26/19 (11 days with no bath); 3/12/19 (14 days with no bath); 3/23/19 (11 days with no bath); 4/3/19 (11 days with no bath); 4/12/19 (9 days with no bath); 4/22/19 (10 days with no bath); 5/3/19 (11 days with no bath); 5/16/19 6/3/19 (18 days with no bath); 6/15/19 (12 days with no bath); 6/21/19 7/11/19 (20 days with no bath); 7/19/19 (8 days with no bath); 7/30/19 (11 days with no bath); 8/9/19 (10 days with no bath). Interview with the DON (Director of Nursing) on 9/03/19 at 4:30 PM revealed the residents were to receive at least 1 bath a week. The DON confirmed Resident 28 was not receiving at least 1 bath a week. Review of Resident 28's MDS schedule revealed Resident 28 not been out of the facility, or unavailable for receiving a bath. Interview with the DON on 9/03/19 at 5:46 PM revealed they did not find any documentation Resident 28 had refused any baths and the DON confirmed Resident 28 had not out of the facility, or unavailable for receiving a bath. The DON revealed ensuring the residents received their baths had been an issue. Review of the facility policy Bathing revised 10/17 revealed no documentation of how often residents were to receive a bath. Review of the untitled document identified by the DON as the bath schedule revealed Resident 28 was on the schedule to receive a bath on Fridays.",2020-09-01
5311,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-01-23,309,D,1,0,5YZX12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2 AND 175 NAC 12-006.09 Based on observation, record review and interview; the facility staff failed implement interventions and re-evaluate a pain management program for 1 (Resident 19) of 3 sampled residents and failed to complete wound treatments for 2 (Resident 19 and 1) of 3 sampled residents. The facility staff identified a census of 96. Findings are: [NAME] Record review of a Order Summary Report (OSR) printed on 3-13-2017 revealed Resident 19 admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further review of the OSR printed on 3-13-2017 revealed Resident 19's physician had ordered a treatment for [REDACTED]. Record review of Resident 19's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated 2-27-2017 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental status(BIMS), score was a 14. According to the MDS Manuel, a score of 13 to 15 indicates a person is cognitively intact. -Supervision with eating. -Required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. -No scheduled pain medications. -Had pain that limited daily activities with a pain rating of 6. Observation of the wound treatment on 3-14-2017 at 7:35 AM revealed Licensed Practical Nurse (LPN) A and LPN B entered Resident 19's room washed hands and donned gloves. Resident 19 was observed to be laying in bed. LPN B assisted Resident 19 into an upright position seating Resident 19 on the edge of the bed. LPN B started to remove the dressing to the left BKA site. Resident 19 cried out, started to moan, face turned red and stated oh my god that hurts. LPN B continued to remove the dressing as Resident 19 moaned, groaned, yelled out and stated oh that hurts, its so painful. Further observation revealed the treatment was not stopped and evaluated if Resident 19 had additional medications for pain. Resident 19 face was observed to be red with furrowed brow. LPN A using a wound cleansing agent, began to clean the Left BKA wound site. Resident 19 started to moan, groan, stated oh that hurts so much, Resident 19's face was red with deeply furrowed brows. LPN B obtained a dressing used to be inserted into the wound. As LPN B inserted the dressing into the wound, Resident 19 yelled out, face turned red, moans and stated oh my god, Oh my god that hurts. LPN A asked Resident 19 if the pain medication Resident 19 had received was working with Resident 19 stating no. LPN A asked on a scale of 0 to 10 was was the current pain level, Resident 19 stated 7. Without stopping the treatment, LPN A applied Stump Shrinker to Resident 19 Left BKA area. Resident 19 screamed out, moaned, stated oh my god that hurts, oh god. After completing the wound treatment LPN A and LPN B assisted Resident 19 into a laying position with Resident 19 stating oh my god that hurt. Record review of Resident 19's Medication Administration Record [REDACTED]. Further review of Resident 19's MAR for (MONTH) (YEAR) revealed the [MEDICATION NAME] had been given 13 times . Of the 13 times the medication was given, Resident 19 had a pain rating of 7 on 1 occasion, a pain level of 8 on 5 occasions and a pain level of 9 on 3 occasions. There was not information provided that staff had evaluated the effectiveness of the pain medication and what level of pain Resident 19 had after receiving the medication. Record review of Resident 19's Care Plan (CP) imitated on 3-13-2017 revealed Resident 19 had pain related to the Left BK[NAME] The goal identified on Resident 19's CP was that Resident 19 would not have an interruption of normal activities. The CP did not identify what Resident 19's goal for pain management was and what levels of pain was acceptable to Resident 19. Record review of Resident 19's Pain Assessment Sheet (PAS) dated 2-21-2017 revealed Resident 19 had post surgical pain. Section D identified Resident 19's most recent pain level as a 9. Section [NAME] of the PAS titles Effects of Pain On ADL's (Activities of Daily Living) revealed pain was effecting Resident 19's sleep, social activities, appetite, physical activity and mobility and emotions. Section F of the PAS identified methods of alleviating pain was pain medications. On 3-14-2017 at 7:52 AM an interview was conducted with LPN A and LPN B. During the interview, both LPN A and LPN B reported Resident 19 was very painful. LPN B confirmed during the interview the treatment for [REDACTED]. LPN A confirmed the treatment was not stopped and that Resident 19 was very painful through out the treatment. LPN A further confirmed Resident 19's pain management program should be re-evaluated and should have determined if there were pain medications for Resident 19. On 3-14-2017 at 8:20 AM an interview was conducted with Resident 19. During the interview when asked how often Resident 19 was painful, Resident 19 reported all the time. When asked what pain level on a scale of 0 to 10 with 10 being the worst, Resident 19 reported during treatments were an 8 to 9. Resident 19 reported (gender) pain level was usually a 7. When asked what level of pain would be acceptable, Resident 19 reported would accept a level of a 4 at this point in time. On 3-14-2017 at 12:15 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported the treatment for [REDACTED]. B. [NAME] Record review of a Order Summary Report (OSR) printed on 3-13-2017 revealed Resident 19's physician had ordered a treatment for [REDACTED]. Record review of Resident 19's Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed the wound treatment for [REDACTED]. Observation of the wound treatment on 3-14-2017 at 7:35 AM revealed Licensed Practical Nurse (LPN) A and LPN B entered Resident 19's room washed hands and donned gloves. Resident 19 was observed to be laying in bed. LPN B assisted Resident 19 into an upright position seating Resident 19 on the edge of the bed. LPN B started to remove the dressing to the left BKA site. Observation of the dressing revealed it was dated 3-13-2017 with initialed by the wound nurse on the day shift. On 3-14-2017 at 7:35 AM during the observation of the treatment to Resident 19's Left BKA site, Resident 19 reported that the treatment had not ben done last night. On 3-14-2017 at 7:52 AM an interview was conducted with LPN B. During the interview LPN B confirmed the dressing had not been changes on the night shift and the dressing LPN B removed during the observation was from the previous morning treatment. On 3-14-2017 at 12:15 PM an interview was conducted with the DON. During the interview review of Resident 19's TAR for (MONTH) (YEAR) was reviewed. The DON confirmed resident 19's treatment had not been completed on the evening shift of 3-13-2017 and further confirmed the treatment had not been completed on 3-11-2017 on the AM shift. C. Record review of a Nursing Summary sheet dated 9-08-2016 revealed Resident 1 had a wound to the back of the right hand on admission. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 9-29-2016 and revised on 11-14-2016 revealed Resident 1 had a skin tear on the right hand from rubbing and bumping it on the bed. The CCP identified Resident 1 was refusing the treatment and removing the dressing. Record review of a physician's orders [REDACTED]. Record review of a POSPN dated 12-23-2016 revealed Resident 1's practitioner ordered a new treatment and ordered that the 15 minutes, 24 hours per day checks continue. Review of Resident 1's medical record revealed there was not evidence the facility staff had started and completed 15 minute checks from 12-15-2016 through 12-20-2016, from 12-28-2016 through 12-30-2016 and from 1-05-2017 to 1-06-2017. In addition, the 15 minute checks were started and not completed from 12-21-2016 through 12-27-2016 and from 1-02-2017 through 1-4-2017. On 3-14-207 at 11:47 AM an interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed the 15 minute checks had not been completed as ordered.",2020-01-01
5051,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-02-02,309,D,1,0,KFCK11,"**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 staff failed identify skin breakdown for 1(Resident 9) of 3 sampled residents. The facility staff identified a census of 79. Findings are: Record review of an Admission Record sheet printed on 2-2-2017 revealed Resident 9 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of an admission skin assessment dated [DATE] revealed Resident 9's buttocks were red. Record review of an Orders Summary Report sheet signed by facility staff on 1-18-2017 revealed weekly skin checks were to be completed for Resident 9. Request of all of Resident 9's weekly skin checks revealed 2 were provided for the dates of 1-23-2017 and 1-30-2017. A review of the 2 provided revealed there were no opens areas identified. Observation of Resident 4 buttocks area on 2-1-2017 at 9:39 AM revealed Registered Nurse (RN) H cleansed Resident 4's buttocks. An open area was noted on the right buttocks that measured approximately 2.0 centimeters (cm) by 0.8 cm wide and a left inner buttock open area that measured approximately 0.5 cm by 0.7 cm. An interview with RN H was conducted on 2-1-2017 9:39 AM during the observation. RN H stated that new and reported not knowing the open area was there. On 2-01-2017 the facility staff provided a Copy of their evaluation of the open areas. The facility staff findings were as follows: -Right inner buttock, 2.8 cm by 1.0 cm by 0.1 cm with blistering noted along the gluteal folds of 5.0 cm by 0.2 cm. -Left inner buttock measured 0.6 cm by 0.4 cm by 0.1 cm with the same blistering along the gluteal folds that measured 5.0 cm by 0.2 cm.",2020-02-01
1019,PRESTIGE CARE CENTER OF PLATTSMOUTH,285104,602 SOUTH 18TH STREET,PLATTSMOUTH,NE,68048,2018-02-27,684,D,1,0,W9MF11,"**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 staff failed to identify and monitor bruising for 1 (Resident 21) of 5 sampled residents. The facility staff identified a census of 78. Findings are: Record review of Resident 21's Comprehensive Care Plan (CCP) dated 1-10-2018 revealed Resident 21 admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further review of Resident 21's CCP revealed Resident 21 was at risk for bruising related to taking [MEDICATION NAME] medication. The interventions included staff were to inspect skin for bruising/unusual bleeding daily during cares. Observation on 2-21-2018 at 10:48 AM revealed Resident 21 had a bruise to the back of the left hand that measured approximately 3.0 centimeters (cm) and was dark purple in color and the back of the right hand had a bruise that measured approximately 2.0 cm and was purplish in color. Review of Resident 21's record revealed there was not evidence the facility staff had identified or was monitoring the bruising to Resident 21's hands. On 2-21-2018 at 4:35 PM an interview was conducted with the Director of Nursing (DON). During the interview, the DON reported the bruising was seen .last week.The DON confirmed there was no monitoring of the bruising.",2020-09-01
5939,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2016-07-26,309,D,1,0,10VG11,"**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 staff failed to identify bruising for 1 resident (Resident 2). The facility staff identified a census of 163. Findings are: Record review of an undated Face Sheet revealed Resident 2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Observation on 7-25-2016 at 9:31 AM revealed Nursing Assistant (NA) A and NA B transferred Resident 2 to the toilet. NA A and NA B pulled down Resident 2's pants and removed a adult brief. Observation at this time revealed Resident 2 had a dark purple bruise to the upper portion of the back of the right leg. Record review of Resident 2's medical record that included the treatment sheet and chart revealed the bruise to the right upper back leg had not been identified. On 7-25-2016 at 1:20 PM an interview was conducted with Registered Nurse (RN) C. During the interview, RN C reported that (gender) was not aware of the bruising to the back of the right upper leg. RN C stated no when asked if the NAs had reported the bruising. RN C confirmed that staff were to report any new areas to the charge nurse. RN C reported the bruised area measured 7 centimeters (cm) by 9 cm.",2019-07-01
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
5608,FLORENCE HOME,285173,7915 NORTH 30TH STREET,OMAHA,NE,68112,2016-12-22,314,D,1,0,E5X011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2 Based on record review, observations and interviews: the facility failed to provide care and treatment to prevent and heal pressure ulcers for 3 (Residents 2, 3, and 4) of 4 sampled residents. The facility census was 89. Findings are: Review of a telephone order dated 12-16-16 revealed an order for [REDACTED]. Review of Resident 2's Care Plan last updated on 12/16/16 revealed that the resident had a Pressure ulcer to the right heel. An observation was made on 12-22-16 at 10 am of the Wound Nurse that provided a treatment to Resident 2's right heel. The observation revealed Resident 2's right heel had a small area on the heel that was a dark burgundy color. No signs of [MEDICATION NAME] were noted on the heel. The Wound Nurse then cleansed the heel and then painted the area on the heel with [MEDICATION NAME]. Review of Resident 2's Treatment Administration Sheet (TAR) for (MONTH) (YEAR) revealed no entries for the [MEDICATION NAME] treatment to Resident 2's pressure ulcer. An interview conducted on 12-22-16 at 10:50 AM with Registered Nurse (RN) C that was working on the floor caring for Resident 2 revealed that RN C was unaware if Resident 2 had any pressure sores. An interview conducted on 12-22-16 at 10:55 AM with Nurse Aide (NA) D working on the floor caring for Resident 2 revealed that NA D was unaware if Resident 2 had any pressure sores. An interview conducted on 12-22-16 at 11:10 AM with Medication Aide (MA) F working on the floor caring for Resident 2 revealed that MA F was unaware if Resident 2 had any pressure sores. An interview with the Wound Nurse on 12-22-16 at 1 PM revealed that the Wound Nurse considered Resident 2's right heel a pressure ulcer staged at a suspected deep tissue injury. The Wound Nurse confirmed that the floor staff should have been aware that Resident 2 had a pressure ulcer to be able to provide care and treatments to it. The Wound Nurse confirmed that the [MEDICATION NAME] treatment order was not on the TAR and it should have been as this was how staff documented the treatment was completed. The Wound nurse confirmed that there was no documented evidence that Resident 2 had received the treatment to the pressure ulcer on the right heel as ordered. B. Observation of Resident 4 on 12/22/16 at 11:23 AM , revealed Resident 4 was lying in bed with no prevalon boots ( Prevalon boots help to minimize pressure, friction and shear on the feet, heels and ankles of non-ambulatory individuals, by off-loading the heel, it delivers total, continuous heel pressure relief) , or [MEDICAL CONDITION] Wear (a stocking to deliver effective compression of the subcutaneous fat and to move water back to the heart on the bilateral lower extremities). Record review of Resident 4's physician orders revealed that: - On 12/8/16, the physician ordered Prevalon boots to feet while in bed and - On 12/15/16, the physician ordered [MEDICAL CONDITION] wear on in the AM and off at bedtime. Observation of Resident 4's feet on 12/22/16 at 12:05 PM, with the facility Wound Nurse, revealed that Resident 4 had two area's that were black on the Left heel. Interview on 12/22/16 at 12:05 PM, with the facility Wound Nurse, revealed that the treatment that the physician had ordered for the prevention and treatment of [REDACTED]. Record review of the Treatment Administration Record (TAR) for Resident 4 revealed that, on 12/22/16, Nurse C had applied the [MEDICAL CONDITION] Wear and the Prevalon boots had been removed (due to being out of bed), and Prevalon boots had been applied on 12/21/16 at bedtime. Interview with Nurse A on 12/22/16 at 12:32 PM confirmed that the facility had not obtained [MEDICAL CONDITION] Wear or Prevalon boots for Resident 4. Nurse A confirmed that Resident 4 had not received Prevalon boots that were ordered on [DATE] and had not received [MEDICAL CONDITION] Wear that had been ordered on [DATE], and that the facility was in process of obtaining both items for Resident 4. Record review of Resident 4's nursing notes on 12/11 at 04:10 AM, 12/12/16 at 5:15 AM, and 12/13/16 at 12:05 PM revealed that Nurse H had applied [MEDICATION NAME] (an Antiseptic Solution) to bilateral heels. Interview with the facility Wound Nurse on 12/22/16 at 12:05 PM confirmed that there was not a physicians order for [MEDICATION NAME] to Resident 4's heels, that Resident's 4's physician did not want to use the [MEDICATION NAME], and the choice of wound prevention and treatment for [REDACTED]. Interview with the facility MDS (Minimum Data Set - a federally mandate assessment tool used for careplanning) Coordinator, on 12/22/16 at 11:50 AM, confirmed that Resident 4's physician orders did not include [MEDICATION NAME] solution to the heels. C. Record Review for Resident 3 revealed the resident was admitted on [DATE]. Resident 3 had [DIAGNOSES REDACTED]. Interview conducted on 12/22/16 at 9:55AM with LPN (License Parctical Nurse) G revealed Resident 3 had a wound on coccyx. LPN G reported the wound looked horrible and that it was being treated with [MEDICATION NAME] (a cream used to prevent and treat wound infections) to the edges and Calcium Alginate (a topical wound dressing made with the ingredient alginate which is a highly-absorbent substance that is extracted from the cell walls of brown seaweed) to the rest of the wound. Observation of wound care to coccyx completed on Resident 3 on 12-22-16 at 11:05 AM revealed the wound was had a yellow colored center with a pink colored outer border. LPN B documented the measurements to be 4.1 centimeters (cm) by 3.6cm by 0.2cm. LPN B use [MEDICATION NAME] (A transparent dressings can be used to cover and protect wounds and catheter sites) to form a frame around the wound. LPN B spread [MEDICATION NAME] onto the [MEDICATION NAME] AG (a highly absorbent antimicrobial alginate dressing for moderate to heavily exuding partial to full thickness wounds) and then place it into the wound. LPN B then covered the wound with [MEDICATION NAME] (a foam dressing that has a silicone adhesive border, waterproof backing). Interview conducted on 12/22/16 at 11:30 AM with LPN B revealed that the coccyx wound started out as 2 small blisters related to [DIAGNOSES REDACTED], but grew together. LPN B reported that the wound kept getting bigger and deeper and was classified as a pressure ulcer by the doctor on 12/8/16. Record review of Physician Order Sheet and Progress Note for Resident 3 dated 12/20/16 revealed an order for [REDACTED]. The dressing was to be changed daily and prn (as needed) due to soiling. Interview conducted on 12/22/16 at 1:30 PM with LPN B revealed that LPN B had indeed framed the wound with [MEDICATION NAME] and placed [MEDICATION NAME] into the entire wound. LPN B reviewed the physician order dated 12/20/16 and confirmed that wound treatment was applied incorrectly.",2019-11-01
6366,GOOD SAMARITAN SOCIETY - MILLARD,285098,12856 DEAUVILLE DRIVE,OMAHA,NE,68137,2016-03-31,314,G,1,0,F7L611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2A Based on observation, record review and interview; the facility staff failed to implement identified interventions for pressure ulcer treatment and prevention for 1 resident (Resident 5). The facility staff identified a census of 85. Findings are: Record review of a Face Sheet printed on 3-30-2016 revealed Resident 5 was admitted to the facility on [DATE]. Record review of Resident 5's comprehensive Care Plan (CCP) dated 4-25-2013 with a revision date of 3-30-2016 revealed Resident 5 had pressure ulcers. The interventions listed on the CCP to prevent complications included to provide pressure relieving equipment. Further review of the CCP revealed Resident 5 requested assistance for all activities of daily living Record review of a Wound Data Collection sheet (WDCS) dated 2-28-2016 revealed Resident 5 was evaluated with having excoriation to the coccyx area that measured 5 centimeter (cm) by 2 cms. Record review of a WDCS dated 2-28-2016 revealed Resident 5 was evaluated as having excoriation to the left buttocks that measured 1 cm by 1 cm. Record review of a Skin Observation sheet dated 3-02-2016 revealed Resident 5 was evaluated as having a coccyx/sacrum opening that measured 5 cm by 2 cm with slough (dead tissue) present. Record review of Resident 5's progress notes dated 3-8-2016 revealed Resident 5 had been discharged to the hospital. Record review of Resident 5's progress note dated 3-17-2016 revealed Resident 5 had been readmitted to the facility. Record review of a WDCS dated 3-18-2016 revealed Resident 5 was evaluated as having an unstagable pressure ulcer to the sacrum that measured 4.5 cm by 4.3 cm with 25% slough and 75 eschar (leather looking dead tissue). The comments section of the WDCS dated 3-18-2016 revealed Resident 5 was to have an air mattress, Roho cushion (a speciality pressure reliving cushion), repositioning, nutrition and an indwelling catheter (tube placed into the bladder to drain urine). Record review of a WDCS dated 3-18-2016 revealed Resident 5 was evaluated as having a unstageable pressure ulcer to the right buttock that measured 2 cm by 5 cm with 40% slough, 25% eschar and 35% granulation tissue (beef looking, healthy new tissue). The comments section of the WDCS dated 3-18-2016 revealed Resident 5 was to have the air mattress. Roho cushion, nutrition and an indwelling catheter. Record review of a WDCS dated 3-18-2016 revealed Resident 5 was evaluated as having 3 unstageable pressure ulcer to the left buttock with the superior pressure ulcer measured as 0.7 cm by 1.3 cm, the inferior measured 2.5 cm by 2 cm and the lateral pressure ulcer measuring 2.6 cm by 2.5 cm. The comments section of the WDCS dated 3-18-2016 revealed Resident 5 was to have the air mattress, Roho cushion, nutrition and an indwelling catheter. The Additional information section of the WDCS dated 3-18-2016 identified the resident had limited mobility, poor nutrition and was receiving hospice services. Record review of a WDCS dated 3-18-2016 revealed Resident 5 was evaluated as having a right heel blister that measured 3.5 cm by 2.5 cm. The facility staff evaluated the blister as fluid-filled blister intact. The comments section of the WDCS dated 3-18-2016 identified the resident was to have an air mattress. the heels were to be off loaded and that the facility was obtaining Prevalon boots ( a special type of boot that relieves pressure to the heels. Review of the WDCS dated 3-23-2016 revealed Resident 5's heel was evaluated as having 2 area's that measured 1.3 cm by 1.1 cm, dark brown and 2.3 cm by 2.1 cm's that was identified as a dark purple/brown blister reabsorbing. Record review of a WDCS dated 3-23-2016 revealed the left buttocks pressure ulcer measured 6 cm by 4.1 cm The comments section identified that the Hospice agency was obtaining a Roho cushion. Record review of a WDCS dated 3-23-2016 revealed Resident 5 was identified as having multiple stage 2 pressure ulcer (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) to the right buttocks that measured 0.5 cm by 0.4 cm and 0.1 cm, 0.6 cm by 0.3 cm by 0.1 cm, 0.4 cm by 0.5 cm by 0.1 cm, and 0.6 cm by 0.5 cm by 0.1 cm. The information identified on the WDCS dated 3-23-2016 revealed the areas measured from top to bottom. The comment section identified the hospice provider was obtaining a Roho cushion. Observation on 3-29-2016 at 1:42 PM revealed Resident 5 was up in a wheelchair without a Roho cushion in the wheelchair. Observation on 3-29-2016 at 4:22 PM revealed Resident 5 was in bed without Prevalon boots on. Observation on 3-30-2016 at 5:10 AM, 5:35 AM, 7:51 AM and 8:32 AM revealed Resident 5 had been placed into the left laying position. Resident 5 was not observed to have the Prevalon boots on or to have the heels off loaded. Observation on 3-30-2016 at 2:06 PM of the wound care treatment by Registered Nurse (RN) A and Resident 5's assigned Hospice Nurse. revealed the right heel had 2 black areas that measured 1.5 cm by 1.0 cm and 2.3 cm roundish. The wound care treatment revealed Resident 5 had a new pressure ulcer to the left heel that measured 3.1 cm by 2.5 cm. The area had black tissue and the skin was intact. Observation of the sacrum revealed the wound contain necrotic tissue surrounded by whitish tissue. The area measured 3.1 cm by 4.1 cm. The left buttock was observed to have excoriation that covered approximately 2/3 of the buttock cheek. There were areas of necrotic looking skin through out the left buttock area. the measurements of the left buttocks as reported by RN A was 9.5 cms by 21.5 cms. RN A reported the right buttocks areas had merged and reported the measurements as 7.7 cm by 2.5 cms, 4.5 cm by 3 cm and 2.0 cm by 0.8 cms. RN A completed the treatments for Resident 5 and consulted with the Hospice Nurse RN on wound care treatment changes. Observation on 3-31-2016 at 10:00 AM revealed Resident 5 was in bed, no Prevalon boots on and Resident 5's heels were on the mattress and not elevated. Observation on 3-31-2016 at 11:19 AM revealed Resident 5 was in the dining room for lunch. Resident 5 was observed to be without Prevalon boots or the Roho cushion. Further observation revealed Resident 5's heels were resting on the unpadded edges of the foot pedals on the wheelchair. An interview on 3-31-2016 at 11:21 AM was conducted with Licensed Practical Nurse (LPN). During the interview, observation of Resident 5 was completed with LPN B related to the use of Prevalon boots. LPN B confirmed Resident 5 did no have any type of boot on and that Resident 5's heels were on the edges of the unpadded foot pedals. Observation on 3-31-2016 at 1:44 AM with LPN C revealed Resident 5 was in bed without Prevalon boots on or heels off loaded. Observation of Resident 5's wheelchair revealed the cushion in the wheelchair was not a Roho. LPN C adjusted Resident 5's feet off the mattress and confirmed the resident did not have the Prevalon boots. LPN C further confirmed Resident 5's wheelchair did not have a Roho cushion. An interview with RN A and the Director of Nursing (DON) was conducted on 3-31-2016 at 12:33 PM. During the interview RN A confirmed the Roho and Prevalon boots should have been obtained and had not been. According to RN A the hospice provider was to bring the Roho and Prevalon boots to the facility. The DON, when asked what the expectation was to obtain the Prevalon boots and Roho cushion, the DON stated 3 days.",2019-03-01
6017,BEAVER CITY MANOR,285269,"P O BOX 70, 905 FLOYD STREET",BEAVER CITY,NE,68926,2016-07-27,314,G,1,0,VTBH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on interviews and record review, the facility failed to implement measures to prevent pressure sores for Resident 1. The facility census was 17 at the time of survey. Findings are: Review of Resident 1's face sheet revealed an admission date of [DATE] and a discharge date of [DATE]. Confidential interview on 7/27/2016 at 12:40 PM revealed that Resident 1 had pressure sores on both buttocks that were discovered when Resident 1 was transferred to the hospital from the facility on 4/27/2016. These pressure sores were not present when Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Departmental Notes dated 4/14/2016 revealed no documentation that pressure sores were present on Resident 1's buttocks upon admission to the facility. Review of Resident 1's Admission MDS (Minimum Data Set) dated 4/21/2016 revealed that Resident 1 required assistance from staff for bed mobility, transfer, and locomotion and there was no documentation that Resident 1 had pressure sores present upon admission. Review of Resident 1's Daily Skilled Nurses Notes dated 4/23/2016 revealed documentation that Resident 1 had a 2.5 cm (centimeter) by 1 cm open area to the right buttock and a 2 cm by 1 cm open area to the left buttock. A dressing was applied to the areas. Review of Resident 1's Daily Skilled Nurses Notes for 4/14/2016 to 4/27/2016 revealed no documentation that Resident 1's health care provider or responsible party were notified about the open areas to Resident 1's buttocks, that the areas were being monitored, and there was no documentation that further treatment was applied to heal the areas after they were initially treated on 4/23/2016. Review of Resident 1's physician's orders [REDACTED]. Review of Resident 1's eMAR (Medication Administration Record) revealed no documentation of treatment to the open areas on Resident 1's buttocks. Review of Resident 1's Care Plan dated 4/14/2016 revealed no documentation of interventions implemented to prevent or heal the open areas on Resident 1's buttocks. Interview with RN-A (Registered Nurse) on 7/27/2016 at 3:27 PM revealed the facility did not have a formal procedure for monitoring residents for skin breakdown. RN-A revealed the nurse aides were to let the charge nurses know if they found any issues. RN-A confirmed that if skin breakdown was found, the charge nurses were to document it, notify the provider and family. RN-A revealed they were to record the area in the resident's medical record so that it was monitored and interventions were to be implemented if needed. Interview with the facility Administrator on 7/27/2016 at 4:45 PM revealed the facility did not have a policy or procedure in place for monitoring residents for potential skin issues.",2019-07-01
4825,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2017-06-14,314,D,1,0,QWSE11,"**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 repositioning for 1 of 4 sampled residents (Resident 3) identified at risk for skin breakdown. The facility identified a census of 24 at the time of survey. Findings are: Review of Resident 3's Quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 4/24/2017 revealed an admission date of [DATE]. Resident 3 was totally dependent upon staff for bed mobility, transfer, and locomotion on and off the unit, dressing, toilet use, personal hygiene, dressing and bathing. Resident 3 was at risk of developing pressure ulcers. Observation of Resident 3 on 6/14/2017 revealed Resident 3 was sitting in the wheelchair at 8:02 AM, 8:08 AM, 8:14 AM, 9:19 AM, 9:23 AM, 9:50 AM, 10:25 AM, 10:47 AM, 10:55 AM, 11:00 AM, 11:37 AM, 12:04 PM and 12:50 PM. Interview with NA-B on 6/14/2017 at 11:02 AM revealed that Resident 3 had been gotten up that morning at 5:45 AM. Interview with NA-A (Nurse Aide) on 6/14/2017 at 10:31 AM revealed if a resident is at risk for skin breakdown they are to be repositioned every 2 hours including getting them out of bed or out of their chair. Interview with the DON (Director of Nursing) on 6/14/2017 at 11:03 AM revealed residents were to be turned as needed. Interview with the Administrator on 6/14/2017 at 11:39 AM revealed the facility did not have a policy for preventing skin breakdown. Review of the National Institutes of Health/U.S. National Library of Medicine MedlinePlus article Preventing Pressure Ulcers with a review date of 5/17/2016 revealed the following: Change your position every 1 to 2 hours to keep the pressure off any one spot. Review of the Mayo Clinic article Bedsores (pressure ulcers) copyrighted 1998-2017 revealed repositioning about once an hour was recommended. Review of the Journal of Rehabilitation Research & Development article Patient repositioning and pressure ulcer risk-Monitoring interface pressure of at-risk patients dated (MONTH) 10, 2012 revealed repositioning patients regularly-every 2 hours-to prevent sustained high pressure on any particular tissue area is the standard of care.",2020-03-01
4062,HILLCREST MILLARD,285302,13225 WESTWOOD LANE,OMAHA,NE,68144,2019-03-21,686,G,1,0,EZUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on observation, record review and interview; the facility failed to evaluate causal factors and re-evaluate interventions to prevent pressure ulcer development for 2 (Resident 2 and 10) of 3 sampled residents. The facility staff identified a census of 53. The findings are: Record review of the Policy and Procedure for Assessment Prevention Treatment Documentation for Skin Integrity dated 8/9/2018 revealed that licensed clinical members will perform a head to toe assessment upon admission/readmission and continue to do so weekly and as needed. [NAME] Review of Resident 10's Medical Record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Admission Evaluation sheet dated 01/02/2019 for Resident 10 revealed the facility staff assessed Resident 10's skin as intact. Record review of Weekly Skin assessment dated [DATE] revealed the facility staff assessed Resident 10's skin as not intact with further documentation of an abrasion to the Right 4th toe, but did not identify any pressure areas. Record review of Re-admission Evaluation sheet for Resident 10 dated 01/16/2019 revealed Resident 10's skin was not intact with further documentation of Bruise/ Diabetic Ulcer. Further review of the 01/16/2019 Re-admission Evaluation sheet revealed the location of the Bruise/Diabetic Ulcer was not identified. Record review of Weekly Skin Assessment for dated 01/24/2019 revealed Resident 10's skin was assessed as being intact. Review of Resident 10's medical record revealed there was no evidence of further weekly skin assessments until 02/07/2019 which revealed Resident 10's skin was not intact with further documentation of a facility acquired Stage II Partial Thickness Pressure Ulcer (the top layer of the skin is broken creating an open sore) to Left Buttocks. Record review of Resident 10's medical record revealed there was no evidence of further weekly skin assessments until 03/14/2019 which revealed that Resident 10's skin was not intact with further documentation of Stage II Partial Thickness Pressure Ulcer to Left Buttocks. Review of the current Comprehensive Care Plan dated 2/5/2019 revealed that Resident 10 was at risk for skin issues due to decreased mobility and [DIAGNOSES REDACTED]. The goals included Resident 10 would have reduced risk for skin breakdown and Resident 10 will have no skin breakdown. The interventions were as follows: 1. Float heels while in bed or recline recliner as needed. 2. Keep head of bed elevated. 3. Encourage footwear when up for protection. 4. Encourage ambulation as tolerated for pressure relief. 5. Pressure reduction mattress. 6. Wheelchair cushion. Observation of wound care 3/21/2019 at 09:38 AM revealed that Resident 10 had an open area to the left buttocks. Record review of the Policy and Procedure for Assessment Prevention Treatment Documentation for Skin Integrity dated 8/9/2018 revealed that licensed clinical members will perform a head to toe assessment upon admission/readmission and continue to do so weekly and as needed. Interview conducted with Director of Clinical Service on 3/21/2019 at 02:39 PM confirmed that Resident 10 did not have skin assessments completed weekly, there was no evaluation of causal factors for why Resident 10 developed a pressure ulcer, and Resident 10 developed a facility acquired pressure ulcer. B. Review of Resident 2's Medical Record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Weekly Skin Evaluation form dated 12/30/2018 for Resident 2 revealed an open wound to right heel present on admission. Record review of Resident 2's Medical Record revealed there was no evidence of weekly skin assessments being completed until 01/21/2019 which revealed that Resident 2's skin was not intact and the rest of the assessment was incomplete. Record review of Resident 2's Medical Record revealed there was no evidence of weekly skin assessments completed from 1/21/2019 until 02/28/2019 when the facility staff assessed Resident 10 with a deep tissue injury (a pressure-related injury to skin tissues under intact skin) to the right heel and left heel. Review of Resident 2's Comprehensive Care Plan dated 2/8/2019 revealed that Resident 2 was at risk for skin integrity due to immobility, history of skin breakdown. The goal for Resident 2 was to have no further skin breakdown. The interventions were as follows: 1. Treatment per MD order. 2. Air mattress. 3. Assist with repositioning. 4. Dietary interventions. 5. Wheelchair cushion. The Comprehensive Care Plan for Resident 2 further identified a Right Heel Pressure Ulcer with a goal of Ulcer will heal. Interventions were as follows: 1. Check for incontinence. 2. Adjust diet/supplements as indicated. 3. Refer to treatment record for current order. 4. Use pillows, pads, wedges to reduce pressure on heels and pressure points. Turn and reposition. 5. Air mattress and pressure-reducing pads when sitting. Interview conducted with Director of Clinical Service on 03/21/2019 at 02:39 PM confirmed that skin assessments for Resident 2 were not completed weekly and Resident 2 developed a facility acquired pressure ulcer.",2020-09-01
6473,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7350 GRACELAND DRIVE,OMAHA,NE,68134,2016-02-09,314,G,1,0,G0GG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on observation, record review and interview; the facility staff failed evaluate weekly skin condition, implement treatment, evaluated factors and implement additional interventions to improve pressure ulcer healing and prevent additional pressure ulcers for 2 residents (Resident 4 and 5) The facility staff identified a census of 60. Findings are: A. Record review of the facility Policy and Procedure for skin assessment dated ,[DATE] revealed the following information: -Policy: -A full skin assessment will be preformed weekly. -Purpose: -To identify resident at risk for skin breakdown and institute appropriate preventative measures. B. Record review of Resident 4's Comprehensive Care Plan (CCP) dated 6-08-2015 revealed Resident 4 was admitted to the facility on [DATE]. According to the CCP, Resident 4 was at risk for pressure ulcer development. The goal identified on the CCP dated 6-08-2015 was Resident 4 would be free of pressure ulcer development. Interventions identified on the CCP included: pressure reducing devices, Air overlay and Roho (pressure reducing chair cushion) cushion, Prevalon (Pressure reducing boots to relieve pressure on the heels) boots in bed and while up in wheelchair, and weekly head to toe skin at risk assessments. Record review of Resident 4's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 11-19-2015 revealed the facility staff assessed the following about the resident: -Scored a 15 on the Brief Interview for Mental Status. According to the MDS Manuel, a score of 13 to 15 indicated cognitively intact. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Record review of Resident 4's Braden Scale ( a tool use to predicting pressure sore risk) dated 9-02-2015 revealed Resident 4 scored a 15. According to the information on the Braden Scale form, a score of 15 indicated low risk for the development of a pressure ulcer. Record review of a LN (Licensed Nurse) Skin Assessment /Evaluation PRN (as needed) and Weekly (LNSAE) sheet dated 11-28-2015 revealed Resident 4 was not identified as having a pressure ulcer. Review of Resident 4's record revealed there was not any evidence the facility staff had evaluated Resident 4 skin for breakdown weekly from 11-28-2015 to 12-16-2015 ( a 2 week time frame). Record review of Resident 4's LNSAE sheet dated 12-16-2015 revealed Resident 4 was not identified as having a pressure ulcer. Review of Resident 4's record revealed there was not any evidence the facility staff had evaluated Resident 4 skin for breakdown weekly from 12-16-2015 to 02-01-2016 ( a 6 week time frame). Record review of a LNSAE dated 2-01-2016 revealed Resident 4 was identified as having a open area to the left gluteal fold that measured 3 centimeters (cm) by 4 cm, with a depth of 1 cm. According to the information on the LNSAE dated 2-01-2016, the wound was evaluated as having beefy red wound bed, wound edges were light pink with a yellow stringy substance that was also observed in the wound. Record review of Resident 4's LNSAE dated 2-02-2016 revealed the area to the left gluteal fold was identified as a stage 3 (Stage III - 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. (MONTH) include undermining or tunneling). Record review of a information sheet dated 2-02-2016 revealed the facility had informed Resident 4's practitioner of the open area and on 2-03-2016, Resident practitioners gave orders to use the facility protocol for the treatment of [REDACTED]. Review of Resident 4's medical record revealed there was not a comprehensive evaluation of why Resident 4 had developed a pressure ulcer. Observation on 2-08-2016 at 6:43 PM of the pressure ulcer treatment, with the facility Director of Nursing (DON) revealed Registered Nurse (RN) A obtained the treatment supplies for Resident 4. RN A cleansed the pressure ulcer to the left gluteal fold area. RN A, using a measuring device, evaluated Resident 4's wound. RN A reported the pressure ulcer measured 5 cm by 6 cm with a depth of 2 cm. RN A identified wound tunneling at position of 12:00 that measured 1.5 cm. At 9:00, tunneling was evaluated as 2.0 cm. At the 6:00 position, tunneling was measured at 2.0 cm. Observation of the wound revealed black tissue with string like tissue hanging out of the pressure ulcer. RN A completed the treatment for [REDACTED]. Record review of an in information sheet revealed the facility staff had notified Resident 4's practitioner of the open area and would start the facility protocol for the wound ulcer. According to an undated Wound Care Protocol sheet revealed a Stage 3 pressure ulcer was to be treated daily and as needed until healed. Record review of Resident 4's Treatment Administration Record (TAR) for 2-01-2016 through 2-29-2016 revealed the entry on the TAR indicated the order date was 2-08-2016 and there were no entries of the pressure ulcer treatment being completed. Record review of Resident 4's progress notes dated 2-06-2016 revealed the treatment to Resident 4's pressure ulcer. Further review of Resident 4's progress notes from 2-2-2016 through 2-07-2016 revealed there was no evidence the pressure ulcer treatment had been completed for Resident 4. An interview on 2-08-2016 at 7:10 PM was conducted with the DON. During the interview, when asked what the stage of the pressure ulcer was for Resident 4, the DON reported the pressure ulcer was a stage 4 ( Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). An interview was conducted on 2-08-2016 at 5:05 PM with the facility Nurse Consultant (NC). The NC confirmed, during the interview, the weekly skin evaluations had not been completed for Resident 4. According to the NC, it was the facility policy to have the weekly skin evaluation completed. An interview was conducted on 2-09-2016 at 10:01 AM with the DON and the facility NC. During the interview, the NC confirmed there were no skin evaluations from 12-16-2015 through 2-01-2016. The facility NC confirmed there was not a comprehensive evaluation of the casual factors for the development of the pressure ulcer for Resident 4. The NC confirmed there was not evidence the pressure ulcer treatment had been completed daily. C. Record review of Resident 5's CCP dated 7-20-2015 revealed Resident 5 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further review of Resident 5's CCP revealed Resident 5 had developed a pressure ulcer to the left buttock. The goal identified for Resident 5 was to be free from further pressure ulcer development and the pressure ulcer to the left buttock would progress towards healing. Interventions listed on the CCP included weekly head to to skin at risk assessments. Record review of Resident 5's Braden scale dated 9-22-2015 revealed a score of 14. According to the information on the Braden's scale form, a score of 14 placed Resident 5 at moderate risk of developing a pressure ulcer. Record review of a Resident 5's LNSAE sheet dated 11-11-2015 revealed Resident 5 had a pressure ulcer that measured 0.8 cm by 0.4 cm to the right buttocks. The area was identified a Stage 2 (Stage II - 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) pressure ulcers and had a Stage 2 pressure ulcer to the left buttocks that measured 1.6 cm by 1.4 cm with an onset dated of 7-06-2015. Record review of Resident 5's record revealed the LNSAE had not been completed from 11-25-2015 through 12-09-2015 ( a 2 week time frame). Further review of Resident 5's record revealed from 12-16-2015 through 1-07-2016 the weekly LNSAE had not been completed for Resident 5. In addition, there was no evaluation of Resident pressure ulcers from 1-14-2015 to the start of the survey on 2-8-2016. Observation on 2-08-2016 at 11:57 AM revealed Licensed Practical Nurse (LPN) B obtained the required supplies for the pressure ulcer treatment. Observations of Resident 5 during the treatment revealed the left and right buttock were fire red that measured approximately 7 cm and were roundish. Inside the red area were several dark colored areas. LPN 5 applied the treatment as order. An interview was conducted on 2-09-2016 at 9:25 AM with the DON and facility NC. During the interview, the facility NC confirmed the weekly skin evaluation had not been completed for Resident 5.",2019-02-01
4748,"SORENSEN CARE AND REHABILITATION CENTER, LLC",285107,4809 REDMAN AVENUE,OMAHA,NE,68104,2017-06-15,314,G,1,1,F9RW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on observation, record review and interview; the facility staff failed to evaluate casual factors for the development of a pressure ulcer for 1 (Resident 36) and failed to complete pressure ulcer treatments for 2 (Resident 36 and 49) for 3 residents reviewed. The facility staff identified a census of 67. Findings are: Record review of an admission orders [REDACTED]. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling) to the sacrum. Record review of Resident 36's Nursing Admission assessment dated [DATE] revealed under the section titled Skin Assessment, that the facility staff had identified Resident 36 had a pressure ulcer to the sacrum. No other pressure ulcer was identified for Resident 36. Record review of Resident 36's Weekly Skin Check (WSC) dated 4-25-2017 revealed the directions to complete the form was for the facility staff to identify skin injuries such as pressure ulcers, bruises, abrasions, lacerations and abnormal skin discoloration by marking the areas on a body diagram. Further review of the WSC dated 4-25-17 revealed the facility staff had identified the pressure ulcer to the sacrum and a [MEDICAL TREATMENT] to the right chest. Record review of Resident 36's WSC sheet dated 5-30-2017 revealed staff had not identified any areas of skin injuries. Record review of a Follow Up Visit wound sheet for Resident 36 dated 5-26-2017 revealed the physician assessed Resident 36 with a pressure ulcer to the left heel that measured 3.40 centimeters (cm) by 2.80 cm with a depth of 0.10 cm. The physician ordered a treatment to the left heel that was to be completed twice a day. The facility staff were to clean the wound with the cleanser of the facility choices, apply a skin preparation and apply a special type of boots that prevents pressure to the heels. Record review of Resident 36's WSC dated 6-01-2017 revealed one skin injury was identified on the WSC and that was the pressure ulcer to the sacrum. Observation on 6-15-2017 at 8:18 AM with Licensed Practical Nurse (LPN) [NAME] revealed Resident 36 was observed to have an area to the left heel that measured approximately 3.2 cm, roundish in shape, and darker in color. LPN [NAME] confirmed at this time that Resident 36 had a pressure ulcer to the left heel. Review of a Follow Up Visit wound sheet dated 6-16-2016 revealed Resident 36 continued to have a pressure ulcer to the sacrum and a pressure ulcer to the left heel. The physician identified under the [DIAGNOSES REDACTED]. Record review of Resident 36's medical record revealed there was no evidence that the facility had identified the pressure ulcer to Resident 36's left heel or had evaluated the casual factors of why Resident 36 had developed a pressure ulcer to the left heel. On 6-15-2017 at 12:01 PM an interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed the treatment to Resident 36's left heel had not been completed as ordered by the physician and further confirmed the facility staff had not monitored the left heel ulcer for healing. B. Record review of Resident 36's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed the treatment to the left heel was not identified as being completed for Resident 36. Record review of Resident 36's MAR and TAR from 6-1-2017 through 6-15-2017 revealed the wound treatment for [REDACTED]. On 6-19-2017 at 8:09 AM a follow up interview was conducted with the DON. During the interview, the DON confirmed Resident 36 had a pressure ulcer to the left heel and that the DON was not able to provide an evaluation of casual factors for Resident 36 developing a pressure ulcer to the left heel. The facility did not provide additional information related to the development of the left heel pressure ulcer prior to exit. B. A review of Resident 49's Admission Record dated 6/14/17 revealed Resident 49 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of Resident 49's Pressure Ulcer Care Plan dated 10/15/12 revealed on 3/9/17 the resident had a Stage 3 pressure ulcer (a pressure related wound that involves full thickness tissue loss) to the right buttocks. An observation conducted on 6/14/17 at 11:16 AM of Licensed Practical Nurse (LPN) D performing the dressing change to Resident 49's right buttock revealed LPN D placed Calcium Alginate AG (a highly absorbent antimicrobial dressing that contains silver) into the wound, moistened the Calcium Alginate AG with Saline, and placed the silicone border dressing (a foam dressing with silicone adhesive border) over the wound. An interview conducted on 6/14/17 at 11:16 AM with LPN D revealed that they had always been moistening the Calcium Alginate AG with saline for Resident 49's dressing changes. A review of Resident 49's medical record revealed an order dated 3/9/17 to cover the right buttock wound with Calcium Alginate AG and a silicone border dressing. A review of Resident 49's medical record revealed an order dated 5/10/17 to apply Calcium Alginate AG to the wound and cover with a silicone border dressing. An interview conducted on 6/15/17 at 2:38 PM with the facility's Regional Vice President of Operations confirmed LPN D did not complete the dressing change as ordered by the physician.",2020-03-01
5510,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2016-11-17,314,D,1,0,6OYM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on observation, record review and interviews; the facility failed to prevent a pressure sore from developing on the heel of 1 resident (Resident 7) out of 3 sampled residents. The facility census was 76. Findings are: Review of the undated census sheet revealed Resident 7 was admitted on [DATE]. Review of the undated face sheet revealed Resident 7 had current [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 10-13-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 8 which indicated Resident 7's cognition was moderately impaired. Resident 7 required extensive assistance of 2 staff with bed mobility, dressing and personal hygiene. Resident 7 required total assistance with toileting and bathing. The resident had a urinary catheter (a tube place into the bladder to drain the urine). Resident 7 had enteral nutrition (a tube placed into the stomach and received all nutrition by a liquid formula). Resident 7 did not get out of bed during the 7 day assessment period. The resident was identified at risk for pressure ulcers and did not have any current pressure ulcers at the time of the assessment. On the MDS, the CAA's (Care Area Assessment) triggered for pressure ulcers and the care plan team documented to continue to care plan the resident's risk of pressure ulcers. Review of the Care Plan revealed the care plan team had addressed the resident's risk for pressure ulcers dated 5-25-16 with the interventions for the Nurse Aides to elevate the heels off of the bed. Review of the Progress Notes revealed on 10-30-16 a fluid filled blister to the right heel was observed. The Progress Notes dated 11-8-16 revealed an area to the right heel was black in color and spongy to touch, no drainage from the wound. The Progress Notes dated 11-14-16 revealed Wound Rounds: Suspected Deep Tissue Injury to the heel measured 3.0 x 2.4 cm with orders to paint with [MEDICATION NAME] and float the heels. Review of the NPUAP (National Pressure Ulcer Advisory Panel) revealed the definition of a Suspected Deep Tissue Injury pressure ulcer was a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Observation on 11-17-16 at 9:10 AM of Resident 7's right heel with LPN-A (Licensed Practical Nurse) revealed an intact, circular, dark maroon color wound on the posterior prominence of the right heel. Interview on 11-17-16 at 10:42 AM with RN-B (Registered Nurse) revealed Resident 7 was compliant with repositioning in bed and the resident's lower legs were to be elevated with pillows so the heels were floating. RN-B revealed approximately 1-2 month ago the pillows were sliding from under the resident's lower legs and were ending up so the heels were resting directly on the pillows instead of the heels floating. RN-B revealed now the resident was too weak and unable to move so the pillows once placed under the lower legs remained there and floated the heels. Interview on 11-17-16 at 3:30 PM with RN-C, Unit Manager revealed before the pressure sore developed the resident would instruct the staff to move the pillows from under the lower legs to under the knees which caused the heels to rest directly on the bed instead of keeping the heels elevated. RN-C denied another intervention was initiated by the facility to elevate the heels to replace the pillows. Review of the NPUAP (National Pressure Ulcer Advisory Panel) revealed The reduction of pressure and shear at the heel is an important point of interest in clinical practice. The posterior prominence of the heels sustains intense pressure, even when a pressure redistribution surface is used. Repositioning for preventing heel pressure ulcers: Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. Heel suspension devices are preferable for long term use, or for individuals who are not likely to keep their legs on the pillows.",2019-11-01
5052,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-02-02,314,G,1,0,KFCK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on record review and interview; the facility staff failed evaluate causal factors for the development of pressure ulcers and failed to implement addition interventions to prevent addition pressure ulcer development for 1(Resident 1) of 3 residents. The facility staff identified a census of 79. Findings are: Record review of an Admission Record sheet dated 2-02-2017 revealed Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 6-01-2016 revealed Resident 1 was at risk or had actual pressure ulcer development. The goal that was identified on Resident 1's CCP was to have intact skin. Interventions listed on the CCP included weekly skin inspection, pressure reducing cushion to wheelchair, pressure reducing mattress. Further review of Resident 1's CCP revealed had written entries dated 1-7-2017 revealed Resident 1 had open areas to the left buttocks and on 12-5-2016 had an open area to the penis. Review of a Fax sheet dated 1-07-2017 revealed the facility had notified the practitioner that Resident 1 had skin breakdown to the scrotum, buttocks and coccyx areas and request a treatment. Record review of Resident 1's Weekly Skin Check sheet dated 1-03-2017 revealed the skin breakdown that had been identified was the wound to the penis. Record review of a Weekly Wound Assessment sheet (WWA) dated 1-19-2017 revealed on 1-07-2017, Resident 1 was assessed with [REDACTED]. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) to the Right Ischium that measured 2.3 centimeter (cm) by 2.3 cm by 2.9 cm. The Stage IV pressure ulcer was acquired at the facility. Record review of a WWA sheet dated 1-19-2017 revealed Resident 1 was assessed as having a stage 1 (Stage I - An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: - Skin temperature (warmth or coolness); - Tissue consistency (firm or boggy); - Sensation (pain, itching); and/or - A defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.) The pressure ulcer measured 1.0 cm by 1.0 cm. Record review of a WWA sheet dated 1-19-2017 revealed Resident 1 was assessed as having a 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) to the right buttocks that measured 0.6 cm by 0.3 cm by 0.1 cm that was identified on 1-07-2017. Record review of Resident 1's medical record revealed there was no evidence of the facility staff evaluation of casual factors as to why Resident 1 developed the Stage IV pressure ulcer. Record review of a WWA sheet dated 1-13-2017 revealed Resident 1 was assessed as having a pressure ulcer to the right heel. The staging of the pressure ulcer was identified as suspected Deep Tissue Injury. According to the information on the WWA sheet, a suspected deep tissue injury is a localized area of discolored intact skin due to pressure or shearing. Record review of a WWA sheet dated 1-19-2017 revealed on 1-17-2017 Resident 1 was assessed as having a Stage 3 (Stage III - 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. (MONTH) include undermining or tunneling) to the left lower leg that measured 3.3 cm by 1.8 cm. Further review of Resident 1's medical record revealed there was no evidence the facility staff had implemented intervention and evaluated casual factors for the development of the additional pressure ulcers . On 2-02-2017 at 12:59 PM an interview was conducted with the facility Assistant Director of Nursing (ADON). During the interview, the WWA sheets were reviewed. The ADON confirmed, during the interview, that Resident 1 had developed the pressure ulcers at the facility. The ADON confirmed the casual factors for the development of pressure ulcers had not been completed for Resident 1.",2020-02-01
2163,LEGACY GARDEN REHABILITATION & LIVING CENTER,285186,200 VALLEY VIEW DRIVE,PENDER,NE,68047,2017-07-20,314,G,1,1,E93U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on record review and interview; the facility staff failed to implement interventions for pressure ulcer treatments for 1 (Resident 39) of 2 sampled residents. The facility staff identified a census of 31. Findings are: Record review of a communication sheet from the hospital dated 2-28-2017 revealed Resident 39 had [DIAGNOSES REDACTED]. (MONTH) also present as an intact or open/ruptured blister) to the right heel, [MEDICAL CONDITIONS] and a right Pelvic fracture. Record review of a Referral Form dated 3-27-2017 revealed Resident 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 39's Comprehensive Care Plan (CCP) dated 3-16-2017 revealed Resident 39 was identified as having the 2 pressure ulcers. The goal for Resident 39 was the pressure ulcer would heal without complications and have no recurrent pressure ulcers. Interventions listed on Resident 39's CCP included Resident 39 would see a wound nurse, weekly skin checks, pressure relieving mattress and cushions, a special boot to relieve pressure to the right foot. Record review of a fax sheet dated 3-16-2017 revealed Resident 39's physician was notified Resident 39 had a pressure ulcer to the right buttocks that measured 1.7 centimeters (cm) by 0.5 cm and was superficial. The facility staff had assessed the pressure ulcer as a stage 2. Record review of a Skin Care Instruction (SCI) sheet dated 3-29-2017 revealed Resident 39 was assessed as having a new stage 1 to the right second toe and a stage 2 on the right 5th toe. According to the information in the SCI sheet, the cause was identified as Resident 39's shoes appear to be fitting tight and that Resident 39 had some foot swelling ([MEDICAL CONDITION]). The recommendation was that Resident 39 was to have wider shoes and to have compression stockings. Record review of Resident 39 Progress notes dated 4-03-2017 revealed Resident 39 had discharged from the facility. An interview on 7-20-2017 at 9:01 AM an interview was conducted with the Director of Nursing (DON) and the facility Social Services Director (SSD). During the interview, the DON and the facility SSD confirmed there was no evidence the facility had followed through with the wound clinics recommendation for wider shoes.",2020-09-01
5945,GRAND ISLAND PARK OPERATIONS LLC,285105,610 NORTH DARR AVENUE,GRAND ISLAND,NE,68803,2016-07-06,314,D,1,0,HDGT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on record review and interviews, the facility failed to treat a facility acquired area of skin impairment and prevent it from developing into a pressure ulcer for Resident 100. The facility census was 55. Findings are: Review of Resident 100's Face Sheet dated 6-9-16 revealed Resident was admitted from the hospital on 6-1-16 and discharged from the facility on 6-18-16. [DIAGNOSES REDACTED]. Interview on 7-6-16 at 5:31 PM with Resident 100's family revealed the resident was transferred from the facility to an acute hospital on 6-18-16 because of low oxygen. Upon initial assessment of the resident at the hospital, the doctor discovered the resident had pressure ulcers on both heels and the buttocks at the base of the spine. The skin was black in all 3 areas. Review of the MDS (Minimum Data Set - a federally mandated comprehensive assessment tool used for care planning) dated 6-13-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 7 which indicated Resident 100's cognition was severely impaired. Review of the functional status revealed resident required extensive assist of 2 with bed mobility, transfers, dressing, and toileting. The resident required extensive assist of one person with personal hygiene. The resident's skin assessment revealed at risk for pressure ulcers but did not have any current pressure ulcers at the time of the assessment. Review of the Resident 100's Progress Notes revealed a late entry dated 6-16-16 at 4:00 PM which was entered in the progress notes on 6-21-16. The documentation revealed a nurse aide discovered a reddened area to Resident 100's coccyx during the bath. The nurse aide reported it to an LPN (Licensed Practical Nurse) who then assessed the area and discovered the area was blanchable and not open. A full assessment was completed at that time and no other new areas were noted. Review of the Progress Notes from 6-16-16 to 6-18-16 at the time of discharge to the acute hospital revealed no further documentation about the red area on the resident's coccyx. Review of Resident 100's Care Plan revealed Resident 100 was at Risk for Altered Skin Integrity related to a red, blanchable area on the coccyx. Interventions listed were a Nursing order for Z-Guard (a protective cream) to be applied to the red area after peri-cares with date initiated as 6-21-16. Also listed was Glucerna initiated due to poor intake and skin integrity with the date initiated listed as 6-21-16 was on the care plan. Interview on 7-5-16 at 6:15 PM with the ADON (Assistant Director of Nursing) revealed that, on the Care Plan, the date initiated indicated when the entry was entered on the care plan. The ADON confirmed the entry of 6-21-16 would have been after the resident was discharged to the hospital on 6-18-16. The ADON also revealed the nurses had been educated to place the Z-Guard treatments for wounds on the TARs (Treatment Administration Record). Review of the (MONTH) (YEAR) TAR revealed no treatment for [REDACTED]. Review of the Physician orders [REDACTED].",2019-07-01
5676,"BROKEN BOW CARE AND REHABILITATION CENTER, LLC",285120,224 EAST SOUTH E STREET,BROKEN BOW,NE,68822,2016-10-11,314,D,1,0,EZTD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on interviews and record review, the facility failed to provide the services to promote healing of a pressure sore for Resident 402. This affected 1 of 2 sampled residents. The facility identified a census of 32 at the time of survey. Findings are: Review of Resident 402's Quarterly MDS (Minimum Data Set-a comprehensive resident assessment tool used for developing a resident's care plan) dated 9/15/2016 revealed an admission date of [DATE] and that Resident 402 had a Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed; may also present as an intact or open/ruptured blister) pressure ulcer. Interview with the DON (Director of Nursing) on 10/11/2016 at 10:05 AM revealed that Resident 402 had a pressure ulcer on the right lateral foot. Review of Resident 402's pressure ulcer documentation dated 10/3/2016 revealed an area present to the right lateral foot measuring 1.2 cm (centimeters) by 0.8 cm. Review of Resident 402's Order Review Report dated (MONTH) 11, (YEAR) revealed an order for [REDACTED]. Review of Resident 402's Treatment Administration Record for 10/1/2016 to 10/31/2016 revealed no documentation the dressing change had been completed on (MONTH) 2nd or (MONTH) 5th and no documentation the weekly skin review had been completed on Saturday (MONTH) 8th. Interview with the DON on 10/11/2016 at 3:05 PM confirmed there was no documentation the dressing changes or skin assessment had been completed as ordered and there should have been.",2019-10-01
2999,OMAHA NURSING AND REHABILITATION CENTER,285240,4835 SOUTH 49TH STREET,OMAHA,NE,68117,2018-04-23,686,G,1,0,VOD611,"**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 staff failed to evaluate nutritional requirements for pressure ulcer healing, failed to evaluate casual factors for the development of a pressure ulcer and failed to evaluate the condition of a pressure ulcer for 1(Resident 3) of 3 sampled residents. The facility staff identified a census of 63. Findings are: [NAME] Record review of a Physicians Order Sheet and Progress Notes (POSPN) form revealed the facility staff had requested the practitioner evaluate a blister that was forming on Resident 3's left heel. According to the POSPN dated 2-09-2018, the practitioner ordered Prevalon (type of pressure reliving intervention) boots when in bed, a treatment to the left heel blister and for the facility to have the Wound Physician see Resident 3. Record review of a Mobile Wound Solutions (MWS) assessment dated [DATE] for Resident 3 revealed the practitioner had assessed Resident 3 with a stage 2 (Stage 2 Pressure Ulcer: Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) pressure ulcer to the left heel that measured 4.50 centimeters (cm) by 3.70 cm with depth being 0.10 cm. Record review of Resident 3's MWS assessment dated [DATE] revealed the practitioner assessed Resident 3 with a stage 2 pressure ulcer to the left heel that measured 6.20 cm by 6.0 cm and 0.10 depth. The left heel pressure ulcer remained at a stage 2 pressure ulcer level. Record review of Resident 3's MWS assessment dated [DATE] revealed Resident 3 was assessed with [REDACTED]. Observation on 4-23-2018 at 9:58 AM revealed Registered Nurse (RN) A obtained the required treatment supplies for Resident 3's left heel. Observation of the pressure ulcer revealed it was approximately 6.2 cm oblong, with black tissue in the center. No drainage was noted. Record review of Resident 3's medical record revealed there was no evidence the facility staff had evaluated Resident 3's nutritional requirements for wound healing for the pressure ulcer to the left heel. On 4-23-2018 at 2:57 PM an interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed a nutritional evaluation had not been completed for pressure ulcer healing and reported a nutritional evaluation for pressure ulcer healing should have been completed. B. Record review of a Skin Ulcer Non-Pressure Weekly sheet dated 3-22-2018 revealed the facility staff had evaluated Resident 3 with a pin point open area to the right buttocks. Review of Resident 3's record revealed there was no evidence the facility had monitored the wound to the right buttock. Record review of Resident 3's progress notes dated 4-16-2018 and 4-22-2018 revealed Resident 3 had a pressure ulcer to the right buttocks. Further review of Resident 3's medical record revealed there was no evidence the facility had evaluated the condition of the right buttocks that included the size, the depth, and if there was drainage from the pressure ulcer or, how Resident 3 developed the pressure ulcer. Observation on 4-23-2018 at 2:15 PM of the pressure ulcer to the right buttocks with the DON and RN A revealed the DON removed a dressing to Resident 3's right buttocks revealing a quarter sized area with whitish tissue in the center of the pressure ulcer. On 4-23-2018 at 2:25 PM an interview was conducted with the DON. The DON confirmed the area to Resident 3's buttocks was pressure and was unstageable. Record review of the facility Policy and Procedure for the Care and treatment of [REDACTED]. -Policy: -A resident having a pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. -Procedures: -Assessment of the ulcer: -Type, Stage, Characteristics, Progress towards healing or potential complications, Infection and treatment. -3. Treatment: -Nutrition and Hydration management.",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
1364,LIFE CARE CENTER OF ELKHORN,285134,20275 HOPPER STREET,ELKHORN,NE,68022,2019-02-19,684,D,1,0,2BLY11,"**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 staff failed to obtain an treatment order for a heel wound for 1(Resident 5) of 3 sampled residents. The facility staff identified a census of 105. Findings are: Record review of a Weekly Skin Integrity Data Collection (WSIDC) sheet dated 2-7-19 revealed Resident 5 was evaluated with having a 0.25 centimeter (cm) area to the right heel. Review of Resident 5's medical record revealed there was no evidence the facility staff had obtained an order for [REDACTED]. Observation on 2-11-19 at 2:28 PM with Licensed Practical Nurse (LPN) F of Resident 5's right heel revealed an open area that measured approximately 0.3 round appearing area to Resident 5's right heel. On 2-11-19 at 4:07 PM a interview was conducted with LPN F. During the interview LPN F reported (gender) was the facility wound nurse. LPN F confirmed Resident 5 had an open area and did not have a treatment for [REDACTED].",2020-09-01
2986,OMAHA NURSING AND REHABILITATION CENTER,285240,4835 SOUTH 49TH STREET,OMAHA,NE,68117,2019-01-02,686,D,1,0,UQIO11,"**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 staff failed to monitor a pressure area for 1 (Resident 40) of 3 sampled residents. The facility staff identified a census of 58. Findings are: Record review of Resident 40's Comprehensive Care Plan (CCP) dated 3-15-2018 revealed Resident 40 had a stage 3 (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar (dead tissue) may be visible but does not obscure the depth of tissue loss) to the left heel and an unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). Record review of a LN (Licensed Nurse) Skin Pressure Weekly (LNSPW) sheet dated 12-26-2018 revealed the size of the left heel pressure area measured 2.2 centimeters (cm) by 1.9 cm with a depth of 0.2 cm. Observation on 12-31-2018 at 12:18 PM of the treatment of [REDACTED]. Further observations of the left heel revealed a dark black looking area that was area oblong looking position more on the left heel. Record review of Resident 40's Physical Therapy Treatment Encounter Notes(PTTEN) dated 11-29-2018 revealed Physical Therapist (PT) C identified Resident 40 with a stage 3 pressure on the left medial heel and an unstageable pressure ulcer below the left heel pressure area. Record review of Resident 40's PTTEN dated 12-12-2018 revealed PT C identified Resident 40 with a stage 3 pressure area on the left medial heel and an unstageable pressure ulcer below the left heel pressure area. Record review of Resident 40's PTTEN dated 12-17-2018 revealed PT C identified Resident 40 with a stage 3 pressure area on the left medial heel and an unstageable pressure ulcer below the left heel pressure area. Record review of Resident 40's PTTEN dated 12-19-2018 revealed PT C identified Resident 40 with a stage 3 pressure area on the left medial heel and an unstageable pressure ulcer below the left heel pressure area. Record review of Resident 40's PTTEN dated 12-24-2018 revealed PT C identified Resident 40 with a stage 3 pressure area on the left medial heel and an unstageable pressure ulcer below the left heel pressure area. Record review of Resident 40's PTTEN dated 12-26-2018 revealed PT C identified Resident 40 with a stage 3 pressure area on the left medial heel and an unstageable pressure ulcer below the left heel pressure area. Review of Resident 40's medical record that included CCP, Treatment Administration Record (TAR) and LNSPW revealed there was not any evidence there was ongoing monitoring of the new pressure ulcer. On 12-31-2018 at 3:55 PM an interview was conducted with PT C. During the interview review PT C reported Resident 40 had developed additional pressure ulcer to the left heel and confirmed no measurement had been taken of the new pressure ulcer. On 1-02-2019 at 8:28 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported not being aware of an additional pressure ulcer to Resident 40's left heel and was not able to provide monitoring of the new pressure ulcer. On 1-02-2019 at 11:21 AM a follow up interview was conducted with the DON. During the interview the DON confirmed Resident 40 had developed additional pressure ulcer to the left heel.",2020-09-01
4435,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-08-31,314,G,1,0,I5FW11,"**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 staff failed to obtain treatment orders for a pressure ulcer, failed to identify the development of a pressure ulcer, and failed to implement interventions to prevent pressure ulcer development for 1 (Resident 4) of 4 sampled residents. The facility staff identified a census of 60. Findings are: [NAME] Record review of a Admission Record sheet printed on 8-31-2017 revealed Resident 4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a fax sheet dated 7-15-2017 revealed Resident 4's physician was notified Resident 4 had developed an open area to the left heel that measured 0.9 centimeters (cm) by 0.3 cm and requested a treatment. Further review of the fax sheet revealed Resident 4's physician responded on 7-24-2017, a span of 9 days with an order for [REDACTED].>Record review of Resident 4's Skin Grid for Pressure Skin Impairments (SGPSI) dated 7-15-2017 revealed the measurements of the pressure ulcer was 0.9 cm by 0.3 cm with a depth of less than 0.1 cm. The pressure ulcer had a small amount of drainage with slough (dead tissue). Record review of Resident 4's SGPSI sheet dated 7-19-2017 revealed the pressure ulcer measured 0.9 cm by 0.2 cm with a depth of 0.1 cm. No further evaluation was identified on the SGPSI form. Record review of Resident 4's SGPSI sheet dated 7-26-2017 revealed the pressure ulcer measured 1 cm by 0.6 cm with slough remaining in the pressure ulcer. Record review of Resident 4's SGPSI dated 8-2-2017 revealed the pressure ulcer measured 1 cm by 0.6 cm by 0.1 cm. No further evaluation of the pressure ulcer was identified on the SGPSI. Record review of Resident 4's SGPSI dated 8-10-2017 revealed the pressure ulcer measured 1.3 cm by 1.5 cm, drainage was identified as scant with red and white slough. Record review of Resident 4's Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed the treatment to the left heel was started on 7-24-2017. Record review of Resident 4's Comprehensive Care Plan (CCP) dated 7-20-2017 identified Resident 4 had an unstageable left heel wound and that the facility was to follow up with Mobile Wounds Solution as ordered. Record review of a Mobile Wound Solutions assessment sheet dated 8-18-2017 revealed the practitioner assessed the left heel as an unstageable pressure ulcer and order a treatment to the left heel. Observation on 8-31-2017 at 9:30 AM of the pressure ulcer treatment to the left heel with Registered Nurse (RN) A and Licensed Practical Nurse (LPN) B revealed RN A removed the dressing covering the left heel pressure ulcer. Observation of the heel ulcer revealed the area measured approximately 0.8 cm roundish. The wound bed has some whitish slough tissue. RN A competed the treatment as ordered to the left heel. Observation of Resident 4's right foot with RN A and LPN B revealed a calloused area to the right heel that had tissue that was lose from the foot. RN A measured the heel ulcer and reported the measurements were 1.5 cm by 2 cm's. Review of Resident 4's record revealed there was no evidence the facility had identified and were monitoring the area to the right heel. On 8-31-2017 at 9:20 AM, an interview was conducted with the Director of Nursing (DON). During the interview, review of the fax sheet dated 7-15-2017 and the SGPSI sheet with the date of 7-15-2017 through 8-10-2017 was completed. The DON confirmed the facility did not follow up on the fax sheet and should have and further confirmed Resident 4 had gone 9 days without an order to treat the left heel ulcer. The DON reported that faxes needed to be followed up with if there have been no response back within 3 days. The DON confirmed the weekly evaluation of the left heel was not completed and confirmed the condition of the left heel pressure sore had declined.",2020-06-01
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
2922,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2018-07-02,686,D,1,0,EO8U11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on record review and interview; the facility staff failed to monitor and obtain pressure ulcer treatment for 1 (Resident 103) of 3 sampled residents. The facility staff identified a census of 54. Findings are: Record review of Resident 103's Comprehensive Care Plan (CCP) dated 6-22-2018 revealed staff had identified Resident 103 had a PI (pressure issue) to the left buttocks related to the air mattress not working. Record review of a After Visit Summary sheet dated 6-25-2018 revealed Resident 103's physician ordered a treatment for [REDACTED]. Record review of a fax sheet dated 6-26-2018 revealed the facility staff requested clarification of the pressure ulcer treatment for [REDACTED]. Observation on 6-28-2018 at 9:45 AM of pressure ulcer care revealed Licensed Practical Nurse (LPN) A and RN F gathered the required supplies for the treatment. Resident 103 was positioned onto the left laying position. LPN A removed a dressing to the and right buttocks areas. RN F measured the right buttocks indicating the size of the pressure ulcer was 0.7 centimeters (cm) by 0.5 cm and the left was measured as 0.2 cm by 0.3 cm. The pressure areas wound beds were red with no indications of necrotic tissue. LPN A after cleaning the pressure ulcer applied the dressing as ordered. Record review of Resident 103's Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed the ordered pressure ulcer treatment started on 6-27-2018. Review of Resident 103's record revealed not evidence the facility staff had completed an evaluation of the pressure ulcers on 6-22-2018 that included measurement. On 6-28-2018 at 2:08 PM an interview was conducted with Registered Nurse (RN) F. During the interview RN F reported the facility staff should have requested pressure ulcer treatment within 24 hours.,2020-09-01
5334,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-01-31,314,D,1,0,BKZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on record review, observations and interviews; the facility failed to ensure interventions were in place to promote healing of pressure ulcers for 1 of 3 residents (Resident 79) sampled. The facility census was 69. Findings are: Review of Resident 79's face sheet revealed Resident 79 admitted to the facility on [DATE] with diagnosis' of Obesity, Diabetes, and [MEDICAL CONDITION] (an infection to the tissues of the body). An interview with the Director of Nursing on 01/23/2017 revealed that Resident 79 had 2 unstageable Pressure ulcers to both heels and 2 stage II Pressure ulcers to Resident 79's bottom and that Resident 79 goes to the wound clinic every other week for assessment and treatments. Review of Resident 79's Progress notes revealed that on 01/23/2017 the left heel measured 8.5 cm x 11 cm and the right heel measured 5.5 cm x 3.6 cm and resident refused to have staff assess ulcers to Resident 79's bottom. Resident 79 was to see the wound clinic on 01/24/2017. Review of dietary progress note dated 12/14/2016 revealed that the resident was on double protein portions at meals to assist with wound healing. Review of the Care Plan for Resident 79 last updated on 01/23/2017 revealed that Resident 79 had a potential nutritional problem related to pressure wounds with an intervention of double meat portions. The care plan also stated that Resident 79 had actual pressure ulcers of: unstageable ulcers to left and right heels, and stage II pressure ulcers to left and right gluteal and a stage I to coccyx with interventions to serve diet as ordered, monitor intake and record. An observation made on 01/25/2017 at 12:20 PM of Resident 79 eating lunch revealed, Resident 79 was served a taco salad and corn bread and mandarin oranges. Resident 79 took 2 bites of the salad and pushed away from the table and stated I'm done it tastes like cow[***] Two aides were observed in the area and both laughed at this statement but did not offer Resident 79 anything else to eat. Review of Resident 79's dietary meal slip (no date) on Resident 79's lunch tray on 01/25/2017 revealed that Resident 79 was to get double protein at meals and disliked lettuce salads. An observation made on 01/26/2017 at 8:28 AM of Resident 79 eating breakfast revealed Resident 79 was served one hardboiled egg, a piece of toast with butter and jelly, cold cereal and hot cereal. Resident 79 ate all but the hot cereal. An interview conducted on 01/26/2017 at 9 AM with Cook L revealed that the cereal had no protein added to it as the facility did not serve any type of super cereal and confirmed that Resident 79 only got one egg for breakfast. An interview conducted on 01/26/2017 at 10:24 AM with the Registered Dietician (RD) confirmed that Resident 79 was to have double protein at meals for wound healing. The RD reported that Resident 79 should have gotten served 2 eggs at breakfast. The RD confirmed that Resident 79's diet slip stated Resident 79 did not like lettuce salads and Resident 79 should not have been served the taco salad. The RD stated that when staff noticed Resident 79 did not like what was served then something else should have been offered. The RD reported that nutrition was very important to Resident 79's would healing since the resident has multiple pressure ulcers.",2020-01-01
4434,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-08-31,309,D,1,0,I5FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2c Based on observation, record review and interview; the facility staff failed to identify, monitor and obtain a treatment for [REDACTED]. The facility staff identified a census of 60. Findings are: Record review of an Admission Record sheet printed on 8-31-2017 revealed Resident 4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Observation of Resident 4's right foot on 8-31-2017 at 9:30 AM with RN (Registered Nurse) A and LPN (Licensed Practical Nurse) B revealed on the outside of the right great toe was a black area. RN A evaluated the skin and reported the blacken area was hard to touch and measured 1.3 centimeters (cm) by 1.4 cm. In an interview on 8-31-2017 at 9:30 AM, RN A reported not being aware of the areas to the right foot and no treatment was being done to the area. LPN B reported not being aware of the blacken area to Resident 4's right great toe and reported not sure how it occurred. Record review of Resident 4's medical record that included Treatment Administration Record, Progress Notes and skin assessment sheets revealed there was no evidence the facility had identified Resident 4's right Great toe had a black area or that a treatment was being provided to the wound area.",2020-06-01
2915,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2017-05-09,315,D,1,0,JLWU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2c Based on observation, record review and interview; the facility staff failed to implement a toileting program that would help to keep the resident from being incontinent for 1 (Resident 2) of 3 sampled residents. The facility staff identified a census of 60. Record review of an Admission Record sheet printed on 12-01-2015 revealed Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) Record review of a Bowel and Bladder Evaluation form dated 2-09-2017 revealed the facility staff had assessed the resident as a 15 on the form. According to the information on the Bowel and Bladder form, a score of 15 indicated the resident was an unlikely candidate for a bowel and bladder re-training program. Record review of Resident 2's medical record revealed there was no evidence the facility staff had attempted to identify when Resident 2 was incontinent and what interventions were to be utilized in an attempt to manage Resident 2's incontinence. Record review of Resident 2's Comprehensive Care Plan (CCP) dated 8-31-2015 revealed the facility staff had identified Resident 2 was frequently incontinent of bowel and bladder. The goal for Resident 2 was to remain free of complications associated with incontinence. Interventions identified on the CCP included assist Resident 2 with toileting needs at routine and as needed. The CCP did not identify what routine intervals were for Resident 2. Observation with the Director of Nursing (DON) on 5-08-2017 at 1:10 PM revealed Nursing Assistant (NA) A and NA B assisted the resident into bed using a mechanical lift from Resident 2's wheelchair. Observation of Resident 2's wheelchair once Resident 2 was lifted into bed revealed the wheel chair seat was wet. NA A and NA B positioned Resident 2 onto the right laying position. Observation at this time revealed Resident 2's pants were wet. Both NA A and NA B stated yes when asked if Resident 2's pants were wet. Further observation revealed Resident 2 wore an adult brief that was saturated when NA B removed the brief. On 5-08-2017 at 1:25 PM an interview was conducted with NA B. During the interview NA B reported Resident 2 was had been changed just before lunch. NA B reported Resident 2 was always wet and goes a lot. On 5-08-2017 at 3:30 PM an interview was conducted with the DON. The DON confirmed Resident 2 had been incontinent through clothing and onto the wheelchair seat. The DON confirmed Resident 2 did not have a toileting plan to manage Resident 2's incontinence.",2020-09-01
1056,PRESTIGE CARE CENTER OF PLATTSMOUTH,285104,602 SOUTH 18TH STREET,PLATTSMOUTH,NE,68048,2017-06-07,309,D,1,0,MSQJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2c Based on observation, record review and interview; the facility staff failed to monitor a skin wound for 1 (Resident 3) of 3 residents reviewed. The facility staff identified a census of 87. Findings are: Record review of Resident 3's Comprehensive Care Plan (CCP) printed on 5-18-2017 revealed Resident 3 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of a treatment to Resident 3's buttocks by Registered Nurse (RN) A on 5-11-2017 at 11:00 AM revealed RN A completed the wound care as ordered to Resident buttocks. During the observation of the buttock treatment Resident 3 was observed to have a Band-Aid covering the left knee. The Band-Aid stuck to RN A's elbow as RN A completed the buttocks treatment. Observation of the left knee area revealed an abrasion that measured approximately 3 centimeters roundish. The wound abrasion had a small amount of drainage with a scab like covering. Review of Resident 3's medical record revealed there was not evidence the facility staff had evaluated the left knee wound or was monitoring the healing of the wound. An interview was conducted with RN A on 5-11-2017 at 11:45 AM. During the interview RN A reported that the area to the left knee was new and had not been aware of the wound. RN A reported there was no wound tracking for the wound to the left knee and there should have been monitoring. Review of a Weekly Skin Check sheet dated 5-11-2017 revealed the abrasion had occurred on 5-08-2017.",2020-09-01
3576,BRIGHTON GARDENS OF OMAHA,285274,9220 WESTERN AVENUE,OMAHA,NE,68114,2019-06-24,684,G,1,0,Q72M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2c Based on observation, record review and interview; the facility staff failed to re-evaluate interventions to prevent skin breakdown for 1 (Resident 35) of 3 sampled residents. The facility staff identified a census of 30. The findings are: Observation of wound care on 6/24/19 at 11:43 AM revealed open areas to bilateral buttocks. Record review of Resident 35's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 3/25/2019 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) was a 10. According to the MDS Manuel, a score of 8-12 indicates moderately impaired cognition. -Required extensive assistance with bed mobility, transfers, and toileting. -Frequently incontinent of urine and always incontinent of bowel with no toileting program. -No skin issues identified. Record Review of the Tissue Analytic documentation for Resident 35 dated 6/12/19 revealed left buttocks wound with a [DIAGNOSES REDACTED]. Record review of the Tissue Analytic documentation for Resident 35 dated 6/19/19 revealed left buttocks wound with a [DIAGNOSES REDACTED]. Record review of the facility weekly wound evaluation for Resident 35 dated 6/12/19 revealed left buttocks wound documented as MASD and Trauma as deteriorated since last assessment. Review of the facility weekly wound evaluation for Resident 35 dated 6/19/19 revealed left buttock has deteriorated since last assessment. Record review of Resident 35's CCP (Comprehensive Care Plan) with an original date of 9/27/16 and revised on 4/24/19 revealed a focus of MASD to bilateral buttocks with a goal of maintain clean and intact skin with no further skin breakdown. Record review of Resident 35's medical record revealed there was no evidence that the facility staff had evaluated interventions to minimize moisture that was the cause of MASD. Interview conducted on 6/24/19 at 1:45 PM with Director of Clinical Service confirmed there was no evaluation for interventions to minimize moisture.",2020-09-01
5593,LIFE CARE CENTER OF OMAHA,285137,6032 VILLE DE SANTE DRIVE,OMAHA,NE,68104,2016-11-01,315,D,1,0,9J9911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 (1) Based upon observation, interview and record review; the facility failed to ensure catheter care was performed according to facility protocol for 1 of 3 residents sampled (Resident 4). The facility staff identified a census of 94. Findings are: [NAME] Record review of Resident 4's undated face sheet revealed that Resident 4 was admitted to the facility on [DATE] for some of the following medical Diagnoses: [REDACTED].); [MEDICAL CONDITION], unspecified; Shortness of breath. An observation of pericare/catheter care for Resident 4 on 10/31/2016 at 10:43 AM by Nursing Assistant A (NA A) and Nursing Assistant B (NA B). NA A washed hands, got the wipes, towels and bags prepared, applied gloves, then, NA A pulled up and removed the top sheet, the Foley bag was attached to the top sheet and NA A unclipped the bag from sheet. NA A then set the Foley bag on the edge of the bed and the bag then fell on the floor into a puddle of fluid on the floor. At 10:46 AM, after NA B washed hands and applied gloves, NA B picked up the Foley bag from the floor, urine leaked out on to the floor and bed. NA B closed the bag's drain, then got paper towels from the bathroom and dried the floor. NA B then preformed hand hygiene and reapplied gloves. NA B then put the Foley bag back on the floor. NA A then began to do pericare to the front using pre-moistened wipes. NA A did not spread Resident's 4 legs apart enough to access the resident's labia and the catheter's insertion site. NA A did clean the tubing from skin folds to tube attachment of the Foley bag. Gloves were changed and then NA B picked up the Foley bag from the floor by the tubing and placed it on the bed by the resident's feet. Both NAs then rolled the resident to the left side and cleaned the resident's buttocks. Upon finishing cleaning the buttocks, they rolled the resident back to their back. The Foley bag was then clipped to the sheet on the bed. An interview with Resident 4 on 10/31/2016 at 11:07 AM, confirmed that (gender) felt the aide did not clean very well and confirmed that Resident's 4 legs were not pulled apart enough to get down to the resident's labia and the catheter's insertion site. An interview with NA A on 10/31/2016 at 11:39 AM, confirmed that NA A did not clean the resident down to the Foley catheter insertion site and the Foley drainage bag was on the floor without a dignity bag present and that there should be a dignity bag present. An interview with NA B on 10/31/2016 at 11:55 AM also confirmed the above observations and stated that NA A should have cleaned down to the insertion site and that the Foley drainage bag should not have been on the floor and that there was no dignity bag present and there should be one present. An interview with the Director of Nursing (DON) on 10/31/2016 at 12:22 PM, confirmed that the expectation is that the Foley tubing is to be cleaned from the insertion site and that the insertion site is to be cleaned as well. DON also confirmed that a dignity bag is to be used at all times and that the Foley bag should never be on the floor. A record review of the undated facility policy Personal Hygiene Care for the Female Resident revealed the following under the section Procedural Steps bullet 16-NOTE: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. A record review of the undated facility policy Daily Catheter Care revealed the following under the section Key Procedural Points bullet 14-Make sure the catheter tubing and drainage bag are kept off the floor.",2019-11-01
5855,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2016-08-10,315,D,1,0,142711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on observation, record review and interview; the facility staff failed to complete perineal care in a manor to prevent Urinary Tract Infection [MEDICAL CONDITION] for 1 resident (Resident 1). The facility staff identified a census of 164. Findings are: A. Record review of an undated Resident Face Sheet revealed Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 8-05-2016 revealed the facility staff assessed the following about the resident: -Short and long term memory problem with severely impaired cognition. -Required total assistance with bed mobility, transfers, locomotion, dressing, eating, personal hygiene. -Required extensive assistance with toilet use. -Always incontinent of bowel and bladder. -Had indicators of pain or possible pain with possible pain observed 3 to 4 times out of 5 days. -Other [DIAGNOSES REDACTED]. Observation on 8-09-2016 at 7:56 AM of personal care revealed Nursing Assistant (NA) E and NA G washed hands and donned gloves. Resident 1 was observed to have a splinting device to the right leg. NA E and NA G unfastened the adult briefs Resident 1 was wearing. NA G using a white washcloth wiped the resident's groin folds revealing brown stains on the wash cloth. NA G without glove change and handwashing, obtained another wash cloth and wiped down the vaginal area. Resident 1 was then positioned onto the left laying position. NA G without changing the soiled gloves cleansed in between each buttock. Further observation revealed Resident 1's buttocks were not cleansed. NA G without changing the soiled gloves obtained a clean adult brief and placed it onto Resident 1. An interview with NA G was conducted on 8-09-2016 at 10:13 AM. During the interview, NA G confirmed Resident 1's buttocks had not been cleansed and the soiled gloves had not been changed and should have been. Record review of the facility Perineal Care Policy dated 12-2006 revealed the following: -Procedure: -15. Lather wash cloth and wash rectal area and buttocks if using soap and water, otherwise use peri-wash.",2019-08-01
4436,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-08-31,315,D,1,0,I5FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on observation, record review and interview; the facility staff failed to ensure incontinence cares were completed for 1 (Resident 4) and failed to completed catheter care for 1 (Resident 2) of 2 sampled residents. The facility staff identified a census of 60. Findings are: [NAME] Record review of an Admission Record sheet printed on 8-31-2017 revealed Resident 4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 4's Comprehensive Care Plan (CCP) dated 3-15-2017 revealed Resident 4 was incontinent of bladder. Observation on 8-30-2017 at 1:25 PM of personal care revealed Nursing Assistant (NA) C and NA D transferred Resident 4 from a wheelchair to the bed using a mechanical lift. NA C and NA D removed Resident 4's pants and unfastened an adult brief. NA C, using a cleansing wipe, cleaned the groin folds and pubic area. NA C reported Resident 4 was incontinent of urine. Resident 4 was positioned to the right laying position and NA C applied barrier cream. Resident 4's buttocks area was not cleansed from being incontinent of bladder. Resident 4 was placed onto the left laying position and addition barrier cream was applied by NA D. On 8-30-2017 at 1:55 PM an interview was conducted with NA C. During the interview, NA C confirmed Resident 4's buttocks area had not been cleaned after Resident 4 was incontinent. B. Record review of an Admission Record sheet printed on 4-6-2016 revealed Resident 2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 2's CCP revised on 10-23-2016 revealed Resident 2 had an indwelling catheter (tube placed into bladder to drain urine). Observation on 8-30-2017 at 11:25 AM of personal cares revealed NA C and NA D unfastened an adult brief and position Resident 2 onto the left side revealing Resident 2 was incontinent of bowel. NA C, using a cleansing wipe, cleansed Resident 4's buttocks. Resident 4 was position onto the right laying position and NA D, using a cleansing wipe, completed the cleansing of Resident 2's buttocks and applied barrier cream to the buttock. NA C and NA D obtained a clean adult brief and applied it to Resident 2. During the observation, catheter care was not completed for Resident 2. On 8-30-2017 at 1:50 PM an interview was conducted with NA C and NA D. During the interview, NA C and NA D confirmed catheter care was not completed for Resident 2. C. Record review of the facility Policy and Procedure for Perineal Care revised on 4-2013 revealed the following information: -Purpose: -To promote cleanliness and prevent infection. -Procedure: -#16. Position resident to expose, clean the bottom of the scrotum and the anal area.",2020-06-01
5079,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2017-02-22,315,D,1,0,KLLA11,"**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 provide care and treatment for [REDACTED]. This affected 1 of 3 sampled residents. The facility identified a census of 25 at the time of survey. Findings are: Review of Resident 5's Admission Record revealed an admission date of [DATE]. Review of Resident 5's physician's orders [REDACTED]. Review of Resident 5's progress notes dated 2/7/2017 revealed Resident 5 had a catheter in place. Review of Resident 5's care plan dated 1/26/2017 revealed no documentation of interventions to provide care and treatment for [REDACTED]. Review of Resident 5's Treatment Administration Record for (MONTH) (YEAR) revealed orders for catheter care every shift and monitor Foley catheter output every shift that had been discontinued on 2/4/2017. There was no documentation of catheter care and monitoring of the catheter output being provided after the catheter was reinserted on 2/6/2017. Interview with the DON (Director of Nursing) on 2/22/2017 at 2:53 PM confirmed Resident 5 had a catheter in place. The DON revealed the catheter had been discontinued on 2/4/2017 and reinserted on 2/6/2017. The DON revealed that catheter cares and monitoring were not initiated after the catheter was reinserted on 2/6/2017. The DON also confirmed there were no interventions to manage the catheter on Resident 5's care plan. The DON confirmed that staff should have implemented interventions to manage the catheter.",2020-02-01
1366,LIFE CARE CENTER OF ELKHORN,285134,20275 HOPPER STREET,ELKHORN,NE,68022,2019-02-19,690,D,1,0,2BLY11,"**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 a toileting program for 1 (Resident 9) of 3 sampled residents. The facility staff identified a census of 105. Findings are: Record review of a Physician order [REDACTED]. Record review of Resident 9's Minimum Data Set (Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 11-26-18 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) was a 12. According to the MDS Manuel, a score 8 to 12 indicates moderately impaired cognition. -Required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. -Frequently in continent of bowel and bladder with no toileting program. On 2-12-19 at 1:30 PM a confidential interview was completed. During the interview it was reported that Resident 9 had not been toileted several times. Record review of Resident 9's medical record revealed there was not evidence the facility staff had evaluated Resident 9 for a toileting program. On 2-12-2019 an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed Resident 9 had not been evaluated for a toileting program.",2020-09-01
5685,"PREMIER ESTATES OF KENESAW, LLC",285166,"P O BOX 10, 100 WEST ELM AVENUE",KENESAW,NE,68956,2016-10-05,315,D,1,0,ZLX211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(1) Based on observation, interviews, and record review; the facility staff failed to maintain Resident 2's catheter (a tube inserted into the bladder to drain urine) to prevent potential infection and injury. This affected 1 of 3 sampled residents. The facility identified a census of 46 at the time of survey. Findings are: Review of Resident 2's face sheet revealed an admission date of [DATE]. Observation of Resident 2 on 10/5/2016 at 10:11 AM revealed Resident 2's catheter drainage bag hanging on the bed rail which was in the elevated position at the top 1/3 of the bed. This caused urine to pool and drain back towards the bladder. Observation of Resident 2 on 10/5/2016 at 1:07 PM revealed the catheter drainage bag was hanging on the bed rail. Interview with the DON (Director of Nursing) on 10/5/2016 at 2:21 PM revealed the catheter drainage bag was up too high and should not be hanging from the bed rail. Observation of Resident 2 on 10/5/2016 at 2:35 PM revealed Resident 2's catheter drainage bag was hanging on the bed rail and it was above the level of Resident 2's bladder. Observation of Resident 2's catheter care completed by RN-A (Registered Nurse) and RN-B on 10/5/2016 at 3:16 PM revealed RN-B hung the catheter drainage bag on the bed rail after completing catheter care. The bed rail was observed to be movable as RN-A lowered the rail prior to completing care then RN-B raised the rail after completing care prior to hanging the catheter drainage bag on it. Interview with RN-A on 10/5/2016 at 3:16 PM confirmed the catheter drainage bag was up too high and it should be hung from the bed frame, not the bed rail. Review of the facility policy Catheter Care dated 01/2013 revealed the following: Position catheter and drainage bag below the level of the resident/patient bladder to facilitate flow of urine. Hang drainage bag on the bed frame, not on the bed rails. Review of the Centers for Disease Control Healthcare Infection Control Practices Advisory Committee Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009 revealed the following: Keep the collection bag below the level of the bladder at all times.",2019-10-01
4905,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2017-12-21,690,D,1,0,7XZQ11,"**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 evaluate the current incontinence status for Residents 1 and 2, and to implement interventions to prevent further decline. The facility census was 37 and the total sample size was 8. Findings are: [NAME] Review of the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/6/17 revealed the following related to Resident 1: -severe cognitive impairment; -required extensive assistance with bed mobility, transfers, dressing and toileting, and total assistance with personal hygiene; -was always incontinent of bladder and occasionally incontinent of bowel; and -was currently on a toileting program (scheduled toileting, prompted voiding and/or bladder training) to manage urinary incontinence. Review of the most recent Bladder and Bowel Data Collection/Evaluations (tools used to assess the resident's incontinent status) dated 5/20/17 revealed the following: -a history of incontinence; -did not require prompting to void; -was able to transfer to a toilet or commode with the assistance of 2; -did not consistently communicate the urge to void or evacuate bowels; -was not able to consistently follow directions; -the urinary incontinence was likely irreversible; and -the resident was unable to participate in a toileting program. Review of Resident 1's current Care Plan dated 11/18/17 indicated the resident had bowel incontinence related to immobility, and bladder incontinence related to confusion and impaired mobility. Nursing interventions included the following: -check every 2 to 3 hours and as needed for incontinence; -assist with toileting as needed; and -toilet upon waking in the morning, before and after meals, and before bed. During observation on 12/20/17 from 11:15 AM until 11:25 AM, Nursing Assistant (NA)-D and NA-G provided incontinent care for Resident 1. The resident was lying in bed and the incontinent brief was soiled with urine. NA-D and NA-G provided perineal hygiene, applied a clean incontinent brief, and transferred Resident 1 to the wheelchair using the sit-to-stand mechanical lift. The resident was not offered the opportunity to go to the toilet and was wheeled to the front of the building to await the noon meal. During interview on 12/20/17 at 11:25 AM, NA-D indicated the following related to Resident 1's incontinence care: -toileted in the morning and usually right after meals; -when found to have a wet incontinent brief, they clean the resident but do not transfer to the toilet; and -resident tells them when has to use the bathroom. During interview on 12/20/17 at 2:52 PM, the Director of Nursing (DON) verified the expectation was that residents be taken to the toilet every 2 hours, and that simply checking and changing this resident was not adequate. B. Review of the MDS dated [DATE] revealed the following related to Resident 2: -cognitively intact; -required extensive to total assistance with bed mobility, transfers, dressing, toileting and personal hygiene; -was always incontinent of bladder and bowel; and -was not currently on a toileting program. Review of the most recent Bladder and Bowel Data Collection/Evaluations dated 6/12/17 revealed the following: -a history of incontinence; -required prompting to void; -was able to transfer to a toilet or commode with the assistance of 2; -was consistently able to communicate the urge to void or evacuate bowels; -was able to consistently follow directions; -the bladder and bowel incontinence were likely irreversible; and -was able to participate in a training program and/or bowel management program. Review of Resident 1's current Care Plan dated 12/5/17 indicated the resident had bowel and bladder incontinence related to impaired mobility. Nursing interventions included the following: -check every 2 to 3 hours and as needed for incontinence; -assist with toileting as needed; -observe pattern of incontinence and initiate toileting schedule as indicated; and -toilet upon waking in the morning, before and after meals, and at bedtime. During observation on 12/21/17 from 7:54 AM until 8:18 AM, NA-D and NA-F provided morning care for Resident 2. The resident was positioned on back in bed as incontinent care was provided. The resident's incontinent brief was wet with urine. The resident was observed to smear fecal material as perineal cleansing wipes were used to clean the buttocks area. A new incontinent brief was applied, and the resident was dressed, pivot transferred to the wheelchair, and pushed up to the sink to brush teeth. The resident was not offered the opportunity to go to the toilet. During interview on 12/1/17 at 8:18 AM, NA-F indicated the following related to Resident 2's incontinent care: -the resident would tell them if had to go to the toilet for a bowel movement; -the resident was checked and changed in bed because the incontinent brief was already wet; and -if the incontinent brief was found to be dry, the resident would be ambulated to the bathroom using the walker.",2020-03-01
4911,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2018-02-05,690,D,1,0,15YY11,"**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 failed to provide care and assistance to prevent urine incontinence for Residents 7 and 27. The sample size was 4 and the facility census was 36. Findings are: [NAME] Review of a Bladder Incontinence Data Collection/Evaluation dated 11/2/17 revealed Resident 7 did not have a history of urine incontinence and/or was not currently incontinent. Review of Resident 7's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/9/17 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the 11/9/17 MDS revealed the following related to Resident 7: -severe cognitive impairment; -required extensive assistance with toileting; -was occasionally incontinent of urine; and -a toileting program had not been attempted. Review of the MDS dated [DATE] revealed Resident 7 continued to require extensive assistance with toileting, was occasionally incontinent of urine and a toileting program had not been attempted. Review of Progress Notes dated 12/30/18 at 6:18 PM revealed a staff member witnessed Resident 7 exiting the bathroom independently. The resident's pants were around the resident's ankles and the staff member assisted the resident. There was no evidence Resident 7's urine incontinence was assessed and interventions to prevent further decline were not developed. Review of Progress Notes from 1/1/18 through 1/10/18 revealed Resident 7 remained non-complaint in waiting for assistance with transferring and toileting as evidenced by the following: -1/1/18 at 4:45 PM- .Not always compliant with wait for assist, takes self to the bathroom; -1/4/18 at 1:21 PM- .has been incontinent of bowel and bladder; -1/6/18 at 2:10 AM- .Reminded to ask for assistance and reoriented to call light. Pt. (patient) self transferred several times this shift .Up several times this evening wandering in halls .Limited assist of 1 with ADL's (activities of daily living) and toileting; and -1/10/18 at 6:38 PM-The resident was not always compliant with waiting for assistance and did not make needs known consistently. Review of a Bladder Incontinence Data Collection/Evaluation dated 1/11/18 revealed Resident 7 had a history of [REDACTED]. Documentation indicated the resident was not consistently able to communicate the urge to urinate and 2 assists were required to transfer the resident to the toilet. There was no evidence Resident 7 was assessed for a toileting program or a scheduled toileting plan. Review of Progress Notes dated 1/11/18 at 6:21 AM revealed Resident 7 was found lying on the floor with the left hip externally rotated. The resident was transported to the emergency room . Review of the facility Abuse Investigation Summary (an investigation regarding Resident 7's fall) dated 1/16/18 revealed the causal factor was the resident was incontinent of urine and fell when walking to the bathroom without assistance. Interview with the Director of Nurses on 2/5/18 at 12:10 PM confirmed Resident 7's urine incontinence was not assessed until 1/11/18 and there was no evidence interventions were developed in an attempt to prevent urine incontinence. B. Review of Resident 27's current undated Care Plan revealed the resident had bladder incontinence related to confusion and impaired mobility. Interventions included toileting Resident 27 upon waking in the morning, before and after meals, and before bed (approximately 8 times per day). Review of Resident 27's Task documentation dated 1/23/18 through 2/5/18 revealed documentation that the resident's toileting was completed only 1-2 times daily. Interview with Registered Nurse-G on 2/5/18 at 1:30 PM confirmed Resident 27 was on a toileting program and should have been taken to the bathroom upon waking in the morning, before and after meals, and before bed. Interview with Nursing Aassistant- B on 2/5/18 at 1:57 PM confirmed Resident 27 was not toileted prior to lunch on 2/5/18.",2020-03-01
3848,OLD MILL REHABILITATION (OMAHA TCU),285289,1131 PAPILLION PARKWAY,OMAHA,NE,68154,2018-08-08,675,D,1,0,56Q411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(5) Based on record review and interview; the facility staff failed to re-evaluate interventions and implement additional interventions for bowel care for 1 (Resident 2) of 1 sampled resident. Record review of Resident 2's Care Plan (CP) printed on 8-8-2018 revealed Resident 2 was at risk for constipation. Interventions included staff were to monitor medications for side effects of constipation, record bowel movements as needed. Record review of Resident 2's Bowel Monitoring Report (BMR) sheet for the month of (MONTH) (YEAR) revealed from 8-01-2018 to 8-07-2018 Resident 2 did not have a bowel movement (BM). On 8-08-2018 12:30 PM an interview was conducted with Resident 2. During the interview Resident 2 reported not having a BM for 8 days. Resident 2 reported the normal routine for a BM was daily. Record review of Resident 2's Medication Administration Record [REDACTED]. According to www.Drugs.com, both [MEDICATION NAME] and [MEDICATION NAME] have side effects of constipation. Further review of Resident 2's MAR for (MONTH) (YEAR) revealed Resident physician had ordered medications for bowel care that included [MEDICATION NAME] ( stool softer) suppository, Senna (type of medication was an laxative affect) tab as needed and Magnesium [MEDICATION NAME] ( commonly known as milk of magnesium) as needed. According to Resident 2's MAR for (MONTH) (YEAR) revealed Resident 2 had received the Senna tablet on 8-01-2018 and twice on 8-07-2018 with unknown effect or ineffective. Further review of Resident 2's MAR for (MONTH) (YEAR) revealed Resident 2 received Magnesium [MEDICATION NAME] on 8-02-2018 and on 8-07-2018, both with results identified as unknown. Record review of a undated Physicians Standing Orders sheet revealed the protocol for bowel management: -Milk of Magnesium 30 milliliters (ml) for no BM in 3 days. -[MEDICATION NAME] suppository if no BM in 4 days. -Fleets enema in 5 days and to notify the physician if greater then 5 days without a BM. Review of Resident 2's MAR for (MONTH) (YEAR) revealed the [MEDICATION NAME] suppository or fleets enema was not administered. Record review of Resident 2's medical record revealed there was not evidence the facility staff had evaluated the interventions used for bowel care or that the facility staff had re-evaluated the use of medications for bowel care for Resident 2. On 8-8-2018 at 3:20 PM an interview was conducted with the Director of Nursing (DON). During the interview, review of Resident 2 bowel care was reviewed with the DON. The DON confirmed Resident 2's bowel management plan had not been completed and re-evaluated for effectiveness.",2020-09-01
3654,RIDGEWOOD REHABILITATION & CARE CENTER,285279,624 PINEWOOD AVENUE,SEWARD,NE,68434,2018-06-05,690,D,1,1,RVGM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(6) Based on interviews, observation and record review; the facility failed to ensure a resident admitted with an indwelling Foley catheter (a tube inserted into the bladder for removal of urine) was assessed for the continued need of the catheter for Resident #66. This has the potential to affect one resident (Resident #66). The facility census was 73. Findings are: Review of an Admission Record revealed Resident #66's original admitted was 03/06/2018, another admission date of [DATE]. The resident had [DIAGNOSES REDACTED]. Review of records revealed that the resident did not have an indwelling Foley catheter on original admission of 03/06/2018. Review of the undated Summary of Care Document with a print stamp at the bottom dated 4/11/18, revealed Lines, Tubes and Drains Instructions, PEG, Urinary Catheter, maintain Foley for [MEDICAL CONDITION]. Review of a Resident Admission Note dated 3/6/2018 at 4:00 PM revealed Resident #66 was continent of bladder and continent of bowel. Review of an undated Summary of Care Document with a print stamp at the bottom dated 4/11/18, revealed a problem list that included Foley catheter in place dated 4/10/18. Review of Resident 66's Baseline Care Plan dated 4/11/18 revealed: Section C Bowel and Bladder 1. Urinary continence marked 0. always continent 2. Bowel continence marked 0. always continent 3. Constipation present marked 0 No 4. Bowel and bladder appliances a, Indwelling catheter (not marked) e. NONE THE ABOVE was selected. Nursing Note dated 4/18/2018 at 2:26 PM revealed that Hematuria (visible blood present in urine) was noted in the catheter following transfers, light yellow urine shortly following. No external injury noted to urethra. Review of the Bladder Assessment Form dated 4/18/18 revealed the resident had an indwelling Foley catheter that was expected to remain in for more than 14 days. The resident had a terminal illness or severe impairments, which made positioning or clothing changes uncomfortable. Care Plan completed with appropriate [DIAGNOSES REDACTED]. 1. Bowel and Bladder Summary for determining the current individualized toileting based on the comprehensive Bowel and Bladder Assessments, Resident was not appropriate for a toileting or retraining program due to an indwelling catheter in place. Review of the 'Medicare A/Skilled Nursing Note dated 05/10/2018 at 03:05 revealed the resident was found on the floor bedside the resident's bed Review of the ER (emergency room ) transfer record dated 5/10/18 revealed Hematuria after a fall. Review of physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of the resident's Care Plan dated 5/17/18 revealed Resident #66 had an UTI (urinary tract infection) present. On 05/31/18 at 03:10 PM interview with Staff C which included a review of an Admission Baseline Care Plan dated 4/11/18 showed the Indwelling Foley catheter box was not checked. Staff C said I did review and update the baseline care plan and care plan today. I asked for the [DIAGNOSES REDACTED]. When I faxed (Resident #66's) physician previously, physician [MEDICAL CONDITION] isn't really an appropriate [DIAGNOSES REDACTED]. Staff C said the physician was originally faxed on (MONTH) 11.",2020-09-01
2870,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2018-01-02,688,D,1,1,51KH11,"**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 staff failed to implement a specific Nursing Restorative Program (NRP) for 1 (Resident 3) of 1 sampled resident. The facility identified a census of 66. Findings are; Record review of Resident 3's Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) on completed on 10-03-2017 revealed the facility staff assessed the following about the resident: -BIMS was a 15. According to the MDS Manuel, a score of 13 to 15 indicates intact cognition. -Total dependence for bed mobility, transfers, dressing, eating, toilet use and personal hygiene with 2 plus people assisting with bed mobility, transfers, dressing and personal hygiene. -[DIAGNOSES REDACTED]. On 12-26-2017 at 5:04 AM a interview was conducted with Resident 3. During the interview Resident 3 reported (gender) was not receiving Range of Motion (ROM) exercise and was not able to use a standing frame ( A specialized device to provide support for standing). [NAME] Record review of Resident 3's Comprehensive Care Plan (CCP) dated 8-28-2017 revealed Resident 3 was to receive a NRP for active range of motion to upper and lower extremities for 15 repetitions for 3 to 5 days a week. In addition , the CCP contained information that Therapy had been working with staff and (Resident 3) to use standing frame. Record review of a Physical Therapy Evaluation and Plan of Treatment (PTEPT) sheet dated 11-02-2016 revealed the Restorative nursing aid will be compliant 100% with Passive Range of Motion (PROM) exercises of BLE (bilateral lower extremities) in seated and supine position to be able to maintain CLOF (current level of function) and prevent restriction of LE (lower extremities) ROM (Range Of Motion) joints. Record review of Resident 3's Restorative Nursing (RN) sheet dated from 11-19-2017 to 12-20-2017 revealed Resident 3 was receiving Active ROM. The RN sheet did not identify how many times the repetitions were to be preformed, did not identify what parts of the body were to have ROM services or how it was to be completed for the resident. Review of Resident 3 record revealed there was not evidence an actual NRP had been evaluated and implement. The facility staff after multiple request were not able to provide a NRP that identified how the program would be implemented and evaluated. On 12-27-2017 at 11:00 AM an interview was conducted with Restorative Assistant (RA) P. During the interview, RA P reported completing the NRP for Resident 3, 3 to 5 times a week. RA P reported ROM was completed to lower extremities. B. Record review of Resident 3's PTEPT sheet dated 10-25-2017 revealed the short term goal for Resident 3 was Resident 3 would tolerate upright standing in the standing frame for 30 minutes with out symptoms with the assistance of 2 people in order to improve standing tolerance and improve weight bearing through the joints to reduce the risk of contractures. Further review of the PTEPT sheet dated 10-25-2017 revealed the Long Term Goal was that Restorative and nursing staff would be able to demonstrate 100% compliancy with the slide board technique and be able to get Resident 3 on and off the standing frame. The PTEPR sheet contained information that it was Resident 3's goal to have nursing place Resident 3 into the standing frame regularly in order to get weight bearing through Lower Extremities (LE) joints and to get stretching of the LE muscles. Review of Resident 3's medical record revealed there was no evidence the facility staff had implemented a RNP for the use if the standing frame. On 12-27-2017 at 8:52 AM an interview was conducted with the Director of Nursing (DON). During the interview, confirmed there was not a NRP for the use of the standing frame.",2020-09-01
2947,RIDGECREST REHABILITATION CENTER,285239,3110 SCOTT CIRCLE,OMAHA,NE,68112,2018-01-23,744,E,1,0,L1D311,"**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 staff failed to provide specific resident centered activities for 4 (Resident 21, Resident 22, Resident 23 and Resident 24) of 4 residents with a [DIAGNOSES REDACTED]. The facility staff identified a census of 60. Findings are: [NAME] Record review of Resident 21's Comprehensive Care Plan (CCP) dated 11-20-2017 revealed Resident 21 lived in the MSU and had the [DIAGNOSES REDACTED]. Record review of a Preferences for Customary Routine and Activities (PCRA) sheet dated 8-02-2017 revealed it was important to Resident 21 to listen to music, be around animals, going outside for fresh air when the weather was good and somewhat important to do things with groups of people and to do favorite activities. Observation on 1-18-2018 at 11:55 AM revealed Resident 21 was in the dining room for lunch with Resident 21's tablemate's. Nursing Assistant (NA) H and NA B were in the dining room seated in chairs. Further observations revealed a TV was on and NA B and NA H did not encourage Resident 21 for an activity while waiting for lunch or engage Resident 21 in conversation. Observation on 1-08-2018 at 2:25 PM revealed Resident 21 was seated at a table and there were no activities being provided. NA H and NA B were observed to be talking about their personal business to one another and did not engage Resident 21 in a resident centered activity. Observation on 1-08-2018 at 6:15 PM revealed Resident 21 was in the dining room waiting for the evening meal. NA H and NA F were in the dining room, talking with each other and did not provide Resident 21 with a resident centered activity while waiting for supper or engage the resident in conversation. B. Record review of Resident 22's CCP dated 5-30-2017 revealed Resident 22 had [DIAGNOSES REDACTED]. Record review of a PCRA sheet dated 5-24-2017 revealed it was very important for Resident 22 to listen to music, be around animals, do things with groups of people, do favorite activities, get out when the weather was good and participate in religious services or practices. Observation on 1-08-2018 at 11:55 AM revealed Resident 22 was in the dining room for lunch with Resident 22's tablemates. Nursing Assistant (NA) H and NA B were in the dining room seated in chairs. Further observations revealed a TV was on and NA B and NA H did not encourage Resident 22 for an activity while waiting for lunch or engage Resident 22 in conversation. Observation on 1-08-2018 at 2:25 PM revealed Resident 22 was seated at a table and there were no activities being provided. NA H and NA B were observed to talking about their personal business to one another and did not engage Resident 22 in a resident centered activity. Observation on 1-08-2018 at 6:15 PM revealed Resident 22 was in the dining room waiting for the evening meal. NA H and NA F were in the dining room, talking with each other and did not provide Resident 22 with an activity while waiting for supper, engage the resident in conversation or encourage Resident 22 to interact with tablemates. C. Record review of an Observation Details sheet dated 7-20-2017 revealed Resident 23 preferred activities were to be in the day/activity room, 1 to 1's and liked activities in the afternoon. Record review of Resident 23's CCP dated 12-29-2017 revealed Resident 23 had the [DIAGNOSES REDACTED]. Observation on 1-08-2018 at 12:02 PM revealed Resident 23 was in the dining room waiting for the lunch meal. Nursing Assistant (NA) H and NA B were in the dining room seated in chairs. Further observations revealed Resident 23 would start to wander away from the tables and NA B would go to Resident 23, remind Resident 23 lunch was on its way and place Resident 23 back at the table. There was not a resident centered activity provided to Resident 23. Further observations revealed Resident 23 attempted to wheel self from the table with NA B or NA H moving Resident 23 back to the table. There was not any activity provided for Resident 23 while Resident 23 waited for lunch. Resident 23's lunch arrived at 12:20 PM on 1-08-2018. Observation on 1-08-2018 at 2:22 PM revealed Resident 23 was in the dining room seated in a wheelchair with locked brakes. No activities were being provided to Resident 23. Resident 23 was observed attempting to move forward in the locked wheelchair when NA F would unlock the wheelchair, pull Resident 23 backwards and re-lock the brakes on the wheelchair. NA F did not attempt to provide any activities or engage the resident in a positive conversation. Observation on 1-08-2018 at 6:15 PM revealed Resident 23 was in the dining room waiting for the evening meal. NA H and NA F were in the dining room, talking with each other and did not provide Resident 23 with a resident centered activity while waiting for supper. D. Observation on 1-08-2018 at 2:40 PM revealed Resident 24 was in the dining room seated at a table with the TV on. Resident 24 was not watching the TV and was staring around in the room. Further observations revealed NA B and NA H were observed to be talking about their personal business to one another and did not engage Resident 22 in the conversation. Observation on 1-08-2018 at 6:15 PM revealed Resident 24 was in the dining room, no activities were being provided for Resident 24. On 1-10-2018 at 1:05 PM an interview was conducted with the Activity Director (AD). During the interview the AD confirmed there were not resident centered activities being provided for Residents 21, 22, 23 and 24. An interview on 1-08-2018 at 7:05 PM was conducted with the Facility Administrator. During the interview the Administrator confirmed activities had not been provided during the observation. E. On 1-23-18 at 9:56 AM the facility Nurse Consultant (NC) confirmed there was no policy and procedure for activity services to be provided in the memory support unit. Cross reference to F839. The facility failed to ensure staff working in the MSU had completed ongoing training for dementia.",2020-09-01
2472,CROWELL MEMORIAL HOME,285210,245 SOUTH 22ND STREET,BLAIR,NE,68008,2018-07-11,744,D,1,0,NDLY11,"**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 staff failed to implement additional interventions to manage wandering behavior for 1 (Resident 2) of 1 resident reviewed. The facility staff identified a census of 67. Findings are: Record review of Resident 2's Comprehensive Care Plan (CCP) dated 4-4-2018 revealed Resident 2 admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further review of Resident 2's CCP dated 4-10-2018 revealed staff had identified behaviors since admission included wandering the halls. Interventions identified on the CCP included for staff to re-direct Resident 2 when entering unsafe area. Record review of Resident 2's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 7-02-2018 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) revealed staff were not able to complete the screening as Resident 2 was not able to answer the questions correctly. -Behavior was identified as wandering daily. Record review of Resident 2's Nursing Notes (NN) dated 3-22-2018 revealed Resident 2 .has been in and out of other residents rooms. Record review of Resident 2's NN dated 4-06-2018 revealed Resident 2 was wondering around in the hall ways and opening other resident doors. Record review of Resident 2's NN dated 5-12-2018 revealed Resident 2 was informed Resident 2 was .not allowed in other residents room. Record review of Resident 2's NN dated 6-01-2018 revealed Resident 2 had entered another residents room. Record review of Resident 2's NN dated 6-05-2018 revealed Resident 2 was was in the hall, walking around and opening other residents doors and peaked in. Record review of Resident 2's NN dated 7-06-2018 revealed Resident 2 was . going in other residents rooms for a while . Observation on 7-10-2018 at 10:39 AM revealed Resident 2 was wandering in the hall. Observation on 7-10-2018 at 11:02 AM revealed Resident 2 was in the hall and staff assisted Resident 2 into the Resident Lounge area. Observation on 7-10-2018 at 2:05 PM revealed Resident 2 was in (gender) room and then comes out and starts to wander the hall. Observation on 7-11-2018 at 4:15 AM revealed Resident 2 was wandering the hall. On 7-10-2018 at 10:25 AM an interview was conducted with Resident 1. During the interview Resident 1 reported Resident 2 would wander into (gender) room many times in the last 2 months. Resident 1 reported informing the nursing staff of Resident 2's wandering into the room. Resident 1 reported Resident 2 continues to wander into Resident 1's room. On 4-10-2018 at 10:40 AM an interview was conducted with Nursing Assistant (NA) [NAME] During the interview NA A reported Resident 2 does go into other residents rooms and staff re-direct Resident 2. NA A reported some times when Resident 2 goes into residents who are alert and oriented, Resident 2 startles them causing those residents to yell out. On 7-10-2018 at 11:00 AM an interview was conducted with Licensed Practical Nurse (LPN) B. During the interview LPN B reported Resident 2 does wander the halls and into other residents room. LPN B reported staff can not always monitor Resident 2. On 7-10-2018 at 3:10 PM an interview was conducted with Registered Nurse (RN) C. During the interview RN C reported Resident 2 wanders in and out of other residents rooms. RN C reported 1 of the facility residents become very upset when Resident 2 enters their room. RN C reported Resident 2 wanders at all times including night time. On 7-11-2018 at 4:08 AM an interview was conducted with NA E. During the interview NA [NAME] reported Resident 2 does wander the hall. According to NA E, Resident 2 had entered Resident 1's room and that caused Resident 1 to be very upset. NA [NAME] reported staff were to re-direct and offer a snack. On 7-11-2018 at 8:05 AM an interview was conducted with the Social Services Director (SSD). During the interview with the SSD, Resident 2's CCP was reviewed. The SSD confirmed during the interview there were not changes in how to manage Resident 2's wandering behaviors.",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
6619,OMAHA NURSING AND REHABILITATION CENTER,285240,4835 SOUTH 49TH STREET,OMAHA,NE,68117,2015-12-07,328,D,1,0,JX0E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D6 Based on observation, record review and interview; the facility staff failed to verify placement of a feeding tube for 1 resident (Resident 4). The facility staff identified a census of 60. Findings are: Record review of a Resident Information sheet printed on 12-07-2015 revealed Resident 4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 4's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 11-30-2015 revealed the facility staff assessed the following about the resident: -Resident 4 cognition was severely impaired. -Required extensive assistance with bed mobility, transfers, dressing and toilet use. -Required total assistance with personal hygiene. - Used a feeding tube. Observation on 12-03-2015 at 2:59 PM revealed Registered Nurse (RN) C revealed Resident 4's feeding needed to be restarted. RN C flushed Resident 4's feeding tube with 30 cc's ( cubic centimeters)without checking to verify placement of the feeding tube in the stomach. An interview with RN C was conducted on 12-03-2015 at 3:14 PM. During the interview RN C confirmed placement of the feeding tube had not been completed and should have been. Record review of the facility Policy and Procedure for Gastrostomy Tube revised on 5-2007 revealed the following: -Before every feeding, verify the tube position.",2018-12-01
1283,ARBOR CARE CENTERS-NELIGH LLC,285124,"PO BOX 66, 1100 NORTH T STREET",NELIGH,NE,68756,2019-03-11,689,E,1,1,UV2T11,"**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 ensure water temperatures were maintained at a level to prevent [MEDICAL CONDITION] the Whirlpool Bathtub. This had the ability to affect all of the residents that took a tub bath. The facility census was 36. Findings are: Review of the facility's Tub Bath competency form with a copyright date of (YEAR) revealed the water in the bath tub should be between 105 and 110 degrees. During the Environment Tour on 3/11/19 from 9:35 AM to 10:00 AM, with the housekeeping/laundry supervisor, the Hall C Whirlpool Bathtub water temperature was 120 degrees. During an interview with the housekeeping/laundry supervisor on 3/11/19 at 9:54 AM it was revealed that all the residents that wanted a tub bath in the building used the Hall C Whirlpool Bathtub. Review of the facility maintenance logs revealed no evidence to indicate water temperature in the Hall C Whirlpool Bathtub were monitored. During interviews on 3/11/19 at 9:55 AM and 10:07 AM Nursing Assistant (NA)-L revealed NA-L was the full-time bath aide. NA-L stated when NA-L gave baths the water temperature was usually between 102-104 degrees, with one resident liking theirs around 106 degrees. NA-L stated I don't like to go much above that. NA-L did not recall being trained on safe water temperatures or a maximum water temperature to prevent potential burns. During an interview with NA-B on 3/11/19 at 10:05 AM, NA-B was unsure what a safe water temperature was for baths. NA-B stated NA-L was the full-time bath aide, but if NA-L wasn't working another staff member gave baths. NA-B revealed last week NA-C gave baths. During interviews with the Director of Nursing (DON) on 3/11/19 from 10:10 AM to 11:30 AM, the DON confirmed if the full-time bath aide wasn't available another staff member gave baths. The DON confirmed there was no evidence to indicate training had been completed for any NA's (other than NA-L) on water temperature safety when giving a bath to prevent potential burns. Further interview confirmed bath water temperatures were not being manually checked as there was a miscommunication between nursing and maintenance.",2020-09-01
2451,WAKEFIELD HEALTH CARE CENTER,285209,306 ASH STREET,WAKEFIELD,NE,68784,2018-06-14,689,E,1,0,9BG111,"**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 put interventions in place to prevent injuries for 3 residents (Residents 1, 2, and 3) related to bruising and/or skin tears. The sample size was 3 and the facility census was 25. Findings are: [NAME] Review of Resident 1's Physician order [REDACTED]. Interview with the Director of Nursing (DON) on 6/14/18 at 1:30 PM revealed Resident 1 had a known history of [MEDICAL CONDITION] and bruised easily. The bruising would then expand downwards due to gravity. Review of Resident 1's current undated Care Plan revealed the Care Plan did not identify the resident's increased risk for bruising, and no interventions were identified to prevent potential injuries related to bruising. Review of Resident 1's Event Report dated 5/20/18 revealed the resident had a large bruise to the right inner thigh. Further review revealed no interventions had been identified to prevent potential recurrence. Review of a facility investigation titled Wakefield Health Care Center Incidents, Accidents, and Unusual Occurrences Detailed Investigation with an investigation date of 5/24/18 revealed Resident 1 bruised easily and the bruising would spread with gravity. Further investigation revealed on 5/17/18 Resident 1 wandered into room [ROOM NUMBER] and sat on the bed in room [ROOM NUMBER]. Metal mattress holders were present on all four corners of the bed in room [ROOM NUMBER] and matched the approximate location of Resident 1's bruising. Further review revealed no interventions had been identified to prevent potential recurrence. Observation of Resident 1's bed and the bed in room [ROOM NUMBER] on 6/14/18 at 9:00 AM revealed metal mattress holders remained on the bed corners. B. Review of Resident 2's Event Report dated 6/5/18 revealed the resident received a skin tear from hitting the resident's left elbow on the table. Further review revealed no interventions had been identified to prevent a potential recurrence. Review of Resident 2's Event Report dated 6/11/18 revealed the resident received a bruise to the left elbow after bumping it on the doorway of the tub room. The bruise measured 5 centimeters (cm) by 4cm. Further review revealed no interventions had been identified to prevent a potential recurrence. C. Review of Resident 3's Event Report dated 6/3/18 revealed the resident had a bruise to the resident's coccyx that measured 8cm by 1.5cm. The bruise was thought to have been caused by a slide board transfer. Further review revealed no interventions had been identified to prevent a potential recurrence. D. Interview with Licensed Practical Nurse-B on 6/14/18 at 12:55 PM confirmed causal factors should be identified for all new bruises or skin tears, and then an intervention should be put in place to prevent a potential recurrence. Interview with the DON on 6/14/18 at 1:30 PM confirmed interventions were not put into place to prevent the potential recurrence of injuries related to bruising and/or skin tears for Residents 1, 2, or 3.",2020-09-01
6077,"SORENSEN CARE AND REHABILITATION CENTER, LLC",285107,4809 REDMAN AVENUE,OMAHA,NE,68104,2016-06-14,323,D,1,0,4LQ711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, interviews and record review; the facility failed to ensure supervision to prevent an elopement for Resident 1 and failed to ensure interventions for safe smoking were in place for Resident 1. The facility census was 39. Findings are: A. Review of Resident 1's face sheet revealed Resident 1 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 1's care plan dated 4-24-16 revealed Resident 1 forgot things, had short term and long term memory loss, made poor decisions, created safety risk,and was on an antipsychotic medication and a mood stabilizer medication. Interventions were for staff to help Resident 1 make safe choices daily. The care plan also stated Resident 1 was at risk for elopement related to anger at placement (homeless) with interventions to redirect Resident 1 from doors. Review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool used for care planning) assessment dated [DATE] stated resident had inattention and disorganized thinking and that Resident 1 did not need physical help from staff to ambulate in room or corridor. The MDS also stated that Resident was a current tobacco user. Resident 1 was observed outside in back smoking area of the facility on 6-13-16 at 8:45 PM. When the back door was opened to the smoking area, the alarms sounded. The alarms continued sounding. At 8:55 PM, Nurse Aide (NA) A came to the door and entered the code to silence the alarm. NA A did not come outside to see how the alarm was set off nor check on possible residents outside. Interview with Resident 1 on 6-13-16 at 8:45 PM revealed that Resident 1 left the facility a few days ago overnight. Resident 1 stated that Resident 1 wanted to smoke so Resident 1 went outside with some other residents, through the front Resident 1 then decided to leave for a walk but Resident 1 came back the next day. Resident 1 was asked if the front door was locked and Resident 1 said yes, but other residents there know the door code. Resident 1 stated that Resident 1 knew the code to the back door but not to the front door. Review of nurse progress notes dated 6-9-16 revealed Resident 1 was last seen at 8:30 PM outside smoking and at 11:18 PM Resident 1 was still not found in the building. Interview with NA A on 6-13-16 at 9 PM revealed that the front doors lock automatically at 8 PM although most residents know the code to the door and can go out if they want to. On 6-14-16 at 9:25 am, observation revealed that Resident 1 walked to the back door of the facility, entered door code, walked outside and smoked. The alarm sounded but no staff responded. The alarm shut off when the door closed. No staff were present. Interview with the Director of Nursing (DON) on 6-13-15 at 9:20 PM revealed that Resident 1 had poor judgment and decision making skills. On 6/9/16, Resident 1 was last seen outside smoking at 8:30 PM. At 9:45 PM, staff could not locate the resident after a thorough search of the building and grounds. Resident 1's emergency contacts were called and they also had not seen Resident 1. The police department was called and notified and a report was filed. The DON stated Resident 1 returned to the facility the next day, 6/10/16 at 10 am, and was seen by the Advanced Practice Registered Nurse who ordered a drug and alcohol screen. The DON stated the resident's pupils were dilated and speech was slurred. Resident 1 tested positive for cocaine. The facility put a wanderguard bracelet on Resident 1 and received an order to hold medications for 72 hours. Resident 1 was put on 15 minute checks for 72 hours. The DON confirmed the cocaine had to have been used outside of the facility while Resident 1 had eloped. Interview with the DON on 6-14-16 at 9:30 am revealed that if a staff member heard a door alarm going off, the staff were to go outside and look to see if there were any residents in the area. If some residents knew the door code, then it needed to be changed immediately. The DON stated that the DON was unaware if any residents knowing the code. The DON confirmed Resident 1's care plan stated Resident 1 was to be redirected from doors. B. On 6-13-16 at 8:45 PM, Resident 1 was observed outside the facility in the smoking area smoking by self. No staff were present and no smoking apron was on Resident 1. Smoking aprons were noted hanging by the door to go outside. An interview with NA A revealed that the assigned resident smoke times were 9 AM, 1 PM, 4 PM, and 7 PM. However, most of the residents do not adhere to that. An interview with NA B on 6-14-16 at 9:20 AM revealed that residents were allowed to keep their lighters and cigarettes on themselves. Residents that were not capable were to have these items kept with the nurse. NA B stated Resident 1 could keep the cigarettes and lighter with (gender). Observation of Resident 1 on 6-14-16 at 9:25 AM revealed the resident walking from room to outback to smoke. Cigarette and lighter were in Resident 1's front shirt pocket. Resident 1 stated was allowed to keep cigarettes and lighter at all times. Resident 1 then proceeded to go to back door, enter door code. The alarm sounded at Resident 1 walked outside and started smoking without staff present or a smoking apron on. Review of Resident 1's care plan dated 4-24-16 revealed Resident 1 was at risk for smoking related injury and to provide smoking apron while smoking and review smoking policy with patient. Interview with DON on 6/14/16 at 11 AM confirmed that Resident 1 was not supervised while smoking and so staff could not know if Resident 1 wore a smoking apron for safety. Review of the facility Smoking and Tobacco Use Guideline with revision date of 3/24/16 stated: Residents may smoke only at the designated times. Each Living Center will develop and specify the smoking times. Smoking will be supervised by a staff member. Smoking garments/aprons will be worn by all residents while smoking for safety.",2019-06-01
4024,SANDHILLS CARE CENTER,285298,143 N FULLERTON STREET,AINSWORTH,NE,69210,2018-10-01,689,D,1,0,LLSM11,"**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 1 (Resident 26) of 3 sampled residents with a history of falls. The facility census was 20. Findings are: Review of Resident 26's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/26/18 revealed a [DIAGNOSES REDACTED]. Review of Progress Notes dated 4/2/18 at 4:05 PM revealed Resident 26 was found on the floor in front of the recliner in the resident's room. The resident stated .that chair just threw me out. Review of a Post Fall assessment dated [DATE] revealed Resident 26 fell at 4:00 PM that day when the resident attempted to get up from the recliner to go to the bathroom. An intervention to prevent further falls was placement of non-skid tape on the floor in front of the recliner. Review of Progress Notes dated 6/9/18 at 11:30 AM revealed at 10:50 AM, Resident 26 was found sitting on the floor and the resident stated the chair threw the resident out. Documentation further indicated staff intervened when the resident was found during room checks to be standing between the footrest and the chair. Review of a Post Fall assessment dated [DATE] revealed Resident 26 fell that day. The resident stated, That damn chair threw me out. Documentation further indicated Restorative Therapy (RT) would assess the resident's chair for placement of sandbags (additional weight placed at the base behind the recliner to prevent the chair from tipping forward). Review of Resident 26's current Care Plan (undated) included the following fall prevention interventions: -place non-skid tape on the floor in front of the recliner to prevent the resident from slipping and falling; and -RT will evaluate the recliner in regards to putting sandbags down to prevent the chair from leaning forward. If sandbags will work, RT will leave the sandbags on the feet of the recliner. Resident 26 was observed seated in a recliner in the resident's room on 10/1/18 at 11:10 AM. There was no non-skid tape on the floor in front of the resident's recliner and there were no sandbags on the base of the recliner. Interview with the RT Assistant on 10/1/18 at 1:45 PM confirmed there were no sandbags in use on the base of Resident 26's recliner. The RT Assistant indicated the facility assessed that the sandbags would not work with Resident 26's recliner but there was no documentation or evidence to support this decision. Interview with the Director of Nurses on 10/1/18 at 2:00 PM confirmed the non-skid tape was supposed to be in place on the floor in front of Resident 26's recliner in an attempt to prevent the resident from slipping and falling.",2020-09-01
5942,STANTON HEALTH CENTER,285102,"P O BOX 407, 301 17TH STREET",STANTON,NE,68779,2016-07-19,323,E,1,0,4OYT11,"**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 3 residents (Residents 1, 5 and 3). The facility census was 61. Findings are: A. Review of the facility Fall Risk Assessment policy (revision date 7/2004) revealed residents were to be assessed to determine their risk of falling and individualized approaches were to be implemented for the prevention of falls. The policy further indicated residents who were at risk for falls but were competent and oriented .may be left unattended on the toilet per their choice. B. Review of Resident 5's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/28/16 indicated the resident had [DIAGNOSES REDACTED]. The MDS further indicated the resident had severe cognitive impairment. Review of the current Care Plan initiated 12/1/15 revealed Resident 5 was at risk for falls due to severe dementia and cognitive deficits. The Care Plan indicated the resident could not always voice wants/needs. Interventions for the prevention of falls included the following: -use of a pressure alarm (a resident is seated on a pad which sounds an alarm when the resident attempts to stand) and a pull type alarm (tabs alarm-a device which sounds an alarm when a resident attempts to rise to a standing position) at all times -use of a pull type alarm while the resident was seated on the toilet. Review of Progress Notes dated 6/24/16 at 10:36 AM revealed Resident 5 fell off of a commode (portable toilet) at 7:15 AM that day. Review of a Post Fall QI (Quality Improvement) Investigation Tool (a form used to investigate causal factors of falls) dated 6/28/16 revealed Resident 5 was left unattended while seated on a bedside commode on 6/24/16 at 7:15 AM. Documentation indicated the tabs alarm sounded and the resident was found sitting on the floor. Documentation further indicated the recommendation to prevent additional falls was for staff to stay with the resident .while in the bathroom. Review of the current Care Plan (revised 7/6/16) revealed the intervention for staff to stay with the resident during toileting was not addressed. Licensed Practical Nurse (LPN)-A and Nursing Assistant (NA)-B were observed to assist Resident 5 onto the toilet in the shower room on 7/18/16 at 1:35 PM. A tabs alarm was observed in place on the back of the toilet. Interview with LPN-A at 1:44 PM on 7/18/16 revealed Resident 5 was frequently toileted in the shower room during the day. LPN-A confirmed there was a tabs alarm on the back of the toilet in this room. LPN-A indicated the tabs alarm was used when Resident 5 was seated on the toilet. LPN-A indicated that at times Resident 5 was left unattended while seated on the toilet in the shower room but during these occasions staff remained right outside the closed bathroom door. Interview with NA-D at 3:40 PM revealed a tabs alarm was used while Resident 5 was seated on the toilet. NA-D confirmed that at times Resident 5 was left alone in the bathroom while the resident was seated on the toilet. Interview with the interim Director of Nursing (DON) on 7/19/16 at 7:45 AM confirmed residents who were at risk for falls should not be left unattended after being assisted onto the toilet. C. Review of Resident 3's Care Plan initiated 10/28/15 revealed the resident was at increased risk for falls. Interventions included the use of a pressure alarm and a pull type alarm. Review of Resident 3's Progress Notes dated 7/13/16 at 2:10 PM revealed the resident was found lying on the floor next to the recliner in the resident's room. Review of the Post Fall QI Investigation Tool dated 7/16/16 revealed the fall alarms were not in use. Documentation indicated Activity Staff transferred the resident from the wheelchair into the recliner and did not move or activate the fall alarms. The immediate intervention for prevention of falls was identified as staff education. D. Review of Resident 1's MDS dated [DATE] indicated the resident was cognitively intact, required extensive assistance with activities of daily living, had problems with balance during transfers and mobility, and had a history of [REDACTED]. Review of Resident 1's Care Plan dated 5/20/16 revealed the resident required extensive assistance with transfers and was at risk for falls. Nursing interventions included the following: -be sure the call light is within reach and encourage the resident to use it for assistance as needed, -the resident needs prompt response to all requests for assistance, and -pressure alarm to recliner, bed and wheelchair at all times. Review of Nursing Progress Notes dated 7/10/16 at 10:10 AM indicated staff found Resident 1 lying on the floor on right side at the foot of the bed. The resident was transferred to the emergency room for evaluation. Review of the Fall/Incident Report dated 7/10/16 indicated the following: -Resident 1 reported getting up independently, going to the room door, looking into the hallway in search of staff, then turning around and falling; -Resident 1 did not call for staff assistance prior to getting up from the chair; and -the pressure alarm was not in the seat of the recliner that Resident 1 was sitting in. Review of the Investigative Report dated 7/10/16 indicated interventions to prevent the incident from reoccurring included staff education regarding alarms and resident education related to use of the call light. During interview on 7/18/16 at 3:55 PM, the DON and LPN-F verified Resident 1 shared a room with spouse and there were 2 recliners in the room, 1 by Resident 1's bed and the other by the door to the room. They further verified Resident 1 sat in either of the recliners, and a pressure alarm probably should have been in both recliners. During interview on 7//19/16 at 7:45 AM, the DON verified there was no evidence staff members were educated regarding placement and activation of fall alarms. The DON further indicated no monitoring was completed to assure fall alarms were in place as planned.",2019-07-01
5856,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2016-08-10,323,D,1,0,142711,"**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 fail to implement interventions to protect 2 residents (Resident 4 and 2) who made suicidal statements and failed to implement assessed interventions to prevent falls for 1 resident (Resident 3). The facility staff identified a census of 164. Findings are: A. Record review of the facility Policy and Procedure for Suicide Precautions dated 10-25-2011 revealed the following: -Policy: -Provide a safe and secure environment for all residents. -Purpose: -To instruct the nursing staff in the management of the resident who may be suicidal. -Indications: -1. Resident is expressing feelings of suicide either with or without a specific plan ex: I want to kill myself, I'm going to hurt myself. -2. Resident is attempting or has harmed himself/herself. Possible examples cuts on wrist, medication seeking with intent to overdose. -Procedure: -In the event that the resident has expressed a desire to commit suicide or harm themselves, the resident will be immediately assessed by an Registered Nurse (RN), Licensed Practical Nurse (LPN) or Social Worker for suicide intent, using the four question Suicide Risk Assessment Tool (SRAT). -If the assessment indicates a high risk for suicide attempt: 1. Nursing will notify the physician to discuss the circumstances and obtain orders to transfer to the hospital emergency room (ER) for admit. 3. If the resident is to be transported to the hospital, the resident is to remain in line of sight of the charge nurse until the ambulance arrives. 4. Staff are to search the residents room, remove any items that pose a physical threat to the resident and document the results of the search. -If the assessment indicates a low risk for suicidal attempt: -Staff are to search the resident room and remove any items that pose a physical threat to the resident. -Upon the residents return from the hospital: 1. 15 minute checks will be documented for the first 24 hours. 2. 30 minute checks will be documented for the second and third day after transfer from the hospital. 3. On the fourth day, contact the residents physician to give an update and ask for an order to discontinue the 30 minute checks. B. Record review of an undated Resident Face Sheet revealed Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 4's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 7-01-2016 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 a person was cognitively intact. -Required extensive assistance with bed mobility,transfers,locomotion, toilet use, and personal hygiene. Record review of Resident 4's Nurse's Notes (NN) dated 7-28-2016 at 1:45 AM revealed Resident 4 was going to slice their wrist and kill (gender) self. According to Resident 4's NN dated 7-28-2016, Resident 4's room was checked for sharp objects, placed on 15 minute checks and the Director of Nursing (DON) was called. There was no information in Resident 4's medical record to show the nursing staff immediately assessed Resident 4 for suicide intent or that Resident 4's physician or family were notified of the suicidal statements. Record review of an Interview Worksheet dated 7-28-2016, section I, revealed Resident 4 had thoughts of being better of dead or hurting yourself in some way. The symptom frequency was identified as 2 to 6 days. Record review of an undated Brief Suicide Risk Assessment Tool (BSRAT) revealed Resident 4 had answered, yes to feeling hopeless and having suicidal thoughts in the last week. According to the BSRAT information an answer of yes, 2 or more times to the 4 questions placed Resident 4 at High suicide risk. An interview on 8-09-2016 at 1:28 PM was conducted with the DON (Director of Nursing). During the interview, Resident 4's progress note dated 7-28-2016 was reviewed with the DON. The DON confirmed Resident 4 had not been immediately assessed for suicide risk, Resident 4's physician had not been notified, Resident 4's room had not been searched for other items that my pose a physical threat and Resident 4 had not been sent to the hospital. On 8-10-2016 at 10:15 AM, the DON reported Resident 4 had been re-evaluated for suicidal ideation. According to the DON, Resident 4 was sent to the hospital on 8-09-2016 and returned to the facility on [DATE]. The DON confirmed 15 minute checks had not been completed after Resident 4 returned to the facility from the hospital. C. Record review of a Physician Order Report sheet signed on 7-29-2016 revealed Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 2's MDS dated [DATE] revealed Resident 2 was assessed with [REDACTED]. According to the MDS Manuel a score between 8 and 12 indicated some cognitive impairment. On- 8-8-2016 at 11:40 AM, during an observation, Resident 2 reported having so much pain that I feel like committing Hari Kari. Resident 2's self harm statement was reported to Resident 2's charge nurse for follow up. Record review of Resident 2's NN dated 8-08-2016 at 12:30 PM revealed Resident 2's room was searched and .did not finding any items that could cause harm (no sharp objects notes). Observation on 8-8-2016 at 2:27 PM revealed Resident 2 was out of the room. Further observation revealed the resident's call light cord and the remote cord to the bed function was attached to the bed and with in reach of where Resident 2 sat in the room. An interview was conducted on 8-8-2016 at 3:12 PM with Licensed Practical Nurse (LPN) B. During the interview observation of Resident 2's room was completed. LPN B confirmed the call cord and remote to the bed were within reach of where Resident 2 would sit. LPN B confirmed Resident 2 could have reached the cords. D. Record review of Resident 3's MDS signed as completed on 6-04-2016 revealed the facility staff assessed the following about Resident 3: -Short and long term memory impairments. -Required extensive assistance with transfers,eating, toilet use and personal hygiene. -Required limited assistance with bed mobility and walking in the corridor and had a fall in the facility. Record review of Resident 3's Comprehensive Care Plan (CCP) dated 7-08-2015 revealed an admission date of [DATE] with the [DIAGNOSES REDACTED]. Further review of Resident 3's CCP revealed an updated problem area that identified Resident 3 at risk for falls and injury due to impaired cognition, and use of an antidepressant medication. The goal was Resident 3 would be free from falls and injuries. A new intervention to prevent falls dated 5-21-2016 was that Resident 3 was to have a fall mat in place. Record review of a Daily Activity of Daily Living (ADL) Guide dated 5-01-2016 revealed Resident 3 was at risk for falls with the low bed, fall mat and scoop mattress checked. Observation on 8-09-2016 at 4:21 PM revealed Resident 3 was in bed. The bed was at a medium height and the fall mat was up against the wall. An interview with Nursing Assistant (NA) C was conducted on 8-09-2016 at 4:23 PM. During the interview, NA C confirmed the fall mat was not in place and should have been.",2019-08-01
4368,"BCP COLUMBUS, LLC",285152,1112 15TH STREET,COLUMBUS,NE,68601,2018-04-10,689,E,1,1,9GM911,"**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 keep the residents' environment free of accident hazards as 1) Resident 13 was allowed to leave the facility to smoke unsupervised without an assessment for smoking safety and despite being identified at risk for elopement (leaving the facility unattended and without staff knowledge), and 2) causal factors for falls were not determined for Residents 23 and 19, and new interventions for the prevention of falls were not implemented. The total sample size was 18 and the facility census was 36. Findings are: [NAME] Review of Resident 13's Admission Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/16/17 revealed the following; -[DIAGNOSES REDACTED]. -cognitively intact; -required extensive assistance with transfers; -required limited assistance with ambulation and locomotion; -utilized a walker and/or wheelchair for mobility; and -did not use tobacco products. Review of Resident 13's initial Care Plan dated 5/9/17 indicated an admission assessment (for risk of elopement) was completed and a Wanderguard bracelet (a device attached to the resident that sets off an alarm when the resident passes by facility exits that are equipped with sensor devices that are activated by the bracelet) was applied as an intervention to prevent elopement from the facility. Review of Nursing Progress Notes revealed the following related to Resident 13 smoking: -8/3/17 at 8:00 PM - Resident's child took the resident outside to smoke despite having a nicotine patch; -8/3/17 at 10:00 PM - Hallway had a burning odor and the resident denied smoking in the room; cigarettes and lighter taken from the resident and locked up; -8/17/17 at 11:00 AM - Resident smoking on grounds and became very angry when told cigarettes were going to be locked up; and -8/20/17 at 9:00 AM - A cigarette butt was found in a styrofoam cup with a lid on the bedside stand in the resident's room. Review of the Release Of Responsibility For Leave of Absence forms (used by the resident to sign out of the facility when going out to smoke, and sign in upon return) dated 8/5/17 through 8/22/17 revealed Resident 13 signed out to smoke 14 times and was inconsistent with signing in upon return. There was no evidence in the medical record that a Safe Smoking Evaluation was completed prior to Resident 13 being allowed to smoke. Review of Nursing Progress Notes dated 8/22/17 at 9:15 AM revealed Resident 13 was observed walking down the street about a block and a half from the facility. At 9:26 AM the police were notified as the resident refused to return to the facility. Staff waited with the resident until the police arrived. The resident was returned to the facility at 10:00 AM. Review of the Wandering/Elopement Risk Evaluation Tools revealed the following: -a score of 16 on 8/22/17; -a score of 13 on 11/7/17; -a score of 8 or above indicated the resident was at high risk for elopement; and -continued use of the Wanderguard bracelet was recommended. Review of the Release Of Responsibility For Leave of Absence forms revealed the following related to Resident 13 smoking: -signed self out approximately 46 times from 8/23/17 through 10/10/17; -no evidence of going out to smoke from 10/11/17 through 1/7/18; -signed out at 9:45 AM on 1/8/18; and -no evidence of going out to smoke since 1/8/18. Review of a Social Services Progress Note dated 3/30/18 indicated Resident 13 recently started smoking again, a smoking assessment was completed, and smoking was added to the Care Plan. Review of the Safe Smoking assessment dated [DATE] indicated Resident 13 smoked 2 to 4 cigarettes daily, was not interested in quitting, and was determined to be safe to smoke independently. Review of the current Care Plan dated 3/30/18 indicated Resident 13 was at risk for injuries related to smoking. Nursing interventions included the following: -reevaluate quarterly, annually and with significant change; -smoke times are not supervised; -smoke in designated area only; -independent with smoking and will sign in and out of the facility each time goes out to smoke; -cigarettes and lighter will be locked up and kept by staff; and -will be provided a smoke apron (a burn resistant apron that shields the resident from hot ashes and/or dropped cigarettes) as needed. During observations in the resident's room on 4/4/18 at 1:55 PM and in the dining room on 4/5/18 at 11:12 AM, Resident 13 was seated in the wheelchair and a Wanderguard bracelet was observed attached to the back of the wheelchair on the left side. During interview on 4/9/18 at 9:45 AM, Licensed Practical Nurse (LPN)-G indicated that in order to smoke, Resident 13 had to be able to self propel out the back door behind the nurses station and to the area outside that was designated for smoking. The resident had to be alert and able to sign self out. Cigarettes and lighter were dispensed from the nurses station, and the resident was required to wear a smoking apron. LPN-G verified the location of the designated smoking area. Observation of the designated smoking area on 4/9/18 at 9:55 AM revealed the following: -there was a 3 ring binder stored in a wall-mount storage sleeve on the wall to the right of the East Exit door behind the Nurses Station, containing forms titled Release Of Responsibility For Leave of Absence and individually identified with residents' names, including several for Resident 13; -immediately outside the East Exit door was a fenced-in area of yard; -there was a sidewalk outside the exit door that veered to the left and extended across the fenced-in area to an entry gate on the North side; -the gate was open and the sidewalk extended directly onto a paved parking lot where several vehicles were parked; -at the far North end of the parking lot, and positioned on the sidewalk immediately off the curb to the street, was a lawn chair with an outdoor cigarette/butt receptacle positioned next to it; and -the designated smoking area was not readily visible due to the distance from the building and obstruction from vehicles parked in the parking lot. During interview on 4/9/18 from 1:40 PM to 2:10 PM, the facility Administrator verified Resident 13 was at risk for elopement and had a Wanderguard bracelet. The Administrator further verified the resident was recently observed going out to smoke and probably should be supervised. During interviews on 4/10/18 from 8:20 AM until 12:51 PM, the Director of Nursing (DON) and Social Services Director (SSD) verified elopement risk assessments were to be completed on admission, semiannually, and with a significant change in condition. They verified Resident 13 was not assessed for risk of elopement since 11/7/17. Furthermore, they verified a Safe Smoking Assessment was not completed for Resident 13 until 3/30/18. B. Review of Resident 23's Annual MDS dated [DATE] revealed the following: -[DIAGNOSES REDACTED]. -severe cognitive impairment; -required supervision with bed mobility and transfers; -independent with ambulation; and -no problems with balance. Review of Resident 23's current Care Plan, with an initial date of 3/6/14, indicated the resident was at risk for falls and fall related injury due to independent ambulation in a quick manner through the facility, likes to goof around with staff and other residents at times, and a [DIAGNOSES REDACTED]. Nursing interventions included the following: -call light within reach at all times while in room; -keep room and hallways free of clutter to provide a safe environment; -encourage to wear non-slip footwear; -work with Restorative Therapy to maintain strength and mobility as needed; -keep bedside table close to the bed and all necessary items within reach; and -4/14-sometimes I will put myself on the floor. Review of Nursing Progress Notes dated 1/22/18 at 4:35 PM indicated the resident was observed sitting on the floor and stated left foot went numb. The resident was able to stand and ambulate without difficulty. Review of a Post Fall Investigation dated 1/22/18 revealed the following related to Resident 23: -not at risk for falls; -no previous falls; -was found sitting on the floor in the living room; and -the intervention recommended was for Restorative Therapy to provide exercises. There was no evidence the circumstances surrounding Resident 23's fall were evaluated to determine the causal factors, and there was no evidence in the medical record that the resident was receiving Restorative Therapy services. During interview on 4/9/18 at 10:30 AM, LPN-A verified Resident 23 was not on a Restorative Therapy program. C. Review of Resident 19's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was admitted [DATE] with short term/long term memory problems, hospice services, and had experienced falls prior to admission but had not fallen since admission. Review of Resident 19's Nurse's Notes dated 3/8/18 at 7:30 PM revealed the resident slid out of the wheelchair onto the floor. Documentation indicated a plan for Occupational Therapy (OT) to evaluate and treat for wheelchair positioning. There was no evidence additional interventions for the prevention of falls were developed. Review of Nurse's Notes dated 3/9/18 at 10:50 AM revealed OT was aware of Resident 1's recent fall. OT indicated a tilt in space wheelchair (a specialized chair that allows the whole chair to tilt and promotes proper seating alignment) would be delivered and OT would .be out next week to eval (evaluate) it. Review of Resident 19's Nurse's Notes dated 3/13/18 at 5:30 PM revealed the wheelchair had not been delivered (4 days later). Review of Nurse's Notes dated 3/14/18 at 8:30 PM revealed Resident 19 slid out of the wheelchair and was found sitting on the wheelchair foot pedals. Review of Resident 19's Care Plan dated 3/15/18 revealed Hospice delivered a tilt wheelchair on that day (6 days after the fall on 3/9/18). Review of an OT Visit Note dated 3/15/18 confirmed Resident 19 received a tilt wheelchair on that day. OT evaluated the resident's positioning in the new wheelchair and made adjustments to accommodate the resident's needs. Review of Resident 19's Nurse's Notes from 3/15/18 through 4/5/18 revealed Resident 19 had not had any falls since the new wheelchair was provided. Resident 19 was observed seated in the tilt in space wheelchair on 4/5/18 at 9:59 AM, 11:25 AM and 11:50 AM with body in alignment and no evidence of sliding forward out of the wheelchair. Staff interview with Nursing Assistant (NA)-D on 4/5/18 at 11:50 AM indicated since Resident 19 got a different wheelchair there had not been any further problems with the resident sliding out of the wheelchair.",2020-08-01
6079,O'NEILL OPERATIONS LLC,285108,"PO BOX 756, 1102 NORTH HARRISON",O' NEILL,NE,68763,2016-06-15,323,D,1,0,Z9G111,"**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 interventions and to provide supervision to prevent ongoing falls for Residents 8 and 4. The facility census was 69. Findings are: A. Review of Progress Notes dated 5/21/16 at 3:30 PM revealed a nursing assistant .came into resident's bathroom after resident had fallen off toilet and pulled (resident's) call light. Review of Resident 8's current Care Plan (revision date 5/30/16) indicated the resident had [DIAGNOSES REDACTED]. The Care Plan indicated Resident 8 had short and long term memory problems and required assistance with decision making. The Care Plan further indicated the resident was at risk for falls and required extensive assistance with transfers and toileting. Interventions for the prevention of falls included completion of 15 minute visual checks. On 6/15/16 at 9:15 AM, Nursing Assistant (NA)-C and NA-D were observed to assist Resident 8 out of a wheelchair and onto the toilet in the bathroom. An alarm device was in place on the bathroom door which sounded an audible alarm when the bathroom door was opened. NA-C indicated the alarm was to alert staff if the resident attempted to go into the bathroom independently. After the resident was seated on the toilet, NA-C and NA-D exited the bathroom, closed the bathroom door, exited the resident's room and closed the room door. NA-C indicated it was usual procedure to leave the resident alone in the bathroom and commented the resident would use the call light when finished on the toilet. Interviews with the Interim Director of Nurses on 6/15/16 at 9:26 AM and the Administrator on 6/15/16 at 1:25 PM confirmed residents who were at risk for falls should not be left unattended after being assisted into the bathroom. B. Review of Resident 4's current undated Care Plan revealed the resident was at risk for falls. Fall prevention interventions included the following: - Alarm system to be in place in the bed and wheelchair. -Check placement and functioning of chair and bed alarm every shift. -Place dycem (a type of material that prevents sliding) on the seat under alarm system in bed. C. Review of Resident 4's (MONTH) (YEAR) Treatment Administration Record revealed an order to check the chair alarm placement every shift with an order date of 5/19/16. On 6/15/16 at 9:00 AM, NA-A and NA-B were observed to assist Resident 4 from the bed to the wheelchair. Resident 4's alarm system was not placed in the wheelchair. Interviews with NA-A and NA-B on 6/15/16 at 9:15 AM confirmed the resident's alarm was not placed in the wheelchair. Interview with Licensed Practical Nurse-F on 6/15/16 at 10:05 AM confirmed Resident 4 should have had an alarm on when in the wheelchair. D. Observation of Resident 4's room on 6/15/16 at 9:23 AM revealed a pressure pad alarm (an alarm that sounds when pressure is removed from the alarm pad) placed on the bed with no dycem underneath. Interview with NA-B on 6/15/16 at 12:20 PM confirmed the facility did not use dycem under Resident 4's bed alarm.",2019-06-01
5607,WISNER CARE CENTER,285151,1105 9TH STREET,WISNER,NE,68791,2016-11-28,323,D,1,0,29ZS11,"**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 interventions for the prevention of falls for Resident 2. Furthermore, following a fall incident by Resident 2, the facility failed to review and revise interventions to prevent future falls. The sample size was 3 and the facility census was 36. Findings are: Review of Resident 2's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/18/16 indicated [DIAGNOSES REDACTED]. The MDS indicated Resident 2 was severely cognitively impaired, required extensive assistance with transfers and mobility, and had a history of [REDACTED]. Review of Resident 2's Care Plan dated 11/25/16 indicated the resident was at risk for falls related to altered standing balance and unsteady gait. Nursing interventions included the following: -encourage to ask for assistance, -call light within reach, -ensure resident wears non-slip footwear for all transfers and ambulation, -raised edge mattress (sides of mattress are raised to define the edges of the bed) on bed, -high/low bed (allows resident's bed to be lowered as close to the floor as possible), -fall mat at side of bed, -bed pull (an alarm used while in bed that alerts staff to the resident's movements), -w/c (wheelchair) strip (an alarm device in the seat of the wheelchair that alerts staff to the resident's movements), and -when resident wishes to sit in room be sure the door is open so the alarm can be heard to alert staff of attempts to self transfer. Review of Nursing Progress Notes dated 11/2/16 at 6:42 PM revealed Resident 2 leaned forward in wheelchair and fell on to the floor, sustaining abrasions on the nose, left forehead, left eyebrow, and left hand. There was no evidence that causal factors were identified and new interventions put in place for the prevention of further falls. During observations of the noon meal on 11/28/16 from 11:27 AM until 12:16 PM, Resident 2 was seated in a regular chair at the dining room table. There was a tabs alarm (An alarm device with a cord extending from it, and a clip at the end of the cord that can be attached to the resident ' s clothing. When the resident attempts to stand, the cord pulls tight and sets off the alarm, thus alerting staff to the resident ' s movement) attached to the left side of the dining room chair. However, the cord was dangling and the clip had not been attached to Resident 2's clothing. During interviews on 11/28/16 the following was revealed: -From 1:01 PM to 1:18 PM, Licensed Practical Nurse (LPN)-F, Nursing Assistant (NA)-D, and NA-G verified the tabs alarm was supposed to be attached to Resident 2 when seated in the dining room chair for meals. -At 2:20 PM, the Director of Nursing (DON) verified there were no new interventions developed following Resident 2's fall on 11/2/16.",2019-11-01
5937,ROSE BLUMKIN JEWISH HOME,285059,323 SOUTH 132ND STREET,OMAHA,NE,68154,2016-07-21,323,D,1,0,6HYA11,"**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 staff failed to follow Physical Therapy (PT) recommendations on transfers for 1 resident (Resident 1). The facility staff identified a census of 92. Findings are: Record review of a Diagnosis/History sheet dated 7-14-2016 revealed Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 6-24-2016 revealed Resident 1 had a history of [REDACTED]. Interventions identified on the CCP dated 6-24-2016 to prevent falls identified that staff were to use one person to assist when transferring Resident 1. Record review of Resident 1's departmental Notes (DN) dated 7-04-2016 revealed Resident 1 had been readmitted to the facility after being hospitalized . Record review of Resident 1's DN dated 7-05-2016 revealed Resident 1 had orders for Physical Therapy (PT) and Occupational Therapy (OT) to evaluate and treat. Record review of Resident 1's DN dated 7-05-2016 revealed PT A was working with Resident 1 in therapy. Further review of the DN dated 7-05-2016 revealed PT A identified Resident 1 was to have the assistance of 2 staff for all transfers in order to . maximize patient and caregiver safety. Record review of Resident 1's PT Therapist Progress note dated 7-18-2016 revealed PT A had educated staff on the need to have 2 assisting Resident 1 with transfers. Observation on 7-21-2016 at 7:14 AM revealed Nursing Assistant (NA) C transferred Resident 1 from the toilet to the wheelchair without other staff assistance. An interview with NA C was conducted on 7-21-2016 at 10:42 AM. When asked how many staff it took to transfer Resident 1, NA C reported it took one staff member. An interview on 7-21-2016 at 9:53 AM an interview was conducted with PT A. During the interview when asked how Resident 1 transferred, PT A reported Resident 1 was a 2 person transfer for safety. An interview on 7-21-2016 at 11:05 AM was conducted with Licensed Practical Nurse (LPN) B. LPN B confirmed during the interview that Resident 1 should have been transferred using 2 people. LPN B further confirmed PT A's direction to have 2 staff when transferring Resident 1 had not been completed.",2019-07-01
5494,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2017-01-10,323,E,1,0,GC9U11,"**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 staff failed to implement assessed intervention to prevent falls for 2 (Resident 2 and 3) of 3 residents and failed to ensure the laundry room door was locked on the secured unit of the facility. The facility staff identified there were 5 cognitively impaired self mobile residents who resided on the secured unit. The facility census was 50. Findings are: [NAME] Record review of Resident 2's Comprehensive Care Plan (CCP) dated 7-07-2016 revealed the facility staff had identified Resident 2 was at risk for falls. The goal for Resident 2 was not to have a serious injury due to falls. The interventions identified on the CCP included for staff not to leave the resident alone in the bathroom, ensuring the call light is in reach, floor mat next to bed and use a bed electronic alarm. Record review of a Accidents sheet dated 12-2-2016 revealed Resident 2 had been placed on the toilet by a Nursing Assistant (NA) on 11-27-2016 at 6:40 AM. According to the Accidents sheet information, the NA had communicated with Resident 2 to remain on the toilet while the NA obtained slacks. According to the Accidents sheet information, The NA arrived back at the bathroom and found Resident 2 laying on the right side face down. Resident 2 was evaluated as having a Y shaped laceration to the forehead that required sutures. An interview with the Director of Nursing (DON) was conducted on 1-10-2017 at 11:25 AM. During the interview, review of the accident sheet dated 12-2-2016 and Resident 2's CCP were reviewed with the DON. The DON reported that the NA had left Resident 2 alone in the bathroom to obtaining clothing and further confirmed Resident 2's CCP directed that Resident 2 was not to be left alone in the bathroom. B. Record review of a Admission Record sheet printed on 1-09-2017 revealed Resident 3 admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 3's Care Plan dated 12-27-2017 revealed the facility staff had evaluated Resident 3 as being at risk for falls. The goal for Resident 3 was to be free of falls. Interventions listed on the Care Plan included a different wheelchair was issue to Resident 3, in addition, alarms were placed onto the wheelchair. Observation on 1-10-2017 at 6:40 AM revealed Resident 3 was seated in a wheelchair in the hallway. Resident 3 was not observed to have alarms on or attached. Observation on 1-10-2017 at 1-10-2017 at 8:15 AM revealed Resident 3 was in the dining room having breakfast. There were no alarms attached or being used for Resident 3. An interview with the DON on 1-10-2017 at 8:34 AM. During the interview the DON after observing Resident 3 in the dining room confirmed alarms were not in placed for Resident 3. C. Observation on 1-10-2017 at 5:26 AM revealed the laundry room door on the secured unit was open. Observation of the laundry room revealed there were no staff present. Further observations revealed there were dryers,washers, cleaning cloths, stand upright fan, multi bags of soiled laundry. In addition, there were chemicals as follows: -Solid Soft Plus laundry softener. Review of the Material Safety Data Sheet (MSDS) revealed that if swallowed, was harmful and can cause severe chemical burns of the mouth, throat and stomach. -Solid Stainaway. Review of the MSDS sheet revealed that if the produce was swallowed to rinse the mouth, the to drink 1 to 2 large glasses of water. Do not induce vomiting and to immediately call a poison control lab or a Physician or the supplier medical emergency number. -Solid Ultra surge. Review of the MSDS revealed the effects of over exposure to the eyes and skin could cause severe chemical burns and if swallowed could be harmful or fatal, it causes chemical burns of the mouth, throat and stomach. On 1-10-2017 at 5:28 AM, the DON confirmed the laundry door was open and unattended and should have not been. On 1-10-2017 at 11:00 AM the Housekeeping and Laundry Supervisor (HLS)provided a list to the amount of chemical are as follows: -Solid Soft Plus there was 1 container. -Solid Ultra Surge, there 5 containers. -Solid Stainaway, there were 3 containers. On 1-10-2017 at 12:12 PM an interview was conducted with the HLS. During the interview the HLS confirmed the laundry room door should have been locked.",2020-01-01
5886,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2016-08-04,323,G,1,0,IWFH11,"**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 staff failed to implement assessed interventions and failed to evaluate casual factors to prevent falls for 1 resident (Resident 1) and failed to implement additional interventions after a fall for 1 resident (Resident 2). The facility staff identified a census of 89. Findings are: A. Record review of an Admission Record sheet dated 7-22-2016 revealed Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 5-03-2016 revealed Resident 1 was at risk of falling. The goal was that Resident 1 would not have fall related injuries. The interventions listed on the CCP dated 5-03-2016 included for staff to keep environment well lit and free of clutter, call light and personal items in reach and assess the resident for pain. Further review of Resident 1's CCP revealed Resident 1 required 2 staff to assist with transfers. Record review of a Verification of Investigation (VOI) dated 5-28-2016 revealed Resident 1 had fallen in (gender) room. According to the VOI dated 5-28-2016, interventions implemented were non-skid socks, bed in low position, mat at bed side, commode at bed side and alarm box moved out of the resident's reach. Record review of a Post Fall Analysis/Plan sheet (PFAPS) dated 6-07-2016 revealed Resident 1 had fallen. According to the PFAPS dated 6-07-2016 the resident had a history of [REDACTED]. The new intervention was to apply wireless alarms to the bed as Resident 1 was able to turn of the previous type of alarms. Record review of a VOI dated 6-12-2016 revealed Resident 1 had fallen onto the floor. According to the VIO dated 6-12-2016 Resident 1 was transferring from a wheelchair to the bedside commode. Record review of the PFAPS dated 6-12-2016 revealed the facility staff identified that Resident 1 had impaired safety awareness/judgement. According to the PFAPS dated 6-12-2016, therapy was working with Resident 1 to use a walker. The PFAPS did not have information on how the facility staff were implementing interventions to prevent falls when Resident 1 was not working with therapy. Record review of an Interdisciplinary Progress Note (IPN) dated 6-14-2016 revealed Resident 1 was found on the floor with a wheelchair partially on top of Resident 1. According to the IPN dated 6-14-2016, Resident 1 was going to the bathroom. Record review of a PFAPS dated 6-15-2016 revealed the intervention was to assess the environment. The PFAPS did not contain information on how the environment was to be assessed or what interventions were implemented in an attempt to prevent falls while the environment was assessed. Further review of the PFAPS dated 6-15-2016 revealed there was no evidence on how the facility staff were assisting Resident 1 with toileting needs. Record review of a VOI dated 7-05-2016 revealed the resident was found sitting on the floor. According to the information on the VOI dated 7-05-2016 Resident 1 would often get up without using the call light. Record review of a VOI dated 7-7-2016 revealed Resident 1 had fallen when attempting to go to the bathroom. The VOI dated 7-7-2016 identified that Resident 1 had removed the alarms. The intervention identified on the VOI dated 7-7-2016 was to get Resident 1 up in the wheelchair and have staff sit with Resident 1 if Resident 1 continually set off the alarm of bed and commode. The VOI dated 7-7-2016 identified the CCP had not been revised with the intervention. Record review of Resident 1's CCP dated 5-03-2016 revealed the intervention for staff to get Resident 1 up in the wheelchair and have staff sit with Resident 1 if Resident 1 continually set off the alarm of bed and commode was not on the CCP. Record review of the PFAPS dated 7-7-2016 did not have any additional interventions to prevent falls for Resident 1. Record review of a VOI dated 7-17-2016 revealed the resident had fallen in the dinning room. According to the VOI dated 7-17-2016, Resident 1 had a possible fracture and was sent to the Hospital. No new interventions were identified on the VOI to prevent falls when Resident 1 would return to the facility. Record review of a Progress Note dated 7-20-2016 revealed Resident 1 was readmitted to the facility with a fractured right elbow. Record review of a Resident Cardex Information sheet (a basic information sheet for nursing assistant on how to take care of residents) printed on 8-4-2016 revealed it did not identify staff were to sit with the resident, the resident was to have a low bed or that a fall mat was to be in place. Observation on 8-03-2016 at 9:52 AM revealed Resident 1 was seated in a wheelchair in (gender) room. The call light was out of reach and Resident 1's bed was in the medium height. Observation on 8-03-2016 at 11:03 AM with Licensed Practical Nurse (LPN) A revealed Nursing Assistant (NA) B using a gait belt transferred Resident 1 from the bed to the wheelchair without an additional staff assisting. An interview was conducted with LPN A on 8-04-2016 at 7:02 AM. During the interview, LPN A confirmed Resident 1's bed was not in the low position during the observation on 8-03-2016 at 9:52 AM and further confirmed Resident 1 was transferred with one staff member. LPN A further reported that Resident 1 was impulsive and needed more monitoring. An interview was conducted with the Director of Nursing (DON) on 8-04-2016 at 7:30 AM. During the interview, the DON reported that there was not any trending of Resident 1's falls. Review of Resident 1's CCP also was conducted with the DON. When asked to offer Resident 1 to use the bathroom on rounds was an intervention, the DON stated no, they should have been doing that. The DON further confirmed that new interventions to prevent falls had not been implemented when Resident 1 returned from the hospital. On 8-04-2016 at 8:52 AM an interview was conducted with the Assistant Director of Nursing (ADON). Review of the VOI dated 7-17-16 was conducted with the ADON. The ADON reported that Resident 1 was impulsive and needed more supervision. The ADON confirmed Resident 1 had been left alone in the dining room when Resident 1 fell . B. Record review of an Admission Record sheet printed on 8-02-2016 revealed Resident 2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 2's CCP dated 2-25-2016 revealed the facility staff had identified Resident 2 was at risk for falls. The goal for Resident 2 was not to have any fall related injuries. Interventions to prevent falls included call light or personal items in reach, use gait belt with transfers, keep environment clutter free and provide foot wear to prevent slipping. Record review of Resident 2's Progress notes identified the resident was alert and oriented. Record review of an Abuse, Neglect or Misappropriation sheet dated 8-2-2016 revealed Resident 2 had fallen on 7-27-2016 with a resulting fracture. Review of the resident's medical record that included progress notes, CCP and physician orders [REDACTED]. An interview was conducted with the DON on 8-03-2016 at 5:05 PM. During the interview, the DON confirmed there were no new interventions to prevent falls. Record review of the facility undated Falls Management Guideline revealed the following: -Process: -Following a residents fall appropriate interventions are implemented. -Care plan updated. -Residents with Multiple Falls: -Trending of falls for the individual-time of day, reason for fall, location of fall etc. Cross reference to F315 for failure to implement a toileting program for Resident 1.",2019-08-01
4064,HILLCREST MILLARD,285302,13225 WESTWOOD LANE,OMAHA,NE,68144,2019-07-11,689,D,1,0,9M1111,"**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 staff failed to implement identified interventions to prevent falls for 2( Resident 5 and 3) of 5 sampled residents. The facility staff identified a census of 65. Findings are: [NAME] Record review of Resident 5's Comprehensive Care Plan (CCP) effective 5-16-2019 revealed Resident 5 had the [DIAGNOSES REDACTED]. The goal identified on Resident 5's CCP was Resident 5 would have reduced risk for falling. Interventions identified on Resident 5's CCP included keeping items in reach, slipper socks when up and a reminder sign in room to call for assistance. Observation on 7-11-2019 at 6:45 AM revealed there was not a sign in the room to remind Resident 5 to ask for assistance prior to transferring. Observation on 7-11-2019 at 11:50 AM revealed there was not a sign posted in Resident 5's room to remind Resident 5 to as for assistance prior to transferring. On 7-11-2019 at 12:00 PM an interview was conducted with Unit Manager (UM) B. During the interview UN B reported a yellow sign should have been in Resident 5's room, reminding Resident 5 to ask for assistance and confirmed the sign had not been posted in Resident 5's room. On 7-11-2019 at 12:00 PM an interview was conducted with Clinical Consultant (CC) [NAME] During the interview CC A reported all residents should have a gait belt on during a transfer including residents who require stand by assistance with transfers. B. Observation on 7-11-2019 at 12:00 PM revealed Nurse Tech (NT) B brought a chair scale into Resident 5's room. NT C cued Resident 5 to obtain Resident 5's weight. With out a gait belt being applied around Resident 5's waist, Resident 5 transferred from a wheelchair to the chair scale and back to the wheelchair. C. Record review of Resident 3's CCP effective 6-21-2019 revealed Resident 3 was at risk for falls. Further review of Resident 3's CCP effective 6-21-2019 revealed Resident 3 had the daiagnoses that included the following: -difficulty walking, -fall on same level from slipping, tripping, and stumbling without subsequent striking against object, -fracture of unspecified part of neck of left femur, -subsequent encounter for closed fracture with routine healing, history of falling, and unsteadniness on feet. Record review of a Tinetti Balance assessment Tool sheet dated 7-01-2019 revealed Resident 3 was evaluated as a high risk for falls. Observation on 7/10/2019 at 2:19 PM revealed that there was no fall mat beside the bedside and no fall alarms were noted on the Resident's chair. There was no Call dont fall sign as related to the facility policy. Review of the facility Fall Risk Management Program policy date effective 10/10/2018 revealed Resident 3 was to have a Yellow sign placed in room stating Call don't fall.",2020-09-01
5422,"BCP BLUE HILL, LLC",285144,414 NORTH WILLSON,BLUE HILL,NE,68930,2017-01-30,323,G,1,0,D8BS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, record reviews, and interviews; the facility failed to ensure staff followed the plan of care for fall interventions for one resident (Resident 104) of the 3 sampled residents. The facility census was 32. Findings are: Review of Resident 104's undated face sheet revealed an admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 11-10-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 14 which indicated intact cognition. Resident 104 required limited assist of 2 staff with bed mobility, transfers, walking, locomotion, toileting, and personal hygiene. The resident required extensive assist of 2 staff with dressing. Resident 104 was always continent of the bowels and occasionally incontinent of the bladder. Review of the Nursing Notes dated 12-31-16 at 06:25 AM revealed the staff found Resident 104 on the floor in the resident's room. The resident was assessed and complained of pain in the left hip with any movement. Resident 104 was transferred to the hospital and required a surgical repair for a fractured left hip. Review of the Post Fall Investigation form for the fall dated 12-31-16 revealed the resident's bed alarm sensor pad was in place but the alarm box was not connected. Interview with the ADM (Administrator) confirmed the Facility Investigation report revealed Resident 104 had 2 different types of fall alarms used the night of 12-31-16, a bed alarm and a personal alarm or known as a TABS alarm. (A bed alarm utilized a pressure sensitive pad the resident lays on connected to an alarm box which rings with resident movement from the bed. The TABS alarm had a string attached to the resident's clothing with a clip. The other end of the string had a magnet attached to the alarm box. The alarm box had to be secured to a permanent fixture so when the resident stood and moved away from the alarm, the string pulled the magnet off the box and the alarm would ring. If the alarm box was not secure, the alarm magnet would not disconnect from the box and the alarm could not ring to alert the staff.) The ADM confirmed the staff interviewed revealed that , on 12-31-16, the night shift who worked with Resident 104 were unable to secure the TABS alarm box to a secured surface. Therefore, when Resident 104 attempted to get out of bed unassisted, the TABS alarm did not alert the staff of the resident's unwanted movement. The ADM also confirmed that, at the time of the fall, the investigation revealed the bed alarm sensor pad was on the bed but not connected to the bed alarm box so it did not ring and alert the staff when the resident independently got out of the bed. Interview on 01-30-17 at 1:00 PM with Nurse-C revealed the Facility was in a 3 week roll out phase of alarms which was a trial of eliminating fall alarms in the facility. Last week, the facility eliminated all fall alarms in the dining room during meals. Starting 01-31-17, the facility began only bed alarms to be used when in bed at night time. Nurse-C revealed there were only 2 residents that had alarms and Resident 104 was one of the two residents. Review of the Care Plan dated 09-14-16 revealed Resident 104 was a high risk for falls related to advanced age, weakness after having had pneumonia, and several actual falls with dates listed. Interventions listed included: educated resident to not get up fast and to sit before position changes, reminded the resident to use the walker when standing up, leave a night light on; educated the resident on the importance to use the call light when feeling weak, the staff to offer the toilet during rounds, keep the bed in a low position, keep a foot cradle on the bed (dated 10-19-16); keep the call light within reach, keep fall alarms on while in the bed and in the chair; Observation on 01-30-17 at 1:47 PM of Resident 104 revealed the resident was asleep in the resident's bed. The call light cord laid on the floor at the foot of the bed out of the reach of the resident. The foot cradle was not on the bed but on the floor on the opposite side of the room from the bed. The bed alarm cord extended from the bed and laid on the floor. There was no alarm box observed connected to the bed alarm. On 01-30-17 at 1:50 PM, NA-A (Nurse Aide) entered Resident 104's room. Interview with NA-A confirmed the call light was on the floor at the foot of the bed and not within the resident's reach. NA-A confirmed the foot cradle was supposed to be on the foot of the bed to help prevent a fall caused by the resident's feet from getting tangled in the covers. NA-A confirmed the resident was to have the bed alarm on when in the bed both during the day and at night. NA-A also confirmed the bed alarm sensor pad was not connected to an alarm box and an alarm box was not in the resident's room. NA-A obtained an alarm box and applied it to resident bed alarm. Interview on 1-30-17 at 1:55 PM with NA-B revealed today was the first day that the residents were to wear the bed alarms only when in bed for the roll out phase of alarms and currently there were only 2 residents with alarms. Resident 104 was one of the 2 residents. NA-B confirmed Resident 104 was to have a bed alarm on anytime the resident was in bed, this included during the day for a nap. Interview on 1-30-17 at 1:56 PM with NA-E revealed today was the first day that the residents were to wear the bed alarms only when in bed for roll out phase of alarms and currently there were only 2 residents with alarms. Resident 104 was one of the 2 residents. NA-E confirmed Resident 104 was to have a bed alarm on anytime the resident was in bed, this included during the day for a nap. Interview on 01-30-17 at 4:50 PM with Nurse D confirmed Resident 104 was one of the residents to have a bed alarm on only when in bed which started 01-30-17. Nurse D confirmed the bed alarm should be on whenever the resident was in bed anytime during the day or night. Interview with the DON (Director of Nursing ) on 01-30-17 at 4:45 PM confirmed the facility had started a roll out phase of alarms on (MONTH) 23, (YEAR). The DON revealed the plan was the residents with alarms were only to use the bed alarms when in bed at night only effective 01-30-17 for 1 week, then next week no alarms at all. The DON revealed staff were educated but confirmed there must be some miscommunication based off of the observations and interviews from today. The DON confirmed the DON educated the staff at a meeting on 01-18-17 to be successful with no fall alarms, the staff were educated to ensure the other fall interventions must be used such a call lights within reach at all times and any other fall interventions care planned for a specific resident such as the foot cradle for Resident 104.",2020-01-01
6031,ROCK COUNTY HOSPITAL LONG TERM CARE,2.8e+279,100 EAST SOUTH STREET,BASSETT,NE,68714,2016-12-14,323,E,1,1,K1OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record review and interview; the facility failed to assess causal factors and develop, revise and implement interventions for the prevention of falls for 4 residents (Residents 26, 17, 29 and 4). The sample size was 23 and the facility census was 28. Findings are: A. Review of Resident 26's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/26/16 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was cognitively intact (able to maintain attention, orientation and register/recall information) and the resident had 1 fall with no injury since the last assessment. Review of Resident 26's Progress Notes dated 6/3/16 at 4:20 AM revealed the resident was sleeping on the edge of the bed and rolled off, landing on knees. Review of Resident 26's Progress Notes dated 6/11/16 at 1:07 PM revealed the resident was found on the floor at the foot of the bed. Documentation indicated the resident fell while going to get a magazine. Review of Resident 26's current Care Plan (undated) revealed a Temporary Problem List which identified the following: -6/11/16-the resident had a fall and the intervention was to remind the resident to call for assistance. -6/13/16-the resident rolled out of bed and interventions were to remind the resident to call for assistance and the bed was placed in the low position. Review of Resident 26's Progress Notes dated 10/13/16 at 5:21 AM revealed the resident slid out of bed. Documentation further indicated the bed was in the lowest position and the call light was in reach. The resident was reminded to call for assistance. There was no evidence potential causal factors were assessed and additional interventions for the prevention of falls were not developed. Review of Resident 26's Progress Notes dated 12/9/16 at 9:22 AM revealed a staff member attempted to wheel the resident out of the dining room and the resident's .shoes stuck to floor and under wheelchair and fell forward on knees. Review of Resident 26's Temporary Problem List dated 12/9/16 revealed the resident's fall from the wheelchair was identified. The intervention to prevent another fall from the wheelchair was to Make sure feet are up. Resident 26 was observed seated in a wheelchair in the dining room at 11:24 AM on 12/13/16. The resident's feet were positioned directly on the floor. The wheelchair foot pedals were stored in a bag hanging on the back of the wheelchair. At 12:11 PM on 12/13/16, Registered Nurse (RN)-B was observed to wheel Resident 26 out of the dining room and down the corridor to the resident's room. RN-B did not reattach the wheelchair foot pedals and Resident 26's feet were observed to slide along the floor while being transported to the room. At 2:22 PM on 12/13/16, an Activity Volunteer was observed to wheel Resident 26 from the resident's room, down the corridor and into the dining room. The wheelchair foot pedals were not in use and the resident's feet were observed to slide along the floor while being transported into the dining room. Interview with the Director of Nurses (DON) on 12/14/16 at 1:15 PM confirmed foot pedals were to be used when staff were transporting Resident 26 in the wheelchair. B. Review of Resident 17's MDS dated [DATE] indicated the resident had severe cognitive impairment and required extensive staff assistance with activities of daily living. The assessment identified [DIAGNOSES REDACTED]. Review of the resident's Morse Fall Scale dated 10/4/16 revealed a score of 65 indicating the resident was at high risk for falls. Review of Resident 17's current Care Plan (revision date of 10/6/16) revealed the resident had a history of [REDACTED]. The following interventions were identified: -Complete a Morse Fall Scale Assessment quarterly or with any change in condition. Resident at high risk for falls. -Keep the resident's call light close. -Staff to provide assist with stabilizing resident when unsteady and to use a gait belt. -Bed alarm to mattress. Review of Resident 17's Progress Notes dated 11/16/16 at 11:06 AM revealed the resident was walking with a staff member out of the bathroom and back to bed. The resident's legs buckled and the resident lost consciousness. Staff then lowered the resident to the floor. Review of Resident 17's Progress Notes dated 11/19/16 at 4:11 AM revealed the resident was having a difficult time with walking. The resident was assisted to the side of the bed and was then slid to the floor. During interview on 12/13/16 at 4:30 PM the DON verified after the resident fell on [DATE] and on 11/19/16 no causal factors were identified and fall prevention interventions were not revised nor were new interventions developed in an attempt to prevent ongoing falls. C. Review of Resident 4's current undated Care Plan revealed: - On 9/11/16 the resident fell while out of the facility with a friend. The interventions included a tabs alarm to be used when the resident was in the chair and the bed, and to remind the resident to use the call light. There was no evidence that causal factors were assessed to determine appropriate fall prevention interventions. - On 9/19/16 the resident fell out of a chair. No new interventions were identified, and there was no evidence that causal factors were assessed. Review of Resident 4's Progress Notes revealed: - On 9/10/16 at 4:47 PM the resident returned to the facility and reported the resident fell in the bathroom while out of the facility with a friend. There was no evidence that causal factors of the fall were assessed. - On 9/15/16 at 11:27 PM the resident fell while being assisted into the recliner after supper. The chair slid back and the resident was lowered to the floor. No new interventions were identified. - On 9/19/16 at 3:35 PM the resident was found on the floor beside the resident's bed. - On 9/20/16 at 8:55 AM the resident's physician reviewed the results of the urinalysis (UA) obtained after the resident fell on [DATE] and no new orders were given. There was no evidence the facility assessed any other potential causal factors following the UA results, and no new interventions were identified. - On 10/27/16 at 4:45 PM the resident's tabs alarm sounded and the resident was found on the floor beside the resident's recliner. There was no evidence that causal factors were assessed, and no new interventions were identified. D. Review of Resident 29's undated Care Plan revealed the resident was at risk for falls. Fall interventions included a tabs alarm on when the resident was in the bed and the recliner. The Care Plan indicated the resident was forgetful and would try to get up independently. Further review revealed the resident needed supervision with bed mobility and personal hygiene. Review of a Progress Note dated 11/2/16 at 2:41 PM revealed Resident 29 was found sitting on the resident's bathroom floor. The resident complained of slight right arm and right leg pain. Review of a Progress Note dated 11/2/16 at 6:48 PM revealed the resident complained of right femur (a bone in the leg) pain when getting up for supper. During an interview on 12/14/16 at 9:48 AM, Nursing Assistant (NA)-H revealed residents that required a tab's alarm on when in the chair and/or the bed needed to be supervised when in the bathroom, unless they had a tabs alarm attached while in the bathroom. During an interview on 12/14/16 at 9:33 AM, NA-K confirmed the process for a resident requiring a tabs alarm while in the chair and/or the bed was for the resident to be supervised when in the bathroom.",2019-07-01
3285,COMMUNITY MEMORIAL HEALTH CENTER,285257,"P O BOX 340, 1015 F STREET",BURWELL,NE,68823,2018-09-25,689,E,1,1,E7OB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record reviews and interviews, the facility failed to: 1) implement fall prevention interventions for Resident 44; 2) evaluate causal factors and develop new interventions to prevent ongoing falls for Resident 36; and 3) ensure Resident 4 was free from accident hazards as bed rails were used without an assessment or evaluation of the resident's change in condition. 6 residents were sampled related to falls and/or accidents and the facility census was 50. Findings are: [NAME] Review of Resident 44's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/11/18 included [DIAGNOSES REDACTED]. The MDS further indicated the resident had severe cognitive impairment and experienced 2 or more falls with no injury since the last assessment. Review of an Incident/Accident Form dated 8/21/18 at 5:54 PM revealed Resident had been seated in a recliner in the resident's room. Documentation further indicated at 5:35 PM Resident 44 was found sitting on the floor and the resident commented about trying to go to the bathroom. 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 seat of the resident's recliner. Review of Resident 44's current Care Plan (undated) revealed a fall prevention intervention dated 8/21/18 to place Dycem in the resident's recliner. On 9/20/18 at 11:40 AM, Nursing Assistants (NA)-F and NA-K were observed to enter Resident 44's room. Resident 44 was seated in the recliner. NA-F and NA-K assisted the resident to transfer from the recliner and into a wheelchair. There was no Dycem in the seat of the resident's recliner. Interview with NA-F at 11:47 AM on 9/20/18 confirmed Resident 44 did not have a Dycem in the seat of the recliner. NA-F stated the resident was supposed to have a Dycem in the seat of the recliner as a fall prevention intervention. B. Review of Resident 36's MDS dated [DATE] revealed the following: -severe cognitive impairment; -physical behaviors directed at others, rejection of cares and wandering which occurred on 1-3 days out of the 7 day assessment period; -required extensive assistance with bed mobility, transfers, dressing, toileting and with personal hygiene; -frequently incontinent of bowel and bladder; and -1 fall with no injury identified since the previous assessment. Review of the current Care Plan (undated) indicated Resident 36 was at risk for falling due to weakness and dementia. Nursing interventions included the following: -pressure pad fall 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) applied to bed; -provide x1 staff assistance with ambulation; -do not rush or redirect resident out of her personal space; -bed in the low position with adequate clearance to ensure safety when resident exits the bed; -non-slip socks or shoes to be on at all times; and -limit bed linens to a fitted sheet and only 1 blanket. Review of an Incident/Accident Form dated 6/17/18 at 2:45 AM revealed the resident had been awake on and off throughout the night and had voiced complaints about clothing feeling too tight. Staff heard the resident's fall alarm sounding and responded to the alarm. Upon entering the resident's room, the resident was observed falling to the floor and striking right posterior back on the bedside table. The resident sustained [REDACTED]. A new intervention to notify the Social Service Director about the need for different clothing was identified. Review of an Incident/Accident Form dated 6/22/18 at 6:45 AM revealed the staff heard the resident's fall alarm sounding and the resident was found on the floor of the resident's room. Further review of the form revealed the resident was not wearing gripper socks or shoes and the resident's bed had not been placed in the low position. An intervention for staff education was identified to assure fall prevention interventions were always implemented. Review of a Nursing Progress Note dated 6/27/18 at 5:50 PM revealed the resident was in room with a family member. The resident had been seated on an armless chair at the piano and slid off the chair to the floor. A new intervention was identified for the resident to have only chairs with arms in the resident's room. No injuries were identified. Review of an Incident/Accident Form dated 6/27/18 at 9:50 PM revealed the resident's fall alarm was sounding. Staff entered the resident's room and observed the resident standing between the bed and a bedside table. As the staff attempted to approach the resident, the resident fell backwards onto buttocks. Further review of the form revealed no new interventions were developed and current fall prevention interventions were not revised to prevent further falls. Review of a Nursing Progress Note dated 7/7/18 at 4:10 AM revealed the resident had been restless throughout the night and had set off fall alarms repeatedly. When staff responded to the fall alarm, the resident became more agitated, yelling the staff were trying to kill the resident. The resident was assisted to the bathroom but the resident was resistive and struck out at the staff repeatedly during toileting. Review of an Incident/Accident Form dated 7/7/18 at 4:17 AM revealed the resident's fall alarm was heard sounding. The resident was found on the floor of the resident's room. The resident was confused and agitated and yelled at the staff that it was time to make supper. No injuries were observed and the resident was assisted into the dining room and placed in a recliner. An intervention was identified to approach the family about trying a calming aromatherapy scent when the resident became agitated. Review of a Nursing Progress Note dated 7/7/18 at 11:58 AM revealed staff had contacted the resident's family and family were in agreement regarding use of aromatherapy. Review of a Nursing Progress Note dated 7/10/18 at 4:04 PM revealed the resident was heard exiting the resident's bathroom. Staff went to check on the resident and found the resident down on knees holding onto the resident's walker. Further review revealed no new interventions were developed and current interventions were not revised to prevent further falls. Review of an Incident/Accident Report dated 7/13/18 at 2:00 PM revealed the resident had a fall in the corridor outside of the resident's room. The resident had a 3 cm laceration to the right side of the resident's head. The resident was sent to the emergency room to be evaluated. Resident 26 returned to the facility with sutures to the right side of head. Review of a Post Fall assessment dated [DATE] at 2:00 PM revealed the resident had been having increased falls and behaviors. There was no evidence the facility investigated Resident 26's fall, determined causal factors, and/or developed new interventions for the prevention of further falls. Review of an Incident/Accident Form dated 9/2/18 at 10:25 PM revealed the resident's fall alarm was sounding. Staff responded to the alarm and found the resident seated on the edge of the resident's bed. The resident bent over to inspect the resident's foot, fell forward and bumped head on a table before falling to the floor. An intervention was developed to rearrange the resident's room to assure enough clearance for the resident to safely exit the resident's bed. Review of an Incident/Accident Form dated 9/7/18 at 4:38 AM revealed the resident's fall alarm was heard sounding. Staff entered the resident's room and found the resident on the floor and wrapped up in blankets. The resident had a bump to right forehead with a slight carpet burn. The resident was assisted up from the floor and was taken to the bathroom. An intervention was identified to remove the top sheet from the resident's bed and to allow only 1 blanket to resident's bed to prevent further falls. During interview on 09/25/18 at 10:57 AM, the Director of Nursing (DON) verified the following: -the intervention developed after the resident's fall on 7/7/18 at 4:17 AM for calming aromatherapy when the resident was agitated had been approved by the resident's family, but had never been implemented; -causal factors had not been identified for Resident 26's fall on 7/10/18 at 4:04 PM, current fall prevention interventions were not revised and no new interventions were developed; and -no additional fall prevention interventions were identified after Resident 26's fall with injury on 7/13/18. C. Review of Resident 4's MDS dated [DATE] revealed the following: -admitted [DATE] with a [DIAGNOSES REDACTED]. -moderately intact cognition; -required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene; and -had functional limitations in range of motion (ROM-the full movement potential of a joint) bilaterally in the upper extremities. Review of Resident 4's current Care Plan dated of 6/21/18 revealed a deficit in ADL (activities of daily living) self-care performance with nursing interventions that included top bed rails per request for repositioning. Review of a Bed Rail Evaluation tool dated 6/15/18 included the following related to Resident 4: -able to get in/out of bed; -used the bed rails for positioning or support; -requested bed rails be used while in bed; -the bed rails served as an enabler to promote independence; -the bed rails assisted the resident in holding self to one side and supporting self; and -half rails at the top of the bed were the type of bed rails used. During observation on 9/18/18 at 2:41 PM, Resident 4's bed was unoccupied and there were bilateral half bed rails at the top of the bed and in the elevated position. The right bed rail moved loosely back and forth toward the mattress and back, and there was a gap the width of a closed fist between the bed rail and the mattress. During interview on 9/18/18 at 2:45 PM, Resident 4's spouse verified the resident was unable to use the bed rails for repositioning and was unaware of their purpose. During observations on 9/19/18 at 2:12 PM and on 9/20/18 at 6:59 AM, Resident 4 was in bed and the half bed rails were in the elevated position bilaterally. During observation of nursing care on 9/20/18 from 7:15 AM until 7:44 AM, NA-E and NA -D assisted Resident 4 with morning care. The resident was in bed and the half bed rails were in the elevated position bilaterally. NA-E physically lifted the resident's upper torso off the bed and pivoted the resident to sit at the edge of the bed. The resident's forearms were rigidly positioned in front of the torso, and the hands were tightly closed in fists. Resident 4 made no attempt to assist during the transfer. The resident's arms and hands remained in the same position through remaining transfers to and from the wheelchair, and to the toilet with the assistance of 2 staff. During interview on 9/20/18 at 7:45 AM, Licensed Practical Nurse (LPN)-C verified Resident 4 was unable to use the bed rails for repositioning as severe hand contractures (abnormal shortening of muscle tissue, making it highly resistive to stretching and eventually causing permanent disability) prevented the resident from being able to grasp them. LPN-C further indicated the side rails were usually down and was unaware why they are up at this time. Review of a Nursing Progress Note dated 9/20/18 at 8:12 AM indicated Resident 4 was unable to use the half bed rails for repositioning and, therefore, they were discontinued with the Resident in agreement to do so. During observation on 9/24/18 at 3:30 PM, Resident 4 was lying in bed with the head of the bed elevated. The half bed rails were down but remained attached to the bed frame and functioning. The following was revealed during interviews related to Resident 4's bed rails: -9/24/18 from 3:28 PM until 03:45 PM - LPN-H indicated it was a month or better that the resident was unable to use hands to grasp anything, and therefore, the resident would not be able to use the bed rails. LPN-H further verified the use of bed rails should have been reassessed with [REDACTED]. -9/25/18 at 8:25 AM - The Maintenance Supervisor verified the bed rails were removed from the bed frame to assure inaccessibility and resident safety.",2020-09-01
1912,"PREMIER ESTATES OF KENESAW, LLC",285166,"P O BOX 10, 100 WEST ELM AVENUE",KENESAW,NE,68956,2017-09-06,323,D,1,0,GWOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record reviews, and interviews; the facility failed to ensure a safe transfer technique was used on 2 residents(Resident 411 and 409) out of 3 sampled residents and the facility failed to use the safety belt during the transfer on the whirlpool chair into and out of the whirlpool tub and during the bathing process for Resident 406. Findings are: A Observation on 08-24-17 at 10:03 AM of NA-A revealed the nurse aide transferring Resident 411 from the bed into a wheelchair without the use of a gait belt. NA-A had both arms around the resident's waist. Review of Resident 411's [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 07-25-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 12 which indicated Resident 411 was moderately cognitively impaired. The resident required one staff with extensive assist for transfers, bed mobility, personal hygiene, dressing, and toileting. The resident's balance was not steady, only able to stabilize with staff assistance for moving from seated to standing, moving on/off the toilet, and surface to surface transfers. Review of Resident 411's careplan revealed the intervention dated 07-25-16 the resident requires extensive assist with transferring. Interview on 08-24-17 at 4:40 PM with Resident 411 revealed the staff transfer the resident sometimes with use of the gaitbelt and sometimes not. Interview with NA-B on 08-24-17 at 4:35 PM revealed Resident 411 was a 1-2 staff transfer with use of a gait belt. Interview with the ADM on 09-06-at 4:45 PM revealed the practice of the facility was staff to use a gait belt with all transfers if the resident required assistance. We discussed circumstances of the transfer and the ADM confirmed NA-A should have used a gait belt. B Review of PN (Progress Notes) for Resident 409 dated 08-29-17 revealed the nurse was called to the bath house and found the resident laying on the floor on the resident's left side. The resident report the resident stood up and lost (gender) balance and fell to the floor. Review of the facility investigation report revealed NA-C (Nurse Aide) was with the resident at the time of the fall in the bath house. NA-C stood the resident up from the whirlpool chair and while the resident hung on to the tubs side, NA-C let go of the resident to remove the whirlpool chair and bring the resident's wheelchair into place. When NA-C let go of the resident, the resident fell . Review of Resident 409's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 06-20-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 11 which indicated Resident 409 was moderately cognitively impaired. Resident 409 required one staff with extensive assist for bed mobility, dressing, toilet use, and personal hygiene. The resident required 2 staff with extensive assist for transfers. The resident's balance was not steady and only able to stabilize with staff assistance with moving on/off the toilet, surface to surface transfers, and seated to standing transfers. Review of Resident 409's careplan revealed the resident was at risk for falls related to a gait and balance problem. The intervention dated 08-12-16 revealed the resident required 2 staff assist for transfers to and from bed and recliner, one assist in the bathroom. Interview on 09-06-17 at 2:50 PM with NA-C revealed a gait belt was to be used for resident transfers and NA-C confirmed a gait belt was not used during the transfer when the resident fell in the bath house Interview on 09-06-17 at 2:40 PM with the ADM (Administrator) confirmed NA-C had not used a gait belt during the transfer of Resident 409 and it was the expectation of the facility for a gait belt to be used on all residents who required assistance. The ADM revealed the ADM re-educated this one employee but did not re-educate the rest of the staff on the use of gait belts for resident transfers. C Observation on 09-06-17 at 2:15 PM revealed NA-A gave Resident 406 a whirlpool bath in the 400 unit bath house. NA-A and NA-B transferred the resident with use of a gait belt from the wheelchair into the whirlpool chair. NA-A did not apply a safety belt on the resident in the whirlpool chair. There was not a belt on the whirlpool chair but the chair had metal rings on it as if to hold a safety belt. NA-A lifted the whirlpool chair up about 1-2 feet and place resident into the side-opening tub. NA-A proceeded to wash the resident and at times had to reach for items such as washcloths and soap. NA-A kept both arms outstretched and eyes on the resident at all times, but was not able to keep hand directly on resident while grabbing items. Resident was raised up in the lift chair approximately 2-3 feet so NA-A could wash the residents feet and legs. Resident was lowered and brought out of the tub. Interview on 09-06-17 at 2:30 PM with NA-A revealed the safety belt on the whirlpool was broke and a new one had been ordered. NA-A revealed the nurse aide had asked for guidance what to do since the belt was broke and was instructed the resident did not need a safety belt. Review of Resident 406's undated [DIAGNOSES REDACTED]. Review of Resident 406's MDS dated [DATE] revealed the resident was severely cognitively impaired. The resident required extensive assistance of 1 staff with bed mobility, dressing, eating, toileting, and personal hygiene. The resident required extensive assistance of 2 staff with transfers. Interview on 09-06-17 at 2:50 PM with NA-C revealed the nurse aide had did not use safety belts when given baths in the whirlpool nor had the nurse aide seen other staff use a safety belt except when a bath was given to a resident that was apt to slide out of the chair like (NA-C named another resident). Interview on 09-06-17 at 2:58 PM with NA-D revealed the nurse aide did not use the whirlpool on the 400 unit, only the 100 unit but NA-D had never used a safety belt with any of those residents as they are more independent than the 400 wing. Observation on 09-06-17 at 2:58 PM of the 100 unit bath house accompanied by NA-D revealed no safety belt was on the whirlpool. Interview on 09-06-17 at 3:05 PM with the ADM revealed the ADM was not aware staff had not been given baths with use of a safety belt on all residents or that the belt was broke for the 400 unit. The ADM revealed it was the expectation that the safety belt be used with all residents. Requested from the ADM the policy on whirlpool bathing. Review of the Aqua-Aire Penner Sit Bath System 6900 Safe Operation and Daily Maintenance Instructions revealed to attach the seat belt around the resident using the D-rings on the seat belt prior to placing the resident into the tub. Interview on 09-06-17 at 4:45 PM with the ADM revealed the facility did not have a policy on how to give a whirlpool bath.",2020-09-01
2805,SUNRISE COUNTRY MANOR,285232,"PO BOX A, 610 224TH STREET",MILFORD,NE,68405,2017-05-23,323,D,1,0,2FAT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record reviews, and interviews; the facility failed to put interventions into place to prevent potential injury from falls for 2 (Residents 205 and 207) out of 3 residents sampled. The facility census was 74. Findings are: [NAME] Observation on 5-22-17 at 10:10 AM of Resident 205 revealed the resident was in bed in the resident's room. The resident was awake. The bed was a high-low bed and positioned in the high position. The mattress was a regular mattress. No fall mat was placed on the floor. Review of the undated face sheet for Resident 205 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the quarterly MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 3-14-17 revealed the resident's cognition was severely impaired. The resident required total assistance of 2 staff with bed mobility, transfers, dressing, and toileting. The resident required total assistance of 1 staff for locomotion, personal hygiene, and eating. The Assessment of Risk for Falls form was completed on 09-21-16, 02-17-17 and 3-7-17. Each time the resident scored a 13. Per this assessment tool, a score between 7-18 indicated a high risk for falls. Review of the CAA's (Care Area Assessment) from the MDS dated [DATE] revealed falls was triggered. Review of the CAT (Care Area Triggers) dated 12-21-16 revealed the resident had impaired balance. The resident also had internal risk factors of incontinence, [DIAGNOSES REDACTED], seizure disorder, traumatic brain disorder, delirium, and cognitive impairment. Resident 205 was a 2 assist with use of a Hoyer (a mechanical lift device that does not require the resident to bear weight on the legs) lift for transfers. The care plan team decided not to care plan the resident as a potential risk for falls. Review of Resident 205's care plan revealed a potential for falls was not addressed. Interview on 5-22-17 at 2:45 PM with Staff D revealed Resident 205 was not ambulatory, could not communicate verbally, and did not use the call light. The resident had a tilt-n-space wheelchair that was put in a tilted position for positioning so the resident did not fall out of the chair. Interview on 5-23-17 at 10:46 AM with MDS -C revealed Resident 205 had a tilt-n-space wheelchair for pressure relief and positioning because of the history of seizures and to help prevent falls if the resident would have a seizure while in the chair. Resident 205's last fall was (MONTH) 2009. The resident did exhibit behaviors at times and would grab at staff when upset. The resident could move the upper extremities and could cross ankles. MDS-C revealed the care plan team determined not to care plan the resident as a risk for falls since the resident had not had a fall since 2009. B. Observation on 5-22-17 at 10:15 AM of Resident 207 revealed a light yellow bruise to the right facial cheekbone approximately 1.5 inches in size. The resident had a chair alarm on the wheelchair and anti-tip bars on the wheelchair. Review of the undated face sheet for Resident 207 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was moderately cognitively impaired with inattention and disorganized thinking. The resident required limited assist of 1 staff with bed mobility, dressing, and personal hygiene. Resident 207 required limited assist of 2 staff with transfers and walking in the hall. The resident's balance was not steady without staff assist. Review of the Progress Notes dated 05-12-17 revealed the resident was found on the floor lying next to the bed in the resident's room. Resident 207 received a bruise to the right cheek. On 05-13-17, Resident 207 was witnessed to be reaching and leaning forward in the wheelchair. Resident 207 slid out of the chair and landed on the knees and hands. The resident received a small abrasion to the right knee. On 05-15-17, the resident was witnessed attempting to stand up and attempted to scoot self back into the wheelchair. The chair rolled out from behind the resident and Resident 207 landed on the floor on the buttocks. No injuries resulted. Review of the care plan revealed falls were addressed with interventions but the interventions were not dated. Interview on 5-23-17 at 11:20 AM with LPN-A (Licensed Practical Nurse) revealed the Incident reports were reviewed and the interventions were listed. The intervention for the 5-12-17 fall was a fall mat was placed by the resident's bed. For the 5-13-17 fall, an intervention was not initiated as this was an agency nurse. For the 5-15-17, fall the intervention was to put anti-roll back brakes on the wheelchair. However, hospice would not pay for them so the brakes had not been obtained yet. The facility was still working on it.",2020-09-01
2686,HERITAGE OF EMERSON,285222,607 NEBRASKA STREET,EMERSON,NE,68733,2018-12-03,689,D,1,0,BWYO11,"**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 develop additional interventions for the prevention of falls for 1 resident (Resident 50). The sample size was 4 and the facility census was 31. Findings are: Review of Resident 50's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/31/18 revealed the resident had short term and long term memory problems, and had experienced 1 fall with no injury since the last assessment. Review of Resident 50's Care Plan (undated) revealed the resident had a history and/or potential for falls. Interventions included the following: -Assist the resident to the toilet after meals and between 3:00 PM and 4:00 PM; -Ensure properly fitting non-skid footwear for ambulation; -Maintain environment free of clutter and safety hazards; and -Place items frequently used by the resident within easy each. Review of Progress Notes dated 11/11/18 at 7:20 AM revealed Resident 50 was observed sitting on the floor in front of the room door and bathroom. The resident sustained [REDACTED]. Documentation further indicated the laceration was 6 centimeters in length and required staples. The resident was to remain overnight at the hospital for observation. Review of Progress Notes dated 11/12/18 at 10:45 AM revealed Resident 50 returned from the hospital that day. Documentation indicated the resident ambulated with a walker and stand by assistance. There was no evidence causal factors of Resident 50's fall on 11/11/18 were assessed and additional interventions for the prevention of falls were not developed. Review of Progress Notes dated 11/13/18 at 11:10 AM revealed Resident 50 had a fall without injury in the dining room after attempting to transfer without assistance. Interview with the Director of Nurses on 12/3/18 at 3:15 PM confirmed additional interventions for the prevention of falls were not developed after Resident 50 fell on [DATE].",2020-09-01
2117,BUTTE SENIOR LIVING,285180,210 BROADWAY,BUTTE,NE,68722,2017-07-19,323,G,1,0,PFZV11,"**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 implement and/or revise interventions for the prevention of falls for 2 residents (Residents 1 and 3) who were determined to be at risk for falling. Resident 1 sustained injury fractured hip following a fall that resulted from failure to transfer the resident in a safe manner. For Resident 3, interventions were not implemented and causal factors were not assessed in an attempt to prevent falls. 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 was admitted to the facility on [DATE] with flaccid [DIAGNOSES REDACTED] (paralysis affecting one side of the body) affecting the left side and a right leg below the knee amputation. Further review revealed on 7/7/17 the resident required 2 staff assistance for transfers and positioning. Review of the Resident Incident Report dated 7/7/17 revealed Resident 1 had fallen on 7/7/17 at 9:20 PM. The resident was transferred from the wheelchair into bed by Nursing Assistant (NA) - C. When NA-C turned away from the resident to move the resident's wheelchair, the resident rolled onto the floor. Review of the Investigative Report submitted to the State Agency on 7/12/17 revealed on 7/8/17 (the day after the fall) Resident 1 complained of left hip pain, was transferred to the emergency room , and was diagnosed with [REDACTED]. Interview with NA-A on 7/19/17 at 10:25 AM confirmed on 7/7/17 at the time of Resident 1's fall, the resident required 2 staff members for transfers and positioning. The resident was currently a 2 staff assist with the full-body mechanical lift as a result of being non-weight bearing due to the left hip fracture that was sustained during the fall. During an interview on 7/19/17 at 12:35 PM, the Administrator confirmed on 7/7/17 Resident 1 required 2 staff members assistance for transfers and positioning. Further interview confirmed Resident 1's fall, which resulted in a fractured left hip, was the result of the resident being transferred by 1 staff member instead of 2. B. Review of the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/7/17 revealed the following related to Resident 3: -had a [DIAGNOSES REDACTED]. -was cognitively intact; -required limited assistance of 2 for transfers and ambulation in the resident's room; -required extensive assistance of 2 for toilet use; -was unsteady and only able to stabilize with staff assistance during transitions and walking; and -had a history of [REDACTED]. Review of Resident 3's Care Plan dated 1/23/17 indicated the resident had limited physical mobility and was at risk for falls. Nursing interventions included the following: -required assistance of 1 for mobility and transfers, and use of a gait belt (a safety device used during transfers and ambulation to help prevent falling); -dycem (an anti-slip material) on seat of wheelchair to prevent sliding; -sign placed on the wall stated (resident) always ring your call light for help you are unable to walk by yourself; -bed in lowest position with fall mat (a mat placed on the floor next to the bed to provide padding in case of a fall from the bed) in place; and -call light within reach. Review of Nursing Progress Notes revealed the following related to Resident 3's history of falls: -3/26/17 at 4:56 AM, found on the floor mat next to the bed following an attempt to go to the bathroom independently; encouraged to use the call light; educated that it is very important to have staff assistance until therapy feels (the resident) can go independently; -5/12/17 at 5:47 AM, fell at 5:30 AM while walking from the bed to the bathroom; knees buckled and staff lowered the resident to the floor; and -6/7/17 at 3:30 AM, went to the bathroom independently, and on the way back attempted to sit on the recliner, slid off and sat onto the floor mat. Review of the Fall Investigation dated 6/7/17 at 3:30 AM revealed Resident 3 activated the call light at 3:10 AM and requested to go to the bathroom. NA-D informed the resident (gender) was scheduled to go at 3:30 AM according to the bowel/bladder plan. At 3:30 AM (20 minutes after the resident's request to use the bathroom), NA-D returned to the resident's room and found the resident on the floor. The resident verbalized going to the bathroom independently. The investigation further documented that the resident was last taken to the toilet by staff at 1:30 AM and was dry at that time. There were no new interventions initiated in an attempt to prevent further falls. Review of Nursing Progress Notes dated 6/22/17 at 5:10 AM indicated Resident 3 was heard kicking the room door and was found on the floor yelling get towels I peed. The resident was incontinent of urine and indicated the fall occurred while going to the bathroom. There was no evidence to indicate the facility assessed causal factors for Resident 3's falls, or reviewed and revised interventions to prevent further falls. During interview on 7/19/17 at 1:42 PM, the Director of Nursing (DON) verified causal factors for Resident 3's falls had not been assessed.",2020-09-01
5700,COMMUNITY PRIDE CARE CENTER,285208,901 SOUTH 4TH STREET,BATTLE CREEK,NE,68715,2016-10-06,323,E,1,0,U8GT11,"**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 ensure that residents were protected from injury related to the application of ice packs. Resident 12 developed blisters following the application of ice packs. Additional interventions were not developed and/or implemented to assure 3 residents (Residents 11, 13 and 15) who were currently receiving ice packs were protected from injury. The sample size was 4 and the facility census was 44. Findings are: Review of the facility policy titled Applying an Ice Pack or Soak (undated) included the following: -Wrap ice pack in a cloth to protect skin from frost bite or other injury; -Apply to directed area for 15 to 20 minutes or as long as directed; -Check the resident's skin often. Look for blanched skin (turning white), skin becoming pale or bluish, lips and fingernails turning blue; -If any of the above conditions are observed, cease the treatment and summon the staff/charge nurse at once. Review of Resident 12's Treatment Record (TR) dated 9/2016 revealed an order dated 8/31/16 for application of an ice pack to the right shoulder for 15 to 20 minutes 4 times per day. Review of Resident 12's electronic medical record revealed a progress note dated 9/17/16 at 11:39 AM which indicated the resident had redness measuring 8 x 11 cm (centimeters) and 4 small fluid-filled blisters to back R (right) shoulder. Resident notifies nurse of this ice bag being placed to upper backside of R shoulder and not removed. Does c/o (complain of) pain now. Review of a statement dated 9/17/16 by Nursing Assistant (NA)-C revealed 2 ice packs were found in Resident 12's room on the morning of 9/17/16 when NA-C was assisting the resident out of bed. NA-C indicated 1 ice pack was on the resident's bed and the other had been placed under the resident's shirt on the right shoulder. NA-C reported the resident had a red blistered area where the ice pack had been pressed against the shoulder. Review of the Incident Type (incident report) dated 9/17/16 at 1:41 PM revealed Resident 12's blistered skin area of the right upper back was noted at 6:45 AM and the possible cause was the ice pack left in place without cloth barrier between skin and ice. Documentation further indicated staff members were educated on the proper use of ice packs. Review of an internal memo dated 9/17/16 at 2:16 PM revealed all staff members were educated regarding use of ice packs. Staff members were reminded to place a barrier (pillow case) between the ice pack and the resident's skin. Documentation further indicated residents were not to lay on ice packs and ice packs were not to be left on longer than 20 minutes or per physician's order. The condition of the resident's skin was to be assessed when using ice packs (before and after). Review of an internal memo dated 9/17/16 at 6:59 PM revealed Licensed Practical Nurse (LPN)-I was educated on the use of ice packs. LPN-I stated Resident 12's ice pack had been placed in a pillow case and wrapped 3 times before placing it on the resident. LPN-I .stated that resident had requested to keep ice pack longer. Review of Resident 12's TR revealed the ice packs were discontinued on 9/17/16. Interview with LPN-A on 10/5/16 at 1:50 PM confirmed LPN-I had not removed the ice packs as ordered on [DATE]. LPN-A indicated the facility implemented a system with their computer program to assure application and removal of ice packs would be documented on the TR. LPN-A further indicated there were currently 3 residents (Residents 11, 13 and 15) who were receiving ice packs. Review of TR's dated 10/2016 for Resident 11, 13 and 15 revealed no evidence the application and removal of ice packs was documented. Interview with Registered Nurse (RN)-B on 10/5/16 at 2:40 PM confirmed the computer program had not been changed to ensure documentation was completed regarding the application and removal of ice packs for Residents 11, 13 and 15. Interview with the Director of Nurses and LPN-A on 10/6/16 at 7:28 AM confirmed additional interventions were not developed and/or implemented to ensure ice packs did not slide out of the cloth cover during use and to ensure ice packs were removed as ordered.",2019-10-01
5802,COMMUNITY PRIDE CARE CENTER,285208,901 SOUTH 4TH STREET,BATTLE CREEK,NE,68715,2016-09-08,323,D,1,0,CN7211,"**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 identify causal factors and develop additional interventions for the prevention of falls for 2 (Residents 1 and 5) of 3 residents reviewed who were at risk for falls. The total sample size was 8 and the facility census was 43. Findings are: A. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/23/16 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had no cognitive impairment and had no falls since admission to the facility on [DATE]. Review of Progress Notes dated 6/28/16 at 1:58 AM revealed at 1:29 AM, Resident 1 .had a bowel movement and tried to get out of bed. The resident did not use the call light to request assistance and was found on the floor. Documentation indicated the resident was educated on the use of the call light and additional interventions for the prevention of falls included a plan to anticipate needs and toilet the resident per personal schedule. There was no evidence to indicate an assessment was completed to identify Resident 1's specific toileting needs and a personalized toileting schedule was not developed. Review of Progress Notes dated 7/19/16 at 1:11 PM revealed at 11:49 AM, Resident 1 was found face down on the floor in front of the automatic lift recliner which was in the elevated position. Documentation indicated the resident used the control device to raise the automatic lift recliner and then slid out of the recliner onto the floor. The resident sustained [REDACTED]. Documentation indicated the resident was instructed on the use of the recliner controls however, the intervention for prevention of additional falls was to keep the chair controls out of the resident's reach. There was no further assessment to determine why the resident attempted to get out of the automatic lift recliner independently. Review of the MDS dated [DATE] revealed Resident 1's cognitive status had declined. The MDS further indicated the resident had moderate cognitive impairment, evidence of an acute change in mental status and displayed fluctuating psychomotor retardation (unusually decreased level of activity such as sluggishness, staring into space, staying in 1 position and/or moving very slowly). Review of Progress Notes dated 8/18/16 at 4:37 PM revealed at 4:09 PM, Resident 1 was found on the floor in front of the recliner with the recliner in the elevated position. The resident did not use the call light to request assistance and slid out of the chair. The resident voiced the need to use the bathroom. Documentation did not indicate whether or not the resident had been toileted prior to the fall. Documentation further indicated the resident was educated on the use of the call light and the automatic lift recliner was replaced with a regular recliner. Interview with the Director of Nurses (DON) on 9/8/16 at 9:14 AM confirmed a toileting schedule had not been developed specific to Resident 1's needs and in an attempt to prevent further falls. The DON verified the interventions following Resident 1's fall on 7/19/16 were not appropriate as 1 intervention indicated the resident was educated about using the automatic lift recliner controls and another intervention identified placing the controls out of the resident's reach. B. Review of Resident 5's MDS dated [DATE] revealed a Brief Interview for Mental Status (An assessment of a resident's mental status with a score of 0-7 indicating severe cognitive impairment) score of 3. Review of Resident 5's post fall assessment dated [DATE], revealed the resident fell out of bed while attempting to self-transfer without calling for staff assistance. New interventions put into place included discontinuing the pressure pad alarm (an alarm placed under a resident that sounds when pressure is removed) from the resident's bed and initiating a mat alarm (an alarm that sounds when pressure is applied) to the floor beside the resident's bed. There was no evidence that causal factors were assessed or addressed in the implementation of the post fall interventions. Review of Resident 5's post fall assessment dated [DATE] revealed Resident 5 fell on [DATE] during a self-transfer from the resident's wheelchair to the bathroom without calling for staff assistance. The new intervention identified was for the resident to call for staff assistance. There was no evidence of causal factors being assessed or addressed. During an interview with the DON on 9/7/16 at 2:30 PM, the DON confirmed there was no evidence to indicate causal factors were assessed following Resident 5's falls on 6/6/16 and 8/31/16. Further interview confirmed a new intervention was not put in place following Resident 5's fall on 8/31/16, as the resident was not cognitively aware enough to be educated on calling for staff assistance.",2019-09-01
5585,"BROKEN BOW CARE AND REHABILITATION CENTER, LLC",285120,224 EAST SOUTH E STREET,BROKEN BOW,NE,68822,2018-05-17,689,D,1,1,1IGA11,"**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 implement interventions for one resident (Resident 14) out of one resident sample to prevent the potential for elopement. The facility census was 30. Findings are: Review of Resident 14's undated Face Sheet revealed [DIAGNOSES REDACTED]. Review of Resident 14's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 2-13-18 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 8 which indicated Resident 14's cognition was moderately impaired. The resident was independent with bed mobility, walking in room and hall, and locomotion on and off the unit. Resident 14 required supervision and/or cueing with dressing, toileting, and personal hygiene. The assessment revealed the resident had not wandered. Review of the Quarterly/Annual/Significant Change Nursing Evaluations form on the Elopement section dated 5-2-18 for Resident 14 revealed an assessment risk score of 11. The form revealed a score of 10 or higher placed a resident at risk for elopement. Record review of Resident 14's PN (Progress Notes) dated 5-12-18 revealed the resident started pacing the halls at 5 AM with the resident's coat. The resident told the staff the resident was going home. At 7:30 AM the resident attempted to exit the facility through the north side door and again told the staff the resident wanted to go home. Review of ADL (Activity of Daily Living) charting for behaviors revealed Resident 14 wandered on 4-18-18 at 4:41 AM. Review of Resident 14's Careplan revealed absence of documentation for any interventions to prevent the resident from elopement. Interview on 5-16-18 at 3:03 PM with the DON (Director of Nursing) revealed the DON was not aware of the 2 documented incidents where the resident had wandered on 4-18-18 and attempted to exit and was prevented by the staff on 5-2-18. The DON confirmed there were no interventions put into place for the resident being at risk for elopement.",2019-11-01
2963,RIDGECREST REHABILITATION CENTER,285239,3110 SCOTT CIRCLE,OMAHA,NE,68112,2019-07-30,689,D,1,0,CJZM11,"**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 implement interventions to prevent falls for 3 (Resident 1, 2 and 4) of 4 sampled residents. The facility staff identified a census of 73. Findings are: [NAME] Record review of Resident 1's Comprehensive Care Plan (CCP) dated 3-01-2019 revealed Resident 1 had falls and the goal for Resident 1 was not to have major injuries with falls. Interventions identified on the CCP included the following: -Remove Resident 1's residents walker. -Helmet was re-offered and the VA to provide. Record review of an information sheet taped to Resident 1's door frame dated 8-14-2019 revealed Resident 1's family member did not ant Resident 1's wheelchair in the room and to leave the wheelchair outside of Resident 1's room. Observation on 7-30-2019 at 6:50 AM revealed Resident 1's walker was in the room located next to the window on the left hand side as you walk into Resident 1's room. Observation on 7-30-2019 at 9:01 AM of a transfer revealed Resident 1's walker remained in the room. No helmet was applied. Observation on 7-30-2019 at 11:00 AM revealed Resident 1's wheelchair was in Resident 1 room as Resident 1 slept in a recliner. Resident 1 did not have a helmet on. Observation with Licensed Practical Nurse (LPN) B on 7-30-2019 at 11:25 AM revealed Resident 1's wheelchair remained in the room. During the observation with LPN B, LPN B confirmed Resident 1's wheelchair was not to be kept in Resident 1's room. On 7-30-2019 at 2:35 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed there was not evidence Resident 1 should not be wearing a helmet. B. Record review of Resident 4 CCP dated revealed Resident 4 was at risk for falls. The goal identified for Resident was to be free of falls. Interventions identified on Resident's CCP included keeping the call light within reach and to provided a pillow while up in the wheelchair for positioning. Observation on 7-30-2019 at 10:05 AM revealed Resident 4 was up in a wheelchair asleep. Resident 4 did not have the call light or pillow in place. Observation on 7-30-2019 at 11:02 AM revealed Resident 4 was up in a wheelchair asleep. Resident 4 did not have the call light or pillow in place. Observation on 7-30-2019 at 11:25 AM revealed Resident 4 was up in a wheelchair asleep. Resident 4 did not have the call light or pillow in place. On 7-30-2019 at 11:25 AM an interview was conducted with LPN C. During the interview LPN C confirmed Resident 4's call light was not in reach and that Resident 4 did not have a pillow in place. C. Record review of Resident 2's Resident Face Sheet revealed Resident 2 had a [DIAGNOSES REDACTED]. Review of Resident 2's Progress notes dated 6/12/2019 Resident 2 was sent to the hospital ER for evaluation and treatment. Review of Resident 2's Event Report dated 6/12/2019 Resident 2 was wandering in the halls prior to being found on the floor and the fall was unwitnessed. Resident 2 was determined to have swelling and a laceration above the right eye. Review of Resident 2's care plan revealed Resident 2 was at risk of falls related to cognitive deficits and high risk medications. Review of the facility document titled: Daily Huddles-Agenda dated 6/13/2019 lists a new intervention for falls for Resident 2 as to keep Resident 2 involved with activities. Interventions is not placed on Resident 2's care plan. Review of Resident 2's medical record revealed no notes regarding if this intervention had been implemented. Interview of 7/30/2019 at 10:55 AM with the Assistant Director of Nursing revealed the intervention was not placed on the care plan for staff to implement.",2020-09-01
1232,ARBOR CARE CENTERS-FULLERTON LLC,285115,"PO BOX 648, 202 NORTH ESTHER",FULLERTON,NE,68638,2019-11-25,689,D,1,1,9W9U11,"**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 determine causal factors for repeated incidents of falling for Residents 5 and 51, and to implement, develop and/or revise interventions for the prevention of further falls. The facility census was 55 and the sample size was 3. Findings are: [NAME] Review of Resident 51's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/17/19 revealed [DIAGNOSES REDACTED]. The MDS indicated the resident had moderately impaired cognition; behaviors which included wandering, delusions and other behaviors not directed at others; and indicated the resident had unsteady balance. Review of a Fall Report dated 6/15/19 at 11:10 AM revealed the resident attempted to get up and out of bed independently. The resident's feet got wrapped up in a blanket and the resident fell on to right side. No injuries were noted. Further review of the report revealed the resident was confused at the time and orientated to person only. No causal factors or additional fall prevention interventions were identified. Review of a Fall Report dated 11/12/19 at 4:15 PM revealed the resident had attempted to stand from the resident's bed and fell to the floor onto left hip. The resident reported increased pain with movement of left hip and the resident was transferred to the hospital. No causal factors were identified. Review of Resident 51's current Care Plan (undated) revealed the resident was at high risk for falls related to an unsteady gait, history of falls and need for reminders to slow down with ambulation. The following fall prevention interventions were identified: -do not leave alone in the bathroom; -bed in the lowest position; -call light and personal care items to be kept within reach; -restorative program; -therapy referral; -11/12/19 sent to emergency room for evaluation; and -11/15/19 mat on floor beside the resident's bed, room door to remain open and to increase rounding to hourly. Interview on 11/21/19 at 1:55 PM with the Registered Nurse (RN) Consultant revealed staff were to assess the resident after each fall for potential injuries, determine causal factors for the fall and then develop new interventions or revise current interventions in an attempt to prevent further falls. The RN Consultant confirmed no causal factors were assessed for Resident 51's falls on 6/15/19 and on 11/12/19. In addition, no new interventions were developed after the resident's fall on 6/15/19 B. Review of Resident 5's MDS dated [DATE] revealed cognitive impairment and delusional behaviors with resistance during cares. The resident was identified with [DIAGNOSES REDACTED]. Further review of the assessment revealed the resident required staff supervision with transfers, toileting and bed mobility and limited assistance with dressing and personal hygiene. Review of a Fall Report dated 2/5/19 at 9:10 AM revealed staff were attempting to weigh the resident, the resident slipped off the scale, lost balance and fell . The report identified the resident's lost balance as the causal factor for the fall. A new intervention was developed for 2 staff to assist the resident when weighing. Review of a Fall Report dated 4/6/19 at 4:30 PM revealed the resident had stood up independently from wheelchair and fell on to left side. The resident received 2 skin tears to fingers on the resident's right hand. The report indicated a causal factor of the resident self-transferring. An intervention to remove the foot pedals from the resident's chair was identified. Review of a Fall Report dated 5/28/19 at 11:30 AM revealed the resident's roommate alerted staff that Resident 5 was on the floor. The resident struck head and sustained a laceration to the back of head. No causal factors were identified. A referral was sent to physical therapy for an evaluation. The resident refused the referral to therapy. No further interventions were developed and there was no evidence current fall prevention interventions were revised. Review of a Fall Report dated 7/30/19 at 9:00 AM revealed the resident was found sitting on the floor of the resident's room. No injuries were observed. Further review of the report revealed no causal factors were assessed and no additional fall prevention interventions were developed. Review of a Fall Report dated 9/17/19 at 1:42 PM revealed the resident was found seated on the floor of the resident's room and next to the resident's bed. No injuries were noted. No causal factors were assessed. An intervention was identified to ensure the resident's wheelchair brakes were locked. Review of a Fall Report dated 11/14/19 at 11:11 AM revealed the resident was found sitting on the floor between the resident's bed and wheelchair. The resident's foot pedals were on the wheelchair. No injuries were identified. Further review of the report revealed the root cause of the resident's fall were the wheelchair foot pedals. An intervention was identified to remove the wheelchair from the resident's room. Review of Resident 5's current Care Plan (undated) revealed the resident was at risk for falls with impaired balance and mobility. The resident has a history of falls and of refusal at times to allow staff to assist with cares. Interventions included the following: -anticipate needs; -observe for changes in gait; -encourage use of proper footwear; -place call light within reach; -referral to therapy as needed; -2/5/19 2 staff to assist with getting resident's weight; -4/6/19 remove foot pedals from wheelchair; and -5/29/19 physical therapy to screen. During interview on 11/21/19 at 10:35 AM, Licensed Practical Nurse (LPN)-A verified the following regarding Resident 5: -high risk for falls -4/6/19 resident fell over foot pedals of wheelchair when attempting to self-transfer. An intervention was developed to remove the foot pedals from the wheelchair; -5/28/19 no causal factors were identified for resident's fall. A new intervention was developed for a therapy referral which the resident refused. No additional interventions were developed; -7/30/19 the resident was found on the floor of the resident's room. No causal factors were identified and no additional interventions and/or revision of current fall interventions were indicated; -9/17/19 the resident was again found on the floor of the resident's room. No causal factors were identified; and -11/14/19 the causal factor related to the resident's fall was the wheelchair foot pedals. The foot pedals were to have been removed from wheelchair after the resident's fall on 4/6/19.",2020-09-01
2102,HILLCREST CARE CENTER,285178,702 CEDAR AVENUE,LAUREL,NE,68745,2018-07-17,689,E,1,0,KN7V11,"**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 implement assessed interventions and to develop new interventions to protect 3 (Residents 1, 2 and 3) of 5 sampled residents from potential elopement. The facility census was 27. Findings are: [NAME] Review of the undated facility policy and procedure for Wander-guard (a bracelet worn by the resident and sounds an alarm if the resident comes within a certain distance of the exit door) Management identified the policy was put into place to avoid elopement incidents for residents at risk for wandering. The policy indicated the following procedures: -All residents to be assessed for risk of wandering on admission and then quarterly with the MDS (Minimum Data Set- a federally mandated comprehensive assessment tool used for care planning). If the resident was mobile and able to wander on foot or in a wheelchair then recommendation was to use Wander-guard signaling device to keep the resident safe. -The Director of Nursing (DON) or designee was to document the decision to apply a Wander-guard system in the resident's care plan. The wandering assessment tool was to be kept in the resident's medical record to validate decision. B. Review of Resident 1's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated the following: -severe cognitive impairment; -displayed episodes of disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject); and -wandering behavior which occurred on a daily basis. Review of a Wandering assessment dated [DATE] at 12:33 PM revealed the resident had a history of [REDACTED]. The assessment identified a Wander-guard bracelet was placed on the resident. review of the resident's medical record revealed [REDACTED]. Review of the resident's current Care Plan dated 2/21/18 revealed the following interventions related to the resident's history of wandering: -staff to keep the resident near them if wandering; -monitor resident closely when spouse leaves the facility after a visit with the resident; and -monitor placement and functioning of Wander-guard bracelet every shift. Review of a Nursing Progress Note dated 6/30/18 at 7:19 AM revealed a late entry for 6/29/18 . at approximately 8:15 PM, the alarm was sounding on the B-wing from the doors to the Assisted Living. The note further indicated the resident had set off the Wander-Guard alarm on the Assisted Living doors and staff had to redirect the resident away from the doors on several occasions that evening. When staff responded to the Wander-guard door alarm at 8:15 PM, the resident was not visible in the Nursing Home corridor or in the Assisted Living Wing. The Assisted Living staff had been in a resident's room assisting with a bath. The rooms of the Assisted Living and the Nursing Home were searched and the resident was not located. The Assisted Living staff was instructed to look outside and the resident was found lying on the ground at the bottom of a flight of stairs which led to a sidewalk in front of the Assisted Living. The resident was evaluated at the emergency room of the hospital and found to have a skin tear which measured 3 centimeters (cm) by 2 cm on the right elbow, multiple bruises to the top of the resident's right hand, a laceration, abrasion and bruising above the resident's right eye and abrasions to both knees. Review of the facility investigation of Resident 1's elopement identified the following interventions to prevent the resident from further potential elopements: -when attempts to go outside without supervision, staff to redirect and offer diversional activities; -elopement drills to be completed on all shifts the week of 7/9/18 and then on a monthly basis; and -staff training regarding elopement to be completed the week of 7/9/18. Review of a form titled Elopement Drill dated 7/3/18 revealed the signatures of 10 facility staff members. During an interview on 7/17/18 from 9:01 AM to 10:00 AM, the DON confirmed the following: -interventions to monitor and to redirect Resident 1 when wandering had already been in place prior to the resident's elopement on 6/29/18; -quarterly assessments to monitor the resident's wandering and risk for elopement were not being completed; and -only 1 elopement drill had been completed. C. Review of Resident 2's MDS dated [DATE] revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. No behaviors were identified. Review of a Doctor's Order and Progress Note for Resident 2 dated 6/20/18 revealed an order for [REDACTED]. During an interview on 7/17/18 at 1:00 PM, Nursing Assistant (NA)-D confirmed Resident 1 was wearing a Wander-guard which had just been placed last month. NA-D identified hearing on report, Resident 2 had attempted to leave the facility, but NA-D had not worked on 6/20/18 and did not know what had really happened. Interview with Registered Nurse (RN)-E on 7/17/18 at 2:00 PM revealed the resident was confused but usually re-directed very easily. RN-E identified not working 6/20/18 but indicated hearing later the resident had attempted to elope and now was wearing a Wander-guard. Review of Resident 2's medical record revealed no evidence the resident had behaviors of wandering or had made an attempt to elope. Interview with the DON on 7/17/18 from 2:10 PM to 2:30 PM confirmed an order for [REDACTED]. D. Review of Resident 3's MDS dated [DATE] revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. No wandering was identified. Review of Resident 3's current Care Plan dated 7/18/18 revealed interventions for the staff to observe the resident for wandering and to provide the resident with redirection. The care plan further identified the resident wore a Wander-guard to alert staff if the resident attempted to go outside. Review of an admission Wandering assessment dated [DATE] revealed the resident had a history of [REDACTED]. The assessment further indicated the family had requested a Wander-guard bracelet be placed on the resident as the family felt the resident might attempt to leave the facility. Interview on 7/17/18 with the DON at 1:30 PM confirmed the resident had a Wander-guard bracelet placed on admission. The DON indicated a Wandering Assessment had been completed at admission but no further assessments had been done to determine of the resident remained at risk for elopement or to determine if further interventions should be developed to ensure the resident's safety.",2020-09-01
2101,HILLCREST CARE CENTER,285178,702 CEDAR AVENUE,LAUREL,NE,68745,2019-06-03,689,D,1,0,BCE011,"**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 implement assessed interventions to protect 1 (Residents 1) of 3 sampled residents from an elopement. The facility census was 22. Findings are: [NAME] Review of the facility policy entitled Wandering and Elopements with revision date 3/19 revealed the facility was to identify residents who were at risk for unsafe wandering and to protect them from harm, while maintaining the least restrictive environment. The policy identified that if a resident was determined to be at risk for wandering, elopement or other safety issues, the resident's care plan was to include strategies and interventions to maintain the resident's safety. B. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/10/19 revealed [DIAGNOSES REDACTED]. The MDS further indicated the following: -severe cognitive impairment; and -wandering behavior which occurred on a daily basis. Review of a Nursing Progress Note dated 6/30/18 at 7:19 AM revealed a late entry for 6/29/18 . at approximately 8:15 PM, the alarm was sounding on the B-wing from the doors to the Assisted Living. The note further indicated the resident had set off the Wander-Guard alarm on the Assisted Living doors and staff had to redirect the resident away from the doors on several occasions that evening. When staff responded to the Wander-guard door alarm at 8:15 PM, the resident was not visible in the Nursing Home corridor or in the Assisted Living Wing. The Assisted Living staff had been in a resident's room assisting with a bath. The rooms of the Assisted Living and the Nursing Home were searched and the resident was not located. The Assisted Living staff was instructed to look outside and the resident was found lying on the ground at the bottom of a flight of stairs which led to a sidewalk in front of the Assisted Living. Review of an Elopement Risk assessment dated [DATE] at 4:36 PM revealed the resident remained at risk for elopement and identified a wander-guard bracelet (a bracelet worn by the resident and sounds an alarm if the resident comes within a certain distance of the exit door) remained in place. Review of the resident's current Care Plan dated 1/21/19 revealed the following interventions related to the resident's history of wandering: -1:1's as needed if the resident is exit seeking without accepting redirection; -monitor the resident's location when in wheelchair to assure resident is not going into other resident's rooms; -if exit seeking, direct resident to a different area, offer food/fluids or an activity to distract the resident; -Wander-guard doors/alarms checked every shift to assess function; -Wander-guard bracelet to be checked every shift for placement and functioning; and -elopement risk assessment to be completed every quarter and with any significant change of status. Review of a Progress Note dated 5/26/19 at 7:30 PM revealed Resident 1 was found outside of the facility, lying on the ground by the Assisted Living front entrance. The note indicated the resident apparently went through the double doors exiting the Nursing Home and entering the Assisted Living and then through both Assisted Living entrance doors. The resident then fell from the top of the stairs in the resident's wheelchair to the concrete below. The resident was sent per ambulance to the emergency room for evaluation. Review of a Progress Note dated 5/26/19 at 10:30 PM revealed the resident returned to the facility. The resident had bruising and scrapes identified to bilateral knees, bruising to the right elbow, abrasions to the resident's right hand and a large bruise to right side of the resident's face. Further review of the resident's care plan revealed a new intervention dated 5/26/19 for the resident to be supervised at all times when seated in the wheelchair. In addition, staff were to encourage the resident to transfer into the recliner in the resident's room or into the resident's bed in the afternoons to prevent further attempts at elopement. During an interview on 6/3/19 at 9:00 AM the facility Administrator confirmed the following regarding Resident 1: -history of wandering and exit seeking; -had a wander-guard bracelet to alert staff of any attempts to elope; -had an elopement on 5/26/19 at 7:30 PM; and -the resident did activate the wander-guard system when the resident exited from the Nursing Home into the Assisted Living on 5/26/19 but staff did not respond to the alarm in time to prevent the resident's elopement and subsequent fall.",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
5053,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-02-02,323,G,1,0,KFCK11,"**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 residents were supervised when receiving hot liquids for 2 (Resident 3 and 4) of 3 residents reviewed. The facility staff identified a census of 79. Findings are: Record review of an Admission record sheet printed on 1-11-2017 revealed Resident 3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of an Injury of Unknown Origin (IOUO) sheet dated 1-11-2017 revealed on 1-7-2017 Resident 3 was assessed as having a 9 centimeters (cm) by 3 cm red area with 4 blisters that measured individually as 3 cm by 3 cm, 2 cm by 1 cm, 2 cm by 0.2 cm, and 2 cm by 1.0 cm. According to the information on the IOUO sheet, Resident 3 was in the dining room and yelled for help. \ Dietary Assistant (DA) A was the first to respond with a nurse coming into the dining room. According to the IOUO, both the DA and the nurse saw Resident 3 dropped the coffee Resident 3 was drinking into the lap area. Record review of an undated, handwritten statement revealed DA A reported hearing another resident yell for help and the resident reported Resident 3 dropped hot coffee into (gender) lap. According to the written statement, DA A obtained towels and assisted the resident to clean up the coffee. DA A documented that medication assistant walked into the dining room and assisted Resident 3 to the nurse. Record review of Resident 3's Comprehensive Care Plan (CCP) dated 12-15-2016 revealed the facility staff identified Resident 3 was at risk for injury related to hot liquid burns. Interventions identified on the CCP dated 12-15-2016 revealed staff were to complete a hot liquid assessment on admission and place a lid on all hot liquid containers. If spills occurred, staff were to notify the physician, family and Director of Nursing (DON ). On 2-01-2017 at 1:43 PM, an interview was conducted with DA [NAME] During the interview, DA A reported that another resident saw Resident 3 drop hot coffee into the lap area. DA A reported there was not a lid on the hot liquid container. In addition, DA A reported there was no one in the dining supervising the residents. On 1-31-2017 at 5:19 PM an interview was conducted with Resident 3. During the interview, Resident 3 reported that staff had provided the hot coffee. Resident 3 reported spilling the hot coffee and stated boy did that hurt. Observation on 1-17-2017 at 9:57 AM with the Assistant Director of Nursing (ADON) of Resident 3 inner thigh area revealed a redden area that measured approximately 5 centimeters (CM) long and 2 cm wide. No blistering was observed at this time. Record review of an educational form dated by staff on 1-09-2016 revealed staff were educated on ensuring residents who triggered the hot liquid protocol were to have lids on their hot beverages. Further review of the educational form dated 1-09-2017 revealed there was no education on ensuring residents were supervised to prevent hot liquid spills. B. Record review of an Admission Record sheet dated 1-30-2017 revealed Resident 4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 4's Care Plan (CP) dated 12-15-2016 revealed the facility staff had identified Resident 4 was at risk for hot liquid spills. Further review of Resident 4's CP dated 12-15-16 revealed a hand written update, dated 1-29-2017, that Resident 4 had sustained a burn to the right inner thigh and, on 10-17-2016, Resident 4 was to be on a 1 to 1 assistance in the dining area . Record review of an Accident/Unusual Occurrence (AUO) from dated 2-03-2017 revealed that, on 1-29-2017, Resident 4 was evaluated as having burns to both inner thigh area. The right thigh measured 17 cm by 10 cm and the left thigh measured 2 cm by 1 cm. According to the information in the AUO report, there were no witness. Further review of the AUO dated 2-03-2017 revealed Licensed Practical Nurse (LPN) B had reported to the DON that Resident 4 had obtained burns to the thigh area at supper time. Review of a written statement signed by Nursing Assistant (NA) C on 1-29-2017 revealed NA C reported assisting residents to the dining room. According to the written statement, NA C transported Resident 4 to the dining room and left Resident 4 there to transport other residents to the dining room. NA C documented, upon return to the dining room, Resident 4 had a drink. NA C documented seeing a spill on the table and onto the resident's pants. NA C reported cleaning the table, wiped Resident 4's pants off, and then assisted Resident 4 with supper. Review of a statement written by the DON on 2-2-2017 of a follow up interview with NA C revealed NA C reported assisting residents to the dining room for supper, According to the written statement, NA C was the only nursing person in the dining room at 5:40 PM. Observation on 2-01-2017 at 9:09 AM of the burn area with the ADON revealed LPN D removed the soiled dressing revealing a red and blistered area that measured approximately 12 cm by 5 cm's on the right thigh and the left thigh area burn measured approximately 2 cm round open area. An interview was conducted on 2-1-2017 at 2:07 PM with DA E. During the interview, DA [NAME] reported making and giving the coffee to Resident 4. According to DA E, the coffee temperature was a 150 degrees. DA [NAME] further reported that a staff member was with Resident 4. On 2-2-2017 at 5:22 AM, an interview was conducted with Certified Medication Assistant (CMA) F. During the interview, CMA F reported serving Resident 4 supper as NA C was sitting with Resident 4. When asked if a nurse was in the dining room to supervise, CMA F stated no. On 2-2-2017 at 8:15 AM, an interview was conducted with LPN [NAME] During the interview, LPN G reported there was to be a nurse in the dining room at meal times. On 2-2-2017 at 8:38 AM, an interview was conducted with Resident 4. During the interview, Resident 4 reported spilling the coffee into the lap area. When asked if a lid was on the cup being used for coffee, Resident 4 stated yes. When asked if there was any staff in the dining room when the spilled occurred, Resident 4 stated No. Record review of the facility education to staff dated 1-30-17 revealed the topic was spilled hot liquids. Further review of the education sheet revealed requiring supervision in the dining room was not part of the education. On 2-2-2017 at 10:30 AM, an interview was conducted with the DON. During the interview, the DON confirmed a nurse was to be in the dining room at meal times. The DON reported no when asked if they had evaluated if a nurse was in the dining room at the time of the burns for Resident 3 and Resident 4. The DON further confirmed staff education had not been completed after Resident 4 sustained a burn from hot liquids.",2020-02-01
2471,CROWELL MEMORIAL HOME,285210,245 SOUTH 22ND STREET,BLAIR,NE,68008,2018-07-11,689,G,1,0,NDLY11,"**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 identify specific fall interventions and failed to re-evaluate the use of a recliner remote for 1 (Resident 3) of 3 sampled residents. The facility staff identified a census of 67. Findings are: [NAME] Record review of Resident 3's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 9-6-2017 revealed the facility staff assessed the following about the resident: -BIMS (Brief Interview for Mental Status) score of 3. According to the MDS manual a score of 0-7 indicates severe cognitive impairment. -Limited assistance with eating. -Extensive assistance with dressing. -Total dependence with bed mobility, transfers, locomotion on and off the unit, toilet use and personal hygiene. Record review of Resident 3 Comprehensive Care Plan (CCP) dated 12-13-2017 revealed Resident 3 was at risk for falling related to use of narcotics, antidepressant and unsteadiness during transitions related to [MEDICAL CONDITION]. According Resident 3's CCP dated 12-13-2017, Resident 3 used a mechanical lift for transfers and a wheelchair for transportation. The goal for Resident 3 was not to have a fall or have any fall related injuries through next review. Approaches include, complete a fall assessment quarterly, instruct in transfer techniques such as bed to chair, chair to toilet and sit to stand. Resident 3 cannot see what you are doing related to [MEDICAL CONDITION]. Staff were also to monitor medications ([MEDICATION NAME]) (a medication used for Depression) for adverse reactions/side effects including: dizziness, confusion, [MEDICAL CONDITION], abnormal thinking. Record review of Resident 3's medical record revealed there was no evidence the facility had completed the fall assessment. On 7-11-2018 9:23 AM an interview was conducted with the Director of Nursing (DON) during the interview the DON reported fall assessments were taken to the fall committee meetings to evaluate specific interventions to prevent falls. The DON was unable to provide fall assessments for Resident 3 and was unable to provide specific fall interventions for Resident 3. Record review of an Incident Report dated 2-1-2018 revealed Resident 3 was found on the floor in a W Shape Res (Resident) had knees bent back and torso backwards and head. Resident 3 C/O (complained of) pain to bilateral (both) hips. Both feet turned to the left (with) R (right) leg shorter than the L (left). Record review of a Diagnostic report dated 2-02-2018 revealed Resident 3 was diagnosed with [REDACTED]. Record review of a second Diagnostic report dated 2-02-2018 revealed Resident 3 was diagnosed with [REDACTED]. Record review of the facility Fall risk Policy and procedure dated 4-2015 revealed the following: -The objective was to identify residents who are at risk for falls. -1. A fall risk assessment will be completed upon admission, in addition to according to the MDS schedule as needed. B. Review of an Incident Investigation Worksheet (IIW) dated 2-05-2018 revealed the facility staff identified the Root Cause of the fall was the recliner remote was left inside of the armrest next to Resident 3's right leg. According to the IIW dated 2-05-2018, the intervention to prevent recurrence was for staff to place the remote in the side pocket of Resident 3's recliner. Record review of Resident 3's medical record revealed there was not an evaluation of the ability of Resident 3 to use the recliner remote safely. On 7-11-2018 at 9:23 AM an interview was conducted with the DON. During the interview the DON reported an evaluation of Resident 3's ability to use the recliner remote had not been completed.",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
2676,AZRIA HEALTH BROADWELL,285221,800 STOEGER DRIVE,GRAND ISLAND,NE,68803,2018-11-14,689,D,1,0,CPVI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interviews, the facility failed to develop and implement fall prevention interventions for 1 (Resident 30 ) out of 4 residents sampled for falls. The facility census was 60. Findings are: Review of admission PN (Progress Notes) dated 10-22-18 for Resident 30 revealed the resident had [MEDICAL CONDITION] with very spastic movements to the lower extremities. A fall mat was put into place and a bed in low position for fall interventions. 10-27-18 Resident skilled observation and assessment revealed the resident was alert and oriented. Resident 30's pain medication was increased and the fall mat was in place with the bed in low position also. 11-4-18 Resident 30 was having increased leg spasms. Review of PN (Progress Notes) dated 11-11-18 revealed Resident 30 was found on the floor next to the bed on the resident's right side with red marks on the resident's skin on the hip from the legs of the over-bed table, to the ribcage from the bed remote cord the resident was laying on and the shoulder which was on the floor. Lack of documentation about a floor mat being in place on the floor at the time of the fall. Review Resident 30's careplan on 11-14-18 at 9:09 AM revealed the resident was at risk for falls initiated 10-23-18. There were 2 interventions both dated 10-23-18, which was the resident's admitted , revealed My caregivers will ensure that I am wearing appropriately fitting foot wear and clothing and obtain a therapy referral as ordered by Physician. Interview on 11-14-18 at 4:04 PM with NA-A (Nurse Aide) revealed NA-A was not aware of any fall interventions to be used with Resident 30 except for the positioning bar on the bed. NA-A denied knowledge to use fall mats. Interview on 11-14-18 at 4:07 PM with NA-B revealed NA-B was not aware of any fall interventions for the resident, including a fall mat. Interview on 11-14-18 at 4:11 PM with MA-C (Medication Aide) revealed MA-C was not aware of any fall interventions for Resident 30 including a fall mat. Interview on 11-14-18 at 1:30 PM with the ADON (Assistant Director of Nursing) revealed as part of the IDT (interdisciplinary team)the ADON was not aware of the resident having had fall mats by the resident's bed. The ADON confirmed Resident 30 did not have fall mats by the bed as a fall intervention on the night of 11-11-18 at the time of the fall out of bed. The ADON revealed the floor nurses' must have initiated the fall mat upon admission because of the resident's severe leg [DIAGNOSES REDACTED] and concern of it causing the resident to fall out of bed.",2020-09-01
4389,"BCP UTICA, LLC",285161,1350 CENTENNIAL AVENUE,UTICA,NE,68456,2017-09-12,323,E,1,0,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interviews, the facility failed to ensure fall alarms were operational for 3 out of 3 residents (Resident 116, 001, and 002) sampled. The facility census was 33. Findings are: Review of Resident 116 undated census sheet revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the facility investigation revealed Resident 116 was found on the floor on 08-25-17 at 11:30 PM on the resident's hands and knees in the doorway of the resident's room. Resident 116 had slippers on, did not have the walker with (gender), and the bed alarm on the bed where the resident had been prior was not sounding. The resident received a left radius (lower arm) fracture from the fall. The facility initiated a new intervention as a result of the fall to put new batteries into the bed alarm and test the bed alarm to make sure it was operating before each use at bedtime. Interview on 09-12-17 at 11:35 AM with the DON (Director of Nursing) revealed the facility had 3 residents who utilized a fall alarm which used batteries. Resident 116 used a bed and chair alarm. Resident 001 used a bed and chair and TABs alarm. Resident 002 used a chair alarm. The DON confirmed the new intervention of checking to ensure the alarm was operational before each usage was initiated only on the bed alarm of Resident 116 and was not initiated on Resident 116 chair alarm or the other resident's alarms. Interview on 09-12-17 at 1:24 PM with the DON revealed the facility did have a process earlier in (YEAR) whereas the Restorative Nurse Aide changed the batteries in all the fall alarms on a monthly basis and documented it on the Restorative Nursing Equipment/Devices Tracking Form. However this process got dropped due to changes in staffing and had not been done since (MONTH) (YEAR).",2020-08-01
5671,EMERALD NURSING & REHAB LAKEVIEW,285106,1405 WEST HWY 34,GRAND ISLAND,NE,68801,2016-10-04,323,D,1,0,Z2XH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review, and interviews, the facility failed to have fall interventions in place that met the needs of one resident (Resident 113) out of the 3 sampled residents. The census was 65. Findings are: Review of the face sheet dated 03-15-16 revealed Resident 113 was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of the annual MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 09-19-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of zero which indicated Resident 113 was severely cognitively impaired. The resident had exhibited no behaviors. The resident required limited assistance of 2 staff with bed mobility, transfers, walk in room, locomotion on the unit, dressing, eating, toileting, and personal hygiene. Review of the Care Plan revealed Resident 113 was at risk of falls. The resident had 3 falls in (YEAR) with a new intervention added as follows: -On 5-5-16 the resident fell in the bathroom. The new intervention added was the staff watched the resident perform a transfer independently and they continued with the resident's current P[NAME] (plan of care) plus to encourage the resident to call for assist when needed. -On 06-18-16 the resident attempted to transfer independently from the bed to the wheelchair and fell . The new intervention was to have the resident call for assistance. -On 09-11-16 the resident fell in the bathroom. The new intervention was to check on the resident frequently and assess the resident for new shoes (with a comment following this that stated the resident had already received new shoes prior in August). No new intervention replaced the new shoe intervention. Review of the fall incident reports revealed Resident 113 had another fall on 08-17-16. The report revealed the resident fell transferring off of the toilet independently. The report also revealed the resident had a history of [REDACTED]. The new intervention listed was for the staff to remain in the bathroom with the resident at all times. Review of the Care Plan revealed the 08-17-16 fall and the new intervention were not documented. Interview on 10-04-16 at 3:00 PM with NA-A (Nurse Aide) revealed the resident was a limited assist with transfers but liked to be independent and often transferred self independently. NA-A revealed the staff reminded the resident to call staff but the resident did not remember due to the dementia. NA-A revealed that NA-A had knowledge of the resident having recent falls but denied knowledge of any new interventions. Interview on 10-04-16 at 4:00 PM with the DON (Director of Nursing) revealed there was no other new interventions besides what was listed on the resident's Care Plan. The DON also confirmed the repetitive intervention of reminding the resident to call for staff was not an effective intervention for this resident.",2019-10-01
2408,COUNTRYSIDE HOME,285207,703 NORTH MAIN STREET,MADISON,NE,68748,2018-10-09,689,G,1,1,GZ2H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7(a)(b) Based on observation, interview and record review; the facility failed 1) to ensure Residents 66 and 29, who were identified at risk for falls, were free from accident hazards related to the independent use of motorized recliners in their rooms, and 2) to identify causal factors of falls, to develop and/or revise fall prevention interventions, and to implement current interventions for the prevention of falls for Resident 42. 4 residents were reviewed for accidents related to falls, and the total facility census was 66. Findings are: [NAME] Review of Resident 66's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/8/18 revealed the following: -severe cognitive impairment; -limited assistance with bed mobility, transfers, ambulation in the room and corridor; -extensive assistance with toilet use; -unsteady and only able to stabilize with human assistance when moving from a seated to standing position, while walking, when turning around and facing the opposite direction while walking, when moving on and off the toilet, and during surface-to-surface transfers (between bed and chair or wheelchair); and -occasionally incontinent of bowels and bladder. Review of the Care Plan dated 5/28/18 indicated Resident 66 was at medium risk for falls due to impaired mobility related to low back pain, decreased cognition, impaired balance, and decreased safety awareness. Nursing interventions included the following: -limited to extensive assistance with transfers and ambulation; -sit/stand alarm (an alarm that sounds and alerts staff when the resident independently stands up from a seated position) was discontinued on 8/2/17; -encourage to stand straight with ambulation; has a hunched posture; -Occupational Therapy (OT) recommended SBA (stand by assistance) and/or set up assistance in the room due to impaired cognition and poor safety awareness; -provide education on needing to use call light and wait for staff assistance due to impaired safety, high fall risk, and impaired cognition; frequently shuts off alarms and self transfers in room; -educate to lock brakes on walker with all transfers; and -when noted up and walking around in room, provide assistance with finishing the care/task. Review of Progress Notes revealed the following related to Resident 66: -8/5/18 at 2:45 AM - self transferred and ambulated in the hall toward the nurses station. Intercepted by the nurse and provided a wheelchair due to bilateral hands shaking. Stated I want to go home. Returned to room and oriented to place and time of day. Blood sugar level was checked, found to be low, and treated with juice and a sandwich; and -8/13/18 at 5:45 PM - Restorative Therapy Aide (RTA) reported not able to ambulate as far as used to due to decreased activity tolerance. Review of a Rehabilitation Services Screen Request dated 8/16/18 revealed the following: -the resident's physician requests we get resident to sit back in recliner; -screen requested by Physical Therapy (PT) and OT to assess resident leaning forward; -screen completed by OT on 8/22/18 with a request for orders to evaluate and treat to address posture and positioning in the recliner and wheelchair; and -physician approval for OT to evaluate and treat the resident dated 8/28/18. Review of Progress Notes dated 9/1/18 revealed the following related to Resident 66: -2:45 AM - found lying on the left side in front of the motorized recliner in room. The recliner was observed to be in the highest position, and the resident was confused to time and day. There was a 5 cm (centimeter) laceration and surrounding hematoma (swelling) to the left forehead, and a 4 cm tear drop-sized abrasion to the left cheek; -4:45 AM - transported to the emergency room by ambulance; and -10:20 AM - admitted to the hospital with [REDACTED]. Review of the Fall Scene Investigation Report dated 9/1/18 revealed the following related to Resident 66's fall: -was attempting to self-transfer; -had raised the motorized recliner all the way up at other times in the past; -was found on the floor during rounds at 2:30 AM and had not used the call light to call for assistance; -refuses to sleep in bed and usually sleeps in recliner; and -the causal factor for the fall was determined to be motorized recliner in highest position and usually keeps hand control for recliner in lap. There was no evidence in Resident 66's medical record that use of the motorized recliner had been evaluated prior to the fall incident to determine if the resident could safely operate the recliner independently, and to assure the resident's safety. Review of Progress Notes dated 9/5/18 at 6:18 PM indicated Resident 66 was readmitted from the hospital and receiving Hospice services. During observation of nursing care on 10/3/18 from 9:21 AM until 9:50 AM, Nursing Assistant (NA)-H and NA-I provided repositioning and incontinent care for Resident 66. The resident was wearing a rigid cervical collar (neck brace used to immobilize and support the neck) and a wound was observed on the left side of the forehead, immediately above the hairline. During interviews on 10/04/18, the following was revealed: -7:00 AM - Licensed Practical Nurse (LPN)-J indicated at times Resident 66 activated the call light. And before staff could respond, elevated the recliner in order to be ready to go when staff arrived to provide assistance. LPN-J verified the resident required 1 person assist with ambulation to stabilize; and -8:46 AM - the Director of Nursing (DON) verified Resident 66's use of the motorized recliner had not been evaluated to determine if the resident could safely operate the recliner independently, and to assure the resident's safety. The resident would elevate the recliner in order to view birds outside the window, and tended to lean forward in the chair. The OT evaluation and treatment was never initiated due to the occurrence of the fall on 9/1/18 (4 days after the physician's orders [REDACTED]. B. Review of Resident 29's Morse Fall assessment dated [DATE] revealed the resident was at medium risk for falls. Review of Resident 29's current undated Care Plan revealed the resident had muscle weakness and was unable to ambulate. Further review revealed the resident had dementia and decreased cognition and required close supervision for safety. On 10/3/18 at 3:01 PM, Resident 29 was seated in a motorized recliner in the resident's room. The recliner was reclined back and the foot of the recliner was elevated. During an interview on 10/4/18 at 9:57 AM, NA-I revealed Resident 29 was usually placed in the motorized recliner after breakfast and the remote to the recliner was positioned in reach for the resident to use, if desired. During an interview on 10/4/18 at 2:00 PM, the DON confirmed a safety assessment had not been completed on Resident 29 to ensure the resident was safe to operate the motorized recliner. C. Review of an Incident/Accident Report dated 6/20/18 revealed Resident 42 had a fall at 11:10 PM. The resident's sit-to-stand alarm did not sound and the resident ambulated down the hallway and fell . The resident was last toileted at 7:00 PM with evening cares. At the time of the fall the resident was incontinent of a large amount of feces and needed to use the bathroom. The new intervention identified was to change the sit-to-stand alarm (The causal factors/new intervention did not address the resident's toileting needs). Review of an Incident/Accident Report dated 7/5/18 revealed Resident 42 attempted to self-transfer from the bed and the resident's sit-to-stand alarm did not sound. Resident 42 was incontinent of a large amount. The intervention identified was for a new alarm (The causal factors/new intervention did not address the resident's toileting needs). Review of Resident 42's Morse Fall assessment dated [DATE] revealed the resident was at high risk for falls. Review of Resident 42's current Care Plan dated 10/3/18 revealed the resident was at high risk for falls related to impaired mobility, balance issues, and impaired safety awareness. Fall prevention interventions included encouraging toileting every 2 hours and as needed, safety checks every hour and as needed when in bed, and a sit-to-stand alarm was to be on the resident at all times. Observations of Resident 42 from 10/3/18 revealed: - On 10/3/18 at 1:17 PM, the resident was seated in a wheelchair between the dining room and television sitting area. There was no sit-to-stand alarm to the wheelchair; - On 10/3/18 at 2:10 PM, the resident remained seated in a wheelchair between the dining room and television sitting area. There was no sit-to-stand alarm to the wheelchair; - On 10/3/18 at 2:25 PM, the resident was seated in the resident's recliner. There was no sit-to-stand alarm to the recliner; and - On 10/3/18 from 2:35 PM to 2:50 PM, the resident remained seated in the resident's recliner. There was no sit-to-stand alarm to the recliner. During an interview on 10/4/18 at 9:28 AM, NA-L confirmed Resident 42's fall prevention interventions included a sit-to-stand alarm to be used at all times. During an interview with the Special Care Unit (SCU) Coordinator on 10/4/18 at 10:34 AM the SCU Coordinator confirmed the resident was to have a sit-to-stand alarm in place at all times. If the resident had a fall then the Charge Nurse was responsible for assessing the resident, identifying causal factors, and identifying a new fall prevention intervention or revising current interventions.",2020-09-01
1093,EMERALD NURSING & REHAB LAKEVIEW,285106,1405 WEST HWY 34,GRAND ISLAND,NE,68801,2018-05-07,689,D,1,1,QN7C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, interview, and record review; the facility staff failed to prevent potential accident hazards by not storing the steam tables (devices used to hold hot food) in an area accessible to residents, failed to maintain the door over the meal service window to prevent an accident hazard, and failed to prevent Resident 112 from leaving the building unattended. This had the potential to affect 2 of 2 sampled residents (Resident 59 and Resident 112) and an unidentified number of residents who could have access to the steam tables and food service window. The facility identified a census of 55 at the time of survey. Findings are: [NAME] Observation of the hall by the kitchen on 5/01/18 at 9:35 AM revealed 3 steam tables plugged into the electrical outlets. Observation of the hall by the kitchen on 5/02/18 on 2:58 PM revealed Resident 59 was in the area. Observation of the hall by the kitchen on 5/03/18 at 9:24 AM revealed a steam table plugged in to the electrical outlet. B. Observation of the food service window between the kitchen on the dining room on 5/3/2018 at 9:55 AM revealed the rolling door above the food service window came down in from of a visitor who was standing at the window. The visitor had requested a glass of ice and was standing at the window and pulled their hand away as the rolling door came down. Interview with the facility administrator on 5/3/2018 at 11:37 AM revealed the steam tables should not be accessible to residents and the chains on the roller for the door at the food service window were not functioning properly. Interview with the door repair representative on 5/3/2018 at 1:53 PM confirmed the door required repair to keep it from closing spontaneously. Interview with the facility Administrator on 5/3/2018 at 3:34 PM revealed dietary staff would report to maintenance if there was a repair issue in the kitchen. Review of the Environment of Care policy revised 5/1/2011 revealed the following: Policy was to assure that the Maintenance Department provides a safe and healthful workplace which is free from physical, biological, chemical and fire hazards. All facility shall implement a policy to assure that the workplace is maintained in safe, sanitary and efficient manner. 1. Maintenance staff will implement and adhere to all applicable Occupational Safety and health programs established at the facility. 2. Maintenance staff will implement and adhere to all applicable Emergency Management Plan programs established at the facility. 3. Maintenance staff will implement and adhere to all applicable Environment of Care programs established at the facility. Unsafe conditions or actions must be reported to the Safety Committee, Environmental Director/Supervisor or designee and/or Administrator as per the Hazard Notification process. C. Review of a MDS (Minimum Data Set) dated 2/20/18 revealed Resident 112 had no wandering behaviors. No behaviors were noted. Section C noted disorganized thinking with unclear or illogical flow of ideas. Review of Physician order [REDACTED]. Review of [DIAGNOSES REDACTED].>Review of an undated Physician order [REDACTED]. Review of Progress Notes dated 2/19/2018 at 02:50 PM revealed the facility staff spoke with Resident 112's family about moving Resident 112 out of the ACU (Alzheimer's Care Unit) to the long term care wing and the family agreed with the move. The documentation of the Physician being notified of the move was absent. Review of Progress Note dated 2/25/2018 at 05:52 PM revealed the elopement care plan was initiated after Resident 112 was observed in the parking lot at 01:20 PM. Documentation revealed the family was educated to alert charge nurse if the family was leaving the building and this was not on the Elopement Care Plan. Review of undated Care Plan revealed that no elopement interventions had been initiated until Resident 112 was observed in the parking lot on 2/25/18. Interview on 05/07/18 at 08:10 PM with DON (Director Of Nursing) revealed Resident 112 was moved off ACU (Alzheimer's Care Unit) due to a resident to resident altercation that did involve Resident 112 directly. Resident 112 had to share a bathroom with two (2) other residents and one of the other residents had some racial discrimination issues. The other resident acted out so Resident 112 was moved to the other unit. Resident 112's family stayed with the resident constantly and multiple family members were often present at one time. The family member who was staying with Resident 112 stepped out for a short time and then Resident 112 went outside into the parking. Family was notified to let the Staff know when the family was leaving so staff can watch Resident 112 more closely and the family didn't do it.",2020-09-01
3402,WESTFIELD QUALITY CARE OF AURORA,285263,"PO BOX 166, 1313 1ST STREET",AURORA,NE,68818,2019-05-14,689,D,1,1,V7OX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, interview, and record review; the facility staff failed to secure the leg/knee straps on the sit-to-stand lift (a mechanical lift on wheels designed to assist the resident to a standing position then resident is transferred to their desired location without having to walk) while transferring Resident 58 to prevent potential injury. This affected 1 of 7 residents investigated for accidents. The facility identified a census of 57 at the time of survey. Findings are: Review of Resident 58's SCSA (Significant Change in Status) MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 4/19/19 revealed an admission date of [DATE]. Resident 58 had a BIMS (Brief Interview for Mental Status Score) of 15 which indicated Resident 58 was cognitively intact. Resident 58 required extensive assistance of 2 staff persons for transfers and toilet use. Interview with Resident 58 on 5/07/19 at 11:19 AM revealed the facility staff used the lift to transfer them. Review of Resident 58's care plan dated 2/8/2019 revealed Resident 58 used the mechanical lift for transfers with 2 staff support. Observation of NA-M (Nurse Aide), MA-L (Medication Aide), and NA-N on 5/08/19 at 11:26 AM assisting Resident 58 with transferring revealed the following: NA-M, MA-L, and NA-N used the sit-to-stand lift to transfer Resident 58 who was sitting in the recliner. NA-M leaned Resident 58 forward and placed the torso lift sling behind Resident 58 and hooked the strap to the upper portion of the lift after placing Resident 58's feet on the lower platform of the lift. NA-M, MA-L and NA-N were all working with Resident 58 on the sit to stand lift and none of them hooked the leg/knee strap on the lift around Resident 58's legs. NA-N then raised Resident 58 to a standing position with the lift and NA-N and MA-L wheeled Resident 58 on the lift into the bathroom. After Resident 58 was done using the bathroom, NA-N and NA-M then wheeled Resident 58 back to the recliner. The leg/knee straps on the sit to stand lift continued to be unfastened. Interview with MA-L on 5/09/19 at 1:57 PM confirmed the bottom straps on the lift were for the legs. Review of the facility document Standing Transfer with Crossed Straps and Buttock Support Strap dated (MONTH) (YEAR) revealed the following: Move the lift in front of the patient and help the patient place his or her feet on the foot pad with the patient's knees against the knee pad. Snuggly fasten the knee strap behind the patient's knees.",2020-09-01
6303,HILLCREST HEALTH & REHAB,285133,1702 HILLCREST DRIVE,BELLEVUE,NE,68005,2016-04-27,323,G,1,0,IO6811,"**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 staff failed to implement assessed interventions to prevent falls for 2 residents (Resident 6 and Resident 9), and failed to identify and implement additional interventions for 1 resident (Resident 9). The facility staff identified a census of 109. Findings are: A. Record review of an Admission Assessment sheet printed on 4-25-2016 revealed Resident 6 was admitted to the facility on [DATE]. Record review of Resident 6's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 3-29-2016 revealed the facility staff assessed the following about Resident 6: -Short and long term memory problems. -Required supervision for personal hygiene,dressing, eating and locomotion off the unit. -Required extensive assistance with bed mobility, transfers, locomotion on the unit and toilet use. -Balance during transitions and walking was assessed as not steady, only able to stabilize with staff assistance. -[DIAGNOSES REDACTED]. -1 fall since admission to the facility. Record review of a Fall Risk Assessment sheet dated 3-17-2016 revealed Resident 6 scored a 12. According to the Fall Risk Assessment sheet dated 3-17-2016, a score of 10 or above identified that a resident should be considered high risk for potential falls. Record review of Resident 6's Care Plan (CP) printed on 4-25-2016 revealed an effective date of 3-17-2016 to present. Further review of Resident 6's CP identified Resident 6 had falls. The goal was that Resident 6 would not have any falls with injury. The intervention listed on the CP included Falling Leaf as indicated, encourage to use call light, Physical and Occupational therapy as ordered. Further review of Resident 6's CP revealed an additional problem area that Resident 6 was at risk for falls and Resident 6 will have reduced risk for falling. The goal was Resident 6 would demonstrate the ability to ambulate/transfer without fall related injuries over the next 90 days. Interventions listed on the CP included keeping the area free of obstructions, place call bell/light within easy reach, respond promptly to calls for assistance to the toilet, use alarm to monitor attempts to rise and foot wear to fit properly and have non-skid soles. Record review of a Nursing Tech Care Plan ( NTCP, sheet of paper that identified basic information and care needs of Resident 6) dated 3-17-2016 revealed Resident 6 was to have alarms that were pressure (activated) to the bed and Tab alarm. Record review of the NTCP dated 3-18-2016 revealed the pressure or tabs alarms were no longer identified as an intervention to prevent potential falls. Record review of the NTCP dated 3-23-2016 revealed the pressure or tabs alarms were no longer identified as an intervention to prevent potential falls. Record review of a Clinical Notes Report (CNR) sheet dated 3-25-2016 revealed Resident 6 was found sitting on the floor. The alarm was sounding but very softly. According to the CNR dated 3-25-2016 the tab alarm had been placed on Resident 6 when in bed or a chair. Record review of a Causal Factors sheet signed by Registered Nurse (RN) C on 3-25-2016 revealed interventions were to place Resident 6 onto a falling star program, placed a chair alarm, relocated alarm box out of resident sight and blue pads at bed side. An interview on 4-26-2016 at 10:23 AM was conducted with RN C. During the interview review of the NTCP dated 3-18-16 and 3-23-16 for Resident 6 was completed. During the interview, RN C confirmed the interventions for the pressure alarm and Tabs alarm was not identified on the NTCP. RN C stated they should have been. When asked if the pressure alarm had been in place when Resident 6 was found on the floor, RN C reported the pressure alarm was not in place. When asked what interventions were implemented after Resident 6 was found on the floor, RN C reported the pressure alarm and blue pad. Record review of a CNR sheet dated 3-26-2016 revealed Resident 6 was on the floor and the alarm had not sounded. Record review of a CNR dated 3-27-2016 revealed Resident 6's practitioner was informed that Resident 6 was having pain and the right leg was externally rotated. The practitioner ordered an x-ray of the right hip. Record review of a Radiology Report dated 3-27-2016 revealed the results of the x-ray was that Resident 6 had a right femur fracture. On 4-26-16 at 10:51 AM an interview was conducted with RN D. During the interview, review of the facility investigation was completed with RN D. When asked if the pressure alarm and blue pad was in place, RN D stated I'm not sure. Record review of information sheet titled Accidents dated 3-28-2016 revealed the date of the incident was 3-26-2016. The Accident sheet identified bed and chair alarms were to be used and the interventions to prevent the accident/incident from reoccurring was identified as a bed and tab alarm were on the resident and functioning with frequent checks by team member. Further review of the Accident sheet dated 3-28-2016 revealed there was not any indication the mat at bed side was in place or why the pressure alarm did not sound. On 4-27-2016 at 2:21 PM a phone interview was conducted with Licensed Practical Nurse (LPN) F. During the interview, review of Resident 6 being found on the floor on 3-26-2016 was conducted with LPN F. LPN F confirmed during the interview that (gender) was the nurse for Resident 6 on 3-26-2016. When asked if the sensor alarm and blue pad was next to Resident 6's bed, LPN F stated no, they weren't. LPN F further reported that the reason (gender) remembered was the Nurse Tech was going to place one under the resident. B. Record review of Resident 9's Face Sheet dated 04/26/2016 revealed that Resident 9 was admitted on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident 9's Minimum (MDS) data set [DATE] revealed that Resident 9 had a Brief Interview for Mental Status (BIMS) Score of 4; (BIMS scores between 0 and 7 indicate severe cognitive impairment). Record review of Resident 9's care plan for falls dated 04/26/2016 revealed a goal of will have no fall with injury and the following interventions to prevent falls: - Alarms in place all the time/TAB, - Frequent rounding, - Engage patient in activities with rec therapy, - Offer snacks and redirection in the afternoon, - Fall risk assessment completed, - Encourage to use call light. Record review of a Fall Risk assessment dated [DATE] revealed it was started but not completed. This was confirmed by Registered Nurse (RN H) on 04/26/2016. A second fall risk assessment was completed on 04/18/2016 and revealed that Resident 9 had a fall risk score of 16. The assessment states high risk is a score of 10 or above. Record review of Nursing Progress notes, dated 04/10/2016, revealed Resident 9's bed alarm was sounding and Resident was found sitting on the floor. No injuries noted Record review of Nursing Progress notes, dated 04/23/2016, revealed Resident 9 was found on the floor in front of Resident 9's wheel chair. Tab alarm was attached but did not disconnect from the alarm box and sound. No injury noted. Interview with RN H, on 04/26/2016 at 11:18 AM revealed there were no new interventions identified and put in place following two of Resident 9's falls-04/10/2016 fall and the 04/23/2016 afternoon fall.",2019-04-01
5488,GOOD SAMARITAN SOCIETY - WOOD RIVER,285198,1401 EAST STREET,WOOD RIVER,NE,68883,2019-02-11,689,G,1,0,Z7JM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, record review, and interviews, the facility failed to review all falls for two residents (Resident 1 and 2) out of 3 sampled for causal factors to have contributed to the falls and also failed to implement interventions after falls to prevent future falls. Findings are: [NAME] Review of Resident 1's Admission Record dated 2-11-19 revealed a date of admission of 2-2-18 and [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 5-8-18 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 8 which indicated Resident 1's cognition was moderately impaired. The resident required extensive assist of one staff with bed mobility, transfers, and toileting. Resident 1 required limited assist on one staff with walking. Review of Resident 1's Fall Assessment Tool completed on admission on 2-2-18 and last completed on 1-31-19 both scored a 20 which indicated a high fall risk. 1. Review of Resident 1's PN (Progress Notes) revealed the resident was found laying on the floor with the wheelchair behind the resident. There were no injuries to the resident. Review of the POS [REDACTED]. Review of the Incident Report dated 4-20-18 revealed the action plan was absent of a new intervention and the careplan documentation box was blank revealing it had not been updated. Observation on 2-11-19 at 11:15 AM of Resident 1 sitting in the resident's wheelchair in the solarium revealed the wheelchair did not have automatic lock brakes on the wheelchair. Review of Resident 1's Careplan revealed the resident was identified as at risk for falls and had interventions listed. The 4-20-19 fall was listed as no injury resulted but was absent of a new intervention related to the fall. Review of Resident 1's PN dated 4-26-18 revealed staff heard a crash in the dining room and went around the corner and saw the resident laying on the floor with the walker tipped over by the resident. The resident revealed the resident had lost (gender) balance and fell . It was observed by the staff the resident had on non-slick socks and the socks were slippery when touched. Review of the Incident report dated 4-26-18 revealed the resident's fall in the dining room had no injuries. The predisposing factors were listed as the non slips socks were the contributing factor and the new intervention was to wear gripper socks. Review of Resident 1's Careplan revealed the fall of 4-26-18 was listed and the intervention of 'ensure that Resident was wearing appropriate footwear, enclosed soled shoes, when ambulating with the 4 wheeled walker' was initiated 2-10-18 at admission, but not revised until 4-30-18 after the resident had 2 more falls since 4-26-18 fall. Also in the careplan was 'gripper socks when in bed for safety in case the resident decided to walk without notifying staff' but this was intervention was not initiated until 5-29-18. Review of the PN dated 4-27-18 revealed the resident was found on the floor next to the bed in the resident's room. No injuries resulted from the fall. Review of the Incident report and the Post Huddle form dated 4-27-18 both revealed absence of documentation about a new intervention initiated for the fall. Review of Resident 1's Careplan revealed the fall was listed with no injury but absent of a new intervention to prevent future falls. Review of PN dated 4-30-18 revealed the resident was in the resident's room and was a witnessed fall and landed on the floor hitting the resident's head on the bed frame which caused a laceration and hematoma to the back of the head. The resident was transferred to the ER for evaluation. The resident's wound was treated and a CAT scan performed on the head. 2. Review of Resident 1's PN dated 7-14-18 revealed the resident was found on the floor and had decreased range of motion to the right shoulder and complained of pain. The Physician was notified and the resident was evaluated in the ER with x-rays with negative findings for a fracture. Review of the resident's Careplan revealed the fall from 7-14-18 but was absent of a new intervention as a result of the fall with injury. Review of the Incident report dated 7-14-18 revealed the resident had been walking and turned and lost (gender) balance. The resident had not been using the resident's walker at the time of the fall. The report was absent of documentation of a new intervention. Interview with the ADM (Administrator) on 2-11-19 at 3:30 PM confirmed the fall with potential serious injury had been called into APS (Adult Protective Service) but revealed an investigation did not get completed to review the fall and therefore the causal factors and a new intervention must not have been implemented. 3. Review of Resident 1's PN dated 9-14-18 revealed the resident was found on the floor asleep. The resident's fall alarm was in place but did not sound. The resident did not have any injuries. Review of the Careplan revealed the fall was listed as a fall without injury but the careplan was absent of a new intervention. The careplan was also absent of interventions of the resident having any current fall alarms. Observation on 2-11-19 at 11:15 AM of Resident 1 sitting in the resident's wheelchair in the solarium revealed the resident had a fall alarm on. Review of PN dated 9-24-18 revealed the resident was found in the resident's room on the floor yelling for help. The resident had blood pooled under the right side the resident's head. The resident was sent to the ER for evaluation and treatment. Review of the PN dated 10-10-18 revealed the resident was found on the floor in the resident's room with a laceration above the right eye. The resident revealed the resident was getting up to get something. The resident was sent to the ER for evaluation and sutures. Review of the Incident Report dated revealed the resident had predisposing factors of impulsive at times, did not call for help when wants, helps myself. Review of the facility Post Huddle form dated 10-10-18 revealed the resident's personal alarm was working but on the floor. Corrective action taken to prevent recurrence was listed as resident education/training or re-instruction. The Post Huddle form was absent of documentation about what was done to check why the personal fall alarm was not sounding and if it was fixed. Review of the resident's Careplan revealed the fall was listed with injury but absence of an intervention about the resident being reeducation or re-instructed. The careplan did reveal the resident had impaired cognitive function related to dementia / impaired thought processes and scored an 8 out of 15 on the BIMS. The Careplan was absent of interventions about the resident's personal alarms. Interview on 2-11-19 at 5:00 PM with the MDS-C (MDS Coordinator) confirmed the resident wore a fall personal alarm on at all times and that it was not listed on the careplan. Interview on 2-11-19 at 4:30 PM with the ADM revealed the facility had started reviewing a few residents individually in depth for their falls but confirmed Resident 1 was not one of those residents. The ADM confirmed after reviewing the documentation presented to the ADM, not all the falls for Resident 1 had been reviewed for causal factors and/or had new interventions initiated to prevent a future fall. B. Review of Resident 2's Admission Record dated 2-11-19 revealed date of admission 10-31-18 with [DIAGNOSES REDACTED]. Review of Resident 2's MDS dated [DATE] revealed a BIMS of 8 which indicated moderate cognitive impairment. The resident was assessed with [REDACTED]. The resident required extensive assist of one staff with bed mobility, transfers, walking in the room, dressing, and toileting. The resident did not walk in the halls and had a history of [REDACTED]. Review of Resident 2's Careplan revealed the resident was identified as a risk for falls and had 16 falls since admitted [DATE]. Review of Resident 2's PN dated 12-30-18 revealed the resident was found on the floor in a large pool of urine. The resident reported the resident needed to toilet but slipped out of bed onto the floor mat. The resident did not receive any injuries. Review of the Careplan revealed absence of a new interventions under falls or bladder incontinence. Review of PN dated 1-7-19 revealed the resident was found on the floor near the bathroom without any injury. The resident revealed the resident lowered self from the bed then scooted self toward the bathroom. Review of Careplan revealed new intervention dated 1-7-19 Review bowel and bladder continence status and establish and / or review toileting plan based on resident needs. Review of the 'Bladder Incontinence Data Collection Tool' dated 11-3-18 revealed this was the last time this form was completed. Review of the medical record revealed absence of any bladder collection diaries or any other bladder or bowel assessment forms or documentation to reveal the review of the resident's bowel and bladder continence status since the 1-7-19 fall. Interview on 2-11-19 at 4:30 PM with the DON (Director of Nursing) confirmed the absence of assessments or documentation of review of the resident's bowel and bladder continence status since the 1-7-19 fall. The DON also revealed the IDT (Interdisciplinary Team) did discover the resident's [MEDICATION NAME] had been being given twice a day scheduled for in the morning and at supper. This was an intervention they changed the medication to be given to in the morning and noon. Review of the Careplan revealed absence of the intervention to change the [MEDICATION NAME] times and absence of increased toileting schedule in the afternoon. Review of PN dated 1-21-19 revealed the resident was found on the floor and complained of severe left hip pain. The resident was transferred to the ER. The hospital revealed the resident had a fractured left hip.",2020-01-01
6040,ROCK COUNTY HOSPITAL LONG TERM CARE,2.8e+279,100 EAST SOUTH STREET,BASSETT,NE,68714,2018-02-26,689,G,1,0,RFUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observations, record review and interview; the facility failed to assure residents identified at risk for falls were protected from ongoing falls and injury as fall prevention interventions were not implemented for 2 residents (Residents 1 and 4) of 7 sampled residents. The facility census was 24. Findings are: A. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/18/17 revealed [DIAGNOSES REDACTED]. The MDS identified the following: -cognition was severely impaired; -required extensive staff assistance with transfers, bed mobility and toileting; -balance was unsteady during transfers and required physical assist to stabilize; -frequently incontinent of bladder; and -history of falls. A review of Resident 1's Care Area Worksheet (a worksheet used for care plan development) dated 10/18/17 revealed the resident was at risk for falls due to unsteadiness with the need for staff assistance to stabilize, a history of falls with major injury, difficulty focusing and forgetfulness regarding physical limitations. A plan was identified to assist the resident as needed with cares, to encourage continued involvement with the Restorative Program and not to leave the resident alone when toileting. Review of a Morse Fall Scale (assessment used to determine a resident's risk for falling) dated 1/9/18 revealed the resident was at high risk for falls. Review of MDS dated [DATE] revealed no change in assessment of the resident's risk for falls. Review of Resident 1's current Care Plan (revision date 1/11/18) revealed the resident had short and long term memory loss with poor decision making skills. The care plan further identified the resident was at high risk for falls, required extensive staff assistance with cares, was frequently incontinent of bladder and had a history of [REDACTED]. Review of a Nursing Progress Note dated 2/16/18 at 9:05 PM revealed Resident 1 was assisted into the bathroom of the resident's room. A staff member who was in the resident's room at the time, reported the resident jumped up from the toilet and fell before the staff member could reach the resident. Resident 1 was assisted from the floor into a wheelchair with complaints of pelvic and right hip pain. The resident was taken to the emergency room for evaluation and was diagnosed with [REDACTED]. During an interview on 2/26/18 at 9:30 AM, Nursing Assistant (NA)-A verified the following: -NA-A assisted Resident 1 into the bathroom on 2/16/18; -NA-A left the resident alone in the bathroom while gathering supplies for cares and checking on the resident's roommate; and -Resident 1 was at high risk for falls and should not have been left alone in the bathroom. Interview with the Director of Nursing (DON) on 2/26/18 at 12:30 PM verified Resident 1 should not have been left unsupervised in the resident's bathroom. B. Review of Resident 4'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 and had 2 or more falls without injury since the previous assessment. Review of a Morse Fall Scale completed 2/14/18 revealed the resident was at high risk for falls. Review of Resident 4's current Care Plan (revision date 2/17/18) revealed the resident had a history of [REDACTED]. The following fall prevention interventions were identified: -remind resident to use call light for staff assistance with cares; -high/low bed to be in the low position when the resident was in bed; -fall mat on floor next to bed and/or recliner; -resident to be the last one taken to the dining room for meals; -resident not to be left alone in room while positioned in wheelchair; -resident to be assisted per wheelchair out to the dining room for meals, transferred out of wheelchair and into a dining room chair and wheelchair to be removed from dining room. When done eating meal the resident was to be transferred back into wheelchair, assisted to the bathroom and positioned in the recliner in the resident's room; and -Staff to offer assist to the bathroom every 1-2 hours. During observations of Resident 4 on 2/26/18 at 11:55 AM, the resident was seated in a dining room chair for the noon meal. The resident's wheelchair was positioned at a table next to where the resident was seated and within the resident's field of vision. Review of a Nursing Progress Note dated 2/26/18 at 12:20 PM, revealed NA-G had been assisting residents in the dining room when NA-G witnessed Resident 4 stand and attempt to walk toward the resident's wheelchair. Resident 4 fell and landed on the resident's left side against the piano. During an observation on 2/26/18 at 1:23 PM, Resident 4 was in the resident's room and positioned in a recliner with the foot rest elevated. Resident 4 was seated on the footrest and was attempting to stand up from the recliner. NA-B and NA-C entered the resident's room and proceeded to assist the resident to the bathroom. During an interview on 2/26/18 at 1:47 PM, NA-B indicated Resident 4 was trying to get out of the recliner to get to the bathroom. After the resident fell in the dining room, the resident had been taken to the resident's room and positioned directly in the recliner. The resident had not been offered an opportunity to use the bathroom as identified on the resident's Care Plan. During an interview with the DON on 2/26/18 at 2:00 PM, the DON confirmed staff failed to implement current fall prevention interventions for Resident 4 which included removing the resident's wheelchair from the dining room to prevent the resident from attempting to self-transfer and assisting the resident to use the bathroom before positioning the resident in the recliner after the noon meal.",2019-07-01
5541,"WAUSA CARE AND REHABILITATION CENTER, LLC",285111,703 SOUTH VIVIAN,WAUSA,NE,68786,2016-12-14,323,D,1,0,0XL011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observations, record review and interview; the facility failed to implement interventions for the prevention of falls for 1 of 3 residents (Resident 3) reviewed who were determined to be at risk for falling. Total facility census was 24. Findings are: [NAME] Review of the facility Procedure for Ambulation dated 2006 included the following: -apply the gait belt (a safety device used to provide support for a resident during transfers or ambulation, and to help prevent falling), -grasp the gait belt at the resident's back/side with one hand and support the resident as needed with the other hand, and -do not let go of the gait belt. B. Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/25/16 indicated the resident had [DIAGNOSES REDACTED]. The MDS further indicated the following related to Resident 3: -severe cognitive impairment, -required extensive assistance with bed mobility and transfers, -required supervision to limited assistance with ambulation, and -had problems with balance when moving from a seated to standing position, moving on and off the toilet, and during transfers. Review of Resident 3's Care Plan dated 10/31/16 revealed the resident was at risk for falls. Nursing interventions included the use of a gait belt with transfers. The Care Plan further indicated Resident 3 had fallen in the South day room on 11/26/16. The following observations were made on 12/13/16: -2:55 PM - Registered Nurse (RN)-G assisted Resident 3 to ambulate in the East corridor, and no gait belt was used; and -3:00 PM to 3:08 PM - Nursing Assistant (NA)-E assisted Resident 3 to ambulate to the bathroom and get on and off the toilet, and no gait belt was used. During observation on 12/14/16 at 7:10 AM, NA-C assisted Resident 3 to ambulate from the bath house into the South corridor, and then to sit in the wheelchair. No gait belt was used during the transfers. During interview on 12/14/16 at 12:45 PM, the Director of Nursing and Administrator verified a gait belt should be used during transfers.",2019-11-01
6034,ROCK COUNTY HOSPITAL LONG TERM CARE,2.8e+279,100 EAST SOUTH STREET,BASSETT,NE,68714,2017-11-14,323,D,1,0,SRMC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on record review and interview; the facility failed to assure residents identified at risk for falls were protected from injuries as causal factors were not assessed and fall prevention interventions were not revised and/or new interventions developed following ongoing falls for 2 residents (Residents 3 and 8). The facility census was 21 and sample size was 11. Findings are: A. Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/30/17 revealed [DIAGNOSES REDACTED]. The MDS identified the following: -cognition was severely impaired; -required extensive staff assistance with transfers, bed mobility and toileting; -balance was unsteady during transfers and required physical assist to stabilize; -frequently incontinent of bladder; and -history of falls. Review of a Nursing Progress Note dated 3/5/17 at 8:05 PM revealed the resident was discovered on the floor of the resident's room. The resident's 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) had been removed. An intervention was identified for staff to check the resident hourly and to anticipate the resident's needs. Further review revealed no causal factors were identified. Review of a Nursing Progress Note dated 5/1/17 at 3:11 PM revealed the resident was found on the floor at the foot of the resident's bed. Review of a Nursing Progress Note dated 5/5/17 at 5:00 PM revealed staff heard Resident 3's TABs alarm sounding and found the resident on the floor, next to the roommate's bed. review of the resident's medical record revealed [REDACTED]. In addition, fall prevention interventions were not revised and/or new interventions developed in an attempt to prevent ongoing falls. Review of a Nursing Progress note dated 5/11/17 at 12:00 PM revealed the resident was found seated on the floor of the resident's room. The resident's roommate indicated the resident had removed the TABs alarm, stood and then fell . A new intervention was developed to secure the TABS on the back of the resident's clothing so it was out of the resident's reach. Review of a Nursing Progress Note dated 6/5/17 at 6:00 PM revealed the resident self-propelled wheelchair out of the Dining Room after the evening meal. Staff heard the TABs alarm sounding and found the resident on the floor in front of the resident's recliner. review of the resident's medical record revealed [REDACTED]. Review of a Nursing Progress Note dated 7/10/17 at 3:50 PM revealed the resident's TABs alarm was sounding. The resident was found on the floor next to the resident's bed. The resident complained of pain all over and a small open area was found on the back of the resident's head. review of the resident's medical record revealed [REDACTED]. Review of a Nursing Progress Note dated 8/2/17 at 2:26 PM revealed the resident was on the floor in room 104, next to the bed. The resident told the staff after laying down on the bed, the resident had decided to move the wheelchair away from the bed and fell . The resident's fall alarm had been disconnected. review of the resident's medical record revealed [REDACTED]. Review of a Nursing Progress Note dated 8/16/17 at 3:30 PM revealed the resident was discovered on the floor of the resident's bathroom. A new intervention was identified to toilet the resident before and after all meals and for a Velcro, self-releasing safety belt to the resident's wheelchair. Review of a Morse Fall Scale (document which is used to assess a resident's risk for falling) dated 8/29/17 at 3:17 PM revealed the resident was at risk for falls. Review of Resident 3's current Plan of Care with revision date 9/3/17 revealed the resident was at risk for falls due to need for extensive staff assistance with cares and impaired cognition. Interventions included: TABs alarm to wheelchair, bed and recliner; Velcro self-releasing seat belt to wheelchair; keep pathways clear and clutter free and make sure resident wearing non-skid footwear. Review of a Nursing Progress Note dated 9/4/17 at 4:00 PM revealed the resident was heard calling out for help. The resident was found lying on the floor next to the resident's bed with the wheelchair tipped over beside the resident. review of the resident's medical record revealed [REDACTED]. Review of a Nursing Progress Note dated 10/28/17 at 12:20 PM revealed the resident was on the floor beside the resident's wheelchair. review of the resident's medical record revealed [REDACTED]. In addition, fall prevention interventions were not revised and/or new interventions developed in an attempt to prevent ongoing falls. During an interview on 11/14/17 from 9:00 AM to 9:30 AM, the Director of Nursing (DON) confirmed Resident 3 was at high risk for ongoing falls. In addition, the DON confirmed the facility had failed to assess causal factors after each of the resident's falls and the resident's fall prevention interventions were not revised and/or additional interventions developed to prevent potential injury from ongoing falls. B. Review of Resident 8's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The following was identified: -cognition was severely impaired with indicators of delirium; -required extensive staff assistance with bed mobility, transfers and toileting; and -occasionally incontinent of bladder. Review of a Nursing Progress Note dated 1/13/17 at 7:00 AM revealed the resident was found on the floor of the resident's bathroom. The resident was wearing socks and no shoes and indicated slipping when in the bathroom. An intervention was developed to encourage the resident to wear shoes or gripper socks to prevent ongoing falls. Review of a Nursing Progress Note dated 2/11/17 at 7:40 AM revealed the resident's spouse called out for help as staff walked by the resident's room. Resident 8 was on the floor next to the resident's bed. review of the resident's medical record revealed [REDACTED]. Review of a Nursing Progress Note dated 2/13/17 at 7:15 AM revealed the resident's spouse had again alerted staff Resident 8 was on the floor. Urine was observed on the floor around where the resident was positioned. A new intervention for a timed toileting schedule was initiated. Review of a Nursing Progress Note dated 4/21/17 at 6:45 AM revealed the resident had self-transferred out of bed and fell to the floor. Review of a Nursing Progress Note dated 5/6/17 at 1:50 PM revealed the resident attempted to sit down in a recliner, missed the seat and fell to the floor. review of the resident's medical record revealed [REDACTED]. In addition, fall prevention interventions were not revised and/or new interventions developed in an attempt to prevent ongoing falls. Review of a Morse Fall Scale dated 9/12/17 at 10:29 AM revealed the resident was at risk for falls. Review of Resident 8's current Care Plan revised on 9/19/17 revealed the resident was at risk for falls due to need for staff assist with cares and cognitive impairment. Interventions included: shoes with non-skid soles or gripper socks; keep the resident's bed at an appropriate height; keep frequently used items close to the resident; and provide adequate lighting in the resident's room and bathroom. Review of a Nursing Progress Note dated 9/25/17 at 7:45 AM revealed the resident was discovered on the floor in the bathroom of room 108. The resident had sustained a 2 centimeter (cm) skin tear on the resident's right wrist. Review of a Nursing Progress Note dated 10/5/17 at 4:37 AM revealed staff heard the resident's room door slam shut. Upon investigation, the resident was found on the floor in front of the door. The resident identified loosing balance when walking to the bathroom. Review of a Nursing Progress Note dated 10/23/17 at 5:00 AM revealed staff heard a loud noise coming from the resident's room. The door to the resident's room was shut tightly and staff were unable to open initially as the resident was behind the door. The resident was able to move away from the door far enough for staff to enter the room. The resident identified the fall occurred when walking to the bathroom. Review of a Nursing Progress Note dated 11/1/17 at 2:00 AM revealed a loud noise was heard coming from the resident's room. The resident was found on the floor in front of the bathroom door. The resident indicated the resident's legs gave out when on the way to the bathroom. Review of Resident 8's medical record revealed when the resident fell on [DATE], 10/5/17, 10/23/17, and on 11/1/17 the resident's fall prevention interventions were not revised and/or new interventions identified to prevent ongoing falls During an interview on 11/14/17 from 9:00 AM to 9:30 AM, the DON confirmed Resident 8 was at high risk for ongoing falls. In addition, the DON confirmed the facility had failed to assess causal factors after each of the resident's falls and the resident's fall prevention interventions were not revised and/or additional interventions developed to prevent potential injury from ongoing falls.",2019-07-01
3670,THE LIGHTHOUSE AT LAKESIDE VILLAGE,285280,17600 ARBOR STREET,OMAHA,NE,68130,2019-09-17,689,G,1,0,49P911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on record review and interview; the facility staff failed implement interventions to prevent falls and failed to evaluate a recliner for safety of use for 1 (Resident 1) of 3 sampled residents. The facility staff identified a census of 33. Findings are: [NAME] Record review of a Admission Record sheet dated 8-30-2019 revealed Resident 1 was admitted to the facility 12-13-2018 and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 12-13-2018 revealed Resident 1 was at risk for falls. Record review of a Summary/ Conclusion Investigation Report (SCIR) sheet dated 6-08-2019 revealed Resident 1 was found sitting in front of Resident 1's recliner. Record review of Resident 1's Progress Notes (PN) dated 6-10-2019 revealed Resident 1 was observed trying to get out of a recliner with the leg rest extended. Record review of Resident 1's PN dated 7-19-2019 revealed Resident 1 was found on the floor between the recliner and medication cabinet. Record review of a SCIR sheet dated 7-31-2019 revealed on 7-26-2019 Resident 1 had been sent out to the hospital for an evaluation of let leg pain. Further review of the SCIR dated 7-31-2019 revealed the facility staff had been informed Resident 1 had sustained a non-displaced [MEDICAL CONDITION] sacral area. Record review of a Adult Abuse/Neglect Report for Licensed/Certified Facilities (ABNRLCF) dated 7-26-2019 revealed Resident 1 had been resting in a recliner. According to the information on the ABNRLCF sheet dated 7-26-2019, Resident 1 exited the recliner with the foot rest elevated and was found on the floor. Review of Resident 1's medical record revealed there was not evidence the facility staff had evaluated the safety of recliner for Resident 1's use. Record review of a Witness Statement (WS) sheet dated 8-25-2019 revealed a staff member seen Resident 1 laying on the floor. According to the WS sheet information, the staff member called for assistance and positioned Resident 1's head on a pillow. The information in the WS sheet dated 8-25-2019 identified Resident 1 was laying on (gender) side and the recliner was reclined. Record review of a ABNRLCF sheet dated 8-26-2019 revealed Resident 1 had sustained a right radius and alnar [MEDICAL CONDITION]. B. Review of the SCIR sheet signed and dated 7-31-2019 revealed Resident 1 was found laying on the right side between the recliner and medication cabinet. New interventions identified was to obtain orthostatic Blood Pressure (BP, measurement of BP, usually laying, sitting and standing, monitoring for hypotensive issues when standing) for 3 days. Record review of Weights and Vitals Summary sheet printed on 9-18-2019 revealed Resident 1's Orthostatic BP's results: -7-20-2019 at 9:25 AM, BP laying was 152/71 milligrams of mercury (mmHg), -7-20-2019 at 9:28 AM, BP sitting was 160/73. -7-20-2019 at 9:30 AM, BP standing was 138/72, a drop of 22 mmHg of the systolic reading ( the top number of a BP reading). -7-21-2019 at 8:48 AM , BP laying was 167/71 mmHg. -7-21-2019 at 9:48 AM, BP sitting was 153/73 mmHg. -7-21-2019 at 9:51 AM, BP standing was 145/73 mmHg. ( An hour and 3 minutes after the laying BP was obtained). -7-22-2019 at 9:35 AM, BP laying was 154/69 mmHg. -7-22-2019 at 10:03 AM, BP sitting was 164/77 mmHg. -7-22-2019 at 10:05 AM BP was 148/72 mmHg. Review of Resident 1's record revealed there was not evidence the facility staff had provided information of Orthostatic BP results to Resident 1's Practitioner. On 9-18-2019 at 9:38 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported Resident 1's recliner had not been evaluated for safety of use by Resident 1. Review of Resident 1's Orthostatic BP results was completed with the DON. The DON reported there was not a facility policy and procedure on how staff were to obtain orthostatic BP. The DON reported orthostatic BP should be completed laying, sitting and standing, one after the other. The DON confirmed the orthostatic BP's would not be accurate due to the length of time in between BP readings. The DON confirmed there were not other interventions implemented related to 7-19-2019 injury in an attempt to prevent further falls for Resident 1. Record review of a Assessment Measuring Orthostatic Blood Pressure by the CDC found at www.cdc.gov/steadi revealed the following information: -1. Have the patient lie down for 5 minutes. -2. Measure blood pressure and pulse rate. -3. Have the patient stand. -4. Repeat the blood pressure and pulse rate measurements after standing 1 and 3 minutes. A drop in BP greater than 20 mmHg systolic or 10 mmHg diastolic (bottom number of a BP reading), or experiencing lightheadedness or dizziness is considered abnormal. Record review of a SCIR signed and dated 8-30-2019 revealed Resident was observed in a recliner and later staff seen Resident 1 on the floor. Resident 1 complained of pain and was sent to the hospital for an evaluation. According to the SCIR sheet signed and dated 8-30-2019 the facility staff were notified Resident 1 had sustained a right arm radius and ulnar fracture.",2020-09-01
6419,LYONS LIVING CENTER,285301,1035 DIAMOND STREET,LYONS,NE,68038,2018-05-10,689,E,1,0,2CLY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a, 175 NAC 12-006.09D7b(1)(3), 175 NAC 12-006.18E(1)(4)(5) Based on observations, record review and interview; the facility failed to protect residents from potential accident hazards as (1) no smoking safety assessments were completed for Residents 3, 6 and 7 who were allowed to smoke, and facility protocol related to safe smoking was not followed; (2) Residents 3 and 4 were not assessed for risk for wandering and/or interventions were not implemented to prevent elopement (leaving the facility unattended and without staff knowledge); (3) interventions were not implemented to assure safe transfers by Resident 7 who used a motorized wheelchair for locomotion throughout the facility; and (4) the environment was not maintained in a manner to prevent potential accidents as windows in residents' rooms were not secured to prevent elopement, hazardous chemicals were observed unsecured and unattended in the Laundry Room and on the Housekeeping Cart, the Boiler Room was left unlocked and unattended, and the Maintenance tool storage utility cart was observed unattended and unsecured in a resident room. The total sample size was 14 and the facility census was 23. Findings are: A. Review of the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/7/18 revealed the following related to Resident 7: -admitted [DATE] with [DIAGNOSES REDACTED]. -cognitively intact; -required extensive assistance with activities of daily living (ADL); -had functional impairment of range of motion (ROM-the full movement potential of a joint) on one side; and -currently used tobacco products. Review of Resident 7's current Care Plan dated 5/1/18 indicated the resident smoked cigarettes. Nursing interventions included the following: -all cigarettes and lighting material will be kept at the nurses station; -assess quarterly for independent or supervised smoking; -resident sometimes loudly demands to be taken out to smoke when it is between scheduled supervised smoking; -gently remind you will be happy to take out when the scheduled time comes; -document episodes of non-compliance; -smoking allowed only in designated smoking areas and not inside the facility at any time; and -smoking materials to be returned to the nurses' station after smoke break. Review of the medical record revealed no evidence that Resident 7 was assessed to determine capability to smoke in a safe manner and/or interventions required to decrease the risk for injury related to smoking. During observation on 5/10/18 at 8:00 AM, Resident 7 was seated in the motorized wheelchair in the room. The bedside stand was positioned on the left side of the resident and there were 2 boxes of cigarettes and a container of smokeless tobacco lying on top. The resident opened one of the boxes and revealed a lighter was stored in the box with the cigarettes. B. Review of the Admission MDS dated [DATE] revealed the following related to Resident 3: -admitted [DATE] with [DIAGNOSES REDACTED]. -severe cognitive impairment; -independent/supervision with ADL; and -did not use tobacco products. There was no evidence in the current Care Plan dated 4/30/18 that Resident 3 smoked cigarettes, and no interventions to prevent smoking injuries. Furthermore, there was no evidence the resident was assessed to determine capability to smoke in a safe manner. The following observations were made of Resident 3 on the patio outside the Exit door of the 100 Hall smoking cigarettes with other residents: -5/7/18 at 9:45 AM and 3:14 PM - supervised by a staff person, seated, and wearing a smoking apron (a non-flammable apron fastened around the resident's neck and covering the trunk and upper thighs, used to protect against dropped ashes/cigarettes); and -5/10/18 from 1:28 PM until 1:32 PM - supervised by a staff person, walking about the patio area while smoking the cigarette, and not wearing a smoking apron. C. During interview on 5/10/18 at 9:55 AM, the Director of Nursing (DON) revealed the following: -smoking safety assessments were supposed to be completed on admission and annually; -there were no smoking safety assessments completed for Residents 3 and 7; -there were no written policies related to smoking; -residents have to wear a smoking apron, and if refused they can't smoke; and -cigarette lighters were not allowed in resident rooms. D. Review of the Policy titled Wandering, Unsafe Resident dated 12/13/16 included the following: -staff will identify residents who are at risk for harm because of unsafe wandering (including elopement); -staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering; -the resident's Care Plan will indicate the resident is at risk for elopement or other safety issues; and -interventions to maintain safety, such as a detailed monitoring plan, will be included. E. Review of the Admission MDS dated [DATE] revealed the following related to Resident 3: -admitted [DATE] with [DIAGNOSES REDACTED]. -severe cognitive impairment; -independent/supervision with ADL; and -wandered on 1 to 3 days of the 7 day assessment period; and -wandering placed the resident at significant risk of getting to a potentially dangerous place (such as stairs or outside the facility). Review of Resident 3's current Care Plan dated 4/30/18 indicated the resident was at risk for elopement and wandering related to dementia and history of an attempt to leave the facility unattended. Nursing interventions included the following: -distract from wandering by offering diversions, structured activities, food, conversation, television, book; -wears a Wanderguard alert bracelet (a device attached to the resident that sets off an alarm when the resident passes by facility exits that are equipped with sensor devices activated by the bracelet); check for placement per protocol; and -provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Review of Nursing Progress Notes dated 4/18/18 (day after admission) revealed the following related to Resident 3: -1:21 AM - asking for keys to get back home; -8:59 PM - pacing up and down halls; and -9:04 PM - comes to front desk and asks for keys because wants to go home; told didn't have have keys; gets upset and states get my (expletive) keys and walks away. There was no evidence in the medical record that Resident 3 was assessed for risk of wandering and/or elopement, or that interventions were implemented to prevent the resident from leaving the facility. Review of the Incident/Accident Investigation dated 4/20/18 at 6:58 PM indicated another resident informed the Charge Nurse that this resident went out the front door. The nurse immediately went to the front door, found Resident 3 sitting outside, and returned the resident to the facility. Documentation indicated a Wanderguard bracelet was in place but didn't alarm the door, and the Wanderguard bracelet was replaced with a new one. Review of Resident 3's Treatment Administration Record (TAR) dated 4/2018 revealed the following: -an order dated 4/20/18 at 9:00 PM for Wanderguard for resident safety, check placement every shift; and -documentation that the Wanderguard was checked initially at 9:00 PM on 4/20/18 and every 12 hours following. During interview on 5/10/18 at 10:55 AM, the Administrator verified an elopement risk assessment was not completed for Resident 3. F. Review of the MDS dated [DATE] revealed the following related to Resident 7: -admitted [DATE] with [DIAGNOSES REDACTED]. -cognitively intact; -required extensive assistance with ADL; and -had functional impairment of ROM on one side. Review of Provider Orders recommended by the Occupational Therapist (OT) dated 3/29/18 revealed the following related to Resident 7: -in a trial power (motorized) chair (wheelchair) and is doing well; -discontinue use of the power chair if runs into anyone or anything, and place back in a manual wheelchair; -notify OT of any occurrence of such; and -a physician's orders [REDACTED]. Review of OT Progress Notes dated 4/24/18 indicated Resident 7 was educated on safety with the motorized wheelchair, and if runs into something or someone, the wheelchair will be discontinued for safety. The note further documented that nursing reported the resident injured staff member with wheelchair. The OT had not verified this and wanted to review the (incident) report. There was no evidence in the medical record that an incident occurred with Resident 7's motorized wheelchair on 4/24/18. Review of Nursing Progress Notes dated 4/29/18 at 5:10 AM indicated a resident reported Resident 7 ran into another resident during a smoke break. Resident 7 was observed seated in the motorized wheelchair at the following times on 5/7/18: -9:45 AM - outside the facility while on smoke break; -1:00 PM - self propelling in the corridor between the 200 Hall and the 300 Hall; and -2:55 PM - in the resident's room watching television. An anonymous resident interview on 5/7/18 at 3:00 PM revealed concern that Resident 7 was unable to maneuver the motorized wheelchair in a safe manner and was a hazard to self and others. There was no evidence that Resident 7's use of the motorized wheelchair was addressed in the current Care Plan, or that nursing interventions related to safety and the prevention of accidents and injury were implemented. During interview on 5/10/18 at 9:45 AM, the OT verified Resident 7 had incidents of running into other residents and/or items during transfers in the motorized wheelchair. The OT verified documentation related to the incidents was requested but never received from the facility. During interview on 5/10/18 at 10:57 AM, the facility Administrator verified no incident reports and/or investigations were completed related to incidents involving Resident 7's motorized wheelchair. G. Review of the Material Safety Data Sheet (MSDS) dated 12/22/15 for Quat Stat Neutral Disinfectant Cleaner revealed the following: -harmful if swallowed, in contact with skin, or if inhaled; -causes severe [MEDICAL CONDITION] eye damage; and -store locked up. Review of the MSDS dated 11/20/15 for ABC Accelerated Bowl Cleaner revealed the following: -causes severe [MEDICAL CONDITION] eye damage; -may cause respiratory irritation; and -store locked up. H. During the Initial Tour of the facility on 5/7/18 from 9:15 AM through 9:45 AM, the following environmental hazards were identified: -The door to the Boiler Room on the 200 Hall was unlocked and the room was unattended. There were 3 cement steps immediately inside the door that led to the cement floor of the room, and the room was full of mechanical/electrical equipment; -The door to Resident room [ROOM NUMBER] was closed but unlocked, and the room was not occupied. There were 2 double paned windows in the room that opened to a height that would allow a crawl space to the outside of the building. There were no screens on the windows, and there was a 2 to 3 foot drop to the ground outside the window; and -The door to the Laundry Room was unlocked and the room was unattended. There was a spray bottle labeled Quat Stat Disinfectant Cleaner and a bottle of ABC Accelerated Bowl Cleaner unsecured in the washing machine area. Further observations on 5/7/18 included the following: -11:00 AM - the Boiler Room door remained unlocked while the room was unattended; -12:10 PM to 12:15 PM - the Housekeeper was wet mopping the floors in the corridors at the front of the Nurses' Station and from the Nurses' Station to the front door of the facility, mopping the entire floor surfaces without leaving a dry path for traffic through the areas, and repeatedly warning persons as they walked through the areas Please don't slip. Please don't slip.; and -2:20 PM - the Boiler Room door remained unlocked while the room was unattended. The following observations were made on 5/10/18 from 7:30 AM until 8:20 AM: -The door to the Laundry Room was unlocked and the room was unattended. The spray bottle labeled Quat Stat Disinfectant Cleaner and the bottle of ABC Accelerated Bowl Cleaner remained in the washing machine area and unsecured; -The door to Resident room [ROOM NUMBER] was closed and there was a sign on the door Work in Progress Do not Enter. There was a utility cart immediately inside the door that was stacked with various tools, including a skill saw, power drill, crowbar and saw blades; -There were 2 double paned windows in Resident rooms [ROOM NUMBERS] that opened to a height that would allow a crawl space to the outside of the building. There were screens on the windows that were easily removable; and -There was a double paned window in Resident room [ROOM NUMBER] that opened to a height that would allow a crawl space to the outside of the building, and there was no screen on this window. During interview on 5/10/18 from 10:55 AM through 3:23 PM, the facility Administrator verified the windows in the facility were supposed to be secured so they would open no more that 2 to 4 inches and would not allow access to the outside of the building. The Administrator further verified the Boiler Room was to be locked when unattended, the utility cart of tools was to be locked up when not in use, and the Laundry Room was supposed to be locked when the room was unattended. On 5/10/18 from 1:20 PM until 1:32 PM, the Housekeeping Cart was observed parked in the corridor outside Resident room [ROOM NUMBER] and unattended. There was a bottle of Quat Stat Disinfectant Cleaner stored on top of the cart unsecured. I. Observation of Resident 6 on 5/7/18 at 10:10 AM revealed the resident was seated outside smoking with a staff member present. Interview with Nursing Assistant (NA)-B on 5/7/18 at 3:02 PM revealed a staff member went outside with the residents at all designated smoking times. NA-B went on to state Resident 6 was, however, allowed to sit outside after smoking was completed without a staff member present. Further interview revealed Resident 6 was in charge of the resident's own smoking materials, and kept cigarettes and a lighter with the resident and/or in the resident's room. Interview with Resident 6 on 5/10/18 at 10:00 AM confirmed the resident kept cigarettes and a lighter in the pocket of the resident's shirt. Review of Resident 6's Smoking Safety Screen dated 2/19/18 revealed the document was opened but had not been filled out. Review of Resident 6's current undated Care Plan revealed the resident would follow the schedule for smoking and staff would assist the resident outside to smoke. Further review of the Care Plan revealed no evidence to indicate the resident's ability to smoke safely and the resident's ability to safely keep the resident's cigarettes and a lighter with the resident had been addressed. Interview with the Provisional Administrator on 5/10/18 at 9:08 AM confirmed the facility did not have a smoking policy in place. J. On 5/7/18 at 8:45 AM Resident 4 was observed ambulating independently throughout the facility. Review of Resident 4's Wandering Risk Scale dated 4/28/18 revealed the resident was at high risk for elopement. Review of Resident 4's current undated Care Plan revealed no evidence to indicate a plan of care had been created to address Resident 4's risk for elopement. Interview with Registered Nurse-L on 5/10/18 at 9:20 AM revealed Resident 4 could ambulate independently. Further interview confirmed the resident did not use a wander guard.",2019-03-01
2492,PIONEER MANOR NURSING HOME,285212,"P O BOX 310, 318 N 3RD STREET",HAY SPRINGS,NE,69347,2017-06-13,323,D,1,0,1JY511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on interview and record review, the facility failed to assess for causal factors and implement interventions to prevent potential falls and injury for 2 of 3 sampled residents (Residents 1 and 4). The facility identified a census of 49 at the time of survey. Findings are: [NAME] Review of Resident 1's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 1/5/2017 revealed Resident 1 was admitted to the facility on [DATE]. Resident 1 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated Resident 1 had moderate cognitive impairment. Resident 1 required extensive assistance from 1 staff person for bed mobility, transfer, walking in room, locomotion on and off unit, dressing, toilet use, personal hygiene, and bathing. Resident 1 had a history of [REDACTED]. Resident 1's CAA (Care Area Assessment) revealed falls triggered as an issue and was indicated as care planned. Review of Resident 1's progress notes revealed Resident 1 fell on [DATE]. Resident 1 fell again on 6/5/2017. Review of Resident 1's care plan dated 5/15/2017 revealed no documentation of interventions implemented to prevent falls and injury after Resident 1 fell on [DATE] and 6/5/2017. B. Review of Resident 4's admission MDS dated [DATE] revealed an admission date of [DATE]. Resident 4 had a BIMS score of 14 which indicated Resident 4 was cognitively intact. Resident 4 required extensive assistance from one staff person for bed mobility, transfer, walking in room and corridor, and locomotion on and off the unit. Resident 4 had a history of [REDACTED]. Resident 4's CAA summary revealed falls triggered as an issue and was indicated as care planned. Review of Resident 4's care plan dated 5/30/2017 revealed no documentation that Resident 4 was at risk for falls and no documentation of interventions to prevent falls and injury. Review of Resident 4's assessment records revealed no documentation a fall assessment had been completed. Interview with the DON (Director of Nursing) on 6/13/2017 at 6:19 PM revealed there was no documentation on Resident 1's care plan of fall interventions implemented after Resident 1 fell on [DATE] and 6/5/2017. The DON confirmed there was no documentation of interventions to prevent falls and injury on Resident 4's care plan. Interview with LPN-A (Licensed Practical Nurse) on 6/13/2017 at 6:44 PM revealed a fall risk assessment had not been completed for Resident 4 and should have been. Interview with LPN-B on 6/13/2017 at 6:44 PM confirmed fall interventions had not been implemented on Resident 4's care plan after Resident 4's admission MDS had been completed indicating that falls were an issue for Resident 4. Interview with the DON on 6/13/2017 at 6:44 PM revealed the facility did not have a policy regarding assessing fall risk and implementing interventions to prevent falls and injury after residents had been identified at risk.",2020-09-01
4342,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-04-11,323,D,1,0,T8J411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on interviews and record review, the facility staff failed to evaluate causal factors for falls for Resident 1 and failed to implement measures to prevent falls and potential injury for Resident 6. This affected 2 of 3 sampled residents. The facility identified a census of 114 at the time of survey. Findings are: [NAME] Review of Resident 1's Admission Record revealed an admission date of [DATE]. Review of Resident 1's Significant Change in Status MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 3/3/2017 revealed that Resident 1 had a BIMS (Brief Interview for Mental Status) score of 9 which indicated moderate cognitive impairment and Resident 1 required extensive assistance from 1 staff person for transfers and locomotion. Resident 1 also had 2 or more falls with injury since admission/entry, reentry, or prior assessment. Review of Resident 1's Fall by the Week log revealed documentation that Resident 1 fell on [DATE], 3/5/2017, three times on 3/6/2017, and 2 times on 3/7/2017. Review of Resident 1's Fall reports for 3/4/2017, 3/6/2017, and the first fall on 3/7/2017 revealed no documentation that causal factors for the falls was evaluated. Interview with LPN-A (Licensed Practical Nurse) on 4/11/2017 at 3:12 PM revealed causal factors for the falls had not been evaluated and should have been. B. Review of Resident 6's Admission Record revealed an admission date of [DATE]. Review of Resident 6's Admission MDS dated [DATE] revealed that Resident 6 had modified independence with daily decision making and required supervision from staff for transfers and locomotion. Resident had a fall history that included a fall with a fracture in the 6 months prior to admission/entry or reentry. Resident 6's Care Area Assessment (CAA) revealed that falls triggered as an issue and the care plan decision indicated that the fall risk would be addressed on Resident 6's care plan. Review of Resident 6's assessments revealed no documentation a fall assessment had been completed and was flagged as overdue on the assessment schedule. Review of Resident 6's care plan revealed a focus to address falls was initiated on 4/2/2017. Documentation on the care plan revealed that Resident 6 had a fall on 3/19/2017. Interview with the interim DON (Director of Nursing) on 4/11/2017 at 3:03 PM confirmed that interventions had not been implemented to prevent Resident 6 from falling on 3/19/2017. Review of the facility policy Falls Management dated 4/2015 revealed the following procedure: Assess and review resident risk factors for falls and injuries upon admission, with a significant change in condition or after a fall. Complete the Fall Risk Assessment within the electronic medical record (EMR). Implement goals and interventions with resident/patient/family for inclusion in the Interdisciplinary Plan of Care (IP[NAME]) based on individual needs. Fall Injury Prevention-Post Fall: Assess the resident/patient and immediately implement appropriate measures to prevent injury. Adjust/add interventions on the Plan of Care-Fall Risk Reduction. Review and revise Interdisciplinary Plan of Care.",2020-08-01
5023,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2017-02-21,323,D,1,0,3Y2S11,"**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 failed to implement interventions to prevent falls and potential injury for Resident 199 and Resident 65. This affected 2 of 4 sampled residents. The facility identified a census of 81 at the time of survey. Findings are: Findings are: [NAME] Review of Resident 199's Admission MDS (a comprehensive assessment tool used to develop a resident's care plan) dated 1/7/2017 revealed Resident 199 had an admission date of [DATE]. Resident 199 required extensive assistance from 1 staff person for transfers and toilet use and Resident 199 had a history of [REDACTED]. Review of Resident 199's IDPN (Interdisciplinary Progress Notes) dated 2/5/2017 revealed Resident 199 fell and was sent to the emergency room for treatment of [REDACTED]. Review of Resident 199's IDPN revealed documentation that Resident 199 fell on [DATE] and 1/30/2017. Review of Resident 199's care plan dated 1/12/2017 revealed no interventions were documented on the care plan to prevent further falls and injury after Resident 199 fell on [DATE], 1/30/2017, and 2/5/2017. B. Review of Resident 65's MDS dated [DATE] revealed that Resident 65 was admitted to the facility on [DATE]. Resident 65 was rarely/never understood, required extensive assistance for transfers, and Resident 65 had a history of [REDACTED]. Observation of Resident 65 on 2/21/2017 at 1:50 PM revealed Resident 65 leaning forward in the wheelchair requiring staff members to physically push Resident 65 back into the wheelchair to prevent Resident 65 from falling out of the wheelchair. 2 staff then proceeded to transfer Resident 65 out of the wheelchair into a recliner with a full lift. Review of Resident 65's care plan dated 2/16/2017 revealed no documentation of interventions to prevent Resident 65 from falling out of the wheelchair due to leaning forward and an increased need for assistance with transfers. Interview with the ADON/DON (Assistant Director of Nursing/Director of Nursing) on 2/21/2017 at 3:29 PM confirmed there was no documentation on Resident 65's care plan of Resident 65's current transfer status and no documentation of interventions to prevent Resident 65 from falling out of the wheelchair due to Resident 65 leaning forward.",2020-02-01
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
6232,O'NEILL OPERATIONS LLC,285108,"PO BOX 756, 1102 NORTH HARRISON",O' NEILL,NE,68763,2016-05-04,323,D,1,0,OPK411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on observation, record review and interview; the facility failed to implement interventions and to provide supervision to prevent ongoing falls for Resident 8. Facility census was 69. Findings are: Review of Resident 8's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/17/16 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had severe cognitive impairment; required extensive assistance with toileting and limited assist with transfers; and had 1 fall without injury since the previous assessment. Review of Resident 8's current Care Plan (revision date 3/17/16) indicated the resident was at risk for falls related to incontinence, history of falls, impaired safety awareness, insomnia and noncompliance with fall prevention interventions. The Care Plan further identified the resident would frequently lean forward in the wheelchair and the resident had been fitted for a new wheelchair. The resident was to have foot pedals in place and a pillow to the right side of the wheelchair at all times to improve the resident's positioning and to reduce risk for falls. Nursing interventions included: -Every 15 minute visual checks due to noncompliance with use of bed and chair alarms. -Pillow to be propped on resident's right side and feet to be positioned on foot pedals to ensure proper positioning when seated in wheelchair. -Bed to be in low positron when resident in bed. -Call light within reach at all times when resident in bed. -Fall mat on floor next to resident's bed. Review of Nursing Progress Notes revealed the following: -4/3/16 at 6:36 PM- The resident had been self-propelling the wheelchair out to the dining room and the resident had been leaning forward in the chair. The resident was then found seated on the floor in front of the wheelchair. -4/4/16 at 6:56 AM- The resident attempted to self-transfer from the bed to the wheelchair and fell , hitting head on a trash receptacle at bedside. The note further identified the resident was non-compliant with calling for staff assistance with transfers. -4/5/16 at 3:15 PM- The resident was in the resident's room seated in the wheelchair without foot pedals in place. While self-propelling the wheelchair, the resident got feet too far underneath of the wheelchair and fell forward onto knees. -4/23/16 at 7:10 AM- The resident was found on the floor of the resident's room. The resident indicated the resident had been attempting to dress self. -4/26/16 at 11:00 PM- The resident was seated in the wheelchair in the resident's room and was self-propelling about the room. At 11:15 PM staff heard a loud noise and the resident was found on the floor in front of the wheelchair by the bathroom door. During an interview on 5/3/16 at 5:00 AM, Licensed Practical Nurse (LPN)-A confirmed Resident 10 was at high risk for falls. LPN-A identified the resident was to be visually observed every 15 minutes due to repeated falls related to the resident leaning forward in the wheelchair and the resident's non-compliance with fall prevention interventions. In addition, the resident had received a new wheelchair and the resident was to have foot pedals in place to the chair and a pillow propped on the resident's right side to prevent the resident from leaning forward. LPN-A further identified due to staffing concerns it was difficult to complete the 15 minute checks and to assure fall prevention interventions were in place. During observations of Resident 8 the following were noted: -5/3/16 at 10:00 AM- The resident was seated in a wheelchair in the Library Room of the Alzheimer Care Unit (ACU-an enclosed wing or hallway which specializes in care of residents with dementia or Alzheimer's disease) playing the keyboard piano. The resident was leaning forward to reach the keyboard. No wheelchair pedals and no pillow were in place to assure proper positioning to prevent falls. No staff were present in the Family Room -5/3/16 from 10:30 AM to 11:15 AM- The resident remained seated in the wheelchair without benefit of a pillow propped on the right side of the chair and without foot pedals. Resident 10 was self-propelling the chair in the corridor of the ACU. Nursing Assistant (NA)-I walked by the resident in the corridor but did not stop to adjust the resident's positioning in the chair. -5/3/16 at 12:35 PM- The resident was positioned at the Dining Room table on the ACU in a wheelchair. No foot pedals and no pillow were in place to the wheelchair.",2019-05-01
1020,PRESTIGE CARE CENTER OF PLATTSMOUTH,285104,602 SOUTH 18TH STREET,PLATTSMOUTH,NE,68048,2018-02-27,689,D,1,0,W9MF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on observation, record review and interview; the facility staff failed to implement interventions to prevent potential hot [MEDICAL CONDITION] 1 (Resident 31) of 3 sampled residents. The facility staff identified a census of 78. Findings are: Observation on 2-21-2018 at 6:20 PM revealed Resident 31 was in the dining room for supper. Resident 31 was served coffee and the coffee cup did not have a lid. Record review of Resident 31's Hot Liquid Safety Evaluation (HLSE) sheet dated 10-10-2017 revealed Resident 31 had scored a 5. According to the information on the HLSE sheet dated 10-10-2017, if the resident scored a 3 or higher, staff were to proceed to the care plan for hot liquid safety. Record review of Resident 31's Comprehensive Care Plan (CCP) printed on 2-21-2018, revealed there were no interventions identified for the hot liquid safety for Resident 31. On 2-27-2018 at 10:28 AM an interview was conducted with the Assistant Director of Nursing (ADON). During the interview, review of Resident 31's CCP printed on 2-21-2018 was conducted with the ADON. The ADON confirmed during the interview that Resident 31 was at risk for hot [MEDICAL CONDITION] there were not any interventions identified to prevent hot [MEDICAL CONDITION] Resident 31.",2020-09-01
5800,FAIRVIEW MANOR,285206,255 F STREET,FAIRMONT,NE,68354,2016-09-22,323,D,1,0,ZKCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on observation, record review, and interviews; the facility failed to implement a fall intervention after a resident had a fall for one resident (Resident 213) out of 3 sampled residents. The facility census was 35. Findings are: Review of Resident 213's undated face sheet revealed admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of the Fall Incident report dated 07-26-16 revealed Resident 213 was sitting at the dining table at 4:10 PM when the resident stood up and started to turn and fell to the floor. Upon assessment, the resident was in severe pain with movement of the left hip. The resident was sent to the emergency room and hospitalized for [REDACTED]. Review of the facility fall investigation report dated 07-27-16 revealed a new approach would be initiated when the resident returned from the hospital. Review of the Progress Notes revealed the resident returned to the facility after the hip repair surgery on 08-19-16. Review of the notes from 08-19-16 to 09-22-16 revealed no documentation of a new fall intervention initiated as a result of the 07-26-16 fall. Review of the Care Plan revealed documentation of the 07-26-16 fall without a new intervention documented. Observation on 09-22-16 at 2:54 PM of Resident 213 in resident's room laying in bed in the supine (on the back) position with the call light on the resident's lap. No fall alarms were observed on the resident and no safety mats on the floor on either side of the bed. Observation on 09-22-16 at 3:08 PM of Resident 213 in bed without safety mats on the floor on either side of the bed. Observation of the room revealed no floor mats stored in the closet, in the bathroom, or anywhere else in the resident's room. Interview with MA-B (Medication Aide) on 09-22-16 at 3:12 PM revealed the fall interventions for Resident 213 were to have the bed in the low position, which resident had the low bed since before the fractured hip, and to watch the resident closely when in the recliner as the resident had a tendency to scoot forward. MA-B denied Resident 213 had a personal fall alarm or safety mats on the floor by the bed and revealed (gender) was not aware of any new interventions since the resident returned from the hospital. Interview on 09-22-16 at 2:58 PM with LPN-A (Licensed Practical Nurse) revealed Resident 213 had a low bed and the new fall intervention for the resident after the fractured hip was the safety floor mats to be placed on both sides of the bed when the resident was in the bed. Observation, accompanied by LPN-A, on 09-22-16 at 3:30 PM of Resident 213 in resident room revealed the resident was laying in bed with the bed in a low position and the safety mats were on the floor on both sides of the bed. Interview on 09-22-16 at 3:30 PM with LPN-A revealed LPN-A had placed the safety floor mats on the floor after our interview when LPN-A had found resident in bed without the safety floor mats on the floor. The LPN-A confirmed the mats were not in the residents room and had to be obtained from a room across the hall.",2019-09-01
5810,"SUTTON COMMUNITY HOME, INC.",285277,1106 NORTH SAUNDERS,SUTTON,NE,68979,2016-09-13,323,D,1,0,OVZV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on observation, record reviews, and interviews; the facility failed to identify the causal factor of a hot liquid burn and failed to implement interventions to reduce the risk of another burn on 1 (Resident 03) out of 3 residents sampled. The facility census was 26. Findings are: Review of Resident 03's face sheet dated 09-13-16 revealed an admission on 04-22-15 with [DIAGNOSES REDACTED]. Review of the MDS(Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 08-17-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 03 had no cognitive impairment. Review of the incident report dated 09-05-16 revealed the bath aide noted a blister on the Resident 03's abdomen when undressing the resident for a bath and reported it to the charge nurse. The resident revealed that, the day before, the resident spilled a cup of coffee on self at lunch time. The incident report did not reveal exactly how the resident spilled the coffee on the abdomen. The intervention initiated was the resident was encouraged to inform staff immediately the next time this happened. Interview on 09-13-16 at 2:00 PM revealed the staff all now pour the resident's coffee from the machine and take it to the table instead of the resident obtaining it from the machine ever since the burn incident. Review of the Progress Notes from 08-21-16 through 09-07-16 did not reveal how the resident spilled the coffee on self. Review of the Care Plan did not reveal how the resident spilled the coffee on self and did not document a new intervention to prevent another hot liquid burn. Interview on 09-13-16 at 12:30 PM with the SW (Social Worker) revealed the SW was aware of the coffee burn to Resident 03 as it had been discussed at a care plan meeting and the new intervention was to treat the burn wound by nursing. The SW revealed that, if the SW was to serve the resident a cup of coffee now, the SW would put some ice cubes in the coffee to cool it down as the intervention to prevent another burn. The SW denied knowing exactly how the burn was caused and thought it happened when the resident was bringing the cup of coffee to the resident's mouth to take a drink. Interview on 09-13-16 at 12:35 PM with the AD (Activities Director) revealed that, if the AD was to serve Resident 03 a cup of coffee now, the AD would ask the resident if the resident wanted ice water or ice cubes put into the coffee to cool it down before serving. The AD also revealed the AD was told at the care plan meeting the resident spilled the coffee on self when trying to drink the coffee and tipped the cup too soon before it reached the mouth. Interview on 09-13-16 at 12:45 PM with the DM (Dietary Manager) revealed the DM was unsure how the coffee burn happened but, as an intervention, the DM asked the resident's spouse to bring in a cup with a lid. The DM revealed the spouse had not brought it in yet and the DM had not followed up on it or provided a cup with a lid. Interview on 09-13-16 at 1:30 PM with Resident 03 revealed the coffee burn happened when the resident was pouring the coffee from the coffee machine into the cup in the Dining room. The resident was visiting with another resident and became distracted and started to overflow the cup. The resident over reacted, grabbed the cup and brought it towards self, and that is when the spill occurred. The resident denied the act of trying to take a drink of the coffee when the burn occurred. The resident denied the staff having asked exactly how the burn occurred.",2019-09-01
4904,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2017-12-21,689,D,1,0,7XZQ11,"**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 investigate the occurrence of a fall for Resident 1, to identify causal factors and develop interventions for the prevention of further falls. The facility census was 37 and the total sample size was 8. Findings are: [NAME] Review of the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/6/17 revealed the following related to Resident 1: -severe cognitive impairment; -required extensive assistance with bed mobility, transfers, dressing and toileting, and total assistance with personal hygiene; -was not steady, and only able to stabilize with human assistance, when moving from a seated to standing position, moving on and off the toilet, and during surface-to-surface transfers; and -had 1 fall with no injury since the previous assessment. Review of the current Care Plan dated 11/18/17 indicated Resident 1 was at risk for falling due to unawareness of safety needs, confusion, gait and balance problems and incontinence. Nursing interventions included the following (all interventions were dated as initiated on 5/11/16): -anticipate and meet the resident's needs; -ensure call light is within reach and encourage the resident to use it for assistance; -provide a safe environment, including floors free from spills/clutter, adequate and glare-free lighting, working and reachable call light, bed in low position at night, personal items within reach; -uses a lap belt with electronic alarm (a type of wheelchair seat belt fastened around a resident with a Velcro closure that alarms when the belt is removed); -ensure the lap belt is in place as needed, and check to see if the resident is still able to remove it on command; and -use sit-to-stand mechanical lift with 2 staff members for transfers to prevent falls during transfers. Review of Nursing Progress Notes dated 11/22/17 at 8:45 PM indicated Resident 1 was found on floor in front of wheelchair and calling out for help. The incident was unwitnessed and there were no noted injuries or complaints of pain. The resident was assisted into bed and monitored. There was no evidence the facility investigated Resident 1's fall, determined causal factors, and/or developed new interventions for the prevention of further falls. Review of Nursing Progress Notes dated 11/28/17 at 1:45 AM revealed Resident 1 was observed laying on the floor on right side in of the wheelchair. There was a small abrasion noted to the right knee measuring 2 cm (centimeters) x (by) 2 cm. Review of a Post Fall assessment dated [DATE] indicated Resident 1's fall occurred on 11/27/17 at 7:40 PM and the immediate intervention for the prevention of further falls was to remind Resident 1 to ask for assistance when transferring from the wheelchair. There was no evidence the facility determined causal factors of the fall, and/or reviewed and revised the Care Plan to include new interventions for the prevention of further falls. Resident 1 was observed seated in the wheelchair with the straps of the lap belt hanging loosely at the back and unsecured at the following times on 12/20/17: -7:00 AM until 7:40 AM in the front lobby area; -11:25 AM until 12:20 PM in the Medication Room for a dressing change, and in the dining room for the noon meal; and -1:00 PM until 1:31 PM in front of the television in the resident's room. During interviews on 12/20/17 from 2:07 PM until 2:20 PM, NA-F indicated the lap belt on Resident 1's wheelchair was there for safety when (the resident) was falling but isn't needed anymore, and staff don't know how to remove it from the wheelchair. During interview on 12/20/17 at 2:52 PM, the Director of Nursing (DON) revealed the following: -verified an investigation was not completed following Resident 1's fall on 11/22/17 and new interventions were not developed; -the resident used a lap belt as a fall intervention at one time but they stopped attaching it because the resident was constantly taking it off and still falling; and -use of the lap belt was discussed as an intervention since the resident's last fall on 11/28/17 but a determination had not yet been made.",2020-03-01
4874,ARBOR CARE CENTERS-NELIGH LLC,285124,"PO BOX 66, 1100 NORTH T STREET",NELIGH,NE,68756,2017-03-02,323,D,1,0,042P11,"**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 assure 2 (Residents 1 and 5) of 6 sampled residents identified at risk for accidents were protected from injuries as fall prevention interventions were not implemented. The facility census was 44. Findings are: [NAME] Review of Resident 5's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/6/17 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident required extensive assistance with transfers and mobility and was incontinent of bowel and bladder. Review of Nursing Progress Note dated 1/2/17 at 5:39 PM revealed the resident was found sitting on the footrest of the recliner in the resident's room and the resident had the recliner tipped up. Staff assisted the resident up and into a wheelchair. Review of Fall Risk assessment dated [DATE] revealed the resident was at high risk for falls. Review of Nursing Progress Note revealed on 2/7/16 at 2:26 AM the resident was found sitting on the floor beside the resident's bed with back against the side of the bed. The resident's fall alarm was sounding. The resident indicated the resident was trying to get up. A new intervention was identified for a fall mat on the floor next to the resident's bed when the bed was occupied. Review of a Nursing Progress Note dated 2/28/17 at 2:05 PM revealed the resident was found on the floor of the resident's room between the bed and the recliner. The resident's fall alarm was sounding. The resident sustained [REDACTED]. elbow. A new intervention was developed to keep the foot rest of the recliner in the down position when the resident was seated in the recliner in the resident's room. Review of Resident 5's current Care Plan (undated) indicated the resident was at risk for falls related to history of falls, restlessness and occasional confusion. The Care Plan further identified the resident had a fall out of bed on 2/7/17 and another fall on 2/28/17 when the resident attempted to crawl out of a recliner. Nursing interventions included: -Bed/chair alarm at all times, check for proper function. -Floor mat beside bed when occupied. -Footwear to prevent slipping. -High/low bed: keep bed in the low position when occupied. -To sit in recliner with foot rest down. If resident wants to nap or to sleep then to assist the resident to lay down. During an observations of Resident 5 on 3/2/17 at 9:05 AM, Nursing Assistant (NA)-F and Licensed Practical Nurse (LPN)-E positioned the resident in a recliner in the resident's room. The resident was observed to have the fall alarm to the seat of the recliner and the call light positioned within reach of the resident. However, the foot rest of the resident's recliner was placed in the upright position before staff exited the resident's room. During an interview on 3/2/17 at 9: 20 AM, NA-F confirmed Resident 5 was at high risk for falls. NA-F identified the resident was to be closely monitored when left alone in the resident's room especially when the resident was seated in the recliner. NA-F further identified the resident had a history of [REDACTED]. Observations of Resident 5 on 3/2/17 revealed the following: -9:30 AM to 11:30 AM, the resident remained positioned in the recliner in the resident's room with the foot rest elevated. -2:30 PM, the resident was positioned in the recliner in the resident's room. The foot rest of the recliner was in an upright position. B. Review of Resident 1's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had 2 or more falls since the last assessment. Review of Resident 1's current Care Plan (undated) indicated the resident was at risk for falls and the resident had falls on 12/3/16, 12/6/16 and 2/3/17. Interventions for the prevention of falls included: -Bed in low position when occupied and a scoop mattress (a defined edge mattress); -Floor mat alarm bedside the bed and a padded floor mat next to the bed when occupied; -Pummel wheelchair cushion (pommel-a wedge shaped device used to prevent sliding out of a wheelchair); -Seat belt alarm (a device which sounds an alarm when the seat belt is unfastened) when in the wheelchair; and -Walk to dine program (resident is ambulated to meals) and to sit in a regular chair with alarm (device which sounds an alarm when a resident attempts to rise) while in dining room to eat. Review of Resident 1's Progress Notes revealed the following: -1/31/17 at 6:29 P-The bed/chair/floor alarms remained in place for safety; -2/2/17 at 4:43 PM and 4:46 PM-The pummel wheelchair cushion was discontinued due to the resident's decline in condition and admission to hospice services; and -2/2/17 at 6:42 PM-This afternoon was noted to be kneeling on the floor mat. Review of a Verification of Investigation form regarding Resident 1 dated 2/3/17 revealed the following: -Resident 1 was seated in a wheelchair at the dining room table at 6:20 PM; -At 6:30 PM the resident was found lying on the floor and sustained a 4 cm circular hematoma (an abnormal collection of blood outside the blood vessels and most commonly caused by injury to the wall of a blood vessel) on the left part of the forehead; -The resident stated yes when asked if the resident had a headache. Further review of the 2/3/17 Verification of Investigation form revealed Resident 1 was on hospice services and had made no attempts at self transfers (although the resident was found kneeling on the bedside floor mat on 2/2/17 at 6:42 PM). Documentation further indicated the seat belt alarm was discontinued as the seat belt alarm would not adapt to the wheelchair supplied by hospice. The pummel cushion was continued as the resident tended to lean sideways without it (although Progress Notes dated 2/2/17 indicated the pummel cushion was discontinued). Interview with the Director of Nursing (DON) on 3/2/17 at 1:13 PM revealed the seat belt alarm was removed as they determined the resident was only restless while in bed and not while seated in the chair. The DON indicated the pummel cushion had been in place at the time of the resident's fall on 2/3/17 and no chair or seat belt alarms were in use. The DON confirmed there were conflicting interventions for the prevention of falls for Resident 1.",2020-03-01
1740,"PREMIER ESTATES OF PAWNEE, LLC",285157,"P O BOX 513, 438 12TH STREET",PAWNEE CITY,NE,68420,2018-08-02,689,G,1,0,JSXJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on record review and interview, the facility failed to ensure the fall assessment was completed and interventions were implemented for Resident # 1 resulting in a fall with fracture. The facility census was 32 and the total sample size was 4. Findings are: Record review of the Electronic Medical Record for Resident #1 revealed there was no assessments for falls and no interventions for falls. The admission assessment had not been not completed. Record review of the paper chart revealed a nurse aide care plan with transfer status and there were no interventions for fall prevention. This document was not signed or dated. Resident #1's admitted was 7/17/18. Record review of a care plan note dated 7/17/18, by the Interim Director of Nurses revealed the resident was admitted to room [ROOM NUMBER] for short term to recuperate and then return to home. Resident #1 was unsteady on their feet due to weakness. Review of nurse's notes dated 7/18/18 revealed Resident #1 was found on floor in room and when assisted up the resident complained of pain. Resident #1 was sent to the hospital for evaluation. Resident #1 reported that the resident slept in a recliner at home. The recliner was in the upright position. Record review of Fall Reduction and Risk Management Procedure revealed: 1. Complete admission/Re-admission Documents and initial care plan and or change in condition evaluation to assist in identifying resident/patient specific fall risk factors. 2. Identify if the resident at higher risk of falling by placing a star symbol in an identified area near the resident. Higher risk is identified as: 2 or more falls in the last 6 months, IDT team, History of falls prior to admission. 3. Each resident is evaluated upon admission, with change in condition and quarterly to determine indicators of fall risk. 4. Individual interventions are implemented to decrease the risk of a fall. 5. Fall risk indicators reviewed if a fall occurs to determine if any changes are needed. Interview conducted on 8/2/18 at 09:47 with the Administrator and Interim DON (Director of Nurses) confirmed that Resident # 1 was in the swing bed at the hospital. A Registered Nurse was on duty at the time of the fall there was no initial care plan for Resident # 1 that was started. Interview conducted on 8/2/18 at 12:30 PM with the Administrator and the Interim DON (Director of Nurses confirmed for Resident #1 there was no documentation for the fall assessment on admission, no interventions in place for fall prevention. The Administrator and DON confirmed that the care plan had not addressed falls or prevention. The Administrator confirmed that the assessments were not complete related to the resident being tired.",2020-09-01
5072,"NORFOLK CARE AND REHABILITATION CENTER, LLC",285101,1900 VICKI LANE,NORFOLK,NE,68701,2018-03-08,689,D,1,1,2SKI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on record review and interview; the facility failed to develop interventions to prevent injuries for 1 (Resident 13) of 24 sampled residents. The facility staff identified a census of 52. Findings are: Review of Resident 13's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/27/17 revealed [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive staff assistance with bed mobility, transfers and with toileting. Review of a Nursing Progress Note dated 1/16/18 at 4:27 PM revealed the resident reported a painful area to the resident's lower right posterior leg. A hard lump was observed to the area. The resident reported the area was painful and the pain increased when the area was palpated. No redness or bruising was noted. Review of Resident 13's medical record revealed no evidence an investigation was completed regarding the area to the resident's right lower posterior leg. In addition, there was no evidence interventions were developed to prevent a reoccurrence of the injury. Review of a Nursing Progress Note dated 2/11/18 at 4:24 PM revealed the resident was transferred with a Sit-to-stand mechanical lift (mobile lift that allows for patient transfers from a seated position to a standing position. This lift is used for bed to chair transfers and toileting. This lift is designed to support only the upper body of the resident and requires the resident to have some weight-bearing capability) and obtained a 0.9 cm by 0.8 cm skin tear to the resident's right elbow. Staff received re-education regarding transfers and safety with use of the lift and the resident was re-educated on keeping elbows close to the body during transfers. Review of a Nursing Progress Note dated 2/28/18 at 10:37 AM revealed Resident 13's practitioner was notified of scattered bruises to the resident's bilateral elbows. Interview with the resident revealed the resident identified bumping elbows on the bathroom door frame during transfers. The note identified the resident refused to wear arm protectors. Further review of the resident's medical record revealed [REDACTED]. During an interview with the Director of Nursing (DON) on 3/8/18 at 3:30 PM, the DON revealed the following: -No investigation was completed regarding the resident's complaint of pain and the hard lump to the resident's right lower posterior leg. In addition, no interventions were developed to prevent ongoing injuries. -Resident 13 required use of the Sit-to-stand mechanical lift and staff assistance for all transfers. The bruising to the resident's arms which was identified on 2/28/18 occurred when staff assisted the resident into the bathroom with the lift. No interventions were developed to prevent potential ongoing injuries with use of the mechanical lift.",2020-02-01
1479,"PREMIER ESTATES OF PIERCE, LLC",285139,"P O BOX 189, 515 EAST MAIN STREET",PIERCE,NE,68767,2019-02-04,689,D,1,0,582011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on record review and interview; the facility failed to identify causal factors and develop interventions for the prevention of further falls for Resident 3. The sample size was 6 residents. The facility census was 39. Findings are: Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/29/19 revealed [DIAGNOSES REDACTED]. The assessment further revealed the following related to Resident 3: -severe cognitive impairment; -required extensive assistance with bed mobility, transfers, dressing, toilet use and with personal hygiene; -was not steady, and only able to stabilize with human assistance, when moving from a seated to standing position, moving on and off the toilet, and during surface-to-surface transfers; -frequently incontinent of bowel and of bladder; and -had 2 falls with no injury and 1 fall (except major) with injury since the previous assessment. Review of the current Care Plan dated 11/1/18 indicated Resident 3 was at risk for falling related to confusion, gait/balance problems, incontinence, and poor communication. The resident was identified as being unaware of safety needs. Nursing interventions included the following: -11/1/18 anticipate and meet the resident's needs; -11/1/18 ensure call light is within reach and encourage the resident to use it for assistance; -11/1/18 educate staff to ensure alarms are in proper placement and functioning; -11/1/18 encourage the staff to sit the resident in the commons area until they are ready to assist with cares and lay down; -11/1/18 ensure the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair; -11/1/18 to provide resident with visual prompts to ask for help; -11/1/18 physical therapy to evaluate and to treat as needed; -11/1/18 review information on past falls and attempt to determine cause of falls. Record possible root causes; -11/1/18 pressure 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) to bed/chair and 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 wheelchair; -11/1/18 keep needed items within residents reach; -11/13/18 resident not to be left alone in the bathroom; and -11/13/18 provide independent activities of resident interest (western magazines, books and puzzles). Review of a Nursing Progress Note dated 12/16/18 revealed at 11:00 AM the resident was found sitting on the floor by the front door. The resident had blood to the resident's head with a small laceration noted. Review of a Post Fall assessment dated [DATE] at 11:23 PM revealed the resident was unable to identify what the resident was trying to do at the time of the fall. The assessment indicated the resident had last been toileted at 9:00 AM (2 hours previously). No interventions were identified on the assessment to indicate an intervention was developed to prevent further falls. Review of a Nursing Progress Note dated 12/17/18 at 7:42 PM revealed the resident was standing and had attempted to open the front exit door several times. Review of a Nursing Progress Note dated 12/19/18 at 9:14 PM revealed the resident was confused and very restless with multiple attempts to self-transfer out of wheelchair and to exit out the front door. Review of a Nursing Progress Note dated 12/21/18 at 10:11 PM revealed the resident continued attempts to self-transfer which resulted in ongoing falls. Review of a Nursing Progress Note dated 12/24/18 at 11:51 PM revealed the resident was forgetful with multiple attempted self-transfers. Resident alarmed at all times. Review of a Nursing Progress Note dated 12/29/18 at 3:59 AM revealed the staff responded to the resident's fall alarm and found the resident sitting on the floor next to the resident's bed. The resident indicated a need to use the bathroom. Review of a Post Fall assessment dated [DATE] at 3:45 AM revealed the resident's fall had occurred in the resident's room and was unwitnessed. The assessment indicated the resident's room had poor lighting and the resident was barefoot. The resident had last been toileted at 1:00 AM (2 hours and 45 minutes before the fall occurred). Review of the immediate interventions listed to prevent further falls revealed the resident was toileted and reoriented. Review of a Nursing Progress Note dated 1/1/19 at 11:19 PM revealed the resident was self-propelling wheelchair throughout the facility with a pressure pad alarm on at all times. The note further identified the resident had a fall mat next to the resident's bed which was to be kept in the low position, the resident required extensive assistance of 2 with transfers and was mostly incontinent. Review of a Nursing Progress Note dated 1/6/19 at 12:30 AM revealed the staff responded to the resident's fall alarm and witnessed the resident standing at bedside, when the resident's legs gave out and the resident sat down on the floor. Review of a Post Fall assessment dated [DATE] at 12:30 AM revealed the resident indicated the resident was going home when the resident's fall occurred. The immediate intervention to prevent ongoing falls was to reinforce body pillow. Review of Resident 3's current Care Plan reveal an updated fall prevention intervention dated 1/6/19 to place a body pillow to outer aspect of the resident's bed for repositioning and to define borders and for a scoop mattress (mattress with a raised, defined edge which helps to reduce the risk of falls out of bed) to the resident's bed. Review of a Nursing Progress Note dated 1/7/19 at 12:01 AM revealed the staff had responded to the resident's fall alarms. The resident was attempting to self-transfer out of bed. Staff provided the resident education regarding self-transfers and the resident became angry and screamed at the staff to get out of the resident's room. Review of a Nursing Progress Note dated 1/12/19 at 7:20 PM revealed the staff heard the resident's fall alarm sounding and the resident was found sitting on the floor by the facility front door. Review of a Post Fall assessment dated [DATE] at 7:30 PM revealed the resident indicated on interview the resident was trying to get out the front door. The assessment identified the resident was last toileted at 4:30 PM (2 hours and 50 minutes since the resident was last toileted). Review of interventions to prevent further falls included toileting, frequent rounding, bed in low position and pressure pad alarm (interventions which were already in place). Review of a Nursing Progress Note dated 1/14/19 at 2:51 AM revealed the staff heard a thud and found the resident on the floor close to the bathroom door. The resident was educated to use the call light to seek staff assist with cares. The call light and urinal were placed within the resident's reach and the body pillow was again placed beside the resident to remind the resident to stay in bed. Review of a Post Fall assessment dated [DATE] at 2:58 AM revealed the resident needed to use the bathroom and tried to walk on my own. The resident had been wearing regular socks at the time of the fall. The resident was assessed for injury and assisted up into the wheelchair. No new interventions for fall prevention were identified. Review of the resident's current Care Plan revealed a fall prevention intervention dated 1/14/19 for a laser alarm to the resident's bed. Review of a Nursing Progress Noted dated 1/22/19 at 7:00 PM revealed the resident had a fall in the resident's room. Resident 3 had attempted to self into bed. Review of a Post Fall assessment dated [DATE] at 7:00 PM revealed the resident had no injuries related to the fall. An intervention was identified to keep the resident at the Nurses' Station until bedtime. Review of Resident 3's current Care Plan revealed a fall prevention intervention dated 1/22/19 to encourage the resident to sit in the commons area until the resident is ready for bed. During interview on 2/4/19 at 2:52 PM, the Director of Nursing (DON) revealed the following: -Fall Risk Assessments indicated Resident 3 was at high risk for falls; -facility staff were to complete Post Fall Assessments after each resident's fall to determine potential causal factors and to revise current fall prevention interventions or to develop new interventions to prevent ongoing falls; and -difficult to come up with new interventions for Resident 3 due to current status, behaviors and repeated numbers of falls.",2020-09-01
2119,BUTTE SENIOR LIVING,285180,210 BROADWAY,BUTTE,NE,68722,2019-08-27,689,D,1,1,8LBO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on record review and interview; the facility failed to identify causal factors and to revise and/or develop interventions to prevent ongoing falls for Resident 130. The sample size was 3 and the facility census was 29. Findings are: Review of Resident 130's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/3/19 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS further revealed the following regarding Resident 130: -severe cognitive impairment; -required extensive assistance with transfers and toileting; -frequent bowel and occasional urine incontinence; -no toileting program such as scheduled toileting, prompted voiding (urination) or bladder training; and -history of falls with a fracture related to a fall in the last 6 months. Review of a Morse Fall Scale (assessment form used to identify risk for falls) dated 12/20/18 at 3:23 PM revealed the resident had a history of [REDACTED]. The assessment identified the resident was at high risk for falls with interventions to assure the resident was wearing appropriate footwear (shoes) with ambulation and to provide staff assistance with positioning in bed. Review of a Resident Incident Report dated 12/26/18 at 11:30 AM revealed the resident was found lying on the floor in the middle of the resident's room. The report indicated the resident had rolled/slid out of bed and the fall had been unwitnessed. The resident's walker was not within the resident's reach. A new intervention to change the position of the resident's bed was developed and the resident was screened by Physical Therapy. Review of a Resident Incident Report dated 2/26/19 at 8:00 AM revealed the resident reported having fallen in the doorway of the resident's bathroom, but was able to get up and off the floor independently. The report indicated the resident had more confusion and had required increased assistance with cares. A urinalysis was obtained to check the resident for a urinary tract infection [MEDICAL CONDITION] and was negative. Review of Resident 130's medical record revealed no evidence that current fall interventions were revised or that additional interventions were developed to prevent ongoing falls. Review of a Resident Incident Report dated 3/9/19 at 8:25 PM revealed staff heard the door of the resident's room slam and upon investigation, the resident was found on the floor of the resident's bathroom. The report indicated the resident had been given evening medications at 8:00 PM and at that time, the resident was not wearing shoes or socks and did not have the walker within reach. The resident was assisted to sit in the recliner and given the walker. The resident was instructed to wait in the recliner until staff could assist the resident into bed. The report indicated the resident had recently been discharged from therapies. An intervention was identified for the resident to wear gripper socks when not wearing shoes. In addition, a sign was placed on the inside and on the outside of the bathroom door, to remind the resident to use the walker when ambulating. Review of a Resident Incident Report dated 3/17/19 at 11:30 AM revealed the resident was found sitting on the bathroom floor of the resident's room. The resident indicated walking to the bathroom with the walker, and then catching a foot on the walker when trying to get around it. Further review of the incident report revealed the resident was incontinent of urine but the report did not identify when the resident was last toileted. An intervention was identified for Physical Therapy to screen the resident and to evaluate the resident's walker. In addition, a urinalysis was completed and was found to be negative for infection. Review of a Resident Incident Report dated 3/22/19 at 11:25 AM revealed the resident was found kneeling on the floor next to the resident's bed. The resident indicated having slid out of bed but when the resident tried to get up, the resident's socks were too slippery. Further review of the report revealed no causal factors were identified to indicate why the resident fell but only addressed why the resident was unable to get up off the floor independently. The resident agreed to let the staff leave the room door open to allow closer monitoring of the resident and new gripper socks were ordered. Review of a Nursing Progress Note dated 4/1/19 at 1:15 AM revealed the resident reported having slipped out of bed. The resident was found in the bathroom, with the walker turned around backwards, and the resident was attempting to change clothing. The resident identified sliding out of bed, crawling to the recliner and then using the recliner to get up from the floor. The resident then ambulated into the bathroom. No injuries were observed. Further review of the resident's medical record revealed [REDACTED]. Review of a Nursing Progress Note dated 5/26/19 at 4:16 PM revealed the resident was found kneeling next to the resident's bed. The resident reported sliding out of bed but was then unable to get up and off the floor independently. Further review of the resident's medical record revealed [REDACTED]. An intervention was identified to replace the resident's gripper socks with new ones. Review of a Nursing Progress Note dated 6/4/19 at 4:30 PM revealed the resident's room door was closed. When staff opened the door, the resident was found to be seated on the floor in front of the resident's closet. The resident had sustained an abrasion to the left elbow and a bump to the top of the resident's scalp. Review of a Post Fall Data Collection form dated 6/4/19 at 4:30 PM revealed the following regarding Resident 130: -therapy services ended on 5/2/19 and therapy had made a recommendation for the resident to receive assistance with ambulation; -severe cognitive impairment; -frequently observed to self-transfer and to ambulate without assistance; -unsteady at times with use of walker; and -the resident had been ambulating without assistance and was incontinent at the time of the resident's fall. Review of an investigation dated 6/4/19 at 4:30 PM revealed causal factors for the resident's fall included increased weakness with an unsteady gait and increased confusion. An intervention to provide additional customer service rounds was identified. Review of a Nursing Progress Note dated 6/24/19 at 2:05 AM revealed staff heard a noise and on investigation, found the resident lying on the floor on the resident's left side. The resident was between the resident's bed and the bathroom. Due to complaints of left hip pain, the resident was transferred to the emergency room for evaluation. Review of a Nursing Progress Note dated 6/24/19 at 11: 22 AM revealed the resident returned from the hospital at 6:20 AM with a recommendation for ice to the left hip and to call the hospital if the resident's pain grew worse. In addition, the resident was to use a wheelchair for the next few days and then to encourage ambulation. The resident was noted to be drowsy upon return from the hospital and only ate bites at the breakfast meal. review of the resident's medical record revealed [REDACTED]. Additional interventions were developed to prevent further falls. Review of a Nursing Progress Note dated 6/24/19 at 2:15 PM revealed when the resident was assessed, the resident's left leg was noted to be shorter than the right. The resident's physician was notified and indicated upon review of the x-rays, the resident was found to have a fracture to the resident's pelvis. The physician indicated the resident was to receive assistance of 2 staff for pivot transfers and to have a therapy evaluation. During an interview on 8/22/19 at 10:17 the Director of Nursing (DON) confirmed the following: -causal factors were to be determined for each fall to identify need for revision of current fall prevention interventions or development of new interventions; -Resident 130 was admitted from the Assisted Living due to problems with the resident falling; -after the resident's fall on 2/26/19 at 8:00 AM, a urinalysis was completed due to increased confusion but was found to be negative. No additional interventions were put into place; -after the resident's fall on 4/1/19 at 1:15 AM no causal factors were identified and current interventions were not revised or additional interventions developed; -with fall on 6/4/19 at 4:30 PM an intervention was identified for the staff to provide additional customer service rounds. The DON indicated staff were already checking the resident every 2 hours and there was no evidence additional rounds were completed; and -after the resident's fall on 6/24/19 the resident required increased assistance with all activities of daily living. Causal factors were not assessed as to why the resident fell and no additional interventions were identified.",2020-09-01
1003,STANTON HEALTH CENTER,285102,"P O BOX 407, 301 17TH STREET",STANTON,NE,68779,2019-06-06,689,D,1,0,7S5V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on record review and interview; the facility failed to identify causal factors for the development and/or revision of fall prevention interventions to prevent injuries for 1 (Resident 4) of 4 sampled residents. The facility census was 60. Findings are: Review of Resident 4's undated current Care Plan revealed the resident was at risk for falls due to a history of falls. The resident continued to display unsteadiness and loss of balance with ambulation and transfers. The resident was identified as residing on the Special Care Unit (SCU- secured area used to protect and better meet dementia residents' needs and to address behaviors associated with dementias). Fall prevention interventions included the following: -ensure the resident's walker was kept next to the bed and within easy reach, which was dated 3/31/18; -scoop mattress (mattress with a raised, defined edge which helps to reduce the risk of falls out of bed) to bed, which was dated 4/3/18; -ensure resident wearing appropriate footwear; -every 2 hour toileting schedule; and -follow the facility fall protocol. Review of Nursing Progress Notes dated 5/16/19 at 8:35 PM indicated Resident 4 was observed laying on the floor of the resident's room on the resident's right side and next to the resident's bed. Staff attempted to roll the resident onto the resident's back, but the resident cried out in pain and refused to straighten the resident's right leg. The resident was sent to the emergency room for evaluation. Review of an Incident Report dated 5/16/19 at 8:30 PM revealed the resident's fall was unwitnessed and the resident was unable to be interviewed due to impaired cognition. An immediate intervention was identified to keep the resident's wheelchair positioned away from the resident's bedside. Review of a Post Fall Investigation Tool dated 5/16/19 revealed staff were to assess fall trends, environmental factors, changes in the resident's recent health status, current medications and treatments as well as potential conditions related to assistive devices to determine causal factors for a fall or incident. Further review of the form revealed the document had not been completed by staff. review of the resident's medical record revealed [REDACTED]. Review of a facility form titled Staff Education Documentation dated 5/16/19 revealed staff were to assure bed alarms were on the resident's bed and staff were not to position the resident's wheelchair next to the resident's bed. Review of the resident's current Care Plan revealed a new fall prevention intervention dated 5/17/19 for a full body pillow to the resident's bed to assist with defining the edge of the resident's bed even though the resident already had an intervention for a scoop mattress in place. Review of a Nursing Progress Note dated 5/20/19 at 2:00 PM revealed the staff heard a loud noise in the resident's room and found the resident lying on the floor. The resident has a dime sized hematoma to the back of the resident's head. There was no evidence the facility determined causal factors of the fall even though the resident's fall was unwitnessed. Review of the resident's current Care Plan revealed an intervention for a sounding bed alarm to the resident's bed to alert staff to attempts to self-transfer out of bed and staff were to continue interventions on the at-risk plan. During interview on 6/6/19 at 11:00 AM, the Director of Nursing (DON) verified the following: -the facility staff were to complete assessments after each resident fall to determine causal factors to assist with developing new interventions or revising current interventions to prevent ongoing falls; and -staff failed to complete post fall assessments for the Resident's falls on 5/16/19 and on 5/20/19.",2020-09-01
6245,WILBER CARE CENTER,285172,611 NORTH MAIN,WILBER,NE,68465,2016-05-02,323,D,1,0,SCLK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b3 Based on interview and record review, the facility failed to prevent the potential for accidents for one resident (Resident 1) by not implementing a fall intervention after the resident had had a fall with injury and did not develop and implement interventions for another resident (Resident 4) after the resident had an injury from spilling hot soup. The facility census was 55. Findings are: A. Review of an Unusual Occurrence Investigation Form dated 4/10/16 revealed that Resident 1 had the following risk factors related to falls: Alzheimer's, history of fracture, blindness and unsteady gait. Review of the facility Injury Report dated 4/10/16 revealed that Resident 1 was found on the floor beside bed with a laceration to head and bed alarm was sounding. The resident was sent to the hospital and received stitches. The plan was to determine the best bed height for the resident to get out of bed if attempted to transfer self. Review of Resident 1's Care Plan dated 9/20/13 revealed the resident had a [DIAGNOSES REDACTED]. The care plan further indicated Resident 1 had a fall on 4/10/16 and that the bed should be at a good height for the resident to get out of with ease if attempted. On 5/2/16 at 1:12 PM Licensed Practical Nurse A (LPN A) stated that when Resident 1 was in bed the bed should be in the low position. At 1:14 PM on 5/2/16 Nursing Assistant B (NA B) was asked about the bed height for Resident 1 and stated that when the resident was in bed it should be at the lowest position. LPN C also stated that when Resident 1 was in bed the bed should be in the lowest position. This interview was conducted on 5/2/16 at 1:34 PM. On 5/2/16 at 1:25 PM the Director of Nursing (DON) indicated that the bed height for Resident 1 should be at a medium height for the resident to be able to easily get out of the bed if attempting to transfer self in order to decrease the fall risk. The DON said that the changes to the care plan had been communicated to the staff and confirmed that staff did not seem to be aware of the change. B. Review of Resident 4's Progress Notes dated 11/14/15 revealed, .the resident spilled soup on upper abdomen .red areas noted. On 11/15/15 a Progress Note indicated the area on abdomen was still pink. Review of the Unusual Occurrence Investigation Form dated 11/14/15 indicated Resident 4 had arthritis and used a wheelchair. Description of the occurrence indicated it happened in resident's room. Soup was on tray table and resident tipped bowl and spilled soup onto abdomen. The section of the form marked Interventions was blank. The care plan revision area was also left blank. Review of the resident's current care plan did not reveal any issues related to hot liquids. On 5/2/16 at 4:22 PM during an interview with the DON and the Administrator, it was confirmed that no new interventions were put in place after the soup burn.",2019-05-01
6618,OMAHA NURSING AND REHABILITATION CENTER,285240,4835 SOUTH 49TH STREET,OMAHA,NE,68117,2015-12-07,325,D,1,0,JX0E11,"**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 staff failed to ensure 1 resident ( Resident 4) received continuous feedings and failed to ensure nutritional supplements were given to 1 resident (Resident 3). The facility staff identified a census of 60. Findings are: A. Record review of a Resident Information sheet printed on 12-07-2015 revealed Resident 4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of an Order summary Report sheet printed on 12-07-2015 revealed Resident 4 was NPO (nothing by mouth), had a feeding tube and was to receive continuous feeding of [MEDICATION NAME] (feeding formula). Observations on 12-03-2015 at 12:31 PM, 1:10 PM, 1:34 PM and at 2:57 PM revealed Resident 4 did not have any formula being given. An interview with RN C was conducted on 12-03-2015 at 2:59 PM. RN C confirmed Resident 4 did not have any formula being given. B. Record review of a Admission record printed on 12-03-2015 revealed Resident 3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Order Summary Report sheet printed on 12-03-2015 revealed Resident 3 was to receive 2 cal (supplement), 3 times a day if Resident 3 ate less than 50%. Record review of Resident 3's meal intake record revealed Resident 3 ate between 26 to 50% of the meal for the following dates: 10-21-2015, 10-28-2015, 10-30-2015, 11-19-2015, 11-27-2015 and 11-30-2015. Review of Resident 3 Medication Administration Record [REDACTED]. An interview was completed on 12-03-2015 at 4:00 PM with the facility Director of Nursing (DON). During the interview the DON reported meal intakes were documented in quarters of what a resident eats. The DON reported that if Resident 3 had eaten between 26 and 50% the 2 cal should have been given. On 12-07-2015 at 4:53 AM a follow up interview was conducted with the DON. During the interview the DON confirmed the 2 cal was not given and should have been.",2018-12-01
1285,ARBOR CARE CENTERS-NELIGH LLC,285124,"PO BOX 66, 1100 NORTH T STREET",NELIGH,NE,68756,2019-03-11,692,D,1,1,UV2T11,"**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 monitor weights for Resident 14 who was assessed at risk for weight loss and to revise nutritional interventions to prevent ongoing weight loss. The sample size was 3 and the facility census was 36. Findings are: Review of Resident 14's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/15/19 revealed [DIAGNOSES REDACTED]. The assessment indicated the resident's cognition was severely impaired and the resident required total staff assistance with nutritional intakes. The resident was identified as holding food/fluids in mouth after meals and coughing and/or choking during meals. The resident was listed as having a mechanically altered diet. Review of Weights and Vitals Summary Sheet (document used to record the resident's weights) revealed the resident's weight on 10/9/18 was 147 pounds. Review of a Nutritional Progress Note by the Registered Dietician (RD) on 10/16/18 at 10:31 AM revealed the resident's dietary intakes had decreased to 25-75% at meals. The resident remained on a regular pureed diet. The note indicated the resident received fortified cereal (additional calories and nutrients added to food for weight loss prevention) for breakfast and Yogurt twice a day. No new recommendations were identified. Review of the Weights and Vitals Summary Sheet revealed the following regarding Resident 14's weights: -11/8/18 weight was 146 pounds (down 1 pound in a month); and -11/15/18 weight was 144 pounds (down 2 pounds in 1 week). Review of the Weights and Vitals Summary Sheet revealed the resident's weight on 12/16/18 was 138 pounds (down 6 pounds or a 4% weight loss in 1 month). Review of Resident 14's medical record revealed no evidence the resident's weight was obtained from 11/16/18 through 12/15/18 (1 month). In addition, the RD did not evaluate the resident's potential for ongoing weight loss and decreased dietary intakes during this time and no additional nutritional interventions were developed. Review of a Nutritional Progress Note dated 12/18 /18 at 10:05 AM by the RD revealed the resident's weight was 138 pounds and the resident's meal intakes had declined further from bites to 50%. Per recommendations by the Speech Therapist the resident's Yogurt was discontinued on 11/21/18 as the resident was having increased phlegm production and the resident was to receive no dairy products. The resident did continue to receive the fortified cereal at breakfast. A new recommendation was identified for the resident to receive Menu Magic Cup (nutritional supplement with added calories). Review of Weights and Vitals Summary Sheet revealed the resident's weight on 2/27/19 was 143 pounds (up 5 lbs. in 2 months). Interview with the Dietary Manager (DM) and the RD on 3/6/19 at 11:07 AM revealed no weights had been obtained for Resident 14 from 11/16/18 through 12/15/18 as the bath scale was broken. The RD indicated awareness the resident's dietary intakes were declining but without a current weight did not want to initiate any new nutritional interventions. During an interview on 3/11/19 at 9:04 AM, the Director of Nursing (DON) confirmed the facility did not have a scale available to obtain and monitor Resident 14's weights from 11/16/18 through 12/15/18 and no interventions were developed to prevent weight loss even though the resident's intakes had declined and the resident was no longer receiving the Yogurt as a nutritional supplement.",2020-09-01
4065,HILLCREST MILLARD,285302,13225 WESTWOOD LANE,OMAHA,NE,68144,2019-07-11,692,D,1,0,9M1111,"**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 staff failed to obtain weights for 1 (Resident 5) of 3 sampled residents. The facility staff identified a census of 65. Findings are: [NAME] Record review of a physician's orders [REDACTED]. Record review of Resident 5's record revealed no evidence the daily weights were obtained (MONTH) , 4,8,14,18,22,24 and the 29th. In addition, there was no evidence the facility staff obtained daily weights on (MONTH) 1, 3 and 5th. B. Record review of Resident 5's (MONTH) 2019 Treatment Administration Record (TAR) revealed the following information on Resident 5's weight: -6-02-2019 weight was 240.5 and on 6-03-2019 Resident 5's weight was 244.5, a gain of 4 pounds. Review of Resident 5's record revealed there was not evidence the facility had notified the provider and cardiology of the weight gain. Record review of Resident 5's weight work sheet provided by the facility on 7-11-2019 revealed Resident 5's weight on 6-26-2019 was 223. 0 pounds. Record review of Resident 5's TAR for (MONTH) 2019 revealed on the 27th of (MONTH) Resident 5's weight was 230.5 pounds, a gain of 7.5 pounds. Review of Resident 5's record revealed there was not evidence the facility had notified the Provider and Cardiology of the weight gain. On 7-11-2019 at 2:15 Pm an interview was conducted with the Clinical Consultant (CC). During the interview the CC confirmed Resident 5's weights had not been obtained as ordered and the Provider and Cardiology had not been notified of the weight gain.",2020-09-01
1367,LIFE CARE CENTER OF ELKHORN,285134,20275 HOPPER STREET,ELKHORN,NE,68022,2019-02-19,692,D,1,0,2BLY11,**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 staff failed to obtain weights for 1 (Resident 9) of 1 sampled resident. The facility staff identified a census of 105. Findings are: Record review of a Physician order [REDACTED]. Further review Physician orders [REDACTED]. Record review of Resident 9's weights provided by the facility staff revealed from 12-19-18 to 1-29-19 Resident 9 had been weighed 8 times out of 14 times weights should have been obtained. On 2-12-19 at 4:58 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed Resident 9's weights were not obtained as ordered.,2020-09-01
2944,RIDGECREST REHABILITATION CENTER,285239,3110 SCOTT CIRCLE,OMAHA,NE,68112,2018-01-23,692,H,1,0,L1D311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observation, record review and interview; the facility staff failed to identify significant weight loss and failed to implement interventions to prevent weight loss for 4 of 4 sampled residents (Resident 20, 23, 24, and 25). The facility staff identified a census of 60. Findings are: [NAME] Record review of a Face Sheet dated 8-18-2017 revealed Resident 20 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 20's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) signed as completed on 12-26-17 revealed the facility staff assessed the following about the resident: -Totally depended for bed mobility, transfers, dressing, eating, dressing, toilet use and personal hygiene. Record review of a weight record sheet (WRS) provided by the facility revealed Resident 20's weight on 9-13-17 was 268 pounds. Further review of the WRS revealed Resident 20's weight on 11-8-17 was 233.4 pounds, a loss of 34.6 pound weight loss or 11.39% indicating a significant weight loss. Record review of a Progress Note (PN) dated 12-9-17 (a 31 day span from the significant weight loss identified on 11-8-17) revealed the facility Registered Dietician (RD) identified Resident 20 had lost weight, According to the RD PN dated 12-9-17, Resident 20 had not been hungry and Resident 20's weight loss was greater than 1 pound a week .which indicates a caloric deficit resulting in loss. Further review of Resident 20's RD, PN dated 12-9-17 revealed there was no evaluation of Resident 20's nutritional requirements, no evaluation of Resident 20's medical condition related to the weight loss or what interventions were to be implemented to stabilize Resident 20's weight. Record review of Resident 20's Comprehensive Care Plan (CCP) dated 5-9-16 revealed Resident 20 had impaired nutritional status. According to Resident 20's CCP dated 5-9-17 with an updated intervention dated 7-7-2016 revealed Resident 20 was to have large portions of foods at meal times. Further review of Resident 20's CCP date 5-16-17 revealed there was not an indication any weight loss was planned for Resident 20. Record review of an undated dietary food tray slip revealed Resident 20 was to receive large portions. Observation on 1-9-18 at 8:07 AM revealed Resident 20 was served for breakfast, 2 pancakes, 2 link sausage, small bowel of cut up fruit and several drinks. On 1-9-2018 at 8:10 AM an interview was conducted with the Dietary Services Manager (DSM). During the interview the DSM confirmed Resident 20 was to receive large portions at meals and further confirmed Resident 20 was served a regular sized portion for breakfast on 1-9-18 at 8:07 AM. On 1-9-2018 at 4:45 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed Resident 20 had a significant weight loss and did not have interventions to stabilize Resident 20's weight. B. Record review of Resident 25's CCP dated 11-9-2013 revealed Resident 25 had the potential for a nutritional deficit. The goal identified for Resident 25 was to maintain weight. Interventions identified on the CCP included monitor weights, a lip plate and covers for drinks. Further review of Resident 25's CCP revealed on 7-24-16 a new intervention was identified to give Resident 25 finger foods. Record review of Resident 25's Dietary Card (DC) revealed Resident 25 was on a regular diet that was mechanically altered. There was no indication on Resident 25's DC that Resident 25 was to be offered or receive finger foods. Record review of Resident 25's WRS dated 10-25-17 revealed Resident 25's weight was 170 pounds. Review of Resident 20's WRS dated 12-27-17 revealed a weight of 158 pounds, a loss of 12 pounds or 7.05 percent. Record review of the WRS dated 1-8-18 revealed Resident 25's weight was 149.8, a loss of 20.2 pounds or 11.88% compared to the weight on 10-25-2017. Review of Resident 25's record revealed there was no evidence Resident 25's weight loss on 12-27-17 and again on 1-8-18 had been evaluated or any additional interventions were implemented to stabilize Resident 25's weight. Observation on 1-9-18 at 12:40 PM revealed Resident 25 was served chicken cut up, long noodles, vegetables served on a lip plate, a slice of chocolate cake and several types of drinks. The lip part of the plate had been positioned away from Resident 25. Resident 25 was not able to scoop food up against the raised part of the plate to get food resulting in food being dropped onto Resident 25 or the floor. Further observations revealed Resident 25 was in a wheelchair and positioned as if Resident 25 was sliding out of the wheelchair resulting in Resident 25 struggling to reach the lunch meal, in addition, Resident 25 did not have finger foods provided. On 1-10-18 at 9:00 AM an interview was conducted with the facility Nurse Consultant (NC). During the interview the facility NC confirmed Resident 25 had weight loss with resulting significant weight loss and did not have an evaluation completed or additional interventions implemented to stabilize Resident 25's weight. The NC further confirmed Resident 25 had not received finger foods at lunch on 1-9-18 at 12:40 PM. On 1-10-18 at 11:40 AM an interview was conducted with the facility RD. During the interview, the facility RD reported while the weight identified on 12-27-2017 .is of significant concern as (Resident 25) was trending down wards. The RD reported during the interview Resident 25 should have had an assessment completed at that time and did not. C. Record review of Resident 23's CCP dated 7-22-17 revealed Resident 23 was at risk for nutritional problems. The goal for Resident 23 was to maintain weight. Interventions identified on the CCP included large supper, magic cup and to offer snacks. Record review of Resident 23's PN dated 12-10-17 revealed the facility RD had identified interventions which included magic cup, superceral, fortified potatoes and 2 eggs at breakfast. Record review of an undated DC for Resident 25 revealed Resident 25's staff were to give Resident 23 a large meal in the evening, superceral and 2 eggs for breakfast. In addition, the DC identified Resident 23 was allergic to chocolate and tomatoes. Observation on 1-8-2018 at 6:25 PM revealed Resident 23 was served a BBQ sandwich, baked beans, cooked cabbage, desert and drinks. On 1-8-18 at 6:30 PM the NC replaced Resident 23's meal with 1 ground hamburger, soup and a new desert. Observation on 1-9-18 at 8:20 AM revealed Resident 23 was served cold cereal (cheerio type), 2 pancakes, 2 sausage with gravy and several drinks. On 1-9-18 at 8:35 AM an interview was conducted with Nursing Assistant (NA) [NAME] During the interview NA A confirmed Resident 23 did not have eggs or supercereal. On 1-10-18 at 2:40 PM an interview was conducted with the DSM. During the interview, the DSM reported a large portion would be 1 and 1/2 portions of a regular sized portion. The DSM confirmed 1 hamburger was not a large portion. D Record review of Resident 24's CCP dated 4-28-17 revealed Resident 24 was at nutritional risk. The goal identified for Resident 24 was to maintain weight. Interventions included double portions at all meals. Record review of Resident 24's DC revealed Resident 24 was to have double portions at meals. Observation on 1-8-18 at 6:27 PM revealed Resident 24 was served 1 BBQ sandwich, baked beans, cook cabbage, desert and fluids. Observation on 1-9-18 at 8:20 AM revealed Resident 24 was served 2 pancakes, 2 sausage, cereal and fluids. On 1-9-18 at 8:36 AM an interview was conducted with NA [NAME] During the interview NA A confirmed Resident 24 did not receive double portions for breakfast. Record review of the facility Policy and Procedure for Weight Assessment and intervention dated 4-2012 reveled the following information: -Analysis: -Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding: -a. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake. -c. The relationship between current medical condition or clinical situation and recent fluctuations in weight.",2020-09-01
2259,ELMS HEALTH CARE CENTER,285191,"P O BOX 628, 410 BALL PARK ROAD",PONCA,NE,68770,2019-03-13,692,D,1,0,M4L711,"**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 assess/revise nutritional interventions and to implement interventions to prevent ongoing weight loss for 2 (Residents 1 and 2) of 6 sampled residents. The facility identified a census of 40. Findings are: [NAME] Review of Resident 1's Minimum Data Set (MDS-a federally mandated assessment tool used for care planning) dated 12/17/18 revealed [DIAGNOSES REDACTED]. The assessment identified the following about the resident: -Cognition was moderately impaired with episodes of hallucinations and delusions. -Supervision provided by staff with dietary intakes. -Weight of 121 lbs. (pounds) with no weight loss or nutritional interventions identified. Review of Resident 1's Vitals Summary Sheet (form used to document a resident's weight, blood pressure, respiration, temperature and pulse) revealed the resident's weight on 1/11/19 was 124 lbs. Review of a Nutritional Progress Note by the Registered Dietician (RD) dated 1/29/19 at 8:24 AM revealed the resident's current body weight was 122 lbs. Intakes were identified as erratic with bites to 75% (percent). Breakfast fortified for additional calories and protein. Fortified milk 240 cubic centimeters (cc) provided at all meals. History of refusal to drink nutritional supplements such as 2 cal., Mighty Shakes, Ensure Clear and Carnation Instant Breakfast drinks. No new recommendations at this time but to continue to monitor closely due to poor intakes. Review of a Vitals Summary Sheet revealed the resident's weight on 2/15/19 was 115 lbs. (down 9 lbs. or a 7% loss in 1 month). Review of a Nutritional Progress Note by the Dietary Manager (DM) dated 2/20/19 at 8:03 AM verified the resident's current body weight was 115 lbs. The RD identified the resident's meal intakes had declined and the resident was now consuming bites to 50%. The DM was to notify the RD of the resident's weight loss for further recommendations. Review of a Nutritional Progress Note dated 2/25/19 at 12:32 PM by the RD revealed no new nutritional recommendations. Review of Resident 1's current Care Plan dated 2/28/19 revealed the resident was at risk for weight loss due to poor appetite and refusal of nutritional supplements. Resident had confusion at times especially if the resident had a urinary tract infection. The following interventions were identified: -Offer 240 cc of fortified milk with each meal. -Offer the resident a bedtime snack and record amount of snack the resident consumed. -Offer foods and fluids the resident likes for meals. -Provide with a fortified breakfast of super cereal (made with extra sugar, butter and half and half). -Provide with a regular diet. Review of the resident's meal intakes for 2/2019 revealed the following: -for the breakfast meal the resident consumed less than 50 % on 2/1, 2/2, 2/4, 2/7, 2/8, 2/16, 2/18 and on 2/20/19 (8 out of 28 days); less than 25% on 2/5, 2/9, 2/19, 2/23 and on 2/26 (5 out of 28 days); and the resident refused the breakfast meal on 2/3, 2/10, 2/11, 2/13, 2/14, 2/15, 2/17, 2/21, 2/22, 2/24, 2/25, 2/27 and on 2/28 (13 out of 28 days) -for the noon meal the resident ate less than 50% on 2/2, 2/4, 2/18, and on 2/28 (4 out of 28 days); less than 25% on 2/6, 2/7, 2/8, 2/22, and on 2/24 (5 out of 28 days); and the resident refused to eat the noon meal on 2/5, 2/9, 2/10, 2/12, 2/15, 2/17, 2/19, 2/21, and on 2/27 (9 out of 28 days). There was no documentation of the resident's breakfast intakes on 2/1, 2/3, 2/11, 2/13, 2/14, 2/16, 2/20, 2/23, 2/25 and on 2/26 (10 out of 28 days). -for the evening meal the resident ate less than 50% on 2/1, 2/5, 2/7, 2/14, 2/17, 2/20 and on 2/24 (7 out of 28 days); less than 25% on 2/11, 2/16, and on 2/27 (3 out of 28 days); and the resident refused to eat the evening meal on 2/12, 2/13, 2/15, 2/18, 2/23 and on 2/28 (6 out of 28 days). There was no documentation of the resident's meal intakes on 2/2, 2/3, 2/8, 2/9, 2/10, 2/19, 2/21, 2/25 and on 2/26 (9 out of 28 days). Review of a Vitals Summary Sheet revealed the resident's weight on 3//1/19 was 109 lbs. (down 6 lbs. or a 5% loss in 2 weeks). Review of the resident's meal intakes for 3/1 through 3/3 revealed the following: -for the breakfast meal the resident consumed less than 25% on 3/2 and on 3/3. There was no documentation of the resident's breakfast intakes on 3/1. -for the noon meal the resident had no documentation of meal intakes on 3/1 and on 3/2 with refusal documented on 3/3. -for the evening meal the resident had no documentation of intakes on 3/2 and on 3/2. review of the resident's medical record revealed [REDACTED]. In addition, there was no documentation in the resident's medical record to indicate the amount of evening snack the resident consumed. Interview with the DM on 3/13/19 from 11:00 AM to 11:15 AM confirmed the following: -the dietary staff were to document the resident's meal intakes after each meal; -the dietary staff did not document the amount of super cereal the resident consumed at breakfast; -the resident was to receive 240 cc of fortified milk at each meal. The dietary staff failed to document the amount of fortified milk the resident had consumed at meals; -without documentation of the resident's intakes of the assessed nutritional interventions, it was difficult to determine if the interventions were effective or if the interventions required revision; and -no additional nutritional interventions were developed despite the resident's ongoing weight loss. Interview with the Director of Nursing on 3/13/19 from 11:30 AM to 11:45 AM revealed the following regarding Resident 1: -had a history of [REDACTED]. -had a history of [REDACTED]. -frequently requested to sleep late; and -if the resident was not out for the breakfast meal, was offered cold cereal instead of the fortified super cereal. B. Review of Resident 2's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The resident's cognition was moderately impaired and the resident required set up assistance and supervision with eating. The assessment further revealed the resident's weight was 131 pounds and the resident had a weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 months. The resident was not on a physician prescribed wright loss regimen. Review of a Vitals Summary Sheet revealed Resident 2's weight on 11/29/18 was 141 lbs. Review of a Nutritional Progress Note dated 12/3/18 at 9:57 AM by the DM revealed the resident was a recent admission to the facility. The resident was admitted with an order for [REDACTED]. Review of a Vitals Summary Sheet revealed Resident 2's weight on 12/18/18 was 137 lbs. (down 4 lbs. in 2 weeks). Review of a Nutritional Progress Note dated 12/18/18 at 8:46 AM by the RD revealed the resident's intakes remained poor but had improved to 25 to 75%. The RD made a recommendation to start the resident on Mighty Shakes 120 cc daily to ensure nutritional needs are met. Review of a facsimile (fax) sent to Resident 2's practitioner on 12/18/18 revealed the facility had sent the RD's recommendation to the practitioner regarding the Mighty Shake and requested an order for [REDACTED]. Review of Resident 2's Medication Administration Record [REDACTED]. Review of Resident 2's Vitals Summary Sheet revealed the following: -on 1/4/19 weight was 134 lbs. -on 1/21/19 weight was 131 lbs. (down 3 lbs. in 2 weeks and down 10 lbs. in 2 months for a 7% weight loss). Interview with the DON on 3/13/19 from 12:50 PM to 1:15 PM revealed the RD hade evaluated Resident 2 on 12/18/18 and had made a recommendation for Mighty Shake 120 cc daily for ongoing weight loss. A fax was sent to the resident's practitioner on 12/18/18 but was not returned to the facility until 12/28/18 (10 days later). In addition, after the facility received an order on 12/28/18 for the resident to start on the nutritional supplement, the facility did not initiate the Mighty Shake until 12/31/18 (3 days after the order was received and 13 days after recommendation by the RD.",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
6018,BEAVER CITY MANOR,285269,"P O BOX 70, 905 FLOYD STREET",BEAVER CITY,NE,68926,2016-07-27,327,G,1,0,VTBH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D9 Based on observation, interviews, and record review; the facility failed to implement interventions to prevent dehydration to Resident 1. The facility census was 17 at the time of survey. Findings are: Review of Resident 1's face sheet revealed that Resident 1 was admitted to the facility on [DATE] and discharged on [DATE]. Review of Resident 1's face sheet revealed that Resident 1 had [DIAGNOSES REDACTED]. Review of Resident 1's admission MDS (Minimum Data Set-a comprehensive assessment tool used for developing a resident's care plan) dated 4/21/2016 revealed that Resident 1 required assistance from staff for bed mobility, transfer, locomotion, dressing, personal hygiene, toileting, bathing, and eating. Resident 1 also had a urinary catheter (a tube placed in the bladder to drain urine) and no dehydration. Confidential interview on 7/27/2016 at 12:40 PM revealed that Resident 1 had a transplanted kidney and required plenty of fluids to keep from getting dehydrated. The interview further revealed that Resident 1 was showing signs of dehydration with decreased urinary output and staff having difficulty obtaining blood samples while Resident 1 was still residing in the facility. Review of Resident 1's Dietary Note dated 4/19/2016 revealed that Resident 1's fluid needs were 2897 cc's (cubic centimeters-or approximately 96 ounces) per day. Review of Resident 1's Intake and Output Roster for 4/14/2016 to 4/27/2016 revealed the following daily amounts of fluid intake: 4/14/2016- 580 cc 4/15/2016-2310 cc 4/16/2016-1310 cc 4/17/2016-1100 cc 4/18/2016-1960 cc 4/19/2016-3180 cc 4/20/2016-2360 cc 4/21/2016-1560 cc 4/22/2016-2850 cc 4/23/2016-2370 cc 4/24/2016-2800 cc 4/25/2016-2850 cc 4/26/2016-1240 cc Review of Resident 1's Intake and Output Roster for 4/14/2016 to 4/27/2016 revealed that Resident 1's daily fluid needs were met only once during the time Resident 1 was in the facility. Observation of Resident 2, Resident 3, and Resident 4 on 7/27/2016 at 2:15 PM revealed all 3 residents were in their rooms in their recliners and did not have anything to drink within reach. Observation of Resident 2, Resident 3, and Resident 4 on 7/27/2016 at 4:17 PM revealed all 3 resident were in their rooms in their recliners and did not have anything to drink within reach. Interview with Resident 2 and Resident 4 on 7/27/2016 at 4:17 PM revealed they were able to drink on their own, however, they were not able to get up to get something to drink without assistance so the fluids needed to be within reach. Review of Resident 1's Departmental Notes dated 4/22/2016 revealed documentation that Resident 1's spouse was in the facility and expressed concern about poor urinary output from Resident 1's catheter and that Resident 1 had a temperature of 99.5 F (Fahrenheit) and was complaining of nausea. Review of Resident 1's eMAR (Medication Administration Record) for (MONTH) (YEAR) revealed that Resident 1 was administered milk of magnesia and a [MEDICATION NAME] suppository (laxatives) on 4/24/2016 and magnesium [MEDICATION NAME] (a laxative) on 4/26/2016 for constipation. Review of Resident 1's 'Daily Skilled Nurses Notes dated 4/26/2016 revealed Resident 1 did not have any results from the laxatives administered. and that bowel tones were very hypoactive (slow) and almost not present. Review of Resident 1's Daily Skilled Nurses Notes dated 4/25/2016 revealed documentation that Resident 1's urine was slightly dark in color. Review of Resident 1's Daily Skilled Nurses Notes dated 4/24/2016 revealed documentation that Resident 1's urine was dark yellow. Review of Resident 1's Daily Skilled Nurses Notes dated 4/23/2016 revealed that Resident 1's urine was amber (dark yellow to tan) colored. Review of Resident 1's Daily Skilled Nurses Notes dated 4/21/2016 revealed that Resident 1's urine was amber colored. Review of Resident 1's Daily Skilled Nurses Notes dated 4/17/2016 revealed that Resident 1's urine was amber colored. Review of Resident 1's Daily Skilled Nurses Notes dated 4/16/2016 revealed that Resident 1's urine was dark yellow colored. Review of Resident 1's Intake and Output Roster for 4/14/2016 to 4/27/2016 revealed the following daily urinary outputs: 4/14/2016-2200 cc 4/15/2016-2400 cc 4/17/2016-1000 cc 4/18/2016-1350 cc 4/19/2016-3825 cc 4/20/2016-1375 cc 4/21/2016-625 cc 4/22/2106-1400 cc 4/23/2106-2300 cc 4/24/2106-1150 cc 4/25/2016-775 cc 4/26/2016-1075 cc Review of the Mayo Clinic Kidney transplant Diet and Nutrition guidelines copyright date 1998-2016, revealed that kidney transplant patients were to stay hydrated by drinking adequate water and other fluids each day. Review of the Mayo Clinic Dehydration Symptoms copyright date 1998-2016 revealed that mild to moderate dehydration is likely to cause decreased urine output. A better indicator of the body's need for water is urine color. Clear or light-colored urine means you're well hydrated, whereas a dark yellow or amber color usually signals dehydration. Mild to moderate dehydration is likely to cause decreased urine output and constipation. Severe dehydration can cause fever. Review of the facility's policy and procedure Fluid Offered for Hydration dated 8/2/2007 revealed that it was the policy of the facility to ensure all residents were provided with sufficient fluid intake to maintain proper hydration and health. Drinking water would be made available at all resident bedsides, staff were to offer fluids to residents whenever entering resident rooms, or at least every 2 hours and if an individual resident required extra fluids, staff were to offer extra per resident likes and dislikes.",2019-07-01
3912,HILLCREST COUNTRY ESTATES-COTTAGES,285293,6082 GRAND LODGE AVENUE,PAPILLION,NE,68133,2017-05-04,272,D,1,1,POAF11,"**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 Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) was coded to reflect a terminal illness for one of one residents (Resident 37). The facility census was 46. Findings are: An interview with Cottage Guide C revealed that Resident 37 was receiving hospice services for end of life care. Review of Resident 37's hospice admitted d 2/22/17 revealed that Resident 37 had a terminal [DIAGNOSES REDACTED]. Record review of MDS dated [DATE] revealed that section J, Prognosis and life expectancy of less than 6 months, was marked no. Interview with Facility MDS consultant on 5/4/17 confirmed that section J of the MDS did not reflect the accurate current status for Resident 37 and that Resident 37 did have a terminal [DIAGNOSES REDACTED].",2020-09-01
2470,CROWELL MEMORIAL HOME,285210,245 SOUTH 22ND STREET,BLAIR,NE,68008,2018-07-11,657,D,1,0,NDLY11,"**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 the Comprehensive Care Plan (CCP) for interventions to prevent falls for 2 (Resident 4 and Resident 6) of 3 sampled residents. Facility staff identified a census of 67. Findings are: A Record review of Resident 4's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 4/11/18 revealed a BIMS (Brief Interview for Mental Status) score of 5. According to the MDS manual a score of 0-7 indicated severe impairment. Record review of Resident 4's CCP dated 4/16/18 revealed that Resident 4 was at risk for falling related to ADL/mobility deficits. Interventions included a fall risk assessment quarterly, leave the night light on in the room and front wheel walker. Record Review of an undated Incident Investigation Worksheet (IIW) revealed Resident 4 had a fall from the recliner. According to the IIW the physician and resident representative was notified 6/9/18. Further review of the IIW new intervention was to have therapy involvement. Record Review of an undated IIW revealed Resident 4 had a fall when slipped out of bed. According to the IIW the physician and resident representative was notified 6/21/18. Further review of the IIW revealed a new intervention was a Bolster Mattress (a mattress with sides). Review of an undated IIW revealed Resident 4 had a fall while needing to go to the bathroom. According to the IIW the physician and resident representative was notified 7/2/18. Further review of the IIW revealed a new intervention was Bolster Mattress and assist to bathroom between 4:00-4:30. Record review of Resident 4's CCP dated 4/16/18 revealed the new interventions of therapy, bolster mattress, and assisting Resident 4 to the bathroom between 4:00-4:30 was not on Resident 4's CCP. Interview with the Director of Nursing (DON) on 7/11/2018 at 9:23 AM confirmed that the interventions for falls occurring 6/9, 6/21, 7/2 were not on the CCP. B. Record review of Resident 6's MDS dated [DATE] revealed a BIMS of 4. According to the MDS manual a score of 0-7 indicated severe impairment. Record review of Resident 6's CCP dated 6/27/18 revealed Resident 6 was at risk for falling related to ADL/mobility deficits. Interventions included a fall risk assessment quarterly, remind Resident 6 not to ambulate/transfer without assist, and wheelchair. Record Review of an undated IIW revealed Resident 6 had a fall trying to get up to go to the bathroom. According to the IIW the physician and resident representative was notified 5/19/18. Further review of the IIW revealed new intervention was to assist to the bathroom. Record review of an undated IIW revealed Resident 6 had a fall entering the resident's room. According to the IIW the physician and resident representative was notified 5/25/18. Further review of the IIW revealed a new intervention was to assist Resident 4 to upright position. Record Review of an undated IIW revealed Resident 6 had a fall due to being up most of the night and exhibiting hallucinations. According to the IIW the physician and resident representative was notified 7/6/18. Further review of the IIW revealed a new intervention was to administer antibiotics and pain medication. Record Review of an undated IIW revealed Resident 6 had a fall attempting to get out of bed. According to the IIW the physician and resident representative was notified 7/6/18. Further review of the IIW revealed a new interventions was to administer pain medication as ordered and monitoring effectiveness of an antibiotic. Record review of Resident 6's CCP dated 6/27/18 revealed the new interventions of assist to upright position, and administer antibiotics and pain medication was not on the CCP. On 7/11/2018 9:23 AM an interview was conducted with the DON. During the interview the DON confirmed that interventions for falls occurring 5/19, 5/25, and 7/6/2018 were not on the CCP.",2020-09-01
6617,OMAHA NURSING AND REHABILITATION CENTER,285240,4835 SOUTH 49TH STREET,OMAHA,NE,68117,2015-12-07,314,G,1,0,JX0E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09d2b Based on observations record review and interview; the facility staff failed to evaluate the presence of pressure ulcers on admission, failed to monitor and implement a treatment for [REDACTED]. The facility staff identified a census of 60. Findings are: Record review of a Resident Information sheet printed on 12-07-2015 revealed Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 4's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 11-30-2015 revealed the facility staff assessed the following about the resident: -Resident 4's cognition was severely impaired. -Required extensive assistance with bed mobility, transfers, dressing and toilet use. -Required total assistance with personal hygiene. - Used a feeding tube. Record review of a LN (Licensed Nurse) Admission Assessment Comprehensive (AAC) sheet dated 11-17-2015 revealed Resident 4 had had an open area to the right ankle bone that measured 1 centimeter (cm) by 1 cm, left heal had eschar (dead tissue) 0.2 cm by 0.2 cm's and area on right inner buttock that measured 5.5 cm by 2.9 cm. Record review of Resident 4's undated Comprehensive Care Plan (CCP) revealed the open area was identified as a stage 3 (Stage III - 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. (MONTH) include undermining or tunneling) to the (right) buttocks, and an unstageable pressure ulcer to the right ankle and left heel. Record review of Resident 4's LN-Skin Pressure Ulcer Weekly (LN-SPUW) sheets dated 12-03-2015 revealed the facility staff assessed the right buttocks as a stage 3 pressure ulcer (PU) that measured 2 cm by 2.2 cm with a depth of 0.1 cm. The Right outer ankle was assessed as unstageable that measured 0.8 cm by 0.9 cm and had slough/eschar (dead tissue) and the left heel measured 0.5 cm by 0.5 cm and was unstageable. Record review of a Fax sheet dated 11-23-2015 revealed the facility Registered Dietician (RD) recommended [MEDICATION NAME] 1 scoop mixed with 2 to 4 ounce's of water via peg tube ( tube placed through the abdominal area into the stomach for feeding, water and medications) for additional protein to aid in wound healing. Record review of Resident 4's record revealed there had not been a response to the fax as of the start of survey on 12-3-2015. An interview on 12-03-2015 was conducted with the facility Assistant Director of Nursing (ADON). During the interview, review of the fax sheet dated 11-23-2015 of the RD recommendation was completed with the ADON. The ADON confirmed the recommendation had not been followed up on and should have been. Observations on 12-07-2015 at 5:30 PM with Licensed Practical Nurse (LPN) A and Nursing Assistant (NA) B revealed Resident 4 was positioned onto the left side. LPN A reported Resident 4 had a pressure ulcer on the right buttock. Observation of the right buttock pressure ulcer revealed the size measured approximately 2 cm round. The wound bed had blackish tissue and the bed of the wound was not visible. LPN A reported the PU was unstageable. Further observations revealed Resident 4 had a pressure ulcer to the coccyx that measured approximately 0.6 cm by 0.2 cm and had black looking tissue and the wound bed was not visible. The resident also had a pressure ulcer to the sacrum that measured approximately 0.6 cm's. The LPN reported Resident 4 was admitted with the pressure ulcers. On 12-07-2015 at 7:25 AM a follow up interview was conducted with LPN A. During the interview, LPN A reported Resident 4's PU were worse. On 12-07-2015 at 11:14 AM an interview was conducted with the ADON. During the interview the ADON confirmed the PU to the coccyx and sacrum were not identified on the admission assessment, no treatment had been implemented and there was no monitoring of the areas. The ADON confirmed Resident 4's PU had worsened.",2018-12-01
3399,WESTFIELD QUALITY CARE OF AURORA,285263,"PO BOX 166, 1313 1ST STREET",AURORA,NE,68818,2019-05-14,658,D,1,0,V7OX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10 Based on observation, record review and interview, the facility failed to follow doctors orders for 1 of 3 sampled residents (Resident 24). The facility census was 57 Findings are: Observation on 5/08/19 at 8:32 AM revealed that MA-E (Medication Aide) administered medications to Resident 24 which included the medication Levothyroxin (used to treat an underactive [MEDICAL CONDITION]) along with the medication Memantine (used to treat Dementia). Review of Physician order [REDACTED]. Obsevation of Resident 24 on 5/8/19 at 8:32 AM was the resident was sitting in the main dining room with an empty plate of food sitting in front of this resident. When resident was asked by MA-E how the breakfast was, resident relied, I ate everything. Review of the Nursing Drug handbook (YEAR) by Wolters Kluwer for administration instruction for [MEDICATION NAME] revealed a drug to drug interaction with [MEDICATION NAME] and Memantine a SSRI (Select Serotonin Reuptake Inhibitor) and when given together more of the [MEDICATION NAME] may be required. 05/09/19 02:50 PM Interview with DON (Director of Nursing) confirmed the order for the medication [MEDICATION NAME] and that it was given with the other medications.",2020-09-01
2895,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2019-04-22,658,D,1,1,BJ6K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10 Based on record review and interview; the facility staff failed to obtain an antibiotic medication and failed to administer insulin within time frames for 1 (Resident 108) of 5 sampled residents. The facility staff identified a census of 60. Findings are: [NAME] Record review of a Physicians Progress Notes sheet dated 3-28-2019 revealed Resident 108's practitioner order [MEDICATION NAME] 2.4 million units to be administered today (3-28-2019) and then the following week. Record review of a medication error report dated 4-02-2019 revealed the [MEDICATION NAME] had not be administered as ordered. B. Record review of a Order Summary Report sheet signed on 4-04-2019 revealed Resident 108's practitioner had order medications that included Detemir Insulin, 45 units to be given at bed time. Record review of Resident 108's Medication Administration Record [REDACTED] -3-26-2019, the Detemir insulin was given at 5:07 AM. -3-28-2019, the Detemir insulin was given at 2:07 AM. -3-29-2019, the Detemir insulin was given at 12:28 AM. -4-04-2019, the Detemir insulin was given at 1:05 AM. -4-07-2019, the Detemir insulin was given at 12:49 AM. On 4-09-2019 at 12:18 PM an interview was conducted with the Director of Nursing (DON). During the interview review of Resident 108's MARs for (MONTH) 2019 and (MONTH) 2019 was completed. The DON confirmed when insulin is administered it is then documented. The DON confirmed the Detemir insulin given after bed time were errors and further confirmed the [MEDICATION NAME] was not administered as ordered.",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
4870,ARBOR CARE CENTERS-NELIGH LLC,285124,"PO BOX 66, 1100 NORTH T STREET",NELIGH,NE,68756,2017-03-02,176,D,1,0,042P11,"**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 to assess 1 (Resident 2) of 9 sampled residents to determine if the resident could safely administer a prescription medication which was kept at the bedside. The facility census was 44. Findings are: [NAME] Review of the facility policy/procedure for Self-Administration of Medication by Residents (dated 6/2015) revealed the following was to be completed if a resident self-administered medication: -An assessment was to be conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out the responsibility of self-administering medications; -The interdisciplinary team was to determine the residents ability to self-administer medications by means of a cognitive and skill assessment; and -The results of the interdisciplinary team assessment were to be recorded on a Medication Self-Administration assessment form, which was to be placed in the resident's health care medical record. B. Review of Resident 2's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 12/5/16 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had severe cognitive impairment with behaviors which included delusions and wandering. Review of a Physician Order dated 11/11/16 revealed Resident 2 had an order for [REDACTED]. During an observation on 3/1/17 at 3:15 PM, a container of Vicks [MEDICATION NAME] was observed in the top drawer of a bedside dresser in Resident 2's room. Review of Resident 2's medical record revealed no evidence to indicate the resident had been deemed cognitively and physically capable or had the visual acuity to provide the medication according to physician's directions or completion of a Self Administration of Medication assessment. The Director of Nurses (DON) indicated, during interview on 3/2/17 at 1:13 PM, that a self-administration of medication assessment should be completed whenever a resident had an order for [REDACTED].",2020-03-01
4744,"SORENSEN CARE AND REHABILITATION CENTER, LLC",285107,4809 REDMAN AVENUE,OMAHA,NE,68104,2017-06-15,176,D,1,1,F9RW11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10A1 Based on record review and interview; the facility staff failed to evaluate 1(Resident 11) of 1 residents for the ability to self medicate. The facility staff identified a census of 67. Findings are: Record review of a Admission Record sheet dated 7-05-2016 revealed Resident 11 was admitted to the facility with the [DIAGNOSES REDACTED]. Record review of Resident 11's physician orders [REDACTED]. Record review of a Doctor's Order sheet dated 1-17-2017 revealed Resident 11 practitioner ordered that Resident 11 was able to keep an [MEDICATION NAME] inhaler at bedside. An interview on 6-14-2017 at 10:39 AM was conducted with Resident 11. During the interview Resident 11 reported not being able to apply the muscle cream and would like to do that on (gender) own. Record review of Resident 11 medical record revealed there was not evidence the facility had evaluated Resident 11's ability to self medicate. On 6-14-2017 at 1:59 AM an interview was completed with the Regional Vice President of Operations (RVO). During the interview the RVO confirmed an evaluation of Resident 11's ability to safely administer medication had not been completed for Resident 11.,2020-03-01
4405,GOOD SAMARITAN SOCIETY - ATKINSON,285177,409 NEELY STREET,ATKINSON,NE,68713,2017-04-19,425,E,1,0,VDBU11,"**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 medications were available for use in a timely manner for Residents 10, 3, and 7. The sample size was 13 and the facility census was 46. Findings are: [NAME] Review of Resident 10's Progress Note dated 4/5/17 revealed the resident had a dry cough with expiratory wheezes and a respiratory rate of 20-24 breaths per minute (with a normal range of 12-20). Review of Resident 10's Physician order [REDACTED]. Review of Resident 10's Medication Administration Record [REDACTED]. B. Culture results of Resident 3's ear dated 4/9/17 revealed a large amount of Methicillin-resistant Staphylococcus aureus (MRSA-an infection caused by a type of bacteria that is resistant to many antibiotics). Review of Resident 3's MAR indicated [REDACTED]. The order was received on 4/9/17 and the ear gtts were not started until 4/12/17 (3 days later). Interview with Registered Nurse-C on 4/19/17 at 4:15 PM confirmed the Gentamicin was not started until 4/12/19 because it was not available. C. Review of Resident 7's current physician's orders [REDACTED]. Observation of medication administration on 4/19/17 at 9:05 AM revealed Resident 7's Cholecalciferol was not available for administration. Review of Resident 7's MAR indicated [REDACTED]. Interview with the Consultant Pharmacy Technician on 4/19/17 at 4:10 PM revealed the Cholecalciferol was used on another day and had not been replaced.",2020-08-01
4917,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2018-04-03,726,D,1,0,F6ND11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10A3 Based on observation, record review and interview; the facility failed to ensure staff maintained an active Nurse Aide license before providing assistance with food and fluid intake at meal service for 2 (Residents 5 and 6) of 8 sampled residents. The facility census was 35. Findings are: [NAME] Review of the Administrator's Certification of Nebraska Licensure form indicated the Administrator's Nurse Aide license was lapsed as of 5/8/17. B. Review of Resident 5's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/4/18 revealed the resident's cognition was severely impaired. The assessment identified [DIAGNOSES REDACTED].; the resident required total staff assistance with eating and the resident had a therapeutic diet due to difficulties with swallowing. During an observation on 4/3/18 at 7:45 AM, the resident was seated in a wheelchair at a table in the dining room. The resident was served a bowl of hot cereal and a puree portion of an egg casserole. Seated immediately next to the resident was the facility Administrator who provided the resident assistance with eating the breakfast meal. C. Review of Resident 6's MDS dated [DATE] revealed the resident's cognition was severely impaired. The resident was identified as having [DIAGNOSES REDACTED]. During an observation on 4/3/18 at 7:50 AM, Resident 6 was seated in a tilt-n-space wheelchair (chair which provides alternatives in positioning with tilting or reclining of chair which allows resident to be self-mobile when in an upright position) in the dining room. The wheelchair was positioned in front of a tray table which had been pushed up to the dining table. The resident had a bowl of hot cereal and a small portion of egg casserole on the tray table. Resident 6 made no attempt to eat the breakfast meal. The resident was seated at an assist table and next to the resident was the facility Administrator. The Administrator was positioned between Resident 5 and Resident 6 and provided both residents assist with eating. D. During an interview on 4/3/18 at 10:00 AM, the Director of Nursing (DON) confirmed the Administrator had not completed the Paid Feeding Assistant course but indicated the Administrator was a licensed Nurse Aide. E. During an interview on 4/3/18 at 10:45 AM, the Administrator was unaware the Nurse Aide license had lapsed.",2020-03-01
3068,PARKSIDE MANOR,285245,"P O BOX 350, 607 NORTH MAIN STREET",STUART,NE,68780,2017-08-15,499,E,1,1,ITND11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10A3 Based on record review and interview, the facility failed to ensure 1 staff member was qualified to give medications before giving medications to 4 residents (Residents 24, 6, 16 and 22). The sample size was 20 and the facility census was 25. Findings are: Review of the facility undated Medication Aide (MA) Job Description revealed the education requirements for a MA included successful completion of the 40 hour MA course. Review of MA-F's Certification of Nebraska Licensure form revealed MA-F was issued a MA license on 7/28/14. However, the form indicated MA-F was not licensed as a 40 hour MA as indicated per the facility MA Job Description and in accordance with State requirements. Review of Resident 24's Medication Administration Record [REDACTED] -[MEDICATION NAME] (Tylenol) 500 milligrams (mg) at bedtime (HS); -[MEDICATION NAME] (used to treat high blood pressure) 5 mg at HS; and -[MEDICATION NAME] Sodium (used to treat constipation) 100 mg at HS. Review of Resident 6's MAR indicated [REDACTED] -Artificial tears (eye drops) one drop in each eye at HS; -Senna (used to treat constipation) one tablet in the evening; and -[MEDICATION NAME] (an anticoagulant or blood thinner) 6 mg at HS. Review of Resident 16's MAR indicated [REDACTED] -[MEDICATION NAME] (used to prevent gout and kidney stones) 300 mg at HS; -[MEDICATION NAME] (a muscle relaxer) 20 mg at HS; -[MEDICATION NAME] (used to treat high cholesterol) 160 mg at HS; -[MEDICATION NAME] (a nasal spray used to treat congestion and allergies [REDACTED]. -[MEDICATION NAME] (cough syrup) 4 milliliters at HS; -[MEDICATION NAME] (used to treat high cholesterol) 40 mg at HS; and -Tamsulosin (used to relax muscles in the prostate and bladder neck making it easier to urinate) .4 mg one capsule at HS. Review of Resident 22's MAR indicated [REDACTED] -[MEDICATION NAME] 1000 mg; -Acidophilus (dietary supplement) 1 capsule; -Atorvastatin (used to treat high cholesterol) 40 mg; -Carvedilol (used to treat high blood pressure and heart failure) 6.25 mg; -[MEDICATION NAME] (used to treat high blood pressure) .5 mg; and -Magnesium Oxide (a mineral supplement) 400 mg. Interview with the Administrator and Office Manager on 8/14/17 at 12:15 PM confirmed MA-F did not have the qualifications to administer medications as MA-F did not have a 40 hour MA license.",2020-09-01
2902,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2019-04-22,759,D,1,1,BJ6K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on Record Review and Observation, the facility staff failed to insure medication error rate of less than 5%. Observation of 25 medication administered, revealed 3 errors for 2 ( Resident 29, 41) resulting in a medication error rate of 12 % . The facility staff identifed census of 60: Findings are: [NAME] Record review of Resident 29's Meddication Administration Record (MAR) for (MONTH) 2019 revealed resident 29 had orders for Novalog insulin 10 units before meals. Sliding scale ( Amount of insulin to be given based on Blood Sugar levels) According to Resident 29's MAR for (MONTH) 2019 Resident 29 was to receive 3 units of Novalog Sliding Scale insulin if the blood sugar level was between 201-250. On 4/8/19 at 8:00am an Observation was conducted with Registered Nurse ( RN) M. During the observation RN M reported that Resident 29 Blood sugar was 215 requiring 3 additional units of [MEDICATION NAME]based on the sliding scale order. RN M went to prepare insulin pens and noticed they were out of [MEDICATION NAME]. RN M obtained a new Novalog Pin and placed the new insulin pin in Resident 29 insulin box after drawing up correct dose without removing the empty insulin pin from the box. On 4/8/19 at 8:05am an Observation of RN M revealed RN M went to Resident 29's room and prepared to administer [MEDICATION NAME] insulin. RN M attempted to administer the [MEDICATION NAME]with the empty [MEDICATION NAME]pen. Further observation revealed RN M obtained the full [MEDICATION NAME] pen and without priming the pin RN M administered the insulin. On 4/8/19 at 8:10am an interview was conducted with RN M. During the interview when asked if the insulin pen had been primed RN M reported no need to prime the pen. According to [MEDICATION NAME]pen package insert instruction for use , the pen should be primed with 2 units of insulin before selecting dose. B. Record Review of Resident 41's Physican orders signed on 4/4/19, Medication Card (the packet that contains the medication to be administered) and MAR for (MONTH) 2019 for Resident 41 revealed an order for [REDACTED]. On 4/9/19 an observation was conducted with Medication Assistant (MA) N. During observation MA N administered Resident 41's medications without obtaining a pulse. Review of the medication label for Carvedilol 6.25mg revealed Resident 41 was to receive 1 tablet by mouth and to hold the Carvedilol if pulse was less than 55. On 4/9/19 8:04 AM an interview was conducted with MA N. During the interview MA N confirmed the pulse was not obtained.",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
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
6690,SUNRISE COUNTRY MANOR,285232,"PO BOX A, 610 224TH STREET",MILFORD,NE,68405,2015-11-09,332,D,1,1,HZ1311,"**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 medications were administered with a medication error rate of less than 5%. Twenty-six medication opportunities were observed with two medication errors resulting in an 7.69% medication error rate. The facility census was 72. Findings are: A. Observation of Resident 32's blood sugar monitoring and insulin administration revealed: -On 11/3/15 at 7:41 am, LPN (Licensed Practical Nurse) N checked the resident's blood sugar and the glucometer (machine used to test blood sugar levels) registered 185. -At 7:44 am, LPN N drew up 1 unit of Humalog (fast acting insulin) and injected the insulin into the resident's right thigh. The bottle of Humalog was dated as open on 10/1/15. -LPN N told the resident that staff would be back in 15-20 minutes to get the resident up for breakfast. There was no food or fluids within reach of the resident. -At 8:05 am, staff was assisting the resident with morning cares. -At 8:19 am, the resident was seated in the resident's recliner. There was no food or fluids within reach. The resident had not been served breakfast. -At 9:04 am, the resident's room tray still remained in the kitchen. -At 9:06 am, the resident had not been served breakfast and no food or fluids were in the resident's reach. Interview with LPN N on 11/3/15 at 7:44 am revealed that the Humalog insulin dated as opened 10/1/15 was outdated. The LPN stated that there probably was not any other insulin in the building and the LPN administered the outdated insulin to Resident 32. Interview on 11/13/15 at 9:04 am with the Cook revealed that the staff had called for a room tray 10-15 minutes ago, but the resident's room tray remained in the kitchen. Review of Resident 32's 10/9/15 physician's orders [REDACTED]. Review of the facility's Medication Administration-Specific Information Insulin Vial Administration Dated (MONTH) 2013 did not address fast acting insulin and when it would be administered. Interview with the ADON (Assistant Director of Nursing) on 11/5/15 at 1:15 pm revealed that there was not a policy specific to rapid acting insulin in their policy. It was expected that nurses should know it should be given 15 minutes prior to meals. According to Davis's Drug Guide for Nurses Fourteenth Edition Humalog vials can be opened and kept at room temperature for 28 days and then discarded. Humalog should be given 15 minutes before a meal or 20 minutes after a meal. B. Observation of Resident 23's blood sugar testing and insulin administration on 11/4/15 revealed: -LPN L checked the resident's blood sugar and stated it was 242. -LPN drew up 10 units of [MEDICATION NAME] (fast acting) insulin and administered into the resident's right abdomen at 11:39 am. -LPN L told the resident to go to lunch. -The resident did go in the dining room and begin eating until 12:10 pm. Interview on 11/4/15 at 11:40 am revealed that Resident 23 ate lunch at 12:15 pm.",2018-11-01
4404,GOOD SAMARITAN SOCIETY - ATKINSON,285177,409 NEELY STREET,ATKINSON,NE,68713,2017-04-19,333,D,1,0,VDBU11,"**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 1 (Resident 4) of 13 residents were free from a potential significant medication error. The sample size was 13 and the facility census was 46. Findings are: Review of the facility policy titled Medication Errors revised on 1/2017 revealed a medication error was an occurrence of any preventable event that may cause or lead to inappropriate medication use by a resident while the medication was in the control of the nurse, medication aide, or the resident. This may include prescribing errors, dispensing errors, medication administration errors, resident compliance errors, and adverse drug events. Review of Resident 4's Medication Administration Record [REDACTED]. Review of a Physician's Order dated 4/4/17 revealed Resident 4's [MEDICATION NAME] 12.5mg was discontinued on 4/4/17 due to the resident having episodes of low blood pressure and heart rate readings. On 4/19/17 at 8:40 AM Licensed Practical Nurse (LPN)-A was observed to prepare Resident 4's morning medication from Alixa packets (sealed plastic bags with more than one type of medication in each bag). LPN-A opened the bag and placed the medications into the medication cup for administration and indicated the medications would be administered to the resident. Upon questioning, LPN-A verified [MEDICATION NAME] 12.5mg was in the medication cup. LPN-A verified the [MEDICATION NAME] had been discontinued and should not be given, and removed it from the medication cup. LPN-A confirmed the [MEDICATION NAME] had been discontinued because the resident was having difficulty with low heart rates. LPN-A stated the resident's heart rate had dropped down into the 30's. LPN-A then stated the medication was discontinued a while ago and LPN-A thought the medication would have been removed from the Alixa packets by this time. Interview with the Consultant Pharmacy Technician on 4/19/17 at 1:40 PM, indicated the medications were packaged in another state and then sent to the facility. Further interview revealed when a medication was changed or discontinued it would remain in the sealed packets until the next set of medications was sent out. All new orders and changes had to be submitted to the pharmacy by Tuesday for the medications to be delivered on Friday (one week's worth of medications was sent at a time). When a medication was discontinued the nurse was responsible to identify which medication in the multi-use package was discontinued and the nurse was to remove the medication.",2020-08-01
1132,ARBOR CARE CENTERS-O'NEILL LLC,285108,"PO BOX 756, 1102 NORTH HARRISON",O' NEILL,NE,68763,2018-06-11,759,D,1,0,PFPI11,"**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 percent (%) as 2 residents' (Residents 1 and 4) medications were not administered timely, resulting in an error rate of 8%. The sample size was 7 and the facility census was 47. Findings are: [NAME] Review of [NAME]'s Drug Guide for Nurses, Fifteenth Edition, revealed nursing implications for the following medications: [REDACTED] -[MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] reflux disease (GERD) and other conditions caused by excess stomach acid) - Administer doses before meals, preferably in the morning; and -[MEDICATION NAME] (a medication used to treat an underactive [MEDICAL CONDITION]) - Administer on an empty stomach, 30 to 60 minutes before breakfast. B. Review of Resident 1's Medication Administration Record [REDACTED]. During observation of the medication pass on 6/11/18 at 9:09 AM Medication Aide (MA)-B prepared medications for Resident 1 that included [MEDICATION NAME] 20mg. Resident 1 had just left the dining room after eating breakfast when MA-B completed administration of the medications. C. Review of Resident 4's MAR indicated [REDACTED]. During observation of the medication pass on 6/11/18 at 9:28 AM MA-A prepared medications for Resident 4 that included [MEDICATION NAME] 50mcg. The resident was seated at the dining room table and was finishing the breakfast meal when MA-A completed administration of the medications. D. During an interview with the Director of Nursing (DON) on 6/11/18 at 1:45 PM, the DON confirmed [MEDICATION NAME] and [MEDICATION NAME] were to be scheduled at 7:00 AM.",2020-09-01
2665,AZRIA HEALTH BROADWELL,285221,800 STOEGER DRIVE,GRAND ISLAND,NE,68803,2019-06-06,759,D,1,1,IQ3V11,"**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 6 sampled residents (Residents 4, 52, and 43). The facility identified a census of 62 at the time of survey. Findings are: [NAME] Observation of MA-P (Medication Aide) on 6/3/2019 at 4:23 PM revealed they administered one drop of Muro 128 eye drops into each of Resident 4's eyes. Review of Resident 4's Medication Admin Audit Report dated 6/6/2019 revealed an order for [REDACTED]. B. Observation of MA-P on 6/03/19 at 4:30 PM revealed they administered KCL (Potassium Chloride) 10 millequivalents 2 capsules to Resident 52 with a glass of water. Resident 52 did not have any food or drink with the KCL. Observation of Resident 52 on 6/03/19 at 4:56 PM revealed they did not have any food or drink. C. Observation of MA-J on 6/06/19 at 8:00 AM revealed they administered [MEDICATION NAME] (a medication used to treat abnormal heart rhythms) 125 micrograms 1 tablet to Resident 43. MA-J did not check Resident 43's pulse prior to or after administering the [MEDICATION NAME] to Resident 43. Review of Resident 43's Medication Administration Audit Report dated (MONTH) 6, 2019 revealed no documentation MA-J checked a pulse before administering the [MEDICATION NAME]. Interview with MA-J on 6/06/19 at 12:04 PM revealed they did not check Resident 43's pulse before MA-J administered the [MEDICATION NAME]. MA-J revealed there was not an order to check a pulse. MA-J pointed out on the MAR (Medication Administration Record) that there was not an order to check Resident 43's pulse. Review of the Nursing2018 book revealed the following: For [MEDICATION NAME]: Excessively slow pulse rate (60 beats/minute) or less may be a sign of [MEDICATION NAME] toxicity. Withhold drug and notify prescriber. For KCL: Patient should take with meals and a full glass of water or other liquid to minimize risk of GI irritation. Interview with the DON (Director of Nursing) on 6/06/19 at 10:54 AM revealed the KCL should have been given with food. Review of the facility policy General dose Preparation and Medication Administration with a revision date of 1/1/13 revealed the following: Facility staff should comply with facility policy, applicable law and the state operations manual when administering medications. Facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct residents; Follow manufacturer medication administration guidelines.",2020-09-01
3419,WESTFIELD QUALITY CARE OF AURORA,285263,"PO BOX 166, 1313 1ST STREET",AURORA,NE,68818,2019-11-13,759,D,1,0,P0CC11,"**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 administer medications to 3 of 3 sampled residents (Residents 8, 9, and 10) with a medication error rate below 5%. The facility staff had 4 medication errors out of 31 opportunities resulting in a medication error rate of 12.9%. The facility identified a census of 64 at the time of survey. Findings are: [NAME] Observation of MA-B (Medication Aide) on 11/13/2019 9:58 AM revealed they administered the following medications to Resident 10: [MEDICATION NAME] 1 tablet PO (by mouth) QD (every day); Senna 8.6 mg (milligrams) 1 tablet PO BID (twice a day); Ziprasidone 20 mg 2 caps (40 mg) BID with food; [MEDICATION NAME] 20 mg 1 PO QD 60 minutes before meal; [MEDICATION NAME] 100 mg 2 caps PO BID; [MEDICATION NAME] 80 mg ET 1 tab PO QD; [MEDICATION NAME] 0.5 mg 1 PO BID; [MEDICATION NAME] 1 T (tablespoon) PO QD in 6 ounces water/liquid of choice. Review of Resident 10's MAR (Medication Administration Record) for (MONTH) revealed all of the medications were scheduled to be given at 0800 (8 AM) except the [MEDICATION NAME] which was scheduled at 0700 (7 AM). This resulted in 1 medication error for not administering the [MEDICATION NAME] before the meal. B. Observation of MA-B on 11/13/2019 at 10:11 AM revealed they administered the following medications to Resident 8: [MEDICATION NAME] 80 mg 1 PO before meals; ASA 81 mg 1 PO QD; Calcitrol 0.25 mg 1 PO QD; carvedilol 3.125 mg 1 PO BID with food; [MEDICATION NAME] 40 mg 1 PO QD; [MEDICATION NAME] 10 mg 1 PO QD; [MEDICATION NAME] 200 mg 2 tabs (400 mg ) PO TID (three times a day); [MEDICATION NAME] 150 mg 1 PO QD; [MEDICATION NAME] 10 mg 1 PO QD; [MEDICATION NAME] 50 mcg 1 spray each nostril QD; Azelastine HCL nasal spray 2 sprays each nostril BID; [MEDICATION NAME] 160-4.5 2 puffs BID; rinse mouth after administering; [MEDICATION NAME] 325 mg 2 tablets (650 mg) PO Q 4 hours PRN (as needed). Review of Resident 8's MAR (Medication Administration Record) for (MONTH) revealed all of the medications were scheduled to be given at 0800 (8 AM) except the [MEDICATION NAME] which was scheduled at 0730 (7:30 AM). This resulted in 1 medication error for not administering the [MEDICATION NAME] before the meal. C. Observation of MA-B on 11/13/2019 at 10:19 AM revealed they administered the following medications to Resident 9: [MEDICATION NAME] 20 mg 1 PO daily before breakfast; [MEDICATION NAME] 5 mg 1/2 tablet (2.5 mg) PO QD, give 30 minutes before meal; ASA 81 mg 1 PO QD; atorvastatin 40 mg 1 PO QD; Carvedilol 3.125 mg 1 PO BID take with food; [MEDICATION NAME] 40 mg 1 PO QD; [MEDICATION NAME] 10 mg 1 PO QD; [MEDICATION NAME] 500 mg 1 PO BID take with food; Vitamin C 500 mg 1 PO QD. Review of Resident 9's MAR (Medication Administration Record) for (MONTH) revealed all of the medications were scheduled to be given at 0800 (8 AM) except the [MEDICATION NAME] which was scheduled at 0700 (7 AM) and the [MEDICATION NAME] which was scheduled at 0730. This resulted in 2 medication errors for not administering the [MEDICATION NAME] and [MEDICATION NAME] before the meal. Interview with MA-B on 11/13/2019 at 10:24 AM confirmed all 3 of the residents MA-B gave medications late to (Residents 8, 9, and 10) had eaten their breakfast already. They stayed in their rooms for breakfast and got room trays. MA-B was just now getting to them to give them their medications. Review of the Medication Admin Audit Reports for 11/13/2019 revealed Resident 10's medications were documented they were administered at 9:58 AM; Resident 8's medications were documented they were administered at 10:17 AM; and Resident 9's medications were documented at 10:19 AM. Review of the Medication Review Reports revealed Resident 8's orders were signed by the medical provider on 10/28/2019; Resident 8's [MEDICATION NAME] order read to give before meals; Resident 10's medication orders were signed by the medical provider on 10/16/2019 and Resident 9's medication orders were signed by the medical provider on 11/1/2019. Review of the facility policy Medication Administration dated 2019 revealed the following: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Administer medication as ordered in accordance with manufacturer specifications. Review of the Nursing2018 Drug Handbook revealed the following: [MEDICATION NAME]: give immediate-release tablet about 30 minutes before meals. [MEDICATION NAME]: give drug at least 1 hour before meals.",2020-09-01
5074,"NORFOLK CARE AND REHABILITATION CENTER, LLC",285101,1900 VICKI LANE,NORFOLK,NE,68701,2018-03-08,759,D,1,1,2SKI11,"**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 assure a medication error rate of less then 5% as Resident 22's medications were not administered timely, resulting in an error rate of 7.69%. The total sample size was 24 and the facility census was 52. Findings are: [NAME] Review of Davis's Drug Guide for Nurses, Fifteenth Edition, revealed nursing implications for the following medications: [REDACTED] -[MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] reflux disease (GERD) and other conditions caused by excess stomach acid) - Administer doses before meals, preferably in the morning; and -[MEDICATION NAME] (a medication used to treat an underactive [MEDICAL CONDITION]) - Administer on an empty stomach, 30 to 60 minutes before breakfast. B. Review of Resident 22's Medication Administration Record [REDACTED] -[MEDICATION NAME] 20 mg (milligrams) 1 capsule every day at 7:30 AM; and -[MEDICATION NAME] 75 mcg (micrograms) 1 tablet every day at 7:00 AM. During observation of the medication pass on 3/6/18 from 8:52 AM until 9:00 AM, Medication Aide (MA)-C poured medications for Resident 22 that included 1 tablet of [MEDICATION NAME] 75 mcg and 1 capsule of [MEDICATION NAME] 20 mg. The resident was seated at the dining room table and finishing the breakfast meal when MA-C completed administration of the medications at 9:00 AM. C. During interview on 3/6/18 at 10:33, MA-C verified the [MEDICATION NAME] and [MEDICATION NAME] should have been administered to Resident 22 prior to the breakfast meal.",2020-02-01
6648,AZRIA HEALTH AT MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2015-11-19,332,D,1,0,85KR11,"**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 then 5 %. The med error rate was 12%. This affected Resident 107 and Resident 63. The facility census was 121. Findings are: A. Observed Licensed Practical Nurse(LPN) A on 11-18-15 at 8:35 am administer medications to Resident 107. Resident 107's Medication Administration Record [REDACTED]. Observed LPN A administer the [MEDICATION NAME] to Resident 107, Resident 107 swallowed it with a drink of water, and then LPN A checked Resident 107's BP. Resident 107's BP was 117/70. Interview with the Director of Nursing (DON) on 11-19-15 at 11:27 AM revealed that Resident 107's BP should have been checked prior to administration. B. Observed LPN A on 11-18-15 at 8:43 AM administer medication to Resident 63. Resident 63's MAR indicated [REDACTED]. Observed LPN A enter Resident 63's room and administer the [MEDICATION NAME] and [MEDICATION NAME] to Resident 63, Resident 63 swallowed both with a drink of water. LPN A then left Resident 63's room. Interview with LPN A on 11-18-15 at 8:45 AM revealed that LPN A did not check Resident 63's BP. Interview with the Director of Nursing (DON) on 11-19-15 at 11:27 AM revealed that Resident 63's BP should have been checked prior to administration.",2018-11-01
4878,LIFE CARE CENTER OF OMAHA,285137,6032 VILLE DE SANTE DRIVE,OMAHA,NE,68104,2017-03-29,333,D,1,0,YJ8Z11,"**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 1) of 3 sampled residents were free of significant medication errors. The facility staff identified a census of 77. Findings are: Record review of Resident 1's Physician order [REDACTED]. In addition, Resident 1's physician order [REDACTED]. -Less than 150 give no insulin. -201 to 250 give 4 units (U) of [MEDICATION NAME] Regular (R, fast acting) insulin. -251 to 300, give 6U of R insulin. -301 to 350, give 8U of R insulin. -351 to 400, give 10U of R insulin. -401 and greater give 20U of R insulin. [NAME] Record review of Resident 1's Sliding Scale Insulin (SSI) flow sheet revealed the following: -3-22-2017,7 AM, BS level was 400, Resident 1 received 20 U of Regular insulin, According to the physician order, Resident 1 should have received 10 U of Regular insulin. -3-18-2017, 5 PM, BS was 400, Resident 1 received 20 U of Regular insulin and should have received 10 U of the Regular insulin. -3-02-2017, 8 PM, BS was 245, no SS insulin was given, Resident 1 should have received 4 U of the Regular insulin. -3-18-2017, 8 PM, BS was 239, no SS insulin was given, Resident 1 should have received 4 U of insulin. -3-19-2017, 8 PM, BS was 257, no SS insulin was given, Resident 1 should have received 6 U. -3-20-2017, 8 PM. BS was 154, no SS insulin was given, Resident 1 should have received 2 U of insulin. -3-22-17, 8 PM, BS was 264, no SS insulin was given, Resident 1 should have received 6 U of insulin, -3-23-2017, 8 PM, BS was 214, no SS was given, Resident 1 should have received 4 U of the regular insulin. B. Observation on 3-28-2017 of an Accucheck revealed Certified Medication Assistant (CMA) B obtained Resident 1's BS with the result being 311. Observation on 3-28-2017 at 11:28 AM revealed Licensed Practical Nurse (LPN) A administer 5 U of Humalog insulin, no sliding scale insulin was administered. When asked if Resident 1 would be receiving any additional insulin, LPN A reported Resident 1 did not have anything more until 4 or 5 PM. On 3-28-2017 at 11:40 AM a follow up interview was conducted with LPN [NAME] During the interview, LPN A confirmed Resident 1 should have received SS insulin of 8 U of the regular insulin. On 3-28-2017 at 1:00 PM an interview was conducted with the Director of Nursing (DON). During the interview review of Resident 1's Sliding Scale Insulin flow sheet was reviewed for (MONTH) (YEAR). The DON confirmed given to much insulin and not giving any insulin would be a significant medication error.",2020-03-01
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
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
2928,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2018-07-02,760,D,1,0,EO8U11,"**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 2 (Resident 104 and 108) of 4 sampled residents were free of significant medication errors. The facility staff identified a census of 54. Findings are: [NAME] Record review of Resident 108 Medication Administration Record [REDACTED]. Further review of Resident 108's MAR for (MONTH) (YEAR) revealed Resident 108's insulin was not given for the following dates: -6-02-2018. -6-06-2018. -6-07-2018. -6-08-2018. -6-22-2018. -6-26-2018. Further review of Resident 108's MAR for (MONTH) (YEAR) revealed there was not an order to hold the scheduled Detemir insulin in the AM. On 6-28-2018 at 10:33 AM an interview was conducted with Consultant H. During the interview Consultant H confirmed not administering the Detemir insulin without an order to hold would be a significant medication error. B. Observation on 6/27/2018 at 8:00 PM of eye drop medication administration for Resident 104 by Licensed Practical Nurse (LPN)-C revealed LPN-C administered 1 drop of [MEDICATION NAME] solution for [MEDICAL CONDITION] (high eye pressure) medication in each eye. Review of a physician order [REDACTED]. Review of Resident 104's Medication Administration Record [REDACTED]. Review of a Verbal Order Authorization dated 6/5/2018 received from the pharmacy indicates the medication was to be given three times a day. This was not signed by the physician. Review of Resident 104's MAR indicated [REDACTED]. Review of Resident 104's MAR indicated [REDACTED]. Interview on 7/2/2018 at 10:30 AM with RN-F revealed the eye drops were not started until 6 days after being ordered by the physician and could have resulted in significant discomfort to the resident related to the [MEDICAL CONDITION] (an eye disease causing pressure in the eye).",2020-09-01
1167,PRESTIGE CARE CENTER OF NEBRASKA CITY,285109,1420 NORTH 10TH STREET,NEBRASKA CITY,NE,68410,2019-07-17,760,E,1,0,TP0511,"**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 3 (Resident 1, 2 and 3) were free of significant medication errors. The facility staff identified a census of 45. Findings are: [NAME] Record review of a Orders Summary Report (OSR) printed on 7-16-2019 revealed Resident 1's practitioner had ordered medications that included [MEDICATION NAME]30 units to be administered with meals and to give additional insulin based on blood sugar levels. Observation on 7-16-2019 at 12:05 PM revealed Licensed Practical Nurse (LPN) A obtained Resident 1's blood sugar level with a result of 166. LPN A obtained Resident 1's insulin pan, dialed 32 units as Resident 1 required additional insulin, gave the insulin. LPN A did not prime the insulin pen prior to administering the insulin. B. [NAME] Record review of a OSR printed on 7-16-2019 revealed Resident 2's practitioner had ordered medications that included [MEDICATION NAME]10 units to be administered with meals and to give additional insulin based on blood sugar levels. Observation on 7-16-2019 at 11:55 AM revealed LPN A obtained Resident 1's blood sugar level with a result of 316 requiring an addition 25 units of insulin. LPN A obtained Resident 2's insulin pen, dialed 35 units and gave the insulin. LPN A did not prime the insulin pen prior to administering the insulin. C. Record review of a OSR printed on 7-01-2019 revealed Resident 3's practitioner had ordered medications that included [MEDICATION NAME]10 units to be administered with meals and to give additional insulin based on blood sugar levels. Observation on 7-16-2019 at 11:45 AM revealed LPN A obtained Resident 3's blood sugar level with a result of 230 requiring an addition 2 units of insulin. LPN A obtained Resident 3's insulin pen, dialed 12 units and gave the insulin. LPN A did not prime the insulin pen prior to administering the insulin. On 7-16-2019 at 12:15 PM an interview was conducted with LPN [NAME] During the interview LPN reported not being taught to prime insulin pens and did not prime the insulin pens for Residents 1, 2 and 3. On 7-16-2019 at 12:35 PM an interview was conducted with the Assistant Director of Nursing (ADON). During the interview the ADON confirmed not priming the insulin pens would be a significant medication error. Record review of the facility How to Use Insulin [MEDICATION NAME] dated 7-05-2019 revealed the following information: -#10. Preform a test dose,prime, the needle by dialing in 2 units and injecting into air.",2020-09-01
2588,AZRIA HEALTH MIDTOWN,285218,910 SOUTH 40TH STREET,OMAHA,NE,68105,2018-07-17,760,D,1,0,SQOO11,"**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 3 (Resident 507, 508 and 509) of 6 resident were free of significant medication errors. The facility staff identified a census of 51. Findings are: [NAME] Record review of a Medication Review Report (MRR) printed on 7-17-2018 revealed Resident 508's physician had ordered medications that included [MEDICATION NAME]( according to Drugs.com, [MEDICATION NAME] is a fast-acting form of insulin and should be given within 5 to 10 minutes before a meal) 5 units to be given before a meal and additional [MEDICATION NAME]to be given based on blood sugar (BS) level. Observation on 7-16-2018 at 11:28 AM revealed Licensed Practical Nurse (LPN) A prepared 17 units of the [MEDICATION NAME]for Resident 508. LPN A indicated Resident 508's BS was 321. According to Resident 508's physician order [REDACTED]. Further observation revealed LPN A administered the 17 units of insulin. On 7-16-2018 at 11:43 AM an interview was conducted with LPN [NAME] During the interview, LPN A confirmed the [MEDICATION NAME] was given to early and that Resident 508 would not be eating until 12:00 PM. B. Record review of a MRR printed on 7-17-2018 revealed Resident 507's physician ordered medications that included [MEDICATION NAME]28 units once a day using a flex pen injector Observation on 7-16-2018 at 11:32 AM revealed LPN A prepared 28 units of [MEDICATION NAME]for Resident 507 using a insulin flex pen ( a pen looking device that contains insulin with a dial to measure the amount of insulin to be given. The flex pen needle is used once and requires the user to prime the needle with 2 units prior to dialing the ordered amount of insulin). LPN A administered the insulin to Resident 507. On 7-16-2018 at 1143 AM an interview was conducted with LPN [NAME] During the interview, LPN A confirmed the insulin pen was not primed with 2 units prior to giving Resident 507 insulin and confirmed the insulin was given to early as Resident 507 eats at 12:00 PM. C. Record review of a MRR printed on 7-17-2018 revealed Resident 509's physician ordered medications that included [MEDICATION NAME] 12 units to be given once a day. Observation on 7-16-2018 at 11:48 AM revealed LPN B prepared the [MEDICATION NAME]pen of 12 units and administered the insulin to Resident 509. LPN B did not prime the insulin pen with 2 units to ensure the correct amount of insulin was administered to Resident 509. On 7-16-2018 at 11:50 AM an interview was conducted with LPN B. During the interview, LPN B confirmed the insulin pen was not primed prior to given Resident 509 the insulin. On 7-17-2018 at 5:55 AM an interview was conducted with the Director of Nursing (DON). During the interview, the DON reported the insulin errors would be a significant medication error.",2020-09-01
5313,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-01-23,332,E,1,0,5YZX11,"**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 5 medication administration errors for 4 (Resident 4, 5, 6 and 10) of 5 residents reviewed resulting in a medication error rate of 19.23%. The facility staff identified a census of 103. Finding are: [NAME] Record review of a Physician order [REDACTED]. Record review of a Fax sheet dated 11-12-2016 revealed Resident 4's Physician had ordered medications that included [MEDICATION NAME] (anti-anxiety medication) 1 milligram (mg) by mouth every 8 hours. Record review of a Medication Administration Record [REDACTED]. Observation on 1-23-2017 at 3:07 PM revealed Registered Nurse (RN) A prepared medication for administration that included the [MEDICATION NAME] 1 mg. RN A entered Resident 4's room, explained the procedure and after checking placement of the PEG tube, administered the medication, including the [MEDICATION NAME] through the tube. An interview was conducted on 1-23-2017 at 3:15 PM with RN [NAME] during the interview, RN A confirmed the [MEDICATION NAME] was administer through Resident 4's PEG tube. Review of the label for the [MEDICATION NAME] was completed with RN [NAME] RN A confirmed the [MEDICATION NAME] label indicated the medication was to be given by mouth. RN A confirmed the order for the [MEDICATION NAME] should have been clarified as Resident 4 was NPO. B. Record review of a After Visit Summary order sheet revealed Resident 5's physician had ordered medications that included [MEDICATION NAME] ( medication to help lower blood sugars levels) 500 mg PO twice a day and a Calcium 600 mg with Vitamin D3 to be taken daily. Observation of the medication administration for Resident 5 revealed Licensed Practical Nurse (LPN) C prepared Resident 5 medications including the [MEDICATION NAME]. During the observation, LPN C placed 2 tables (for a total of 1000 mg's) of [MEDICATION NAME] into a medication cup. The calcium 600/D3 tablets were not available to be given. During an interview on 1-23-2017 at 9:20 AM prior to the medication being given, review of the medications prepared was reviewed with LPN C. When asked if LPN C was going to administer the medications, LPN C stated yes. Review of the order for the [MEDICATION NAME] 500 mg 1 tablet twice a day and calcium 600/D3 was completed with LPN C. LPN C confirmed a 1000 mg's of [MEDICATION NAME] was going to be given and it should have been 500 mg's and further confirmed the calcium 600/D3 was not available to be given to Resident 5. C. Record review of Resident 6's MAR for (MONTH) (YEAR) revealed Resident 6 received liquids and medication through a PEG tube. Observation on 1-23-2017 at 1:03 PM of the medication administration for Resident 6 revealed LPN B prepared Resident 6's medication and took them to Resident 6's room. LPN B checked the placement of the PEG tube prior to the administration of the medication. After checking placement of the PEG tube, LPN B flushed Resident 6's tube with 15 milliliters (ml) of water. LPN B then administered the medication and flushed the tube with 20 ml of water. An interview was conducted with LPN B on 1-23-2017 at 3:00 PM. During the interview LPN B confirmed the Resident 6's tube was not flushed with 30 ml of water before and after and should have been. D. Record review of an Order Summary Report sheet printed on 1-23-2017 revealed Resident 10 had orders for medications that included polyethylene [MEDICATION NAME] (laxative medication) 8.5 grams by mouth once a day. Observation on 1-23-2017 at 3:40 PM revealed LPN B prepared Resident 10's medications including the Polyethylene [MEDICATION NAME]. During the observation LPN B filled the cap full of the Polyethylene and placed it into water. LPN B then administered the medications to Resident 10. An interview with LPN B was conducted on 1-23-2017 at 3:50 PM. During the interview, review of the order for the Polyethylene [MEDICATION NAME] was reviewed with LPN B. Observation of the inside of the Polyethylene cap with LPN B revealed the amount administered to Resident 10 was 17 grams. LPN B confirmed too much Polyethylene was given to Resident 10. Record review of an undated Policy and Procedure for Medication Administration through an Enteral Tube revealed the following information: -#14. Flush the feeding tube with at least 30 ml of preferably warm water before and after medications are administered.",2020-01-01
1440,LIFE CARE CENTER OF OMAHA,285137,6032 VILLE DE SANTE DRIVE,OMAHA,NE,68104,2018-03-19,759,D,1,1,93SH12,"**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 32 medications administered revealed there were 6 errors for 2 (Resident 44 and 35) of 2 residents resulting in an error rate of 18.75%. The facility staff identified a census of 78. Findings are: [NAME] Record review of an undated Face Sheet revealed Resident 44 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Physicians Orders sheet signed on 4-17-2018 revealed Resident 44's practitioner's ordered medications that included [MEDICATION NAME] ([MEDICAL CONDITION] reflux medication) 20 milligrams (mg) every day before meals, Potassium Chloride 30 miliequivlant (mEg) or 22.5 milliliter (ml), 2 times a day, and [MEDICATION NAME] 17 grams in 4 to 8 ounces of water on Wednesdays. Observation on 5-07-2018 (Monday) at 8:27 AM revealed Registered Nurse (RN) A began to prepare to administer the morning medications that included the [MEDICATION NAME], Potassium Chloride and [MEDICATION NAME] to Resident 44. Further observation on 5-07-2018 at 8:27 AM revealed RN A poured the liquid Potassium Chloride into plastic cup that had measurements listed on the side. RN A was unable to measure the amount of Potassium Chloride. RN A measured 17 grams of the [MEDICATION NAME] and placed that into a plastic cup. RN A picked up the medications that had been prepared and took them to Resident 44. Observation at this time revealed Resident 44 had eaten breakfast. RN A prepared to administer the medications to Resident 44 when Resident 44 reported to RN A that [MEDICATION NAME] was to be administered on Wednesdays. After several attempts to have the resident take the [MEDICATION NAME], RN A left Resident 44's room the check the order. On 5-7-2018 at 9:10 AM an interview was conducted with RN [NAME] During the interview RN A reported the [MEDICATION NAME] was given to Resident 44 after Resident 44 had eaten. RN A reported was not able to measure the Potassium Chloride and confirmed the amount of Potassium Chloride given was not correct and further confirmed RN A was prepared to give the [MEDICATION NAME] to Resident 44. B. Record review of an undated Face Sheet revealed Resident 35 was admitted to the facility on [DATE]. Record review of Resident 35's Medication Administration Record [REDACTED]. Observation on 5-07-2018 at 9:45 AM revealed RN B prepared Resident 35's medications that included [MEDICATION NAME], Pantoprazole and eye drops Brinzolamide and Brimonideine-[MEDICATION NAME]. Further observation revealed Resident 35 was in the therapy after and reported having eaten breakfast. RN A gave 2 sprays of the Ipratropum to each nostril, gave Pantoprazole medication, gave [MEDICATION NAME]-[MEDICATION NAME] 1 drop to Resident 35's left eye and gave Brinzolamide 2 minutes to Resident 35's left eye. On 5-07-2018 at 10:27 AM an interview was conducted with RN B. During the interview RN B confirmed the Pantoprazole was given to Resident 35 after Resident 35 had eaten. RN B reported during the interview there should be 5 minutes in between eye drops and that the order for the [MEDICATION NAME] order was to give 1 spray to each nostril and 2 were given. According to the Nursing (YEAR) Drug Handbook by Wolters Kluwer , pager 230 revealed the following information: -If a patient is using more than one ophthalmic drug, apply them at least 5 minutes apart.",2020-09-01
6304,HILLCREST HEALTH & REHAB,285133,1702 HILLCREST DRIVE,BELLEVUE,NE,68005,2016-04-27,332,D,1,0,IO6811,"**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%. Observations of 30 medications administered revealed 2 errors resulting in an error rate of 6.66%. The errors were for 2 residents (Resident 15 and 16). The facility staff identified a census of 109. Findings are: A. Record review of a physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Observation on 4-25-2016 at 8:34 AM revealed Registered Nurse (RN) A obtained Resident 15's medications that included the [MEDICATION NAME]. RN A without explaining how to administer the medication, gave Resident 15 the [MEDICATION NAME] spray bottle. Resident 15 sprayed twice into each nostril and handed the spray bottle back to RN A. An interview with RN A was conducted on 4-25-2016 at 8:40 AM. During the interview RN A confirmed the order for the [MEDICATION NAME] was 1 spray into each nostril. RN A confirmed Resident 15 had sprayed twice into each nostril. B. Record review of a physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. a day. The instructions for use of the [MEDICATION NAME] medication was to check the pulse rate prior to administering the medication. Observation on 4-25-2016 at 8:20 AM revealed RN B obtained Resident 16's mediations including the [MEDICATION NAME]. RN B administered the medication to resident 16 without obtaining a pulse. An interview on 4-25-2016 at 8:30 AM was conducted with RN B. During the interview, RN B confirmed Resident 16's pulse had not been taken prior to administering the [MEDICATION NAME] medication.",2019-04-01
5535,PRESTIGE CARE CENTER OF NEBRASKA CITY,285109,1420 NORTH 10TH STREET,NEBRASKA CITY,NE,68410,2016-11-02,332,D,1,0,0B0V11,"**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%. Observations of 32 medications administered revealed 3 errors resulting in an error rate of 9.37%. The medication errors affected 2 of 3 residents (Resident 1 and 4). The facility staff identified a census of 44. Findings are: [NAME] Record review of a Discharge Medication Orders sheet signed on 10-24-2016 revealed Residents 1 medical practitioner ordered medications that included Pantoprazole ( anti ulcer agent) 40 milligrams (mg) to be given before breakfast and [MEDICATION NAME] (inhaler) 160-4.5 micrograms (mcg), 2 puffs twice a day. Observation on 11-01-2016 at 9:45 AM revealed Certified Medication Assistant (CMA) A prepared the morning medications that included the Pantoprazole and [MEDICATION NAME] inhaler. CMA A administered the medications there were to be swallowed and then handed Resident 1 the [MEDICATION NAME] inhaler without instructing Resident 1 on how to use the inhaler, including rinsing the mouth after use. Resident 1 took 2 puffs of the inhaler and handed the device to CMA [NAME] Resident 1 did not rinse the mouth after use. Record review of information at www.ncbi.nlm.nih.gov revealed the following for use of the [MEDICATION NAME] inhaler: -How to use: -When you have finished all your inhalations, rinse your mouth out with water. Do not swallow the water. On 11-01-2016 at 11:20 AM an interview was conducted with CMA [NAME] During the interview confirmed Resident 1's medications were given after breakfast and that Resident 1 did not rinse out the mouth after using the [MEDICATION NAME] inhaler. B. Record review of a Discharge Instructions sheet dated 10-31-2016 revealed Resident 4's physician had order medications that included [MEDICATION NAME] Nasal Spray, 2 sprays each nostril daily. Observation on 11-01-2016 at revealed CMA A prepared resident 4's medications for administration. During the preparation, CMA A reported that Resident 4's [MEDICATION NAME] was not at the facility and reported we will need to order that. CMA A confirmed was not available for use for Resident 4.",2019-11-01
2887,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2018-04-18,759,E,1,0,X2J611,"**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%. Observations of 32 medications administered revealed there were 4 errors resulting in an error rate of 12.5%. The errors affected 4( Resident 3, 4, 5 and 6 ) of 7 residents. The facility staff identified a census of 49. Findings are: [NAME] Record review of a current Medication Review Report (MRR) printed on 4-18-2018 revealed Resident 3 had orders for medications that included [MEDICATION NAME] ([MEDICATION NAME] contains a combination of [MEDICATION NAME] and [MEDICATION NAME]. [MEDICATION NAME] is a steroid that reduces inflammation in the body. [MEDICATION NAME] is a [MEDICATION NAME][MEDICATION NAME] that relaxes muscles in the airways to improve breathing) to be administer 2 times a day. According to the order for [MEDICATION NAME], the directions were to administer 2 puffs and than rinse the mouth after use. Observation on 4-18-2018 at 8:28 AM revealed Licensed Practical Nurse (LPN) A prepared medications, including the [MEDICATION NAME] for administration to Resident 3. LPN A gave Resident 3, 2 puffs of the [MEDICATION NAME] and did not have Resident 3 rinse the mouth. On 4-18-2018 at 8:48 AM a interview was conducted with LPN [NAME] During the interview review of the order for [MEDICATION NAME] was completed with LPN [NAME] LPN A confirmed Resident 3 was not instructed to rinse the mouth and should have. B. Record review of Resident 5's current MRR printed on 4-18-2018 revealed Resident 5 had orders for medications that included [MEDICATION NAME], 2 puffs , 2 times a day. Observation on 4-18-2018 at 8:02 AM revealed LPN B administered 2 puff of the [MEDICATION NAME] to Resident 5. LPN B did not have Resident 5 rinse the mouth after the puffs. On 4-18-2018 at 8:04 AM an interview was conducted with LPN B. During the interview LPN B confirmed Resident 5 did not rinse the mouth after receiving the Symbicourt medication. LPN B further confirmed Resident 5 was not instructed to rinse the mouth after receiving the [MEDICATION NAME] medication and should have. C. Record review of Resident 4's current MMR sheet printed on 4-18-2018 revealed Resident 4 had orders for medications that included Deglu[DATE] units of insulin to be given with an insulin pen (An insulin pen is a device used to inject insulin). Observation on 4-18-2018 at 7:55 AM revealed LPN B obtained the insulin pen and administered the insulin to Resident 4. LPN B did not prime the insulin pen prior to administering the insulin to Resident 4. On 4-18-2018 at 8:04 AM an interview was conducted with LPN B. During the interview, LPN B reported the insulin pen was not primed. Record review of a information sheet from the facility consultant dated 2-2018 titled Insulin Issues revealed the following about the insulin pen: -Insulin pens must be primed with 2 units prior to each use to ensure the proper dose is administered. D. Record review of a current NRR printed on 4-18-2018 revealed Resident 6 had medication orders that included Artificial Tears drops to be given 3 times a day. according to the order for the Artificial tears, staff were to administer 1 drop in each eye. Observation on 4-18-2018 at 7:42 AM revealed LPN C administered 1 drop to the left eye. On 4-18-2018 at 7:44 AM an interview was conducted with LPN C. During the interview, LPN C confirmed the eye drops were not administered to both eyes. According to Drugs.com revealed after inhalation of the [MEDICATION NAME] , the patient should rinse the mouth with water without swallowing.",2020-09-01
1460,LIFE CARE CENTER OF OMAHA,285137,6032 VILLE DE SANTE DRIVE,OMAHA,NE,68104,2018-12-12,759,D,1,0,IZ5L11,"**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%. Observations of 33 medications revealed 4 errors for 1 (Resident 4) of 2 sampled residents resulting in an error rate of 12.12%. The facility staff identified a census of 93. Findings are: Record review of Resident 4's Medication Administration Record [REDACTED]. Observation on 12-11-2018 at 7:11 AM revealed Registered Nurse (RN) A prepared Resident 4's medications that included the [MEDICATION NAME]. Further observations revealed the [MEDICATION NAME], Movantik and Pantoprazole were not available to be given. RN A administered the medications to Resident 4 that included the [MEDICATION NAME]. The [MEDICATION NAME] was not administered with the AM meal. On 12-11-2018 at 9:12 AM an interview was conducted with RN [NAME] During the interview, RN A confirmed the medications of [MEDICATION NAME], Pantoprazole, and Movantil were not available to give to Resident 4 and confirmed the [MEDICATION NAME] was not given with a meal or food.",2020-09-01
4484,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2019-04-01,759,D,1,1,OJJK11,"**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 28 medications administer revealed 5 errors for 2 (Resident 15 and 29) of 3 sampled residents resulting in a medication error rate of 17.85%. The facility staff identified a census of 52. Findings are: [NAME] Record review of a Active Orders Summary Report (AOSR) printed on 3-27-2019 revealed Resident 15 had orders for medications that included the following: -[MEDICATION NAME] ( broncodilater medication) inhaler, 2 puffs inhalation twice a day and to rinse the mouth after use. -[MEDICATION NAME] (nasil spray) 2 sprays to each nostril 1 time a day. -[MEDICATION NAME] ( medication to manage blood pressure) 12.5 milligrams (mg) to be given 1 time a day. Staff were to hold the medication of the systolic ( top number of a blood pressure reading) was below 100 or Resident 15's pulse was less than 60. -Diltiazam 120 mg to be given 1 time a day. Staff were to hold the medication of the systolic ( top number of a blood pressure reading) was below 100 or Resident 15's pulse was less than 60. Observation on 3-27-2019 at 8:03 AM revealed Certified Medication Assistant (CMA) T prepared Resident 15 medication. CMA T took the medications to Resident 15 room, handed Resident 15 the [MEDICATION NAME] inhaler to take the inhalations. Resident 15 completed using the inhaler and CMA T did not cue Resident 15 to rinse the mouth . Further observation revealed CMA T handed Resident 15 the [MEDICATION NAME] Nasal spray. Resident 15 sprayed 1 squirt into each nostril. CMA T did not instruct Resident 15 to spry 2 squirts into each nostril. CMA T handed Resident 15 medication to be taken orally that included the [MEDICATION NAME] and the [MEDICATION NAME]. CMA did not obtain Resident 15's blood pressure prior to giving the medications as order. On 3-27-2019 at 8:10 AM an interview was conducted with CMA T. During the interview when asked if Resident 15's blood pressure had been obtained, CMA T reported the blood pressure had not been obtained. CMA T further reported not being aware of what Resident 15's blood pressure was. CMA T confirmed Resident 15 should have rinsed the mouth, sprayed 2 squirt into each nostril of the [MEDICATION NAME] and not obtaining Resident 15 blood pressures were errors. B. Record review of a Active Orders Summary Report (AOSR) printed on 3-27-2019 revealed Resident 29 had orders for medications that included Breo Elliptapta inhaler (medication is used to prevent and decrease symptoms caused by asthma and ongoing lung disease), 1 inhalation and to rinse the mouth after use. Observations on 3-27-2019 at 8:20 AM revealed Registered Nurse (RN) S prepared Resident 29's medication. RN S handed Resident 29 the Breo Elli inhaler and Resident 29 took 1 inhalation and handed the inhaler back to RN S. RN S did not cue Resident 29 to rinse the mouth after using the inhaler. On 3-27-2019 at 8:28 AM an interview was conducted with RN S. During the interview RN S confirmed Resident 29 had not been cued to rinse the mouth after using the Breo Ellipta inhaler.",2020-06-01
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
2948,RIDGECREST REHABILITATION CENTER,285239,3110 SCOTT CIRCLE,OMAHA,NE,68112,2018-01-23,759,D,1,0,L1D312,"**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 30 medications administered revealed 6 errors resulting in an error rate of 20%. The medication errors were related to 3 (Resident 22, 27 and 30) of 5 residents observed. The facility staff identified a census of 56. Findings are: [NAME] Record review of a Prescribing Sheet dated 4-2017 from the manufacture revealed the following information: -Patient Information sheet section: -[MEDICATION NAME] starts acting fast. you should eat within 5 to 10 minutes after taking the does of [MEDICATION NAME]. B. Record review of Resident 22's physician's orders [REDACTED]. Observation on 4-02-2018 at 4:40 PM revealed Licensed Practical Nurse (LPN) A obtained Resident 22's blood sugar level of 155. According to the physician order [REDACTED]. No food was observed to to Resident 22. Observation on 4-02-2018 at 6:10 PM revealed Resident 22 was served the evening meal. C. Record review of Resident 30's physician's orders [REDACTED]. Observation on 4-02-2018 at 4:55 PM revealed LPN A obtained Resident 30's blood sugar levels of 237. According to the physician order [REDACTED]. No food was offered to Resident 30. Observation on 4-02-2018 at 6:12 PM revealed resident 30 was in the dinning room and served the evening meal. D. Record review of a physician's orders [REDACTED]. Observation on 4-02-2018 at 5:02 PM revealed LPN A obtained Resident 27's blood sugar level of 304. According to the physicians order for sliding scale insulin, Resident 27 was to receive 8 additional units of Humalog insulin. LPN A administered a total of 13 units of Humalog insulin. No food was offered to Resident 27. Observation on 4-02-2018 at 6:10 PM revealed Resident 27 was served the evening meal. On 4-02-2018 at 5:12 PM an interview was conducted with LPN [NAME] During the interview, LPN A reported Humalog insulin should be given within 15 minutes of eating. LPN A reported evening meal started at 6:00 PM. LPN A confirmed insulin administered to Resident 22, 27 and 30 were errors. On 4-02-2018 at 5:34 PM an interview was conducted with the Director of Nursing (DON). The DON reported during the interview that Humalog insulin should be given within 15 to 30 minutes of residents eating. The DON confirmed insulin administered to Resident 22, 27 and 30 would be errors if a hour before meals. The DON confirmed there were 6 insulin errors for Resident 22, 27 and 30.",2020-09-01
5789,HILLCREST HEALTH & REHAB,285133,1702 HILLCREST DRIVE,BELLEVUE,NE,68005,2016-09-29,332,D,1,0,QWZ111,"**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 30 medication administered revealed 4 errors resulting in an error rate of 13.33%. The medication errors effected 2 (Resident 5 and 6) of 3 sampled residents. The facility staff identified a census of 101. Findings are: A. Record review of Resident 5's physician's orders [REDACTED]. The directions were that resident 5 was to have 1 spray in each nostril. The instruction for use of the [MEDICATION NAME] medication was that Resident 5's pulse was to be taken prior to the administration. Observation on 9-29-2016 at 9:40 AM revealed Certified Medication Assistant (CMA) C prepared the morning medications that included the [MEDICATION NAME] and [MEDICATION NAME] and entered Resident 5's room. CMA C without obtaining a pulse gave Resident 5 the medications that were to be swallowed. CMA C then prepared to administer the nasal spray when Resident 5 reported (gender) would do the nasal spray. CMA C without cuing Resident 5 on the use of the nasal spray gave it to Resident 5. Resident 5 sprayed 2 sprays into each nostril. An interview with CMA C was conducted on 9-29-2016 at 9:50 AM. During the interview, CMA C confirmed Resident 5's pulse was not obtained prior to the administration of the [MEDICATION NAME] and Resident 5 used 2 sprays instead on one in each nostril. B. Record review of Resident 6's Medication Administration Record [REDACTED]. Observation on 9-29-2016 at 8:28 AM revealed Licensed Practical Nurse (LPN) B prepared Resident 6's medications. During the preparation LPN B reported Resident 6's Vitamin A, C and Zinc and [MEDICATION NAME] were not available to be given to Resident 6. On 9-29-2016 at 9:50 AM a follow up interview was conducted with LPN B. During the interview LPN B confirmed Resident 6 did not receive the [MEDICATION NAME] or the Vitamin A, C and Zinc combination.",2019-09-01
1624,MAPLE CREST HEALTH CENTER,285149,2824 NORTH 66TH AVENUE,OMAHA,NE,68104,2019-02-13,759,D,1,0,GHG411,"**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. This had the potential to affect 2 residents (Resident 5 and Resident $) The error rate was 12%. The facility census was 148. Findings are: Review of the facility policy titled Medications Administration Procedure dated 11/30/17 revealed the following: - Medications shall be administered in a safe and timely manner, in accordance with the written orders of the attending physician. - Medications may not be prepared in advance and must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). - The individual administering the medication must check the label THREE (3) times to verify the 5 Rights are always verified before administering medications -the right medication; the right dose; the right resident; the right route; and the right time. [NAME] Observation on 02/13/2019 at 9:00 AM of Medication Aide (MA)- A administering medication to Resident 5 revealed the [MEDICATION NAME] 5 mg (a diabetic medication to lower blood sugar) was provided to Resident 5 with other scheduled medications. Review of the pharmacy label on the medication container revealed [MEDICATION NAME] 5mg should be given 30 minutes prior to a meal. Observation on 02/13/2019 at 9:00 AM of Resident 5 revealed Resident 5 had consumed part of breakfast. Interview on 02/13/2019 at 2:40 PM with the Director of Nursing (DON) and Administrator revealed [MEDICATION NAME] should be given 30 minutes prior to a meal. B. Observation on 02/13/2019 at 9:30 AM of MA -B administering medication to Resident 4. The [MEDICATION NAME] 137 Micrograms (a medication to treat an underactive [MEDICAL CONDITION]) was included in the medications provided to Resident 4 with other scheduled medications. Review of the pharmacy label on the medication container revealed [MEDICATION NAME] 137 MCG should be given on an empty stomach 30 minutes prior to a meal. Observation on 02/13/2019 at 9:30 AM of MA -B administering medication to Resident 4. The [MEDICATION NAME] 40 MG (a medication used to treat used to treat symptoms of [MEDICAL CONDITION] reflux disease (GERD)) was included in the medications provided to Resident 4 with other scheduled medications. Review of the pharmacy label on the medication container revealed [MEDICATION NAME] 40 MG should be given on an empty stomach 60 minutes prior to a meal. Observation on 02/13/2019 at 9:35 AM revealed Resident 4 was assisted eating the breakfast meal. Interview on 2/13/19 at 2:47 PM with the DON revealed medications were not given at the designated times.",2020-09-01
3951,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,760,D,1,1,OLWQ11,"**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 1resident (Resident 17) on 2 occasions was free from significant medication errors when a rapid acting insulin was given and food was not given to prevent a potential hypoglycemic reaction out of 4 opportunities observed. The census was 34. Findings are: [NAME] Observation on 3-14-18 at 8:08 PM of LPN-A (Licensed Practical Nurse) administered [MEDICATION NAME] Insulin 6 units SQ (subcutaneous) to Resident 17. LPN-A did not provide the resident with any food at the time of administration of the insulin. Continued observation of the resident until 8:45 PM revealed the resident did not receive a snack or drink. Review of the Medication Administration Policy dated 1-5-17 revealed [MEDICATION NAME] Insulin should be given immediately within 5-10 minutes of a meal or have the resident eat something within this time frame. B. Observation on 3-19-18 at 11:08 AM of RN-C (Registered Nurse) administered [MEDICATION NAME] Insulin 4 units to Resident 17 in the resident's room. The resident's spouse was in the room at the time of the injection. RN-C did not provide the resident with a snack or drink at the time of the injection. Continued observation of the resident for 30 minutes revealed the resident did not receive any further food or drink. Interview on 3-19-18 at 12:03 PM with Resident 17's spouse revealed the resident had not received anything to eat such as a meal, snack or a drink since the resident had received the insulin injection. The spouse revealed the resident ate the noon meal daily in the resident's room and the meal was not scheduled to arrive until closer to 12:30 PM. Interview on 3-19-18 at 4:08 PM with the DON (Director of Nursing) confirmed the Medication Administration Policy did instruct a meal or food was to be given within 5-10 minutes of administration of [MEDICATION NAME] Insulin. Review of the manufacturer of [MEDICATION NAME]'s prescribing information revealed [MEDICATION NAME] is a rapid acting insulin and should be given within 5-10 minutes before a meal. The risk of [DIAGNOSES REDACTED] (abnormally low level of blood sugar) after an injection is related to the duration of action of the insulin is highest when the glucose (blood sugar) lowering effect of the insulin is maximal. Factors which may increase the risk of [DIAGNOSES REDACTED] include change in meal pattern (timing of meals).",2020-09-01
1399,LIFE CARE CENTER OF ELKHORN,285134,20275 HOPPER STREET,ELKHORN,NE,68022,2018-10-11,760,D,1,0,PGI211,"**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 2) of 6 sampled residents was free of a significant medication error. The facility census was 99. Observation of medication administration on 10/10/2018 at 12:26 PM revealed RN A completed an Accu-check (method of checking blood sugar levels) for Resident 2. Review of Resident 2 MAR (Medication Administration Record) revealed that Resident 2 was to receive 10 Units of [MEDICATION NAME] Insulin before meals. Further observation of medication administration revealed that RN C was unable to administer insulin as ordered due to insulin being unavailable for Resident 2. A interview was conducted with RN C on 10-10-2018 at 12:26 PM AM. During the interview RN C confirmed Resident 2's insulin was not available for use.",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
2587,AZRIA HEALTH MIDTOWN,285218,910 SOUTH 40TH STREET,OMAHA,NE,68105,2018-07-17,759,E,1,0,SQOO11,"**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 staff failed to ensure a medication error rate of less than 5%. Observations of 28 medications administered revealed there were 9 errors resulting in a medication error rate of 32.14%. The medication errors were related to 5 (Resident 505, 506, 507, 508 and 509) of 6 sampled residents. The facility staff identified a census of 51. Findings are: [NAME] Record review of a Medication Review Report (MRR) printed on 7-17-2018 revealed Resident 508's physician had ordered medications that included [MEDICATION NAME]( according to Drugs.com, [MEDICATION NAME] is a fast-acting form of insulin and should be given within 5 to 10 minutes before a meal) 5 units to be given before a meal and additional [MEDICATION NAME]to be given based on blood sugar (BS) level. Observation on 7-16-2018 at 11:28 AM revealed Licensed Practical Nurse (LPN) A prepared 17 units of the [MEDICATION NAME]for Resident 508. LPN A indicated Resident 508's BS was 321. According to Resident 508's physician order [REDACTED]. Further observation revealed LPN A administered the 17 units of insulin. On 7-16-2018 at 11:43 AM an interview was conducted with LPN [NAME] During the interview, LPN A confirmed the [MEDICATION NAME] was given to early and that Resident 508 would not be eating until 12:00 PM. B. Record review of a MRR printed on 7-17-2018 revealed Resident 507's physician ordered medications that included [MEDICATION NAME]28 units once a day using a flex pen injector Observation on 7-16-2018 at 11:32 AM revealed LPN A prepared 28 units of [MEDICATION NAME]for Resident 507 using a insulin flex pen ( a pen looking device that contains insulin with a dial to measure the amount of insulin to be given. The flex pen needle is used once and requires the user to prime the needle with 2 units prior to dialing the ordered amount of insulin). LPN A administered the insulin to Resident 507. On 7-16-2018 at 1143 AM an interview was conducted with LPN [NAME] During the interview, LPN A confirmed the insulin pen was not primed with 2 units prior to giving Resident 507 insulin and confirmed the insulin was given to early as Resident 507 eats at 12:00 PM. C. Record review of a MRR printed on 7-17-2018 revealed Resident 509's physician ordered medications that included [MEDICATION NAME] 12 units to be given once a day. Observation on 7-16-2018 at 11:48 AM revealed LPN B prepared the [MEDICATION NAME]pen of 12 units and administered the insulin to Resident 509. LPN B did not prime the insulin pen with 2 units to ensure the correct amount of insulin was administered to Resident 509. On 7-16-2018 at 11:50 AM an interview was conducted with LPN B. During the interview, LPN B confirmed the insulin pen was not primed prior to given Resident 509 the insulin. D. Record review of a MRR printed on 7-17-2018 revealed Resident 506's physician had ordered medications that included Potassium Chloride 10 mill equivalents (MEQ) once a day and to be given with food, Ziprasidone (antipsychotic medication) 20 milligrams (mg) to be given twice a day with meals and [MEDICATION NAME] (medication used to treat diabetes) 1000 mg to be given twice a day. According to Mayoclinic.org, [MEDICATION NAME] should be taken with meals to help reduce stomach or bowel side effects. Observation on 7-17-2018 at 7:19 AM revealed Certified Medication Assistant (CMA) C administer medications to Resident 506 that included the Potassium Chloride, Ziprasidone and the [MEDICATION NAME]. CMA C administered the medications with water and no food. ON 7-17-2018 at 7:40 AM an interview was conducted with CMA C. During the interview, CMA C confirmed the medications were given with water and no food. E. Record review of a MRR printed on 7-17-2018 revealed Resident 505's physician had ordered medications that included Carvedilol (medication used for high blood pressure) 6.25 mg's twice a day with meals, [MEDICATION NAME] Magnesium ( prevents the production of acid in the stomach) 40 mg's to be given twice a day and [MEDICATION NAME] 1000 mg's to be given twice a day with meals. Observation on 7-17-2018 at 7:50 AM Revealed CMA D prepared Resident 505's medications that included the [MEDICATION NAME], Carvedilol and the [MEDICATION NAME] Magnesium. Further observations revealed the label on the [MEDICATION NAME] directed the medication be given 1 hour before meals. CMA D administered the medications to Resident 505 with water and no food. On 7-17-2018 at 7:58 AM an interview was conducted with CMA D. During the interview CMA D confirmed no food was given at the time of the administration of the Carvedilol and [MEDICATION NAME]. On 7-17-2018 at 8:40 AM a follow up interview was conducted with CMA D. CMA D reported obtaining a meal tray right after the interview at 7:58 AM on 7-17-2018 resulting in less than 1 hour prior to a meal for the medication [MEDICATION NAME].",2020-09-01
1398,LIFE CARE CENTER OF ELKHORN,285134,20275 HOPPER STREET,ELKHORN,NE,68022,2018-10-11,759,E,1,0,PGI211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observations, record review and interviews; the facility staff failed to ensure a medication error rate of less than 5%. Observation of 36 medication administered revealed 32 medication errors for 5 (Resident 2, 4, 5, 6 and 8) of 6 residents resulting in an error rate of 88.88%. The facility staff identified a census of 99. Findings are: [NAME] Record review of Physician order [REDACTED]. -Xarelto (anticoagulant)10 milligrams (mg), 1 table by mouth daily. -Calcium with Vitamin D (supplement) 500/200 mg, 1 by mouth twice a day. -Fludrocortisone (steroid) 0.1 mg, 1 table by mouth daily. -Senna 8.6 mg, give 2 tabs by mouth daily. -Occuvite (vitamin),1 capsule daily. -[MEDICATION NAME] (anticonvulsant), 300 mg by mouth 2 times a day. Observation on 10-10-2018 at 10:20 AM revealed Registered Nurse (RN) D administered the medications that included the Xarelto, Calcium with Vitamin D, Fludrocortisone, Senna Occuvit and [MEDICATION NAME]. On 10-10-2018 at 10:30 AM an interview was conducted with RN D. During the interview RN D confirmed Resident 4's medications had been administered late. B. Observation of the Medication pass on 10/10/2018 at 09:30 AM-10:10 AM with Licensed Practical Nurse (LPN) A revealed LPN A administered the following medications to Resident 5: -Stool Softener 100 mg 1 tablet. -Bactrim DS (an antibiotic) 800 mg 1 tab. -[MEDICATION NAME] (a medication for high blood pressure) 12.5 mg 1 tab. -[MEDICATION NAME] (a medicine for digestive health) 1 cap. -[MEDICATION NAME] 325 mg 2 tabs. Review of the Current physician orders [REDACTED]. Interview with LPN A on 10/10/2018 at 11:00 AM confirmed Resident 5's medications were ordered for 8:00 AM and were given late. C. Observation of the Medication pass on 10/10/2018 at 09:45 AM-10:10 AM with LPN A revealed LPN A administered the following medications to Resident 6: -Fish Oil 1000 mg 2 tabs. -Galantamine (a medication used for Alzheimer's) 24 mg 1 tab. -Refresh Eye Drops 1 drop each eye. -Senna (a medication used for constipation) 8.6 mg 3 tabs. -Oxybuytin (a medication used for overactive bladder) 10 mg 1 tab. -[MEDICATION NAME] (a medication used for [MEDICAL CONDITION]) 300 mg 1 tab. -Clearlax (a medication used for constipation) 17 gm 1 capful. Review of current PO's dated 8-29-2018 revealed the medications were ordered for 8:00 AM. Interview with LPN A on 10/10/2018 at 11:00 AM confirmed that the medications were ordered for 8 AM and were given late. D. Observation on 10-10-2018 at 10:25 AM revealed Resident 8 received the following medications by CMA: -[MEDICATION NAME] (a medication for diabetes) 5 mg 1 tab. -[MEDICATION NAME] (a medication used for enlarged prostate) 1 tab. -[MEDICATION NAME] (medication used to reduce extra fluid) 10 mg 1 tab. -Eplerenone (medication used for high blood pressure) 25 mg 1 tab. -[MEDICATION NAME] (medication used for irregular heart rate) 200 mg 1 tab. -Carvedilol (medication used to treat heart failure) 12.5 mg 1 tab. -[MEDICATION NAME] (medication used to treat chest pain) 30 mg 1 tab. -Folic Acid 1 mg 1 tab. -Vitamin B 12 1 tab. -Aspirin 81 mg 1 tab. -[MEDICATION NAME] (a stool softener) 100 mg 1 tab. -Iron 325 mg 1 tab. -Culterelle (a medication for digestive health) 1 capsule. -[MEDICATION NAME] ( a medication to treat [MEDICAL CONDITION]) 2 puffs. Review of a PO's sheet signed on 9-17-2018 revealed the medications were ordered for 8:00 AM. Interview with CMA B on 10/10/2018 at 10:45 AM confirmed the medications were ordered for 8:00 AM and given late. E. Observation of accucheck (method for checking blood sugar level) for Resident 2 at 12:26 PM revealed blood sugar results of 257. RN C was unable to give the ordered 10 Units of [MEDICATION NAME]due to it being unavailable. An interview was conducted with RN C on 10-10-2018 at 12:26 PM AM. During the interview RN C confirmed Resident 2's insulin was not available for use. A interview was conducted with the DON on 10/10/2018 at 3:45 PM. During the interview the DON confirmed that medication administration should occur within the timeframe of 1 hour before and 1 hour after ordered time.",2020-09-01
1651,MAPLE CREST HEALTH CENTER,285149,2824 NORTH 66TH AVENUE,OMAHA,NE,68104,2018-12-18,760,D,1,1,864P11,"**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 ensure insulin was given in accordance with the standards of practice for 1 (Resident 36) of 1 sampled resident. The facility staff identified a census of 138. Findings are: Observation of blood sugar check for Resident 36 performed by LPN C at 08:15 AM on 12/13/2018 revealed a blood sugar result of 174. Observation of medication pass conducted on 12/13/2018 at 08:20 AM with LPN C revealed LPN C administered 10 Units of [MEDICATION NAME] Insulin to Resident 36. Review of the current physician orders [REDACTED].>Observation of Resident 36 on 12/13/2018 from 08:20 AM to 09:00 AM revealed that Resident 36 had not received breakfast until 09:00 AM. Interview conducted with LPN C on 12/13/2018 at 09:05 AM revealed the [MEDICATION NAME] Insulin should be given no more than 30 minutes prior to meals and Resident 36 did not receive breakfast for 40 minutes. Interview conducted on 12/17/2018 at 08:00 AM with RN D confirmed the [MEDICATION NAME] Insulin should be given no more than 15 minutes prior to meals.",2020-09-01
4063,HILLCREST MILLARD,285302,13225 WESTWOOD LANE,OMAHA,NE,68144,2019-03-21,760,D,1,0,EZUW11,**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 administer medication for the prevention of kidney transplant rejection for 1 (Resident 10) of 1 sampled resident. The facility staff identified a census of 53. The findings are: Review of Resident 10's Medical Record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record Review of Resident 10's current physician orders [REDACTED]. Record Review of Resident 10's Medication Administration Record [REDACTED]. The facility staff documented the reason for omission of the medication was that it was not available. Review of the Policy and Procedure for Medication Administration and Provision dated 12/29/2017 revealed that if a medication is listed on the Medication Administration Record [REDACTED]. Interview with the DCS (Director of Clinical Service) 3//21/2019 at 02:45 PM confirmed that the medication had not been administered. The DCS further revealed that there was no documentation on when the medication had been reordered or that the pharmacy or nurse on call had been notified.,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
2987,OMAHA NURSING AND REHABILITATION CENTER,285240,4835 SOUTH 49TH STREET,OMAHA,NE,68117,2019-01-02,760,D,1,0,UQIO11,"**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 37) received medications as ordered by the physician of 1 resident sampled. The facility staff identified a census of 58. Findings are: Record review of a Admission Record sheet printed on 1-02-2019 revealed Resident 37 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Transition Orders and Information For the Continuation Of Patient Care sheet revealed Resident 37 was discharged to the facility on [DATE] with orders for medications that included [MEDICATION NAME] ( anti-convulsant medication) ER (extended release) 500 milligrams, 1 tablet in the AM and 2 tablets at hour of sleep (HS) and [MEDICATION NAME] (anti-convulsant medication) 150 mg to be taken twice a day. Both medication carried the [DIAGNOSES REDACTED]. Record review of Resident 37's Progress Notes (PN) dated 12-29-2018 revealed medication had not arrived on the evening shift. Record review of Resident 37's Medication Administration Record [REDACTED]. On 1-02-2019 at 11:27 AM an interview was conducted with Pharmacist [NAME] During the interview Pharmacist A reported not receiving the [MEDICATION NAME] and [MEDICATION NAME] would be a significant error.",2020-09-01
4274,HILLCREST SHADOW LAKE,2.8e+300,1507 E GOLD COAST ROAD,PAPILLION,NE,68046,2017-08-14,333,D,1,1,728T11,"**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 95) of 5 sampled residents received insulin as ordered by the physician . The facility staff identified a census of 102. Findings are: Record review of a physician's orders [REDACTED]. Record review of Resident 95's Medication Administration Record [REDACTED]. Review of Resident 95's MAR from 8 01 (YEAR) to 8 07 (YEAR) revealed the [MEDICATION NAME]was not given 6 times. On 8 14 (YEAR) at 11:30 AM, an interview was conducted with the facility Pharmacist. During the interview when asked if not giving insulin as ordered would be a significant medication error, the Pharmacist reported it would be a significant error.",2020-09-01
4940,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2018-12-31,760,D,1,0,2L0S11,"**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 ensure Resident 1 was not over sedated related to the use of [MEDICATION NAME] (an opioid narcotic pain medication). The sample size was 4 and the facility census was 31. Findings are: [NAME] Review of Resident 1's undated Care Plan revealed the resident had chronic pain and medications were to be administered as ordered by the physician. The facility was to monitor/document pain medication side effects. Further review revealed the Care Plan was updated on 11/30/18 as the resident was having acute episodes of confusion. Review of Resident 1's Progress Notes revealed: - 11/26/18 at 7:14 AM, the resident was alert and oriented to person/place/situation. Respiratory rate was 20 with even, non-labored breathing. The resident was talking and laughing with staff. - 11/27/18 at 2:27 AM, the resident had occasional periods of being awake and respirations were shallow. - 11/27/18 at 12:00 PM, staff were assisting the resident to get ready for an appointment and did not feel the resident was stable enough for transport due to lethargy and poor trunk control. - 11/28/18 at 5:13 AM, the residents respirations were very deep at times and the resident had very little verbal response to stimulus. - 11/28/18 at 9:39 PM, all medications were crushed and attempted to be given to the resident, however the resident was not able to swallow. The resident's breathing was shallow with some circumoral cyanosis (blue discoloration of the skin around the mouth) present. - 11/29/18 at 8:37 PM, the resident remained unable to swallow. - 11/30/18 at 2:08 AM, the resident was having periods of rest and restlessness. - 11/30/18 at 9:00 AM, the resident was lethargic and had received pain medication that morning and throughout the night. - 11/30/18 at 10:20 AM, the resident left the facility by ambulance. The resident had a respiratory rate of 16 and was mouth breathing. - 11/30/18 at 4:00 PM, the facility received a phone call stating the resident was taken to the emergency room for pneumonia and the emergency room had to administer [MEDICATION NAME] (a medication used to treat narcotic overdose in an emergency situation). Review of Resident 1's Medication Administration Record [REDACTED] - [MEDICATION NAME] Solution 10 milligrams (mg) per (/) milliliter (ml) give 1 ml orally every 1 hour as needed (PRN). - [MEDICATION NAME] Extended Release tablet 30 mg to be given 2 times daily. - [MEDICATION NAME] Solution 10 mg/ml give 2 ml orally every 1 hour PRN. - The 2 ml dose of PRN [MEDICATION NAME] Solution was not given from 11/2/18 to 11/27/18. - The 2 ml dose of PRN [MEDICATION NAME] Solution was signed off as given on 11/28/18 at 11:30 AM, 11/29/18 at 10:00 AM and 1:30 PM, and on 11/30/18 at 4:42 AM and 10:00 AM. Review of the Medication Label dated 11/21/18 revealed the [MEDICATION NAME] Solution administered was [MEDICATION NAME] Solution 20 mg/ml (twice the concentration from the dose listed on the MAR). Review of Davis's Drug Guide for Nurses Fifteenth Edition dated (YEAR) revealed when using [MEDICATION NAME] the following should be considered: - Assess geriatric patients frequently, older adults are more sensitive of the effects of opioid medication and may experience side effects of respiratory complications more frequently. - Assess level of consciousness, blood pressure, pulse, and respirations before and periodically during administration. - Adverse effects/side effects include confusion, sedation, dizziness, hallucinations, and respiratory distress. During an interview with the Administrator on 12/31/18 at 1:35 PM, the Administrator confirmed the resident's level of consciousness fluctuated greatly throughout the day and from one day to the next. During an interview with the Registered Nurse Consultant (RNC) on 12/31/18 at 3:05 PM, the RNC confirmed the concentration of the [MEDICATION NAME] Solution administered was 20 mg/ml.",2020-03-01
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
3896,LITZENBERG MEMORIAL COUNTY HOSPITAL,285292,1715 26TH STREET,CENTRAL CITY,NE,68826,2018-02-05,759,D,1,1,B5KI11,"**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 2 errors resulting in an error rate of 8 %. The errors affected 1 resident (Resident 23). The facility census was 27. Findings are: Observation on 01-29-18 at 10:39 AM revealed MA-F (Medication Aide) administered morning medications to Resident 23 of [MEDICATION NAME], Aspirin, [MEDICATION NAME], and [MEDICATION NAME] which were all scheduled as [NAME]M. medications. MA-F also administered [MEDICATION NAME] 100 mcg 1 tab (a medication given for [MEDICAL CONDITION] disorder) and NAME] delayed release 40 mg 1 tab (a stomach medication) at the same time as the other medications. On both the the [MEDICATION NAME] and the Pantoprazole the medication card had a bright pink sticker on them beside the pharmacy label that said Early a.m. None of the other medication had the bright pink sticker on the medication cards. Interview on 01-31-18 at 3:30 PM with the DON revealed the medication Pantoprazole should have been given early in the morning and not with the rest of the medications. The [MEDICATION NAME] the DON revealed the previous Pharmacy they used had okayed for the facility to give the [MEDICATION NAME] with the medications at the later time. The DON revealed the current pharmacy must have been communicated this information on Resident 23. However the DON confirmed MA-F should not have given the medication at 10:39 AM with the other medications without first consulting with the charge nurse.",2020-09-01
3950,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,759,D,1,1,OLWQ11,"**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 3 errors resulted in an error rate of 12 %. The errors affected 2 residents (Resident 17 and 22). The census was 34. Findings are: [NAME] Observation on 3-14-18 at 2:22 PM revealed MA-D (Medication Aide) administered to Resident 12 Artificial Tears Solution 1 drop to both eyes. Review of the label on the Artificial Tears Solution revealed to administer 2 drops TID (three times a day) PRN (as needed) for dry eye irritation. Review of the (MONTH) (YEAR) MAR (Medication Administration Record) revealed Artificial Tears (white [MEDICATION NAME]-mineral oil) Ophthalmic ointment 83-15% amount to administer 1 drop OU (both eyes) QID (four times a day) 1 drop with the order date of 7-6-17. Review of the Physician order [REDACTED]. Interview with MA-D on 3-14-18 at 2:25 PM confirmed the label on the Artificial Tear Solution was not the same medication as the orders for Artificial Tears Ointment as listed on the MAR. B. Observation on 3-14-18 at 8:08 PM of LPN-A (Licensed Practical Nurse) administered [MEDICATION NAME] Insulin 6 units SQ (subcutaneous) to Resident 17. LPN-A did not provide the resident with any food at the time of administration of the insulin. Continued observation of the resident until 8:45 PM revealed the resident did not receive a snack or drink. Review of the Medication Administration Policy dated 1-5-17 revealed [MEDICATION NAME] Insulin should be given immediately within 5-10 minutes of a meal or have the resident eat something within this time frame. Review of the manufacturer of [MEDICATION NAME]'s prescribing information revealed [MEDICATION NAME] is a rapid acting insulin and should be given within 5-10 minutes before a meal. C. Observation on 3-19-18 at 11:08 AM of RN-C (Registered Nurse) administered [MEDICATION NAME] Insulin 4 units to Resident 17 in the resident's room. The resident's spouse was in the room at the time of the injection. RN-C did not provide the resident with a snack or drink at the time of the injection. Continued observation of the resident for 30 minutes revealed the resident did not receive any further food or drink. Interview on 3-19-18 at 12:03 PM with Resident 17's spouse revealed the resident had not received anything to eat such as a meal, snack or a drink since the resident had received the insulin injection. The spouse revealed the resident ate the noon meal daily in the resident's room and the meal was not scheduled to arrive until closer to 12:30 PM. Interview on 3-19-18 at 4:08 PM with the DON (Director of Nursing) confirmed the Medication Administration Policy did instruct a meal or food was to be given within 5-10 minutes of administration of [MEDICATION NAME] Insulin.",2020-09-01
5464,GOOD SAMARITAN SOCIETY - WOOD RIVER,285198,1401 EAST STREET,WOOD RIVER,NE,68883,2017-03-22,332,D,1,1,HUVK11,"**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 3 errors resulted in an error rate of 12%. The errors affected 3 residents (Resident 85, 79, and 42.). The facility census was 59. Findings are: [NAME] Observation on 3-14-17 at 09:11 AM revealed Nurse CC used a 5 oz. (ounce) paper cup filled about 3/4 full of water to administer [MEDICATION NAME] 17 gm (gram) to Resident 42 instead of with 8 ounces of water as the Physician's order directed to. The paper cups on the medication cart revealed on the bottom of the cup 5 oz. Review of Resident 42's Physician order revealed [MEDICATION NAME] 17 gm every other day give in 8 oz. of water for constipation. Interview on 3-16-17 at 10:30 AM with the DM (Dietary Manager) revealed the DM took a solo cup 5 oz. from the medication cart and measured it to the brim and revealed filled to the very top the cup held 5 oz. of water. B. Observation on 3-15-17 at 5:06 PM revealed Nurse B administered the medications [MEDICATION NAME] and Dilitizam to Resident 85 through a [DEVICE] (gastrostomy tube: a tube directly through the abdominal wall in the stomach or colon). Nurse B checked for placement but did not flush the [DEVICE] before or after Nurse B administered the medication. Nurse B did not administer any extra water except for the water that was mixed with the [MEDICATION NAME] and Dilitizam which were mixed together. Resident was on a continuous EN (enteral nutrition) and Nurse B reconnected the [DEVICE] started the EN. C. Observation on 3-15-17 at 3:35 PM revealed Nurse B administered the medications to Resident 79 through a [DEVICE]. Nurse B checked for placement but did not flush the [DEVICE] with water before or after Nurse B administered the medications of [MEDICATION NAME]. Review of the facility policy titled 'Medication Administration' dated 11-2013 revealed when medications were administered through a [DEVICE], a water flush of 30 cc (cubic centimeters) was to be performed before and after each medication pass. Interview on 3-15-17 at 6:00 PM with the ADON (Assistant Director of Nursing) revealed the expectation of the Nursing Administration was to have the nurses check placement and to flush with water before and after meds were given.",2020-01-01
4054,HILLCREST FIRETHORN,285300,8601 FIRETHORN LANE,LINCOLN,NE,68520,2018-06-14,760,D,1,0,U8OO11,"**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 medications were administered per Practitioner's order and/or Manufacturer's recommendations for residents receiving [MEDICAL TREATMENT] (the process of removing excess water, solutes and toxins from the blood in those whose native kidneys have lost the ability to perform these functions naturally). This failure had the potential to affect one resident (Resident 41); and the facility failed to ensure 2 residents (Resident 66 and 44) on 1 occasion each was free from significant medication errors when a rapid acting insulin was given and food was not given to prevent a potential hypoglycemic (low blood glucose level) reaction out of 2 opportunities observed. The census was 30. Findings are: A review a CARE PLAN REPORT, date range: 5/1/18-6/13/18, revealed Resident 41 was considered complex medical related to [DIAGNOSES REDACTED]. The report did not include documentation related to the disease process, co-morbidities, or signs and symptoms to monitor in order to identify changes in the Resident's condition requiring notification of Medical Practitioners. An observation on 6/13/18 at 8:33 AM of Resident 41 revealed the resident eating breakfast in the resident's room. Interview with the Resident revealed (gender) had not received any of scheduled morning medications. Blood Glucose level had not been checked this am, and that the assessment was usually completed late. Yesterday's lunch time check was completed at 2:00 PM. A review of the Medication Administration Record [REDACTED]. The medications were scheduled to be given 6:00-9:30 AM and the documentation did not indicate they had been administered as of 9:30 AM on 6/13/18. Per Nursing Drug Handbook (YEAR), [MEDICATION NAME] is a polymeric [MEDICATION NAME] binder and is to be given with meals. The drug may bind with other medication and decrease bioavailability. Recommendation is to give other drugs 1 hour before or 3 hours after this medication. Per article Phosphorus Binders ([MEDICATION NAME] Binders) and the [MEDICAL TREATMENT] Diet www.davita. Com, Phosphorus binder [MEDICATION NAME] was routinely ordered for persons requiring [MEDICAL TREATMENT]. This medication is taken 5-10 minutes prior to meals or immediately after meals. A review of Medication Administration Records, dated for (MONTH) and (MONTH) (YEAR), revealed Resident 41 routinely received insulin (medication used to treat [MEDICAL CONDITION]-increased blood glucose (sugar) and the Resident's blood glucose levels were ordered to be assessed with [REDACTED]. A review of information on the American Diabetes Association website revealed [MEDICAL CONDITION] can be a serious problem. If not treated, a condition called ketoacidosis (diabetic coma) could occur. Ketoacidosis is life-threatening and needs immediate treatment. B. Observation on 6-14-18 at 11:20 AM revealed LPN-E (Licensed Practical Nurse) administered Humalog Insulin 2 units SQ (subcutaneous) to Resident 44. LPN-E did not provide the resident with any food at the time of administration of the insulin. Continued observation of the resident until 12:09 PM revealed the resident did not receive a snack or drink. C. Observation on 6-14-18 at 11:37 AM of LPN-E administered Humalog Insulin 3 units SQ to Resident 66 in the resident's room. LPN-E did not provide the resident with a snack or drink at the time of injection. Continued observation of the resident until 12:10 PM revealed the resident did not receive any further food or drink. Interview with RN-A (Acting Director of Nursing Services Corporate Registered Nurse) on 6-14-18 at 11:53 AM revealed that the staff do not inject insulin unless the resident has food in their room or has already ordered their meal. RN-A stated that once the meal is ordered it doesn't take that long for it to be delivered to the resident. Review of the manufacturer of Humalog's prescribing information revealed Humalog is a rapid acting insulin and should be given within 5-10 minutes before a meal. The risk of [DIAGNOSES REDACTED] (abnormally low level of blood sugar) after an injection is related to the duration of action of the insulin is highest when the glucose (blood sugar) lowering effect of the insulin is maximal. Factors which may increase the risk of [DIAGNOSES REDACTED] include change in meal pattern (timing of meals).",2020-09-01
3657,RIDGEWOOD REHABILITATION & CARE CENTER,285279,624 PINEWOOD AVENUE,SEWARD,NE,68434,2018-06-05,760,D,1,1,RVGM12,"**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 medications were administered per Practitioner's order and/or Manufacturer's recommendations for Resident 66 who had a [MEDICAL CONDITION] disorder. Sample size was 1. The facility census was 71. Findings are: Record Review of Resident #66's Progress Notes revealed that [MEDICAL CONDITION] activity occurred in the bath spa, 911 was notified and Resident #66 was transferred to the hospital via ambulance. Record Review of the Face Sheet for Resident #66 from the hospital stay dated 6/6/18 revealed Diagnosis: [REDACTED]. Record Review of Transfer to LTC/AL/NH (Long Term Care/Assisted Living/Nursing Home) for Resident #66 dated 6/6/18 revealed that Resident #66 was admitted with an UTI (urinary tract infection and shaking). Diagnostics performed in the hospital included observe for [MEDICAL CONDITION] activity. Problems listed included a high risk for injury and a knowledge deficit for [MEDICAL CONDITION]. Record Review of Patient Visit Information for Resident #66 dated 6/6/18 revealed Resident #66 had a new prescription for Levetriacetam ([MEDICATION NAME]: a medication used to treat [MEDICAL CONDITION] which is an anticonvulsant) 500 mg [DEVICE] (a gastrostomy tube- a tube inserted through the abdomen that delivers nutrition directly to the stomach, used to deliver food/nutrition and medications). The prescription read Levetiracetam ([MEDICATION NAME]) 500 mg g-tub twice a day 30 days #300 ml (milliliters) 100 mg/ml Refills: 3 Record Review of Home Medication List for Resident #66 dated 6/9/18 revealed New Medications- These are new medications to start taking at home included Levetriacetam ([MEDICATION NAME]) 500 mg g-tub twice a day. Last taken: 06/08/18 19:35 500 mg 30 days. Record Review of Order Summary Report for Resident #66 revealed there was no diagnosis listed for [MEDICAL CONDITION] disorder and [MEDICATION NAME] Tablet 500 mg (Levetiracetam) Give one tablet via [DEVICE] two times per day for [MEDICAL CONDITION] activity 30 days started 6/9/2018.Record Review of Resident #66's Medication Administration Record [REDACTED]. Interview with the DON (Director of Nursing) on 7/31/18 at 4:15 PM regarding Resident #66's [MEDICATION NAME] medication revealed that [MEDICATION NAME] was discontinued on 7/31/2018. Clinical Record Review of the Patient Visit Information form with the DON confirmed the [MEDICATION NAME] order was for 30 days with 3 refills and stated so the [MEDICATION NAME] should not have been discontinued and the facility had a call to the physician saying the medication was disconitnued without tapering. Per [NAME]'s Drug Guide for Nurses 15th edition/2017. [MEDICATION NAME] is an anticonvulsant that should be administered whole, do not administer partial tablets. Do not break, crush, or chew XR tablets. [MEDICATION NAME] should be discontinued gradually to minimize the risk of increase in [MEDICAL CONDITION] frequency. Its important to use a calibrated measuring device for accurate dosing, Take missed doses as soon as possible unless almost time for the next dose. Do not double doses. Do not discontinue abruptly; may cause increase in frequency of [MEDICAL CONDITION],",2020-09-01
6230,PRESTIGE CARE CENTER OF PLATTSMOUTH,285104,602 SOUTH 18TH STREET,PLATTSMOUTH,NE,68048,2016-05-09,365,D,1,0,OPH711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.11A2 Based on record review and interview, the facility failed to clarify food consistency preference for one resident (Resident 2) who was served a regular consistency diet with orders for a mechanically altered diet. The facility census was 90. Findings are: Review of Resident 2's admission nutrition progress note dated 5/2/14 revealed the resident was on a pureed diet (food that has been blended to a soft, smooth, pudding consistency) with extra gravy and thin liquids. The progress note for nutrition on 5/6/14 indicated the resident's Power of Attorney did sign a waiver for resident to have regular texture food. Review of Resident 2's Nutrition Data V2.1 sheet with an effective date of 2/1/16 revealed this resident had a [DIAGNOSES REDACTED]. Review of a document titled, Informed Consent and Release of Liability dated 5/4/14 revealed that Resident 2's family member had acknowledged a risk of choking if the resident was served a regular consistency diet instead of pureed consistency. The document indicated the family member was making an informed choice and assumed all risks of the resident eating regular textured food even though it was not recommended by the physician or speech therapy. In an interview with Medication Assistant E on 5/9/16 at 3:00 PM it was revealed that the kitchen did not always send out a mechanical soft diet for Resident 2, at times it was regular consistency. In an interview with the Dietary Manager (DM) and Administrator on 5/12/16 at 11:10 AM it was confirmed that Resident 2's diet consistency was changed to mechanical soft at some point after the waiver was signed. The Administrator and the DM confirmed that the waiver, related to the desire for regular consistency food, was not revisited or clarified after the order was changed to mechanical soft and further confirmed Resident 2 was served a regular consistency diet at times.",2019-05-01
3420,WESTFIELD QUALITY CARE OF AURORA,285263,"PO BOX 166, 1313 1ST STREET",AURORA,NE,68818,2019-11-13,809,D,1,0,P0CC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.11B Based on interview and record review, the facility failed to ensure facility residents received 3 meals per day. This affected 2 of 3 sampled residents (Residents 3 and 4). The facility identified a census of 64 at the time of survey. Findings are: [NAME] Interview with anonymous on 11/13/2019 at 12:56 PM revealed they had witnessed Resident 3 leaving the dining room several times after waiting an hour for food that they never received. B. Interview with anonymous on 11/13/2019 at 4:50 PM revealed the facility staff failed to ensure Resident 4 received supper on an unspecified date. Anonymous revealed a family member had to leave the facility and go downtown and retrieve some food for Resident 4 as it was late and the facility staff were unable to provide Resident 4 with the meal the rest of the residents had been served for supper. Anonymous revealed the facility staff offered Resident 4 a cold sandwich for supper. C. Review of Amount Eaten by Resident 3 revealed Resident 3 had 2 meals on 10//17/19; 2 meals on 10/24/19 and 2 meals on 10/29/19 there was no documentation of refusals for a meal. Review of PN (Progress Notes) for Resident 3 revealed: PN dated: 10/18/19 at 8:46 PM Resident very upset about supper. States resident was tired of sitting in the dining room for long periods of time waiting for residents food. States staff don't feed resident in a timely manner. States that resident can't transfer by self anymore to bed or bathroom and that upsets resident. Tried to comfort and talk with resident regarding the meals. Informed resident that meals are rotated with who staff serve first and that do to staffing. 400 hall and those that need assistance need to come first. D. Review of Amount eaten by Resident 4 revealed that Resident 4 had 2 meals recorded on 11/7/19; 1 meal on 11/8/19; 2 meals on 11/9/19; and 2 meals on 11/10/19 there was only one documentation of a meal not received for Resident 4. Review of PN ( Progress Notes) for Resident 4 revealed there was no documentation stating resident refused meals. There was a documentation of the following. PN dated: 11/7/19 at 9:13 PM Resident did not receive room tray at supper do to staff error. Spouse went outside of facility and bought resident supper. Dietary and staff educated on this and the responsibilities of room trays. Dietary states resident was on a long term list for room trays and staff are aware of that. An interview on 11/13/19 at 11:10 AM with LPN-A (Licensed Practical Nurse) revealed the Charge Nurse documents in the progress notes if the resident refused a meal. Also the staff can document that the Resident refused the meal. The only time Resident 4 goes out of the facility was for a physician's appointment. Review of a Concern/Compliment Form filed by Resident 4 revealed after an investigation was completed that staff were aware Resident 4 did not go into the dining room. There was no documentation on the grievance to indicate Resident 4 was taken a room tray or if Resident 4 refused. Review of the notes from the staff meeting held on 11/7/19 at 1:00 PM & 2:15 PM, prior to the Concern/Compliment Form being filed for Resident 4, revealed *Room tray changes/pick up trays in timely manner. We can work as a team on this. Open for suggestions to make this go [MEDICATION NAME] with an undated hand written note -staff decided to chart own room trays on their assigned halls. An interview on 11/13/19 at 5:32 PM with the DON (Director of Nursing) the dietary staff charts the meal if the resident is in the dining room. Nursing documents the room tray when the trays are picked up by staff. The dietary staff also keep track of what the intake was on the Room Tray slips. The staff are aware that documentation is done. The previous dietary staff were to document the room trays. The staff were informed that when a resident refuses anything the charge nurse needs to be informed and the charge nurses are told to document any refusal. Review of the documentation of the Room Trays revealed documentation for the reason for the room tray such as Never out, Just being mean, was out but got taken back to room, never comes out, doesn't want to, hand leftovers for noon, sick, and out with family. There was no documentation on the meals consumed on (MONTH) 9, 2019 and (MONTH) 10, 2019.",2020-09-01
5466,GOOD SAMARITAN SOCIETY - WOOD RIVER,285198,1401 EAST STREET,WOOD RIVER,NE,68883,2017-03-22,425,D,1,1,HUVK11,"**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 a bottle of insulin for 1 resident (Resident 23) out of 3 sampled insulin bottles matched the physician's orders [REDACTED]. Findings are: Observation on 3-15-17 at 5:54 PM revealed Nurse B prepared Novolog Insulin 3 units and administered to Resident 23. Review of the (MONTH) (YEAR) MAR (Medication Administration Record) revealed to give 3 units of insulin. Review of the Pharmacy label on the Novolog Insulin box revealed to give 5 units of insulin daily. The box was absent of any special label which instructed the nurse to check the Physician orders [REDACTED]. Interview on 3-15-17 at 5:55 PM with Nurse B revealed the Physician just recently changed the insulin orders from 5 to 3 units. Review of the Physician orders [REDACTED]. One order was to give 3 units one time daily and the other to give 5 units BID (twice a day). Both of the Novolog insulin orders were dated 7-22-16. Interview on 3-16-17 at 10:52 AM with Nurse D revealed when a new order was received for a medication that required a label change, the process was to send the order to the pharmacy through a fax and also put a sticker on the medication that alerts the nurses to check the orders for a new order.",2020-01-01
6110,"PREMIER ESTATES OF CRETE, LLC",285170,830 EAST 1ST STREET,CRETE,NE,68333,2016-06-08,425,G,1,0,L0XK11,"**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 staff failed to ensure medication was administered as ordered which resulted in increased anxiety for 1 resident, Resident 7. The facility census was 52. Findings are: Record review of Resident 7's face sheet revealed [DIAGNOSES REDACTED]. Record review of the admission orders [REDACTED]. Record review of the Medication Administration Record [REDACTED]. Record review of Resident 7's Nurses Notes on 5-21-16 revealed that Resident 7 needed continuous encouragement and assurance. Record review of Social Services Progress Notes for Resident 7 on 5-24-16 revealed that Resident 7 tends to get very easily anxious .face gets red and (gender) cries because (gender) is unsure how to deal and cope. (Gender) stated that (gender) feels 'terrified' . Interview with Resident 7 on 6-8-16 at 2:00 PM revealed that the stroke was the most horrible thing that ever happened to (gender) and stated things are much better now. Interview with Licensed Practical Nurse (LPN) C on 6-8-16 at 1:30 PM, revealed that on 5-20-16, on admission, LPN C faxed Resident 7's medication list to the pharmacy. LPN C further stated that the pharmacy requested a written prescription from the physician before sending the medication. LPN C stated that Resident 7's physician was faxed requesting the prescription and that this request was also placed in the Physician Communication Book (a binder kept at the nurses station for doctors to review when at the facility making rounds). Record review of Resident 7's physician orders [REDACTED]. Further review revealed that the Physician's Assistant wrote the prescription for the Alprazolam on 5-27-16. During an interview on 6-8-16 at 1:45 PM, LPN C revealed that after starting the Alprazolam, Resident 7 was more calm, smiling and interacting, compared to when not on the Alprazolam and was very tearful. The interview further revealed that LPN C did not know if Resident 7's physician was notified that Resident 7 was not receiving the Alprazolam as ordered or that Resident 7 had continued anxiety while not on this medication. Record review of a psychiatric note on 5-31-16 revealed anxiety much better since Alprazolam restarted.",2019-06-01
4407,OMAHA NURSING AND REHABILITATION CENTER,285240,4835 SOUTH 49TH STREET,OMAHA,NE,68117,2017-04-13,425,D,1,0,5FQK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.12 Based on record review and interviews, the facility failed to ensure that medications were available for use in a timely manner related to Resident 1. The facility census was 57. Findings are: Record review of Resident 1's face sheet revealed the resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Progress Notes for Resident 1 revealed on 3/21/17 Resident 1 admitted to the facility at noon. Review of Resident 1's Neurological Consult dated 2-6-17 revealed that Resident 1 had a long and complicated health history and was a brittle diabetic. Review of Resident 1's admission orders [REDACTED] -Humalog 4 units before meals -Humalog sliding scale based on Blood Sugar (BS) results of: 201-250=2 units, 251-300=3 units, 301-350=4 units, 351-400=5 units, 401-999=6 units, if higher than 600 call the doctor, give before meals and at bedtime. -Lantus 12 units at bedtime -Humalog 20 units one time order to be administered on 3/21/17 Review of Resident 1's Medication Administration Record [REDACTED]. Resident 1 received 6 units of insulin per the sliding scale, and 4 units of scheduled insulin. At 9 PM Resident 1's BS was 598, the physician was called and ordered 20 units of insulin to be given for a one time order and Resident 1 received 12 units of Lantus insulin. An interview with Resident 1's family member conducted on 4-12-17 at 1:20 PM revealed that Resident 1's insulin was given late on 3/21/17, it was not given before supper and was told by the nurse working that the resident's insulin had not come in yet from pharmacy. An interview with Licensed Practical Nurse (LPN) A conducted on 4-12-17 at 1:45 PM revealed that LPN A had worked the evening shift on 3/21/17 and did remember Resident 1. LPN A did not remember what time the insulin had arrived at the facility but that it was later in the evening and LPN A had to call pharmacy to ask when it would be coming. LPN A revealed that Resident 1 did not receive insulin until after supper as the insulin was unavailable. LPN A found an extra pen of Humalog insulin in the fridge in the medication room that did not have a resident label on it that was not expired and used that to give Resident 1 insulin as Resident 1's BS was getting high and kept going higher and the pharmacy had not given LPN A a time of arrival for the insulin. LPN A thought that the extra insulin pen was kept in the facility fridge for this purpose. LPN Labeled the insulin with Resident 1's name and then destroyed it when the residents insulin arrived from pharmacy later in the evening. Review of the pharmacy delivery slip dated 3-21-17 revealed Resident 1's insulin did not arrive to the facility until 9:05 PM. An interview with the Director of Nursing (DON) conducted on 4-12-17 at 4 PM revealed that they don't always but they will at times keep spare insulin's in the fridge for emergencies. The DON confirmed that Resident 1 admitted to the facility at noon on 3/21/17 and confirmed that Resident 1's insulin did not arrive to the facility until 9:05 PM. The DON agreed that it took the pharmacy too long to get the insulin to the facility. Review of the facility policy for Ordering & Recieving Medication From Pharmacy (NO DATE) revealed: 3. New medications, except for emergency or stat medications are ordered as follows: B. Require timely delivery on new orders so that medication administration is not delayed.",2020-08-01
3952,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,761,D,1,1,OLWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.12 Based on record review, interview, and observation; the facility did not ensure 1 medication label for Resident 12 was labeled in accordance with the current order out of 25 labels sampled. The census was 34. Findings are: Observation on 03/14/18 at 02:22 PM of Resident 12's Artificial Tears Solution bottle label revealed 2 drops TID (three times a day) PRN (as needed) for dry eye irritation. Review of the Physician orders [REDACTED]. The order was started on 7-6-17. Interview with MA-D (Medication Aide) on 03/14/18 at 02:25 PM confirmed the label on the bottle of the Artificial Tears did not match the order for the directions as to how often the medication should be given. Interview on 03/14/18 at 07:50 PM with RN-C (Registered Nurse) revealed when a medication dosage was changed the facility sent back the medication to the pharmacy to be relabeled. The pharmacy made a delivery to the facility 6 days a week.",2020-09-01
6639,COMMUNITY MEMORIAL HEALTH CENTER LTC,285257,"P O BOX 340, 295 NORTH 8TH STREET",BURWELL,NE,68823,2015-12-16,431,E,1,0,ICXF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.12 E1 Based on observations and interview, the facility failed to secure medications to prevent access from unauthorized persons as the medication cart was left unlocked and unattended. This had the potential to affect 18 residents who currently resided on the Sunset Wing of the facility. The facility census was 52. Findings are: Observations of the Sunset Wing on 12/16/15 revealed the following: -At 5:40 AM, an unlocked medication cart was positioned in the corridor across from the Nurses Office. Licensed Practical Nurse (LPN)-O was in a resident room located next to the Nurses Office. -At 5:42 AM, LPN-O exited the resident room and entered the Nurses Office. -From 5:54 AM until 6:09 AM, LPN-O was in Resident room [ROOM NUMBER] with the door closed. Resident room [ROOM NUMBER] was at located at the opposite end of the corridor from the Nurses Office. The unlocked medication cart remained positioned and unattended in the corridor across from the Nurses Office until 6:09 AM when LPN-O returned to the area by the medication cart (15 minutes). Interview with LPN-O on 12/16/15 at 6:20 AM confirmed the medication cart was supposed to be locked when not in a staff member's direct line of vision.",2018-12-01
1131,ARBOR CARE CENTERS-O'NEILL LLC,285108,"PO BOX 756, 1102 NORTH HARRISON",O' NEILL,NE,68763,2018-06-11,755,D,1,0,PFPI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.12A Based on interview and record review, the facility failed to ensure medications were available for administration for 2 residents (Residents 1 and 3) who required assistance with medication administration. The sample size was 7 and the facility census was 47. Findings are: [NAME] Review of Resident 1's current undated Care Plan revealed the resident received multiple medications to treat [DIAGNOSES REDACTED]. Medications were to be given as ordered. Review of Resident 1's Medication Administration Records (MAR) dated 5/2018 and 6/2018 revealed the following medications were not signed off as administered; -On 5/31/18: -[MEDICATION NAME] (a medication used to treat high cholesterol and triglyceride levels) 20 milligrams (mg) every night, and -[MEDICATION NAME] (a medication used to treat depression) 75mg every evening. -On 6/1/18: -Fish-Flax-Borage capsule (a supplement containing fatty acids) 1 time daily, -[MEDICATION NAME] (a medication used to treat high blood sugar levels in people with diabetes) 5mg 1 time daily, -[MEDICATION NAME] 20mg every night, -[MEDICATION NAME] (a vitamin B1 supplement) 100mg 1 time daily, -[MEDICATION NAME] (a medication used to treat high blood pressure) 2.5mg 1 time daily, and -[MEDICATION NAME] 75mg every evening. -On 6/2/18: - [MEDICATION NAME] (a medication used to treat constipation) 100mg 1 time daily, - Fish-Flax-Borage capsule 1 time daily, - [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION]) 0.4mg 1 time daily, - [MEDICATION NAME] 5mg 1 time daily, - [MEDICATION NAME] (a medication used to treat GERD) 20mg 1 time daily, - [MEDICATION NAME] 100mg 1 time daily, and - [MEDICATION NAME] 2.5mg 1 time daily. Interview with the Director of Nursing (DON) on 6/11/18 at 11:30 AM confirmed some medications were not administered to Resident 1 as ordered on [DATE], 6/1/18, and 6/2/18. The medications had not been delivered from pharmacy and were therefore not available for use. B. Review of Resident 3's current undated Care Plan revealed the resident had a current [DIAGNOSES REDACTED]. Review of Resident 3's Order Summary Report revealed an order for [REDACTED]. Review of Resident 3's MAR indicated [REDACTED] -The residents [MEDICATION NAME] was not signed off as given on 5/9/18, and -The residents [MEDICATION NAME] was not signed off as given on 5/10/18. Review of Resident 3's Progress Notes from 5/9/18 to 5/10/18 revealed the following: - On 5/9/18, there was no documentation to indicate Resident 3's [MEDICATION NAME] had been changed as ordered. - On 5/10/18, documentation stated a new [MEDICATION NAME] was not placed on the resident as ordered, as there were no [MEDICATION NAME]es available for use. C. Interview with Licensed Practical Nurse-D on 6/11/18 at 1:55 PM revealed each medication needed to be individually re-ordered when it was running low and sometimes medications got missed and were not re-ordered in time. During an interview with Medication Aide-A on 6/11/18 at 2:10 PM, MA-A stated medications were available for administration about 95 percent of the time.",2020-09-01
3418,WESTFIELD QUALITY CARE OF AURORA,285263,"PO BOX 166, 1313 1ST STREET",AURORA,NE,68818,2019-11-13,755,D,1,0,P0CC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.12A Based on interview, observation and record review; the facility failed to administer medications for Residents 8, 9, and 10 within the time frame scheduled for medications. This affected 3 of 3 sampled residents. The facility identified a census of 64 at the time of survey. Findings are: [NAME] Observation of MA-B (Medication Aide) on 11/13/2019 9:58 AM revealed they administered the following medications to Resident 10: [MEDICATION NAME] 1 tablet PO (by mouth) QD (every day); Senna 8.6 mg (milligrams) 1 tablet PO BID (twice a day); Ziprasidone 20 mg 2 caps (40 mg) BID with food; [MEDICATION NAME] 20 mg 1 PO QD 60 minutes before meal; [MEDICATION NAME] 100 mg 2 caps PO BID; [MEDICATION NAME] 80 mg ET 1 tab PO QD; [MEDICATION NAME] 0.5 mg 1 PO BID; [MEDICATION NAME] 1 T (tablespoon) PO QD in 6 ounces water/liquid of choice. Review of Resident 10's MAR (Medication Administration Record) for (MONTH) revealed all of the medications were scheduled to be given at 0800 (8 AM) except the [MEDICATION NAME] which was scheduled at 0700 (7 AM). B. Observation of MA-B on 11/13/2019 at 10:11 AM revealed they administered the following medications to Resident 8: [MEDICATION NAME] 80 mg 1 PO before meals; ASA 81 mg 1 PO QD; Calcitrol 0.25 mg 1 PO QD; carvedilol 3.125 mg 1 PO BID with food; [MEDICATION NAME] 40 mg 1 PO QD; [MEDICATION NAME] 10 mg 1 PO QD; [MEDICATION NAME] 200 mg 2 tabs (400 mg ) PO TID (three times a day); [MEDICATION NAME] 150 mg 1 PO QD; [MEDICATION NAME] 10 mg 1 PO QD; [MEDICATION NAME] 50 mcg 1 spray each nostril QD; Azelastine HCL nasal spray 2 sprays each nostril BID; [MEDICATION NAME] 160-4.5 2 puffs BID; rinse mouth after administering; [MEDICATION NAME] 325 mg 2 tablets (650 mg) PO Q 4 hours PRN (as needed). Review of Resident 8's MAR (Medication Administration Record) for (MONTH) revealed all of the medications were scheduled to be given at 0800 (8 AM) except the [MEDICATION NAME] which was scheduled at 0730 (7:30 AM). C. Observation of MA-B on 11/13/2019 at 10:19 AM revealed they administered the following medications to Resident 9: [MEDICATION NAME] 20 mg 1 PO daily before breakfast; [MEDICATION NAME] 5 mg 1/2 tablet (2.5 mg) PO QD, give 30 minutes before meal; ASA 81 mg 1 PO QD; atorvastatin 40 mg 1 PO QD; Carvedilol 3.125 mg 1 PO BID take with food; [MEDICATION NAME] 40 mg 1 PO QD; [MEDICATION NAME] 10 mg 1 PO QD; [MEDICATION NAME] 500 mg 1 PO BID take with food; Vitamin C 500 mg 1 PO QD. Review of Resident 9's MAR (Medication Administration Record) for (MONTH) revealed all of the medications were scheduled to be given at 0800 (8 AM) except the [MEDICATION NAME] which was scheduled at 0700 (7 AM) and the [MEDICATION NAME] which was scheduled at 0730. Interview with MA-B on 11/13/2019 at 10:24 AM confirmed all 3 of the residents MA-B gave medications late to (Residents 8, 9, and 10) had eaten their breakfast already. They stayed in their rooms for breakfast and got room trays. MA-B was just now getting to them to give them their medications. Review of the Medication Admin Audit Reports for 11/13/2019 revealed Resident 10's medications were documented they were administered at 9:58 AM; Resident 8's medications were documented they were administered at 10:17 AM; and Resident 9's medications were documented at 10:19 AM. Review of the Medication Review Reports revealed Resident 8's orders were signed by the medical provider on 10/28/2019; Resident 10's medication orders were signed by the medical provider on 10/16/2019 and Resident 9's medication orders were signed by the medical provider on 11/1/2019. Review of the facility policy Medication Administration dated 2019 revealed the following: Administer (medications) within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Interview with the facility BOM (Business Office Manager) on 11/13/2019 at 6:55 PM revealed the facility charge nurses were expected to help the medications aides.",2020-09-01
1311,THE AMBASSADOR OMAHA,285127,1540 NORTH 72ND STREET,OMAHA,NE,68114,2019-08-29,755,D,1,0,XEJI11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.12A Based on record review and interview; the facility failed to obtain medications for 1 (Resident 5) of 4 sampled residents. The facility staff identified a census of 91. Findings are: Record review of a Doctor's Orders and Progress Notes sheet dated 6-15-2019 revealed Resident 5's practitioner [MEDICATION NAME](an antibiotic medication) drops to both eyes every 2 hours while awake for 5 days related to pink eye. Record review of Resident 5's Medication Administration Record [REDACTED]. Record review of Resident 5 Progress Notes (PN) dated 6-16-2019 revealed the Charge Nurse followed up with the facility Pharmacy at 10:34 AM related to when the antibiotic medication would be delivered. Further review of Resident 5's PN dated 6-16-2019 revealed the pharmacy reported being notified of the antibiotic order on 6-15-2019 and would be delivering it on 6-16-2019. On 8-29-2019 at 1:15 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed resident 5 had not received the antibiotic eye drops as the medication was not available.,2020-09-01
6677,CAREAGE CAMPUS OF CARE,285135,811 EAST 14TH STREET,WAYNE,NE,68787,2015-11-17,425,E,1,0,KXTF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.12A Based on record review, observation, and interview; the facility failed to administer medications to Residents 4, 5, 3, 1, 2 and 10 in accordance with practitioners' orders. Facility census was 41. Findings are: A. Observation of the medication pass on 11/17/15 from 7:40 AM to 8:00 AM revealed Medication Aide (MA)-D placed Resident 10's medications in a medication cup, including the following: -Hydrocodone (used to treat pain) 7.5/325 mg (milligrams) 1 tablet 2 times daily (BID), -Calcium with Vitamin D (used as a dietary supplement) 600/400 mg 1 tablet daily, -Culturelle (a dietary supplement) 1 capsule daily, -Digoxin (used to strengthen and regulate heart beat) 0.125 mg 1 tablet daily, -Diltiazem (used to treat high blood pressure) ER (Extended Release-the active ingredients are released over a much longer period of time than with regular medications) 120 mg 1 capsule daily, -Escitalopram (used to treat depression) 10 mg 1 tablet daily, -Metoprolol Succinate (used to treat high blood pressure) ER 25 mg 1 tablet daily, -Omeprazole (used to treat acid reflux) 20 mg 1 capsule daily, -Prednisone (used to treat inflammation) 10 mg 1 tablet daily, - Senior Multivitamin (used as a dietary supplement) 1 tablet daily, -Vitamin C (used as a dietary supplement) 1 tablet daily, and -Potassium Chloride (used to treat low potassium) 20 meq (milliequivalent) 1 tablet BID. MA-D then removed Resident 10's capsules of Diltiazem ER and Omeprazole from the medication cup, opened the capsules, and sprinkled the contents into applesauce. MA-D then crushed the remaining oral medications, combined them with the Diltiazem and Omeprazole in the applesauce, and administered the medications to Resident 10. During interview on 11-17-15 at 1:30 PM, MA-D verified opening capsules of Diltiazem and Omeprazole and crushing the remaining medications for Resident 10's morning medication pass. MA-D further indicated this was how the MA was trained to administer Resident 10's medications. Review of Resident 10's Order Summary Report (current physician's orders [REDACTED]. According to Davis's Drug Guide for Nurses, Thirteenth Edition, Copyright 2013, Extended Release capsules or tablets, including Metoprolol Succinate ER and Diltiazem ER, should be swallowed whole and not broken, crushed or chewed due to their special pharmaceutical formulations and/or characteristics. B. Review of Resident 2's Medication Administration Record [REDACTED] -Amoxicillin (an antibiotic used to treat infections) Suspension 400-57 mg/5 ml (milliliter) give 10 ml BID, -Digoxin 125 mcg (micrograms) 1 tablet daily, -Buspirone (used to treat anxiety) 15 mg 1 tablet 3 times daily (TID), and -Diltiazem 60 mg 1 tablet 4 times daily (QID). Documentation on Resident 2's MAR indicated [REDACTED] -the 8:00 PM dose of Amoxicillin on 2 days; -the 9:00 AM dose of Digoxin on 1 day; -the 2:00 PM dose of Buspirone on 4 days; -the 4:30 AM dose of Diltiazem on 2 days; and -the 2:00 PM dose of Diltiazem on 4 days. C. Review of Resident 1's MAR indicated [REDACTED] -Muro 128 Solution 2% (used to reduce swelling in the eyes) instill 1 drop in left eye QID, and -Diltiazem ER 240 mg 1 capsule daily. Documentation on Resident 1's MAR indicated [REDACTED] -the 1:00 PM dose of Muro 128 Solution on 2 days; -the 5:00 PM dose of Muro 128 Solution on 6 days; and -the 8:00 AM dose of Diltiazem on 1 day. D. Review of Resident 3's Medication Review Report (current physician's orders [REDACTED]. -Artificial Tears Solution (used to treat dry eyes) 1 drop in both eyes QID, -DuoNeb Solution (a mixture of Albuterol and Ipratropium, used to treat respiratory problems) 1 vial by inhalation TID -Effexor (used to treat depression) 37.5 mg 2 capsules daily, -Ativan (used to treat anxiety) 0.5 mg at bedtime (HS), -Seroquel (used to treat psychotic disorders) 400 mg at HS, -Symbicort Aerosol (used to treat respiratory problems) 2 puffs inhaled BID, -Topamax (used to treat seizures or as a mood stabilizer) 100 mg at HS, and -Proventil Aerosol (used to treat respiratory problems) 2 puffs inhaled BID. Documentation on Resident 3's MAR indicated [REDACTED] -the 8:00 AM dose of Effexor on 4 days; -the 7:00 AM dose of DuoNeb inhalation on 12 days; -the 1:00 PM dose of DuoNeb inhalation on 15 days; -21 doses of the Artificial Tears eye drops at various times/days; and -an order for [REDACTED]. Documentation on Resident 3's MAR indicated [REDACTED] -the 5:00 PM dose of Proventil on 10/8/15; -the 9:00 PM doses of Seroquel, Symbicort Aerosol, Topomax and Ativan on 11/8/15; -5 doses of Artificial Tears eye drops at 5:00 PM and 9:00 PM on 4 different days; and -the 7:00 AM dose of DuoNeb inhalation on 4 days, the 1:00 PM dose on 5 days, and the 7:00 PM dose on 1 day. E. Review of Resident 4's Order Summary Report dated 4/9/15 revealed physician's orders [REDACTED]. -Lasix (used to treat fluid retention) 40 mg BID, -Lipitor (used to treat high cholesterol) 20 mg at HS, -Namenda (used to treat dementia) 10 mg BID, and -Senna (used to treat constipation) 1 tablet BID. Documentation on Resident 4's MAR's revealed the following medications were not administered as ordered: -4/2015 - the HS doses of Lipitor, Namenda and Senna on 4/14/15; -5/2015 - the HS dose of Lipitor on 5/18/15 and 5/21/15; and -6/2015 - the HS dose of Lipitor on 6/5/15 and 6/21/15, the HS dose of Senna on 6/29/15, the 6:00 PM dose of Namenda on 6/29/15, and the noon dose of Lasix on 6/30/15. F. Review of Resident 5's admission physician's orders [REDACTED]. -Aspirin 81 mg daily, -Lasix 40 mg daily, -Lanoxin (used to regulate heart rate) 0.25 mg daily, -Senokot (used to treat constipation) 1 tablet daily, and -Seroquel 100 mg daily. Documentation on Resident 5's MAR indicated [REDACTED] -the 9:00 AM dose of Ativan on 10/9/15; -the 6:00 PM dose of Seroquel on 10/8/15 and 10/12/15; and -the 6:00 PM doses of Aspirin, Lanoxin, Lasix and Senokot on 10/12/15. G. During interview on 11/17/15 at 9:40 AM, Licensed Practical Nurse (LPN)-A revealed the documentation omissions on residents' MAR's indicated they probably didn't chart them, however, verified there was no way to know if the medications were actually administered or not. H. During confidential resident interviews conducted on 11/17/15 from 9:00 AM until 10:30 AM, 2 of 5 residents revealed they felt medications were not being administered in accordance with their practitioners' orders.",2018-11-01
4906,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2017-12-21,755,E,1,0,7XZQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.12A, 175 NAC 12-006.12E(4) Based on record review and interview, the facility failed 1) to ensure the availability of medications required by physician's orders [REDACTED]. The facility census was 37 and the total sample size was 8. Findings are: [NAME] Review of Resident 3's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of Resident 3's Nursing Progress Notes dated 12/20/17 at 8:39 AM revealed the daily dose of [MEDICATION NAME] was not available for administration. B. Review of Resident 2's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of Resident 2's Nursing Progress Notes dated 9/14/17 at 10:16 AM revealed the daily dose of Ultimate [MEDICATION NAME] Formula was not available for administration. Review of Resident 2's MAR's dated 10/2017 and 12/2017 revealed the following related to the physician's orders [REDACTED].>-to be administered in a dose of 17 grams (gm) daily in an 8 ounce glass of water; -was not administered 10/5/17 or 12/1/17; and -directions were to See Nurse Notes for further explanation. Review of Resident 2's Nursing Progress Notes dated 10/5/17 at 9:20 AM and 12/1/17 at 8:46 AM revealed the daily doses of [MEDICATION NAME] Powder were not available for administration. C. Review of Resident 5's MAR indicated [REDACTED] -[MEDICATION NAME] (an anticonvulsant medication used to treat mood disorders) 25 mg at bedtime for major [MEDICAL CONDITION] was not administered 9/10/17; -[MEDICATION NAME] (a medication used to treat depression) Extended Release 24 hour 37.5 mg daily for major [MEDICAL CONDITION] was not administered 9/23/17 and 9/24/17; -[MEDICATION NAME] (a medication that changes the action of chemicals in the brain and is used to treat symptoms of psychotic conditions) 5 mg daily for major [MEDICAL CONDITION] was not administered on 9/28/17; and -directions were to See Nurse Notes for further explanation. Review of Nursing Progress Notes revealed the following medications were not available for administration to Resident 5: -9/10/17 at 8:40 PM - [MEDICATION NAME] 25 mg; -9/23/17 at 12:45 PM and 9/24/17 at 7:46 AM - [MEDICATION NAME] 37.5 mg; and -9/28/17 at 4:04 PM - [MEDICATION NAME] 5 mg. D. During interviews on 12/20/17, the following staff verified medications were not always available for administration: -at 8:25 AM - Licensed Practical Nurse (LPN)-B; and -at 11:40 AM - Registered Nurse (RN)-[NAME] E. During tour of the Medication Storage areas on 12/21/17 from 9:05 AM through 10:08 AM, accompanied by RN-A, the following were found stored in the top drawer of the treatment cart: -an open [MEDICATION NAME] (a type of insulin) [MEDICATION NAME] (a pre-filled, dial-a-dose insulin pen) labeled for use by Resident 6 that was not dated as to when it was opened; -an open vial of [MEDICATION NAME]solution labeled for use by Resident 7 that was not dated as to when it was opened; and -an open [MEDICATION NAME] labeled for use by Resident 8 that was not dated as to when it was opened. During interview on 12/21/17 from 9:05 AM until 10:08 AM, RN-A verified all insulin was to be dated when opened and disposed of after 28 days from the date of opening.",2020-03-01
3948,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,756,E,1,1,OLWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.12B Based on interview and record review, the facility consultant pharmacist failed to report to the provider recommendations made during monthly medication review for Residents 18, 22, 4, 21, and 13; and failed to identify duplicate therapy for sleep for Resident 18. This affected 5 of 5 residents. The facility identified a census of 34 at the time of survey. Findings are: [NAME] Review of Resident 18's Monthly Drug Regimen Review dated 2/2/2018 revealed the facility consultant pharmacist identified duplicate therapy for constipation and [DIAGNOSES REDACTED]. The consultant pharmacist documented a Physician's Action Report was sent. Review of Resident 18's medical record revealed no documentation the Physician's Action Report was completed or sent to the provider. Interview with the DON (Director of Nursing) on 3/14/18 at 3:09 PM confirmed there was no documentation the Physician's Action Report was completed or sent to the provider. Interview with the ward clerk MA-D (Medication Aide) on 3/15/18 at 12:33 PM revealed they were the person responsible for filing the Physician's Action Reports and they had not received the reports for (MONTH) (YEAR) from the consultant pharmacist yet so they had not been filed in the charts. Interview with the DON (Director of Nursing) on 3/15/18 at 12:40 PM confirmed the Physician Action Report should have been sent to the provider. B. Review of Resident 18's Physician's Progress Notes dated 2/12/2018 revealed Resident 18 was having issues with terminal [MEDICAL CONDITION]. The provider documented Resident 18 was taking [MEDICATION NAME] (an antianxiety medication) at bedtime and receiving [MEDICATION NAME] (an antidepressant also used for treating pain) for chronic pain. The provider documented Resident 18 goes to bed about 9-930 and wakes up about 2 in the morning and cannot go back to sleep. The provider added 25 mg (milligrams) of [MEDICATION NAME] (an antidepressant used for sleep disorders) at bedtime to see if this helps with this. Review of Resident 18's Physician order [REDACTED]. Interview with the SSD (Social Services Director) on 3/14/18 at 2:59 PM confirmed the pharmacist did not make recommendations for the duplicate medication therapy for sleep. C. Review of Resident 22's Monthly Drug Regimen Review form revealed on 02-2-18 the RP (Registered Pharmacist) documented duplicate therapy of medications for constipation [MEDICAL CONDITION](hypertension: high blood pressure). A PAR (Physician Action Report) was sent for the action taken. Review of Resident 22's medical record revealed absence of a PAR dated 2-2-18 or any date since. Interview on 3-14-18 at 4:33 PM with the DON revealed the DON and the[NAME] Clerk searched and were unable to find the PAR from the 2-2-18 visit. The DON revealed the RP did not provide communication to the DON of the monthly drug reviews in any of the previous months. Interview on 3-14-18 at 4:35 PM with the[NAME] Clerk revealed the[NAME] Clerk did not recall ever seeing the PARs from the (MONTH) pharmacy visit yet. Interview on 3-15-18 at 3:03 PM with the SSD revealed the SSD spoke with the RP and the RP had the (MONTH) PARs and the SSD confirmed they had not been sent to the Physician yet. D Review of the Monthly Drug Regimen Review for (YEAR) and (YEAR) identified that the consultant pharmacist did not recommend any dose reductions for Resident 4 who was prescribed an antipsychotic, an antidepressant and an antianxiety. The consultant pharmacist made no recommendations for a gradual dose reduction and after the physician did the bi-monthly rounds, the consultant pharmacist would document that the dose reduction was denied by the physician. There was no communication from the consultant pharmacist through a PAR (Physician Action Report) to the physician. Review of the bi-monthly physician rounds for Resident 4 identified physician visits on 6/30/1, 8/31/17, 11/03/17, 1/09/18 and 3/06/18 with the physician completing a gradual dose reduction for the antipsychotic, antidepressant and antianxiety after each of those rounds without any recommendations from the consulting pharmacist. Then, the consulting pharmacist would document the month following the rounds, that the physician denied the dose reduction. Interview with the SSD (Social Services Director) on 3/14/18 at 2:59 PM confirmed the pharmacist did not make recommendations to the physician prior to the physician's rounds and documented the denied dose reductions after those rounds were completed. The SSD also confirmed that the physician completed the dose reductions after each of the bi-monthly physician rounds but not from recommendations from the pharmacist. Interview with the DON (Director of Nursing) on 3/14/18 at 3:09 PM confirmed that the consulting pharmacist did not make dose recommendations to the physician and that the physician was completing the dose reductions after each of the monthly rounds without the communication from the pharmacist. E. Review of Resident 21's Monthly Drug Regimen Review form revealed on 02/02/18 the RP documented duplicate therapy of medications for [MEDICAL CONDITION]. A PAR was sent for the action taken. Review of Resident 21's medical record revealed absence of a PAR dated 2-2-18 or any date since that the medication of [MEDICATION NAME] was ordered every bedtime as needed for [MEDICAL CONDITION], or becomes restless or obsessed with minor issues, that medication should be discontinued as it is a prn (as needed) medication and had not been used by the resident for over two weeks. Interview on 03/14/18 at 4:33 PM with the DON revealed that the DON and the[NAME] Clerk searched and were unable to find the PAR from the 2-2-18 visit. The DON revealed the RP did not provide communication to the DON of the monthly drug reviews in any of the previous months. Interview on 3-14-18 at 4:35 PM with the[NAME] Clerk revealed the[NAME] Clerk did not recall ever seeing the PAR's from (MONTH) pharmacy visit. Interview on 3-15-18 at 3:03 PM with the SSD revealed the SSD spoke with the RP and the RP had the (MONTH) PAR's and the SSD confirmed they had not been sent to the Physician yet. F. On 03/14/18 a review of the paper chart for Resident 13 revealed no formal reviews by the Registered Pharmacist (RP). There was a PHYSICIAN ACTION REPORT dated 2/5/2018 which had a nurse requesting the rational for duplicate therapies or other concerns. The physician signs them during rounds in the facility. The GDR's (gradual dose reduction) reviews are done at that time and the RP signs them after monthly rounds are complete. On 03/14/18 at 04:43 PM an interview with DON revealed no form of communication is sent by the RP about medication reviews. DON confirmed the MD (Medical Director) receives no communication either from the RP. DON divulged the PHYSICIAN ACTION REPORT is made out by the nurse, the physician signs them on their facility rounds.",2020-09-01
5467,GOOD SAMARITAN SOCIETY - WOOD RIVER,285198,1401 EAST STREET,WOOD RIVER,NE,68883,2017-03-22,428,E,1,1,HUVK11,"**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 pharmacy failed to ensure monthly documentation in each residents medical record for the monthly MRR (Medication Regimen Review) for 4 out of 4 records sampled (Resident 81, 6, 47). This had the potential to affect all residents. The facility census was 59. Findings are: A) Review of the undated census sheet for Resident 81 revealed an admission date of [DATE] Review of the undated [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 2-21-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 5 which indicated Resident 81's cognition was severely impaired. Review of Resident 81's medical record revealed an initial MRR was completed on 1-24-17 but (MONTH) (YEAR) MRR was absent. Interview on 03-15-17 at 4:24 PM with HIM (Health Information Management) confirmed a (MONTH) (YEAR) MRR was not completed for Resident 81. B) Review of the undated census for Resident 6 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1-17-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) the resident was severely cognitively impaired. Review of Resident 6's medical record reveal a MRR was completed in the months of (MONTH) (YEAR) through (MONTH) (YEAR). MRR prior to (MONTH) (YEAR) were absent. C) Review of the undated census sheet for Resident 47 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-28-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 3 which indicated Resident 47 had severe cognition impairment. Review of Resident 47's medical record revealed a MRR was completed for the months of October, November, (MONTH) (YEAR) and (MONTH) (YEAR). (MONTH) (YEAR) MRR was absent. Interview with QA (Quality Assurance) Consultant on 3-15-17 at 3:27 PM confirmed QA a (MONTH) (YEAR) MRR was not completed for Resident 47. Interview on 3-15-17 at 3:26 PM with RP (Registered Pharmacist) revealed the monthly MRR have only been documented in each resident's medical record since (MONTH) (YEAR) throughout the entire facility. Licensure Reference Number 175 NAC 12-006.12B Resident 40 Resident was admitted on [DATE] Resident is diagnosed with [REDACTED]. Resident MDS (Minimum Data Set- a federally mandated comprehensive assessment tool utilized to develop resident care plans) from 1/31/2017 revealed Residents Cognitive Skills for Daily Decision Making are Severely Impaired. Resident has short and long term memory problems and received Antipsychotic Medications 7 of the 7 days of the resident review period. BASED ON RECORD REVIEW AND INTERVIEWS, the facility failed to do monthly MRR, ensure the resident was free from unnecessary medications, and ensure labs were orders as recommended by the RP for Residents 81, 40, 6, and 47.",2020-01-01
4276,HILLCREST SHADOW LAKE,2.8e+300,1507 E GOLD COAST ROAD,PAPILLION,NE,68046,2017-08-14,428,D,1,1,728T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.12B(5) Based on record review and interview; the facility Pharmacist failed to identify 1(Resident 95's) medications were not given and failed to follow up on a medication denial for 1 (Resident 32) of 5 sampled residents. The facility staff identified a census of 102. Findings are: [NAME] Record review of a physician's orders [REDACTED]. medications that included the following: Moxifloxacin 0.5% (antibiotic) eye drop. Novolog insulin 6 units three times a day. Prednisolone (steroid) 1% eye drop four times a day. Renvela (controls phosphorus blood levels) 800 (milligrams) mg three times a day. Brimonidine (reduces eye pressure) 0.2% eye drops. Coreg (medication to control blood pressure) 6.25 mg. -Lisinopril 20(medication to controll blood pressure) mg every day. Record review of Resident 95's Medication Administration Record [REDACTED] Brimonidine 0.2% was not given 14 times in July. Lisinopril 20 mg was not given 12 times. Novolog insulin 6 units 3 times a day was not given 15 times. Renvela 800 mg was not given 18 times. Record review of a Monthly Pharmacy Chart Review sheet dated from 4 14 (YEAR) through 7 13 (YEAR) revealed the pharmacist had not identified Resident 95's medications were not being given. On 8 14 (YEAR) at 11:30 AM, an interview was conducted with the facility Pharmacist. During the interview, the Facility Pharmacist reported the medications not being given should have been identified on the Monthly Pharmacy Chart review. B. Record review of Resident 32's Urology Consult Form dated 5/10/17 revealed that Resident 32 was to receive Premarin Cream 0.625 mg for a new [DIAGNOSES REDACTED]. The lack of estrogen weakens the bladder (which holds urine) and the urethra, the tube that carries urine out of the body, compromising their ability to control urinary function * Colorado Women's Health). Record review of Resident 32's Medication Administration Record [REDACTED]. MAR indicated [REDACTED] received the Premarin due to the Premarin was not available for use. Interview with the facility Director of Nursing (DON), on 08/14/2017 at 7:52 AM confirmed that the facility did not have the Premarin available for use for Resident 32. The DON confirmed that the order was received for the Premarin Cream on 5/10/17. The DON revealed that the facility followed the process of sending the physician order [REDACTED]. The Pharmacy confirmed that they called Resident 32's ordering physician's office with no return call. The DON confirmed that the Pharmacy did not follow up with the physician or the facility regarding denial of payment of the medication and the Pharmacy would not be making the medication available for use. The DON confirmed that upon Resident 32's 2 month follow up appointment with the prescribing Physician, the order was changed to an acceptable alternative cream. The DON confirmed that the system in place for the facility to be notified of medications that were denied by payment source had failed.",2020-09-01
1312,THE AMBASSADOR OMAHA,285127,1540 NORTH 72ND STREET,OMAHA,NE,68114,2019-08-29,756,D,1,0,XEJI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.12B(5) Based on record review and interview; the facility pharmacist failed to notify the facility of a discrepancy on the method of medication administration for 1 ( Resident 3) of 4 residents. The facility staff identified a census of 91. Findings are: Record review of Resident 3's Comprehensive Care Plan (CCP) dated 7-09-2018 revealed Resident 3 was dependent on a tube for feedings, hydration needs and medication use. Record review of Resident 3's Physicians Order Report (POR) sheet from 7-29-2019 through 8-29-2019 revealed Resident 3 had a Gastric Tube ( Tube placed through the abdomen into the stomach). Further review of the POR dated 7-29-2019 through 8-29-2019 revealed orders for medications that included the following: -Milk of Magnesia 30 milliliters (ml) as needed to be taken orally with an order dated of 6-27-2018. -Multivitamin, give 1 tablet daily to be taken orally with an order date of 6-27-2018. -[MEDICATION NAME] -[MEDICATION NAME], give 5 ml's orally with a order date of 7-14-2018. -Carvedilol 3.125 milligrams (mg) 1 table orally with an order date of 5-21-2019. -Narco( pain medication) 5-325 mg to be given orally as needed with an order date of 5-21-2019. Observation on 8-29-2019 at 7:55 AM revealed Registered Nurse (RN) A administered all medication through the gastric tube. On 8-29-2019 at 8:05 AM an interview was conducted with RN [NAME] During the interview RN A confirmed Resident 3 was Nothing by Mouth (NPO). On 8-29-2019 at 1:30 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported not being notified by the facility pharmacist of Resident's 3's discrepancy of orders for medications to be taken orally. The DON confirmed Resident 3 was NPO.",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
2180,GOOD SAMARITAN SOCIETY - SUPERIOR,285187,1710 IDAHO STREET,SUPERIOR,NE,68978,2019-01-03,761,D,1,1,USFU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1b Based on record review and interview, the facility failed to keep safely store controlled medications for 1 of 1 sampled resident (Resident 43). The facility census was 43. Findings are: Interview on 1/3/19 at 9:28 AM with the DON (Director of Nursing) revealed that when a controlled substance such as a narcotic medication was discontinued or the resident was discharged , the narcotics are kept on the medication cart and counted until destroyed by the Pharmacist. As was done Resident 43 was discharged from the facility. When DON was asked about the discrepancy of narcotics with Resident 43, DON revealed that the shortage/discrepancy had gone through 48 hours of access before the DON and Administrator were notified of the discrepancy. All the Charge Nurses and Medication Aides who had access to the cart had to be interviewed and drug tests conducted. Review of the investigation report for Resident 43 dated 4/2/18 revealed that the bubble packs of [MEDICATION NAME] (Narcotic medication to treat moderate to severe pain) belonging to a Resident 43 revealed that two pills that were not [MEDICATION NAME] had been placed in the bubble pack and then taped over. Review of the Policy and Procedure controlled Substances revealed for Procedure #4. If the count is NOT in agreement with the record, the error must be found or an incident report must be completed and signed prior to the end of the shift and reported to the director of nursing services or designee before leaving the building. Review of the [MEDICATION NAME]/APAP ([MEDICATION NAME]) sheet dated from 3/24/18 to 4/1/18 revealed that the controlled medication was being counted 3 times a day. On 3/28/18 at 1400 (2:00 PM) the Narcotic count was noted to be short one pill. Staff continued to count the medication until there was another discrepancy in the count on 4/1/18 at which time the DON was notified. Interview on 1/03/19 10:21 AM with the DON revealed that the DON was not aware of the count discrepancy on 3/28/18.",2020-09-01
3947,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,755,F,1,1,OLWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E4 Based on observation, record reviews, and interview; the facility failed to ensure medications from the ER (Emergency Box) had not expired which had the potential to affect all residents. The census was 34. Findings are: Observation on 03/14/18 at 08:47 PM of the ER box in the medication room revealed the ER box had a Medication List on the outside of the box which listed all of the medications inside the box. The Medication List revealed the dosage, the amount of medications, and the expiration dates of each medication. The Medication List revealed the following 11 medications which had expired in (MONTH) (YEAR). [MEDICATION NAME]/[MEDICATION NAME] 2.5 mg (milligram) /0.25 4 tabs (tablets) [MEDICATION NAME] 0.5 mg 8 tabs [MEDICATION NAME] 10 mg 4 tabs [MEDICATION NAME] 20 mg 8 tabs [MEDICATION NAME][MEDICATION NAME] 25 mg 8 tabs [MEDICATION NAME] 250 mg 4 tabs [MEDICATION NAME] 250 mg 4 tabs [MEDICATION NAME]/[MEDICATION NAME] DS 800 mg/160 mg 4 tabs [MEDICATION NAME] 250 mg 8 tabs [MEDICATION NAME] 25 mg 8 tabs [MEDICATION NAME] 50 mg 8 tabs Interview on 03/14/18 at 08:55 PM with LPN-A (Licensed Practical Nurse) confirmed the 11 medications were outdated. Review of the Emergency Drug Box policy last revised 3-5-18 revealed the Emergency Box will be inspected by the consulting Pharmacist at least once every 30 days to review the expiration dates. Interview on 03/19/18 at 04:24 PM with the DON (Director of Nursing) revealed the consulting RP (Registered Pharmacist) had been to the facility in (MONTH) (YEAR). The DON confirmed the ER box had expired medications in it.",2020-09-01
5586,"BROKEN BOW CARE AND REHABILITATION CENTER, LLC",285120,224 EAST SOUTH E STREET,BROKEN BOW,NE,68822,2018-05-17,761,E,1,1,1IGA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E7 Based on observation, interview, and record review; the facility staff failed to label medications with directions for use for 2 of 10 residents observed receiving medication (Resident 133 and Resident 7). The facility identified a census of 30 at the time of survey. Findings are: [NAME] Record review of Resident 133's [MEDICATION NAME](a medication used to regulate blood sugar levels) label revealed Resident 133 was to receive 10 units of insulin before breakfast. Observation on 5/17/18 at 11:49 AM revealed LPN-B (Licensed Practical Nurse) administer 12 units of insulin per sliding scale (certain amount of insulin given based on the resident's blood sugar level) to Resident 133. Interview with LPN-B on 5/17/2018 at 11:49 AM revealed the instructions to give the insulin per sliding scale was not on the label. B. Record review of Resident 7's medication containers revealed the following: [MEDICATION NAME] (an anti-anxiety medication) 1/2 a mg (milligram) via PEG tube (a tube inserted in the stomach used to administer medications and liquid nutrition) three times a day. Pramipexole (a medication used to treat tremors) 1/2 a mg via PEG tube three times a day [MEDICATION NAME]/[MEDICATION NAME] (a medication used to treat tremors) 25/250 one and 1/2 tablets via PEG tube four times a day. Observation on 5/17/2018 at 12:24 PM revealed LPN-B crushed the [MEDICATION NAME], Pramipexole, and [MEDICATION NAME]/[MEDICATION NAME], mixed them with applesauce, and administered them to Resident 7 by mouth. Interview with the DON (Director of Nursing) on 5/17/18 at 2:36 PM revealed Resident 12's insulin was not labeled correctly. Resident 7 had physician's orders to administer medication either by mouth or via PEG tube. They documented which route they gave them on the MAR (Medication Administration Record). Interview with the DON on 5/17/18 at 3:19 PM confirmed the insulin should be labeled with the directions for Resident 133's sliding scale and the medications for Resident 7 should have both routes (PEG tube and oral) on the label. Review of the facility policy Medication Ordering and Receiving from Pharmacy. Medication Packaging dated 6/15 revealed the following: Each prescription medication label includes: Resident's name. Specific directions for use.",2019-11-01
1641,MAPLE CREST HEALTH CENTER,285149,2824 NORTH 66TH AVENUE,OMAHA,NE,68104,2017-11-02,431,D,1,1,I4SU11,"**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 staff failed to ensure medication labels reflected the physicians order for 1 ( Resident 129) of 3 sampled residents. The facility staff identified a census of 145. Findings are: Record review of a Telephone order dated 12-28-2016 revealed the practitioner gave an order for [REDACTED]. Observation on 11-01-2017 at 7:25 AM revealed Registered Nurse (RN) AL prepared medications for administration including Calcium Carbonate and Vitamin D3 capsule every day. Further observation revealed the labels for both, the Calcium carbonate and the Vitamin D3 indicated the medications were to be given by mouth. RN L administered all medications observed via the G Tube. On 11-02-2017 at 8:04 AM an interview was conducted with Certified Medication Assistant (CMA) Q. During the interview CMA Q confirmed Resident 129 medications were to be given per [DEVICE] by the nurses. CMA Q further confirmed the labels for the calcium and the Vitamin D3 indicated it was to be given orally.",2020-09-01
3918,HILLCREST COUNTRY ESTATES-COTTAGES,285293,6082 GRAND LODGE AVENUE,PAPILLION,NE,68133,2017-05-04,406,D,1,1,POAF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.13 Based on record review and interviews, the facility failed to ensure recommendations from the PASRR (Preadmission Screening and Resident Review- An assessment to determine if residents are appropriate for a nursing home) were completed for 1 (Resident 24) of 1 residents reviewed, related to a psychiatric evaluation. The facility census was 46. Findings are: Findings are: Review of Resident 24's face sheet revealed that the resident was originally admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident 24's PASRR, completed on 2-28-17, revealed Resident 24 had a [DIAGNOSES REDACTED]. Service Recommendations were for ongoing medication review by a Psychiatrist. The PASRR went on to say that Resident 24 would benefit from psychiatric consultation as well as regular periodic reviews of [MEDICAL CONDITION] medications by a psychiatrist. Review of Resident 24's Medication Administration Record [REDACTED]. Review of Resident 24's care plan with a start date of 11-10-15 revealed a listed problem for Resident 24 of loneliness with interventions of referrals as needed. Review of Resident 24's physician progress notes [REDACTED]. An interview conducted on 5/4/17 at 1:23 PM with the Assistant Administrator confirmed that Resident 24 had not had a Psychiatrist visit or medication review and confirmed it should have been done as recommended in the PASRR.",2020-09-01
4343,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-04-11,514,D,1,0,T8J411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.16B Based on observation, interviews and record review; the facility staff failed to provide document catheter care for Resident 2 and Resident 3. This affected 2 of 3 sampled residents. The facility identified a census of 114 at the time of survey. Findings are: [NAME] Review of Resident 2's Admission Record revealed an admission date of [DATE]. Review of Resident 2's annual MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 2/24/2017 revealed that Resident 2 had an indwelling catheter (a tube inserted and left in the bladder to drain urine). Observation of Resident 2 on 4/11/2017 at 10:59 AM revealed Resident 2 had an indwelling catheter and the urine in the catheter bag was light amber colored and cloudy, not yellow and clear. Review of Resident 2's care records revealed no documentation of catheter care being provided. Review of Resident 2's care plan dated 4/9/2015 revealed that indwelling catheter care was to be provided every shift and as needed. B. Review of Resident 3's Admission Record revealed an admission date of [DATE]. Review of Resident 3's annual MDS dated [DATE] revealed that Resident 3 had an indwelling catheter. Review of Resident 3's care plan dated 8/27/2015 revealed that indwelling catheter care was to be provided every shift and as needed. Review of Resident 3's care records revealed no documentation of catheter care being provided. Interview with the ADON (Assistant Director of Nursing) on 4/11/2017 at 3:17 PM confirmed there was no documentation of catheter care being provided for Resident 2 or Resident 3.",2020-08-01
4907,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2017-12-21,842,D,1,0,7XZQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.16B(2) Based on observation, record review and interview; the facility failed to provide accurate documentation related to the use of a foot cradle (a device attached to the foot of the bed that holds bedding up and off the resident's feet to prevent eventual wounds or deformities of the feet) in Resident 3's medical record. The facility census was 37 and the total sample size was 8. Findings are: [NAME] Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/10/17 indicated the resident had [DIAGNOSES REDACTED]. The MDS further indicated Resident 3 required extensive to total assistance with activities of daily living, including bed mobility and transfers. Review of Resident 3's Medication Administration Record [REDACTED] -ordered 7/13/17 to keep bedding off of toes and to be used daily; -it was used on 17 of the 30 days reviewed; and -it was not used on 13 days and directions were to See Nurse Notes for further explanation. Review of Nursing Progress Notes dated 9/4/17 at 7:55 PM through 9/28/17 at 7:56 PM revealed there were 13 days that Resident 3's foot cradle was not used because it was not available. Review of Resident 3's MAR indicated [REDACTED] -it was used on 12 of the 26 days reviewed; and -it was not used on 13 days and directions were to See Nurse Notes for further explanation. Review of Nursing Progress Notes revealed the following: -from 10/2/17 at 9:58 PM through 10/25/17 at 10:21 PM there were 12 days that Resident 3's foot cradle was not used because it was not available; and -10/26/17 at 10:27 PM - the foot cradle was not used because it was currently in need of repair. Facility maintenance aware. Review of Resident 3's MAR indicated [REDACTED] -it was used on 30 of the 56 days reviewed; and -it was not used on 26 days and directions were to See Nurse Notes for further explanation. Review of Nursing Progress Notes dated 10/30/17 at 8:23 PM through 12/20/17 at 7:51 PM revealed there were 26 days that Resident 3's foot cradle was not used because it was not available. During observations on 12/20/17 from 7:40 AM to 8:00 AM, and from 9:55 AM until 11:51 AM, Resident 3 was positioned on back in bed. There was no foot cradle attached to the foot of the bed, or available in any other area of the resident's room. During interview on 12/21/17 from 9:21 AM until 9:29 AM, RN-A indicated Resident 3 had a foot cradle on the bed in the past but it wasn't currently being used as it was broken. RN-A verified documentation on the MAR indicated [REDACTED].",2020-03-01
2916,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2017-05-09,441,F,1,0,JLWU11,"**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 infection control program in place to help reduce the potential spreading of scabies in the facility. This had the potential to affect all residents in the facility. The facility staff identified a census of 60. Findings are: On 5-08-2017 at 7:40 AM Resident 3 was seated in a wheel chair in Resident 3's room. Resident 3 was observed to be itching the back of (gender) hands that had several scratch marks. Record review of Resident 3's record revealed on 5-05-2017 the practitioner ordered Ivermectin (Ivermectin is an anti-parasite medication) 15 milligrams by mouth once and to give another dose in 7 days. In addition, to the medication, staff were to deep clean the resident's room. On 5-08-2017 at 8:11 AM an interview was conducted with Licensed Practical Nurse (LPN) D. During the interview LPN D reported Resident 3 was being treated for [REDACTED]. On 5-08-2017 at 1:48 PM an interview was conducted with the Housekeeping Supervisor (HS). When asked if Resident 3's room had been deep cleaned, the HS stated we clean them, but not deep cleaned them. The HS reported there were other resident rooms with possible scabies. On 5-09-2017 at 7:00 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported that all the facility residents were not evaluated for the possibility of scabies, the facility did not implement an investigation to determine the possible starting point of the potential scabies and could not provide evidence that facility staff had been educated on the potential scabies in the facility. The DON restated that the facility did not have a policy or procedure on what to do if there were indicators of scabies in the facility. An interview on 5-09-2017 at 7:30 AM was conducted with Registered Nurse (RN) C. When asked if RN C had been educated on the possibility of scabies in the building and what to do to prevent the spread, RN C stated no. On 5-09-2017 at 7:38 AM an interview was conducted with LPN D. When asked if LPN D had received education by the facility on the possibility of scabies and what to do to prevent the spread of scabies, LPN D stated no. On 5-09-2017 at 8:45 AM an interview was conducted with Nursing Assistant (NA) E. During the interview when asked if NA [NAME] had received education on the potential scabies and how to prevent the spread of the scabies, NA [NAME] stated no. On 5-09-2017 at 9:00 AM, the Director of Nursing provided a list 4 other resident rooms that potentially had scabies. Record review of the facility Infection Control Policy/Procedure revised on 5-2007 revealed the following information: -Goals: -[NAME] Decrease the risk of infection to patients and personnel. -B. Monitor for occurrence of infection and implement appropriate control measures. -II, Scope of the Infection Control Program: -B. Implementation of Control Measures. -C. Prevention of infection: -Staff patient education is done to focus on the risk of infection and practices to decrease risk.",2020-09-01
4437,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-08-31,441,F,1,0,I5FW11,"**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 staff failed to implement infection control process, failed utilize hand washing and gloving techniques during the provision of care for 2 (Resident 3 and 4) of 2 sampled residents, failed to implement isolation procedures for potential scabies for 1 (Resident 4) of 1 resident, and failed to have an effective infection control program that identified organism for infection and culture and sensitivity related to antibiotic use. This had the potential to affect all residents in the building. The facility staff identified a census of 60. Findings are: [NAME] Record review of an Admission Record sheet printed on 8-31-2017 revealed Resident 4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 4's Comprehensive Care Plan (CCP) dated 3-15-2017 revealed Resident 4 was incontinent of bladder. Observation on 8-30-2017 at 1:25 PM of personal care revealed Nursing Assistant (NA) C and NA D transferred Resident 4 from a wheelchair to the bed using a mechanical lift. NA C and NA D removed a sling that was used for the transfer and placed it onto Resident 4's floor. NA C and NA D removed Resident 4's pants and unfastened an adult brief. NA C, using a cleansing wipe, cleaned the groin folds and pubic area. NA C reported Resident 4 was incontinent of urine. NA C, without changing gloves or completing hand washing, touched Resident 4's hip, blanket, arm and barrier cream with the soiled gloves. Resident 4 was positioned to the right laying position and NA C applied barrier cream and, without changing the soiled gloves, touched Resident 4's blanket, pants and TV remote. NA C bagged the soiled items and left Resident 4's room and placed the soiled items into a hopper. NA C removed the gloves and did not wash the hands. Further observation revealed NA D removed the mechanical lift from Resident 4's room and, without cleaning the lift, used it for another resident. On 8-30-2017 at 1:55 PM an interview was conducted with NA C and NA D. During the interview, NA C confirmed the soiled gloves were not removed and had touched clean item. NA C further confirmed hands were not washed after taking the soiled items to the hopper. NA D confirmed the mechanical lift was not cleaned after use. B. Record review of an Admission Record sheet printed on 4-6-2016 revealed Resident 2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 2's CCP revised on 10-23-2016 revealed Resident 2 had an indwelling catheter (tube placed into bladder to drain urine). Observation on 8-30-2017 at 11:25 AM of personal cares revealed NA C and NA D removed pillows that were under Resident 2's leg and placed them onto the floor. NA C and NA D unfastened an adult brief and position Resident 2 onto the left side revealing Resident 2 was incontinent of bowel. NA C, using a cleansing wipe, cleans Resident 4's buttocks and, without hand washing or sanitizing, donned clean gloves. Resident 4 was position onto the right laying position and NA D, using a cleansing wipe, completed the cleansing of Resident 2's buttocks. NA D removed the soiled gloves and, without hand washing, donned clean gloves. NA D applied barrier cream to the buttock. NA C and NA D obtained a clean adult brief and applied it to Resident 2. On 8-30-2017 at 1:50 PM, an interview was conducted with NA C and NA D. During the interview, both NA C and NA D confirmed Resident 2's pillows were placed onto the floor and should not have been. NA C and NA D confirmed hands were not washed and should have been when removing soiled gloves. C. Record review of a fax sheet dated 8-10-2017 revealed a facility staff member had notified Resident 4's physician that Resident 4 had . skin rash/infestation consistent (with) scabies. More predominant in creases/skin folds. Causes irritation for resident as (gender) relentlessly itches. Rash is pimple like papules. Review of Resident 4's medical record that included Progress Notes Comprehensive Care Plan (CCP), Treatment Administration Record (TAR) and infection control log revealed there was no evidence the facility staff had implemented isolation process for the potential scabies. On 8-30-2017 at 2:25 PM, an interview was conducted with the Director of Nursing (DON) and the facility Nursing Consultant. During the interview, the DON provided a policy on the management of scabies dated 3-2015. The DON confirmed isolation procedures should have been implemented until resolution. Record review of the facility policy for Scabies Management revealed the following information: -Procedure: -3. Implement contact precautions in a suspected case of scabies until a [DIAGNOSES REDACTED]. -3a. Utilize a private room for resident/patient who can use good hygiene. -4. Wear long sleeve gowns during close contact with residents/patient, their clothing, or bed linens. -11. Restrict the resident/patient to their room for 24 hours during the treatment period. D. Record review of the facility infection control log from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the section of the form for recording the date and results of the culture and sensitively were not completed and the logs did not contain information as to what the causative organism for the infection was. On 8-31-17 at 8:50 AM, an interview was conducted with the DON. During the interview, the DON confirmed the culture and sensitivity and the organism was not identified or completed. The DON confirmed that, without the culture and sensitivity, they would not be able to determine if an antibiotic was effective. Record review of the facility Infection Prevention & Control Program dated 3-2015 revealed the following information: -Overview: -The goal of the program is to identify and reduce the risks of acquired and transmitting infections among residents/patients, employees, volunteers and visitors. The program includes a system to monitor and investigate infection trends.",2020-06-01
2410,COUNTRYSIDE HOME,285207,703 NORTH MAIN STREET,MADISON,NE,68748,2018-10-09,880,D,1,1,GZ2H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observations, record review, and interview; the facility failed to provide care and management of Resident 45's indwelling urinary catheter to prevent potential cross contamination. The sample size was 2 and the facility census was 66. Findings are: [NAME] Review of the facility procedure titled Management of Urinary Catheters with a review date of 11/21/17 revealed: - The purpose of the procedure was to prevent catheter associated urinary tract infections; - Standard precautions were to be used when handling or manipulating the drainage system; and - Staff must ensure the catheter tubing and drainage bag were kept off the floor. B. Review of Resident 45's current Care Plan dated 10/3/18 revealed the resident had a history of [REDACTED]. Review of Resident 45's Departmental Notes revealed on 9/11/18 at 6:52 AM red blood and yellow puss was observed coming from the catheter insertion site with a foul odor. Review of a physician's orders [REDACTED]. Observations of Resident 45 on 10/3/18 from 11:40 AM to 1:27 PM revealed the following: - At 11:40 AM the resident was seated in a wheelchair at the dining room table. The Resident's urinary catheter drainage bag was covered, but the bag and tubing was lying directly on the floor. - At 1:20 PM Nursing Assistant (NA)-E and NA-F wheeled Resident 45, towards the resident's room. The urinary catheter drainage tubing drug on the floor of the corridor, until NA-E noticed and picked the tubing up. Once in the room, the urinary catheter drainage bag was removed from the cover which hung under the seat of the chair. The resident was transferred into the bathroom with a sit-to-stand mechanical lift. The urinary drainage collection bag lay directly on the base of the lift where the resident's feet were placed. NA-E picked the urinary drainage bag up and attempted to hang it back on the base of the lift. The urinary drainage bag again fell on to the foot rest of the mechanical lift. During an interview with the Director of Nursing (DON) on 10/4/18 at 12:06 PM the DON confirmed the urinary catheter drainage bag and drainage tubing should not be in contact with the floor.",2020-09-01
5316,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-01-23,441,D,1,0,5YZX12,"**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 complete a treatment program for potential scabies for 1 (Resident 1) of 1. The facility staff identified a census of 96. Findings are: Record review of a Progress note dated 12-22-16 revealed Resident 1's physician had order [MEDICATION NAME] cream (commonly known as [MEDICATION NAME] for treatment of [REDACTED]. Record review of Resident 1's Medication Administration Record (MAR) for (MONTH) (YEAR) revealed Resident 1 had an order for [REDACTED]. The instructions were to apply the cream to the entire body every day and night shift for scabies [MEDICATION NAME]. According to the instructions, the staff were to apply the cream, leave it on for 12 hours and then wash the cream off. Staff were to discontinue the order once the treatment was completed. Further review of Resident 1's MAR for (MONTH) (YEAR) revealed Resident 1 received the treatment on 12-5-2016 and on 12-19-2016, a 14 day span. Review of Resident 1's MAR for (MONTH) (YEAR) revealed Resident 1 received the [MEDICATION NAME] cream 5% on 1-02-2017 14 days from the treatment on 12-19-2016. Review of an undated Recommended Scabies Treatment/Management Protocol sheet provided by the facility revealed the following information: -Sample Order for Asymptomatic Roommates: -Apply [MEDICATION NAME] 5%cream as directed for [MEDICATION NAME] treatment of [REDACTED]. Repeat application and removal steps in 7 days. On 3-14-2017 at 11:47 AM an interview was conducted with the Director of Nursing (DON) and the facility Administrator. During the interview the DON confirmed Resident 1 had been treated for [REDACTED]. The DON confirmed Resident 1 had been treated 2 weeks apart. On 3-14-2017 at 2:00 PM a follow up interview was conducted with the Administrator. During the interview, review of the Scabies Protocol that was provided by the facility staff was reviewed with the Administrator. The Administrator confirmed Resident 1's scabies treatment was not completed as indicated on the Scabies Protocol.",2020-01-01
4277,HILLCREST SHADOW LAKE,2.8e+300,1507 E GOLD COAST ROAD,PAPILLION,NE,68046,2017-08-14,441,F,1,1,728T11,"**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 an effective infection control program related to the failure to obtain culture and sensitivity (C&S) testing, failed to identify the organism that caused infection, failed to evaluate indications of gastric symptoms in 37 residents and failed to complete hand hygiene during the provision of care and treatments for 2 (Resident 40 and 111) of 6 sampled residents. The facility staff identified a census of 102. Findings are: [NAME] Record review of the facilities Infection Control Log (ICL) for (MONTH) (YEAR) revealed the following information: -On A hall between 6 09 (YEAR) and 6 12 (YEAR), 4 residents were identified with loose stools, nausea or vomiting(N/V). -On B hall between 6 10 (YEAR) and 6 13 (YEAR), 6 residents were identified with loose stools or N/V. -On C hall between 6 11 (YEAR) and 6 15 (YEAR), 6 residents were identified with N/V and diarrhea. -On D hall between 6 11 (YEAR) 6 12 (YEAR), 9 residents were identified with N/V and/or diarrhea. -On [NAME] hall between 6 12 (YEAR) and 6 14 (YEAR), 6 residents were identified with N/V and/or Diarrhea. -On E2 hall between 6 10 (YEAR) and 6 14 (YEAR), 6 residents were identified with N/V and/or diarrhea. B. Record review of the facility ICL for (MONTH) (YEAR) revealed 8 residents were identified with a Urinary Tract Infection (UTI). Further review of the ICL for (MONTH) (YEAR) revealed 7 of the UTI's were not identified as having a culture and sensitivity testing and were started on an antibiotic medication. Record review of the ICL for (MONTH) (YEAR) revealed 3 residents were identified as having UTI's. According to the information on the ICL for (MONTH) (YEAR), 2 resident did not have culture and sensitivity testing and were started on an antibiotic medication. On 8 10 (YEAR) at 9:43 AM, an interview was conducted with Licensed Practical Nurse (LPN) I. During the interview LPN I reported (gender) was the Infection Control Nurse (ICN). During the interview, review of the ICL's for April, (MONTH) and (MONTH) (YEAR) were completed with LPN I. During the interview, LPN I confirmed C&S's were not always obtained prior to starting an antibiotic medication. LPN I confirmed that, without a C&S, they would not be able to determine if the antibiotic was effective for the organism causing the UTI. LPN I reported that LPN I had reported to the Director of Nursing (DON) multiple residents were have N/V and/or diarrhea. On 8 10 (YEAR) at 10:17 AM, an interview was conducted with the DON. During the interview, review of the (MONTH) (YEAR) ICL was completed with the DON. The DON reported staff were educated on effective handwashing and wearing gloves. The DON reported resident with symptoms were kept in their rooms. The DON reported that an evaluation of the large number of residents with N/V and/or Diarrhea had not been completed for potential causes of the illness. The DON reported there was not an action plan that identified the steps the facility was taking to prevent additional and control the spread of the N/V and/or diarrhea. Record review of the facility undated Infection Prevention and Control Program revealed the following information: -Policy: -[NAME]crest Shadowlake will observe standard precautions or other infection control, to prevent and control infections. -Procedure: -The facility must ensure the infection control program has provisions for implementation of practices for: -1. Identifying, reporting, investigating and controlling infections and communicable diseases of guest and team members. -2. Early detection of infection that identifies trends so any outbreak may be contained to prevent further spread of infection. C. An observation was conducted on 8/9/17 at 11:23 AM of Registered Nurse (RN) [NAME] providing wound care for Resident 111 with assistance from the Director of Nursing (DON) to hold limbs. The observation revealed RN E, with gloves on, cleansed the wound on the resident's right heel and redressed the heel. RN [NAME] realized they did not have a supply and asked the DON to go get the supply. The DON removed their gloves and left room without performing hand hygiene, returned to the room with the supply, and put on fresh gloves without performing hand hygiene. While the DON was out of the room, RN E, without changing gloves, applied [MEDICATION NAME] to the resident's left great toe. With the same gloves on, RN [NAME] then cleansed the wound on the resident's right heel. RN [NAME] then sent the DON out for another forgotten supply. The DON removed gloves and, without performing hand hygiene, left the room to get the supply. The DON returned to the room with the supply and put on a fresh pair of gloves without performing hand hygiene. RN E, with the same gloves on, then finished dressing the wound on the resident's left heel. An interview conducted on 8/10/17 at 2:08 PM with the Education Specialist revealed that the expectation was that staff were perform hand hygiene when they remove gloves. An interview conducted on 8/10/17 at 2:23 PM with the DON revealed that RN [NAME] should have changed gloves between each wound. A review of the facility's Gloving Policy dated 6/17/14 revealed the following: Procedure: 1. Wash hands. 2. Put on clean gloves if coming into contact with blood or body fluids (except sweat), mucous membranes, secretions, excretions, or non intact skin. 3. It may be necessary to change gloves several times during the care of one guest: a. If you are wearing gloves and must move to an area of the body with non intact skin or mucous membranes, you should remove your gloves, wash your hands, and then reapply clean gloves immediately before proceeding to the non intact skin or mucous membranes. b. If your gloves come into contact with potentially infectious material, removed your gloves, wash your hand, and immediately reapply clean gloves before continuing care. c. Once you complete direct care associated with potentially infectious material (i.e., stool or urine), remove your gloves and wash your hands. D. Record review of the facility Handwashing Policy, un dated, revealed that: Team members will ensure proper handwashing technique between every guest contact, after handling contaminated articles, before starting any procedure, or when hands are grossly contaminated. Team member to cleanse the hands between guest contacts including, but not limited to, during medication and treatment administration, and to help prevent spread of infection. Observation of Registered Nurse (RN) F on 8/9/17 at 7:18 AM revealed RN F to enter Resident 40's room to perform an injection. Observation revealed that RN F did not perform handwashing or application of gloves prior to performing the injection of medication into Resident 40's abdomen. Observation revealed RN F leaving the Resident 40's room without performing hand hygiene. RN F was observed to go to a computer system and use the key board of the computer system. RN F was then observed to place hands on the handle of a resident's wheelchair/ and push the resident to the dining area. RN F was then observed to return to the computer keyboard. Interview with RN F on 8/9/17 at 7:20 AM confirmed that, for standard precautions, gloves were to be worn with injections of any kind into resident skin, related to the risk of bleeding. RN F confirmed that gloves had not been worn when performing Resident F's injection. RN F confirmed that hand hygiene was to be performed upon entering a resident room, upon removing gloves, and before touching environmental surfaces to prevent spread of microorganisms. Interview with the facility Director of Nursing (DON) on 8/9/17 at 7:54 AM confirmed that glove were to be worn with administration of injections and that hands hygiene was to be performed before injection and after removal of gloves.",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
2600,SOUTHLAKE VILLAGE REHABILITATION & CARE CENTER,285219,9401 ANDERMATT DRIVE,LINCOLN,NE,68526,2019-03-27,880,D,1,1,M46K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.17, 12-006.17D Based on observation, interview, and record review, the facility failed to ensure that staff performed hand hygiene between glove changes for 1 resident (Resident 65) of 6 residents reviewed for infection control practices, failed to ensure that catheter tubing did not touch the floor, failed to ensure the catheter bag was kept below the level of the bladder, failed to change the surface of the wipe during cleansing of the catheter tubing, and failed to ensure trash bags were not kept on the floor for 1 resident (Resident 80) of 6 residents reviewed for infection control practices. The facility census was 112. Findings are: [NAME] Review of Resident 65's undated care plan revealed [DIAGNOSES REDACTED]. Review of Resident 65's (MONTH) MAR (medication administration record) revealed the resident received a continuous feed of [MEDICATION NAME] 1.2 (a high protein formula for tube feeding) with a water flush. Resident 65's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Observation on 03/26/19 at 7:13 AM of LPN-A (Licensed Practical Nurse) revealed the resident received the continuous feed on a pump. LPN-A raised Resident 65's bed to waist height. LPN-A performed hand hygiene and prepared to administer the resident's medications. LPN-A then donned gloves and disconnected the continuous feed tube from the resident's PEG tube (a flexible feeding tube placed through the abdominal wall and into the stomach) feeding port. LPN-A connected a syringe to the feeding port and aspirated a small amount of stomach contents, then returned the stomach contents through the PEG tube. LPN-A then clamped the PEG tube, disconnected the syringe, removed the plunger from the syringe, and reattached the syringe to the feeding port of the PEG tube. LPN-A flushed the tubing with water, administered the Resident 65's medications, and flushed the tubing with water again. LPN-A disconnected the syringe, capped the feeding port, removed gloves, and did not perform hand hygiene. LPN-A discarded the supplies used during medication administration, touched the feeding pump to check the feed and flush volumes, and documented those numbers. LPN-A then touched the pump to remove the current tubing and discarded in a trash can. LPN-A then applied gloves without performing hand hygiene, opened the new feed tubing and bags, and filled the flush bag with water. LPN-A loaded the new tubing into the feed pump, removed gloves, and did not perform hand hygiene. LPN-A then touched cabinet doors in the resident's room while getting 4 cartons of [MEDICATION NAME] 1.2 and filled the feed bag. LPN-A touched the feeding pump to set the feed and flush speeds. LPN-A then applied gloves without performing hand hygiene, touched the pump to prime the tubing, and connected the tubing to Resident 65's PEG tube. LPN-A then removed gloves, did not perform hand hygiene, and lowered the resident's bed to its original position. Interview on 03/26/19 at 10:48 AM with LPN-A confirmed LPN-A did not perform hand hygiene between glove changes. Per standard of practice hand hygiene should be performed each time gloves are changed. B. Record review of Comprehensive Care Plan (CCP) dated 2/28/19 revealed that Resident 80 was at high risk for infection related to having a Foley catheter (tube that drains urine from the body) inserted. The CCP also stated that catheter care should be performed with proper technique. Observation on 3/21/19 at 04:00 PM, 03/25/19 at 10:51 AM and 1:29 PM revealed Resident 80 self-propelled a wheelchair with the catheter tubing touching the floor. Observation on 03/25/19 at 01:33 PM revealed NA [NAME] and NA F transferred Resident 80 from the wheelchair to the toilet. NA F removed the catheter bag from the wheelchair and held it above level of bladder while handing it to NA E, who then placed catheter tubing on the other side of Resident 80. Observation on 03/26/19 at 07:02 AM revealed NA F and NA G provided catheter care for Resident 80. Both NA F and NA G washed their hands and applied gloves. NA G performed catheter care using peri-wipes, followed by alcohol pads. NA G used an alcohol pad to wipe downward on the catheter tubing once and then, with the same surface of the alcohol pad, touched the catheter and wiped downward again on the catheter tubing. After completing catheter care NA G removed her gloves and, with no hand hygiene, immediately put on another pair of gloves to clean the buttock area. A plastic trash bag was on the floor during catheter care. Interview on 03/27/19 at 12:49 PM with ADON H and Education Coordinator/Infection Control Coordinator (ED/ICC) I confirmed that Foley catheter tubing when a resident is in a wheelchair should not touch the floor but should be clipped up. The catheter tubing should not be lifted above the level of the bladder. ADON H and ED/ICC I confirmed that when providing catheter care, the wipe used to wipe the tubing should only be used once and then discarded. Hand hygiene should be performed whenever gloves are removed and before putting on gloves and that the plastic bag used for trash should not be placed on the floor.",2020-09-01
2908,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2019-04-22,880,F,1,1,BJ6K11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.17A1 Based on record review and interview; the facility staff failed to identify the organism that causes infection in the facility infection control process. This would have the potential to effect all residents in the facility. The facility staff identified a census of 60. Findings are: Record review of the facility Infection Control Log (ICL) for (MONTH) 2019 revealed there were 2 residents identified with Urinary Tract Infections [MEDICAL CONDITION]. Further review of the (MONTH) 2019 ICL revealed the organism responsible for the infection was not identified. Record review of the ICL for (MONTH) 2019 revealed there were 4 residents identified with UTI's. There was not information identified on the ICL of what the organism causing the infect was. Review of the (MONTH) 2019 ICL revealed 1 resident was identified with a UTI. The section for identifying the organism had written in no. Record review of the ICL form (MONTH) 1st to (MONTH) 6th revealed 1 resident was identified with a UTI and no organism was identified. On 4-11-2019 at 8:40 AM an interview was conducted with the Director of Nursing (DON). During the interview review of the ICL's were completed. The DON confirmed the ICL were not completed and did not contain information on the organism causing the infection.,2020-09-01
3958,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,880,F,1,1,OLWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C1 Based on observation, interview, and record review; the facility staff failed to handle linen to prevent potential cross contamination for Residents 235, 34, and 6; failed to complete dressing changes to prevent potential cross contamination for Residents 3, 29, 9, 24, and 34; failed to maintain oxygen equipment to prevent potential cross contamination for Resident 18; failed to perform catheter care to prevent potential cross contamination for Resident 34; failed to clean glucose monitoring machines for Residents 3, 17 and 4 to prevent potential cross contamination; failed to perform hand hygiene to prevent potential cross contamination during dining service which affected Resident 2; and failed to store medical supplies to prevent potential cross contamination which had the potential to affect all of the residents in the facility. The facility identified a census of 34 at the time of survey. Findings are: [NAME] Observation of Hskp-J (Housekeeper) on 3/14/18 at 8:59 AM revealed Hskp-J walking down the hall with a pile of folded bedspreads up against their smock. Hskp-J then placed the bedspreads on a 3 level cart and HA-M (Housekeeper Aide) covered it and took it down the hall. HA-M took the cart into Resident 235's room. On 3/14/18 at 9:05 AM HA-M was observed taking linens from the cart and making Resident 235's bed. The linen on the cart was uncovered in Resident 235's room. There was enough linen on the cart to make several beds. On 3/14/18 at 9:11 AM Hskp-J was in Resident 34's room with the same cart and was making the bed. The cart was uncovered. On 3/14/18 at 9:34 AM HA-M was observed in Resident 6's room with the same cart, uncovered, making the resident's bed. There was a bucket on the 2nd shelf of the cart and washcloths. HA-M was observed wiping the bed down with the washcloth before making it. The blue bucket and washcloths were on the 2nd shelf of the cart and the sheets/pillowcases were on the top shelf. The bedspreads were on the bottom shelf. Review of the undated facility policy Linen Handling revealed the following: Take only linen needed for a specific resident into the room and place it on the resident's clean over-bed table. Interview with the facility administrator on 3/19/18 at 4:04 PM revealed the administrator expected the linen to be handled in a way that was not going to be an infection control issue. The staff were to take just what linen was needed into the room. Everything should be wrapped and not exposed and the cart should not be taken room to room and linens should not be up against the staff's clothing. room to room and linens should not be up against their clothing. B. Review of Resident 18's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 1/24/2018 revealed an admission date of [DATE]. Oxygen was used. Observation of Resident 18's room on 3/14/18 at 8:58 AM revealed an oxygen concentrator with tubing connected to it and the nasal cannula lying on the floor. Resident 18 revealed at this time that they used the oxygen at night. Observation of Resident 18's room on 3/14/18 at 3:45 PM revealed the oxygen nasal cannula was lying on the floor. Review of Resident 18's Physician's Orders revealed an order for [REDACTED]. Observation of Resident 18's room on 3/15/18 at 7:35 AM revealed the oxygen nasal cannula was lying on the floor. Interview with Resident 18 on 03/15/18 at 9:22 AM revealed they did not know how often the facility staff changed the oxygen tubing or the nasal cannula. Resident 18 stated they knew the facility staff did not change it last night. Observation of Resident 18's room on 3/15/18 at 9:23 AM revealed the oxygen cannula was lying on the floor. Observation of Resident 18's room with the DON (Director of Nursing) on 3/15/18 at 9:34 AM revealed Resident 18's oxygen nasal cannula was lying on the floor. The DON revealed the oxygen nasal cannula was not supposed to be on the floor and needed to be in a bag. At this time the resident stated it's on the floor most of the time. Review of the MAR (Medication Administration Record) for (MONTH) (YEAR) revealed no documentation the oxygen cannula was changed after it was observed on the floor. Review of the undated facility policy and procedure revealed oxygen tubing will be changed weekly on Wednesday. Black bags to hold oxygen tubing will be changed on the last Wednesday of the month. C. Interview with Resident 29 on 3/13/18 at 3:22 PM revealed they were being treated for [REDACTED]. Resident 29 revealed they were supposed to go to the hospital last week and get the pressure ulcer surgically closed but it got infected so that got put on hold. Review of Resident 29's annual MDS dated [DATE] revealed an unhealed Stage 3 pressure ulcer present at admission/entry or reentry. Review of Resident 29's Wound Evaluation Flow Sheet dated 8/29/17 revealed the pressure ulcer to the left ischium (hip/buttock) measured 1.4 cm x 1.4 cm x 1.8 cm. The pressure ulcer was a Stage 3 (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) at that time. Review of Resident 29's Wound Evaluation Flow Sheet dated 12/5/2017 revealed the pressure ulcer to the left ischium measured 2 cm x 2 cm x 2 cm. Review of Resident 29's Wound Evaluation Flow Sheet dated 2/12/2018 revealed Resident 29 had a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer to the left ischium (hip/buttock) that measured 2.7 cm (centimeters) by 2.2 cm and was 3.2 cm deep. The documentation on the Wound Evaluation Flow Sheet indicated the pressure ulcer had gotten larger and deeper. Observation of pressure ulcer care for Resident 29 on 3/13/2018 at 11:33 AM revealed the following: MA-B (Medication Aide) moved Resident 29's personal belongings from the over the bed table. RN-C (Registered Nurse) then placed the supplies for the dressing change on the table which included scissors, dressings, and tubing. RN-C did not clean the table or apply a barrier before putting the dressing supplies on the table. RN-C donned gloves then turned off the [DEVICE] pump that was sitting on the floor. RN-C clamped the tubing from the [DEVICE] pump to the dressing on Resident 29's left hip then removed the soiled dressing. RN-C then removed the gloves, applied hand sanitizer and rubbed hands for 2 seconds then donned another pair of gloves. RN-C then washed the wound with a washcloth they had retrieved from the bathroom. RN-C then opened the dressing package and cut the foam and clear adhesive dressings with the scissors that had been lying on the table. RN-C then laid the cut dressings onto the outside of the dressing package and the table. RN-C then placed one of the cut foam dressings into the pressure ulcer. RN-C then applied another piece of foam dressing that had been lying on the table onto the wound. RN-C then applied the clear adhesive dressings over the foam dressings then used the scissors that had been lying on the table to cut a hole into the clear adhesive dressings. RN-C then removed their gloves, washed hands for 3 seconds then applied another pair of gloves. RN-C then used a pre-moistened wipe to wash Resident 29's back side. RN-C applied a clean brief then assisted with repositioning Resident 29 to their back by touching the turn sheet then proceeded to wipe Resident 29's front side of the perineum. RN-C did not change gloves after cleaning Resident 29's back side, before touching the clean brief, turning sheet, and cleaning Resident 29's front side. RN-C then removed the gloves, donned another pair of gloves then finished dressing Resident 29's bottom. RN-C then removed the gloves, then touched the bed rail and gave Resident 29 the call light cord, which Resident 29 then proceeded to touch. RN-C then picked the scissors up off the table that they had used during the dressing change and put them in their pocket. RN-C did not wipe the table off or the scissors and did not perform hand hygiene after removing gloves. Review of Resident 29's Progress Notes for 12/15/2017 to 3/15/2018 revealed Resident 29 was treated with antibiotics for wound infection. Review of Resident 29's Wound Culture Reports dated 2/27/18, 1/9/18, 12/27/17, and 12/22/17 revealed the pressure ulcer to Resident 29's left ischium showed infection. Review of Resident 29's Resident Progress Notes dated 3/6/2018 revealed the wound had signs of infection including thick green exudate (drainage) with a foul odor. Interview with LPN-G (Licensed Practical Nurse) on 3/15/18 at 11:14 AM confirmed that Resident 29's pressure ulcer to the left ischium was infected. D. Review of Resident 3's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 3 had a Stage 4 pressure ulcer that was not present at the time of admission. Observation of RN-C on 3/19/2018 at 11:22 AM doing dressing change for Resident 3's pressure ulcer to coccyx/sacrum (tailbone area) being treated with a [DEVICE] revealed the following: RN-C did a 1 second hand scrub with hand sanitizer and applied gloves. The hand sanitizer did not cover all surfaces of RN-C's hands and RN-C's hands did not appear wet. RN-C then closed Resident 3's room curtains touching the rod with the gloved hands. RN-C then lowered the head of the bed touching the bed control with the same gloved hands. RN-C then picked the trash can up by the rim and moved it to where RN-C was working. RN-C then got more gloves out of the box in the bathroom and put them in the dressing bin. RN-C did not change gloves after touching the trash can before touching the gloves they put in with the other dressing supplies. RN-C then got supplies including [MEDICATION NAME] and dressings, touching them with the same gloved hands. RN-C then touched the bed control to raise the bed. RN-C then took the reservoir out of the [DEVICE] pump and removed the tubing. RN-C then removed the soiled dressings from Resident 3's pressure with the same gloves touching the wound. Resident 3 hollered out twice while RN-C was pulling the old dressing off. RN-C then rummaged around the bin of supplies with the soiled gloves and retrieved more supplies. RN-C then touched the wound edge and the dressing sponge that was in the wound with the same gloves. RN-C then discarded the sponge, put new gloves on, and squirted the [MEDICATION NAME] (pain medication) in the wound without performing hand hygiene. RN-C then put the new canister in the [DEVICE] pump that they had already touched with the dirty gloves. RN-C then opened the clean dressing package and touched the sponge. RN-C then took a pair of scissors out of their pocket and cut the sponge. RN-C did not clean the scissors or change gloves. RN-C then cut the transparent dressings with the scissors that were in their pocket. RN-C then washed the wound with soap and water on a washcloth and used a plain wet washcloth to rinse. RN-C then sprayed Resident 3's wound with wound cleanser and rinsed with saline, touching the canister of wound cleanser before placing it back in the bin with the remainder of the dressing supplies. RN-C then changed gloves without performing hand hygiene. RN-C then got a dressing out of the tub that they had been rummaging in. RN-C then cut the sponge with the scissors they had taken out of their pocket and used without cleaning and placed it in the wound. RN-C then placed the cut transparent dressings around and over the wound and the sponge. RN-C then attached the hose to the canister after applying the adhesive dressings. RN-C then changed gloves without performing hand hygiene. RN-C then tore a hole in the dressing that was in the wound with a gloved finger. RN-C then turned the [DEVICE] pump on that was sitting on the floor. RN-C then put the scissors in their pocket without cleaning them. Review of Resident 3's Wound Evaluation flow sheet dated 2/28/2018 revealed documentation that Resident 3's pressure had potential signs of infection including green slime exudate (drainage). Interview with the DON on 3/19/18 at 04:08 PM revealed that standard protocol was that hands are cleaned after gloves are used. After touching a dirty area with the hands or gloved hands staff were expected to clean hands and put on clean gloves. The DON confirmed the dressing changes were to be done as a clean procedure; by clean you would go from dirty to clean. Staff were expected to use a clean surface, wash the scissors, get their stuff together first and then put their gloves on and not touch everything. Review of the facility policy Pressure Ulcer Care revised 11/29/07: Resident having pressure ulcers receive necessary treatment and serves to promote healing, prevent infection, and prevent new pressure ulcers from developing. Standard precautions will be utilized during wound care. E. Observation of the noon meal service on 3/13/18 at 12:02 PM revealed RN-C was using a pen to fill out self-select menus. RN-C was observed using a pen out of the pocket that RN-C had put soiled scissors in when RN-C got done with a dressing change on 3/13/2018 at 11:33 AM. RN-C wrote on the menus and put them on a cart. RN-C then did a hand scrub with hand sanitizer for 2 seconds. Observation of RN-C on 3/13/18 at 12:12 PM revealed RN-C did a 3 second hand scrub with hand sanitizer then took a cup of coffee to Resident 2. The hand sanitizer did not cover the surfaces of the hands and hands did not appear wet. Resident 2 was then observed drinking from the coffee cup. Review of the facility policy hand hygiene revised 3/18 revealed the following: Purpose: to prevent the spread of infection through adherence of good hygiene practices. Policy: all personnel shall wash their hands with soap and water or use hand sanitizer to prevent the spread of infections. Wash hands with antimicrobial soap and water when hands are visibly soiled. Use an alcohol-base waterless antiseptic for routinely decontaminating hands when hands are not visibly soiled . When to practice hand hygiene: between resident contacts; after removing gloves; anytime hands are soiled; when going from a dirty to clean function on the same resident. Hand hygiene methods: antiseptic hand rub: apply adequate amount of alcohol-based waterless solution to palm of one hands. Rub hands together, covering all surfaces of hands and fingers, until hands are dry. Antiseptic hand wash: Moisten hands with water then apply enough soap to produce a lather. Rub hands vigorously for at least 10-15 seconds. F. Observation on 03/14/18 at 05:11 PM of RN-C performing a skin treatment on Resident 9 of a PRN (as needed) application of [MEDICATION NAME] powder to affected areas of redness and maceration under the breasts. The resident complained of itching to the areas. RN-C washed hands and applied gloves. With a wash towel, the nurse washed and dried the resident's reddened skin areas. Without changing gloves, the nurse picked up the bottle of [MEDICATION NAME] and applied the powder to the resident's skin with the contaminated gloves. Review of the Hand Hygiene policy revised last on 3/5/18 revealed the act of hand hygiene should be completed after removing gloves and when going from a dirty to clean function on the same resident. Interview on 03/19/18 at 03:14 PM with the DON confirmed RN-C should have removed the gloves and performed hand hygiene then applied new gloves before the application of the [MEDICATION NAME] powder to follow the practice of preventing cross contamination when going from a dirty site to a clean site. [NAME] Observation on 03/14/18 at 04:54 PM of RN-C (Registered Nurse) performing a glucose monitor test on Resident 3. RN-C cleaned the glucometer machine in less than 10 seconds with a Sani-Wipe disinfectant wipe then threw the wipe in the trash can and placed the glucometer back into the case. Review of the instructions on the Super Sani Wipe container revealed the surface of the item to be cleaned was to be wiped down then to allow the surface to remain wet for a full 2 minutes, then allow the item to air dry. Observation on 3-14-18 at 8:08 PM of LPN-A (Licensed Practical Nurse) performing a glucose monitor test on Resident 17. When completed, LPN-A cleaned the glucometer machine with a Super Sani Disinfectant Wipe in less than 10 seconds then threw the wipe in the trash can. Interview on 3-14-18 at 8:15 PM with LPN-A revealed LPN-A's practice of cleaning the glucometer machines was to wipe them with the disinfectant wipe as (gender) had done after each use of the machine. Observation on 03/15/18 at 10:36 AM of LPN-Q checking an oxygen saturation level with an oximeter on Resident 4. LPN-Q cleaned the machine with a Super Sani-Wipe in less than 8 seconds then threw the wipe away in the trash can. Interview on 03/15/18 at 10:50 AM with LPN-Q revealed the practice to clean the oximetry machine was to wipe it off with the Super Sani wipe after each resident use. Interview on 3-15-18 at 08:00 AM with the DON (Director of Nursing) revealed there was not a cleaning policy for the oximeters. The Policy to clean the Glucometer machines was to refer to the manufacture manual Assure Prism Multi-and Blood Glucose Monitoring System Quality Assurance / Quality Control Reference Manual. The manual revealed the glucometer should be cleaned after each use with the Super Sani-wipes and follow the manufacture instructions of the wipes. H. Observation on 03/13/18 at 10:40 AM with MM-S (Material Manager) revealed MM-S went to the store room and the medical supplies were such as syringes were in boxes on the floor as well as cushions. The boxes were not 6 inches above the floor. Interview on 03/13/18 at 11:30 AM with MM-S confirmed that the items on the floor in the store room were not six inches above the floor. I. Observation on 3-15-18 at 2:30 PM revealed LPN-G did a dressing change on Resident 24's pressure ulcers on the resident's lower legs and right heel. After LPN-G cleansed the resident's wounds, the nurse reached into the clean supply bag with the contaminated gloves on. The nurse obtained the needed supplies and continued with the dressing. When the nurse went to wrap the dressing, LPN_G had dropped their scissors on the floor. LPN-G had put clean gloves on when the LPN-G started the dressing change. While LPN-G worked with the dressings, LPN-G picked up the scissors from the floor and used them without disinfecting the scissors prior to cutting the dressings. Interview on 3-15-18 at 2:45 PM with LPN-G revealed LPN-G had picked the scissors up from the floor where they had fallen during the dressing change. Interview on 3/20/18 at 09:25 AM with the DON revealed that the dressing changes should be in a clean or sterile manner. [NAME] Observation on 03/19/18 at 02:34 PM during a dressing change on Resident 34's left heel and the back of the left ankle, RN-C washed hands. RN-C then pulled a trash can over to the side of Resident 34's wheelchair. RN-C placed a white cloth on the floor by the wheelchair. RN-C placed soapy clothes on the white cloth on the floor. RN-C placed a plastic bag which contained numerous items of dressings, bandages, tape, ointments, and Saline Spray on Resident 34's bed. RN-C then put on gloves. RN-C sat down, on the floor, in front of Resident 34's wheelchair. The white cloth was on the floor just to the right of RN-C. RN-C began to remove Resident 34's sock and shoe from the left foot. RN-C then began to remove the old dressing, which was soaked with bloody drainage, from Resident 34's foot and back of ankle. RN-C then reached into the pocket of RN-C's uniform and removed a pair of scissors. The scissors were placed on the white cloth with the other clean items for the dressing change. The bloody dressing became stuck to the skin. RN-C reached into the plastic bag which contained numerous supplies for dressing changes. RN-C dug into the bag several times and was unable to locate what item was needed. RN-C then slid the bag of supplies to the uncovered floor, not on the white cloth, and removed the can of Saline Spray. RN-C sprayed the soiled dressing, which began to run down and drip onto the scissors and other items on the white cloth on the floor. RN-C sprayed the dressing again and it came off. RN-C then took two (2) 4 X 4 gauze pads, touched the tube of [MEDICATION NAME] gel and squeezed the ointment onto the two (2) 4 X 4 gauze pads. RN-C did not change gloves, wash hands or use hand sanitizer. RN-C then placed the one (1) 4 X 4 gauze pad onto the wound on the back of the left ankle. RN-C then needed to apply skin prep (a protective coating that helps guard the skin against irritations) to the ulcer on the left heel. RN-C applied the skin prep. RN-C then applied one (1) 4 X 4 gauze pad on the left heel. RN-C reached into the plastic bag of supplies, took out a roll of Kerlix wrap and secured the 4 X 4 dressings into place. RN-C then used tape to hold the Kerlix wrap into place. The tape and [MEDICATION NAME] were placed back into the plastic bag. RN-C then placed the scissors back into their uniform pocket. RN-C informed Resident 34 that the dressing and cleaning of the suprapubic catheter site would be done next. (Suprapubic catheter is a surgically created connection between the bladder and the skin used to drain urine from the bladder when a person has an obstruction (blockage) of normal urine flow). RN-C took off the gloves from the previous dressing change. No washing of hands or use of hand sanitizer was observed. RN-C gathered the supplies needed with ungloved hands. RN-C with an ungloved hand moved the trash can closer to the resident's wheelchair. RN-C then applied gloves, without washing hands or using hand sanitizer. RN-C prepared the wash cloths to clean the catheter site. RN-C removed the old dressing and placed it into the trash can. New gloves were applied and the area around the site was cleaned. Gloves were not changed and the new dressing was applied and secured with tape. The tape placed back into the plastic bag of supplies. Resident 34's clothing was adjusted and trash picked up from room. RN-C replied, I will wash my hands later. RN-C went into bath house and used hand sanitizer. During an interview on 03/19/18 at 02:34 PM with RN-C revealed the soiled gloves were not removed during the dressing change. RN-C revealed RN-C didn't do many glove changes. Review of the Hand Hygiene policy revised on 3/5/18 revealed the act of hand hygiene should be completed after removing gloves and when going from a dirty to clean function on the same resident.",2020-09-01
3412,WESTFIELD QUALITY CARE OF AURORA,285263,"PO BOX 166, 1313 1ST STREET",AURORA,NE,68818,2019-05-14,880,F,1,1,V7OX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C1 Based on observation, interview, and record review; the facility staff failed to transport clean linen in a manner to prevent potential cross contamination for the residents residing in the SU (Secure Unit); failed to change gloves when contaminated when providing restorative care for Resident 58, failed to failed to clean scissors with an approved disinfectant and failed to use a clean surface for a dressing change for Residents 33, 36, and 48; and failed to store respiratory equipment off the floor for Resident 58. This affected 3 of 4 residents whose treatments observed; 1 of 1 sampled residents observed for restorative care; 1 of 4 residents observed with respiratory equipment; and had the potential to affect the 15 residents who resided in the SU. The facility identified a census of 57 at the time of survey. Findings are: [NAME] Observation of the SU on 5/06/19 at 12:20 PM revealed Housekeeper-I carried a pile of clothing protectors into the SU dining room and put them in the cupboard. Housekeeper-I had several clothing protectors in a a tall stack and they were holding them against their clothing. B. Observation of NA-R (Nurse Aide) providing restorative care (exercises) to Resident 58 on 5/08/19 at 9:30 AM revealed NA-R had gloves on and worked with Resident 58's hands then worked with Resident 58's feet and legs. NA-R was touching the bottom of Resident 58's shoes with their gloved hands. After working with Resident 58's feet and legs, NA-R then picked up the pitcher of water from the bedside table and gave Resident 58 a drink; NA-R touched the straw Resident 58 was drinking from. NA-R had not changed their gloves after touching the bottom of Resident 58's shoes. NA-R then started working on range of motion exercises with Resident 58's head and neck. NA-R then touched Resident 58's oxygen tubing that was on their face to move it and while NA-R was moving Resident 58's head. NA-R had both gloved hands on Resident 58's face, head and neck. On 5/08/19 at 9:33 AM NA-R finished the exercises and touched Resident 58's hands with the same gloved hands. NA-R then adjusted Resident 58's oxygen tubing with the same gloved hands. NA-R then gave Resident 58 another drink and touched the pitcher and straw. NA-R then opened the window a couple of inches, moved the wheelchair back by lifting up on the seat and grabbing the handles, then took Resident 58's shoes off and laid them on the bed. NA-R then picked up the TV remote and put the activity calendar on the table with the same gloved hands. NA-R did not change their gloves or perform hand hygiene after touching Resident 58's shoes before touching their water pitcher, straw, oxygen tubing, wheelchair handles, TV remote, activity calendar, and Resident 58's face, head, and neck. C. Observation of RN-A completing wound care for Resident 48 on 5/09/19 at 9:34 AM revealed RN-A placed the dressing supplies on Resident 48's overbed table. RN-A did not clean the table or place a barrier down before placing the supplies on it. Resident 48's personal items were observed on the table. RN-A then used an alcohol wipe to clean the scissors. RN-A then cut a piece of calcium alginate (a type of dressing) with the scissors and placed it into the wound on Resident 48's tailbone. LPN-R was present during the dressing change. Interview with LPN-R on 05/09/19 at 2:46 PM reveled the nurses used the scissors for multiple residents. D. Observation of Resident 58's room on 5/08/19 at 8:26 AM revealed the [MEDICAL CONDITION] (Continuous Positive Airway Pressure-a device used during sleep to keep airways open) mask was on the floor. Observation of Resident 58's room on 5/8/2019 at 9:10 AM revealed the [MEDICAL CONDITION] mask was still on the floor. Interview with RN-H on 5/08/19 at 12:02 PM revealed the [MEDICAL CONDITION] mask would need to be cleaned before use since it had been on the floor. Interview with RN-H on 5/09/19 at 11:08 AM revealed gloves should be changed if they touch the feet before moving to the face. When gloves are soiled/saturated they should change them. Clothing protectors should not be touching the staff clothing; resident items should be kept away from personal uniforms. Interview with the facility Administrator on 05/09/19 11:46 AM revealed Housekeeper-I should have used a cart to distribute the clothing protectors and not carry them against their clothing. Review of the facility policy Handling Soiled Linen dated (YEAR) revealed the following: Clean linen shall be delivered to resident care units on covered linen carts with covers down. Review of the facility policy Glove Use-Non-sterile dated 10/1/14 revealed the following: Facility employees will use gloves when needed to prevent contamination or the spread of infection. Before touching uncontaminated items and surfaces, remove contaminated gloves and re-glove as needed. Disposable gloves must be replaced as soon as practical when contaminated, torn, punctured, exhibiting signs of deterioration or when their ability to function as a barrier is comprised (sic). Gloves do not replace proper hand washing. Review of the facility policy Clean Dressing Change dated (YEAR) revealed the following. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application. If the table is soiled, wipe clean. Place a disposable cloth or linen saver on the overbed table. Place only the supplies to be used per wound on the clean field at one time. Review of the facility policy Disinfection of Re-usable Medical Equipment dated (YEAR) revealed the following: The facility will ensure medical equipment will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. Equipment should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective [MEDICAL CONDITION].[MEDICAL CONDITION] and [MEDICAL CONDITION] virus, etc. Equipment should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. Procedure: Retrieve 2 disinfectant wipes from container. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of equipment. After cleaning, use second wipe to disinfect thoroughly with the disinfectant wipe. Discard disinfectant wipe in waste receptacle. E. Review of Resident 33's Admission Record dated 5-8-19 revealed the date of admission of 8-24-18 with [DIAGNOSES REDACTED]. Review of Resident 33's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4-8-19 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 11 which indicated the resident cognition was moderately impaired. The resident required extensive assist of 2 staff with bed mobility, transfers, dressing, and toileting. Resident 33 did not walk and required extensive assist of 1 staff for locomotion, personal hygiene, and eating. The resident had pain but was not on any scheduled pain medication. Resident 33 used PRN (as needed) pain medications and nonpharmalogical interventions for pain control. The resident had an indwelling catheter. The resident was at risk for pressure ulcers and had 1 current pressure ulcer which was unstageable. Observation on 5/8/19 at 11:00 AM of RN-A and RN-H performed the 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) dressing change on Resident 33. RN-A cleansed the overbed table with a disinfectant wipe then laid out the wound supplies. Both RN's washed their hands with soap and water x 20 seconds and applied gloves. RN-A removed the old external and internal wound dressing then removed both gloves and put on new gloves. [MEDICATION NAME] soap was poured onto sterile 4x4 gauze and cleansed the inside of the wound. RN-A removed the soiled gloves and donned new gloves. Next the nurse dried the wound with sterile gauze then removed the gloves. RN-A cleansed a pair of scissors that were on the table with alcohol wipes. Without performing hand hygiene, RN-A put on sterile gloves from the wound VAC supplies and used the scissors to cut up the wound dressing into strips to be used on the resident VAC dressing. RN-A used the same scissors to cut the black foam to cut it down to size to fit inside the resident's stage 3 PU (Pressure Ulcer: Full thickness skin loss: Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling). At one point, RN-A placed the black foam inside the wound, then pulled the black foam back out with visible wet drainage on the black foam and used the scissors to cut the foam even smaller. RN-A placed the scissors back on the table and continued with the dressing. Once the black foam was placed inside the wound, the contaminated scissors were used again to cut up more of the dressings which were used on the outside of the wound. When the dressing was completed, RN-A cleansed the scissors with an alcohol wipe then placed the scissors into the nurse's uniform pocket. Interview at 11:45 AM with RN-A revealed the nurse used the nurse's own personal scissors for the treatment and carried them in the nurse's uniform pocket. Review of the CDC's Guidelines for Disinfection and Sterilization in Healthcare Facilities (2008), with format change in (YEAR), methods of sterilization and disinfection revealed high-level items to be disinfected are those items which will come in contact with mucous membrane or nonintact skin (such as a stage 3 pressure ulcer). [MEDICATION NAME] alcohol (70-90% ), the alcohol wipes, as a disinfectant was only effective in intermediate and low level disinfection items, not high-level items. F. Record review of Resident 36's Admission Record dated 5-7-19 revealed date of admission 7-9-18 with [DIAGNOSES REDACTED]. Review of Resident 36's admission MDS dated [DATE] revealed resident had 1 current stage 3 pressure ulcer. (Stage 3: Full thickness skin loss: Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling.) The most recent measurement on 5-6-19 of the left lateral foot revealed a stage 3 measured at 1.2 x 1.9 x 0.01 cm described as beefy red wound bed with red exudate. Observation on 5-9-19 at 1:55 PM of RN-A and LPN-B performed the treatment to Resident 36's left foot PU. The resident was laying in bed on the back without the heels being floated or heel boots on when we entered the room. Interview with LPN-B revealed the resident had a shower before lunch, then had lunch, then was laid down by the nurse aides. Both nurses washed hands x 20 seconds. RN-A had a pair of scissors with the treatment supplies obtained from the treatment cart prior and cleaned the scissors with an alcohol wipe instead of a disinfectant wipe. The nurses applied gloves and RN-A removed the old dressing from the wound then removed the old gloves then applied new gloves and applied the new collagen wound dressing to the wound followed by the foam dressing on top. After completion of the dressing change. Old gloves were removed and both nurses looked for the heel boots to be placed on the resident feet but they could not find them anywhere in the room. They searched the closet, the drawers, and could not find them. LPN-B revealed LPN-B would ask the staff in case the heel boots had became soiled and someone placed in the laundry. The nurses placed 2 pillows under the feet and floated the heels. RN-A cleansed the scissors with alcohol wipes then placed them back into the treatment cart. Both nurses cleaned their hands with soap and water x 20 seconds at least. Interview with RN-A revealed the resident had interventions for the foot of repositioning every 2 hours because the resident did not move self at all in bed and the heel boots were to be worn at all times. Observation of the resident's bed revealed absence of an air mattress on it. [NAME] Observation on 5-9-19 at 09:10 AM revealed LPN-B performed the wound treatment of [REDACTED]. To begin, LPN-B was at the treatment cart at the nurses station and gathered the supplies. Then we walked to the resident's room and entered together. LPN-B raised the bed with ungloved hands then donned gloves without performing hand hygiene. The treatment of [REDACTED]. The resident's socks were reapplied and the resident was made comfortable. Before leaving the room, LPN-B washed hands for 10 seconds with soap and water. Review of the CDC (Centers for Disease Control and Prevention) revealed Indications for handwashing and hand antisepsis: decontaminate hands before having direct contact with patients. and Hand-hygiene technique: When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet.",2020-09-01
1343,HILLCREST HEALTH & REHAB,285133,1702 HILLCREST DRIVE,BELLEVUE,NE,68005,2018-05-31,880,D,1,0,Y3V611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B and 175 NAC 12-006.17D Based on observation, interview, and record review, the facility staff failed to perform hand hygiene to prevent potential cross-contamination of dirty to clean wound dressings for 2 (Resident 5 and Resident 7) of 3 sampled residents. The facility staff identified a census of 119. Findings are: [NAME] A record review of the Facility policy for Non Sterile Dressing Change dated 11/27/2017 revealed; -Ensure any necessary equipment has been disinfected. -Place supplies on a clean field. -Wash hands. -Apply non-sterile gloves prior to removing old dressing. -Discard gloved with old dressing. -Complete hand hygiene and put on new gloves. -Clean wound as ordered. -Remove and discard gloves. -Perform hand hygiene. -Apply medication and/or new dressing per physician order. -Remove gloves and wash hands. A record review of the Facility policy for Hand Washing dated 11/27/2017 revealed that hand washing should last for at least 20 seconds using friction. An observation on 5/31/2018 at 8:12 am to 8:40 am of wound care provided to Resident 7 by Staff A revealed; Staff A entered Resident 7's room to complete the dressing change. Staff A went in to Resident 7's bathroom and preformed washed hands for 6 seconds. Staff A returned to Resident 7's bedside and covered the bedside table with a disposable incontinence protector. Staff A removed gloves from their scrub pants pocket, put the gloves on, scissors were removed from an open package and cleaned with an alcohol wipe. Staff A placed the scissors on the opened package on Resident 7's bed. Using the scissors, Staff A removed the old dressing and discarded the dressing and gloves. Staff A returned to Resident 7's bathroom where they prepared 2 packages of 4 inch by 4 inch gauze (4 X 4) to clean Resident 7's wound. One package was filled with soap and water while the other was filled with only water. At this time Staff A washed their hands for 15 seconds. Following the preparation of the 4 X 4 gauze. Staff A removed gloves from their scrub pants pocket and put them on. Resident 7's wound was then wiped with the soapy 4 X 4 then wiped with the 4 X 4 soaked in water only. Staff A patted the wound dry with a dry 4 X 4. Staff A removed the old gloves and returned to the resident's bathroom. While in the bathroom, Staff A removed a large amount of gloves from the box on the wall and placed them in the pocket of their scrub pants. Following this Staff A washed hands for 20 seconds. Staff A returned to Resident 7 and placed Vaseline gauze into the wound bed, the Vaseline gauze was cut to fit using the scissors that had been used to cut off the old dressing without re-cleaning the scissors. Staff A removed their gloves and disposed of the old gloves. Staff A took gloves from their scrub pants pocket and put them on without hand hygiene. Staff A placed an abdominal pad on the wound securing it with rolled gauze. The rolled gauze was cut with the un-cleaned scissors and taped. The tape was labeled the date and their initials. Staff A placed a compression wrap on Resident 7's leg. Staff A removed their gloves and without hand hygiene put on another pair of gloves. Staff A put on Resident 7's sock and shoe and cleaned up the working area. Staff A washed their hand for 16 second and left Resident 7's room. An observation on 5/31/2018 at 9:54 am to 10:12 am of wound care provided to Resident 7 by Staff A revealed; Staff A entered Resident 7's room to complete the wound care and shut Resident 7's entry door. Staff A entered Resident 7's bathroom and prepared two packages of 4 x 4 gauze. One package was filled with soap and water while the other was filled with only water. Following the preparation of the 4 X 4 gauze, Staff A returned to Resident 7's bedside. No clean field was prepared. Staff A was in a kneeling position and placed the two packages of 4 x 4 on their right thigh. Staff A removed gloves from their scrub pants pocket and put them on. Staff A wiped Resident 7's toes with the soapy gauze followed by wiping the the toes with the water soaked 4 x 4 and dried with a clean 4 x 4. Staff A removed their gloves and disposed of them. Without hand hygiene Staff A put on a new pair of gloves that had been in their pocket. Staff A applied [MEDICATION NAME] to Resident 7's toes and allowed the [MEDICATION NAME] to dry. Staff A returned to the bathroom and washed their hands for 15 seconds. Staff A returned to Resident 7's bedside and applied new gloves. Staff A applied Gentamicyn ointment (an antibiotic ointment) to Resident 7's toes and removed their gloves. Staff A did not complete hand hygiene and put on a new pair of gloves, Staff A put on Resident 7's sock and shoe and removed gloves. B. An observation on 5/31/2018 at 11:00 am to 11:20 am of wound care provided to Resident 5 by Staff A revealed: Staff A entered Resident 5's room to complete the wound care and shut Resident 5's entry door. Staff A set up a clean field using a disposable incontinence pad, including cleaning a scissor with an alcohol wipe. Staff A entered Resident 5's bathroom and prepared two packages of 4 x 4 gauze. One package was filled with soap and water while the other was filled with only water. Staff A washed their hands for 20 seconds and returned to the resident's bedside. Staff A removed the old dressing using scissors and removed their gloves and disposed of them both. Staff A applied hand sanitizer and new gloves. Staff A washed the wound on Resident 5's knee with the soapy 4 x 4 followed by the 4 x 4 with only water and patted it dry with a clean 4 x 4. The wound was rinsed with normal saline. Staff A removed gloves, used hand sanitizer and applied new gloves. Skin prep (a wipe containing a liquid skin barrier) was applied to the inside of the right ankle. Staff A took off the gloves and used hand sanitizer, as Staff A was putting on the new gloves, one glove was dropped on to the floor. Staff A picked up this glove and put it on their hand. Staff A packed medicated packing tape into the wound and cut the packing tape with the scissors that had been used to cut off the old dressing without first cleaning the scissors. Staff A then wrapped Resident 5's leg with rolled gauze, cutting it with the un-cleaned scissors, followed by ace wraps. Staff A removed their gloves and completed hand hygiene. Staff A cleaned up the work area. An interview on 5/31/2018 at 3:00 pm with the Director of Nursing (DON) revealed it is the expectation that during hand hygiene staff will wash their hands for a minimum of 20 seconds. It is the expectation nursing staff wash their hands prior to a wound dressing change, any time staff go from a dirty area to a clean area of a dressing change, at the end of the dressing change and any time that the hands become visibly soiled. The DON expects that scissor are cleaned at the beginning of the dressing change and anytime going from dirty to clean areas. The DON stated that disposable gloves should not be kept in the pocket of staff and be maintained in the manufactures box. The DON described an appropriate clean field is, a clean table with some type of clean barrier (i.e. a clean towel or clean disposable incontinence pad).",2020-09-01
2672,AZRIA HEALTH BROADWELL,285221,800 STOEGER DRIVE,GRAND ISLAND,NE,68803,2019-06-06,880,E,1,1,IQ3V11,"**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 staff failed to clean the lifts between residents before using it on Resident 44. Failed to change gloves when they were soiled and to perform hand hygiene when performing care to Resident 44, Resident 7, Resident 4, Resident 52, Resident 39, Resident 53, Resident 47 and Resident 10 when necessary. Failed to clean the glucometers (a machine used to test a resident's blood sugar) after use for Resident 50. Failed to maintain measures to prevent cross contamination by having uncovered catheter bag laying on the floor. Failed to update the policies for Infection Control and Prevention. This affected 8 of 24 sampled residents. The facility identified a census of 62 at the time of survey. Findings Are: [NAME] Observation of NA-K (Nurse Aide) on 6/05/19 at 10:00 AM revealed NA-K took the STS (sit to stand-a type of lift with bars the resident holds on to while being lift into a standing position to facility transfers) lift from Resident 4's room into Resident 44's and used the lift to take Resident 44 into the bathroom. NA-K did not clean the lift before taking it from Resident 4's room into Resident 44's room. Observation of Resident 44's room on 6/05/19 at 10:29 AM revealed the STS lift is sitting in Resident 44's room with the legs of the lift under the bed and the lift bars over the bed. Resident 44 was observed sitting in their wheelchair next to the lift shaving. Observation of Resident 44's room on 6/5/219 at 11:09 AM revealed the STS lift was still in Resident 44's room in the same position it was at 10:29 AM. B. Observation of MA-P (Medication Aide) on 6/03/19 at 4:05 PM revealed they donned gloves and gave Resident 44 eye drops. MA-P then removed the gloves and documented on the computer without performing hand hygiene. At 4:11 PM MA-P donned gloves and administered eye drops to Resident 7. MA-P then removed the gloves and did not perform hand hygiene. At 4:18 PM MA-P Prepared medications for Resident 4 by touching the medication cup and the punch cards the medications were in. MA-P got a bottle of eye drops out of the drawer then MA-P placed the medication cup and the bottle of eye drops back into the cart and walked down the hall. MA-P then returned and took the same medication cup and bottle of eye drops out of the drawer, took them into Resident 4's room and gave them the medications by pouring them into Resident 4's hand. At 4:23 PM Resident 4 put the medications into their mouth and took a drink out of the pitcher of water that MA-P offered. MA-P then donned gloves and placed the eye drops into Resident 4's eyes. MA-P then removed the gloves and documented on the computer by touching the keyboard without performing hand hygiene. MA-P then put the bottle of eye drops back into the cart drawer without performing hand hygiene. At 4:30 PM, MA-P prepared medications for Resident 52 by touching the medication cup and the medication punch card. No hand hygiene after putting the eye drops into the drawer before documenting and touching the computer keyboard before setting up medications for Resident 52. MA-P then poured the medication out of the medication cup into Resident 52's mouth. C. Observation of RN-I (Registered Nurse) on 6/04/19 on 5:19 PM revealed they checked a blood sugar for Resident 50. RN-I poked Resident 50's finger with a lancet and place a drop of blood on the test strip that was sticking out of the glucometer. RN-I then put the glucometer away in the drawer with several other glucometers. RN-I did not clean the glucometer after they used it to check Resident I's blood sugar. On 6/04/19 at 5:52 PM RN-I checked Resident 45's blood sugar in the same manner as Resident 50's blood sugar check. RN-I then put the glucometer away into the drawer with the other glucometer without cleaning it. D. Observation of MA-Q and NA-E on 6/05/19 at 10:45 AM revealed they both washed hands and donned gloves. MA-Q opened the closet door and a drawer with the gloved hands and got a brief out of the drawer. MA-Q then lowered the head of the bed and raised the bed with the electric control with the same gloved hands. MA-Q then took several pre-moistened wipes out of a package and laid them on the bed. MA-Q wiped both sides of Resident 39's groin, around the catheter site, then they helped Resident 39 roll to their side and MA-Q wiped Resident 39's back side. MA-Q then removed their gloves and put on another pair of gloves. MA-Q did not change gloves before providing the catheter care after touching the closet door, drawer, and bed control. Interview with the DON (Director of Nursing) on 6/06/19 at 9:47 AM revealed the facility staff were to clean the glucometers after use. Staff should change their gloves and perform hand hygiene by either washing their hands or using the hand sanitizer when they have contaminated them. Interview with the DON on 6/6/19 at 10:27 AM revealed the staff facility staff were to clean the lifts between residents. Review of the facility policy Hand Washing dated 10/1/17 revealed the following: Proper hand washing/hand hygiene technique must be used at all times when indicated. Hand washing is preformed when hands are visibly soiled or contaminated. After contact with an object or source where there is a concentration of microorganisms such as mucous, non-intact skin, body fluids or wounds. Before and after applying or administering eye drops or ointment. Before applying and after removal of medical/surgical or utility gloves. After removal of medical/surgical utility gloves. After gloves are removed, between resident contact, and when otherwise indicated to avoid transfer of microorganisms to other residents. Review of the facility policy Blood Glucose Monitoring dated 9/1/2018 revealed the following: If a blood glucose meter that has been used for one resident must be reused for another resident, the device is cleaned and disinfected with a bleach preparation; There was no documentation in the policy to clean the residents own meters and they are all kept in the same drawer in the cart. Review of the facility policy Cleaning & Disinfection of Nursing Equipment dated 6/1/2018 revealed the following: Equipment and surfaces are cleansed and disinfected with an EPA-registered and approved disinfectant according to a specified frequency/schedule. In addition, equipment and surfaces are cleansed as needed to be free of soil and contamination with infectious substances. E. Observation on 6/04/19 at 1:28 PM revealed RN-A (Registered Nurse) and the DON (Director of Nursing) performed the wound VAC (vacuum assisted closure: 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) dressing change to Resident 53. RN-A first wiped off the over-bed table with a Sani-cloth Bleach germicidal disposable wipe in 10-15 seconds then threw the wipe in the trash can. Immediately and while the table was still visibly wet and without a barrier placed on the table, the wound supplies were placed on the table. Review of the Sani-cloth Bleach germicididal disposable wipe instructions on the packet revealed to reach a disinfectant level use a wipe to remove heavy soil. Then unfold a clean wipe and thoroughly wet the surface of the item being cleaned. The treated surface must remain visibly wet for a full 4 minutes. Use additional wipes if needed to assure continuous 4 minute wet contact time. Observation continued. RN-A washed hands with soap and water for 12 seconds and then applied gloves. With assistance of the DON Resident 53 was rolled onto the resident's right side as the resident had a soiled brief of incontinent feces. RN-A performed peri-cares with disposable wipes and placed a new brief on. Without changing gloves, RN-A removed the old wound VAC dressing which had been bridge up on the left buttock. RN-A removed both gloves and washed hands with soap and water for 13 seconds and applied new gloves. The resident had 2 wounds: 1 unstageable to the left buttock as it was 100% covered with green slough (dead tissue) approximate 2 x 2 cm (centimeter) and the 2nd wound was to the coccyx approx 4 x 4 cm with 2 cm - 3 cm depth with 50% beefy red granulation tissue around the edges and 50% green slough with most of the slough at the bottom of the wound bed causing the wound bed not to be evaluated therefore another unstageable wound. RN-A cleansed both wounds with normal saline. Without changing gloves, the new dressing was applied to the left buttock wound. The nurse then grabbed a pair of scissors from the over-bed table to cut the wound dressing supplies for the coccyx wound. RN-A removed the right hand glove to better work with the ostomy wafer but kept the same contaminated left glove on. When ostomy wafer was applied to the edges, the left hand glove was removed and new gloves applied. RN-A finished the dressing changed to the coccyx. When connecting the new tubing to the wound VAC, the nurse placed the open ended tubing of the new tubing on the bed sheets where the resident had been laying. After placing the new canister into the machine, the nurse picked up the two tubing ends from the bed and connected them without wiping the tips off with a disinfectant. RN-A cleaned up the work area but the scissors used on the resident's wound when placed directly on the resident was not cleaned/disinfected and the nurse placed the scissors directly back into the treatment cart. RN-A washed hands with soap and water for 13 seconds. Interview on 6/06/19 at 3:30 PM with the DON confirmed handwashing was to be for 20 seconds and hand were to be washed with the changing of gloves. The DON also confirmed the equipment cleaning should be cleaned according to the manufacture direction and between resident use. F. Observation on 6/04/19 at 7:40 PM of NA-G (Nurse Aide) performed bedtime cares on Resident 47. Resident was informed of tasks as she did them. NA-G applied gloves and walked with the resident to the restroom. While Resident 47 sat on the toilet, NA-G removed the resident's soiled incontinence brief then removed the gloves and washed both hands with soap/water x 13 seconds. Interview on 6/06/19 at 3:30 PM with the DON confirmed handwashing was to be for 20 seconds and hand were to be washed with the changing of gloves. Review of Hand Washing policy dated 10-1-17 revealed hands should be washed with soap and water for 20 seconds using friction. Hand washing was to be performed when moving from a contaminated body site to a clean body site during resident care and when assisting with toileting. [NAME] Record review of the Infection Control policies: Antibiotic Stewardship, Infection Prevention and Control Program Overview, Influenza, Resident Health Program, and Hand Washing were all dated as last reviewed 10-1-17. Interview on 6-6-19 at 4:33 PM with RN-B revealed the facility had printed the Infection Control Policies from the computer but the facility Infection Control policies were kept in a manual and there was a form the Infection Control Nurse signed when reviewed annually. Review of the Infection Prevention and Control Policy and Procedure Manual Overview and Approval form revealed the last date the Infection Control policies were reviewed were 2-15-18. Interview 6/06/19 at 4:33 PM with RN-B confirmed the Infection Control policies/procedures had not been updated annually and were over one year old. H. Review of Physician orders for Resident 10 revealed the following orders: -To the rt. heel wound apply [MEDICATION NAME] Prizma moistened with saline and cover with [MEDICATION NAME] border dressing. Change on Sun, Wed, and Fri. per wound nurse instructions. -Daily Wound Review - Wound #2 Location: Monitor right heel daily with dressing changes. one time a day for Wound Management Document: Wound Bed, Drainage amt, Odor, Surrounding skin and pain level. Notify medical practitioner if any signs of wound deterioration are noted -Apply [MEDICAL CONDITION] wear to RLE daily, remove at HS every morning and at bedtime -Float heels off bed at all times. Pressure area to R) heel. every shift -Keep feet elevated as much as possible, float heels, continue to use heel protector when in w/c. every shift Observation on 6/05/19 at 1:29 PM of RN-A (Registered Nurse) doing the treatment of [REDACTED]. RN-A entered room after knocking and informed Resident 10 of what was going to be done. The RN-A washed hands in the bathroom sink for 10 seconds before beginning the dressing change. The RN-A then removed Resident 10's gripper sock, [MEDICAL CONDITION] ware and then the old dressing. RN-A's hands were contaminated at this point. RN-A laid clean dressing an unclean surface, the arm of the recliner in Resident 10's room. The dressing of 4 X 4's that was in a sterile container was opened by RN-A with contaminated hands and the Prizma dressing was removed from the package. Removing the dressings with unwashed hands contaminated the dressing as well as the bag. RN-A removed a pair of scissors from the right uniform pocket of RN-A uniform and cut the dressing. The scissors were laid on the seat of the recliner which caused the scissors to be contaminated. RN-A then washed hands for 10 seconds and applied gloves. RN-A took the 4 X 4's from the package and a pink tube of saline and cleaned the wound on the right heel. The wound had a small area of black escar present. Unable to visualize the wound bed due to the escar present. No signs of infection was present and no drainage. RN-A then removed gloves and washed hands for 10 seconds. The new dressing was applied and held in place by [MEDICATION NAME] dressing. RN-A then replaced Resident 10's [MEDICAL CONDITION] ware and gripper sock. RN-A did not do hand hygiene or use hand sanitizer and placed the unused dressing of the Prizma and 4 X 4's into the plastic bag. ADON in the room removed the trash bag from the trash can with the old dressing in it. RN-A, who did the treatment, replaced the trash bag in the trash can. RN-A then washed hand for 10 seconds and then took the contaminated bag of dressing and placed it into the treatment cart. The contaminated scissors were placed on top of the treatment cart. RN-A then reached over and slipped the contaminated scissors into the right uniform pocket of RN-A's uniform. 06/06/19 02:38 PM Interview with DON/ADON (Interim Director of Nursing/Assistant Director of Nursing) confirmed the breaks in infection control and potential cause of cross contamination during the dressing change to Resident 10's right heal. The observations you described of the handwashing, not placing a clean barrier for dressing items and using contaminated scissors are not our usual practice and competencies are done annually regarding wound care. I. Observation on 6/03/19 at 1:43 PM found the bedside drainage bag for Resident 10 was hanging from bedframe with no cover over the bag. The drainage spigot for the bag was in contact with the fall mat lying on the floor by the edge of the bed. Observation on 6/05/19 at 11:15 AM found the catheter bag for Resident 10 was hanging uncovered from the right side of the bed. Left side of the bed was against the wall. The catheter bag was hanging down and the spigot which was not in the pocket that houses the spigot was lying on the floor by the fall mat. Observation on 6/5/19 at 2:37 PM of NA-E (Nurse Aide) completing catheter care and peri care on Resident 10. NA-E knocked announced self and entered the room. NA-E explained what was being done. NA-E washed hands for 45 seconds. Obtained gloves, paper towel, graduate for measuring urine output and a clean brief. NA-E applied gloves and placed the graduate on the floor by the catheter bag on top of the paper towel. NA-E had placed a barrier between the graduate and the floor. The drainage bag and spout for emptying the bag were lying on the floor. NA-E placed the spigot over the graduate and without cleaning the contaminated spigot emptied the bag. The spigot was closed and NA-E then cleaned the bag with a non-alcohol wipe used for cleaning residents after incontinence episodes. There was no germicidal or bactericidal properties in the wipes. The bag was then placed back onto the floor. NA-E washed hand again after emptying the bag for 45 seconds. Clean gloves were applied by NA-E. NA-E explained the procedure for the resident about the peri cares and then adjusted the resident's clothing. A wipe was obtained and used on the left side of the groin then thrown away. A new wipe was obtained and the right side of the residents was wiped and that wipe was thrown away. A new wipe was then used to wipe down the middle of the labia. Wiping was done from front to back and a new brief was not needed. Resident was not incontinent or had a bowel movement. NA-E adjusted the residents clothing and NA-E washed NA-E's hands for 45 seconds. Review of the Policy for Urinary Catheter and Drainage Bag Care revealed general information: That state: Appropriate measures for controlling common infections are a critical component of the over all plan of care for residents with a urinary catheter. 6. Do not allow the catheter bag holder, tubing, or spigot to touch the floor. 8. Maintain a closed drainage system. If the system must be opened, disinfect (eg. with an alcohol wipe) the catheter tube junction before disconnection. Procedures 11 Empty drainage bag regularly (every shift, using a separate measuring graduate for each resident). Wear a non-sterile glove when emptying drainage bags. Do not allow the drainage spigot and non-sterile collecting container to touch. Interview on 6/06/19 at 2:38 PM with DON/ADON confirmed the breaks in infection control when NA-E did not use an alchohol wipe but used a peri wipe to clean the catheter bag spigot. Which caused cross contamination during the emptying of the urinary catheter drainage bag.",2020-09-01
1454,LIFE CARE CENTER OF OMAHA,285137,6032 VILLE DE SANTE DRIVE,OMAHA,NE,68104,2019-06-03,880,D,1,1,9YPS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.17b Based on observation and interview, the facility failed to ensure that a Nephrostomy ( a tube used to drain fluids from the Kidney) drainage bag was not stored on the floor for 2 (Resident 12 and 30) of 2 residents reviewed. The facility census was 89. Findings are: [NAME] Observation on 5/29/19, at 12:30 PM, revealed Resident 12 in bed with Nephrostomy drainage bag laying on the floor uncovered next to the bed. Interview on 5/29/19 at 12:35 PM with CNA B confirmed that the Nephrostomy drainage bag was on the floor uncovered. CNA B agreed that the bag should not be laying on the floor which could increase the risk for cross contamination and potential for urinary tract infection. B. Observation on 05/29/19 at 2:14 PM of administering tube feeding and dressing change to jejunostomy tube (J-tube) (a tube placed through the skin of the stomach into the small intestine to deliver food and medication) site revealed Licensed Practical Nurse (LPN) A washed hands, donned gloves and removed Resident 30's dressing around J-tube insertion site. LPN A then removed gloves, washed hands and donned clean gloves. LPN A then cleaned around J-tube insertion site using different sides of same wipe for each swipe around the tube, then removed gloves and donned another pair of gloves without performing hand hygiene. Further observation revealed that LPN A then emptied containers of [MEDICATION NAME] (a liquid nutritional formula) into feeding bag, primed the tubing, removed gloves and left room without performing hand hygiene. Observation on 05/30/19 at 12:01 PM of Nursing Assistant (NA) A performing personal care revealed that NA A performed hand hygiene and donned gloves, then removed Resident 30's brief and wiped groin area. Further observation revealed that NA A then removed gloves and donned new gloves without performing hand hygiene and then proceeded to wipe Resident 30's back side. Review of facilities Hand Hygiene policy, effective date of 3/6/19, revealed that hand hygiene is appropriate for decontaminating the hands before putting on gloves and after removing gloves. Interview with DON on 06/03/19 at 01:13 PM confirmed that hand hygiene should be done after removal of gloves and before putting on gloves.",2020-09-01
2650,AZRIA HEALTH BROADWELL,285221,800 STOEGER DRIVE,GRAND ISLAND,NE,68803,2019-06-06,584,D,1,1,IQ3V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18 Based on observation, interview, and record review; the facility staff failed to investigate damage to property and failed to have documentation they had given the facility policy for personal items to Resident 60 and failed to maintain resident rooms in good repair for Resident 6, Resident 14, Resident 48, Resident 60, Resident 39, Resident 53, and Resident 21. This affected 8 of 24 sampled residents. The facility identified a census of 62 at the time of survey. Findings are: [NAME] Review of Resident 60's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 5/2/2019 revealed an admission date of [DATE]. Resident 60 had a BIMS (Brief Interview for Mental Status) score of 14 which indicated Resident 60 was cognitively intact. Interview with Resident 60 on 6/03/19 at 11:30 AM they had lost a lot of clothes. Resident 60 reported the facility had not replaced them because the facility staff told Resident 60 the facility staff weren't responsible. Resident 60 reported they were told the items had to be listed on the inventory sheet but the facility had not provided assistance to update the inventory sheet. Resident 60 also revealed that an unidentified nurse aide had dropped their bottom dentures ad it was broken. Resident 60 revealed they did not know if the facility would pay to repair it. Observation of Resident 60's room on 6/05/19 at 7:01 PM revealed a broken bottom denture in a clear plastic sandwich bag on the over the bed table. Interview with Resident 60 at this time revealed they had reported the broken denture to the charge nurse. Review of Resident 60's Progress Notes revealed the following: 5/26/2019 16:04 (4:04 PM) Health Status Note: Resident gave broken bottom dentures to this nurse, (gender) stated they were fine when (gender) took them out of (gender) mouth at bedtime last night. Dentures are at nurses' station in office due to holiday weekend. Will pass information on to the next shift. Interview with the SSD (Social Services Director) on 6/05/19 at 6:33 PM revealed the facility had a policy for Facility Criteria for the Retention of Personal Possessions but they did not have any documentation they had given the policy to Resident 60. Interview with SSD on 6/05/19 at 4:08 PM revealed there was no documentation of an investigation into Resident 60's broken denture as they were unaware Resident 60 had a broken bottom denture. The SSD revealed the facility would be responsible for paying for the damages if it was determined the facility staff were at fault but there had not been an investigation done to determine the cause of the damage to Resident 60's dentures. The SSD revealed the facility staff were to assist the residents with updating their inventory sheets when something new was brought in or discarded. Interview with the facility Administrator on 6/05/19 at 7:02 PM revealed broken resident property was to be reported to the administrator so an investigation could be completed. B. Tour of the room occupied by Resident 23 on 6/3/19 at 9:47 AM found the bathroom walls and room walls are marred and have holes, room door frame, room door, closet door are marked, bathroom faucet corroded and caked with hard water deposits. The hot water in the bathroom was barely a trickle and temperature was 75 degrees Fahrenheit. Tour of the room occupied by Resident 6 on 6/3/19 at 11:19 AM found the room and bathroom door marred. Tour of the room occupied by Resident 14 on 6/3/19 at 10:42 AM found the bathroom wall marred. Tour of the room occupied by Resident 48 on 6/3/19 at 11:15 AM found the hot water temp was only 90.1 degrees Fahrenheit. The room door frame, room door, closet door marred; walls in room and bathroom marred. Tour of the room occupied by Resident 60 on 6/03/19 at 11:21 AM found holes in the wall by the bathroom and the bottom trim was coming away from the wall. Tour of the room occupied by Resident 39 on 6/3/19 at 11:17 AM found the room door and walls were marred. Tour of the room occupied by Resident 53 on 6/3/19 at 10:45 AM found the door frame, room bathroom and closet doors marred. The bathroom sink was slow to drain and the faucet was corroded and caked with hard water deposits. Tour of the room occupied by Resident 21 on 6/3/19 at 9:00 AM found the door frames, room door, closet door, bathroom door, wall in room and bathroom marred and hot water temp was only 90.1 Fahrenheit. An interview with the ADM (Administrator) on 6/6/19 5:41 PM revealed and confirmed the environmental issues of the marred room and bathroom walls, the marred doors and door frames, the marred closet door, cooler water temperatures, and the corroded and caked on hard water deposits on the bathroom faucets.",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
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
6354,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2016-03-10,246,D,1,0,L3TD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B1 Based on observations, record reviews, and interviews; the facility failed to provide a wheelchair fitted to Resident 4's height and to support the resident's legs when Resident 4 had a change in condition. The facility census was 120. Findings are: Review of Resident 4's [DIAGNOSES REDACTED]. Review of Resident 4's most recent MDS (Minimum data Set, a federally mandated comprehensive assessment tool used for care planning) dated 2-11-16, revealed a BIMs (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 4 which indicated Resident 4's cognition was severely impaired. Observation on 3-10-16 at 09:30 AM revealed Resident 4 sitting in the dining room in an upright position at 90 degrees in a tilt-n-space wheelchair, however Resident 4's tip of the toes only were able to reach and touch the wheelchair pedal plates due to the length of the pedals. Observation on 3-10-16 at 09:45 AM revealed Resident 4 sitting in the tilt-n-space wheelchair at an approximate 45 degree angle in Resident 4's room. Resident 4's legs were dangling from the wheelchair without any support. The wheelchair pedals were on but the long length prevented Resident 4's feet from reaching the pedal plates and the pedals did not have any calf supports to keep Resident 4's legs elevated/supported. Further examination of the pedals revealed both pedals were adjustable for length and could have been adjusted shorter. The left pedal had a heel guard on the pedal which would help a foot from falling off the back of the pedal and the right heel guard was missing. Interview on 3-10-16 at 09:45 AM with Resident 4 revealed Resident 4 was not comfortable in the tilted back position. Interview on 3-10-16 at 09:35 AM with MA-B revealed Resident 4 had a fall recently and the tilt-n-space wheelchair was the new intervention and when staff were not with Resident 4 they were to tilt the wheelchair back for positioning. Review of a Restorative note in the Progress Notes dated 3-1-16 at 9:38 AM revealed the staff gave Resident 4 a tilt-n-space wheelchair for positioning due to Resident 4 leaning forward and for comfort when Resident 4 was up. Interview on 3-10-16 at 1:55 PM with Infinity Rehab OT (Occupational Therapist) revealed the OT had not received any order to fit or process Resident 4 for a tilt-n-space wheelchair. The OT explained the facility's practice when a resident was given a different wheelchair was for the OT to fit the resident to the wheelchair to help prevent any future skin impairment or other potential injury from a wheelchair that was the wrong size. The OT explained since Resident 4 was on hospice, the hospice provider would have provided this service. The OT also revealed the facility had extra wheelchairs on hand and the facility staff placed residents in the extra wheelchairs until a resident was fitted by the OT person and this could be a possibility with Resident 4. Interview on 3-10-16 at 2:15 PM with Hospice RN revealed the Hospice Provider did not provide Resident 4 with a tilt-n-space wheelchair. The Hospice RN confirmed with the equipment provider, Frontier, the last wheelchair provided to Resident 4 was a standard wheelchair measured 20 x 18 on 2-5-16. The Hospice RN confirmed Hospice RN was not aware Resident 4 had been placed in a tilt-n-space wheelchair as the fall intervention. Interview on 3-10-16 at 11:00 AM with the DON (Director of Nursing) revealed the facility's expectation when a resident was placed in a new or different wheelchair was to have the wheelchair fitted by an OT. Observation of Resident 4 on 3/9/16 prior to the supper meal in the common area by front door lounge, revealed Resident 4 to be tipped back in wheelchair with lower legs and feet dangling (hanging from edge of wheelchair seat) without any support. Director of Nursing and LPN (Licensed Practical Nurse) - J were interviewed at 5:38 pm on 3/9/16 as to any additional support for Resident 4's lower legs and feet to reach the pedals for comfort and safety. LPN -J went to Resident 4 room and came back out stating was not able to find any leg supports. On 3/9/16 at 5:40 pm observation of Resident 4's lower legs/shins revealed bright fiery red color and puffy in appearance with swelling present. Resident 4 stated the socks were cutting into skin and did not feel good. Resident 4 further stated did not like to be tipped back in chair as could not clear throat of congestion. Resident was receiving oxygen via a nasal cannula and oxygen concentrator machine. Resident 4's voice was gurgly sounding when speaking while tipped back in chair.",2019-03-01
6296,GRAND ISLAND LAKEVIEW CARE AND REHABILITATION CENT,285106,1405 WEST HWY 34,GRAND ISLAND,NE,68801,2016-04-21,246,D,1,0,5PD711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B1 Based on observations, record reviews, and interviews; the facility failed to resolve grievance/complaint to provide a temporary wheelchair for Resident 401 which would meet Resident's physical needs to be able to shift Resident's weight independently when in the temporary wheelchair while Resident's regular wheelchair was being repaired. The facility census was 78. Findings are: Interview with Resident on 4-21-16 at 11:12 AM revealed Resident 401's electric wheelchair had been a tilt-n-space wheelchair recommended by OT (Occupational Therapy) due to Resident 401's history of chronic pressure ulcers and ongoing need to independently shift weight in the wheelchair frequently. On 4-5-16, Resident 401's electric wheelchair broke down and the facility nursing staff, without consulting the OT department, placed resident into a manual wheelchair that was not a tilt-n-space. The arms of the manual wheelchair had to be removed so Resident 401 could reach the wheels to propel independently throughout the facility. However, without the arms of the manual wheelchair, Resident 401 was unable to shift weight in the wheelchair independently. Resident 401 was upset because the electric wheelchair broke down on 4-5-16 and, even though facility had worked with the Vendor on repairing it, as of 4-21-16, the resident was still in the same manual wheelchair the resident was placed in on 4-5-16 which resident felt was not adequate to meet physical needs. Observation on 4-21-16 at 11:12 AM revealed Resident 401 in a manual wheelchair which was not a tilt-n-space. The wheel chair was without any arms on either side. Resident 401 demonstrated an attempt to using own arms by pushing from the seat of the wheelchair to lift body weight. But the resident's arms are short and the resident's was obese so, the resident was unable to lift buttocks/thighs up off of the seat of chair. Interview on 4-21-16 at 11:45 AM with OT revealed OT had not been aware of Resident 401's being temporarily moved to a manual wheelchair while the electric wheelchair was being repaired. OT also confirmed that, when a resident's wheelchair was downgraded from an electric tilt-n-space wheelchair to a manual wheelchair and the resident had a history of [REDACTED]. Record review of OT notes revealed OT was not involved in the decision of which type and accommodations of a manual wheelchair Resident 401 was placed into while the resident's electric wheelchair was being repaired. Interview on 4-21-16 at 12:50 PM with the DON (Director of Nursing) revealed nursing chose the manual wheelchair for Resident 401 to be temporarily placed in while the electric wheelchair was being repaired and did not consult the Occupational Therapist. The DON confirmed the Occupational Therapist should have been involved in the decision of what wheelchair with what type of accommodations would have been the best to meet resident's physical needs.",2019-04-01
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
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
2871,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2018-01-02,689,E,1,1,51KH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E1 Based on observation, record review and interview; the facility staff failed to implement assessed interventions to prevent falls for 1(Resident 38), and failed to utilize a gait belt in a manner to prevent potential accidents for 2 (Resident 12 and 21) of 5 sampled residents. The facility staff identified a census of 66. Findings are: [NAME] Record review of Resident 38's Comprehensive Care Plan (CCP) dated 8-24-2017 revealed Resident 38 was at risk for falls. Record review of Resident 38 notes dated 12-09-2017 revealed Resident 38 was on the floor with Resident 38's roommates wheelchair next to Resident 38's bed. The new intervention that was to be implemented was to ensure the roommates wheelchair was away from Resident 38's bed. Observation on 12-26-2017 at 7:51 AM revealed Resident 38 was in bed and Resident 38's roommates wheelchair was next to Resident 38. On 12-27-2017 at 7:57 AM an interview was conducted with Licensed Practical Nurse (LPN) [NAME] During the interview LPN G confirmed Resident 38's roommates wheelchair was next to Resident 38's bed. B. Record review of Resident 3's MDS dated as completed on 10-03-2017 revealed the facility staff assessed the following about the resident: -BIMS was a 15. -Total dependence for bed mobility, transfers, dressing, eating, toilet use and personal hygiene with 2 plus people assisting with bed mobility, transfers, dressing and personal hygiene. -No pressure ulcers were identified for Resident 3. Record review of Resident 3 smoking assessment dated [DATE] revealed Resident had dexterity problems, could not light own cigarette and needed 1 to 1 assistance for smoking. Further review of the smoking assessment dated [DATE] revealed the facility staff were unable to determine if Resident 3 could smoke safely. Observation on 12-20-2017 at 3:30 PM revealed Resident 3 was outside smoking unsupervised. On 1-02-2017 at 7:30 AM an interview was conducted with LPN B. During the interview LPN B reported Resident 3 comes and goes as (gender) pleases. When asked if Resident 3 smokes independently, LPN B reported (gender) shouldn't, but does. Record review of a undated facility Policy and Procedure for Smoking and Tobacco Free Policy revealed the following: -#5. Residents wishing to smoke must be physically able to smoke without assistance of staff. Resident who can not physically smoke may call on volunteers to provide smoking assistance during the scheduled smoking times. Record review of the facility policy for Gait Belt Transfer revealed: Policy: It is the policy of this facility to 1. Provide safety for the unsteady and or confused resident 2. Aid in the transfer of the dependent resident 3. Prevent injuries to employees and residents 4. Allow the resident and aide to feel more secure during transfer. Transfer from bed to chair, commode, or wheelchair: (two person transfer; resident able to bear weight) 5. Place gait belt around resident's waist; snug but not tight. avoid ribs, hip bone, or breasts. 9. Grasp the gait belt on either side. 10 Staying close to the resident, the assistants should rock back and forth, synchronizing movements and shifting weight from one leg to the other while maintaining a backward pelvic tilt. With hips and knees bent, and on the count of three, lift and carry resident to the chair. C. Record review of Resident 21 face sheet revealed that Resident 21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 21's Comprehensive Care Plan revealed that Resident 21 had a self care performance deficit and was resistive to care at times, refuses gait bet at time and will accuse staff or other of being the devil. Interventions for care included, Transfer with 1 staff participation with gait belt and walker or grab bars. Toileting to be performed every 3 hours and as needed, requiring one assist and walker. Observation on 12/21/17 at 12:25 PM, Resident 21 was observed being provided personal hygiene cares by NA (nursing assistant) R and NA J, also present in the room was the facility Consultant RN N. NA R was observed to place a gait belt around Resident 21. Upon standing Resident 21 from the wheel chair, NA J removed Resident 21's incontinent brief, and to provide care. Resident 21 became agitated and started to yell at NA R that was killing her. Observation revealed that the gait belt had moved into a position that was around upper chest and in the underarm area. Resident 21 continued to yell out that they had killed her. Resident 21 attempted to kick NA R to let go of her and let her sit. NA R continued to stand resident during cares. NA J revealed that this was not the way that they usually perform this task, NA J revealed that Resident 21 should have been placed in the bad to change the brief, and that Resident 21 had difficulty with the gait belt high and that other, NA R , was holding her up for a long period of time. NA J recognized that Resident 21 was uncomfortable with the use of the gait belt. Interview with the facility consultant RN N confirmed that the gait belt had not been used properly during the care provided to Resident 21. RN N revealed that Resident 21 frequently repeats that someone had killed her and that was resistive to care. RN N confirmed that Resident 21 did become agitated during the care the longer that NA R held her up from the chair with the gait belt that was pulling Resident 21's arms upward and the belt was in the axillary area and not around Resident 21's waist. 12/26/17 03:33 PM Interview with Kirsten and Rose who were the facility managers in with both Gait belt transfers, confirmed that the gait belt was not used properly on either resident, confirmed that when the resident was yelling to stop, or yelling your killing me the staff should have stopped, sat the person down and repositioned the gait belt. Rose revealed she was the one who wrote the note the next day regarding her assessment of Resident pain in shoulder and arm area the following day, resident was on routine pain medications also. Interview with the facility ADON (Assistant Director of Nursing) on 12/21/17 at 3:30 PM confirmed that there were not competencies performed with the staff on gait belt use, and that education had not been provided for use of gait belts to NA J (contracted staff) or NA R. D. Record review of Resident 12 face sheet revealed that, Resident 12, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 12's Comprehensive Care Plan, revealed that Resident 12 had short term memory impairment with severely impaired cognitive function. Resident 12 also had Self care performance deficits and can become resistive to cares at times, yelling out. Interventions included toilet use by self, independently at times, provide 1 assist as needed. Transfer may require 1 assist related to being resistive to cares. Observation on 12/21/17 at 3:19 PM of transfer from wheel chair to toilet by NA S and NA T, also present in the room was RN U observing . Gait belt was placed around resident and she was assisted from wheelchair/ to toilet without difficulty. Upon NA S standing resident ,after toilet use, Resident started yelling that the gait belt was hurting her back. The gait belt was no longer around the resident waist but was up around the back and above the breasts, with the right breast area exposed. The resident became agitated and yelled that it was causing pain in the back area and under arm area. The two NA's continued to provide incontinent care. Resident 12 continued to tell the NA's it was causing pain. Record review of nurses note, for Resident 12, dated 12/22/17 at 4:33 PM, revealed that while providing back rub with lotion, the resident jumped and said ouch. skin of back and underarms were assessed for discoloration or marks/injuries with none noted by RN N. Interview with the facility RN U confirmed that the gait belt had not been used properly during the care provided to Resident 12. RN U confirmed that Resident 12, did become agitated during the care the longer that NA S had held Resident 12, up from the chair with the gait belt that was pulling her arms upward and the belt was in the axillary area and not around Resident 12's waist. 12/26/17 03:33 PM Interview with RN N and RN U, confirmed that the gait belt was not used properly on Resident 12, and confirmed that when the resident was yelling to stop, that the staff should have stopped, sat the person down and repositioned the gait belt. RN U revealed she was the one who wrote the note the next day regarding her assessment of Resident pain in shoulder and arm area the following day, resident was on routine pain medications also. Interview with the facility ADON (Assistant Director of Nursing) on 12/21/17 at 3:30 PM confirmed that there were not competencies performed with the staff on gait belt use, and that education had not been provided for use of gait belts to NA J (contracted staff) or NA R. E. Observation of the dining room ( on the ground level), on 12/20/17 at 1:15 PM, Residents 56, 21 and 19 were alone in the dining room. No facility staff was present to observe the following residents to complete their meals. Observation on 12/26/17 at 12:45 Resident had eaten 50% of meal and the other 50% remained with the resident, who continued to eat. Observation of the dining room (on the ground level), on 12/26/17 at 12:45 PM, Residents 56, 21, and 19 were observed to be in the area with no staff. Other residents were present but without meals in front of them. Resident 56 was observed to place an over filled large spoon of mashed potatoes, into mouth that had already had food present. Record review of Resident 56's MDS, Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) on 10/18/17 revealed that Resident 56 had no teeth, and required mechanical altered diet (change in texture of foods or liquids). Observation on 12/26/17 at 12:45 Resident had eaten 50% of meal and the other 50% remained with the resident, who continued to eat. Resident 21 was observed with full plate of food and was requesting additional beverage of milk. Record review of Resident 21's MDS dated [DATE] revealed that Resident 21 required a mechanically altered diet. Observation on ,12/26/17 at 12:45 PM, Resident had full plate of food present and a beverage. Resident 19 was observed with more than 75% of meal on the plate. Record review of Resident 19's MDS dated [DATE] revealed that Resident 19 had a BIMS of 3 BIMS (Brief Interview for Mental Status) of 3/15 BIMS scored as follows 13-15 points: the person is intact cognitively. 9-12 points: the person is moderately impaired. 0-7 points: the person is severely impaired The MDS also revealed that Resident had continuously had disorganized thinking and inattention did not fluctuate. Record review revealed that Resident 56 had dementia as a diagnosis. Observation on ,12/26/17 at 12:45 PM, Resident 19 had eaten 25 % of meal and 75% of meal remained present. Interview on 12/20/17 at 1:20, with NA R confirmed that Resident's were not to alone in the dining room and that the Resident's present Resident 19, 56, and 19 were at risk for choking on foods. Interview on 12/20/17 at 1: 25 with NA J confirmed that a staff member was to be in the dining room at all times when Residents were eating, NA J confirmed that there was not enough staff members present to provide that service, other resident's that had been taking from the dining room were requesting toileting and cares. Interview on 12/20/17 at 1:30 PM MDS coordinator confirmed that a staff member was to be in the dining room when resident's were eating, due to choking risks. Interview with the facility Administrator on 12/26/17 at 3:30 PM confirmed that one staff member was to be in the dining room until all resident's meals had been completed.",2020-09-01
3715,AVERA CREIGHTON CARE CENTRE,285284,"P O BOX 289, 1603 MAIN STREET",CREIGHTON,NE,68729,2019-07-16,689,E,1,1,PBQK11,"**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 identify causal factors, to develop and/or revise interventions and to implement assessed interventions for the prevention of further falls for 3 (Residents 34, 29 and 30) of 5 sampled residents. The facility census was 46. Findings are: [NAME] Review of Resident 34's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/3/19 revealed the following: -cognitive status was moderately impaired; -required extensive assistance with bed mobility, transfers, dressing, toilet use and with personal hygiene; -was not steady, and only able to stabilize with human assistance, when moving from a seated to standing position, moving on and off the toilet, and during surface-to-surface transfers; and -had 2 falls with no injury and 1 fall with injury (except major) since the previous assessment. Review of the current Care Plan dated 11/27/17 indicated Resident 34 was at risk for falls due to weakness and an increase in symptoms from [MEDICAL CONDITION]. Nursing interventions included the following: -12/4/17 remind resident to put recliner back to the down position before sitting: -1/29/18 remind resident to use call light and to wait for staff to assist with transfers; -4/9/18 gripper socks to be placed on the resident when not wearing shoes; -6/28/18 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) to all chairs and bed; -7/3/18 keep wheelchair out of resident's line of sight when in room to prevent self-transfers and keep chair lift controls out of resident's reach; -8/4/18 frequent room checks; -8/4/18 raised edge mattress to assist resident with identifying edge of the bed; -8/17/18 fall mat on floor by bed when resident in it; -10/11/18 place the resident's walker in reach when in the room; and -12/2/18 monitor to ensure resident is not in room alone when positioned in the wheelchair. Review of an Incident Report dated 1/1/19 at 12:50 PM revealed a Nursing Assistant (NA) had been walking with the resident from the wheelchair to the recliner. The resident lost balance and was lowered to the floor. No injuries were sustained. New interventions for use of 2 staff to assist with transfers as needed or for use of the sit-to-stand mechanical lift (mobile lift that allows for patient transfers from a seated position to a standing position. This lift is designed to support only the upper body of the resident and requires the resident to have some weight-bearing capability) were identified. Review of the Incident/Accident log dated 2/1/19 at 10:55 AM revealed the staff heard the resident's fall alarm sound and found the resident on the floor in front of the recliner in the resident's room. The resident's walker was on the floor next to the resident. The resident's call light was available to the resident but had not been used. Further review of the Incident Report revealed no documentation as to whether the resident's recliner was in the proper position or to indicate potential causal factors for the resident's fall. A new intervention was identified for the resident to be screened for possible treatment by the Physical Therapist. Review of an Incident Report dated 2/16/19 at 8:05 PM revealed the resident was found on the floor next to the resident's recliner. The fall was unwitnessed. The report identified the battery was missing from the box of the resident's fall alarm and was not functioning. The battery was replaced and a cover was put on the back of the alarm box to prevent the battery from falling out again. The resident was encouraged to use the call light to seek staff assistance. Review of an Incident Report dated 3/16/19 at 3:30 PM revealed the resident was found on the floor of the resident's room. The resident indicated getting up to try and tune in the television as the picture was fuzzy. The resident was again reminded to use the call light for staff assistance and a new cord was placed on the television to improve the quality of the picture. Review of Resident 34's Care Plan revealed a new intervention dated 3/27/19 to discontinue the TABS alarms and to utilize alarms which were to be connected to the call light system. The alarms were to be inaudible and were to go directly to the staff radios. Review of an Incident Report dated 4/7/19 at 3:10 PM revealed staff responded to the resident's call light and found the resident on the floor with the resident's walker. The resident indicated attempting to walker to bed to lay down. review of the resident's medical record revealed [REDACTED]. Review of an Incident Report dated 4/27/19 at 8:30 PM revealed staff heard the resident's alarm sounding and when staff entered the resident's room, the resident was on the floor. The resident was unable to identify the reason for the fall. review of the resident's medical record revealed [REDACTED]. Review of an Incident Report dated 5/14/19 at 8:30 PM revealed the resident's alarm was sounding and staff found the resident up and ambulating independently in room with the walker. The resident became unsteady when staff identified themselves and was then lowered to the floor. review of the resident's medical record revealed [REDACTED]. No additional interventions were developed to prevent additional falls. Review of an Incident Report dated 5/23/19 at 3:30 PM revealed the resident was founding sitting on the floor of the resident's room. The resident indicated having gotten tangled up in the walker and then falling down. Further review of the report revealed the resident's fall alarm did not sound when the resident fell . A new chair alarm was placed in the resident's wheelchair and staff assured it was functioning. Review of an Incident Report dated 6/2/19 at 9:30 PM revealed the fall alarm which was attached to the call light system was activated. The resident was found on left knee next to the resident's bed. The resident was attempting to reach a trash receptacle as the resident indicated a need to spit. An intervention was identified to assure the trash receptacle was within the resident's reach when in bed. Review of an Incident Report dated 6/6/19 at 5:15 PM revealed the resident's call light was on and when staff responded, the resident was found on knees next to the resident's bed. The resident was incontinent of bowel and bladder and identified trying to get to the bathroom. An intervention for the staff to assist the resident to the bathroom after activities and before going to the evening meal was developed. Review of an Incident Report dated 6/28/19 at 10:30 AM revealed the resident was found on the floor of the resident's room with the walker next to the resident. The resident was incontinent of urine. review of the resident's medical record revealed [REDACTED]. Review of an Incident Report dated 7/7/19 at 10:00 AM revealed the resident had an unwitnessed fall in the resident's room. The resident was on the floor in front of the recliner and the recliner was in the raised position. The resident indicated having slid off the seat. The resident was reminded regarding use of the call light and proper positioning of the lift recliner. review of the resident's medical record revealed [REDACTED]. Resident 34 was observed seated in the lift recliner in the resident's room with the controls held in the resident's hands on 7/11/19 from 10:00 AM to 11:30 AM. During an observation on 7/15/19 from 7:42 AM to 8:05 AM, NA-C removed a cord which was connected to the resident's call light. The opposite end of the cord was connected to an alarm box which led to a sensor pad on the seat of the resident's recliner. NA-C secured the alarm box to the back of the resident's wheelchair and placed the sensor pad from the recliner seat to the wheelchair seat. NA-C then connected the alarm box to the sensor pad in the wheelchair. NA-C indicated Resident 34 was the only resident whose fall alarm was attached to the call light system. However, once the alarm was detached from the call light system, the alarm was to make an audible noise to alert staff of potential self-transfers. NA-C attempted to demonstrate the audible alarm to the resident's sensor pad but the alarm did not function. NA-C indicated a need to alert the Charge Nurse the alarm was not working. NA-C assisted the resident out of the resident's room and out to the dining room. The non-functioning alarm remained attached to the resident's wheelchair. During observations on 7/15/19 at 2:26 PM and on 7/16/19 at 9:42 AM, Resident 34 was seated in the lift recliner in the resident's room. Resident 34 had the controls for the lift chair held securely in the resident's hand. During interview on 7/15/17 at 10:43 AM, the Director of Nursing (DON) revealed the following: -verified an investigation was not completed following Resident 30's falls on 2/1/19 at 10:55 AM, 4/7/19 at 3:10 PM, 4/27/19 at 8:30 PM, 5/14/19 at 8:30 PM, 6/28/19 at 10:30 AM and on 7/7/19 at 10:00 AM. Causal factors were not identified, new interventions were not developed and/or current interventions revised; -an evaluation had never been conducted to determine the resident's safety regarding use of the lift recliner in the resident's room; and -the resident was to have a sounding TABs alarm to the wheelchair to alert staff to attempts to self-transfer. B. Review of Resident 30's Care Plan with a start date of 1/8/18 revealed the resident was at risk for falls due to a history of falls with a recent hip repair. Interventions included a bed alarm and a chair alarm. A floor alarm was initiated on 4/17/19. Review of Resident 30's post fall Incident Report dated 4/15/19 revealed at 5:30 AM the resident's alarm was sounding. The resident was found sitting on the bathroom floor. The alarm was in place. (There was no evidence that causal factors were looked at regarding the resident's bowel/bladder needs) Review of Resident 30's post fall Incident Report dated 4/17/19 revealed at 1:55 AM the resident's alarm was sounding. The resident was found on the floor. The bed alarm was in place and working and gripper socks were on. The new intervention was for a floor alarm. (There was no evidence to indicate causal factors were looked at) C. Review of Resident 29's Care Plan with a start date of 11/4/17 revealed the resident was at risk for falls. The resident had poor safety awareness and would transfer and ambulate unassisted. Interventions included: - Make sure automatic brakes on the wheelchair are working and if not notify maintenance to fix them, - keep resident up in the wheelchair until the resident isn't restless to help prevent self-transfers, - continue with the chair sensor alarm and change the bed alarm to a floor alarm, and - when assisting Resident 29 keep a hand on the gait belt. Review of a Post Fall assessment dated [DATE] revealed at 10:30 PM Resident 29's alarm sounded and the resident was found sitting on the floor in the door way, the resident's wheelchair and walker were on the other side of the room. The new intervention was to keep the resident up in the wheelchair until not restless, to prevent self-transfers. (There was no evidence that the cause of the resident's fall was investigated and no evidence to support the resident being potentially restless prior to the fall) Review of a Post Fall assessment dated [DATE] revealed Resident 29 was observed in the bathroom, the resident stood up from the wheelchair and immediately tried to sit back down but the wheelchair rolled and the resident fell . A new intervention was to put anti-roll brakes on the resident's wheelchair. (There was no evidence that the resident's bowel/bladder needs were looked at as potential causal factor as well) During an interview on 7/16/19 at 10:40 AM, Registered Nurse-G revealed after a fall the nurse did the initial investigation and they should be looking at causal factors and putting interventions into place.",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
2925,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2018-07-02,689,D,1,0,EO8U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E1 Based on record review and interview; the facility staff failed to implement interventions related to suicidal statements for 1 (Resident 107) of 1 resident review. The facility staff identified a census of 54. Findings are; Record review of Resident 107's Order Summary Report printed on 6-28-2018 revealed the [DIAGNOSES REDACTED]. Record review of Resident 107's Comprehensive Care Plan (CCP) dated 7-18-2015 revealed Resident 107 was identified as having verbal behaviors directed to staff, screams loudly and is easily agitated. Record review of Resident 107's Progress Note (PN) dated 6-21-2018 revealed Resident 107 reported (gender) was going to kill (gender). Further review of Resident 107's PN dated 6-21-2018 revealed Resident 107's door was left open and Resident 15 was placed on 15 minute checks. Review of Resident 107's PN dated 6-21-2018 revealed there was not evidence the facility staff had evaluated Resident 107's for dangerous items or if Resident 107 could be left alone, in addition, there was not evidence the facility staff had evaluated the ability to remove the 15 minute checks for Resident 107. Record review of the facility Policy and Procedures for Suicide Precautions dated 5-2007 revealed the following information: -Policy: It is the policy of this facility to provide for the safety of all residents and prevent injury from suicide attempts. It is the policy of this facility that we will not admit or keep as residents, persons that are active suicide risk. -Procedures: -2. If a resident verbalizes an intent to attempt suicide or take any actions that could be interpreted as a suicide attempt, the following must occur: [NAME] Do not leave resident alone. B. Attempt to calm resident. D. Remove razors and other sharp or potentially dangerous objects from the resident's room. 3. Request orders for emergency transportation of resident to an emergency room or psychiatric evaluation facility as soon as possible. on 6-28-2018 at 2:01 PM an interview was conducted with the Director of Nursing (DON). During the interview review of the Policy and Procedures for Suicide Precautions was conducted with the DON. The DON confirmed during the interview the all of the interventions were not implemented for Resident 107 and should have been.",2020-09-01
2649,AZRIA HEALTH BROADWELL,285221,800 STOEGER DRIVE,GRAND ISLAND,NE,68803,2019-06-06,558,D,1,0,IQ3V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E2 Based on observation, record review, and interview, the facility failed to ensure one resident, Resident 213, was able to access the resident's bathroom sink and toilet in the resident's room because the doorway was too narrow to accommodate the standard size wheelchair. Findings are: Record review of Resident 213's Census sheet revealed the resident lived in room [ROOM NUMBER] until (MONTH) 2019 when the resident was moved to room [ROOM NUMBER]. Observation on 6-6-19 at 1:02 PM of room [ROOM NUMBER] bathroom doorway from the room into the bathroom measured at 33 inches. room [ROOM NUMBER] doorway between the room and the bathroom measured at 25.5 inches. Review of Resident's medical record revealed the resident was in a standard size wheelchair. Interview on 6-6-19 at 1:05 PM with the Physical Therapist revealed a standard wheelchair seat required 32 inches to be able to go through a doorway to accommodate for the width of the entire chair and a resident's hands. Interview on 6-6-19 at 1:15 PM with the ADM revealed the resident was moved to room [ROOM NUMBER] on a temporary basis and the ADM had not been aware the bathroom did not accommodate the size of the wheelchair.",2020-09-01
3941,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,689,E,1,1,OLWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E3 Based on observation, record review and interview, the facility failed to maintain hot water temperatures to prevent a potential hot water scald for 6 out of 20 sampled residents (Residents 3, 29, 21, 24, 30, and 33); failed to ensure hazardous chemicals on the housekeeping cart were stored securely from residents. This had the potential to affect Residents 23 and 34. The facility census was 34. Findings are: [NAME] -Tour of the room occupied by Resident 3 on 3/13/18 at 11:03 AM identified a hot water temperature of 122 degrees F (Fahrenheit). Resident had a BIMS (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.) score of 4 which identified the resident with severe impaired cognition. The resident was identified as not able to take self to the sink. -Tour of the room occupied by Resident 29 on 3/13/18 at 11:02 AM identified a hot water temperature of 122 degrees F. Resident had a BIMS score of 15, which identified resident as cognitively intact. Resident stated that they cannot take self to the sink. -Tour of the room occupied by Resident 21 on 3/13/18 at 11:23 AM identified a hot water temperature of 122.9 degrees F. Resident had a BIMS score of 13 which identified resident as cognitively intact. Resident stated that they turned on the cold water with the hot water. Also, stated that the water had been hot for some time. -Tour of the room occupied by Resident 24 on 3/13/18 at 10:52 AM identified a hot water temperature of 122.5 degrees F. Resident had a BIMS score of 11, which identified the resident with moderate impaired cognition. Resident was identified as not able to take self to the sink. -Tour of the room occupied by Resident 33 on 3/13/18 at 11:55 AM identified a hot water temperature of 120.5 degrees F. Resident had a BIMS score of 15 which identified resident as cognitively intact. Resident stated that the hot water is generally hot and turned on the cold water to make it comfortable. Resident was identified to be able to take self to the sink. An interview was held on 3/13/18 at 1:00 PM with the ADM (Administrator) and the MD (Maintenance Director) to discuss the issue of hot water temperatures in 5 of the resident's room. MD stated that there was no documentation as to when the hot water temperatures were monitored in the resident's room. ADM and MD stated that they would check the hot water heater's thermostat and check all of the resident's rooms hot water temperature on the 300 and 400 halls. Review of the MD's preventive maintenance binder did not identify that the hot water temperatures in the resident rooms had been monitored for the past several months. ADM stated that the MD was new to the position and the previous MD was terminated for not following through on assignments. Interview on 3/13/18 at 5:00 PM with the ADM and MD identified that the hot water temperatures were checked in the resident rooms on the 300 and 400 halls and all of the rooms were in compliance with the required hot water temperature. Review of the water temperature log identified the water temperatures were within the required temperatures. MD stated that the hot water temperatures would be monitored throughout the night by the nursing staff and documented on the hot water temperature log. The nursing staff was directed to call the MD with any issues. A copy of the hot water temperature log was given to Surveyor on 3/14/18 at 8:00 AM and identified that the hot water temperature was still within the required temperatures. LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E4 B. Observation on 3-15-18 at 10:25 AM a housekeeper car in the hallway in front of a resident room doorway. On top of the housekeeper cart was 2 ice cream buckets each filled approximately 1/2 full with water. One bucket was brownish colored water and the other a yellow color. One bucket was labeled Neutral Floor Cleaner and the other was labeled Multi-Surface Cleaner/Disinfectant. Observation of the cart revealed no staff were observed in the area of the cart for 4 minutes. During this time, Resident 23 wheeled self independently by the housekeeping cart. The resident stopped and visited for approximately 30 seconds then wheeled self-down the hall. At 10:29 AM Hskp-J (Housekeeper) appeared from the resident bathroom in which the housekeeping cart was parked in front of. Interview on 3-15-18 at 10:30 AM with Hskp-J revealed the Housekeeping staff keep the buckets on top of the cart with the Multi-Surface Cleaner/Disinfectant and Neutral Floor Cleaner in them unsecured because the housekeeping cart had one locked compartment and it was used for their spray and other chemicals they used and therefore no room for the buckets. Hskp-J confirmed the housekeeping cart was not within site when Hskp-J was in the resident's bathroom. Review of the MSDS (Material Safety Data Sheets) for the Multi-Surface Cleaner/Disinfectant revealed the chemical was harmful if swallowed or if it came into contact with the skin. It could also cause severe [MEDICAL CONDITION] eye damage. Review of the MSDS for the Neutral Floor Cleaner revealed a warning that the chemical caused irritation if contact with the eye. Review of Resident 23's MDS dated [DATE] (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 3 which indicated the resident was severely cognitively impaired. The resident wandered daily. C. Observation on 03/13/18 at 01:31 PM of a bottle of 70% [MEDICATION NAME] Alcohol sitting in Resident 34's room by the sink. Interview on 03/13/18 at 01:31 PM with Resident 34 revealed Resident 34 did not know why [MEDICATION NAME] Alcohol was being used. Observation and review of the label on the bottle of [MEDICATION NAME] Alcohol revealed, Caution: If taken internally, serious gastric disturbances will result. In case of accidental ingestion seek professional assistance or contact a poison control center immediately. Review of MDS (minimum data set, a federally mandated assessment used for care planning) Resident 34's BIMS (brief interview for mental status, screening tool used in nursing homes to assess cognition) was 05 which indicates severe cognitive impairment. Interview on 03/19/18 at 03:05 PM with the DON (Director Of Nursing) verified the observation of the bottle of rubbing Alcohol in Resident 34's room. The DON revealed that it was not known why the chemical was in the room.",2020-09-01
5246,MITCHELL CARE CENTER,285287,1723 23RD STREET,MITCHELL,NE,69357,2017-02-08,323,D,1,0,N9SQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E4 Based on observation, interview, and record review; the facility failed to secure potentially hazardous chemicals from potential access by Resident 27. This affected 1 of 3 sampled residents. The facility identified a census of 49 at the time of survey. Findings are: Review of Resident 27's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 11/28/2016 revealed that Resident 75 had a [DIAGNOSES REDACTED]. Observation of Resident 27's room on 2/8/2017 at 1:10 PM revealed 2 eight ounce bottles of peri-wash (liquid skin cleanser) 1/2 full (one McKesson brand and one In Between) in Resident 75's bathroom and 1 eight ounce bottle of In Between peri-wash 2/3 full on Resident 75's dresser. All of the items were within reach of a resident who could walk without assistance. Observation of Resident 27 on 2/8/2017 at 1:37 PM revealed Resident 27 walked without assistance and wandered. Review of the MSDS (Material Safety Data Sheet) for In Between peri-wash revealed do not take internally. Review of the MSDS for McKesson peri-wash revealed that ingestion would require medical attention and that the material may cause mild eye irritation and gastrointestinal (stomach) disturbance. Interview with the DON (Director of Nursing) on 2/8/2017 at 2:14 PM revealed that Resident 27 had a history of [REDACTED]. Interview with the facility administrator on 2/8/2017 at 2:24 PM revealed that staff had been directed to remove items from Resident 27's room that were not to be ingested and confirmed the peri-wash should have been removed from Resident 27's room. The administrator confirmed the peri-wash could be located in other residents' rooms so a plan would need to be developed to keep potentially hazardous materials out of reach of cognitively impaired residents.",2020-02-01
4176,MEMORIAL COMMUNITY CARE,2.8e+192,1423 SEVENTH STREET,AURORA,NE,68818,2018-04-02,689,D,1,1,2JT811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E4 Based on observations and interviews, the facility failed to ensure potential hazardous chemicals were stored securely in the 400 unit bath house which had the potential to affect 8 residents (Resident 28, 22, 24, 39, 15, 12, 30, and 19) who lived on the 400 hallway. The facility census was 43. Findings are: Observation on 3-27-18 at 12:09 PM revealed the bath house door on the 400 unit was open. Inside the bath house was an unsecured cabinet and inside was a prescription bottle of [MEDICATION NAME] shampoo for Resident 15, a prescription bottle of Anti-Dandruff shampoo for Resident 22, and a bottle of rubbing alcohol. There was no residents observed in the unit hallway. Observation on 3-28-18 at 1:59 PM revealed the bath house door on the 400 unit was open. Inside the bath house was an unsecured cabinet which contained a prescription bottle of [MEDICATION NAME] shampoo for Resident 15, a prescription bottle of Anti-Dandruff shampoo for Resident 22, and a bottle of rubbing alcohol. There was no residents observed wandering in the unit hallway. Observation on 3-29-18 at 11:55 PM revealed the bath house door on the 400 unit was open. Inside the bath was a cabinet with one door wide open and the other door closed. Inside the cabinet was a prescription bottle of [MEDICATION NAME] shampoo for Resident 15, a prescription bottle of Anti-Dandruff shampoo for Resident 22, and a bottle of rubbing alcohol. There was no residents observed wandering in the unit hallway. Interview on 3-29-18 at 11:55 PM with the RN-E (Registered Nurse) confirmed the door to the cabinet was open and inside was a prescription bottle of [MEDICATION NAME] shampoo for Resident 15, a prescription bottle of Anti-Dandruff shampoo for Resident 22, and a bottle of rubbing alcohol. Interview on 04-02-18 at 3:42 PM with the DON (Director of Nursing) confirmed the facility had no resident who wandered.",2020-09-01
3000,OMAHA NURSING AND REHABILITATION CENTER,285240,4835 SOUTH 49TH STREET,OMAHA,NE,68117,2018-04-23,689,D,1,0,VOD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.D7a Based on observation and record review; the facility staff failed to ensure the correct type of transfer sling was used for a mechanical lift transfer for 1 (Resident 2) of 3 sampled residents. The facility staff identified a census of 63. Findings are: Record review of Resident 2's Comprehensive Care Plan (CCP) dated 1-03-2017 revealed Resident 2 had the [DIAGNOSES REDACTED]. Further review of Resident 2's CCP revealed Resident 2 required the use of a Hoyer (mechanical) lift for transfers. Observation on 4-23-2018 at 6:48 AM of a transfer for Resident 2 revealed Nursing Assistant (NA) B and NA C obtained a transfer sling that was green with blue trim. NA B and NA C placed the sling under Resident 2 and then connected the sling to the Hoyer left. NA B and NA C lift Resident 2 up in order to obtained Resident 2's weight. According to the scale on the Hoyer lift, Resident 2 weight was 270.4 pounds. NA B and NA C transferred Resident 2 from the bed to a wheelchair and removed the sling. On 4-23-2018 at 8:30 AM an interview was conducted with the Director of Nursing (DON). During the interview, the DON reported the size of the sling was based on a resident's weight and staff would go by the trim color on a sling chart for correct sling size with the resident's weight. Review of undated sling chart revealed the title of the chart was Hoyer Sling Color Codes and hand written at the bottom of the Sling Chart was the staff were to use The outside seam color determines size. Further review of the sling chart revealed based on Residents 2's weight the staff should have used a a sling with green trim. During the interview observation of the sling used for Resident 2 with the DON was a green with blue trim. The DON confirmed the sling that was used for the transfer was not correct. Record review of the facility Policy and Procedure for the use of Lift Slings dated 4-2018 revealed the following information: -Policy: Each resident requiring a mechanical total-body lift with transfers will be transferred with the use of a lift sling appropriate for the lift being used and each resident's size and weight. -Procedures: -When it is determined that a resident requires the use of a mechanical total-body lift, obtain a resident's weight prior to selecting a sling. -Each sling is color coded according to a range of weights. Select a sling with the weight range into which the resident's weight falls.",2020-09-01
5517,PRESTIGE CARE CENTER OF PLATTSMOUTH,285104,602 SOUTH 18TH STREET,PLATTSMOUTH,NE,68048,2016-11-14,323,D,1,0,VVYQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.D7b Based on observation, interview and record review; the facility failed to review and revise fall interventions for one of four sampled residents (Resident 3) and failed to implement a fall intervention for another resident (Resident 1). The facility census was 84. Findings are: Review of Resident 3's nursing progress note dated 11/2/16 revealed the resident had a fall and was found on the floor of room. Resident 3 reported being unsure of what caused the fall. Resident was sent to the emergency room for evaluation. Resident 3 ' s Progress note dated 11/12/16 indicated the resident had another fall in their room and reported getting up to go to the bathroom, sat on the bedside and then slid to the floor. Review of Resident 3's care plan identified that the resident was at risk for falls related to a history of falls and a history of seizures. The care plan did not identify these two falls or any revised interventions to prevent a reoccurrence of the falls. On 11/14/16 at 2:30 PM Nursing Assistant A, (NA A) who worked the day shift, was asked what fall interventions were in place for Resident 3 and NA A was not aware of any fall interventions. NA B was interviewed on 11/14/16 at 2:57 PM about fall interventions for Resident 3 and NA B identified one intervention of keeping an eye on the resident. The Director of Nursing (DON) was interviewed on 11/14/16 at 2:07 PM about Resident 3's falls on 11/2 and 11/12/16. The DON confirmed that the resident had falls on those dates and that the plan of care had not been reviewed and new interventions had not been identified. B. Review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 10/26/16 revealed the resident required extensive assistance of one for transfers and that the resident had moderately impaired cognition. Review of Resident 1's care plan revealed a problem related to falls that was initiated on 4/14/16. A problem was listed that related to the need for assistance with Activities of Daily Living (ADL). This was initiated on 8/30/16. The care plan indicated Resident 1 fell on [DATE] and a bed and chair alarm were added as an intervention to prevent a reoccurrence. On 11/14/16 at 9:57 AM observation was made of Resident 1 in the therapy room. There was no chair alarm in the resident's wheel chair. At 10:02 AM on 11/14/16 NA A was interviewed about fall interventions for Resident 1. NA A stated that (gender) had gotten the resident up and confirmed that (gender) had not put the alarm in the wheel chair.",2019-11-01
2903,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2019-04-22,760,D,1,1,BJ6K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 2-006.10D Based on record review and interview the facility staff failed to administer medication as ordered by the physician for 1 (Resident 43) of 1 sampled resident. The facility staff identified a census of 60. The finding are: Record Review of a Fax document for Resident 43 to the physician dated 9/29/2018 revealed a note from the nurse stating that Resident 43 complained of increased anxiety and restlessness. Resident 43 has been pacing the floors and is unable to sleep. Resident 43 is also stating that he is unable to stay still. Resident 43 is in room cursing someone who is not there as well. Resident 43 states the anxiety is caused by his recent prescription of [MEDICATION NAME] (a medication used to treat anxiety). The nurse asked if there was something that can be prescribed. Further documentation on the fax document dated 9/29/2018 revealed a note that patient should be evaluated by the provider at the nursing facility signed 10/1/2018. [MEDICATION NAME] (a medication used to treat certain mental and mood conditions) 25mg BID (twice a day) was written at the bottom of the fax document, with no date. The order was not noted by a nurse. At the top of the fax document dated 9/28/2018 for Resident 43 was written for an appointment for 10/2 at 0820. Record Review of Resident 43's MAR (Medication Administration Record) for (MONTH) and (MONTH) (YEAR) revealed there was no [MEDICATION NAME] 25mg BID. Record review of nursing progress notes for Sept and (MONTH) (YEAR) revealed no documentation regarding the [MEDICATION NAME] order or documentation regarding the resident going to an appointment on 10/2/2019. Interview conducted with Clinical Resource Registered Nurse [NAME] on 4/9/2019 at 10:58 AM confirmed that the order on the bottom of the fax form dated 9/29/2018 had not been noted or carried forward to the MAR and there was no documentation regarding an appointment on 10/2/2018.",2020-09-01
3915,HILLCREST COUNTRY ESTATES-COTTAGES,285293,6082 GRAND LODGE AVENUE,PAPILLION,NE,68133,2017-05-04,314,G,1,1,POAF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC12-006.09D2a,12-006.09D2b Based on observation, record review and interview; the facility failed to identify new pressure ulcer, and failed to implement interventions to prevent a decline in the condition of a pressure ulcer for Resident 55. One of three residents sampled. The facility census was 46. Findings are: Observation of Resident 55's wound care on 5/3/17 , revealed the removal of a Negative-pressure wound therapy (NPWT) (a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing). Wound assessment revealed a stage IV wound ( full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, undermining and sinus tracts also may be associated with stage IV pressure ulcers), to Resident 55's left heel area. The wound measurements were 4.7 centimeters (CM) in length, 5 cm in width with 1.2 cm depth. There was undermining present of 1.2 cm depth. Present on the top of this leg, where the foot and lower leg join, was a new area that had developed. RN (Registered Nurse) H was performing the wound care. Upon completion of wound care, it had not been identified by RN H. Upon the surveyor identifying the area, it was determined by RN H to be a new area. Interview with RN H on 5/3/17 at 2:07 PM confirmed that the wound doctor was present today and did confirm that Resident 55 had a new stage II (partial thickness skin loss) pressure ulcer on anterior ankle area. RN H confirmed that this Stage II was a newly developed pressure area that it occurred from pressure related to [MEDICAL CONDITION] wear and the boot used to prevent pressure to the heel. Record review of Resident 55's electronic medical record revealed, under Census, that Resident 55 was admitted to the facility on [DATE]. Record review of a wound record dated 12/21/16 revealed that the original date for documentation of the wound to left heel was 12/21/16. The description of the wound was, [MEDICAL CONDITION] left lower post foot. Wound size was 2.5 cm x 1.5 cm x 0.1 cm. (LxWxD). Skin prep was being used on the wound as a treatment. A second wound was described as a pressure ulcer to left medial heel measuring 2.1 x 1.5 x 0.1 with a treatment of [REDACTED]. Record review of, wound consultant's report, for Resident 55, by Mobile Wound Solutions, LLC (MWS), dated 2/1/17, revealed that the pressure ulcer to left posterior heel had deteriorated. Measurements were 4.5 cm x 2.1 cm x 0.4 cm. Debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) was necessary. Record review of, wound consultant's report, for Resident 55, by MWS note dated 3/1/17, revealed that left heel wound was unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, gray, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and or eschar is removed to expose the base of the wound, the true depth, and therefore category/stage, cannot be determined). Dressing to be performed by the facility was to cleanse the wound and apply santyl for enzymatic debridement. Record review of MWS note for Resident 55, dated 3/22/17, revealed to discontinue current treatment and the treatment was changed to santyl with a carbo-flex dressing with bordered gauze and to change the dressing daily. MWS note revealed that, wound status was deteriorated. Wound size was 7.2cm x 5.2 cm x 0.8 cm. A wound note revealed that the physician felt that it was time for wider surgical debridement and recommend referral to a surgeon. Record review of MWS note for Resident 55, dated 3/29/17, revealed that Resident 55 had recent surgical debridement and NPWT was started. Record review of Resident 55's comprehensive plan of care, revealed no dates as to when pressure ulcer prevention was initiated. Resident goal revealed that Resident 55 would remain free of skin breakdown. Interventions are undated and reveal that staff was to assess skin for redness, skin tears, swelling or pressure areas. Other interventions, also undated, revealed that Resident 55 often declined repositioning; that staff were to use pillow, pads or wedges to reduce pressure on heels and pressure points; and to turn and reposition. An intervention, undated, was to use an air mattress for increased pressure relief and a cushion to wheelchair. Record review of Resident 55's comprehensive plan of care revealed a problem of Pressure ulcer, unstageable to left heel which was undated. The goal was for the pressure ulcer to decrease with evidence of healing over next 30 days. Undated interventions included to assess and record the size, drainage and assess for pain. Heel lift boots and wound vac were to be used. Interview with RN H on 5/3/17 confirmed that Resident 55 had developed pressure area to left heel and that the wound had deteriorated. RN H confirmed that the wound had on the left heel had increased in size.",2020-09-01
1561,"BCP BLUE HILL, LLC",285144,414 NORTH WILLSON,BLUE HILL,NE,68930,2019-03-21,609,D,1,1,118W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.02 (8) Based on interview and record review, the facility failed to report a fall with significant injury to the state agency within the required time frame. This affected 1 (Resident 29) out of 8 residents investigated for accidents during the survey process. The facility identified a census of 31 at the time of survey. Findings are: Review of Resident 29's annual MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 3/11/2019 revealed an admission date of [DATE]. Resident 29 had a BIMS (Brief Interview for Mental Status) score of 10 which indicated moderate cognitive impairment. Resident 29 required extensive assistance from staff for bed mobility, locomotion on and off the unit, dressing, personal hygiene, transfers, and toilet use. Interview with Resident 29 on 3/18/19 at 4:14 PM revealed they had fallen out of their chair and bruised their shoulder. Review of Resident 29's Progress Notes revealed the following: On 12/30/2018 at 10:45 AM, Resident 29 was found on the floor seated on their buttocks next to the recliner in their room. On 12/31/2018 at 8:15 AM the nurse placed a call to the medical provider to notify that Resident 29 had left shoulder pain and a decrease in ROM (range of motion). On 12/31/2018 at 8:57 AM the nurse notified the medical provider of Resident 29's left shoulder pain and recent fall. On 12/31/2018 at 1:22 PM a new order was received from the medical provider for a 2 view x-ray of left shoulder due to pain and recent fall if resident and family agreeable. On 1/2/2019 at 1:00 PM Resident 29 went out of the facility per facility van to the hospital for X-ray to left shoulder as ordered. Review of Resident 29's XR (x-ray) shoulder complete minimum 2 views left report dated 1/2/2019 revealed a left acromioclavicular (shoulder) separation sprain and left lateral rib fractures with mild displacement that were age indeterminate. There was no documentation in the Progress Notes that Resident 29's fall with significant injury was reported to the state agency. Interview with the facility Administrator on 3/21/19 at 12:00 PM confirmed there was no documentation Resident 29's fall with significant injury was reported to the state agency. Review of the facility policy Abuse, Neglect, and Exploitation Prohibition and Prevention Program dated 9/1/2018 revealed the following: all allegations of abuse, neglect, and exploitation are promptly investigated in accordance with the facility's policy on conducting internal investigations. All covered individuals including mandated reporters, employees, and LTC (Long Term Care) communities have an obligation to report all allegations of abuse, neglect, or exploitation to the appropriate state authorities as required, immediately, but no later than 24 hours after the allegation or occurrence. A report of the investigation is provided to the appropriate state agency within five working days of the incident, unless otherwise indicated by state law or regulations.",2020-09-01
1634,MAPLE CREST HEALTH CENTER,285149,2824 NORTH 66TH AVENUE,OMAHA,NE,68104,2019-09-12,609,D,1,0,WF7F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.02(8) Based on record review and interview; the facility staff failed to notify the State Agency of an elopement within the required time frame for 1 (Resident 100) 3 residents reviewed. The facility staff identified a census of 151. Findings are: Record review of a Order Summary Report revealed Resident 100 admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 100's Comprehensive Care Plan (CCP) dated 11-01-2017 revealed Resident 100 had cognitive decline related to [MEDICAL CONDITION], including short and long term memory loss. Record review of Resident 100's Progress Note (PN) dated 6-08-2019 revealed a Visitor had alerted a Registered Nurse (RN) that Resident 100 . got out side when other visitors were entering the facility. Further review of Resident 100's PN dated 6-08-2019 revealed Resident 100 was in the parking lot and was refusing to return to the facility. According to Resident 100's PN dated 6-08-2019, revealed 2 Nursing Assistants and another RN responded in attempt to have Resident 100 return to the building. According to the PN dated 6-08-2019, Resident 100 continue to refuse to return to the facility. On 9-12-2019 at 12:55 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed Resident 100's elopement on 6-08-2019 had not been reported to the required State Agency. Record review of the facility policy of Abuse Investigation revised on 8-2006 revealed the following information: -Policy Statement: -All reports of resident abuse, neglect, misappropriation of resident property and injuries of unknown source shall be promptly and thoroughly investigated. - Notification pf Adult Protective Services (APS). -The person in charge of the abuse investigation will notify Nebraska Health and Human services (NHHS)- APS and local Law enforcement (depending on severity of the incident) that an abuse investigation is being conducted immediately, but no later than 2 hours after the allegation is made.",2020-09-01
1633,MAPLE CREST HEALTH CENTER,285149,2824 NORTH 66TH AVENUE,OMAHA,NE,68104,2019-08-19,745,D,1,0,1O2T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.04E3 Based on record review and interview; the facility Social Services failed address changes in mood for 2 (Resident 1 and 5) of 3 sampled residents. The facility staff identified a census of 150. Findings are: A. Record review of Resident 1's Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) dated 7-20-2019 revealed the facility staff assessed the following about Resident 1: -Brief Interview of Mental Status (BI[CONDITION]) revealed a score of 15. According to the MDS Manuel, a score of 13 to 15 indicates a person is cognitively intact. -Had feelings of feeling down and Depressed. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Record review of Resident 1's Progress Notes dated (PN) 6-24-2019 revealed Resident 1 had been upset due to not being able to talk with a family member prior to the family member leaving the country. According to the PN dated 6-24-2019 Resident 1 wanted staff to kill (gender) and if the staff would not, Resident 1 reported Resident 1 would kill (gender). According to the PN dated 6-24-2019, Resident 1 did not have a plan for to commit suicide. Resident 1 was placed onto 15 minute checks. Record review of a 15 Minute Visual Check Record with a date of 7-21- (2019) revealed Resident 1 was placed on 15 minute visual checks due to Suicidal Ideation's. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 12-10-2019 revealed Resident 1 had the potential for a decline in mood. Interventions identified on Resident 1's CCP included 1 to 1 PRN (as needed) for emotional support. On 8-14-2019 at 12:26 PM an interview was conducted with Social Services (SS) B. During the interview when asked if SS B had followed up with Resident 1 after making suicidal statements, SS B reported (gender) had not followed up with Resident 1. On 8-14-2019 at 12:26 PM an interview was conducted with SS A. During the interview SS A confirmed not being involved in removing Resident 1 from 15 minute checks. SS A reported not routinely being involved with Resident 1. SS A confirmed SS A had not followed with with Resident 1 after the suicidal statements on 6-24-2019 and 7-21-2019. Record review of the Job Description for the facility Social Worker dated 8-2017 revealed the following information: -Job Summary; -Social worker is responsible for providing assessment, counseling and supportive services in accordance with the interdisciplinary plan of care which promote the mental, psychosocial, and spiritual health of the residents along the Community's continuum of care. Ensures compliance with current social work practices, all applicable laws and regulations. -Duties and Responsibilities: -Provides counseling, as appropriate, to individuals and groups to maximize strengths and to promote healthy adjustment to physical limitations and other losses imposed by the aging process. -Provides crisis intervention to residents and significant others as needed. B. Review of Resident 5's Progress note dated 6/6/2019 revealed Resident 5 was admitted Post hospitalization for suicidal thoughts. Review of Resident 5's Progress note dated 6/11/2019 at 9:16 AM revealed Resident 5 was weepy in morning. Review of Resident 5's Progress note dated 6/16/2019 at 9:36 AM revealed Resident 5 was tearful regarding new roommate. Nursing was going to notify Social Worker B. Review of Resident 5's Progress notes for 6/16/2019 did not contain a note to indicate that Social Worker A or Social Worker B completed 1:1 with Resident 5. Review of Resident 5's Behavior Note dated 6/25/2019 at 5:45 revealed Resident 5 became upset and started crying and making threats of wanting to kill herself. Review of Resident 5's Behavior Note dated 6/26/2019 at 5:42 PM revealed Resident 5 is weepy before lunch. Review of Resident 5's Spiritual Care Note date 6/28/2019 revealed the facility chaplain made a routine spiritual care visit to Resident 5 and Resident 5 started to cry and said that if Resident 5 couldn't go home, Resident 5 wanted to die Review of Resident 5's Behavior Note dated 7/5/2019 Resident 5 was in bed crying the nurse offered emotional support and spoke to social worker. Review of Resident 5's Behavior Note dated 7/7/2019 revealed Resident 5 had 2 weepy episodes Review of Resident 5's Behavior Note dated 7/14/2019 revealed Resident 5 was tearful, upset and happy at various times thru the shift. Review of Resident 5's Behavior Note dated 7/21/2019 revealed Resident 5 is very tearful and upset at this time. Resident wanting to talk to social worker tomorrow. Review of Resident 5's Progress note revealed no note indicating that Social Worker A or Social Worker B talked to Resident 5 on 7/22/2019. Review of Resident 5's Spiritual Care Note dated 7/26/2019 revealed the chaplain was asked to visit Resident 5 because she was having a bad day and had told nurse she wanted to kill herself. Interview on 8/14/2019 at 12:40 PM with Social Worker B regarding what Social Worker B does to promote Resident 5's Psycho-social wellbeing Social Worker B states one to one visits are if nursing brings a problem to Social Worker B. Review of Resident 5's medical record revealed no follow up notes from Social Worker A or Social Worker B related to Resident 5 being tearful or making self-harm statements. Review of Resident 5's care plan initially created by Social Worker B revealed Resident 5 to have statements of: -Resident 5 has a potential for decline in mood state. -Resident 5 has a history of making suicidal comments and a history of attempting suicide. -Resident is diagnosed with [REDACTED]. Resident 5's care plan goals were: -Resident will have no increase ins/s of Anxiety Disorder -Resident will have no increase ins/s of [MEDICAL CONDITION] Disorder. -Resident will have no increase ins/s of [MEDICAL CONDITION]. -Resident will have no increase ins/s of Major [MEDICAL CONDITION] -Resident will interact appropriately with others. - Resident will make no suicidal comments. - Resident will remain free from self-harm. Interventions for Social Worker involvement include: -1:1 prn(as needed) for emotional support. -Administer PHQ-9 quarterly and prn. -Assist resident in developing healthy coping skills prn. -Behavior chart to monitor for any changes in mood/behavior. -Communicate with resident's responsible party regarding resident's mood. - Evaluate effectiveness and side effects of meds for possible decrease/elimination of [MEDICAL CONDITION] drugs. - Monitor for s/s of anxiety- agitation, restlessness, and picking at skin, repetitive physical movements- and report to MD as needed. o - Monitor for s/s of [MEDICAL CONDITION] disorder- shifts in mood, energy, thinking, lows and highs, problems with concentration and sleeping- and report to MD as needed. -Monitor for s/s of depression i.e.-isolative, withdrawn behaviors, crying, tearfulness and report to MD as needed. - Monitor for s/s of [MEDICAL CONDITION] disorder- loss of interest, paranoid thoughts and ideas, hallucinations, manic mood, tearfulness- and report to MD as needed. - Notify resident appropriate MD if resident makes suicidal statements or attempts harm to self or others. - Remove any potentially dangerous items and sharp objects from resident's room and possessions. Interview on 8/14/2019 at 12:40 PM with Social Worker B revealed Social Worker B is assigned to Resident 5 but does not work with Resident 5 much because Social Worker B had identified that Resident 5's behaviors increase with interactions with Social Worker B.",2020-09-01
3905,LITZENBERG MEMORIAL COUNTY HOSPITAL,285292,1715 26TH STREET,CENTRAL CITY,NE,68826,2019-12-12,657,D,1,0,U6U411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.09C1c Based on interview and record review, the facility staff failed to review and revise the care plans for Residents 1, 2, and 3 to prevent further incidents and potential injury after residents had falls. Findings are: A. Review of Resident 1's Admission Record revealed an admission date of [DATE]. Review of Resident 1's Care Plan dated [DATE] revealed no documentation that the care plan was reviewed and revised with measures for new interventions to prevent Resident 1 from falling. Review of Resident 1's Progress Note dated 11/26/19 at 4:00 PM revealed resident was found on lying on the floor. B. Review of Resident 2's Admission Record revealed an admission date of [DATE]. Review of Resident 2s Care Plan dated 12/5/19 revealed no documentation that the care Plan was reviewed and revised with measures for new interventions to prevent Resident 2 falling. Review of Resident 2's Progress Note dated 12/09/19 at 07:37 AM revealed the resident Was found lying beside wheelchair. C. Review of Resident 3's Admission Record revealed an admission date of [DATE]. Review of Resident 3's Care Plan dated 11/23/19 revealed the care plan was reviewed and revised with new interventions to prevent Resident 3 from falling. Review of Resident 3 Progress Note dated 11/23/19 at 11:15 AM reviewed resident was found on floor in room. Interview with NA (Nurse Aide)-A on 12/12/19 at 1:00 PM revealed they get the information they need to care for the residents from the care plan. Interview with the DON (Director of Nursing on 12/12/19 at 1:30 PM confirmed there was no documentation on the care plans for Resident 1 and 2 of review and revision with measures implemented to prevent further falls. The DON confirmed that Resident 3 care plan was reviewed and had revision with measures implemented to prevent further falls.",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
2156,LEGACY GARDEN REHABILITATION & LIVING CENTER,285186,200 VALLEY VIEW DRIVE,PENDER,NE,68047,2020-01-15,689,D,1,1,0XIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.09D7 Based on record review and interview; the facility staff failed to implement identified interventions to prevent elopement for Resident (14). The facility staff identified a census of 32 . Findings are: A. Record review of Resident 14's Comprehensive Care Plan (CCP) effective 7-12-18 revealed Resident 14 had a risk of elopement. Further review of Resident 14's CCP effective 7-12-18 revealed Resident 14 wore a wanderguard (device which alarms when at a facility exit). The goal identified on Resident 14's CCP was Resident 14 is at risk for elopement and wandering. An Intervention identified on Resident 14's CCP I may only leave facility on short outing with staff only and I wear a wanderguard that alerts staff if I attempt to leave the facility. Record review of the facility investigation revealed on 9/24/2019 at approximately 0520 a resident was noted to have ambulated out the front door and not being witnessed by staff until he was part way down the sidewalk. The resident was later identified as Resident 14. Further review of the facility investigation reveals that the wanderguard alarm was sounding at the front door and the nurse ambulated Resident 14 back inside the building. The report states that when Resident 14 returned inside the building, he went over to a recliner by the nurses' station and fell asleep. The report also revealed that Resident 14 has a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS a federally mandated assessment tool used for care planning) revealed Resident 14 has a BI[CONDITION] (Brief Interview for Mental Status) score of 12 which, according to the MDS a score of 8-12 indicated moderately impaired cognition. On 1/14/2020 at 2:30 PM an interview was conducted with the Director of Nursing and the Administrator. During the interview the Administrator reported that the nurse aides were back in the hallways assisting other residents, and probably did not hear the alarm sounding until they stepped out of the room.",2020-09-01
4026,SANDHILLS CARE CENTER,285298,143 N FULLERTON STREET,AINSWORTH,NE,69210,2019-10-09,689,E,1,0,Y6PW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.09D7b Based on observations, record review, and interview; the facility failed to identify causal factors, develop new interventions and/or revise current interventions, and failed to implement interventions for the prevention of further falls for 3 (Residents 1, 2 and 3) of 8 sampled residents. The facility census was 21. Findings are: A. Review of Resident 2's current Care Plan with a review date of 8/28/19 revealed the resident was at high risk for falls related to cognitive impairment and generalized weakness. Further review revealed the resident had fallen on 5/15/19, 6/13/19, 6/19/19, 8/19/19, 9/26/19, and 10/7/19. The following fall prevention interventions were identified. - Place pancake light at the resident's side so when the resident got up the call light and fall mat would alarm, - the physician was consulted regarding the resident's urinary frequency, - the resident had a medication change due to urinary frequency, - staffing was assessed, - a bed/chair alarm was initiated, - a bolster pillow placed on the resident's side when sleeping, - a scoop mattress was placed on the resident's bed, - the resident was not to be left in the dining room unsupervised, and - staff would offer the bathroom when the resident got up in the morning, before and after every meal, before and after every activity, and before going to bed at night. Review of Resident 2's Post Fall assessment dated [DATE] revealed the resident fell at 5:25 AM in the resident's room. Further review revealed the resident was trying to go to the bathroom. The root cause analysis identified the problem was the resident was attempting to go to the restroom due to the need to urinate as the resident had not been up during the night. The fall intervention did not address the causal factor and the report did identify when the resident was last taken to the bathroom. Review of Resident 2's Post Fall assessment dated [DATE] revealed the resident fell at 7:45 PM in the resident's room. The root cause analysis identified the problem as the resident trying to get out of the resident's chair unassisted due to dementia and not knowing the resident's limits. The fall intervention identified was to assess staffing. The report did not indicate the last time the resident was taken to the bathroom. Review of Resident 2's Incident Report dated 9/26/19 revealed the resident fell at 6:57 PM. Further review revealed the report did not identify possible causal factors for the resident's fall. Review of Resident 2's Post Fall assessment dated [DATE] revealed the resident fell at 11:15 AM trying to go to the bathroom. The root causal analysis was not completed and the assessment did not identify the last time the resident was taken to the bathroom. The new intervention identified was to toilet after lunch (the fall was identified as happening prior to lunch at 11:15 AM). Observations of Resident 2 on [DATE] revealed the following: - At 10:10 AM, the resident was seated in the activity room during a bowling activity. - At 11:00 AM, the resident was assisted from the bowling activity and was sat in the dining room facing out the window. - At 11:20 AM, the resident remained in the dining room facing out the window. - At 11:51 AM, the resident was seated at the dining room table with the resident's drinks in front of the resident. Interviews with Nursing Assistant (NA)-C, NA-D, and NA-F on [DATE] from 11:44 AM to 11:55 AM revealed the resident was last taken to the bathroom between 9:30 AM and 10:00 AM. Further interviews revealed the staff each had though the other staff had taken the resident to the bathroom before lunch (none of them had). The staff went on to state the resident would not be taken to the bathroom again until after lunch, which would be between 1:00 PM and 1:30 PM (approximately 3-4 hours since the previous toileting). Interviews with the Director of Nursing (DON) on [DATE] from 1:19 PM to 1:25 PM confirmed an Incident Report and Post Fall Investigation should have been completed after falls to help identify causal factors. Continued interview confirmed those forms were not completed consistently following Resident 2's falls. B. Review of the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/24/19 revealed the following related to Resident 1: -cognitive impairment with impaired decision making skills; -required extensive assistance with bed mobility, transfers, dressing and toileting, and total assistance with personal hygiene; -was not steady, and only able to stabilize with human assistance, when moving from a seated to standing position, moving on and off the toilet, and during surface-to-surface transfers; and -frequently incontinent of urine. Review of the current Care Plan with a revision date of 8/5/19 indicated Resident 1 was at risk for falling due to impaired cognitive function, incontinence and need for assistance with cares. The care plan identified the resident had an unwitnessed fall on 9/30/19. Nursing interventions included the following: -remind resident to wait for assistance with toileting; -staff to offer assistance with toileting when the resident gets up in the morning, before or after meals, before or after activities and when going to bed; -extensive staff assistance with transfers, toileting, bed mobility, personal hygiene and ambulation; -ensure bed is in the lowest position when napping or at night; -call light within reach at all times; -frequent checks on resident as will frequently forget to use the call light and will call out when needs assistance; -sign placed in the resident's room to remind to use call light; and -non-skid tape on the floor by the resident's recliner to prevent slipping and falling. Review of the Resident's Morse Fall Scale dated 8/21/19 at 9:58 AM revealed the resident was at high risk for falls. Review of Nursing Progress Notes dated 9/15/19 revealed the following: -2:27 PM the resident hollers out instead of using the call light; and -3:42 PM the resident attempted to self-transfer x2 (times). The resident refused to use the call light and instead called out to staff for assistance to the bathroom. Review of a Nursing Progress Note dated [DATE] at 10:35 PM revealed the resident had been calling out for assistance to use the bathroom. The resident was re-educated on use of the resident's call light and safety. Review of a Nursing Progress Note dated 9/18/19 at 5:12 AM revealed the resident had hollered out for help 5x's this shift The resident was assisted to the bathroom and was provided with snacks and fluids. The resident was reminded of using the call light instead of screaming. Review of Nursing Progress Notes dated [DATE] revealed the following: -5:24 AM the resident had hollered out for snacks and toileting x9 this shift; and -11:29 PM the resident hollered several times for snacks and toileting. In addition, the resident had attempted to self-transfer to the bathroom [ROOM NUMBER] times. Review of Nursing Progress Notes dated 9/26/19 revealed the following: -2:38 AM the resident was frequently on the call light (13 times) and wanted to use the bathroom; and -11:20 PM the resident had attempted to ambulate independently from the dining room after the evening meal with multiple episodes of calling out for help. Review of Nursing Progress Notes dated 9/30/19 revealed the following: -5:49 AM the resident had called out numerous times to use the bathroom and requesting snacks; -1:40 PM the resident was heard calling for help. When staff entered the resident's room, the resident was found on the floor between the bed and the recliner. The resident indicated a need to urinate. The resident denied pain and was able to move all extremities. The resident was stood with 2 assist from the floor and identified pain to the right leg when bearing weight. The resident was assisted to the bathroom and then back to bed; Review of an Incident Report dated 9/30/19 at 2:16 PM revealed the resident's fall was unwitnessed and had occurred in the resident's room. The immediate action taken to prevent further falls indicated the resident was assisted to the bathroom and the staff made sure the resident could move all extremities. Further review of the form revealed the staff failed to assess the resident's pain, level of consciousness and mental status at the time of the resident's fall. Further review of the resident's medical record revealed [REDACTED]. Review of Nursing Progress Notes dated 9/30/19 revealed the following: -1:08 AM the resident hollered ouch when assisted to sit on the side of the bed. The resident's right hip and upper thigh was painful to the touch. The resident was transferred with the sit-to-stand lift from the bed to the bathroom; and -2:03 AM the resident was continually hollering out. The resident was restless and indicated the resident had to do something. The resident identified it never hurt like this before. Review of Nursing Progress Notes dated [DATE] revealed the following: -2:00 PM seen at the clinic for an x-ray; -3:22 PM returned from the clinic and x-ray revealed fracture to the resident's right hip; and -5:46 PM transported per ambulance to the hospital. During interview on [DATE] at 10:40 AM, NA-A identified the resident continued to be at high risk for falls, made attempts to self-transfer and continued to call out to staff for assistance to the bathroom due to frequency with urination. Interview on [DATE] at 11:35 AM with the DON verified the following: -the resident remained at risk for falling; and -the investigation completed after the resident's fall on 9/30/19 at 1:40 PM did not identify causal factors or interventions to prevent further falls. C. Review of Resident 3's MDS dated [DATE] indicated that Resident 3 had a [DIAGNOSES REDACTED]. Resident 3's Plan of Care reviewed/revised on 3/24/19 indicated: Resident 3 had severe cognitive impairment related to a [DIAGNOSES REDACTED]. Resident 3 had interventions in place to prevent falls including remaining in wheelchair for meals, toileting for restlessness, one on one activities, keeping the resident's call light in reach, assessing the resident for pain, keeping the resident's bed in a low position and against the wall on one side, and ambulation by staff for restlessness. Review of the Resident 3's medical record revealed; -Resident 3 fell from bed on 5/15/2019 at 4:28 PM and the facility implemented a measure to use a bolster under the resident's sheet in bed. -Resident 3 fell on [DATE] at 5:11 PM from a wheelchair and the facility implemented an intervention to offer resident snacks when restless. -Resident 3 fell from a wheelchair on 06/17/19 at 4:47 PM and the facility implemented an intervention to offer a quieter environment away from noise. Review of medical record revealed no evidence present that the facility identified causal factors for Resident's 3's falls on 05/15/2019, 05/19/19 or 6/6/19. 10/09/2019 at 1:30 PM: Interview with DON confirmed that resident falls should be evaluated for cause and interventions should be developed to protect the resident from subsequent falls. Further interview confirmed that the facilities fall review policy is not being implemented in order to identify causal factors.",2020-09-01
1632,MAPLE CREST HEALTH CENTER,285149,2824 NORTH 66TH AVENUE,OMAHA,NE,68104,2019-08-19,689,D,1,0,1O2T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.09D7b Based on record review and interview; the facility staff failed to re-evaluate continued monitoring for suicidal statements for 3 (Resident 1, 6 and 5) of 3 sampled residents. The facility staff identified a census of 150. Findings are: A. Record review of the facility Policy for Screening for Suicidal Ideation dated 10-09-2017 revealed the following information: -Policy Interpretation and Implementation: -Passive Suicidal Ideation -thought that one would be better off dead without a plan or intent to harm self. If a resident does not have a plan or intent to harm self and express passive suicidal ideation only, the charge nurse will notified of the resident's statements. The charge nurse is to notify the MD (Medical Doctor) and the resident will be placed on 15 minute checks for [AGE] hours. Visual checks can be stopped by Nurse Managment, Social Services and the Resident's MD/Psychiatrist if determined not necessary. B. Record review of Resident 1's Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) dated 7-20-2019 revealed the facility staff assessed the following about Resident 1: -Brief Interview of Mental Status (BI[CONDITION]) revealed a score of 15. According to the MDS Manuel, a score of 13 to 15 indicates a person is cognitively intact. -Had feelings of feeling down and Depressed. -Required extensive assistance with bed mobility, transfers, dressing, toielt use and personal hygiene. Record review of Resident 1's Progress Notes dated (PN) 6-24-2019 revealed Resident 1 had been upset due to not being able to talk with a family member prior to the family member leaving the country. According to the PN dated 6-24-2019 Resident 1 wanted staff to kill (gender) and if the staff would not, Resident 1 reported Resident 1 would kill (gender). According to the PN dated 6-24-2019, Resident 1 did not have a plan for to commit suicide. Resident 1 was placed onto 15 minute checks. Review of Resident 1's record revealed there was no evideance the facility staff had evaluated Resident 1's ability to be removed from the 15 minute checks. Record review of a 15 Minute Visual Check Record with a date of 7-21- (2019) revealed Resident 1 was placed on 15 minute visual checks due to [MEDICAL CONDITION]. Further review of Resident 1's record revealed there was not evideance the facility staff had evlauated Resident 1 for removing the 15 minute checks. On 8-15-2019 at 2:15 Pm an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed Resident 1 had not been evaluated to for the removal of the 15 minute checks on 6-24-2019 and on 7-19-2019 and should have bee. C. Record review of Resident 6's CCP revealed an admitted d of 9-03-2010. Further review of Resident 6's CCP revealed Resident 6 had the [DIAGNOSES REDACTED]. Record review of Resident 6's PN dated 4-23-2019 revealed Resident 6 reported being suicidale and attempted to choke self. Further review of Resident 6's PN dated 4-23-2019 revealed the Practitioner and Family were notified of this behavior and in addition, 15 minute checks were iniated. Review of Resident 1's medical record revealed there was no evideance the facility had evaluated Resident 1 for removeale of the 15 minute checks. On 8-19-2019 at 2:25 PM an interview was conducted with the DON. During the interview the DON confirmed Resident 6 had not been evalaued to be removed form the 15 minute checks. D. Review of Resident 5's Medicare Daily Documentation dated 6/6/2019 revealed the reason for Resident 5's admission was for care Post hospitalization for suicidal thought. Review of Resident 5's Care plan revealed Resident 5 has the following [DIAGNOSES REDACTED]. Review of Resident 5's Behavior Note dated 6/20/2019 revealed Resident 5 asked to speak with Social Worker B. Resident 5 stated If I have to stay here I will just kill myself. I'm not going to stay here and I just want to go home. Social Worker B asked if Resident 5 had a plan. Resident 5 stated Resident 5 would use whatever was available in the room. Review of Resident 5's Health Status Note dated 6/20/2019 revealed Resident 5's health care practitioner was notified and initiated 15 min checks. Resident 5 was given [MEDICATION NAME] (a medication for anxiety). Review of Resident 5's medical record revealed no Suicidal Risk Assessment was found when 15 minute checks were initiated or when they were stopped. Review of a Behavior Note dated 6/25/2019 revealed Resident 5 stated Bring me a bird so I can kill myself. Dean List notified and informed that 15 minute checks were going to be initiated. Review of Resident 5's medical record revealed no Suicidal Risk Assessment was completed prior to initiating 15 minute checks or on discontinuing checks. Review of a Behavior Note dated 7/13/2019 revealed Resident 5 states that she wants to hurt others before going outside and Go into traffic. Review of Resident 5's medical record revealed no Suicidal Risk Assessment was completed prior to initiating 15 minute checks or on discontinuing checks. Review of Spiritual Care note dated 7/26/2019 revealed Resident 5 expressed the desire to die and would cut Resident 5's wrists. Chaplain checked with nurse and was told that these statements were within Resident 5's normal behavioral baseline. Review of Resident 5's medical record revealed no Suicidal Risk Assessment was completed prior to initiating 15 minute checks or on discontinuing checks. Review of Resident 5's individual care plan revealed Resident 5 had a potential for decline in mood state. This resident has made and has a history of making suicidal comments. Resident 5 has a history of attempting suicide. Interventions are to include Social Worker to Administer PHQ-9 (an assessment used to identify symptoms of depression) quarterly and PRN (as needed). Interview on 8/14/2019 at 12:20 PM with Social Worker A revealed a Suicide risk assessment is completed on all allegation of suicidal ideation. Interview on 8/19/2019 at 2:30 PM with the Director of Nursing revealed no Suicidal Risk Assessment was completed when resident 5 expressed suicidal ideation and no Suicidal Risk Assessment was completed when Resident 5 was removed from 15 minute checks. 15 minute checks expire after [AGE] hours.",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
1569,"BCP BLUE HILL, LLC",285144,414 NORTH WILLSON,BLUE HILL,NE,68930,2019-03-21,880,D,1,1,118W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.17A, 12-006.17B AND 12-006.17D Based on observation, interview, and record review; the facility staff failed to follow contact precautions, failed to perform hand hygiene, failed to clean lifts used for multiple residents after use, failed to use PPE (Personal Protective Equipment-gowns, gloves, masks) for Resident 29 during contact precautions, failed to track and trend infections not treated with antibiotics, and failed to clean the facility glucometer (a machine used to check blood sugar levels) per facility policy. This had the potential to affect all of the facility residents. The facility identified a census of 31 at the time of survey. Findings are: A. Review of Resident 29's annual MDS dated [DATE] revealed an admission date of [DATE]. Resident 29 had a BIMS (Brief Interview for Mental Status) score of 10 which indicated moderate cognitive impairment. Resident 29 required extensive assistance from staff for transfer and toilet use. Resident 29 was occasionally incontinent of bowel. Review of Resident 29's Order Summary Report dated 3/21/2019 revealed an order for [REDACTED]. Masks, gowns, and gloves as well as standard precautions must be used by health care providers when in the infected patient's room) with an active date of 12/28/2018 Review of Resident 29's care plan dated 1/20/2019 revealed Resident 29 was on contact isolation per protocol to reduce risk for spreading[DIAGNOSES REDACTED]. Staff will encourage resident about the need to wash (gender) hands with soap and water frequently and to avoid touching peri-area (bottom)/stools. Observation of Resident 29's room on 3/18/19 at 10:42 AM revealed a sign on Resident 29's door for visitors to report to the nurses' station before entering the room and there was a 3 drawer plastic bin outside the door with PPE in it. Interview with RN (Registered Nurse)-G on 3/18/2019 at 8:55 AM revealed revealed the staff were to follow contact precautions for Resident 29 when in contact with BM (Bowel Movement) because Resident 29 had [DIAGNOSES REDACTED] ([MEDICAL CONDITION] (klos-TRID-e-um dif-uh-SEEL), often called [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. To help prevent the spread of [DIAGNOSES REDACTED]icile, hospitals and other health care facilities follow strict infection-control guidelines). RN-G revealed Resident 29 had been hospitalized and returned to the facility on [DATE] and the precautions had been in place since then. Resident 29 had received [MEDICATION NAME] (antibiotic to treat [DIAGNOSES REDACTED]) and the provider did not want to do another stool culture. Resident 29 had loose stools again and they came back positive for [DIAGNOSES REDACTED] so the precautions were left in place. Interview with Resident 29 on 3/18/19 at 4:17 PM revealed they had an infection in their colon. Observation of Resident 29's room on 3/18/19 at 3:46 PM revealed NA-A (Nurse Aide) and MA-B (Medication Aide) took the STS (sit to stand-a lift that assists the resident to a standing position to facilitate transfers) into Resident 29's room. They did not gown and glove. NA-A told MA-B that they were going to take Resident 29 to the bathroom. NA-A and MA-B did not don the PPE before entering Resident 29's room. They then closed the door after entering Resident 29's room. Observation of Resident 29's room on 3/18/2019 at 3:53 PM revealed MA-B pushed the sit to stand lift out into the hall. MA-B not clean the lift then left it in the hall before walking back into Resident 29's room. MA-B then put hand sanitizer on their hands then then squirted some birthday cake with sparkles hand sanitizer into Resident 29's hands, the same hand sanitizer MA-B had used on their own hands. MA-B then pulled the trash out of the trash can in Resident 29's room and put it on the floor. MA-B then then put hand sanitizer on their hands. Interview with NA-A on 3/18/2019 at 3:53 PM revealed they used the lifts for all of the residents in the facility. NA-A revealed the wipes to clean the lifts were in the storage room. Interview with Resident 29 on 3/18/19 at 4:30 PM confirmed they used hand sanitizer for hand hygiene and they sometimes used the staff's hand sanitizer. Observation of the facility on 3/18/19 at 4:56 PM revealed Resident 29 was sitting in the lounge with other residents. The lift the staff had used to assist Resident 29 with the transfer was still sitting in the hall way. Interview with NA-A on 3/18/19 at 5:21 PM revealed they provided care to all of the residents in the facility. Interview with the DON (Director of Nursing) on 3/18/19 at 5:22 PM confirmed the lifts were used for multiple residents. The DON confirmed the lift the staff were using for Resident 29 should have been designated for Resident 29 or it should have been cleaned in a manner to prevent the spread of infection to others. The DON revealed they had tried to get the contact precautions lifted but Resident 29 was still having loose stools. Interview with the facility Administrator on 3/18/2019 at 5:23 PM confirmed the staff should have been trained to follow the Contact Precautions. Review of the facility policy [MEDICAL CONDITION] dated 10/1/2017 revealed the following: Hand sanitizers are not effective against [MEDICAL CONDITION] spores. Contact precautions are to be used with residents with [MEDICAL CONDITION] for the duration of episodes of diarrhea. Employees must wash their hands: After incontinence care; after helping toilet a resident; after handling potentially contaminated items. Wear gowns when potential for soiling of clothing with feces is likely. Equipment for resident needs to be dedicated or disposable equipment. Disinfect all surfaces that could be contaminated by the resident's hands with bleach and water or a disinfectant which specifically removes [MEDICAL CONDITION]. This will help decrease the likelihood of re-infection after treatment. Wash resident's hands when soiled with feces; after they handle items which may be contaminated; and before self-feeding. B. Observation of Resident 2's room on 3/18/19 at 3:52 PM revealed NA-C staff pushed the total lift out of Resident 2's room into the hallway. NA-C then walked away and left the lift in the hall without cleaning it. C. Observation of Resident 14's room on 3/18/19 at 3:53 PM revealed NA-F pushed the sit to stand lift out of Resident 14's room into the hallway. NA-F walked away and left the lift in the hall without cleaning it. There were no disinfectant wipes on the lifts. The list of residents who were transferred with the facility lifts received from the administrator revealed the following: Resident 9 STS; Resident 29 STS; Resident 2-full body lift; Resident 14-STS; Resident 7-STS; Resident 25 -full body lift; Resident 11-full body lift; Resident 18-full body lift or STS. Review of the facility policy Cleaning & Disinfection of Nursing Equipment dated 6/1/2018 revealed the following: Equipment and surfaces are cleansed and disinfected with an EPS-registered and approved disinfectant according to a specified frequency/schedule. In addition, equipment and surfaces are cleansed as needed to be free of soil and contamination with infectious substances. D. Interview with the DON on 3/21/19 at 11:52 AM revealed the facility staff had not been tracking and trending resident infections that were not being treated with antibiotics or did not require treatment with antibiotics. The DON confirmed that if a resident had [DIAGNOSES REDACTED] they would do a stool culture and implement precautions. Review of the facility policy Surveillance of Infections dated 10/1/2017 revealed the following: Surveillance of infections includes all activities conducted to identify, analyze, and to prevent and control nosocomial infections. Surveillance data is used to identify infections, calculate infections rate, prevent and control infections and epidemics, and plan educational programs. Process surveillance reviews practices directly related to resident care in order to identify whether the practice complies with establish policies and procedures. Outcome surveillance is designed to identify and report evidence of an infection and to monitor rates over time with the goal of reducing infections. The Infection Prevention and Control Coordinator or designee, with document, review, and work to minimize infections in the community, by detecting, documenting and reviewing trends and possible outbreaks of infections in the community; collecting retrospective concurrent and prospective data necessary for making infection prevention and control decisions by walking rounds, obtaining infection data from nursing staff reports, chart reviews, laboratory reports, monitoring antimicrobial usage, and clinical observation; instituting controls for outbreaks of infections in the community; performing weekly surveillance to determine if a nosocomial infection is present; comparing collected data with standard definition (criteria) of infection; developing an action plan based on findings. E. Observation on 3-17-19 at 4:25 PM of LPN-H (Licensed Practical Nurse) performed a blood glucose to Resident 33. When done with the procedure, LPN-H took Sani-cloth (purple top) disinfectant wipe and quickly wiped off any debris from the glucometer machine then threw the wipe away in the trash can. LPN-H did not perform a wet-set time with a disinfecting wipe on the machine. Review of the Sani-Cloth disinfectant wipe bottle back label revealed To Disinfect and deodorize: to disinfect nonfood contact surface only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two (2) minutes. Let air dry. For heavily soiled surfaces, use a wipe to pre-clean prior to disinfecting. Interview on 3-17-19 at 6:35 PM with the DON (Director of Nursing) revealed the DON was aware of the wet-set time to be used with the Sani-Cloth disinfectant wipes. Review of the facility policy 'Cleaning and Disinfection of Nursing Equipment' dated 6-1-18 revealed the glucometer was to be cleaned with approved wipes according to the manufactures recommendations.",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
2116,BUTTE SENIOR LIVING,285180,210 BROADWAY,BUTTE,NE,68722,2017-07-19,282,D,1,0,PFZV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 75 NAC 12-006.09C Based on record review and interview, the facility failed to implement Care Plan interventions for Residents 1 and 3 related to the prevention of falls. The sample size was 3 and the total facility census was 30. Findings are: [NAME] Review of the MDS (Minimum Data Set: a federally mandate assessment used for care planning purposes) dated 6/7/17 revealed the following related to Resident 3: -had a [DIAGNOSES REDACTED]. -was cognitively intact; -required limited assistance of 2 for transfers and ambulation in the resident's room; -required extensive assistance of 2 for toilet use; -was unsteady and only able to stabilize with staff assistance during transitions and walking; and -had a history of [REDACTED]. Review of Resident 3's Care Plan dated 1/23/17 indicated the resident had limited physical mobility and was at risk for falls. Nursing interventions included the following: -required assistance of 1 for mobility and transfers, and use of a gait belt (a safety device used during transfers and ambulation to help prevent falling); -dycem (an anti-slip material) on seat of wheelchair to prevent sliding; -sign placed on the wall stated (resident) always ring your call light for help you are unable to walk by yourself; -bed in lowest position with fall mat (a mat placed on the floor next to the bed to provide padding in case of a fall from the bed) in place; and -call light within reach. Review of a Fall Investigation dated 6/7/17 at 3:30 AM revealed Resident 3 activated the call light at 3:10 AM and requested to go to the bathroom. NA-D informed the resident (gender) was scheduled to go at 3:30 AM according to the bowel/bladder plan. At 3:30 AM, NA-D returned to the resident's room and found the resident on the floor. The resident verbalized going to the bathroom independently. NA-D failed to respond to Resident 3's request to use the bathroom in accordance with the Care Plan which indicated the resident was unable to walk independently and was to call for staff assistance. During interview on 7/19/17 at 1:42 PM, the Director of Nursing (DON) verified fall prevention interventions were not implemented in accordance with the Care Plan. B. Review of Resident 1's current undated Care Plan revealed the resident was admitted to the facility on [DATE] with flaccid [MEDICAL CONDITION] (paralysis affecting one side of the body) affecting the left side and a right leg [MEDICAL CONDITION]. Further review revealed on 7/7/17 the resident required 2 staff assistance for transfers and positioning. Review of the Resident Incident Report dated 7/7/17 revealed Resident 1 had fallen on 7/7/17 at 9:20 PM. The resident was transferred from the wheelchair into bed by NA- C. When NA-C turned away from the resident to move the resident's wheelchair, the resident rolled onto the floor. Interview with NA-A on 7/19/17 at 10:25 AM confirmed on 7/7/17 at the time of Resident 1's fall, the resident required 2 staff members for transfers and positioning. The resident was currently a 2 staff assist with the full-body mechanical lift as a result of being non-weight bearing due to the left [MEDICAL CONDITION] that was sustained during the fall. During an interview on 7/19/17 at 12:35 PM, the Administrator confirmed on 7/7/17 Resident 1 required 2 staff members assistance for transfers and positioning. Further interview confirmed Resident 1's fall, which resulted in a fractured left hip, was the result of the resident being transferred by 1 staff member instead of 2.",2020-09-01
2885,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2018-01-22,610,D,1,0,5LPG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER NAC 175 12-006.02 Based on observation, interview and record review; the facility failed to ensure a complete investigation of abuse for, one resident of 3 residents sampled, (Resident 1). The facility census was 66. Findings are: A record review of the facility policy, dated 11/28/16, titled Abuse Prevention, revealed the following: Indications of Abuse: * Identify events, such as but not limited to, suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. 1. Bruises, skin tears and injuries of unknown source will be investigated to rule out abuse. * Investigation: all identified events are reported to the Administrator/Designee immediately and will be thoroughly investigated. When an incident or allegation of resident abuse or injury of an unknown source is identified, the Administrator/Designee will initiate an investigation. A licensed nurse shall immediately examine the resident upon receiving reports of alleged physical abuse or sexual abuse. The findings of the examination shall be recorded in the resident's medical record. The investigation shall const of the following: 1. An interview with the person(s) reporting the incident; 2. An interview with the resident(s); 3. Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; 4. A review of the resident's medical record; 5. An interview with staff members (on all shifts) having contact with the resident(s) during the period; of the alleged incident; 6. Interviews with other other residents to whom the accused employee provides care of services; 7. An interview with staff members (on all shifts) having contact with the accused employee; 8 A review of all circumstances surrounding the incident. The person reporting the incident or allegation must follow the Abuse Prohibition Program checklist. Observation of Resident 1, on 1/22/18 11:10 AM, Resident 1 was in bed, in room in hospital gown, bruise present to right hand from knuckles to above wrist, Also observed a bruise to right shin area middle of lower leg, larger than softball. Record review revealed no assessment or investigation in to the cause of the bruise to, Resident 1's, right lower leg. Resident 1's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) on 12/28/17 revealed a BIMS score of 3/15 (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). Record review of the facility investigation revealed: * Licensed Piratical Nurse (LPN) A, observed Nursing Aide (NA) B, on 1/11/18 at approximately 1:30 PM, to abuse Resident 1 and reported it immediately to the Director of Nursing (DON). LPN A reported that Resident 1 was heard to scream, and that LPN A witnessed NA B to grab Resident 1's right arm and swing it around in a circular motion. Resident 1 was heard to yell ouch, NA B was then heard to call Resident 1 a [***] . * Assessment by the facility Administrator and DON revealed that Resident 1 had sustained a skin tear and had bruising to right hand. * Statement was taken from LPN A ,that had witnessed, NA B abusing Resident 1 as stated above. * Statement was taken from NA B, who was removed from the unit during the investigation. NA B had stated that, if suspended during the investigation she would not return. NA B had stated to the DON and Administrator, that if the DON and Administrator were going to believe the nurse over her she would not return. NA B stated that Resident 1 had kicked, NA B, from behind and had grabbed at NA B's arm. NA B stated that the circular motion was NA B pulling gender arm away from Resident one, and that had not called her a name. * Interview of Resident 1 (with a BIMS's of 3/15) revealed that someone had hit Resident 1. Resident 1 description of the person was a person with a big bushy beard. * Observation of Resident 1 showed the resident's right arm was slightly reddened with a small skin tear of 0.5 cm x 0.5 cm., and Resident 1's hand had a bruise. * A second interview with LPN A revealed that the scenario as described by the NA had no occurred and that what LPN A observed was what had happened. * 5 additional staff interviewed and had knowledge of how and what to report regarding abuse. * The results of the investigation are inconclusive as we cannot substantiate abuse occurred. Interview with the facility DON on 1/22/18 at 11:30 AM revealed that, the DON, was not aware of Resident 1's BIMS being a 3/15. The DON confirmed that Resident 1 was not on the Interviewable Resident List presented to the surveyor on entrance. The DON confirmed that Resident 1 had a [DIAGNOSES REDACTED]. Interview with the facility DON on 1/22/18 at 1:30 PM revealed that Resident 1 did have a bruise to the right hand, revealed that no investigation had been performed to the cause of the bruise prior to Abuse Allegation. DON confirmed that Resident 1 did have a bruise to the right lower leg. The DON was unable to provide a investigation as to the cause of the bruise to Resident 1's right lower leg. The DON was unable to produce documentation that the facility had interviewed other staff members and what questions were asked regarding employee NA B. The DON was unable to produce documentation that other residents who received care from NA B had been interviewed. The DON confirmed that other residents had not been interviewed who had been provided care by NA B. Interview with the DON, on 1/22/18 at 2:10 PM, confirmed that the facility had taken the word of Resident 1, who had a BIMS score of 3, over the witnessing LPN, when unsubstantiating the allegation of abuse. The DON confirmed that the facility had not performed a complete and through investigation into the allegation of abuse toward Resident 1. The facility DON confirmed that NA B had resigned on 1/11/18.",2020-09-01
1785,PLUM CREEK CARE CENTER,285159,1505 NORTH ADAMS STREET,LEXINGTON,NE,68850,2019-11-14,686,D,1,0,4F4Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER NAC 175 12-006.09D2a Based on observation, record review, and interview, the facility failed to ensure interventions were implemented to prevent pressure ulcers (bedsores (decubitus ulcers) are caused to areas of skin when resting in a position for too long. Complications can be serious) affecting 2 of 3 sampled residents (Resident 3 and Resident 4). The facility had a census of 38 at the time of the survey. Findings are: A. Review of admission status under the census tab for Resident 3 revealed an admission date of [DATE]. Observation on 11/14/19 at 10:15 AM revealed Resident 3 was lying on the back on an air mattress and the air mattress was not inflated. Resident was covered with a blanket and pillow placed under residents head. The green light which indicated the mattress was on and working was not illuminated. This surveyor was unable to slide an opened hand with palm up between Resident 3 and the air mattress. Observation on 11/14/19 at 11:30 AM revealed the air mattress for Resident 3 was not inflated and the green light was not illuminated. Resident 3 was observed for over an hour on the back without mattress inflated. An interview on 11/14/19 at 11:32 AM with the DON (Director of Nursing) revealed and confirmed that the air mattress had not been inflated. The plug in had come out of the electric socket. When DON was asked who checks on the air mattress to ensure they are working it was revealed the Charge Nurse does this. The documentation of the air mattress was to be completed in the eTAR (Electronic Treatment Administration Record) by the Charge Nurse. An interview on 11/14/19 at 11:37 AM with RN-D (Registered Nurse) revealed the air mattress documentation was located on the eTAR (Electronic Treatment Administration Record) and was done twice a day. Charge Nurse stated the air mattress had not been checked on at this time. Review of the MDS dated [DATE] (Minimum Data Set, a federally mandated comprehensive assessment used for care planning) revealed for Section C the question: Should Brief Interview for Mental Status (an assessment to determine cognitive deficit) be conducted? The answer was No (resident is rarely/never understood). Section G: Functional status for Activities of Daily Living that Resident 3 was for bed mobility (turns side to side and positions body while in bed) an extensive assist with 2 plus person for physical assist. Review of the Initial Weekly Wound Documentation Form dated 11/12/2019 which states, This initial wound sheet is to be completed when a wound is first discovered. Weekly wound sheet done each week thereafter until healed. Revealed a shearing wound to right buttock with stage II (2) documented. Review of the Initial Weekly Wound Documentation Form dated 11/12/2019 revealed a pressure ulcer to left ankle that was unstageable. Review of the Initial Weekly Wound Documentation Form dated 11/12/2019 revealed a wound to right ankle that was unstageable. Review of other Weekly Wound Forms revealed Resident 3 had a Stage IV (4) pressure area to coccyx. Review of the undated Care Plan for Resident 3 revealed interventions of Air mattress to bed, staff to encourage resident to reposition every 2 hours and that resident can reposition self in bed. There were no interventions listed to prevent pressure ulcers from developing on the ankles. Review of the eTAR (Electronic Treatment Administration Record) for November revealed the air mattress was to be documented on as working twice a day on the 6 AM to 6 PM shift and on the 6 PM to 6 AM shift. Review of the eTAR at 1:33 PM revealed that the air mattress had not been initialed as check to determine if it was working. Review of the eTAR at 4:30 PM revealed the air mattress had not been initialed as check to determine if it was working. B. Review of admission status under the census tab for Resident 4 revealed an admission date of [DATE]. Observation on 11/14/19 at 10:10 AM of Resident 4 lying in bed on residents back revealed there were no pillows or blankets noted between the residents' legs and ankles. Observation of Resident 4 on 11/14/19 at 11:30 AM revealed resident lying on residents back with bed room slippers on bilateral feet and blanket over the legs. No pillows observed on the bed except under the residents' head. Observation on 11/14/19 at 1:48 PM revealed Resident 4 lying in bed on his back with house slippers on bilateral feet. An interview on 11/14/19 at 1:48 PM with Resident 4 revealed that staff are not always good about repositioning the resident. Resident 4 stated that resident has not been able to move self or reposition in the bed. There are not enough staff to assist the resident. Review of the undated Care Plan revealed the interventions in place were pressure redistributing mattress on bed and to monitor weekly by nurse during bathing. There were interventions for areas to buttocks and heels but no interventions to prevent or promote healing of pressure ulcers to ankles. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment used in care planning) revealed Section C: A BIMS (Basic Interview for Mental Status, an assessment to determine cognitive deficit) revealed a score of 13 which indicates cognitively intact. Section G Extensive assist with 2+ person for bed mobility (turns side to side and positions body while in bed). An interview on 11/14/19 at 2:00 PM with the DON (Director of Nursing) revealed and confirmed there were no interventions in place to prevent pressure ulcers from developing or to promote healing of ulcers on the ankles. Review of the Progress Notes for Resident 4 revealed no documentation of interventions to prevent pressure ulcer development or to promote healing of the ulcers on the ankles. Review of the Prevention of Pressure Ulcers Policy dated March 2019 revealed the purpose of this procedure was to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. The procedure: 1. Review the resident's care plan to assess for any special needs of the resident. 2. See policy and procedure for specific task, such as bathing, incontinence care, repositioning. General Guidelines: 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. Interventions and Preventative Measures-General Preventive Measures: 2. For a person in bed: a. Change position at least every two hours or more frequently if needed; b. Determine if resident needs a special mattress; c. If a special mattress is needed, use one that contains foam, air, gel, or water, as indicated d. Raise the head of the bed as little and as short a time as possible, and only as necessary for meals, treatments and medical necessity. 4. When repositioning, reduce friction and shear by lifting (using appropriate lifting technique and equipment) rather than dragging.",2020-09-01
1500,AZRIA HEALTH ASHLAND,285140,1700 FURNAS STREET,ASHLAND,NE,68003,2019-03-19,880,D,1,0,YCLW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER175 NAC 12-006.17B. Based on observation, interview and record review; the facility failed to implement isolation precautions/procedures to prevent the spread of infection for one Resident 1, who was diagnosed with [REDACTED]. [MEDICAL CONDITION] is a contagious microorganism (spore) that has the potential to survive for 5 months on inanimate (not alive) surfaces and can be spread by person to person contact or by direct contact with contaminated objects and surfaces for example clothing, door handles, equipment, privacy curtains and faucets). This had the potential to effect 3 out of 5 residents sampled (Residents 2, 3, and 4). The facility also failed follow its Transmission Precaution: Contact Policy related to Cohorting residents with the same infectious microorganisms this had the potential to effect 2 residents (Resident 1 and 2). The facility census was 73. Findings are: [NAME] Observation with the DON (Director of Nursing) on 03/19/19 at 10:09 AM revealed; Resident 1 was lying in bed with red bag/boxes located at the foot of the bed with the privacy curtain rested against the red bag. Record review of Resident 1's Admission Record revealed; admitted d of 11/25/15 and [DIAGNOSES REDACTED]. introduction of food). Record review of Initiating Isolation Procedures Policy dated 10/01/09 revealed; the Purpose was to provide a safe environment, isolation precautions will be initiated when there is reason to believe that a resident has an infectious or communicable disease. To provide a physical, mechanical, or chemical barrier between resident and staff, other residents has an infectious or communicable disease. Record review of Transmission Precautions: Contact Policy dated 10/01/09 revealed; In addition to standard precautions, contact precautions are used for resident known or suspected to be infected or colonized with epidemiological important microorganisms that can be transmitted by direct contact with resident or indirect contact (touching) with environmental surfaces or resident care items. Procedure was to review the need for a private room. When a private room is not available cohort the resident in a room with a resident who has infection or is colonized with the same microorganism but not a different organism. Record review of [MEDICAL CONDITION] Policy dated 10/01/09 revealed; isolate if colonized. Place in private room when possible. Cohorting is allowed. Record review of MAR (Medication Administration Record) dated (MONTH) 2019 revealed; Resident 1 had an order for [REDACTED]. Record review of Care Plan with target date of 04/04/19 revealed; 1) Resident 1 had Impairment of the immunity system related to infection with an intervention of contact isolation. There was no other interventions related to specific infection. 2) Resident 1 had an alteration in bowel/bladder elimination and required 1-2 person assistance to meet needs related to disease process and immobility with interventions to provide care after each incontinent episode, and with morning and evening cares. 3) Resident 1 had an alteration in ADL (Activities of Daily Living included bed mobility, transfers, toileting and personal hygiene) the interventions were: Resident 1 was dependent and needed 2 person assist with toileting, and transferred with a Hoyer lift. Interview on 03/19/19 at 09: 30AM with Housekeeping staff member A revealed; the housekeeping staff had cleaned room [ROOM NUMBER] with verex. Housekeeper A reported that the bathroom between Resident 1 and 2's room was shared with Resident's 3 and 4. Interview on 03/19/19 at 10:09 AM with the DON confirmed; Resident 1 did have [MEDICAL CONDITION] and the direct care staff used the bathroom for hand washing after placing soiled PPE (Personal Protective Equipment- gown, gloves and masks to prevent the spread of infection) the red bag. The DON confirmed it could have been a potential for cross contamination for Resident 3 and 4 who had also used the bathroom for toileting/hygiene purposes. The DON confirmed; that the privacy curtain had touched the red bag and that was a potential for cross contamination for all who had come into contact with the privacy curtain. The DON confirmed that Resident 2 did not have [MEDICAL CONDITION]. Interview on 03/19/19 at 11:00 AM with the DON revealed; the facility would be attempting to call family for permission to move Resident 1 to a private room. B. Observation on 03/19/19 at 10:09 AM revealed; resident 2 was lying in bed in the same room as Resident 1, watching television privacy curtain partially pulled between resident areas. Record review of Resident 2's Admission Record with an admission date of [DATE] revealed; [DIAGNOSES REDACTED]. Record review of Resident 2's Care Plan with a target date of 3/7/19 revealed; 1) Resident 2 has a history [MEDICAL CONDITION] ([MEDICAL CONDITION] (a bacterium that causes infection in different parts of the body that is resistant to some commonly used antibiotics) with ulcerative [MEDICAL CONDITION] in 4/2013. The interventions were Cohort [MEDICAL CONDITION]. 2) Resident 2 had an alteration in ADL's (Activities of Daily Living- daily tasks as personal hygiene, toileting, bed mobility and transfers) with interventions of dependence with bed mobility, toilet use and transfers. 3) Resident 2 had an alteration in urinary output related to disease process with interventions of check for incontinence every morning, evening, before and after meals and as needed and incontinence care as needed. 4) Alteration in bowel elimination related to disease process with interventions of incontinence care as needed, extensive assistance to toilet before and after meals in the morning and evening and as needed. Interview on 03/19/19 at 10:09 AM with the DON confirmed that Resident 2 did not have [MEDICAL CONDITION] and that Resident 2 had not used the bathroom and was incontinent. C. Observation on 03/19/19 at 09:30 AM of Resident 3 resting on bed, had come to a sitting position on their own, when staff entered the room. Record review of Resident 3's Admission Record revealed; a [DIAGNOSES REDACTED]. Record review of Care Plan with target date of 05/09/19 revealed; 1) Resident 2 had an alteration in ADL's related to disease process and had an intervention of Independent for toileting and personal hygiene. Interview on 3/19/19 at 11: 40 AM with Housekeeping Manager revealed; Housekeeper A was confused and had come from Resident 3 and 4's room. Housekeeping Manager confirmed that Clorox disinfecting wipes and Clorox Bleach dilution for cleaning in isolation rooms. Interview on 03/19/19 at 10:09 AM with the DON confirmed; that Resident 3 had used the an adjoining bathroom that was used for hand washing post care for a resident with infectious microorganisms for toileting and hygiene and this could have been a potential for cross contamination. Resident 4 Record review of Admission Record for Resident 4 revealed; a [DIAGNOSES REDACTED]. Record review of Resident 4 Care Plan revealed that Resident 4 had been independent with transfers, toileting, ambulation, and personal hygiene. Interview on 03/19/19 at 10:09 AM with the DON confirmed; Resident 4 had used the an adjoining bathroom that was used for hand washing post care for a resident with infectious microorganisms for toileting and hygiene and this could have been a potential for cross contamination.",2020-09-01
1484,"PREMIER ESTATES OF PIERCE, LLC",285139,"P O BOX 189, 515 EAST MAIN STREET",PIERCE,NE,68767,2017-10-11,155,D,1,1,3PT811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC ,[DATE].05(4) Based on interview and record review, the facility failed to ensure Resident 1's code status (choice for or against Cardio-Pulmonary Resuscitation-CPR) was reviewed following a change in condition and conflicting orders. The sample size was 24 and the facility census was 31. Findings are: Review of the facility policy titled Advanced Directives/DNRO Log dated ,[DATE] indicated code status forms would be completed upon admission, reviewed and updated quarterly, and review and updated with a change in condition. Review of a Progress Note dated [DATE] revealed Resident 1 had a change in condition and a change in condition form was in progress/completed. Review of the Physician's Transfer Orders from the hospital dated [DATE] listed Resident 1's code status as a Do not Resuscitate (indicting CPR would not be initiated). Review of Resident 1's Order Summary Report dated [DATE] signed by the resident's physician listed the resident's code status as a full-code (indicating CPR would be initiated). Review of a Progress Note dated [DATE] revealed Licensed Practical Nurse-M initiated CPR on Resident 1. Review of Resident 1's Medical Record revealed no evidence to indicate the resident's code status was reviewed and/or updated following an identified change of condition on [DATE] or following the resident's conflicting code status orders on [DATE]. During an interview on [DATE] at 8:50 AM the Director of Nursing (DON) confirmed CPR was initiated on Resident 1 on [DATE]. Further interview confirmed there was no evidence to indicate the resident's code status had been reviewed and/or update (if applicable).",2020-09-01
4400,"NORTH PLATTE CARE CENTER, LLC",285165,2900 WEST E STREET,NORTH PLATTE,NE,69101,2017-04-25,225,D,1,0,TDQ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.02(8) Based upon record review and interviews, the facility failed to report allegations of verbal abuse to the State Agency with in the regulatory requirements. This affected 2 of 3 sampled residents (Residents 1 and 2). The facility census was 49 at the time of the complaint investigation. Findings are: Review of the facility investigation of an allegation of verbal abuse on 4/5/17 at 6:00 PM. Revealed RN-C (Registered Nurse) stated I am not going to listen to your bullshit. Further review found no documentation the allegation of verbal abuse had been reported to the State Agency until the following day some 24 hours later. Interview with RN-A on 4/25/2017 at 3:15 PM revealed verbal abuse was witnessed on 2 different incidents. One incident was with a wheelchair resident (Resident 1) said something to RN-C, which I did not hear. RN-C stated (he/she) was not going to listen to that bull[***]and told the aide to remove the resident from the area. Resident 1 was in the foyer and had just came from the evening meal. The Resident had a habit of making inappropriate comments. The other incident involved Resident 2 when RN-C told the resident shut up wasn't going to listen to help me, help me for another 12 hours tonight. RN-A revealed RN-C worked the whole shift Interview with NA-B (Nurse Aide) on 4/25/2017 at 3:30 PM revealed Resident 2 said help me, help me and RN-C stated I am not going to listen to our bull[***]for the next 12 hours, shut up. Also heard RN-C scream at another resident to get the hell out of here now. NA-B revealed RN-C worked the whole shift. Interview with the Administrator and the Director of Nurses on 4/25/17 at 3:30 PM revealed the facility had not reported to the State Agency the allegations of abuse until 4/6/16 at 6:45 PM some 12 hours later. The Director of Nurses revealed RN-C had work the whole shift 4/5/17 plus 2 hours on 4/7/17. Review of the Facility form entitled Risk Management Abuse Prevention Program and Reporting Policy dated 4/17 revealed to report the incident immediately to the Administrator, and Director of Nursing. Any staff member with knowledge of the event is responsible for notifying the Administrator and/or DON. Notify the appropriate State Agency immediately by fax or telephone on on-line reporting after identification of alleged suspected abuse. Person initially identifying potential abuse, by State law, were accountable to make initial call.",2020-08-01
4337,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2017-04-04,225,E,1,0,IZYY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.02(8) Based upon record review, observations and interviews, the facility failed to report falls with injury. This affected 2 of 10 sampled residents (Residents 2 and 3) and the facility failed to report allegations of abuse to State Agency, investigate those allegations and submit those investigation to the State Agency within 5 business days. This affected 2 of 10 sampled residents (Residents 8 and 10). The facility census was identified as 53. FINDINGS ARE: [NAME] A record review of Incident/Accident Report dated 3/22/17 revealed the following: Resident 2 had fallen and had suffered the following injuries-'gash' to forehead, nose and mouth bleeding. Resident 2 was taken to the hospital for evaluation and admitted laceration of the forehead and displaced nasal bone fracture secondary to fall and [MEDICAL CONDITION] activity. B. A record review of Incident/Accident Report dated 3/21/17 revealed the following: Resident 3 had fallen and had suffered the following injuries-bruising to forehead, right temple, lower lip with abrasions and left knee skin tear as well as left hip, neck and facial pain. Resident 3 was sent to the hospital, cleared and returned to the facility. C. Interview with the Facility Administrator (FA) [NAME] on 4/3/2017 at 4:05 PM revealed that the falls for both Residents 2 and 3 were not called into the APS because it was the FA's understanding that since these injuries were not due to abuse or a resident to resident altercation, it was not reportable. D. A record review of an untitled report by the Social Services Director (SSD) dated 2/13/17 revealed that Resident 10 had reported to the SSD that someone had hit the resident in the face and upper body repeatedly. And in an interview with a another resident it was revealed that Resident 10 told this other resident which staff member it was that had hit Resident 10. At the bottom of the document, the SSD stated that the information would be passed on to the FA and the DON (Director of Nursing). E. A record review of a facility Grievance/Complaint Report dated 3/14/ revealed that an outside outpatient clinic staff member called the facility to report that Resident 8 reported that a bruise on Resident 8's arm was due to staff transferring the resident to the resident's wheel chair and the resident reported to yell out in pain when the arm was bumped into the wheel chair. Then the same staff member told the Resident-You yell one more time and I am out of here. The facility staff member was identified by name-Licensed Practical Nurse A (LPN A). The form further states the administrator (former) and DON was informed the reported information. F. A record review of employee plan of correction dated 3/15/17 revealed that the employee identified LPN A and the date of warning was crossed out and handwritten was education. Under the section 'Describe incident:' I received information from our SSD that Resident 8 complained to the (outpatient) clinic staff about our nursing staff. The resident complained that staff told (gender) they would leave the resident's room if (gender) didn't stop screaming. Under the section 'Employee comments:' on 3-15-17, I spoke to LPN A about what occurred. The nurse informed me that the resident was screaming loudly at staff and making threats. LPN A explained to Resident 10 that (gender) should not be disrespectful to staff because it makes it very difficult for them to do their job. The resident was not distressed or in need of immediate attention. Nursing staff was simply attempting to calm down the resident in order to provide care. [NAME] Interview with DON on 4/4/2017 at 2:50 PM-confirmed that (gender) was aware of both incidents, but was not involved with any interviews or outcomes as they were being handled by the former administrator. The DON also stated that after reading both reports (gender) concurs that both are allegations of abuse and that they should have been investigated and LPN A should have been suspended pending the outcome of the investigations. The DON confirmed that the DON did not notify Adult Protective Services (APS) of the allegations. H. Interview with SSD on 4/4/2017 at 3:11 PM revealed the following: with the report dated 2/13/17, (gender) did investigate and turn it over to the former administrator at the time. SSD confirmed that (gender) did not call APS. The SSD confirmed that it was the same with the second report, the SSD concurred that it was an abuse allegation but again turned it over to the administrator at the time. The SSD further confirmed that in both cases, these were abuse allegations and that (gender) did not call APS. I. Record review of the facility's Addendum to Resident Incidents Policy dated 5/6/06 revealed the following: in the 'What should be reported' section: any allegation of abuse, neglect . In the 'Who to report to:' HHS Adult Protective Services (APS).",2020-08-01
1068,PRESTIGE CARE CENTER OF PLATTSMOUTH,285104,602 SOUTH 18TH STREET,PLATTSMOUTH,NE,68048,2019-09-23,580,G,1,0,KJCO11,"**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 assess and monitor 2 of 6 residents reviewed (Residents 1 and 4) with a change of condition to prevent hospitalization . The facility Census was 66. Findings are: Review of Resident 1's Electronic Medical Record (EMR) revealed progress notes dated 8/17/2019 at 09:52 as a Nursing Late Entry(indicates when a note is written at a time other than when the incident occurred) created by RN-A on 8/18/2019 4:01 PM for events on 8/17/2019. Review of Progress note for 8/17/2019 revealed at 9:52 Resident 1 was not talking and was staring in one direction. An assessment was completed and RN -A and revealed grips were weak and vital signs are stable with no documentation of what the vital sign readings were. RN-A discussed Resident 1's condition with co-workers and considered it might be caused by a recent medication change, however did not call Resident 1's physician to report Resident 1's condition and documented the staff will continue to monitor Resident 1. Review of Resident 1's MAR indicated [REDACTED]. Review of Resident 1's EMR revealed no documentation of further monitoring of Resident 1's condition or repeated vital signs. Review of Resident 1's progress note dated 8/17/2019 at 7:02 PM revealed Resident 1 was transported to the hospital by emergency ambulance and left the facility at 6:50 PM. Review of Progress note dated 8/17/2019 at 7:02 PM revealed Resident 1 was unresponsive to verbal commands, staring and unable to move eyes when asked. Resident did not respond when spoken to by family member. Progress notes dated 8/17/2019 at 7:03 PM revealed Resident 1's physician was notified of Resident 1's condition and transport to the hospital. Review of Resident 1's EMR revealed no follow up documentation on monitoring from 9:52 AM until 6:30 PM when Resident 1 was sent out to the hospital emergently and no documentation the physician was notified of Resident 1's change of condition at 9:52 AM. Review of letter dated 9/24/2019 received from the facility Medical Director revealed Resident 1 was admitted to the hospital with [REDACTED]. Interview on 9/23/2019 at 2:45 PM with the director of Nursing (DON) revealed RN-A did not document further monitoring for Resident 1. RN-A should have documented vital signs at the time they were assessed and not a summary on a late entry. DON revealed changes in Resident 1's condition should have been called to the physician. C. Record review of Resident 4's progress notes dated 9/17/19 at 6:13 AM revealed: - Resident 4 did not wake for supper the previous night and had snoring like breaths . - Resident 4 had heavier breathing at 4:30 AM and short panting breaths with abdominal accessory (indicating the presence of a disorder affecting a person's ability to breathe) usage. - at 5:20 AM Resident 4 was hot to the touch, sweaty, and vital signs revealed a temperature of 101.5 blood pressure of 170/70, pulse of 80 and respirations were 28 to 30 with abdominal accessory usage noted with breaths. -Resident 4 would not respond to verbal or tactile stimulation and only fluttered the eyes. Review of progress notes dated 9/17/19 at 7:12 AM revealed blood pressure was higher than previous, temperature and respiratory rate was still elevated above normal and O2 saturation rate was 92% (amount of oxygen in the blood). Resident 4 was sent to the emergency room via ambulance transport, admitted to the hospital and diagnosed with [REDACTED]. Review of progress notes dated 9/17/19 revealed that between the hours of 5:20 AM and 7:12 AM there were no vital signs documented for Resident 4. An interview conducted on 9/23/19 at 2:45 PM with the DON, revealed the DON agreed that there should have been more monitoring and assessments completed",2020-09-01
5005,AZRIA HEALTH AT MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2017-02-28,157,D,1,0,SFQT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.04C3a(6) Based upon record review and interview, the facility failed to notify the primary care practitioner in a timely manner following an incident. This affected of 1 resident (Resident 2) of 3 sampled residents. The facility census was 136. The facility census was 136. Findings are: [NAME] Record review of Resident 2's admission record dated 2/28/2017 revealed that Resident 2 was admitted on [DATE] for the following Diagnoses: [REDACTED]. An observation on 2/23/2017 at 6:00 PM showed Resident 2 to be wheeling self the in hall on the way back from the dining room. There was a large older bruise on the left side the resident's face. This bruise was an older bruise as it was more colored mid to light green and yellow. An observation on 2/27/2017 at 2:19 PM revealed the resident was in bed with the entire left side of the resident's face still colored light green to yellow. An interview with Resident 2 on 2/27/2017 at 2:19 PM revealed that (gender) fell out of bed and landed on (gender's ) face. Resident 2 could not state when the fall occurred or what the resident was doing when the fall occurred. A record review of the resident's progress notes dated 2/11/2017 and timed at 5:45 PM revealed the resident was found on the floor face down by the roommate. A contusion (bruise) and hematoma (swelling) were noted to left side of forehead above left eye. Resident 2 complained of a headache and neurological checks were started. A record review of the neurological assessment flow sheet dated 2/11/17 revealed that, on the 2030 (8:30 PM) check, the resident was complaining of some nausea/ dizzy. A record review of the physician notification fax dated 2/12/2017 at 6:25 AM revealed the physician was notified that the resident had rolled out of bed on 2/11/2017 at 5:45 PM. Resident 2 had a hematoma 3 cm (centimeters) by 3 cm on the forehead over the left eye which had moved down causing the eye to be swollen and purple. An interview with the Director of Nursing (DON) on 2/28/2017 at 3:05 PM revealed that the expectation for notifying the resident's primary care physician (PCP), depending on the severity of the incident, should be completed within 2-3 hours. The DON was asked if the finding of nausea or dizzy during neurological checks was abnormal and should be reported to the PCP. The DON confirmed that those findings should be reported to the PCP. The DON also confirmed that there was no evidence that the PCP was notified within that time frame for this incident. The DON also confirmed that there was no evidence that the PCP was notified of the abnormal neurological check note of nausea and dizzy found during the 2/11/2017 8:30 PM neurological check.",2020-02-01
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
1636,MAPLE CREST HEALTH CENTER,285149,2824 NORTH 66TH AVENUE,OMAHA,NE,68104,2017-11-02,278,D,1,1,I4SU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09C(1) Based on observation, record review and interview; the facility failed to ensure the MDS (Minimum Data Set) reflected the status of one of three residents sampled (Resident 187) at the time the MDS was completed. The facility census was 145. Findings are: Record review of Resident 145's Face Sheet, undated, revealed that Resident 145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the facility Resident Assessments Policy, dated as revised (MONTH) 2006, revealed that: The facility will develop and implement procedures governing the practice of completing timely resident assessments and coordination of individualized Interdisciplinary Team Care Plans. j. The complete assessment and care plan shall be based on oral and written communication, resident and or family interviews, and assessments provided by nursing, dietary, resident activities and social work staff. When ordered by the physician or advanced practice nurse, assessments shall also be provided by other health care professionals. K. The care plan shall include measurable objectives with interventions based on the resident care needs and means of achieving each goal. Record review of the facility policy Bowel and Bladder Assessment, dated revised (MONTH) 2008, revealed that: 1. The licensed nurse will complete a Bladder Function Assessment Form and a Bowel Function Assessment Form for each resident upon admission, re-admission and whenever there is a change in condition. 3. A comprehensive bowel and or bladder assessment is completed on all residents to assist in determining the most effective and appropriate treatment and management of incontinence. The Bladder Function Assessment Form includes: a. Physical Exam b. Review of Resident's Medical History c. Review of Resident's Functional and Cognitive capabilities d. Review of Environmental Factors and Assist Devices. The Licensed nurse assures the Bowel and Bladder Function Assessment forms, any accompanying documentation and an individualized care plan is evident in the medical record. Observation on 11/01/17 at 10:23 AM revealed Resident 145 being assisted to the bathroom by Nursing Assistant (NA) I. NA I assisted Resident 145 to ambulate to the toilet where assisted to use the toilet. Resident 145 had not been incontinent of urine. Resident 145 had voided into the toilet with cues and prompting. Interview with NA I on 11/1/17 at 11:36 AM revealed that if Resident 145 is taken to use the toilet every 2 hours continence is maintained. NA I revalued that Resident 145 had a plan of care to toilet Resident 145 every 2 hours to prevent incontinence. Record review of Bladder assessment dated [DATE] revealed that Resident 145 was always incontinent, and has problems with leaking urine. Record review of Bladder assessment dated [DATE] revealed current toileting program. When awakens in morning, before and after meals and before bed time to be toileted. Record review of Resident 145's plan of care dated 6/12/17 revealed that Resident 145 had urinary incontinence. Resident 145 had a goal to decrease wetness and number of episodes of incontinence with toileting plan, and will continue to be free from signs and symptoms of Urinary Tract Infection. Interventions to achieve this goal included a toileting schedule of assisting Resident 145 to toilet before breakfast, in between meals, before dinner and every 2 hours at night as needed. Record review of the Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) signed 6/7/17, revealed that Resident 145 was always continent of urine. Record review of MDS signed 9/7/17 revealed that Resident 145 was occasionally incontinent of urine. Record review of look back period documentation, for urinary continence, for the 6/7/17 MDS, revealed 16 continent episodes and 1 incontinent episode of urine for Resident 145. Record review of look back period documentation, for urinary continence, for the 0/1/17 MDS, revealed 12 incontinent episodes and 22 continent episodes for Resident 145. Interview on 11/1/17 at 4:10 PM with Facility Administrator, and MDS Coordinator revealed the following: The Administrator confirmed that when a resident is admitted to the facility and the MDS is performed that the MDS coordinator does not use the written documentation obtained by the licensed nurse performing the Bowel and Bladder Assessments. The MDS Coordinator confirmed that although this information is used for Resident plan of care, it is not being used for the MDS data completion. The Administrator confirmed that, the facility policy for completion of the MDS, stated that, the complete assessment and care plan shall be based on oral and written communication, of resident and or family interviews and assessments provided by nursing. The MDS coordinator confirmed that the MDS was inaccurate based on the look back period for the 6/7/17 MDS, that the 1 episode of incontinents would change Resident 145 from always continent to occasionally incontinent, and if the assessment was used to make this determination it would also have changed the MDS data. The Administrator confirmed that the Bladder Assessment revealed that Resident 145 was always incontinent, and that there is a discrepancy in the assessments compared data. The MDS Coordinator confirmed that the MDS for 9/7/17 did not include the toileting program that was in place for Resident 145, making the MDS inaccurate.",2020-09-01
3903,LITZENBERG MEMORIAL COUNTY HOSPITAL,285292,1715 26TH STREET,CENTRAL CITY,NE,68826,2017-11-13,280,E,1,0,K7NZ11,"**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 revise the comprehensive care plan related to falls for 3 of 4 sampled residents (Resident 2, 3, and 4). The facility census was 21. Findings are: [NAME] Review of the facility incident report dated 10/22/2017 at 7:30 PM; identified that Resident #2 had a fall with a fracture. The report identified that the resident was confused, had a gait imbalance and the alarms were sounding. Review of the comprehensive care plan for Resident 2 with a revised date of 10/22/2017; identified that the resident had a fall on 10/22/2017 but did not identify any fall interventions or causal factors that would prevent any further falls. Interview with the Administrator on 11/13/2017 at 1:30 PM confirmed that there were no causal factors nor no new interventions identified on Resident 2's comprehensive care plan from the resident's fall on 10/22/2017. Interview with 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.) Coordinator on 11/13/2017 at 1:40 PM confirmed that there were not any new fall interventions nor any causal factors identified on the resident's care plan. MDS Coordinator also stated, there are so many things that you can do for a resident with dementia. B. Review of the facility incident report dated 10/29/2017 at 8:55 AM; identified that Resident 3 was lowered to the floor by the nursing staff when the resident was trying to transfer self to the wheelchair. Review of the resident's comprehensive care plan revealed that the resident's fall on 10/29/2017 was not identified on the resident's care plan nor were any fall interventions. The care plan identified that the resident had a history of [REDACTED]. Review of the facility document titled, Falls Tool, dated 10/29/2017; identified that Resident 3 was lowered to the floor on 10/29/2017 at 8:55 AM. The tool also revealed that the resident's care plan would be updated. Interview with the Administrator on 11/13/2017 at 1:30 PM confirmed that Resident 3 had a fall on 10/29/2017 but the fall was not identified on the care plan and that there were not any fall interventions included on the resident's care plan. Interview with the MDS Coordinator on 11/13/2017 at 1:40 PM confirmed that Resident 3 had a fall on 10/29/2017 but the fall was not identified on the care plan and also confirmed that there were not any fall interventions included on the resident's care plan. C. Review of the facility incident report on 8/31/2017 at 10:20 AM; identified that Resident 4 had a fall on 8/31/2017. The report identified that the resident was confused, had impaired memory, had gait imbalance, had personal alarm system in use but the alarms did not sound. Review of the resident's comprehensive care revealed that the resident's fall on 8/31/2017 was not identified on the resident's care plan nor were any fall interventions updated to the resident's fall. Interview with the Administrator on 11/13/2017 at 1:30 PM confirmed that Resident 4 had a fall on 8/31/2017 and that there were not any fall interventions updated to the resident's fall. The administrator also confirmed that the resident's fall on 8/31/2017 should have been identified on the care plan. Interview with the MDS Coordinator on 11/13/2017 at 1:40 PM confirmed that Resident 4 had a fall on 8/31/2017 and that it was not identified on the resident's care plan. The MDS Coordinator also confirmed that the fall should have been identified on the resident's care plan.",2020-09-01
6590,ASHLAND CARE CENTER,285140,1700 FURNAS STREET,ASHLAND,NE,68003,2015-12-16,312,E,1,0,61U611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D1c Based on record review and staff interview; the facility failed to provide bathing in accordance with bath schedules for four residents requiring assistance with bathing tasks (Residents 8, 9, 10 and 11). Facility census was 70. Findings are: A. Review of Resident 8's MDS (Minimum Data Set -a federally mandated comprehensive assessment tool used for care planning) dated 11/27/15 indicated that Resident 8 was totally dependent with assistance of one for bathing. Record review of the facility's undated bath schedules for Resident 8 revealed Resident 8 was to receive two baths per week. Record review of Resident 8's bath flow sheet (form used to record provision of each resident's shower/bath) for (MONTH) and (MONTH) (YEAR) indicated Resident 8 only received a bath on 11/2/15, 11/9/15, 11/19/15, 11/24,15 and 12/9/15 and not twice a week as scheduled. Interview with Resident 8 and Resident 8's family member on 12/16/15 at 4:20 PM revealed Resident 8 was supposed to be getting two baths per week but had only been getting one per week and wasn't sure why this was occurring. Resident 8 further stated there were days when the facility did not have enough staff working. Resident 8's family member responded that one bath per week was just not enough for Resident 8. B. Review of Resident 9's MDS dated [DATE] indicated the resident was totally dependent with assistance of one for bathing. Record review of the facility's undated bath schedules for Resident 9 revealed Resident 9 was to receive two baths per week. Record review of Resident 9's bath flow sheets for (MONTH) and (MONTH) (YEAR) indicated Resident 9 received a bath on 11/5/15, 11/10/15, 11/19/15, 12/1/15, 12/8/15 and 12/10/15 and not twice a week as scheduled. Interview with Resident 9 on 12/16/15 at 4:10 PM revealed Resident 9 was no longer getting 2 baths per week because the facility was having trouble finding staff to get both baths done. C. Review of Resident 10's MDS dated [DATE] indicated the resident was totally dependent with assistance of one for bathing. Record review of the facility's undated bath schedules for Resident 10 revealed Resident 10 was to receive two baths per week. Record review of Resident 10's bath flow sheet for (MONTH) and (MONTH) (YEAR) indicated Resident 10 received a shower on 11/3/15, 11/10/15, 11/20/15, 11/25/15, 12/3/15, 12/8/15 and 12/10/15 instead of twice a week as scheduled. D. Review of Resident 11's MDS dated [DATE] indicated the resident required physical assistance of one to transfer into the bath. Record review of the facility's undated bath schedules for Resident 11's revealed Resident 11 was to receive two baths per week. Record review of Resident 11's bath flow sheet for (MONTH) and (MONTH) (YEAR) indicated Resident 11 received a bath on 11/6/15, 11/13/15, 11/20/15, 11/27/15, 12/1/15, 12/8/15 and 12/12/15 instead of twice a week as scheduled. Record review of the minutes from Resident Council Meetings from (MONTH) to (MONTH) (YEAR) revealed reoccurring monthly complaints that baths were not being given as scheduled. Interview with NA (Nursing Assistant) A on 12/15/15 at 2:15 pm revealed that residents are scheduled for 1 or 2 baths per week. NA A stated that NA A had gotten pulled from baths to work the floor about 1 time per week.",2018-12-01
5070,"NORFOLK CARE AND REHABILITATION CENTER, LLC",285101,1900 VICKI LANE,NORFOLK,NE,68701,2018-03-08,684,D,1,1,2SKI11,"**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 provide care and treatment to prevent and to ensure wound healing for 1 (Resident 13) of 24 sampled residents. The facility census was 52. Findings are: Review of Resident 13's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/27/17 revealed [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive staff assistance with bed mobility, transfers and with toileting. The assessment further identified the resident had 1 unhealed venous ulcer (wounds which occur due to poor circulation). Review of a Nursing Progress Note dated 1/16/18 at 4:27 PM revealed the resident reported a painful area to the resident's lower right posterior leg. A hard lump was observed to the area. The resident reported the area was painful and the pain increased when the area was palpated. No redness or bruising was noted. Review of a Weekly Wound Evaluation dated 1/26/18 at 7:45 PM revealed the resident had a blister which measured 2 centimeters (cm) by 2 cm with a depth of 0.1 cm to the posterior lower right leg. The assessment identified a popped blister from a hematoma. Current treatment was to monitor the area. Review of a Nursing Progress Note dated 1/30/18 at 2:33 PM revealed the resident was seen by the practitioner. The practitioner indicated uncertainty regarding the origin of the wound to the resident's right posterior lower leg and identified it was initially described as a bruise and then a blister that popped. A wound culture was obtained to the wound with an order for [REDACTED]. The practitioner also made a recommendation for the resident to be seen at the Wound Clinic. Review of a Nursing Progress Note dated 1/31/18 revealed an order to discontinue use of [MEDICATION NAME] and to start Bactrim (antibiotic used to treat infections) twice a day for 7 days. Review of a Weekly Wound Evaluation dated 2/1/18 at 6:05 PM revealed the blister to the resident's right posterior lower leg now measured 3 cm by 3 cm with a depth of 0.1 cm. The wound bed was black with undefined margins. Review of a Nursing Progress Note dated 2/2/18 at 3:29 PM revealed a new order to discontinue use of Bactrim and to start [MEDICATION NAME] (medication used to stop the growth of bacteria) 1 gram daily for 5 days and for [MEDICATION NAME] (medication used to treat a wide variety of bacterial infections) every 12 hours for 7 days. Review of a Progress Note by the Wound Clinic on 2/6/18 at 9:45 AM revealed a measurement of 3.1 cm by 2.5 cm with a depth of 0.1 cm of the wound to the resident's right posterior lower leg. The wound was described as a venous leg ulcer caused by trauma. Debridement (removal of unhealthy tissue from a wound to promote healing) was completed by the clinic. Recommendations to elevate legs 3 times a day and to increase protein intake were identified. Review of a note from the resident's practitioner's dated 2/9/18 revealed the resident identified poor pain control to right lower leg. An order was received for [MEDICATION NAME] (medication used to treat moderate to moderately severe pain) 50 mg every 8 hours as needed for the pain. Review of a Weekly Wound Evaluation dated 2/15/18 at 7:28 AM revealed the venous ulcer to the resident's right lower posterior leg measured 3.1 cm by 2.5 cm with a depth of 0.1 cm. Review of a Nursing Progress Note dated 2/21/18 at 5:47 PM revealed the resident's right lower leg was swollen, red and warm to the touch. The resident's practitioner was notified and a new order was received for Bactrim 1 tablet twice a day for 10 days for [MEDICAL CONDITION] (infection of the skin). Review of a Weekly Wound Evaluation dated 2/22/18 at 7:52 AM revealed the wound to the resident's right lower posterior leg measured 4.0 by 3.5 cm with a depth of 0.1 cm. The form indicated the resident was seen by the Wound Clinic 2/21/18 and the wound was debrided at the appointment. Review of a Progress Note by the Wound Clinic dated 2/26/18 at 8:30 AM revealed the wound to the resident's right lower posterior leg now measured 4.5 cm by 4.2 cm with a depth of 0.2 cm. The wound was again debrided at the clinic appointment. In addition, the resident was identified as having [MEDICAL CONDITION] (swelling of body tissues due to fluid accumulation that may be demonstrated by applying pressure to the swollen area. If the pressing causes an indentation that persists for some time after the release of the pressure, it is referred to as [MEDICAL CONDITION]). An order was identified for the resident to elevate legs as much as possible. Review of a Nursing Progress Noted dated 2/27/18 at 3:51 PM revealed the resident was seen by the practitioner with a new order for the resident to seen for a consult regarding surgical debridement of the wound to the resident's right lower leg. Review of a Weekly Wound Evaluation dated 3/1/18 at 2:34 PM revealed the wound to the resident's right lower leg measured 4.5 cm by 4.2 cm with a depth of 0.2 cm. Review of a Nursing Progress Note dated 3/2/18 at 1:00 PM revealed a new order for placement of a midline PICC (peripherally inserted central catheter which is inserted into a large vein of the arm and ends in a large vein in the heart. Used to give medications intravenously (IV) which are irritating to veins) and to start IV [MEDICATION NAME] (antibiotic used to treat certain bacterial infections) 1500 mg daily for the next 10 days. In addition, an order was received to discontinue use of the Bactrim and to start [MEDICATION NAME] (antibiotic used to treat bacterial infections of the skin) 500 mg daily for the next 7 days. During an interview on 3/5/18 at 9:48 AM, Resident 13 identified the wound to the resident's right lower leg occurred during a transfer. The resident indicated Nursing Assistant (NA)-Q lifted the resident's legs onto the bed and the resident felt a sharp pain to the resident's right lower leg. The resident further indicated the staff had an object on their uniform or in their pocket which caused the injury. Observations of Resident 13 on 3/6/18 revealed the following: -10:06 AM to 11:00 AM the resident was seated in a wheelchair in the resident's room. No foot pedals were observed to the resident's wheelchair and the resident's legs were hanging dependent. -1:18 PM the resident remained positioned in a wheelchair with bilateral foot pedals noted to the wheelchair. The resident's feet were positioned on the foot pedals, but the resident's legs were not elevated. -2:00 PM the resident was in the Dining Room and involved in a group activity. The resident's positioning in the wheelchair was unchanged. Observations of Resident 13 on 3/7/18 revealed the following: -6:35 AM the resident was positioned in the wheelchair in the resident's room. No foot pedals were observed to the wheelchair and the resident's legs were hanging dependent. -10:40 AM the resident remained positioned in the wheelchair in the resident's room. No foot pedals were positioned on the wheelchair and the resident's legs continued to hang dependent. -11:34 AM the resident exited the facility per wheelchair for surgical debridement of the wound to the resident's right lower leg. During an interview on 3/7/18 at 4:00 PM, the Director of Nursing (DON) verified Resident 13 had complained of pain on 1/16/18 related to a transfer into bed by NA-Q. An assessment of the area revealed a hard lump without an open area, bruising or redness. The DON interviewed NA-Q who confirmed the resident had complained of pain during the transfer and identified an object in the pocket of the staff's uniform could have caused the injury. Review of a Physician Visit Report dated 3/7/18 revealed the resident had surgical debridement of the wound to right posterior lower leg. A [DEVICE] (therapeutic technique using a vacuum dressing to promote healing in acute or chronic wound) was in place to the resident's right lower leg. An order was received to keep the [DEVICE] on at all times and to keep the resident's right leg elevated as much as possible. Observations of Resident 13 on 3/8/18 revealed the following: -6:50 AM the resident was seated in a wheelchair in the resident's room with foot pedals to bilateral sides of the chair. The resident's feet were positioned on the foot pedals, however the resident's right leg was not elevated. -9:00 AM to 10:45 AM the resident remained in the wheelchair in the resident's room. The resident's right leg was not elevated. During an interview on 3/8/18 at 3:30 PM, the DON confirmed Resident 13 was to have legs elevated as much as possible to assist with healing of the wound to the resident's right lower leg.",2020-02-01
1483,"PREMIER ESTATES OF PIERCE, LLC",285139,"P O BOX 189, 515 EAST MAIN STREET",PIERCE,NE,68767,2019-06-26,684,D,1,0,ASM111,"**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 provide care and monitoring to ensure wound healing for Resident 1 (Resident 1) of 3 sampled residents. The facility census was 44. Findings are: [NAME] Review of the facility policy titled Skin Care & Wound Management dated 06/2015 identified the following components of skin care and wound management: -identification of residents at risk for developing pressure ulcers; -implementation of prevention strategies to minimize the potential for developing pressure ulcers and skin integrity issues; -weekly monitoring of skin status; -daily monitoring of existing wounds; and -review and modification of treatments plans. B. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/29/19 revealed [DIAGNOSES REDACTED]. The same assessment indicated the resident required extensive staff assistance with bed mobility, personal hygiene, toilet use and transfers. In addition, the assessment indicated the resident had 6 Stage 2 (the staging system is a method of summarizing characteristics of pressure ulcers, including the extent of tissue damage. A Stage 2 pressure ulcer is a partial thickness skin loss that presents as an abrasion, blister or shallow crater) pressure ulcers and 1 Unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough which may be tan, brown or black in color) pressure ulcer. Review of a Nursing Admission Data Collection form dated 2/22/19 at 10:20 AM revealed the resident had excoriation to bilateral buttocks and the perineal area. The form indicated the resident was at moderate risk for pressure ulcer development. Review of a Nursing Progress Note dated 2/25/19 at 1:19 AM revealed the resident's perineal area and coccyx were red and irritated. Review of a Nutrition Progress Note dated 2/28/19 at 9:14 PM revealed completion of an initial assessment by the Registered Dietician (RD) which indicated no skin concerns except for a red coccyx from loose stools. Review of the resident's care plan dated 3/6/19 revealed the resident was at risk for potential pressure ulcer development related to immobility, and [DIAGNOSES REDACTED]. The following interventions were identified: -administer treatments as ordered and document effectiveness; -assess/record/monitor wound healing (weekly). Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvement and declines to physician; -assist with repositioning at least every 2-3 hours and more often as needed and requested; and -air mattress to bed. Review of a Nursing Progress Note dated 3/21/19 at 1:54 PM revealed the resident's coccyx was becoming very sore. The note also indicated the resident did not always allow staff to turn or to reposition. Review of a Pressure Injury Weekly assessment dated [DATE] at 3:02 PM revealed the following facility acquired pressure ulcers were identified: -coccyx with a 1.8 centimeter (cm) x (by) 1.0 cm Stage II; -coccyx with a 3.0 cm x 3.0 cm Stage II; -coccyx with a 4.0 cm x 2.5 cm Stage II; -left gluteal fold with a 4.0 cm x 2.5 cm Stage II pressure ulcer; and -left gluteal fold with a 5.0 cm x 3.4 cm Stage II pressure ulcer. Review of a Pressure Injury Weekly assessment dated [DATE] at 6:50 PM revealed the following facility acquired pressure ulcers were identified: -left gluteal fold 3.0 cm x 3.0 cm Unstageable; and -right gluteal fold 1.4 cm x 1.0 cm Stage II. Review of a Change of Condition facsimile (fax) which was sent to the resident's physician on 3/22/19 revealed a notification regarding the breakdown to the resident's buttocks and coccyx areas with a request for orders to treat the areas. Further review of the fax revealed new orders from the physician dated 4/10/19 (19 days later) for Calcium Alginate non-stick foam and [MEDICATION NAME] (dressings designed to be super-absorbent while maintaining a moist healing environment) to treat the resident's areas of skin breakdown. Review of a Pressure Injury Weekly assessment dated [DATE] at 10:19 AM revealed the following facility acquired pressure ulcers were identified: -right buttock with 4 cm x 3.8 cm with a depth of 0.1 cm Stage II: -left buttock with a 5.2 cm x 3 cm with a depth of 0.1 cm Stage II; -left buttock with a 9 cm x 1.5 cm with a depth of 0.1 cm Stage II; and -left thigh with a 2 cm x 2 cm Stage II. review of the resident's medical record revealed [REDACTED]. was notified regarding changes in the assessment or the additional areas indicated. Review of a Pressure Injury Weekly assessment dated [DATE] at 8:44 AM revealed the following facility acquired pressure ulcers were identified: -right buttock with 8.9 cm x 5 cm Stage II: -left buttock with a 2.9 cm x 4.0 cm Stage II; and -left thigh with a 2 cm x 2 cm Stage II. Further review of this assessment revealed the areas had large amounts of red drainage. review of the resident's medical record revealed [REDACTED]. Review of a Pressure Injury Weekly assessment dated [DATE] at 2:30 PM revealed a facility acquired Unstageable pressure ulcer was identified to the resident's left outer ankle which measured 2.5 cm x 3.0 cm. Review of a Change of Condition fax to the resident's physician dated 4/10/19 revealed the physician was notified of the resident's left outer ankle pressure ulcer. Further review of the fax revealed a new order dated 5/2/19 (22 days later) for staff to apply [MEDICATION NAME] 3 times a day to the pressure ulcer. Review of a Pressure Injury Weekly assessment dated [DATE] at 11:05 AM revealed the following facility acquired pressure ulcers were identified: -right buttock with 2.4 cm x 3.2 cm with a depth of 0.1 cm Stage II: -left buttock with a 8.8 cm x 4.9 cm with a depth of 0.1 cm Stage II; and -left gluteal fold with a 1.7 cm x 1.7 cm with a depth of 0.1 cm Stage II. review of the resident's medical record revealed [REDACTED]. Review of a Pressure Injury Weekly assessment dated [DATE] at 5:40 PM revealed the following facility acquired pressure ulcers were identified: -right buttock with 2.4 cm x 3.0 cm with a depth of 0.1 cm Stage II: -left buttock with a 8.7 cm x 4.5 cm with a depth of 0.1 cm Stage II; and -left gluteal fold with a 1.5 cm x 1.0 cm with a depth of 0.1 cm Stage II. Review of a Pressure Injury Weekly assessment dated [DATE] at 12:40 PM revealed the following facility acquired pressure ulcers were identified: -right buttock with 1.8 cm x 1.2 cm with a depth of 0.1 cm Stage II: -left buttock with a 7.2 cm x 2.8 cm with a depth of 0.1 cm Stage II; and -left gluteal fold with a 1.0 cm x 1.0 cm with a depth of 0.1 cm Stage II. Review of a Pressure Injury Weekly assessment dated [DATE] (15 days since the previous assessment) at 12:45 PM revealed the Unstageable facility acquired pressure ulcers to the resident's left outer ankle measured 2.3 cm x 1.8 cm. Review of a Pressure Injury Weekly assessment dated [DATE] at 12:01 PM revealed the following facility acquired pressure ulcers were identified: -right buttock with 0 cm x 0 cm Stage II: -left buttock with a 3 cm x 2 cm with a depth of 0.1 cm Stage II; -left buttock with a 4 cm x 3 cm with a depth of 0.1 cm Stage II; and -left gluteal fold with a 1.5 cm x 1.7 cm with a depth of 0.1 cm Stage II. review of the resident's medical record revealed [REDACTED]. Review of a Pressure Injury Weekly assessment dated [DATE] (13 days since the previous assessment) at 2:17 PM revealed the Unstageable facility acquired pressure ulcers to the resident's left outer ankle measured 1.5 cm x 1.5 cm. Review of a Pressure Injury Weekly assessment dated [DATE] at 4:01 PM revealed the following facility acquired pressure ulcers were identified: -right buttock with 1 cm x 0.3 cm with a depth of 0.1 cm Stage II: -right buttock with a 5.0 cm x 3.0 cm with a depth of 0.1 cm Stage II; -left buttock with a 10 cm x 3 cm with a depth of 0.1 cm Stage II; and -left buttock with a 4 cm x 2 cm with a depth of 0.1 cm Stage II; Review of a Pressure Injury Weekly assessment dated [DATE] at 4:16 PM revealed the following facility acquired pressure ulcers were identified: -left gluteal fold with a 1.0 cm x 2.0 cm with a depth of 0.1 cm Stage II; -left gluteal fold with a 1.0 cm x 2.0 cm with a depth of 0.1 cm Stage II; and -right gluteal fold with a 2.0 cm x 2.0 cm with a depth of 0.1 cm Stage II. Review of a Change of Condition fax dated 5/8/19 revealed the resident's physician was notified of additional open areas with an increase in drainage to the resident's wounds. Further review of the fax revealed the physician did not provide any additional orders or change treatment to the areas but the physician did indicate this had been going on for years. Review of a Pressure Injury Weekly assessment dated [DATE] at 1:34 PM revealed the following facility acquired pressure ulcers were identified: -left gluteal fold with a 1.0 cm x 1.6 cm with a depth of 0.1 cm Stage II; -left gluteal fold with a 1.0 cm x 1.8 cm with a depth of 0.1 cm Stage II; and -left gluteal fold with a 1.8 cm x 1.8 cm with a depth of 0.1 cm Stage II. Review of a Pressure Injury Weekly assessment dated [DATE] at 1:44 PM revealed the following facility acquired pressure ulcers were identified: -right buttock with 1 cm x 0.3 cm with a depth of 0.1 cm Stage II: -right buttock with a 2.8 cm x 1.8 cm with a depth of 0.1 cm Stage II; and -left buttock with a 2 cm x 2 cm with a depth of 0.1 cm Stage II. Review of a Pressure Injury Weekly assessment dated [DATE] (9 days since the previous assessment) at 1:50 PM revealed the Unstageable facility acquired pressure ulcers to the resident's left outer ankle measured 0.7 cm x 0.7 cm with a depth of 0.1 cm. Review of a Change of Condition fax dated 5/15/19 revealed the resident's physician was notified the resident's buttocks and gluteal folds continued to show improvement and then to worsen. Areas were noted to be extremely moist. Resident 1's physician indicated this was the resident's pattern and the areas were from moisture. The physician indicated staff were to continue to reposition the resident and identified the air mattress was essential. Review of a Pressure Injury Weekly assessment dated [DATE] at 3:09 PM revealed the Unstageable facility acquired pressure ulcers to the resident's left outer ankle measured 1.4 cm x 1.4 cm. Review of a Non-Pressure Weekly Skin Record dated 5/22/19 at 2:58 PM revealed the resident had an open area which was first observed on 5/8/19 on the resident's left buttock which measured 3 cm x 1.7 cm with a depth of 0.1 cm. Review of a Non-Pressure Weekly Skin Record dated 5/22/19 at 3:21 PM revealed the resident had an open area which was first observed on 3/20/19 to the resident's right buttock. The area measured 2.2 cm x 1.2 cm. Review of a Non-Pressure Weekly Skin Record dated 5/22/19 at 3:34 PM revealed the resident had an open area which was first observed on 3/20/19 on the resident's left buttock which measured 3.2 cm x 2.0 cm. Review of a Non-Pressure Weekly Skin Record dated 5/22/19 at 3:37 PM revealed the resident had an open area which was first observed on 5/15/19 on the resident's left gluteal fold which measured 1.0 cm x 1.0 cm with a depth of 0.1 cm. Review of a Non-Pressure Weekly Skin Record dated 5/22/19 at 3:39 PM revealed the resident had an open area which was first observed on 3/20/19 on the resident's right gluteal fold which measured 1.0 cm x 1.8 cm with a depth of 0.1 cm. Review of a Non-Pressure Weekly Skin Record dated 5/22/19 at 3:41 PM revealed the resident had an open area which was first observed on 5/8/19 on the resident's left buttock which measured 1.8 cm x 1.8 cm with a depth of 0.1 cm. Review of a Non-Pressure Weekly Skin Record dated 5/29/19 at 3:00 PM revealed the resident had an open area which was first observed on 5/8/19 on the resident's left buttock which measured 1.5 cm x 1.5 cm with a depth of 0.1 cm. Review of a Non-Pressure Weekly Skin Record dated 5/29/19 at 3:06 PM revealed the resident had an open area which was first observed on 3/20/19 on the resident's left gluteal fold which measured 0.9 cm x 0.8 cm with a depth of 0.1 cm. Review of a Non-Pressure Weekly Skin Record dated 5/29/19 at 3:10 PM revealed the resident had an open area which was first observed on 3/20/19 on the resident's right buttock which measured 1.9 cm x 0.7 cm with a depth of 0.1 cm. Review of a Non-Pressure Weekly Skin Record dated 5/29/19 at 3:12 PM revealed the resident had an open area which was first observed on 3/20/19 on the resident's right buttock which measured 2.0 cm x 1.2 cm with a depth of 0.1 cm. Review of a Pressure Injury Weekly assessment dated [DATE] at 3:14 PM revealed the Unstageable facility acquired pressure ulcers to the resident's left outer ankle measured 1.4 cm x 1.4 cm. Review of a Change of Condition fax to Resident 1's physician dated 5/29/19 revealed notification the wound to the resident's left outer ankle was covered with slough (dead skin or tissue). Further review of the form revealed a new order dated 6/4/19 (5 days later) to change the treatment to cleansing the wound with normal saline then to apply Calcium Alginate and cover with a [MEDICATION NAME] dressing daily. Review of a Non-Pressure Weekly Skin Record dated 5/29/19 at 3:37 PM revealed the resident had an open area which was first observed on 5/8/19 on the resident's left gluteal fold which measured 0.7 cm x 1.5 cm with a depth of 0.1 cm. Review of a Non-Pressure Weekly Skin Record dated 6/5/19 at 2:20 PM revealed the resident had an open area which was first observed on 3/20/19 on the resident's left buttock which measured 2.3 cm x 1.0 cm with a depth of 0.1 cm. Review of a Non-Pressure Weekly Skin Record dated 6/5/19 at 2:22 PM revealed the resident had an open area which was first observed on 3/20/19 on the resident's left buttock which measured 1.4 cm x 0.5 cm with a depth of 0.1 cm. Review of a Non-Pressure Weekly Skin Record dated 6/5/19 at 2:45 PM revealed the resident had an open area which was first observed on 3/20/19 on the resident's left gluteal fold which measured 0.5 cm x 0.3 cm with a depth of 0.1 cm. Review of a Non-Pressure Weekly Skin Record dated 6/5/19 at 2:47 PM revealed the resident had an open area which was first observed on 3/20/19 on the resident's left gluteal fold which measured 1.9 cm x 0.5 cm with a depth of 0.1 cm. Review of a Non-Pressure Weekly Skin Record dated 6/5/19 at 2:49 PM revealed the resident had an open area which was first observed on 3/20/19 on the resident's right buttock which measured 1 cm x 1 cm with a depth of 0.1 cm. Review of a Pressure Injury Weekly assessment dated [DATE] at 2:51 PM revealed the Unstageable facility acquired pressure ulcers to the resident's left outer ankle measured 1.5 cm x 1.5 cm. The ulcer was noted to have a slight odor with a scant amount of serosanguinous drainage. Interview with the Director of Nursing on 6/26/19 from 1:30 PM to 2:00 PM confirmed the following: -Resident 1 was at risk for pressure ulcer development and/or skin breakdown; -if a wound, skin concern or pressure ulcer were identified, staff were to assess and then to document the assessment on a weekly basis to assure healing; -staff were to assure each area of skin breakdown were identified clearly with routine assessment of each are; -if a change was identified in the condition of the area, then staff were to notify the physician to review current treatment orders for a potential change to assure continued healing; and -if a response was not received from the physician within 24 hours, then staff should re-fax or should call the physician to assure timely notification.",2020-09-01
4909,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2018-02-05,684,D,1,0,15YY11,"**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 provide monitoring to ensure wound healing for Resident 24. The sample size was 4 and the facility census was 36. Findings are: Review of the facility policy titled Skin Care & Wound Management dated 06/2015 revealed for ongoing wound monitoring the resident's Care Plan would contain resident specific interventions. Review of Resident 24's current undated Care Plan revealed the resident had a surgical wound from a skin graft to the left ischial hip. Interventions included monitoring and documenting the location, size, and treatment of [REDACTED]. Review of Resident 24's Skin Grid revealed on 12/30/17 the wound to the resident's left ischial hip measured 2 centimeters (cm) by 1cm with a depth of 4.5cm. On 2/3/18 the wound measured 3cm by 2 cm with the depth varying between 3cm and 4.5cm. There was no evidence to indicate the wound had been measured between 12/30/17 and 2/3/18. During an interview on 2/5/18 at 1:15 PM Licensed Practical Nurse-F indicated Resident 24's wound to the left ischial hip had not changed much over the last 5 months. Further interview revealed the resident did refuse re-positioning at times and did leave the facility with family for extended periods of time in the resident's wheelchair. Interview with the Director of Nursing on 2/5/18 at 3:45 PM, confirmed there was no evidence to indicate Resident 24's wound had been measured between 12/30/17 and 2/3/18.",2020-03-01
5006,AZRIA HEALTH AT MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2017-02-28,309,D,1,0,SFQT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2 Based upon record review and interview, the facility failed to monitor bruises post incident for 3 (Residents 1, 2 and 3) of 3 sampled residents. The facility census was 136. Findings are: [NAME] Record review of Resident 1's admission record dated 2/28/2017 revealed that Resident 1 was admitted on [DATE] for the following Diagnoses: [REDACTED]. Record review of an incident report for Resident 1, dated 2/16/2017, revealed the injury type was bruise. In the notes section, the report stated the resident sustained [REDACTED]. Record review of Weekly Skin Assessment Sheets dated 02/13/2017 revealed no bruising charted. Record review of the Weekly Skin Assessment Sheets dated 02/20/2017 revealed facial bruising charted. Interview with the DON (Director of Nursing ) on 02/28/2017 at 10:45 AM, the DON confirmed that there was no evidence of monitoring of the bruises post incident for Resident 1. B. Record review of Resident 2's admission record dated 2/28/2017 revealed that Resident 2 was admitted on [DATE] for the following Diagnoses: [REDACTED]. A record review of the resident's progress notes, dated 2/11/2017, revealed the resident was found on the floor face down by roommate. A contusion (bruise) and hematoma (swelling) were noted to left side of forehead above left eye. Resident 2 complained of a headache and neurological checks were started. Record review of Weekly Skin Assessment Sheets dated 02/13/2017 revealed there was a 7x10 purple reddish area to left forehead and a 5 cm (centimeter) x 0.3cm under right eye. Record review of the Weekly Skin Assessment Sheets dated 02/20/2017 revealed, to left side of the face, 15x11 bruising from the fall. Interview with the DON on 02/28/2017 at 10:45 AM, the DON confirmed that there was no evidence of monitoring of the bruises post incident for Resident 2 other than the weekly skin assessment. C. Record review of Resident 3's admission record, dated 2/28/2017, revealed that Resident 3 was admitted on [DATE] for the following Diagnoses: [REDACTED]. A record review of the incident report dated 2/17/2017, revealed, under the sections Injuries Type, an abrasion on the back of the right hand and, under Injuries Report Post Incident, a bruise to right shoulder and skin tear to right palm. Record review of Weekly Skin Assessment Sheets dated 02/19/2017 revealed a bruise to the right shoulder, which measured 6 by 4, and scabs to palm side of the right hand that measured 2 by 2 and 2 by 1. Record review of the Weekly Skin Assessment Sheets dated 02/26/2017 revealed a right shoulder bruise that was faded and measured 6 1/2 cm by 2 1/2 cm. Record review of the Weekly Skin Assessment Sheets dated 02/27/2017 revealed a right shoulder bruise that measured 13 by 10. Interview, on 02/28/2017 at 10:45 AM revealed, the DON confirmed that there was no evidence of monitoring of the bruises post incident for Resident 2 other than the weekly skin assessment.",2020-02-01
2835,BELLE TERRACE,285237,1133 NORTH THIRD ST,TECUMSEH,NE,68450,2017-06-08,314,D,1,0,LUKH11,"**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 assess pressure sores for one (Resident 8) of 17 sampled residents. The facility had a total census of 56 residents. Findings are: Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Physician and Facility Communication dated 4/4/17 reported Resident 8's boot was removed from the right foot to check skin. The fax stated an area .3 x 3 cm (centimeter) was observed over medial malleolus with 3.5 x .9 purple area just above heel slightly medially and 2.2 x 2.3 cm pink area on inferior to medial malleolus. Skin was noted to be intact with 1-2 plus [MEDICAL CONDITION] of right foot and leg. Orders to leave boot off and apply ace wrap and re-apply twice a day. A Physician and Facility Communication dated 4/10/17 reported Resident 8 had a 5 cm x 4 cm bruise to right inner heel. Area was identified as being caused by walking boot that had been discontinued. Orders were received on 4/10/17 for skin prep to site twice a day until resolved and then continue for 2 weeks following to help promote tissue integrity and Prevalon boot (a pressure relieving boot) to right foot at all times to off load heel. A review of physician orders [REDACTED]. Wounds were to be washed with soap and water with each dressing change. Prevalon boot to right foot 24 hours per day/7 days per week. A review of physician orders [REDACTED]. Wounds were to be washed with soap and water with each dressing change. A review of Skin Condition Record for Non-Pressure Ulcer Skin conditions for Resident 8 revealed the following assessments of the bruise on the right foot/heel: -4/9/17 first observed; Bruise to inner right foot (heel) 5 cm x .4 cm. Identified that Resident 8 did have pressure from walking boot that had been discontinued. Condition was identified as a bruise. -4/16/17 5 cm length x 0.4 cm width dark purple with pink surrounding skin and surrounding tissue intact. -4/28/17 4 cm length x 0.4 width dark purple with surrounding skin within normal limits and intact. Bleeding with dressing changes was noted. -5/6/17 4 cm length x .4 cm width dark wound bed with surrounding within normal limits and intact. Bleeding with dressing changes was noted. Progress was identified as not changed. -5/15/17 4 cm length x .4 cm width dark purple wound bed with surrounding within normal limits and intact. Bleeding with dressing changes was noted. Progress was identified as not changed. -5/22/17 4 cm length x .4 cm width dark wound bed with surrounding within normal limits and intact. Bleeding with dressing changes was noted. Progress was identified as not changed. -5/29/17 4 cm length x .4 cm width dark wound bed with surrounding within normal limits and intact. Bleeding with dressing changes was noted. Progress was identified as not changed. A review of Wound/Skin Healing Record dated 4/16/17 for Resident 8 identified a Stage 2 to left ankle. The following assessments were documented: -4/16/17 stage 2; .5 cm length x .5 cm width, .3 cm depth with small serous exudate, granulation tissue and pink surrounding skin. -4/16/17 stage 2; .5 cm length x .5 cm width, no depth, scant serous exudate, granulation tissue and pink surrounding skin. -4/28/17stage 2; 0.5 cm length x .5 cm width, .3 cm depth, scant serous exudate, granulation tissue and pink surrounding skin. Observations of Resident 8's right foot and ankle on 6/8/17 at 11:38 AM revealed an area on the right ankle, a dark circular area on the right heel and a small area on the right great toe with a dark toenail. The following measurements were documented for Resident 8's wounds on 6/8/17 at 11:38 AM right inner ankle 1.5 cm length x 1.3 cm width x .3 cm depth; right heel 4 cm x 4 cm; and toe .3 cm toenail is darkened and intact. In an interview on 6/7/17 at 3:34 PM, the Assistant Director of Nursing reported doing the charting on wounds. The Assistant Director of Nursing reported trying to assess wounds once per week but is behind on completing the assessments. In a follow up interview on 6/8/17 at 12:02 PM and 2:02 PM, the Assistant Director of Nursing reported the left ankle on the wound /skin healing record was actually the right ankle and was a stage 2 pressure sore. The Assistant Director of Nursing confirmed there was no documented assessment of the ankle since 4/28/17 and the heel was a deep tissue injury. According to the Assistant Director of Nursing, the heel was healing from the inside out and was getting larger. In an interview on 6/13/17 at 8:55 AM, the Assistant Director of Nursing reported the area on Resident 8's right great toe had resulted from having a toenail cut too short. The Assistant Director of Nursing reported a monitoring record had not been started as this area was not open. A review of an undated facility policy titled Wound Care: Prevention, Assessment, Treatment, and Documentation revealed assessments of wounds will be completed weekly and as needed with documentation to be completed on the wound record.",2020-09-01
2869,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2018-01-02,686,H,1,1,51KH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2a Based on observation, record review and interview; the facility staff failed to identify pressure ulcers and failed to implement assessed interventions to prevent development of pressure ulcers for 4(Resident 3, 36, 51 and 160) of 4 sampled residents. The facility staff identified a census of 66. Findings are: [NAME] Record review of Resident 51's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 12-06-2017 revealed the facility staff assessed the following about Resident 51: -Brief Interview for Mental Status (BIMS) was a 14. According to the MDS Manuel a score of 13 to 15 indicates a person is cognitively intact. -Required supervision with eating. -Required extensive assistance with 2 or more persons assisting with bed mobility, transfers, dressing, toilet use and personal hygiene. -Always incontinent of bowel and bladder. -Identified Resident 51 at risk for the development of pressure ulcers. Record review of Resident 51's Braden Scale (tool used for predicting pressure sore risk) dated 12-06-2017 revealed Resident 51 scored a High Risk rating. Record review of Resident 51's Comprehensive Care Plan (CCP) dated 11-24-2017 revealed Resident 51 had the [DIAGNOSES REDACTED]. Further review of Resident 51's CCP updated on 12-06-2017 revealed Resident 51 had returned from the hospital with an open wound to the sacrum and prevalon boots (type of pressure relieving foot wear) in place to both feet. According to Resident 51's CCP, the prevalon boots were worn at all times. Observation on 12-20-2017 at 2:49 PM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Observation on 12-21-2017 at 11:00 AM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Observation on 12-21-2017 11:22 AM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Observation on 12-21-2017 at 1:10 PM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Further observation on 12-21-2017 at 1:10 PM revealed Resident 51's Family member was in the room with Resident 51. Resident 51's Family member stated see (gender) doesn't have (gender) boots on and with a pointing movement indicated the prevalon boots were placed in a chair in Resident 51's room. Resident 51's family member confirmed the prevalon boots were to be on Resident 51. Observation on 12-21-2017 2:00 PM with Licensed Practical Nurse (LPN) B of Resident 51's heels revealed Resident 51 had an approximately 5 centimeters (cm) roundish fluid looking blister to the left heel. On 12-21-2017 at 2:00 PM an interview was conducted with LPN B. During the interview, LPN B confirmed Resident 51 did not have the prevalon boots on (gender) feet. LPN B further reported not being aware Resident 51 had a wound to the left heel. Record review of Resident 51's record revealed there was no evidence Resident 51 had a pressure area to the left heel. Further review of Resident 51's medical record revealed there was no evidence the facility had completed daily monitoring of Resident 51's feet. Record review of a Skin Pressure Ulcer Weekly (SPUW) sheet dated 12-21-2017 with a time of 2:50 PM revealed the area to Resident 51's left heel was measured as 2.9 cm by 2.5 cm and staged as a Suspected Deep Tissue Injury ( SDTI). The description of the left heel SDTI was identified as black/brown, eschar (dead tissue). According to Woundeducators.com, a SDTI is A deep tissue injury is a unique form of pressure ulcer. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. B. Record review of Resident 3's MDS dated as completed on 10-03-2017 revealed the facility staff assessed the following about the resident: -BIMS was a 15. -Total dependence for bed mobility, transfers, dressing, eating, toilet use and personal hygiene with 2 plus people assisting with bed mobility, transfers, dressing and personal hygiene. -No pressure ulcers were identified for Resident 3. Record review of a Skin Evaluation sheet dated 12-17-2017 revealed there were not any pressure ulcers identified for Resident 3. Record review of a Braden Scale evaluation sheet dated 9-21-2017 revealed Resident 3 was evaluated as low risk for the development of pressure ulcers. Record review of Resident 3's CCP dated 10-13-2017 revealed Resident 3 was to have Prafo (type of pressure relieving boots) while in bed. Further review of Resident 3's CCP dated 12-17-2017 revealed Resident 3 had the potential for impaired skin integrity and pressure. The goal for Resident 3 was to remain free of sign and symptoms of new skin breakdown. Interventions identified were to assist with repositioning, Prafo boots while in bed, pressure reducing mattress and wheelchair cushion. On 12-21-2017 at 4:12 PM an interview was conducted with Resident 3. During the interview Resident 3 reported having a pressure ulcer to the right heel. Review of Resident 3's medical record revealed there was no evidence the facility staff had identified a pressure ulcer on the resident's right heel. On 12-26-2017 at 5:04 AM an interview was conducted with Resident 3. Resident 3 reported (gender) had a pressure ulcer to the right heel. On 12-26-2017 at 5:20 AM observation of Resident 3's right heel with Registered Nurse (RN) D revealed a had a dark purple looking area to the right heel. Record review of a SPUW sheet dated 12-27-2017 revealed Resident 3 was identified with an unstageable pressure ulcer to the right heel that measured 1.5 cm by 4.0 cm. The wound bed was identified as black/brown eschar. On 12-27-2017 at 7:26 AM an interview was conducted with Registered Nurse (RN) E. During the interview RN [NAME] reported there was no monitoring of the right heel ulcer for Resident 3. C. Record review of Resident 160's MDS dated as completed on 12-20-2017 revealed the facility staff assessed the following about the resident: -BIMS was a 6. According to the MDS Manuel, a score of 0 to 7 indicates severe cognitive impairment. -Required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. -Resident 160 was identified at risk for developing pressure ulcers. -No pressure ulcers were identified for this resident. Record review of a Braden Scale form dated 12-07-2017 revealed the facility assessed Resident 160 as a low risk for the development of pressure ulcers. Observation on 12-27-2017 at 6:30 AM revealed Resident 160 was in bed, in a back laying position. Observation on 12-27-2017 at 7:45 AM revealed Resident 160 was in bed, in a back laying position. Observation on 12-27-2017 at 8:25 AM revealed Resident 160 was in a back laying position. Observation on 12-27-2017 at 1:35 PM with RN [NAME] revealed Resident 160 had several red areas with defined edges. Record review of a SPUW sheet dated 12-27-2017 timed at 7:47 PM revealed the facility staff assessed Resident 160 with 3, stage 1 (Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED] (redness) caused from pressure) pressure ulcer. The 3 pressure ulcers were identified as the following: -Site 1, left buttocks, stage, with measurements of 2.0 cm by 0.6 cm. -Site 2, lower left buttocks, stage 1 with measurements of 2.0 cm by 0.6 cm. -Site 3, right buttocks, stage 1 with measurements of 2.0 by 1.0 cm. C. Review of Resident 36's Comprehensive Care Plan (CCP) revealed a problem statement of: Alteration in skin integrity. Resident 36 requires assistance with repositioning. The CCP revealed on12/13/17 Resident 36 was identified as having a pressure ulcer on the coccyx (tailbone). Review of Resident 36's Comprehensive Care Plan for Bed Mobility revealed Resident 36 required extensive assistance of 1 staff to reposition and turn in bed and staff to assist Resident 36 every 2 hours and as needed. 12/27/2017 observations of Resident 36 revealed the resident was in the following positions: -6:30 AM; On back. -7:00 AM; On back -7:50 AM; On back, -8:35 AM; On back, -9:15 AM; On back, -9:40 AM; On back. Observation on 12/27/2017 at 9:40 AM of Resident 36 revealed an area on Resident 36's coccyx bony prominence was open. Interview on 12/27/2017 at 9:40 AM with the Assistant Director of Nursing (ADON) revealed Resident 36 should have been turned at least every 2 hours. Review of a facility form dated 12/18/2017 revealed Resident 36 had a pressure ulcer on the resident's coccyx identified on 10/30/2017 as unstageable which was assessed as healed on 12/18/2017. Review of wound documentation dated 12/23/2017 revealed Resident 36 had no alteration of skin integrity. Review of the facility document dated 9/2017 titled Wound Management revealed the purpose of the policy was to ensure the resident did not develop pressure ulcers unless clinically unavoidable and the facility provided care and services to prevent the development of additional pressure ulcers. Interview on 12/27/2017 at 2:00 PM with LPN-C revealed Resident 36 did have an area on the coccyx that had previously healed and did reopen and is a stage 2 area with a small unstageable area in the center.",2020-09-01
1637,MAPLE CREST HEALTH CENTER,285149,2824 NORTH 66TH AVENUE,OMAHA,NE,68104,2017-11-02,314,G,1,1,I4SU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2a and 12-006.09D2b Based on observation, record review, and interview; the facility failed to prevent development of a pressure ulcer for Resident 208 and failed to implement treatment for [REDACTED]. Record review of the facility policy, dated revised 12/07, revealed the following: -Provide catheter care at least every eight hours. -Be sure that the catheter remains secured. -When a stat lock is used, please ensure that it is at the right distance so it is not pulling on the meatus. -Report unsecured catheters to the supervisor. Be observant of skin irritation. Record review of the Face Sheet for Resident 208 revealed that, Resident 208 was admitted to the facility on [DATE]. Resident 208's [DIAGNOSES REDACTED]. Morbid (Severe) Obesity Due to Excess Calories, and Foley Catheter for [MEDICAL CONDITION]. Observation on 11/01/17 from 1:49 PM to 2:15 PM , staff members Registered Nurse (RN) and Nursing Assistant (NA) O were present in the room of Resident 208. NA O began performing Foley Catheter Care ( Foley catheter is a tube that is placed into the bladder thru the opening in the Penis called the Meatus). Resident 208 was observed to have a stat lock (Stat lock is a securement device to hold the catheter in place to prevent repeated motion found to cause increased risk of Urinary Tract Infections). Resident 208 was observed to have the stat lock to the left inner thigh, and it was observed to be secured in a manner that pulled the tubing taunt. During the cleansing performed by NA O, it was found that where the Foley catheter was pulled taunt against the skin, the skin had developed an open area. RN N observed the new area and confirmed, at that time, that the catheter had been secured too tightly causing a pressure area to open on the foreskin of the residents penis. RN N then went and returned with Staff nurse P. Staff nurse P confirmed that the stat lock was pulling the tubing taunt, and that the area that was now open was new and had not been noted before. Interview with Resident 208's family member, present, on 11/1/17 at 2:26 PM, confirmed that there had not been an open area present prior to today. B. Record review of an Admission Record sheet printed on 11-01-2017 revealed Resident 143 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 143 Progress Notes sheet (PNS) dated 9-23-2017 revealed Resident 143 was evaluated with having .two darken spots,(on each heel) on the back bottom of (gender) heels. There was no evidence the facility had evaluated the sizes of the dark areas on Resident 143's heels. Record review of a Skin Risk Data sheet dated 9-26-2017 revealed the facility staff had assessed Resident 143's heel wounds as a stage 2 (Stage II - 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) pressure ulcer. There was no evidence the facility staff had evaluate the sizes of the pressure ulcers. Record review of a PNS dated 9-26-2017 revealed Resident 143's practitioner was notified of the pressure ulcers. According to the PNS dated 9-26-2017. Resident 143's practitioner had ordered a treatment for [REDACTED]. Record review of Resident 143 (MONTH) (YEAR) Treatment Administration Record (TAR) revealed the ordered treatment was not started. Record review of a Mobile Wound Solutions (MWS) sheet dated 10-02-2017 revealed Resident 143 was assessed with [REDACTED]. According to the MWS sheet dated 10-02-2017 the Right Heel measured 2.50 centimeters (cm) by 1.80 cm and was unable to determine pre-depth and the Left Heel measured 1.50 cm by 2.50 cm and was unable to determine pre-depth. The practitioner ordered a treatment that was to be completed daily and as needed. The practitioner further ordered that Resident 143 wear specialty boots when Resident 143 was in bed or sitting in a recliner. According to the MWS sheet dated 10-02-2017, the quality of the tissue and the status of the pressure ulcers to the Right and Left heels had deteriorated. Record review of an undated Skin Monitoring Report (SMR) provided by the facility Administrator revealed Resident 143 had developed the pressure ulcers to the Left and Right heels at the facility. Observation on 11-01-2017 at 11:36 AM of the pressure ulcer treatments with Registered Nurse (RN) J revealed Resident 143 had dark black areas that measured approximately 1.5 cm roundish. RN J reported at the time of the treatment, the areas to Resident 143's heels were hard to touch. Observation on 11-01-2017 at 12:32 PM revealed Resident 143 was sitting in a recliner without heel boots on. Observation on 11-01-2017 at 12:43 PM revealed Resident 143 was sitting in a recliner without heel protecting boots on. 11-01-2017 at 1:01 PM revealed Resident 143 was sitting in a recliner and did not have the heel protecting boots on. On 11-01-2017 at 1:13 PM an interview was conducted with RN [NAME] During the interview, RN J confirmed Resident 143 was not wearing the heel boots and should have been. On 11-02-2017 at 12:20 PM an interview was conducted with Licensed Practical Nurse (LPN) K. During the interview, LPN K confirmed an order for [REDACTED].",2020-09-01
3910,HILLCREST COUNTRY ESTATES-COTTAGES,285293,6082 GRAND LODGE AVENUE,PAPILLION,NE,68133,2017-05-04,248,D,1,1,POAF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D5b Based on record review, observations, and interviews; the facility failed to evaluate and provide an activity program to meet the needs and preferences of 2 (Resident 63 and 44) of 3 sampled residents. The facility census was 46. Findings are: Findings are: [NAME] Review of Resident 63's face sheet revealed Resident 63 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 63's MDS (Minimum Data Set- a federally mandated assessment tool used for care planning) completed on 3/16/2017 revealed Resident 63 had moderately impaired decision making and memory loss. Observations were made of Resident 63 doing the following activities: - 5-1-17 at 10 15 am, Resident 63 was sitting at the bar in the kitchen staring off. No activities were going on. - 5-1-17 at 2 PM, Resident 63 was sitting at a table in the dining room. No activities were going on. The activity calendar posted for the cottage for (MONTH) had (MONTH) Day Hats listed for the day with no time. - 5-2-17 at 11:10 am, Resident 63 was sitting at the bar in kitchen. No activity going on. The resident (res) was staring off. Per the activity calendar posted for the cottage for May, there was to be a sing-a-long at 11 AM. - 5-2-17 at 2:45 PM, Resident 62 was sitting at the bar in Kitchen, with a fall alarm on. The res. was just staring. There was a magazine closed in front of the resident. Staff were present but not encouraging the resident to look at the magazine. The activity calendar posted for the cottage for (MONTH) had no afternoon activity listed. - 5.3.17 at 2 PM, Resident 63 was sitting at a dining table. The resident was alone staring off. The activity calendar for the cottage for (MONTH) listed Movement and Music with staff with no listed time. Review of Resident 63's Preferences assessment done on 5-2-17 had no activity preferences listed. Review of Resident 63's electronic medical record (EMR) progress notes, assessments, attachments, and visit notes revealed no activity evaluation for the resident and no activity documentation. An interview conducted on 5/03/2017 at 11:57 AM with the Assistant Administrator confirmed there was not an activity evaluation for Resident 63 and stated that the facility needed a better activity program. B. Review of Resident 44's face sheet revealed Resident 44 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 44's MDS completed on 12-2-16 revealed Resident 44 had a BIMS (Brief interview for mental status) of 8/15 indicating moderate cognitive impairment. Review of Resident Preferences Assessment for Resident 44 with no completion date stated likes and dislikes of: resident played guitar, was in the Navy and was a police chief. Resident 44 liked football, Westerns and to talk about adventures while looking at Resident 44's scrapbook. Observations were made of Resident 44 doing the following activities: - 5-1-17 at 11 am, Resident 44 was asleep in a wheelchair. - 5-1-17 at 2 PM, Resident 44 was sitting at the bar at the kitchen counter asleep. The activity calendar for the cottage for (MONTH) had listed Ball Toss without a time and Bingo in the afternoon without a time. - 5-2-17 at 10:45 am, Resident 44 was in their room asleep. The activity calendar for the cottage for (MONTH) had listed 10:30 sing-a-long, and 4 PM Rosary. - 5-3-17 at 10 am, Resident 44 was asleep in bed. The activity calendar for the cottage for (MONTH) had listed Musical Morning and 1:1 visits with no times listed. - 5-3-17 at 3 PM, Resident 44 was in their room in a wheelchair asleep. Review of Resident 44's electronic medical record (EMR) progress notes, assessments, attachments, and visit notes revealed no activity evaluation for the resident and no activity documentation. An interview conducted on 5/03/2017 at 11:57 AM with the Assistant Administrator confirmed there was not an activity evaluation for Resident 44 and stated that the facility needed a better activity program.",2020-09-01
5121,CLOVERLODGE CARE CENTER,285201,301 NORTH 13TH STREET,ST EDWARD,NE,68660,2017-02-16,323,E,1,0,51TK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D7b Based on observation, record review and staff interview; the facility failed to identify causal factors for bruising and have in place interventions to prevent future bruising, reevaluate current interventions for effectiveness to prevent future bruising or identify new interventions to prevent future bruising. This affected 3 of 3 sampled residents (Residents 1, 2 and 3). The facility identified the census as 35. Finding are: [NAME] Record review of incident log dated (MONTH) 15, (YEAR) revealed Resident 1 had 4 reports of bruising on 01/11/2017, 01/18/2017, 01/25/2017 and 02/08/2017. Record review of Resident 1's face sheet, dated 02/16/17, revealed Resident 1 was admitted with the following medical Diagnosis: [REDACTED]. Record review of Resident 1's incident report, dated 01/11/2017, revealed Resident 1 had a bruise to right elbow measuring 9.5cm (centimeters) by 7cm. There is no cause documented to show how or when Resident 1 obtained the bruise. Also, there was no documentation of any interventions to prevent recurrence of the injury. Record review of Resident 1's Incident Investigation/Interdisciplinary Team Review, dated 01/11/2017, revealed that the root cause was-Resident has poor safety awareness and bumps into things, wear arm sleeve protectors on right arm which is hemiparesis d/t (due to) CVA (Cerebrovascular accident or stoke). On Plavix (a medication used to thin the blood) and ASA (aspirin). There was no documentation of when and/or where the resident may have bumped into anything. Also, there was no documentation of any interventions to prevent recurrence of the bruising. Record review of Resident 1's incident report, dated 01/18/2017, revealed there were 4 new bruises identified: Left lower forearm measuring 2.5cm by 5 cm, Left wrist measuring 2.8cm by 3.5cm and 2 bruises on the Posterior (back side) left upper arm. The first was 2.3cm by 1.6cm and the second was 10cm by 1cm. There was no other documentation about the how the bruises occurred or when they occurred. Also, there was no documentation of any interventions to prevent recurrence of the bruises. Record review of Resident 1's Incident Investigation/Interdisciplinary Team Review form, dated 01/18/2017, revealed that the root cause was-poor safety awareness, continues only able to use left side d/t CVA, continues Plavix. There was no documentation of when and/or where the resident may have bumped into anything. Also, there was no documentation of any interventions to prevent recurrence of the bruising. Record review of incident report dated 01/25/2017 revealed there 2 bruises present to the left arm that measured 8.5cm by 4cm and left elbow that measured 12cm by 8cm. There was no other documentation about the how the bruises occurred or when they occurred. Also, there was no documentation of any interventions to prevent recurrence of the bruises. Record review of Incident Investigation/Interdisciplinary Team Review form, dated 01/25/2017, revealed that the root cause was-Resident has poor safety awareness when wheels down the hallway in wheel chair-bumps left arm on handrails. There was no other documentation about when they occurred. Also, there was no documentation of any interventions to prevent recurrence of the bruises. Record review of incident report dated 02/08/2017 revealed there was a new bruise present on the left arm that measured 4.3cm by 7cm. There was no other documentation about the how the bruises occurred or when they occurred. Also, there was no documentation of any interventions to prevent recurrence of the bruises. Record review of Incident Investigation/Interdisciplinary Team Review form, dated 02/08/2017, revealed that the root cause was-Resident mobilizes self in wheel chair at facility level, uses left arm. Also, has poor safety awareness bumps into handrails in the hallways, refuses arm sleeve protector on left arm. There was no other documentation about when the bruises occurred. Also, there was no documentation of any interventions to prevent recurrence of the bruises. Record review of the interdisciplinary notes for the dates 01/11/2017, 01/18/2017, 01/25/2017 and 02/08/2017 revealed there was no documentation about the bruises prior to being identified on these dates. There was only monitoring of the bruises for 3 days after they were identified. Record review of the care plan for the problem-Potential for Skin Breakdown dated 08/18/2010, revealed that, for the dates of 01/11/2017, 01/18/2017, 01/25/2017 and 02/08/2017, there was no documentation of interventions to prevent new bruises only the documentation of the bruises' locations and measurements. An observation with Resident 1 on 02/15/2017 at 5:49 PM, revealed the resident was self-mobile in a wheel chair. Resident 1 was observed to take self to the dining room independently. There were no observations of the resident hitting the wall or hand rails. An interview on 02/16/2017 at 7:55 AM with RN B (Registered Nurse B) confirmed that there was not enough information documented to determine a root cause and that there were no new interventions to prevent future bruising for Resident 1. An interview with FA (Facility Administrator) and RN A on 02/16/2017 at 9:30 AM confirmed that, for Resident 1, there was not enough information documented to determine a root cause and that there were no new interventions put in place to prevent future bruising nor were any new interventions identified and added to the Resident 1's care plan. B. Record review of incident log dated (MONTH) 15, (YEAR) revealed Resident 2 had 2 reports of bruising on 01/18/2017 and 02/04/2017. Record review of Resident 2's face sheet, dated 02/16/17, revealed Resident 2 was admitted with the following medical Diagnosis: [REDACTED]. This tissue makes it hard to stretch the area and prevents normal movement), right wrist. Record review of Resident 2's incident report, dated 01/18/2017, revealed Resident 2 had a bruise to right medial (inside or facing the trunk of the body) upper forearm measured 3cm by 3.5cm and a scab to the left hand knuckleweb between the 2nd and 3rd fingers measured at 0.7cm by 0.6cm. There was no cause documented to show how or when Resident 2 obtained the bruise or scab. Also, there was no documentation of any interventions to prevent recurrence of the injuries. Record review of Resident 2's Incident Investigation/Interdisciplinary Team Review, dated 01/18/2017, revealed that the root cause was-Resident unable to use right side due to CV[NAME] Uses left arm for everything. Has been wheeling more independently. There was no documentation of when and/or where the resident may have bumped into anything to cause these injuries. Record review of Resident 2's incident report, dated 02/04/2017, revealed there was a new bruise identified on the Left forearm measuring 1 cm by 2.5cm. There was no other documentation about the how the bruise occurred or when they occurred. Also, there was no documentation of any interventions to prevent recurrence of the bruises. Record review of Resident 2's Incident Investigation/Interdisciplinary Team Review, dated 02/04/2017, revealed that the root cause was-Resident use that arm to wheel self in (gender) wheelchair. There was no documentation of when and/or where the resident may have bumped into anything to cause these injuries. Also, there was no documentation of any new interventions to prevent recurrence of the bruises. Record review of the interdisciplinary notes for the dates 01/18/2017 and 02/04/2017 revealed there was no documentation about the bruises prior to being identified on these dates. There was only monitoring of the bruises for 3 days after they were identified. Record review of the care plan for the problem Potential for skin breakdown, dated 04/25/2016, revealed that, for the dates 01/18/2017 and 02/04/2017, there was no documentation of interventions to prevent new bruises. There was only the documentation of the bruises' locations and measurements. An observation was conducted with Resident 2 on 02/15/2017 at 4:28 PM. No bruising was noted on the left arm aside from an old phlebotomy (blood draw) site bruise on the mid forearm. An interview on 02/16/2017 at 7:55 AM with RN B (Registered Nurse B) confirmed that there was not enough information documented to determine a root cause and that there were no new interventions to prevent future bruising for Resident 2. An interview with FA (Facility Administrator) and RN A on 02/16/2017 at 9:30 AM confirmed that, for Resident 2, there was not enough information documented to determine a root cause and that there were no new interventions put in place to prevent future bruising nor were any new interventions identified and added to the Resident 2's care plan. C. Record review of incident log dated (MONTH) 15, (YEAR) revealed Resident 3 had 3 reports of bruising on 01/11/2017, 02/01/2017 and 02/08/2017. Record review of Resident 3's face sheet, dated 02/16/17, revealed Resident 3 was admitted with the following medical Diagnosis: [REDACTED]. Record review of Resident 3's incident report, dated 01/11/2017, revealed Resident 3 had a bruise to the Mid-lower abdomen, which measured 2.5cm by 4.5cm; a bruise to the Right upper arm measuring 10cm by 9cm with a skin tear that measured 1cm by 0.8cm; and a bruise to the left upper arm that measured 1cm by 1.5cm. There was no cause documented to show how or when Resident 3 obtained the bruises. Also, there was no documentation of any interventions to prevent recurrence of the bruising. Record review of Resident 3's Incident Investigation/Interdisciplinary Team Review, dated 01/11/2017, revealed that the root cause was-Uses sit to stand lift to transfer working with PT/OT (Physical Therapy/ Occupational Therapy) also. There was no documentation of when and/or where and/or how Resident 3 may have gotten these bruises. Also, there was no documentation of any interventions to prevent recurrence of the bruising. Record review of Resident 3's incident report dated 02/01/2017 revealed there were 2 bruises identified: one on the Left lateral forearm that measured 4.5cm by 3.5cm and one on the left hand that measured 2.2cm by 3.7cm. There was no other documentation about the how the bruise occurred or when they occurred. Also, there was no documentation of any new interventions to prevent recurrence of the bruises. Record review of Resident 3's Incident Investigation/Interdisciplinary Team Review, dated 02/01/2017, revealed that the root cause was-Resident has forgetfulness, has jerking of extremities when sleeping/dozing. Has arm sleeve protectors on. There was no documentation of when and/or where the resident might have caused these bruises. Also, there was no documentation of any new interventions to prevent recurrence of the bruises. Record review of Resident 3's incident report, dated 02/08/2017, revealed Resident 3 had a bruises to the Right lateral forearm that measured 7.5cm by 4cm and a bruise to the Right posterior upper arm 1.1cm by 2.5cm. There was no cause documented to show how or when Resident 3 obtained the bruises. Also, there was no documentation of any interventions to prevent recurrence of the bruising. Record review of Resident 3's Incident Investigation/Interdisciplinary Team Review, dated 02/08/2017, revealed that the root cause was-Resident wears arm sleeve protectors, still has frequent jerking/twitching of extremities even when awake. Uses sit/stand lift to transfer. There was no documentation of when and/or where and/or how Resident 3 may have gotten these bruises. Also, there was no documentation of any interventions to prevent recurrence of the bruising. Record review of the interdisciplinary notes for the dates 01/11/2017, 02/01/2017 and 02/08/2017 revealed there was no documentation about the bruises prior to being identified on these dates. There was only monitoring of the bruises for 3 days after they were identified. Record review of the care plan for the problem Potential for skin breakdown, dated 11/11/2013, revealed that, for the dates 01/11/2017, 02/01/2017 and 02/08/2017, there was no documentation of interventions to prevent new bruises; only the documentation of the bruises' locations and measurements. An observation with Resident 3 on 02/15/2017 at 4:35 PM revealed the resident alert and orientated to person, place and time. No bruising was noted. Mild tremors are noted bilaterally (both sides) of arms. Resident 3 was wearing a sweatshirt, at this time. An interview on 02/16/2017 at 7:55 AM with RN B confirmed that there was not enough information documented to determine a root cause and that there were no new interventions to prevent future bruising for Resident 3. An interview with FA (Facility Administrator) and RN A on 02/16/2017 at 9:30 AM confirmed that, for Resident 3, there was not enough information documented to determine a root cause and that there were no new interventions put in place to prevent future bruising nor were any new interventions identified and added to the Resident 3's care plan.",2020-02-01
1638,MAPLE CREST HEALTH CENTER,285149,2824 NORTH 66TH AVENUE,OMAHA,NE,68104,2017-11-02,332,D,1,1,I4SU11,"**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 staff failed to ensure a medication error rate of less than 5%. Observation of 30 medications administered revealed 5 errors resulting in an error rate of 16.66%. The medication errors affected 2 (Resident 129 and 107) of 3 residents observed. The facility staff identified a census of 145. Findings are: [NAME] Record review of an Admission Record sheet dated 8-22-2017 revealed Resident 129 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Transition Orders and information sheet dated 12-28-2016 revealed Resident 129 was readmitted to the facility with medication orders that included [MEDICATION NAME] 50 milligrams (mg) or 5 ml twice a day, [MEDICATION NAME] 1000 mg per G tube (tube placed into stomach usually through the abdominal area for feeding , medications and fluids) or 31.2 Millimeters (ml), 3 times a day. Observation on 11-01-2017 at 7:25 AM with Registered Nurse (RN) L revealed RN L obtained the [MEDICATION NAME] liquid and poured it into a plastic measuring cup. Observation of the amount of liquid [MEDICATION NAME] in the plastic measuring cup was between 25 ml and 30 ml. RN L then obtained the [MEDICATION NAME], measured 5 ml and immediately poured into a cup with the liquid [MEDICATION NAME]. RN L gathered the addition medications and when into Resident 129's room. RN L identified that the medication were to be given via the [DEVICE] and checked for placement of the tube. RN L flushed the tube with approximately 60 ml of water and gave Resident 129 the scheduled medication. RN L did not flush in between each medication with water and had mixed the [MEDICATION NAME] and [MEDICATION NAME] together. On 8:50 AM an interview was conducted with RN [MI] During the interview RN L confirmed the [MEDICATION NAME] and [MEDICATION NAME] were mixed, confirmed a syringe was not use to measure the [MEDICATION NAME] liquid to ensure correct measurement and further confirmed medications were administered without flushing in between. Record review of the facility Policy and Procedure for Medication Administration/Enteral Feedings dated 12-2008 revealed the following information: -Administration: -Administer each medication separately starting with thin liquids. -Flush tube with at least 30 ml of room temperature of water. B. Record review of a Medication Review Report sheet dated 11-01-2017 revealed Resident 107 had orders for medications that included [MEDICATION NAME] (a laxative medication) 17 grams, 2 times a day. Record review of a practitioners order dated 9-06-2017 revealed Resident 107 was to receive [MEDICATION NAME] ([MEDICATION NAME]) 50 micrograms (mcg) 2 sprays in each nostril daily. Observation on 11-01-2017 at 11:00 AM revealed Certified Medication Assistant (CMA) M began to prepare Resident 107's medications that included the [MEDICATION NAME] 17 gm and [MEDICATION NAME]. Further observations revealed CMA M without using the measuring cup provided with the medications that contained the measuring line for the correct amount, used the screw on cap that did not have a line to measure the amount and then poured the powder of [MEDICATION NAME] into the cap and then into a cup with water. CMA M completed the preparation of medication and took them to Resident 107 room. CMA M gave the medication that were to be swallowed to Resident 107. Resident 107 took them without difficulty including the [MEDICATION NAME]. CMA M handed Resident 107 the [MEDICATION NAME] medication and Resident 107 sprayed 1 spray in the right nostril and 2 sprays into the left nostril. CMA M did not instruct Resident 107 on the need to use 2 sprays in each nostril of the [MEDICATION NAME]. On 11-01-2017 at 11:00 AM, CMA M confirmed the [MEDICATION NAME] was not measured correctly and Resident 107 used 1 spray of the [MEDICATION NAME] in the right nostril.",2020-09-01
5324,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-01-03,332,D,1,0,R6LS11,"**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 ensure a medication rate of less than 5%. Observation of 30 medications administered revealed 4 errors resulting in a medication error rate of 13.33%. The errors affected 3 residents (Residents 15, 19, 20) of a facility staff identified census of 88. The findings are: [NAME] Observation on 12/29/2016 at 12:05 PM of Licensed Practical Nurse (LPN) A's administration of medications to Resident 15 revealed LPN A opening a bottle of Calcium [MEDICATION NAME] 250 mg (milligram) and placing one tablet into the medication cup. LPN A then delivered medication cup to Resident 15, who took the medication orally. LPN A went back to the medication cart and documented the medication as given. Record review of Resident 15's Order Summary Report signed 12/22/2016 revealed an order for [REDACTED]. Interview conducted with Registered Nurse (RN) B on 1/3/2017 at 7:05 am revealed that the medication given by LPN A on 12/29/2016 did not match the physician's orders [REDACTED].>Interview conducted with LPN C on 1/3/2017 at 7:20 am revealed that the only dosage of Calcium [MEDICATION NAME] available for administration was 250 mg and the resident needed eight tablets to get the dosage in the physician's orders [REDACTED].>B. Observation on 1/3/2017 at 8:45 am of LPN D ' s administration of medications to Resident 19 revealed LPN D opening a bottle of [MEDICATION NAME] 200mg and placing one tablet into the medication cup along with other medications. LPN D then delivered the medication cup to Resident 19, who took the medication orally. LPN D went back to the medication cart and documented the medication as given. Record Review of Resident 19's Order Summary Report signed 12/20/2016 revealed an order for [REDACTED]. Interview conducted on 1/3/2017 at 10:00am with LPN D confirmed there was 1 tablet of [MEDICATION NAME] administered. LPN D confirmed the medication record read 2 tablets. C. Observation on 1/3/2017 at 9:00 AM of Certified Medication Assistant (CMA) I's administration of medications to Resident 20 revealed CMA I taking one and a half tablets from a medication card of [MEDICATION NAME] 5 mg and placing the tablets in the medication cup. CMA I delivered the medication cup to Resident 20, who took the medication orally. CMA I went back to the medication cart and documented the medication as given. Record review of Resident 20's After Visit Summary dated 12/15/2016 revealed an order for [REDACTED]. Interview with conducted with RN J on 1/3/17 at 10:35 am confirmed the order for the [MEDICATION NAME] was 5 mg 1 tablet. RN J with CMA I confirmed the medication card used contained [MEDICATION NAME] 5 mg one and a half tablets. D. Observation on 1/3/2017 at 9:00 AM of CMA I administration of medications to Resident 20 revealed CMA I took two tablets out of a medication card labeled Potassium Chloride 20 MEQ (milliequivalents) and placed them in the medication cup while stating the order was for 2 tablets. CMA I delivered the medication cup to Resident 20, who took the medication orally. CMA I went back to the medication cart and documented the medication as given. Record review of Resident 20's After Visit Summary dated 12/15/2016 revealed an order for [REDACTED]. Interview conducted on 1/3/17 at 10:35 am with RN J confirmed the order for the Potassium Chloride was 10 MEG 2 tablets. RN J with CMA I confirmed the medication card used contained Potassium Chloride 20 MEQ tablets. Review of facility Medication Administration Policy revealed, under Procedure, 10. Verify the pharmacy prescription label on the drug and the manufacturer's identification system matches the MAR (medication administration record). If there is a discrepancy, check the original physician's orders [REDACTED]. Do not give the medication until clarified. 12. Verify the correct medication, expiration date, dose, dosage form, route, and time again by comparing to MAR before administering.",2020-01-01
4042,HILLCREST FIRETHORN,285300,8601 FIRETHORN LANE,LINCOLN,NE,68520,2019-03-18,759,D,1,1,WLS511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.10D Based on record review, observation and interview the facility failed to ensure medication error rate was under 5%, the medication error rate total was 11%. This affected 2 residents (Resident 23 and Resident 132) Findings are: Observation on 03/13/19 7:26 AM of medication pass for Resident 23 by Licensed Practical Nurse (LPN-E) revealed that [MEDICATION NAME] 28U was given instead of 26U as ordered. Observation on 03/13/19 7:26 AM of medication pass for Resident 23 by LPN-E revealed that Vitamin D3 2,000 unit tablet was given with water and no food as ordered. Interview with LPN-E) on 03/13/19 7:29 AM revealed that the [MEDICATION NAME] pen was dialed to 28U in order to prime the pen by 2 units. Observation on 03/13/19 at 7:45 AM and 7:50 AM of Resident 23 in room revealed no meal/food was being consumed by Resident 23. Interview with Director of Nursing (DON) on 03/13/19 9:15 AM revealed that policy is to waste 2 units and then dial to the correct units to be given. Record review on 03/13/19 at 2:00 PM of physician's orders [REDACTED]. Record review on 03/13/19 at 2:00 PM of physician's orders [REDACTED]. Record review on 3/13/19 of [NAME]crest Firethorn Insulin Flex Pens policy dated 5/23/17 revealed statement Make sure the guest ready to eat within 5-10 minutes after injection if this is fast acting insulin. Observation on 03/14/19 at 10:30 AM of medication pass for Resident 132 revealed that Registered Nurse (RN-B) put one Vitamin D3 1000 unit tablet in cup and would have administered to Resident 132 until surveyor questioned the directions since label didn't specify how many to give, RN-B then reread the Medication Administration Record [REDACTED]. Record review on 03/14/19 at 11:45 AM of physician's orders [REDACTED]. Record review on 03/18/19 at 1:32 PM of package insert of [MEDICATION NAME]reveals that food should be given within 5-10 minutes of administration of [MEDICATION NAME] insulin.",2020-09-01
5314,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-01-23,333,G,1,0,5YZX11,"**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 ensure that residents were free of significant medication errors. This affected one resident (Resident 1). The facility census was identified as 103. Findings are: [NAME] Record review of Resident 1's EMR (Electronic Medical Record) revealed Resident 1 was admitted on [DATE] for the following medical Diagnoses: [REDACTED]. Record review of Resident 1's MAR (Medication Administration Record) for the month of (MONTH) (YEAR) revealed the resident was to receive [MEDICATION NAME] (muscle relaxer used to treat spasm, pain, and stiffness) Solution- 1 ml (milliliter) or 10 mg (milligrams) via [DEVICE] (gastrostomy tube) three times a day for muscle spasms. The [MEDICATION NAME] Solution concentration was 10 mg per 1ml. Record review of the facility Medication Regimen report of Incident dated 01/18/2017 revealed that Resident 1 received 19 ml or a total of 190 mg of [MEDICATION NAME] Solution at 5:00 AM on 01/18/2017. It further revealed that the resident was sent emergently to the hospital at 11:30 AM due to the resident vomiting profusely. An interview with the 4th floor charge nurse revealed the resident was to return to the facility from the hospital sometime on 01/23/2017. The resident had been hospitalized for [REDACTED]. An interview with the DON (Director of Nursing and the ADON (Assistant Director of Nursing) on 01/23/2017 at 12:08 PM revealed the nurse involved, RN D (Registered Nurse D), was suspended, educated and then completed a Medication Pass Competency. They further stated that they plan to educate and competency test the rest of the nursing staff. Both of them stated that this was a significant medication error. An interview with RN D on 01/23/2017 at 2:43 PM revealed that RN D confirmed that (gender) had given the medication and that it was the wrong dose. RN D further confirmed that the medication error was a significant medication error.",2020-01-01
4040,HILLCREST FIRETHORN,285300,8601 FIRETHORN LANE,LINCOLN,NE,68520,2019-03-18,755,D,1,1,WLS511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.12 Based on observation and interview, the facility failed to properly label stock and emergency medications. Record review revealed there were narcotics delivered to the facility from the pharmacy that were not secured. The improper labeled emergency drug box had the potential to affect all current residents in the facility. The missing narcotics affected Resident 33. Findings are: On 3/14/19 at 10:20 AM, observation of west nurse's station medication storage area revealed an opened bottle of Milk of Magnesia without date when opened. On 3/14/19 at 10:22 AM, interview with Clinical Care Coordinator (CCC-D) confirmed that bottle of Milk of Magnesia had been opened and no date was on bottle indicating when opened. On 3/14/19 at 10:40 AM, observation of east nurse's station medication storage area revealed emergency box medications with outside labels showing expiration dates of 10/1/2018. On 3/14/19 at 11:05 AM, interview with Registered Nurse (RN-B) confirmed that emergency box medication labels showed expiration dates of 10/1/2018. On 3/18/19, review of Resident 33 records revealed that pharmacy delivered a narcotic to the facility on [DATE]. The narcotic medication was received by facility staff, who informed a facililty nurse of it's arrival but then left the narcotic medication unsecured in the nures's workroom and was not placed in locked area per facility policy. The facility was unable to locate the narcotic medication the next day, 1/15/19 when Resident 33 requested a dose.",2020-09-01
4971,"PREMIER ESTATES OF CRETE, LLC",285170,830 EAST 1ST STREET,CRETE,NE,68333,2018-06-26,921,E,1,0,IIN011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.18A Based on observations, record review and interviews; the facility failed to ensure that 1) room [ROOM NUMBER] was clean; 2) room [ROOM NUMBER] was clean ; 3) room [ROOM NUMBER]'s toilet was clean; 4) resident doors did not have peeling paint; 5) Hall 400 didn't have flooding of water; 6) the chair scale didn't have peeling nonskid strips; 6) ceilings weren't cracked; 7) the fire door wasn't blocked open and that the Clinatron bed was clean for Resident 11. There were 16 residents on sample and 57 current residents. Findings are: Observation on 6/26/18 at 0930AM revealed Resident 11 resting in bed, on a Clinatron bed, and the call light was on. Resident 11 was unkempt. The Clinatron bed was heavily soiled and odorous. The floor in the room had brown colored dried material on the tiles. The ambulatory roommate had tracked over the area to get the bathroom. Interview on 6/26/18 at 0945AM with the Director of Nurses (DON) confirmed that the dried area on the floor was a concern as well as the heavily soiled bed. The DON confirmed this was an infection control concern. Interview on 6/26/18 at 10:00 AM with the Corporate Nurse confirmed that the bed was heavily soiled and had not been changed or cleaned since the resident had been put in the bed. There was no record of the bed being cleaned. The Corporate Nurse and Administrator confirmed that HIllrom had been called and they would bring a new mattress and a spare mattress and the company would be coming weekly to clean the mattress. The cover would be laundered weekly and as needed. Also a staff member would be assigned to do daily audits and they would be completed for 4 week and monthly for 2 months to ensure the room was clean. The Corporate Nurse and the Administrator asked the resident's permission to change the room assignment so a deep cleaning of the room with tile removal could occur. that the DON and Administrator reported that Resident 11 at times urinated on the floor. The tour of the facility on 6/25/18 at 09:00 AM revealed there was no resident in room [ROOM NUMBER] and the bed sheet had a visible stain on it. The Director of Nurses on 6/25/18 at 09:30 AM confirmed this room had been cleaned and was ready for an admission. The tour of the facility on 6/25/18 at 09:00 AM revealed there was no resident in room [ROOM NUMBER] and there was a cloth recliner in the room with visible brown stains on the right arm. The Director of Nurses on 6/25/18 at 9:30 AM confirmed the room was ready for an admission and the arm of the chair was stained. The tour of the facility on 6/25/18 at 09:00 AM revealed in room [ROOM NUMBER] there was a heavy bubbled layer of caulking at the base of the toilet where there was brown matter in multiple grooves in the caulking. During the tour it was noted that there were several doors in each of the hallways that were peeling with paint. The Director of Nurses on 6/25/18 at 9:30 AM confirmed that there were numerous doors with peeling paint. The tour revealed the exit to the courtyard off of the 400 hallway was flooding back into the building, there were multiple bath blankets on the floor and there were 2 wet floor signs posted outside the area. On 6/25/18 at 9:30 AM the Director of Nurses confirmed that this was a safety risk. During the tour it was noted on the 400 hallway that there was a chair scale and the non-skid strips were peeling off. On 6/25/18 at 9:30 AM the Director of Nurses confirmed the chair scale had missing non- skid strips. The tour revealed ceiling tiles in every hallway that were cracking and there was debris hanging from them, in some areas the ceiling tiles were discolored. On 6/25/18 at 9:30 AM the Director of Nurses confirmed that there were cracked ceiling tiles, debris hanging from ceiling tiles and some of the tiles were discolored. During the tour, it was observed that one of the fire doors to the south lounge was blocked open by a wheelchair. On 6/25/18 at 9:30 AM the Director of Nurses confirmed the door was being blocked open with a wheelchair.",2020-03-01
4970,"PREMIER ESTATES OF CRETE, LLC",285170,830 EAST 1ST STREET,CRETE,NE,68333,2018-06-26,908,D,1,0,IIN011,"**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 provide a safe environment to protect residents from hazards in room [ROOM NUMBER]. Census: 57 residents: Sample size 16. Findings are: [NAME] Observation with the Director of Nurses on 6/25/18 at 09:00AM revealed room [ROOM NUMBER] had the door open and no staff member was present in the room. On the floor was a sharp electric tile scrapper that was plugged into the wall. A box cutter was on the floor next to the scrapper. Several cans of paint were noted to be open with a tray with paint in it as well. The Director of Nurses was notified and the items were collected and taken to the front office. Interview with the Director of Nurses on 6/25/18 at 09:00AM the Director of Nurses confirmed this was a safety hazard.",2020-03-01
4981,"QUALITY LIVING, INC",28A060,6404 NORTH 70TH PLAZA,OMAHA,NE,68104,2017-03-16,221,D,1,0,P8NM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: NAC 12-006.05 (8) Based upon observation, interview and record review, the facility failed to assess causal factors prior to the implementation of restraints for one resident (Resident 1) of 5 sampled residents and the facility failed to obtain a valid medical order prior to the implementation of the restraints for Resident 1. The facility census was identified as 115. Findings are: [NAME] A record review of Resident 1's face sheet dated 1/19/2017 revealed the following: Resident 1 was admitting for the following medical diagnoses-Unspecified intracranial injury (closed head injury) with loss of consciousness of unspecified duration, history of intracranial bleed (bleeding inside the skull), post VP shunt (Ventriculoperitoneal or VP shunting is a surgical procedure to treat excess cerebrospinal fluid (CSF) in the brain ([DIAGNOSES REDACTED] (Water on the brain))), dysphagia (Difficulty Swallowing) and Abdominal Aortic Aneurysm (this occurs in the part of the aorta running through the abdomen) (the aorta is the main artery that runs from the heart through the chest and abdomen) (An aneurysm is a bulge or ballooning in the wall of an artery). A record review of Resident 1'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.) with an Assessment Reference Date of 01/18/2017, revealed a BIMS (Brief Interview for Mental Status) score of 11/15 (scores between 0 and 7 indicate severe cognitive impact, scores between 8 and 12, moderate impairment while scores above 13 show little to no impairment). A record review of an incident report dated 2/15/17 revealed that Resident 1 sustained a laceration above the right eye due to (gender) glasses, Resident 1 had fallen in (gender) room while attempting to self-transfer and hit (gender) head on the table. Post fall interventions that were implemented were a video monitor and pin release seatbelt in both Resident 1's wheel chair and recliner. A record review of the Clinical Update Report dated 2/22/17 revealed that the Resident 1 wears AFO's (Ankle Foot Orthoses or braces) and it was further noted the resident was attempting to self-transfer, so on 2/9/17 and fall alarm was installed next to the bed and recliner. This alarm was sounding when Resident 1 fell on [DATE] and when the resident was at the hospital for the stiches, a scan of Resident 1's head found two bleeding areas within the head, so Resident 1 was admitted . Interventions to protect Resident 1 post fall included a video monitor in (gender) room and a pin release seat belt for the recliner and wheel chair. The pin release seatbelt was installed in (gender) recliner and wheel chair so that it would take him more time to unfasten. It is not classified as a restraint since Resident 1 showed the ability to take it off with a pin. An observation of Resident 1 on 3/13/2017 at 5:40 PM revealed the following: Resident 1 was awake, alert and sometimes confused. Resident 1 was assisted by staff with a gait belt and walker from the commons area back to Resident 1's room. Resident 1 appeared clean and the clothing was appropriate for the weather. Resident 1 was able to maintain eye contact, but did during the interview suddenly begin to be looking around the room for no apparent reason. An interview with Resident 1 on 3/13/2017 at 5:40 PM revealed the following: When asked about the belt in (gender) chair, Resident 1 explained that the belt is there to help remind (gender) to not get up without calling for assistance. Resident 1 was able to secure the belt. When asked if (gender) would demonstrate the removal of the buckle, Resident 1 stated that (gender) can't without a tool. When asked where the tool was, Resident 1 stated that the staff has it. When asked if Resident 1 has ever removed it, Resident 1 answered No. When asked if this was acceptable to (gender) and Resident 1 stated that it does keep (gender) safe, but Resident 1 doesn't like it. It was also noted that there was a floor pad alarm at Resident 1's feet that was not plugged into the call light system. Resident 1 stated since I was present, and not alone, that was why it was not plugged in. Otherwise, Resident 1's feet moving on the pad would activate it all the time and sent staff running into (gender) room. An interview with Rehabilitation Trainer A (RT A) on 3/13/2017 at 5:40 PM confirmed the following: RT A confirmed that Resident 1 is not able to remove the buckle; only staff does and when asked where the tool is to remove the buckle, RT A went across the room to a shelf and took the pin and disengaged the buckle and replace the tool back to the same spot. A record review of Resident 1's Occupational Therapy Activity Monthly Summary dated (MONTH) (YEAR) revealed in the comments section of the document *from 2/24/17-pin release used as restraint (no access to pin) secondary to continued impulsivity and high risk for falls. This is in place on recliner and wheelchair. A record review of the Restraint/Protective Devices policy dated 9/95 rev. 8/06; 12/16 is only a document with the definition of a restraint, definition of a protective device and the goal of having a restraint free facility. The document does not have any of the following present: How the physician is ordering the use of the device? What criteria must be met for the device's use? How it is determined the restraint is needed? How the device will be monitored? How often the resident is assessed while in the device? How often the device is removed for exercise? What goals are to be met for the device's removal? How the family and physician is informed and updated of its use? Interview with Director of Clinical Services (DCS) and VP of LTC on 03/16/2017 at 11:00 AM-both confirmed that there is no order for the restraints. DCS also stated that the reassessments are done monthly by the OT (Occupational Therapy). Neither could state if there was any documentation of reassessments following the application of the belt as a restraint or who would do it. An interview with the DON (Director of Nursing) on 03/16/2017 at 1:20 PM revealed that nursing assessment are done as needed. The DON further confirmed, there have not been any assessments since the nursing assessment completed at admission. A record review of the policy Resident Assessments dated QLI 1/92 Rev. 4/94; 1/99; 12/16 revealed the following: Resident assessment are conducted to provide information helpful in program development and to monitor resident progress. Both normative and criterion based assessments may be used. Issues of reliability and validity should be considered when interpreting assessment results. There is no information about: Who conducts the assessments What assessments are to be conducted Time frame for assessments to be done How the assessment data is used and by whom Who is informed about any abnormal assessment data An interview with OT G on 03/16/2017 at 12:58 PM revealed that (gender) fills out the Occupational Therapy Activity Monthly Summary, and then writes a monthly report as the per the insurance company requirements. OT G sees Resident 1 once a week on average and OT G states that (gender) is in constant contact with the house coordinators and the rest of the medical team. The belt as a restraint was determined to be needed as Resident 1 is still impulsive and a very high safety risk. The decision was made in conjunction with the family and the rest of the medical team. When asked for documentation about how the decision was made, she confirmed that there is none. When asked if Resident 1 had fallen since the fall on 2/15/17, OT G confirmed that Resident 1 has not fallen to the best of OT G's knowledge. A record review of Psychosocial notes dated 2/15/17 thru 3/3/17 revealed that on 2/16/17 House Coordinator F (HC F) informed Resident 1's mother about the fall and the interventions and approved the interventions of the pin release seat belt, floor alarm and monitor. An additional note dated 2/24/17 revealed HC F again spoke with Resident 1's mother and I informed (name) that since we have put the pin release seat belt in place Resident1 is still in doing (gender) belt consistently and starting to get up out of (gender) recliner without staff present. We agreed that it would be best if Resident 1 didn't have access to the pin. We discussed the risk and benefits of this, given that (gender) would no longer have access to the pin and be able to get up without staff. An interview with HC F on 03/16/2017 at 11:43 AM confirmed that Resident 1 has no fallen since the fall on 2/15/2017. HC F stated that (gender) communicates with the family as needed if the HC F is directed to do so. HC F confirmed that (gender) is not a licensed medical professional (Registered nurse (RN), Licensed Practical Nurse (LPN) or OT or Physical Therapist (PT)). HC F stated that OT G had requested HC F to contact the family to discuss the updated interventions 2/24/17 and confirmed that HC F wrote the Psychosocial Notes for Resident 1 dated 2/15/17 thru 3/3/17. When asked who the we was in the note dated 2/24/17; HC F stated the medical team was the we. When asked when the medical team had discussed this, HC F could not answer and could not state where the documentation of the discussion was if there was any documentation. An interview of Resident 1 on 03/16/2017 at 12:45 PM revealed the following: When asked about who the surveyor was, Resident 1 was able to correctly articulate what the surveyor's name was, why the surveyor was there and was asking when the seat belt would be removed. Resident 1 did state the purpose for the seat belt and that (gender) would like to have it removed. Resident 1 hasn't spoken to the staff or (gender) parents about the belt and the desire to have it removed. Resident 1 did states that (gender)'s parents know about the belt.",2020-03-01
6585,LIFE CARE CENTER OF OMAHA,285137,6032 VILLE DE SANTE DRIVE,OMAHA,NE,68104,2015-12-23,309,D,1,0,RFLU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: NAC 175 12-006.09D5 Based upon record reviews and interviews; the facility failed to implement additional interventions to manage behaviors for one Resident (Resident 1). Facility census was 95. Findings are: A. Record review of a Resident to Resident report dated 12/01/2015 revealed Resident 1 was attempting to park Resident 1's wheelchair and bumped into another Resident's wheelchair. Resident 1 then stuck the other Resident on the forearm. Record review of Resident 1's undated Face Sheet revealed that Resident 1 was admitted on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 11/19/2015, revealed Resident 1 had a Brief Interview for Mental Status (BIMS) score of 2 out of a possible 15 points-(According to the MDS Manual- 0-7 points: the person is cognitively severely impaired.) Record review of Resident 1's care plan, dated 04/17/2015 with a targeted date 07/17/2015 and with revised target dates of 09/17/15, 12/17/15, 12/17/16, under the section entitled behavior, revealed two hand written entries: Resident 1 had a Resident to Resident altercation dated 04/29/2015 with the intervention of monitor behavior for aggression towards others times 1 week. And another dated 10/01/2015, Resident to Resident-hit another Resident with open hand, with the interventions of order labs and have MD (Medical Doctor)/PA (Physician Assistant) review medications. There are no hand written interventions or notations found in reference to the 12/01/2015 Resident to Resident altercation. An interview with Licensed Practical Nurse C (LPN C) on 12/23/2015 at 10:49 AM revealed the following: After the event (on 12/01/2015) the staff separated the 2 residents (Resident 1 and other Resident) and then continued to monitor Resident 1 to ensure that there are no further events. LPN C further revealed that this intervention, of monitoring, was an ongoing intervention. An interview with Director of Nursing (DON) on 12/23/2015 at 11:17 AM revealed the following: There were no new interventions added to Resident 1's care plan following the incident on 12/01/2015. DON further revealed that the intervention of monitoring the resident was an ongoing intervention.",2018-12-01
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
5475,GOOD SAMARITAN SOCIETY - WOOD RIVER,285198,1401 EAST STREET,WOOD RIVER,NE,68883,2017-11-27,226,E,1,0,RPK711,"**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 submit a written report of abuse to the State Agency within 5 working days affecting Residents 3, 7, 6, 1, 2, 5 and 4. The facility census was 50. Findings are: [NAME] Review of the undated and unsigned facility document, titled, Report to State of Nebraska; revealed that the facility reported to the state agency that Resident 3 fell on [DATE] at 7:20 PM and suffered no injuries. The facility conducted an investigation and completed a report. The report was not dated and was not signed by the facility staff. B. Review of the undated and unsigned facility document, titled, Report to State of Nebraska; revealed that the facility reported to the state agency that Resident 7 had reported an allegation of misappropriation on 7/25/17 at 6:33 PM. The facility conducted an investigation and completed a report. The report was not dated and was not signed by the facility staff. C. Review of the undated and unsigned facility document, titled, Report to State of Nebraska; revealed that the facility reported to the state agency that Resident 6 had pinched Resident 3 on the right buttock on 9/19/17 at 6:53 PM. The facility conducted an investigation and completed a report. The report was not dated and was not signed by the facility staff. D. Review of the undated and unsigned facility document, titled, Report to State of Nebraska; revealed that the facility reported to the state agency an abuse allegation by Resident 1 on 9/20/17 at 7:00 AM. The facility conducted an investigation and completed a report. The report was not dated and was not signed by the facility staff. E. Review of the undated and unsigned facility document, titled, Report to State of Nebraska; revealed that the facility reported to the state agency an abuse allegation between Residents 1 and 2 on 10/23/17 at 10:28 AM. The facility conducted an investigation and completed a report. The report was not dated and was not signed by the facility staff. F. Review of the undated and unsigned facility document, titled, Report to State of Nebraska; revealed that the facility reported to the state agency an abuse allegation by Resident 5 on 9/22/17 at 6:25 PM. The facility conducted an investigation and completed a report. The report was not dated and was not signed by the facility staff. G. Review of the undated and unsigned facility document, titled, Report to State of Nebraska; revealed that the facility reported to the state agency a resident to resident abuse allegation between Residents 4 and 5 on 10/20/17 at 4:34 PM. The facility conducted an investigation and completed a report. The report was not dated and was not signed by the facility staff. Interview with the SSD (Social Services Director) on 11/16/17 at 12:16 PM revealed that the SSD stated that the written reports were faxed to the state agency. The SSD could not provide documentation as to when the written reports were faxed to the state agency. The SSD confirmed that the written reports needed to contain the date and the name of the person that completed the report. The SSD also confirmed that the facility needed to provide documentation as to when the written reports were sent to the state agency.",2020-01-01
5476,GOOD SAMARITAN SOCIETY - WOOD RIVER,285198,1401 EAST STREET,WOOD RIVER,NE,68883,2017-11-27,280,D,1,0,RPK711,"**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 revise the comprehensive care plan for fall interventions for Resident 3. The facility census was 50. Findings are: Review of the nursing progress notes on 11/1/17; identified that Resident 3 had a fall with no injuries at 7:20 PM. Resident was assessed and sent to the hospital for evaluation. The hospital took x-rays and completed some lab work, then sent the resident back to the facility. Review of a Falls Tool Assessment, dated 11/01/17, identified that Resident 3 had changed in mobility related to muscle weakness or strength, impaired balance or coordination, and changed in weight bearing ability; observed unsafe use of equipment, forgot to use the call light and had unsafe footwear/inappropriate clothing; had a current or history of [MEDICAL CONDITION], was confused and impulsive. The action plan from the fall assessment was to refer the resident to therapy and to restorative nursing. Review of the nursing progress notes on 11/13/17; identified that Resident 3 was found on the floor at 12:00 AM and had complained of left shoulder/arm and neck pain. Resident was transferred to the hospital and was found to have a fractured left arm. Review of the resident's comprehensive care plan identified the resident's fall on 11/01/17 but without any therapy or restorative nursing interventions. The care plan was revised on 11/15/17 for PT/OT to evaluate and treat, labs and UA (urine analysis) ordered. Interview with the DON (Director of Nursing) on 11/16/17 at 12:10 PM revealed that the DON was not aware that the charge nurse who completed the Falls Tool assessment on 11/01/17 had referred the resident to therapy and restorative nursing. The DON confirmed that Resident 3 was not referred to therapy nor was on restorative nursing at that time and the resident's care plan was not revised with those interventions for the fall on 11/01/17. The DON also confirmed that the order for therapy to evaluate and treat was received after the resident fell on [DATE] and the care plan was revised on 11/15/17.",2020-01-01
2914,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2017-05-09,309,D,1,0,JLWU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE: 175 NAC 12-006.09D2c Based upon record review and interview; the facility failed to ensure that wound care was provided according to practitioner's orders for one resident (Resident 1) of four sampled residents. Facility census was 60. FINDINGS ARE: [NAME] A record review of nursing progress notes dated 02/21/2017, revealed the following: the Bath Aide alerted the RN (Registered Nurse) that the resident (Resident 1) had an open area on the resident's left buttock. The RN sent a message to the PCP (Primary Care Physician) at this time to inform the PCP of the new wound and was awaiting orders from the PCP to treat the wound. A record review of the return fax from the PCP signed 02/22/2017 and noted by the RN on 02/23/2017 revealed that the wound was to be treated by applying barrier cream to the open area and monitor until resolved. A record review of Resident 1's TAR (Treatment Administration Record) for the month of (MONTH) (YEAR) revealed that there were no treatment records found for the left buttock wound. An interview with the DON (Director of Nursing) on 05/09/2017 at 10:10 AM confirmed that there was an order received for the treatment of [REDACTED].",2020-09-01
6365,GOOD SAMARITAN SOCIETY - MILLARD,285098,12856 DEAUVILLE DRIVE,OMAHA,NE,68137,2016-03-31,157,D,1,0,F7L611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REVERENCE NUMBER 175 NAC 12-006.04C3a Based on record review and interview, the facility staff failed to notify the physician of an electrical burn for 1 resident ( Resident 6). The facility staff identified a census of 85. Findings are: Record review of a Face Sheet printed on 3-30-2016 revealed Resident 6 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident 6's progress notes dated 3-29-2016 revealed Resident 6 had returned to the facility from a hospital admission. Record review of incident report dated 3-4-2016 revealed Resident 6 had been receiving a electrical stimulation ( E-Stim) to the left hip for pain management. According to the incident report dated 3-4-2016, Resident 6 on 3-4-2016 was observed with a blister to the left hip area. According to the documentation on the incident report dated 3-4-2016 the facility Wound Nurse had identified the area as a electrical burn on 3-9-2016. Record review of a Wound RN Assessment sheet dated 3-09-2016 revealed Resident 6's physician was notified of the electrical burn on 3-09-2016. An interview on 3-30-2016 at 12:08 AM was conducted with Registered Nurse (RN) A. During the interview, RN A reported Resident 6's physician was not notified of the electrical burn until 3-09-2016. RN A confirmed the physician should have been notified within 24 hours.",2019-03-01
4078,"QUALITY LIVING, INC",28A060,6404 NORTH 70TH PLAZA,OMAHA,NE,68104,2019-02-26,686,D,1,0,HOS211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > License Reference Number 175 NAC 12-006.02 Based on record review and interview the facility failed to ensure that doctor orders for pressure ulcer treatment were followed for one resident (Resident 6) out of three residents reviewed. The facility census was 107. Findings are: On 2/26/19 a record review of Resident 6 treatment order dated 11/27/18, revealed apply [MEDICATION NAME] (an absorbent dressing for pressure ulcers), change dressing if it is leaking, falling off, or has been on the wound for 2 days. On 2/26/19 a record review of Resident 6 QLI wound assessment form revealed from 1/9/19 to 1/12/19 (4 days) the dressing was intact, from 1/31/19 to 2/3/19 ( 4 days) the dressing was intact, 2/5/19 to 2/8/19 (4 days) the dressing was intact, 2/11/19 to 2/16/19 (7 days) the dressing was intact, 2/18/19 to 2/21/19 (3 days) the dressing was intact, 2/23/19 to 2/25/19 (3 days) the dressing was intact. On 2/26/19 at 4:50 pm an interview with the DON (Director of Nursing) confirmed that the word intact on the QLI Wound assessment form meant that the dressing was not changed and that the doctor's order was not being followed.",2020-09-01
6336,BIRCHWOOD MANOR,285247,1120 WALNUT ST,NORTH BEND,NE,68649,2018-05-30,610,D,1,0,L3Z411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > License Reference Number 175 NAC 12-006.02(8) Based on record reviews and interview, the facility failed to report and investigate an injury for Resident 1. Facility sample size was 3 and facility census was 48. Findings are: Review of the facility Abuse/Neglect policy revealed the facility must report allegations immediately to Local, State, and Federal Agencies and a report must be sent into the state agency within 5 working days. Record review of Resident 1's Progress notes revealed that resident fell out of wheelchair on 5/18/18 at 6:30 AM at 2:00 PM of that day Resident 1 complained of pain in Right arm. Mobilex there at the facility on 5/21/18 at 11:39 AM to X-Ray right arm. The X-ray confirmed that resident 1 had a [MEDICAL CONDITION] Humerus. Interview with the facility Administrator and Director of Nursing on 5/30/2018 at 5:30 PM confirmed that the facility failed to call in the incident to Adult Protective Services and send in a report to Department of Health and Human Services within 5 working days of the time of the incident.",2019-04-01
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
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
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
2873,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2018-01-02,692,G,1,1,51KH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > License Reference Number: 175 NAC 12-006.09D8b Based on observation, record review and interview; the facility failed to assist 1 of 1 residents (Resident 36) with nutritional intake to avoid a continued significant weight loss. The facility census was 66. Findings are: Review of a Physician order [REDACTED]. Observation on 12/21/2017 at 9:50 AM revealed Resident 36 in a nightgown in bed. Resident 36 was attempting to eat independently. Resident 36 stated to staff entering the room that the resident's neck was sore and staff lowered the head of the resident's bed and removed Resident 36's breakfast tray. Resident 36 had attempted to eat the cooked cereal that was served but no other food had been touched. The sausage on the plate was not cut. Resident 36 received no assistance or encouragement for eating. Observation on 12/26/2017at 9:30 AM revealed Resident 36 received a room tray for breakfast. At 9:55 AM Resident 36 was in a semi seated position with the tray table in front of Resident 36. No one was in the room assisting Resident 36 at this time. Approximately 50% of the meal was eaten. Observation on 12/27/2017 at 9:40 AM revealed Resident 36 had not received a breakfast tray. Interview on 12/27/2017 at 9:40 AM with the Assistant Director of Nursing (ADON) revealed it did not appear Resident 36 had received a tray. Review of dietary notes dated 10/3/2017 revealed Resident 36's weight was 92-93 pounds which was equal to a 5.1% loss in 30 days and the resident had developed a new pressure ulcer. No new interventions were initiated until the resident was placed on hospice care and had a further decline to 89 pounds. Interview on 12/27/2017 at 10:30 AM with the Director of Nursing (DON) revealed that if the resident had an order to assist the resident with meals, a staff member should have been in the room with the resident during meals at assist the resident in eating their meal.",2020-09-01
3724,GOOD SAMARITAN SOCIETY - GRAND ISLAND VILLAGE,285285,4061 TIMBERLINE STREET & 4055 TIMBERLINE STREET,GRAND ISLAND,NE,68803,2017-05-25,502,D,1,1,IQ0211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > License and Reference Number 175 NAC 12-006.15 Based on record review and interview, the facility failed to complete physician ordered lab work. This had the potential to affect one resident (Resident 10) of 3 reviewed. The facility census was 59. Findings are: Record review of a Physician order [REDACTED]. Record review of the (MAR) Medication Administration Record [REDACTED]. [MEDICATION NAME] was last administered on 4/20/17 in the morning. Record review revealed there was no documentation of the lab work being completed. On 05/25/2017 at 11:33 AM an interview with the DON (Director of Nursing) confirmed this lab work was not completed as ordered.",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
4010,BROOKESTONE VIEW,285297,850 LAUREL PARKWAY DRIVE,BROKEN BOW,NE,68822,2019-02-25,580,G,1,0,8H5311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Number 175 NAC ,[DATE].04C3a(6). Based on record review and interviews, the facility failed to notify the primary physician for 2 out of 3 (Resident 45 and 53) residents' change in condition and medications being held. The facility census was 58. Findings are: [NAME] Review of Resident 45's Admission Record dated [DATE] revealed date of admission of [DATE] and date of death of [DATE]. Review of the Admission Record dated [DATE] revealed [DIAGNOSES REDACTED]. Review of Resident 45's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated [DATE] revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 14 which indicated Resident 45 had no cognitive impairment. The resident was assessed to have had no behaviors and no depression. Resident 45 required extensive assist of 2 staff with bed mobility, transfers, dressing, and toileting and was totally dependent on 1 staff for locomotion in the facility. Review of Resident 45's undated Physician orders [REDACTED]. The resident was on the medications for the resident's cardiac conditions of [MEDICATION NAME] 2 mg (milligram) BID (twice a day), a diuretic (a water pill to decrease the amount of fluid retained in the body), [MEDICATION NAME] 50 mg BID (a beta-blocker and used to treat high-blood pressure), and had also been on [MEDICATION NAME] 60 mg (a diuretic) for 7 days (MONTH) 8th -14th for localized [MEDICAL CONDITION] in the legs which was re-started on (MONTH) 29 - (MONTH) 2 at the facility's request for [MEDICAL CONDITION]. Review of the Initial Pharmacy Review dated [DATE] revealed the Pharmacist recommended to monitor a weekly BP (blood pressure) and pulse because the resident was on a beta-blocker medication. Review of Resident 45's Weights and Vitals Summary report for the month of (MONTH) revealed a BP had been taken nearly every day at various times of the days for the month of January. On 17 different occurrences, the resident's BP value was low and ranged systolic (top number) from 78 to 99 and diastolic (bottom number) from 44 to 67. Review of the PN (Progress Notes) dated [DATE] revealed the resident reported not feeling well that morning and refused to take the morning medications at that time or to attend a hair appointment later that morning. The resident's vital signs were 97.6 temperature, pulse 73, respirations 18, oxygen saturation 94% on 2 L (liters) of oxygen, and BP ,[DATE]. Inteview on [DATE] at 12:05 PM via phone with RN-A (Registered Nurse) revealed the nurse had held the resident's medication that morning because the resident had complained of feeling dizzy and not feeling well. About 45 minutes later the resident reported (gender) was feeling better so RN-A gave the resident all of the regular morning medications except for the [MEDICATION NAME]. RN-A confirmed the Physician had not been notified. RN-A confirmed the 2nd scheduled dose of [MEDICATION NAME] at 5:30 PM was administered to the resident. Interview on [DATE] at 12:04 PM with the DON (Director of Nursing) revealed the Charge Nurse for Resident 45 on [DATE] had come to the DON for advice that morning about whether to give the resident the [MEDICATION NAME] and informed the DON of the low BP that morning. The DON revealed the DON instructed RN-A to hold the [MEDICATION NAME] and to notify the Primary Provider for further instructions. The DON revealed the DON was not aware if RN-A notified the Primary Physician Provider. Review of Resident 45's PN for the month of (MONTH) revealed documentation about the resident's weigh gain and how the IDT (Interdisciplinary Team) felt it was related to [MEDICAL CONDITION] so had requested from the Physician to restart the resident back on the [MEDICATION NAME] to diuresis (remove more fluid from the body) the resident. Further review of the PN revealed absence of notification to the Physician about the resident's low blood pressures throughout the month. Review of documentation on [DATE] revealed absence of documentation about the Primary Provider being notified of the resident's condition change of [DATE] and the [MEDICATION NAME] being held in the morning. Review of PN dated [DATE] revealed while the staff were assisting the resident with bedtime cares, the resident became unresponsive verbally with a B/P of ,[DATE] and pulse of 55. The resident was transferred to the hospital and expired on [DATE] at 10:06 PM. B. Review of Resident 53's Admission Record dated [DATE] revealed admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident 53's MDS revealed a BIMs score of 15 which indicated the resident had no cognitive impairment. Review of the MAR (Medication Administration Record) revealed Resident 53 had the routine medication of [MEDICATION NAME] (a beta-blocker used to treat high blood pressure) 25 mg twice a day hold if SBP (systolic blood pressure: top number of the blood pressure) was less than 110 and/or the pulse was less than 60 bpm (beats per minute). The (MONTH) 2019 MAR indicated [REDACTED]. The medication [MEDICATION NAME] (medication used to treat high blood pressure) 5 mg daily, hold if SBP was less than 110 and/or the pulse was less than 60. was held for 10 doses in (MONTH) 2019 and 17 doses from (MONTH) 1 through [DATE]. Review of Resident 53's blood pressures documented on the (MONTH) MARs revealed the resident's BP value was low and ranged systolic (top number) from ,[DATE] and diastolic (bottom number) from ,[DATE]. On the (MONTH) MAR indicated [REDACTED]. Review of Resident 53's PN since admission on [DATE] revealed absence of documentation of the primary Physician or the referring Cardiologist being informed of the resident's low blood pressures and the high number of times the resident's cardiac medications were held in the month of (MONTH) and/or February. Review of Resident 53's Nursing Home Visit by the Primary Care Provider on [DATE] revealed Per staff they are having a hard time tracking blood pressures, BP's are being checked 3 x (times) a day. The Physician continued current medications. The visit note was absent of documentation about notification of the blood pressures being low and of the staff holding the cardiac medications. Interview on [DATE] at 2:30 PM with the DON revealed when a Primary Care Physician completed a resident's re-certification, a one week worth of vital signs were provided to the Provider to review. The DON reviewed the BP's and confirmed the Primary Care Physician should have been notified.",2020-09-01
4011,BROOKESTONE VIEW,285297,850 LAUREL PARKWAY DRIVE,BROKEN BOW,NE,68822,2019-02-25,684,G,1,0,8H5311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Number 175 NAC ,[DATE].09D Based on record review and interviews, the facility failed to provide monitoring and assess for one resident (Resident 45) out of 3 residents sampled for [MEDICAL CONDITION] and change of condition. The facility census was 58. Findings are: Review of Resident 45's Admission Record dated [DATE] revealed date of admission of [DATE] and date of death of [DATE]. Review of the Admission Record dated [DATE] revealed [DIAGNOSES REDACTED]. Review of Resident 45's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated [DATE] revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 14 which indicated Resident 45 had no cognitive impairment. The resident was assessed to have had no behaviors and no depression. Resident 45 required extensive assist of 2 staff with bed mobility, transfers, dressing, and toileting and was totally dependent on 1 staff for locomotion in the facility. Review of Resident 45's undated Physician orders [REDACTED]. The resident was on the medications for the resident's cardiac conditions of [MEDICATION NAME] 2 mg (milligram) BID (twice a day), a diuretic (a water pill to decrease the amount of fluid retained in the body), [MEDICATION NAME] 50 mg BID (a beta-blocker and used to treat high-blood pressure), and had also been on [MEDICATION NAME] 60 mg (a diuretic) for 7 days (MONTH) 8th -14th for localized [MEDICAL CONDITION] in the legs which was re-started on (MONTH) 29 - (MONTH) 2 at the facility's request for [MEDICAL CONDITION]. Review of the Initial Pharmacy Review dated [DATE] revealed the Pharmacist recommended to monitor a weekly BP (blood pressure) and pulse because the resident was on a beta-blocker medication. Review of Resident 45's Weights and Vitals Summary report for the month of (MONTH) revealed a BP had been taken nearly every day at various times of the days for the month of January. On 17 different occurrences, the resident's BP value was lower than the resident's usual BP of SBP (systolic blood pressure, the top number) above 100. On 7 of the occurrences, the resident's blood pressure in the month of (MONTH) was hypotensive (low blood pressure). Review of the United States Department of Health and Human Services, National Heart, Blood, and Lung Institute in Baltimore, [NAME]land, a hypotensive state was an abnormally low blood pressure lower than ,[DATE]. Signs and symptoms which may go along with a low blood pressure were dizziness and nausea or sickness to the stomach. Review of Resident 45's PN (Progress Notes) for the month of (MONTH) revealed documentation about the resident's weigh gain and how the IDT (Interdisciplinary Team) felt it was related to [MEDICAL CONDITION]. The facility notified the Primary Provider twice about [MEDICAL CONDITION] and had requested from the Physician to restart the resident back on the [MEDICATION NAME] to diuresis (remove more fluid from the body) which was done twice in (MONTH) for 7 days each. However, further review of the PN revealed absence of notification to the Physician about the resident's low blood pressures throughout the month. Review of the PN dated [DATE] revealed the resident reported not feeling well that morning and refused to take the morning medications at that time or to attend a hair appointment later that morning. The resident's vital signs were 97.6 temperature, pulse 73, respirations 18, oxygen saturation 94% on 2 L (liters) of oxygen, and BP ,[DATE]. Review of the documentation for the rest of the day [DATE] revealed absence of any follow-up monitoring of vital signs or assessments of the resident's condition until the staff performed bedtime cares at 8:00 PM on [DATE] and the resident became unresponsive. Inteview on [DATE] at 12:05 PM via phone with RN-A (Registered Nurse) revealed the nurse had held the resident's medication that morning because the resident had complained of feeling dizzy and not feeling well. About 45 minutes later the resident reported (gender) was feeling better so RN-A gave the resident all of the regular morning medications except for the [MEDICATION NAME] because of the low blood pressure. RN-A confirmed the Physician was not notified of the resident's condition changes that day. RN-A revealed the 2nd scheduled dose of [MEDICATION NAME] was administered at 5:30 PM to the resident. RN-A revealed RN-A would have checked the blood pressure before the medication was given if it was required on the MAR (Medication Administration Record). Review of the (MONTH) MAR indicated [REDACTED]. Review of the Vital Signs for [DATE] at 5:30 revealed absence of a blood pressure recorded. Review of documentation on [DATE] revealed absence of documentation about the Primary Provider being notified of the resident's condition change of [DATE] of the low blood pressure with accompanying signs and symptoms of dizziness and not feeling well. Review of PN dated [DATE] revealed while the staff were assisting the resident with bedtime cares, the resident became unresponsive verbally with a B/P of ,[DATE] and pulse of 55. The resident was transferred to the hospital and expired on [DATE] at 10:06 PM. Interview on [DATE] at 4:24 PM with the ADON (Assistant Director of Nursing) revealed the ADON had not been aware of the low BP's but confirmed the resident's Physician should have been notified of the low BP's during the month of (MONTH) and on [DATE] the RN charge nurse should have done an assessment on the resident and the reviewed the resident's medical records.",2020-09-01
1997,GOOD SAMARITAN SOCIETY - ARAPAHOE,285175,"P O BOX 448, 601 MAIN STREET",ARAPAHOE,NE,68922,2019-02-13,689,G,1,0,VM3X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Number 175 NAC 12-006.09D7a. Based on observation, record review, and interviews, the facility failed to follow use the safety equipment of the seat belts with the whirlpool bath lifts and resulted in a fall with injury for one resident (Resident 100 ) out of 3 residents sampled. The census was 29. Findings are: Record review of Resident 100's Admission Record dated 2-13-19 revealed date of admission of 9-23-14 and [DIAGNOSES REDACTED]. Review of Resident 100's PN (Progress Notes) dated 1-25-19 revealed the resident had received a bath and the nurse was called to the bath house to find the resident laying on the floor with a blanket over the resident and staff by the resident's side. The resident was assessed and the left leg was abducted (away) from the body. The resident was transferred to the emergency room to be evaluated at the emergency room . Review of the Hospital X-rays dated 1-25-19 revealed a proximal tibial fracture ([MEDICAL CONDITION] just below the kneebone). Interview on 2-23-19 at 2:23 PM with the ADM (Administrator) revealed the facility investigation had revealed the practice of the facility had been to not use the w/p (whirlpool) tub safety belt on the w/p lift chair if any resident was able to sit straight up in the chair. Resident 100 had been one of the resident's who had been able to sit straight up in the w/p lift chair and had not been wearing the safety belt at the time of the fall. Review of the 'Cascade Patient Transfer Lift System Safe Operation and Daily Maintenance Instructions' by Penner Patient Care, Inc. revised 7-13-12 operational manual for the w/p tub revealed only personnel who had been thoroughly trained in the operation of the transfer chair lift should operate the equipment. Operation of the equipment by untrained personnel could result in injury to the patient. Failure to secure the resident properly with the seat belt could result in injury to the resident. All residents must always be securely belted at the waist when using the w/p bath chair lift system. For residents who are unable to support themselves in an upright position, Penner supplied a second (chest) belt which allowed the facility staff to secure the resident in an upright position. Interview on 2-23-19 at 2:34 PM with the MDS-C ((Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) revealed immediately after Resident100's fall, the DON (Director of Nursing) communicated to the staff to use the safety belt on all residents. The MDS-C provided a note that had been wrote in the nursing communication book that read to Use the safety belt with every bath . Interview on 2-23-19 at 2:34 PM with the ADM revealed the facility had not completed competencies on use of the Penner w/p tub and lift chair the facility used and the ADM could not provide documentation to show all the staff had read the communication about the use of the safety belt with bathing in the w/p. Review of the facility policy titled Bathing revised 10/17 revealed to use appropriate safety measures and equipment to prevent accidents: safety belts used for bathing units, shower chairs and bathing lifts were to be used at all times. The Manufactures's directions for operating and maintaining equipment should be followed. The ADM also provided a 'Bathing Clinical Skill Checklist: tub (whirlpool) and shower bathing competency that went with the policy. Interview with the ADM 2-13-19 at 2:34 PM revealed the facility had not completed the 'Bathing Clinical Skill Checklist: tub (whirlpool) and shower bathing competencies prior to the resident's fall.",2020-09-01
6390,FLORENCE HOME,285173,7915 NORTH 30TH STREET,OMAHA,NE,68112,2016-03-01,425,D,1,0,RXGF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Referance Number: 175 NAC 12-006.12 Based on record review and interview, the facility failed to provide an antibiotic as ordered by the healthcare practitioner for Resident 6. The facility census was 95. Findings Are: Review of Resident 6's ID (interdisciplinary) notes dated 2/22/16 at 1:58 PM revealed. Resident 6 had an oral surgery procedure on 2/22/16 and returned with an order for [REDACTED]. Review of Resident 6's MAR Medication Administration Record, [REDACTED] - Given on 2/22/16 or 2/23/16. This resulted in 5 missed doses. - Initiated until 2/24/16 at 1800. Resulting in 3 additional missed doses on 2/24/16. Review of Resident 6's MAR indicated [REDACTED]. Interview on 3/1/16 at 8:45 AM with DON (Director of Nursing) revealed the expectation was that an antibiotic should be started as soon as it can be obtained from the pharmacy but never over 24 hours. If waiting for an authorization, the facility would provide the antibiotic until the authorization was obtained. Documentation should be in the ID notes to indicate attempts to get approval or order filled from the pharmacy. Interview on 3/1/16 at 8:45 AM with DON revealed that, if the order was received by the facility at 1400, there was time to obtain it from the pharmacy on the day it was ordered or in the AM of the next day, if waiting for authorization. Medication should have been obtained from the pharmacy and started pending authorization from PACE.",2019-03-01
2965,RIDGECREST REHABILITATION CENTER,285239,3110 SCOTT CIRCLE,OMAHA,NE,68112,2017-10-11,225,E,1,1,09Y611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference 175 12-006.02 Based on observation, record review and interview; the facility failed to investigate and report to the State Agency allegations of abuse and misappropriation for 3 of 35 residents (Resident 103,68,and 43). The facility census was 65. Findings are: Record review of the facility policy Preventing, Reporting and Investigating Abuse, dated as revised (MONTH) (YEAR), revealed the following: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and promptly and thoroughly investigated by facility management. 4. To help with recognition of incidents of abuse, the following definitions of abuse are provided. a. Abuse, means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual , including a caretaker, of goods or services that are necessary to attain or maintain physical mental, and psychosocial well-being. Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitates or enabled through the use of technology. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. b. Neglect is the failure of the facility , it's 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. e. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. [NAME] Record review of Resident 103's face sheet dated 10/11/17 revealed that Resident 103 was admitted on [DATE] to the facility. Resident 103 was on Hospice. Record review of Resident 103's progress notes revealed that on 10/6/17 at 10:00 PM was without viable signs of life. Interview with Resident 103's family on 10/04/17 at 10:09 AM revealed that they had reported to the facility, that there was a nurse aide that was mean to Resident 103. The family revealed that the nurse aide stated that, was not going to be in the room all day, and threw the urinal at Resident 103 and told them not going to return. Record review of facility's grievance log revealed that, Resident 103. The Grievance Form revealed that on 10/2/17, family reported that intentional acct on the part of a caregiver. The facility investigation on 10/2/17 revealed that Resident 103's family stated that during the process of Resident 103 having to urinate and assisting him, stated was not going to stand there all day and wait on the resident to urinate, then tossed the urinal and stated when your done you can put it anywhere and left the room. Interview with the facility Social Service Director (SSD) ,on 10/10/17 at 10:00 AM confirmed that the family had reported the incident to the SSD and the Administrator. Interview with the Director of Nursing(DON) on 10/10/17 at 10:46 AM confirmed that the facility had received the grievance. The DON confirmed that per the facility policy this incident would be considered as abuse until the investigation was completed. The DON confirmed that the facility had not investigated the family complaint as abuse and had not reported it to appropriate state agency. B. Interview with Resident 68, with family present, on 10/4/17 at 11:00 AM, revealed that there was a nursing assistant that had taken the call bell, and had not been very nice to patient. Record review of Facility Grievance log revealed that on 7/17/17 Resident 68's family had spoken to the Assistant Director of Nursing (ADON), and voiced that Resident 68 had been left wet in recliner from Sunday night to Monday morning. Record review of the facility Grievance revealed a letter from Department of Veterans Affairs revealed that there was a quality of care concern for Veteran (Resident 68), and requested that the facility investigate the allegations that included incontinent/tilting , call light response and medication administration. The letter included that Resident had been very upset and did not want to stay at the facility anymore because they didn't change Resident 68's incontinent brief from approximately 8 PM that night till day shift came on. Family stated that Resident 68 reported that when used the call bell, staff would come in and turn it off and not return form long periods of time. Interview with the Director of Nursing(DON) on 10/10/17 at 10:46 AM confirmed that the facility had received the grievance. The DON confirmed that per the facility policy this incident would be considered as abuse until the investigation was completed. The DON confirmed that the facility had not investigated the family complaint as abuse and had not reported it to appropriate state agency. C. Interview with Resident 43, on 10/04/17 at 10:25 AM, revealed that he has had Pepsi go missing from the small refried in his room and it has happened often. Resident 43 revealed that it has happened often and that the facility is aware and has not done anything about it. Observation on 10/4/17 at 10:40 AM, of Resident 43 telling Registered Nurse (RN) B, that there was Pepsi missing from the small refrigerator. Revealed to the RN that the Pepsi was present this am, and upon returning from [MEDICAL TREATMENT] it was missing. Interview with the DON on 10/10/17 at 10:46 AM revealed that there was no Grievance Form was made for Resident 43 and missing Pepsi. Confirmed that Resident 43 does have a small refrigerator in his room and he does purchase his own soda. DON confirmed that RN B had not reported that Resident 43 had misappropriation of items. The DON confirmed that there had not been an investigation into Resident 43's misappropriation of Pepsi. Interview with RN B on 10/11/17 at 11:15 AM confirmed that there was no action taken on Resident 43's missing items. RN B confirmed that it had not been reported to the DON or Administrator.",2020-09-01
6352,ROSE BLUMKIN JEWISH HOME,285059,323 SOUTH 132ND STREET,OMAHA,NE,68154,2016-03-09,323,G,1,0,C4FQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference 175 NAC 12-006.09D7b. Based on observation, interview, and record review; the facility failed to complete an evaluation of potential causal factors for falls and implement interventions based on that evaluation for two residents (Residents 1 and 4). The facility had a total census of 90. Findings are: A. Resident 4 was admitted to the facility on [DATE] with unspecified dementia (a group of thinking and social symptoms that infers with daily functioning) without behavioral disturbance according to the Face Sheet. Observations on 3/10/16 at 5:03 AM revealed the call light was going off and the light was flashing over Resident 4's door. On entering Resident 4's room, Resident 4 was observed seated on the floor mat next to the bed. Resident 4's bed was in a low position with an U shaped pillow on the bed. Resident 4 was calling out. In an interview on 3/10/16 at 5:15 AM, LPN A (Licensed Practical Nurse) said that Resident 4 had been up to the bathroom at 4:30 AM and had been given medication for pain. LPN A reported Resident 4 was usually up at this time but may be up all night. A review of Resident 4's Care Plan revealed a problem dated 12/10/15 that said the resident needed assistance with activities of daily of living due to a [DIAGNOSES REDACTED]. Fall prevention interventions included low bed with mats, safety alarm when unsupervised, private caregiver provided at times, and monitor whereabouts. Resident 4's care plan was updated on 2/1/16 to indicate Resident 4 could walk with 2 assist, a wheeled walker, and a gait belt. A review of Resident Incident Reports revealed Resident 4 had 3 other falls between 4 AM and 6:19 AM between 12/25/15 and 2/29/16. A review of a Resident Incident Report dated 12/25/15 at 6:19 AM revealed Resident 4's bed alarm sounded and Resident 4 was sitting on the floor mat with Resident 4's sitter beside Resident 4. The resident was found to not have an injury. A Nurses Note dated 12/26/15 at 2:42 AM as a late entry for 12/25/16 at 6:41 AM revealed Resident 4's sitter reported that Resident 4's right arm had a cast from the right hand to elbow and had been on top of the pressure alarm and it had prevented the alarm from sounding sooner. An Adverse Event Investigation dated 12/25/15 indicated an intervention of keeping the pressure sensitive alarm on Resident 4. A review of a Resident Incident Report dated 2/9/16 at 4 AM revealed Resident 4 opened the door and fell . According to the Resident Incident Report, Resident 4's bed alarm did not go off. Resident 4 was found on their right side. Resident 4 had 4 cm (centimeter) abrasion to top of left shoulder, 2 cm abrasion to right knee, 6 cm laceration to middle of forehead and two 6-7 cm abrasions to the scalp. Resident 4 was transferred to the hospital. According to the facility investigation as a follow up report to 2/10/16, Resident 4 received stitches to their forehead and returned to the facility. A review of the facility investigation revealed Resident 4's bed alarm was replaced. A review of a Resident Incident Report dated 2/29/16 at 4:41 AM revealed Resident 4 was found on the floor mat next to bed. Resident 4's bed alarm had failed to sound. Resident 4 had sustained a small abrasion to the right upper arm. Post Incident Actions dated 2/29/16 at 4:41 AM stated Resident 4's alarm was checked and was found to be working. A review of Nurses' Notes dated 3/1/16 at 10:46 AM and an Adverse Event Investigation dated 2/29/16 revealed staff felt possibly repeated awakening to check and change the resident's brief could have contributed to the resident being awake and rolling out of bed. Interventions implemented included completion of an overnight brief assessment to see if waking Resident 4 less would allow Resident 4 to sleep through the night. A review of Resident 4's Sleep-Incontinent-Behavior Assessment revealed the assessment was to be completed for 3 days. Resident 4's Sleep-Incontinent-Behavior Assessment was started at 8 PM on 2/29/16 and completed through 1 PM on 3/1/16. The assessment was not completed between 2 PM on 3/1/16 and 7 AM on 3/2/16 or between 10 AM and 1 PM on 3/2/16. In an interview on 3/10/16 at 9:17 AM, the Director of Nursing confirmed the Sleep-Incontinence-Behavior Assessment had not been completed. The Director of Nursing reported no changes in Resident 4's care plan had occurred related to Resident 4 being up at night or the resident's brief changes at night. B. Resident 1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations on 3/18/16 at 5:02 PM revealed Resident 1 asleep in bed with the bed in the low position. The fall alarm was on and functioning with a wheeled walker next to the bed. A review of Resident 1's care plan revealed a problem dated 5/22/14 of activity of daily living deficit and at risk for falls due to falls at home. Interventions for fall prevention was listed as silent alarm when in bed or in chair and unsupervised by private caregiver. Resident 1 was identified as ambulating with wheeled walker and stand by assist. A review of a Resident Incident Report dated 11/29/15 at 3:15 AM revealed Resident 1 had been found lying on the floor after Resident 1's bed alarm went off. Resident 1 reported Resident 1 was trying to answer the phone. Resident 1 was evaluated with no apparent injuries found. The Immediate Post Incident Actions included continue to have bed at low setting, with bed alarm, call light in reach, and continue to check frequently. The Adverse Event Investigation for the fall on 11/29/15 listed interventions of resistive to any cares, seen by geriatric psychology, and alarm on door. The Resident Incident Report dated 2/20/16 at 4:45 PM revealed Resident 1 had been found lying on their back and crying. Resident 1 was bleeding from the head and had sustained a 2.5 cm x .5 cm head injury on the left parietal side of head with a hematoma surrounding the wound. Pressure was applied to the head wound to contain bleeding and the resident was sent to the emergency room . Immediate post incident actions were for staff to continue with present interventions in place and respond to bed alarm faster. Nurse's Notes dated 2/20/16 at 6:08 PM revealed Resident 1's bed alarm had gone off and the nurse aide had immediately responded to bed alarm but it was too late and the resident had hit their head on the room door. A review of an undated facility investigation stated Resident 1 was admitted to the hospital on [DATE] for continued observation and returned to the facility on [DATE]. Resident 1 received staples to Resident 1's head wound. An Adverse Event Investigation for the event on 2/20/16 was not completed for explanation of the event and causal factors. In the intervention section, appropriate interventions in place was written in. In an interview on 3/10/16 at 9:10 AM, the Director of Nursing confirmed the explanation of the event and causal factors section was not completed on the adverse event investigation. The Director of Nursing confirmed no other interventions had been attempted after Resident 1 fell on [DATE].",2019-03-01
6277,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2016-05-05,157,D,1,0,7DPY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number ,[DATE].04C3a(6) Based on record review and interview, the facility failed to notify a resident's Primary Care Provider of a change in condition. This failure had the potential to effect one resident, (Resident 1). The facility census was 30. Findings are: A review of INTERDISCIPLINARY PROGRESS NOTES for Resident 1 dated [DATE] revealed at 4:30 AM the resident was found on the floor on stomach and face with bleeding noted from the resident's nose and mouth. First Aide was administered and the PAC (Certified Physician's Assistant) for the PCP (Primary Care Provider) listed on Resident 1's face sheet was notified. The PAC gave verbal orders to continue the current treatment and the PAC would consult with the listed PCP. An entry at 6:00 AM revealed Resident 1 reported I think I broke my nose. The documentation indicated: the resident's nose was swollen and red with a small pinch mark by the right eyebrow and an occasional trickle of blood was noted from each nostril; respirations sound moist ?(question if) clot in throat-unable to assess lung sounds; and no other bruising or injuries were noted. An entry at 11:00 AM documented Neurological checks were within normal limits up to this point-Resident is unable to form words-makes mumbling sounds at this time-was able to form words up until this time. Pupils (of eyes) are equal in size and reactive to light, but roll to the right side of orbital socket and up, none of Resident 1's usual tongue thrashing was noted. Does open eyes spontaneously and when spoken too but only for brief moment-when tapping done to hands turns eyes back toward person-very lethargic at this time but does awaken and tries to focus-answers simple yes and no questions by nodding head-spouse at bedside-will continue to monitor. The entry did not indicate whether or not the resident's PCP was notified related to this noted change in condition. Continued review of the PROGRESS NOTES revealed the entries at 1:00 PM and 2:00 PM indicated continued concerns with Resident 1's condition without documentation of notification of the resident's PCP. An entry at 3:30 PM documented Resident 1's condition declined again with increased lethargy noted-the resident's PCP was notified of the resident's condition and will be in to see the resident at approximately ,[DATE] PM- Res 1's spouse was updated related to the length of time before the PCP could visit the resident and would like to wait for the resident's new PCP to see the resident before any other arrangements are made-reiterated that the PCP would not be able to be here until 6 or 7 PM-again spouse would like to wait and see what the PCP says. An entry at 7:15 PM indicated the PCP was here to see Res 1 and visited with spouse feels resident needs to go to hospital related to a possible massive stroke. An interview on [DATE] at 3:20 PM with Licensed Practical Nurse (LPN)-A revealed that when the LPN started the shift scheduled on [DATE], the LPN received report from the off going Charge Nurse which indicated the following information related to Resident 1: had fallen out of bed, nose was swollen, was alert, knew the nurse and answered questions appropriately; and that the Resident's PCP had been notified of the fall and swollen nose. The LPN reported that at 11:00 AM a change in Resident 1's condition was noted with the resident mumbling verbalizations, not making eye contact, and not exhibiting tongue movements which were normal for the resident. The resident's vital signs were within normal limits and spouse was at the resident's bedside. We continued to do what the resident's wife requested as orders for DNR (Do Not Resuscitate-No CPR to be initiated) were in place, the DON was updated and agreed. At 3:30 PM the LPN notified Resident 1's PCP office and received report that the MD would not be able to come to the facility to visit the resident until 6 or 7 PM. This message was relayed to the resident's wife who continued to decline offers to have Resident 1 sent to the hospital for assessment/treatment. An interview on [DATE] at 5:35 PM with LPN-A confirmed the LPN did not notify Resident 1's PCP immediately of the noted change of condition on [DATE]. An interview on [DATE] at 5:45 PM with the DON (Director of Nursing) revealed the DON was aware of but did not notify Resident 1's PCP of the noted change in the resident's condition as the DON thought the LPN had been in correspondence with the MD.",2019-05-01
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
4270,HILLCREST SHADOW LAKE,2.8e+300,1507 E GOLD COAST ROAD,PAPILLION,NE,68046,2017-08-14,225,D,1,1,728T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 12-006.02(8) Based on record review and interviews, the facility failed to report and investigate potential abuse for 2 residents (Residents 70 and 130) of 6 residents sampled. The facility staff identified the census at 102. The findings are: A review of the facility's Abuse, Neglect, Misappropriation investigation form dated 8/29/16 that was completed due to a resident to resident abuse allegation that involved Resident 130 revealed the incident took place on 8/22/16 at 5:30 PM. The Director of Nursing (DON) was notified of the incident on 8/22/16 at 5:35 PM. The incident was reported to Adult Protective Services (APS) on 8/24/16 at 4:45 PM. An interview conducted on 8/14/17 at 10:15 AM with the DON confirmed that the incident was called to APS 2 days after the incident occurred and that was outside the required reporting timeframe of 24 hours. A review of the facility's Reporting Allegations of Abuse/Neglect/Exploitation Policy dated 5/1/17 revealed the following: Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation: 2. The Director of Clinical Services, Administrator, or designee will: a. Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. B. Record review of an Admission Record sheet dated 9 01 (YEAR) revealed Resident 70 was admitted to the facility on 6 01 (YEAR) with the [DIAGNOSES REDACTED]. Record review of Resident 70's Progress Notes dated 9 02 (YEAR) with a time entry of 9:23 PM revealed Resident 70 was sitting in a chair when another resident came up to Resident 70 and shook their finger at Resident 70. Resident 70 .hit other residents hand away . Further review of Resident 70's Progress Notes dated 9 02 (YEAR) with a time entry of 9:27 PM revealed Resident 70 walked up to another resident and hit the resident on the back. Review of Resident 70's record revealed there was no evidence the facility had reported to the State Agency or had completed an investigation into the altercation. On 8 14 (YEAR) at 8:45 AM, an interview was conducted with the DON. During the interview, the DON confirmed the resident to resident altercation dated 9 02 (YEAR) had not been reported to the Required State Agency and further confirmed an investigation had not been completed.",2020-09-01
4956,"PREMIER ESTATES OF CRETE, LLC",285170,830 EAST 1ST STREET,CRETE,NE,68333,2018-01-24,725,F,1,0,TMI511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 12-006.04 Based on record review, interview, and observation; the facility failed to ensure staff were available to assist with resident care needs without adverse effects. This failure had the potential to affect all 58 residents residing in the facility. Findings are [NAME] A review of the facility's grievances dated 10/1/17-01/24/18 revealed Resident 12 had reported several concerns related to care received at the facility and lack of staff to provide toileting assistance in order to prevent the resident from being incontinent (unable to hold urine or stool). Several of the remaining grievance forms, including concerns voiced by the Resident Council, documented resident concerns related to long call light waits with incontinence reported as the effect. An interview with Resident 12, on 1/23/18 at 5:00 PM, revealed the same concerns which were documented in the Grievance/Concern/Complaint Reports related to lack of staff and long call light wait times. Resident 12 became teary eyed and reported that the lack of staff or the extended amount of time the staff takes to answer the resident's call light has caused the resident to be incontinent of both bowel and bladder. B. An observation on 1/24/18 at 3:15 PM revealed a call light notification alarm sounding for approximately 20 minutes. A red light was visible on a panel across from the Nurse's Station along with the alarm sounding. Licensed Practical Nurse (LPN)-C was noted to be inside the Nurse's Station and when asked, the LPN reported inability to hear the alarm while inside the station. The LPN looked at the panel and reported the alarm was a resident call light on the 400 Hallway. As this Surveyor proceeded toward the 400 hallway, the LPN used the overhead paging system to request an aide to the 400 hall. Continued observation at 3:20 revealed the call light was activated for room [ROOM NUMBER], and there were no staff visible in the area. At 3:22 PM LPN-C entered the 400 hallway pushing a medication cart. Another staff member was noted to approach the LPN, and was asked if the staff member could answer the call light. The other staff member reported that the caregiver's shift was over and wanted to make sure the LPN was aware that there were only 2 Nursing Assistants working at this time. The LPN went into room [ROOM NUMBER], closed the door, and the call light was turned off.",2020-03-01
3721,GOOD SAMARITAN SOCIETY - GRAND ISLAND VILLAGE,285285,4061 TIMBERLINE STREET & 4055 TIMBERLINE STREET,GRAND ISLAND,NE,68803,2017-05-25,279,D,1,1,IQ0211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 12-006.09C Based on record review and interview, the facility failed to develop a Comprehensive Care Plan (CCP) related to respiratory care and equipment for 1 (Resident 65) of 35 residents reviewed. The facility census was 59. Findings are: Record review of Resident 65's admission 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 5/13/17 identified that Resident 65 was cognitively intact and used a Continuous Positive Airway Pressure ([MEDICAL CONDITION]) Machine (a device used to assist breathing by an outside flow of air. This is done for people who are not able to keep enough oxygen in the blood without help.) while a resident and not while a resident of the facility. The MDS identified that Resident 65 had a [DIAGNOSES REDACTED]. Interview 5/23/17 at 4:41 PM with Resident 65 confirmed the use of a [MEDICAL CONDITION] device during the night to assist with sleeping comfortably. The resident stated that the facility staff assisted with application of the device if needed. Record review of Resident 65's Treatment Administration Records dated (MONTH) (YEAR) revealed the daily use of a [MEDICAL CONDITION] device used at bedtime for Apnea (airflow blockage) related to OS[NAME] Record review of Resident 65's CCP dated 5/13/17 revealed no identified problem, goals or specific interventions related to the respiratory condition of Obstructive Sleep Apnea or the nightly use of a [MEDICAL CONDITION] device. Interview on 05/24/17 at 4:13 PM with the Director of Nursing (DON) confirmed that Resident 65 had the medical condition of OSA and used a [MEDICAL CONDITION] device nightly. The DON confirmed that a CCP had not been developed related to the use of the [MEDICAL CONDITION] device or the concern of OSA and did not have goals or specific interventions related to respiratory care concerns. The DON confirmed that a CCP should have been developed to address respiratory issues for Resident 65.",2020-09-01
4273,HILLCREST SHADOW LAKE,2.8e+300,1507 E GOLD COAST ROAD,PAPILLION,NE,68046,2017-08-14,314,G,1,1,728T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 12-006.09D2b Based on observation, interviews and record reviews, the facility failed to monitor pressure ulcers for 2 residents (Residents 111 and 118) of 2 residents sampled. The facility staff identified the census at 102. The findings are: [NAME] Record review of a Weekly Skin Assessment sheet dated 11 25 (YEAR) revealed Resident 118 was admitted to the facility with wound ulcers to the right toe, shin, foot and on top of the left foot and left 2nd toe. Record review of a Wound Tracking Tool (WTT) sheet dated 12 1 (YEAR) revealed Resident 118 had excoriation to the buttocks with barrier cream applied. Record review of a WTT sheet dated 12 06 (YEAR) revealed Resident 118 had developed a pressure ulcer to the right buttock that measured 3 centimeters (cm) by 3 cm with a depth of 0.10 cm. No staging of the pressure ulcer was completed. Record review of a WWT dated 12 08 (YEAR) revealed Resident 118's pressure ulcer measured 3.0 cm by 3.0 cm by 0.20 cm. No staging of the pressure ulcer was identified. Also identified on the WTT dated 12 08 (YEAR) was that Resident 118 had also developed a pressure ulcer to the left lower gluteal fold and right lower gluteal fold. No measurements were identified for the left lower gluteal fold and right lower fold. No staging of the pressure ulcer was identified. Record review of a WTT dated 1 5 (YEAR) revealed Resident 118's pressure ulcer to the left buttocks measured 1.0 cm by 0.70 cm, with the left lower gluteal fold measured 4.0 cm by 5.0 cm and the right lower gluteal fold measured 4.0 cm by 6.0 cm. No staging of the pressure ulcer was completed. Record review of a WTT dated 2 13 (YEAR) revealed Resident 118's left buttocks pressure area measured 10.00 cm by 2.0 cm, the right buttocks pressure ulcer measured 5.0 cm by 2.0 cm. In addition, a pressure ulcer to the left lower scrotum measured 6 cm by 7 cm's. No staging of the pressure ulcers were completed. Record review of a WTT dated 3 06 (YEAR) revealed Resident 118 continued to have pressure ulcers to the left buttocks, right buttocks and left lower scrotum. No measurements or staging of the pressure ulcers were completed. Record review of a WTT dated 3 15 (YEAR) revealed Resident 118's pressure ulcer to the left buttocks measured 5.0 cm by 1.0 cm and the pressure ulcer to the right buttocks measured 8.0 cm by 3.0 cm. There was no indication for the status of the pressure ulcer to the left lower scrotum. Observation on 8 9 17 at 9:20 AM of the left buttock pressure ulcer treatment revealed it to be approximately quarter sized roundish with an unmeasured deep looking hole. The DON (Director of Nursing) applied a wound vac (device that assist in increasing the blood flow to a wound area and removes drainage) to the pressure ulcer. On 8 10 (YEAR) at 12:35 PM, an interview was conducted with the DON. The DON reported during the interview that Resident 118 did have pressure ulcers on admission, however, there were no measurements of the pressure ulcer. During the interview, the DON confirmed Resident 118's pressure ulcers were not consistently monitored and that Resident 118 started going to the wound clinic on 3 07 (YEAR). The DON reported the pressure ulcer to the left buttock was a stage 4 ( Stage 4 Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). B. A review of Resident 111's Face Sheet dated 8/10/17 revealed that Resident 111 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of Resident 111's medical record revealed Wound Tracking Tools were completed on 6/16/17, 7/3/17, 7/17/17, 7/28/17, 8/4/17, and 8/10/17. An interview conducted on 8/10/17 at 2:23 PM with the Director of Nursing (DON) revealed that Wound Tracking Tools were to be completed weekly.",2020-09-01
3605,LANCASTER REHABILITATION CENTER,285275,1001 SOUTH STREET,LINCOLN,NE,68502,2018-12-04,688,D,1,1,ESLD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 12-006.09D4 Based on interviews and record reviews the facility failed to implement a specific Nursing Restorative Program care and treatment plan to improve or maintain range of motion for 1 resident (Resident 95). The facility census was 217. Findings are: An interview on 11/27/18 at 04:13 PM with Resident 95 reported a decline in function since admission. Resident 95 reported upon admission was able to transfer alone. Resident 95 reported inability to transfer unattended, related to weakness from [MEDICAL TREATMENT] and leg muscle loss. Resident 95 confirmed had not been on an exercise program since discharge from Therapy Services. Observation on 11/27/18 at 04:13 PM of Resident 95 self-propelling in a wheel chair. Record review of Therapy service revealed the last date of service was on 11/19/18. A note dated 11/19/18 revealed that Resident 95 had responded well to therapeutic interventions and had achieved functional independence levels that should have allowed safe discharge to a Functional Maintenance Program with Restorative Nurse Supervision/assistance. An interview on 11/29/18 at 02:18 PM with DON (Director of Nurses) confirmed that Resident 95 had not started on a Functional Maintenance Program per Therapy recommendations. An interview on 11/29/18 at 02:27 PM with the DON confirmed that the Therapy Department had not written a restorative program for resident 95.",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
1734,"PREMIER ESTATES OF PAWNEE, LLC",285157,"P O BOX 513, 438 12TH STREET",PAWNEE CITY,NE,68420,2017-05-11,155,E,1,1,MMVU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC ,[DATE].05(4) Based on interview and record review, the facility failed to ensure staff who provided resident transportation services were certified to perform CPR (Cardiopulmonary Resuscitation). This failure had the potential to affect eight residents (Resident 2, 27, 29, 47, 25, 19, 32, and 9) out of a sample of 8 whose Advanced Directive indicated CPR was requested. The facility census was 40. Findings are An interview on [DATE] at 9:23 AM with Transportation Aide-E revealed the staff member assisted with providing transportation for the facility's residents on a part time basis and that there were two other staff members who shared the responsibility of providing residents with needed transportation (Staff D and F). The Transportation Aide reported that (gender) CPR certification had expired. An interview on [DATE] at 2:38 PM with Transportation Aide-D revealed the staff member did assist with resident transportation and was not CPR certified. An interview on [DATE] at 9:12 AM with the Administrator revealed none of the three staff members (Staff Members D, E, and F) who provided resident transportation services were certified to perform CPR. A review of an Order Listing Report for Advanced Directive dated [DATE] revealed the facility had eight residents whose Advanced Directive was for CPR/Full Code. A review of a facility form titled CLINICAL SERVICES-EMERGENCY CARE/CPR dated ,[DATE] revealed the facility had staff available 24 hours per day who were certified to perform Heart Saver CPR as defined by the American Heart Association.",2020-09-01
6577,"PLATTSMOUTH CARE AND REHABILITATION CENTER, LLC",285104,602 SOUTH 18TH STREET,PLATTSMOUTH,NE,68048,2015-12-03,155,J,1,0,YK8X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC ,[DATE].05(4) Based on interview and record review, the facility failed to follow the cardiopulmonary resuscitation (CPR) directive for one resident (Resident 1). The facility census was 100. Findings are: Review of Resident 1's Resuscitation Orders dated [DATE] revealed that in the event of cardiac and/or respiratory arrest Resident 1 wanted CPR initiated. Review of Resident 1's Nurses Notes, dated [DATE], revealed that the resident was found at 7:05 PM with no vitals or respiration. CPR was initiated and 911 was called, Director of Nursing (DON) was notified. During an interview with Licensed Practical Nurse A (LPN A) on [DATE] at 2:40 PM, LPN A revealed that, on the evening shift of [DATE], LPN A came up to the nurses station on the central unit while LPN B and Registered Nurse C (RN C) were having a discussion that Resident 1 had died and that they were unsure of Resident 1's CPR status. LPN A informed them that Resident 1's directive was to initiate CPR and that 911 needed to be called. LPN A stated that LPN A got the crash cart (a mobile cart carrying medical equipment used for resuscitation) and went to Resident 1's room but didn't have the key to turn the oxygen tank on and had to go back to get it. LPN A said that this all took about 5 minutes. LPN B was interviewed by telephone on [DATE] at 2:10 PM. LPN B said that on [DATE] after supper, RN C came to the nurses station and told LPN B that Resident 1 had died . LPN B said that, We kinda thought (Resident 1) was a no code. LPN B said it was ,[DATE] minutes before CPR was started on Resident 1. On [DATE] at 5:31 PM, RN C was interviewed by telephone. RN C stated that RN C found Resident 1 in room and unresponsive at 7:05 PM. RN C went to the nurses station and called LPN B and checked the resident's chart for the code status. Asked how long from the time Resident 1 was found unresponsive until CPR was initiated, RN C said, about 10 minutes. Review of the facility's CPR policy, with an effective date of [DATE], revealed that: 1) CPR sequence was to: -Check patient for responsiveness -Check for breathing or no normal breathing -Call for help -Check a pulse for no more than 10 seconds -Give 30 compressions -Open airway and give 2 breaths -Resume compressions -No more than 10 seconds hands off time 2) Compressions should be initiated within 10 seconds of recognition of the arrest. Review of a document titled Verification of Investigation (VOI) dated [DATE] revealed that another resident (Resident 2) was admitted to the facility on [DATE]. Resident 2 was alert and oriented and signed a code status at that time indicating Resident 2 wanted CPR. Under Summary And Outcome of Investigative Findings on the VOI, it stated that, (Resident 2) had a [DIAGNOSES REDACTED]. The resident's health status declined and the resident was found with no pulse or respirations at 1:15 AM. Resident was not given CPR. On [DATE] at 11:41 the DON was interviewed about Resident 2 and how the facility responded to the resident not getting CPR. The DON said that education was provided to all nursing staff on CPR policies at that time and audits were done on all charts to ensure all CPR status' were current. On [DATE] at 5:15 PM the DON agreed to immediately implement the following: -Immediately educate all direct care staff currently on duty about what do and how to respond when a resident is found unresponsive/without vitals -Initiate a plan on how the facility would educate each shift and the remaining direct care staff before the staff began their work shift.",2018-12-01
6471,BELLE TERRACE,285237,1133 NORTH THIRD ST,TECUMSEH,NE,68450,2016-02-24,155,D,1,0,TIKE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC ,[DATE].05(4) Based on interview and record review, the facility failed to follow the cardiopulmonary resuscitation (CPR) directive for one resident (Resident 2) and failed to immediately initiate CPR for one resident (Resident 3). The facility census was 43. Findings are: A. Review of Resident 2's Cardio [MEDICAL CONDITION] Resuscitation (CPR) Form dated [DATE] revealed that in the event of cardiac and/or respiratory arrest Resident 2 wanted CPR initiated. Further review of the same form revealed Resident 2's physician had signed an order for [REDACTED]. Review of Resident 2's Nurses Notes dated [DATE] revealed at 6:15 AM, LPN (Licensed Practical Nurse) A had performed a visual check of Resident 2 and respirations were noted to be even and shallow with oxygen intact. Nurses Notes at 7:30 AM revealed, Observed resident (with) no respirations pulseless, breathless, pupils fixed. DON (Director of Nursing) notified. PCP (Primary Care Physician) called. At 7:35 AM, the APRN (Advanced Practitioner Registered Nurse) had called and given an order to release the body to the mortuary and notify the county coroner of the death. Interview with the DON on [DATE] at 11:40 AM revealed LPN A no longer was employed at the facility and confirmed that LPN A had not initiated CPR for Resident 2 when found to be absent of all vital signs. The DON further explained that by the time the DON arrived at the facility the APRN had been called and had given orders to release Resident 2 to the mortuary. The DON further stated that after this occurred that all licensed nursing personal were educated on performing CPR when a resident elected to have CPR performed. Review of the agenda for a Charge Nurse Meeting dated [DATE] revealed the DON reviewed the meaning of a Code Status and that a resident's desire to have CPR should be respected and followed. B. Review of Resident 3's Cardio [MEDICAL CONDITION] Resuscitation (CPR) Form dated [DATE] revealed that in the event of cardiac and/or respiratory arrest, Resident 3 wanted CPR initiated. Further review of the same form revealed Resident 3's physician had signed an order for [REDACTED]. Review of Resident 3's Nurses Notes dated [DATE] revealed LPN B was called to Resident 3's room at 1:40 AM and noted Resident 3 had no respirations and no heart beat. LPN B documented that LPN B then called and notified the DON and returned to initiate CPR for Resident 3 at 1:45 AM. Further review of the same nurses notes revealed the DON arrived at the facility at 1:55 AM and 911 was called at 2:12 AM. Interview with LPN B on [DATE] at 1:04 PM revealed when a resident requests CPR that staff are to call 911 and initiate CPR right away. Review of the facility's policy for CPR/no CPR status dated [DATE] revealed, In the event of cardiac and/or respiratory arrest, a yes to CPR means that (facility staff) will initiate the following procedure: CPR will start immediately All efforts will be made to keep the resident alive until the ambulance arrives.",2019-02-01
1606,AZRIA HEALTH CENTRAL CITY,285147,2720 SOUTH 17TH AVENUE,CENTRAL CITY,NE,68826,2019-07-30,684,G,1,1,7WHV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC ,[DATE].09 Based on observation, interview, and record review; the facility failed to monitor Resident 63 following a change in condition and failed to assess and identify Resident 49's potential for self-harm. The sample size was 2 and the facility census was 59. Findings are: [NAME] Review of the facility policy titled Resident Condition Changes that Require Physician Notification Guidelines with an effective date of [DATE] revealed an Emergent situation/condition warranted immediate physician notification and intervention. Emergent situations included an acute onset of chest pain or deviation of vital signs where interventions must be immediate. An urgent situation was identified as a situation/condition that required physician notification and physician response within ,[DATE] hours. Urgent situations included a fever greater than 101 degrees that responded to interventions or changes in vital signs or level of consciousness in a resident who had a do not resuscitate order. Further review revealed the licensed nurses were expected to recognize resident situation/conditions that required physician notification. The nurse should complete an assessment of the condition to determine the level of urgency. The resident's condition would be documented in the resident's chart with a notation made every shift for at least 72 hours. Review of Resident 63's undated Care Plan revealed the resident had hypertension (high blood pressure), [MEDICAL CONDITIONS] (build up in the arterial walls), [MEDICAL CONDITION] (a group of lung diseases that block airflow and make it difficult to breathe), [MEDICAL CONDITION] (a circulatory condition in which narrowed blood vessels reduce blood flow to the extremities), and type 2 diabetes mellitus. The resident was to report any chest pain and the facility was to alert the physician to any changes in status. Review of Resident 63's Progress Notes and Vitals Summary dated [DATE] through [DATE] revealed: - On [DATE] at 10:02 PM, the resident had a temperature of 100.2 degrees (with an average normal body temperature being 98.6 degrees). - On [DATE] at 10:04 PM, the resident complained of having chest pains off and on. - There was no evidence to indicate any further vital signs had been taken on [DATE], [DATE], or [DATE]. There was also no evidence to indicate the physician had been notified. - On [DATE] at 4:15 AM the resident complained of not feeling well. The resident had a temperature of 101.1 degrees with an oxygen saturation level of 76 percent (%) (with values under 90% being considered low). The resident refused oxygen but a breathing treatment was provided. The intervention decreased the resident's temperature to 98.7 degrees and improved the resident's oxygen saturation level to 82%. - On [DATE] at 5:54 PM, it was noted the resident had been seen by the Physician for coarse lung sounds and dyspnea (shortness of breath) with new orders for a cough syrup, an antibiotic, and a steroid medication. -There was no evidence to indicate the resident's vital signs had been taken after returning from the physician on [DATE]. No further vital signs were documented on [DATE] and [DATE]. - On [DATE] at approximately 7:00 AM, the resident was found to be deceased . During interviews with the Minimum Data Set (MDS) Coordinator on [DATE] at 2:40 PM and 3:06 PM the MDS Coordinator revealed Resident 63 had a significant heart history. Further interview confirmed the resident's status and vital signs should have been monitored more frequently. B. Review of facility Health Status Note [DATE] revealed Resident 49 was observed to have burn areas to bilateral wrists. Left wrist measuring at 1.2 cm x 0.8 cm and right wrist at 1 cm x 0.9 cm. Observation of Resident 49 on [DATE] 3:06 PM revealed reddened burn areas to anterior area of bilateral wrists. Size and shape [MEDICAL CONDITION] to the tip of a cigarette. Also observed numerous old scarred burn areas on bilateral upper arms of similar size and shape to the newly observed burns. Interview with the Director of Nursing (DON) with Registered Nurse (RN) B present on [DATE] 9:58 AM revealed the old burn wounds for Resident 49 should have been identified and communicated to the nursing staff after having been observed by staff during bathing and other cares. This behavior should have been identified and care planned to have a staff person watching the resident very closely and/or have additional safety interventions in place while smoking. Interview with RN B on [DATE] at 8:00 AM revealed that the nurse had seen the circular wounds on Resident 49 and the old scars were consistent with self injury behaviors. This should have been identified on the admission assessment. Interview with LPN D on [DATE] at 9:50 AM revealed there was no real tool for identifying or tracking these older injuries as behaviors. Interview with NA Y on [DATE] at 9:22 AM revealed bath aids are directed to report any skin issues identified during bathing. The NA had just bathed Resident 49 and had reported the healed burn areas on the resident's upper arms and also the new burn marks on bilateral wrists. Resident 49 had been bathed multiple times since admission. Review of the Minimum Data Set (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) for Resident 49 dated [DATE] revealed a [DIAGNOSES REDACTED]. Review of a History and Physical for Resident 49 dated [DATE] revealed the self injury behavior of hitting head against the wall. An assessment of Resident 49's old burn wounds was requested from the Administrator on [DATE] at 10:21 AM. An assessment identifying the numerous old scarred burn areas on bilateral upper arms was not provided during survey. Review of Resident 49's PCC Skin and Wound - Total Body Assessment, dated [DATE] did not identify the resident's numerous old scarred burn areas on bilateral upper arms.",2020-09-01
1378,LIFE CARE CENTER OF ELKHORN,285134,20275 HOPPER STREET,ELKHORN,NE,68022,2018-02-27,684,E,1,1,YXZR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC ,[DATE].09 Based on observations, interviews, and record reviews; the facility failed to follow practitioner's orders for oxygen for 1 resident (Resident 13) of 1 resident sampled and skin preventative measures and treatments for 1 resident (Resident 80) of 7 residents sampled. The facility also failed to complete monitoring for skin conditions for 1 resident (Resident 33) of 2 residents sampled, and failed to provide treatments for an infection for 1 resident (Resident 9) of 3 residents sampled. The facility staff identified the census at 101. The findings are: [NAME] A review of Resident 13's undated Face Sheet revealed Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 13 expired on [DATE]. A review of Resident 13's Initial Data Collection Tool dated [DATE] revealed that the resident was receiving Oxygen at 3.5 liters per minute. A review of Resident 13's physician's orders [REDACTED]. A review of Resident 13's Treatment Administration Record for (MONTH) (YEAR) revealed an order for [REDACTED]. The order was documented as completed for the night shift on [DATE]. The order was documented as completed for the night shift on [DATE], but that the resident only received 1.5 liters per minute that shift. A review of Resident 13's Progress Note dated [DATE] at 7:38 AM revealed the resident was receiving Oxygen at 3 liters per minute. A review of Resident 13's Progress Note dated [DATE] at 1:19 AM revealed the resident was receiving Oxygen at 3 liters per minute. A review of Resident 13's Progress Note dated [DATE] at 3:45 PM revealed the resident was receiving Oxygen at 3 liters per minute. A review of Resident 13's Progress Note dated [DATE] at 4:56 AM revealed the resident's Oxygen was increased from 1.5 to 2 liters per minute because the resident was unable to maintain a sufficient Oxygen level. B. A review of Resident 80's Medication Administration Record [REDACTED]. The [MEDICATION NAME] was documented as completed every day except [DATE], [DATE], and [DATE]. An observation conducted on [DATE] at 7:52 AM revealed that Resident 80 had abrasions to their right knee and left upper shin just below the knee that were not covered with a bandage. C. An observation conducted on [DATE] at 12:07 PM revealed Resident 33 had bruises on their right hand. A review of Resident 33's Weekly Skin Integrity Data Collection form dated [DATE] revealed the resident had intact skin and there was no documentation of bruising to the resident's hands. A review of Resident 33's Non-pressure Skin Condition Record dated [DATE] revealed Resident 33 had bruising to their hand but it was resolved. An interview conducted on [DATE] at 9:48 AM with the Director of Nursing (DON) revealed that there was no documentation that the bruises were identified and monitored. D. Record review of a facility Policy and Procedure for Medication Administration revised [DATE] revealed the policy that each medication administered at the time of the administration must be promptly recorded in the resident's individual medication record per initial of the licensed nurse who must sign his or her first name on the Medication Administration Record. Record review of Nurse Notes dated [DATE] revealed that Resident 9 returned from the Hospital emergency room with orders for [MEDICATION NAME] 2% ointment apply to lower right lip x 7 days. Nurses Notes dated [DATE] revealed that Resident 9 was on an oral antibiotic for infectious mouth process with lips and cheek swollen. Record review of a Consent to Procedure or Minor Surgery dated [DATE] revealed that Resident 9 had an incision and drainage of the right lower lip abscess (a hole filled with pus and surrounded by swollen tissue) on [DATE]. Physicians orders dated [DATE] included orders for Mucipocin 2% nasal ointment commonly known as [MEDICATION NAME] (a topical antibiotic) apply to right lower lip 2 times per day for 7 days ([DATE] through [DATE]) and [MEDICATION NAME] (an antibiotic) 100 mg twice a day x 14 days ([DATE] through [DATE]). Record review of a Physicians follow up visit dated [DATE] revealed that Resident 9 had been evaluated for an abscess of the lip. Physicians instructions recommended the continued daily use of [MEDICATION NAME] to the right lip excoriation and [MEDICATION NAME] 100 mg tabs by mouth two times per day x 14 days ([DATE] through [DATE]). Record review of Resident 9's Medication Administration Records (MAR) for (MONTH) (YEAR) revealed that Resident 9 did not receive a daily treatment of [REDACTED]. Interview on [DATE] at 09:10 AM with the Director of Nursing (DON) confirmed that there was no documentation on those dates that the medication had been received. The DON stated that Resident 9's infection was bad and that the missed doses of the medication could have contributed to the slow healing of the infection. The DON stated that if the doses had not been administered for some reason that it should have been documented on the back side of the MAR. The DON confirmed there was no documentation on the back side of the MAR.",2020-09-01
2164,LEGACY GARDEN REHABILITATION & LIVING CENTER,285186,200 VALLEY VIEW DRIVE,PENDER,NE,68047,2017-07-20,323,D,1,1,E93U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC ,[DATE].09D7 Based on observations, interviews, and record reviews; the facility failed to ensure safe transfer technique for 1 resident (Resident 28) of 2 resident sampled. The facility staff identified the resident census at 31. An observation conducted [DATE] at 10:40 AM of Nursing Assistant A transferring Resident 28 from the wheelchair to the bath chair revealed NA A placed the EZ Way Smart Stand lift (a mechanical lift that assists the resident to a standing position) in front of Resident 28. Resident 28 placed their left foot on the platform with their toes of their right foot on the platform. NA A did not assist Resident 28 to put their feet on the platform and did not attach the leg support strap around the resident's legs. NA A then lifted Resident 28 in the stand lift to a standing position, only the top third of the resident's right foot was observed on the platform. While resident was up in the lift getting undressed and the nurse removing the dressing, the resident began to sway side to side. NA A steadied the resident in the stand lift and then continued on to provide perineal cleaning prior to lowering the resident into the shower chair while the resident's foot remained only a third of the way on the platform. An interview conducted [DATE] at 11:07 AM with Licensed Practical Nurse (LPN) B revealed that the resident's feet are both supposed to be completely on the platform when transferring residents in the stand lift. LPN B reported that they thought the leg strap was to be used on all residents when they are transferred in the stand lift. An interview conducted on [DATE] at 11:10 AM with the Director of Nursing (DON) revealed that the resident's feet should have been firmly on the platform and the leg strap was to be used on all residents unless their care plan stated not to use the strap. A review of Resident 28's Comprehensive Care Plan dated [DATE] revealed no documentation that the leg strap was not to be used on Resident 28. An review of the EZ Way Smart Stand Operator's Instructions dated [DATE] revealed the following: Transferring the patient: Position EZ Way Smart Stand in front of patient 3) Have patient place feet (help patient if needed) on foot plates and position their shins into the shin pad.",2020-09-01
2307,"CALLAWAY GOOD LIFE CENTER, INC",285200,"PO BOX 250, 600 WEST KIMBALL STREET",CALLAWAY,NE,68825,2019-01-03,689,G,1,0,4X3Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC ,[DATE].09D7 Based on record reviews and interview, the facility failed to provide interventions to prevent falls with injuries for one closed record resident reviewed (Resident 1) and for one current sampled resident (Resident 2). The facility census was 30 with five current sampled residents and one closed record. Findings are: [NAME] Review of Resident 1's Departmental Notes, dated [DATE], revealed the resident was admitted to the facility from the hospital post surgical revision of a shunt (device to divert flow from one main route to another, from the brain to the abdomen) secondary to a brain bleed and Acute [MEDICAL CONDITION] (brain disorder). Review of the Care Plan, goal date [DATE], revealed the resident had a history of [REDACTED]. Review of the Departmental Notes revealed the following including: - [DATE] at 2:35 PM gait unsteady and periods of of confusion; - [DATE] at 4:45 PM poor safety awareness; - [DATE] at 3:27 PM periods of confusion, poor safety awareness, gets up unassisted and doesn't remember to ask for help; - [DATE] at 3:33 PM frequent episodes of confusion, gait unsteady; - [DATE] at 3:16 PM ambulated on own; - [DATE] at 3:46 PM periods of confusion, required verbal cues to use the call light and wait for assistance; - [DATE] at 8:30 AM Nursing assistant reported the resident had increased difficulty ambulating to the bathroom, leaned backwards and to the right and while standing in the bathroom leaned forward in front of the toilet; 11:00 AM remained confused to place; 12:15 PM assisted to ambulate to the dining room with use of wheeled walker, gait unsteady with shuffling gait; 3:30 PM found on the floor by the doorway to room, did not respond to verbally and had bright red drainage from right back of head; 3:40 PM call placed to 911 for transport to the hospital; 3:45 PM resident remained unresponsive, continued to have bright red drainage from the right back of head, pulse 68, respirations labored and blood pressure ,[DATE]; 4:00 PM the resident was transported to the hospital per rescue unit; 6:45 PM call from spouse to report that the resident had bleeding at the brain and they chose no surgical interventions at this time. Review of the facility Investigation Report, dated [DATE], revealed the resident expired at the hospital on [DATE]. Interview with the DON (Director of Nursing) on [DATE] at 10:45 AM confirmed the resident was a high risk for falls and interventions in place were not effective to prevent the fall and injuries. B. Review of Resident 2's Care Plan, goal date [DATE], revealed the resident had a recent fall with a brain bleed and had a [DIAGNOSES REDACTED]. The resident had periods of forgetfulness and confusion, history of hallucinations and delusions (visual images and ideas not based on reality), had some impaired hearing, [DATE] was treated for [REDACTED]. The resident required staff assistance for bed mobility, transfers, toileting,ambulation with a walker and used a wheelchair for mobility due to weakness, unsteady gait and poor balance. Review of the Departmental Notes revealed the following including: - [DATE] at 12:25 PM resident was admitted to the facility; - [DATE] at 11:00 AM resident tried to arise without utilizing the call light, rose from the wheelchair with brakes unlocked and the walker across the room, educated to use the call light for assistance; 12:13 PM the resident was up with walker to the bathroom, call light was not activated, continued to have poor safety awareness; - [DATE] at 4:00 PM resident had been getting up on own and staff reminded the resident to call for help to prevent a fall; - [DATE] at 4:30 PM food intake remained poor; - [DATE] at 9:25 PM found the resident on the floor beside the bed, resident stated hit head on the floor and possibly the bottom of the bedside table, noted a hematoma (swelling of blood) on top of the head and a spot of blood on the eye brow, educated to use the call light for assistance; - [DATE] at 10:48 PM periods of confusion, ambulated from room to another resident room, abrasion on forehead from incident last evening; - [DATE] at 3:00 PM periods of confusion, intake remained poor, abrasion to right forehead and fading bruising to right cheek; - [DATE] at 11:09 AM very impulsive, attempted several times to self transfer; - [DATE] at 10:17 PM attempted to get out of bed; - [DATE] at 4:00 PM periods of confusion, gait slow and unsteady, intake remained poor, fading area of bruising to the left cheek and abrasion to the right forehead; - [DATE] at 5:26 PM required two staff assistance with ambulation with walker, gait slow and unsteady; - [DATE] at 3:02 PM not feeling well, slow to respond, left eye darker than the right, gait very unsteady, Tylenol given for complaints of a headache, did not eat any breakfast or dinner; - [DATE] at 11:42 PM resident had trouble swallowing supper and medications; - [DATE] at 11:48 AM on an antibiotic for a urinary tract infection, appetite poor; - [DATE] at 8:30 PM found resident sitting on the floor in front of the lift chair was in a high lift position, stated slid out of the chair, no injuries noted, instructed to use the call light for assistance to get up; - [DATE] at 12:05 PM found resident on the floor in front of the lift recliner with the recliner in high standing position, confused to place, stated slipped out of the chair, denied hitting head; - [DATE] at 6:00 PM found the resident on the floor in front of the recliner with head on the bottom bar of the tray table, call light not activated; - [DATE] at 1:43 PM the sit to stand mechanical lift was used for transfers as resident was shaking and not able to help with the transfer; - [DATE] at 1:08 PM the resident required one to two assistance with transfers and at time, the lift had to be used as the resident was unable to stand, had a tendency to lean back, appetite poor; - [DATE] at 12:20 AM the resident had a fair appetite at supper; - [DATE] at 12:00 PM refused lunch and refused to go to room, confused, had problems following commands and leaned backwards with ambulation; - [DATE] at 4:30 PM the resident was confused to place, doesn't remember to use the call light, gait very unsteady, required two assist with activities of daily living, transfers and ambulation; [DATE] at 11:30 AM physical therapy and occupational therapy reported that the resident had a severe posterior lean and change in exterior tone and had to use the mechanical sit to stand lift for transfers at the end of the session, the resident's cognition continued to be poor and if not getting worse, unable to be reoriented, call placed to family member who approved the resident to be seen at the local hospital to evaluate the resident's change in condition; - [DATE] at 1:00 PM the clinic called to report that the resident would be transported to the hospital for a brain bleed. Interview with the DON on [DATE] at 11:00 AM confirmed that effective fall interventions were not in place to prevent recurrent falls and injuries.",2020-09-01
2168,LEGACY GARDEN REHABILITATION & LIVING CENTER,285186,200 VALLEY VIEW DRIVE,PENDER,NE,68047,2017-07-20,431,E,1,1,E93U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC ,[DATE].12E4 Based on observation and interviews, the facility failed to ensure expired medication were not available for use for 3 residents (Residents 7, 9 and 22) and expired medical supplies were not available for use. The facility staff identified the resident census at 31. An observation conducted on [DATE] at 2:44 PM of the facility medication cart revealed the following: -A card of Docusate Sodium (a stool softener) 100mg soft gels for Resident 22 that expired in (MONTH) (YEAR). -A card of Tylenol 325mg tablets for Resident 9 that expired in (MONTH) (YEAR). -A bottle of Debrox ear drops for Resident 7 that expired in (MONTH) (YEAR). An interview conducted on [DATE] at 2:44 PM with Licensed Practical Nurse (LPN) B confirmed the medications were expired and were still available for resident use. An observation conducted on [DATE] at 2:50 PM of the facility medication room revealed an Irrigation Tray (syringe and receptacle used to irrigate catheters) that expired in (MONTH) 2013. An interview conducted on [DATE] at 2:50 PM with LPN B confirmed the Irrigation Tray was expired and still available for resident use.",2020-09-01
4417,"SCHUYLER CARE AND REHABILITATION CENTER, LLC",285110,2023 COLFAX STREET,SCHUYLER,NE,68661,2018-07-18,636,D,1,1,NXEG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC .09B1(3) Based on observation, interview, and record review; the facility failed to ensure comprehensive assessments were accurate and complete for 1 of 13 sampled residents (Resident 79). The facility census was 28. Findings are [NAME] An observation of and interview with Resident 79, on 07/12/18 at 10:57 AM, revealed the Resident's upper extremities (arms) had multiple bruises in different stages of healing. The Resident reported the bruising was the result of taking too much aspirin, prior to being admitted to the Skilled Nursing Facility. -Further interview with Resident 79 revealed the resident thought there was blister to right heel. The resident reported that when staff looked at the area, they poked and popped it. -Further observation in Resident 79's room revealed an oxygen concentrator and tubing positioned next to the Resident's bed. Resident 79 reported needing to use the oxygen sometimes after walking related to shortness of breath. The resident went on to report the oxygen therapy was new and had been started since admission to the facility. A review of physician's orders [REDACTED]. Medications ordered upon admission (6/22/18), for the resident, included: [MEDICATION NAME] (an antidepressant), [MEDICATION NAME] (a diuretic-assists to remove excess fluid from the body) given every other day, [MEDICATION NAME] (used to treat symptoms of overactive bladder, such as frequent or urgent urination, incontinence (urine leakage), and increased night-time urination), [MEDICATION NAME] (an antidepressant), and [MEDICATION NAME] (used to reduce anxiety). Aspirin 81 mg was ordered to be given one time daily for hypertension (increased blood pressure). [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] given to assist with clearing secretions from lungs) nebulizer and [MEDICATION NAME] 15mg tablets were ordered one time daily related family history of asthma and other chronic lower respiratory diseases. [MEDICATION NAME] (a non-narcotic cough medicine) was ordered to be given every 8 hours, as needed for cough. [MEDICATION NAME] 325 mg with 2 tabs to be given daily at bedtime for headache; mild pain. The [MEDICATION NAME] had been increased to be given daily on 7/14/18 for increased [MEDICAL CONDITION] (swelling), to be held (not given) if Systolic (the top number) Blood Pressure was less than 100. A review of Progress Notes for Resident 79, dated 6/22/18-7/6/18 (the look back period for MDS-mandatory comprehensive assessment used for care planning) revealed no documentation of Nursing Assessments completed prior to sending, the reason for the need, or Assessment upon return; related to ER visits for evaluation occurring twice. -A note dated 6/26/18 indicated Resident 79's Primary Care Provider (PCP) was notified related to resident complaints of being short of breath. An order was received for therapeutic O2 (oxygen). The note did not include information related to further assessment completed prior to notification of the PCP. Further review of the note revealed that: O2 was applied via nasal cannula, the resident's oxygen saturation (amount of oxygen in blood) was assessed on room air at 93%; the resident reported O2 was helping. -A noted dated 6/30/18 indicated the resident was transferred to ER and a chest x ray was completed, PCP was faxed results and is aware. Further review of the notes revealed no documented evidence of Nursing Assessments completed following Resident 79's return from ER. -A note dated 7/4/18 revealed Resident 79 had redness/irritation under breast, slightly open small area under right breast, no pain. The resident requires 1 assist with taking showers and uses bra. The note did not include documentation of further recommendation, notification of PCP, or interventions implemented to prevent further skin breakdown. -Notes dated 7/6/18 indicated Resident 79 requested to be sent to ER related to increased leg pain, rated at an '8' on scale of 1-10. The resident returned to the facility following an x-ray on left leg and blood work. There was no acute injury seen on the x-rays. The resident was to follow up with PCP next week at the clinic. A note indicated the facility assessed Resident 79's vital signs upon return from the ER. The note did not include documentation related to the resident's pain level or interventions implemented to prevent reoccurrence of the concern. A review of Weekly Skin Check documents, dated 7/11/18, revealed Resident 79 had 'redness under breast' and an intact fluid filled blister to inner aspect of right lower leg. Neither of the documents contained information related to treatment or preventative measures put into place. A review of MDS (Minimum Data Set) for admission, dated 7/3/18, revealed Resident 79 was admitted from the Community (an Assisted Living Facility) and had not had a Medicare qualifying hospital stay. The BIMS (Brief Interview for Mental Status) score was documented as 11 (indicating a slight cognitive decline) and Mood Score documented '0' (indicating no symptoms of depression). Section [NAME] of the assessment indicated the resident exhibited no adverse behaviors. Section G indicated no functional limitation in range of motion and a walker was used for mobility. Section H indicated Resident 79 was frequently incontinent of bladder and a trial toileting program had not been attempted. Section I did not include arthritis, [MEDICAL CONDITION], anxiety disorder, or asthma/[MEDICAL CONDITIONS]/[MEDICAL CONDITION]; as active diagnosis. Section J indicated Resident 79 reported no pain or shortness of breath for last 5 days. Section M indicated no pressure ulcers or other skin issues. An interview on 07/18/18 at 3:46 PM with the MDS Coordinator and the Director of Nursing revealed Resident 79 had previously resided in the Facility and had been discharged to an Assisted Living Facility approximately one year ago. The comprehensive assessment for the resident's current admission on 6/22/18 had a look back period of 14 days and was due to be completed on 7/6/18. The MDS Registered Nurse (RN) reported the facility's electronic medical record system will automatically pull information from previous stays into the assessment and care planning documents. The RN went on to report that a new comprehensive assessment had not been completed for Resident 79's admitted d 6/22/18. B. Record review on 07/18/18 at 03:45 PM revealed that the Minimum Data Set (assessment for comprehensive plan of care), for Resident 79, reflected that the resident was not short of breath and that there was no oxygen in use. The Nurses note dated 6/26/18 for Resident 79 revealed that the resident was short of breath on 6/26/18 and oxygen had been ordered. Interview on 07/18/18 at 03:46 PM with MDS Coordinator and the Administrator confirmed that Resident 79 was on oxygen since (MONTH) 26, (YEAR), and that the MDS was not correct.",2020-07-01
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
1272,DUNKLAU GARDENS,285119,450 EAST 23RD STREET,FREMONT,NE,68025,2017-10-30,332,D,1,1,PYXG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.01D Based on observation and record review, the facility failed to ensure medication error rate below 5%, related to not following manufacturers recommendations for administration. This failure had the potential to effect two of seventeen residents sampled (Residents 22 and 111). The facility census was 78. Findings are: Observations during medication administration task revealed 2 medication errors out of 24 opportunities, for a 8.3% medication administration error rate. [NAME] On 10/3/17 at 12:07 PM, Medication Aide (MA)-A was observed to administer a tablet of [MEDICATION NAME] (an anti-ulcer medication) to Resident #22. A review of the MAR (Medication Administration Record) dated 10/25/17, for Resident #22, revealed an undated medication order for [MEDICATION NAME] to be given on an empty stomach, 1 hour before or 2-3 hours after eating. A review of [NAME]'s Drug Guide for Nurses fifteenth edition revealed the [MEDICATION NAME] was to be given at least one hour before a meal. The medication was given approximately 30 minutes prior to the lunch time meal. B. On 10/3/17 at 11:40 AM, MA-B administered a tablet of Potassium Chloride (a Potassium supplement) to Resident 111. The resident swallowed the medication with water supplied by the M[NAME] A review of the MAR indicated [REDACTED]. There was no indications that Resident 111 received a food item with the ordered medication. A review of [NAME]'s Drug Guide for Nurses fifteenth edition revealed Potassium should be administered with or after meals to decrease GI (stomach) irritation. The medication was given approximately 50 minutes prior to the lunch time meal. Review of the facility's listed meal times revealed lunch was served at 12:30 PM.",2020-09-01
1812,ST. JOSEPH'S REHABILITATION & CARE CENTER,285160,401 NORTH 18TH STREET,NORFOLK,NE,68701,2018-09-12,609,D,1,1,7Q7511,"**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 falls resulting in significant injuries for Residents 30 and 52 and an incident of potential neglect for Resident 22 were reported and the investigations were sent to the State Agency within the required time frames. The sample size was 3 and the census was 57. Findings are: [NAME] Review of the facility Freedom from Abuse, Neglect, Misappropriation of Property and Exploitation Policy (dated 08/18) revealed the following: -the facility will report any alleged abuse/neglect, injuries of unknown origin, exploitation or misappropriation of resident property in accordance with state regulations; -the facility will conduct an investigation of such allegations in accordance with state law; and -the facility will report all investigation findings to the state in accordance with state regulations. B. Review of Resident 30's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 7/17/18 revealed the resident had [DIAGNOSES REDACTED]. The facility staff assessed the following regarding Resident 30: -was cognitively intact; -required extensive staff assistance with bed mobility, transfers, dressing and toilet use; and -was frequently incontinent of bowel and bladder. Review of the resident's current Care Plan with revision date 4/26/18 revealed the resident had chronic pain due to [MEDICAL CONDITION] and lumbar degeneration. The resident was at risk for falls related to need for staff assistance with transfers, incontinence and limited range of motion. The care plan further revealed the resident had a history of [REDACTED]. The resident was again sent to the emergency room following a fall on 9/2/18 with [DIAGNOSES REDACTED]. Review of a Nursing Progress Note dated 9/2/18 revealed at 2:20 AM the staff had found Resident 30 on the floor next to the resident's bed. The resident was moaning and repeated help me, help me. Resident 30 reported having severe pain to elbow, knee and hip with a large laceration to the resident's left knee. The Progress Note further identified the resident was sent to the emergency room for further evaluation. Review of a Nursing Progress Note dated 9/2/18 revealed the resident had returned to the facility at 7:30 AM. The resident was drowsy and lethargic, would open eyes and then fall back asleep right away. The resident's left knee was reddened with a large skin tear that had been covered with a dressing and a golf ball sized bruise was observed to the resident's right knee. The note further identified the following impression from the hospital transfer sheet: contusions to the right hip, right shoulder and bilateral knees and a closed head injury. Review of the facility investigations of potential abuse/neglect from 9/1/18 to 9/12/18 revealed no report had been filed to the State Agency regarding a fall with significant injuries for Resident 30 on 9/2/18. During interview on 9/11/18 at 2:07 PM, the Director of Nursing (DON) verified Resident 30's fall on 9/2/18 with significant injuries had not been reported and no investigation had been sent to the State Agency. C. Review of Resident 52's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was cognitively intact and had fallen in the last month prior to admission to the facility. Review of Nursing Progress Notes dated 8/12/18 at 6:00 PM revealed Resident 52 was found lying on the floor in the resident's room. The resident sustained [REDACTED]. The resident was subsequently transferred to the emergency room for evaluation. Review of Nursing Progress Notes dated 8/12/18 at 8:03 PM revealed Resident 52 returned to the facility with sutures (stitches) to the right eyebrow area. Review of facility investigations of potential abuse/neglect for 8/2018 revealed no evidence the State Agency was notified of Resident 52's injury which required medical treatment. Interview with the DON on 9/11/18 at 10:40 AM confirmed Resident 52's fall with injury was not reported to the State Agency. D. Review of Resident 22's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was cognitively intact and had sustained a fracture related to a fall in the 6 months prior to admission. Review of Nursing Progress Notes dated 8/31/18 at 7:50 AM revealed Resident 22 fell forward out of the wheelchair while being wheeled by a staff member. Documentation indicated the resident's foot or toe caught on the carpet which resulted in the resident falling forward from the wheelchair and landing on the right knee. The resident was subsequently transferred to the emergency room for evaluation. Review of a Post Fall Investigation dated 8/31/18 revealed wheelchair foot pedals were not in use when the staff member was wheeling the resident. The resident's foot was caught under the wheelchair while being wheeled over a bump in the carpet at the entry area of the corridor and the resident fell forward out of the wheelchair. Documentation indicated staff were to be educated on the use of foot pedals with wheelchair use. Review of facility investigations of potential abuse/neglect for 8/2018 and 9/2018 revealed no evidence the State Agency was notified of a potential incident of resident neglect by a staff member which resulted in Resident 22 falling out of a wheelchair. Interview with the DON on 9/12/18 at 7:20 AM confirmed Resident 52's fall with injury was not reported to the State Agency.",2020-09-01
5734,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2016-09-20,226,E,1,0,TD4511,"**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 1) ensure that staff members reported allegations of staff to resident abuse so that interventions were in place to protect residents from further abuse for unidentified residents residing in the SCU (Special Care Unit). The facility census was 114 with 18 residents in the SCU. And 2) ensure Adult and child protective services checks for 2 employees (Employees W and X). Findings are: A. Review of the facility policy Preventing, Investigating, and Reporting Alleged Sexual Assault and Abuse Violation, reviewed 2/12/16, revealed the following including: Policy Statement: It is the responsibility of all employees to immediately report and reasonable suspicion of a crime, alleged violation of abuse, neglect, injuries of unknown source and misappropriation of resident property. It is also the policy of this center to take appropriate steps to ensure that all alleged violations of federal or state laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property (alleged violation) are reporting immediately to the Executive Director or Director of Nursing of the Living Center. B. Interview with the Administrator on 9/20/16 at 8:30 AM revealed that APS (Adult Protective Services) called on 9/19/16 and reported an allegation of staff to resident abuse on the SCU which came from an anonymous staff member. The Administrator suspended the staff member, who was identified on the APS report, pending an investigation and interviewed 12 employees who work in the SCU and one family member of a resident who resided in the SCU. The Administrator stated that the investigation showed no evidence that staff to resident abuse occurred so the staff member returned to work on 9/20/16. Further interview revealed that no staff member reported any allegation of staff to resident abuse to the Administrator per facility policies and procedures to ensure that the residents were protected from abuse. Interview with Staff - T , SCU staff member who requested to remain anonymous, on 9/20/16 at 7:20 AM, revealed that (gender) did not feel comfortable to report any mistreatment or concerns related to resident cares because of fear of getting into trouble or losing job. Interview with Staff - S, SCU staff member who requested to remain anonymous, on 9/20/16 at 7:30 AM, revealed that (gender) observed rough treatment of [REDACTED]. Interview with the DON on 9/20/16 at 8:15 AM revealed that no one reported any allegations of staff to resident abuse on the SCU. Further interview confirmed that the staff were to follow the facility abuse prohibition policies and procedures, which included to report any suspected staff to resident abuse immediately, to ensure that the residents were protected from abuse. Licensure Reference Number: 175 NAC 12-006.04A3 C. Review of the facility policy, Preventing, Investigating, and Reporting Alleged Sexual Assault and Abuse violation dated 2/12/16 revealed, Staff screening to include reference checks .Criminal background check pursuant to center policy or state law. Interview on 9/20/16 at 4:00 PM with the Administrator and the Director of Nursing verified that there were no results in the records of Employee W and X for Adult/Child Protective Services. Further interview verified the Adult/Child Protective Services were one of the facility requirements and should have been checked. D. Review of the Personnel Files for 2 sampled employees (Employee W and X) did not contain written confirmation of Adult and Child Protective Services checked.",2019-09-01
3537,NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER,285271,2100 CIRCLE DRIVE,SCOTTSBLUFF,NE,69361,2018-03-20,609,D,1,0,6E5M11,"**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 ensure that a an allegation of neglect was reported and the investigation was sent to the State Agency within the required time frames for one closed record sampled resident (Resident 1). The facility census was 56 with five current sampled residents and one sampled closed record reviewed. Findings are: Review of the facility Verification of Investigation, dated 2/20/18, revealed that the DON (Director of Nursing) was notified on 2/16/18 by a hospital employee that five [MEDICATION NAME] (opiod [MEDICATION NAME]) patches were found on Resident 1 when examined in the emergency room . Interview with the DON on 3/20/18 at 10:45 AM confirmed that APS (Adult Protective Services) was not notified of the incident on 2/16/18. Interview with RN (Registered Nurse) - C, on 3/20/18 at 11:00 AM, revealed worked as the Interim Director of Nursing for a couple of weeks. RN - C stated was notified of the incident on 2/20/18 and APS was notified of the incident and that an investigation would be conducted. Further interview confirmed that the completed investigation was not sent to the State Agency until 3/1/18. Interview with the Administrator on 3/20/18 at 1:30 PM confirmed that the State Agencies were not notified as required and that the investigation was not sent in within the required time frames. The Administrator confirmed that APS was to be notified right away and the investigation report was to be sent in within five working days.",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
6396,NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER,285271,2100 CIRCLE DRIVE,SCOTTSBLUFF,NE,69361,2016-03-31,225,D,1,0,F1ZC11,"**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 submit investigations to the State Agency within five working days as required for two sampled residents (Resident 1 and 2) who had falls with injuries. The facility census was 44. Findings are: A. Review of the Resident Face Sheet revealed that Resident 1 was readmitted to the facility on [DATE] post hospitalization for treatment after a fall. Review of the Resident Progress Notes, dated 3/17/16, revealed that the resident fell in the room and complained of pain in hips and neck. Resident 1 was transferred to the hospital for evaluation. Further review revealed that the resident returned to the facility on [DATE] for a neck fracture. B. Review of the Resident Face Sheet revealed that Resident 2 was readmitted to the facility on [DATE] post hospitalization for treatment after a fall. Review of the Care Plan, dated 3/22/16, revealed that the resident fell on [DATE] and fractured the left wrist. C. Interview on 3/31/16 at 9:30 AM with the Director of Nursing confirmed that the investigation reports for these two residents were not sent to the State Agency within the required time frames.",2019-03-01
4444,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2018-03-08,610,E,1,1,VCTE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.02(8) Based on interviews and record reviews, the facility failed to investigate allegations of abuse related to resident to resident incidents for 4 residents (Residents 310, 27, 306, 4) of 9 residents sampled. The facility staff identified the census at 54. The findings are: [NAME] A review of Resident 4's Admission Record dated 3-8-18 revealed Resident 4 was admitted to the facility 12-31-16 with [DIAGNOSES REDACTED]. A review of Resident 306's Admission Record dated 3-8-18 revealed Resident 306 was admitted to the facility 7-8-16 with [DIAGNOSES REDACTED]. A review of Resident 4's Progress Note dated 10-22-17 revealed that the nursing staff had heard Resident 306 yell get out of my room twice followed by 2 loud slapping sounds and Resident 4 yelling out in pain. As the nursing staff responded to the room they heard something fall. When the nursing staff got to the room they found Resident 4 sitting on the floor. When the nurse attempted to evaluate Resident 4, the resident raised their arms to block the nurse from touching them. Once the nursing staff was able to evaluate Resident 4, they found reddened areas on the resident's back and rib area. A review of Resident 306's Progress Note dated 10-22-17 revealed that the nursing staff had heard Resident 306 yell get out of my room twice followed by 2 loud slapping sounds and Resident 4 yelling out in pain. As the nursing staff responded to the room they heard something fall. When the nursing staff got to the room they found Resident 4 sitting on the floor. When the nurse attempted to evaluate Resident 4, the resident raised their arms to block the nurse from touching them. Once the nursing staff was able to evaluate Resident 4, they found reddened areas on the resident's back and rib area. Resident 306 gave several stories to staff regarding what happened. A review of Resident 306's Progress Note dated 10-22-17 revealed that Resident 306 continued to talk about the altercation with Resident 4 the night before and gave multiple different stories as to what happened. A review of Resident 4's untitled incident report form dated 10-21-17 revealed that Resident 4 was confused and was wandering at the time of the altercation with Resident 306. The report revealed that the facility administrator, physician, and the Resident 4's responsible party were notified of the altercation and Resident 4 was placed on 15 minute checks. A review of the facility's investigations for (YEAR) revealed no investigation of the altercation between Residents 4 and 306. An interview conducted on 3-7-18 at 3:39 PM with the Administrator confirmed an investigation was not completed for the altercation between Residents 4 and 306. An interview conducted on 3-8-18 at 10:40 AM with the Administrator revealed that the resident to resident incident report was still an active report in the medical record due to the report not being signed off by the Administrator. The Administrator reported they did not address the active reports from prior to their date of hire. A review of the facility's Abuse Prevention Program and Reporting Policy dated 4/17 revealed the following: Each employee is responsible to immediately report any suspected abuse. Each incident will be investigated and required reporting completed. and Resident to Resident Abuse Procedure: 7. Report results of investigation to the proper authorities as required by State law. B. Record review of an Incident that occurred on 9/21/2017 between Resident 311 and Resident 27. Resident 311 backed up Resident 311's wheelchair and ran over Resident 27's foot. Resident 27 then struck out at Resident 311. Review of the report reveals that the previous Administrator did call the incident to the state agency but did not complete and investigation. Interview on 03/08/18 at 10:59 AM with the current Administrator revealed no knowledge of the incident and did not complete and investigation on the incident. Interview on 03/08/18 at 11:00 AM with the Administrator revealed the incident reporting system does track incidents and incidents that are not signed off remain in the system as open. Administrator revealed she had not reviewed and closed the incident report for this incident. No investigation was completed within the regulatory timeframe.",2020-06-01
4126,PIONEER MEMORIAL COMMUNITY HOSPITAL,2.8e+176,"P O BOX 578, 206 NW 4TH STREET",MULLEN,NE,69152,2017-12-13,609,D,1,0,R3WN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.02(8) Based on interviews and record reviews, the facility failed to report an incident of a fall that resulted in a fracture to the State Agency within the prescribed timeframe for 1 sampled resident (Resident 108). The facility failed to complete the written investigation and send to the State Agency within five working days. Sample size was 3 current residents. The Facility census was 21 residents. Findings are: Record review of Resident 108's medical file revealed the resident fell on [DATE]. Resident was seen in the cardiologist office on 1/22/17 when the fracture was discovered by x-ray. Review of Resident 108's progress note dated 11/22/2017 revealed LPN-B (Licensed Practical Nurse) became aware of the pelvic fracture. Review of the facility investigation revealed the incident was called to the State Agency on 11/25/2017. The written investigation did not reach the State Agency within five working days. Interview with the DON (Director of Nurses) on 12/13/2017 at 10:50 AM confirmed the discovered pelvic fracture was not called to the State agency within the required timeframe. The written investigation did not reach the State Agency within five working days. Review of the facility policy entitled Individual Injury, unknown date of origin, revealed the Completed Internal Investigation needed reported to the State Agency within 5 working days from the allegation.",2020-09-01
3713,AVERA CREIGHTON CARE CENTRE,285284,"P O BOX 289, 1603 MAIN STREET",CREIGHTON,NE,68729,2019-07-16,609,D,1,1,PBQK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.02(8) Based on observation, interview, and record review; the facility failed to ensure incidents of potential abuse were reported to the State Agency for Residents 25 and 35. The sample size was 2 and the facility census was 46. Findings are: The facility Patient/Resident Abuse and Neglect policy with a review date of 4/2019 defined Abuse as any willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Mental Abuse was defined as verbal or non-verbal conduct which caused or had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. When there was reason to suspect or believe abuse had occurred or an allegation had been made or conditions were present that could result in abuse investigating and reporting was to take place as follows: - Immediately take steps to protect the individual, - notify the administration, - begin an internal investigation, - immediately report to Adult Protective Services (APS), - conduct an internal investigation, and - submit a completed investigation to the State Agency within 5 working days. Review of Resident 25's and Resident 35's Progress Notes revealed: - On 2/23/19, at 9:15 PM there was a verbal exchange between Resident 25 and Resident 35 (who were roommates). Resident 35 was unhappy that Resident 25 had the television and lights on. The verbal exchange elevated to discord between the residents. The nurse intervened and requested Resident 25 either use head phone or turn the television off. Resident 25 became teary eyed and the back and forth argumentative conversation went on for 3 minutes. A note was left for the Director of Nursing (DON) and the Social Services Director (SSD), suggesting a new arrangement may be necessary to diffuse the current roommate situation. - On 2/24/19, Resident 25 voiced concerns about Resident 35 not allowing the resident to watch television after 9:00 PM. Resident 25 generally would stay up until midnight and had the television on late into the night. - On 3/6/19, Resident 25 had a few words with Resident 35 before bed and was upset following the conversation. The nurse allowed Resident 25 to vent, but remained neutral. - On 3/9/19, at 9:05 PM the nurse overheard Resident 25 and Resident 35 shouting YOU [***] to each other several times. Resident 25 was noted to have a shaky voice and was teary eyed and Resident 35 was visibly upset. Staff asserted firmly that this behavior was not respectful. Resident 25 was encouraged to get ready for bed. Resident 35 was visibly upset that even after taking a sleeping aid it was hard to fall asleep. Resident 35 asked to speak with the nurse and voiced concerns about being a heart patient and did not want any stress. - On 3/10/19, Resident 25 made the strangling gesture towards Resident 35 and stated I'm done. Resident 35 saw this and ignored it. - On 3/13/19, the SSD spoke with Residents 25 and 35 in their room about the verbal agreement. Both residents agreed on shutting the main lights off at 9:15 PM as well as turning the television volume off/wearing head phones. Resident 35 argued that the television needed to be shut off because the light from the television was bothersome. The agreement was signed by Resident 25 but Resident 35 refused to sign the agreement and left the room. - On 3/25/19, the nurse reported to Resident 25's Power of Attorney (POA) that the police and APS were called on Friday (3/22/19) as Resident 25 had threatened to strangle/drown Resident 35. Review of the facility Investigation Reports submitted to the State Agency between 2/1/19 and 3/31/19 revealed no evidence to indicate any incidents between Resident's 25 and 35 (other than the incident on 3/17/19) had been reported to the State Agency. Review of the facility Investigation Report submitted to the State Agency on 3/22/19 revealed an incident occurred on 3/17/19 at 9:15 PM between Resident 25 and Resident 35. Resident 25 threatened to strangle and drown Resident 35 and used foul language towards Resident 35. Resident 25 had a history of [REDACTED]. The outcome of the investigation confirmed Resident 25 had shown aggression toward and threatened Resident 35 multiple times since they became roommates on 2/22/19. Further review revealed APS was not contacted until 3/22/19 (5 days later). No new interventions were identified and the resident's remained roommates. During an interview on 7/15/19 at 12:09 PM Licensed Practical Nurse (LPN)-F revealed Resident 25 could become aggressive. LPN-F revealed neither Resident 25 nor Resident 35 wanted to move to a different room as both residents were very stubborn personalities. During an interview with the SSD on 7/16/19 from 10:45 AM to 11:05 AM, the SSD verified working as the social worker for the facility since the beginning of 2019. The SSD confirmed both Resident 25 and Resident 35 had behaviors. The residents did not get along but neither one would agree to move to another room. A contract was established between the roommates to try and improve the situation, which the SSD felt helped to a certain extent. The SSD confirmed no other interventions were attempted when the current interventions were unsuccessful. Further interview revealed potentially reportable incidents were reviewed by the SSD and DON together to decide if they were state reportable. The SSD stated in deciding if the facility would report an incident to the State Agency the facility would first speak with the residents and see how they wanted to proceed and handle the situation, or if the residents felt they could work it out.",2020-09-01
2094,HILLCREST CARE CENTER,285178,702 CEDAR AVENUE,LAUREL,NE,68745,2019-03-25,609,D,1,1,F0S011,"**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 1) to complete and submit to the State agency an investigation of an injury of unknown origin for Resident 1, and 2) to report a fall sustained by Resident 15 that resulted in significant injury. The sample size was 8 and the total facility census was 27. Findings are: [NAME] Review of the Abuse/Neglect and Exploitation Policy (undated) included the following: -Indicators of physical abuse may include, but are not limited to, the following: 1) Burns, especially unusual location, pattern or shape; 2) Bruises and/or hematomas (a large collection of blood caused by an injury or trauma); 3) Bilateral on arms (may indicate shaking, grabbing or rough handling); 4) Bilateral on soft parts of the body; 5) Inner arm or thigh; 6) On top of head; 7) Clustered on the trunk from possible repeated striking; and 8) Presence of old and new at the same time as from repeated injuries; -If events are identified as being suspicious of abuse, neglect, exploitation, or if it is an injury of unknown source, it is the responsibility of the employee to report their findings as soon as possible to the charge nurse on duty, who must immediately assess the situation and the resident's condition, and notify the Director of Nurses (DON) and Administrator/designee of the reported incident; -Abuse incidents will be reported within 2 hours if the event causes serious bodily injury, or no later than 24 hours if the event did not result in serious bodily injury, to the State agencies; -The DON and the Administrator/designee will further review and investigate the reported incident and take necessary action; and -Within 5 working days, the results of the facility investigation will be reported to the State agency. B. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/8/19 revealed the resident's cognition was severely impaired with [DIAGNOSES REDACTED]. The assessment indicated the resident required extensive staff assistance with transfers, bed mobility, dressing, toileting and personal hygiene. Review of a Nursing Progress Note dated 8/5/18 at 5:00 PM revealed Resident 1 had been resting on the resident's bed. Staff entered the resident's room and a large amount of blood was observed to the resident's bed linens and to the padded legging on the resident's left lower leg. The legging was removed and revealed a laceration which measured 5.6 centimeter (cm) x (by) 0.3 cm to the resident's left outer leg. The resident was transferred to the emergency room and received 10 sutures to the wound. review of the resident's medical record revealed [REDACTED]. During an interview on 3/25/19 at 7:37 AM the Administrator verified the following: -Adult Protective Services (APS) was notified of the resident's injury on 8/5/18 at 7:08 PM; -APS was notified the resident had a laceration and the resident had been sent to the hospital. The resident did have a history of skin tears however, this was different and the resident was unable to identify what had happened due to the resident's cognition; and -there was no evidence an investigation was conducted to determine how the resident had received the injury of unknown origin which resulted in an emergency room visit and the need for 10 sutures to close the wound. C. Review of the MDS dated [DATE] included the following related to Resident 15: -admitted [DATE] with [DIAGNOSES REDACTED]. -cognitively intact; -required extensive 1 person physical assistance with transfers, ambulation and toilet use; -was unsteady and only able to stabilize with human assistance during transfers and walking; and -had a history of [REDACTED]. Review of Nursing Progress Notes revealed the following related to Resident 15: -3/3/19 at 1:45 PM - Resident had an unwitnessed fall in room this morning. Stated was wanting to go to the bathroom, got out of bed, started walking with walker and lost balance, tried to break the fall and ended up on the floor. Stated put left arm out to try to stop the fall and has some pain in the shoulder/neck area. The physician and responsible party were notified of the fall; -3/4/19 at 7:00 AM - Continued left shoulder pain. Stated the ice helped; -3/4/19 at 1:30 PM - Out of the facility per facility van for appointment with physician for shoulder; -3/4/19 at 2:45 PM - Returned from clinic with orders to have Physical Therapy (PT) evaluate and treat for left shoulder pain; -3/5/19 at 2:42 PM (Recorded as Late Entry) - 03/4/19 at 11:00 PM Resident complained of pain to left shoulder, has ice pack for pain, states it helps but I think it might be broken. Informed will possibly have an appointment to see the physician in the morning. Resident has bruising to left chest area, slight swelling noted, ice pack appears to help with pain and swelling. Resident appears comfortable no complaints of pain at this time, will continue to monitor throughout the night; and -3/5/19 at 10:45 AM - Noted to have a significant hematoma from the fall. Stated it remains sore. Review of the Physician's Progress Notes dated 3/7/19 revealed Resident 15's arm and shoulder were x-rayed and looked to be intact. Documentation further revealed had been hoping to get (the resident) over to Assisted Living, but that is looking like that backed (the resident) up a little bit and now we are going to continue to work with therapy. During interview on 3/20/19 at 1:30 PM, Resident 15 verified going to the physician's clinic the day following the fall. X-rays were completed and no problems were identified. The resident described the bruising as purple from the neck to the waist on the entire front side of the body, and verified using ice packs to the area frequently to begin with, but this had decreased with time. Resident 15 further verified the fall occurred a few days prior to a planned discharge to the Assisted Living. There was no evidence Resident 15's fall was reported to the State agency despite seeking treatment outside the facility, the occurrence of a significant injury, and the impact made on the resident's functional capabilities and pending plans for discharge.",2020-09-01
2677,HERITAGE OF EMERSON,285222,607 NEBRASKA STREET,EMERSON,NE,68733,2017-08-31,226,D,1,1,AEM711,"**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 notify the state agency within required timeframes for reportable incidents for 2 of 5 incidents reviewed (Residents 13 and 36). The facility census was 30. [NAME] Record review of the facility policy, titled, Abuse and Neglect Prevention Standard, revised 3/17 revealed All allegations of abuse and or neglect would be investigated and reported in accordance with the state and federal laws. Allegations resulting in serious bodily injury will be reported immediately, but no later than 2 hours. B. Record review of Resident 13's Face Sheet, dated 4/19/16, revealed that Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of a facility self-report revealed that, on 4/6/17 at 09:00 AM, Resident 13 fell , while trying to go up a ramp into the facility van, and hit head on a retaining wall. Resident 13 received a laceration measuring 6 cm to the top of her head, on the right side. Resident 13 was taken to an emergency facility where the laceration required staples and additional testing. Record review revealed that the facility did perform an investigation. The facility self-reported on 4/12/17, 6 days after the incident. The facility fax to Department of Health and Human Services (DHHS) and Adult Protective Services (APS) was dated 4/12/17 at 4:22 PM, 6 days after the incident. Interview with the Facility Administrator (Adm) and the Director of Nursing (DON) on 8/30/17 at 11:15 AM confirmed that the facility had not reported the incident as per policy and regulation. The DON confirmed that the facility consultant had provided education regarding the need to report this type of injury to state agencies within 2 hours and perform an investigation with results submitted within 5 working days. B. Record review of Resident 36's Face sheet, dated 8/30/17, revealed that Resident 36 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 36's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 6/16/17 revealed that Resident 36's Brief Interview of Mental Status (BIMS) was 15 (Cognitively Intact). Record review of facility Complaint/Grievance Report dated 6/26/17 revealed that Resident 36 had told the Occupational Therapist (OT) that on 6/22/17 that a Nursing Assistant (NA) had dropped them in the morning, picked them up from the floor, and didn't want to report it to the charge nurse or management staff. The investigation revealed that 2 NA's did drop Resident 36 and lifted Resident 36 off the floor and neglected to report the incident. Record review of Resident 36's Progress Notes and the Complaint/Grievance Report revealed the facility failed to provide documentation that an assessment of Resident 36 was performed on 6/26/17, when it was determined that Resident 36 had been dropped on 6/22/17. Interview with the Facility Adm and the DON on 8/30/17 at 11:15 AM confirmed that the facility had not investigated the incident as neglect. The Adm and DON confirmed that the NA had not reported that a resident was dropped during transfer, which met the facility policy for neglect. The Adm. and DON confirmed that an assessment of the resident for injury was not performed upon the facility being notified that the resident fell to the floor. The Adm. And DON confirmed that an investigation was not performed, only that a complaint/grievance report was completed, and that an investigation and State Agency notification should have been performed.",2020-09-01
6416,LYONS LIVING CENTER,285301,1035 DIAMOND STREET,LYONS,NE,68038,2018-05-10,609,D,1,0,2CLY11,"**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, investigate and then to submit the investigation to the State Agency, an allegation of abuse related to a resident to resident incident for 2 (Residents 1 and 2) of 14 residents sampled. The facility census was 23. Findings are: A. Review of the facility policy Resident to Resident Altercations dated 12/13/16 revealed all altercations, including those that may represent resident to resident abuse, shall be investigated and reported to the Director of Nursing (DON) and the Administrator. If 2 residents are involved in an altercation the staff will: -separate the residents and institute measures to calm the situation; -identify and implement interventions to prevent reoccurrence; -update the resident's care plans; and -report the incident and corrective measures to the appropriate state agencies. B. Review of the facility policy titled Protecting Residents during Abuse Investigations dated 12/13/16 revealed if the alleged abuse involves another resident, the accused resident's representative, and Attending Physician were to be informed of the incident. In addition, the accused resident was to be restricted from visiting other resident's rooms. Within 5 working days of the alleged incident, the facility was to give the state agency a written report of the findings of the investigation and a summary of corrective action taken to prevent the incident from recurring. C. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/7/18 revealed the resident was admitted on [DATE] from an acute care hospital. The resident's cognition was severely impaired and the resident had a behavior of wandering identified. The wandering placed the resident at significant risk for getting into a potentially dangerous area but did not significantly intrude on the privacy of other residents. The MDS identified a [DIAGNOSES REDACTED]. Review of Resident 1's Nursing Progress Note dated 3/19/18 at 3:00 AM revealed the resident was found in the resident's room with Resident 2. Resident 2 was seated on the side of the bed and Resident 1 was on knees, in an inappropriate position between Resident 2's legs. Both residents were covered with a blanket. The residents were immediately separated and the DON was notified of the incident. D. Review of Resident 2's MDS dated [DATE] revealed the resident had short and long term memory loss with severely impaired decision making skills. The resident had behaviors which included hallucinations and wandering. But wandering did not place the resident at significant risk of getting to a potentially dangerous place and wandering did not intrude on the privacy of others. The resident had [DIAGNOSES REDACTED]. Review of Resident 2's Nursing Progress Notes dated 3/19/18 at 3:45 AM revealed the resident was found in the room of another resident on the Memory Support Unit at 3:00 AM. Resident 2 was seated on the edge of the bed and Resident 1 was on knees in an inappropriate position between Resident 2's legs. A blanket covered both of the residents. The blanket was removed and the residents were separated. E. Review of the facility investigations of potential abuse/neglect from 12/1/17 to 5/7/18 revealed no report had been filed to the State Agency regarding an allegation of resident to resident abuse related to Residents 1 and 2. During interview on 5/10/18 at 10:00 AM the Provisional Administrator confirmed there was no investigation of the incident which occurred on 3/19/18 between Residents 1 and 2 and the incident had not been reported to the state agency.",2019-03-01
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
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
6393,SKYVIEW CARE AND REHAB AT BRIDGEPORT,285224,505 O STREET,BRIDGEPORT,NE,69336,2016-03-31,225,D,1,0,ZNCE11,"**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 ensure that an allegation of neglect/abuse was reported to the State Agency within the 5 working day requirements. Facility census was 27. Findings are: Review of the facility files for reporting to the State Agency revealed that there was no written documentation of a report sent in for a resident with a fall and significant injury (Resident 3) on 1/1/16. Interview with the DON (Director of Nursing) on 3/31/15 at 11:00 AM revealed that Resident 3 did have a fall with an injury and was sent to the hospital for for evaluation and to suture a laceration to the head. Further interview revealed that the resident also had a CAT scan of the head to rule out a head injury that was negative. Interview on 3/31/16 at 1:00 PM with the Administrator and the DON verified that Resident 3 did have a fall at the facility with a significant injury that required a hospital visit to the emergency room for sutures for a [MEDICAL CONDITION]. Further interview verified that a report was not sent to the State Agency. Continued interview verified that a report should have been sent to the State Agency as Resident 3 did have a major injury requiring medical intervention at the hospital.",2019-03-01
1380,LIFE CARE CENTER OF ELKHORN,285134,20275 HOPPER STREET,ELKHORN,NE,68022,2018-02-27,725,F,1,1,YXZR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.04C Based on observation, interview and record review; the facility failed to ensure sufficient staffing was in place to meet the care needs of the residents in the facility. This had the potential to affect all the residents in the facility. The facility staff identified the census at 101. The findings are: [NAME] An interview conducted on 2-20-18 at 12:08 PM with Resident 33 revealed that the resident was having difficulty with urinary incontinence that the resident reported was due to waiting to long for staff to assist with toileting. The resident reported that it was embarrassing for someone their age to urinate on themselves and that the resident had cried a few times when they had been incontinent. An observation conducted on 2-22-18 at 7:09 AM revealed Resident 33's call light was on. Resident 33 was lying in bed shaking and crying. There was a puddle of liquid under the resident's bed with a drip pattern under the edge of the bed. An interview conducted on 2-22-18 at 7:09 AM with Resident 33 revealed that the resident had been turning on their call light since 3:10 AM requesting to go to the bathroom, but the nursing staff had been shutting it off because the resident must have fallen asleep. The resident reported their current call light had been on since 6:45 AM. The resident reported that a nurse had brought in their early morning medications and that the resident refused to take one of the medications because they needed to go to the bathroom. The nurse left and did not return. The resident reported that they had not spilled anything on the floor and they thought the puddle may have been urine from wetting the bed 3 times since 3:10 AM. An observation conducted on 2-22-18 at 7:18 AM revealed Registered Nurse (RN) B cleaned up the puddle with towels. The liquid had a yellow tint when soaked up into the white towel and had a urine odor. RN B confirmed these observations. An observation conducted on 2-22-18 at 7:23 AM revealed Nursing Assistant (NA) C entered Resident 33's room and asked the resident what they needed help with. Resident 33 was in bed crying and shaking and told NA C that they needed to go to the bathroom and get cleaned up because they had urinated in their bed 3 times. NA C told Resident 33 that they had not had time to pay attention to the call lights on the 200 Hall, where Resident 33 lived, because the NA was also assigned to the 100 Hall. NA C explained to Resident 33 that they normally work on the 100 Hall and that the residents on the 100 Hall were more at risk for falls because they were more independent. NA C explained they did not want any of their 100 Hall residents to fall while the NA was helping the residents on the 200 Hall so they were not going to help any of the 200 Hall residents until the 100 Hall residents were all up for the day. B. Observations conducted on 2-21-18 revealed the following call light times and staffing: -2-21-18 at 7:56 AM. The call light was on for room [ROOM NUMBER]. The medication cart was parked outside room [ROOM NUMBER] and there was a nurse working at the medication cart. At 8:05 AM the nursing assistant approached the medication cart outside room [ROOM NUMBER] and had a conversation with the nurse. At 8:06 AM the nurse and nursing assistant ended their conversation and both went to other resident rooms. At 8:16 AM the nurse at the medication cart parked outside room [ROOM NUMBER], stepped into the entryway of room [ROOM NUMBER] and stepped back out. At 8:37 AM the nursing assistant entered room [ROOM NUMBER] and shut off the call light. -2-21-18 at 7:56 AM A resident on the 400 Hall was repeatedly yelling for help and yelling that they needed to go to the bathroom. The resident continued yelling. At 8:06 AM the nurse on the 400 Hall went to the resident's room and told the resident they needed to be patient that the nursing assistant was busy. At 8:13 AM the resident began yelling repeatedly again that they needed to go to the bathroom. At 8:22 AM the nursing assistant went into the resident's room to assist them. -2-21-18 at 8:17 AM the call light went on for room [ROOM NUMBER]. The call light was answered at 8:38 AM. -2-21-18 at 5:52 PM Resident 40 turned on their call light, but when the light was answered at 6:06 PM the resident could not remember what they wanted and was encouraged to turn their light on again if they remembered. -2-21-18 at 6:21 PM room [ROOM NUMBER] turned on their call light. There were 2 nursing assistants on the 300 Hall assisting other residents. At 6:33 PM the 2 nursing assistants from the 300 Hall came to the nurses station gathered their belongings and left the facility. At 6:42 PM the Director of Nursing answered the call light in room [ROOM NUMBER]. -2-21-18 at 6:30 PM room [ROOM NUMBER] turned on their bathroom call light. At 6:41 PM Nursing Assistant M answered the call light and the resident asked for assistance with toileting. -2-21-18 at 6:21 PM revealed a Nursing Assistant came to the facility to check the schedule. The Director of Nursing (DON) asked the Nursing Assistant to stay and work until the residents were all in bed. The Nursing Assistant agreed. The DON told the Nursing Assistant to choose between 2 halls because neither hall had a Nursing Assistant. C. A review of the facility's Facility Assessment Tool dated 10/2017 revealed that the facility's average census was 95. The facility's staffing plan for an average census of 95 was to utilize 16 licensed nurses providing direct care and 28 nursing assistants per day. An interview conducted on 2-20-18 at 9:12 AM with the facility's Administrator revealed the resident census was 101. A review of the facility's Daily Assignment Sheet for 2-20-18 revealed there were 13 licensed nursing positions filled and 17 nursing assistant positions filled. A review of the facility's Daily Assignment Sheet for 2-21-18 revealed there were 13 licensed nursing positions filled and 17 nursing assistant positions filled. A review of the facility's Daily Assignment Sheet for 2-22-18 revealed there were 12 licensed nursing positions filled and 19 nursing assistant positions filled. A review of the facility's Daily Assignment Sheet for 2-23-18 revealed there were 13 licensed nursing positions filled and 22 nursing assistant positions filled. A review of the facility's Daily Assignment Sheet for 2-24-18 revealed there were 13 licensed nursing positions filled and 21 nursing assistant positions filled. A review of the facility's Daily Assignment Sheet for 2-25-18 revealed there were 12 licensed nursing positions filled and 23 nursing assistant positions filled. An interview conducted on 2-22-18 at 4:51 PM with the facility's Administrator confirmed the Facility Assessment Tool was the current staffing expectation for a census of 95. D. Cross Reference to F677 Failure to provide bathing. Cross Reference to F686 Failure to monitor pressure related skin conditions. E. Confidential group Interview completed with residents representing the resident council. Residents were all in agreement that the following occur on a regular basis: - Call lights are consistently on for an hour to hour and a half. - Care staff come in and shut off call light and say they will be back and don't come back. - Residents were heard yelling help for an hour and a half straight and no one came. - Someone could fall or have a [MEDICAL CONDITION] and no one could respond. - Don't get any fresh drinking water throughout the day. - All residents are getting to bed late at night. - Resident call lights are not getting answered and residents are not getting what they need. - One night there was 1 aide for 3 halls. - They all agree there are not enough staff. Review of Resident council minutes dated 11/9/2017, 12/15/2017, and 1/18/2018 revealed residents voiced concerns regarding call lights. Review of Resident council minutes for 11/9/2017, 12/15/2017, and 1/18/2018 revealed residents voiced concerns regarding baths. Observations, record reviews and interviews completed during the survey confirmed care issues related to staffing. Interview on 2/27/2018 at 8:40 AM with the DON revealed that the care area concerns voiced by the Resident Council Committee were due to the lack of staff.",2020-09-01
2926,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2018-07-02,725,E,1,0,EO8U11,"**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 ensure staffing levels to provide treatment for [REDACTED]. The facility census was 54. [NAME] Review of Resident 105's Care plan dated 5/15/2018 revealed Resident 105 has abdominal/inguinal fold with moisture associated skin damage with an intervention to administer treatments as ordered. Review of Resident 105's progress note revealed on 6/29/2018 LPN I did not complete the treatments to Resident 105's skin conditions stating it was because LPN I was the only nurse for all residents in the facility. Review of the facility nursing schedule as worked for 6/29/2018 revealed LPN I was the only nurse on the schedule for the evening shift. Interview on 7/2/2018 at 3:30 PM with the Director of Nursing revealed the nurse should have completed the treatments or called for direction and additional staff. B. Interview on 6/27/2018 at 6:30 PM with Resident 104 revealed the staff do not answer call lights very quickly. Review of the Device Activity Report for call lights revealed call lights over 15 minutes on the following dates: - 6/24/2018 3:36 pm 44 minutes - 6/24/2018 9:46 pm 26 minutes - 6/25/2018 8:14 PM 21 minutes - 6/25/2018 9:54 PM 30 minutes - 6/28/2018 9:10 AM 29 minutes C. On 6-27-2018 at 1:55 PM an interview was conducted with Resident 103. During the interview Resident 103 reported call light can take a long time to answer. Resident 103 reported up to and some times over an hour. Record review of a Device Activity Report for the residents call light for Resident 103 revealed the following information: -6-22-2018 at 5:12 AM revealed the call light was on for 27 minutes. -6-22-2018 at 10:03 AM revealed the call light was on for 38 minutes. -6-22-2018 at 8:58 PM revealed the call light was on for 50 minutes. -6-23-2018 at 2:47 AM revealed the call light was on for 42 minutes. -6-24-2018 at 9:16 AM revealed the call light was on for 44 minutes. -6-25-2018 at 9:05 PM revealed the call light was on for 31 minutes. -6-25-2018 at 11:54 PM revealed the call light was on for 33 minutes. -6-26-2018 at 6:03 AM revealed the call light was on for 52 minutes. -6-27-2018 at 6:24 AM revealed the call light was on for 34 minutes. -6-28-2018 at 12:58 AM revealed the call light was on for 31 minutes. -6-28-2018 at 9:50 AM revealed the call light was on for 35 minutes. -6-30-2018 at 6:12 AM revealed the call light was on for 38 minutes. -6-30-2018 at 7:29 AM revealed the call light was on for 178 minutes. -6-30-2018 at 5:06 AM revealed the call light was on for 112 minutes. D. On 7-02-2018 at 11:20 AM an interview was conducted with Resident 107. During the interview Resident 107 reported it takes a long time for staff to answer the call light. -7-30-2018 at 12:5 Record review of a Device Activity Report for the residents call light for Resident 107 revealed the following information: -6-22-2018 at 5:55 PM revealed the call light was on for 83 minutes. -6-24-2018 at 4:58 AM revealed the call light was on for 24 minutes. -6-24-2018 at 7:09 AM revealed the call light was on for 146 minutes. -6-24-2018 at 2:47 PM revealed the call light was on for 17 minutes. -6-24-2018 at 7:02 PM revealed the call light was on for 27 minutes. -6-24-2018 at 9:05 PM revealed the call light was on for 31 minutes. -6-24-2018 at 10:29 PM revealed the call light was on for 20 minutes. -6-25-2018 at 1:09 PM revealed the call light was on for 44 minutes. -6-25-2018 at 5:30 PM revealed the call light was on for 84 minutes. -6-26-2018 at 12:35 AM revealed the call light was on for 66 minutes. -6-26-2018 at 12:43 PM revealed the call light was on for 67 minutes. -6-27-2018 at 7:18 AM revealed the call light was on for 44 minutes. -6-27-2018 at 8:07 AM revealed the call light was on for 58 minutes. -6-27-2018 at 12:06 PM revealed the call light was on for 32 minutes. -6-29-2018 at 7:52 AM revealed the call light was on for 71 minutes. -6-29-2018 at 10:20 AM revealed the call light was on for 69 minutes. -6-30-2018 at 6:17 PM revealed the call light was on for 159 minutes. -7-02-2018 at 7:53 AM revealed the call light was on for 30 minutes. On 7-02-2018 at 3:10 PM an interview was conducted with the Director of Nursing (DON). During the interview when asked what the expectation was for staff to answer call light, the DON stated not more than 15 minutes. Cross reference the following: F561. The facility failed to provide bathing for 3 sampled residents. F684. The facility failed to monitor bruising and skin tears for 3 sampled residents. F688. The facility failed to provide a Nursing restorative Program for 1 sampled resident.",2020-09-01
4352,"BCP MILFORD, LLC",285132,1100 WEST 1ST STREET,MILFORD,NE,68405,2019-07-18,725,E,1,1,UNXJ11,"**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 sufficient staffing levels for the provision of A) wound care, weekly measurements for pressure wounds for 3 residents (Resident 26, 40 and 15), B) restorative for 1 resident (Resident 1) and C) ensuring call lights were promptly answered this had the potential to affect 8 Residents (Resident 20, 33, 40, 17, 43, 11, 4, and 15). The facility census was 48. Findings are: [NAME] An interview on 07/17/19 at 01:49 PM with the DON (Director of Nurses) revealed; that the wound documentation (weekly pressure measurements) had not been done consistently related to pulling the Wound Nurse to the floor to be the charge nurse. Record review of MAR (Medication Administration Record) revealed dated 6/26/19; take a picture of the right heel non blanchable area weekly for measurements if IPOD (electronic device for documentation)not functioning measure wound and document in the progress note measurements, wound bed description and surrounding tissue conditions weekly every Tuesday. (MONTH) 2 2019 had no documentation. B. An interview on 07/15/19 at 01:09 PM with Resident 1, Resident 1 reported that they ride the Nustep daily and see restorative for communication. Resident 1 reported that at times had not been receiving exercises related to the restorative person being pulled to the floor for staffing problems. Record review of restorative documentation for (MONTH) revealed; Nustep bilateral upper and lower extremities daily for 15 minutes, that the following days Resident 1 did not receive restorative on : (MONTH) 1,2, 9,10, 15, 16, 19,22, 29 and 30. An interview on 07/17/19 02:03 PM with the DON confirmed that Resident 1 had not been receiving restorative services daily related to not having a restorative person on those dates the second restorative person had retired in (MONTH) the facility had not replaced the restorative at that time, a new restorative person was training. C. Interview with Resident 15 on 7/17/19 at 14:00 PM revealed there are times when it takes well over 30 minutes to get a nurses aide or nurse to come to room and help resident with toileting and other cares. Review of device that monitors call light times 7/17/19 revealed that the call lights times were in excess of 30 minutes for Resident 15. An interview on 7/17/19 at 2:09 PM with the DON (Director of Nurses) revealed that call light times are longer today, as several employees called in sick, DON confirmed call lights were excessive and she would expect staff to be more timely answering the call light and helping the residents. Record review revealed wound cares for Resident 15 were not documented on wound care sheets, and the measurements with an order to be done weekly, were not done or documented. 07/18/19 at 03:02 PM Interview with DON (Director of Nursing) revealed that the staff at times have to do other things beside care of wounds. DON revealed that the wound nurse many times had been moved to do medications or be in charge, rather than completing wound care. DON confirmed that the nursing staff had not been measuring Stage lV pressure ulcer since admission, and also confirmed Physician had ordered wound measurements weekly D. Review of Resident 40's Admission Record dated 07/16/19 revealed [DIAGNOSES REDACTED]. Review of Resident 40's (MONTH) MAR (Medication Administration Record) revealed the wound to the resident's left ankle was to be cleansed, have skin prep applied, and covered with gauze. The wounds to the resident's left leg and right shin were to be cleansed, have [MEDICATION NAME] ointment (an antibiotic ointment) applied, and covered with a dry dressing daily and as needed. These treatments were marked incomplete on (MONTH) 24. Review of Resident 40's Progress Notes dated 6/24/19 revealed the dressing change to Resident 40's left leg, right skin, and left ankle were not completed that shift due to workflow. The [MEDICATION NAME] ointment was also not applied that shift due to workflow. Interview on 07/18/19 at 2:04 PM with the DON (Director of Nursing) revealed the nurse responsible for wound care was being moved to pass medications. E. Review of the Device Activity Report dated 7/17/19 revealed Resident 20's call light was on for 26 min and 45 seconds, then reset at 12:27 PM. Resident 20's call light was on again for 6 minutes and 51 seconds, then reset at 12:59 PM. Review of the Device Activity Report dated 7/17/19 revealed Resident 33's call light was on for 47 min 55 seconds, then reset at 12:25 PM. Review of the Device Activity Report dated 7/17/19 revealed Resident 40's call light was on for 61 min 23 seconds, then reset at 11:43 AM. Review of the Device Activity Report dated 7/17/19 revealed Resident 17's call light was on for 53 min 4 seconds, then reset at 11:35 AM. Review of the Device Activity Report dated 7/17/19 revealed Resident 43's call light was on for 53 min 2 seconds, then reset at 11:34 AM. Review of the Device Activity Report dated 7/17/19 revealed Resident 11's call light was on for 43 min 51 seconds, then reset at 11:00 AM. Review of the Device Activity Report dated 7/17/19 revealed Resident 4's call light was on for 36 min 59 seconds, then reset at 11:36 AM. Review of the Device Activity Report dated 7/17/19 revealed Resident 15's call light was on for 31 min 38 seconds, then reset at 10:57 AM.",2020-08-01
2817,NYE POINTE HEALTH & REHAB CTR,285235,2700 LAVERNA STREET,FREMONT,NE,68025,2019-05-16,726,F,1,0,K8AU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.04C Based on record review and interview, the facility failed to ensure that 4 (Registered Nurse (RN) A, B, C and D) of 5 nursing personnel were knowledgeable and had demonstrated competency and skills set to perform medication administration and care of residents with IV (Intravenous) therapy with a Midline catheter (a soft catheter that is placed in veins for short term (2-4) week IV therapy), the facility also failed to ensure that nursing personnel were knowledgeable and had demonstrated competency and skills set to perform nursing duties. This had the potential to affect all residents. The facility census was 40. Findings are: Record review of competency dated for (YEAR) revealed that 2 of the facility RN's (Registered Nurses) had been competencies for IV use A record review for RN A's Competency dated 03/2017 revealed RN A had a competency for PICC (Peripherally Inserted Central Catheter, a long thin soft catheter that is inserted into a vein in your arm or neck to be used for blood draws, medications, or nutrition) line, Dressing Change for PICC line and Blood Draw PICC Line. The facility was unable to provide competency documentation of medication administration through IV, PICC line or Midline catheters. A record review for RN B's Competency dated 03/2017 revealed RN B had a competency for PICC line, Dressing Change for PICC line and Blood Draw PICC Line. The facility was unable to provide competency documentation of medication administration through IV, PICC line or Midline catheters. Record review of orientation check list for RN C that was dated 9/13/17 revealed; that RN C did not have competencies for IV, PICC line or Midline catheter care. The facility was unable to provide documentation of any competencies completed. Record review of orientation check list for RN D that was dated 12/09/14 revealed; that RN D did not have competencies for IV, PICC line or Midline catheter care. The facility was unable to provide competency documentation dated 03/2017 any competencies completed. Interview on 5/16/19 at 9:58 AM with the DON (Director of Nurses) confirmed that the nursing staff had not received competency training since (MONTH) (YEAR). The DON reported that the facility is unable to provide documentation of competencies since (YEAR). The DON reported that the facility RN's were the staff to manage IV access. The DON confirmed that the facility had hired an educator for the building 3 months ago and they had been planning to educate the staff and provide competencies. During the interview the DON revealed that there were 5 RN's for the building and they work the day shifts and IV's are scheduled according to when the RN's were on duty. Interview on 5/16/19 at 10:06AM with RN D confirmed that the facility had competencies in the year (YEAR). RN D reported that the medications were administered per the physician orders [REDACTED]. RN A confirmed that they had done cares for Resident 5 and had administered medications through the Midline.",2020-09-01
4974,"PREMIER ESTATES OF CRETE, LLC",285170,830 EAST 1ST STREET,CRETE,NE,68333,2018-09-18,725,E,1,0,MJX011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.04C Based on record review and interviews; the facility failed to ensure sufficient numbers of nursing staff were available to provide care and services in assisting residents with activities of daily living that included bathing per the resident's preference as listed on the resident care plan. Confidential staff interviews voiced concern that there was not enough staff available to meet the resident's needs. This affected Residents 3, 4 and 5 that were on sample. The sample size was 5 and the facility census was 52. Findings are: Record Review of the Daily Bath Aide Sheet dated 9/17/18 Monday revealed 16 Resident names on the list. There were two names that had been completed and the other 14 were left blank. [NAME] Interview on 9/18/18 at 10:50AM with Resident 4 revealed that Resident 4 was scheduled to have a bath on Monday, 9/17/18 and was not provided. Resident 4 stated that according to Resident 4's preference Resident 4 is to have two baths per week. Resident 4 was still in bed at the time of the interview and had the call light on since 10:00AM requesting assistance with getting out of bed for the day. B. Interview on 9/18/18 at 11:25AM with the Corporate Nurse revealed that the interpretation of having empty boxes on the form meant the baths had not been provided. C. Confidential staff Interview on 9/18/18 at 12:15PM revealed that there is not always enough staff scheduled so bathing is one area that is omitted when the staffing is short. D. Interview on 9/18/18 at 2:15PM with Resident 5 revealed that Resident 5 was scheduled to have a bath on Monday, 9/17/18 and it was not provided. Resident 5 stated that Resident 5 is supposed to have two baths per week and usually only one is provided. E. Interview on 9/18/18 at 2:45PM with Resident 3 revealed that Resident 3 was scheduled to have a bath on Monday, 9/17/18 and it was not provided. Resident 3 said that Resident 3 is to have two baths per week and that usually only receives one. Resident 3 also stated having to wait up to four hours at times to be assisted to use the bedpan. F. Record review of Fall incident for Resident 2 dated 8/29/18 at 10:50PM revealed the staff left the resident on the side of the bed to notify the nurse on duty that Resident 2 sitting on the side of the bed. When staff entered Resident 2's room, the resident was found sitting upright on buttocks beside the bed. The resident obtained a [MEDICAL CONDITION] in the fall.",2020-03-01
5275,BLUE VALLEY LUTHERAN CARE HOME,2.8e+280,"P O BOX 166, 755 SOUTH 3RD STREET",HEBRON,NE,68370,2017-08-16,281,E,1,0,GVE611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.04C1(3) Based on record review and interview, the facility failed to ensure Neurological Checks (assessments of the conscious state of a person) were completed following resident falls, according to current Standard of Practice for Nursing Services. This failure had the potential to effect 3 of 3 sampled residents (Residents 1, 4, and 2) who had documented falls. The facility had a total of 38 residents at the time of survey. Findings are: [NAME] A review of Resident 1's Progress Notes, dated 8/13/17, revealed the resident was noted to have 2 unwitnessed falls. At 9:20 AM, the resident was found on the floor with no apparent injuries noted. At 11:45 AM, Resident 2 was found on the floor in the commons area of the facility. A hematoma (a collection of blood outside of a blood vessel) was noted to the right side of the resident's forehead and Neurological Checks were initiated. A review of NEUROLOGICAL CHECK LIST(s) dated 8/13/17 for Resident 1 revealed Neurological Checks (Neuro Checks) were completed at 11:45 AM, 12:45 PM, and 1:45 PM. Comments included on all of the documented Neuro Checks included: a [DIAGNOSES REDACTED]. A review of an undated facility form titled POST FALL NEURO ASSESSMENT GUIDELINE revealed that, when a resident had an un-witnessed fall or was observed on the floor, a Neuro Assessment would be completed. The frequency of the Neuro Assessments would then be as follows: every 1 hour x 2, every 2 hours x 2, ever 4 hours x 2, and then every shift x 2. If the resident did not have an obvious head injury or wound, was not observed hitting their head, and vital signs and Neuro Assessment were WNL, after initial the time frequency would be as follows: initial, every 1 hour x 2 then every shift for at least 24 hours. An interview on 8/16/17 at 3:46 PM with Registered Nurse (RN)-A revealed the nurse recalled that previous training had indicated Neuro Checks, following a suspected head injury, were to be conducted every 15 min x 4 for first hour and, if no concerns, then every hour x 4 hours. The RN reviewed the Facility's guideline and reported it did not outline the procedure the way RN-A was taught. B. An interview on 8/16/17 at 2:00 PM, with the DON (Director of Nursing) revealed Resident 4 had a history of [REDACTED]. The DON confirmed that the Neuro Checks were completed per facility guideline and did not follow current Standard of Practice, which included the completion of the checks every 15 min for the 1st hour following initiation for a resident with an oblivious head injury. A review of Neurological Check List(s) dated 3/10/17 revealed Resident 4 was found on the floor at approximately 4:20 PM, with a moderate amount of blood to the resident's forehead and nose area, and purplish bruising was noted to bridge of the resident's nose. Neuro checks were documented as completed at 4:20 PM, 5:20 PM, 6:20 PM, 7:20 PM, 8:20 PM, 10:20 PM, and on 3/11/17 at 00:20 AM. C. A review of the Facility's Risk Management Log of incidents dated 5/22-8/16/17, revealed Resident 2 had an unwitnessed fall on 5/22/17 at 1:20 AM. A review of Resident 2's medical record revealed no documented evidence of Neurological Checks being completed following an unwitnessed fall on 5/22/17. Progress notes dated 5/22/17 indicated the resident was found on the floor next to the bed, no injuries were identified, and all assessments were WNL for the resident. An interview on 8/16/17 at 2:00 PM with the DON, revealed Resident 2 was found on the floor (so an unwitnessed fall) on 5/22/17. No injuries and no evidence of hitting head were noted. The DON revealed that Neurological Checks were not initiated for Resident 2 following the unwitnessed fall. The DON confirmed that per facility guideline, Neuro Checks were to be completed for any unwitnessed resident fall. D. A review of POST FALL 72 HOUR MONITORING REPORT, posted on healthinsight.org (an approved CMS (Centers for Medicare/Medicaid) website) revealed Neurological Checks were to be completed at the following intervals: every 15 minutes x 4, every 30 min x 2, every 1 x 2, then every shift for 72 hours. Neurological checks are required for falls that are unwitnessed, or in which the head is struck.",2020-02-01
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
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
4051,HILLCREST FIRETHORN,285300,8601 FIRETHORN LANE,LINCOLN,NE,68520,2018-06-14,580,D,1,0,U8OO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.04C3a Based on record review and interview, the facility failed to notify the Medical Practitioner of noted change in a resident's functioning ability from a baseline (stable) assessment. This failure prevented the Practitioner from being aware of the residents (Guests) signs and symptoms, in order to assess the resident and make adjustments to treatments and medications, to prevent further decline in a timely manner for one resident, Resident 41. The facility census was 30. Findings are A review of Progress Notes for Resident 41 dated 6/5/18 at 9:18 AM-6/7/18 at 12:13 AM (midnight), revealed the resident exhibited signs of a change in the Resident's cognitive and functioning ability. On 6/5/18, documentation indicated Resident 41 was alert and oriented, required 2 person assistance to pivot transfer. A note dated 6/6/18 at 10:41 PM indicated Resident 41 was alert with slight confusion and further assessment revealed an increased blood glucose level and complaints of too many loose stools. Documentation indicated PRN (as needed) orders were followed and the Resident's symptoms had subsided within 2 hours (the Resident was again able to voice wants and needs), will continue to monitor. On 6/7/18 at 12:13 AM, Resident 41 was noted to require a heavy 2 person assist when normally required 1 person to assist. The note documented that Resident 41 exhibited slowed late speech and answered questions late, now the Resident had slurred speech and smelled of alcohol on breath. Staff will continue to monitor. Further review of the Progress Notes revealed no indication the Resident's Medical Practitioners were notified related to the noted changes in Resident 41's condition. A review a CARE PLAN REPORT, date range: 5/1/18-6/13/18, revealed Resident 41 was considered complex medical related to [DIAGNOSES REDACTED]. The report did not include documentation related to the disease process, co-morbidities, or signs and symptoms to monitor in order to identify changes in the Resident's condition requiring notification of Medical Practitioners. An interview on 6/14/18 at 2:30 PM, with the Facility's Medical Director (MD) indicated Resident 41's needs were being met. The MD reported the resident: went out for [MEDICAL TREATMENT] three times a week; required paracentesis (a procedure intended to remove fluid that has collected in the abdomen (peritoneal fluid), also known as ascites), related to ascites every 3 weeks. Resident 41's [DIAGNOSES REDACTED]. A review of Medication Administration Records, dated for (MONTH) and (MONTH) (YEAR), revealed Resident 41 routinely received insulin (medication used to treat [MEDICAL CONDITION]-increased blood glucose (sugar) and the Resident's blood glucose levels were ordered to be assessed with [REDACTED]. A review of information on the American Diabetes Association website revealed [MEDICAL CONDITION] can be a serious problem. If not treated, a condition called ketoacidosis (diabetic coma) could occur. Ketoacidosis is life-threatening and needs immediate treatment. Symptoms include: breath that smells fruity. Review of the Facility's policy and procedure for NOTIFICATION OF CHANGE, dated 5/23/17 revealed the facility will as soon as possible notify the resident's physician as applicable. -Paragraph B indicated significant change in the guest's physical, mental or psychosocial status in either life threatening conditions- such as [MEDICAL CONDITION], stroke or clinical complications such as development of [MEDICAL CONDITION], recurrent urinary tract infections, x-ray results, or on-set of depression. -Paragraph C indicated a need to alter treatment significantly ( i.e., a need to discontinue an existing form of treatment due to an adverse consequence such as an adverse drug reaction or to start a new form of treatment that has not been tried before on this resident.) This can include lab results that may result in alteration of treatment of [REDACTED]. Continued interview on 6/14/18 at 2:45 PM, with the Medical Director confirmed that the Practitioner had not been informed of Resident 41's condition changed, 6/5-6/7/18. The Medical director confirmed the Resident's current [DIAGNOSES REDACTED].",2020-09-01
1376,LIFE CARE CENTER OF ELKHORN,285134,20275 HOPPER STREET,ELKHORN,NE,68022,2018-02-27,656,D,1,1,YXZR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.04C3a(5) Based on record review and interview, the facility failed to develop a Comprehensive Care Plan (CCP) related to behaviors for 1 (Resident 40) of 56 sampled residents. The facility census was 101. Findings are: Record review of Resident 40's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 11/22/17 identified that Resident 40 was cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 7, had delusions present, exhibited verbal behaviors 4-6 days per week and exhibited other behavioral symptoms not directed toward others 1-3 days per week. Record review of resident 40's Progress Notes on the following dates revealed: - 10/10/17 at 2:04 PM: hit another resident and appeared agitated. - 10/12/17 at 11:56 AM: Resident at times still aggressive expression with arm or hand swing. - 10/17/17 at 11:35 PM: Resident with angry outbursts, trying to hit staff, shaking wheelchair arm. - 12/06/17 at 11:14 AM: Spends the day going about the facility in the wheelchair. Mood varies from expressing anger when spoken to or comes close, is combative at times and will strike out. Record review of Resident 40's Behavior Monitoring Intervention Flow sheets for Jan (YEAR) revealed the following target behaviors: - Easily angered - Combative - Rummaging - Throws food and fluids - Sad, flat affect - Fidgety Record review of Physician order [REDACTED]. Record review of a Physician /Nurse Communication form dated 2/15/18 indicated that Resident 40 was becoming more agitated and appeared angry most of the time. The Physician responded with new orders for an increase in pain medication and to reposition every 2 hours while in the wheelchair. Record review of Resident 40's CCP dated 12/5/17 revealed that no target behaviors or specific interventions to address resident behaviors were identified or included in the CCP. Interview on 02/22/18 at 10:12 AM with the Director of Nursing confirmed that Resident 40's CCP did not include any information related to Resident 40's behaviors or specific interventions to address behaviors.",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
2305,"CALLAWAY GOOD LIFE CENTER, INC",285200,"PO BOX 250, 600 WEST KIMBALL STREET",CALLAWAY,NE,68825,2019-01-03,580,D,1,0,4X3Y11,"**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 notify the practitioner of changes in condition including 1) elevated blood pressures, increased confusion and difficulty with ambulation for one closed record sampled resident (Resident 1) and 2) declines in cognition and activities of daily living, increased weakness and leaning backwards with ambulation for one current sampled resident (Resident 2). The facility census was 30 with five current sampled residents and one closed resident record reviewed. Findings are: [NAME] Review of Resident 1's Departmental Notes revealed the following including: - 12/10/18 The resident was admitted from the hospital post surgical revision of a shunt (device to divert flow from one main route to another) secondary to a brain bleed and Acute [MEDICAL CONDITION] (brain disorder). The resident had incisions at the right back of head and four incisions at the abdomen; - 12/14/18 morning blood pressure was 191/107 and after medications were given the blood pressure was 182/74; - 12/16/18 at 8:30 AM - Nursing Assistant reported that the resident had increased difficulty ambulating to the bathroom, leaned backwards and to the right and leaned forward when standing in the bathroom; 2:00 PM attempted to contact spouse regarding the resident's difficulty ambulating and increased confusion. Further review revealed no documentation that the practitioner was notified of the elevated blood pressure readings or the resident's increased difficulty with ambulation and increased confusion. Interview with the DON (Director of Nursing) on 1/3/19 at 10:45 AM confirmed there was no documentation that the resident's practitioner was notified of the resident's changes in condition when indicated to determine the need for medical interventions. B. Review of Resident 2's Admission MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 12/7/18, revealed that the resident's BIMS (Brief Interview for Mental Status) score was 13 out of a total of 15. Further review revealed that the resident required extensive assistance with one person physical assist with bed mobility, transfers, ambulation and toileting. Review of the MDS, dated [DATE], revealed that the resident's BIMS score declined to 6 out of a total 15. Further review revealed that the resident required extensive assistance with two persons physical assist with bed mobility, transfers, ambulation and toileting and had new symptoms of delusions (false belief brought about without appropriate external stimulation and inconsistent with the individual's own knowledge and experience. Interview with the DON on 1/3/19 at 11:00 AM confirmed there was no documentation that the resident's practitioner was notified of the resident's changes in condition to determine the need for medical interventions.",2020-09-01
1756,"PREMIER ESTATES OF PAWNEE, LLC",285157,"P O BOX 513, 438 12TH STREET",PAWNEE CITY,NE,68420,2019-09-16,802,D,1,1,R7CE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.04D Based on Observations, record review and interviews the facility failed to ensure dietary staff served the meal within a timeframe to meet resident preferences. This had the potential to affect all residents who consume food from the facility kitchen. The facility census was 33. Findings are: [NAME] Observation on 09/10/19 at 11:58 AM of residents seated in Dining Room. All residents seated at tables were observed to have a glass of fluids. Observation on 09/10/19 at 12:23 PM of 2 nurse aides starting to serve a bowl of fruit to each of the residents in the dining room. Observation on 09/10/19 at 12:30 PM of Resident 12 signaling for me to come to her table. Resident 12 proceeded to tell me she was getting really hungary and shortly after that was served a bowl of fruit. Observation on 09/10/19 at 12:46 PM that all residents seated in the Dining Room had been served a plate of food. Observation on 09/10/19 at 12:55 PM that all room trays had been delivered to residents in their room. Observation on 09/10/19 at 01:00 PM of Resident 19 outside of the porch, crying and yelling and states is mad because had to wait too long for noon meal and now doesn't want it. B. Observation on 09/10/19 from 11:25 - 12:30PM in the kitchen revealed 2 dietary staff Cook F and Dietary aide G preparing noon meal to be served at 12:00 PM daily. The Dietary Manager and the Dietician arrived at 12:15PM to assist with getting the meal out. The kitchen staff was unorganized and were preparing hamburger buns with lettuce, tomato, and onion on prep station then handing plates over prep table to hot line then to the dietary aid placing plate on the tray. The first tray left the kitchen at 12:23P.M Observation on 09/12/19 revealed cook f called in sick and the social services director and administrator were cooking and serving breakfast and lunch. Observation on 09/16/19 and 09/17/19 revealed Social Services Director and Administrator were cooking breakfast and lunch due to not Cook F being ill and no calling no showing. C. Record review of The Facility assessment dated [DATE] revealed the following part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident population Every Day and During Emergencies. Require 1 Dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services, 5 food and nutrition services staff. D. Record Review of Dietary Staff Schedule dated 09/2019 revealed the following the day and evening dietary staff consisted of 1 cook and 1 dietary aide. From 09/01/19-09/17/19 the day cook was scheduled to cook all 3 meals for 5 days. E. Interview on 09/17/19 at 10:00 AM with Administrator revealed the Social Services Director and Administrator had been working in kitchen last 6 days to cover the day cook position. The contracted Dietary manager started on 09/16/19.",2020-09-01
1372,LIFE CARE CENTER OF ELKHORN,285134,20275 HOPPER STREET,ELKHORN,NE,68022,2018-02-27,550,G,1,1,YXZR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05 (21) Based on observations, interviews, and record reviews; the facility failed to provide toileting assistance to Resident 33 in a manner to maintain dignity. Due to the facility staff's failure to answer the call light for Resident 33, the resident experienced incontinent episodes. 33 residents were sampled. The facility staff identified the census as 101. The findings are: A review of Resident 33's undated Face Sheet revealed Resident 33 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An interview conducted on 2-20-18 at 12:08 PM with Resident 33 revealed that the resident was having difficulty with urinary incontinence that the resident reported was due to waiting to long for staff to assist with toileting. The resident reported that it was embarrassing for someone their age to urinate on themselves and that the resident had cried a few times when they had been incontinent. An observation conducted on 2-22-18 at 7:09 AM revealed Resident 33's call light was on. Resident 33 was lying in bed shaking and crying. There was a puddle of liquid under the resident's bed with a drip pattern under the edge of the bed. An interview conducted on 2-22-18 at 7:09 AM with Resident 33 revealed that the resident had been turning on their call light since 3:10 AM requesting to go to the bathroom, but the nursing staff had been shutting it off because the resident must have fallen asleep. The resident reported their current call light had been on since 6:45 AM. The resident reported that a nurse had brought in their early morning medications and that the resident refused to take one of the medications because they needed to go to the bathroom. The nurse left and did not return. The resident reported that they had not spilled anything on the floor and they thought the puddle may have been urine from wetting the bed 3 times since 3:10 AM. An observation conducted on 2-22-18 at 7:18 AM revealed Registered Nurse (RN) B cleaned up the puddle with towels. The liquid had a yellow tint when soaked up into the white towel and had a urine odor. RN B confirmed these observations. An observation conducted on 2-22-18 at 7:23 AM revealed Nursing Assistant (NA) C entered Resident 33's room and asked the resident what they needed help with. Resident 33 was in bed crying and shaking and told NA C that they needed to go to the bathroom and get cleaned up because they had urinated in their bed 3 times. NA C told Resident 33 that they had not had time to pay attention to the call lights on the 200 Hall, where Resident 33 lived, because the NA was also assigned to the 100 Hall. NA C explained to Resident 33 that they normally work on the 100 Hall and that the residents on the 100 Hall were more at risk for falls because they were more independent. NA C explained they did not want any of their 100 Hall residents to fall while the NA was helping the residents on the 200 Hall so they were not going to help any of the 200 Hall residents until the 100 Hall residents were all up for the day. An observation conducted on 2-22-18 at 7:27 AM revealed NA C, with the assistance of NA D, assisted Resident 33 to get dressed and cleaned up. The brief that Resident 33 had been wearing was saturated with urine. The protective pad on the bed was saturated. The bed sheet had a large area of wetness that extended to the outer edge of the sheet on the side of the bed that the drip pattern had been observed earlier. The outer edge of wetness on the sheet had a brown staining that suggested the sheet was starting to dry. NA D removed the sheet from the bed and revealed liquid standing in the creases of the mattress cover. NA D confirmed the above observations. An observation conducted on 2-22-18 at 3:53 PM of Resident 33 at the Resident Council meeting revealed the resident started crying as the resident expressed concerns about their call light not being answered that morning and urinating in the bed 3 times. A review of Resident 33's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 10-20-17 revealed Resident 33 had Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). The resident required extensive assistance with toileting and was continent of both bowel and bladder. A review of Resident 33's Comprehensive Care Plan dated 1-4-17 revealed that Resident 33 was usually continent and required extensive assistance with toileting. A review of Resident 33's Urinary Incontinence assessment dated [DATE] revealed the resident was continent of urine.",2020-09-01
3799,MITCHELL CARE CENTER,285287,1723 23RD STREET,MITCHELL,NE,69357,2018-03-22,583,D,1,0,TJRM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05 (21) Based on record reviews and interviews, the facility failed to ensure that interventions were in place to reduce the risk of a confused resident wandering in the room for two current sampled residents (Residents 2 and 4). The facility census was 50 with six current sampled residents. Findings are: [NAME] Interview with Resident 4 on 3/22/18 at 8:45 AM revealed that was waken during the night by Resident 3 who was touching shoulder and leg. The resident stated that nothing was done to prevent the resident from coming into the room again. Further interview revealed that Resident 3's room is right across the hallway and the resident continues to wander around the hallways. Review of the Care Plan, goal date 1/9/18, revealed that on 3/1/18 Resident 3 entered the resident's room. Further review revealed no interventions to address Resident 3's wandering and to protect the resident's privacy. B. Interview with Resident 2 (Resident 4's roommate) on 3/22/18 at 11:15 AM revealed woke up during the night and saw Resident 3 standing over Resident 4's bed, rubbing Resident 4's leg. Resident 2 stated started screaming for help and then Resident 3 came over and removed a blanket from legs and grabbed the water cup on the table threatening to throw it. Further interview revealed kept screaming for help and the nurse responded. Resident 2 stated that a nurse responded and Resident 3 was yelling and threatening the nurse and it took several minutes to get the resident out of their room. Further interview revealed that, since that incident, nothing was done to prevent that resident from entering their room again. The resident stated that Resident 3 continues to wander around the hallways and they are both concerned that would wander into their room again. The resident stated that a family member brought in a [MEDICATION NAME] to use if Resident 3 wandered into their room again. Review of the Care Plan, goal date 4/30/18, revealed that on 3/1/18, Resident 3 enters resident room occasionally and the intervention is that the resident has a [MEDICATION NAME] to notify staff. Interview with the Administrator on 3/22/18 at 1:15 PM confirmed that effective interventions are not in place to promote the resident's privacy in their room.",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
2444,WAKEFIELD HEALTH CARE CENTER,285209,306 ASH STREET,WAKEFIELD,NE,68784,2018-05-01,561,D,1,0,X08C11,"**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 provide Resident 3 a choice related to the resident's use of a motorized wheelchair. The sample size was 18 and the facility census was 24. Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/10/18 revealed the resident's cognition was moderately impaired; the resident had verbal behaviors which were directed at others and the resident had [DIAGNOSES REDACTED]. Review of the facility policy titled Motorized Wheelchair and Scooter: Criteria for Outdoor Use dated 12/2016 revealed any resident wishing to operate a motorized wheelchair was to successfully complete an evaluation by the facility staff to determine the appropriateness for safe use of the chair. An evaluation was to be conducted at least annually or with any significant changes in the resident's condition. If the resident was only able to meet some of the guidelines, than training was to be provided by the facility staff or through an outside professional therapy service. Review of a form titled Motorized Wheelchair and/or Scooter Criteria for Outdoor Use revealed on 7/6/17, the Director of Nursing (DON) and a Restorative Aide completed an assessment of Resident 3's safe use of the resident's motorized wheelchair. The assessment identified the resident was not able to demonstrate competency with outside use of the wheelchair. The form identified the resident would be reassessed in 1 week. Review of a Physician Facsimile (fax) dated 7/13/17 revealed the resident's physician was notified Resident 3 was unable to successfully demonstrate safe use of the resident's motorized wheelchair. A new order was received for Occupational Therapy (OT) to evaluate and treat the resident for wheelchair safety. The facility had also requested an order for [REDACTED]. Review of a Nursing Progress Note dated 7/20/17 at 4:00 PM, revealed the resident voiced frustration that a re-evaluation of the resident's motorized wheelchair use had yet to be completed. The note identified a call was placed to the OT and the OT indicated the evaluation had never been scheduled. Review of a Plan of treatment for [REDACTED]. The form indicated the resident was seen for an evaluation only. The OT identified concerns regarding the resident's impulsivity and patience and indicated the resident could be at risk with independent use of the wheelchair due to a potential need for quick decisions to maintain safety when on the roads. Review of Resident 3's medical record revealed no evidence the resident was provided with any additional training by the facility to assist the resident with improving skills to promote safe and independent use of the resident's motorized wheelchair. Review of a Physician Order Report dated 8/9/17 revealed the resident's physician documented the following regarding Resident 3 is capable of operating a power wheelchair the physician also indicated it was up to the facility regarding use of the chair. Review of the resident's current Care Plan revealed an intervention dated 10/11/17 which identified the facility was to complete a quarterly wheelchair safety assessment with the resident for outside use of the motorized wheelchair. Review of a Nursing Progress Note dated 10/20/17 at 2:01 PM revealed the facility had received an order for [REDACTED]. Review of an Outpatient Neuropsychological Consultation Report dated 1/9/18 (5 months and 3 weeks after the facility originally requested the neuropsychological evaluation) revealed the following recommendations: -repeat a neuropsychological evaluation in 9 to 12 months to document the course of the resident's illness; -continue mental health therapy; and -regarding use of the motorized wheelchair, decision-making is best deferred to the OT. The resident does not demonstrate severe levels of cognitive impairment and it would be expected that the resident would remain generally competent with adequate judgments. A review of the resident's medical record from 7/27/17 through 3/26/18 revealed no evidence that a quarterly assessment had been completed for the resident's outdoor use of the motorized wheelchair. Review of a Motorized Wheelchair Criteria for Outdoor Use assessment completed by the facility Social Service Director (SSD) dated 3/28/18 revealed the resident was unable to demonstrate competency for unsupervised use of the resident's motorized wheelchair. During an interview with Resident 3 on 4/30/18 from 1:43 PM to 2:00 PM, the resident indicated the facility staff were not doing the assessments regarding competency with use of the motorized wheelchairs every 3 months. The resident further indicated the resident's physician and neuropsychologist had written reports stating the resident was capable of using the chair outside without staff supervision. The resident identified a preference to use the motorized wheelchair for outings and identified use of the wheelchair enhanced the resident's quality of life. During an interview with the SSD, the DON and the Administrator on 5/1/18 from 11:30 AM to 11:45 AM the following was confirmed regarding Resident 3's motorized wheelchair: -the resident had expressed on numerous occasions a preference to use the motorized wheelchair when attending outings in the community; -an assessment was to be completed on a quarterly basis to identify the residents' ability to safely use the motorized wheelchair outside and the facility had failed to complete on a quarterly basis; -the staff completed an assessment on 7/6/17 regarding the resident's outside use of the wheelchair and the resident was unable to demonstrate competency. The assessment indicated the resident was to be reassessed in 1 week but no assessment was repeated in this time frame; -7/13/17 an order was received for an OT evaluation regarding the resident's use of the motorized wheelchair. The facility also addressed with the physician the possibility of obtaining a neuropsychological evaluation of the resident's cognitive status; -OT evaluation was not completed until 7/26/17 (13 days after the order was received from the resident's physician); -10/20/17 an order was received for the resident to have a neuropsychological assessment of cognitive function. The order was received over 3 months after it was first addressed with the resident's physician; -1/9/18 the resident was assessed by the neuropsychologist. The assessment occurred over 5 months after the staff first addressed with the resident's physician; -the facility failed to complete another assessment regarding use of Resident 3's electric motorized wheelchair until 3/28/18, which was over 8 months since the resident's last assessment; and -the facility failed to provide the resident with any training to improve the resident's skills and safety with use of the motorized wheelchair.",2020-09-01
1349,HILLCREST HEALTH & REHAB,285133,1702 HILLCREST DRIVE,BELLEVUE,NE,68005,2017-08-02,242,D,1,1,YKIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05 (4) Based on interviews and record reviews, the facility failed to ensure bathing preferences were followed for 1 resident (Resident 569) of 40 residents sampled. The facility staff identified the census at 110 . The findings are: A review of Resident 569's Face Sheet dated 7-31-17 revealed that Resident 569 was admitted to the facility on [DATE]. A review of Resident 569's Admission assessment dated [DATE] revealed that the resident was asked about bathing preferences and had requested 3 baths a week. A review of Resident 569's Care Plan dated 7-12-17 revealed that the resident was care planned as wanting 3 baths a week in the morning . An interview conducted on 7-25-17 at 3:20 PM revealed that Resident 569 did not get a choice in bathing frequency as they had only had one bath in 2 weeks. Resident 569 reported they preferred to receive 3 baths a week. An interview conducted on 8-1-17 at 8:11 AM with the Director of Nursing (DON) revealed that residents were asked about their bathing preferences during the admission assessment and then again during the comprehensive Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning). The DON reported that the resident's preferences were entered into the nurse tech care plan. An interview conducted on 8-1-17 at 8:19 AM with Nursing Assistant (NA) B revealed that Resident 569 was to get 3 baths per week on Tuesday, Thursday, and Saturdays unless the resident refused . NA B reported that, if a resident refused a bath, they would document the refusal and tell the nurse. NA B reported that, if the resident refused, they were to try again the next day. An interview conducted on 8-1-17 at 8:21 AM with the Education Specialist revealed that, if a nursing assistant charted a refusal, it would be found in the behavior charting and the nurse's documentation would be found in the progress notes. A review of Resident 569's Behavior Report dated 7-12-17 to 8-1-17 revealed no documentation of refusal of cares. A review of Resident 569's Progress Notes dated 7-12-17 to 8-1 -17 revealed no documentation of refusal of baths. A review of Resident 569's bathing report for 7-12-17 to 8-1-17 revealed that there was no documentation to indicate the resident was offered a bath until 5 days after admission on 7-17-17 which was refused and the resident received a bath 7-18-17. The resident refused baths on 7-20-17 and 7-22-17. There was no documentation to indicate the resident was offered a bath again until 6 days later on 7-28-17 when the resident did receive a bath. There was no documentation to indicate the resident was offered a bath on 7-31-17 which was the resident's next scheduled bath day.",2020-09-01
4745,"SORENSEN CARE AND REHABILITATION CENTER, LLC",285107,4809 REDMAN AVENUE,OMAHA,NE,68104,2017-06-15,242,D,1,1,F9RW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05 (4) Based on interviews and record reviews; the facility failed to implement bathing preference for 1 resident (Resident 13) and failed to evaluate rising time for 1 resident (Resident 97) of 3 residents sampled. The facility staff identified the census at 68. [NAME] An interview conducted on 6/13/17 at 8:58 AM with Resident 13's responsible party revealed that Resident 13 had not been getting bathed per their past preferences and was receiving only 3-4 baths a month. A review of Resident 13's Admission Nursing assessment dated [DATE] revealed that Resident 13 preferred a shower. A review of Resident 13's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) revealed that it was very important for Resident 13 to choose bathing preferences. A review of Resident 13's bathing documentation for (MONTH) (YEAR) revealed there were no baths documented yet that month. A review of Resident 13's bathing documentation for (MONTH) (YEAR) revealed Resident 13 received four sponge baths the entire month. A review of Resident 13's bathing documentation for (MONTH) (YEAR) revealed Resident 13 received two showers and three sponge baths the entire month. An interview conducted on 6/14/17 at 3:50 PM with the Administrator confirmed the bathing documentation above was the only documentation of Resident 13's bathing. An interview conducted on 6/15/17 at 3:33 PM with the Regional Vice President of Operations revealed that they thought Resident 13 had been refusing baths, but did not have any documentation to show Resident 13 had refused. B. On 6-12-2017 at 11:30 AM, an interview was conducted with Resident 97. During the interview when asked if Resident 97 made the decision when to get up in the morning, Resident 97 reported no. Review of Resident 97's medical record revealed there was not evidence that the facility had evaluated Resident 97's waking time. On 6-15-2017 at 12:47 PM, an interview was conducted with the Regional Vice President of Operation (RVO). During the interview the RVO reported not being able to find information that Resident 97's waking time had been evaluated.",2020-03-01
3573,BRIGHTON GARDENS OF OMAHA,285274,9220 WESTERN AVENUE,OMAHA,NE,68114,2017-05-25,242,E,1,1,38CN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05 (4) Based on interviews, and record reviews; the facility failed to accommodate resident choices in regards to bathing for 3 residents (Resident 99, 124, and 23) of 3 residents sampled. The facility identified the census at 38. The findings are: [NAME] A review of Resident 23's Admission Record dated 5/25/17 revealed Resident 23 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An interview conducted on 5/22/17 at 3:15 PM with Resident 23 revealed the resident felt they were not given a choice on their bathing schedule. Resident 23 reported they preferred a shower every other day, but was only getting a shower once a week. A review of Resident 23's Activities of Daily Living (ADL) documentation for (MONTH) (YEAR) revealed resident was scheduled for bathing on Mondays and Thursdays. Resident 23 was documented as having received a bath on 5/2/17, 5/4/17, 5/14/17, and 5/18/17. A review of Resident 23's Resident Preference assessment dated [DATE] revealed preference in regards to bathing frequency was not addressed. An interview conducted on 5/25/17 at 8:31 AM with Registered Nurse (RN) C revealed that the NA's (Nurse Aides) were to complete the Resident Preference Assessment for every resident on admission that addressed the residents' bathing preferences. RN A reported the nurses were to use this form to answer the bathing preferences section of the Skilled Nursing Service Evaluation and Health Assessment and then send to form to the Activities Director. RN A reported the facility offered baths twice a week to all residents. An interview conducted on 5/25/17 at 10:48 AM with Activities Assistant D revealed that their department would receive the Resident Preference Assessment forms from the nursing department and would input the information into the resident's care plan. Activities Assistant D reported they did not know if the form addressed how many times a week a resident would like a bath or shower. An interview conducted on 5/15/17 at 1:28 PM with the Director of Nursing (DON) confirmed that the Resident Preference Assessment form did not address the residents' preference for bathing frequency. The DON confirmed Resident 23's bathing documentation indicated the Resident did not receive a bath between 5/4/17 and 5/14/17. B. A review of Resident 99's Admission Record dated 5/25/17 revealed Resident 99 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An interview conducted on 5/22/17 at 11:11 AM with Resident 99 revealed the resident felt they were not given a choice on their bathing schedule. Resident 99 reported they preferred a shower every other day, but was only receiving a shower twice a week if the staff could get to it. A review of Resident 99's ADL documentation for (MONTH) (YEAR) revealed Resident 99 was scheduled to receive showers every Tuesday and Saturday, but only received showers on 5/6/17, 5/14/17, 5/20/17, and 5/23/17. A review of Resident 99's Skilled Nursing Service Evaluation and Health assessment dated [DATE] revealed that the section regarding bathing preference was left blank for preferred days. A review of Resident 99's Resident Preference assessment dated [DATE] revealed that the preference in regards to bathing frequency was not addressed An interview conducted on 5/15/17 at 1:28 PM with the DON confirmed that Resident 99 had only received 4 showers for the month of May. C. A review of Resident 124's Admission Record dated 5/25/17 revealed Resident 124 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An interview conducted on 5/23/17 at 9:41 AM with Resident 124 revealed the resident felt they were not given a choice on their bathing schedule. Resident 124 reported they preferred a shower every other day, but that morning they had received their first shower since admitting to the facility. A review of Resident 124's ADL documentation for (MONTH) (YEAR) revealed resident was scheduled for bathing on Saturdays and Tuesdays. There was documentation present for 5/18/17 that read not applicable. A review of Resident 124's Skilled Nursing Service Evaluation and Health assessment dated [DATE] revealed that the section regarding bathing preference was left blank. A review of Resident 124's Resident Preference assessment dated [DATE] revealed that the preference in regards to bathing frequency was not addressed. An interview conducted on 5/15/17 at 1:28 PM with The DON revealed that the DON thought the resident received a bath on 5/18/17, but confirmed the documentation did not indicate whether Resident 124 received a bath.",2020-09-01
3909,HILLCREST COUNTRY ESTATES-COTTAGES,285293,6082 GRAND LODGE AVENUE,PAPILLION,NE,68133,2017-05-04,242,E,1,1,POAF11,"**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 accommodate resident choices in regards to bathing for 2 residents (Resident 203 and 201) and wake up times for 2 residents (Resident 203 and 137) of 3 residents sampled. The facility identified the census at 46. The findings are: [NAME] A review of Resident 203's Admission Assessment, signed 4/29/17, revealed Resident 203 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 203 reported, on the Admission Assessment, that they preferred to take 2-3 baths per week and usual wake time was 8:00 AM. An interview conducted on 5/1/17 at 11:55 AM with Resident 203 revealed that Resident 203 preferred to get up at 9:00 AM, but was not given a choice by facility staff. Resident 203 reported the facility staff would just do what they wanted. Resident 203 also reported they had not received a bath or shower since arriving at the facility. A review of Resident 203's Activities of Daily Living documentation, dated 4/28/17 to 5/4/17, revealed Resident 203 did not receive a bath or shower until 5/3/17. An observation conducted on 5/1/17 at 11:55 AM of Resident 203 revealed Resident 203 had an overgrowth of facial hair. An observation conducted on 5/2/17 at 7:24 AM revealed facility staff in Resident 203's room assisting Resident 203 to get up and dressed for the day. An observation conducted on 5/3/17 at 8:04 AM revealed facility staff in Resident 203's room assisting Resident 203 to get up and dressed for the day. An observation conducted on 5/4/17 at 7:09 AM of morning cares for Resident 203 revealed Nursing Assistant (NA) A entered Resident 203's room and woke Resident 203. NA A asked if they were ready to get up and dressed for the day. Resident 203 responded No, not really. NA A then asked Resident 203 what clothes they wanted to wear that day and pulled some clothes out of the closet. NA A then sat Resident 203 up on the side of the bed and walked Resident 203 into the bathroom. NA A then assisted Resident 203 to get dressed for the day. Resident 203 was observed to have an overgrowth of facial hair and was not shaved during morning cares. An interview conducted on 5/4/17 at 8:37 AM with Resident 203 revealed Resident 203 felt they were woken up too early in the morning and would like to have been able to sleep later. Resident 203 reported that their electric razor was not working right and would like to be shaved. A review of Resident 203's Care Plan dated 4/28/17 revealed an intervention to allow for Resident 203's own decision making. B. A review of Resident 137's Admission Assessment, signed 4/14/17, revealed Resident 137 was admitted on [DATE] with the [DIAGNOSES REDACTED]. Resident 137's usual wake up time was 9:00 AM. An interview conducted on 5/1/17 at 2:45 PM with Resident 137 revealed that Resident 137 felt the facility staff wake them too early in the morning and did not feel they had a choice. Resident 137 reported they preferred to get up at 9:00 AM. An observation conducted on 5/3/17 at 8:17 AM revealed Resident 137 was dressed and sitting in the dining room eating breakfast. An observation conducted on 5/4/17 at 7:38 AM revealed Resident 137 was in the bathroom with facility staff getting dressed for the day. Resident 137's bed was observed to be already made with their clean clothes sitting at the foot of the bed. An interview conducted on 5/1/17 at 8:33 AM with Resident 137 in the facility dining room revealed Resident 137 felt it was too early to be dressed for the day and eating breakfast. A review of Resident 137's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 4/21/17 revealed Resident 137 had indicated to facility staff that it was very important for them to choose their own bedtime. A review of Resident 137's Care Plan dated 4/14/17 revealed an intervention to allow for Resident 137's own decision making. C. A review of Resident 201's Admission Assessment, signed 4/29/17, revealed Resident 201 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 201 reported, on the Admission Assessment, that they preferred to 3-4 baths per week. An interview conducted on 5/1/17 at 3:51 PM with Resident 201 revealed Resident 201 felt they were not given a choice regarding bathing preferences. Resident 201 reported they would like a bath or shower every other day, but had not received one since admitting to the facility. Resident 201 was observed to have an overgrowth of facial hair. An interview conducted on 5/2/17 at 3:29 PM with Resident 201 revealed they still had not received a bath or shower. Resident 201 was observed to have an overgrowth of facial hair. A review of Resident 201's Activities of Daily Living documentation dated 4/28/17 to 5/3/17 revealed that Resident 201 did not have a bath or shower documented during this time period. A review of Resident 201's Clinical Notes revealed a note dated 5/2/17 indicating that Resident 201's spouse had asked about Resident 201 receiving a bath and the spouse was shown the bath rotation for those residents that have no preference for baths. The note revealed that the spouse was agreeable with the schedule, but asked that Resident 201's hair get cleaned between shower days. A review of Resident 201's Care Plan dated 4/28/17 revealed an intervention to allow for Resident 201's own decision making. An interview conducted on 5/4/17 at 9:16 AM with the Director of Clinical Services (DCS) B revealed that they felt the facility was small enough and they had consistent staffing so everyone should know what every resident's preference was. The DCS B reported they did not know what the preferences were for Residents 201, 203, and 137. The DCS B reported that the bath schedule was set up for every resident to receive 2 baths a week and could be modified if a resident wanted a bath more often.",2020-09-01
5816,SIDNEY REGIONAL MEDICAL CENTER-EXTENDED CARE,285290,549 KELLER DRIVE,SIDNEY,NE,69162,2016-09-27,221,D,1,0,CZTZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05 (8) Based on observations, record reviews and interviews; the facility failed to ensure that assessments were completed to determine if seatbelts utilized in wheelchairs were physical restraints and that they were the least restrictive yet effective device to reduce the risk for falls and injuries for two sampled residents (Residents 2 and 3). The facility census was 50. Findings are: A. Observations on 9/13/16 at 10:00 AM revealed Resident 1 seated in a wheelchair in the hallway with an alarming seatbelt in place. Further observation at 11:30 AM revealed the resident seated in the wheelchair in the dining room with the alarming seatbelt in place. Review of the Care Plan, goal date 10/11/16, revealed that the resident had cognitive problems related to dementia, impaired decision making skills and some symptoms of depression and anxiety at times. Further review revealed that the resident was at risk for falls related to weakness and interventions included a Pommel cushion (special cushion with a raised center to prevent the resident from sliding out of the wheelchair) in the wheelchair. The care plan did not include the use of an alarming seatbelt in the wheelchair. B. Observations on 9/13/16 at 10:15 AM revealed Resident 2 seated in a wheelchair with a seatbelt in place. Further observations at 12:00 PM revealed the resident seated in the wheelchair in the dining room with the seatbelt in place. Review of the Long Term Care Plan, goal date 10/25/16, revealed that the resident was at risk for falls and interventions included the use of a seatbelt in the wheelchair. Further review revealed that the resident was not able to release the alarming seatbelt consistently and reliably. Review of the facility policy Restraints, reviewed (MONTH) (YEAR), revealed the following including: It shall be the policy of (facility name) that physical restraints shall be used if there is a medical [DIAGNOSES REDACTED]. Restorative Nurse shall complete a Restraint/Bed Device assessment when the restraint is ordered and this assessment shall be reviewed every three months during plan of care and dated and initialed by Restorative Nurse. This form shall become a permanent part of the medical record. Interview with the Director of Nursing on 9/27/16 at 11:00 AM confirmed that these residents utilized seatbelts in their wheelchairs to reduce the risk for falls. Further interview confirmed that assessments were not completed to determine if the seatbelts were physical restraints or to ensure that they were the least restrictive yet effective devices to use to reduce the risk for falls and injuries.",2019-09-01
2093,HILLCREST CARE CENTER,285178,702 CEDAR AVENUE,LAUREL,NE,68745,2019-03-25,600,E,1,1,F0S011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05 (9) Based on observation, record review and interview: the facility failed to have interventions in place to protect Resident 1 from potential abuse related to an injury of unknown origin, ongoing skin tears and bruising and from physical abuse related to a resident to resident altercation with Resident 6. In addition, the facility failed to protect Residents 19 and 26 from misappropriation. The sample size was 8 and the census size was 27. Findings are: [NAME] Review of the Abuse/Neglect and Exploitation Policy (undated) revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes deprivation, by an individual of goods or services necessary to attain or maintain physical, mental and psychosocial wellbeing. The following terms were also defined: -physical abuse includes hitting, slapping, pinching, kicking or striking to control behavior through corporal punishment; and -misappropriation of funds/property is the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The policy further revealed indicators of physical abuse, may include but are not limited to bruises or hematomas to bilateral arms and soft parts of the body with the presence of old and new at the same time as from repeated injuries. If events are identified as an injury of unknown source, it is the responsibility of the employee to report their findings as soon as possible with an assessment completed of the resident's condition and an investigation conducted for the development of interventions to protect the resident and to prevent potential ongoing abuse. B. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/8/19 revealed the resident's cognition was severely impaired with [DIAGNOSES REDACTED]. The assessment indicated the resident required extensive staff assistance with transfers, bed mobility, dressing, toileting and personal hygiene. Review of a Nursing Progress Note dated 7/2/18 at 11:11 PM revealed the resident was ambulated from the bathroom and back to the resident's bed. When the resident was assisted to sit on the side of the bed, the resident started to slide and was then lowered to the floor. The resident had been holding onto a walker and the walker hit the resident's forearm causing a large skin tear (16 centimeters (cm) x (by) 2 cm) to the left arm. Further review of the resident's medical record revealed [REDACTED]. Review of a Nursing Progress Note dated 7/14/18 at 10:16 PM revealed the resident had a 6 cm x 4 cm skin tear to the right lower leg with a 10 cm x 12 cm bruise and a 6 cm x 9 cm bruise to the resident's left lower leg. An intervention was identified to place padded leggings on the resident's lower legs to prevent further injury. Further review of the resident's medical record revealed [REDACTED]. Review of a Nursing Progress Note dated 8/5/18 at 5:00 PM revealed Resident 1 had been resting on the resident's bed. Staff entered the resident's room and a large amount of blood was observed to the resident's bed linens and to the padded legging on the resident's left lower leg. The legging was removed and revealed a laceration which measured 5.6 cm x 0.3 cm to the resident's left outer leg. The resident was transferred to the emergency room and received 10 sutures to the wound. review of the resident's medical record revealed [REDACTED]. Review of a Nursing Progress Note dated 9/16/18 at 3:18 PM revealed a late entry for 9/15/18 at 2:00 PM which identified the resident was found to have a dark purple bruise to the top of the resident's left hand which extended into the 3rd and 4th fingers and measured 7 cm x 6 cm. When interviewed, the resident was unable to identify how the bruising had occurred. There was no evidence in the resident's medical record to indicate further investigation was conducted to determine the cause of the bruising or that interventions were revised and/or developed to protect the resident from further bruising. Review of a Nursing Progress Note dated 10/10/18 at 1:54 PM revealed during the resident's weekly skin assessment, the resident was observed to have a dark purple bruise which measured 10 cm by 8 cm to the resident's left lower leg. review of the resident's medical record revealed [REDACTED]. Review of Resident 1's current Care Plan with revision date of 12/19/18 revealed the resident was at risk for skin concerns related to urinary incontinence, and the need for staff assistance with activities of daily living. The following interventions were identified: -apply Cavelon (skin protectant cream with a water proof barrier) to coccyx/buttocks weekly; -pressure relief mattress to bed; -staff to use extreme caution when assisting to change the resident's disposable urinary incontinence brief; -monitor for skin irritations and/or reddened areas; and -weekly skin assessment by a nurse. Review of a Nursing Progress Note dated 1/3/19 at 9:37 AM revealed during the resident's weekly skin assessment, the resident was found to have a 10 cm x 8 cm dark purple bruise to the left lower leg and a 17 cm x 10 cm bruise to the right lower leg. In addition the resident had a 5 cm x 7 cm bruise to the left elbow and bruising to the resident's bilateral groin areas. Further review of the resident's medical record revealed [REDACTED]. Review of a Nursing Progress Note dated 1/17/19 at 8:30 PM revealed the resident was transferred with the use of a mechanical lift (assistive device that allows residents to be transferred between a bed and a chair using hydraulic power) into the bathroom. The resident's right elbow was bumped on the doorframe causing a 1.8 cm skin tear. There was no evidence a new intervention was developed to prevent further injury to the resident during transfers with the mechanical lift. Review of a Nursing Progress Note dated 2/26/19 at 11:45 AM revealed the resident was observed to have bruising to the resident's bilateral groin areas. The note indicated the staff felt the bruising was caused by the resident's disposable urinary incontinence brief. An intervention was developed to use a larger size brief on the resident. Review of a Weekly Skin assessment dated [DATE] at 4:15 PM revealed the resident was found with a 4 cm skin tear to the left lower leg, an 11 cm x 27 cm bruise to the left shin area, a 0.4 cm x 0.6 cm bruise to the top of the left foot second toe, a 10 cm x 9 cm bruise to the right lower leg and a 5 cm x 3 cm bruise to the top of the right foot. In addition, the assessment indicated the resident had several bruises to bilateral arms. A new intervention was developed for a more form fitted leg protector to be placed on both of the resident's lower legs. review of the resident's medical record revealed [REDACTED]. Review of a Nursing Progress Note dated 3/14/19 at 3:45 PM revealed the resident had no injury related to being struck on the arm by another resident's doll. The note indicated Adult Protective Services (APS) was notified. C. Review of Resident 6's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. In addition, the resident was identified as having verbal behaviors directed at others which occurred on 1-3 days of the assessment period and wandering which occurred daily. Review of Resident 6's Nursing Progress Notes dated 3/13/19 at 5:49 PM revealed the resident was witnessed striking Resident 1 with a doll and then tried to strike Resident 1 with Resident 6's walker. Review of an Event Report dated 3/14/19 at 5:16 PM revealed Resident 1 had been positioned at assigned area in the dining room and was holding onto a doll and talking to the doll. Resident 6 approached Resident 1 with walker. Resident 6 began to verbally abuse Resident 1, to stare at the resident and then to growl at the resident. Resident 6 then grabbed the doll from Resident 1 and began to strike Resident 1 on the arm with the doll. The report indicated Resident 1 was removed from the table and was placed at an adjacent table. Staff sat next to Resident 6 and provided redirection. Review of an Observation Detail List Report dated 3/15/19 at 9:35 AM revealed an intervention to remove Resident 6's baby doll, as the doll was not completely soft and to replace with a stuffed animal. In addition, it was identified that Resident 1 was moved to another table. Observations of the facility dining room on 3/20/19 from 8:06 AM to 9:00 AM and at 11:55 AM to 12:30 PM, revealed Resident 1 and Resident 6 were seated side by side at the same dining room table. Dietary and Nursing staff walked by the resident's table and provided the residents with occasional cues and set-up assistance to eat. However, the residents did not receive constant 1:1 supervision to assure no further physical abuse occurred. During an interview on 3/20/19 at 12:40 PM, the Dietary Manager (DM) confirmed Resident 1 and Resident 6 remained seated at the same table. The DM denied any knowledge of the physical altercation between the residents and indicated the dietary staff were unaware of the need to provide monitoring of the residents. The DM indicated the residents should not be seated at the same table. D. Review of Resident 19's MDS dated [DATE] revealed the resident was cognitively intact with [DIAGNOSES REDACTED]. During an interview on 3/19/19 at 9:26 AM, the resident was asked about the loss of any personal items. Resident 19 indicated several months ago, the resident lost about 200.00 dollars. The resident identified the money had been in a billfold on a table in the resident's room. The resident discovered the money was missing when the resident returned from the dining room. The resident did report the missing money to the facility staff. The resident was unaware of the outcome of any potential investigation but indicated the money had not been returned or replaced. The resident was unaware of any interventions to prevent further potential misappropriation of the resident's personal property. Review of a facility investigation dated 9/7/19 revealed on 9/3/18 at 2:04 PM, Resident 19 reported to Registered Nurse (RN)-A the resident was missing money. The resident had 150.00 to 200.00 dollars in a wallet the resident kept on a table in the resident's room. The resident indicated the money was there that morning, but was missing when the resident returned after the noon meal. The investigation further indicated the facility had a recent pattern of missing property as one resident was missing jewelry and another resident had reported the loss of an I-Pad tablet. The facility was not able to recover the missing items and no one was found to be the guilty party. The residents were encouraged not to keep valuables in their rooms or to put valuables in a locked box at the Nurse's Station. E. During an interview on 3/25/19 at 7:37 AM, the Administrator verified the following: -from 7/2/18 through 3/6/19, Resident 1 had multiple injuries including skin tears, lacerations and bruises. Despite these injuries, no investigations were completed to determine how these injuries had occurred and the only additional intervention developed to prevent ongoing injuries was the use of a more form fitting legging; -Resident 1 and Resident 6 had a resident to resident altercation on 3/13/19 at 5:49 PM in which Resident 6 struck Resident 1 on the arm. The residents were separated at the time of the altercation but then the residents were placed back at the same table in the dining room placing Resident 1 at risk for further physical abuse; and -the facility did have several episodes of misappropriation over the last few months. Interviews of the staff were completed but the facility was never able to recover the missing items. No additional interventions were put into place to prevent potential misappropriation of the resident's property. F. During an interview with Resident 26 on 3/19/19 at 1:30 PM, the resident revealed many nice pieces of the resident's jewelry had been stolen. This included a gold nugget with a heavy gold chain, a diamond necklace, and a gold cross necklace. Resident 26 stated the rest of the resident's nice jewelry had to go home with family to ensure it didn't get stolen as well. The resident expressed sadness and stated the pieces of jewelry were really missed. Review of Resident 26's MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 (with a score between 13-15 indicating the resident was cognitively intact). Review of a Grievance Report revealed on 8/23/18 Resident 26 reported a missing necklace. The resident stated the necklace was taken off on 8/22/18 before bed and placed on the bedside table. The resident stated the next day between breakfast and lunch the resident went to put the necklace back on and discovered it was gone. The resident then looked at the other jewelry and noticed many other pieces were gone as well. The facility searched the resident's room, trash, and laundry. The facility did notify law enforcement. Further review of the facility investigation revealed there was no evidence to indicate what staff members were interviewed or the outcome of the interviews. There was also no evidence to indicate what staff members were working during the time of the missing item to cross-reference with other similar incidents that happened around the same time. During an interview with the Administrator on 3/25/19 at 11:50 AM, the Administrator confirmed there was no documentation of the staff interviews that were completed and the Administrator was unsure what staff were working around the time of the incident.",2020-09-01
5327,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-01-31,223,G,1,0,BKZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05 (9) Based on observation, record review and interview; the facility failed to protect 3 resident from abuse (Resident 44, 76, 87) out of11 sampled residents. The facility census was 69. Findings are: [NAME] Record review of the facility policy titled Abuse Prevention Program and Reporting Policy dated, revised on 8/16 revealed that physical abuse included hitting, slapping, pinching, scratching, spitting and being handled roughly. The facility was to provide for the immediate safety of the resident upon identification of suspected abuse, neglect, mistreatment and/or misappropriation of property. This protection included immediately separating the resident from the alleged perpetrator, moving the resident to another room, provide one to one monitoring or implement discharge if the resident was a danger to self or others. B. Record review revealed that Resident 84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 84's MDS (Minimum Data Set (MDS): 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) with an Assessment Reference Date of 12/5/16 revealed that Resident 84 could understand and was understood. Resident 84 had a Brief Interview for Mental Status (BIMS) score of 12 of 15 possible points. Resident 84 had a Resident Mood Interview that had recognized that Resident 84 had feelings of hopelessness and feeling depressed. Resident 84 had little interest or pleasure in doing things and was feeling bad about self Resident 84 had felt like a failure and had let self and family down. It also identified that Resident 84 had feelings of hurting self in some way or would be better off dead. This was recorded as Resident 84 had the above symptoms/feelings 12 of 14 days of the review period. It was recorded that responsible staff or provider were informed that there was a potential for resident self harm. The MDS section regarding resident behavior recorded that Resident 84 was rejecting care 1 of 3 days and had verbal behaviors 1 of 3 days in the assessment period. Resident 84's Comprehensive Plan of Care revealed : Resident 84 had been physically abusive to staff and other residents. Resident 84 would often swing at others with arms and feet. The plan of care was initiated on 10/04/2016 and revised on 1/9/17. The goals included that the resident would have improved mood state, be happier and be calmer. The care plan also revealed that Resident 84 would show no signs or symptoms of depression, anxiety or sadness through the review date of 3/6/17. Interventions included to monitor, record, and report to the physician any of Resident 84's risk for harm to self. The care plan also revealed that Resident 84 had a history of [REDACTED]. These interventions were initiated on 10/4/17. The care plan also included that the facility was to monitor, record and report to the physician when Resident 84 was at risk of harming others, had increased anger, was experiencing a labile mood or had agitation. This was initiated on 10/04/2016. The intervention that Resident 84 was not to be unsupervised when out of room was initiated on1/23/17 on the care plan. Observation on 01/24/2017 at 10:59 AM revealed Resident 84 was out of the room and was coming down the hall in a wheel chair. No staff were in the area providing supervision. Resident 84 was yelling at another resident when Resident 84 got to the exit to smoke. Resident 84 continued to yell until staff arrived and intervened. Resident 84 was observed to go outside into the courtyard and smoke. Continued observation revealed that Resident 84 was observed going backwards in the wheelchair at a very rapid pace. And that other residents and carts were in the hallway. Resident 84 ran into a resident in a tilt back wheelchair and Resident 84 yelled at that resident. No staff member was supervising Resident 84 at the time Resident 84 returned to Resident 84's room. The hallway that Resident 84 was rapidly going down passed 10 rooms on one side. Record review of Resident 84's medical record did not reveal that Resident 84 had behavior services or psychiatric consultation from the time of the resident's admission to present. C. Record review of Resident 76's progress note dated 1/7/17 at 7:00 PM revealed that Resident 84 had been observed by staff yelling at Resident 76 and kicking at Resident 76. The note revealed that the Social Service Director was notified as well as Resident 76's family of the incident. Record review of a Progress Note dated 1/17/2017 at 1:27 PM revealed Resident 84 had been yelling at Resident 76. Staff visualized the situation. Resident 84 was ramming Resident 76 (who also required a wheelchair) in the legs with the wheelchair foot rests. Resident 84 made contact with Resident 76's legs multiple times. Staff attempted to intervene and Resident 84 went after the staff attempting to strike staff. Resident 84 continued to yell and use profanity. Resident 84 was not able to be stopped until the Assistant Director of Nursing became involved and intervened. Record review of Resident 76's Admission Record revealed that Resident 76 was admitted on [DATE] and had the [DIAGNOSES REDACTED]. Record review of Resident 76's MDS dated [DATE] revealed that Resident 76 could not complete a cognitive BIMS review. Resident 76's MDS revealed that Resident 76 required extensive assistance of one persons to provide locomotion on the unit (this would be how the resident would move between locations in the room and in the corridor). Record review of Resident 76's Comprehensive Care Plan revealed no revisions had been made related to the 1/7/17 or the 1/17/17 incident to provide staff with measures to protect Resident 76 from Resident 84. Record review of Resident 84's Comprehensive Care plan revealed no revisions had been made to the plan of care related to the 1/7/17 or the 1/17/17 incident to provide staff with measures to prevent re-occurrence of the resident to resident aggression. D. Record review of Resident 44's Electronic Medical Record revealed that, Resident 44 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A Progress note for Resident 44 dated 1/21/2017 at 5:54 PM revealed that Resident 44 was sitting in the hallway next to the wall when Resident 84 was in a wheelchair heading down the hall. Resident 84 requested that Resident 44 move and Resident 44 replied that there was plenty of room for Resident 84 to go around. Resident 84 had then raised a right hand, made a fist, and hit Resident 44 in the back. Both residents were immediately separated. An assessment was completed on Resident 44 and revealed a 10cm (centimeter) x10cm reddened and bruising area to the mid back. The progress note revealed that the family and physician were notified for Resident 44. Record review of Resident 44's MDS dated [DATE] revealed a BIMS review of cognitive status could not be completed for Resident 44. The MDS revealed that Resident 44 was independent with no setup or physical help for locomotion in the unit. Record review of Resident 44's Comprehensive Care Plan revealed no revisions were made related to the 1/21/17 incident to provide staff with measures to keep the resident safe. An interview with the DON on 01/26/2017 at 8:44 AM revealed that to protect residents, the staff had been trying to observe Resident 84 when in the hall. The DON confirmed that Resident 84 was not being supervised when in the hallway at all times and that Resident 84 only came out of the room on the odd hours for smoking. The DON confirmed that Resident 84 was self-mobile in the wheelchair making it difficult for staff to know when Resident 84 was out of room. The DON confirmed that Resident 84's room was down Wing 9 and that Resident 84 would pass 10 rooms coming down that hall, pass the nursing station and then would have go down Wing 5 to smoke. The DON confirmed that other residents were at risk for abuse from Resident 84. An interview with the Administrator on 01/26/2017 at 8:44 AM confirmed that Resident 84 was to have staff at Resident 84's side at all times when in the hallway. The Administrator revealed that Resident 84 was to be discharged on [DATE]. The Administrator confirmed that the plan to supervised the Resident 84 when out of the resident's room was not being implemented and that placed other residents at risk for abuse from Resident 84. Interview with the Administrator on 1/26/17 at 1:10 PM revealed that staff attempted to keep Resident 76 sitting in the wheel chair near the nursing station to be observed and protected from others. The Administrator confirmed that Resident 76 was vulnerable to others. E. Record review of Resident 12's Admission Record revealed that Resident 12 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 12 was discharged on [DATE] due to death. Resident 12 had the [DIAGNOSES REDACTED]. Record review of Resident 12's MDS dated [DATE] revealed that Resident 12 had a memory problem and a BIMS score was not completed. The MDS for Resident 12 revealed that Resident 12 was independent with locomotion on the unit with set up only. Record review of Resident 12's Comprehensive Plan of Care, initiated on 4/11/16, revealed that Resident 12 had behavior problems related a developmental disability. Resident 12 would refuse cares and treatments. The goal for Resident 12 was that there would be decreased episodes of behaviors to no more than 2 per day or 14 per week thru the next review. Interventions to be used for Resident 12 to meet this goal included the Administration of medications as ordered, Anticipate and meet Resident 12's needs, and praise any indication of progress toward goals. Record review of Resident 12's progress notes dated 12/17/2016 at 6:33 PM revealed that the nurse had been notified that Resident 12 had hit another resident at the nursing station and the family was notified. The DON was notified at this time also. Record review of Resident 12's progress notes failed to produce additional documentation of the incident. F. Record review of Resident 87's Admission Record revealed that Resident 87 was admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 87's MDS, dated [DATE], revealed a BIMS score of 10 out of15 and that Resident 87 was independent with locomotion on the unit with set up help. Record review of Resident 87's progress note dated 12/17/20 at 6:45 PM revealed that Resident 87 was involved in a physical aggression with another resident and was hit by that resident and that the family and the DON had been notified of incident. Record review of the facility investigation revealed that staff had heard someone scream Stupid and had ran towards the yelling. Resident 12 and Resident 87 were in a physical altercation next to the water dispenser. The residents were yelling at each other. Resident 12 had pulled back their arm and struck Resident 87. Resident 87 was waving a plastic cup and requesting some water. Resident 12 continued to punch Resident 87 until staff separated them. Interview on 01/26/2017 at 8:38 AM with DON and ADON regarding the incident on 12/17/2016 at 6:33 PM with Resident 87 striking Resident 12 revealed that Resident 87 had a medical decline and passed away. The DON confirmed that no measures were put into place to protect Resident 12 from abuse and that no measures were put into place to prevent Resident 87 from abusing other residents. G. Record review of Resident 16's Admission Record revealed an admission date of [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 16's MDS, dated [DATE], revealed a BIMS score of 11 out of15 and that Resident 16 was independent with locomotion on the unit after set up. Record review of Resident 16's Comprehensive Plan of Care, initiated on 9/18/15, revealed that Resident 16 had potential to demonstrate verbally and physical abuse, was socially inappropriate with disruptive behaviors and resisted cares. The goal for Resident 16 was that coping skills would be effectively demonstrated through a target date of 4/23/17. Interventions include to assess and anticipate the resident's basic needs, assess coping skills and support system and staff to intervene when the resident becomes agitated before the resident can become more agitated. Record review of Resident 16's medical record failed to reveal documentation that indicated that Resident 16 had struck Resident 76. Record review of Resident 76's progress note, dated 9/22/2016 at 7:03 PM, revealed that Resident 76 had been punched in the head by Resident 16 at approximately 5 PM. Resident 76 had been sitting in a wheel chair when Resident 16 had been walking by using a walker. Resident 16 ambulated to Resident 76's side then began to punch Resident 76 in the head. Resident 76 had been assessed for injury and neurological checks were performed. Family and physician were notified. Interview with the Administrator on 1/26/17 at 1:10 PM revealed that the staff had attempted to keep Resident 76 sitting in a wheel chair near the nursing station to be observed and protected from others. The Administrator confirmed that Resident 76 was vulnerable to others. An interview with the DON on 1/26/17 at 1:15 PM confirmed that there was no record of Resident 16 striking Resident 76, in Resident 16's record. The DON confirmed that the facility no longer used a Behavior log and that all behavior documentation was found in the progress notes. The DON confirmed that Resident 76's care plan did not provide staff direction to keep Resident 76 near the nursing station or that Resident 76 was vulnerable to residents with behaviors. The DON confirmed that no measures were put into place to protect Resident 76 from abuse and that no measures were put into place to prevent Resident 16 from abusing other residents.",2020-01-01
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
4867,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2018-10-10,602,D,1,0,0EVE11,"**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 ensure that interventions were in place to protect resident property for one current sampled resident (Resident 2). The facility census was 25. Findings are: Review of Resident 2's Admission Record, printed 8/17/18, revealed that the resent had [DIAGNOSES REDACTED]. Review of the Care Plan, printed 8/17/18, revealed that the resident had impaired cognitive function or impaired thought processed related to diagnosis. Review of the facility Investigation Report Misappropriation, dated 8/17/18, revealed that on 8/14/18, the AD (Activities Director) reported to the Administrator that the resident had a visitor on some weekends who asks the resident for money. Further review revealed that the resident was educated that the resident was not required to give money to visitors and the resident stated understanding. Interview with the resident on 10/10/18 at 9:50 AM revealed reported missing money. The resident stated may have taken out to the ranch and left it there but not sure. The resident stated I forget a lot of stuff sometimes. Further interview with the resident at 12:45 PM revealed would like a locked box in the room to keep money. Interview with the Administrator on 10/10/18 at 1:00 PM revealed that the resident's cognition varied and that the resident had memory loss. Further interview confirmed that staff reminders not to give a visitor money may not be effective. Interview with the Social Services Director on 10/10/18 at 1:00 PM revealed that the resident could have a locked box in the room for valuables.",2020-03-01
5456,GOOD SAMARITAN SOCIETY - WOOD RIVER,285198,1401 EAST STREET,WOOD RIVER,NE,68883,2017-03-22,223,J,1,1,HUVK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05 (9) Based on record review, observation, and interview; the facility failed to ensure residents were not subjected to physical abuse. This violation effected one of five sampled residents, Resident 40. The facility census was 59. Findings are: A review of the Facility's policy and procedure titled ABUSE AND NEGLECT, last revised 11/16, revealed the purpose of the policy was to ensure 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 A review of the facility's documentation of Investigation of ABUSE, NEGLECT, OR MISAPPROPRIATION dated 2/22/17, revealed that on 2/9/17, Resident 81 was observed by staff to be hitting Resident 40 on the head with a hairbrush. The residents, who resided in the same room on the facility's Special Care Unit (SCU)-for Memory Care, were immediately separated. Resident 81 was sent out to an area Hospital's Behavioral Unit for evaluation and returned to the facility on [DATE] . The outcome of the facility investigation was to continue to monitor Resident 81's interactions with roommate as well as other residents, and make a room change when one was available. A review of Nurses Notes for Resident 40 revealed a note dated 2/9/2017 at 12:41 which documented that the resident was struck with a hairbrush on the resident's head by roommate (Resident 81). Two staff members were in the resident's room when incident occurred. Residents 40 and 81 were immediately separated and no injuries are noted at the time for Resident 40. The documentation indicated that Safety precautions are being advised. Further review of Resident 40's Nurses Notes, dated 2/9-3/5/17, revealed no further documentation related to the incident on 2/9/17 nor interventions which were put into place to ensure Resident 40's safety following readmission of Resident 81. A review of MDS (Minimum Data Set-a mandatory comprehensive assessment tool used for care planning) information for Resident 40 revealed an Annual assessment, dated 1/31/17, which indicated: BIMS (Brief Interview for Mental Status)=03 (scores=00-07 indicate severe impairment), the resident exhibited behaviors not directed at others 1-3 days of the assessment period. Resident 40's behaviors had worsened since the previous review and significantly interfered with the residents participation in activities or social interactions, intruded on privacy/activity of others, and was disruptive to care and the living environment. The resident required: extensive assist of two staff members for bed mobility, transfers, and personal hygiene; extensive assist of one for dressing, eating, and toilet use; walking in room occurred once or twice, walking in corridor was dependent with 1 assist, and a wheelchair was used for most locomotion both on and off the unit. A review of Resident 81's Care Plan printed on 3/6/17 revealed the resident: had impaired cognitive function (dementia or impaired thought processes), had a mood problem of anxiety and major [MEDICAL CONDITION] evidenced by tearful episodes about not being able to go back home, and exhibited behavior symptoms toward roommate and staff. The resident wandered into others rooms. The resident would swear/yell at staff, hit, and use care equipment as weapons by swinging items toward others in a defensive manner. Documented interventions included: provide a structured environment in the SCU, consult with Psychiatric Advanced Practice Registered Nurse (APRN) related to behaviors and use of antipsychotic medications, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention and remove from situation, and offer diversionary activities such as folding towels, dusting, sorting items. Revisions dated 2/22/17 were: continue to monitor interactions with roommate and other residents throughout the day to ensure others' safety, consult with pharmacy and health care provider to consider dosage reduction when clinically appropriate, and redirect with conversation and a walk in the fenced in area of the Special Care Unit if weather permitted . The Care Plan did not include new interventions put into place to protect Resident 81's roommate (Resident 40) from further physical abuse upon Resident 81's readmission on 2/14/17. . An interview on 3/6/17 at 1:30 PM with Nursing Assistant (NA)-DD revealed Resident 40 was dependent upon staff for ADLs (Activities of Daily Living), yelled out/verbalized almost constantly during cares, was unable to voice needs, required a sit/stand mechanical lift for transfers, used tilt in space w/c for locomotion, was assisted with toileting every 2 hrs. and laid down in bed after meals. Continued interview with NA-DD revealed the NA was unaware of any new interventions put into place following the readmission of Resident 81 (Resident 40's roommate) to ensure no further abuse occurred. The NA reported staff were aware of the need for increased supervision in the SCU and tried to keep one staff member in the commons area with any residents who were there. The other scheduled staff member would monitor the hallway and resident rooms. An interview on 3/6/17 at 1:15 PM with Medication Aide (MA)-EE revealed Resident 40 (Resident 81's roommate) was cognitively impaired and dependent upon staff for ADLs. Resident 40 also did a lot of screaming or calling out, which seems to upset Resident 81. The MA reported that since Resident 81 returned to the facility following psychiatric evaluation, some medication changes have been made, and things seem to be better with the resident's roommate. A motion alarm was in place in the room shared by Resident 40 and 81, which alerted staff to when Resident 81 crossed to the roommate's side of the room. The motion alarm was not a new intervention and the MA denied knowledge of new interventions put into place to protect Resident 40 following Resident 81's readmission to the facility and room [ROOM NUMBER]. MA-EE reported that Resident 81 spent a lot of time in the commons area and ambulated independently throughout the Special Care Unit. An observation on 3/6/17 at 1:30 PM revealed room [ROOM NUMBER] was shared by Residents 40 and 81. A motion sensor alarm was noted at the edge of the floor mat near the privacy curtain splitting the room. The Immediate Jeopardy was abated and the severity lowered to a 'D' level in the late afternoon of 3/6/17. The facility assessed all residents that could be at risk for ongoing abuse. The facility interviewed all interviewable residents and also interviewed the family members of non-interviewable residents. Staff were educated on abuse/neglect reporting and protection of residents from abuse situations. Residents were moved to separate rooms and staff monitoring of the aggressive resident was increased to ensure that no other resident was being targeted by the aggressor. The aggressive resident's behavior monitoring plan was revised to include immediate staff interventions for the resident's behaviors.",2020-01-01
4170,REGIONAL WEST GARDEN COUNTY NURSING HOME,2.8e+181,1100 WEST 2ND,OSHKOSH,NE,69154,2018-11-07,600,D,1,0,9TU811,"**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 interventions were in place for one sampled resident (Resident 2) to prevent resident to resident abuse involving two current residents (Residents 1 and 10). The facility census was 25 with 10 sampled residents. Findings are: Review of The Resident Face Sheet, printed 11/7/18, revealed that Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 11/14/18, revealed that the resident had behavioral symptoms, was a threat to self and/or others due to multiple adverse behaviors related to [DIAGNOSES REDACTED]. Current socially inappropriate/disruptive behavior pattern includes wandering, agitation, verbal and physical aggression and disrobing. Review of the Nurses Notes revealed the following including: - 8/30/18 Resident slapped the nurse during cares; - 9/4/18 Resident tried to take Resident 10's walker in hall. Resident said no and Resident 1 started shaking the walker and grabbed Resident 10's right hand with a very tight grip. The nurse was able to get resident away and no injuries were noted to either resident; - 9/4/18 Resident aggressive with cares, slapped at staff; - 9/5/18 New orders received from the psychiatrist for increased agitation; - 9/5/18 Resident tore up papers at the nurses station, swung at nurses, difficult to provide bedtime cares; - 9/6/18 Resident combative with staff, anxious, wandered in other resident's rooms who called staff to remove the resident, resident grabbed the threshold of the door and would not leave the room; - 9/6/18 Resident combative and slugged nursing assistant in the stomach during cares; - 9/7/18 Resident pushed residents in wheelchairs against their will; - 9/8/18 Resident hit and kicked at staff; - 9/9/18 Resident combative, hit staff and twisted staff's fingers, slapped at staff several times, medications not effective, refused cares; - 9/10/18 Psychiatrist increased medication dosage, resident undressed and urinated in the dining room, combative and hit the nurse with cares; - 9/11/18 Resident physically aggressive towards staff on three separate occasions, hit staff during cares slapped a nursing assistant and nurse across the face; - 9/12/18 Resident hit the nurse several times on the back, side and head during cares, slapped staff; - 9/13/18 Resident combative, hit staff, resistant to redirection, wandered into other resident rooms, medications given with little improvement; - 9/14/18 Resident had combative and agitated behaviors, hit staff several times during cares, medications given with little help; - 9/15/18 Resident continued wandering in other resident's rooms, tried pushing residents in wheelchairs, hard to redirect, agitated with cares; - 9/17/18 Resident aggressive and hit staff during cares; - 9/18/18 Resident knocked a television off counter in another resident's room, set off door alarms, aggressive and angry, hit, slapped and pinched staff; - 9/20/18 Resident agitated and resistive, wandered into other resident's rooms and went through their belongings, resisted redirection from staff, medication given with little improvement; - 9/24/18 Resident physical aggressive, combative, wandered in other resident's room; - 9/25/18 Resident hit staff during cares; - 9/27/18 Orders received for geri -sight (sic) testing; - 9/28/18 Resident agitated and combative, physically aggressive with staff with cares and redirection from other resident's rooms, medications given with little effect, attempted to take other resident's walkers, non pharmacological interventions such as redirection, snacks, drinks, toileting and magazines not effective ; - 10/7/18 Resident agitated with cares; - 10/8/18 Resident slapped nurse and nursing assistant; - 10/9/18 Resident propelled self in the wheelchair to chair that Resident 1 was sitting in and put feet up on the chair. Resident 1 said your feet don't belong up here, staff member was present and attempted to assist the resident to move feet, resident quickly became agitated and struck out at staff and then hit Resident 1 upper left arm with an open hand. The resident's were separated. Resident 1 had no injuries or pain; - 11/4/18 Resident bent nursing assistant's fingers back and combative with cares. Interview with the DON (Director of Nursing) on 11/7/18 at 2:30 PM confirmed that the resident had ongoing aggressive and abusive behaviors directed towards staff and residents as documented in the Nurses Notes. Care Plan approaches were not effective to manage the resident's behaviors and to prevent the resident to resident altercations documented on 9/4/18 with Resident 10 and on 10/9/18 with Resident 1.",2020-09-01
2053,GOOD SAMARITAN SOCIETY - VALENTINE,285176,601 WEST 4TH STREET,VALENTINE,NE,69201,2018-12-11,600,D,1,0,B7PS11,"**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 protect one sampled resident (Resident 8) from physical abuse from one sampled resident (Resident 7). The facility census was 35 with six current sampled residents. Findings are: Review of the Admission Record, printed 12/10/18, revealed Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan, goal date 2/28/18, revealed the resident had impaired cognitive function related to dementia, memory loss, confusion, impaired vision and hearing and used a wheelchair for mobility. Review of the facility Investigation Report, dated 11/15/18, revealed on 11/15/18 at 5:15 PM Resident 7 struck Resident 8 in the back with a glass vase, and Resident 8 showed no injuries from the contact. Further review revealed Resident 7 had a history of [REDACTED]. Review of Resident 7's Progress Notes revealed the resident exhibited physical and verbal behaviors directed towards staff on 9/6/18, 9/10/18, 9/11/18, 9/27/18, 10/4/18, 10/10/18, 10/24/18, 10/28/18, 11/8/18, 11/11/18, 11/14/18, 11/15/18, 11/16/18, 11/19/18, 11/20/18, 12/5/18, 12/6/18, 12/8/18 and 12/9/18. Further review of the Progress Notes revealed Resident 7 exhibited aggression towards other residents including the following: - 10/28/18 grabbed the Halloween pumpkin off of the piano and tried to hit a resident (unidentified) who was sitting next to the piano; - 11/8/18 hollered at staff and other residents, blocked a resident and staff in the hallway, threatened them, yelled and threatened tablemate (unidentified) in the dining room; - 11/14/18 blocked residents who tried to get around the resident; - 11/14/18 violently assaulted resident (Resident 8), hit resident in the back with a glass vase; - 11/16/18 went into residents' rooms tried to fix things and moved furniture and blankets and blocked residents who tried to get around the resident. Interview with the Director of Nursing on 12/11/18 at 2:30 PM confirmed effective interventions were not in place to protect Resident 8 from physical abuse from Resident 7.",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
3181,EL DORADO MANOR NURSING HOME,285253,"71434 HWY 25, BOX 97",TRENTON,NE,69044,2017-11-02,223,E,1,1,Y76H11,"**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 identify risk factors and provide interventions to prevent resident to resident abuse for three current sampled residents (Residents 18. 19 and 37). The facility census was 32 with 14 current sampled residents. Findings are: [NAME] Review of the Face Sheet, printed 10/31/17, revealed that Resident 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility abuse investigation summary report, dated 5/21/17, revealed that Resident 19 yelled at Resident 18, threw rings at Resident 18 and attempted to move Resident 18's bed from the room. Review of the Care Plan, goal date (MONTH) (YEAR), revealed that the resident had short term and long term memory deficits and was confused at times. Further review revealed no care plan to address risk for resident to resident abuse, the episode of resident to resident abuse or interventions to prevent recurrence. Interview with the SSD (Social Services Director) on 11/1/17 at 2:00 PM revealed that risk factors related to resident to resident abuse were not identified for Resident 19. Interview with the DON (Director of Nursing) on 11/1/17 at 2:00 PM confirmed that interventions were not in place to prevent the resident to resident abuse altercation. B. Review of Resident 18's Face Sheet, printed 10/31/17, revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility Investigation Report on Resident to Resident Altercation revealed that on 6/27/17 at 5:30 PM, Resident 18 kicked Resident 37 in the lower extremities Review of the facility Investigation Report on Resident to Resident Altercation revealed that on 6/27/17 at 6:05 PM, Resident 18 hit Resident 19's arm with a closed fist. Review of the resident's Care Plan, goal date (MONTH) (YEAR), revealed that the resident had a potential for verbal and physical behaviors related to powerlessness, anxiety and depression and gets agitated easily and may yell or lash out. Interview with the DON on 11/1/17 at 2:00 PM confirmed that care plan interventions were not in place and were not effective to prevent altercations with other residents.",2020-09-01
1635,MAPLE CREST HEALTH CENTER,285149,2824 NORTH 66TH AVENUE,OMAHA,NE,68104,2017-11-02,241,E,1,1,I4SU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05(21) Based on observation and interview, facility failed to ensure that resident's dignity and respect were maintained as evidenced by the presence of slings (a cloth device used to assist in full lift transfers) exposed in plain sight and staff placed clothing protectors on residents without obtaining residents permission or giving them a choice. The practice affected 8 (Residents 69, 92, 100, 125, 142, 146, 161 and 165) of 55 Residents that ate in the main dining room. The facility census was 145. Findings are: Observation on 10/30/17 between 8:00 AM and 8:45 AM in the Benson Terrace dining area revealed Nurse Aide (NA) A placed clothing protectors on Residents 92, 161, 100 and 142 without asking or saying anything to the residents. Residents 92, 161, 100 and 142 had slings beneath them in their wheelchairs and the slings were exposed and in plain sight. Observation on 11/01/2017 between 12:22 and 12:30 PM in the main dining area revealed Residents 165, 69, 146 and 125 had slings beneath them in their wheelchairs that were exposed and in plain sight. NA A, NA B, NA C and NA D placed clothing protectors on Residents 165, 69, 146 and 125 without asking. Interview on 11/01/2017 at 12:56:31 PM with RN [NAME] confirmed that the slings should not have been exposed and should have been tucked down in so they couldn't be seen. RN [NAME] confirmed that the NA's should always ask the residents prior to putting on clothing protectors so that the residents had a choice. RN [NAME] confirmed that it could cause embarrassment and could single them out as those who required assistance with transfers. It could be a dignity issue if they are not given a choice whether or not to use a clothing protector. RN [NAME] confirmed that Residents 69, 92, 100, 125, 142, 146, 161 and 165 were cognitively impaired. Record 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.) for the following residents revealed the following information: - MDS dated [DATE] revealed Resident 142 was severely cognitively impaired and required extensive assistance with transfers. - MDS dated [DATE] revealed Resident 146 was severely cognitively impaired and required total assistance with transfers. - MDS dated [DATE] revealed Resident 125 was severely cognitively impaired and required total assistance with transfers. - MDS dated [DATE] revealed Resident 165 was severely cognitively impaired and required extensive assistance with transfers - MDS dated [DATE] revealed Resident 100 was moderately cognitively impaired and required extensive assistance with transfers - MDS dated [DATE] revealed Resident 161 was moderately cognitively impaired and required extensive assistance with transfers - MDS dated [DATE] revealed Resident 69 was severely cognitively impaired and required extensive assistance with transfers - MDS dated [DATE] revealed Resident 92 was severely cognitively impaired and required extensive assistance with transfers Interview on 11/02/2017 at 2:08:58 PM with the Administrator confirmed a total of 55 residents ate in the main dining room of the facility.",2020-09-01
4441,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2018-03-08,561,D,1,1,VCTE11,"**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 1 resident (Resident 48) of 21 residents sampled was bathed according to their bathing preference. The facility staff identified the census at 54. The findings are: A review of Resident 48's Admission Record dated 3-8-18 revealed that the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An interview conducted on 3-5-18 at 1:21 PM with Resident 48 revealed that the resident preferred 2 baths a week, but was receiving less than 1 bath a week. A review of Resident 48's Documentation Survey Report for (MONTH) (YEAR) revealed Resident 48 received a bath on 3-1-18 with no further baths received. A review of Resident 48's Documentation Survey Report for (MONTH) (YEAR) revealed Resident 48 received baths on 2-3-18 and 2-13-18. A review of Resident 48's Comprehensive Care Plan dated 9-22-15 revealed that Resident 48 required staff assistance with bathing. An interview conducted on 3-7-18 at 3:28 PM with the Director of Nursing revealed that Resident 48 preferred a bath 2 times a week in the evening and was on the bath schedule for twice a week. An interview conducted on 3-7-18 at 4:50 PM with the Administrator revealed that the Administrator had talked to Resident 48 and the resident confirmed they were not receiving their baths.",2020-06-01
5908,"PREMIER ESTATES OF PIERCE, LLC",285139,"P O BOX 189, 515 EAST MAIN STREET",PIERCE,NE,68767,2016-08-30,242,D,1,0,4DW611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05(4) Based on observation, interviews, and record review; the facility failed to allow Resident 19 a choice in what time to go to bed at night. Facility census was 38. Findings are: Review of Resident 19's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 5/31/16 indicated it was very important to Resident 19 to have choices regarding daily routines for going to bed at night. The assessment further identified the resident required extensive staff assistance with transfers and bed mobility and the resident had [DIAGNOSES REDACTED]. Observation of Resident 19 on 8/29/16 at 7:30 PM revealed the resident was seated in a wheelchair in the doorway of the resident's room. Resident 19 was dressed in a hospital gown and a pair of slacks. Interview with Resident 19 on 08/29/16 at 7:40 PM revealed that staff usually put the resident to bed at 9:00 PM. The resident indicated this was too late and the resident preferred to go to bed early, at about 7:00 PM. Observations of Resident 19 on 8/29/16 revealed the following: -7:42 PM the resident remained seated in a wheelchair, dressed in a hospital gown and a pair of slacks. The resident rocked the wheelchair back and forth in the doorway of the resident's room and into the corridor outside of the resident's room. -7:45 PM Nursing Assistant (NA)-D walked by the resident and stated, You are next and then proceeded past the resident, exited the corridor outside of the resident's room and then continued down the adjoining corridor. -7:57 PM the resident remained positioned in the corridor directly outside of the resident's room. NA-D again walked by the resident's room and stated it will be about 5 to 10 more minutes. -8:00 PM to 8:15 PM the resident remained seated in the wheelchair in the corridor outside of the resident's room. -8:16 PM the facility Housekeeping Supervisor walked by the resident's room. The resident asked staff to bring the sit-to-stand mechanical lift (mobile lift that allows for patient transfers from a seated position to a standing position. This lift is used for bed to chair transfers; toileting and performing perineal care/changing incontinent briefs) to the resident's room. The Housekeeping Supervisor encouraged the resident to wait for the nursing staff to provide assistance and stated I would help you if I could. -8:18 PM NA-C walked past the resident's room. The resident called out for NA-C to assist the resident into bed. NA-C stated, Just a minute and continued to walk past the resident's room. -8:27 PM NA-C again walked past the resident's room and stated to the resident don't worry I haven't forgotten about you . -8:37 PM NA-D propelled the sit-to-stand mechanical lift into Resident 19's room and transferred the resident into bed. Interview with NA-D on 8/29/16 at 8:47 PM revealed Resident 19 preferred to go to bed early and frequently requested to be in bed by 7:00 PM. NA-D further revealed it was usually closer to 9:00 PM before the resident was assisted to bed.",2019-08-01
5732,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2016-09-20,224,D,1,0,TD4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05(9) Based on interviews and record reviews, the facility failed to ensure that 2 sampled residents (Residents 11 and 133) were protected from misappropriation. Facility census was 114. Findings are: A. Review of the mandatory report sent to the State Agency on 6/6/16 revealed a report and investigation for missing money for Resident 11. Further review of the report revealed a written intervention of offering a lock box and education of the resident and family. There was no written documentation to support that the staff had been educated on misappropriation. The money was accounted as accurate and missing by the resident's son. Interview on 9/12/15 at 10:00 AM with Resident 11 revealed that the resident was missing money. Resident 11 reported the missing money and stated that the facility provided as a lock box and replaced the money. In reviewing the facility grievances, it was noted that there were 7 other residents with misappropriation of money from the month of (MONTH) (YEAR) through (MONTH) (YEAR). In reviewing each one, the solution was to get the money in a lock box and repay the funds back to the resident. Education with the family and the resident. Further review revealed no written documentation of education with the staff or investigation with the staff. Interview with the Administrator and the Director of Nursing on 9/20/16 at 4:00 PM confirmed that Resident 11 did have money that was taken. Continued interview verified that the facility replaced the money and gave the resident a lock box and education was completed with the son and the resident. Further interview verified that there was no written documentation of an investigation into the 8 accounts of misappropriation of money to look for the causal factors and no written education with the staff in regards to misappropriation. Further interview confirmed that the person doing the investigating should have looked or identified potential causal factors or suspicions for the missing money to prevent the misappropriation from occurring so often. B. Record review of a facility incident report and investigation confirmed that Resident 133 had been prescribed 60 [MEDICATION NAME] pills that had been delivered to the facility and signed off by an Licensed Practical Nurse (LPN-unidentified) upon delivery then handed it to a Medication Aide (MA-R) to deliver to the appropriate floor. The pills were not on the appropriate floor at change of shifts. The report reveled that MA-R was under suspicion for medication coming up short or missing in the past. Interview with Resident 133 on 9/20/2016 at 10:48 AM revealed that they were alert and oriented and knew what pain medications they took and at what times. The resident revealed that they were never denied medication or missed a dose. Interview with the Administrator on 9/20/2016 at 2:30 PM confirmed that MA-R had been taken off the medication cart prior to this incident due to coming up short with medications in the past. The Administrator confirmed that MA-R should not have taken the pills to deliver to the floor. The Administrator revealed that the facility was able to replace the missing pills and no residents went without the prescribed medication.",2019-09-01
2247,ELMS HEALTH CARE CENTER,285191,"P O BOX 628, 410 BALL PARK ROAD",PONCA,NE,68770,2019-01-24,600,D,1,1,E2LJ11,"**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 ensure Residents 3 and 19 were free from abuse related to smoking and the use of the Behavior Contract and Making Smart Choices form. The sample size was 7 and the facility census was 38. Findings are: [NAME] Review of the facility Abuse and Neglect Policy (undated) revealed it was the policy of the Elms Health Care Center to protect the residents from mistreatment, neglect, and abuse. Review of the facility Abuse, Neglect, or Misappropriation reporting form (undated) revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. B. Review of an Encounter Telehealth Psych Progress Note dated 11/20/18 revealed Resident 3 exhibited bizarre behaviors. The resident presented with impaired judgment, severely impaired attention/concentration, impaired recent memory, and severely impaired cognitive flexibility. (There was no evidence to indicate the practitioner felt a behavior contract would be beneficial to the resident). Review of Resident 3's Behavior contract and Making Smart Choices form dated 12/26/18 revealed the following: - If the resident hollered or screamed the resident may not be allowed to smoke. - If the resident did not eat at least 50 percent of the meal the resident may not be allowed to smoke. - The contract was signed by the resident and the Director of Nursing (DON) on 12/26/18. - There was no evidence to indicate the resident's Power of Attorney (POA) had signed or been informed of the contract. Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/8/19 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7 (with a score from 0-7 indicating severe cognitive impairment). Review of Resident 3's current Care Plan with a revision date of 1/19/19 revealed the resident was at times sad or angry and unable to tell the staff why. The resident didn't always understand what was going on and would lash out physically because of it and had trouble making decisions. The resident's [DIAGNOSES REDACTED]. Review of Resident 3's Progress Notes revealed the following: - On 10/9/18 at 7:28 PM, the resident yelled and became upset about not being included in the smoking group. The residents tantrum built with other residents then chastening the resident for the resident's behavior. - On 10/10/18 at 7:58 PM, the resident's POA spoke with the facility and wanted to ensure the resident had enough money for cigarettes. The POA would send more money if needed. - On 12/19/18 at 11:04 PM, at supper the resident started crying and yelling. Staff told the resident to stop or else the resident would not get to go out for the 7:00 PM smoke break. The resident continued to yell. Once the resident was quite, the staff took the resident to the resident's room without a cigarette break. The resident was told that the staff were not going to reward bad behavior. - On 1/2/19 at 12:48 AM, the resident was not allowed to go outside for the 7:00 PM smoke break per the resident's contract since the resident didn't eat half of the supper meal. The resident then asked to go to bed right away and the staff made special effort to take the resident to bed immediately as a consolation for not getting a cigarette. When the resident saw the resident's coat on the bed the resident started begging and yelling to go outside. When the smoke break was again refused and the contract reiterated the resident began hitting and kicking at staff. - On 1/7/19 at 1:21 AM, the staff reported the resident swung at tablemates and at staff during cares. The resident was upset about not getting a cigarette break due to contract. - On 1/20/19 at 1:11 AM, after supper a staff member assisted the resident with the resident's coat when the resident got upset and scratched the staff's face. The resident was not allowed to go out to smoke because of the aggression per the resident's contract. - On 1/20/19 at 1:32 PM, the resident was near the nurse's station and hit a cup of water off of the nurse's station spilling the water. While staff cleaned the spill the resident kicked and yelled out loudly. The resident was not allowed to smoke. An interview with Registered Nurse (RN)-B on 1/23/19 at 10:24 AM revealed RN-B tried to limit Resident 3's smoking because the resident had to be supervised while smoking, needed assistance with putting on a coat and apron, needed help lighting the cigarette, and took a longer time to smoke. RN-B stated RN-B tried to let Resident 3 only smoke about every other smoke break because of the time extra time it took. RB-B confirmed Resident 3 had increased behaviors when the resident wasn't included on a smoke break. RN-B stated I don't let the staff get the resident up and down for smoke breaks, if the resident wanted to smoke then the resident had to stay up after the smoke break. RN-B stated cigarette breaks were also taken away based on the behavior contract. During an interview with the Director of Nursing (DON) on 1/23/19 at 10:40 AM, the DON confirmed a behavior contract was created by the DON in an attempt to improve the resident's behaviors through smoking restrictions. The DON confirmed the resident's physician was not involved in the development or implementation of the behavior contract. C. Review of the facility policy titled Resident Smoking Policy (undated) revealed the facility's intent was to provide a safe and healthy environment for residents, visitors and employees, including safety as related to smoking. The following guidelines were identified: -smoking was to be prohibited in all areas except the designated smoking area. A Designated Smoking Area sign was to be prominently posted; -residents that smoke were to be further assessed, using the Resident Safe Smoking Assessment to determine whether or not supervision was required for smoking, or if the resident was safe to smoke at all; and -any resident who was deemed safe to smoke, with or without supervision, was to be allowed to smoke in the designated smoke areas (weather permitting) at the designated smoke times and in accordance with the residents plan of care. D. Review of Resident 19's MDS dated [DATE] revealed the resident had [DIAGNOSES REDACTED]. The resident was cognitively intact with signs and symptoms of [MEDICAL CONDITION] which included inattention (difficulty focusing attention) and altered level of consciousness (repeatedly dosing off when being asked questions and difficult to arouse or keep aroused during an interview). The assessment indicated these behaviors fluctuated in severity. In addition, the resident was identified as having verbal behaviors, rejection of cares and wandering which occurred 1-3 days of the assessment period. Resident 19 was identified as using tobacco. Review of a Smoking Risk assessment dated [DATE] at 9:15 PM revealed Resident 19 had requested to return to smoking. The resident had both chewed tobacco and smoked in the past, but had stopped chewing. The resident had not fully stopped smoking as the resident smoked when on facility outings. The assessment further revealed the resident had burnt the resident's fingers when out smoking on this date and the facility had provided the resident with a cigarette holder to prevent further burns. The assessment further identified a moderate problem with the resident's general behaviors and interpersonal interactions. The assessment indicated the resident was a safe smoker as long as the resident followed the facility policy. Review of the resident's current Care Plan with revision date 11/23/18 revealed the resident had a strong identification with past roles and life status related to the resident's desire to smoke. The following interventions were identified: -allow the resident to express feelings. The resident has stated that smoking helps to calm the resident's nerves; -allow the resident to smoke as the resident desires following the smoking policy; and -provide opportunity for the resident to maintain personal roles and allow the resident to have a cigarette at the scheduled smoke times. Review of a form titled Behavior Contract and Making Smart Choices dated and signed by Resident 19 and the Director of Nursing (DON) on 12/19/18 revealed the following behaviors and consequences for the resident: Behavior: if I am sticking my hand down my throat and mouth. Consequence: I will not be allowed to go out on the next cigarette time. Behavior: if I am angry and threatening to break things. Consequence: I will have to stay in my room until the anger passes. My cane may be taken from me if I am using it as a weapon. Behavior: I will take my meds (medications) when the nurse/ MA (Medication Aide) brings them to me. Consequences: I will not be allowed a cigarette the next time. Behavior: I will get up and come out to the DR (Dining Room) on time for my meals. Consequence: I will not be allowed to go on the next outing. The Charge Nurse or the DON will be the ones to enact the consequences. Observations of Resident 19 on 1/17/19 from 1:30 PM to 2:01 PM revealed the following: -1:30 PM the resident entered the DON's office and the resident asked if the DON would help the resident to calm down. The DON asked the resident if calming down meant smoking and the resident indicated smoking would help the resident. The DON stated it was not time for the resident to smoke. The resident closed eyes and began to moan and to sway back and forth. The DON then asked the resident to leave the DON's office and to go to the resident's room; -1:36 PM the resident ambulated from the resident's room and out to the dining room. The resident was wearing a ball cap and the resident's coat. The resident passed by the Nurse's Station and sat in a chair immediately opposite of the exit door for the patio which had been designated as the Smoking Area. Licensed Practical Nurse (LPN)-D who was working as the Charge Nurse, was seated at the Nurses Station and addressed the resident as the resident walked by the Nurse's Station; -1:57 PM MA-A approached the resident and indicated it was time to go out to smoke. MA-A placed a cigarette in a cigarette holder and gave the items to Resident 19. MA-A opened the exit door and then held the door for Resident 19. The resident walked out to the Smoking Area and sat down in a patio chair. MA-A lit the resident's cigarette; -1:58 PM LPN-D called for the DON and indicated the resident was not to be smoking. LPN-D asked the DON to take the cigarette away from the resident. The DON proceeded out to the Smoking Area, removed the cigarette holder and the lit cigarette from Resident 19 and placed the cigarette in a trash receptacle. The DON then re-entered the facility; -2:01 PM the DON held open the patio door and indicated the resident was to come back into the facility. Resident 19 returned inside and then walked down the corridor to the resident's room. Review of Resident 19's medical record revealed no evidence the resident had any of the behaviors which had been identified on the resident's Behavior Contract which would indicate a consequence of the resident not being allowed to smoke. Interview with the DON on 1/23/19 at 2:35 PM confirmed the following: -LPN-D had approached the DON on 1/17/19 at 2:00 PM and told the DON that Resident 19 was outside smoking and the resident was not supposed to be allowed to smoke; -the DON was unaware of the reason Resident 19 was not supposed to be smoking; -there was no documentation in the resident's medical record to indicate the resident had a behavior which was identified on the Behavior Contract as a reason for the resident to be denied the right to smoke at the designated smoke times; and -staff should not be using the resident's smoking privileges as a punishment when the staff did not approve of the resident's behaviors.",2020-09-01
6414,LYONS LIVING CENTER,285301,1035 DIAMOND STREET,LYONS,NE,68038,2018-05-10,600,K,1,0,2CLY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05(9) Based on observation, record review and interview; the facility failed to protect residents from residents with adverse behaviors. This affected all residents (Residents 1, 2, and 10) who were residing on the Memory Support Unit (an enclosed wing or hallway which specializes in care of residents with dementia or [MEDICAL CONDITION]). The sample size was 14 and the facility census was 23. Findings are: A. Review of the facility policy titled Preventing Resident Abuse dated 12/13/16 revealed a facility goal to achieve and maintain an abuse free environment. The abuse prevention/intervention program included the following: -assisting or rotating staff working with difficult residents; -training staff to understand and manage a resident's verbal, physical and sexual aggression; -assessing, care planning and monitoring residents with needs and behaviors that may lead to conflict; -assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behaviors; -involving qualified psychiatrists and other mental health care professionals to help the staff manage difficult or aggressive residents; and -striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met. B. Review of the facility policy Resident to Resident Altercations dated 12/13/16 revealed all altercations, including those that may represent resident to resident abuse, shall be investigated and reported to the Director of Nursing (DON) and the Administrator. If 2 residents are involved in an altercation the staff will: -separate the residents and institute measures to calm the situation; -identify and implement interventions to prevent reoccurrence; -update the resident's care plans; and -report the incident and corrective measures to the appropriate state agencies. C. Review of the facility policy titled Protecting Residents during Abuse Investigations dated 12/13/16 revealed if the alleged abuse involves another resident, the accused resident's representative, and Attending Physician were to be informed of the incident. In addition, the accused resident was to be restricted from visiting other resident's rooms. Within 5 working days of the alleged incident, the facility was to give the state agency a written report of the findings of the investigation and a summary of corrective action taken to prevent the incident from recurring. D. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/7/18 revealed the resident was admitted on [DATE] from an acute care hospital. The resident's cognition was severely impaired and the resident had a behavior of wandering identified. The wandering placed the resident at significant risk for getting into a potentially dangerous area but did not significantly intrude on the privacy of other residents. The MDS identified a [DIAGNOSES REDACTED]. Review of the resident's undated current Care Plan revealed the resident had impaired decision making skills with memory loss related to a [MEDICAL CONDITION] from a suicide attempt in (MONTH) of (YEAR). The resident had poor decision making skills with a short attention span and made occasional inappropriate comments. No interventions were identified on the residents' plan of care related to cognitive loss or the resident's occasional inappropriate comments. Review of Resident 1's Nursing Progress Notes revealed the following: -2/28/18 at 12:43 PM, (late entry for 2/27/18) the resident was admitted to the Memory Support Unit. The resident was exit seeking but redirected easily. -3/5/18 at 4:56 AM, the resident was wandering in the Unit with an occasional attempt to exit seek. -3/7/18 at 7:45 AM, the resident approached the Nurse's Station and asked if the nurse wanted to have sex. Behavior was easily redirected. -3/19/18 at 3:00 AM, the resident was found in the resident's room with Resident 2. Resident 2 was seated on the side of the bed and Resident 1 was on knees, in an inappropriate position between Resident 2's legs. Both residents were covered with a blanket. The residents were immediately separated and the DON was notified of the incident. Review of Resident 1's medical record revealed no evidence the resident's care plan had been updated regarding the inappropriate sexual behaviors and/or new interventions developed to address the resident's behaviors. Review of Resident 1's Nursing Progress Notes revealed the following: -3/29/18 at 5:20 AM, the resident was making perverted, sexually inappropriate comments to the staff. -4/5/18 at 6:13 AM, the resident has made sexual comments to the staff, asking if staff was a virgin. The resident later came out of the resident's room with the resident exposed and asked the staff member if the resident could stick it up the staff's ass. -4/7/18 at 11:00 PM, the resident was thrusting hips behind a staff member's back. -4/9/18 at 2:40 AM, the resident pulled pants down below buttocks and stated come on to the staff. -4/10/18 at 5:06 AM, the resident came up to staff and stated I want to [***] you. -4/11/18 at 3:30 AM, the resident asked staff if the resident could stick it up the staff member's ass. -4/12/18 at 4:17 AM, the resident was identified as making sexual comments to the staff. Resident asked to eat out the staff member. -4/12/18 at 5:38 PM, the resident asked staff repeatedly about whether or not the staff member was a virgin. -4/12/18 at 6:00 PM, the resident answered the phone on the Memory Support Unit. Staff removed the phone from the resident. The resident then asked if the resident could f--k (obsenity) the staff member in the butt. -4/12/18 at 8:32 PM, the resident had been sexually harassing the staff throughout the shift. The resident came out of the resident's room exposed. The resident asked staff if the resident could f--k (obsenity) staff in the ass. The resident continued to make sexually inappropriate comments and threw a plastic cup at staff. -4/13/18 at 12:45 AM, two Nursing Assistants (NA) entered the Memory Support Unit to assist with rounds. The resident came up behind one of the staff members, placed a hand over the staff member's mouth and used the other arm to grasp the staff member's body and to pull staff up against the resident. The staff member exited the Unit when released and refused to return. -4/13/18 at 4:48 AM, the resident asked staff if the resident could f--k (obsenity) the staff member in the ass. -4/13/18 at 5:13 AM, the resident continued to make sexual comments and gestures to the staff. The resident became angry when the staff attempted to redirect. -4/13/18 at 8:08 PM, the resident swatted the staff's backside 3 times throughout the shift. An appointment was made with the resident's primary physician. -4/16/17 at 3:50 PM, the resident was identified as asking staff inappropriate, sexual questions, requesting sex and inappropriately touching staff on multiple occasions. On 4/18/18 at 3:15 PM a facsimile (fax) was sent to the resident's physician to notify of the sexually inappropriate behaviors toward the staff. The fax indicated the resident had covered a staff member's mouth after coming up behind the staff and was then humping the staff member. The fax further indicated this had happened numerous times. An order was received for [MEDICATION NAME] (medication used to treat anxiety and depression) 300 milligrams (mg) three times a day to help control inappropriate behaviors. Review of Nursing Progress Notes revealed the following: -4/18/18 at 4:26 PM, the resident was kicking the window. The resident identified a desire to get out of the facility. The resident was exposed and asked staff if the resident could stick it in the staff member's vagina. -4/19/18 at 1:48 AM, the resident continued to make sexually inappropriate comments and walked around exposed. -4/20/18 at 1:50 AM, the resident was identified as having 2 episodes of sexually inappropriate behaviors throughout the shift. -4/20/18 at 2:40 PM, the resident continued to display sexually inappropriate behaviors throughout the shift. -4/21/18 at 5:44 AM, the resident came out of room without wearing any pants or underwear. -4/21/18 at 12:30 PM, the resident was identified as having inappropriate behaviors and the resident's physician ordered the resident to be placed in Emergency Protective Custody (EPC-part of the mental health commitment act which permits law enforcement officers to take into custody a mentally ill, dangerous person that is likely to harm themselves or others before a mental health commitment hearing can be held). The resident was taken to Oakland Mercy Hospital. Review of a Nursing Progress Note dated 4/27/18 at 7:00 AM revealed the resident was readmitted to the Memory Support Unit. New interventions were identified to have 2 staff working in the unit at all times and for staff to provide and document every 15 minute checks of the resident. Review of Resident 1's Nursing Progress Notes revealed the following: -4/30/18 at 11:15 PM, the resident attempted to open the exit door and when the door would not open, the resident exposed self and walked through the hallway. -5/1/18 at 12:05 PM, the resident came out of the resident's room and asked staff can I f--k (obsenity) you?' and can you f--k (obsenity) me?. -5/1/18 at 2:00 AM, the resident came to the Nurse's Station and told staff it's time to f--k (obsenity). -5/1/18 at 2:08 AM, the resident was in the bathroom. The resident began to yell out for the staff. When asked what the resident needed the resident responded your pussy. -5/1/18 at 4:00 AM, the resident came out of the resident's room completely naked. -5/1/18 at 5:04 PM, an order was identified for the resident to receive psychiatric evaluation at Fremont Behavioral Health and for psychiatric counseling. -5/2/18 at 5:48 PM, The resident and another resident were discovered by staff about to fight with each other. No physical altercation occurred. After being redirected from the other resident, Resident 1 came up behind a staff member and asked staff if they wanted to f--k (obsenity). Resident redirected to room but remained in the hallway with hands in the resident's pants and touching self. -5/3/18 at 4:20 AM, the resident was at the Memory Support Nurse's Station completely naked. -5/5/18 at 11:35 PM, resident was walking around unit with no pants and private area exposed. Review of the resident's medical record from 5/1/18 through 5/8/18 revealed no evidence an appointment had been scheduled for a psychiatric evaluation or that the resident had received any psychiatric counseling despite the resident's continued behaviors. Review of Resident 1's Nursing Progress Notes revealed the following: -5/9/18 at 5:06 AM, the resident asked the staff do you want to f--k? (obsenity) -5/9/18 at 1:41 PM, the resident asked staff if resident could see the staff's pussy. The resident was redirected and told this was an inappropriate comment. The resident then stated let me stick it in your ass. -5/9/18 at 4:06 PM, the resident told staff all you need to do is open your legs or bend over. E. Review of Resident 2's MDS dated [DATE] revealed the resident had short and long term memory loss with severely impaired decision making skills. The resident had behaviors which included hallucinations and wandering. But wandering did not place the resident at significant risk of getting to a potentially dangerous place and wandering did not intrude on the privacy of others. The resident had [DIAGNOSES REDACTED]. Review of Resident 2's undated current Care Plan revealed the resident could become angry or anxious at times related to Alzheimer's dementia. An intervention was developed to document all behaviors and mood issues and to keep the charge nurse updated. Review of Resident 2's Nursing Progress Notes dated 3/19/18 at 3:45 AM revealed the resident was found in the room of another resident on the Memory Support Unit at 3:00 AM. Resident 2 was seated on the edge of the bed and Resident 1 was on knees in an inappropriate position between Resident 2's legs. A blanket covered both of the residents. The blanket was removed and the residents were separated. Review of facility investigations of potential abuse/neglect from 12/1/17 to 4/1/18 revealed no investigation had been completed regarding the incident which had occurred between Resident 1 and Resident 2 on 3/19/18; the incident had not been reported and no interventions were put into place to protect Resident 2 from any potential ongoing sexual abuse. Review of a facility investigation dated 4/26/18 revealed on 4/21/18 at 11:58 AM, the staff had walked into a vacant room on the Memory Support Unit and had found Resident 1 and Resident 2 with their pants down and with their perineal area fully exposed. Resident 1 was holding Resident 2 in a bent over position so the resident's torso was on the bed. Resident 1 was attempting to have anal sex with Resident 2. Resident 2 appeared frightened and Resident 1 was resistive when the staff attempted to remove the resident from the situation. The report indicated Resident 1 had a recent increase in sexual comments towards the staff but had displayed no sexual tendencies toward other residents. An order was received for Resident 1 to be EPC'd and staff remained with Resident 1 until the police arrived. The resident was taken to Oakland Mercy Hospital and then to the Lancaster Mental Health Crisis Center. The resident returned to the facility on [DATE] and was readmitted to the Memory Support Unit. New interventions were identified for staff to provide and to document every 15 minute checks on Resident 1. Resident 1 was to be seen by a psychiatrist and was to receive counseling. In addition, the facility was to pursue more appropriate placement for Resident 1. Review of a Nursing Progress Note for Resident 2 dated 4/27/18 at 10:50 AM revealed staff were made aware that Resident 1 was to be readmitted . Staff to complete and document every 15 minute checks of the residents. The resident's family was notified and indicated they would trust the facility to make sure Resident 2 was not in any danger. F. Review of Resident 10's MDS dated [DATE] revealed the resident's cognition was severely impaired. The resident had behaviors which included resistance with cares and wandering and had [DIAGNOSES REDACTED]. Review of Resident 10's undated current Care Plan revealed the resident had cognitive loss due to [DIAGNOSES REDACTED]. Review of staff documentation related to the 15 minute checks of the residents on the Memory Support Unit revealed the following on 5/2/18: -9:30 AM, Resident 10 walked into Resident 1's room. Resident 1 told Resident 10 to get out. Resident 10 refused and Resident 1 stated, I will punch you and drew back fist. The residents were separated by the staff. -11:00 AM, Resident 10 was standing in the doorway to Resident 1's room. Resident 1 was at the end of the hallway, saw Resident 10 outside of room and came down the hallway with fists drawn. The residents were again separated. Review of a Nursing Progress Note for Resident 10 dated 5/2/18 at 5:55 PM revealed the resident tried to get into a physical altercation with another resident. G. Observations of the Memory Support Unit on 5/7/18 from 9:00 AM to 12:30 PM revealed the following: -9:07 AM, Resident 1 was lying on the resident's bed with eyes closed. Resident 10 entered the resident's room and stood next to Resident 1's bed. -9:11 AM, NA-B entered Resident 1's room and led Resident 10 away from Resident 1's bed. NA-B assisted Resident 10 to the bathroom in Resident 10's room. NA-B closed the door to Resident 10's room while assisting the resident with toileting. NA-B was unable to visualize Resident 1 and Resident 2 and no other staff was available on the unit. -9:11 AM, Resident 2 ambulated out of the dining room and into Resident 1's room and closed the door. -9:11 AM to 9:22 AM, Resident 1 and Resident 2 remained in the room with the door closed. NA-B remained in Resident 10's room with the door closed. -9:22 AM, NA-B exited Resident 10's room and looked in the dining room and then in the corridor for Resident 2. NA-B opened the door to Resident 1's room and assisted Resident 2 out of the room. NA-B closed Resident 1's room door. NA-B led Resident 2 to the Living Room area and placed a movie on the television for Resident 2 to watch. -9:22 AM, Resident 10 entered Resident 1's room and closed the room door. -9:25 AM, Resident 10 opened the door to Resident 1's room but remained in the doorway of the room. Resident 10 glanced up and down the corridor, re-entered Resident 1's room and again closed the room door. NA-B remained in the Living Room with Resident 2. No other staff was available on the Memory Support Unit to monitor the residents. -9:29 AM, NA-B approached Resident 10's room and when unable to locate Resident 10, opened the closed door to Resident 1's room. Resident 10 was again assisted out of Resident 1's room and was taken into the Living Room to watch a movie with Resident 2. -9:30 AM to 12:30 PM, NA-B was the only staff member working on the Memory Support Unit. During an interview on 5/7/18 from 1:30 PM to 2:00 PM, NA-B identified the following: -Resident 1 started having an increase in sexual behaviors about 2 weeks after the resident was admitted to the facility; -when Resident 1 was re-admitted on [DATE] the Memory Support Unit was to be staffed with 2 Nurse Aides. However, the facility is short staffed and after the first couple of days, there has never been more than 1 Nurse Aide at a time scheduled on the unit; -staff are to complete and document every 15 minute checks on Resident 1, Resident 2 and Resident 10. These are the only residents on the unit; -staff have been instructed to keep Resident 2 and Resident 10 out of Resident 1's room. However, both residents try repeatedly each day to gain access and it takes up the whole day just redirecting the residents; -Resident 2 requires 1-2 staff for an every 2 hour check and change schedule for incontinence; -Resident 10 requires cues and assistance every 2 hours for toileting and incontinence cares; and -when assisting Resident 2 or Resident 10 with cares, there is no one available to monitor the remaining residents to assure no abuse occurs. During an interview with the Provisional Administrator on 5/7/18 from 2:00 PM to 2:30 PM the following was confirmed: -incident on 3/19/18 at 3:00 AM between Resident 1 and Resident 2 was not reported or investigated and this incident occurred prior to the current Administrator and DON's start dates and both were unaware of the incident. -no interventions were developed or implemented to protect Resident 2 after the incident which occurred on 3/19/18; -Resident 1 had escalating sexual behaviors directed at the staff. The resident made inappropriate sexual comments, exposed self and touched staff inappropriately; -on 4/21/18 Resident 1 was found with Resident 2 in an empty room on the Memory Support Unit. Both residents were exposed and Resident 1 was attempting to have anal sex with Resident 2; -the resident's physician was notified and an order was received for the resident to be EPC'd. -the resident was taken to Oakland Mercy Hospital and was evaluated in the emergency room . The resident was found to be medically stable and was cleared to return to the facility. -the facility felt they were unable to meet the resident's needs as not enough staff available to have 1:1 with the resident. The resident's family drove the resident from Oakland Mercy Hospital to Lincoln per request of the Administrator and was to be admitted to Bryan East Medial Center for an inpatient psychiatric evaluation; -upon arrival in Lincoln the family contacted Bryan Medical Center who indicated no availability for the psychiatric evaluation and refused to admit the resident; -the resident was taken home with the family until the resident had inappropriate sexual behaviors with a minor child in the home; -the resident was then taken to the Lancaster Mental Health Crisis Center by the police where the resident remained until he was readmitted to the facility on [DATE]; -with the residents readmission the facility was to ensure 2 staff were scheduled for the Memory Support Unit at all times and staff were to conduct and document every 15 minute checks on the residents; -Resident 1 continues to have inappropriate sexual behaviors; -the facility was unable to schedule 2 staff at all times for the unit as not enough staff were available; -as of 5/7/18 the facility had not made an appointment for Resident 1 to be seen for Psychiatric Evaluation or an appointment made for the resident to receive counseling; and -was unaware of the resident to resident altercation between Resident 1 and Resident 10 on 5/2/18 and no further interventions had been into place to maintain the residents safety and to protect the residents from potential abuse. G. ABATEMENT STATEMENT Based on the following, the facility removed the immediacy of the situation and the Immediate Jeopardy situation was abated: 1). Memory Support Unit to have 2 staff members scheduled around the clock. One of the staff assigned to the Unit was to be with Resident 1 at all times. If the other staff member needed assistance with completing cares for Resident 2 or 10, then they needed to call off the Unit for a third staff member. 2). New form was developed for the staff to document the 15 minute checks on the residents. The Form must be used by all the staff on the Unit and must be filled out completely each shift. 3). Education provided to all staff working on the Memory Support Unit to assure the staff's safety when working with Resident 1. Education included the following: -never turn your back to Resident 1; -always carry a walkie-talkie with you to maintain communication with other staff; -Charge Nurse to check on staff working on the Unit every hour; and -if feeling threatened to immediately call for help. 4). Nursing schedule completed to assure adequate coverage for the Unit. 5). Resident was seen by Advanced Practice Nurse Practitioner on 5/9/18 with a new order for [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorders) 5 mg at bedtime. The immediacy had been removed, however, the deficit practice was not totally corrected. Therefore, the scope and severity was been lowered to an E.",2019-03-01
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
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
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
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
2487,PIONEER MANOR NURSING HOME,285212,"P O BOX 310, 318 N 3RD STREET",HAY SPRINGS,NE,69347,2019-02-13,600,D,1,0,U39J11,"**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 provide interventions to manage ongoing sexual behaviors for one closed sampled resident (Resident 6) to prevent sexual abuse towards one current sampled resident (Resident 5). The facility census was 51 with nine current sampled residents and one closed record reviewed. Findings are: [NAME] Review of the Resident Face Sheet, printed 2/11/19, revealed that Resident 6 was readmitted to the facility on 10/19/18 with [DIAGNOSES REDACTED]. Review of the Resident Progress Notes revealed the following including: - 10/20/18 at 1:57 PM Resident is overly TOUCHY with nursing staff; - 10/22/18 at 10:01 AM Resident was inappropriate with nursing assistant; grabbed another resident's hand, squeezed and twisted it and staff intervened; grabbed the housekeepers arm, squeezed it and left a red fingerprint mark; - 10/24/18 at 5:56 PM Resident grabbed staff in buttocks and touched staff several times; - 10/25/18 at 4:59 PM Resident grabbed the nurse from behind; - 10/26/18 at 4:05 PM Resident slapped the therapist's buttocks during therapy; - 11/5/18 at 2:27 PM Resident asks to touch nursing assistant's breasts during cares; - 11/8/18 at 5:59 PM Resident making physical contact with staff; - 11/13/18 at 3:41 PM Resident attempted to inappropriately grab a younger nursing assistant this shift; - 11/16/18 at 8:30 PM Resident asked nursing assistant and therapist to grope their breasts, attempted to grab another nursing assistant's buttocks while in the dining room for evening meal; - 11/17/18 at 3:29 PM Resident grabbed nursing assistant's breast, kissed a female resident (Resident 5) on the mouth; - 11/18/18 at 2:48 AM Resident attempted to touch female staff. Review of the Care Plan, goal date 1/2/19, revealed a problem Inappropriately Touching Staff and interventions included offer resident diversional activities when becomes inappropriate, redirect staff from touching other staff and remind the resident that inappropriately touching is not allowed. Further review revealed that the resident's cognition was severely impaired and was not able to make good decisions. B. Review of the Resident Face Sheet, printed 2/11/19, revealed that Resident 5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes revealed the following including: - 11/17/18 at 3:43 PM Resident was alert and confused, had periods of clarity and delusions and staff observed that the resident was kissed by a resident. Review of the Care Plan, goal date 2/21/19, revealed that the resident's cognition was impaired with confusion and lethargy noted and most conversations were disorganized and delusional. Interview with the Administrator on 2/13/19 at 10:15 AM confirmed that interventions were not in place to manage Resident 6's ongoing behaviors to prevent sexual abuse towards Resident 5.",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
6067,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2016-06-22,514,D,1,0,PVZX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.08A Based on record review and interview, the facility failed to ensure residents had a history and physical examination [REDACTED]. The facility census was 75. Findings are: A review of Resident 23's MINIMUM DATA SET (MDS) information for a 30 day Assessment revealed Resident 23 was admitted to the facility on [DATE]. A review of a History & Physical (H & P) for Resident 23 with MD signature dated 3/1/16, revealed the resident was hosptalized on [DATE]. The resident was treated for [REDACTED]. The Patient stabilized and was able to be discharged to a Specialty Hospital for further care. Further review of Resident 23's medical record revealed no other documentation related to the Resident's history or progress toward goals prior to admission to the facility. A review of a REPORT OF CONSULTATION, with the Primary Care Physician's (PCP) signature dated 5/3/16, revealed Resident 23 was admitted from another Skilled Nursing Facility yesterday . The report indicated Resident 23: was wheelchair bound, had a left leg clot, cannot walk, wants to go home, exhibited [DIAGNOSES REDACTED] to left side of body, was alert, was oriented, was frustrated about a decline in range of motion on the left. The resident's [DIAGNOSES REDACTED]. The PCP's recommendations were for Physical Therapy to evaluate left lower extremity weakness, gait, balance, and follow up as needed. The report did not address urinary elimination or the use of an indwelling catheter. An interview on 6/22/16 at 3:30 PM with the DNS (Director of Nursing Services) revealed the H & P, dated 3/1/16 for Resident 23, was the information received from the transferring facility. The DNS reported the facility did not ensure that an H & P for Resident 23 was completed 30 days prior to or 14 days after admission.",2019-06-01
1508,AZRIA HEALTH ASHLAND,285140,1700 FURNAS STREET,ASHLAND,NE,68003,2019-04-16,684,D,1,1,19PP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09 Based on interview, observation and record review; the facility failed to follow Provider ' s orders to promote optimal wound healing for 1 resident (Resident 3) of 4 residents reviewed for wound cares. The facility census was 69. Findings are: An interview on 04/10/19 at 09:00 AM with Resident 3 confirmed that the resident had an amputation. Resident 3 reported a bath time of 615am. Resident 3 reported that at times wound care was not completed for a lengthy time after the bath. An observation on 04/10/19 at 09:00 AM of the left leg wound open to air. Record review with the DON (Director of Nurses) revealed; that in the Month of (MONTH) 2019 omitted treatments for Resident 3's wound care were: Order: Weekly Skin Assessment every Tuesday. This treatment was omitted on (MONTH) 29, 2019. Order: [MEDICATION NAME] Ointment 500Unit/GM(Gram) apply to incision top of leg topically two times a day for surgical wound this treatment was omitted for the Day shift on the 25th and for the evening shift on the 23rd, 25th, ,and 30th. Order: Wash incision line to the left leg twice a day with soap and water, rinse and pat dry apply thin layer of [MEDICATION NAME], pack open areas with [MEDICATION NAME] gauze and cover with Xeroform gauze and wrap with Kerlix and ace wrap for compression. This treatment was omitted on the day shift on (MONTH) 25, 2019 and on the evening shift on (MONTH) 18th, 20th, 21st, 22nd, 26th, 30th, and 31st. Record review with the DON revealed that in the Month of (MONTH) 2019 omitted treatments for Resident 3's wound care were: Order: [MEDICATION NAME] Ointment 500Unit/GM apply to incision top of leg topically two times a day was omitted on the Day shift on (MONTH) 5 and the Evening shift on the 4th. Order: Wash the incision line to the left leg twice a day with soap and water rinse and pat dry. Apply thin layer of [MEDICATION NAME] pack open are with [MEDICATION NAME] gauze and cover with Xeroform gauze wrap with Kerlix and ace wrap for compression were omitted on the day shift of the (MONTH) 5th and the evening shift on the 4th. Order: Apply Saline moistened gauze covered by dry gauze to the left lower leg amputation site twice a day after washing with soap and water. [MEDICATION NAME] to the left lateral aspect left lower leg BID were omitted on the Day shift (MONTH) 26th and the evening shift on (MONTH) 14th, 18th, 19th, 20th, 21st, and 24th. Record review with the DON revealed that in the Month of (MONTH) 2019 omitted treatments for Resident 3's wound care were: Order: Santyl ointment 250 Units/GM Apply to LLE (lower left extremity) topically every day shift for wound care. Clean wound with saline, apply Santyl to wound bed, Apply Calcium Alginate and wrap with gauze daily and as needed. The treatment was omitted (MONTH) 22. Order: Daily wound Evaluation left outer knee stump scab- surgical monitor for signs/symptoms of infection such as redness/warmth/swelling/odor/increased drainage was omitted (MONTH) 19, 2019. Order: Apply [MEDICATION NAME] to lateral aspect left lower leg amputation incision twice a day this was omitted on the evening shift on (MONTH) 4th, 5th and 11th. Record review with the DON revealed that in the Month of April, 2019 omitted treatments for Resident 3's wound care were as follows: Order: Daily wound evaluation Left knee/stump-surgical monitor for signs/symptoms of infection such as redness/warmth/odor/increased drainage. This was omitted on (MONTH) 2, 2019. Order: Monitor if dressing is intact prior to dressing change by nurse every day. This was omitted on (MONTH) 2, 2019. Order: Weekly Skin assessment every Tuesday was omitted on (MONTH) 2, 2019. Record review of Lab dated 3/11/19 revealed; wound culture of L leg Left side of stump, Corynebacterium species (diphtheroids) Staphylococcus Aureus, Serrata marcescena, and [DIAGNOSES REDACTED] oxytoca. Record review of Provider order for [MEDICATION NAME] 750mg one daily for 7 days dated 3/12/19. An interview on 04/11/19 at 02:45PM with the DON (Director of Nurses) confirmed that a blank space in the TAR were omitted treatments. The DON confirmed that those omitted treatments were not in the incident logs as a medication error. The DON reported that they had someone come to the facility in Feb and do educations about the documentation of the Medications and Treatments. Event Monitoring (Cardiac) for 30 days starts on 1/18/19 every shift- omitted dates for day shift (MONTH) 19, 25, and 28th for evening shift were 18, 20, 21, 22, 23, 26, 30, and 31, and for the night shift were 18, 21, 22, 23, 24, 26, 27, 28, 29, 30, and 31. (MONTH) omitted day shift were the 5, 12, 16, 17 the evening shifts were 4, 5, 6, 7, 8, 9, 10, 13, and 15 and the night omitted were 4, 5, 8, 9, 10, 12, 13, 14, and 15th. An observation on 4/5/19 at 10:00AM of wound care for Resident 3. The wound was covered by a sock no dressing on wound. Record review of care plan with target date of 7/25/19 revealed that Resident 3 was at risk for impaired skin integrity related to a non-healing surgical wound located on the left below knee amputation stump. On 03/21/19 an infection to left knee surgical wound. The goal was Resident 3 ' s surgical wound will be maintained through the goal date. Interventions were reviewed resident 3 related to infection to left knee surgical wound. Prior to infection [DIAGNOSES REDACTED]. Res now has daily dressing changes and new nursing order started to record if res is removing own dressing prior to dressing changes by nurse. Record review of Physician order [REDACTED]. an order for [REDACTED]. Record review dated 02/15/19 of Tissue Analytics revealed; the wound measured Length 3.22cm (centimeters) x Width 5.82cm x Depth 2.30cm. Treatment was [MEDICATION NAME], Calcium Alginate, Gauze Wrap, Tape, excisional debridement, every other day as needed, Exposed structure was bone. Record review dated 02/05/19 of Tissue Analytics revealed; the wound measured Length 3.71cm x Width 6.48 cm, depth 2.20cm. Record review dated 02/26/19 of Tissue Analytics revealed; the wound measured Length 2.97cm x Width 4.88cm x Depth 2.20cm. Wound care orders were for Saline, [MEDICATION NAME], calcium alginate, gauze wrap and tap every 3 days exposed structure would be bone. Record review dated 3/05/19 of Tissue Analytics revealed; the wound measured Length 2.76cm x Width 4.1cm x Depth 0.2cm. Wound care orders for Saline, [MEDICATION NAME], calcium alginate, gauze wrap and tape every 3 days exposed structure would be bone. Record review dated 3/12/19--Tissue Analytics revealed; the wound measured Length 2.48cm x Width 4.36cm x Depth 0.1cm. Wound care orders for [MEDICATION NAME], Calcium Alginate, Gauze, and Tape every 3 days. Record review dated 03/19/19 omitted Tissue Analytic assessment. Record review dated 3/25/19 of Tissue Analytics revealed; the wound measured Length 2.28cm x Width 5.29cmx Depth 0.1cm. Wound care orders for cleanse daily with saline, apply Santyl to entire wound bed, apply calcium alginate to heavily draining areas, cover with gauze wrap and secure with tape. Record review dated 4/1/19 of Tissue Analytics revealed; the wound measured 2.43cm x Width 4.47 cm x Depth 0.10cm Wound care orders to cleanse daily with saline, apply Santyl to entire wound bed, apply calcium alginate to heavily draining areas, cover with gauze wrap and secure with tape. Record review dated 4/8/19 of Tissue Analytics revealed; the wound measured Length 2.07cm, width 5.30cm depth 0.1cm wound care order for Cleanse daily with saline, apply Santyl to entire wound bed, apply calcium alginate to heavily draining areas, cover with gauze wrap and secure with tape. An interview on 04/15/19 at 03:36 PM with a Medical Professional confirmed that in some cases it would have affected the wound healing if the orders from the provider were not followed.",2020-09-01
6375,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2016-03-01,309,D,1,0,LUTH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09 Based on observation, record review, and interview; the facility failed to ensure resident cares were completed per physician's orders [REDACTED]. The facility census was 85. Findings are: A review of Report of Consultation from the Wound Clinic for Resident 5 dated 1/13/16 revealed an order for [REDACTED]. Review of a Report of Consultation for Resident 5 dated 2/17/16 revealed orders including: reposition every 2 hours to prevent skin breakdown. Continue compression garments to bilateral lower extremities (legs). Position out of the chair during the day to minimize lower extremity and scrotal [MEDICAL CONDITION]. Observation on 2/29/16 at 12:21 PM revealed Resident 5 seated in a w/c (wheelchair) in the doorway of the resident's room requesting a push to the dining room. NA (Nursing Assistant)-A assisted Resident 5 to straighten non-slip stockings which were in place to both of the resident's feet and to position the resident's feet onto the foot pedals of the wheelchair prior to pushing the resident's w/c toward the dining room. The resident's lower legs were noted to be [MEDICAL CONDITION] (swollen). The skin appeared dry and flakey. There was no evidence of Resident 5 wearing [MEDICAL CONDITION] wear, leg wraps, or ted hose to bilateral lower extremities (LE). An observation on 2/29/16 at 2:10 PM revealed Resident 5 was in a w/c in the resident's room. The resident's room did not contain an easy or reclining chair for Resident 5 to be repositioned into. An interview on 2/29/16 at 2:35 PM with NA-B revealed Resident 5 needed much encouragement to lay down and usually chose to remain up in gender's w/c throughout the day. A review of the TAR (Treatment Administration Record) dated Feb (YEAR) for Resident 5 on 2/29/16 at 3:30 PM revealed the order for [MEDICAL CONDITION] wear to be put on in the AM (morning) and the area was not initialed as completed for the morning of 2/29/16. Further review of the TAR revealed the order for [MEDICAL CONDITION] WEAR ON AM OFF AT BEDTIME dated 1/6/16 had initials with a circle around them indicating the treatment was not completed as ordered on the following dates: 2/5-2/13/16, 2/16/16, and 2/18/16. There was no evidence of supporting documentation related to reasons the [MEDICAL CONDITION] wear was not applied. An observation on 2/29/16 at 3:40 PM with RN (Registered Nurse)-C confirmed Resident 5 did not have [MEDICAL CONDITION] wear to bilateral LE. An interview on 2/29/16 at 3:44 PM with RN-C revealed Resident 5 didn't want to wear the [MEDICAL CONDITION] wear socks. The RN reported Resident 5 would often times refuse offered assistance with cares. An interview on 3/1/16 at 1:00 PM with the Director of Nursing revealed there was no documented evidence that Resident 5's Physician(s) had been updated of the resident's refusals to reposition and to wear [MEDICAL CONDITION] wear.",2019-03-01
1736,"PREMIER ESTATES OF PAWNEE, LLC",285157,"P O BOX 513, 438 12TH STREET",PAWNEE CITY,NE,68420,2017-05-11,309,D,1,1,MMVU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09 Based on observation, record review, and interview; the facility failed to identify pain indicators, failed to assess for pain, and failed to assess effectiveness of interventions used to treat pain for one resident (Resident 32). The facility census was 40. Findings are: Observations of Resident 32 throughout the facility's annual survey, 5/8/17-5/11/17, revealed the resident spent most of waking hours self propelling wheel chair ad lib (as much as wanted) in the common's area surrounding the nurses desk. The resident's face frequently appeared to be grimacing (a sharp contortion of the face expressive of pain, contempt, or disgust ). A review of an electronic form titled NURSING ADMISSION DATA COLLECTION, dated 1/6/17, revealed Resident 32's admitting [DIAGNOSES REDACTED]. The area of the form which addressed pain indicated that the dx supported the likelihood of pain, the resident was able to self-report discomfort and/or pain, and that pain impacted the resident's ability to perform ADL's (Activities of Daily Living). The resident reported a current pain intensity level of 6, on scale of 1-10; the pain was dull, on a moderate level , occurred intermittently and was exacerbated with movement; Tylenol relieved discomfort/pain. The documentation did not include clinical and/or observed pain behaviors of discomfort and/or pain. The treatment and history effects indicated Resident 32 had feelings of sadness or loss of control as a result of discomfort/pain; had been diagnosed or treated for [REDACTED]. Review of the CAA (Care Area Assessments) WORKSHEET portion of the MDS (Minimum Data Set-a mandatory comprehensive assessment tool used for care planning) for Resident 32 with an ARD (Assessment Review Date) of 1/13/2017 revealed the following areas were effected by pain as follows: -Cognitive loss/Dementia was an actual problem as the resident had short term memory loss, with decreased ability to make self understood or to understand others. Documentation indicated that the resident's pain and its relationship to cognitive loss and behavior should be determined as well as the relationship between pain and cognitive status. -ADL (Activities of Daily Living) Functional/Rehabilitation Potential was indicated as an actual problem related to Resident 32's recent hospitalization with repair of a [MEDICAL CONDITION]. Pain was listed as a possible underlying problem that may affect the resident's function and limit factors resulting in need for assistance with ADLs. -Urinary Incontinence (inability to control bladder function) was an actual problem with pain listed as a modifiable factor which could be contributing to the resident's incontinence. -Activities-pain was listed as a health issue potentially resulting in reduced activity participation and little interest or pleasure in doing things. -Potential problems of falls and nutritional concerns included pain as a conditions that could affect the resident's needs. -Pain was an actual problem as the resident complained of pain in left hip related to recent fracture. Triggering conditions included limited day to day activity because of the resident's verbal descriptor of pain and reports of frequent pain, which had caused effects on Resident 32's function including adversely affects mood and limits day to day activities. The document indicated that Pain would be addressed on Resident 32's Care Plan with a goal of symptom relief or palliative measure. Review of the Medication Administration Record [REDACTED]. Pain levels were to be recorded with each administration which were scheduled for AM, Lunch, and Eve; and ranged from 0 to 5, (on scale of 1-10). Continued review of the MAR indicated [REDACTED]. The [MEDICATION NAME] was discontinued on 1/13/17. [MEDICATION NAME]-[MEDICATION NAME] was scheduled to be given every AM, Lunch, Eve, and HS (hour of sleep) and started with the HS dose on 1/13/17; pain level ranged from 0-10. The [MEDICATION NAME]-[MEDICATION NAME] order was changed on 1/19/17 to be given five times daily for pain, every 4 hours while awake and was scheduled to be given at 0600, 1000, 1400 (2PM), 1800 (6PM), and 2200 (10PM); and was ordered to be given at these intervals through 2/21/17. Pain levels during the period ranged from 0-10. Review of Progress Notes for Resident 32 dated 1/6/17-1/9/17 indicated the resident was alert, oriented, and able to make needs known. The resident fed self and ate 100% of meals, used a urinal at bedside at night to void (urinate), and was given PRN medications for complaints of some discomfort. On 1/10/17, the resident exhibited signs of confusion and resistance to staff assist; unable to remember disposition of car or the reason for being in the facility. On 1/11/17 an order was received for Speech Therapy to evaluate and treat for swallowing and cognition. Notes dated 1/12/17-1/18/17 indicated the resident's confusion continued and was found on the floor next to the bed. Notes dated 1/13/17 indicated an order for [REDACTED]. The notes did not include information related to the use of non-pharmacological interventions used for pain management; nor follow up related to the effectiveness of the alternate narcotic pain medication started on 1/13/17. A review of Resident 32's Care Plan revealed the resident was admitted to the facility on [DATE]. Further review of the Care Plan revealed Resident 32's pain was not included as a care concern/problem until 5/9/17 . An interview on 5/11/17 at 3:30 PM with RN-B (Registered Nurse), confirmed Resident 32's Care Plan did not address the resident's pain. RN-B reported the facility had provided the resident with pain medications but did not always follow up to ensure effectiveness. The RN was unable to say why pain was not included in the Care Plan, as the CAA Worksheet was a tool the RN used when setting up individualized interventions, as well as the [DIAGNOSES REDACTED]. A review of a facility document titled PAIN MANAGEMENT, revised 04/2013, revealed components of the pain management and comfort promotion program included, but were not limited to: identification of current discomfort and pain levels, potential for pain and circumstances in which to anticipate pain; implementation of individualized interventions to improve comfort and minimize pain; evaluation of effectiveness of interventions in promoting comfort and minimizing pain; interdisciplinary review of each resident requiring pain management; and analysis of facility pain management data for quality improvement opportunities.",2020-09-01
2056,GOOD SAMARITAN SOCIETY - VALENTINE,285176,601 WEST 4TH STREET,VALENTINE,NE,69201,2018-12-11,684,D,1,0,B7PS11,"**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 ensure that A) medications were administered as ordered by the practitioner for one current sampled resident (Resident 4), and B) wound care treatments were done as ordered by the practitioner for one closed record reviewed (Resident 2). The facility census was 35 with six current sampled residents and two closed records reviewed. Findings are: [NAME] Review of the Admission Record, printed 12/10/18, revealed that Resident 4 was admitted to the facility on [DATE]. Review of the Medication Record, dated (MONTH) (YEAR), revealed the following medications were not administered as ordered by the practitioner : - 10/16/18 bedtime doses of [MEDICATION NAME] (supplement) and Vitamin C (supplement); - 10/16/18 morning doses of [MEDICATION NAME] (stool softener) and Lactobacilus (for diarrhea); - 10/16/18 noon and evening doses of Eloquis (for [MEDICAL CONDITION]); - 10/16/18 morning and evening doses of [MEDICATION NAME] (pain); - 10/16/18, 10/17/18 and 10/18/18 morning, noon and evening doses of [MEDICATION NAME] ([MEDICAL CONDITION]); - 10/16/18 morning, noon and evening doses of [MEDICATION NAME] (orthostatic [MEDICAL CONDITION]) and Sevelamer HCI ([MEDICAL CONDITION]). Interview with the Director of Nursing on 12/11/18 at 1:50 PM confirmed the nurses were to administer medications as ordered by the practitioner to ensure that the resident's needs were met. B. Review of the Admission Record, printed 12/10/18, revealed that Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Treatment Record, dated (MONTH) (YEAR), revealed an order, dated 10/11/18 for wound care to coccyx wound, cleanse with normal saline, pat dry, apply Collagen and Hydrogel and cover with a bordered dressing, change daily and as needed. Further review revealed no documentation the treatment was done as ordered on [DATE], 10/13/18 and 10/16/18. Interview with the Director of Nursing on 12/11/18 at 2:10 PM confirmed the nurses were to complete wound care as ordered by the practitioner to promote healing.",2020-09-01
4418,"SCHUYLER CARE AND REHABILITATION CENTER, LLC",285110,2023 COLFAX STREET,SCHUYLER,NE,68661,2018-07-18,655,D,1,1,NXEG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.091C1a Based on observation, interview, and record review; the facility failed to ensure baseline care plan interventions were identified and implemented within required 24 hour period for newly admitted residents. This failure had the potential to affect 1 of 1 sampled residents recently admitted to the facility. The facility census was 28. Findings are An observation of and interview with Resident 79, on 07/12/18 at 10:57 AM, revealed the Resident's upper extremities (arms) had multiple bruises in different stages of healing. The Resident reported the bruising was the result of taking too much aspirin, prior to being admitted to the Skilled Nursing Facility. A review of Medications ordered upon admission (6/22/18), for the resident, included: [MEDICATION NAME] (an antidepressant), [MEDICATION NAME] (a diuretic-assists to remove excess fluid from the body) given every other day, [MEDICATION NAME] (used to treat symptoms of overactive bladder, such as frequent or urgent urination, incontinence (urine leakage), and increased night-time urination), [MEDICATION NAME] (an antidepressant), and [MEDICATION NAME] (used to reduce anxiety). Aspirin 81 mg was ordered to be given one time daily for hypertension (increased blood pressure). [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] given to assist with clearing secretions from lungs) nebulizer and [MEDICATION NAME] 15mg tablets were ordered one time daily related family history of asthma and other chronic lower respiratory diseases. [MEDICATION NAME] (a non-narcotic cough medicine) was ordered to be given every 8 hours, as needed for cough. [MEDICATION NAME] 325 mg with 2 tabs to be given daily at bedtime for headache; mild pain. A review of the Care Plan, printed on 7/16/18, for Resident 79 indicated admission date of [DATE]. The document indicated the Resident's [DIAGNOSES REDACTED]. PHASE, OTHER ABNORMALITIES OF GAIT AND MOBILITY, [MEDICAL CONDITION] AND [MEDICAL CONDITION] FOLLOWING CEREBRAL INFARCTION AFFECTING UNSPECIFIED SIDE, MUSCLE WEAKNESS (GENERALIZED), [MEDICAL CONDITION], ALLERGIC RHINITIS, DRY EYE SYNDROME OF UNSPECIFIED LACRIMAL GLAND - The Care Plan included no documented evidence of: respiratory issues, the bruising related to reported overuse of aspirin, or other identified skin issues. Further review revealed that all of the documented Focus, Goal, and Interventions; were created on 4/4/17, revised and initiated on 6/22/18. Further review of Resident 79's Care Plan, printed on 7/16/18, revealed a Focus created on 4/4/47, revised and initiated on 6/22/18, indicating the resident needs pain management and monitoring related to: arthritis and chronic pain. The documented Goal indicated the resident will maintain adequate level of comfort as evidenced by no s/sx of unrelieved pain or distress, or verbalizing satisfaction with level of comfort. Interventions included: administer pain medication as ordered, evaluate and establish level of pain on numeric scale/evaluation tool, evaluate characteristics and frequency/pattern of pain, evaluate need for bowel management regimen, evaluate need for routinely scheduled medications rather than PRN (as needed) pain med administration, evaluate what makes the patient's pain worse, rest, and Therapy screens. The document did not contain further information related to the location of, interventions put into place to improve or prevent an increase in the pain, the resident's tolerable pain level, or evidence that need for bowel (or bladder) regimen had been completed. An interview on 07/18/18 at 3:46 PM with the MDS Coordinator and the Director of Nursing revealed Resident 79 had previously resided in the Facility and had been discharged to an Assisted Living Facility approximately one year ago. The MDS Registered Nurse (RN) reported the facility's electronic medical record system will automatically pull information from previous stays into the assessment and care planning documents. The RN went on to report that a new baseline care plan had not been completed for Resident 79's admission on 6/22/18.",2020-07-01
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
4027,OLD CHENEY REHABILITATION,285299,5431 SOUTH 16TH STREET,LINCOLN,NE,68512,2019-01-03,641,E,1,1,KV8H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09B The facility failed to ensure that MDS (Minimum Data Set, a standardized, federally mandated assessment used to complete a person centered care plan) was coded correctly to reflect the current resident status. This had the potential to affect 3 residents, Residents #24, 85 and 93. the facility census was 23. Findings are: Resident # 24; Interview on 12/26/18 01:17 PM with RN (Registered Nurse) F revealed; Resident 24 had [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. Record review of MDS Admission Assessment, Dated 12/9/18 revealed; Section O 0100 Treatments Special Treatments and Programs other treatments, H. IV Medications and [NAME] [MEDICAL TREATMENT] had not address Resident 24's need for IV (Intravenous) use and [MEDICAL TREATMENT] while a resident at the facility. Interview on 01/02/19 at 08:59 AM with the Interim DON (Director of Nursing) revealed MDS, Section O 0100 Treatments Special Treatments and Programs H. IV Medications and [NAME] [MEDICAL TREATMENT] did not address the Resident 24's need for IV (Intravenous) use and [MEDICAL TREATMENT] while a resident at the facility. Resident # 85 Record review of the MDS Admission assessment dated [DATE] MDS, Section J 1700 Fall History on Admission/Entry or Reentry question C. Did the resident have any fracture related to fall in the 6 months prior to admission/entry or reentry revealed the answer no. Record review of MDS Admission assessment dated [DATE] MDS, Section I revealed Resident 85 had [DIAGNOSES REDACTED]. Record review of Hospital after Visit Summary dated 12/19/18 revealed; problems List of: Acute pain, Acute Post Hemorrhagic [MEDICAL CONDITION], Heart failure, Closed Fractured of Multiple Ribs. [MEDICAL CONDITIONS], CAD, Fall, Frequent Falls, Gout, OSA, Skin Tear of Hand, Elbow, Traumatic Ecchymosis of Forearm, Shoulder, Right Upper Extremity, Left Lower Leg, Right Lower Leg, Diabetes, UTI (Urinary Tract Infection) and Weakness. An Interview on 01/03/19 at 08:40 with the Interim DON revealed; the MDS Admission Assessment Section J 1700 Falls, Did the resident have any fracture related to fall in the 6 months prior to admission/entry or reentry should have been answered yes. Resident # 93; Record review of Resident # 93's discharge return not anticipated MDS dated [DATE] revealed the MDS entry indicated discharged to an acute care hospital. Record review of Resident #93's nurses notes dated 10/9/18 revealed; Reviewed discharge instructions with patient, patient verbalized understanding. Sent patient's remaining medications home with patient, reviewed each medication with patient, patient verbalized understanding. Patient continues to deny need for home health assistance with dressing change. Discharge paperwork signed by patient and nurse. Record review of Resident # 93's Physicians orders dated 10/9/18 revealed; discharge to home. On 1/3/19 at 1:30 PM an interview with the interim DON confirmed the MDS entry for Resident # 93 dated 10/9/18 was incorrect.",2020-09-01
5739,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2016-09-20,272,D,1,0,TD4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09B(10) Based on observations, interviews, and record reviews; the facility failed to complete a comprehensive assessment on the dental status of Resident 120. The facility census was 114. Findings are: Review of the Admission Record dated as printed on 9/8/16 for Resident 120 revealed an admission date of [DATE] to the facility. Further review revealed [DIAGNOSES REDACTED]. Review of the Care Plan dated 7/22/16 for Resident 120 revealed that the Resident had a physical functioning debility . self care impairment inspect skin, oral cares, observe remaining teeth for cavities, chips, cracks and observe gums for swelling, bleeding and complaints of pain, dental exams as necessary. Review of the Clinical Health Status dated 7/17/16 for Resident 120 revealed the condition of teeth/oral cavity as; no dentures, gum margins intact, and mucous membrane moist. Further review revealed that option of broken, loose or carious teeth. Observation on 9/7/15 at 12:13 PM of Resident 120 in the residents' room revealed that the resident did have a large protruding tongue and a few broken teeth on the lower right jaw. Observation on 9/20/16 at 8:10 AM revealed Resident 120 eating a pureed diet. Further observation revealed that the resident did not have to chew the food as it was a pureed diet. Interview on 9/7/15 at 12:13 PM with Resident 120 revealed that the resident would like to have teeth. Further interview reveled that the resident wanted to be able to eat real food and be able to chew real food. Continued interview revealed that the resident verbalized missing and broken teeth, with no mouth pain. Further interview revealed that the resident would like to bite and chew the food items served. Interview on 9/20/16 at 9:00 AM with Resident 120 revealed that the resident would like to see the dentist about options for teeth, as the resident still desired to have something done so that eating real foods was an option. Further interview revealed that the resident was unsure of how many teeth were still remaining or the condition of the teeth. Interview on 9/20/16 at 4:00 PM with the Administrator and the Director of Nursing verified that Resident 120's oral condition to include broken teeth should have been assessed with [REDACTED]. Furthermore the resident's care plan should have reflected that the resident did have broken, missing teeth with potential problems to watch for such as weight loss, chewing and swallowing issues.",2019-09-01
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
5482,GOOD SAMARITAN SOCIETY - WOOD RIVER,285198,1401 EAST STREET,WOOD RIVER,NE,68883,2018-05-22,637,D,1,0,NLW911,"**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 MDS (a multi-disciplinary assessment tool used to identify care planning needs) information reflected significant changes in condition following a readmission from an Acute Care Hospital for one resident (Resident 5) and following the identification of concerns related to declining skin integrity for one resident (Resident 7) for 2 of 5 residents sampled for MDS review. The facility census was 39. Findings are [NAME] A review of Progress Notes for Resident 5, dated 3/1/18, revealed the resident was readmitted from an Acute Hospital following treatment for [REDACTED]. Notes indicated the resident's admission orders [REDACTED] A review of the MDS Assessment information for Resident 5 revealed the following assessments: a Discharge with return expected dated 2/19/18, an Entry Tracking record dated 3/1/18, and a Quarterly dated 4/3/18. The assessment did not include information related to Resident 5's terminally declining status or the need for added Hospice Services. On 5/22/18 at 12:00 PM, an interview with Registered Nurse (RN)-C confirmed the discrepancies in MDS information for Resident 5. The RN reported an assessment related to a significant change in condition should have been completed for Resident 5, upon readmission to the facility on [DATE]. B. A review of the MDS assessments for Resident 7, revealed a Quarterly document dated 4/17/18 and another Quarterly document dated 5/8/18. On 5/22/18 at 12:015 PM, an interview with Registered Nurse (RN)-C confirmed the discrepancies in MDS information for Resident 7. The RN reported an assessment related to a significant change in condition should have been completed on 5/18/18, related to the identification and treatment of [REDACTED].",2020-01-01
4029,OLD CHENEY REHABILITATION,285299,5431 SOUTH 16TH STREET,LINCOLN,NE,68512,2019-01-03,656,D,1,1,KV8H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09C Based on interview and record review the facility failed to complete the Comprehensive Care Plan (a comprehensive interdisciplinary plan to ensure the provision of quality of care for one resident, Resident # 24. The Facility Census was 23. Findings are: Interview on 12/26/18 01:17 PM with RN (Registered Nurse) F revealed; Resident 24 had [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. Record review of Admission Record revealed Resident 24 initial admitted was 11/29/18. Resident 24 was readmitted on [DATE]. The [DIAGNOSES REDACTED]. Interview on 12/27/18 at 10:30 AM with Interim DON (Director of Nurses) revealed; the Comprehensive Care Plan did not address the Resident 24's need for [MEDICAL TREATMENT] three times per week. The Interim DON confirmed that the Comprehensive Care Plan needed to be completed on 12/24/18 and was not competed to reflect the current needs of Resident 24.",2020-09-01
2584,AZRIA HEALTH MIDTOWN,285218,910 SOUTH 40TH STREET,OMAHA,NE,68105,2018-06-12,656,E,1,1,BXNG11,"**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 comprehensive care plan related to [MEDICAL CONDITION] drug use for 1 resident (Resident 44) of 5 residents sampled, failed to develop a comprehensive care plan related to the use of anticoagulant medication for 2 residents (Residents 203 and 51) of 5 residents sampled, and failed to develop a comprehensive care plan related to falls for 1 resident (Resident 203) of 3 residents sampled. The facility staff identified the census at 48. Findings are: [NAME] A record review of Resident 44's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated (MONTH) 10th, (YEAR) revealed an admitted (MONTH) 3rd, (YEAR). Within the Care Area Assessment (CAA) Summary it was revealed that the following areas should be included in the Comprehensive Care Plan (a guide to the care required by the resident) psychosocial well-being and [MEDICAL CONDITION] drug use. The Medication section of the MDS identified that Resident 44 had taken an antipsychotic 7 out of the last 7 days. The Antipsychotic Medication Review of the MDS revealed that Resident 44 received Antipsychotics on a routine basis and that a gradual dose reduction was contraindicated. A record review of Resident 44's physician orders [REDACTED]. A record review of Resident 44's CCP on (MONTH) 6th, (YEAR) revealed that antipsychotic medication use had not been addressed in the care plan. An Interview with the Director of Nursing (DON) on (MONTH) 11th, (YEAR) from 2:30 PM to 3:00 PM confirmed the CCP did not address Resident 44's antipsychotic drug use. B. A review of Resident 51's Admission Record dated 6-11-18 revealed that Resident 51 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 51's (MONTH) (YEAR) Medication Administration Record [REDACTED]. A review of Resident 51's Comprehensive Care Plan revealed that the care plan did not address the resident's [MEDICATION NAME] usage. A review of Resident 51's Baseline Care Plan dated 5-8-18 revealed that the resident's [MEDICATION NAME] usage was not addressed. An interview conducted on 6-11-18 at 3:35 PM with the Director of Nursing revealed confirmed that [MEDICATION NAME] usage was not addressed in Resident 51's care plan and [MEDICATION NAME] usage should be addressed in the care plan. C. A review of Resident 203's Admission Record dated 6-11-18 revealed that Resident 203 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 203's (MONTH) (YEAR) Medication Administration Record [REDACTED]. A review of Resident 203's Comprehensive Care Plan initiated on 5-17-18 and revised on 6-11-18 revealed that the care plan did not address the resident's [MEDICATION NAME] usage. An interview conducted on 6-11-18 at 3:35 PM with the Director of Nursing confirmed that [MEDICATION NAME] usage was not addressed in Resident 203's care plan and [MEDICATION NAME] usage should be addressed in the care plan. D. A review of Resident 203's Admission Record dated 6-11-18 revealed that Resident 203 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An interview conducted on 6-5-18 at 11:14 AM with Resident 203 revealed that the resident had fallen a couple of times since admitting to the facility. A review of Resident 203's Progress Note dated 5-31-18 revealed that the resident had an unwitnessed fall that morning. A review of Resident 203's Progress Note dated 6-4-18 revealed that the resident had a fall that morning. A review of Resident 203's Comprehensive Care Plan initiated on 5-17-18 and revised on 6-11-18 revealed that there was a care plan in in place for falls dated 6-3-18, but there were no interventions related to falls. An interview conducted on 6-11-18 at 3:35 PM with the Director of Nursing confirmed that there were no interventions on Resident 203's care plan to address falls and there should have been.",2020-09-01
6417,LYONS LIVING CENTER,285301,1035 DIAMOND STREET,LYONS,NE,68038,2018-05-10,656,E,1,0,2CLY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09C Based on observation, interview, and record review; the facility failed to ensure individualized Care Plans were developed to address: 1) Smoking safety for Residents 6 and 3; 2) Resident 4's elopement (leaving the facility unattended and without staff knowledge) risk; and 3) Resident 1's inappropriate behaviors towards Resident 2. The sample size was 14 and the facility census was 23. Findings are: A. Observation of Resident 6 on 5/7/18 at 10:10 AM revealed the resident was seated outside smoking with a staff member present. Interview with Nursing Assistant (NA)-B on 5/7/18 at 3:02 PM revealed a staff member went outside with the residents at all designated smoking times. NA-B went on to state Resident 6 was, however, allowed to sit outside after smoking was completed without a staff member present. Further interview revealed Resident 6 was in charge of the resident's own smoking materials, and kept cigarettes and a lighter with the resident and/or in the resident's room. Interview with Resident 6 on 5/10/18 at 10:00 AM confirmed the resident kept cigarettes and a lighter in the pocket of the resident's shirt. Review of Resident 6's Smoking Safety Screen dated 2/19/18 revealed the document was opened but had not been filled out. Review of Resident 6's current undated Care Plan revealed the resident would follow the schedule for smoking and staff would assist the resident outside to smoke. Further review of the Care Plan revealed no evidence to indicate the resident's ability to smoke safely and the resident's ability to safely keep the resident's cigarettes and a lighter with the resident had been addressed. Interview with the Provisional Administrator on 5/10/18 at 9:08 AM confirmed the facility did not have a smoking policy in place. B. On 5/7/18 at 8:45 AM Resident 4 was observed ambulating independently throughout the facility. Review of Resident 4's Wandering Risk Scale dated 4/28/18 revealed the resident was at high risk for elopement. Review of Resident 4's current undated Care Plan revealed no evidence to indicate a plan of care had been created to address Resident 4's risk for elopement. Interview with Registered Nurse-L on 5/10/18 at 9:20 AM revealed Resident 4 could ambulate independently. Further interview confirmed the resident did not use a wander guard. C. Review of Resident 1's current Care Plan (undated) revealed the resident had impaired decision making skills with memory loss related to a [MEDICAL CONDITION] from a suicide attempt in (MONTH) of (YEAR). The resident had poor decision making skills with a short attention span and made occasional inappropriate comments. No interventions were identified on the residents' plan of care related to cognitive loss or the resident's occasional inappropriate comments. Review of a Nursing Progress Note for Resident 1 revealed on 3/19/18 at 3:00 AM the resident was found in the resident's room with Resident 2. Resident 2 was seated on the side of the bed and Resident 1 was on knees, in an inappropriate position between Resident 2's legs. Both residents were covered with a blanket. The residents were immediately separated and the Director of Nursing (DON) was notified of the incident. On 4/18/18 at 3:15 PM a facsimile (fax) was sent to the resident's physician to notify of sexually inappropriate behaviors toward the staff. The fax indicated the resident had covered a staff member's mouth after coming up behind the staff and was then humping the staff member. The fax further indicated this had happened numerous times. An order was received for [MEDICATION NAME] (medication used to treat anxiety and depression) 300 milligrams (mg) three times a day to help control inappropriate behaviors. Review of a facility investigation dated 4/26/18 revealed on 4/21/18 at 11:58 AM, the staff had walked into a vacant room on the Memory Support Unit and had found Resident 1 and Resident 2 with their pants down and with their perineal area fully exposed. Resident 1 was holding Resident 2 in a bent over position so the resident's torso was on the bed. Resident 1 was attempting to have anal sex with Resident 2. Resident 2 appeared frightened and Resident 1 was resistive when the staff attempted to remove the resident from the situation. The report indicated Resident 1 had a recent increase in sexual comments towards the staff but had displayed no sexual tendencies toward other residents. An order was received for Resident 1 to be placed in Emergency Protective Custody (EPC- part of the mental health commitment act which permits law enforcement officers to take into custody a mentally ill, dangerous person that is likely to harm themselves or others before a mental health commitment hearing can be held). The resident was taken to Oakland Mercy Hospital and then to the Lancaster Mental Health Crisis Center. The resident returned to the facility on [DATE] and was readmitted to the Memory Support Unit. New interventions were identified for staff to provide and to document every 15 minute checks on Resident 1. Resident 1 was to be seen by a psychiatrist and was to receive counseling. In addition, the facility was to pursue more appropriate placement for Resident 1. Review of a physician fax dated 5/1/18 at 5:04 PM revealed an order for [REDACTED]. Review of Resident 1's care plan revealed the residents care plan had never been updated regarding the resident's ongoing inappropriate sexual behaviors to the staff and to Resident 2. In addition, there were no interventions identified on the resident's care plan to address the resident's behaviors. D. The following observations were made of Resident 3 on the patio outside the Exit door of the 100 Hall smoking cigarettes with other residents: -5/7/18 at 9:45 AM and 3:14 PM - supervised by a staff person, seated, and wearing a smoking apron (a non-flammable apron fastened around the resident's neck and covering the trunk and upper thighs, used to protect against dropped ashes/cigarettes); and -5/10/18 from 1:28 PM until 1:32 PM - supervised by a staff person, walking about the patio area while smoking the cigarette, and not wearing a smoking apron. There was no evidence in the current Care Plan dated 4/30/18 that Resident 3 smoked cigarettes, and no interventions to prevent smoking injuries.",2019-03-01
6307,GOOD SHEPHERD LUTHERAN HOME,285148,2242 WRIGHT STREET,BLAIR,NE,68008,2016-04-26,279,D,1,0,OVE011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09C Based on observation, record review and interview; the facility failed to develop a care plan to address behaviors for Resident 8 and failed to revise interventions after a fall for Resident 1. The facility census was 69. A. Observation on 4/26/16 at 9:00 AM revealed Resident 8 sitting in a wheelchair. Resident did yell out and have jerking movements. Review of Resident 8's Medical [DIAGNOSES REDACTED]. Interview on 4/26/16 at 3:10 PM with Nurses Aide (NA)-B revealed Resident 8 does yell out but usually needs some assistance and will quiet down when Resident 8's needs are met. Review of Resident 8's MDS (Minimum Data Set: a federally mandated assessment tool for developing a plan of care) dated 1/19/16 revealed Resident 8 have verbal behavioral symptoms directed at others that occurred daily. Review of Resident 8's MDS dated [DATE] revealed Resident 8 had verbal behavioral symptoms directed toward others 4 to 6 times during the assessment period. Review of Resident 8's care plan dated 2/17/16 revealed no care plan related to Resident 8's behaviors. Interview on 4/26/16 at 4:45 PM with the Social Services Director revealed there is no care plan to address Resident 8's behaviors and there should be one. B. Review of Resident 1's progress notes dated 4/14/16 revealed Resident 1 sustained a ground level fall on 4/8/16 resulting in a [MEDICAL CONDITION] while transferring independently. Review of Resident 1's care plan dated 4/6/16 prior to the residents fall revealed the following interventions to prevent falls : - needs a safe environment with a working and reachable call light - be sure call light is in reach - encourage resident to use call light for assistance as needed - PT evaluate and treat as ordered Review of Resident 1 care plan dated 4/14/16 revealed no new interventions had been put in place to protect Resident 1 from falls. Interview on 4/26/16 at 4:50 PM with the Director of Nursing revealed no new interventions had been put in place and the care plan had not been updated.",2019-04-01
6642,MITCHELL CARE CENTER,285287,1723 23RD STREET,MITCHELL,NE,69357,2015-12-21,282,D,1,0,BM5D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09C Based on observations, interviews, and record reviews; the facility failed to ensure that care plan interventions were implemented for one sampled resident (Resident 4). The facility census was 47. Findings are: Review of the Resident admitted d as printed 12/21/15 for Resident 4 revealed [DIAGNOSES REDACTED]. Review of the Care Plan for Resident dated as initiation 3/31/15 revealed a focus: At high risk for falls .wheelchair and recliner alarms . Observation on 12/21/15 at 10:00 AM revealed that Resident 4 was seated in a wheelchair beside the resident's bed. Further observation revealed that the resident was asleep. Continued observation revealed that there was not a wheelchair alarm in place. Observation on 12/21/15 at 11:00 AM revealed that Resident 4 remained seated in the wheelchair and was awake. Further observation revealed that there was not a wheelchair alarm in place under the resident. Interview on 12/21/15 at 11:00 AM with (Licensed Practical Nurse) LPN - A revealed that there was not a wheelchair cushion in place under Resident 4 while the resident was seated in the wheelchair. Interview on 12/21/15 at 11:10 AM with LPN - B verified that there was not a wheelchair alarm under Resident 4 while the resident was seated in the wheelchair. Continued interview verified that Resident 4 had an intervention on the care plan for a wheelchair and recliner alarm. Interview on 12/21/15 at 3:15 PM with the Administrator and the Director of Nursing verified that Resident 4's care plan contained written documentation to support that the resident was to have an alarm in the wheelchair and the recliner for fall interventions. Continued interview verified that the care plan interventions for Resident 4 had not been implemented for the alarm in the wheelchair.",2018-12-01
3127,IMPERIAL MANOR NURSING HOME,285252,"P O BOX 757, 933 GRANT STREET",IMPERIAL,NE,69033,2018-03-06,656,D,1,0,RFWA11,"**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 interventions on Resident #3's initial care plan related to the resident's history of falls. Sample size was 5. Census was 33. Record review of Resident 3's facesheet printed on 3/7/2018 revealed the resident was admitted on [DATE]. Record review of Resident #3's History and Physical dated 2/7/2018 identified the following problems: weakness and history of falls. Record review of Resident 3's baseline care plan dated 2/13/18 revealed a safety problem of history of falls and had not developed any interventions related to methods of preventing falls or injuries. 3/7/2018 at 10:45 AM interview with the DON (Director of Nursing) and MDS Coordinator (Minimum Data Set) confirmed the careplan of Resident #3 was not updated and no interventions related to falls were developed on the residents initial careplan.",2020-09-01
4955,"PREMIER ESTATES OF CRETE, LLC",285170,830 EAST 1ST STREET,CRETE,NE,68333,2018-01-24,656,D,1,0,TMI511,"**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 ensure resident care plans included all individualized care needs for three residents, (Resident 10 related to elimination needs, behavioral symptoms, or infection control; Resident 11 related to infection control and behavioral symptoms; and Resident 12 related to the amount of assistance needed to complete: toileting, personal hygiene, transfers, and dressing.) Facility cnesus was 58. Findings are [NAME] An interview on 1/23/18 at 5:00 PM with Licensed Practical Nurse (LPN)-A, revealed Resident 10 was admitted to the facility with septic pressure ulcers. Resident 10's [DIAGNOSES REDACTED]. The LPN reported Resident 10 had good control and use of upper extremities; was alert, oriented, and able to voice needs. Resident 10 exhibited noncompliant behaviors including: smearing stool all over self and not calling for needed assist with [MEDICAL CONDITION] cares; declines offers of assistance and refuses to allow for repositioning out of the power wheelchair during the day due to need for usual activity and socialization. A review of Resident 10's care plan, initiated on 10/2/17, with admitted [DATE] revealed no documentation related to the resident's elimination needs, infection control concerns, or behavioral symptoms exhibited. An interview on 1/24/18 at 3:45 PM with the Director of Nursing confirmed Resident 10's care plan did not include information related to the resident's elimination needs, behavioral symptoms, or for the identified infection control concerns. B. An interview on 1/23/18 at 5:05 PM LPN-A revealed Resident (11) was admitted to the facility with [DIAGNOSES REDACTED]. The LPN reported Resident 11 was non-compliant with recommendations related to the care of the pressure ulcer and would dig at and remove the dressing from the wound on the resident's coccyx (sacral-tail bone) area. The resident will deny the behavior and report to the staff that someone else must have taken the dressing off of the area. A review of Resident 11's Care Plan with admitted d 9/27/17 revealed: a [DIAGNOSES REDACTED]. Continued review of the care plan revealed no documentation related to infectious [DIAGNOSES REDACTED]. A review of the website CDC.gov (Center for Disease Control) last updated 1/16/18 revealed [MEDICAL CONDITION] is a liver infection caused by the [MEDICAL CONDITION] virus (HCV). [MEDICAL CONDITION] is a blood-[MEDICAL CONDITION]. An interview 1/24/18 at 2:00 PM with the MDS (Multidisciplinary Data Set-a tool used for resident assessments) Nurse confirmed that Resident 11's care plan did not include documentation related to individualized behavioral symptoms or [DIAGNOSES REDACTED]. C. An interview with Resident 12, on 1/23/18 at 5:00 PM, revealed the facility had not provided the needed DME (Durable Medical Equipment) supplies needed for the resident's care including: a bariatric commode (currently using a bedpan for elimination), a wheel chair which was wide enough for the resident to sit without discomfort, and a chair for the res to sit on in order to get out of bed (spouse brought in reclining lift chair). A review of Resident 12's care plan revealed documentation related to the resident being at risk for nutritional problems, and the potential for low activity involvement and social isolation. The care plan did not include information related to the resident's toileting needs, difficulty obtaining needed equipment, or the amount of assistance needed for activities of daily living. An interview on 1/24/18 at 3:55 PM with the Director of Nursing confirmed Resident 12's care plan did not include information related to the resident's elimination needs, the facility's difficulty obtaining needed equipment, or the amount of assistance needed for activities of daily living. .",2020-03-01
3652,RIDGEWOOD REHABILITATION & CARE CENTER,285279,624 PINEWOOD AVENUE,SEWARD,NE,68434,2018-06-05,657,D,1,1,RVGM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09C1 Based on observation, record review, and interview; the facility failed to ensure care plans were revised to reflect the resident's overall care needs related to: the potential for infection, dysphasia (difficulty swallowing), and a recurring skin condition. This failure had the potential to affect one resident, Resident 32. The facility census was 73. Findings are An observation of morning cares on 5/31/17 at 7:25 AM, for Resident 32, revealed the resident was dependent upon staff for repositioning, transfers, dressing, toileting, and grooming. Resident 32 was able to feed self with set up and minimal assistance. A tilt in space (mechanisms to allow repositioning) type wheelchair was used for positioning and mobility. Staff utilized a calm voice while working with Resident 32 and explained steps in the process to the resident prior to providing needed assist with tasks at hand. A review of an undated care plan for Resident 32 revealed the resident was admitted to the facility on [DATE]. A care plan Focus, initiated on 4/8/17, indicated the resident had a potential risk for infection related to being dependent for cares, history of infection/antibiotic use during the last 6 months, and swallowing issues. The care plan did not indicate the type of infection or antibiotic which Resident 32 had a history of [REDACTED]. Further review of the undated care plan revealed a Focus, initiated on 4/7/18, indicating a potential for skin breakdown related to fragile skin, immobility, and incontinence (inability to control bladder). Interventions implemented by the facility, on 4/7/18, included pressure relieving devices to chair and bed at all times, and to assist with repositioning. The interventions were not revised until Critic Aid cream to coccyx area until healed was added on 4/23/18. No further revisions for this focus were identified. A review of Progress Notes for Resident 32, dated 2/28/18-4/24/18, indicated the resident had a reoccurring open area to coccyx (tail bone area). An interview on 06/04/18 at 03:02 PM with Registered Nurse (RN)-M, confirmed Resident 32's care plan did not include documentation related to: what kind of infection, the resident's dysphasia, or reoccurring open coccyx area. The RN also confirmed the care plan did not include preventative measures put into place related to the issues.",2020-09-01
4028,OLD CHENEY REHABILITATION,285299,5431 SOUTH 16TH STREET,LINCOLN,NE,68512,2019-01-03,655,E,1,1,KV8H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09C1a Based on record review, interview and observation the facility failed to develop a Baseline Care Plan (a plan of care developed within 48 hours of admission that out-lines the services and treatments necessary to properly care for the resident until the Comprehensive Care Plan can be developed) within 48 hours of admission for 5 Residents (Residents 20, 21, 24, 85 and 187) Findings are: [NAME] Resident #21; Record Review of Resident #21 revealed the resident [DIAGNOSES REDACTED]. Resident #21 was admitted [DATE] and no baseline carnelian written at all, a comprehensive care plan was completed on 2/14/18. Interview on 01/03/19 at 11:44 AM with the Director of Nursing revealed that a baseline care plan was not found for Resident #21 and the baseline care plan should have been completed by 12/02/18. The only care plan documented was the comprehensive care plan 12/13/18. B. Resident # 20; Record Review for Resident #20 revealed the resident was admitted on [DATE] and a diagnosis, of trauma fall with fractures to pelvis, acute pain, alcohol disturbance, anxiety, right ischium fracture with healing, [MEDICAL CONDITION], recurrent fall and stumbling without subsequent routine healing, , tripping and stumbling without subsequent striking against object, gastro [MEDICAL CONDITION], reflux disease without esophagitis, frequency of micturition. The record review also revealed no baseline care plan for the resident within 48 hours of admission. Initiation of comprehensive care plan was 12/13/18. Interview on 01/03/19 at 11:44 AM with the Director of Nursing revealed that a baseline care plan was not found for Resident #20 and the baseline care plan should have been completed by 12/03/18. The care plan documented was the comprehensive care plan on 12/13/18. C. Interview on 12/26/18 01:17 PM with RN (Registered Nurse) F revealed; Resident 24 had [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. Record review of care plan printed on 12/27/18 revealed; Resident 24 was admitted on [DATE]. The Baseline Care Plan for Resident 24, related to [MEDICAL TREATMENT] was not found. Interview on 12/27/18 AT 10:30 with the Interim DON (Director of Nurses) revealed; that the Baseline Care Plan did not address Resident 24's need for [MEDICAL TREATMENT] three times per week. Interview with Interim DON 01/02/19 08:59 AM revealed; Resident 24 had admitted prior to 12/3/18, the staff had been using the previous care plan related to Resident 24 being readmitted less than 30 days later. The staff had discontinued the Care Plan on 12/7/18 and began a new Baseline Care Plan. The Interim DON confirmed the new Baseline Care Plan did not address [MEDICAL TREATMENT]. Record review of the Baseline Care Plan Policy dated (YEAR) revealed; that the baseline will be developed within 24 hours of admission with the following initial goals, physician orders, diet orders, therapy services, social services, PASSR. Information should be gathered from the admission physical assessment, hospital transfer, physician orders, and discussion with the resident. Once gathered initial goals would be established that reflected the resident's current needs. Interventions would address the resident's current needs any health, safety concerns to prevent decline. Identified needs for supervision, behavioral interventions and assistance with activities of daily living would be addressed. Any special needs such as IV therapy [MEDICAL TREATMENT], or wound care would be addressed. Once established, goals and interventions would be documented in the designated format. A written summary of the base line care plan would be provided to the resident and the representative in a language that the resident can understand. The summary would include at a minimum the following 1. Initial goals, 2. a summary of the resident medication and dietary restrictions. 3. Any services and treatment to be administered by the facility and personnel acting on behalf of the facility. D. Record review of MDS Minimal Data Set (is a standardized federally mandated assessment used to complete a person centered care plan) dated 12/26/18 revealed the admitted was 12/21/18. On Section G 0110 Functional Status revealed; Resident 85 required one person extensive assist for bed mobility, transfers, walking in the room, Locomotion on and off the unit, dressing, toilet use and personal hygiene. Record review of Hospital Discharge orders dated 12/19/18 revealed; problems List of: Acute pain, Acute Post Hemorrhagic [MEDICAL CONDITION], Heart failure, Closed Fractured of Multiple Ribs. [MEDICAL CONDITIONS] CAD ([MEDICAL CONDITION]), Fall, Frequent Falls, Gout, Obstructive Sleep Apnea, Skin Tear of Hand and Elbow, Traumatic Ecchymosis of Forearm, Shoulder, Right Upper Extremity, Left Lower Leg and Right Lower Leg Diabetes, UTI (Urinary Tract Infection) and Weakness. Record review of MAR (Medication Administration Record) Revealed Resident 85 had the following medications for pain relief, Tylenol 325 mg 2 tablets every 6 hours for pain, and [MEDICATION NAME] 5-325 mg 1-2 tablets every 6 hours for pain. Resident 85 had Miramax 17 GM daily PRN (As needed) and Sennosides-[MEDICATION NAME] 8.6-50 mg 2 tablets daily for constipation. Resident 85 took [MEDICATION NAME] 500 mg 2 tabs twice daily for infection. Record review of Baseline Care Plan to be completed on 12/23/18 revealed; on 12/21/18 a focus Baseline Care Plan for Self Care was initiated. On 12/26/18 a focus for Diabetes, falls, and Wound Care/Wound VAC (a machine that aides in wound healing) were initiated. On 12/31/18 a Baseline care plan for Polypharmacutical and bladder incontinence was initiated. Record review of Admission assessment dated [DATE] revealed Resident 85 was in pain rated a 6 on a scale of 1-10. Resident 85 is incontinent of urine and used incontinence products. Resident 85 had poor balance, coordination with a history of falls. Resident 85 did not have an infection. Resident 85 Skin Assessment revealed; Scattered abdominal bruising, base of right great toe old blister, left ankle bruising, left arm scattered bruising, left arm cut, left back several bruises, left hand skin tear, left heal callous, left outer lower leg wound VAC, lower legs scattered bruises, nail left great toe black, right hand skin tear 2 on knuckles, right ankle bruising, right arm bruising, right inner calf bruising, right inner calf wound VAC in place, right inner forearm bruise, right wrist bruise, right waist line skin tear, upper chest faded Interview on 1/3/19 at 0840 AM with Interim DON confirmed that the Baseline Care Plan should have been completed by the nursing staff on 12/20/18 related to the areas of pain, skin, Diabetes Mellitus II, falls, mobility, ADL assistance, and wound care. C. Observation on 12/26/18 at 10:00 AM of Resident 187 during interview of dressing on abdomen, [MEDICAL CONDITION] (a surgical opening in the abdomen to move waste/stool out of the body) bag and JP drain (a closed suction medical device used after surgery to remove body fluids from the surgery site) attached to clothing. Record review of Nursing Admit assessment dated revealed; Resident 187 admitted on [DATE]. Resident 187 Physical Status revealed an [MEDICAL CONDITION] and JP drain. The Head to toe skin assessment revealed wounds to the abdomen/anal area that has sutures and staples. Record review of care plan revealed that Resident 187 admitted on [DATE] the Baseline Care Plan for Pain, Wound Care with JP Drain were not located on the care plan. Baseline Care Plan Focus dated 12/26/18 were ADL Care, Assistance with Activities, bladder incontinence, falls, limited physical mobility An interview on 12/27/18 at 10:30 AM with the interim DON confirmed that the baseline care plan for resident 187 did not address pain. An interview on 12/27/18 at 11:21 AM with the Interim DON confirmed that the care plan did not address wound care and the [MEDICAL CONDITION] for resident 187.",2020-09-01
2055,GOOD SAMARITAN SOCIETY - VALENTINE,285176,601 WEST 4TH STREET,VALENTINE,NE,69201,2018-12-11,655,D,1,0,B7PS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09C1a Based on record reviews and interview, the facility failed to develop a baseline care plan on admission, to include safe transfer instructions for one current sampled resident (Resident 5). The facility census was 35 with six current sampled residents and two closed records reviewed. Findings are: Review of the Admission Record, printed 12/10/18, revealed that Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan, goal date 1/16/19, revealed a focus area initiated on 10/25/18 the resident had an activities of daily living self care performance deficit related to stroke as evidenced by the need for limited to extensive assistance with activities of daily living. Interventions included (date initiated 10/25/18) transfer between surfaces with one staff assist, gait belt (belt applied around the resident's waist and used to hold onto the resident during transfers) and walker to ambulate. Interview with the Director of Nursing on 12/11/18 at 2:10 PM confirmed there was no documentation of a baseline care plan developed on admission to address safe transfer instruction for the resident.",2020-09-01
2715,SKYVIEW CARE AND REHAB AT BRIDGEPORT,285224,505 O STREET,BRIDGEPORT,NE,69336,2018-10-01,656,E,1,0,V0GT11,"**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) recurrent UTIs (Urinary Tract Infections) for one current sampled resident (Resident 1), 2) loose stools, decreased energy and increased sleepiness for one current sampled resident (Resident 2) and 3) ongoing itching for one current sampled resident (Resident 3). The facility census was 38 with six sampled residents. Findings are: [NAME] Review of the Face Sheet revealed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. Review of the Care Plan, goal date 12/20/18, revealed to problem identified to address the resident's recurrent urinary tract infections and the use of an antibiotic daily. B. Review of the Departmental Notes for Resident 2 revealed that the resident received [MEDICATION NAME] (antidiarrheal) on 8/23/18, 8/24/18 and 8/25/18 for complaints of loose stools. Review of the Departmental Notes revealed that on 9/25/18, the resident made statements of lack of energy and wanting to sleep all the time. C. Observations of Resident 3 on 10/1/18 at 10:45 AM and 12:30 PM revealed resident scratching arms. Interview with the resident on 10/1/18 at 12:30 PM revealed I itch all over most of the time. Review of the Physician Orders, dated 9/18/18, revealed a [DIAGNOSES REDACTED]. Review of the Departmental Notes revealed that [MEDICATION NAME] ([MEDICATION NAME]) was administered on 8/24/18, 8/27/18, 8/28/18, 8/30/18, 8/31/18, 9/27/18, 9/28/18, 9/29/18, and 9/30/18 for itching. Review of the Care Plan, goal date 12/23/18, revealed no care plan to address the resident's ongoing complaints of itching. Interview with the Director of Nursing on 10/1/18 at 3:30 PM confirmed that care plans need to be developed to address the resident's conditions described above to ensure consistent and effective care.",2020-09-01
1034,PRESTIGE CARE CENTER OF PLATTSMOUTH,285104,602 SOUTH 18TH STREET,PLATTSMOUTH,NE,68048,2018-05-21,657,D,1,0,8OXW11,"**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 review and revise the Care Plan related to additional interventions to prevent abuse for 1 resident (Resident 23) of 23 resident. The facility staff identified the census at 62. The findings are: A record review of Resident 23's Face Sheet dated 5/16/2018 revealed an admission date of [DATE] and a [DIAGNOSES REDACTED]. A record record review of Resident 23's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 3/5/2018 revealed, the Brief Interview for Mental Status (BIMS, 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 of residents. A score in the range of 0-7 points indicates that the resident is severely impaired.) for Resident 23 was scored at 4. A record review of Resident 23's Nursing Notes dated 5/9/2018 at 11:08 PM revealed documentation of 3 small bruises on the inner right thigh of Resident 23. An Interview with Social Services Director on 5/16/2018 at 11:25 revealed, Resident 23's family and the Facility Management had a meeting on 5/15/2018 at 10:00 AM regarding alleged sexual abuse that had happened within the Facility. During this meeting it was agreed upon that visitations with Resident 23 would be supervised by staff, in common areas and no blankets would be allowed to cover Resident 23 during visits. A record review of Resident 23's care plan updated on 3/23/2018 revealed additional interventions to prevent further sexual abuse were not included in the Care Plan. An interview with the Director of Nursing (DON) on 5/17/18 at 10:35 AM confirmed that visits were required to be in a common area, supervised by staff and blankets were not allowed to cover Resident 23 during visits. The DON confirmed that the Care Plan did not include the additional interventions to prevent further abuse and needed to be updated.",2020-09-01
6235,SUTHERLAND CARE CENTER,285141,"P O BOX 307, 333 MAPLE STREET",SUTHERLAND,NE,69165,2016-05-10,280,D,1,0,IG3I11,"**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 the care plan interventions for 2 sampled residents (Resident 1 and 2) were updated after a fall. Facility census was 43. Findings are: A. Review of the Resident Admission Record for Resident 1 revealed an admission date of [DATE] to the facility with [DIAGNOSES REDACTED]. Review of the facility, Incident Form dated 4/30/16 for Resident 1 revealed an unwitnessed fall in the bathroom. Review of the facility, Quality Improvement Post Fall Investigation form dated 4/30/16 for Resident 1 revealed an unwitnessed fall and that the resident was, found on the floor. Further review revealed that the resident was weak and did not have any injuries at the time of the fall. Continued review revealed that the fall intervention had been updated to educate the resident to use call light for help related to being tired and weak. Review of the Care Plan dated 4/21/12 for Resident 1 revealed a problem of, Resident at risk for falling. Continued review of the interventions to prevent falls revealed no written documentation of the education of the resident to use call light on 4/30/16. Observation on 5/10/16 at 11:30 AM of Resident 1 lying in bed, the bed did have bed canes that were covered and secured. Further observation revealed that the revealed that the was in a high/low bed in the low position. Observation on 5/10/16 at 3:00 PM of Resident 1 revealed that the resident remained in bed. No opportunities of seeing the resident get up could be completed by the end of the survey. Interview with Resident 1 on 5/10/16 at 11:30 AM revealed that the resident did not want to get out of bed today. Further interview revealed that the resident was just really tired today. Continued interview revealed that the resident stated the ability to get up on their own except when really weak. Interview with (Licensed Practical Nurse) LPN - A on 5/10/16 at 11:40 PM revealed that Resident 1 did experience days of weakness and fatigue. Further interview revealed that most of the time Resident 1 was able to get up and transfer without assistance but required assistance on days of weakness. LPN - A did verify that Resident 1 had a fall in the bathroom. Interview on 5/10/16 at 4:00 PM with the Administrator, the Director of Nursing and the MDS Coordinator (a minimum data set, a federally mandated comprehensive assessment tool utilized to develop resident care plans), verified that Resident 1 did have a fall in her bathroom on 4/30/16 with no injuries. Further interview confirmed that the care plan for Resident 1 did not contain written documentation to support that it had been updated post fall with interventions to prevent further falls. B. Review of the Resident Admission Record for Resident 1 revealed an admission date of [DATE] to the facility. Further review revealed [DIAGNOSES REDACTED]. Review of the Incident Report dated 4/28/16 for Resident 2 revealed a fall in the bathroom. Further review revealed that the resident was found on the floor and after the fall did have a serious injury. The resident was transferred to the hospital. Review of the Quality Improvement Post Fall Investigation form dated 4/28/16 for Resident 2 revealed that the resident did have an unwitnessed fall in the bathroom. Further review revealed that the Tabs alarm was sounding, and the resident did have an unsteady gait. Continued review revealed that the resident did have a fractured tibia on the right from the fall. Further review revealed written documentation that the fall interventions had been updated on 4/28/16. Review of the Documents Review Report/Discharge Plan dated 4/29/16 for Resident 2 revealed written instructions to wear the fracture boot for weight bearing for 8 weeks. Further review revealed orders that the boot could be taken off for bathing but if the resident got up at night the boot needed to be on. Interview on 5/10/16 at 11:55 AM with LPN - A revealed that Resident 2 had increased confusion due to the Dementia diagnosis. Further interview verified that Resident 2 did have a recent fall with a fractured fibula. Continued interview verified that the resident had a boot that needed to be put on before weight bearing and removed at bedtime and, put on if the resident was up at night. Interview on 5/10/16 at 4:00 PM with the Administrator, the MDS Coordinator and, the Director of Nursing confirmed that Resident 2 had an unwitnessed fall in the bathroom. Further interview verified that the Discharge orders from the hospital for Resident 2 of the need to wear the boot for weight bearing and when to take the boot off had not been transferred to the residents care plan. Continued interview verified that there was no written documentation to support that the post fall orders had been transferred to the care plan.",2019-05-01
2678,HERITAGE OF EMERSON,285222,607 NEBRASKA STREET,EMERSON,NE,68733,2017-08-31,280,E,1,1,AEM711,"**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 revise the care plan with new fall interventions for 2 residents (Residents 24 and 11), failed to address pain on the care plan for 1 resident (Resident 4), and failed to update prevention of pressure ulcer interventions for 1 resident (Resident 8) of 16 residents sampled. The facility staff identified the resident census at 30. The findings are: [NAME] A review of Resident 24's Admission Record dated 8-31-17 revealed Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 24's fall report dated 8-21-17 revealed the resident fell out of bed on 8-21-17 and sustained abrasions to their knees and skin tears to their right ear and face. One of the actions taken to prevent future falls was to add a scoop mattress (special mattress with raised edges) to the resident's bed. A review conducted on 8-30-17 of Resident 24's undated care plan revealed the intervention for a scoop mattress was not on the care plan. An interview conducted on 8-31-17 at 12:23 PM with Registered Nurse (RN) A revealed that the scoop mattress was initiated on 8-23-17 and that RN A had not updated the care plan with the intervention until 8-30-17. B. A review of Resident 11's Admission Record dated 8-31-17 revealed Resident 11 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Resident 11's fall report dated 8-21-17 revealed that, on 8-21-17, the resident was found lying on the floor by the nurses station. The resident was last seen sitting in a chair at the nurses station waiting for staff assistance to get ready for bed. The action taken to prevent further falls was to educate the staff and to take the resident directly to their room after supper, toilet them, and assist them to bed. A review of Resident 11's undated care plan revealed no intervention to assist the resident directly after supper to their room, toilet them, and assist them to bed. An interview conducted on 8-30-17 at 2:01 PM with the Director of Nursing (DON) revealed that the new intervention for Resident 11 after their fall on 8-21-17 was to take the resident directly to their room after supper, toilet them, and assist them to bed and that intervention should have been on the residents care plan. C. A review of Resident 4's Admission Record dated 8-31-17 revealed Resident 4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An observation conducted on 8-29-17 at 8:17 AM of Resident 4 revealed Resident 4 was approaching staff and visitors and telling them that their shoulder was hurting. An interview conducted on 8-30-17 at 9:44 AM with Resident 4 revealed the resident was experiencing pain in their shoulder. An interview conducted on 8-30-17 at 11:33 AM with Resident 4 revealed that resident was experiencing pain in their left shoulder. An interview conducted on 8-30-17 at 1:33 PM with Resident 4 revealed that resident was experiencing pain in their left shoulder. A review of Resident 4's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 7-12-17 revealed that Resident 4 was experiencing occasional moderate pain at that time. A review of Resident 4's Physician Visit/Communication Form dated 8-22-17 revealed the resident was experiencing consistent complaints of right shoulder pain. A review of Resident 4's Medication Administration Record [REDACTED]. A review of Resident 4's undated care plan revealed no care plan to address Resident 4's pain. An interview conducted on 8-31-17 at 11:28 AM with the DON confirmed that Resident 4 did not have a care plan to address pain and should have had one. D. Record review of Resident 8's Face Sheet revealed the admission date of [DATE], with [DIAGNOSES REDACTED]. Observation on 8/31/17 at 9:56 revealed RN B performing wound care to coccyx area. Interview with Nursing Assistant (NA) C on 8/31/17 at 10: 00 AM revealed that Resident 8 did not have an open area only a red area in the past and NA C was not aware that Resident 8 had a new open area. NA C revealed that, if NA's were aware of a wound, it would be the practice to have the resident lie down to relieve pressure. NA C confirmed that Resident 8 got up in the AM, went to breakfast, and sat in the chair that reclined in the room until the evening meal. Resident 8 did not go to the dining room for lunch. NA C confirmed that Resident 8 remained in the chair from breakfast until evening meal. Interview with RN B on 08/31/2017 10:01:17 AM revealed that Resident 8 acquired the wound in the facility. Record review of Resident 8's Plan of care with target date of 8/29/17 revealed a potential for skin breakdown with interventions that included pressure reliving device in chair and bed at all times, provide peri care after each incontinent episode, encourage to reposition, Braden Scale quarterly, and weekly and prn skin monitoring by professional nurse. Interview with DON on 08/31/2017 10:31:19 AM confirmed that Resident 8 was at risk for pressure ulcers based on the Braden scale and that Resident 8 did remain in chair from breakfast until evening meal. DON confirmed that Resident 8's Plan of Care did not reflect the newly acquired pressure area, that no change in interventions were made with the pressure ulcer development, and that the NA's were not aware of need to reposition or have Resident 8 lie down to relieve pressure during day.",2020-09-01
4127,REGIONAL WEST GARDEN COUNTY NURSING HOME,2.8e+181,1100 WEST 2ND,OSHKOSH,NE,69154,2019-04-23,657,D,1,0,21NW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09C1c Based on observations, record reviews and interviews; the facility failed to updated care plans to reflect changes in safe transfers for two current sampled residents (Residents 3 and 6). The facility census was 28 with six current sampled residents. Findings are: [NAME] Review of Resident 3's Resident Profile revealed that on 4/17/19 the resident sustained [REDACTED]. Review of the Nurse's Notes revealed that on 4/17/19 at 9:00 AM two staff members transferred the resident from the wheelchair to the recliner and as the resident took small steps to turn they heard loud pops followed by complaints of increased pain for the resident. Review of the resident's Care Plan, target date 7/10/19, revealed that the resident was at risk for falls related to medications, gait instability related to chronic pain due to [MEDICAL CONDITION] Arthritis and [MEDICAL CONDITION]. Approaches included to assist the resident with ambulation short distances as tolerated and ensure the room, hallways, and all other resident areas had adequate lighting and are free of clutter. Further review revealed no approaches to address the resident's non weight bearing status and safe transfer instructions. Observations on 4/22/19 at 12:45 PM revealed NA (Nursing Assistant) C and NA - F transferred the resident from the wheelchair to the whirlpool chair with a full mechanical lift. Interview with NA - C on 4/22/19 at 12:45 PM revealed that the resident is transferred with the full mechanical lift due to pain in legs. Interview with the DON (Director of Nursing) on 4/23/19 at 11:45 AM confirmed that the care plan needed to be updated to instruct the staff to use the full mechanical lift for transfers due to the no weight bearing orders for the right leg. B. Review of Resident 6's Care Plan, target date 4/17/19, revealed that the resident fell in the bathroom on 3/21/19 and X-rays showed that the resident sustained [REDACTED]. Observations on 4/22/19 at 1:20 PM revealed NA - C transferred the resident from the wheelchair to the toilet with a sit to stand mechanical lift. Interview on 4/22/19 at 1:20 PM with NA - C revealed that the sit to stand mechanical lift was used because of the resident's pelvic fracture and pain when standing. Interview with the DON on 4/23/19 at 11:45 AM confirmed that the care plan should have been updated with instructions to use the sit to stand mechanical lift for transfers.",2020-09-01
1974,FLORENCE HOME,285173,7915 NORTH 30TH STREET,OMAHA,NE,68112,2019-08-12,657,D,1,0,JS4R11,"**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 the interdisciplinary care plan related to constipation and fecal impaction for 1 resident (Resident 1) of 3 residents reviewed. The facility census was 80. Findings are: Review of Resident 1's ID (Interdisciplinary) notes dated 7/9/2019 revealed Resident 1 was transferred to the hospital for a fall resulting in a [MEDICAL CONDITION] and Resident 1 returned to the facility on [DATE]. Review of ID notes dated 7/19/2019 revealed Resident 1 was transferred to the hospital and diagnosed with [REDACTED]. Review of Resident Care plan dated 8/2/2019 revealed no care plan for Resident 1's fecal impaction [DIAGNOSES REDACTED]. Interview on 8/12/2019 at 3:00 PM with the Unit Manager revealed Resident 1's care plan had not been updated with interventions for prevention of constipation or fecal impaction.",2020-09-01
2612,WAUNETA CARE AND THERAPY CENTER,285220,"PO BOX 520, 427 LEGION STREET",WAUNETA,NE,69045,2017-07-20,280,D,1,1,3Q2711,"**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 plans were updated to include 1) actual falls and changes in approaches to reduce the risk of recurrent falls and 2) specific instructions for assistance needed for safe ambulation and transfers for one current sampled resident (Resident 34). The facility census was 31 with 11 sampled residents. Findings are: Review of the (MONTH) (YEAR) Departmental Notes revealed that the resident fell on [DATE], 6/25/17 and 6/26/17. Review of the Care Plan, goal date 9/5/17, revealed a problem, dated 6/6/17, that the resident had a history of [REDACTED]. Further review revealed no care plan to address the falls on 6/9/17, 6/25/17 and 6/26/17 and changes in approaches to reduce the risk for further falls. Review of the Care Plan, goal date 9/5/17, also revealed a problem that the resident had a history of [REDACTED]. Further review revealed approaches including the resident required limited assistance with transfers, ambulation and toileting with 1-2 persons assistance. Interview with the Director of Nursing on 7/19/17 at 2:20 PM confirmed that the care plan should be updated to include each fall and approaches changed to reduce the risk for further falls. Further interview confirmed that the care plan should include specific instructions for the amount of assistance the resident needed for transfers, ambulation and toileting to ensure consistent and safe care.",2020-09-01
6378,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2016-03-31,309,D,1,0,Z6YJ11,"**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 ensure Resident 20's disruptive behaviors were addressed when indicated. The facility census was 83. Findings are: A. A review of the facility's Care Plan for Resident 20 last revised on 10/19/15 indicated the resident had an ADL self-care performance deficit related to [DIAGNOSES REDACTED]. The resident required extensive assist of two staff members using a gait belt for transfers and utilized a w/c (wheelchair) for mobility. Resident 20 exhibited behavioral symptoms which were documented as socially inappropriate and disruptive and was resistive to cares at times. The Care Plan included the potential for pain related to depression, dementia, diabetes, [MEDICAL CONDITION], obstructive sleep apnea, restless leg syndrome, and a history of falls. The Care Plan did not indicate whether or not Resident 20 exhibited signs or symptoms of pain or discomfort, was continent of bowel or bladder, or if the resident was able to voice needs or use the call light to alert staff of needed assistance. A review of Resident 20's Progress Notes dated 3/29/16 revealed the resident had a [DIAGNOSES REDACTED]. An observation on 3/30/16 from 8:30 AM to 12:00 PM revealed Resident 20 to be seated in a wheelchair (w/c) in the resident's room. The resident was noted to be verbalizing repetitive statements, calling out, [MEDICATION NAME], and singing. The television was turned on in the resident's room and the call light was noted to be attached to the wall out of Resident 20's reach. Nursing staff did not enter Resident 20's room or interact with the resident throughout the 3 1/2 hour observation. Interview on 3/30/16 at 9:15 AM revealed Resident 20 would repeat statements or questions, but was unable to conduct a conversation. Interview on 3/30/16 at 12:00 PM with LPN (Licensed Practical Nurse)-B, who was working as a Nursing Assistant assigned to Resident 20, revealed the LPN was unable to say whether or not the resident had received assistance with toileting or repositioning since breakfast. An observation on 3/30/16 from 12:06 PM to 12:15 PM revealed LPN-B and NA (Nursing Assistant)-C entered Resident 20's room and asked Resident 20 if (gender) needed to use the bathroom, the resident denied the need. The staff members proceeded to apply a gait belt and encouraged Resident 20 to stand up from the wheelchair in order to assess for the need of incontinence care. Resident 20 reported inability to stand with assistance from the two caregivers. The LPN provided verbal cueing and further encouragement as the transfer was attempted a second time. Resident 20 did not move or attempt to stand stating I can't do it. The two staff members then left the room reporting the resident was not going to transfer with two assist and the gait belt. Interviews during the observation on 3/30/16 from 12:06 PM to 12:15 PM with LPN-B and NA-C confirmed the resident had not been repositioned or toileted this morning. When asked whether or not Resident 20 was capable of using the call light, the LPN reported the resident usually propels self into the doorway of the resident's room and calls out when assistance was needed. LPN-B then attached the call light to Resident 20's wheelchair and the two staff members left the room reporting the resident was not going to transfer with two assist and the gait belt Observation on 3/30/16 from 12:15 PM thru 2:00 PM revealed Resident 20 remained seated in a wheelchair in the resident's room talking, singing, and calling out. Nursing staff did not enter the resident's room. At 2:00 PM Resident 20 was noted to propel self in wheelchair using feet (gender's) out of the resident's room and down the hallway. An interview on 3/30/16 at 2:40 PM with the ADON (Assistant Director of Nursing) revealed the ADON was unable to say if Resident 20 had received assistance with toileting or repositioning this shift and reported staff would be located to verify the resident's cares were completed. The ADON returned momentarily and confirmed Resident 20 had not received the needed assist for toileting or repositioning. The ADON reported a NA would assist Resident 20 as soon as possible.",2019-03-01
5931,SIDNEY REGIONAL MEDICAL CENTER-EXTENDED CARE,285290,549 KELLER DRIVE,SIDNEY,NE,69162,2016-08-15,309,D,1,0,39B611,"**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 assess and monitor pain and pain management for three sampled residents. (Residents 3, and 2) with pain. Facility census was 51. Findings are: A) Record review: Resident Admission Sheet reveals a date of admission for Resident 3 as 2/24/2012. [DIAGNOSES REDACTED]. Record review of a Care Plan with an original date of 3/11/2015 and a modify date of 4/27/2016 revealed a problem area of PAIN stated the resident had the potential for chronic pain related to arthritis disease process. The goal was the resident would state/demonstrate relief or reduction in pain intensity within one hour of receiving interventions. The interventions included monitor and report to the nurse the scope and severity of pain and worsening of pain. To report changes in pain location/type/frequency/intensity to provider. Provide comfort measure included repositioning and warm/cold packs. To administer and monitor for effectiveness and possible side effects from routine medications, PRN (as needed) medications and provide diversional activities. Consult PT/OT (Physical Therapy/Occupational Therapy), mental health, as needed. A new intervention was initiated on 8/8/2016 of Monitor for increased pain related to sutures and recent fall. Record review: Facility Pain sheet dated 8/8/2016 to 8/11/2016 reveal Resident 3 reported/expressed actual or suspected pain on: - 8/8/2016: No numeric rating scale was included; - 8/9/2016: the resident did not report any actual or suspected pain but comfort measures to include cold therapy was provided with patient response as tolerating well. No numeric rating scale was included; - 8/11/2016: the resident reported actual or suspected pain with a location of the head. The primary pain was aching. Oral [MEDICATION NAME] was provided. No numeric rating scale was included. No medication effectiveness was recorded Record review of a Fall sheet revealed the resident experienced a fall on 8/8/2016 requiring sutures in the head from a laceration. Discharge interventions dated 8/8/2016 following fall injury included Tylenol 650 mg (milligrams) every 6 hours as needed. Interview with the Administrator on 8/15/2016 at 2:40 PM revealed the resident had fallen on 8/8/2016 and received a laceration to the head which required sutures. The resident had expressed mild pain to the staff sine the incident and the pain has been successfully treated with oral [MEDICATION NAME]. The Administrator confirmed there was no documentation included in the pain assessment sheets to assess effective pain management by use of a pain scale or other documentation to determine medication effectiveness. Record review of Facility Policy: Pain Management Effective Date 3/2007 Review date 06/2016 -Procedure -3.10 Perform a pain assessment using the assessment flowchart that is part of the electronic health record. Only licensed nurses must carry out pain assessment and reassessment . -3.11 Review the resident current pain medication regiment determine the following: 1. Name of drug, dose and frequency ordered. 2. How long the resident has been on this medication. 3. Degree of relief experienced for this medication. Minutes before pain medication is effective. Amount of relief at least 1 hour after administration -3.12 Use a pain scale when the resident described his or her pain and amount of pain relief, a pain scale of 0-10 can be used with residents who can understand the concept. For non-verbal residents the FLACC (face, leg movement, activity, crying, and consolability) assessment shall be used. -3.13 Non-verbal residents shall have pain assessed by a licensed nurse at least weekly and as indicated by non-verbal signs of pain or discomfort. -3.14 The Resident Care Plan and computer system are updated as needed. Documentation in the clinical notes is done according to the protocol. B. Review of the Active MEDICATION ORDERS FOR [REDACTED]. Review of the All Medications sheet for Resident 2 revealed orders of [MEDICATION NAME]-[MEDICATION NAME] (a pain medication) 5/325 mg, administer 1 every 4 hours for pain. This was changed on 8/4/16 to 1-2 tablets every 4 hours for pain. Further review revealed that, on 8/5/16, the order was changed again and, on 8/5/16 changed, again to [MEDICATION NAME] 10 mg twice a day. Review of the Resident Care Plan dated 8/3/16 for Resident 2 revealed a problem identified as Pain, with interventions to administer [MEDICATION NAME] as needed, monitor for effectiveness and report to physician if pain is not controlled or worsens, use pain scale of 0-10, offer other forms of pain relief warm packs, position change . Review of the Pain Sheet documentation for Resident 2 revealed an inconsistency in reporting pain effectiveness on 8/3, 8/4, 8/5 times 2, 8/6 times 2, 8/7, 8/8, 8/9 times 2, 8/10 times 2, 8/11 with a pain rating of 7/10 (as pain scale to rate pain 0 - 10). Further review revealed written documentation of a pain rating on 8/12 but no written documentation of the effectiveness of the pain medication. Review of the Progress Notes dated 8/4/16 through 8/12/16 for Resident 2 revealed written documentation of pain on 8/4 at 6:34 PM 8/6 with rated pain at a 6 on scale of 0-10 with pain medication provided. Further review revealed that the resident requested, at that time, also to get the pain medication at 6:00 AM and 6:00 PM. On 8/8, the resident request to go the the emergency room (ER) as the pain is not in control. On 8/8, the resident returned from ER with additional pain orders and reported pain at 5/10. On 8/9/, the resident requested pain medication and on 8/11/16. Review of the Medication Administration Record [REDACTED]. Interview on 8/15/16 at 11:17 AM with LPN (Licensed Practical Nurse) - A revealed that the residents were asked weekly about pain and pain was also assessed at that time for residents unable to voice pain. The pain scale of 0 - 10 was used and the effectiveness was then to be assessed. Further interview revealed that the Licensed staff were the only staff to do the assessments of pain. Interview on 8/15/16 at 3:00 PM with the Administrator verified that Resident 2 did have issues with pain control. Further interview verified that the Medication Administration Record, [REDACTED]. Further interview confirmed that the facility used the pain rating scale of 0-10 for residents able to communicate and observed other residents one time a week for pain utilizing the signs or symptoms of pain. Continued interview confirmed that the Licensed Nursing staff are the only ones that are able to assess pain and provide the pain medication and that time the pain should be rated by the resident and then the effectiveness of the pain medication should have been assessed. Further interview verified that there was lack of written documentation that this had occurred with each pain medication administered.",2019-08-01
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
4846,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2018-03-06,697,H,1,1,9WK311,"**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) pain assessments were completed and pain was managed for one current sampled resident related to a dislocated shoulder and chronic headaches related to a [DIAGNOSES REDACTED] (Resident 176), 2) pain assessments were completed with pain levels rated severe for one current sampled resident (Resident 11) and 3) assessments were completed and interventions were in place to relieve ongoing pain related to positioning in the wheelchair for one current sampled resident (Resident 22). The facility census was 27 with 16 current sampled residents. Findings are: [NAME] Review of the Admission Record revealed that Resident 176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes, dated 2/25/18 at 12:00 PM revealed that the resident was seated on the toilet and upon rising stated ow and pointed to bicep area. The resident requested spouse be called. Spouse called and stated that the resident's shoulder was dislocated and requested the resident be sent to the emergency room per ambulance. Resident was assessed for pain and was transferred to the hospital per ambulance. Further review revealed that at 2:55 AM, the resident returned to the facility with no documentation of an assessment of the left shoulder until 2:59 PM. Review of the hospital emergency room report, dated 2/25/18 at 12:56 AM, revealed the following including: - Presenting problems included history of [MEDICAL CONDITION] and brain surgery on 2/12/18, spouse received a call from the nursing home that the resident was having severe pain in the left shoulder, found that the left shoulder was dislocated and the left hand was blue, spouse reduced the left shoulder and restored circulation to the left arm. Interview with the resident's spouse on 2/28/18 at 7:45 AM revealed concerns related to pain management. The spouse stated that the resident was not always reliable with communication, when asked if having pain will say no when the resident means yes. Nonverbal symptoms of pain need to be utilized, frowning, shaking head, or grimacing. The spouse stated that the resident had a long history of frequent headaches since diagnosed wih the [DIAGNOSES REDACTED] and typically took Tylenol at least a couple of times a day for lesser pain and [MEDICATION NAME] daily for more severe headaches. The spouse stated that would put hands up and the resident could point to a finger to express the intensity of pain. The spouse was concerned that the resident was having pain that wasn't identified by the staff and medications were not being administered when needed. Review of the care plan, initiated on 2/26/18, revealed no care plan to address pain. Review of the Medication Administration Record, [REDACTED]. Further review revealed that no pain medication was administered until 2/26/18. Further review of the Progress Notes included the following: - 2/26/18 at 9:00 AM [MEDICATION NAME] administered for complaints of pain all over rated 7-10 on the pain scale The pain scale is based on 1 - 10 with 8-10 considered extreme pain; - no documentation of where the pain was located or other interventions in place to manage the pain; - 2/26/18 at 10:33 AM - medication was effective with no further documentation; - 2/26/18 at 10:15 PM - medication was given pain medication earlier for headache; - 2/27/18 at 12:27 AM - [MEDICATION NAME] given for complaints of a headache, no further assessment documented including intensity or other care provided to relieve the headache; - 2/27/18 at 3:06 AM - resident states no pain; - 2/27/18 at 6:03 AM - [MEDICATION NAME] administered for pain , no documentation of the location or intensity; - 2/27/18 at 7:17 AM - medication was effective with no further assessment. Interview with the DON (Director of Nursing) and the Nurse Consultant on 3/5/18 at 8:50 AM confirmed that there was no assessment of the resident's left shoulder injury on 2/24/18 including causal factors, intensity of the pain, or that pain medication was administered to relieve the pain. Further interview confirmed that assessments should have been completed and documented related to the resident's headaches, including non verbal symptoms of pain, to ensure pain was effectively identified and managed to meet the resident's needs. B. Review of the Admission Record revealed that Resident 11 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with the resident on 3/1/18 at 11:30 AM revealed that knee has been killing me and went to the doctor and has an infection in the knee. Review of the care plan, target date 4/28/18, revealed that the resident required assistance with activities of daily living including transfers, mobility, and assess for non verbal indicators of pain and encourage to verbalize pain and discomfort. Further review revealed no care plan to address actual pain and interventions to relieve pain. Review of the Medication Administration Record, [REDACTED]. Further review revealed that in addition [MEDICATION NAME] (narcotic [MEDICATION NAME]) was administered on 2/12/18 at 10:47 AM for pain rated 8, on 2/21/18 at 11:31 AM for pain rated 10 and on 2/27/18 at 12:47 PM for pain rated 10. Further review revealed that the medications were documented as effective. Interview with the DON on 3/5/18 at 3:45 PM revealed that no further assessments were completed or documented to include causal factors of pain, numerical rating to evaluate pain relief after pain medications were administered and non pharmacological interventions in place to prevent or to relieve pain. Further interview confirmed that assessments and follow up should be done to ensure that the resident's severe pain was managed to meet the resident's needs. C. Record Review of Resident 22's Admission Rcord printed on 2/28/18 revealed an admitted to the facility on [DATE]. Observation on 02/27/18 at 9:00 a.m. revealed Resident 22 was sitting in their wheelchair in their room placing clothing items in a dresser and Resident 22 verbally complained about back pain. Observation 02/28/18 at 10:30 a.m. revealed the resident was in the hallway sitting in their wheelchair and Resident 22 was in a slouching position in the wheelchair. Resident 22's back was not against the back of the wheelchair. Record Review of Resident 22's progress note completed by SSD ( Social Services Director) on 02/06/18 at 15:01 verified that Resident 22 had voiced concerns about the wheelchair. Record Review of Resident 22's MDS (Minimum Data Set) identified the resident had occasional pain and it was rated at an 8 on a scale of 0-10. Record Review of Resident 22's Care plan revealed that Resident 22's pain would be at an acceptable level through the next review. The care plan was revised on 2-21-18. Interventions included adjustments made to pain medication, Administer medication as ordered, monitor pain level per pain scale, if pain level not tolerable, notify PCP (Primary Care Physician) for medication adjustment or change. Interview on 02/27/18 at 9.00 a.m. with Resident 22 revealed the resident's wheelchair did not fit the resident correctly and it caused Resident 22 back pain. Interview on 02/28/18 at 10:00 a.m. with Resident 22 revealed when the resident was sitting in the wheelchair there were times that the resident experienced back pain and butt pain. Resident 22 reported the chair was causing the pain. Interview on 03/05/18 at 1:55 p.m. with the SSD ( Social Services Director) confirmed that Resident 22 complained about the wheelchair causing pain and requested to have the wheelchair re-evaluated. The SSD reported it was unclear where PT (Physical Therapy) was with this process but was also unclear who was responsible for the follow up on the wheelchair which may be causing the resident pain. Interview on 03/05/18 at 2:16 p.m. with PTA (Physical Therapy Assistance)-K verified they were not aware about Resident 22's wheelchair not fitting correctly. PTA-K reported that Resident 22's wheelchair had not been reassessed and also had stated the wheelchair was fairly new and was not sure if Medicaid would pay for a new wheelchair. PTA-K reported it was not clear if the wheelchair was causing Resident 22 pain and that the DOR (Director of Rehabilitation)-L would have to be the person to assess Resident 22 and see if the wheelchair was causing the pain. PTA-K reported that DOR-L had not completed another wheelchair assessment since Resident 22's chair was so new and no one had requested to have it re-evaluated. Interview on 03-06/18 at 12:06 p.m. with Resident 22 revealed the wheelchair had not been reassessed to see if this was causing the resident's back and hip pain. Interview on 03/06/18 at 12:23 p.m. with LPN (Licensed Practical Nurse)-D verified there were no orders to have Resident 22's wheelchair reassessed to determine if this was the root cause of the resident's back pain. Interview on 03/06/18 at 2:04 p.m. with the Administrator and Corporate Nursing Consultant verified that follow up had not been completed on the resident's wheelchair to see if this was the root cause of the resident's pain.",2020-03-01
6263,HEMINGFORD COMMUNITY CARE CENTER,285265,"P O BOX 307, 605 DONALD AVENUE",HEMINGFORD,NE,69348,2016-05-03,309,E,1,0,NIM011,"**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) manage ongoing behaviors directed at staff and other residents for three sampled residents (Resident 1, 2 and 3) and 2) assess skin tears and follow up until resolved for one sampled resident (Resident 2). The facility census was 30. Findings are: A. Review of Resident 1's Behavior Flow Sheet, dated (MONTH) (YEAR) for the 6:00 AM - 6:00 PM shift, revealed that the resident had daily verbal behaviors directed toward others, including behaviors directed toward residents, staff and visitors, such as threatening others, screaming, cursing and verbally inappropriate behaviors. Further review revealed daily verbal behaviors directed toward others with documentation for one incident. On 3/18/16, Resident 1 yelled at another resident and told the resident to shut up and quit hacking and 1:1 redirection was not successful. Review of the Behavior Flow Sheet, dated (MONTH) (YEAR) for the 6:00 AM - 6:00 PM shift, revealed 21 days indicated that verbal behaviors occurred. Further review revealed no documentation related to these incidents. Review of the Behavior Flow Sheet, dated (MONTH) (YEAR) for the 6:00 PM - 6:00 AM shift, revealed 14 incidents of verbal behaviors. Further review revealed the following documentation notes: - 4/3/16 Refused HS (bedtime) cares; - 4/13/16 Refused HS cares; - 4/14/16 Refused HS cares; - 4/18/16 Refused cares; - 4/27/16 Threatening to hit another resident, calling the resident names; - 4/29/16 Resident insisted on going into the Assisted Living area to check for leaks, confused stated was the emergency maintenance man, staff stayed with the resident until the resident agreed to return. There was no documentation for the other eight incidents. B. Review of Resident 2's Behavior Flow Sheet, dated (MONTH) (YEAR) for the 6:00 AM - 6:00 PM shift, revealed that physical behaviors directed towards others occurred once on 3/31/16. Further review revealed no documentation notes regarding the incident. Review of the documentation notes revealed that on 3/19/16, the resident attempted to hit staff, push wheelchair through the dining room doors which were closed because the dining room was being cleaned, called staff names with profanity, hit the Director of Nursing in the stomach, attempted to redirect the resident, resident threw a mug across the floor and dumped a bottle of pop on the floor in the commons area. Redirection was unsuccessful. Review of the Behavior Flow Sheet, dated (MONTH) (YEAR) for the 6:00 PM - 6:00 AM shift, revealed that the resident had 10 incidents of physical behaviors directed towards others and 13 incidents of verbal behaviors directed towards others. Review of the notes revealed the following: - 3/3/16 Refused HS cares, refused to get out of bed to toilet; - 3/7/16 [MEDICAL CONDITION], refused to lay in bed; - 3/8/16 [MEDICAL CONDITION]; - 3/8/16 Yelling at staff, profanities, threw water pitcher at staff, refused to leave the dining room, tried to hit staff three times; - 3/9/16 Hitting, kicking, refused all bedtime medications and cares; - 3/10/16 Yelling profanities, kicking staff, refusing cares; - 3/12/16 Refused bedtime cares, yelling profanities, attempting to hit staff; - 3/13/16 Bowel movement mess on resident and bed, refused cares, hitting staff, refused two attempts, cursing at staff; - 3/18/16 Threw a full bottle of soda in commons area, yelling profanities, kicking staff, refused cares; - 3/20/16 Yelling profanities, hit staff with closed fist, refused medications, hitting pills out of staff's hands; - 3/21/16 Yelling at staff, yelling at residents, hitting staff, throwing personal items in room, refused cares; - 3/22/16 Refused cares, trying to hit staff, kicking staff, yelling at staff, throwing belongings; - 3/23/16 Refused cares, hitting and kicking staff, verbally abusive towards staff, threw blankets all over floor; - 3/25/16 [MEDICAL CONDITION]; - 3/26/16 [MEDICAL CONDITION], refused bedtime cares; - 3/27/16 [MEDICAL CONDITION], refused bedtime cares; - 3/30/16 Hitting and kicking staff, throwing blankets, hitting the wall; - 3/31/16 Yelling profanities, hitting staff. Review of the Behavior Flow Sheet, dated (MONTH) (YEAR) for the 6:00 AM - 6:00 PM shift, revealed that the resident had two incidents of physical behaviors directed toward others and 26 incidents of verbal behaviors directed towards others. Further review revealed no documentation of the physical or verbal behaviors. Review of the Behavior Flow Sheet, dated (MONTH) (YEAR) for the 6:00 PM - 6:00 AM shift, revealed five incidents of physical behaviors directed towards others and seven incidents of verbal behavior directed towards others. Review of the notes revealed the following: - 4/1/16 Yelling at other residents, TV and staff, refused cares, hit staff member with a closed fist, threw mug of lemonade at staff, no triggers noted, resident would start yelling randomly and covered head; - 4/2/16 Yelling at staff and residents, attempted to hit staff and residents, throwing things on the floor, resistive to cares; - 4/3/16 Resident yelling at everyone in the commons area, threw full mug full of water and ice at staff, hitting them, hitting staff with fists, tore room apart, bed mattress on the floor, threw dresser drawers all over, recliner tipped over, yelling profanities, hitting the wall, threw remote and refused all cares; - 4/4/16 Yelling at staff and other residents, attempting and threatening to hit staff; - 4/5/16 Refused bedtime care; - 4/8/16 Hitting staff, name calling another resident and wouldn't come out of the other resident's room; - 4/27/16 Threw full water mug, calling staff names and hitting staff. C. Review of Resident 3's Behavior Flow Sheet, dated (MONTH) (YEAR) for the 6:00 AM - 6:00 PM shift, revealed that the resident had three incidents of physical behaviors directed towards others and nine incidents of verbal behaviors towards others. Review of the notes revealed the following: - 3/3/16 - Resident was wandering in the dining room, unwrapping silverware and touching other resident's placemats, attempted to redirect and the resident became combative towards staff, tried to get into the kitchen multiple times, 1:1 redirection unsuccessful; - 3/10/16 Resident 3 entered another resident's room and kicked the wheelchair that the resident was sitting in. Resident was assisted out of the room and was redirected to own room; - 3/18/16 Resident was wandering in commons area and approached other residents, removed another resident's walker and rammed it into the resident, attempted to redirect, successful for a short time and then continued to approach several other residents, touching their wheelchair handles and walkers, redirection unsuccessful; - 3/19/16 - Resident standing by the nurses station, urinating on the floor, assisted to room to change clothes, continued to walk through dirty water on the floor, redirection unsuccessful; Resident was at lunch, sticking fingers into pudding, attempted to redirect to use a spoon and refused, smearing pudding all over self and the table, attempted to remove the pudding cup and the resident grabbed staff's arm, refused to let go, as needed anxiety medication given. Review of the Behavior Flow Sheet, dated (MONTH) (YEAR) for the 6:00 AM - 6:00 PM shift, revealed that the resident had five incidents of physical behaviors directed towards others and 21 incidents of verbal behaviors directed towards others. Review of the notes revealed the following: - 4/6/16 Resident approached another resident and grabbed onto the resident's arm and started shaking it, residents separated; - 4/8/16 Resident in the commons area and approached another resident, without warning began punching the resident several times on the arm, residents separated, no increased agitation prior to the incidents, redirected to chair across the room and continued to glare at that resident; - 4/14/16 Resident in the commons area and picked up another resident's mug, took off the lid and started swatting at the staff when they intervened, refused to let go of the mug, the resident went in to the dining room and started touching other resident's wheelchairs, redirection unsuccessful, attempted to help the resident eat and the resident tried to bite and hit the staff, as needed medication administered and redirected the resident to the activity room for diversion activity. Interviews on 5/3/16 at 2:30 PM with the Administrator, Director of Nursing and Social Services Director revealed that the staff were to utilize the behavior flow sheets to document adverse resident physical and verbal behaviors directed towards others. Further interview revealed that the incidents documented on the form were to have corresponding notes written to include, time, date, location, persons involved, potential triggers for the behaviors, description of the behavior, interventions utilized to manage the behaviors based on individual care plan interventions, response and effectiveness of the interventions and follow up with the resident and other residents involved in the incidents. The Administrator and Director of Nursing confirmed that the documentation listed above did not reflect effective behavior management for these residents with ongoing adverse behaviors. D. Review of Resident 2's Interdisciplinary Progress Notes, dated 4/8/16, revealed that another resident punched the Resident 2's right forearm and caused two skin tears. The skin tears were cleaned, edges approximated and dressing were applied and would be monitored for signs and symptoms of infection. Further review revealed no further documentation related to the size of the skin tears or follow up assessments. Interview on 5/3/16 at 2:45 PM with the Director of Nursing revealed that staff were to utilize a skin assessment form which included a description of the skin tears and follow up documentation until the skin tears were healed. Further interview confirmed that there was no further documentation of the resident's skin tears.",2019-05-01
2717,SKYVIEW CARE AND REHAB AT BRIDGEPORT,285224,505 O STREET,BRIDGEPORT,NE,69336,2018-10-01,684,D,1,0,V0GT11,"**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 follow up assessments related to changes in condition including 1) ongoing loose stools and complaints of lack of energy and increased sleepiness for one current sampled resident (Resident 2) and 2) episode of refusing routine medications due to lethargy (sleepiness) for one current sampled resident (Resident 3). The facility census was 38 with six sampled residents. Findings are: [NAME] Review of the Departmental Notes for Resident 2 revealed that the resident received [MEDICATION NAME] (antidiarrheal) on 8/23/18, 8/24/18 and 8/25/18 for complaints of loose stools. Further review revealed no assessment of the resident's stools, bowel sounds or abdominal discomfort. Review of the Departmental Notes revealed that on 9/25/18, the resident made statements of lack of energy and wanting to sleep all the time. Further review revealed no follow up assessment or documentation related to these statements. Interview with the Director of Nursing on 10/1/18 at 3:30 PM revealed that the resident had a history of [REDACTED]. Further interview confirmed that further assessments should be completed and documented with changes in the resident's condition to ensure that the residents needs were met. B. Review of the Departmental Notes for Resident 3 revealed that on 9/22/18 at 6:00 PM, the resident refused evening medications including [MEDICATION NAME] and [MEDICATION NAME] (anticonvulsants) due to lethargy. Further review revealed no assessment of the resident's condition including any adverse effects of not receiving the routine medications as ordered. Interview with the Director of Nursing on 10/1/18 at 3:20 PM confirmed that follow up assessments should have been done to monitor the resident's increased sleepiness and to ensure that the resident had no adverse effects from not receiving the routine medications as ordered.",2020-09-01
2306,"CALLAWAY GOOD LIFE CENTER, INC",285200,"PO BOX 250, 600 WEST KIMBALL STREET",CALLAWAY,NE,68825,2019-01-03,684,D,1,0,4X3Y11,"**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 ensure further assessments were completed when changes in condition were identified related to 1) increased difficulty with ambulation and increased confusion for one closed record sampled resident (Resident 1) and 2) declines in cognition and activities of daily living for one current sampled resident (Resident 2). The facility census was 30 with five current sampled residents and one closed resident record reviewed. Findings are: [NAME] Review of Resident 1's Departmental Notes, dated 12/10/18, revealed that the resident was admitted from the hospital post surgical revision of a shunt (device to divert flow from one main route to another) secondary to a brain bleed and Acute [MEDICAL CONDITION] (brain disorder). Review of the Departmental Notes, dated 12/16/18, revealed that at 8:30 AM the nursing assistant reported the resident had increased difficulty ambulating to the bathroom, was leaning backwards and to the right. The resident leaned forward while standing in the bathroom. At 2:00 PM attempts were made to contact the resident's spouse regarding the resident's difficulty with ambulation and increased confusion. Further review revealed no documentation of further assessments completed to determine potential causal factors, the need for a referral for further assessments or changes in care to meet the resident's needs. At 3:30 PM, the resident was found on the floor with bright red drainage from the right back of head and unresponsive. At 4:00 PM, the resident was transported to the hospital per ambulance. Interview with the DON (Director of Nursing) on 1/3/19 at 10:45 AM confirmed there was no documentation of further assessments related to the resident's change in condition. B. Review of Resident 2's Admission MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 12/7/18, revealed that the resident's BIMS (Brief Interview for Mental Status) score was 13 out of a total of 15. Further review revealed the resident required extensive assistance with one person physical assist with bed mobility, transfers, ambulation and toileting. Review of the MDS, dated [DATE], revealed the resident's BIMS score declined to 6 out of a total 15. Further review revealed the resident required extensive assistance with two persons physical assist with bed mobility, transfers, ambulation and toileting and had new symptoms of delusions (false belief brought about without appropriate external stimulation and inconsistent with the individual's own knowledge and experience. Interview with LPN (Licensed Practical Nurse) - E, MDS Coordinator, on 1/3/19 at 11:30 AM revealed there was no documentation of further assessments completed, related to the resident's decline in cognition and activities of daily living, to determine potential causal factors, the need for referrals or changes in care interventions to restore function or to prevent further declines.",2020-09-01
4841,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2018-03-06,684,E,1,1,9WK311,"**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 ensure that 1) a change of condition was identified, initial assessments and follow up assessments were completed and care provided for one current sampled resident with increased lethargy, changes in communication ability and a dislocated shoulder (Resident 176) , 2) ongoing diarrhea was identified and addressed for one current sampled resident (Resident 175) and 3) the correct size of disposable briefs were utilized to prevent skin breakdown for one current sampled resident (Resident 15). The facility census was 27 with 16 current sampled residents. Findings are: [NAME] Review of the Admission Record revealed that Resident 176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes revealed that the resident was admitted to the facility on [DATE] at 12:30 PM. Further review revealed the following including: - 2/23/18 at 9:25 PM Resident is alert, pause and repeat questions at times, denies pain, vital signs stable; - 2/24/18 at 7:29 PM Resident is alert, vital signs stable, requires one assist with toileting needs, denies pain; - 2/25/18 at 12:00 AM - Change in condition. Pain in left shoulder and [MEDICAL CONDITIONS] episode while on the toilet. Resident sitting on the toilet, upon rising states ow and points to bicep area, requests spouse be called. Spouse called and stated that the resident's shoulder was dislocated and requests the resident be sent to the emergency room per ambulance. The nursing assistant reported that the resident had a [MEDICAL CONDITION] episode. Resident was assessed for pain, vital signs were within normal limits, resident sitting in wheelchair talking to spouse and answering questions, alert to person, place and situation, transferred to the hospital per ambulance; - 2/25/18 at 2:55 AM Resident returned to the facility with new orders for steroid therapy; - 2/25/18 at 2:59 PM Resident alert and oriented, slow to respond to questions at times, incontinent at times, requires assistance with activities of daily living and transfers, no swelling at extremities and denies pain to the left shoulder. Review of the hospital emergency room report, dated 2/25/18 at 12:56 AM, revealed the following including: - Final Impression: Headaches and reported shoulder dislocation; - Differential Diagnosis: [REDACTED]. Examination showed that the patient has difficulty understanding and following commands at this time, spouse reports that since the [MEDICAL CONDITION] the patient has times periods of being alert and oriented and answers questions to period where the patient cannot follow commands, respond well, can't answer questions. The patient acts like is trying to answer but is unable to get the words out. - Presenting problems included history of [MEDICAL CONDITION] and brain surgery on 2/12/18, spouse received a call from the nursing home that the resident was having severe pain in the left shoulder, found that the left shoulder was dislocated, and left hand was blue, spouse reduced the left shoulder and restored circulation to the left arm. The dislocation may have occurred while trying to assist the patient off of the toilet. The spouse reported that the resident had not received the ordered doses of steroid since admission to the facility for cerebral [MEDICAL CONDITION] (brain swelling) prevention and was increasingly lethargic and sleeping much more than normal, 18 hours today. The resident was given a dose of steroid and orders for tapering doses. Interview with the DON (Director of Nursing) and the Nurse Consultant on 3/5/18 at 8:50 AM confirmed that there was no documentation that the resident's change in condition was identified including sleeping most of the day on 2/24/18 which could be related to not receiving the ordered steroids. Further interview confirmed that there was no assessment of the left shoulder injury on 2/24/18 including causal factors, intensity of the pain or that there was impaired circulation at the left arm. The DON confirmed that there was no further assessment completed including specific symptoms related to the [MEDICAL CONDITION] episode versus potential [MEDICAL CONDITION] activity based on diagnoses. The DON confirmed that there was no documentation of the resident's condition when returned from the hospital at 2:55 AM including pain, responsiveness and activities of daily living and how they were tolerated until 2:59 PM. Further interview confirmed that the care plan was not updated to monitor and manage further potential [MEDICAL CONDITION] activity or changes in cognition, communication or risk for recurrent dislocation of the left shoulder. B. Review of the Admission Record revealed that Resident 175 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with the resident on 2/27/18 at 3:00 PM revealed was recently in the hospital with bowel problems. The resident stated was having problems with diarrhea and bowel incontinence because the staff were not always fast enough to assist to the bathroom. The resident also stated that there there isn't much warning before you have to go to the bathroom. Review of the Progress Notes revealed that the resident was incontinent of bowel on 2/19/18 and 3/5/18. Review of the Bowel Management form, dated 2/20/18 to 3/5/18, revealed that the resident had diarrhea stools (didn't identify if incontinent) on 2/21/18, 2/23/18, 2/26/18, 2/27/18, 2/28/18, 3/1/18, 3/4/18 and 3/5/18. Further review revealed that the resident also had formed/normal bowel movements on 2/20/18, 2/22/18, 2/23/18, 2/25/18, 2/27/18 and 3/3/18. Review of the care plan, goal date 5/16/18, revealed no care plan to address the ongoing diarrhea. Further review revealed that the resident had impaired skin integrity related to immobility and incontinence and interventions included administer treatment as ordered, keep skin clean and dry and turn and reposition every two hours. Review of the Medication Administration Record, [REDACTED]. Interview with the DON on 3/5/18 at 2:00 PM revealed was not aware of the resident's ongoing diarrhea and there was no plan in place to manage the diarrhea. C. Record review of Resident 15's Admission Record printed on 2/28/18 revealed the resident was initially admitted tot he facility on 1/15/2013. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 15's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) revealed a Quarterly review MDS was completed on 12/27/17. Further review of the assessment revealed the resident required Total Dependence for toileting use. Record review of Resident 15's electronic Progress Notes for Resident 15 revealed the following: -1/26/18 an entry documented the discovery of an open area on the resident's left lateral hip noting the resident had fragile skin and was incontinent of bowel. The area measured 1.3 x (by) 0.7cm (centimeters). The medical provider was notified and the facility was awaiting orders - Dietary Note recorded by the Registered Dietitian on 1/30/18 at 10:43 a.m. the resident obtained a blister on the hip likely related to shearing of brief. A faxed communication to the physician reported Resident 15 had obtained a 1.3 x 0.7 centimeter open area on the left lateral hip Believed to be caused from brief being too tight. Record review of Resident 15's Care plan printed on 2/28/18 revealed a Focus problem for potential skin breakdown was created on 12/26/16 and revised with an additional problem on 1/26/2018 which read: Open area to left lateral hip. Interventions for the problem included when changing incontinent products make sure the outside plastic side is not against the skin. Observation of resident cares and transfer from bed to wheelchair on 3/1/18 at 11:20 a.m. revealed NA (Nurse Aide)-E and NA-F were assisting Resident 15 with these cares. Further observation revealed the resident was wearing a size X-tra Large Brief and had a package of X-tra Large Briefs in the closet. A coded card attached to the bathroom wall had a marking of L on the card. Interviews with NA-E and NA-F after the resident was transferred on 3/1/18 at 11:30 a.m. verified the facility had a coding system on cards attached to the bathroom wall for residents wearing incontinent briefs. NA-E and NA-F verified Resident 15's card was marked with an L and stated this provided staff with information that the size of brief for Resident 15 was to be a Large. NA-E and NA-F verified Resident 15 was wearing an X-tra Large Brief but the coding system had sized her to be in a Large. NA-E and NA-F stated that sometimes the facility runs out of a certain size brief and staff have to use a different size. NA-E and NA-F both stated that they sometimes have to use a larger or smaller size brief when changing incontinent briefs on residents. Interview with the Director of Nursing, Corporate Nurse consultant, and Administrator on 3/5/18 at 3:00 p.m. verified the facility uses a coded card system attached to the bathroom walls for residents wearing incontinent briefs. The card systems identify the correct size of brief to be used for the residents. Facility staff were to utilize this system to ensure residents are utilizing the correct size of brief to prevent leakage or skin problems.",2020-03-01
5748,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2016-09-20,329,E,1,0,TD4511,"**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 ensure that 1) there was a supporting [DIAGNOSES REDACTED]. The facility census was 114. Findings are: A. Review of Resident 122's Medication Administration Record, [REDACTED]. Interview with the DON (Director of Nursing) on 9/20/16 at 10:00 AM confirmed that there was no supporting [DIAGNOSES REDACTED]. B. Review of Resident 104's Medication Administration Record, [REDACTED]. Interview with the DON on 9/20/16 at 10:00 AM confirmed that there was no documentation in the medical record that the staff monitored the resident's sleep patterns to determine the effectiveness of the medication or the continued need for the medication. C. Review of the Admission Record dated as printed 9/8/16 for Resident 14 revealed a [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. Interview on 9/12/16 at 10:00 AM with RN (Registered Nurse) - BB revealed that Resident 14 was on a medication of [MEDICAL CONDITION]. Further interview revealed that there was no written documentation to support that the medication was effective or not effective for this resident. D. Review of the Admission Record dated as printed for Resident 120 revealed [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. Interview on 9/12/16 at 10:00 AM with RN - BB revealed that Resident 120 was on a medication of agitation or behaviors. Further interview revealed that there was no written documentation to support that the medication was effective or not effective for this resident routinely or given as needed. E. Review of the Admission Record dated as printed 9/8/16 for Resident 12 revealed [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. Interview on 9/12/16 at 10:05 AM with RN- BB revealed that Resident 12 was on an antipsychotic mediation and that there was no written documentation of behaviors or periods of anxiety to ensure the effectiveness or continued dosing of the antipsychotic medication ([MEDICATION NAME]). F. Interview on 9/20/16 at 4:00 PM with the Administrator and the Director of Nursing verified that the facility did not have any type of form or log to monitor hypnotic for Resident 14. Further interview revealed that behaviors had not been monitored on Residents 120 and 12 for the continued routine Antipsychotics. Further interview confirmed that there were no written tools to measure the effectiveness of the routine medications or the need to continue the medications for Residents 14 and 120 and 12.",2019-09-01
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
5514,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2016-12-19,312,D,1,0,HJD111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D1c Based on interviews and record reviews, the facility failed to ensure that bathing was completed 2 times a week for one sampled resident (Resident 1) who was totally dependent with bathing. The sampled size was 3 with 1 resident affected. The facility census was 117. Findings are: Review of the Admission Record for Resident 1 revealed an admission date of [DATE] to the facility. Further review revealed [DIAGNOSES REDACTED]. Review of the Care Plan for Resident 1 dated as initiated 6/10/16 revealed a focus: Resident has a physical functioning deficit related to self care impairment, mobility impairment with appropriate goals and interventions of use a lift, personal hygiene, toileting and transferring. Review of the 100 Wing Bathing Schedule revealed that Resident 1 was scheduled on Mondays and Thursdays for whirlpool baths. Review of the 24 Hour Resident Care Sheet for Resident 1 dated (MONTH) (YEAR) revealed written documentation a a bath given on 11/10, a bed bath on 11/16 and 11/21, then a bath on 11/26. Further review revealed that from 11/10 through 11/26 Resident 1 received one bath a week instead of two. Interview on 12/19/16 at 10:30 AM with Resident 1 revealed a recent hospitalization for pneumonia and weakness. Further interview revealed that the resident had Diabetes, [MEDICAL CONDITION], and that the resident's legs, just quit working. Continued interview revealed that the resident was unable to transfer without assistance in using a lift. Further interview revealed that the resident had a period when the bath chair was broken and the resident had not had bathing twice a week during that time. Interview on 12/19/16 at 3:00 PM with the Bathing Nursing Assistant (BNA- A) revealed that the bath chair had been broken from the week of 11/10 through 11/26. Continued interview confirmed that Resident 1 had been given bed baths during that time. Further interview confirmed that the written documentation on the 24 Hour Resident Care Sheet from 11/10 through 11/26 did not reveal that Resident 1 had been given two baths a week. Continued interview confirmed that the resident had only received one and was totally dependent on the BNA to administer baths twice a week. Interview on 12/19/16 at 3:15 PM with Unit Supervisor Licensed Practical Nurse (USLPN) - B confirmed that the bathing chair had been broken. Further interview confirmed that Resident 1 was totally dependent on the BNA to administer bathing. Continued interview verified that during the time frame of 11/10 through 11/26 the resident had only received one bath a week and should have received two. Interview on 12/19/16 at 4:00 PM with the Interim Administrator and the Interim Director of Nursing confirmed that the bath chair on the 100 wing had been broken. Further interview verified that Resident 1 was totally dependent with bathing and should have gotten baths completed twice a week during the time frame of 11/10 through 11/26. Continued interview confirmed that the Resident should have been taken to another bathing area in the facility and the services should have been provided for the resident who was totally dependent with bathing, and personal hygiene.",2019-11-01
1377,LIFE CARE CENTER OF ELKHORN,285134,20275 HOPPER STREET,ELKHORN,NE,68022,2018-02-27,677,E,1,1,YXZR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D1c Based on observation, record review and interviews: the facility failed to ensure residents received routine care for bathing and shaving for 7 of 32 residents reviewed (Residents 15, 7, 52, 10, 55, 80, and 33) and ensure Resident 80 received assistance for shaving as requested. The facility census was 101. Findings are: [NAME] Review of Resident 15's Personal Hygiene and bathing record revealed Resident 15 received a shower on 1/5/2018 and no bath or shower was given until 2/7/2018 resulting in Resident 15 not receiving a bath for 33 days. Further review showed from 2/7/2018 until 2/20/2018, no bath was given resulting in 13 days with no bath for Resident 15. Review of MDS (Minimum Data Set) dated 11/22/2017 revealed Resident 15 was dependent on staff for bathing. Interview on 02/27/18 at 8:34 AM with the Director of Nursing (DON) revealed the length of time between baths is longer than the expectation of at least weekly or as indicated by Resident 15's preferences. B. Interview on 02/21/18 at 9:49 AM with Resident 7's Power of Attorney (POA) revealed Resident 7 had not had a bath in over 10 days. Review of Personal Hygiene and bathing report for (MONTH) and (MONTH) (YEAR) revealed Resident 7 had a shower on 1/3 and 1/28 resulting in 25 days without a bath. Resident 7 was given a bath on 2/7 another 10 days later and had no other baths documented as of 2/21/2018 resulting in 14 days since Resident 7's previous bath. Review of Resident 7's MDS dated [DATE] revealed Resident 7 was dependent on staff for assistance with bathing needs. Review of Resident 7's care directive dated 4/21/2018 revealed Resident 7 requested to have a bath 3x per week. 02/27/18 at 08:30 AM, interview with the DON revealed all residents were to receive baths as requested and documented on the care directive. The DON revealed Resident 7 did not receive the number of baths that were requested. C. Observation of Resident 10 on 02/20/18 at 02:42 PM revealed Resident 10's hair appeared greasy. Interview on 2/20/18 at 10:45 AM with Resident 10 revealed Resident 10 had not had a bath for a week. Review of the Personal Hygiene and bathing report revealed Resident 10 had a shower on 1/8/2018 and no bath until 1/23/2018 resulting in 14 days without a bath or shower. Resident 10's next bath was 14 days later on 2/6/2018 and again 7 days later on 2/13/18. Interview on 02/27/18 at 8:30 AM with the DON revealed Resident 10 did not receive the required baths. D. Review of Resident 52's face sheet revealed Resident 52 was admitted with a [DIAGNOSES REDACTED]. Interview on 2/21/2018 at 1:00 pm with Resident 52's POA revealed Resident 52 had not had a bath in 10 days. Review of the Personal Hygiene and bathing records revealed Resident 52 received a shower on 1/3/18 and 7 days later on 1/10/18. Resident 52 then was given a bath 19 days later on 1/29/18 and did not receive a bath for 22 days until 2/20. Review of the resident's last MDS dated [DATE] revealed Resident 52 was dependent on the staff for assistance with bathing. Review of the Care Directive revealed a request for a whirlpool or shower on Tuesday and Friday 2 times per week. Interview on 02/27/18 at 8:30 AM with the DON revealed Resident 52 did not receive the number of baths requested. E. A review of Resident 55's Monthly Flow Report for (MONTH) (YEAR) revealed that Resident 55 did not receive a bath in the month of (MONTH) until 2-13-18. A review of Resident 55's MDS dated [DATE] revealed that the resident did not receive a bath 12-23-17 through 12-29-17. F. A review of Resident 80's Monthly Flow Report for (MONTH) (YEAR) revealed that the resident received a bath on 2-5-18 and did not receive another bath until 2-15-18. A review of Resident 80's Seven Day Look Back for Baths dated 2-26-18 revealed that Resident 80 received a bath on 1-15-18 and did not receive another bath until 1-29-18. [NAME] An interview conducted on 2-20-18 at 12:08 PM with Resident 33 revealed the resident was not being bathed as often as they would like due to the facility no longer scheduling a bath aide. A review of Resident 33's Monthly Flow Report for (MONTH) (YEAR) revealed that Resident 33 received a shower on 2-11-18 and 2-20-18. A review of Resident 33's Monthly Flow Report for (MONTH) (YEAR) revealed that Resident 33 received a shower on 1-5-18, 1-19-18, and 1-26-18. H. An interview conducted on 2-20-18 at 11:40 AM with Resident 80 revealed that the resident wanted to be shaved daily and staff were not assisting the resident to shave daily. An observation conducted on 2-22-18 at 8:15 AM revealed Nursing Assistant (NA) G assisted Resident 80 to get up for breakfast. NA G assisted the resident to get dressed and in their wheelchair and then sent the resident to breakfast without shaving the resident. The resident had visible facial hair growth. An observation conducted on 2-26-18 at 9:11 AM revealed Resident 80 in the dining room for breakfast with visible facial hair growth. A review of Resident 80's Monthly Flow Report for (MONTH) (YEAR) revealed that the resident was documented as being shaved on 2-12-18, 2-15-18, 2-16-18, 2-25-18, and 2-26-18. A review of Resident 80's MDS dated [DATE] revealed that Resident 80 required extensive assistance with personal hygiene.",2020-09-01
6065,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2016-06-02,312,D,1,0,OWDK11,"**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 ensure assistance with grooming was provided for a resident who was unable to complete the task independently. This violation had the potential to affect Residents 2. The facility census was 75. Findings are: An observation on 6/2/16 at 12:18 PM revealed Resident 2 self propelling wheel chair (w/c) using upper extremities (arms/hands) into the dining room for lunch. The Resident's face was not shaved and had approximately 1/4 inch of hair visible on the Resident's cheeks, chin, and neck. An interview on 6/2/16 at 12:15 PM with Nursing Assistant (NA)-A revealed Resident 2 required extensive assist with activities of daily living including grooming. Resident 2 was able to shave self but would rather have staff do it as the Resident has problems seeing what (gender) is doing. An observation on 6/2/16 at 2:35 PM revealed Resident 2 seated in w/c in the resident's room watching television, the resident's face remained unshaven. A review of the facility's care plan for Resident 2 initiated on 3/2/16 revealed the resident had a performance deficit for Activities of Daily Living (ADL) Self Care Performance related to activity intolerance, pain, impaired balance, and a history of noncompliance. The documented interventions included: the resident prefers being shaved daily, and the resident requires extensive assist from staff with personal hygiene. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An interview on 6/2/16 at 2:40 PM with Licensed Practical Nurse (LPN)-B revealed the expectation would be for residents needing assistance to be shaved daily with morning cares. The LPN confirmed Resident 2 had not been shaved today. The LPN reported (gender) had not been informed that the resident refused assistance with shaving this morning.",2019-06-01
6345,CHIMNEY ROCK VILLA,285260,"P O BOX A, 106 EAST 13TH STREET",BAYARD,NE,69334,2016-04-11,312,D,1,0,BQY611,"**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 that personal hygiene was provided to 3 sampled residents (Resident 4, 5, and 6) per the resident's preferences. Facility census was 41. Findings are: A. Review of the Face Sheet for Resident 4 revealed an admission date of [DATE] to the facility. Further review revealed [DIAGNOSES REDACTED]. Review of the Care plan dated 2/23/16 for Resident 4 revealed a problem: Self care deficit .preferred bath type- tub with twice weekly bathing . Review of the Bath Schedule dated 3/1/16 revealed that Resident 4 was scheduled for 2 times a week bathing on Tuesdays and Thursdays. Review of the bathing documentation in the EMR for Resident 4 revealed a bath documented on 1/28 and then on 2/4 (7 days later), a bath on 2/4 then 2/9 and then 2/18 (9 days later), a bath on 2/18 then on 3/3 (14 days later), then 3/8 to 3/15 (7 days later), then 3/15 to 3/22 (7 days later), then 3/24 through 4/5 (12 days later). Observation on 4/11/16 at 10:30 AM of Resident 4's room revealed no odors present in the room. Further observation revealed that resident was at an activity. Observation on 4/11/16 at 11:20 AM of Resident 4 revealed that the resident was lying in bed watching television. Further observation revealed a odor of urine present in the room. Continued observation revealed that the trash cans were empty and there were no dirty clothes on the floor. Further observation revealed a set of clean clothes and a brief on the chair at the resident's bedside. Interview on 4/11/16 at 2:30 PM with (Nursing Assistant) NA - A revealed that Resident 4 was combative at times during bathing. Continued interview verified that resident often refuses bathing. B. Review of the Face Sheet for Resident 5 revealed an admitted d of 7/26/13 to the facility. further review revealed [DIAGNOSES REDACTED]. Review of the Care plan for Resident 5 revealed a problem: Self care deficit .1-2 assist with all activities of daily living .preferred two baths a week in the tub . Review of the bathing documentation in the EMR for Resident 5 revealed a bath documented on 1/29 and then 2/9 (11 days later), 2/9 through 2/18 (9 days later), 2/19 through 3/11 (29 days later), and then 3/11 through 3/30 (19 days later) with one episode of a bath refusal documented. Observation on 4/11/16 at 2:20 PM of Resident 4 lying in bed awake. Continued observation revealed that the resident appeared to be clean and appropriately dressed with no odors present in the room. Observation on 4/11/16 at 3:35 PM of Resident 4 lying in bed awake, no distress noted. Further observation revealed no room odors present. Interview on 4/11/16 at 2:30 PM with NA - A revealed that Resident 4 did refuse baths at times. Further interview revealed that bathing for the resident was completed prior to the NA's shift. C. Review of the Face Sheet for Resident 6 revealed an admitted d to the facility of 9/11/15. Continued review revealed [DIAGNOSES REDACTED]. Review of the Care Plan dated as printed 4/11/16 for Resident 6 revealed a problem, Self care deficit .preferred bath type- tub with twice weekly baths. Review of the Bath Schedule dated 3/1/16 revealed that Resident 6 was scheduled for 2 baths a week on Mondays and Thursdays. Observation on 4/11/16 at 2:00 PM of Resident 6 lying in bed. Further observation revealed that the resident did not have body odor and was dressed appropriately. Observation on 4/11/16 at 3:30 PM of Resident 6 self propelling in a wheelchair to go outside to smoke. Further observation revealed no body odor present. Interview on 4/11/16 at 2:20 PM with NA - A revealed that the NA worked evenings and bathing was completed during the day shift. Further interview revealed that the NA was aware of the resident refusing at times Continued interview revealed that bathing was seldom completed in the evening shift. Interview on 4/11/16 at 4:00 PM with the Acting Administrator, the Interim Administrator and the Director of Nursing verified that Residents 4, 5, and 6 were all care planned for twice a week bathing in the tub, had self care deficits with activities of daily living and, all three were on the bathing schedule for twice a week bathing. Further interview confirmed that according to the written documentation in the EMR that Residents 4, 5, and 6 had not received baths twice a week per the resident's preferences.",2019-04-01
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
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
4972,"PREMIER ESTATES OF CRETE, LLC",285170,830 EAST 1ST STREET,CRETE,NE,68333,2018-09-18,677,E,1,0,MJX011,"**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 provide bathing assistance for 3 residents (Residents 3, 4 and 5). The sample size was 5 and the facility census was 52. Findings are: [NAME] Review of Resident 5's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/9/18 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident required physical help in part of bathing activity. Interview with Resident 5 on 9/18/18 at 2:15PM revealed that the preference is to have two baths per week. Resident stated that no bath was received on 9/17/18 as scheduled. B. Review of Resident 3's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS dated [DATE] also revealed that for Resident 3 Bathing activity itself did not occur during the entire period. Interview on 9/18/18 at 10:45AM with Resident 3 revealed that Resident 3 had not received the scheduled bath on 09/17/18. C. Review of Resident 4's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS review indicated Resident 4 is totally dependent with bathing. Observation of Resident 4 on 9/18/18 at 10:50 AM revealed Resident 4's hair to appear to be greasy. Interview on 9/18/18 at 10:50 with Resident 4 revealed that Resident 4 had not had a bath since 9/13/18, and Resident 4 was supposed to receive a bath on 9/17/18 but did not receive one. Review of the Daily Bath Aide Sheet revealed there were 16 residents listed to have a bath on Monday, 9/17/2018. There was one resident that was charted on the form as receiving a shower on Sunday, 9/16/18 and one resident that was charted as receiving a shower on Monday, 9/17/18. Review of the form revealed that the other 14 residents listed on the form had not received a bath or shower as scheduled. 09/18/18 at 11:25 AM interview with the Corporate Nurse revealed residents were to receive baths as requested and documented on the care plan. The Corporate Nurse also stated that all the blanks on the Daily Bath Aide Sheet dated 9/17/18 are the residents that did not receive their scheduled baths for 9/17/18.",2020-03-01
5743,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2016-09-20,312,D,1,0,TD4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D1c Based on record reviews, observations and interviews; the facility failed to ensure that dependent residents were assisted with 1) meals for two sampled residents (Residents 28 and 93). The facility census was 114. Findings are: A. Observations in the 400 Wing dining room on 9/8/16 at 8:20 AM revealed Resident 28 feeding self pureed foods with fingers. Further observations revealed no staff assisted the resident to eat. Review of the Care Plan, goal date 11/11/6, revealed that the resident was at risk for nutrition problems due to dementia and suboptimal oral intakes and interventions included to provide assistance at meals. B. Observations in the 400 Wing dining room on 9/8/16 at 8:25 AM revealed Resident 93 seated at the assist table with juice and water spilled on the table, resident's lap and on the floor. Further observations revealed no staff assisted the resident to take fluids or clean the spilled fluids. Review of the Care Plan, goal date 11/21/16, revealed that the resident was at nutritional risk due to Dementia and [MEDICAL CONDITION]. Interventions included to provide assistance with meals as needed. Interview on 9/20/16 at 7:10 AM with LPN (Licensed Practical Nurse) - E, Charge Nurse, confirmed that Resident 28 required cueing and assistance with meals. Further interview confirmed that Resident 93 required assistance with meals.",2019-09-01
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
3940,VALLEY VIEW SENIOR VILLAGE,285294,220 SOUTH 26TH STREET,ORD,NE,68862,2018-03-21,686,H,1,1,OLWQ11,"**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 implement interventions to promote the healing of pressure ulcers for 4 of 4 sampled residents including completing assessments, using clean technique for dressing changes, repositioning, and administering nutritional supplements as ordered. This affected Residents 3, 29, 24 and 34. The facility identified a census of 34 at the time of survey. Findings are: [NAME] Review of Resident 3's quarterly MDS (minimum data set-a comprehensive assessment tool used to develop a resident's care plan) dated 3/7/2018 revealed an admission date of [DATE]. Resident 3 had a Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer that was not present at the time of admission. Review of Resident 3's admission MDS dated [DATE] revealed Resident 3 was admitted to the facility on [DATE] and had one Stage 2 pressure ulcer that was not present upon admission/entry or reentry. The date of the oldest Stage 2 pressure ulcer was 8/4/2016. Review of Resident 3's Physician Order Report for 2/6/2018-3/6/2018 revealed a [DEVICE] was being used to treat a sacral (tailbone) wound. Observation of Resident 3 on 3/14/18 at 7:31 AM, 9:28 AM, 1:36 PM, 3:17 PM and 4:20 PM revealed Resident 3 was sitting in the wheelchair. Interview with Resident 3 on 3/14/2018 at 3:17 PM revealed Resident 3 had been up in the chair since 7:30 AM and had not laid down in bed. Review of Resident 3's Resident Progress Notes for 3/14/2018 revealed no documentation Resident 3 had been offered the opportunity to change positions or educated about the risks of refusing to change positions. Observation of Resident 3 on 3/15/18 at 7:09 AM, 10:52 AM, 1:05 PM, 1:49 PM, and 3:20 PM revealed Resident 3 was sitting in the wheelchair. Review of Resident 3's Resident Progress Notes for 3/15/2018 revealed no documentation Resident 3 had been offered the opportunity to change positions or educated about the risks of refusing to change positions. Review of the undated NA (Nurse Aide) Pocket Guide revealed the following instructions for Resident 3: Lay down BID (twice) during the day. Interview with NA-U on 3/19/18 at 1:48 PM revealed the direct care staff carried pocket care plans with care instructions for the residents. Residents with pressure ulcers or who were at risk for skin breakdown were to be repositioned every 2 hours. Review of Resident 3's Medications Flow sheet for January, February, and (MONTH) (YEAR) revealed documentation that Resident 3 had wound area (pressure ulcer) pain and wound vac change pain ranging in intensity of 10/10 (worst pain you can imagine) 8 out of 10 and severe to very severe pain due to the pressure ulcer. Review of Resident 3's Wound Clinic note dated 2/16/18 revealed Resident 3's coccygeal (tailbone) ulcer went deep into the subcutaneous fat and the dressing changes were causing more discomfort. Review of Resident 3's Physician Order Sheet dated 3/7/2018 revealed the following: wound care nurse wrote a note to provider: routine wound vac changes are becoming extremely painful when wound is cleansed. Observation of RN-C (Registered Nurse) on 3/19/2018 at 11:22 AM doing dressing change for Resident 3's pressure ulcer to coccyx/sacrum (tailbone area) being treated with a [DEVICE] revealed the following: RN-C did 1 second hand scrub with hand sanitizer and applied gloves. The hand sanitizer did not cover all surfaces of RN-C's hands and RN-C's hands did not appear wet. RN-C then closed Resident 3's room curtains touching the rod with the gloved hands. RN-C then lowered the head of the bed touching the bed control with the same gloved hands. RN-C then picked the trash can up by the rim and moved it to where RN-C was working. RN-C then got more gloves out of the box in the bathroom and put them in the dressing bin. RN-C did not change gloves after touching the trash can before touching the gloves they put in with the other dressing supplies. RN-C then got supplies including [MEDICATION NAME] (pain medication) and dressings, touching them with the same gloved hands. RN-C then touched the bed control to raise the bed. RN-C then took the reservoir out of the [DEVICE] pump and removed the tubing. RN-C then removed the soiled dressings from Resident 3's pressure with the same gloves touching the wound. Resident 3 hollered out twice while RN-C was pulling the old dressing off. RN-C then rummaged around the bin of supplies with the soiled gloves and retrieved more supplies. RN-C then touched the wound edge and the dressing sponge that was in the wound with the same gloves. RN-C then discarded the sponge, put new gloves on, and squirted the [MEDICATION NAME] in the wound without performing hand hygiene. RN-C then put the new canister in the [DEVICE] pump that they had already touched with the dirty gloves. RN-C then opened the clean dressing package and touched the sponge. RN-C then took a pair of scissors out of their pocket and cut the sponge. RN-C did not clean the scissors or change gloves. RN-C then cut the transparent dressings with the scissors that were in their pocket. RN-C then washed the wound with soap and water on a washcloth and used a plain wet washcloth to rinse. RN-C then sprayed Resident 3's wound with wound cleanser and rinsed with saline, touching the canister of wound cleanser before placing it back in the bin with the remainder of the dressing supplies. The pressure ulcer to Resident 3' tailbone was deep. RN-C then changed gloves without performing hand hygiene. RN-C then got a dressing out of the tub that they had been rummaging in. RN-C then cut the sponge with the scissors they had taken out of their pocket and used without cleaning and placed it in the wound. RN-C then placed the cut transparent dressings around and over the wound and the sponge. RN-C then attached the hose to the canister after applying the adhesive dressings. RN-C then changed gloves without performing hand hygiene. RN-C then tore a hole in the dressing that was in the wound with a gloved finger. RN-C then turned the [DEVICE] pump on that was sitting on the floor. Resident 3 flinched twice after RN-C turned the [DEVICE] pump on and the suction started. RN-C then put the scissors in their pocket without cleaning them. Review of Resident 3's Wound Evaluation flow sheet dated 2/28/2018 revealed documentation that Resident 3's pressure had potential signs of infection including green slime exudate (drainage). Review of the facility policy hand hygiene revised 3/18 revealed the following: Purpose: to prevent the spread of infection through adherence of good hygiene practices. Policy: all personnel shall wash their hands with soap and water or use hand sanitizer to prevent the spread of infections. Wash hands with antimicrobial soap and water when hands are visibly soiled. Use an alcohol-base waterless antiseptic for routinely decontaminating hands when hands are not visibly soiled . When to practice hand hygiene: between resident contacts; after removing gloves; anytime hands are soiled; when going from a dirty to clean function on the same resident. Hand hygiene methods: antiseptic hand rub: apply adequate amount of alcohol-based waterless solution to palm of one hands. Rub hands together, covering all surfaces of hands and fingers, until hands are dry. Antiseptic hand wash: Moisten hands with water then apply enough soap to produce a lather. Rub hands vigorously for at least 10-15 seconds. Review of Resident 3's Wound Evaluation Flow Sheet received 3/14/2018 revealed no documentation Resident 3's pressure ulcer had been assessment since 3/5/2018. Interview with LPN-G (Licensed Practical Nurse) on 3/19/18 at 1:07 PM confirmed there was no documentation Resident 3's pressure ulcer had been assessed since 3/5/2018 (9 days). Review of Resident 3's progress notes for 3/5/2018-3/15/2018 revealed no documentation of an assessment of Resident 3's pressure ulcer. Interview with the DON (Director of Nursing) on 3/19/18 at 01:08 PM it was their expectation that wounds were assessed and documented on weekly. Review of Resident 3's Physician's Orders revealed the following: Peanut butter and jelly sandwich once a day at 3:00 PM with an order date of 10/26/2017, Ensure (dietary supplement) at each meal with an order date of 10/11/2017, and ProStat (protein supplement) 1 ounce twice a day mixed in diet soda with an order date of 3/16/2018. Review of Resident 3's Resident Supplement Chart for 2/17/18 to 3/18/18 revealed incomplete documentation of the supplement intake: PB & J (Peanut Butter and Jelly) sandwich only charted 3 days out of the month. Breakfast supplement (Ensure) was not charted on 2/17, 2/25, 3/9, 3/10, 3/11, and 3/15. Lunch supplement (Ensure) was not charted 2/17, 2/18, 2/24, 2/25, 3/4, 3/9, 3/10, 3/11, 3/15, 3/17, 3/18. Dinner supplement (Ensure) not charted on 2/19, 2/22, 2/24, 3/1, 3/2, 3/7, 3/10,3/11, 3/16, 3/17, and 3/18. Interview with the RD-O (Registered Dietitian) on 3/19/18 at 2:59 PM confirmed Resident 3 had a pressure ulcer that was not healing. RD-O confirmed the dietary supplements were not documented and should have been. RD-O revealed Resident 3 had been receiving Ensure TID (three times a day) and it was changed on 3/16/2018 to ProStat BID that is charted on the MAR (Medication Administration Record). Review of Resident 3's MAR for (MONTH) (YEAR) revealed the ProStat was started on 3/16/2018. The ProStat was documented as administered on 3/18 AM and 1700 (5 PM). It was not documented as administered any other time. B. Interview with Resident 29 on 3/13/18 at 3:22 PM revealed they were being treated for [REDACTED]. Resident 29 revealed they were supposed to go to the hospital last week and get the pressure ulcer surgically closed but it got infected so that got put on hold. Review of Resident 29's admission MDS dated [DATE] revealed an unhealed Stage 3 (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) pressure ulcer 2.0 cm long; 2.0 cm wide and 2.2 cm deep. Review of Resident 29's annual MDS dated [DATE] revealed an unhealed Stage 3 pressure ulcer that was 2.7 cm log, 2.2 cm wide and 3.2 cm deep which indicated the pressure ulcer had gotten larger. Interview with LPN-G on 3/19/18 at 1:34 PM revealed Resident 29 had a Stage 4 pressure ulcer that was marked a Stage 3 pressure ulcer on the annual MDS dated [DATE]. LPN-G confirmed the MDS should have reflected Resident 29 had a Stage 4 pressure ulcer. Review of Resident 29's Wound Evaluation Flow Sheet dated 8/29/17 revealed the pressure ulcer to the left ischium (hip/buttock) measured 1.4 cm x 1.4 cm x 1.8 cm. The pressure ulcer was a Stage 3 at that time. Review of Resident 29's Wound Evaluation Flow Sheet dated 12/5/2017 revealed the pressure ulcer to the left ischium measured 2 cm x 2 cm x 2 cm. Review of Resident 29's Wound Evaluation Flow Sheet dated 2/12/2018 revealed Resident 29 had a Stage 4 pressure ulcer to the left ischium (hip/buttock) that measured 2.7 cm (centimeters) by 2.2 cm and was 3.2 cm deep. The documentation on the Wound Evaluation Flow Sheet indicated the pressure ulcer had gotten larger and deeper. Observation of pressure ulcer care for Resident 29 on 3/13/2018 at 11:33 AM revealed the following: MA-B moved Resident 29's personal belongings from the over the bed table. RN-C then placed the supplies for the dressing change on the table which included scissors, dressings, and tubing. RN-C did not clean the table or apply a barrier before putting the dressing supplies on the table. RN-C donned gloves then turned off the [DEVICE] pump that was sitting on the floor. RN-C clamped the tubing from the [DEVICE] pump to the dressing on Resident 29's left hip then removed the soiled dressing. RN-C then removed the gloves, applied hand sanitizer and rubbed hands for 2 seconds then donned another pair of gloves. RN-C then washed the wound with a washcloth they had retrieved from the bathroom. The pressure ulcer was deep to the left hip. RN-C then opened the dressing package and cut the foam and clear adhesive dressings with the scissors that had been lying on the table. RN-C then laid the cut dressings onto the outside of the dressing package and the table. RN-C then placed one of the cut foam dressings into the pressure ulcer. RN-C then applied another piece of foam dressing that had been lying on the table onto the wound. RN-C then applied the clear adhesive dressings over the foam dressings then used the scissors that had been lying on the table to cut a hole into the clear adhesive dressings. RN-C then removed the gloves, washed hands for 3 seconds then applied another pair of gloves. RN-C then used a pre-moistened wipe to wash Resident 29's back side. RN-C applied a clean brief then assisted with repositioning Resident 29 to their back by touching the turn sheet then proceeded to wipe Resident 29's front side of the perineum (bottom). RN-C did not change gloves after cleaning Resident 29's back side before touching the clean brief, turning sheet, and cleaning Resident 29's front side. RN-C then removed the gloves, donned another pair of gloves then finished dressing Resident 29's bottom. RN-C then removed the gloves then touched the bed rail and gave Resident 29 the call light cord, which Resident 29 then proceeded to touch. RN-C then picked the scissors up off the table that they had used during the dressing change and put them in their pocket. RN-C did not wipe the table off or the scissors and did not perform hand hygiene after removing gloves. Review of Resident 29's Progress Notes for 12/15/2017 to 3/15/2018 revealed Resident 29 was treated for [REDACTED]. Review of Resident 29's Wound Culture Reports dated 2/27/18, 1/9/18, 12/27/17, and 12/22/17 revealed the pressure ulcer to Resident 29's left ischium showed infection. Interview with LPN-G on 3/15/18 at 11:14 AM confirmed that Resident 29's pressure ulcer to the left ischium was infected. Review of Resident 29's [DIAGNOSES REDACTED]. Review of Resident 29's Wound Evaluation Flow sheet revealed documentation the last assessment of Resident 3's pressure ulcer was 2/27/2018. The pressure ulcer was 1.8 cm long, 3.5 cm wide and 3 cm deep. Interview with LPN-G on 3/19/18 at 1:07 PM confirmed there was no documentation Resident 29's pressure ulcer had been assessed since 2/27/2018 (14 days). Review of Resident 29's Resident Progress Notes revealed no documentation of an assessment of Resident 29's pressure ulcer. Interview with the DON (Director of Nursing) on 3/19/18 at 01:08 PM it was their expectation that wounds were assessed and documented weekly. Review of Resident 29's Physician Order Report for 1/26/2018-2/26/2018 revealed an order for [REDACTED]. Review of Resident 29's Resident Supplement Chart documentation for 2/17/2018 to 3/18/2018 for cottage cheese per RD-O revealed there was incomplete documentation on 2/17, 3/6, 3/8, 3/11, 3/12, 3/13, and 3/15. Interview with the DON on 3/19/18 at 04:08 PM revealed that standard protocol was that hands were cleaned after gloves were used. After touching a dirty area with the hands or gloved hands staff were expected to clean hands and put on clean gloves. The DON confirmed the dressing changes were to be done as a clean procedure; by clean you would go from dirty to clean. Staff were expected to use a clean surface, wash the scissors, get their stuff together first and then put their gloves on and not touch everything. Review of the facility policy Pressure Ulcer Care revised 11/29/07 revealed the following: Residents having pressure ulcers receive necessary treatment and serves to promote healing, prevent infection, and prevent new pressure ulcers from developing. The resident's plan of care will be reviewed and revised at least quarterly and more often if a decline in function is apparent. Width and depth for Stage 3 and Stage 4 will be measured weekly. The physician will be notified of any pressure ulcers and a wound consult will be ordered. The physician will be notified weekly of the healing status of the pressure ulcer. Standard precautions will be utilized during wound care. C. Interview on 3-13-18 at 11:08 AM with Resident 24 revealed the resident had skin sores on the right calf and right heel and all had a dressing on them. Record review of the Pressure Ulcer Weekly Physician Notification form for Resident 24 revealed a unstageable (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.) pressure ulcer to the right heel was identified 05/11/17. The initial measurement was documented as 1 cm (centimeter) x 0.8 cm x no depth. Review of the Wound Evaluation Flow Sheet dated 2-15-18 revealed the right heel pressure ulcer had increased in size and measured at 2 cm x 1.8 cm x 0.3 cm with dark eschar with severe pain documented. No further measurements were found of the pressure ulcer on the right heel. Observation of LPN-G on 3-15-18 at 1:30 PM revealed LPN-G performed the dressing changes to Resident 24's pressure ulcer wounds to the right calf and right heel. When LPN-G went to perform the dressing to the right heel, LPN-G revealed the Theraskin was not on the right heel and should have been. Interview on 3-19-18 at 10:01 AM with the LPN-G (Licensed Practical Nurse), who was also the wound nurse) revealed the resident had seen a Physician for the wounds on 2-22-18 and the initial Theraskin (a skin graft treatment to help heal wounds) had been applied to the pressure wounds. LPN-G revealed once the Theraskin had been applied, the dressing was only to be removed one time a week. On (MONTH) 1, LPN-G revealed LPN-G assessed the wound but did not document an assessment of the wounds. On (MONTH) 8 Resident 24 went to the Physician's office and LPN-G confirmed there were no papers received from the Physician's clinic to reveal the assessment of the wound. On (MONTH) 15, LPN-G performed the dressing changed and there was no assessment documented. The only documentation was in the PN (Progress Notes) which Area to R (right) heel appears to not have Thera Skin on. Clarification sent to Physician. Record review of Resident 24's current Careplan revealed the resident was to be in the recliner after breakfast and in bed after lunch for interventions to address the pressure ulcers. Record review of the Turn Schedule dated 3-15-18 to 3-16-18 which was hung on the resident's closet door revealed the resident was not turned for 3 hours from 0600 till 0900 on 3-15-18. Interview on 3-15-18 at 09:12 AM with NA-E (Nurse Aide) revealed the resident was extensive assist with cares. Resident 24 can tell the staff what the resident needs were. NA-E revealed the resident was turned every 2 hours during the night and after breakfast and lunch was laid down. Observation on 3-13-18 at 11:08 AM revealed the Resident sitting in the wheelchair. Observation on 3-14-18 at 09:30 AM revealed Resident 24 sitting in the wheelchair at an activity. Observation on 3-14-18 at 11:30 AM revealed Resident 24 sitting in the resident's room in the wheelchair. Observation on 3-14-18 at 1:37 PM revealed Resident 24 sitting in the resident's room in the wheelchair. Observation on 3-14-18 at 3:10 PM revealed Resident 24 sitting in the wheelchair in the resident's room. Observation on 3-14-18 at 4:07 PM revealed Resident 24 sitting in the wheelchair in the resident's room. Observation on 3-15-18 at 9:10 AM revealed Resident 24 was assisted out of bed by the staff for breakfast. Observation on 3-15-18 at 11:41 AM revealed Resident 24 was sitting in the wheelchair in the resident's room Observation on 3-19-18 at 11:17 AM revealed Resident 24 sitting in the wheelchair with the resident's head slumped forward asleep. Observation on 3-19-18 at 11:54 AM revealed Resident 24 sitting in the wheelchair. Observation on 3-19-18 at 2:30 PM revealed the resident was lying down in bed on the left side. However both of the residents legs, where the pressure ulcers were, were lying flat on the mattress and no offloading of pressure was to the wounds. Interview on 3-15-18 at 1:25 PM with Resident 24 revealed the resident lays down when the staff ask the resident but they had not been asking the resident. D. Review of Progress Notes in Matrix dated 2/22/18 upon admission revealed no measurements or staging of pressure ulcers. Review of Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning purposes) dated 2/28/18 for Resident 34 revealed a BIMS (brief interview for mental status, test how you are functioning cognitively at the moment) score of 5, this indicated severe cognitive impairment. Review of undated [DIAGNOSES REDACTED]. that can cause urination difficulty), Suprapubic indwelling catheter (a surgically created connection between the urinary bladder and the skin around the umbilical region used to drain urine from the bladder), osteo[DIAGNOSES REDACTED] (bone infection), kidney disease, decubitus (pressure) ulcers (resulting from prolonged pressure on the skin), bursitis of the right hip (hip pain), [MEDICAL CONDITION] (decreased blood flow to extremities). Interview on 03/15/18 at 02:50 PM with Resident # 34 revealed, when asked, Do you lay down during the day? Resident 34 replied, Sometimes. They haven't been by to ask me to lay down yet. Interview on 03/15/18 at 03:08 PM with MA-D (Medication Aide-D) revealed staff assist the resident by helping put pants on. Resident 34 was able to do own shirt and other small tasks such as brushing teeth and combing hair. When asked about transfers MA-D stated, Resident can stand and walk pretty good. Doesn't usually lay down after meals and gets one bath a week per resident's request. MA -D confirmed resident has a sore on the the left heel and left hip. During an observation on 03/19/18 at 02:34 PM of dressing change to Resident 34's pressure ulcer on left heel and behind left ankle, RN-C did not remove soiled gloves prior to touching clean items in a plastic bag. Continued observation of the dressing change revealed RN-C placed the plastic bag of items on the floor with no barrier between the floor and the plastic bag. Bloody drainage ran onto items placed on a wash cloth on the floor for the dressing change. RN-C sat on the bare floor to complete the dressing change. RN-C did not change gloves from beginning of dressing change to the end. RN-C did not wash hand or use hand sanitizer. RN-C contaminated a pair of scissors taken from uniform pocket and replaced them into the same pocket without cleaning them. Observation on 03/19/18 at 02:34 PM during a complete dressing change on Resident 34 to left heel and back of left ankle by RN-C. RN-C washed hands. RN-C then pulled a trash can over to the side of Resident 34's wheelchair. Placed a white cloth on the floor by the wheelchair. Placed soapy clothes on the white cloth on the floor. RN-C placed a plastic bag which contained numerous items of dressings, bandages, tape, ointments, and Saline Spray on Resident 34's bed. Saline spray is used to moisten dressings to make them easier to remove when they become stuck. It is clean (sterile) since it is in a closed container. RN-C then put on gloves. RN-C sat down, on the floor, in front of Resident 34's wheelchair. The white cloth is on the floor just to her right. RN-C began to remove Resident 34's sock and shoe from the left foot. RN-C began to remove the old dressing, which was soaked with bloody drainage, from Resident 34's foot and back of ankle. RN-C then reached into the pocket of RN-C's uniform and removed a pair of scissors. The scissors were placed on the white cloth with the other clean items for the dressing change. The bloody dressing became stuck, closer to the skin. RN-C reached into the plastic bag which contained numerous supplies for dressing changes. RN-C dug into the bag several time and was unable to locate what item was needed. RN-C then slid the bag of supplies to the uncovered floor, not on the white cloth, and removed the can of Saline Spray. RN-C sprayed the soiled dressing, which began to run down and drip onto the scissors and other items on the white cloth on the floor. RN-C tried to remove the dressing and Resident 34 stated Ouch! That hurts! RN-C informed Resident 34 that the dressing was stuck. RN-C sprayed the dressing again and it came off. RN-C then took two (2) 4 X 4 gauze pads, touched the tube of [MEDICATION NAME] gel and squeezed the ointment onto the two (2) 4 X 4 gauze pads. RN-C did not change gloves, wash hands or use hand sanitizer. RN-C then placed the one (1) 4 X 4 gauze pad onto the wound on the back of the left ankle. RN-C then needed to apply skin prep (a protective coating that helps guard the skin against irritations) to the ulcer on the left heel. Resident 34 asked if it was going to burn. Resident 34 was hard of hearing and could not hear RN-C. Resident 34 replied, What did you say? RN-C stated, Hold on and applied the skin prep. Resident 34 stated, That hurts! RN-C then applied one (1) 4 X 4 gauze pad on the left heel, making no reply to Resident 34's comment about pain. RN-C reached into the plastic bag of supplies, took out a roll of Kerlix wrap and secured the 4 X 4 dressings into place. RN-C then used tape to hold the Kerlix wrap into place. The tape and [MEDICATION NAME] were placed back into the plastic bag. RN-C then placed the scissors back into uniform pocket. Resident 34 replied several time, My foot still hurts! RN-C informed Resident 34 that it was because the dressing was stuck. RN-C informed Resident 34 that the dressing and cleaning of the suprapubic catheter site would be done next. (Suprapubic catheter is a surgically created connection between the bladder and the skin used to drain urine from the bladder when a person has an obstruction (blockage) of normal urine flow). RN-C took off the gloves from the previous dressing change. No washing of hands or use of hand sanitizer was observed. RN-C gathered the supplies needed with ungloved hands. RN-C with ungloved hand moved trash can closer to the resident's wheelchair. RN-C then applied gloves, without washing them or using hand sanitizer. RN-C prepared the wash clothes to clean the catheter site. RN-C removed the old dressing and placed it into the trash can. New gloves were applied and the area around the site was cleaned. Area cleaned with soap and water, moving from inward at insertion site outward. Gloves were not changed, new dressing was applied and secured with tape. Tape placed back into plastic bag of supplies. Resident 34's clothing was adjusted and trash picked up from room. RN-C replied, I will wash my hands later. RN-C went into bath house and use hand sanitizer. Review of Treatments Flow Sheet dated 3/1/18-3/31/18 revealed dressing changes had been done 3/15/18, 3/18/18 and 3/19/18 with no measurements recorded on the, WOUND EVALUATION FLOW SHEET. Resident 34 had order for Profo Boot-offloading pressure on 3/6/18. Boots did not start getting applied until 3/16/18. Care Plan does not reveal what procedure was being done prior to Profo Boots. Review of Progress Notes dated 2/22/18 through 3/19/18 revealed no documentation since admission of resident refusing to be assisted to bed. Observation for five (5) hours from 09:15 AM until 01:50 PM revealed resident sitting in the wheelchair in various locations around the facility. Review of undated Care Plan revealed Resident 34 has no interventions that include changing positions and documenting refusals to lay down.",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
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
5515,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2016-12-19,314,D,1,0,HJD111,"**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 ensure that one sampled resident (Resident 1) with a pressure sore received wound treatments as prescribed to promote wound healing. The sample size was 3 with the potential to affect 2 other residents with pressure sores. The facility census was 117. Findings are: Review of the Care Plan for Resident 1 dated as initiated 6/10/16 revealed a focus: Resident has actual pressure ulcer or is at risk of pressure ulcer due to pressure ulcer present, assistance required in bed mobility, [DIAGNOSES REDACTED]. Review of the Medication Administration Sheet for Resident 1 dated for 11/1/16 through 11/30/16 revealed an order for [REDACTED]. Continued review revealed no written documentation on 11/12 for the PM dose. Further review revealed no written documentation of administration on both the AM and PM doses for 11/13 and 11/14. Review of the Treatment Administration Sheet for Resident 1 dated for 11/1/16 through 11/30/16 and 12/1/16 through 12/31/16 revealed an order for [REDACTED]. Continued review revealed no written documentation of completion of treatments for the PM doses on 11/23/ 11/25, 11/27, 11/29, 12/23, 12/25, 12/27 and 12/29. Further review of both treatment sheets revealed an order for [REDACTED]. Interview on 12/19/16 at 10:30 AM with Resident 1 revealed that the resident did have a pressure ulcer on the coccyx. Further interview revealed that the resident was to get the [MEDICATION NAME] treatment completed twice daily. Continued interview revealed that on occasions the treatment was not done or only done once a day and not as ordered. Interview on 12/19/16 at 2:00 PM with Unit Coordinator/Licensed Practical Nurse (UC/LPN) - B verified that Resident 1 did have orders for Liqucel twice daily to promote wound healing. Further interview verified that the resident had orders for [MEDICATION NAME] treatments twice daily to pressure ulcers. Continued interview confirmed that all treatments are to be documented on when they are administered. Further interview confirmed that the sheets had numerous treatments with no written documentation of administration of the treatments. Continued interview verified that the Liqucel and the [MEDICATION NAME] were administered to Resident 1 to promote wound healing of the pressure ulcers. Interview on 12/19/16 at 4:00 PM with the Interim Administrator and the Interim Director of Nursing confirmed that Resident 1's Treatment Administration Sheets did not have written documentation to support that the treatments had been completed on several occasions. Further interview verified that the treatments not documented were utilized to promote wound healing and should have been administered to this resident.",2019-11-01
1975,FLORENCE HOME,285173,7915 NORTH 30TH STREET,OMAHA,NE,68112,2019-08-12,684,G,1,0,JS4R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D3 (5) Based on record review and interview, the facility failed to provide bowel elimination management for 3 Residents (Residents 1, 2, 3) of 3 residents reviewed. The facility census was 80. Findings are: [NAME] Review of Resident 1's ID (Interdisciplinary) notes dated 7/9/2019 revealed Resident 1 was transferred to the hospital for a fall resulting in a [MEDICAL CONDITION] and Resident 1 returned to the facility on [DATE]. Review of Resident 1's Discharge paperwork from the hospital revealed Resident 1's last Bowel Movement (BM) in the hospital was on 7/11/2019. Review of Resident 1's ID notes revealed Resident 1 was less mobile than before the fracture and was not eating or drinking fluids well. Review of Resident 1's Medication Adminstration Record (MAR) for (MONTH) 2019 revealed Resident 1 was taking narcotic pain medication. Review of Resident 1's ID notes dated 7/14/2019 revealed Resident 1 was on the bedpan twice during the shift with no results. Review of Resident 1's MAR indicated [REDACTED]. This was Resident 1's third day without a bowel movement. Facility guidelines instructs an assessment of the abdomen by a nurse and a laxative given. Review of Resident 1's bowel tracking log revealed Resident 1 did not have a bowel movement until 7/17/2019 and was not provided a laxative or an abdominal assessment per the facility guidelines. This resulted in Resident 1 having no bowel movement for 6 days. Review of Resident 1's ID notes dated 7/18/2019 revealed Resident 1 complained of increased groin pain despite a medium amount of bowel movement passed. No abdominal assessment documented at this time. Review of Resident 1's ID notes dated 7/19/2019 at 8:40 PM revealed Resident 1 experienced pain in the abdomen and groin area. The nurse assessed Resident 1's abdomen as soft and tender, Bowel sounds were hypoactive (slow). Resident 1 appeared uncomfortable and showing facial grimace. Review of ID notes dated 7/19/2019 revealed Resident 1 was transferred to the hospital and diagnosed with [REDACTED]. Review of the facility Guideline titled Bowel Program dated revised 8/19 revealed the following: - A report is to be pulled at the beginning of each shift and any resident with no BM in 3 days will be considered for a laxative. -The nurse will complete an assessment to include bowel sounds, abdominal distention, and tenderness. -The Medication aide will then be directed to provide resident with bowel care ordered starting with a laxative then suppository and then enema if no results from previous interventions. If no orders for bowel care a call to the physician will be made. Review of Resident 1's MAR indicated [REDACTED]. [MEDICATION NAME] suppository (bowel stimulant) 1 daily as needed for constipation. Both ordered on [DATE] on admission to the facility. No documentation bowel care was provided in July. Review of ID notes dated 7/19/2019 for Resident 1 revealed Resident 1 returned from the hospital after removal of a fecal impaction on 7/19/2019 and was given Milk of magnesia (laxative) on 7/20/2019 with no bowel movement and no abdominal assessment completed. No further intervention was completed until Resident 1 was again given Milk of Magnesia on 7/24/2019 with Medium results. Review of the Bowel tracking log revealed Resident 1 had a medium sized BM on 7/24/2019. Resulting in Resident 1 not having a BM for 4 days after being hospitalized for [REDACTED]. Interview on 8/12/2019 at 3:10 PM with the Unit Manager revealed Resident 1 was not provided with care for bowel elimination according to the facility guidelines after returning from the hospital from a fall with a fracture and using narcotic pain medications that cause constipation and did not follow up with the bowel guidelines after Resident 1 returned from the hospital after a fecal impaction diagnosis. B. Review of Resident 2's Medication Administration Record [REDACTED]. Review of Resident 2's (MONTH) 2019 Bowel tracking revealed Resident 2 had no bowel movement (BM) or Intervention to promote a bowel movement during the following times: (MONTH) 1 -July 6 (5 days) July 19 -July 27 (8 days) July 27 -August 3 (7 days) August 3-August 8 (5 days) Review of Resident 2's care plan revealed the following interventions: - Document Bowel and Bladder habits - Assist to toilet - Anticholesterol (lower cholesterol) medication side effects constipation. Review of Resident 2's (MONTH) 2019 MAR indicated [REDACTED]. Medication was not provided in (MONTH) or (MONTH) 2019 to promote regular bowel movements. The consistency of bowel movements were documented as Hard Interview on 8/12/2019 at 3:15 PM with the Unit Manager revealed Resident 2 was not provided with bowel interventions when bowel movements were over 3 days apart as designated in the facility guidelines for bowel care and no assessments were completed by the nursing staff. Resident 2 should not be having hard stools and should be assessed for use of a stool softener. C. Review of Resident 3's [DIAGNOSES REDACTED]. Review of Resident 3's MAR indicated [REDACTED]. Review of the bowel tracking for Resident 3 revealed Resident 3 went over 3 days without a bowel movement and without assessment or intervention on the following dates: July 18-July 25 (7 days) July 26-July 30 (4 days) Review of Resident 3's MAR for (MONTH) 2019 revealed an order for [REDACTED]. Polyethelene [MEDICATION NAME] 17 gm daily prn (as needed) for constipation. ordered on [DATE] not given in (MONTH) 2019. Review of Resident 3's MAR indicated [REDACTED]. Interview on 8/12/2019 at 11:56 AM with Unit manager revealed all bowel movements should be charted in the Point of Care Documentation. Interview 8/12/2019 at 3:18 PM with the Unit Manager revealed since Resident 3 had a [MEDICAL CONDITION] Resident 3 should have had more regular bowel movements and should not show several days in between and the nurse needs to follow up with nursing assistance immediately and complete an assessment and intervention.",2020-09-01
1352,HILLCREST HEALTH & REHAB,285133,1702 HILLCREST DRIVE,BELLEVUE,NE,68005,2017-08-02,315,G,1,1,YKIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D3 Based on interviews and record reviews, the facility failed to evaluate urinary incontinence on admission and with a decline in continence for 2 residents (Residents 34 and 138) of 2 residents sampled and the facility failed to evaluate the use of an indwelling Foley catheter for 1 resident (Resident 62) of 3 residents sampled. The facility staff identified the resident census at 110 . The findings are: [NAME] A review of Resident 34's Face Sheet dated 8-1-17 revealed the resident was admitted to the facility on [DATE]. A review of Resident 34's comprehensive admission Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 3-7-17 revealed that the resident was not on a toileting plan, had frequent bladder incontinence, and was continent of bowel. The resident required extensive assistance with the help of 2 staff to transfer and use the toilet. A review of Resident 34's ADL (Activities of Daily Living) Verification Worksheet dated 2-28-17 to 3-7-17 revealed the resident was incontinent of 11 out of 16 times bladder elimination was documented. A review of Resident 34's MDS dated [DATE] revealed that the resident was not on a toileting plan, was always incontinent of bladder, and frequently incontinent of bowel. The resident required extensive assist of 1 staff to transfer and use the toilet. A review of Resident 34's ADL Verification Worksheet dated 5-31-17 to 6-6-17 revealed that the resident was incontinent 17 out of 17 times bladder elimination was documented. A review of Resident 34's medical record revealed no documentation of an evaluation of the resident's continence since the resident admitted to the facility. B. A review of Resident 138's Face Sheet revealed the resident was admitted to the facility on [DATE]. A review of Resident 138's comprehensive admission MDS dated [DATE] revealed the resident was not on a toileting plan and was occasionally incontinent of bladder. The resident required extensive assist for transfers and toileting. A review of Resident 138's ADL Verification Worksheet dated 3-14-17 to 3-20-17 revealed the resident was incontinent of urine 1 out of the 22 times bladder elimination was documented. A review of Resident 138's MDS dated [DATE] revealed the resident was not on a toileting plan and was frequently incontinent of bladder. The resident required extensive assist for transfers and toileting. A review of Resident 138's ADL Verification Worksheet dated 6-8-17 to 6-15-17 revealed the resident was incontinent of urine 30 out of the 38 times bladder elimination was documented. A review of Resident 138's Care Plan dated 6-8-17 revealed a goal to have increased continence and an intervention to complete incontinence assessments as indicated. A review of Resident 138's medical record revealed no documentation of an evaluation of the resident's continence since the resident admitted to the facility. C. An interview conducted on 8-1-17 at 10:52 AM with the Education Specialist revealed there had been no incontinence evaluations completed for Resident 138. An interview conducted on 8-1-17 at 11:09 AM with MDS Coordinator [NAME] revealed that the process for a decline in continence was to do an evaluation, talk to the physician if needed, and update the care plan. An interview conducted on 8-1-17 at 11:38 AM with the Director of Nursing (DON) revealed their expectation was that a bowel and bladder evaluation was to be done on admission. The DON reported that if a resident had a decline in continence the staff should check for an infection. If there was no infection present, the staff should complete a bowel and bladder log, determine why the resident had a decline and put interventions into place. An interview conducted on 8-1-17 at 12:40 PM with the DON revealed that the DON had done a random check of residents' medical records and found that incontinence evaluations were not being completed on admission. A review of the facility's Bladder Incontinence Management Program dated 4/2016 revealed Procedure: 1. Bladder assessments will be completed on admission, with a quarterly assessment, and PRN (as needed). C. During Stage 1 staff interviews, on 07/26/2017 at 10:08 AM, interview revealed that Resident 62 had an indwelling Foley catheter (a device that is placed in the bladder to facilitate the drainage of urine) was in use. Record review of Resident 62's admission records dated 06/28/2017 revealed that there were no orders for use of nor any indications for a Foley catheter. Record review of the hospital Continuum of Care Transfer Report for Resident 62 dated 06/27/2017, make no mention of the Foley catheter other than to state it was placed on 06/22/2017. Record review of Resident 62's care plan dated 06/28/2017, under the section interventions, it has the following two interventions: Incontinence assessment as indicated and [DIAGNOSES REDACTED]. Record review of Resident 62's assessments revealed that there was no urinary assessment or incontinence assessment found. An interview with Nurse Tech C (NT C) on 07/31/2017 at 03:50 PM revealed that the resident does not have any reddened or broken skin. An interview with Registered Nurse D (RN D), on 07/31/2017 at 10:20 AM, revealed that the Resident 62 had removed (gender) Foley on Saturday evening (07/29/2017) and that Resident 62 currently did not have another Foley in place. A follow-up interview with RN D on 07/31/2017 at 3:25 PM revealed that RN D just received an order to discontinue the Foley for this resident. RN D could not say if any staff had attempted to replace the Foley, but the process would be to either replace as soon as practically possible or get an order to discontinue the Foley. Interview with the DON on 08/01/2017 at 09:00 AM, revealed that the DON's expectations for Foley usage was that, if a resident was admitted with one, that the use of the Foley should be reevaluated for continued use and, if the Foley usage would not be indicated, that it should be removed within two weeks of admission. The DON stated that hospice wanted the Foley to remain, but confirmed that here was no assessment found to continue the use of the Foley.",2020-09-01
6066,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2016-06-22,315,D,1,0,PVZX11,"**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 ensure the use of an indwelling Foley catheter (a tube inserted into the bladder which allows urine to be eliminated) was medically necessary for one resident (Resident 23). The facility census was 75. Findings are: An observation on 6/22/16 at 12:10 PM revealed Nursing Assistant (NA) A and B assisting Resident 23 to transfer into bed using a sit to stand mechanical lift (a device used to move a person from one surface to another). Resident 23: was alert, oriented, and able to direct care needs; was dependant upon staff to move and position the left arm and leg; independently placed the right foot on the lift platform and right hand held the grab bar of the lift without difficulty. Resident 23 required extensive assist of both NAs to transfer legs onto the bed and to position pillows in accordance with the Resident's wishes. The observation revealed no indication of the staff offering toileting assist to Resident 23. An interview on 6/22/16 at 12:20 PM with NA-A revealed Resident 23 utilized an indwelling Foley catheter for bladder elimination and that the resident currently had a leg bag (a small drainage bag which is strapped to the leg) in place. The NA reported staff checks and empties Resident 23's leg bag approximately every 2 hours, and that the NAs would be assessing the bag again around 1:00 PM. A review of the TREATMENT ADMINISTRATION RECORD (TAR) for Resident 23 for (MONTH) (YEAR), indicated an order dated 5/3/16 for a Foley catheter which was to be changed monthly. The [DIAGNOSES REDACTED]. An interview on 6/22/16 at 1:50 PM with Registered Nurse (RN)-C indicated knowledge of the documented diagnosis (dx) for the use of the Foley catheter documented on Resident 23 ' s TAR, was not an approved dx. The RN went to check Resident 23 ' s medical record and returned momentarily reporting the dx documented on the Residents Care Plan was [MEDICAL CONDITION]. The RN reported knowledge that [MEDICAL CONDITION] also was not an approved dx for the use of an indwelling catheter. When asked what measures the facility had attempted related to discontinued use of the Foley catheter, the RN reported being unaware of any attempted interventions. The RN revealed Bowel and Bladder assessments had not been completed for Resident 23. A review of ADMISSION/RE-ADMISSION DATA form for Resident 23 dated 5/2/16 revealed the resident was not incontinent of bladder or bowel, and utilized a Foley Catheter for urinary elimination. The area of the form which documented the use of the catheter was not completed with the areas including the plan to discontinue, diagnosis, and urine color; not filled in. The area of the form which documented Function Status for toileting, indicated the resident was able to use toilet/commode with extensive assist of two staff members. A review of the facility policy titled BOWEL AND BLADDER CONTINENCE PROGRAM dated 5/2014, revealed that residents were screened upon admission for participation in the Bowel and/or Bladder Continence program. Potential factors or underlying causes that may be contributing to bowel and/or bladder incontinence are identified and addressed by the interdisciplinary team. A resident admitted with an indwelling catheter is assessed to determine if the catheter is assessed to determine if the catheter may be discontinued. A review of Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) information dated 5/30/16 for a 30 day Assessment, revealed Resident 23 was admitted to the facility on [DATE] and utilized an indwelling catheter. The assessment indicated that a toileting program had not been attempted on admission/entry to the facility.",2019-06-01
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
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
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
5280,BLUE VALLEY LUTHERAN CARE HOME,2.8e+280,"P O BOX 166, 755 SOUTH 3RD STREET",HEBRON,NE,68370,2017-10-12,318,E,1,1,QF6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D4 Based on observation, record review and interview; the facility failed to perform Passive Range of Motion (PROM - the moving of a person's joint through its range of motion by another person as an exercise) for three (Residents 22, 13 and 15) of residents with PROM care planned. The facility census was 36. Findings are: Review of Resident 22's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated 9/27/17 revealed Resident 22 had severely impaired cognition, was totally dependent on assistance for completion of Activities of Daily Living and had impaired Range of Motion to both sides of upper and lower extremities. Resident 22 had a [DIAGNOSES REDACTED]. Review of Resident 22's Care Plan revised on 07/18/17 revealed Resident 22 had impaired mobility related to [MEDICAL CONDITION]. The goal was to increase PROM to elbows, shoulders, hands, knees, ankles and feet by performing PROM BID (twice a day) 6-7 days per week. The program would be administered by nursing staff using a written program of PROM exercises and re-evaluation in 90 days. Interventions included approaching Resident 22 with a calm voice and giving positive verbal re-enforcement. Review of Resident 22's Progress Notes dated 10/2/17 revealed Resident 22 tolerated restorative program without difficulty. Resident 22 would occasionally holler with ROM (Range of Motion) or prior to staff performing the PROM. The goal was to increase ROM by performing PROM to bilateral shoulders, elbows, hands, knees, hips, ankles, and feet 10 minutes BID 6-7 times per week. This would be reviewed next quarter, sooner if needed. Restorative staff would address any future restorative needs. Interview with RN (Registered Nurse) I on 10/05/2017 at 08:30 AM revealed Resident 22 had a contracture to the left hand and received ROM exercises by restorative staff. Interview with the Director of Nursing (DON) on 10/10/17 at 4:30 PM revealed the restorative nurse (RN J) had been re-assigned as the interim DON at another facility. The DON went on to explain that the RN J used to do the restorative exercises because the restorative aide had been off work since April. Interview with the RN J on 10/11/2017 at 2:16 PM revealed that, since the restorative aide had been out, the nurse aides, not RN J, have been responsible for completing the resident's restorative exercises. RN J explained that this had been the procedure since April. Review of Resident 22's Restorative documentation on the (MONTH) (YEAR) Documentation Survey Report revealed Resident 22 received PROM exercise one time [MEDICATION NAME] 5 minutes from (MONTH) 1st to (MONTH) 11th on the day shift and reviewed PROM daily on the evening shift for 5 minutes at a time. Resident 22's (MONTH) (YEAR) Documentation Survey Report revealed Resident 22 received PROM 4 times on the day shift, ranging from 1 to 8 minutes at a time, and daily on the evening shift with for 3-5 minutes per day. Observation of Nursing Assistant (NA) K on 10/11/17 at 3:00 PM revealed a slow tender approach was required when performing PROM exercises for Resident 22. Resident 22 was hesitant to allow NA K to begin but with a gentle approach agreed for NA K to proceed. NA K provided PROM to all joints in all planes of movement with a repetition of 10 times at each joint. When NA K got to Resident 22's left hand and fingers, Resident 22 yelled ouch. NA K gently and slowly proceeded and was able to stretch all of Resident 22's fingers and hand and hold for at least 10 seconds. NA K did not finish with the exercises until 3:17 PM. When NA K was asked if all the PROM could be completed in 3-5 minutes as documented, NA K stated it could not. NA K further explained that staff decided that 3-5 minutes of PROM to some joints was better than not getting any at all. NA K could not explain why the PROM was only done once per day instead of BID as care planned. B. An observation on 10/11/17 at 2:10 PM of Resident # 13 revealed contractures of arms, wrists and fingers. A record review of the facility Documentation Survey Report 2 which recorded the amount of times PROM was completed for Resident #13 revealed The goal of the program is to increase the ROM to resident's bilateral shoulders, elbows, hands, hips, knees, ankles and feet by performing PROM exercises 10 minutes twice a day 6-7 times a week to be completed by nursing and revealed that PROM was done for (MONTH) 10 times out of 60 opportunities, (MONTH) 8 times out of 62, (MONTH) 5 times out of 62, (MONTH) 2 times out of 60, and (MONTH) 0 times out of 21. C. An observation on 10/11/17 at 2:30 PM of Resident #15 revealed contractures of arms, wrists and fingers. A record review of the facility Documentation Survey Report 2 which recorded the amount of times PROM was completed for Resident #15 revealed The goal of the program is to increase the ROM to resident's bilateral shoulders, elbows, knees, ankles and feet by performing PROM exercises 10 minutes twice a day 6-7 times a week to be completed by nursing and revealed that PROM was done for (MONTH) 14 times out of 60 opportunities, (MONTH) 6 times out of 62, (MONTH) 9 times out of 62, (MONTH) 3 times out of 60, and (MONTH) 1 time out of 21. An interview on 10/11/17 4:30 PM with the DON confirmed the nurse aides on the floor were to do the PROM 6-7 times a week twice a day for 10 minutes.",2020-02-01
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
4446,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2018-03-08,744,D,1,1,VCTE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D5 Based on interviews, observations, and record reviews; the facility failed to develop and implement interventions and monitoring related to wandering and behavioral management for 1 resident (Resident 4) of 3 residents sampled. The facility staff identified the census as 54. The findings are: A review of Resident 4's Admission Record dated 3-8-18 revealed Resident 4 was admitted to the facility 12-31-16 with [DIAGNOSES REDACTED]. An observation conducted on 3-5-18 at 9:52 AM revealed Resident 4 in their recliner in their room with eyes closed. An observation conducted on 3-5-18 at 2:20 PM revealed Resident 4 in their recliner in their room with eyes closed while there was a Bingo activity in the chapel. An observation conducted on 3-6-18 at 9:29 AM revealed Resident 4 in their recliner in their room with eyes closed, curtains closed, and lights off. An observation conducted on 3-6-18 at 2:09 PM revealed Resident 4 was not in their room and was not at the music activity that was taking place in the chapel. Resident was not observed walking in the halls. An observation conducted on 3-6-18 at 2:37 PM revealed Resident 4 sitting at the nurses station after just receiving a bath while a music activity was taking place in the chapel. An observation conducted on 3-7-18 at 9:52 AM revealed Resident 4 in their recliner in their room with eyes closed, curtains closed, and lights off while there was an ice cream social in the chapel. An observation conducted on 3-7-18 at 2:18 PM revealed Resident 4 in their recliner in their room with eyes closed while there was a church activity taking place in the chapel. An observation conducted on 3-7-18 at 2:36 PM revealed Resident 4 in their recliner in their room with eyes closed. Popcorn had just been passed out to the residents in their rooms, Resident 4 did not receive popcorn. An observation conducted on 3-7-18 at 3:31 PM revealed Resident 4 walking in the hall unattended holding their pant leg up. The resident walked around the nurses station and stumbled over a piece of equipment. A nurse walked up to the resident and took the resident back to their room. A review of Resident 4's progress note dated 10-22-17 revealed that the resident had wandered into another resident's room and was involved in an altercation where the resident fell in the room. A review of Resident 4's progress note dated 11-15-17 revealed that Resident 4 was walking in the hall and reached for another resident's arm to walk with them. The other resident yelled at Resident 4 and poked Resident 4 in the chest. A review of Resident 4's Activity Data Collection dated 11-22-17 revealed the resident's activity interests were music, socials/parties, animal visits, current events, and visits from family and friends. The resident wanders around the facility and has behaviors. A review of Resident 4's Activity Participation Record for (MONTH) (YEAR) revealed the resident actively participated in 1 fingernail painting activity and 1 snack activity. One on one interaction was offered to the resident 2 times. A review of Resident 4's Activity Participation Record for (MONTH) (YEAR) revealed the resident actively participated in 1 music activity and 2 party activities. One on one interaction was offered to the resident 7 times. The resident is documented as having passively participated in the music activity on 3-6-18. A review of Resident 4's Activity Participation Record for (MONTH) (YEAR) revealed the resident actively participated in 1 fingernail painting activity, passively participated in 1 cooking activity, and was offered 8 one on one interactions. A review of Resident 4's Nutrition Care Plan dated 1-4-17 revealed an intervention to invite the resident to activities that promote additional intake. A review of Resident 4's Comprehensive Care Plan dated 1-4-17 revealed no care plan to address the resident's behaviors and wandering. A review of Resident 4's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 2-20-18 revealed that the resident had wandering behaviors that occurred daily. A review of Resident 4's Care Area Assessment Worksheet for Behavioral Symptoms (a guide for developing the Comprehensive Care Plan) dated 12-1-17 revealed that the resident's behaviors would not be care planned. The resident wandered into other residents' room and the resident spent most of their day wandering around the facility talking to people who were not there. A review of Resident 4's Care Area Assessment Worksheet for Cognitive Loss dated 12-1-17 revealed that the resident required frequent reorientation, reassurance, and cueing. An interview conducted on 3-7-18 at 3:39 PM with the Administrator revealed that Resident 4 was more appropriate for a locked Dementia unit, but the staff were attached to the resident and did not want to resident moved to another facility. An interview conducted on 3-8-18 at 8:45 AM with the Activity Director revealed that the resident mostly received one on one activities related to the resident wandering. The Activity Director reported they would invite Resident 4 to activities, but due to the resident's Dementia, the resident was unable to focus long enough to get to the activity. The Activity Director reported they did not take Resident 4 to group activities because the resident would often get up and walk out in the middle of the activity. A review of the facility's Behavior Management Policy dated 5/14 revealed the following: Overview: The components of the behavior management program include, but are not limited to: Identification of resident specific behaviors requiring intervention. Identification and implementation of appropriate interventions to address behaviors. and Intervention and Management: 2. Develop the care pan with input from the interdisciplinary team and the resident/patient and family/responsible party. 3. Identify and implement individualized interventions based on identified triggers/causes of the behaviors. 4. Document individualized goals and interventions to treat underlying causes of the behaviors and reduce/eliminate triggers.",2020-06-01
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
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
5281,BLUE VALLEY LUTHERAN CARE HOME,2.8e+280,"P O BOX 166, 755 SOUTH 3RD STREET",HEBRON,NE,68370,2017-10-12,322,E,1,1,QF6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D6 Based on record review, observation, and interviews for 3 of 3 sampled residents, (Residents 12, 31, and 13), the facility failed to check placement on a [DEVICE] (gastrostomy tube) before administering medication. The census was 36. The findings include: Record review of facility policy titled Administering Medications through an Enteral Tube dated (MONTH) (YEAR) revealed to confirm the placement of feeding tube, flush tube with water before giving the medications. An observation of LPN F (Licensed Practical Nurse) on 10/11/2017 at 09:45 am revealed LPN F gave medication to the resident via [DEVICE] without checking the placement of the [DEVICE] . An observation of LPN F on 10/11/2017 at 09:57 revealed LPN F gave medication to the resident via [DEVICE] without checking the placement of the [DEVICE] . An observation of LPN F on 10/11/2017 at 12:25, gave medication to the resident via [DEVICE] without checking the placement of the [DEVICE] . In an interview on 10/11/2017 at 12:3, LPN F stated that the placement of the [DEVICE] should have been checked to make sure the tube was in the stomach before medications were given. An interview with the DON (Director of Nursing) on 10/11/2017 at 2:10 PM confirmed that, according to the policy, [DEVICE]s were to be checked for placement before giving medications.",2020-02-01
6193,REGIONAL WEST GARDEN COUNTY NURSING HOME,2.8e+181,1100 WEST 2ND,OSHKOSH,NE,69154,2016-06-14,323,D,1,0,BN0W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D7 Based observation, interviews and record reviews, the facility failed to ensure supervision and monitoring for 2 sampled residents (Resident 2 and 7) identified at high risk for falls. Facility census was 30. Findings are: A. Review of the Admission Record dated as printed 9/3/16 for Resident 2 revealed that the resident was admitted to the facility 9/3/13. Further review revealed [DIAGNOSES REDACTED]. Review of the Care Plan for Resident 2 dated 10/21/15 revealed a problem: At risk for falls .tab (a device attached to the resident and chair that alarms when the connection is broken) alarm on in bed and chair to alert staff to potentially movements. Observation on 6/14/16 at 11:05 AM revealed Resident 2 seated in a chair by the nurses station unsupervised. Further observation revealed that there were no staff members at the nurses station or within sight. During the observation, the resident did scoot to the edge of the chair and tried to get up At 11:10 AM a staff member did readjust the resident in the chair. Continued observation revealed no tabs alarm on the resident. Interview with RN (Registered Nurse) - E on 6/14/16 at 11:25 AM revealed that Resident 2 was a high risk for falls. Further interview revealed that Resident 2 was to wear the tabs at all times. Interview on 6/4/16 at 12:15 PM with RN - A verified that Resident 2 was a fall risk and should not have been left unattended without the tabs alarm in place. B. Review of the Admission Record for Resident 7 dated 4/23/16 revealed an admitted d to the facility of 12/19/13. Review of the Nurses Notes for Resident 7 revealed that on 12/21/15, the resident was using hand sanitizer on their face and brushing their teeth with it. Review of the Care Plan dated 12/9/15 for Resident 7 revealed a problem of Cognitive loss/Dementia, resident is unable to make good/safe decisions .poor short term memory loss . Observation on 6/14/16 at 11:00 AM of cares provided to Resident 7 by NA (Nursing Assistant) - F revealed that the NA used a sit to stand device to transfer the resident onto the commode. Continued observation revealed that NA - F did not reapply the tabs alarm. Further observation revealed that NA-F then left the room. Observation on 6/14/16 at 11:20 AM revealed NA - F entered the room, provided peri care and returned the resident to the wheelchair. NA-F then fastened the tabs alarm to the resident. Interview on 6/14/16 at 11:00 AM with NA - F revealed that Resident 7 was a sit to stand transfer. Further interview revealed that the resident had very disorganized thoughts and poor recall. Interview on 6/14/16 at 12:00 PM with RN - A and the Activities Director verified that Resident did have poor memory and recall. Further interview verified that Resident 2 was left attached to the sit to stand on the commode. Continued interview verified that Resident 2 was a high risk for falls and the resident should not have been left attached to the lift, on the commode, without the tabs alarm. Further interview revealed that NA - F should have remained in the room with Resident 7 to ensure safety from falls.",2019-06-01
1607,AZRIA HEALTH CENTRAL CITY,285147,2720 SOUTH 17TH AVENUE,CENTRAL CITY,NE,68826,2019-07-30,689,G,1,1,7WHV11,"**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 ensure that interventions were in place to protect residents from injury while smoking. The facility census was 59 and this affected Resident 31 and 49. Findings are: [NAME] Review of the Minimum Data Set (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) for Resident 49 dated 6/26/19 revealed a [DIAGNOSES REDACTED]. Review of a History and Physical for Resident 49 dated 4/11/19 revealed the self injury behavior of hitting head against the wall. Review of facility Health Status Note 7/24/19 revealed Resident 49 was observed to have burn areas to bilateral wrists. Left wrist measuring at 1.2 cm x 0.8 cm and right wrist at 1 cm x 0.9 cm. Observation of Resident 49 on 07/24/19 3:06 PM revealed reddened burn areas to anterior area of bilateral wrists. Size and shape similar to the tip of a cigarette. Also observed numerous old scarred burn areas on bilateral upper arms of similar size and shape to the newly observed burns. Observation of Resident 49 smoking on 7/25/19 at 11:21 AM revealed the resident was not utilizing smoking gloves for either hand. The resident was utilizing both hands to smoke the cigarette. Observation of Resident 49 smoking on 7-29-2019 at 9:26 AM revealed no cigarette extender or smoking gloves were in use. Review of Resident 49's care plan revealed the intervention dated 7/24/19 of smoking gloves to be worn during smoke breaks. Review of Resident 49's care plan revealed the intervention dated 7/24/19 of smoking tip to be on during smoke breaks. Interview with the Director of Nursing (DON) on 7/25/19 12:37 PM revealed the intervention for glove use for smoking safety had not been utilized by staff as care planned for Resident 49 on 7/25/19 at 11:21 AM. Interview with activity assistant Z on 7/29/19 10:59 AM revealed Resident 49 had not been provided a smoking tip during smoking on 7-29-2019 at 9:26 AM. Resident 49 does not refuse smoking interventions. The updated protocol sheet for smoking was made available after smoke break on 7-29-2019 0915 to 0945. B. An observation on 07/29/19 at 09:26 AM of smoke break revealed 8 residents who were smoking and 1 staff member to monitor Resident 31 had no shoes on- apron placed on chair over the resident's lap and one on the upper body, smoking sleeves were in place for both arms. Staff lit the cigarette and took the cigarette and flicked the ashes. Record review of Investigation Report dated 6/7/18 revealed; Resident 31 had wounds noted to the Right forearm there were 2 circular areas measuring 0.8x0.8CM the areas were flush with skin and had red edges with a white center with dark brown coloring. Resident 31's [DIAGNOSES REDACTED]. The facility concluded that Resident 31 continued to smoke. Resident 31 needed to wear Geri- sleeves, long sleeve shirt or coat, during smoking time along with smoking apron and tip that was already in place for residents safety. Record review of Care Plan dated 6/6/18 revealed; that Resident 31 was noted to have 2 circular red areas to the right forearm. The intervention was to wear arm protectors while smoking. Record review of the investigation report dated 6/17/18 revealed; Resident 31 was smoking on the patio supervised by staff. Staff saw the resident drop it (the cigarette) on the smoking apron it rolled down landing on the foot before the staff get to it Injury to R) top of foot 0.8x 0.7 CM fluid filled area. The conclusion was staff will continue to observe Resident 31 for safety during smoking times with the newest intervention of assuring that Resident 31 had shoes on prior to smoking and or remind the resident of the safety risk if they did not wear shoes. Record review care plan dated 6/17/18 revealed: intervention Resident 31 would have feet covered with socks or shoes during smoke break or if they chooses not to wear shoes take them to the patio, hand them to the resident before the cigarette was lit and ask the resident to put shoes on. Intervention of the Guardian who requested that Resident 31 not be informed of the smoke break times due to safety risk [MEDICAL CONDITION] the resident requested a cigarette during smoke break allow them and follow all care plans for smoking. Annual Assessment MDS dated [DATE] revealed; that Resident 31 used tobacco Section J1300. An interview on 07/29/19 at 11:14 AM with AA (Activities Aide) Z confirmed; that the laminated interventions for smoking had been updated today and was given to the AA Z after the smoke break at 9:15AM. The Activity Aide confirmed; that the list is kept in the Caddy with all the cigarettes and lighter. Record review of Smoking Policy revealed; that the Resident's lighter and cig would be kept in the nurse's station in a locked area. Staff lighters and cig would be kept in a locker. Staff is allowed to smoke in the employee area located outside in the employee area by the garage. Residents were allowed to smoke on the North Patio area with staff supervision. All cigarette buds will be put on and in the dispenser by the staff supervising the event. Facility staff will evaluate safety of the resident upon admission and change of condition in the following was. [NAME] Resident cannot have any significant physical impairment or they will need supervision at all times. B. Staff will observe all new resident upon change of condition of a resident for 3 days to evaluate the safety of the resident on their smoking behavior. C. If resident is assess to be safe during smoking time they will be allowed to go to the smoking area unsupervised. An interview on 07/29/19 at 4:05 PM with the MDS (Minimum Data Set-a federally mandated comprehensive assessment that assist in developing the care planning process.) coordinator confirmed; that the intervention to have shoes on while smoking for Resident 31 was discontinued, and that the staff were to put the shoes on the resident prior to smoking. The MDS coordinator confirmed; that Resident 31 was at risk for burning feet without wearing shoes.",2020-09-01
1750,"PREMIER ESTATES OF PAWNEE, LLC",285157,"P O BOX 513, 438 12TH STREET",PAWNEE CITY,NE,68420,2019-09-16,689,G,1,1,R7CE11,"**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 related to an elopement that resulted in injury for 1 (Resident 30) of 1 resident reviewed for elopement risk and failed to complete a wheelchair safety assessment for 1 (Resident 3) of 1 resident reviewed for wheelchair safety. The facility had a census of 33. The findings are: [NAME] A record review of a Progress Note dated 9/3/18 at 11:44 PM revealed Resident 30 was looking for (gender) lost car and self-propelling in (gender) wheelchair to locate it. A record review of a Progress Note dated 1/7/19 at 7:19 AM revealed Resident 30 was looking for his car the previous afternoon and told staff (gender) wanted to go to Pawnee City. The staff member reminded Resident 30 (gender) was in Pawnee City. A record review of Wandering and at Risk for Elopement assessment dated [DATE] revealed Resident 30 was identified as a moderate risk for wandering and elopement. A record review of a Progress Note dated 3/5/19 at 5:23 AM revealed Resident 30 was confused and thought someone kicked (gender) out of bed and stole (gender) car. Resident 30 was asking multiple staff members to take (gender) home and was difficult to redirect. A record review of a Progress Note dated 5/6/19 at 9:00 AM revealed Resident 30 was in the hallway without any clothes on. A record review of a Progress Note dated 7/12/19 at 9:13 PM revealed Resident 30 was noted sleeping with (gender) feet at the head of the bed at 8:35 PM, then at approximately 9:00 PM asked staff where (gender) was and if (gender) had eaten recently. A record review of the MDS (a standardized assessment tool that measures health status in nursing home residents) dated 8/27/19 identified Resident 30 had a BIMS score (Brief Interview of Mental Status-used to determine cognitive function) of 01. A record review of A Progress Note dated 8/28/19 at 1:01 PM revealed Resident 30 was in the hallway with (gender) pants down and refused assistance when staff tried to help to pull them up. A record review of a Progress Note dated 9/3/19 at 10:00 AM revealed Resident 30 was found by a Physical Therapy staff member laying in the grass across the street from the facility. Resident 30 was then taken to the emergency room by ambulance to be evaluated. A record review of a statement dated 9/3/19 from the Physical Therapy Assistant who found Resident 30 that date revealed (gender) was leaving the parking lot when (gender) noticed a wheelchair tipped over in the street, south of the main facility driveway. The Physical Therapy Assistant called 911. A record review of a Progress Note dated 9/3/19 at 12:28 PM revealed Resident 30 returned to the facility. Resident 30 complained of pain to both thighs and legs, but no bruising or wounds were visible. A record review of Wandering and at Risk for Elopement assessment dated [DATE] revealed Resident 30 was identified as a moderate risk for wandering and elopement. A record review of a Progress Note dated 9/4/19 at 10:02 AM revealed Resident 30 had a bruised right elbow and an abrasion measuring 4cm (centimeters) by 1cm. Resident 30 complained of pain in right thigh and was rubbing it with (gender) hand. The nurse sent a fax to update the physician. A record review of a Progress Note dated 9/4/19 at 5:24 PM revealed a new order from the physician for [MEDICATION NAME] (a pain medication) as needed for Resident 30. A record review of a Progress Note dated 9/6/19 at 7:07 PM revealed Resident 30 had been complaining of right hip discomfort since fall on 9/3/19 and the nurse scheduled a follow-up appointment with Resident 30's physician. A record review of a Progress Note dated 9/7/19 at 9:46 AM revealed Resident 30 complained of right knee and right thigh pain. The nurse assessed Resident 30 and noted inflammation (swelling) and bruising to (gender) right knee and thigh area. A record review of a Progress Note dated 9/10/19 at 3:08 PM revealed the physician looked at Resident 30's x-rays of (gender) knee and hip and stated they were negative for a fracture. A record review of a Progress Note dated 9/14/19 at 4:52 PM revealed Resident 30 continued to heal from the fall on 9/3/19 and had healing bruises to (gender) right thigh and knee and a healing abrasion and bruise on (gender) right elbow. A record review of Elopent Policy dated 6/18/19 revealed, Any resident displaying significant wandering behavior will be evaluated and care planned appropriately. An interview on 9/17/19 at 11:31 with the DON (Director of Nursing), confirmed Resident 30 was found by a Physical Therapy Assistant in the grass, down the hill and across the street from the facility driveway with (gender) wheelchair tipped over on 9/3/19. The DON stated that Resident 30 was taken to the ER and had no acute fractures, but did have an abrasion and swelling to (gender) right elbow. The DON also confirmed Resident 30 was identified as a moderate risk for wandering and elopement prior to this incident. The DON also stated (gender) expectation would be that a resident who had been identified as a moderate risk for wandering and elopement would have a Wanderguard (a device used to alert staff if a resident is exiting the facility) in place and not be outside unsupervised. The DON confirmed that Resident 30 did not have a Wanderguard in place prior to 9/3/19, but does now. The DON also confirmed the incident from 9/3/19 was not reported to the required state agencies. An observation on 9/17/19 at 1:07 PM revealed Resident 30 was sitting in (gender) wheelchair eating a lunch tray. A Wanderguard was on (gender) left ankle. B. Observation on 09/16/19 at 1:50 PM revealed Resident 3 was driving fast in (gender) electric wheelchair in parking lot. Record review of Behavior note dated 9/2/2019 revealed Resident 3 was reminded not to park wheelchair in the parking lot because it is not safe, the person delivering meds from pharmacy stated he almost hit (gender) with his car because he didn't see (gender). Resident reported to staff that he did not. Record review of Behavior note dated 8/30/2019 at 8:45 PM revealed Resident 3 signed self out. It was reported to facility that the resident was parked in (gender) wheelchair on the street at corner of 13th and [NAME] Street. DON was notified at approximately 2030, the situation was discussed with resident in regards to safety concern notice given on 2/13/19; Stated if the resident breaks the law the sheriff's department would be called. The sheriff's department was notified at approximately 2045, with a promise to look into it. Record review of Behavior note dated 8/29/2019 revealed resident was smoking in the facility parking lot in the dark around 8:30 P.M. Resident had signed Smoking Policy listing where the designated smoking area is located. Record Review of Behavior Note dated 8/2/2019 at 06:12PM revealed resident almost ran over a small child at parade when (gender) was racing for candy. Record Review of Health Status Note dated 7/19/2019 revealed resident signed self out of facility at 8:20 PM. A staff member noticed resident was sitting at the base of the driveway in the dark when they left facility. The resident did not have a light or a flag on (gender) wheelchair. The resident could have been hit by car had the staff member not have seen (gender). Record review of Wheel Chair Saftey assessment dated [DATE] revealed resident was completly independent and safe to drive electric wheelchair without supervison. An interview on 09/16/19 at 4:32PM with DON confirmed Resident 3 should have a new wheelchair safety assessment completed.",2020-09-01
5606,GOOD SHEPHERD LUTHERAN HOME,285148,2242 WRIGHT STREET,BLAIR,NE,68008,2016-12-19,323,G,1,0,JMDD11,"**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 transfer a resident in a safe manner to prevent the resident from falling for one of three residents sampled (Resident 1). This fall resulted in an injury to the resident. The facility census was 80. Findings are: Observation of Resident 1 on 12/19/16 at 9:50 AM revealed Resident 1 was lying in bed on their back with their right hand tightly around a cell phone. Resident 1 had the left leg straight in bed with an immobilizer on. The resident had showed facial grimacing with movement. Interview with Resident 1 on 12/19/16 at 9:50 AM revealed that someone had dropped the resident when transferring the resident. Resident 1 rated the their leg pain at 6 on a 10 point scale with 10 being the worst pain the resident had ever felt. Interview with Resident 1 on 12/19/16 at 10:53 AM revealed the resident was in terrible pain and had requested pain medication. Observation of the transfer of Resident 1 on 12/19/16 at 11:20 AM from the bed to the wheelchair by NA C and NA D revealed that Resident 1 had received pain medication of Hydrocodone 5/325 (Norco) at 10:55 AM. Resident 1 was placed in a Hoyer lift by the 2 staff members. One staff member then held resident's leg as the resident was moved to be placed into the wheel chair with the left leg extender on. Resident 1 moaned and cried out in pain during the transfer. Observation of the undated posting of care requirements for Resident 1 located on a hook behind the resident ' s door revealed the transfer requirements were 2 assist, sit/stand as needed (prn) and for toileting 2 assist required. Interview with the Physical Therapist on 12/19/16 at 11:12 AM confirmed that Resident 1 was a 2 person transfer prior to the resident ' s fall. Resident 1 was unable to stand, therefore, was not a one person assist Interview with NA D on 12/19/16 at 1:45 PM revealed that NA D had taken care of Resident 1 before the fall and that transfers and toileting did require assist of two staff because the resident was not able to stand. Record review of the Facility policy of Transfers with one person revealed that residents who require 1 assist will be transferred with a gait belt to prevent resident and employee injuries. Residents that require one assist to transfer will be weight-bearing and need only guidance by the staff. Record review of Resident 1's (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 10/13/16 revealed that Resident 1 required extensive assistance of two persons physical assist for transfer and toilet use. Record review of the facility investigation revealed that on 12/1/16 at 11:50 AM Nursing Assistant (NA) A was transferring Resident 1 from the toilet to the wheelchair when Resident 1 was unable to stand and was lowered to the floor. NA A was not using a gait belt with transfer and did not have a second staff member assisting with transfer. Record review of Physician Nursing Home Rounds dated 12-2-16 revealed that the resident was lowered to the floor on 12-1-16. The resident had complaints of left hip pain and was to have their hip and knee x-rayed. Record review of the Confirmation of Physician Visit dated 12/2/16 revealed that the resident was crying and voicing complaints of pain to their left lower extremity related to a fall on 12/1/16. The resident was sent to the hospital for x ray with the results of a non-displaced femur fracture. The resident was sent from x-ray to see an Orthopedic Surgeon. Resident 1 was placed in a knee immobilizer to the left leg and ordered strict non weight bearing of left leg for 6 weeks. The resident was to follow up with the Orthopedic Surgeon in one week. The resident was to have an extended wheel chair leg for the left leg. Record review of the Confirmation of Physician Visit dated 12/9/16 revealed an x-ray of the displaced distal left femur fracture and additional orders were for Computed Axial tomography scan (CT) Scan that was to be performed on 12/12/16 The resident was to have a history and physical and a cardiology consult for surgery on 12/16/16 for a repair of the Left femur fracture. Interview with the Director of Nursing (DON) on 12/19/16 at 11:45 AM confirmed that Resident 1 was being transferred one staff person with no gait belt when the fall occurred. The DON confirmed that Resident 1 had required assist of two for transfer as recorded on the MDS dated [DATE].",2019-11-01
2681,HERITAGE OF EMERSON,285222,607 NEBRASKA STREET,EMERSON,NE,68733,2017-08-31,323,D,1,1,AEM711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D7 Based on observations, interviews, and record reviews; the facility failed to implement interventions to prevent falls for 1 resident (Resident 11) of 2 residents sampled and failed to evaluate 1 resident (Resident 14) of 1 resident sampled for self administration of medications. The facility staff identified the resident census at 30. The findings are: [NAME] A review of Resident 11's Admission Record dated 8-31-17 revealed Resident 11 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An interview conducted on 8/29/17 at 9:49 AM with Registered Nurse (RN) B revealed Resident 11 had a fall in the past 30 days and had sustained an abrasion to their cheek. A review of 11's fall report dated 8-21-17 revealed that, on 8-21-17, the resident was found lying on the floor by the nurses station. The resident was last seen sitting in a chair at the nurses station waiting for staff assistance to get ready for bed. The resident had sustained an abrasion to their face in the fall. A review of Resident 11's undated care plan for falls revealed an intervention to toilet the resident after meals before sitting them in the living room. An observation conducted on 8/30/17 from 9:54 AM to 10:20 AM revealed Resident 11 was assisted out of the dining room and placed in a chair at the nurses station. Resident 11 sat in the chair and interacted with a baby doll until therapy took resident to the therapy room. An observation conducted on 8/30/17 from 10:20 AM to 11:18 AM revealed Resident 11 in the therapy room working with therapy staff. An observation conducted 8/30/17 11:18 AM to 11:29 AM in Resident 11's room revealed the resident was not brought into room to use the toilet after the completion of therapy. An observation conducted 8/30/17 11:30 AM to 12:04 PM revealed Resident 11 was sitting in a chair by the nurses station interacting with a baby doll until staff assisted the resident to the dining room for lunch. An interview conducted on 8/30/17 at 12:07 PM with Physical Therapy Assistant F revealed Resident 11 was not toileted during the time they were in therapy and was not toileted prior to returning the resident to the chair at the nurses station. An observation conducted on 8/30/17 at 1:29 PM revealed Resident 11 was assisted to walk from the dining room to their bed. Resident 11 was then assisted to lay down on the bed, shoes were removed, and then the resident was covered up to rest before staff left the room. An interview conducted on 8/30/17 at 1:41 PM with the Director of Nursing (DON) revealed Resident 11 was wearing a brief and the brief was still dry. They reported Resident 11 was usually continent and would urinate when placed on the toilet by staff. The DON confirmed the resident was care planned to be taken to the toilet after meals prior to sitting the resident at the nurses station and should have been toileted after breakfast and lunch. B. Findings are: A Record review of a policy for Self-Administration of Medications, dated 12/2/15, revealed A) Allow residents the independence to safely self-administer non-narcotic medications and/or non-psychotropic medications with appropriate physician order [REDACTED]. B) An order must be obtained from the resident's physician for self-administration of the specific medication(s) under consideration. The physician order [REDACTED]. Observation on 08/30/2017 at 7:49:08 AM revealed Resident 14 was sitting in wheelchair taking medications. There were no staff in resident's room or outside resident's doorway. Interview on 08/30/17 at 9:00 AM with RN (Registered Nurse) [NAME] revealed that RN [NAME] left the medication the bedside of Resident 14. RN [NAME] acknowledged that RN [NAME] didn't know if this resident had an evaluation for self-medication at bedside. RN [NAME] acknowledged RN [NAME] did not know if there was a doctor's order to have medications at bedside. In an interview on 08/30/17 11:50 am with the DON, the DON was unable to produce documentation of a physician's orders [REDACTED]. The DON was unable to produce documentation that an assessment was performed to evaluate if Resident 14 was able to safely take medications independently. The DON confirmed that this had not been done.",2020-09-01
3800,MITCHELL CARE CENTER,285287,1723 23RD STREET,MITCHELL,NE,69357,2019-06-10,689,E,1,0,CXX911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D7 Based on observations, record reviews and interview; the facility failed to ensure that care plan interventions were followed to reduce the risk for falls and injuries for two current sampled residents (Residents 1 and 2) and that effective care plan interventions were in place to prevent recurrent falls for one sampled resident (Resident 3). The facility census was 46 with seven sampled residents. Findings are: [NAME] Review of Resident 1's Care Plan, goal date 8/19/19, revealed that the resident was at risk for falls related to recent fractured left hip and intervention included to keep the call light within reach and encourage to use it to call for assistance. Observations on 6/10/19 at 1:00 PM revealed the resident seated in the wheelchair in room with the call light placed behind the resident and attached to the bed. B. Review of Resident 2's Care Plan, goal date 8/5/19, revealed that the resident was at risk for falls and interventions included keep the call light within reach and encourage to use it to call for assistance. Observations on 6/10/19 at 1:00 PM revealed the resident seated in the recliner in room with the call light attached to the bed and not within reach for the resident. Interview on 6/10/19 at 1:00 PM with NA (Nursing Assistant) - C confirmed that the residents couldn't reach their call lights to call for assistance. NA - C placed the call light within reach for the residents. C. Review of Resident 3's Progress Notes revealed that the resident fell on [DATE], 5/14/19 and 6/9/19. Review of the Care Plan, goal date 7/29/19, revealed that the resident was at risk for falls and interventions included observe for unsteady gait, weakness and assist accordingly; and assist back to room if sleeping in the lobby chair; and frequent observations. Interview with the Administrator on 6/10/19 at 4:45 PM confirmed that the staff were to implement the care plan interventions to reduce the risk for falls for the residents. Further interview confirmed that effective care plan interventions needed to be identified and implemented to prevent recurrent falls and injuries.",2020-09-01
4128,REGIONAL WEST GARDEN COUNTY NURSING HOME,2.8e+181,1100 WEST 2ND,OSHKOSH,NE,69154,2019-04-23,689,D,1,0,21NW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D7 Based on observations, record reviews and interviews; the facility failed to ensure that care plan interventions were 1) followed to reduce the risk for falls and injuries for one current sampled resident (Resident 1) and 2) reviewed and updated after a fall with injury to reduce the risk for recurrent falls for one current sampled resident (Resident 2). The facility census was 28 with six current sampled residents. Findings are: [NAME] Observations of Resident 1 on 4/22/19 at 1:30 PM revealed NA (Nursing Assistant) - C and NA - [NAME] transferred the resident from the wheelchair to the bed with a full mechanical lift. Further observations revealed that the bed was raised to waist level for the transfer. Observations on 4/22/19 at 2:25 PM revealed the resident unattended and the bed remained positioned at waist level. Interview with NA - D on 4/22/19 at 2:30 PM confirmed that the resident's bed was not positioned at the lowest level. Interview with NA - C on 4/23/19 at 9:45 AM confirmed that the resident's bed was not placed in the lowest position after cares yesterday afternoon. Review of the Care Plan, dated 4/10/19, revealed that the resident was at risk for falls related to involuntary movements and immobility related to [DIAGNOSES REDACTED]. Further review revealed that the resident was non weight bearing and dependent on staff for all transfers, mobility and activities of daily living needs. Approaches included keep the bed in low position with brakes on when occupied and unattended. Interview with the DON (Director of Nursing) on 4/23/19 at 11:30 AM confirmed that the staff were to ensure that the bed was placed in the low position when occupied and unattended as directed to reduce the risk for falls and injuries. B. Review of Resident 2's Nurses Notes revealed that on 1/15/19 at 7:40 AM the resident was found on the floor near the recliner. The resident complained of left leg pain and sustained a red raised area on the forehead. Review of the Care Plan, target date 6/19/19, revealed a problem, dated 1/22/18, that the resident was at risk for falls related to gait unsteadiness, impaired cognition, impaired vision and chronic medical conditions. Further review revealed that the latest approach date was 9/24/18 which stated may use pressure sensitive alarm to bed and TABS (personal alarm) in chair to alert staff of need for assistance. Interview with the DON on 4/23/19 at 11:45 AM confirmed that care plan approaches needed to be evaluated and changed to prevent or reduce the risk for recurrent falls and injuries.",2020-09-01
2491,PIONEER MANOR NURSING HOME,285212,"P O BOX 310, 318 N 3RD STREET",HAY SPRINGS,NE,69347,2019-04-17,689,D,1,0,XZE911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D7 Based on record reviews and interview, the facility failed to ensure that care plan interventions were 1) changed after increased fall risks were identified for one current sampled resident (Resident 2) and 2) effective to prevent injuries for one current sampled resident (Resident 1) identified as at risk for falls. The facility census was 50 with three current sampled residents. Findings are: [NAME] Review of Resident 2's Care Plan, goal date 5/2/19, revealed the following including: - 1/15/19 fall in the assist dining room and interventions included remind resident not to sit on the walker, resident is not cognizant enough to ask for assistance with walking and will ambulate at will, staff can only direct the resident when seen walking, may need an order for [REDACTED].>- 2/11/19 Resident had a significant change in overall condition, recent declines with recent falls, increased back pain and increased confusion with behaviors; interventions included staff will be aware of decline and give more assistance with activities of daily living and ambulation; - 2/11/19 Resident was forgetful and will ambulate without walker and interventions included to get the resident's walker when the resident forgets it; - 2/12/19 Resident ambulated without walker and interventions included to remind the resident not to ambulate without assistance; - 2/12/19 Resident was a higher fall risk due to poor safety practices and interventions included to keep the walker within reach when the resident was in bed and remind the resident to use the walker at all times. Review of the Progress Notes revealed the following including: - 3/1/19 at 2:07 AM Resident was up in halls twice without the walker, resident was reminded to use the walker when ambulating; - 3/3/19 at 2:58 PM Resident had increased confusion, needed reminders to use the walker and frequently walked off without it; - 4/2/19 at 9:40 PM Resident ambulated with walker by self; - 4/4/19 at 8:10 PM Resident found laying on the floor behind the door in room, stated slipped and fell on left hip, noted that resident did not use walker, wore no shoes and had one sock on, complained of left hip pain, was sent to the hospital who later reported that the resident had a left [MEDICAL CONDITION]. Interview with the ADON (Assistant Director of Nursing) on 4/17/19 at 2:15 PM confirmed that the resident had increased risks for falls and care plan interventions were not changed to prevent falls with injuries. B. Review of Resident 1's Care Plan, goal date 5/2/19, revealed that the resident had confusion due to cognitive loss and Dementia, impaired vision, impaired hearing, required one assist with ambulation and toileting. Further review revealed that the resident was a higher fall risk due to impulsiveness and confusion and needed to be toileted every two hours and as needed. Review of the Progress Notes revealed that on 2/18/19 at 5:28 AM the nursing assistant placed the resident on the toilet and reached around the corner to throw away a wet pad into the trash. The resident fell off of the toilet, landed on right side and sustained a 50 cent sized laceration to the right side of the head and a skin tear on the right elbow. Review of the facility Abuse, Neglect or Misappropriation report, dated 2/18/19, revealed that the resident was transferred to the toilet and the nursing assistant went around the corner to get incontinence products, the resident fell off of the toilet and received two lacerations to the head and a skin tear on the arm. Interview with the ADON on 4/17/19 at 2:30 PM confirmed that care plan interventions should have included to not leave the resident unattended in the bathroom as the resident was a high risk for falls due to impulsive behaviors and confusion.",2020-09-01
3805,MITCHELL CARE CENTER,285287,1723 23RD STREET,MITCHELL,NE,69357,2019-06-25,689,D,1,0,SB8Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D7 Based on record reviews and interview, the facility failed to provide interventions, including supervision, to prevent an elopement from the facility for one current sampled resident (Resident 2). The facility census was 49 with three current sampled residents. Findings are: Review of the facility Investigation Report, dated 6/18/19, revealed that on 6/15/19 at 7:30 AM Resident 2 walked out the door to the facility and was seen walking down the street. The resident was brought back to the facility. Further review revealed that the staff found the resident's Wanderguard (device worn on the wrist or ankle that triggers the door alarms) cut off and in the dresser drawer. The resident had a history of [REDACTED]. Review of the care plan, goal date 7/7/19 and printed 6/25/19, revealed that the resident had behaviors including told other residents was being held against will, called the physician for discharge from the facility orders and had left the facility without anyone knowing. Further review revealed on 6/15/19 cut off the Wanderguard and eloped from the front door of the facility. Interview with the Director of Nursing and the Administrator on 6/25/19 at 11:15 AM confirmed that interventions, including supervision, were not in place to prevent the resident's elopement.",2020-09-01
3139,IMPERIAL MANOR NURSING HOME,285252,"P O BOX 757, 933 GRANT STREET",IMPERIAL,NE,69033,2018-06-04,689,D,1,0,G0OQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D7 Based on record reviews and interviews, the facility failed to ensure that interventions were in place to prevent an elopement from the facility for one current sampled resident (Resident 1) with a history of elopement and exit seeking behaviors. The facility census was 33 with three current sampled residents. Findings are: Review of the Face Sheet revealed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 6/28/18, revealed that the resident was at risk for wandering and elopement as evidenced by a history and attempts to leave the facility unattended. Review of the Department Notes revealed the following including: - 5/15/18 at 2:07 PM resident out of the south door less than five minutes, door alarm activated; - 5/17/18 resident went outside of the facility unattended at 10:30 AM and 1:30 PM; - 5/21/18 resident left the facility this morning without staff knowledge; - 5/24/18 at 1:32 PM resident was exit seeking twice this shift; - 5/26//18 resident self propelled in the wheelchair to the assisted living facility at 10:30 AM, the alarm sounded and the resident returned with staff. Review of the investigation report Elopement, dated 5/23/18, revealed that on 5/21/18 at 7:45 AM, the facility received a call reporting that the resident was downtown at the local coffee shop, approximately seven blocks away from the facility. The resident returned to the facility, accompanied by two staff members, at 7:50 AM. Staff interviews stated that they did not hear the door alarm sounding and the last time they saw the resident was around 6:45 AM. Camera footage showed that the resident went out the south door unattended, the alarm did not sound and no one was observed resetting the alarm. Further review revealed that the resident was out of the facility for approximately 42 minutes and returned with no adverse effects. Interview with the Director of Nursing on 6/4/18 at 3:45 PM confirmed that the resident was identified at risk for elopement, had ongoing exit seeking behaviors and had left the facility unattended on several occasions. Further interview confirmed that interventions were not in place to provide a safe environment for the resident and to prevent the elopement.",2020-09-01
3158,IMPERIAL MANOR NURSING HOME,285252,"P O BOX 757, 933 GRANT STREET",IMPERIAL,NE,69033,2018-12-18,689,E,1,0,VKQN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D7 Based on record reviews and interviews, the facility failed to implement interventions to prevent falls with injuries for three sampled residents (Residents 1,2 and 3). The facility census was 36 with three sampled residents with recent falls. Findings are: [NAME] Review of Resident 1's Care Plan, goal date 2/9/19, revealed the resident was at risk for falls related to weakness, impaired mobility and history of falls. Approaches included: ensure that the resident wore non skid socks or shoes with good grip, remind the resident as needed to call for assistance, does not call for assistance at times and educate as needed about safety measures. Further review revealed that on 12/2/18, the resident fell while ambulating with the walker from the bathroom. The resident stated that feet slipped. The resident was wearing regular socks. The resident was transported by ambulance to the hospital for evaluation of increased pain and left foot rotation. The resident had a [DIAGNOSES REDACTED]. B. Review of Resident 2's Care Plan, goal date 1/10/19, revealed that the resident was at risk for falls related to muscle weakness, difficulty walking, dizziness, age related debility, visual deficit, dementia and repeated falls. Approaches included: one assist with walker and gait belt (belt placed around the resident's waist for staff to hold to steady and guide the resident) for transfers and ambulation, non slip shoes with ambulation and transfers, educate as needed about safety awareness, offer to assist the resident to the bathroom upon wakening, before and after meals, bedtime and as requested and check resident when door is closed as the resident will ambulate in room without assistance. Review of the Departmental Notes revealed that on 12/10/18 at 6:15 AM the nursing assistant heard a loud noise from the resident's room and found the resident on the floor in front of the bedside table. The resident complained of neck and back pain and had an abrasion to the left mid back area and a skin tear to the left forearm. The resident was sent to the emergency room for evaluation and returned to the facility on [DATE]. C. Review of Resident 3's Care Plan, goal date 2/19/19, revealed that the resident was at risk for falls related to muscle weakness, difficulty walking and history of falls. Approaches included one assist with walker and gait belt, one assist with activities of daily living and check frequently as the resident forgets to use the call light. Review of the Departmental Notes revealed the following including: - 12/1/18 at 8:15 AM the resident was found on the floor in room with no injuries, slipper socks were applied; - 12/7/18 at 1:39 PM the resident was found on one knee on the floor in room, no injuries noted; - 12/12/18 at 3:19 PM the resident was found on the floor in room, skin tear to the right elbow; - 12/15/18 at 11:00 AM the resident returned from the hospital with orders to remove sutures to posterior head in seven days, noted skin tear to the right hand and elbow, no complaints of pain; - 12/17/18 at 10:19 AM the resident was found on the floor in room, no injuries noted; - 12/17/18 at 11:15 PM the resident found on the floor in room with a laceration to the back of head and skin tear to the left arm. Interview with the DON (Director of Nurses) on 12/18/18 at 3:00 PM revealed that the resident fell on [DATE] and had a laceration to head, was sent to the hospital for sutures and was kept overnight for observation. Interview with the DON on 12/18/18 at 4:30 PM confirmed that these residents were at risk for falls and care plan interventions were not effective to prevent falls with injuries.",2020-09-01
5318,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2017-01-10,323,D,1,0,9ZI411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D7b Based on observation, record review and interview; the facility failed to ensure fall interventions were followed to prevent falls for 1 of 3 residents (Resident 1) sampled. The facility census was 99. Review of Resident 1 ' s [DIAGNOSES REDACTED]. Review of the care plan dated as revised on 12/27/2017 revealed a new Intervention to check on Resident 1 every hour for needs. Observation on 1/9/2017 from 10:30 PM to 1/10/2017 12:20 AM revealed no staff entered Resident 1 ' s room. Interview on 1/10/2017 at 12:40 AM with Nursing Assistant (NA)-A revealed Resident 1 is checked every 2 hours during the night. Review of Resident 1 ' s Progress notes revealed that resident 1 experienced a fall with no injury on 1/4/2017. Interview on 1/10/2017 at 10:00 AM with the Director of Nursing revealed the staff should have checked on Resident 1 hourly.",2020-01-01
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
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
1839,HOLMES LAKE REHABILITATION & CARE CENTER,285164,6101 NORMAL BLVD,LINCOLN,NE,68506,2019-02-26,689,G,1,0,G7EJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D7b Based on record reviews and interviews; the facility failed to ensure an assessment was completed and interventions were implemented for the use of an electric recliner to prevent a fall with fracture for 1 resident (Resident 1) of 3 sampled residents. The facility census was 61. Findings are: Record review of Nurses note dated 2/3/19 at 01:55 AM revealed; Resident 1 was on the floor on the right side. Resident 1 reported they were trying to walk. The recliner was in the highest position the call light was attached to the residents clothing. A Hoyer lift was used to transfer to the recliner. 0300 AM Resident had large abrasion to the top of head and forehead. Resident complained of right knee pain, abrasion to the right eyebrow and forehead. A second fall on 2/3/19 at 3:45 AM, resident was on floor again, in similar position, to fall at 1:55 AM recliner was in the upright position. At 4:30 AM Resident 1 had increased pain to the right knee, and right knee bruising was present. Record review of a Fall Scene Investigation Report dated 2/3/19 revealed Resident 1's falls that occurred at 01:55 AM and 03:45 AM were documented on the same Fall Scene Investigation Report. There was one new intervention recorded for both falls: frequent safety checks. The root cause analysis of the both falls was: 1) the resident raised the recliner to the highest point 2 times and 2) poor safety awareness. Record review of Resident 1's X-ray report date 2/3/19 revealed; an acute right knee fracture. Record review revealed; the facility was requested to provide a resident recliner assessment form and was unable to provide a recliner assessment for Resident 1. Record review revealed; the facility was unable to provide documentation of Risk/Benefit for Resident 1's recliner use and family education. Record review of [NAME] Lake Rehabilitation and Care Center Investigation Report dated 2/7/19 revealed; Interventions of Neurological and safety checks, the care to skin tears, ice to the right knee, as needed pain medication, consult with provider regarding bed/recliner use upon return to the facility, conversation with DHHS (Department of Health and Human Services regarding request of family to place resident in recliner, education of family regarding benefits of utilizing bed verses chair, and education to family on hospice benefits. Record review of the facilities Guideline for Accidents Involving Falls/Skin Tears/Abrasions and Bruises dated, 2/4/15 revealed; 1) A follow up Assessment to be done every shift for the first 72 hours, Vitals as needed, Pain rate, Range of Motion, and Neurological checks will be done per guidelines. 2) Licensed Nurse will observe 1 transfer in the first 24 hours for potential changes from prior status. 3) After 72 hours is done a Daily Assessment on the shift that the fall occurred for another 4 days. Record review of Care Plan dated 3/28/17 for fall risk revealed; interventions of transfer with sit/stand was discontinued on 2/3/19. Interventions in place were 1) Blood Pressure and Pulse, 2) Fall Risk Assessment Quarterly, 3) anticipate needs 4) low bed with mat next to bed dated 2/4/19, 5) observe for adverse effects of medications, 6) medications as ordered, 7) educate family and resident on potential risk/benefits of medication use, 8) monitor for effectiveness of [MEDICAL CONDITION] medications, 10) Pharmacy review of medications, 11) notify Cheney Psychiatric of any changes in behavior, 12) transfer with a Hoyer Lift dated 2/3/19 and 13)Hinged knee brace Right lower Extremity dated 2/4/19. An interview on 2/26/19 at 09:55 AM with LPN (Licensed Practical Nurse) B revealed; the procedure to follow for the nurse post resident fall was to assess for injury, ask if the resident if they were hurt, assist the resident back to bed, record vital signs, initiate neurological checks, notify the physician and family, fill out the incident report, fall investigation report, physician communication or a telephone order if the resident needed to be sent out, correct the environment if it caused the fall, safety concerns (Gripper socks or shoes). Interview on 2/26/19 at 10:26 AM with the DON (Director of Nurses) confirmed; both of Resident 1's falls were recorded on the same Fall Scene Investigation report. The DON confirmed the interventions on the care plan should correlate with the root cause analysis. The DON confirmed there was not a recliner assessment. Interview on 2/26/19 at 11:49 AM with the Administrator confirmed the facility did not have documentation of interventions on the care plan. Administrator reported the facility did not have documentation of the education to the family in regard to the Risk/Benefits of recliner use after the fall. The Administrator reported the family was adamant about Resident 1 being placed in the recliner. The Administrator reported the nurse on duty had a conversation with the family about the recliner and safety.",2020-09-01
3539,NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER,285271,2100 CIRCLE DRIVE,SCOTTSBLUFF,NE,69361,2019-06-24,689,G,1,0,JJ5W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D7b(3) Based on record reviews and interview; the facility failed to identify and implement interventions to prevent recurrent falls and injuries for one current sampled resident (Resident 2). The facility census was 55 with three current sampled residents. Findings are: Review of Resident 2's Care Plan, goal date 9/17/19 and printed on 6/24/19, revealed that the resident was at risk for falls related to dementia and impaired mobility and safety awareness. The resident had a fall on 4/24/19, was found on the floor in the dining room, attempted to ambulate without assistance, sustained a hematoma (swelling) on the right side of the head and was sent to the emergency room for evaluation. The resident had a fall on 5/1/19 and had a skin tear to the right wrist. The resident transferred self on 6/10/19, was sent to the emergency room to evaluate pain and returned with a [DIAGNOSES REDACTED]. Further review revealed that new approaches were listed after each fall. Review of the Resident Progress Notes, revealed that on 6/10/19 at 11:10 PM, the resident was found on the floor in between the bedroom and the bathroom. The resident stated had hit head and complained of right wrist pain. The right wrist was noted to have a deformity. The resident was sent to the emergency room per ambulance for evaluation. Further review revealed that on 6/11/19 at 7:53 AM, the emergency room nurse reported that the resident had a complex [MEDICAL CONDITION] wrist. Review of the facility Verification of Investigation report, dated 6/10/19, revealed that the resident had Dementia and [MEDICAL CONDITION] with impaired cognition (thinking skills, memory, awareness and reasoning). The resident was found on the floor in room on 6/10/19 at 11:11 PM. The resident had transferred self and attempted to ambulate without staff assistance. Further review revealed that the resident often attempted to self transfer and ambulate without staff assistance. Interviews with the Director of Nurses and RN (Registered Nurse) - B on 6/24/19 at 11:30 AM confirmed that the resident had a history of [REDACTED]. Further interviews confirmed that effective interventions were not identified or in place to prevent recurrent falls with injuries.",2020-09-01
3798,MITCHELL CARE CENTER,285287,1723 23RD STREET,MITCHELL,NE,69357,2019-03-19,689,D,1,0,7I3011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D7b(3) Based on record reviews and interviews, the facility failed to review and update care plan interventions to reduce the risk for recurrent falls and injuries for one current sampled resident (Resident 1) upon return from the hospital for surgical repair of a [MEDICAL CONDITION]. The facility census was 45 with four current sampled residents. Findings are: Review of Resident 1's Progress Notes revealed that on 3/10/19 the resident was observed on the floor, was transferred to the hospital who reported that the resident had a [MEDICAL CONDITION] and was scheduled for surgical repair. Further review revealed that the resident was readmitted to the facility on [DATE]. Review of the Care Plan, goal date 4/2/19, revealed no changes in interventions to reduce the risk for further falls and injuries. Interview with the Administrator on 3/19/19 at 11:45 AM confirmed that the resident was at risk for further falls and injuries. Further interview confirmed that on readmission the care plan interventions should have been updated with interventions to reduce the risk for recurrent falls and injuries.",2020-09-01
5746,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2016-09-20,325,G,1,0,TD4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D8b Based on observations, interviews and record reviews, the facility failed to ensure that one sampled resident (Resident 120) did not experience unplanned, significant weight loss. The facility census was 114. Findings are: Review of the Admission Record for Resident 120 revealed that the resident had an admission date of [DATE] to the facility. Further review revealed [DIAGNOSES REDACTED]. Review of the Nutrition Data collected on 10/20/15 for Resident 120 revealed an admission weight to the facility of 272 pounds and a current weight of 261 pounds. Weight status identified as weight loss. Further review revealed that the resident was overweight and did have swallowing issues. Review of the MDS (Minimal Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) for Resident 120 revealed weights on: - 9/6/16 of 229, - 8/7/16 of 236, - 6/8/16 of 238, - and 3/10/16 of 245. Review of the Care Plan dated 7/22/16 for Resident 120 revealed that the resident had a physical functioning deficit related to self care impairment. Further review of the Care Plan revealed that Resident 120 was Obese with a BMI(Body Mass Index) of greater than 30. The goal was that the resident's weight would not exceed 242 pounds. Review of a fax sent to the physician on 8/2/16 by the Registered Dietician revealed that, Speech therapy has seen the resident in the past and when the diet is changed the resident doesn't want to follow it. Resident 120 is a significant weight loss of 13 pounds in one month. Further review revealed that the resident voiced chewing and swallowing difficulties. Review of a 60 day Recertification visit with the physician on Resident 120 revealed no oral exam or documentation of any exam completed in regards to chewing and swallowing difficulty. The history of present illness revealed that the resident had requested a pureed diet a few months ago due to difficulty with chewing, swallowing and felt like there was something in the throat. Interview on 9/7/16 at 10:00 AM with the Director of Nursing revealed that the facility did not have any residents on planned weight loss. Interview on 9/7/16 at 11:AM revealed that Resident 20 had missing and broken teeth and stated, I would like teeth to chew my foods. Interview with the Resident on 9/19/16 at 9:30 AM revealed that the resident did have a few teeth on the bottom left side of the mouth. The resident stated would like to see the dentist for some teeth so that would be able to chew some foods, and eat better. Continued interview revealed that the resident stated, The foods taste better when I am able to chew them. Interview with the Registered Dietician on 9/20/16 at 9:00 AM revealed that the RD had been following the resident. Further interview revealed that the RD was aware of Resident 120's chewing and swallowing difficulty. The RD did reveal that the initial weight loss on the resident was thought to be a mental issue or not liking a tablemate. Further interview revealed that the resident was moved to another table. Continued interview verified that the resident continued to lose weight after the table move. Further interview revealed that the RD (gender) did not complete of do any dental assessments and only worked with the diet if the person had a chewing or swallowing issue with significant weight loss. Interview on 9/20/16 at 10:20 AM with LPN (Licensed Practical Nurse) - B, the Nurse Manager for Resident 120 verified that the the resident was an unplanned weight loss. Continued interview verified that the resident had a significant weight loss recently. Further interview revealed that LPN- B was aware that the resident did have chewing and swallowing difficulties and had complained of the difficulties since 10/20/15. Continued interview verified that the LPN- B felt that the significant weight loss of this resident could have been due to the lack of teeth to chew foods well and to be able to swallow the chewed foods better. Interview on 9/20/16 at 4:15 PM with the Administrator and the Director of Nursing confirmed that Resident 120 was a significant weight loss that was unplanned. Continued interview verified that the resident did have dental issues with chewing and swallowing and that this resident should have had a dental appointment set up to address the missing, broken teeth, chewing and swallowing difficulties. Further interview confirmed that a dental appointment should have been made when the resident first complained of chewing/swallowing problems and the unplanned weight loss could have been avoided.",2019-09-01
5747,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2016-09-20,327,D,1,0,TD4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D9 Based on observations, interviews and record review; the facility failed to ensure that one sampled resident (Resident 86) on a fluid restriction consumed the minimal amount of fluids required or allowed for the resident every shift. Facility census was 114. Findings are: Review of the Admission Record for Resident 86 revealed an admission date of [DATE] to the facility. Further review revealed a [DIAGNOSES REDACTED]. Review of the Care Plan dated as printed 9/8/16 for Resident 86 revealed an Alteration in kidney function due to end stage [MEDICAL CONDITION] as evidenced by [MEDICAL TREATMENT] .fluid restriction of 32 ounces in 24 hours, and resident non compliant with fluid restriction .diet and fluid restrictions as order by MD, and continue to encourage fluid restrictions. Review of a Physician order dated 9/14/16, written by the Dietary Manager for a Fluid restriction of 32 oz's (ounces)/960 ml (milliliters) in 24 hours for Resident 86. A breakdown of the restriction were as follows: dietary provided 120 ml for breakfast, 120 ml with lunch, and 120 ml with dinner. Nursing provided 600 ml per 24 hours when the 1st shift giving 240 ml of Nepro, 30 ml of Prostat and 10 ml of water twice and 2nd shift giving 240 ml of Nepro, 30 ml of Prostate and 10 ml of water. Review of the facility policy, Fluid Restrictions dated as last reviewed 3/29/16 revealed, Fluids are substances that are liquid at room temperature. These include water, ice . Review of the Medication Administration Record dated 8/1/16 through 8/31/16 for Resident 86 revealed an order dated 8/8/16 for a Fluid restriction of 32 ounces/960 ml in 24 hours with 240 ml for breakfast, 120 ml with lunch and 120 ml with dinner every shift. Further review revealed orders for Magic Cup (like an icecream consistency) every day, Nepro with Carb Steady (a liquid) everyday, [MEDICATION NAME] Renal Liquid 1 can in the evening. Further review revealed no written documentation on amount given in ml/cc and no written documentation of the amount taken in by the resident. Review of the Medication Administration Record dated 9/1/16 through 9/30/16 for Resident 86 revealed the same order as above for the fluid restriction with an order for [REDACTED]. Continued review revealed the Prostat was checked as administered but there was no written documentation to support what the resident drank. Review of the Progress Notes for Resident 86 revealed entries on 9/1, 9/2, 9/4, 9/5, 9/6, 9/7, 9/9, and 9/10/2016 of resident not being compliant with fluid restriction. Observation on 9/12/16 at 4:00 PM, as Resident 86 had returned from [MEDICAL TREATMENT], revealed that the resident was in a wheelchair and was eating from a Styrofoam cup containing ice chips. Observation of 9/19/16 revealed Resident 86 seated in the wheelchair eating ice chips from a Styrofoam cup. Interview on 9/20/16 at 9:10 AM with the Registered Dietician verified that there were no concerns with Resident 86's fluid restrictions. Further interview verified that the exact amounts of liquids that the nursing staff delivered were prefigured to be included in the fluid restriction for breakfast, lunch and dinner. Continued interview confirmed that the liquid supplements were checked on the Medication Administration Record when administered. Further interview verified that there was no written documentation to support that the resident drank all of the liquids given. Interview on 9/14/16 at 7:30 AM with (Licensed Practical Nurse-Nurse Manager) LPN-NM - EE revealed that Resident 86 was on a fluid restriction. Further interview verified that the amounts of liquids administered to the residents were prefigured and there was no written documentation to support that the resident drank all of the prefigured amounts. Continued interview confirmed that the resident may not have taken the full amounts of the liquids administered by the nursing staff per the Medication Administration Record. Further interview confirmed that the resident was non-compliant and also ate ice chips. Continued interview verified that there was a way to measure the ice chips by melting a similar glass of ice chips down to a liquid. Further interview verified that there was no written documentation of the amount of ice chips that the resident had taken in a shift. Interview on 9/9/16 with the with the Administrator and the Director of Nursing at 4:00 PM confirmed that Resident 86 was on [MEDICAL TREATMENT] and was on a fluid restriction. Further interview verified that the resident did receive the fluids by an Licensed Practical Nurse or Medication Aide and the amount given was documented. Continued interview verified that the amount taken by the resident was not documented on the Medication Administration Record. Further interview verified that it was not possible to have an accurate account of fluid intake without figuring the amount of fluids wasted or taken by Resident 86.",2019-09-01
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
6394,SKYVIEW CARE AND REHAB AT BRIDGEPORT,285224,505 O STREET,BRIDGEPORT,NE,69336,2016-03-31,280,D,1,0,ZNCE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09c1c Based on interviews and record reviews, the facility failed to ensure that fall interventions were revised for one resident (Resident 3) to prevent further reoccurrences. Facility census was 27. Findings are: Review of the closed record for Resident 3 revealed an Admission Record with an admission date of [DATE] to the facility. Review of admission orders [REDACTED]. Review of the Physical Therapy Notes dated 1/11/16 revealed that the resident was a sit to stand lift from the recliner to the wheelchair. Interview with the Physical Therapist on 3/31/16 at 10:30 AM revealed that Resident 3 had been on the sit to stand for a while. Review of an Unusual Occurrence Report for Resident 3 dated 1/1/16 at 1:30 PM revealed a fall in the resident's room with injuries to the left side of the head, arm, elbow and forearm. Further review revealed that the physician was notified and sent the resident to the emergency room for an evaluation and for sutures to the head. Review of the Care Plan dated 1/1/16 revealed that Resident 3 had a problem identified as: Falls, history of and at risk for falls or injury due to weakness, poor balance and poor safety awareness. Interventions included 2 person contact guard with gait belt for all transfers, assistance with all average daily living skills; remind and encourage to not get up unassisted; observe frequently while in room .status [REDACTED]. The last written documentation on the care plan for a fall was 1/1/16. Further review revealed that the care plan had not been revised after the fall for the sit to stand lift and also had not been revised after the fall on 1/1/16 for interventions to prevent further reoccurrences. Interview on 3/31/16 at 11:00 AM with the DON (Director of Nursing) verified that Resident 3 did have falls on 12/8/15 and 1/1/16 and the resident's care plan should have had been revised with interventions to prevent further falls of the same nature. Continued interview revealed that, on 12/15/15, the resident returned to the facility and the sit to stand lift had not been added to the residents interventions. On 1/1/16, there were no additional interventions added to prevent further reoccurrences. Further interview verified that care plan interventions were to be revised after falls by the nursing staff. Interview on 3/31/16 at 1:00 PM with the Administrator and the DON verified that the Care Plan for Resident 3 should have been revised following the falls on 12/8/15 and 1/1/16 to prevent further reoccurrences of falls in the same nature.",2019-03-01
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
2069,GOOD SAMARITAN SOCIETY - ATKINSON,285177,409 NEELY STREET,ATKINSON,NE,68713,2017-09-06,222,D,1,1,DZZ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.10A2 Based on interview and record review, the facility failed to ensure Resident 39 was free from the use of a chemical restraint related to use of an as needed antianxiety medication. The sample size was 29 and the facility census was 40. Findings are: [NAME] Review of the facility policy titled Restraints (revised 11/16) revealed the purpose was to ensure the appropriate use of restraints. The policy further indicated residents were to be free of chemical or physical restraints imposed for the purposes of discipline or staff convenience and not required to treat the resident's medical symptoms. Review of Resident 39's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/30/17 indicated the resident had [DIAGNOSES REDACTED]. -cognitively intact with no signs of [MEDICAL CONDITION]; -was delusional with episodes of rejection of cares and wandering; and -wandering did not place the resident at significant risk of getting into a potentially dangerous place. Review of Resident 39's current Care Plan with revision dated 4/11/17 revealed the resident had impaired cognitive function and thought process related to [MEDICAL CONDITION] disease and dementia. The resident's Brief Interview for Mental Status (BIMS- assessment used to identify cognitive impairment) score was 15 which indicated the resident was cognitively intact. The resident was identified as having a potential for elopement. Interventions included the following: -Check resident every 4 hours due to safety concerns. -Wander-guard (a bracelet worn by the resident which sounds an alarm if the resident comes within a certain distance of an exit) to assist staff with monitoring the resident's movement. -Staff to attempt non-pharmacological interventions when behaviors noted. Review of Resident 39's Nursing Progress Notes dated 6/21/17 revealed the following: -4:30 PM, Resident 39 was walking in the 100 corridor. Medication Aide (MA)-Q approached the resident and inquired as to what the resident was doing. Resident 39 indicated a desire to leave the facility with spouse. The resident further indicated a knowledge of all of the codes to the exit doors and then verbalized the codes to MA-Q. Registered Nurse (RN)-E attempted to intervene and Resident 39 pointed to the wander-guard bracelet stating this bracelet won't stop me from getting out the door. RN-E checked the resident's wander-guard and then replaced the wander-guard to assure functioning. RN-E notified Resident 39's practitioner and obtained a verbal order for [MEDICATION NAME] (medication used to treat anxiety and agitation) 2 milligrams (mg's) intramuscularly (IM-technique used to inject medication deep into the muscle which allows the medication to be absorbed more quickly in the bloodstream) and to repeat in 2 hours if medication was not effective. -5:00 PM, RN-E gave Resident 39 an injection of [MEDICATION NAME] 2 mg's without incident. -5:30 PM, Resident 39 was observed to be unsteady with ambulation. The note further indicated at risk for falls at this time . and .to be checked on often, every 30 minutes. -9:37 PM, Resident remained at risk for falls and staff to check on the resident every 30 minutes throughout the night. Review of a Nursing Progress Note dated 6/22/17 at 7:09 AM, revealed Resident 39 refused to take morning medications as they tried knocking me out with a shot yesterday. Review of a Nursing Progress Note dated 7/18/17 at 4:48 PM, revealed RN-E was made aware on 6/27/17 that Resident 39's practitioner had refused to sign the order for the [MEDICATION NAME] 2 mg IM. The note further indicated the practitioner had .wrote on the verbal order print out, I will not sign. for unknown reasons. During an interview on 9/5/17 at 2:45 PM, the Social Service Director (SSD) confirmed the following: -Resident 39 has a history of exit seeking and of elopement; -on 6/21/17 the resident talked about leaving but did not make any actual attempt to exit the building; -the facility had placed a written notation which contained the code for each exit above all the facility doors. Resident 39 was aware of the location of these notations and on 6/21/17, pointed out their locations to MA-Q; -after the resident identified the location of each of the written codes, the SSD removed from all of the exits; and -Resident 39 had returned to the resident's room after the codes were removed and was quietly sitting with the resident's spouse. Resident 39 was not exhibiting any anxious or agitated behaviors. During an interview on 9/5/17 at 3:00 PM, RN-E verified the following: -on 6/21/17, Resident 39 had told MA-Q the resident was going to leave the facility; -Resident 39 had a history of [REDACTED]. RN-E contacted the resident's practitioner and obtained an as needed order for the [MEDICATION NAME] to resolve the problem before it got any worse; -Resident 39 was seated in the resident's room with the resident's spouse. The resident was not anxious or agitated, was no longer talking about leaving the facility or attempting to elope when RN-E administered the [MEDICATION NAME] 2 mg IM; -non-pharmacological interventions were not attempted prior to giving Resident 39 the IM [MEDICATION NAME]; and -after Resident 39 was given the IM [MEDICATION NAME], the resident became unsteady and was at an increased risk for falls. Nursing staff checked on the resident every 30 minutes throughout the remainder of the shift to assure the resident's safety. During an interview on 9/5/17 at 4:30 PM, the Director of Nursing (DON) confirmed RN-E should have reviewed the resident's current Care Plan and attempted non-pharmacological interventions before administering the IM [MEDICATION NAME]. The DON indicated the resident's practitioner had refused to sign the [MEDICATION NAME] order as the practitioner did not feel an accurate assessment had been provided regarding the resident's behaviors when the verbal order was obtained.",2020-09-01
6388,"NORTH PLATTE CARE CENTER, LLC",285165,2900 WEST E STREET,NORTH PLATTE,NE,69101,2016-03-02,425,E,1,0,BM4911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.10A2 Based on observations, record review and interview; the facility failed to ensure that the prescription labels were compared to the physician orders [REDACTED]. The facility census was 47. Findings are: A. Observations on 3/1/16 at 7:15 PM revealed RN (Registered Nurse) - A checked the Routine Medications form and removed an insulin vial from the medication cart for Resident 1. Further observation revealed RN- A drew up the Novolog insulin, placed it back in the medication cart, administered the insulin, returned to the medication cart and documented that the Novolog was administered. B. Observation on 3/11/16 revealed RN A checked the Routine Medications form, pulled out the medication card, poured the medication, placed it back into the cart, administered the medication and then returned to the cart and documented the administration without further verification for the following: - At 7:45 PM, for the administration of Prilosec and Duoneb to Resident 3; - At 7:50 PM, for Prilosec to Resident 4; and - At 8:00 PM, for Wellbutrin, Percocet, Protonix, Lantus and Novolog insulin, and Lumigan eye drops. Review of the facility procedure Medication Administration, dated 1/13, revealed the following including: 1. Verify physician's orders [REDACTED]. 10. Read the Medication Administration Record [REDACTED]. Verify/clarify orders as needed prior to administration. 11. Verify the pharmacy prescription label on the drug and the manufacturer's identification system matches the MAR . 12. Verify that any further medication identifiers match the label and the medication.13. Verify the following, again, by comparing the medication to MAR prior to administering . Interview on 3/2/16 at 3:30 PM with the DON (Director of Nursing) confirmed that the nurses were to follow the nursing standards of practice and the facility medication administration procedure which included comparing the prescription labels with the physician orders [REDACTED].",2019-03-01
3538,NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER,285271,2100 CIRCLE DRIVE,SCOTTSBLUFF,NE,69361,2018-03-20,658,D,1,0,6E5M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.10A2 Based on record reviews and interviews, the facility failed to ensure that medications were administered according to practitioner's orders for one closed record sampled resident (Resident 1). The facility census was 56 with six current sampled residents and one sampled closed record. Findings are: Review of the facility Verification of Investigation, dated 2/20/18, revealed that a hospital employee notified the DON (Director of Nursing) on 2/16/18 that Resident 1 had five [MEDICATION NAME] (opiod [MEDICATION NAME]) patches on when examined in the emergency room . Further review revealed that LPN (Licensed Practical Nurse) - A failed to remove previous [MEDICATION NAME]es when new patches were applied. Review of the facility Policy Statement, dated (MONTH) 2012, revealed Medications shall be administered in a safe and timely manner, and as prescribed. Review of the resident's Physician Order Report, singed 2/12/18, revealed orders dated 2/9/18, for [MEDICATION NAME] 12 micrograms per hour, administer two patches and change patches every 72 hours. Interview with the DON on 3/20/18 at 10:30 AM confirmed that LPN - A did not follow safe medication administration practices and failed to remove the previous pain patches before the application of the new patches.",2020-09-01
1871,"NORTH PLATTE CARE CENTER, LLC",285165,2900 WEST E STREET,NORTH PLATTE,NE,69101,2018-09-11,658,D,1,0,KAOR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.10A2 Based on record reviews and interviews, the facility failed to follow the practitioner's orders for a sampled resident (Residents 100). This had the potential to affect 1 of 6 sampled residents. The facility census was 59 residents. Findings are: Review of Resident 100's physician orders [REDACTED]. -apply ice to wound as instructed; 15 minutes every 2 hours, -to elevate the left leg extremity. Review of Resident 100's TAR (treatment administrative record), dated (MONTH) (YEAR), found a different order: -an entry apply ice to L LE (left lower extremity) for 15 minutes every 2 hours as needed for pain, [MEDICAL CONDITION]. Review of Resident 100's TAR found no documentation the treatment had been carried out. Review of Resident 100's TAR found a different order: -an entry of elevate the L leg as needed for [MEDICAL CONDITION]. Review of Resident 100's (MONTH) TAR found no documentation that either order had been carried out. Interview with the Director of Nurses on 9/11/2018 at 2:10 PM confirmed an error occurred during taking off the orders and the orders had not been carried out as ordered by the practitioner's orders.",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
4080,"QUALITY LIVING, INC",28A060,6404 NORTH 70TH PLAZA,OMAHA,NE,68104,2017-05-16,332,D,1,1,LMUC11,"**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 calculated medication error rate was 11.5 %. This affected 3 residents (Residents 72, 37, and 97). The facility staff identified the resident census as 109. The findings are: [NAME] A review of Resident 72's Face Sheet dated 4/15/17 revealed Resident 72 was admitted on [DATE] with a [DIAGNOSES REDACTED]. An observation conducted on 5/15/17 at 8:43 AM of Registered Nurse (RN) A administering medications to Resident 72 revealed RN A poured and gave Resident 72 a [MEDICATION NAME] (a [MEDICAL CONDITION] hormone replacement medication) 112 micrograms (mcg) and a [MEDICATION NAME] 50 micrograms. A review of Resident 72's physician's orders [REDACTED]. An interview conducted on 5/15/17 at 10:32 AM with RN D confirmed that the most current order for [MEDICATION NAME] was 112mcg. An interview conducted on 5/16/17 at 1:43 PM with the Director of Nursing (DON) confirmed that Resident 72's current [MEDICATION NAME] order was for 112mcg. B. A review of Resident 37's Face Sheet dated 5/15/17 revealed Resident 37 was admitted on [DATE] with [DIAGNOSES REDACTED]. An observation conducted on 5/15/17 at 11:37 AM of RN B administering medications to Resident 37 revealed Resident 37 request 4 [MEDICATION NAME] for pain. RN B went to medication room and poured and administered 4 [MEDICATION NAME] 200mg tablets to Resident 37. A review of Resident 37's medical record revealed hospital discharge orders dated 3/7/17 that did not contain an order for [REDACTED]. from the hospital on [DATE]. A review of Resident 37's Medication Administration Record [REDACTED]. An interview conducted on 5/16/17 at 1:43 PM with the DON revealed that the facility would follow the medication orders that were received on the hospital discharge orders, and they would call the physician to get orders for medications that the resident usually took that were not on the hospital discharge orders. C. A review of Resident 79's Face Sheet dated 4/24/17 revealed Resident 79 was admitted on [DATE] with a [DIAGNOSES REDACTED]. An observation conducted on 5/16/17 at 7:42 AM of Licensed Practical Nurse (LPN) C administering medications to Resident 79 revealed LPN C poured [MEDICATION NAME] liquid (an antifungal mouthwash) into a medication cup and took it to Resident 79. LPN C then assisted Resident 79 to the bathroom and instructed Resident 79 to take the [MEDICATION NAME] liquid and swish it around in their mouth and then spit it out into the sink. Resident 79 did as instructed by LPN C. A review of Resident 79's medical record revealed an order dated 5/15/17 that read [MEDICATION NAME] Swish and Swallow 5 milliliters 4 times a day for 5 days. An interview conducted on 5/16/17 at 12:53 PM with LPN C confirmed that LPN C had Resident 79 swish the [MEDICATION NAME] and then spit it out. An interview conducted on 5/16/17 at 1:43 PM with the DON confirmed that the [MEDICATION NAME] order read to swish and swallow and that instructed Resident 79 to spit out the [MEDICATION NAME] was not following the physician order.",2020-09-01
1420,WAYNE COUNTRYVIEW CARE AND REHABILITATION,285135,811 EAST 14TH STREET,WAYNE,NE,68787,2019-09-16,759,D,1,1,P2S511,"**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 5 percent or less, which affected Resident 15. The medication error rate was 7.69 percent. The sample size was 3 and the facility census was 41. Findings are: Review of the dailymed.gov website revealed extended release [MEDICATION NAME] (a pain relief medication) needed to be swallowed whole; do not crush, chew, spit, or dissolve the tablets. Review of Resident 15's Medication Administration Record [REDACTED]. Observation of medication administration with Licensed Practical Nurse (LPN)-H on 9/16/19 from 7:30 AM to 8:00 AM revealed the following: - LPN-H prepared Resident 15's [MEDICATION NAME] for administration. LPN-H crushed Resident 15's [MEDICATION NAME] (two 650 milligram extended release tablets) and placed them in pudding with the resident's other medications for administration. - LPN-H administered Artificial Tears 1 drop in both of Resident 15's eyes. During an interview with the Director of Nursing (DON) on 9/16/19 at 10:53 AM, the DON confirmed the [MEDICATION NAME] that was prepared for administration was extended release and should not be crushed.",2020-09-01
3014,OMAHA NURSING AND REHABILITATION CENTER,285240,4835 SOUTH 49TH STREET,OMAHA,NE,68117,2017-10-26,332,D,1,0,NEYV11,"**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% with an observed medication error rate of 6.89%. The facility staff identified the census at 59. The findings are [NAME] A review of Resident 7's Admission Record dated 10-26-17 revealed that Resident 7 was admittted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An observation conducted on 10-26-17 at 7:50 AM revealed Registered Nurse (RN) A placed Resident 7's medications in a medication cup, one of those medications was 2 tablets of [MEDICATION NAME] 0.2 milligrams (a medication for hypertension). RN A then walked over to Resident 7 and put the cup of medications on the table in front of the resident and walked away. Resident 7 took the med cup to their mouth to pour the medications in and an orange tablet fell out of the cup and landed on the floor under Resident 7's table. An observation conducted on 10-26-17 at 8:00 AM of Resident 7's medication cards revealed that Resident 7 only took one orange pill which was [MEDICATION NAME] 0.2 milligrams. An interview conducted on 10-26-17 at 8:17 AM with the Administrator confirmed there was an orange pill laying on the floor where Resident 7 had been sitting. An interview conducted on 10-26-17 at 9:25 AM with the Director of Nursing revealed that the nurse was supposed to watch the residents take their medications. A review of Resident 7's Transition Orders dated 7-8-17 revealed an order for [REDACTED].>B. A review of Resident 6's Admission Record dated 10-26-17 revealed Resident 6 was readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An observation conducted on 10-26-17 at 8:22 AM revealed Licensed Practical Nurse (LPN) B placed a Multivitamin with minerals and a Multivitamin a medication cup administered both medications to Resident 6. A review of Resident 6's After Visit Summary dated 10-9-17 revealed Resident 6 had an order for [REDACTED].",2020-09-01
2971,RIDGECREST REHABILITATION CENTER,285239,3110 SCOTT CIRCLE,OMAHA,NE,68112,2017-10-11,332,D,1,1,09Y611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.10D Based on observations and interviews, the facility failed to ensure an medication error rate of less than 5% with an observed medication error rate of 7.7% related to the administration of medications to Resident 72. The facility census was 65. Findings are: Record review of the facility policy Crushing Medications, dated (MONTH) 2011, revealed that Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders. 1. The Medical Director and Director of Nursing services, in conjunction with the Consultant Pharmacist, shall identify appropriate indications and procedures for crushing medications. 2. The nursing staff and/or the Consulting Pharmacist shall notify any Attending Physician who gives an order to crush a drug that the manufacturer states should not be crushed (for example, long acting or [MEDICATION NAME] coated medications). The Attending Physician or Consulting Pharmacist must identify an alternative or the Attending Physician must document why crushing the medication will not adversely affect the resident. Observation, on 10/11/17 at 8:36 AM, of Medication Aide (MA) C administering medications to Resident 72. MA C was observed to place all the medications into a plastic bag and crush them, followed by placing them into pudding and on a spoon administered them to Resident 72. Observation included two medications that were extended release (ER) medication. (Extended release means the pill is formulated so that the drug is released slowly over time. This has the advantage of taking pills less often. Also means that there may be fewer side effects as the levels of the of drug in the body are more consistent in extended release formulations). a. Isosorb Mono 30 mg ER , is a medication used to prevent chest pain. b. [MEDICATION NAME] ER 25 mg, [MEDICATION NAME] is used to treat [MEDICAL CONDITION] (chest pain) and hypertension (high blood pressure). It is also used to treat or prevent [MEDICAL CONDITION]. Interview on 10/11/17 at 8:45 AM, with the Facility Nursing Consultant confirmed that the Isosorb Mono and the [MEDICATION NAME] should not have been crushed for administration. Confirmed with MA C and the Facility Nursing Consultant that the [MEDICATION NAME] label read DO NOT CRUSH, and confirmed that the electronic medical record (EMAR) also read Do Not Crush with the order. Confirmed with the Nursing Consultant that the Isosorb Mono ER did not have the DO NOT CRUSH on the label or in the EMAR. The Facility Nursing Consultant confirmed that the label should have had that information present. Interview with the Facility Pharmacist on 10/11/17 at 11:30 confirmed that medications that are extended release should not be crushed. The Facility Pharmacist confirmed that the ER medications should have Do Not Crush on the label.",2020-09-01
4853,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2018-03-06,759,E,1,1,9WK311,"**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 for three sampled residents (Residents 175, 10 and 5) which resulted in three medication errors with 25 opportunities for errors. The medication error rate was calculated at 12%. The facility census was 27 and five residents were sampled for medication administration observations. Findings are: [NAME] Observations on 3/27/18 at 10:40 AM revealed LPN (Licensed Practical Nurse) - C prepared to administer an insulin injection for Resident 175. LPN - C administered [MEDICATION NAME] R (insulin) 2 units at 10:45 AM. Further observations revealed that the resident didn't eat lunch until 12:15 PM. Review of the Medication Administration Record, [REDACTED]. Interview with the Director of Nursing and the Nurse Consultant on 3/5/18 at 8:50 AM confirmed that the [MEDICATION NAME] R was not administered at the correct time which is 15 minutes before or 15 minutes after a meal. Reference: Nursing Drug Handbook, Lippencott 31st Edition; [MEDICATION NAME] R inject within 15 minutes before or after a meal. B. Observations on 3/1/18 at 6:45 AM revealed LPN - D prepared to administer [MEDICATION NAME] for Resident 10. LPN - D removed the insulin pen from the medication cart and prepared 15 units as directed on the prescription label. When prompted, LPN - D checked the order on the electronic Medication Administration Record [REDACTED]. LPN - D confirmed that the resident was to receive 18 units in the morning. C. Observations on 3/1/18 at 8:00 AM revealed LPN - D prepared to administer morning medications for Resident 5 which included Invocana, [MEDICATION NAME] and Multivitamin with Minerals. LPN - D dropped the dose of [MEDICATION NAME] on the floor and didn't notice it and was prepared to administer four medications to the resident. The dropped medication was given to LPN - D, who threw it away and was again prepared to administer four medications to the resident until prompted that there should be five medications for the resident. LPN - D checked the medications and confirmed that the resident's dose of [MEDICATION NAME] was missing from the medication cup. LPN - D poured another dose of [MEDICATION NAME] for the resident. Interview with the Director of Nursing and the Nurse Consultant on 3/5/18 at 8:50 AM confirmed that the nurses were to administer medications as ordered which was not done until prompted to check the current orders for Resident 10 and recheck the number of medications poured for Resident 5.",2020-03-01
1354,HILLCREST HEALTH & REHAB,285133,1702 HILLCREST DRIVE,BELLEVUE,NE,68005,2017-08-02,332,D,1,1,YKIR11,"**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 a medication error rate of less than 5%. Observation of 25 medications administered revealed 4 errors resulting in a medication error rate of 16%. The errors affected 2 residents (Residents 550 and 93 ) of a facility identified census of 110. [NAME] An observation conducted on 7-27-17 at 7:45 AM of Medication Assistant (MA) H's administration of medications to Resident 93 revealed MA H took 1 tablet from a card of [MEDICATION NAME] (a blood pressure medication) 50 milligrams (mg) and 1 tablet from a card of Potassium (a supplement) 20 milliequivalents and place them in a medication cup. MA H then pulled a tube of Ammonia [MEDICATION NAME] 12% Cream (a lotion used to treat dry, scaly skin), an inhaler, and a nasal spray out of the medication cart and delivered them to Resident 93's room. In Resident 93's room, MA H first gave Resident 93 the medication cup and watched the resident swallow the medications. MA H then administered Resident 93's nasal spray and inhaler. MA H then applied the Ammonia [MEDICATION NAME] 12% cream to the front and sides of Resident 93's left leg. MA H lifted the residen'ts pants up on the right leg but did not apply any cream to it. MA H then took the resident's pulse. A review of Resident 93's medical record revealed: - An order dated 7-26-17 to hold the Potassium for 3 days and - A consultation note dated 7-19-17 that addressed a wound to Resident 93's right ankle with wound care instructions that included Lachydrin (ammonia [MEDICATION NAME]) lotion once daily to surrounding dry skin. A review of Resident 93's MAR for (MONTH) (YEAR) revealed a note on the [MEDICATION NAME] to check the pulse before administering the medication. An interview conducted on 7-27-17 at 1:19 PM with the DON (Director of Nursing) confirmed the Potassium was on hold and should not have been given and the Ammonia [MEDICATION NAME] cream was ordered to be applied to the dry skin surrounding the resident's right ankle wound. An interview conducted on 7-27-17 at 3:27 PM with the DON revealed that they talked to MA H and confirmed that MA H had given Potassium to Resident 93 and that MA H should have checked the resident's pulse prior to giving the [MEDICATION NAME]. B. An observation conducted on 7-25-17 at 11:37 AM of Registered Nurse (RN) G's administration of medications to Resident 550 revealed RN G took 2 tablets from a card of Ropinirole (a medication used to treat tremors in [MEDICAL CONDITION]) 2 mg and placed them in a medication cup. RN G then delivered the medication to Resident 550 and watched the resident take the medication. There was not a meal tray present in the room at the time of the medication administration. A review of Resident 550's medical record revealed hospital discharge instructions date 7-17-17 with an order for [REDACTED].>A review of Resident 550's Medication Administration Record [REDACTED]. An interview conducted on 7-27-17 at 1:19 PM with the Director of Nursing (DON) revealed Resident 550 ordered their lunch on 7-25-17 at 12:10 PM.",2020-09-01
2809,SUNRISE COUNTRY MANOR,285232,"PO BOX A, 610 224TH STREET",MILFORD,NE,68405,2019-09-18,803,D,1,0,BEDC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.11A1 Based on observation, interview and record review; the facility staff failed to ensure 1 resident (Resident 15) received the correct portion size during meal service, and 2 random residents. The facility also failed to ensurethe meals were attractive for one resident (Resident 15). The facility census was 74. Findings are: The facility Menu for 9/17/19 at Lunch was Cheese Burger on a Bun, French Fries, Relish Plate, Mayonnaise, Ice Cream Sundae, coffee and tea. An observation on 09/17/19 at 11:19 AM of Meal Serving the Dietary staff was not using a scoop to measure the amount of food placed on plates. Observation on 09/17/19 at 11:31 AM of a tray made for Resident 15, the tray had 2 fries the cook had mashed up with their fingers and the tray had a small amount of meat without bread and ice cream that had melted to liquid. The DA (Dietary Aide) B picked up the tray to deliver it to the resident. Interview on 09/17/19 at 11:31 AM with DA B confirmed; that they were not sure how much was on the plate and sat the tray down. Interview on 09/17/19 at 11:35 AM with the DM (Dietary Manager) confirmed; that Resident 15 was to get 4 ounces of potatoes and the plate did not have the correct amount of food on it. The DM confirmed that the way the food was presented was the practice. The DM confirmed; that on the 2 plates on the counter that were ready to be served there was a difference between the amounts of fries that were on one plate than another. The DM confirmed that the fries were inconsistent related to not using a measuring utensil. An observation on 09/17/19 at 11:35AM with the DM of the trays with inconsistent amounts of food served to residents in the dining area. An interview on 19/17/19 at 11:42 AM with the DM confirmed; that the ice cream and cottage cheese was not to be placed under the heat lamp. It was noted that on most of the tables the ice cream had been melted to liquid and was served. The dietary manager reported that it should not be melted. Record review of Resident 15 weights on 03/25/19 revealed; (genders) weight was 160 pounds. Record review of Resident 15 weight on 09/11/19 revealed; (gender) weighed was 148 pounds . Record review of Resident 15's Dietary Nutrition readmission note dated 9 revealed; Resident was readmitted on nectar fluids with moist ground meats. Weight as of 7/19/19 down 2 pounds in 30 days (-1.3%) down 17 pounds (10.2 %) in 90 days. Recommended to restart supplement. Record review of Resident 15's dietary note dated 08/02/19 revealed; Weight loss returned as of 07/29/19 with agreement to restart order for ensure Pulse twice daily thickened as per diet orders due to weight loss. Record review of Resident 15 Dietary Note dated 08/23/19 revealed; Resident 15 was offered 8 ounces of Ensure Plus twice a day and had accepted the ensure. Plan: As weight appeared to be stabilizing, BMI (Body Mass Index) WNL (within Normal Limits), Resident was taking supplement well, will recommendations no changes to nutrition P[NAME] (Plan of Care) at this time. Record review of Resident 15's Care Plan revealed; the resident had dentures. Resident 15 was in the process of getting new dentures that fit (genders) mouth properly. Date Initiated: 09/17/2019 o The resident will be free of infection, pain or bleeding in the oral cavity by review date. Date Initiated: 09/17/2019 o The resident will comply with mouth care at least daily through review date. Date Initiated: 09/17/2019 o Coordinate arrangements for dental care (Bright Smiles), transportation as needed/as ordered. Date Initiated: 09/17/2019 o Diet as Ordered. Consult with dietitian and change if chewing/swallowing problems are noted. Date Initiated: 09/17/2019 o Last appointment: 8/30/19 (1 week return visit, gum check, possible impressions for lower dentures) Next appointment: 9/24/19 (Wax Try-in) Date Initiated: 09/17/2019 o Monitor/document/report PRN any signs/symptoms of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, [MEDICAL CONDITION]. Date Initiated: 09/17/2019 o Provide mouth care as per ADL personal hygiene. Date Initiated: 09/17/2019. Record review of time line presented by facility for Resident 15's dental visits revealed; June 19, 2019 Bright Smiles for bridge July 16-19, 2019 hospitalization for aspiration July 29, 2019 Bright Smiles for tooth extraction, start impression for upper partial August 6, 2019 Bright Smiles continue with impressions for upper partial, may do impression of bottom dentures August 15, 2019 Bright Smiles complaints of left mouth/jaw pain radiated to ear August 23 2019, Bright Smiles impression for lower denture, will check for any bone fragments left from surgical extraction at previous visit. August 30 2019 Bright Smile 1 week follow up, gum check possible impression for lower dentures September 10, 2019 Bright Smile wax bite was not ready-had to reschedule September 24 Bright Smile wax try in. Record review of Resident 15's intake revealed; out of 77 meals 55 had a consumption of 76-100 percent.",2020-09-01
5932,SIDNEY REGIONAL MEDICAL CENTER-EXTENDED CARE,285290,549 KELLER DRIVE,SIDNEY,NE,69162,2016-08-15,425,E,1,0,39B611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.12 Based on observations, interviews and record reviews; the facility failed to ensure that physician prescribed medications were available for three sampled residents. (Resident 2, 4 and 1). Facility census was 51. Findings are: A. Review of the Resident Master Information for Resident 2 revealed an admission date of [DATE] to the facility. Further review revealed a discharge date of [DATE]. Review of the All Medications sheet for Resident 2 revealed an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. Interview on 8/15/16 at 11:17 AM with Licensed Practical Nurse - (LPN) A revealed that sometimes the prescribed medications did not come to the facility. The pharmacy used by the residents was closed on Sundays and someone was on call, Further interview revealed that there also could be complications with the insurance companies not wanting to pay for the medications. So then the medications were not sent. Interview on 8/15/16 at 3:00 PM with the Administrator verified that there was an order for [REDACTED]. [REDACTED]. B. Review of the Resident Master Information for Resident 4 revealed an admission to the facility of 8/4/16. Review of the Active MEDICATION ORDERS FOR [REDACTED]. Further review revealed an order dated 8/4/16 for Chlorhexidine (Peridex) topical 0.12% to mucous membrane and to give 1 application twice a day. Review of the Medication Administration Record [REDACTED]. Further review revealed that the Chlorhexidine Topical also had written documentation to supported that it was, Not Available from the pharmacy. Written documentation supports that the Chlorhexidine was, Not Available on 8/6, 8/7, 8/8, 8/9, 8/11, and 8/13. Interview on 8/15/16 at 3:00 PM with the Administrator verified that there was an order for [REDACTED]. [REDACTED]. C. Review of Resident Master Information for Resident 1 revealed an admission date of [DATE] to the facility. Record review Facility Active Medication Orders revealed Resident 1 had orders for: oxycodone 60 mg oral 5 times per day, with the first dose on 6/14/2016; methadone 20 mg, oral BID (twice daily) first dose on 6/21/2016; methadone 20 mg oral daily pain PRN (as needed); and ibuprofen 400 mg oral every 6 hours as needed for pain with the 1st dose on 7/6/2016. Record review Medication Administration Record [REDACTED] -7/15/2016 Medication: Oxycodone, time 0500 (Not Done) medication unavailable; and -8/04/2016 Medication Oxycodone, time 23:00 (Not Done) medication not given. Interview with Resident 1 on 8/15/2016 at 1:30 revealed an incident that occurred on (MONTH) 15, (YEAR) when the resident had not received their routine oxycodone medication and were told by the nursing staff that the pharmacy had not delivered it and the medication was unavailable. An interview with the Administrator on 8/15/2016 at 2:45 PM revealed that the unavailable medication (MONTH) 15, (YEAR) was because the pharmacy used by the facility to have prescriptions filled did not always have the medications in stock or insurance declined the medication and therefore the medications were not available and could not be given. An Interview with Licensed Practical Nurse -A (LPN-A) 8-15-2016 at 2:50 PM revealed the facility uses a local pharmacy to fill prescriptions. LPN-A revealed if the medication was unavailable, the staff marked medication unavailable on the Medication Administration Record [REDACTED]. Interview with LPN-B on 8/15/2016 at 2:50 PM revealed the facility used a local pharmacy to fill prescriptions and the pharmacy delivered Monday through Saturday and on Sundays, if there was an emergency. LPN-B revealed the pharmacy was on-call 24 hours a day for times when a resident may be admitted after hours or over weekends and medications were needed. LPN-B revealed that, if a resident was out of medication, the nurses would chart that they were waiting for pharmacy.",2019-08-01
4851,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2018-03-06,755,H,1,1,9WK311,"**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 that medications were available to administer as ordered 1) on admission for two current sampled residents (Residents 176 and 175), 2) for an antifungal medication to treat a skin disorder for one current sampled resident (Resident 20) and 3) for antibiotics to treat a urinary tract infection for one current sampled resident (Resident 24). The facility census was 27 with 16 current sampled residents. Findings are: [NAME] Review of the Admission Record revealed that Resident 176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record, dated (MONTH) (YEAR), revealed that the following medications were not administered as ordered on admission: - [MEDICATION NAME] daily for Major [MEDICAL CONDITION], start date 2/24/18 and not administered until 2/25/18; - [MEDICATION NAME] Ointment apply daily to wound on upper back, start date 2/24/18 and not applied until 2/25/18; - [MEDICATION NAME] tapering doses, two times a day for Malignant Neoplasm of Brain and Cerebral [MEDICAL CONDITION] (swelling), ordered 2/23/18 and not administered until 2/25/18; - [MEDICATION NAME] every four hours as needed for pain, ordered 2/23/18 and not administered until 2/26/18; - [MEDICATION NAME] every four hours as needed for pain, ordered 2/23/18 and not administered until 2/27/18. Review of the hospital emergency room report, dated 2/25/18 at 12:56 AM, revealed the following including: - Final Impression: Headaches and reported shoulder dislocation; - Differential Diagnosis: [REDACTED]. Examination showed that the patient has difficulty understanding and following commands at this time, spouse reports that since the [MEDICAL CONDITION] the patient has times periods of being alert and oriented and answers questions to period where the patient cannot follow commands, respond well, can't answer questions. The patient acts like is trying to answer but is unable to get the words out. - Presenting problems included history of [MEDICAL CONDITION] and brain surgery on 2/12/18, spouse received a call from the nursing home that the resident was having severe pain in the left shoulder, found that the left shoulder was dislocated, and left hand was blue, spouse reduced the left shoulder and restored circulation to the left arm. The dislocation may have occurred while trying to assist the patient off of the toilet. The spouse reported that the resident had not received the ordered doses of steroid since admission to the facility for cerebral [MEDICAL CONDITION] (brain swelling) prevention and was increasingly lethargic and sleeping much more than normal, 18 hours today. The resident was given a dose of steroid and orders for tapering doses. Interview with the resident's spouse on 2/28/18 at 7:45 AM revealed concerns related to pain management. The spouse stated that the resident has a long history of frequent headaches since diagnosed wih the [DIAGNOSES REDACTED] and typically took Tylenol at least a couple of times a day for lesser pain and [MEDICATION NAME] daily for more severe headaches. The spouse was concerned that the resident was having pain and medications were not being administered when needed. The spouse also stated concerns related to the missed doses of the steroid ordered on admission which may have contributed to the increased lethargy sleeping all day on 2/24/18 and being so out of it on 2/25/18. Interview with the Nurse Consultant on 2/28/18 at 3:00 PM confirmed that the resident's medications listed above were not received from the pharmacy on admission and were not administered until available as documented on the Medication Administration Record. B. Review of the Admission Record revealed that Resident 175 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record, dated (MONTH) (YEAR), revealed that the following medications were not administered as ordered: - [MEDICATION NAME], ordered on [DATE] every evening for Diabetes, not administered until 2/20/18; - Latanoprost eye drops to both eyes for [MEDICAL CONDITION], ordered 2/18/18 and not administered until 2/21/18; - Terozosin every bedtime related to [MEDICAL CONDITION], ordered 2/18/18 and not administered until 2/20/18; - [MEDICATION NAME] daily for [MEDICAL CONDITION] Fibrillation, ordered 2/19/18 and not administered until 2/20/18; - [MEDICATION NAME] two times a day for Partial Intestinal Obstruction, ordered on [DATE] and not administered until evening dose on 2/20/18; - [MEDICATION NAME] ordered two times a day for Diabetes, ordered 2/19/18 and not administered until 2/20/18; - Potassium Chloride ordered two times a day, ordered 2/18/18 and not administered until evening dose on 2/20/18; - Risamine ointment to reddened groin two times a day, ordered 2/18/18 and not applied until the evening dose on 2/20/18; - [MEDICATION NAME] R injections per sliding scale four times a day for Diabetes, ordered 2/18/19 and not administered until 2/20/18. Interview with the Director of Nursing on 3/5/18 at 9:40 AM confirmed that the medications listed above were not received from the pharmacy on admission and were not administered as ordered until available as documented on the Medication Administration Record. C. Review of Resident 20's Medication Administration Record, dated (MONTH) (YEAR), revealed an order, dated 2/10/18, for [MEDICATION NAME] (antifungal) daily for [DIAGNOSES REDACTED] (reddened and chaffing skin) which was not administered on 2/10/18, 2/11/18 and 2/12/18. Further review revealed an order, dated 2/13/18, for [MEDICATION NAME] daily for until 2/20/18 which was not given 2/13/18 through 2/16/18. [MEDICATION NAME] was ordered again on 2/17/18 to be administered daily until 2/23/18. Further review revealed that it was administered daily as ordered on [DATE] through 2/23/18. Interview with the Nurse Consultant on 3/5/18 at 3:00 PM confirmed that there was a mix up with the pharmacy orders and the medication was not available until 2/17/18. Further interview confirmed that the resident's were to receive their medications as ordered which did not occur due to issues with the pharmacy and staff not following the procedures for ordering medications for the residents. D. Record review of Resident 24's Admission Record printed on 2/28/18 revealed the resident was initially admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 24's Progress Notes revealed the following entries: - 2/13/2018 at 5:34 p.m. LPN (Licensed Practical Nurse)-C recorded: Received new orders for UTI (Urinary Tract Infection). [MEDICATION NAME] (antibiotic) 100 mg (milligrams) 2 x (two times) day for 7 days . - 2/14/2018 at 7:38 a.m. MA (Medication Aide)-F recorded the [MEDICATION NAME] was not given due to on order. - 2/15/18 at 4:44 p.m. LPN-D recorded the [MEDICATION NAME] was not given due to waiting to be delivered. - 2/16/18 at 11:59 p.m. LPN-D recorded the [MEDICATION NAME] was not given to the resident due to waiting for delieery (sic for delivery). - 2/16/18 at 1:55 p.m. LPN-D recorded: [MEDICATION NAME] 100 mg first dose started today for UTI. Record review of Resident 24's Medication Administration Record for (MONTH) of (YEAR) revealed [MEDICATION NAME] 100mg was ordered on [DATE] with instructions to administer the medication twice a day for Urinary Tract Infection. Further review of the document revealed the medication was not administered to the resident until 5:30 p.m. on 2/16/18 revealing that five potential doses of the medication were delayed from being administered to the resident as ordered. Interview with the Director of Nursing on 3/5/18 at 3:00 p.m. confirmed Resident 24 was ordered [MEDICATION NAME] on 2/14/18 for a urinary tract infection and the medication was not administered to the resident until 5:30 p.m. on 2/16/18.",2020-03-01
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
6422,LYONS LIVING CENTER,285301,1035 DIAMOND STREET,LYONS,NE,68038,2018-05-10,761,D,1,0,2CLY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.12E7 Based on record review and interview; the facility failed to ensure that Medication Administration Records matched current MEDICATION ORDERS FOR [REDACTED]. The facility census was 23. Findings are: A. Review of the facility policy Administering Medications dated 12/13/16 revealed all medications were to be administered in a safe and timely manner, and as prescribed. The following procedures were identified: -medications must be administered in accordance with the orders; and -the individual administering the medications must check the label three times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication. B. Review of Resident 1's Admission Medication Orders dated 2/27/18 revealed the resident had an order for [REDACTED]. Review of Resident 1's Medication Administration Record [REDACTED]. Review of Resident 1's MAR indicated [REDACTED]. Review of a facsimile (fax) dated 3/13/18 which was sent to the facility from the Registered Consultant Pharmacist revealed notification of a documentation error on Resident 1's MAR for 2/2018 and the MAR for 3/2018 regarding the medication [MEDICATION NAME]. C. Review of Resident 10's admission orders [REDACTED]. Review of Resident 10's MAR for 2/2018 revealed from 2/23/18 through 2/28/18 the resident received [MEDICATION NAME]-[MEDICATION NAME] 5/300 mg at the 6:00 AM administration times. Review of Resident 10's MAR for 3/2018 revealed from 3/1/18 through 3/14/18 the resident continue to receive [MEDICATION NAME]-[MEDICATION NAME] 5/300 mg at the 6:00 AM administration times. Review of a facsimile (fax) dated 3/13/18 which was sent to the facility from the Registered Consultant Pharmacist revealed notification of a documentation error on Resident 10's MAR for 2/2018 and the MAR for 3/2018 regarding the medication [MEDICATION NAME]-[MEDICATION NAME]. D During an interview on 5/7/18 from 2:00 PM to 2:30 PM the Administrator confirmed the following: -documentation on Resident 1's MAR for 2/2018 and for 3/2018 did not match the resident's admission orders [REDACTED] -documentation on Resident 1's MAR indicated [REDACTED] -documentation on Resident 10's MAR for 2/2018 and 3/2018 did not match the resident's admission orders [REDACTED] -documentation on Resident 10's MAR indicated [REDACTED] -facility staff failed to provide medications according to the five rights (standard of practice used to reduce the occurrence of medication errors which involves assuring the right resident, the right drug, the right dose, the right route and the right time for administration of medications).",2019-03-01
5751,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2016-09-20,412,D,1,0,TD4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.14 Based on observations, interviews, and record reviews; the facility failed to ensure that 3 sampled residents (Resident 120, 36, and 78) were provided with routine dental care. The facility census was 114. Findings are: A. Observation on 9/12/16 at 8:12 AM of Resident 120 in the dining room seated behind a pureed meal. Further observation revealed that the resident had obvious broken teeth on the left lower jaw that were visible. Review of the Admission Record dated as printed 9/8/16 for Resident 120 revealed no written documentation of a Dentist or emergency, facility dentist. Review of Resident 120's medical record to include the EMR (Electronic Medical Record) and the hard copy of the resident's chart revealed no written documentation of any routine dental visits provided or offered since admission on 7/17/15. B. Interview on 9/6/16 at 1:30 PM with Resident 36 revealed that the resident was upset with the dental services provided at the facility. Further interview revealed that the resident wanted to see a dentist for routine cleaning and had not been offered or assisted with the dental appointment. Continued interview revealed that the resident did get to see a Dentist but had to ask several times and was frustrated. Review of the Admission Record dated as printed 9/8/16 for Resident 36 revealed no written documentation of a Dentist for routine or emergency dental cares. Review of the Care Plan dated as initiated on 8/20/15 for Resident 36 revealed that the resident was at risk for dental problems related to some or all natural teeth loss with an interventions of, refer for Dental services as needed. Review of the Consultation/Clinic Referral forms for Resident 36 dated 7/16/13 revealed a visit to the dentist with a progress note, Unable to take x-rays or do a thorough exam today due to the patient with gag reflex .unable to clean teeth today. Review of the next Consultation was dated 6/6/14 for dental exam and dental cleaning with a [DIAGNOSES REDACTED]. Further review revealed no further consultation visits with any dentists. Interview on 9/20/16 at 9:00 AM with the (AC) Admissions Coordinator - AA revealed that the facility did not have a contracted Dentist to provide routine or emergency medical care for the residents at the facility. Interview on 9/20/16 at 4:00 PM with the Administrator and the Director of Nursing confirmed that the facility did not have a contracted Dentist to provide routine and emergency dental care to the residents at the facility. Continued interview verified that Resident 36 had not seen a dentist for routine care since 6/6/14 and Resident 120 had not seen a dentist since admission to the facility on [DATE]. Further interview verified that the facility was supposed to have a contracted dentist for routine and emergency dental care for the residents in the facility. C. Observations of Resident 78 on 9/7/16 at 9:40 AM revealed that the resident had missing teeth and broken, discolored teeth. Interview with the resident on 9/7/16 at 9:40 AM revealed that the resident had missing teeth and had sore teeth and gums. Further interview revealed that the resident needed to see a dentist but hadn't seen a dentist because it costs too much. The resident stated that they have to chop up my food and it's embarrassing to have bad teeth. Review of the Care Plan, goal date 10/28/16, revealed that the resident was at risk for dental problems related to some or all natural teeth lost, broken or with cavities. Interventions included to refer to dental services as needed. Interview with LPN (Licensed Practical Nurse) - B, Charge Nurse, confirmed that the staff were aware of the resident's dental problems. Further interview confirmed that the resident needed to see a dentist but an appointment had not been made.",2019-09-01
6425,LYONS LIVING CENTER,285301,1035 DIAMOND STREET,LYONS,NE,68038,2018-05-10,842,E,1,0,2CLY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.16A and 175 NAC 12-006.16B Based on observation, interview, and record review; the facility failed to ensure medical records contained completed information regarding: 1) Smoking Safety Screens for Residents 7, 3, and 6; 2) Nursing Admission Assessments for Residents 4 and 6; and 3) Elopement (leaving the facility unattended and without staff knowledge) Risk Assessments for Resident 3. The sample size was 14 and the facility census was 23. Findings are: A. Review of Resident 6's Smoking Safety Screen dated 2/19/18 revealed the documented was opened but had not been filled out. Review of Resident 6's current undated Care Plan revealed the resident would follow the schedule for smoking and staff would assist the resident outside to smoke. Further review of the Care Plan revealed no evidence to indicate the resident's ability to smoke safely and the resident's ability to safely keep the resident's cigarettes and a lighter with the resident had been addressed. Review of Resident 6's Nursing Admission Assessment with an effective date of 2/20/18 revealed the resident was admitted on [DATE]. Further review revealed pages 10 through 17 of the document were incomplete. B. Review of Resident 4's Nursing Admission Assessment with an effective date of 4/28/18 revealed the resident was admitted on [DATE]. Further review revealed the document had not been filled out. An interview with the Provisional Administrator on 5/10/18 at 1:55 PM confirmed the Nursing Admission Assessments had not been completed. C. Review of Resident 7's current Care Plan dated 5/1/18 indicated the resident smoked cigarettes. Nursing interventions included to assess the resident quarterly for independent or supervised smoking. Review of the medical record revealed no evidence that Resident 7 was assessed to determine capability to smoke in a safe manner and/or interventions required to decrease the risk for injury related to smoking. During observations on 5/7/18 at 9:45 AM and 3:14 PM, Resident 7 was seated in a wheelchair on the patio outside the 100 Hall exit door and smoking a cigarette. D. Resident 3 was observed on the patio outside the exit door of the 100 Hall smoking cigarettes with other residents on 5/7/18 at 9:45 AM and 3:14 PM, and on 5/10/18 from 1:28 PM until 1:32 PM. There was no evidence in the current Care Plan dated 4/30/18 that Resident 3 smoked cigarettes, and no interventions to prevent smoking injuries. Furthermore, there was no evidence the resident was assessed to determine capability to smoke in a safe manner. E. During interview on 5/10/18 at 9:55 AM, the Director of Nursing (DON) verified smoking safety assessments were supposed to be completed on admission and annually. F. Review of Nursing Progress Notes dated 4/18/18 (day after admission) revealed the following related to Resident 3: -1:21 AM - asking for keys to get back home; -8:59 PM - pacing up and down halls; and -9:04 PM - comes to front desk and asks for keys because wants to go home; told didn't have have keys; gets upset and states get my (expletive) keys and walks away. There was no evidence in the medical record that Resident 3 was assessed for risk of wandering and/or elopement, or that interventions were implemented to prevent the resident from leaving the facility. Review of the Incident/Accident Investigation dated 4/20/18 at 6:58 PM indicated another resident informed the Charge Nurse that this resident went out the front door. The nurse immediately went to the front door, found Resident 3 sitting outside, and returned the resident to the facility. During interview on 5/10/18 at 10:55 AM, the Provisional Administrator verified an elopement risk assessment was not completed for Resident 3.",2019-03-01
6389,"NORTH PLATTE CARE CENTER, LLC",285165,2900 WEST E STREET,NORTH PLATTE,NE,69101,2016-03-02,514,E,1,0,BM4911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.16B Based on record reviews and interview, the facility failed to ensure that routine medications administered were documented on theRoutine Medication forms to ensure complete and accurate medical records and to reduce the risk for errors for six sampled residents (Resident 1, 3, 5, 6, 7 and 8). The facility census was 47. Findings are: A. Review of Resident 1's Routine Medications, dated (MONTH) (YEAR), revealed no documentation that Med Pass was administered as ordered at 10:00 AM on 2/2/16 and at 3:00 PM on 2/2/16 and 2/23/16; Mertazapine and [MEDICATION NAME] were administered as ordered at bedtime on 2/7/16; and Refresh Tears were administered as ordered in the afternoon on 2/23/16. B. Review of Resident 3's Routine Medications, dated (MONTH) (YEAR), revealed no documentation that [MEDICATION NAME] was administered as ordered at bedtime on 2/29/16. C. Review of Resident 5's Routine Medications, dated (MONTH) (YEAR), revealed no documentation that [MEDICATION NAME] eye drops were administered as ordered at bedtime on 2/2/16, 2/3/16 and 2/22/16; and [MEDICATION NAME] and [MEDICATION NAME] were administered as ordered at bedtime on 2/23/16. D. Review of Resident 6's Routine Medications, dated (MONTH) (YEAR), revealed no documentation that [MEDICATION NAME] was administered at bedtime as ordered on [DATE]; [MEDICATION NAME] was administered before supper on 2/2/16 and 2/8/16, and Accuchecks were done at 11:00 AM on 2/1/16 and 2/19/16. E. Review of Resident 7's Routine Medications, dated (MONTH) (YEAR), revealed no documentation that [MEDICATION NAME] and [MEDICATION NAME] were administered as ordered at bedtime on 2/22/16, and [MEDICATION NAME] was administered as ordered every afternoon on 2/5/16. F. Review of Resident 8's Routine Medications, dated (MONTH) (YEAR), revealed no documentation that Klonopin was administered as ordered at bedtime on 2/27/16; [MEDICATION NAME] as ordered at 6:00 PM on 2/24/16 and 2/29/16. Interview on 3/2/16 at 3:30 PM with the DON (Director of Nursing) confirmed that the nurses were to document medications administered on the Routine Medications forms after medications were administered to ensure accurate and complete documentation in the medical records and to reduce the risk for errors.",2019-03-01
5516,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2016-12-19,514,D,1,0,HJD111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.16B Based on record reviews and interviews, the facility failed to ensure that routine medications and treatments were documented as administered on the MAR (Medication Administration Record) and TAR (Treatment Administration Record) to ensure complete documentation in the clinical record for two sampled residents (Residents 2 and 3). The sample size was three current residents and the facility census was 117. Findings are: [NAME] Review of Resident 2's TAR for (MONTH) (YEAR) revealed an order for [REDACTED]. B. Review of Resident 3's MAR for (MONTH) (YEAR) revealed an order for [REDACTED]./16, 11/14/16 and 11/29/16. Review of the TAR for (MONTH) (YEAR) revealed an order for [REDACTED]. Review of the TAR for (MONTH) (YEAR) revealed no documentation that the [MEDICATION NAME] cream was applied on the day shift on 12/1/16, 12/2/16, 12/3/16 and 12/4/16 and on the evening shift on 12/1/16 and 12/3/16. Interview with the Interim Director of Nursing on 12/19/16 at 3:15 PM confirmed that the nurses were to document medications and treatments administered to ensure that the clinical records were complete and accurate.",2019-11-01
4385,"BCP UTICA, LLC",285161,1350 CENTENNIAL AVENUE,UTICA,NE,68456,2018-07-26,880,E,1,1,AHI211,"**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 label resident towel bars in semiprivate rooms occupied by 4 current residents (Residents 10, 7, 5, and 15). The failure could potentially result in cross-contamination of towels. Sample size was 12 current residents. Facility census was 30. Findings are: Bathroom observation of semi-private rooms [ROOM NUMBERS] on 7/23/2018 at 3:32 PM revealed towel bars were not marked or identified. Bathroom observation of semi-private rooms [ROOM NUMBERS] on 7/24/2018 at 10:00 AM revealed towel bars were not marked or identified. Interview with the Director of Nursing on 7/25/18 at 3:30 PM confirmed that the Bathrooms in semi-private rooms [ROOM NUMBERS] did not have towel bars marked or identified and this could potentially result in cross contamination of towels.",2020-08-01
1515,AZRIA HEALTH ASHLAND,285140,1700 FURNAS STREET,ASHLAND,NE,68003,2019-06-27,880,D,1,0,86O711,"**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 were done in a manor to prevent cross contamination. This had potential to affect 1(Resident 4) of 4 sampled resident's. The facility census was 69. Findings are: Record Review of Hand Washing Procedure dated 10/01/17 revealed section 3, step 3 rub hands together using friction for 20 (CDC guidelines) seconds. Front and back of hands, finger, in between the fingers, around the nail, cuticle and under the nails should be thoroughly cleaned. Record Review of Personal Protective Equipment Techniques dated 10/01/17 revealed Removing Gloves (sterile and Non-sterile) Step 1. Using one hand, pull cuff down over the opposite hand, turning glove inside out. Step 2. Keep glove in hand after removing. Step 3. With ungloved hand, pull cuff down over the opposite hand turning glove inside out Step 4. Continue pulling until the glove completely encloses the other glove and has its uncontaminated inner surface out. Step 5. Discard gloves in the waste receptacle. Step 6. Wash hands. Observation on 06/27/19 from 10:35AM - 11:55 AM revealed Resident 4 was lying in bed on back with heal protectors on both feet. LPN-A (Licensed Practical Nurse) and RN-B (Registered Nurse) present in room when surveyor arrived. Resident 4 gave permission to have wound care observed. LPN-A washed hands in shared restroom, applied gloves, turned the faucet on with gloved hands and wet wash clothes and placed in clear trash bag. LPN-A placed trash bag with wet wash cloths on bed and had Dimethicone (medicated ointment used to moisture skin) Ointment on the over bed table not on a barrier, over bed table was not cleaned prior to setting supplies on it. The empty trash bag was place on the foot of the bed for soiled linens. LPN-A pulled window curtain closed with gloved hands. RN-B pulled room divider curtain for privacy. LPN-A moved bed side table to other side of bed with the same gloves on and placed clean towel on over bed table. Resident 4 was assisted with lowering of pants and depends (adult disposable underwear) by LPN-A, Resident 4 was then assisted to turn on left side. LPN-A continued to wear same gloves that had touched faucet, the over bed table, curtains, Resident 4's clothing and depend to wash coccyx ( buttocks) area with wet soapy wash cloth, coccyx was rinsed and patted dry. Coccyx was visible pink and red in areas no open wounds were present. LPN-A placed towel used to dry coccyx, beside resident and let resident turn onto (gender) back. Soiled gloves were removed. LPN-A then went to restroom and washed hands for 8 seconds. Turned faucet off with a paper towel. LPN-A applied gloves to both hands and placed a second glove to left hand, assisted resident to turn on to left side, Dimethicone Ointment tube was picked up with gloved hands and squirted into LPN-A's left hand. Dimethicone ointment was applied to coccyx area and rubbed in. LPN-A removed one glove from left hand. Assisted resident to pull up depends and pants, reposition to lying on (gender) back. LPN-A removed gloves. Left room without washing hands, returned to Resident 4's room with skin prep (liquid that forms a dressing to reduce friction) for left heel treatment. Placed skin prep wipes in prepackaged containers on the over bed table. LPN-A entered restroom washed hands for 5 seconds and turned faucet and light switch off with paper towel. LPN-A applied gloves, removed Resident 4's left heal protector and sock, opened skin prep and wiped left heel, removed gloves. Heel left to dry for 3 seconds, LPN-A applied gloves and placed left sock and heal protector back on left foot. Removed gloves, line and waste collected. LPN-A left room without washing hands. Record Review of Resident 4's Care Plan dated 6/14/19 revealed Alteration in ADL's (Activities of Daily Living) R/T (related to) Weakness, poor nutrition, takes [MEDICATION NAME] daily, anxiety, depression, decline in ADL's, requires Extensive assist, dementia, [MEDICAL CONDITION]. Interview on 06/27/19 at 2:34PM with ADON (Assistant Director of Nursing) confirmed hand washing needs to be done for 20 seconds and gloving needs to be done per facility policy.",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
4071,HILLCREST MILLARD,285302,13225 WESTWOOD LANE,OMAHA,NE,68144,2019-09-25,880,D,1,0,EL7411,"**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 staff failed to change gloves during treatments and ensure the cleanliness of equipment to prevent potential for cross contamination for 1 (Resident 10) of 1 sampled resident, The facility staff identified a census of 65. Findings are: Review of Resident 10's current physician orders [REDACTED]. -Left heel wound care, paint wound bed with [MEDICATION NAME] daily. Allow to dry completely and cover with [MEDICATION NAME].-Wound Care Upper [MEDICATION NAME] Back, irrigate wound and undermining areas vigorously with normal saline. Gently pack undermining areas with [MEDICATION NAME] AG Ribbon. Cover with folded abdominal pad and secure with foam tape. Observation of wound care for Resident 10 on 09/24/19 at 11:30 AM with RN D revealed the following: -RN D completed hand hygiene and applied clean gloves. -Supplies for the dressing change were placed on the overbed table with no clean barrier. -Removed the dressing from the left heel and cleansed the heel with Wound Cleanser. -Applied [MEDICATION NAME] to the wound bed. -Removed gloves, sanitized hands and applied clean gloves. -Applied [MEDICATION NAME] dressing to the left heel. -Removed gloves and sanitized. -RN D gathered supplies for wound care to upper [MEDICATION NAME] back. Placed the wound care supplies on the couch with no clean barrier and then moved the supplies to Resident 10's bed with no clean barrier. -Applied clean gloves and removed the old dressing from the wound on upper [MEDICATION NAME] back. Old dressing had large amount of drainage. -Removed the packing from the wound. -Obtained a irrigation syringe from the package on the bed and filled the syringe with Normal Saline. -Irrigated the wound with Normal Saline -Removed gloves, sanitized and applied clean gloves. -Removed Aquagel AG from the package and cut the packing with the scissors. Laid scissor back on bed. Retrieved the syringe from the bed and used the syringe to pack the Aquagel AG into the wound. Retrieved the scissors from the bed and cut the extra Aquagel packing from the wound. - Covered the wound with a folded Abdominal Pad and covered with foam tape. RN D removed the supplies from the bed, removed gloves and performed hand hygiene. Interview conducted with the Director of Clinical Services on 09/24/19 at 03:07 PM revealed an expectation of staff providing wound care to change gloves and perform hand hygiene when going from dirty to clean and having a clean barrier under wound care supplies.",2020-09-01
1605,AZRIA HEALTH CENTRAL CITY,285147,2720 SOUTH 17TH AVENUE,CENTRAL CITY,NE,68826,2019-07-30,584,E,1,1,7WHV11,"**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 A) the flooring was clean and in good repair in the west hall dining area, and the facility failed to ensure the entry to the West dining area dry wall and base board were in good repair. This had the potential to affect 10 residents residing on the west hall. The facility also failed to ensure that bathrooms were clean and in good repair for 8 residents, (Residents 2, 8, 15, 25, 31, 38, 52, and 56). The facility failed to ensure that cloth furniture was cleansed after use in the North dining area this affected 1 resident (Resident 31). The facility census was 59. Findings are: An observation on 07/24/19 at 10:00 AM of a blue straight back cloth chair that had food particles dried on it. An observation on 07/24/19 at 12:15PM of Resident 31 sitting in the blue straight back chair with dried food particles on it. An observation on 07/25/19 at 10:50 AM of Resident 38's Room revealed; the bathroom had 3 tile that was cracked and the caulking around the toilet was black/brown in color. The paint on the wall next to the toilet was peeling. An interview on 07/30/19 11:15 AM with the Nurse on the North Unit confirmed; that they did not know when the blue chair was cleaned or what the cleaning schedule was. An observation with the Administrator on 07/30/19 11:30AM of the Blue chair with food particles dried on it. room [ROOM NUMBER]N (Resident 56 and 25) revealed that the caulking around the toilet that was brown/black in color. room [ROOM NUMBER]N (Resident 2 and 8) had caulking around the toilet that was missing with brown/black in color peeling paint on the wall next to the toilet. room [ROOM NUMBER]N (Resident 38 and 31) had 3 cracked tile on the floor, wall was peeling, bubbled paint and caulking around the toilet was missing/brown black in color. room [ROOM NUMBER] S ( Resident 15 and 52) had red substance in splattered pattern on the wall across from the toilet. An interview on 07/30/19 11:40 AM with the Administrator confirmed that the chair was not clean and that at a minimum the chair needed to be clean at least weekly. The administrator confirmed that the wall in room S7 was dirty that someone had spilled something on the wall and just did not clean it up. The Administrator confirmed that both residents in the S7 had been admitted to the hospital and were not in the facility at this time, the administrator was unaware of how long the residents had been out of the facility. An interview with the Administrator on 07/30/19 12:54 PM revealed that the facility had tags related to the environment and the facility was following a P[NAME] from the last year that involved filling out fix it tickets. The Administrator confirmed that audits had been done for 3 months and discontinued related to the results of the audit. The administrator confirmed that there were no tickets related to caulking around the toilets. The Administrator confirmed that the facility has recently severed ties with the cleaning company related to being unhappy with services. The facility had hired staff and they are responsible for cleaning there was a list that was made for deep cleaning and had not included the chairs for residents. The Administrator reported that they had added chairs to the list on 7/30/19. B. Observation of BTR/West dining room on 7-24-19 at 12:25 revealed Base board coming loose from wall from north side of wall connected to dining area. Duct tape had been applied to the baseboard of a wall adjoining the resident dining and activity room. Chunks of drywall were missing and/or damaged to the corners of the wall exposing the metal edging below. Adhesive remains on both edges of the wall Approximately 3 feet up from the floor . Hair and dirt observed sticking to this area of the wall. Numerous gouges observed to the floor in the entire east section BTR dining room. Interview with Maintenance Director 7/24/19 at 1225 revealed, fixing the wall is 1 of about 90 things on my list to get done. Maintenance Director also stated the gouges in the floor were not new. Interview with Medication Assistant (MA) X on 7-24-19 at 12:25 PM revealed the gouges in the floor in the BTR dining room have been here for months. The wheels from the chairs in the room break and the screws damage the floor. An interview on 07/30/19 at 11:45 AM with the Administrator while on environmental rounds confirmed the wall and the numerous floor gouges were both non cleanable surfaces.",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
2582,AZRIA HEALTH MIDTOWN,285218,910 SOUTH 40TH STREET,OMAHA,NE,68105,2018-06-12,584,E,1,1,BXNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.18 Based on observation and interviews, the facility failed to ensure that walls, floors, doors, fixtures, and door frames were in good repair in 9 of 35 resident rooms (rooms 102, 103, 107, 110, 112, 204, 205, 206, and 217), call cords were not stained in room [ROOM NUMBER], and toilet paper holders were available in 4 resident rooms (rooms 204, 205, 206, and 215). The facility staff identified the census at 48. The findings are: An environmental tour conducted on 6-11-18 between 1:20 PM and 1:45 PM with the Administrator and the Housekeeping Director revealed the following: -room [ROOM NUMBER]- The door frame in bathroom was water damaged and rusty, there was a gouge in the bathroom wall, and there were unfinished walls in the bathroom. -room [ROOM NUMBER]- There was a gouge in the bathroom wall, there was a chipped tile in the bedroom, and the kick plate on door to the room was pulled loose from the door. -room [ROOM NUMBER]- The bathroom call light cord was stained. -room [ROOM NUMBER]- The door frame in bathroom was water damaged and rusty and the caulking around the base of the toilet was cracked. -rooms [ROOM NUMBERS]- The door frame in the shared bathroom was water damaged and rusty. -room [ROOM NUMBER]- There were gouges in bathroom floor, the bathroom faucet was loose, there were unfinished wall patches in the bathroom, and there was no toilet paper holder in the bathroom. -room [ROOM NUMBER]- The towel hooks in bathroom were broken, one towel hook was coming out of the wall, there was a hole in the wall where a towel hook used to be. There was no toilet paper holder in the bathroom. -room [ROOM NUMBER]- There were unfinished wall patches in the bathroom and no toilet paper holder in the bathroom. -room [ROOM NUMBER]- There was no toilet paper holder in the bathroom. -room [ROOM NUMBER]- There were gouges in the bathroom floor and the caulking behind sink was cracked. An interview conducted on 6-11-18 at 1:45 PM with the Administrator confirmed the findings of the environmental tour.",2020-09-01
1988,FLORENCE HOME,285173,7915 NORTH 30TH STREET,OMAHA,NE,68112,2017-12-06,584,E,1,1,CVPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.18A Based on observation and interview, the facility failed to ensure ventilation system vents were free from dust in 4 rooms (rooms 203, 204, 211, and 220); ceilings, walls, and doors were clean and in good repair in 9 rooms (rooms 203, 208, 211,219, 220, 227, 231, 234 and 235); the blinds were in good repair in 4 rooms (rooms 203, 208, 211, and 219); and privacy curtain was free from soiling in 1 room (room [ROOM NUMBER]) of 63 resident rooms. The facility staff identified the census at 68. The findings are: An observation conducted on 12-06-17 from 11:00 AM to 11:42 AM with the facility Administrator and the Maintenance Director revealed the following: -room [ROOM NUMBER] The ventilation system vent had light brown matter resembling dust, the window blinds were missing slats, and the bathroom ceiling tiles were stained. -room [ROOM NUMBER] The ventilation system vent had light brown matter resembling dust. -room [ROOM NUMBER] The ceiling tiles in the bathroom were stained and bulging downward. -room [ROOM NUMBER] The window blinds were missing slats, the base trim was off the wall next to the heating/cooling unit, the wall was not finished with trim leaving exposed dry wall edges around the heating/cooling unit, the ventilation system vent had light brown matter resembling dust, the bathroom ceiling tiles were stained and bulging downward. -room [ROOM NUMBER] The bathroom ceiling support grid had peeling paint and rust, the window blinds had broken slats, there was an unfinished drywall patch. -room [ROOM NUMBER] The ventilation system vent had light brown matter resembling dust, the bathroom ceiling tiles had holes and were stained. -room [ROOM NUMBER] The wall between bathroom and living area was scraped. -room [ROOM NUMBER] The kick plate on bathroom door was chipped with exposed sharp edges. -room [ROOM NUMBER] The wall outside the bathroom was scraped. -room [ROOM NUMBER] The wall outside bathroom had peeling paint. The privacy curtain between the beds was soiled with brown matter. An interview conducted on 12-06-17 at 11:42 AM with the Administrator confirmed the above findings.",2020-09-01
3470,PAPILLION MANOR,285268,610 SOUTH POLK STREET,PAPILLION,NE,68046,2018-05-31,584,E,1,1,ZIX611,"**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 walls and doors were free from scratches and gouges in 7 (resident rooms 106, 114, 207, 210, 510 and 614) of 38 rooms reviewed during the environmental tour of the facility. The facility had a total of 68 occupied rooms. Findings are: Observation during the environmental tour of the facility on 5/30/18 between 3:00 PM to 3:43 PM with the Maintenance Supervisor (MS) and the Housekeeping and Laundry Supervisor revealed the following concerns: - Scratched and gouged areas of walls in resident rooms 106, 114, 207, 210, 510 and 614. - Scratched, gouged area in the wooden door of the bathroom in resident room [ROOM NUMBER]. Interview on 05/30/18 at 03:48 PM with the facility Maintenance Supervisor confirmed the presence of gouges in the walls and door identified on environment tour in room [ROOM NUMBER], 114, 207, 208, 210, 510 and 614. The MS confirmed that they had not been identified prior to the environmental tour of the facility.",2020-09-01
1710,GOOD SAMARITAN SOCIETY - BLOOMFIELD,285156,"P O BOX 307, 300 NORTH SECOND ST",BLOOMFIELD,NE,68718,2019-08-15,558,D,1,1,8FR211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 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 2 (Residents 9 and 25) sampled residents who required assistance with activities of daily living. The facility census was 44 with 28 sampled residents. Findings are: [NAME] Review of Resident 9's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 5/25/19 indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assist of 2 staff for bed mobility, transfers, dressing, personal hygiene and toileting and was frequently incontinent of bladder. During observations on 8/12/19, the following was observed for Resident 9: -6:29 PM the resident's call light was turned on; -6:32 PM the resident's call light was turned off; -6:38 PM the resident's call light was turned on; -6:41 PM the resident's call light was turned off; and -7:01 PM the resident was observed seated in a wheelchair by the entrance of the resident's room. Resident 9's call light was draped across the foot board of the resident's bed. The call light had been secured to the edge of the foot board, directly next to the wall. During an interview on 8/12/19 at 7:05 PM, Resident 9 verified the following: -resident wanted to go to bed and had placed the call light on several times in order to get assistance; -the staff had come into the resident's room, asked the resident what was needed and then turned off the call light indicating someone would be back to assist the resident when staff were available; -required extensive staff assistance with all cares and 2 staff were needed to transfer the resident into bed; -a staff member had removed the call light from the resident's wheelchair arm and had placed the call light on the end of the resident's bed; and -the resident was unable to reach the call light from where it was secured on the foot board of the resident's bed. B. Review of Resident 25's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/9/19 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 dressing, transfers, bed mobility, personal hygiene and toileting. During an observation on 8/14/19 at 10:02 AM, the resident was seated in a wheelchair in the center of the resident's room. The resident had eyes closed with head in downward position toward the resident's chest. The foot pedals of the resident's wheelchair had been pulled to the sides of the wheelchair and the resident's feet were resting directly on the floor. A call light was secured to a positioning bar on the right side of the bed which was between the resident's bed and the wall. A second call light was secured to the arm rest of the resident's recliner. The resident was unable to access either of the call light cords from the resident's position in the wheelchair. During an interview with the Director of Nursing (DON) on 8/15/19 at 9:08 AM the DON confirmed Residents 9 and 25 both required extensive staff assistance with activities of daily living. The DON further confirmed the residents should have their call lights placed within reach to call for assistance when needed.",2020-09-01
2045,GOOD SAMARITAN SOCIETY - VALENTINE,285176,601 WEST 4TH STREET,VALENTINE,NE,69201,2018-06-19,689,G,1,0,6S9R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.98D7b Based on record reviews and interviews, the facility failed to identify causal factors related to falls and ensure that interventions were in place to reduce the risk for further falls for three current sampled residents (Residents 1, 2 and 3) and two fractures for Resident 1. The facility census was 34 with three current sampled residents. Findings are: [NAME] Review of the Admission Record, printed 6/19/18, revealed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that the resident was readmitted to the facility on [DATE] after hospitalization for surgical repair of a fractured left hip. Review of the Progress Notes revealed the following including: - 5/30/18 at 5:20 AM resident hollers out for help, able to use the call light when shown in room but forgets once staff leaves the room and hollers out for help as needed; - 5/31/18 at 9:20 AM it was reported that the resident transferred self from the bed to the wheelchair and the toilet during the night; - 6/1/18 at 4:11 AM needs frequent reminders to wait for assistance before getting up on own; - 6/2/18 at 8:45 PM responded to resident hollering help me, noted resident sitting on the floor, resident stated had been to the bathroom and was backing out of the bathroom when the wheelchair got away and sat on the floor, no apparent injuries noted; - 6/3/18 at 9:30 AM - observed resident's left leg was rotated outward and swelling at the left leg, complained of pain with ambulation, was sent to the hospital for evaluation and x rays showed a fractured left hip. Review of the Care Plan, goal date 6/23/18, revealed that the resident had impaired cognition related to Dementia, short term memory loss, required one assist with transfers and one assist with the wheelchair to meals. Further review revealed that the resident was at risk for falls related to changes in gait and balance and history of falls. The resident had a fall on 6/1/18 with no injury and on 6/3/18 a fall attempting to self-transfer. Review of the facility Investigation Report, dated 6/4/18, revealed that on 6/4/18 at 10:00 AM, the charge nurse heard help me and found the resident on the floor by the bed. The resident stated needed to go to the bathroom, stood up and fell to the left on the previously [MEDICAL CONDITION]. The resident fell on [DATE] and had a [MEDICAL CONDITION] and this fall on 6/3/18 resulted in a fractured femur. B. Review of the Admission Record, printed 6/19/18, revealed that Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes, dated 6/7/18 at 12:37 AM revealed that the resident was found on the floor by the roommate's bed and no injuries were noted. Review of the Care Plan, goal date 7/5/18, revealed that the resident had impaired cognition, memory loss, impaired vision, hearing and communication deficits and transferred with one assistance with a mechanical lift. The resident had falls with no injuries on 3/15/18, 3/21/18, 3/26/18 and 3/27/18. Further review revealed interventions including, assist resident to lay down in bed immediately after meals, bath and socials as the resident's anxiety increased when out of the room. C. Review of the Admission Record, printed 6/19/18, revealed that Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes revealed the following including: - 6/11/18 at 7:10 AM found on the floor by the bed trying to walk and time to eat, no injuries were noted; - 6/12/18 at 2:00 AM found on the floor, crawled out of bed, no injuries noted: - 6/13/18 at 8:32 PM found on the floor in front of the bathroom door, no injuries noted. Interview with the Director of Nursing on 6/19/18 at 3:00 PM revealed that causal factors, related to the falls listed above, were not identified or documented in the resident's medical records. Further interview confirmed that fall interventions were not in place to prevent recurrent falls for these residents.",2020-09-01
4419,"SCHUYLER CARE AND REHABILITATION CENTER, LLC",285110,2023 COLFAX STREET,SCHUYLER,NE,68661,2018-07-18,689,D,1,1,NXEG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.9D7b Based on record review, interview, and observation: the facility failed to identify causal factors of falls for 3 of 4 sampled residents (Residents 25, 20, and 21); the facility failed to implement individualized interventions to prevent falls for 2 of 3 residents sampled (Residents 25 and 21); the facility failed to ensure staff provided assistance with transfers (moving from one surface to another) per recommendations, for 1 of 3 residents sampled (Resident 25). The facility census was 28. Findings are: [NAME] A review of Fall Reports, involving Resident 25, with the following dates: 1/18/18, 2/10/18, 3/15/18, 4/2/18, 5/27/18, and 5/30/18; revealed no documented evidence related to the identification of causal factors for the fall events. -An interview on 7/17/18 at 11:30 AM with the Director of Nursing (DON) and the Minimum Data Set (MDS-a mandatory comprehensive assessment tool used for care planning) Nurse confirmed that no causal factors had been identified for Resident 25's six falls (listed above). Review of a Fall Report dated 4/21/18 revealed NA (Nursing Assistant)-H had attempted to use a Sit to Stand mechanical lift to assist Resident 25, as the staff member felt the resident was not able to stand to transfer with 1 person assist and walker, as indicated on the care plan. The document indicated that the mechanical lift was not used correctly and the resident fell hitting head on the wall. -An interview on 7/18/18 at 9:30 AM with the Administrator revealed staff were unable to locate documentation related to teaching provided to or proficiency testing related to safe resident transfers for NA-H, who is no longer employed by the facility. A review of assessments documented in Resident 25's electronic medical record revealed a Fall Risk assessment dated [DATE], which indicated the resident was a HIGH Risk for falls. Further review of the assessments revealed the document was completed and indicated the HIGH risk on 7 other dates as follows: 5/27/18, 5/11/18, 4/21/18, 4/2/18, 3/15/18, 2/10/18, and 1/18/18. A Review of Care Plan (CP) for Resident 25, with print date 7/17/18 revealed [DIAGNOSES REDACTED]. The Care Plan indicated that new or different safety interventions were implemented following falls occurring on 1/18/18, 2/10/18, 3/15/18, 4/2/18, 4/21/18, 5/11/18, and 5/30/18. An intervention dated 06/20/18 indicated safety alarms were removed due to the Resident's decline in functioning, and admission to hospice care. An observation on 7/16/18 at 11:36 AM of Nursing Assistant (NA)-I and J providing assistance for Resident 25 to transfer from bed to a wheelchair (w/c) revealed a mechanical, full body, lift was then used. While the resident was positioned off the bed, in the lift sling, NA-J was noted to transfer a pressure pad safety alarm from the Resident's bed and place the alarm pad in the seat of the w/c. The resident was then lowered into the chair and positioned with hips to the rear of the seat. -An interview on 7/16/18 at 11:55 AM with NA-J revealed Resident 25 continued to occasionally attempt to self-transfer, therefore the pressure alarm was in use as a safety precaution. B. A review of the Incident/Accident Log revealed Resident 21 was involved in a fall event on 2/19/18. No further documentation was provided for review. -An interview on 7/18/18 at 9:30 AM with the Administrator confirmed Resident 21's fall on 2/19/18. The Administrator reported that a root cause analysis was not completed, therefore causal factors had not been identified for the fall event. C. Record review on 07/16/18 at 01:21 PM revealed Care plan interventions for every 15 minute checks. Record review on 07/16/18 at 02:21 PM revealed no documentation of every 15 minute checks. Interview on 07/16/18 at 02:22 PM with the Director of Nursing confirmed that the Director of Nursing could not find any documentation of Resident 20's 15 minute checks. Record review on 07/16/18 at 03:23 PM revealed 4 falls since 3/2018. In (YEAR) the resident had a fall on 3/13/18, 3/28/18, 4/20/18, and 6/6/18 and 07/17/18 at 7:28 PM. The physician orders [REDACTED]. The fall incident reports dated 3/28/18 at 8:15PM, 4/20/18 at 10:15 AM, 6/6/18 4:37 PM, had no root cause analysis done there was no causal factors found.",2020-07-01
4450,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2018-03-08,923,F,1,1,VCTE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-007.04 D Based on observation and interview, the facility failed to ensure that the ventilation system was operational in 2 rooms (53 and 63) of 47 occupied rooms and failed to complete preventative ventilation checks in resident bathrooms in the facility. This had the potential to affect odor control in the facility in 47 occupied resident rooms. The facility census was 54. Findings are: Observation during the environmental tour on 3/7/18 between 1:00 and 1:30 PM with the facility Maintenance Director (MD) revealed no working ventilation system in the bathrooms in Resident rooms [ROOM NUMBERS]. The MD took a one ply square of toilet paper and held it flat against the ventilation system cover in the bathrooms of Resident rooms [ROOM NUMBERS]. The ventilation system in these 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 3/7/18 at 1:30 PM with the MD confirmed that there was no air draw in those bathrooms. The MD confirmed that the ventilation systems were not routinely checked for draw to ensure they were operational and, if they were not working, could have an affect on odor control in the facility. The MD confirmed that it had been over a year since the ventilation systems were last checked.",2020-06-01
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
2586,AZRIA HEALTH MIDTOWN,285218,910 SOUTH 40TH STREET,OMAHA,NE,68105,2018-06-12,923,E,1,1,BXNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-007.04D Based on observation and interviews, the facility failed to ensure that the ventilation system was operational in 3 of 35 resident rooms (rooms [ROOM NUMBER]). The facility staff identified the census at 48. The findings are: An environmental tour conducted on 6-11-18 between 1:20 PM and 1:45 PM with the Administrator and the Housekeeping Director revealed the bathroom ventilation system was not functional and would not draw a 1 ply toilet paper square in rooms [ROOM NUMBER]. An interview conducted on 6-11-18 at 1:45 PM with the Administrator confirmed the bathroom ventilation system was not functional and would not draw a 1 ply toilet paper square in rooms [ROOM NUMBER].",2020-09-01
4973,"PREMIER ESTATES OF CRETE, LLC",285170,830 EAST 1ST STREET,CRETE,NE,68333,2018-09-18,689,G,1,0,MJX011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-09D7b Based on observations, record reviews and interviews; the facility failed to ensure that interventions were in place to reduce the risk for a fall with injury for one current sampled residents (Resident 2). The facility census was 52 with 5 current sampled residents. Findings are: Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the incident report dated 8/29/19 at 10:50 PM revealed Resident 2 was noted by aide to be trying to get out of bed. Resident 2 was noted to have leg off bed attempting to get up. Staff immediately went to room and found Resident 2 sitting upright on buttocks beside bed. Resident 2's Care Plan listed a focus area dated 10/15/15 Resident 2 being at risk for falls. The Care Plan identified the following interventions for Resident 2 -Anticipate and meet the resident's needs -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. -Follow facility fall protocol. -Keep needed items, water, etc in reach. -Lower resident bed d/t falls of sliding out of bed -PT evaluate and treat as ordered or PRN. An interview on 9/18/18 at 11:25AM with the corporate nurse confirmed that per the report the Nurse Aide had left Resident 2 on the side of the bed attempting to get up to go get the nurse instead of putting on the call light. Record review of Fall incident for Resident 2 dated 8/29/18 at 10:50PM revealed the staff left the resident on the side of the bed to notify the nurse on duty that Resident 2 sitting on the side of the bed. When staff entered Resident 2's room, the resident was found sitting upright on buttocks beside the bed. The resident obtained a [MEDICAL CONDITION] in the fall. Observations on 9/18/18 at 10:45AM, and 2:55 PM revealed the resident positioned on the bed lying supine.",2020-03-01
5132,SOUTHLAKE VILLAGE REHABILITATION & CARE CENTER,285219,9401 ANDERMATT DRIVE,LINCOLN,NE,68526,2017-02-15,323,G,1,0,O8PQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12.006.09D7b Based on record review and interview, the facility failed to ensure safety interventions were appropriate to prevent injury during a fall for two of three residents reviewed (Residents 5 and 235). The facility also failed to identify causal factors related to resident falls for one of three residents reviewed (Resident 235). The facility census was 114. Findings are [NAME] A review of the Community Transfer Form for Resident 5 dated [DATE] revealed: the resident fell and fractured left hip at the Assisted Living Facility where the resident resided in the Memory Support area prior to admission to the Facility. Resident 5 had a [DIAGNOSES REDACTED]. The resident: was alert and oriented to self only, needed assistance with eating and had torn the hip dressing off several times when restless. A review of the Care Plan dated [DATE] revealed interventions the facility put into place upon admission included: appropriate foot wear, call light, frequent checks, and to remind/encourage to use the call light. The Care Plan did not include recommendations related to Resident 5's transfer ability with order for 50% weight bearing to left lower extremity, or toileting needs for the resident who was incontinent of Bowel and Bladder. A review of the facility's Incident Report and Fall Huddle information revealed that, on [DATE] at 8:00 PM, Resident 5 was found on floor, not able to describe what was doing, confused, walker was next to the resident but (gender) didn't use it, needed to go to the bathroom, complaints of pain, and was sent to Hospital returning to the facility the same day . Further review revealed the resident had a Urinary Tract Infection (UTI) with new orders for an Antibiotic. Interventions put into place included: having the resident's room close to the nurses station, try to anticipate residents needs by placing frequently used items within the residents reach, and hourly safety checks/rounding. Further review of the facility reports revealed Resident 5 fell again on [DATE] at 0300 receiving a fracture to right hip. Factors of the fall included: confusion, found on floor unwitnessed, and UTI. A review of the facility's FALL PREVENTION/MANAGEMENT STANDARD dated (MONTH) (YEAR) revealed each resident would receive adequate supervision and assistance to prevent accidents. The facility maintained a practice that allows for a safe environment for all residents. This includes appropriate assessment of all residents for factors that could place them at risk for accidents and falls. An interview on [DATE] at 2:48 PM with the Administrator revealed it was the expectation that staff complete hourly rounds/safety checks on all residents and the rounding was not documented. The Administrator confirmed the safety interventions put into place for Resident 5, upon admission to the facility, were probably not enough to prevent the resident with a [DIAGNOSES REDACTED]. B. Review of the Face Sheet, dated [DATE], for Resident 235 revealed an admission date of [DATE].Further review revealed Resident 235 had the [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated [DATE] revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 235 had no cognitive impairment. Resident 235 required extensive assistance of one staff for bed mobility, toileting, and dressing. The resident required limited assistance of one staff for transfers, locomotion on and off the unit, and personal hygiene. Resident 235 required supervision with set up help only for eating. The resident was not observed ambulating during the assessment period. Resident 235 had no falls and was on hospice. Review of Resident 235's Progress Notes revealed that, on [DATE] on the night shift, the resident was restless off and on throughout the night. The resident attempted to transfer self independently without calling for staff first to use the bathroom. Resident 235 asked the NA (Nurse Aide) to sit with (gender) most of the night. A PRN (as needed) Ativan (medication for anxiety) was given with little effective results noted. Morphine (a medication used for pain and to ease respirations in hospice patients) was given PRN for discomfort/ and shortness of breath. At 02:30 AM, the resident requested to get up and dressed which the staff assisted with and placed the resident in the recliner in the resident's room. At 04:25 AM, the resident was found sitting on the floor in front of the recliner. The resident revealed the resident was getting up from the recliner to go to the bathroom. Review of the care plan, dated [DATE], revealed the intervention initiated on [DATE] was to give verbal reminders not to ambulate or transfer without assistance PRN. Interview on [DATE] at 3:42 PM with the ADM (Administrator) revealed the resident was very alert and oriented and tried to be independent even though the resident required assistance with transfers and was non-ambulatory. Resident 235 refused fall alarms. The ADM revealed the staff completed rounds every 2 hours and toileted the residents at that time. The ADM denied, after reviewing the medical record, that a bladder assessment or diary had been completed on the resident to determine the resident's pattern, the time of day most likely to need to be toilet, or that a change in the resident's toileting schedule was initiated. Review of the Progress Notes dated [DATE] revealed Resident 235 was observed lying on the bathroom floor at 1:13 PM with blood present on the floor. The resident complained of pain with movement of the right shoulder and arm and a scalp laceration was observed. The resident was transferred to the emergency room for a laceration repair to the scalp. The resident returned to the facility on [DATE] at 6:23 PM. Review of the call light report obtained from the ADM for the date of [DATE] for Resident 235's room revealed the call light in the resident's bathroom was turned on at 12:35:18 PM and turned off at 1:14:08 PM. Interview on [DATE] at 3:42 PM with the ADM revealed an investigation had not been completed to review if the long call light was a causal factor to the resident's fall. Review of the care plan dated [DATE] revealed the intervention initiated on [DATE] was to encourage the resident to wear elastic waistband pants or alter current pants. On [DATE] at 1:28 PM, the SW (Social Worker) entered a note which revealed the SW spoke with the family to obtain some elastic waist dress pants. The family agreed and would address the next day. Interview on [DATE] at 3:42 PM with the ADM confirmed no other new fall intervention was put into place before the family or the facility obtained the resident some clothes with elastic pants. Review of the Progress Notes dated [DATE] revealed the Resident 235 was found on the floor at 5:13 PM in the resident's room. While the staff were moving the resident, the resident became unresponsive, ceased breathing and expired. Interview on [DATE] at 3:50 PM with Staff B revealed when the resident was found on the floor on [DATE] at 5:13 PM, the resident was found in the bathroom, had been on the toilet. and must have been trying to go back to the recliner.",2020-02-01
2365,GOOD SAMARITAN SOCIETY - BEATRICE,285203,401 S 22ND STREET,BEATRICE,NE,68310,2018-08-09,689,D,1,1,QMKR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12.006.09D7b Based on record review, interview, and observation; the facility failed to identify and implement individualized interventions in attempts to prevent falls for residents identified at risk for falls. The facility also failed to investigate resident falls to determine casual factors. These failures had the potential to affect one of five sampled residents (Resident 30) who had been involved in falls. The facility census was 69. Findings are A review of a facility policy for FALL PREVENTION AND MANAGEMENT, revised 10/17, revealed the area titled Proactive Approach before a Fall Occurs (e.g., New Admit) indicated a review of applicable documents (i.e., discharge summary from transferring agency, transfer record, H & P (Health and Physical, lab values, nursing admit/readmit data collection) and any additional admit information documentation for fall risk factors. Care Plan the appropriate interventions, including personalizing all (Specify) areas. A review of Fall Risk assessment dated [DATE], for Resident 30, revealed the resident was admitted to the facility on [DATE] and indicated a score=20, or High Risk for falls. A review of MDS (a mandatory comprehensive assessment tool used for careplanning) information revealed an Admission/5 day assessment, dated 3/6/18, indicated Resident 30 required extensive assistance from 1 staff member for toileting needs and dressing. The documented [DIAGNOSES REDACTED]. A review of the care plan for Resident 30, initiated on 2/27/18, revealed the Resident's [DIAGNOSES REDACTED]. WITHOUT ESOPHAGITIS, OTHER FORMS OF DYSPNEA, NAUSEA WITH VOMITING, UNSPECIFIED, GOUT, MUSCLE WEAKNESS (GENERALIZED), NEED FOR ASSISTANCE WITH PERSONAL CARE, UNSTEADINESS ON FEET, COGNITIVE COMMUNICATION DEFICIT, [MEDICAL CONDITION], UNSPECIFIED, REPEATED FALLS, SHORTNESS OF BREATH, L[NAME]AL INFECTION OF THE SKIN AND SUBCUTANEOUS TISSUE, UNSPECIFIED, UNSPECIFIED OPEN WOUND OF LEFT LESSER TOE(S) WITHOUT DAMAGE TO NAIL, SUBSEQUENT ENCOUNTER. The care plan indicated Resident 30 was at risk for falls related to [MEDICAL CONDITIONS] and history of stroke evidence by a history of falls. Interventions included; Review bowel and bladder continence status and establish and/or review toileting plan based on resident's needs, Review resident's history of recent or recurrent falls. Review resident's medical record for medications or combinations of medications that could predispose to falls/increase fall risk. Contact PT (Physical Therapy) for consult for strength and mobility. Documentation did not include immediate safety interventions put into place to prevent falls, or injury during falls. -A Focus, initiated 5/2/2018 and revised on 7/24/18, documented Resident 30 has had actual falls without Injury related to weakness evidenced by need for walker with all transfers. The document indicated: 5-7-18 no injury, 5-27-18 no injury, 6/12/18 no injury, 7/12/18 bump to forehead, 7/24 skin tear. The goal, initiated on 5/7/18 and revised on 5/29/18, indicated the Resident will resume usual activities without further incident through by review date. Interventions included Review bowel and bladder continence status and establish and/or review toileting plan based on resident needs. staff to offer an assist to bathroom at 2330 and 0330 (initiated and revision date: 05/29/2018). Review of the EMR (Electronic Medical Record) for Resident 30 revealed no documented evidence that a Bowel and Bladder (B&B) assessment had been completed. An observation and interview, on 08/09/18 at 10:15 AM, with Resident 30 in the resident's room, revealed the Resident to be seated in a recliner with the foot rest partially elevated and a wheel chair positioned in front of the recliner within the resident's reach. A faint odor of urine was noted in the Resident's room and several items of wet clothing were noted on the floor, between the resident's chair and the bathroom. The resident reported being able to change clothing independently and the staff will come and pick up the laundry when they have time. An interview on 08/09/18 at 11:15 AM, with the Unit Manager, RN (Registered Nurse)-C revealed that a B&B assessment had not been completed for Resident 30, and the documented care plan interventions had not been completely individualized. RN-C reported that the intervention, initiated on 5/29/18 to assist to bathroom at 11:30 PM and 3:30 AM, had been identified as usual times the resident falls. RN-C confirmed the care plan did not contain information related to individualized interventions initiated upon admission to prevent falls for Resident 30, and that actual falls had not been thoroughly investigated in order to identify casual factors.",2020-09-01
4423,"SCHUYLER CARE AND REHABILITATION CENTER, LLC",285110,2023 COLFAX STREET,SCHUYLER,NE,68661,2018-07-18,808,D,1,1,NXEG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12.006.11A4 Based on observation, record review, and interview; the facility failed to ensure practiontitioner orders were implemented related to enteral feedings. This failure had the potential to affect 1 of 2 sampled residents (Resident 7) with enteral feeding tubes. The facility census was 28. Record review on 07/12/18 at 10:31 AM revealed a Physician order: [MEDICATION NAME](liquid nutrition) as needed for if patient eats less than 50% of meal three times per day in the Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube that is inserted into the stomach for nurtrional purposes), give 1 can of [MEDICATION NAME] water flush after each bolus with 100 milliliters of water three times a day. Interview on 07/12/18 at 03:08 PM with Registered Nurse (RN)-C confirmed that it was difficult to tell what 50% was and the Nurse relies on the nurse aides for the information on what percentage that Resident 22 had eaten. Interview on 07/12/18 at 03:46 PM with RN-C and the Director of Nurses (DON) confirmed that the nurses aides reported to the nurse how much Resident 7 ate and then gave the [MEDICATION NAME] according to what the nurses aide told them. In record review the Interim Director of Nurses confirmed that there was no documentation for the [MEDICATION NAME] on (MONTH) 4 and (MONTH) 9. Interview on 07/16/18 at 09:28 AM with the DON confirmed that there was no documentation on the [MEDICATION NAME] and amount of food intake. Record review on 07/16/18 at 09:06 AM revealed that meal intake for Resident 7 at 12:00 PM meal was recorded as zero (MONTH) 4 and (MONTH) 9. There was no documentation of the [MEDICATION NAME] that was given.",2020-07-01
4957,"PREMIER ESTATES OF CRETE, LLC",285170,830 EAST 1ST STREET,CRETE,NE,68333,2018-01-24,880,F,1,0,TMI511,"**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 failed to ensure infection control concerns had been identified and interventions put into place to prevent the spread of potentially infectious pathogens. The facility also failed to implement infection control measures to prevent cross-contamination during the transportation of potentially infectious clothing and linens. These failures had the potential to affect all 58 residents who reside in the facility. Findings are [NAME] An observation and interview on 1/23/18 at 2:55 PM with the Director of Nursing (DON) revealed the nurse was congested and exhibited an audible stuffed up nose and hoarse voice. The DON reported she had just recently returned to work, following being home sick and treated for [REDACTED]. An interview on 1/24/18 at 10:20 AM with the facility's Maintenance Director revealed the staff member was not feeling well, reporting just a cold, I think. The Maintenance Director exhibited a cough, watery eyes, and an increase in nasal secretions. An observation on 1/24/18 at 12:15 PM revealed Nursing Assistant (NA)-B was wearing a yellow mask over nose and mouth. The NA reported wearing the mask because it was the staff member's first day back to work, after being home sick for two days. The NA continued to have an intermittent cough and runny nose, and reported not wanting to get the resident's sick. The NA was not evaluated by a medical professional prior to returning to work. During an interview on 1/23/18 at 4:00 PM the DON revealed that employee illnesses/infections were not included in the facility's Infection Control Program. A review of the facility's policy titled INFECTION SURVEILLANCE, dated 3/2015, Infection Prevention Procedure 8.3.1 (8) revealed the facility would provide an effective employee health program for all employees. B. An interview on 1/23/18 at 5:00 PM with Licensed Practical Nurse (LPN)-A, revealed Resident 10 was admitted to the facility with septic pressure ulcers. Resident 10's [DIAGNOSES REDACTED]. The LPN reported having previously made an observation of Resident 10's ability and technique related to the urinary self-catheterization. During the observation it was noted that Resident 10 would place the catheter into the resident's mouth during the procedure. When the LPN inquired about the behavior, Resident 10 reported not having enough hands and that the resident had used the technique all the time while at home. The LPN reported that repeated education related to proper technique and infection control concerns had been presented to Resident 10, but the resident continued to be noncompliant with recommendations. The LPN indicated that the teaching provided to Resident 10 had not been included in the nurse's documentation. An interview on 1/24/18 at 3:45 PM with the Director of Nursing indicated the facility did not identify the possible need to implement extra infection control interventions for Resident 10. A review of the facility's policy titled INFECTION SURVEILLANCE, dated 3/2015, Infection Surveillance 8.4 revealed the facility will use a systematic method of collecting, consolidating, and analyzing data concerning the distribution and determining factors of a given disease or event. C. An interview on 1/23/18 at 5:00 PM, LPN-A revealed Resident (11) was admitted to the facility with [DIAGNOSES REDACTED]. The LPN reported Res 11 was non-compliant with recommendations related to the care of the pressure ulcer and would dig at and remove the dressing from the wound on the resident's coccyx area. With the resident's mental health concerns, Resident 11 exhibits poor hygiene skills and does not wash hands very often. A review of Resident 11's Care Plan, with admitted [DATE], revealed a [DIAGNOSES REDACTED]. Continued review of the CP revealed no documentation related to infectious diagnosis. -A review of the website CDC.gov (Center for Disease Control) last updated 1/16/18 revealed [MEDICAL CONDITION] is a liver infection caused by the [MEDICAL CONDITION] virus (HCV). [MEDICAL CONDITION] is a blood-[MEDICAL CONDITION]. Chronic [MEDICAL CONDITION] is a serious disease than can result in long-term health problems, even death. The majority of infected persons might not be aware of their infection because they are not clinically ill. An interview on 1/24/18 at 3:50 PM with the Director of Nursing indicated the facility did not identify the possible need to implement extra infection control interventions for Resident 11. D. An observation on 1/24/18 at 12:00 PM revealed a covered cart with 2 bins one marked linens and one marked trash, in the hallway outside of room [ROOM NUMBER]. A staff member was noted to come out of room [ROOM NUMBER] carrying uncovered linen and clothing items, then placed the items into the covered cart and re-entered the room without visible sign of hand hygiene after leaving or before re-entering the room. An interview on 1/24/18 at 12:15 PM with Nursing Assistant (NA)-B revealed the covered cart noted outside of room [ROOM NUMBER] was where staff placed soiled linens and trash gathered while assisting residents with needed care. The NA reported soiled items and trash should be transported to the cart in a plastic bag. The NA went on to report that hand sanitizer dispensers were in place outside of resident rooms and were to be used whenever staff enter or leave a resident's room. A review of the facility's policy titled INFECTION SURVEILLANCE, dated 3/2015, Infection Prevention 8.3.1 (7) revealed the facility would follow current infection prevention standards and procedures for aseptic, precautionary, and sanitation techniques as written.",2020-03-01
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
6469,PIONEER MANOR NURSING HOME,285212,"P O BOX 310, 318 N 3RD STREET",HAY SPRINGS,NE,69347,2016-02-22,157,D,1,0,SLAG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 2-006.04C3a(6) Based on interviews and record reviews, the facility failed to ensure that; 1) the family/Power of Attorney (POA) was notified of a change in medication for one sampled resident (Resident 1) and, 2) the physician was notified in changes of condition for one sampled resident (Resident 2). The facility census was 49. Findings are: A. Review of the Resident Admission Record for Resident 1 dated as printed 2/22/16 revealed an admission date of [DATE] to the facility. Further observation revealed a [DIAGNOSES REDACTED]. Review of the Resident Progress Notes dated 1/13/16 at 11:56 AM for Resident 1 revealed that the facility had received a new order for [MEDICATION NAME] (an antibiotic). Further review of the notes from 1/13/16 through 1/16/16 revealed no written documentation to support that the family/POA had been notified of the new order for Resident 1. Interview on 2/22/16 at 4:20 PM with (Registered Nurse) RN - A revealed that Resident 1 had been started on [MEDICATION NAME] (an antibiotic) for lung congestion on 1/13/16. Further interview verified that the progress notes dated 1/13/16 through 1/16/16 revealed no written documentation to support that the family/POA had been notified of the new order. Continued interview verified that changes in condition or medication changes are to called to the family/POA for notification. Interview on 2/22/16 at 4:45 PM with the Administrator and the (Director of Nursing) DON verified that Resident 1 did have [MEDICATION NAME] (an antibiotic) prescribed on 1/13/16. Further interview confirmed that there was no written documentation in the resident's record to support that the family/POA had been notified of the new order. Continued interview verified that all change in conditions and changes in cares and treatments should be called to the family/POA. B. Review of the Resident Admission Record dated as printed 2/22/16 for Resident 2 revealed an admission date of [DATE] to the facility. Further review revealed [DIAGNOSES REDACTED]. Continued review revealed that Resident 2 did have a family member listed as a POA. Review of the Resident Progress Notes dated 7/10/15 through 7/16/15 for Resident 2 revealed on 7/10/15 at 4:30 AM that Resident 2 had a bowel movement with, an excessive amount of bright red blood. Further review revealed no written documentation to support that the physician had been notified of the bleeding for Resident 2. Further review of the notes dated 7/15/15 at 10:57 AM, Difficult to awaken .has abraded area on toes right foot noted after bath Further review revealed no written documentation of the physician notified of the abraded area to the toes. Interview on 2/22/16 at 2:30 PM with RN - A revealed that Resident 2 was a total assist with all cares. Further interview revealed that facility process of notification of the family/POA and the physician of changes in condition and changes in cares, medications, or treatments by the staff taking the order should be done as soon as possible. Interview with the Administrator and the DON on 2/22/16 at 4:30 PM verified that the Resident Progress Notes for Resident 2 dated 7/10/15 through 7/16/15 did revealed bleeding following a bowel movement and abrasions of the toes. further interview verified the progress notes and the medical record for Resident 2 did not contain written documentation to support that the physician had been notified of the bleeding or the skin issues. Continued interview confirmed that with an change in condition the physician should have been notified either by phone or fax and had not been for Resident 2.",2019-02-01
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
1088,EMERALD NURSING & REHAB LAKEVIEW,285106,1405 WEST HWY 34,GRAND ISLAND,NE,68801,2018-05-07,656,D,1,1,QN7C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC12-006.09B Based on observation, record review, and interview; the facility failed to ensure Resident #13's care plan contained interventions regarding the development of Urinary Tract Infections (UTI's), development of [MEDICAL CONDITION] (swelling of the ankles and feet), and discharge goals. This affected 1 of 35 residents whose care plans were reviewed. The facility identified a census of 55 at the time of survey. Findings are: Review of the Admission Record dated 1/21/2017 revealed Resident #13 was admitted to the facility on [DATE], medical [DIAGNOSES REDACTED]. Review of the quarterly MDS (Minimum Data Set, a federally mandated comprehensive assessment tool for use in care planning) dated (MONTH) 30, (YEAR) revealed a BIMS (Brief Interview for Mental Status, a brief screening took that aides in detecting cognitive impairment) score of 15 which indicated Resident #13 had no cognitive impairment (15-13 = had no cognition problems). 1. Development of UTI's. Resident #13 was admitted to the facility with an indwelling Foley catheter (a tube that drains urine from the bladder) and developed signs and symptoms of an UTI's that were not documented on Resident #13's care plan. On 12/19/2017 Resident #13's physician was notified of signs and symptoms of a UTI and a UA (urinary analysis to determine if a UTI exists) was collected on 12/27/2017; care plan was not updated to reflect UTI. 2. [MEDICAL CONDITION] Interview with Resident #13 on 05/01/18 at 04:04 PM Resident #13 revealed My doctor and the staff know about my [MEDICAL CONDITION], but there's nothing they can do about it Review of Review of SKILLED D[NAME]UMENTATION-V2 DATED 12/13/2017 01:46 revealed Resident 13 had symptoms of fluid overload including shortness of breath and severe swelling. Review of FAX to Resident #13's physician dated 12/16/17 and faxed 12/16/17 (a Saturday) at 1:08 PM Revealed Resident #13 has had a 23 lb. weight gain in 3 days, 3+ (sever swelling) [MEDICAL CONDITION] in lower extremities Review of SKILLED D[NAME]UMENTATION-V2 DATED 12/18/2017 03:36 REVEALED Resident 13 continued to have symptoms of fluid overload including shortness of breath and severe swelling. Review of Care Plan received on 05/03/2018 revealed no care plan focus, goal or intervention for [MEDICAL CONDITION]. On 05/07/18 at 04:39 PM Interview with DON stated The charge nurse is responsible for updating the resident's care plans as changes occur. If it's not updated by the charge nurse, it should be updated with the MDS if it is in the MDS review time frame. 4. Discharge Review of Resident #13 Care Plan received 05/03/2018 revealed Resident is admitted as a short-stay and will be discharging to my independent living situation. Date initiated:12/02/2017 Review of Resident #13 progress notes revealed: Social Services Progress Notes dated 1/16/2018 SSD (Social Services Director) spoke with Resident about DC (discharge) planning today.' Resident #13 doesn't want to return home, but does not know if wants to stay here for LTC (Long Term Care) and doesn't know if can do ALF (Assisted Living Facility. Review of Resident #13 Social Services Progress Notes dated 3/14/2018 revealed SSD, BOM (Business Office Manager), DON spoke with resident #13 on 3/13 regarding DC plans and house. Resident does not want to return home, but does not know for sure where wants to go. Resident considering apartment in the community On 5/7/2018 at 09:37 Interview with SSD regarding Resident #13's discharge plans revealed When Resident #13 first came the plan was for a very short time to return home, but since (MONTH) (YEAR), Resident #13 wants to stay here, not something long term but for now. Review of Resident #13's care plan received 05/03/2018 revealed it has not been revised since 12/05/2017.",2020-09-01
4951,"PREMIER ESTATES OF CRETE, LLC",285170,830 EAST 1ST STREET,CRETE,NE,68333,2017-04-17,314,G,1,0,WP1A11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC: 12-006.09D2 Based on record review, observation and interview; the facility failed to prevent a pressure sore (a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction) from re-occurring, failed to provide proper care and treatment of the pressure sore and failed to identify worsening of ulcer in order to communicate it to the Interdisciplinary Team (IDT) for revisions of treatment for one (Resident 2) of three sampled residents with wounds. The facility's census was 61. Findings are: [NAME] Review of Resident 2's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning), dated 1/25/17, revealed Resident 2 had no cognitive impairment, did not have any pressure ulcers but was at risk to develop them and had a pressure reducing cushion to the chair and mattress. Review of a later MDS for Resident 2, dated 4/4/17, revealed Resident 2 had a stage 2 (partial thickness skin loss) pressure ulcer, continued to have a pressure reducing cushion to the bed and chair and was receiving pressure ulcer care. Review of Resident 2's care plan revealed a problem initiated on 10/22/15 for an acute pressure ulcer related to immobility and incontinence. Interventions initiated on 10/22/15 included: following the facility policy for prevention and treatment of skin breakdown, notifying others if resident refused treatment, educating the resident and family of new areas of skin breakdown, monitoring the resident's nutritional status and notifying the MD (physician) of any changes to the wound. The only revisions in interventions were as follows: - On 10/18/16, Pressure reduction mattress in place, - On 4/13/17, Administer treatments as ordered and monitor for effectiveness, and - On 4/13/17, Assess/record/monitor wound healing, assess and document status, and report improvements or declines to the MD. Review of Resident 2's Progress Notes, dated 12/20/2016, revealed Resident 2 had a 2 cm (centimeter) x 2 cm reddened, round area noted on resident's coccyx. Review of Resident 2's Progress Notes on 1/23/17 revealed the area was healed. Review of a grievance report filed by Resident 2's guardian on 3/20/17 revealed Resident 2 had a 1 inch slit along the coccyx at that time. Review of Resident 2's Doctor's Progress Notes dated 3/28/17 revealed the pressure ulcer to the coccyx measured 1 cm x 6 cm and was between a stage II and III (a full thickness skin loss involving damage to underlying tissue) with 2 1/2 cm ecchymosis (bruising). The Dr. (doctor) wrote an order for [REDACTED]. Review of a fax to Resident 2's physician on 3/31/17 revealed, coccyx doesn't seem to be improving and a new dressing was ordered to again be changed every 3 days and as needed. The next time the pressure ulcer was documented in the progress notes was on 4/3/2017 by the Registered Dietician (RD) who noted Resident 2 now has a pressure sore on coccyx and has increased nutrient needs recommended that be given (supplement) with each meal. Continue to monitor .status of pressure sore. Resident 2's Progress Notes dated 4/9/17 revealed, Wound to coccyx measures 10 cm in length and 4 cm in width. Wound bed yellow, surrounding skin slightly red. Interview with Resident 2's guardian on 4/13/17 at 9:29 AM revealed an incident when Resident 2's family member was there during the provision of pericare and noted fecal matter to be on the pressure ulcer which did not get cleaned during the provision of cares. The guardian continued to report that Resident 2 had a history of [REDACTED]. Review of a Weekly Pressure Ulcer Report Worksheet for Resident 2's pressure ulcer was measured and staged on 3/28/17 and 4/12/17. The pressure ulcer was 9-10 cm by 4 cm and was staged as a stage I pressure ulcer both times. Observation of Resident 2 on 4/13/17 revealed Resident 2 to be up in the wheelchair from breakfast until after lunch at approximately 2 PM. Resident 2 was sitting on a two toned pressure reducing cushion commonly used for the majority of residents. Observation of Resident 2 on 4/13/17 at 3:50 PM revealed Nursing Assistant (NA) A and NA B providing incontinent care to Resident 2. The dressing was beginning to come loose along the bottom end and brown spots were visible on the underside of the dressing. NA B straightened and pressed the dressing back against Resident 2's skin and, when pericare was complete, NA A and NA B closed the clean brief around Resident 2 and declared they were finished with cares. When asked to remove the clean brief so the Director of Nursing (DON) could inspect the dressing, the DON replied that the dressing was in deed dirty and needed changed. The DON identified the brown matter on the dressing as old dried feces. Once the dressing was removed, additional old fecal matter was visible on Resident 2's skin surrounding the pressure ulcer. The dressing had not been dated as to when it had been applied to Resident 2's skin. Once the soiled dressing was removed, the pressure ulcer had a white tissue exposed with missing skin and was surrounded by a large surface of dark red splotchy skin. Licensed Practical Nurse (LPN) C came into the room to place a clean dressing on the wound and reported that the wound looked exactly like it had when LPN C had last observed it on 4/9/17. The Director of Nursing further stated the wound had never been a stage 1 as documented on the Weekly Pressure Ulcer Report Worksheet. The DON confirmed that the 2 tone wheelchair cushion was a standard pressure reducing cushion residents were given when identified at risk and had Resident 2 had not had a new cushion implemented. Interview with the DON on 4/17/17 at 9:45 AM revealed there was no documentation regarding when the pressure ulcer was originally assessed because the wound originally started out as a maceration. The DON also confirmed there was no documentation that the wound or dressing on the wound was checked by staff on a daily basis to ensure its integrity. The DON went on to explain that the Weekly Pressure Ulcer Report was the only documentation used to assess the wound and that report was then distributed to the IDT and the Quality Assurance Committee for the wound to be monitored for a need of revisions of treatment and interventions. Interview with the DON on 4/17/17 at 4:15 PM revealed no changes were made to Resident 2's mattress after the physician's orders [REDACTED]. The DON also confirmed there was no other documentation regarding the origination of the wound or the potential underlying rationale for the occurrence of the pressure ulcer or that the wound was checked daily. The DON confirmed there had been no revision in interventions in an attempt to prevent the pressure ulcer from reoccurring. Interview with the Dietary Manager on 4/17/17 at 4:35 PM revealed that wounds were communicated to them using the Weekly Pressure Ulcer Report worksheet and, when the stage 1 was identified, Resident 2 was initiated on a supplement. The DM further stated being notified today that the pressure ulcer was more likely a stage III. The protocol would be to notify the Registered Dietician that the wound had worsened to evaluate for a revision in supplement needs. The updated Weekly Pressure Ulcer Report completed on 4/14/17 revealed the wound measured 4 cm x 2.5 cm and was staged as an unstageable (when there is full thickness skin loss but the stage cannot be determined) pressure ulcer with slough (a white to yellowish tissue indicating full thickness skin loss) present. Review of the facility's Skin care and Wound Management Policy dated 6/2015 revealed, The IDT evaluates and documents identified skin impairments and pre-existing signs to determine the type of impairment, underlying condition contributing to it, and description of impairment to determine appropriate treatment. Components of the skin care and wound management program include, but are not limited to, the following: Daily monitoring of existing wounds, monitoring for consistent implementation of interventions and effectiveness of interventions, review and modification of treatment plans as applicable. Communicate changes to the caregiving team, resident/patient and/or family/responsible party.",2020-03-01
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
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
2173,LEGACY GARDEN REHABILITATION & LIVING CENTER,285186,200 VALLEY VIEW DRIVE,PENDER,NE,68047,2018-10-04,686,D,1,1,JIFC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175NAC 12-006.09D Based on interview, record review and observation; the facility staff failed to have interventions in place to prevent continued skin breakdown for a pressure injury (localized injury to skin and or underlying tissue usually over bony prominence, as a result of pressure, or pressure in combination with shear or friction) for 1 sampled resident (Resident 5). The facility census was 34. Sample size was 18 residents. Findings are: Record review of Resident 5's Progress Notes dated 7/26/18 revealed an open area to right gluteal cleft measuring 2cm (centimeter ) length x0.5cm width. The open area was assessed by the ADON (Assistant Director of Nurses) and the open area appeared to be moisture related. A call was placed to the RN (Registered Nurse) with Hospice to assess. Record review of Resident 5's Progress Notes dated 8/9/18 revealed that the W[NAME]N (Wound/Ostomy Care Nurse) from Hospice was at facility and saw the resident's bottom. Record review of the Wound Assessment by W[NAME]N for hospice dated 8/9/18 revealed an identified Pressure Ulcer Stage 2 on the coccygeal area. Wound measurements were: Left coccyx/sacrum 1.4cm length x.cm width [MEDICAL CONDITION] depth, 0.3cm length [MEDICAL CONDITION] width and 0.1cm length [MEDICAL CONDITION] depth. The right coccyx/sacrum and 0.5cmlength x0.5cm depth and 0.1cm length x0.3cm depth all pink tissue bases with outer edges of the wound, skin was abraded and fragile. Resident 5 remained incontinent of urine and stool. The treatment was Stoma-adhesive powder. Record review of Resident 5's Progress Notes dated 8/10/18 revealed the area to coccyx measured 1.5cm length x1cm width, wound bed was dark pink and the edges were macerated. There were 2 open areas to the left buttock that were 1cm length x 0.2cm width and 0.3cm length x 0.3 cm width. The right buttock open areas measured 0.2cm length x 0.2cm width and 0.5cm length x 0.5cm width. All the areas were macerated. The treatment was to continue to apply stoma powder to sites with cares. Record review of Resident 5's Progress Notes dated 8/17/18 revealed that the wound was 6.0cm length x4.5cm width maceration to wound edges with peeling. Moisture related area to left buttock measure 2.3cm length width. Record review of Resident 5's Progress Notes dated 8/24/18 for wound measurements revealed no documentation. Record review of Resident 5's Progress Notes dated 8/31/18 revealed that the open area to coccyx healing and measured 3cm length x1cm width. The wound bed was red. Reposition from side to side. The treatment was done as per order. Record review of Resident 5's Progress Notes dated 9/7/18 revealed the open area to coccyx measured 4.5cm length x1cm width x0.2 cm depth and the wound bed was dark pink and had maceration to wound edges. Treatment was to continue treatment as ordered, to reposition from side to side, and leave open to air. Record review of Resident 5's Progress Notes dated 9/14/18 revealed the wound measured 4cm length x 0.5cm width. The wound bed was pink with no drainage and no odor. Record review of Resident 5's Progress Notes dated 9/21/18 revealed the wound size was 4.5cm length x 0.9cm width and the wound bed was dark pink. The wound had macerated wound edges and to reposition the resident side to side and leave the wound open to air as much as possible. Record review of Resident 5's Progress Notes dated 9/28/18 revealed the wound size as 3.5cm length x 1.6cm width. The wound bed was red. The wound edges were macerated. The wound had no drainage and no odor. The treatment was done per order of Calmospetine to the outer wound edges maceration, reposition resident from side to side. Resident 5 was to have the brief left open to get air to the bottom. Record review of the facility's Pressure Injury Care and Monitoring Policy (last revised on 7/2018) revealed Stage II Pressure Injury is a partial thickness loss of dermis presenting as a shallow open injury with a red/pink wound bed without slough. The pressure injury observation will occur at a minimum of weekly. The initial documentation to be done in Wound Management in Matrix. If the resident is under the care of W[NAME]N (Wound Ostomy Continence Nurse) these measurements may be used. The documentation should be entered into Wound Management in Matrix (software program for medical documentation) after every visit by the charge nurse. All will be documented in Wound Management in Matrix. Record review of Care Plan, Category: Pressure Ulcer dated 4/19/18 with a goal date of 10/11/18 revealed an open area to coccyx from moisture and shearing. The Care Plan Goal was: Resident 5's skin will remain intact, but may have occasional redness in the peri area and groin. Interventions were: heel protectors, skin inspection daily, pay attention to bony prominences and to peri area, pressure reduction mattress on bed and wheelchair, [MEDICATION NAME] powder when ordered, incontinence care and Calmospetine to peri area as needed, report signs of break down, treatments as ordered for skin breakdown, and turn from side to side. Record review of additional information sent from facility via fax (an image of a document made by electronic scanning and transmitted as data by telecommunication links) dated 10/9/18 signed by the DON (Director of Nursing) revealed that the W[NAME]N had seen Resident 5 and that the information on the wound had not been communicated to the facility staff and the primary Hospice nurse. The wound had been measured on 08/31/18, 9/7/28, 9/14/18, 9/21/18, 9/28/18 and 10/5/18. The facility policy states that the pressure injuries are to be measured weekly. Observation on 10/3/18 at 11:50 PM of Resident 5 in the dining room revealed the resident sitting on a Hoyer sling while in the dining area. Observation on 10/04/18 at 02:02 PM of Resident 5's wound care treatment by Staff Member C, RN revealed hand washing was done prior to the wound care. Gloves were applied. The RN called for assistance to turn the resident. The wound was not washed and the stoma adhesive was applied to a wash cloth then applied to the wound. The wound bed was red in color, the wound edges were not jagged, and the wound depth was partial thickness loss with maceration to a large area around the wound. The wound was not measured. Interview on 10/03/18 at 03:47 PM with the DON confirmed that the facility did not have the documentation of the wounds from the hospice team. The DON confirmed that the Wound Nurse from hospice did see Resident 5. Interview on 10/04/18 at 1:30PM with the DON confirmed that once a wound was documented as pressure, then the wound stayed pressure until healed. The DON was not aware that the hospice WN[NAME] (Wound Ostomy Continence Nurse) on 8/9/18 had documented that the wound on the coccyx was pressure related. Telephone interview on 10/10/18 at 8:30 AM with W[NAME]N for Hospice confirmed that Resident 5's wound was a combination of pressure and moisture. The W[NAME]N confirmed that they had not seen Resident 5 since 8/17/2018. The W[NAME]N confirmed that Resident 5 was sitting on a Hoyer sling.",2020-09-01
3661,RIDGEWOOD REHABILITATION & CARE CENTER,285279,624 PINEWOOD AVENUE,SEWARD,NE,68434,2019-09-12,689,D,1,0,ZBUL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175NAC 12-006.09D7b Based on observation, record review, and interview the facility failed to ensure that interventions were followed for hot liquid consumption for 1 resident (Resident 66). This had the potential for the resident to [MEDICAL CONDITION] hot liquid spills. The facility census was 69. Findings are: Record review of the nurse progress note dated 6/16/19 at 1:13 PM revealed that Resident 66 spilled hot coffee on the resident's lap in the dining room. Record review of the nurse progress note dated 6/28/19 at 8:00 PM revealed that Resident 66 spilled hot coffee on the resident's groin (the area between the stomach and the thigh). Record review of the Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 66 revealed that the intervention to cool hot liquids with ice prior to serving was implemented on 6/18/19. Observation on 9/10/19 at 11:52 AM revealed Resident 66 seated in the dining room in a wheelchair. Dietary aide A brought a ceramic cup of hot coffee from the serving room and placed the cup on the table in front of the resident. Interview on 9/10/19 at 11:57 AM with Dietary aide A in the dining room confirmed that the coffee was served to Resident 66 without any ice added to it. Observation on 9/11/19 at 12:33 PM revealed that Certified Nursing Assistant (CNA) B entered the serving room. CNA B obtained a brown plastic cup and poured coffee into the cup and placed a lid on the cup without adding ice to it. CNA B placed the cup on the meal tray and carried the tray to Resident 66's room. CNA B knocked on the door and entered Resident 66's room and informed the resident that lunch was there. CNA B placed the meal tray on the over bed table. CNA B then moved the over bed table in front of the resident seated in the recliner and told the resident there you go and left the resident room. Interview with the Director of Nursing (DON) on 9/12/19 at 12:01 PM confirmed that the care plan for Resident 66 contained an intervention to cool hot liquids with ice prior to serving them to the resident and that all staff should have been educated.",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
1480,"PREMIER ESTATES OF PIERCE, LLC",285139,"P O BOX 189, 515 EAST MAIN STREET",PIERCE,NE,68767,2020-02-19,609,E,1,1,ZDMK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 1[AGE] NAC 12-005.02(8) Based on record review and interview: the facility failed to report potential allegations of resident to resident abuse for Resident's 24 and 30, and a fall with injury for Resident 99. The sample size was 12 and the facility census was 46. Findings are: A. Review of the facility Abuse Prevention and Reporting policy revised 8/2019 revealed: -The facility prohibited the mistreatment, neglect, and abuse of residents, misappropriation of resident property by anyone including but not limited to staff, family, or friends. -Residents had the right to be free from verbal, sexual, and mental abuse, neglect, misappropriation of property, corporal punishment, involuntary seclusion, and any physical or chemical restraint. -Residents must not be subject to abuse by anyone including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family member or legal guardians, friends, or other individuals. -Employees are educated on facility abuse prevention procedures during initial orientation, and every 6 months. -The shift supervisor will report abuse to the Administrator and DON (Director of Nursing). -The appropriate State Agency will be immediately notified by facsimile (fax) or phone and will initiate an investigation according to state specified regulations. B. Review of Resident 24's Care Plan with a revision date of [DATE] revealed: -Resident 24 had impaired cognitive function and impaired though processes related to Alzheimer's Dementia (a progressive [MEDICAL CONDITION] disease that causes loss of cognitive function). -When Resident 24 displayed increased behaviors, the facility was to keep the resident away from other residents to prevent incidents. Review of Resident 24's Progress Notes revealed: -On 1/20/20 at 6:32 PM Resident 24 was exit seeking, hollering at an unidentified resident, hit an unidentified resident in the dining room and was subsequently removed from the dining room. - On 1/2/20 at 10:02 PM Resident 24 yelled, screamed, hit, spit at, and kicked staff. Resident 24 was disruptive to other residents, and called Resident 30 a Son of a [***] . Interview on 2/18/20 at 10:15 AM with the facility Administrator and DON confirmed Resident 24's altercations with other residents on 1/20/20 were not reported to the facility Administrator or DON and therefore were not reported to Adult Protective Services or the State Agency as required. C. Review of Resident 99's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/14/19 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had impaired balance with transitions and had a history of [REDACTED]. Review of a Fall Risk assessment dated [DATE] revealed the resident was at moderate risk for falls. Review of a Post Fall assessment dated [DATE] at 9:45 PM revealed the resident reported a fall in the resident's room. The resident indicated hitting head and left hand with fall. The resident sustained [REDACTED]. The resident was provided with education to use the call light if the resident required assistance. Review of a Nursing Progress Note dated 7/17/19 at 10:00 PM revealed the facility had received a phone call from the community ambulance service informing the facility that Resident 99 was being transferred to the emergency room . The resident had a fall and was bleeding from the head. The nURSING Progress Note further revealed the resident had signed self out of the facility at 8:13 PM. The resident later returned to the facility with family and had a 5 cm laceration above the resident's left eye which had been glued closed in the emergency room . Review of a Post Fall assessment dated [DATE] at 10:00 PM revealed a new intervention for the resident to have supervision whenever leaving the facility. Review of a Nursing Progress Note dated 7/18/19 at 2:57 PM revealed the laceration above the resident's left eye was well approximated and the resident now had bruising to the left eye and into the cheek. Review of facility investigations of potential abuse/neglect for 7/2019 revealed no evidence the State Agency was notified of Resident 99's fall with injury. Interview with the Administrator on [DATE] at 9:22 AM confirmed Resident 99's injury from a fall which required an emergency room visit and treatment was not reported to the State Agency.",2020-09-01
1522,AZRIA HEALTH SUTHERLAND,285141,"P O BOX 307, 333 MAPLE STREET",SUTHERLAND,NE,69165,2019-03-05,609,D,1,0,5IWK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 1[AGE] NAC 12-006.02(8) Based on record reviews and interview, the facility failed to verify that an investigation report was submitted successfully per facsimile to the State Agency as required for one closed record sampled resident (Resident 1). The facility census was 40 with one closed resident record and two current sampled resident records reviewed. Findings are: Review of the facility Investigation Report Template revealed that Resident 1 fell on [DATE] and the investigation was completed on 1/11/19. Review of the facility facsimile cover sheet, dated 1/16/19, revealed no verification that the facsimile was successfully submitted to the State Agency. Interview with the Administrator on 3/5/19 at 10:10 AM confirmed that there was no evidence that the investigation was successfully submitted to the State Agency as required.",2020-09-01
1724,GOOD SAMARITAN SOCIETY - BLOOMFIELD,285156,"P O BOX 307, 300 NORTH SECOND ST",BLOOMFIELD,NE,68718,2019-11-18,600,D,1,0,VD1S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 1[AGE] NAC 12-006.05(9) Based on record review and interview: the facility failed to protect Resident 1 after an allegation of potential abuse and/or neglect. The sample size was 4 and the facility census was 36. Findings are: A. Review of the facility Abuse and Neglect Policy (revised 10/2018) revealed the residents had a right to be free from abuse, neglect, misappropriation of resident property and exploitation. If an employee received an allegation of abuse, neglect, exploitation or misappropriation of resident property; the employee was to take measures to protect the resident and to report the allegation to a supervisor. If the allegation is of potential employee to resident abuse, the employee was to be removed from providing direct cares to all residents. Additionally, the employee was to be placed on suspension pending the results of the investigation. B. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/16/19 revealed the resident's cognition was moderately impaired with [DIAGNOSES REDACTED]. No behaviors were documented and the assessment further indicated the resident's behaviors had improved. Review of an Adult Protective Services facility self-report dated 10/25/19 at 9:58 AM, the facility reported an allegation of potential staff to resident abuse. Resident 1 had reported on the evening of 10/24/19, Licensed Practical Nurse (LPN)-F had thrown a cup of medications at the resident and had scratched the resident in the face. The facility reporter indicated an internal investigation was to be completed and LPN-F would continue to work at the facility while the investigation was completed with limited access to Resident 1. Review of the facility Nursing Schedule for 10/2019 revealed LPN-E worked as a Charge Nurse on the following dates and times: -10/24/19 6:15 PM to 6:30 AM; -10/25/19 6:30 PM to 7:00 AM; and -10/26/19 6:30 PM to 12:00 AM. During an interview on [DATE] at 10:30 AM, Registered Nurse (RN)-A confirmed LPN-E continued to work and to provide direct resident cares throughout the investigation of Resident 1's allegation of potential staff to resident abuse. In addition, during this time, LPN-E was the only nurse scheduled and continued to provide Resident 1 with all ordered medications and treatments. RN-A confirmed the facility had failed to follow the Abuse and Neglect policy and LPN-E should have been suspended until the completion of the potential abuse investigation.",2020-09-01
5887,"SORENSEN CARE AND REHABILITATION CENTER, LLC",285107,4809 REDMAN AVENUE,OMAHA,NE,68104,2016-08-16,223,J,1,0,ROML11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number : 175 NAC 12-006.05 (9) Based on observations, record review and interviews; the facility failed to protect Resident 2 from residents with sexual behaviors. The facility census was 69. Findings are: A. Review of the facility investigation dated 8/1/2016 revealed Resident 2 reported to the Social Services Designee(SSD) that Resident 1 came into the sunroom where Resident 2 was reading and Resident 1 exposed genitals to Resident 2. Resident 1 then attempted to kiss Resident 2, at which time, Resident 2 told resident 1 to leave and kicked at Resident 1 who did leave. However, Resident 1 returned to the room dancing with genitalia exposed. Review of Resident 2's most recent MDS (Minimum Data Set: a federally mandated assessment tool used for care planning) dated 5/26/2016 revealed Resident 2 score was 15, indicating Resident 2 was cognitively alert and oriented and able to make decisions. Interview on 8/3/2016 at 10:00 AM with Resident 2 revealed Resident 2 confirmed the same information that was in the facility report. Resident 2 revealed that the incident with Resident 1 was really creepy and made Resident 2 very uncomfortable. Resident 2 stated (gender) did not want Resident 1 around. Resident 2 revealed a similar incident had happened about 1 1/2 years ago and Resident 1 had touched Resident 2 which that was uncomfortable also. Record review of Resident 2's medical record revealed an untitled document dated (MONTH) 27, (YEAR), indicating that Resident 2 was concerned about another resident coming into Resident 2's room. Interview on 8/3/2016 at 2:30 PM with the Administrator revealed the other resident referred to in the document was Resident 1. Interview on 8/3/2016 at 11:30 AM with the Director of Nursing (DON) revealed that Resident 1 did walk outside in the fenced in area and had been seen looking in Resident 2's window before Resident 2 was moved to the current room. Review of Resident 1 MDS dated [DATE] revealed Resident 1 scored an 8 on the cognitive assessment indicating Resident 1 was moderately cognitively impaired. Review of Resident 1's care plan dated 7/26/2016 revealed resident had exhibited behaviors including inappropriate touching toward facility staff and required redirection from staff regarding inappropriate behaviors. Interview on 8/3/2016 at 10:15 AM with the Assistant Director of Nursing (ADON) revealed that, when informed of the allegation by the SSD, the staff were instructed to start 15 minute checks on Resident 1. Record review of Resident 1's facility form titled 15 minute checks revealed no sheet for checks on 8/1/2016, no documented checks from midnight until 6:00 AM on 8/2/2016 and no documented checks from 1:30 PM on 8/2/2016 until 6:00 AM on 8/3/2016. Observation on 8/3/2016 completed of Resident 1's room between 9:15 AM until 10:00 AM revealed no staff opened Resident 1's door to visualize Resident 1 during the 45 minute period. Review of the facility document titled 15 minute checks dated 8/3/2016 for Resident 1 revealed Licensed Practical Nurse (LPN) V documented checks were completed during the 9:15 AM until 10:00 AM timeframe. Interview on 8/3/2016 at 10:10 AM with the DON revealed the expectation for 15 minute checks were that the staff visualize the resident to assure the residents location. The DON stated the staff document on the facility form titled 15 min(minute) checks after checking on the resident. The DON stated, if they did not enter the room or open, Resident 1's door, the staff did not complete the checks. If the 15 minute check form was not completely filled out, it would be considered the checks were not done. Interview on 8/3/2016 at 11:30 AM with LPN-V revealed LPN-V documented Resident 1 was checked because Resident 1's door was shut and Resident 1 usually did not get up until 10:30 or 11:00 AM. When asked if LPN V visualized Resident 1 by opening the door and looking in the room, LPN V stated No . Interview on 8/3/2016 at 4:00 PM with the Administrator revealed the staff were not monitoring Resident 1 in a manner to protect other residents from Resident 1's behaviors. B. As outlined by the Administrator of the facility on 8/3/2016 at 3:00 PM, the facility initiated the following plan to address the immediacy of the situation. Resident 1 was placed on one to one observation with an assigned staff member and staff education would begin with all staff regarding the facility abuse policy, including proper reporting, proper execution of fifteen minute checks, including proper documentation. All employees were to be educated as they reported to work, both clinical and non-clinical. All employees not scheduled to work within the next two days were to be educated in a group setting and/or over the telephone.",2019-08-01
2484,CROWELL MEMORIAL HOME,285210,245 SOUTH 22ND STREET,BLAIR,NE,68008,2017-11-22,279,D,1,1,ROX111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number NAC -006.09C Based on observations, record review and interviews; the facility failed to develop a comprehensive care plan related to potential restraints for 2of 2 residents sampled, (Resident 41 and 67), and for the use of psychoactive medication for 1 of 5 residents sampled (Resident 26). The facility census was 61. Findings are: Record review of Resident 41's Face Sheet dated 11/21/17, revealed that Resident 41was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 11/20/17 at 3:43 PM, Resident 41 was sitting in room with tilt wheelchair tilted to have knees higher than than resident's head and chest. Knees remain in bent position, Resident 41 was sleeping. Interview with Nursing Assistant (NA) C, on 11/20/17 at 10:42 AM, revealed that the tilting wheelchair was tilted so that the Resident 41 could not get up from the wheelchair. Interview with NA D on 11/20/17 at 10:42 AM revealed that, Resident 41 was in the tilted wheelchair for his and others safety. NA D revealed that when in recliner Resident 41 would slide forward to the floor. NA D revealed that Resident 41 is unable to lean forward and fall, and is unable to reach as far when striking out with fists at others. Resident 41 becomes aggressive with other residents and is unable to reach the other residents when tilted back. Interview with facility Licensed Practical Nurse (LPN) [NAME] confirmed that Resident 41 was in he tilted wheel chair to prevent falls. LPN [NAME] revealed that Resident 41 did fall recently, due to someone not tilting the wheelchair back after toileting, Resident 41 was able to lean forward and fall out. Interview with RN F, on 11/21/10:35 AM, confirmed that the facility had not performed an evaluation of the tilt wheelchair, for Resident 41, as a restraint device. RN F confirmed that the interdisciplinary team had not met to review or assess a least restrictive device for Resident 41. RN F confirmed that the Tilt wheelchair was not in Resident 41's plan of care. B. Observation on 11/17/2017 at 2:34 PM of Resident 67 in a Merry Walker (a device to assist residents to walk independently) and was walking in hall with a staff member. Interview on 11/20/2017 at 3:01 PM with Director of Nursing (DON) revealed education was provided to staff regarding the purpose and proper use of the Merry Walker. Review of Resident 67's care plan revealed no intervention for use of Merry Walker were included in the Resident 67's comprehensive care plan and no reason was evaluated for the use of a potential restaint. Interview on 11/20/2017 at 3:05 PM with the DON revealed the Merry Walker should be on the care plan . C. A review of Resident 26's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 8-9-17 revealed that Resident 26 was admitted to the facility on [DATE] and was receiving an antidepressant daily. A review of Resident 26's Care Area Assessment Worksheet dated 8-10-17 revealed that resident was receiving the Antidepressants [MEDICATION NAME] and [MEDICATION NAME] for depression and that this would be addressed on the care plan. A review of Resident 26's Medication Administration Records for (MONTH) (YEAR) and (MONTH) (YEAR) revealed that Resident 26 was receiving both [MEDICATION NAME] and [MEDICATION NAME] on a daily basis. A review of Resident 26's Comprehensive Care Plan revealed that the care plan did not address that the resident was on Antidepressants for depression, the target behaviors to be monitored, or interventions related to the meet the resident's needs. An interview conducted on 11-21-17 at 1:30 PM with the Director of Nursing confirmed that Resident 26's Comprehensive Care Plan did not address the resident's use of medications for depression, behaviors, or interventions and it should have.",2020-09-01
2679,HERITAGE OF EMERSON,285222,607 NEBRASKA STREET,EMERSON,NE,68733,2017-08-31,314,G,1,1,AEM711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number NAC 12-006.09D2a Based on observation, record review and interview, the facility failed to prevent an avoidable pressure ulcer for Resident 8, and failed to assess the pressure ulcer to reflect accurate staging of a pressure ulcer for Resident 13. Facility census was 30 . Findings are: [NAME] Record review of Resident 8's Face Sheet revealed the admission date of [DATE], with [DIAGNOSES REDACTED]. Supra-pubic (above the pelvis) Catheter for urine drainage. Record review of Resident 8's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 5/17/17 revealed that Resident 8 required extensive assistance of one person for bed mobility, transfer, to walk, to dress, and to use the toilet. Observation of Resident 8 on 8/29/17 and 8/30/17 from 9:30 AM to 4: 00 PM revealed Resident 8 was assisted from the dining room after breakfast and placed into the recliner in room. Recliner had two separate cushions to relief pressure, one on top of the other. Resident 8 did not go for lunch on 8/29 or 8/30/17. The resident remained in room seated in the recliner. Interview on 8/30/17 at 4:46 PM with NA (Nursing Assistant ) G revealed that the NA was not aware that Resident 8 had a wound. NA G revealed that, if NA G had been aware of Resident 8 having a pressure area, NA G would have repositioned the resident every two hours to relieve pressure and encouraged Resident 8 to lay down during the day. NA G confirmed that Resident 8 was not repositioned every 2 hours when in the recliner. Interview on 8/31/17 at 8:13 AM with RN (Registered Nurse) B confirmed that, once the NA's get Resident 8 up in the morning, the resident stayed up in the chair all day and did not lay down. RN B confirmed that Resident 8 did have a pressure relief cushion in the chair but was not positioned off the coccyx (tail bone) or asked to lay down in the bed. Observation on 8/31/17 at 9:56 Registered Nurse B observed to perform wound care to Resident 8's coccyx to reveal an open area. Record review of Braden Scale for Predicting Pressure Ulcers, dated 8/16/17 and 8/30/17, revealed Resident 8 was at risk for Pressure sores with the score of 17 (The Braden Scale indicates this is mild risk). Record review of Pressure Ulcer Record for Resident 8, dated 8/31/17, revealed that Resident 8 had a facility acquired Pressure Ulcer. The Pressure Ulcer Record, revealed that date of onset for the coccyx wound was 8/30/17 and it measured 1.5 cm x 0.6 cm (wounds are measured in centimeters (cm) with length x width x depth and any tunneling) that was un-stageable with depth not determined due to slough present in wound. Specialty Interventions needed were wheel chair cushion. Progress note summary revealed that the wound bed had over 50% yellow slough (dead tissue that is separating from the wound bed), and that surrounding tissue was normal for skin tone. The area was covered with [MEDICATION NAME] (a foam dressing with self-adhesive) after cleansing. There were no signs and symptoms of infection at the time. Record of facility plan of care revealed that on 12/3/14 Resident 8 was identified as a Potential for skin breakdown related to decreased mobility. The goal set for Resident 8 was to maintain intact skin integrity. The approaches last updated on 3/8/17 revealed: *weekly and as needed (prn) skin monitoring by professional nurse * Braden Scale quarterly and as needed * offer fluids * Dietician to evaluate resident nutritional status as need * Provide peri care after each incontinent episode * Encourage repositioning. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 8/31/17 at 10:31 AM confirmed that Resident 8 was at risk for pressure ulcers, per the Braden assessment. DON and ADON confirmed that, according to the facility policy of avoidable vs unavoidable, that Resident 8 acquired un-stageable wound would have been avoidable. The DON and ADON confirmed that Resident 8 did not leave the room for lunch and was positioned in the room in the recliner after breakfast until evening meal. B. Record review of the Face Sheet for Resident 36 revealed an admission to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident 36's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated (MONTH) 16, (YEAR) revealed that Resident 36 required: * Extensive assist of two for bed mobility. * Total dependent on assist of two for Transfers. * Unable to walk in room or in corridor * Total dependent on assist of one for locomotion on or off the unit * Extensive assist of two for dressing * Extensive assist of one for personal hygiene. * Resident always occasionally incontinent of urine. * Resident always continent of bowel. * Resident has 1 Un-stageable wound with l sough and or eschar (dark hard, scab like tissue covering the wound), measuring 2.5 cm length x 1 cm width and 1 cm depth. Record review of Resident 36's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated (MONTH) 06, (YEAR) revealed that Resident 36 have changes and required: * Transfer changed to Extensive assist of two * Locomotion on and off unit with supervision one person to assist. * Personal hygiene with limited assist of two persons. * Resident had 1 stage 2 pressure ulcer * No un-stageable pressure ulcers with no measurements. Record review of Pressure Ulcer Record dated 5/8/17 revealed that Resident 36 had a unstageable pressure ulcer to the coccyx/tailbone area that measured 2.5 x 1 x 1 cm with small yellow wound surrounding skin dark red purple. Pain was present related to the wound. Resident was admitted to the facility with pressure ulcer. Record review of Pressure Ulcer record dated 5/28 revealed that Resident 36 had a unstageable pressure measuring 2 cm x 1 cm x 2 cm with undermining and serous (clear liquid) exudate. A small amount of the wound was red/yellow with surrounding skin pink. Pain was present . Record review of Physician visit dated 6/12/17 revealed that Resident 36's had a pressure sore to coccyx with length and width decreasing but had tunneling. Measurements taken were 1.4 cm x 1 cm x 1.2 cm with tunneling measuring 2 cm. Record review of Pressure Ulcer Record date of 7/10/17 revealed Unstageable wound 1.2 x 1 x 2.1 with tunneling, serous and purulent (infected) exudate with odor. The wound bed was red with white gray pallor and surrounding skin macerated. Record review of Consulted Wound Care, dated 8/4/17, revealed that Resident 36 had a pressure ulcer that was a stage III and required culture. Also, Resident 36 was to start on antibiotics. Record review of Consulted Wound Care, dated 8/15/17, revealed that Resident 36's pressure ulcer was a stage IV and measured 1/5 x 1 x 2 cm with tunneling of 3 cm at 11 o'clock. Record review of Consulted Wound Care, dated 8/25/17, revealed Resident 36 had a Stage IV Pressure Ulcer with measurements of 2 cm x 1.5 cm x 2 cm with tunneling of 3 cm at 11 o'clock. Record review of Physician order, dated 6/26/17, revealed an order for [REDACTED]. Record review of Resident 36's Plan of Care, dated 5/8/17 revealed Resident had stage II pressure ulcer to coccyx or potential for ulcer development, with target date of 9/25/17. Interview with DON on 08/29/17 at 3:14 PM revealed that Resident 36 had a Stage II Pressure Ulcer. The DON revealed that, was not aware that it was un-stageable upon admission. The DON confirmed that Resident 36 was going out to receive recommendations from Wound Care Nurse. The DON confirmed that the facility sent a Physician Visit Communication Form with residents for appointments. The DON confirmed that the facility did receive back the form with orders. The DON confirmed that the facility had not requested the Wound Care Center's documentation of the visit with wound measurements or staging. Interview with the DON and ADON, on 8/31/17 at 10:31 AM, that staff (including the DON and ADON) have had no formal training to assess pressure ulcer wounds and that Resident 36's Pressure ulcer did not reflect an accurate assessment of staging of Resident 36's pressure ulcer stages.",2020-09-01
3635,"SUTTON COMMUNITY HOME, INC.",285277,1106 NORTH SAUNDERS,SUTTON,NE,68979,2019-10-29,695,D,1,0,4MH411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number NAC 12-006.09D6 Based on record review, interview, and observation the facility failed to educate residents on the adverse effect of smoking with oxygen on. This affected 1 of 2 residents sampled. The facility census 29. Findings are: Record review revealed that resident 1 had gone outside to smoke and the residents oxygen was on at 2 LPM, the staff immediately went to the resident and educated on [MEDICAL CONDITION] accidents that happen with oxygen wearers and smoking. Record review revealed that care plans, physician orders, educational materials, and smoking safety screen were completed on this resident, on 10/21/19. Physician orders [REDACTED]. Record review revealed nursing staff had an inservice on oxygen of what to do and not do when residents smoke and other occurances that affect oxygen use. Interview with Resident 1, on 10/29/19 at 12:30 PM revealed that the resident had forgotten about oxygen that day, the education was good, and staff reminds the resident and accompanies resident outside. Observation on 10/29/19 at 12:30 PM revealed that Resident 1 was outside smoking with staff and the resident was not wearing oxygen. Interview on 10/29/19 at 3:30 PM with the Director of Nursing, confirmed that the resident had gone out without taking oxygen off, was educated, reevaluated with the Smokers Safety screen tool for this resident.",2020-09-01
5484,GOOD SAMARITAN SOCIETY - WOOD RIVER,285198,1401 EAST STREET,WOOD RIVER,NE,68883,2018-05-22,686,E,1,0,NLW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number NAC 175 ,[DATE].09D2a Based on record review, interview and observations; the facility failed to ensure assessments were accurate and interventions were implemented to prevent pressure ulcers (bedsores (decubitus ulcers) are caused by pressure to areas of skin when resting in a position for too long. Complications can be serious) affecting 4 of 5 sampled residents (Residents 1, 5, 7, and 23). The facility also failed to ensure residents received treatment and services to promote healing, prevent infection and to prevent the decline in condition for 3 of 5 sampled residents. Findings are [NAME] A review of the Care Plan for Resident 1, noted to be closed on [DATE], revealed the resident had an ADL (Activities of Daily Living) self care performance deficit evidenced by inability to walk. The focus was initiated on [DATE], and revised on [DATE]. Interventions included: a wheelchair (w/c) was utilized for locomotion, the resident was able to propel self in the w/c; however, the resident was only to be up an hour at a time. The date initiated: [DATE], with revision on [DATE]. Resident was not toileted, but changed in bed due to Stage IV Sacral (bottom) Decubitus (Stage 4 pressure sores extend to muscle or bone and generally are past the point where they will heal with pressure avoidance or nursing measures--they usually need surgery) with date Initiated: [DATE]. The resident required 1 staff participation to reposition and turn in bed with date Initiated: [DATE], revised and canceled on [DATE]. The resident had a potential impairment to skin integrity evidenced by decreased mobility. An entry dated [DATE], indicated scattered macerated areas to let buttock, on [DATE] a blister to the resident's left lower leg, an entry dated [DATE] identified an area on right 2nd toe, an entry dated [DATE] documented an Untstageable area to coccyx. Seen by wound center for evaluation and debridement with date Initiated: [DATE],and Revision on [DATE]. [DATE]. Interventions included: [DATE] IV (intravenous) antibiotic therapy, Wound vac on hold , and orders for wound care dressing, to monitor location, size and treatment of [REDACTED]. Weekly skin observation by licensed nurse. Date Initiated: [DATE]. The Care Plan did not include documentation related to interventions put into place to prevent new or declining pressure ulcers prior to [DATE]. An entry dated [DATE] indicated the resident had a terminal prognosis related to Stage lV Sacral Decubitus. Interventions included: Air mattress provided by hospice used to maximize comfort. An interview on [DATE] at 10:00 AM with the Facility's Corporate Clinical Registered Nurse (RN-C) revealed the RN had identified that the facility had concerns related to the documentation of wounds and follow up of status, occurring approximately the end of Feb (YEAR). The RN confirmed Resident 1's Care Plan had not been updated to indicate the declining wound area or pressure relief interventions. A review of Resident 1's Discharge Summary, dated [DATE], revealed Resident 1 died . Documentation indicated the resident had very fragile skin. Had [DIAGNOSES REDACTED] (redness of the skin) area to coccyx (tailbone area) which started out as non-pressure area. In short area became open and unable to heal. Resident was receiving special treatment to coccyx wound, on pressure relieving mattress and cushion in wheelchair. B. Review of Progress Notes for Resident 5, dated [DATE]-[DATE], revealed: the Resident was readmitted from an acute hospital. A note dated [DATE] at 3:31 AM indicated an open area was noted to buttocks-the note did not include further description of the resident's wound or documentation of actions taken. A COMMUNICATION/VISIT WITH PHYSICIAN note dated [DATE] at 9:51 PM, indicated the resident had a Stage 3 PU (Pressure Ulcer), without further description of the wound area. Notes dated ,[DATE] and ,[DATE] indicated the resident's buttocks area was referred to as a moisture ulcer without further description of the wound status. On [DATE] an LPN (Licensed Practical Nurse) documented the buttocks was healed and treatment order was discontinued. Further review of the resident's electronic medical record revealed no indication of assessment per Registered Nurse (RN) or Primary Care Practitioner (PCP). A noted dated [DATE] indicated a new air mattress was placed on resident's bed, with no further documentation related to preventative interventions. A review of Resident 5's Care Plan (CP) with print date [DATE] revealed the Resident's original admission to the facility was [DATE]. A Focus, initiated on [DATE], indicating the resident had impaired skin integrity related to decreased mobility and incontinence as evidenced by a history of PU, had not been revised to reflect the open, Stage 3 PU to Resident 5's buttocks (identified in Progress Notes dated ,[DATE]-[DATE]). Review of a Quarterly MDS assessment dated [DATE], for Resident 5 revealed no documented information related to the now healed Stage 3 PU. The facility RNs identified as completing and reviewing the document were RN-A and RN-G. An interview on [DATE] at 1:30 PM, with the Facility's Wound Care Nurse (RN-B) revealed Resident 5's Medical Record did not include the required weekly documentation of assessment and follow up, and confirmed the resident's care plan had not been updated to indicate current level of need, interventions put into place related to prevention and healing of the Resident 5's buttocks wound. C. A review of Wound Data Collection documents for Resident 7 revealed discrepancies related to the number, size, and location of the Resident's wounds. A Review of MDS assessments for Resident 7 revealed discrepancies related to documented skin concerns. An assessment dated [DATE], indicated the resident: was at risk for but did not have pressure ulcers, had no Venous/Arterial (caused from poor blood circulation) or surgical wounds. The assessment did indicate Moisture Associated Skin Damage (MASD) treated with ointment, as well as pressure reducing devices in chair and bed. An assessment dated [DATE], indicated the resident had a Stage 2 Pressure Ulcer which was documented as identified on [DATE] (prior to ,[DATE]'s assessment). Documentation of the Skin and Ulcer Treatments included: pressure reducing devices to chair and bed, turning/repositioning program, nutrition or hydration intervention to manage skin problems, pressure ulcer and surgical wound care. An assessment dated [DATE] continued to indicate one Stage 2 pressure ulcer. The Date of oldest Stage 2 pressure ulcer was documented as [DATE]. An interview on [DATE] at 10:00 AM with Registered Nurse (RN)-Corporate Clinical (C) revealed the RN had identified that the facility had issues related to documentation of wounds and follow up of status. The Corporate RN has been working with the Facility's Wound Care Nurse in attempts to ensure knowledge of the multi-faceted requirements related to resident skin integrity and ultimately improve the facility's outcomes for residents involved. RN-C confirmed the MDS discrepancies and that wound documentation was incomplete and needed to include preventative measures put into place by the facility. D. On [DATE] starting at 1:40PM until 3:00PM Resident 23 was not repositioned for 1 hour and 40 minutes. Observation on [DATE] at 11:45 AM revealed that Resident 23 was in tilt in space wheel chair from breakfast until 11:45 AM. Record review of Resident 23's care plan revealed Resident #23 had no care planned interventions or new goals for new skin integrity issues dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Record review on [DATE] at 4:00PM of Resident 23's wound documentation revealed missing information on documentation that included; description of wound, measurements of wounds and multiple assessments had no documentation on location of wound. Record review on [DATE] 3:45PM revealed no documentation was provided for hourly turning for Resident 23. Interview on [DATE] at 1:30PM with DON (Director of Nursing) confirmed Resident 23 was on an every hour turning schedule and last up first down for meals. Interview on [DATE] at 3:07 with Nurse Aide F revealed Resident 23 was to be repositioned every hour. Interview on [DATE] at 3:08 with Nurse Aide [NAME] revealed that Resident 23 was to be repositioned every 2 hours and this staff member did not know what Resident 23's plan of care was at the time. Interview on [DATE] at 3:45 PM with the Corporate Nurse Consultant confirmed that there was no documentation for the every hour turning and confirmed that the documentation.",2020-01-01
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
5744,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2016-09-20,314,D,1,0,TD4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number NAC 175 12-006.09D2b Based on observations, interviews and record reviews the facility failed to prevent and promote the healing of pressure sores for one sampled resident (Resident 25). The facility census was 114. Findings are: Review of the Admission Record for Resident 25 revealed an admission date of [DATE] to the facility. Further review revealed [DIAGNOSES REDACTED]. Review of the Care Plan dated as initiated 7/12/16 for Resident 25 revealed an actual pressure ulcer, unstageable area to mid back/spine and was at risk for the development of pressure ulcers. Interventions were to provide pressure reduction/relieving mattress, skin care after incontinent episodes and apply skin barrier. Further interventions included turning and repositioning schedule per assessment. Review of the Weekly Skin Review dated 8/24/16 revealed an open area in the curve of the spine, mid back, reddened area to upper back, open area to shoulder blade area, reddened area near arm pit area, reddened area to should blade area, reddened area left trochanter hip, and reddened area to mid calf on right lower leg. Review of an email dated 11/30/15 with the manufacturer (No name) and LPN (Licensed Practical Nurse) - GG revealed, Keep the amount of padding between the resident and bed to a minimum for optimum performance. Further review of an email dated 11/24/16 revealed , choose positioning devices and incontinence pads, clothing and bed linen that are compatible with the support surface. Limit the amount of linen and pads placed on the bed. Observation on 9/14/16 at 10:00 AM revealed Resident 25 lying on a specialized air mattress and positioned onto the left side. Further observation revealed that the special air mattress was covered with a flat white sheet. Continued observation revealed that there was a draw sheet under the resident that was folded x 4 between the resident and the sheet on the special air bed. Further observation revealed that the resident was covered with a blanket. Observation on 9/14/16 at 4:00 PM revealed the dressing change for Resident 25 completed by LPN - DD and LPN - FF. During the repositioning of the resident, it was noted that a draw sheet was on top of the flat sheet covering the air mattress (specialized bed) and the sheet had been folded in half and then folded over again creating 4 layers of draw sheet material between the resident's skin and the flat sheet on the mattress. Interview with LPN - FF on 9/7/16 at 10:00 AM revealed that Resident 25 did have one unstageable pressure area to the mid back spine area and was at risk for pressure ulcers. Continued interview revealed that the resident had multiple reddened area to the back, shoulder blades and the illiac area which have healed, reappeared and healed again. Further interview revealed that the resident was not admitted to the facility with a pressure sore. Continued interview revealed that the resident did have a fair intake with encouragement. Further interview verified that the resident was on hospice cares and was also on a speciality air mattress. Interview on 9/14/16 at 4:30 PM with LPN - DD and LPN - FF after the dressing change for Resident 25 verified that Resident 25 should not have been lying on a draw sheet as the resident was supposed to have the least amount of material between the skin and the air mattress to promote wound healing and pressure relief. Interview on 9/19/16 at 4:00 PM with the Administrator and the Director of Nursing DON revealed that the Resident 25 was on a specialty air bed, did have pressure ulcers and was at risk for developing more pressure ulcers. Further interview verified that placement of the folded draw sheet under the resident on 9/14/16. Continued interview confirmed that the layers of sheets or material under the resident should have been minimized to provide the best possible air flow and reduced pressure to the skin of the resident. Continued interview revealed that the resident did have poor intake, and end of life with the possibility of more pressure ulcers in the coverings on the bed are not conducive to promote healing.",2019-09-01
1993,FLORENCE HOME,285173,7915 NORTH 30TH STREET,OMAHA,NE,68112,2017-12-06,689,D,1,1,CVPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number NAC 175 12-006.09D7a Based on observation, and interview, the facility failed to ensure medications were secured on the 3rd floor, this had the potential to affect 5 residents who were self-mobile with cognitive impairment. The facility census was 68. Observation on, 12/06/17 at 1:26 PM, medications were present on top of medication cart found in hallway, with no staff present. RN H could be heard in nearby room with a resident. Medications found on top of the medication cart included: [MEDICATION NAME] (prescribed pain medication), Senna (laxative/stool softener), [MEDICATION NAME] (stomach acid reducer), Tylenol (over the counter pain medication), Memantine (blood pressure medication), and [MEDICATION NAME] (iron supplement). RN H returned to the medication cart and confirmed the observation of above medications were not secured. RN H confirmed that medications were accessible to self-mobile cognitively impaired residents. Interview with LPN B on 12/6/17 at 1:28 PM confirmed that medications were to be secure at all times and that medications found on top of a medication cart were accessible to self-mobile and cognitively impaired residents present on the unit. The facility identified 5 residents on the unit who were self-mobile and cognitively impaired.",2020-09-01
6472,BELLE TERRACE,285237,1133 NORTH THIRD ST,TECUMSEH,NE,68450,2016-02-24,225,D,1,0,TIKE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC ,[DATE].02(8) Based on record review and interview, the facility failed to investigate and report two incidents of alleged neglect for Resident 2 and failed to report and investigate allegations of resident to resident abuse by one resident (Resident 1). The facility censes was 43. Findings are: A. Review of Resident 2's Cardio [MEDICAL CONDITION] Resuscitation (CPR) Form dated [DATE] revealed that in the event of cardiac and/or respiratory arrest Resident 2 wanted CPR initiated. Further review of the same form revealed Resident 2's physician had signed an order for [REDACTED]. Review of Resident 2's Nurses Notes dated [DATE] revealed at 6:15 AM LPN (Licensed Practical Nurse) A had performed a visual check and respirations were noted to be even and shallow with oxygen intact. Nurses Notes at 7:30 AM revealed, Observed resident (with) no respirations pulseless, breathless, pupils fixed. DON (Director of Nursing) notified. PCP (Primary Care Physician) called. At 7:35 AM the APRN (Advanced Practitioner Registered Nurse) had called and given an order to release the body to the mortuary and notify the county coroner of the death. Interview with the DON on [DATE] at 11:40 AM revealed LPN A no longer was employed at the facility and confirmed that LPN A had not initiated CPR for Resident 2 when found to be absent of all vital signs. Interview with the Administrator on [DATE] at 12:15 PM confirmed that the lack of LPN A to initiate CPR for Resident 2 had not been reported to the appropriate state agencies as an allegation of neglect. Review of the facility's policy for Abuse and Neglect Reporting Revised [DATE] revealed the definition of Neglect as, a failure to provide care, treatment, goods or services necessary to avoid physical harm or mental anguish of a resident . and further revealed any alleged violations involving .neglect must be reported. B. Interview with the Administrator on [DATE] at 4:25 PM revealed LPN A had notified the Administrator that Resident 2 had gone outside to smoke one evening in (MONTH) and had gotten locked out of the facility for an extended amount of time. The Administrator further stated that after looking in to the allegation the Administrator concluded the resident had went outside with out notifying staff and there fore did not take the safety pendant along. The Administrator was unsure of the length of time Resident 2 had been outside but felt it had not been that long. Review of the facility's internal abuse investigations during the month of (MONTH) revealed no written investigations or reports to the state agencies regarding the above allegation that Resident 2 had been locked outside. Interview with the Director of Nursing on [DATE] at 11:45 AM revealed the DON was aware that LPN A had alleged Resident 2 had gotten locked outside but the DON had not completed an investigation into the matter. A follow up interview with the Administrator on [DATE] at 12:15 PM revealed the Administrator had not documented any of the investigation completed regarding Resident 2 and that it had not been reported to the appropriate state agencies. C. Review of Resident 1's Nurses Notes revealed the following incidents: -[DATE] Observed in another resident's room, yelling and flipping off the other resident -[DATE] Became upset at another resident and started screaming and flipping off other resident -[DATE] with resident (of opposite gender) trying to remove other resident's pants -[DATE] In activities room and started yelling at other resident, other resident started crying -[DATE] Resident in activities room yelling at other resident -[DATE] became agitated and started ramming wheelchair into another resident . Interview with the Administrator on [DATE] at 12:20 PM revealed the above resident to resident allegations involving Resident 1 had not been investigated or reported to the appropriate state agencies as required. Review of the facility's policy for Abuse and Neglect Reporting Revised [DATE] revealed alleged cases of mistreatment, neglect or abuse should be reported within 24 hours to Adult Protective Services (APS) and Law Enforcement when applicable. The facility shall then complete and submit an investigation within five working days to the Department of Health and Human Services.",2019-02-01
6041,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2016-06-02,281,G,1,0,88EY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC ,[DATE].04C1(3) Based on record review and interview, the facility failed to re-educate staff to perform Cardio-Pulmonary Resuscitation (CPR) according to staff policy and standards of practice for one resident (Resident 3). The facility census was 185. Findings are: Review of Resident 3's progress notes dated [DATE] revealed Resident 3 was found unresponsive and without a pulse. Licensed Practical Nurse (LPN) A initiated CPR and sent word for another nurse to call a code and get the crash cart. 911 was called and emergency medical professionals arrived at the facility. Review of the Lincoln Fire & Rescue Patient Care Report dated [DATE] revealed, Inadequate bystander CPR being performed on pt (patient) bed on arrival of LFR (Lincoln Fire & Rescue) crew. Review of the facility's internal investigation dated [DATE] revealed LPN B's statement to be, Upon 911 arriving and taking over the scene, resident was moved to the floor per 911 recommendations. CPR resumed. Interview with Registered Nurse (RN) C on [DATE] at 5:15 PM revealed RN C was the nursing supervisor on duty when CPR was performed on Resident 3. RN B explained that the crash cart was kept on each unit and was equipped with a suction machine, gloves, masks and a back board to be used when performing CPR. RN B further reported that upon entering Resident 3's room on [DATE], staff had already initiated CPR and the crash cart had already been brought to the resident's room. RN B could not say if the back board was in use or not. Interview with LPN A on [DATE] at 4:08 PM revealed staff performed CPR on Resident 3 while Resident 3 was in the bed and no back board was used. Interview with LPN B on [DATE] at 2:15 PM revealed that LPN B took the crash cart to Resident 3's room and began to assist with CPR. LPN B further confirmed that CPR was performed while Resident 3 was lying in the facility bed which was equipped with a standard mattress. LPN B reported that 911 personal did not have any comments regarding the way CPR was being completed by the facility upon their arrival. LPN B reported no training or instruction was given on how staff should improve their process when performing CPR. Interview with the Director of Nursing (DON) on [DATE] at 2:30 PM revealed staff were not provided education on the importance of using the back board when performing CPR. Review of the untitled policy and procedure provided by the facility regarding performing CPR printed on [DATE] revealed, 2. Notify staff of the need to bring emergency equipment or code cart to the patient's room .b. CPR board. 4. Place the patient supine on a firm surface. According to the (YEAR) American Heart Association Guidelines, patients should be placed on a hard surface in a supine position for the implementation of CPR.",2019-06-01
5522,"SORENSEN CARE AND REHABILITATION CENTER, LLC",285107,4809 REDMAN AVENUE,OMAHA,NE,68104,2016-11-14,309,J,1,0,7EEE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC ,[DATE].09 Based on record review and interview, the facility failed to assess and provide emergency treatment as needed for Resident 1. Sample size was five residents. The facility Census was 66 The facility policy titled Clinical Health Status Version# 5, dated with an effective date of [DATE] revealed: The process for identification of change of condition included gathering objective data and documenting assessment findings, resident and physician and family notification. A record review of the Admission Record, dated (MONTH) 3, (YEAR), revealed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of a Nurse's note dated [DATE] at 10:30 AM by Registered Nurse (RN) B revealed Resident 1's vital signs were a temperature of 97.2 degrees Fahrenheit. Resident 1's blood pressure had been ,[DATE] and a pulse was 108. Resident 1's respiration rate was 18 breaths per minute and had an oxygen saturation of 96% on room air. Resident 1 was alert and oriented. Resident 1 was independent with transfers and ambulated with a walker. Resident 1 was independent with activities of daily living (ADL's). Resident 1 had no shortness of breath and did not require oxygen. Resident 1 had no complaints of pain and was using the telephone and talking with family and friends. A record review of Resident 1's medical record, titled Progress Note dated [DATE] at 6:00 AM, written by Licensed Practical Nurse (LPN) A, revealed that Resident 1 was yelling and was having trouble breathing. The on-duty, Nursing Assistant (NA) requested that the nurse report to Resident 1's room. Resident 1's oxygen saturation was 84% (Lippencott's Nursing Center states that SpO2, or pulse oximetry, is normal when in the range of 97 to 99 percent). Resident 1 presented with good color and was assisted to bed. An assessment of Resident 1's lungs revealed clear sounds in the upper lungs bilaterally and diminished sounds in lower lungs bilaterally. Oxygen was applied by nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory assistance) at 2 liters. Resident 1's oxygen saturation was then 91%. Resident 1 was reassured and made comfortable in bed. Resident 1 had voiced no additional distress. An interview with LPN A on [DATE] at 4:40 PM revealed that Resident 1 had been under the care of LPN A for three nights. LPN A revealed that Resident 1 had initially, called for help due to having problems breathing at 3 AM. LPN A confirmed that Resident 1 had called for help three times from 3:00 AM till 5:15 AM. LPN A revealed that NA C called over to the west nursing station at 5:15 AM and informed staff that Resident 1 needed help right away and Resident 1 was having difficulty breathing The NA stated that Resident 1 was screaming that Resident 1 was unable to breathe. LPN A revealed at 5:15 AM a check of Resident 1's oxygen level had been performed and it was 84% but came up to 91% after oxygen had been applied. LPN A confirmed that Resident 1 did not have an order for [REDACTED]. LPN A confirmed that no vital signs except the oxygen saturation had been performed on Resident 1 during the three visits to Resident 1's room, for respiratory distress. LPN A confirmed the inhaled medication that was administered to Resident 1 was not documented and that the time it was administered could not be recalled. LPN A confirmed that Resident 1's physician was not notified of the Resident's change in condition. Interview with NA C on [DATE] at 3:40 PM revealed that Resident 1 had turned on the call light at 3:00 AM. Resident 1 had requested an inhaler. NA C revealed that LPN A had arrived within 5 minutes and was observed administering Resident 1's inhaler. NA C revealed that Resident 1 called again and complained of feeling sick and unable to breathe. NA C revealed that LPN A did come at 3:50 AM but another resident had required assistance and NA C had left the room. Resident 1 came out into the hall at 5:15 AM and was screaming. Resident 1 was not feeling good and had trouble breathing. NA C revealed that LPN A had come back to Resident 1's room and checked an oxygen level, and applied some oxygen. Interview with RN D on [DATE] at 12:08 PM revealed that Resident 1 had stopped breathing during RN D's shift on [DATE] at 7:15 AM. RN D revealed that NA [NAME] had called for assistance and that Resident 1 had been found on the toilet and was not responsive. RN D revealed that Resident 1 was without pulse, not breathing, and cool in extremities. RN D revealed that the NA was told to stand-by while RN D had gone to the EMR to check on Resident 1's Code Status (to perform Cardio [MEDICAL CONDITION] Resuscitation (CPR) or Not to perform CPR). RN D revealed that the EMR stated that Resident 1 was a Full Code (Do perform CPR). RN D revealed that NA [NAME] was told to perform CPR and that RN D called 911. RN D revealed that upon looking into the paper chart there had been a document that had been signed by Resident 1's family, and that it stated Resident 1's wish had been Do Not perform CPR. RN D revealed that while checking the chart the 911 crew had arrived and RN D told the 911 crew that Resident 1 did not wish to have CPR. The NA [NAME] was told to stop CPR. RN D stated that the resident had not been revived with the CPR. Interview on [DATE] at 12:18 PM with the Director of Nursing (DON) confirmed that when vitals were recorded it would be found in the nursing notes of the nurse who had taken the vitals. The DON confirmed that no vitals other than oxygen saturation had been performed on Resident 1 on [DATE] from 3 AM to time of death at 7:15 AM. The DON confirmed that an assessment/evaluation would be expected of the nursing professional when a resident was having difficulty breathing or respiratory distress. The DON confirmed that the assessment/evaluation for Resident 1 would have been expected to include blood pressure, pulse rate, respiration rate, temperature, and a head to toe assessment. The DON confirmed that a notification to physician and family should have been done and that this did not occur for Resident 1. The Immediate Jeopardy was abated on [DATE] after the following interventions were put in place: - A Head-to-Toe assessment cheat sheet was put in place. - All licensed nursing staff on duty were educated on acceptable clinical assessment procedures as well as resident change in condition procedures. - All licensed nursing staff were to be educated on acceptable clinical assessment procedures as well as resident change in condition procedures before working their next shift.",2019-11-01
4279,HILLCREST SHADOW LAKE,2.8e+300,1507 E GOLD COAST ROAD,PAPILLION,NE,68046,2018-10-17,684,D,1,1,DHEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC ,[DATE].09 Based on record review and interviews, the facility failed to complete neurological assessments following falls that had the potential to result in a head injury for 3 of 3 residents reviewed (Residents 96, 91 and 256). The facility census was 99. Findings are: [NAME] Review of the facility policy dated [DATE] titled Incident Reporting Investigating revealed if a fall is unwitnessed or the resident hits their head, neurological checks (an assessment to rule out a head injury) will be initiated with documentation on the Neurological Assessment flow sheet and charted for 72 hours. Review of the Neurological Assessment flow sheet revealed checks are to be documented: -Every 15 minutes for the first hour, -Every 30 minutes for the next 2 hours - Hourly for 4 hours -Every 4 hours for 16 hours -Every 8 hours until the end of 72 hours. Resident 256 was assessed for fall risk at a level of High risk on admission to the facility . Review of Resident 256's MDS (Minimum Data Set ) dated [DATE] revealed Resident 256 required extensive assistance for transfers and supervision with ambulation. Review of Resident 256's [DIAGNOSES REDACTED]. - Chronic [MEDICAL CONDITION] (abnormal Heart beat) - Cerebral infarction (Stroke) - Long term and current use of anticoagulants (blood thinning medication) Interview on [DATE] at 7:00 PM with the facility Medical Director revealed Resident 256 was at risk for bleeding related to Resident 256's use of blood thinners. Review of Nursing Progress note dated [DATE] at 4:41 AM revealed Resident 256 was found sitting on the floor in front of Resident 256's recliner. Resident 256 was assessed at the time of the fall. Review of the Neurological Assessment (an assessment to monitor for a head injury) revealed the first assessment of Resident 256 was started on [DATE] at 12:05 AM. Review of Resident 256 medical record revealed inconsistency in documentation of time of fall on [DATE]. Neurological Assessments for Resident 256 were completed: -Every 15 minutes x 4, at 12:05 AM, 12:30 AM, 12:45 AM, and 1:10 AM. -Next assessment was in 1 hour intervals at 210 AM and 3:20 AM. -No further checks were completed after 3:20 AM Review of Resident 265's medical record revealed no evidence that neurological assessments were completed after 3:20 AM. Interview on [DATE] at 4:45 PM with Nursing Technician (NT)-B stated NT-B did not see Resident 256 until NT-B entered Resident 256's room just before 8:00 AM to assist Resident 256 to get up for breakfast. NT-B attempted to awaken Resident 256 and Resident 256 did not respond. NT-B immediately notified Licensed Practical Nurse (LPN)-C. Interview on [DATE] at 5:00 PM with LPN-C revealed LPN-C had been in Resident 256's room at 7:00 AM and had checked to make sure resident was resting but had not completed a neurological assessment at that time because it was not due. LPN-C did assess Resident 256 when notified by NT-B of a change in responsiveness. Interview on [DATE] at 7:30 AM with the Director of Nursing (DON) revealed on arriving at the facility, LPN-C reported to the DON that LPN-C was unable to awaken Resident 256. The DON then went to Resident 256's bedside and determined Resident 256 needed to be transferred to the hospital. Review of Resident 256's CAT (computerized axial tomography) scan (an X-ray image used to visualize the brain) results from the hospital revealed Resident 256 had a Subdural Hematoma (bleeding on the brain). Review of Resident 256's Progress notes dated [DATE] at 4:59 AM revealed the facility received a call from the Hospital stating Resident 256 had died . Interview on [DATE] at 7:45 AM with the DON revealed neurological checks were not completed according to the facility policy for Resident 256. B. Record review of Resident 96's Hospice admission record dated [DATE] revealed the resident was admitted to Hospice for a [DIAGNOSES REDACTED]. Review of Resident 96's Current Care Plan dated [DATE] revealed that Resident 96 was high risk for falls with injuries and had multiple falls with a goal of risk of significant injury will be decreased through next review date. Record review of Resident 96's clinical notes revealed that Resident 96 had a fall on the following dates: [DATE] [DATE] [DATE] [DATE] Record review of Resident 96's Neurological Check Flow sheet dated for the falls on [DATE], [DATE], [DATE] and [DATE] revealed that Neurological checks were completed for the first 15 minutes and then were discontinued by Hospice. Interview conducted with the Director of Clinical Services on [DATE] at 09:25 AM confirmed that Hospice had discontinued the neurological checks and that was not the policy of the facility. C. Record review of Resident 91's Event Report revealed Resident 91 sustained an unwitnessed fall on (MONTH) 30, (YEAR) at 2:00 PM Record review of Resident 91's medical record revealed an unwitnessed fall documented on (MONTH) 30, (YEAR) at 2:38 PM. Resident 91 was found sitting on the floor in front of the wheel chair, between the wheel chair and the bed. It was documented that Neurological checks were initiated at this time. Record review of the facility's undated policy of Incident Reporting Investigation revealed: Incident follow up charting by the nurse manager will include vital signs: a. No injury: chart every shift X 24 hours. b. Injury: chart every shift X 48 hours. C. Head injury: Initiate neurological assessment flow sheet and chart every shift for 72 hours. If a fall is unwitnessed neurochecks will be initiated. Record review of the facility's neurological assessment flow sheet, the following time line will be used to assess residents who require neurological assessment -every 15 minutes for 4 cycles -every 30 minutes for 4 cycles -every hour for 4 cycles -every 4 hours for 4 cycles -every 8 hours for 6 cycles Record review of Resident 91's Neurological Check flow sheet initiated on (MONTH) 30, (YEAR) at 2:00 PM revealed that neurological assessments were not completed on: -[DATE], (YEAR) at; -2:45 PM (forth cycle of 15 minute cycles) -4:00 PM (third cycle of 30 minute cycles) -8:30 PM (fourth cycle of 1 hour cycles) -[DATE], (YEAR) at; -12:30 AM (first cycle of 4 hour cycles) -12:30 PM (fourth cycle of 4 hour cycles) -[DATE], (YEAR) at; -12:30 AM (third of 8 hour cycles) -8:30 PM (fourth of 8 hour cycles) -[DATE], (YEAR) at; -4:30 AM (fifth of 8 hour cycles) -12:30 PM (sixth of 8 hour cycles) An interview with the Director of Nursing on [DATE] at 02:27 PM revealed that Resident 91 fell on [DATE] at 2:00 PM, neurological assessments were indicated and not completed as required.",2020-09-01
5716,NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER,285271,2100 CIRCLE DRIVE,SCOTTSBLUFF,NE,69361,2016-10-03,333,E,1,0,SRLF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC ,[DATE].09D Based on record reviews and interviews, the facility failed to: 1) calculate the correct dose of a narcotic (medication to relieve severe pain) liquid medication administered to one sampled resident (Resident 11) resulting in the administration of twice the ordered dosage; 2) enter a physician ordered anti-hypertensive (medication to reduce blood pressure) into the correct resident's medical record resulting in one sampled resident (Resident 2) receiving the medication without an order and delaying one sampled resident (Resident 9) from receiving ordered medication; and 3) continue an anti-coagulant (medication used to reduce the risk of blood clotting) as ordered for one sampled resident (Resident 10). These failures had the potential of causing side effects or exacerbations of medical condition symptoms for these residents. Sample size was eleven current residents and one closed record. Facility census was 51. Findings are: A. Closed medical record review for Resident 11 revealed from a Resident Face Sheet printed on [DATE], the resident was admitted to the facility on [DATE] with a latest return dated [DATE]. The form documented the resident expired at the facility on [DATE]. Further review of the resident's face sheet revealed a medical [DIAGNOSES REDACTED]. Record review of Resident 11's Medications Administration History between [DATE] and [DATE] revealed an order dated [DATE] for: [MEDICATION NAME] concentrate- Schedule II solution; 100 mg/5 ml (100 milligrams per 5 milliliter of solution). The instructions for the medication directed the Amount to Administer 4 mg . 0.2 ml; sublingual (under the tongue) with a frequency recorded every six hours and every one hour as needed. Record review of Resident 11's Individual Resident's Controlled Substance Record (a record accounting for narcotic medication inventory) revealed on [DATE] at 4:15 p.m. Resident 11 was given a 0.4 milliliter dose of [MEDICATION NAME]. Record review of a facility Medication Error Report revealed Resident 11 received an incorrect dose of [MEDICATION NAME] on [DATE]. The report revealed the type of error was Wrong dose and the medication was not calculated correctly when dose was being administered. Corrective action taken documented the nurse will no longer be calculating dosages without another nurse checking calculation. Interview with the Director of Nursing, facility Administrator, and facility Nurse Consultants on [DATE] at 11:45 a.m. confirmed Resident 11 had received an incorrect dose of [MEDICATION NAME] liquid on [DATE] resulting in a dose twice of the ordered dose due to a miscalculation. The Nurse Consultants confirmed the facility had previously been cited during a complaint investigation on [DATE] with a policy identified in the plan of correction that all liquid narcotic medications were to be double checked before administration. The Director of Nursing and Nurse Consultants verified the policy had not been followed resulting in the error involving Resident 11. B. Record review of Resident 2's Resident Face Sheet printed on [DATE] revealed the resident was admitted to the facility on [DATE] with the latest return recorded [DATE]. Review of the resident's medical [DIAGNOSES REDACTED]. Record review of Resident 2's Medication Administration History report for [DATE] through [DATE] revealed the resident received the following medications for hypertension. [MEDICATION NAME] 5 milligrams administered daily and [MEDICATION NAME] 25 milligrams administered daily. Further review of the history report revealed the resident received a third anti hypertensive medication dose of [MEDICATION NAME] 5 milligrams on [DATE]. Record review of a facility Medication Error Report revealed a medication error involving the administration of [MEDICATION NAME] 5 milligrams to Resident 2 occurred on [DATE] at 7:30 a.m. The Assessment and Summary of Error was recorded as Wrong resident. The Reason for Error(s) was recorded Transcription error. Description of the error on the form revealed a New nurse put order in on wrong res. (resident). Corrective action taken to prevent recurrence was documented: have 2nd nurse on duty double check orders after put in computer . Record review of a facility undated Verification of Investigation form regarding the [MEDICATION NAME] error involving Resident 2 recorded in the detailed description of event allegations that the nurse was on second day of orientation and entered the [MEDICATION NAME] into Resident 2's medical record incorrectly. The description identified the facility had no policy or procedure in place regarding taking off new orders from provider. C. Record review of Resident 9's Resident Face Sheet printed on [DATE] revealed the resident was admitted to the facility on [DATE] with the latest return recorded as [DATE]. Further review of the face sheet revealed medical [DIAGNOSES REDACTED]. Record review of Resident 9's Medications Administration History for [DATE]-[DATE] revealed the resident received [MEDICATION NAME] 5 mg daily beginning on [DATE]. Record review of an undated Verification of Investigation form regarding a medication error revealed in the Interview Summary section an interview was conducted on [DATE] with LPN (Licensed Practical Nurse)-B. LPN-B stated having received instructions from the ADON (Assistant Director of Nursing) to record a progress note regarding a new order for Resident 2. LPN-B researched and discovered the order for [MEDICATION NAME] 5 milligrams was incorrectly entered into Resident 2's record instead of the intended resident identified as Resident 9. Interview with the facility Administrator, Director of Nursing, and facility Nurse Consultants on [DATE] beginning at 11:45 a.m. verified facility staff incorrectly entered MEDICATION ORDERS FOR [REDACTED]. The Director of Nursing and Nurse Consultants verified Resident 2 was already receiving two other anti-hypertensive medications and the error could have resulted in a significant decrease in Resident 2's blood pressure. The Director of Nursing and Nurse Consultants verified an order for [REDACTED]. D. Record review of Resident 10's Resident Face Sheet printed on [DATE] revealed the resident was admitted to the facility on [DATE] with a latest return recorded as [DATE]. The face sheet recorded medical [DIAGNOSES REDACTED]. Record review of a New Order Policy and Procedure with an Effective Date of (MONTH) 12, (YEAR) revealed in the Procedure directions which read: When receiving new order nurse will review and input order. Orders will be put in completely and correctly and called out for clarification when necessary. Another nurse on the same shift will review the order . to ensure that the order is correct and complete . If there is not another nurse on the same shift before report is given, oncoming nurse will check all orders for previous shift with the nurse in the computer and make sure that the orders are put in correctly and completely . Record review of Resident 10's Anticoag (Anticoagulant Medication) Clinic form dated [DATE] revealed the resident had blood testing completed to monitor the resident's clotting time. The indications for therapy were recorded Chronic [MEDICAL CONDITION] with Therapy started- Duration lifelong. Orders documented on the form revealed to cont (continue) 5 mg (of [MEDICATION NAME]) (a medication used to reduce the risk of clotting and improve irregular heart beats) x (times) 5 days a week. 2.5 mg (of [MEDICATION NAME]) Tu, F (on Tuesdays and Fridays). Another order to recheck the blood testing for clotting time was ordered to commence in 2 weeks. The form documented LPN-B at the (facility) verbalized understanding and had no further questions (pertaining to orders). Record review of Resident 10's Anticoag Clinic form dated [DATE] revealed an order to restart ([MEDICATION NAME]) 5 mg x 5 days a week and 2.5 mg Tu, F. The form documented Pt (patient or Resident 10) has had no [MEDICATION NAME] (generic name for [MEDICATION NAME]) since [DATE], order got d/c'd (discontinued). Record review of Resident 10's Medications Administration History for [DATE] through [DATE] revealed the resident's orders for [MEDICATION NAME] 2.5 mg on Tuesday and Fridays; and [MEDICATION NAME] 5 mg daily on Sunday, Monday, Wednesday, Thursday, and Saturday were discontinued on [DATE] and not restarted until [DATE]. Record review of a facility Medication Error Report revealed an error involving Resident 10 occurred from [DATE] through [DATE]. The Assessment and Summary of Error was recorded as an omission with the Reason for Error(s) recorded as Computer error-order entry. The description of the error recorded: Medication had stop date entered to stop on 15th and it was to continue same dose and recheck on the 15th. The outcome to resident section of the form documented: Resident did not receive [MEDICATION NAME] from [DATE]-[DATE]. Interview with the facility Administrator, Director of Nursing, and facility Nurse Consultants on [DATE] beginning at 11:45 a.m. verified facility staff incorrectly entered MEDICATION ORDERS FOR [REDACTED]. The Nurse Consultants verified a new policy for taking off orders to ensure accuracy of medication order entries into the computer medical record was adopted on [DATE] and was not followed by staff resulting in the [MEDICATION NAME] error for Resident 10. The Director of Nursing and Nurse consultants agreed that discontinuation of this medication put the resident at risk for irregular heart beats, potential clotting of the blood, and at risk for additional heart symptoms.",2019-10-01
6168,NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER,285271,2100 CIRCLE DRIVE,SCOTTSBLUFF,NE,69361,2016-06-06,333,J,1,0,VYV311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC ,[DATE].10D Based on record reviews and interviews, the facility failed to clarify dosage calculations prior to administering a narcotic medication to one sampled resident (Resident 5). The failure resulted in overdosing the resident resulting in the resident's death. Facility census was 47. Findings are: Record review of an undated Resident Admission Record for Resident 5 revealed the resident was admitted to the facility on [DATE]. Record review of a Palliative Care Consultation document for Resident 5 dated [DATE] revealed the resident was assessed by a Palliative Care Nurse Practitioner. The Nurse Practitioner described the resident as having steadily declined in the past 2 years since the resident fractured a hip. The resident was assessed sitting in a recliner and answered simple questions. The Nurse Practitioner recorded There are no signs of acute distress at this time. Following assessment of the resident the Nurse Practitioner ordered [MEDICATION NAME] liquid 1 mg (milligram) by mouth or sublingually (under the tongue) q (every) 12h (12 hours). Prescription sent to pharmacy. Record review of an untitled document revealed 30 cc (cubic centimeters or milliliters) of [MEDICATION NAME] was received at the facility on [DATE]. Record review of an Individual Resident's Controlled Substance Record for Resident 5 revealed 30 ml (milliliters) of [MEDICATION NAME] was received on [DATE]. Further review of the record revealed MA (Medication Aide)-J administered a 0.5 ml dose at 9:00 p.m. On [DATE], MA-F administered a 1 ml dose of [MEDICATION NAME] at 8:33 a.m. On [DATE], MA-I administered a 1 ml dose of [MEDICATION NAME] at 8:00 p.m. on [DATE]. Record review of Resident 5's Resident Progress Notes between [DATE] and [DATE] revealed no entry on ,[DATE] and an entry on [DATE] recorded at 8:41 p.m. which read: Entered room @ (at) 2030 (8:30 p.m.), resident has no noted pulse or resp (respirations) Record review of the facility's Medication Error Report forms for Resident 5 revealed the errors occurred on ,[DATE] and [DATE]. Description of the errors revealed the bottle from the pharmacy was correctly labeled c with 0.1 ml per 1 mg. Someone had blacked out the 0.1 ml (on the label). 0.5 ml (5 milligrams) was given on [DATE] @ 2100 (9:00 p.m.) by MA-J and 1 ml (10 mg) at 0830 (8:30 a.m.) by MA-F on [DATE]; and on [DATE] at 2000 (8 p.m.) by MA-I. The document recorded the Outcome to resident was Patient died at 2030 [DATE]. A separate Medication Error Report form for Resident 5 described the same incident and included a handwritten statement on [DATE] from LPN (Licensed Practical Nurse)-L which recorded I (LPN-L) marked out the label to prevent someone from giving wrong dose. MA-F asked me what dose to give as (the med aide) was confused from looking at the label. Phone interview with the Palliative Care Nurse Practitioner on [DATE] at 9:15 a.m. confirmed the Nurse Practitioner consulted for Resident 5 on [DATE] and wrote orders for [MEDICATION NAME] 1 mg to be administered every twelve hours. The Nurse Practitioner stated, that following the assessment of the resident on [DATE], the resident was not in any imminent danger from the disease process and the family and resident chose palliative care for comfort. When questioned in the Nurse Practitioner's opinion, what would affect a 5 mg dose and two subsequent 10 mg doses would have on Resident 5, the Nurse Practitioner stated due to frailty and [AGE] years of age, doses at that level would probably kill (the resident). Phone interview with the pharmacist dispensing the [MEDICATION NAME] for Resident was done on [DATE] at 9:45 a.m. The pharmacist stated having re-checked all orders and labels regarding Resident 5's [MEDICATION NAME] order. The pharmacist confirmed receiving an order from the Palliative Care Nurse Practitioner on [DATE] and verified the order called for [MEDICATION NAME] 1 mg every 12 hours. The Pharmacist verified the label sent out was on a typed label and identified to give 0.1 ml or 1 mg in the instructions. The bottle also identified the strength of the medication in the bottle was 10 mg per milliliter. When asked what a 10 mg dose of [MEDICATION NAME] would result in for Resident 2, the pharmacist replied that in a frail elderly person over [AGE] years of age and as potent as this ([MEDICATION NAME]) is that the first dose would cause some sedation but with progressive dosing accumulation would occur and likely result in death. The pharmacist stated that even a healthy young individual taking a 10 mg dose would experience severe sedation at a minimum. Interview with the facility DON (Director of Nursing) on [DATE] at 2:00 p.m. confirmed the facility staff had overdosed Resident 5 on [DATE] and [DATE]. The DON stated, from investigation, that the resident's [MEDICATION NAME] was received at the facility in a 30 ml bottle on [DATE]. The DON stated, that when logged into the computer, LPN-K had incorrectly typed in the order as 5 mg/ml rather than 10 mg/ml. When MA-J compared label to logged in order, MA-J was confused and asked for direction from LPN-K. LPN-K then directed MA-J to administer 0.5 ml (5 mg) which MA-J complied with and administered the medication at 9:00 a.m. LPN-K had not contacted the pharmacy or prescribing Nurse Practitioner for clarification of the orders. The DON stated that, on [DATE], MA-F also questioned the order and asked LPN-L for directions. LPN-L proceeded to tell MA-F the label was incorrect and crossed out the label instructing to administer 0.1 ml and changed the label to 1 ml without receiving any clarification from the pharmacy or the prescribing Nurse Practitioner. LPN-L instructed MA-F to administer 1 ml (10 mg) of the [MEDICATION NAME] with which MA-F complied at 8:33 a.m. At 8:00 p.m., MA-I administered 1 ml of [MEDICATION NAME] to Resident 5 based on the label change. The DON verified the resident was overdosed by 5 times the order on [DATE] and twice was administered 10 times the order on [DATE]. The DON verified the resident expired a half hour after receiving the third dose. Prior to the survey team exit on [DATE], the facility had terminated two employees regarding the incident. In addition, the facility's nurse consultants and DON arranged for immediate education for licensed nurses including dosing calculations for liquid medications, and review of a new policy for monitoring liquid medication dosages. Due to these measures, the Immediate Jeopardy was abated and scope and severity lowered to a G.",2019-06-01
2080,GOOD SAMARITAN SOCIETY - ATKINSON,285177,409 NEELY STREET,ATKINSON,NE,68713,2018-11-29,641,E,1,1,1GHE11,"**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 the Minimum Data Set (MDS-a federally mandated comprehensive assessment) was accurately completed to the use of a physical restraint for Residents 12, 23, 19, 32, 13, 29, 21, 18, 15 and 31. In addition, Resident 34's assessment did not correctly reflect the resident's discharge status. Sample size included 26 residents. Facility census was 33.rehensive assessment tool utilized to develop resident care plans) was coded correctly to reflect the resident's status Findings are: [NAME] Review of Resident 32's MDS dated [DATE] identified the resident was admitted to the facility on [DATE]. The assessment indicated the resident was coded as having bed rails as a physical restraint on a daily basis during the reference period of 9/30/18-10/6/18. Review of a Physical Device and Restraint Assessment for Resident 32 dated 7/31/18 at 4:46 PM revealed the resident had bed rail/side rails recommended for the resident's use. The assessment further indicated the device allowed the resident to assist with repositioning in the bed and did not prevent the resident from rising from the bed. The device was not identified as a restraint. Review of the resident's current Care Plan with revision date of 8/24/18 revealed the resident had a grab positioning rail to the resident's bed. The rail did not prevent the resident from rising but was used by the resident to bring self up to a seated position in bed. B. Review of Resident 13's MDS dated [DATE] identified the resident was admitted to the facility on [DATE]. The assessment indicated the resident was coded as having bed rails as a physical restraint on a daily basis during the reference period of 9/30/18-10/6/18. Review of Resident 13's current Care Plan with revision date of 2/3/17 revealed the resident had assist bars on both sides of the resident's bed where the bed controls were positioned. The care plan indicated the resident required total staff assistance of 2 with repositioning and transfers. Review of a Physical Device and Restraint assessment dated [DATE] at 12:21 PM revealed the resident had an assist bar and that controls for the resident's bed were attached to the assist bar. The resident had paralysis of both arms and legs and required use of a full mechanical lift (assistive device that allows residents to be transferred between a bed and a chair using hydraulic power) for all transfers. The assist bar was not identified as a restraint. C. Review of Resident 29's MDS with a reference date of 11/7/18 revealed the resident was admitted to the facility on [DATE]. Review of the MDS section for Restraint assessment revealed the MDS recorded the resident had bed rails used on a daily basis as a physical restraint during the reference period of 11/01/18 to 11/07/18. Review of a Physical Device and Restraint Assessment for Resident 29 dated 8/6/18 at 12:03 PM revealed the resident had an assist bar on the left side of the resident's bed. The device was used for the resident to assist self into and out of bed and was not identified as a restraint. D. Review of Resident 18's MDS dated [DATE] revealed the resident was admitted to the facility on [DATE]. Review of the MDS section for Restraint assessment revealed the MDS recorded the resident had bed rails used on a daily basis as a physical restraint during the reference period of the MDS (10/10/18-10/16/18). Review of Resident 18's current Care Plan with revision date 4/26/18 revealed the resident used the assist bar to help position the resident from side to side and the resident required use of the sit-to-stand mechanical lift (a mobile lift that allows for patient transfers from a seated position to a standing position. This lift is designed to support only the upper body of the resident and requires the resident to have some weight-bearing capability) and staff assist to transfer out of the resident's bed. Review of the Physical Device and Restraint Assessment for Resident 18 dated 8/6/18 at 2:34 PM revealed the resident had assist bars to the resident's bed to assist the resident with bed mobility and transfers. The assessment identified the assist bar was not classified as a restraint. E. 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 1.15, (MONTH) (YEAR). Regarding the Restraints and Alarms section of the MDS, the manual instructs staff to: -Review the resident's medical record to determine if physical restraints were used during the 7 day look-back period. -Consult the nursing staff to determine the resident's cognitive and physical status/limitations. -Evaluate whether the device meets the definition of and should be classified as a restraint; bed rails include any combination of partial or full rails along the side of the bed that block three-quarters to the whole length of the mattress from the top to the bottom and bed rails used with residents who are immobile and unable to voluntarily get out of bed because of physical limitation or because proper assistive devices were not present, the bed rails do not meet the definition of a physical restraint. -Determine whether or not the device restricts the resident's freedom of movement or restricts the resident's access to his or her own body. F. Review of Resident 23's MDS dated [DATE] revealed the resident had a physical restraint as bed rails were used daily. Review of the Physical Device and Restraint assessment dated [DATE] indicated Resident 23 had bilateral assist bars to help with bed mobility and transfers. The assessment further indicated the device was not considered a restraint for the resident. Review of the current Care Plan dated 11/7/18 indicated the resident had a physical restraint related to an assist bar attached to the bed for positioning and transferring. The nursing intervention was that the resident was able to call for assistance and reposition self in bed with use of the bars. [NAME] Review of Resident 31's MDS dated [DATE] revealed the resident had a physical restraint as bed rails were used daily. Review of the Physical Device and Restraint assessment dated [DATE] indicated Resident 31 had assist bars to help with bed mobility and transfers. The assessment further indicated the device was not considered a restraint for the resident. Review of the current Care Plan dated 11/9/18 indicated Resident 31 was at risk for ADL self care performance deficit. Nursing interventions included the resident was independent with bed mobility with use of the assist bar. H. Review of Resident 15's MDS dated [DATE] revealed the resident had a physical restraint as bed rails were used daily. Review of the Physical Device and Restraint assessment dated [DATE] indicated Resident 31 had an assist bar to help with bed mobility and transfers. The assessment further indicated the device was not considered a restraint for the resident. Review of the current Care Plan dated 10/3/18 indicated Resident 15 was at risk for ADL self care performance deficit. Nursing interventions included the resident was independent with bed mobility with use of the assist bar. I. During interview on 11/27/18 at 3:24 PM, the Director of Nursing and Registered Nurse (RN)-S verified the assist bars were considered an assistive device and not a physical restraint, and therefore, the MDS's were coded incorrectly. [NAME] Review of Resident 21's MDS dated [DATE] revealed the resident had a physical restraint as 2 bed rails were used daily. Review of the Physical Device and Restraint assessment dated [DATE] revealed Resident 21 used assist bars to participate in repositioning and the assist rails did not keep the resident from arising. The assessment further indicated the device was not considered a restraint for the resident. Review of the current Care Plan (revision date 10/9/18) indicated Resident 21 was independent with the use of the assist bar for bed mobility and was independent with transfers. K. Review of Resident 12's MDS dated [DATE] revealed the resident had a physical restraint as bed rails were used daily. Review of the Physical Device and Restraint assessment dated [DATE] indicated Resident 12 used assist bars for repositioning and getting moved to the edge of the bed. The assessment further indicated the device was not considered a restraint for the resident. L. Review of Resident 19's MDS dated [DATE] revealed the resident had a physical restraint as bed rails were used daily. Review of the Physical Device and Restraint assessment dated [DATE] revealed Resident 19 used assist bars to help with repositioning and getting in and out of bed. The assessment further indicated the device was not considered a restraint for the resident. Review of the current Care Plan (revision date 10/16/18) indicated Resident 19 was independent with the use of the assist bars for bed mobility and transfers. M. Review of Resident 34's Nursing Progress Notes dated 8/29/18 at 11:00 AM revealed the resident was discharged to the resident's home that day. Review of Resident 34's MDS dated [DATE] revealed the resident was discharged to an acute hospital on that date. Interview with the MDS Coordinator on 11/18/18 at 3:25 PM confirmed the MDS completed 8/29/18 was in error as the resident was discharged home and not to an acute care hospital. N. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.15, (MONTH) (YEAR), the Discharge Status section of the MDS, the manual includes the following instructions: -Review the medical record including discharge plan and discharge orders for documentation of the discharge location; -Select the 2 digit code that corresponds to the resident's discharge status: -Use Code 01 for discharge to community (private home/apartment, board/care, assisted living, and group home); and -Use Code 03 for discharge to acute hospital: if discharge location is an institution that is engaged in providing, by or under the supervision of physicians for inpatients, diagnostics services, therapeutic services for medical diagnosis, and the treatment and care of injured, disabled or sick persons.",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
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
4237,GORDON COUNTRYSIDE CARE,2.8e+258,500 EAST 10TH STREET,GORDON,NE,69343,2017-09-07,225,D,1,1,05LY11,"**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: (A) a report was made of an alleged abuse of Resident 12 by a staff member within the required time frame. Sample size was 10 current residents with one closed record. Facility census was 27. Findings are: Record Review of Gordon Memorial Health Services investigation report revealed that, on (MONTH) 25, (YEAR), Resident 12 had a swollen right knee. The charge nurse assessed it and the Director of Nursing was not available for notification. Resident 12 was taken to the emergency room where Resident 12 was assessed and X-Rays were taken. The X-Ray revealed that Resident 12 had a [MEDICAL CONDITION] femur. Resident 12 returned to the facility with a knee immobilizer. Record Review of the facility internal investigation revealed that Resident 12's knee became swollen on (MONTH) 25, (YEAR). The emergency room Provider contacted the Medical Director on 6/26/2017 and 6/28/2017. Family was notified on the morning of (MONTH) 25, (YEAR) that something was wrong with Resident 12. A call was placed to the State Program Manager on (MONTH) 26, (YEAR). The call was returned on (MONTH) 27, (YEAR). A call was then placed to Adult Protective Services on (MONTH) 27, (YEAR). Record Review of Gordon Countryside Care Policy of Suspected Resident Abuse or Neglect revealed that the facility staff report suspected abuse to the charge nurse immediately and the Director of Nursing, Administrator or designee must be notified within 24 hours of the incident or sooner if feasible. On 09/07/2017 2:00:37 PM, interview with the Director of Nursing and Assistant Director of Nursing confirmed that the incident happened on (MONTH) 25, (YEAR) and the Director or Nursing was notified on (MONTH) 26, (YEAR). The Director of Nursing called State Program Manager on (MONTH) 26, (YEAR) and Adult Protective Services on (MONTH) 27, (YEAR), 2 days after the incident. The Director of Nursing confirmed that Adult Protective Services should have been notified on (MONTH) 25, (YEAR).",2020-09-01
6349,GORDON COUNTRYSIDE CARE,2.8e+258,500 EAST 10TH STREET,GORDON,NE,69343,2016-04-12,226,D,1,0,BXK011,"**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 an allegation of staff to resident abuse per The facility policy regarding an incident involving one sampled resident (Resident 1). Facility census was 23. Findings are: Record review of facility abuse investigations revealed an investigation dated 2/26/16 of an alleged incident involving Staff-A and Resident 1 witnessed by Staff-B . Further review of the investigation revealed a statement by Staff-B which read on 2/23/16 Staff-B witnessed Staff A state to Resident 1 I ought to swat you on the butt. Staff-B then stated having witnessed Staff-A smacking Resident 1 two times on the butt. The investigation revealed the Administrator/Director of Nursing was notified of the incident on 2/24/16 at 10:20 a.m. The investigation included an interview conducted by the SSD (facility Social Services Director) with Staff-B on 2/24/16 at 10:10 a.m. in which Staff-B clarified that the incident occurred on 2/23/16 'before breakfast' . Staff B expressed (he/she) should have reported the incident earlier however (he/she) was worried about ''taddling (sic) . Record review of the facility policy and procedure for Suspected Abuse or Neglect revised in (MONTH) of 2009 and an undated policy entitled Abuse and neglect Occurring at the facility revealed instructions in the Procedure which read: Any employee who suspects or observes alleged mistreatment, neglect, misappropriation of resident's property (exploitation); physical, mental, verbal, or sexual abuse; or involuntary seclusion of a resident by a staff member will immediately report his/her concern or observation to the nurse on duty . The Director of Nursing and Administrator must be contacted immediately . and After intervention or if abuse is suspected, the staff member must report it to their charge nurse immediately . Interview with the SSD on 4/12/16 at 11:55 a.m. confirmed that Staff-B reported a witnessed allegation of abuse involving Staff-A and Resident 1 to the facility on [DATE]. The SSD verified Staff-B failed to notify the charge nurse, Director of Nursing, or Administration of the event immediately after witnessing the event on 2/23/16 at breakfast time.",2019-04-01
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
3748,GOOD SAMARITAN SOCIETY - GRAND ISLAND VILLAGE,285285,4061 TIMBERLINE STREET & 4055 TIMBERLINE STREET,GRAND ISLAND,NE,68803,2019-09-26,608,D,1,1,7E3P11,"**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 notify Law Enforcement when a narcotic medication was discovered missing for one sampled resident (Resident 25). Facility census was 59. Sample size was 19. Findings are: Record review of a facility investigation report completed on 8/5/19, the facility investigated an incident which occurred on 7/31/2019. The report recorded that staff members did not perform a narcotic count at the change of shift and had exchanged medication keys during a staff meeting. Staff discovered a [MEDICATION NAME] (Narcotic medication) was missing from Resident 25's inventory. Facility staff did a search for the missing medication and could not find it. The report indicated Law Enforcement was not notified of the missing narcotic finding. Record review of a facility Policy and Procedure of Abuse and Neglect revised in (MONTH) of (YEAR) revealed the Purpose of the policy was to ensure the location has in place an effective system that, regardless of the source prevents . misappropriation of their (Resident) property. Review of the Notification procedures revealed If there is an allegation of . misappropriation of resident property . than it will be reported not later than two hours after the allegation is made to the administrator, and to other officials in accordance with state law. Interview with the interim-Administrator and interim-Director of Nursing on 9/26/19 at 10:15 revealed that a missing narcotic medication meets the definition of a suspected crime and should be reported to Law Enforcement to ensure a criminal investigation is conducted.",2020-09-01
4293,OGLALA SIOUX LAKOTA NURSING HOME,2.8e+301,"7835 ELDERS DRIVE, STATE HIGHWAY 87",RUSHVILLE,NE,69360,2017-11-16,225,D,1,1,XK2J11,"**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 immediately notify law enforcement officials of suspected criminal theft involving two sampled residents (Residents 1 and 19). Sample included 14 current residents. Facility census was 29. Findings are: [NAME] Record review of Resident 1's Admission Record printed on 11/14/17 revealed the resident was admitted to the facility on [DATE]. Record review of a facility investigation dated 10/27/17 of an incident involving Resident 1 revealed on 10/26/17 at 7 a.m. Resident 1 reported to a nursing assistant that the resident was missing $48. The resident reported a man was in the resident's room the prior evening (10/26/17) as was another resident (Resident 24) with the man. The investigation identified that the item was verified in the resident's possession and/or verified by a reliable source by documenting the resident removed $160 from an account on 10/6/17 for a shopping visit and spent $78.78 at that shopping visit. In the section for measures and steps taken following the reported concern, the facility documented to educate the resident to turn money into the business office, provided education and searched the room. The facility documented the money was not found. An attached statement handwritten by NA (Nurse Aide)-D dated 10/27/17 recorded Resident 1 had told NA-D that $48 was missing and reported a man in the resident's room along with Resident 24 the previous night. The resident stated having the money last night but after awakening today the money was gone. NA-D assisted the resident in searching the room but could only find $2. NA-D reported the incident to the Social Services Director. There was nothing in the investigation report whether or not law enforcement officials were notified or investigated the misappropriation of the resident's money. B. Record review of Resident 16's Admission Record printed on 11/14/17 revealed the resident was admitted to the facility on [DATE]. Interview with Resident 19 on 11/15/17 at 9:25 a.m. revealed the resident had kept money in a tin in the resident's room, but that the tin was missing along with money. The resident stated having reported the incident to the staff and neither the tin nor the money was found. Record review of a Resident Grievance/Complaint Investigation Report Form signed on 9/27/17 by the Social Services Director revealed the resident's family member reported to the business office that the resident was missing money out of the resident's tin. The family member stated the tin was missing this monring. The business office manager gave the resident a check to cash on 9/20/17 for $80 and the family member brought back a receipt and $75. NA-E stated counting money for the resident and placing $81 in the resident's tin and placed the tin in the resident's drawer. Findings of the review by the Social Services Director recorded a search of the room was done several times for the tin or money and it was not found. The concern was reported to the State Agency. Record review of a facility investigation report revealed the facility investigated an incident reported by Resident 19 on 9/24/17 at 8:30 a.m. The facility report described the resident had $80 in a tin can in the resident's drawer. NA-E counted the money on 10/22/17 and found $81 in the tin. The (resident's family member) noticed the money was missing. The facility documented they verified the money was in the resident's possession recording NA-E and the Business Manager agreed the resident had $81 in the resident's possession on 9/28/17. The investigation recorded measures and steps taken by the facility were to speak with the resident about keeping money in the business office and that the facility searched for the tin with money and could not find the tin or the money. There was nothing in the facility investigation recording that Law Enforcement officials were notified or investigated the suspected misappropriation of the resident's money. Record review of the facility Abuse policy entitled: Reporting Abuse to State Agencies and Other Entities/Individuals- revised (MONTH) 2009 Should a suspected violation or substantiated incident . be reported, the facility Administrator or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident . Law enforcement officials. Interview with the Administrator on 11/16/17 at 10:45 a.m. confirmed that the facility policy is for any suspected theft of resident property should be reported immediately to a Law Enforcement agency. The Administrator agreed that Resident 1's report of missing $48 and Resident 19's report of missing $80 were not reported to Law Enforcement. The Administrator agreed that the facility was unable to find the missing money or determine how the money disappeared, constituting a suspicion of theft of property.",2020-09-01
5623,HEMINGFORD COMMUNITY CARE CENTER,285265,"P O BOX 307, 605 DONALD AVENUE",HEMINGFORD,NE,69348,2016-11-15,226,D,1,0,4NFQ11,"**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 ensure staff reported an injury requiring medical attention for one sampled resident (Resident 2) to the facility administration and state agency per facility policies. Sample size was 4 current residents. Facility census was 32. Findings are: Record review of an undated summary of a facility investigation of an incident involving Resident 2 revealed the resident had been walking independently with a walker and, on 4/20/16, the resident yelled out and staff responded finding the resident had fallen. The report indicated the resident sustained [REDACTED]. On 4/20/16, LPN (Licensed Practical Nurse)-A called Resident 2's provider and arranged transportation for the resident to be seen in the clinic. Upon return from the clinic, the resident was now in a shoulder immobilizer. The report went on to state that, on 4/21/16, an x-ray report was received indicating the resident sustained [REDACTED]. The stand-up meeting included discussion of the incident and that no one had called APS (Adult Protective Services) to inform them of the resident injury requiring medical attention. After the meeting It was decided that DON would call APS that day. Record review of a facility policy for Abuse and Neglect revised in (MONTH) of 2012 revealed the document instructions for Staff Reporting Requirements included instructions which read: If the reportable event results in serious bodily injury, the staff member shall report the suspicion immediately, but not later than 2 hours after forming the suspicion. In addition the instructions read: Staff must report the suspicion of an incident to the Administrator or designee. The policy defined Serious bodily injury as an injury involving extreme physical pain . loss or impairment of the function of a bodily member . requiring medical intervention . Interview with the facility Administrator on 11/15/16 at 2:00 p.m. confirmed Resident 2 fell on [DATE] and was transported to a medical clinic for evaluation. The Administrator confirmed the resident returned with an immobilizing sling in place on 4/20/16 and x-ray from the clinic revealed the resident sustained [REDACTED].",2019-11-01
4975,"PREMIER ESTATES OF CRETE, LLC",285170,830 EAST 1ST STREET,CRETE,NE,68333,2019-06-05,607,D,1,0,F77P11,"**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 implement their Abuse Prevention Program & Reporting Policy in identifying, investigation, protection and reporting of ongoing behavioral symptoms regarding two sampled residents (Resident 5 and Resident 6). The failure had the potential to affect some of the facility resident from the behaviors exhibited by the residents. The facility census was 50. Findings are: [NAME] Record review of Resident 5's Order Summary Report revealed Resident 5 had been admitted to the facility on [DATE]. Resident 5's [DIAGNOSES REDACTED]. Record review of Resident 5's Care Plan: -Focus: Behaviors related to resident not being patient with staff with requests, also makes inappropriate sexual comments (example asking staff to go to bed with (him/her, yells and curses at staff, asks other residents to assist with tasks such as putting on [NAME]et, picking something up off of the floor. Dated 3/12/19 with Revision 5/20/19. -Goal: resident will have fewer behaviors through next review date. Date Initiated: 3/12/2019 Target Date: 8/12/2019. -Interventions: Res will be waiting patiently when neededing assistance with items such as cigarettes Date Initiated 03/12/2019; Resident to utilize call light/ask staff for needed items/cares. Date Initiated 05/20/2019; Resident will be redirect by staff is uses inappropriate comments. Date Initiated: 03/12/2019 Record Review of Resident 5's Health Status Notes: -5/7/2019 at 11:09 AM Concerns expressed by two residents about Resident 5's foul language used toward them. Spoke with Resident 5 about complaints. Observed one resident shouting obscenities at Resident 5 without return from Resident 5, mostly likely because of staff presence. -5/29/19 at 3:00 PM Discussed reported behavior with resident. Spoke about anger and expression using foul language, name calling and yelling at other residents. Resident 5 tried to express that Resident 5 was provoked. Set expectation that Resident 5 was responsible for Resident 5's behavior and the expectation that no further incidents will be permitted. -5/29/2019 at 3:19 PM Resident has been verbally abusive to residents while smoking and making racial comments. Reported to DON (Director of Nursing) and Administration at this time. -5/31/2019 at 3:49 PM Was reported to this nurse that he was observed giving cigarettes to another resident who is supervised while smoking. This nurse visited with him about giving cigarettes to others and reinforced the smoking policy. B. Record review of Resident 6's Order Summary Report revealed Resident 6 had been admitted to the facility on [DATE]. Resident 6's [DIAGNOSES REDACTED]. Record Review of Resident 6's Care Plan: -Focus: The resident has an actual psychosocial well-being problem r/t Dependent behavior secondary to [MEDICAL CONDITION]. Date Initiated: 3/27/2019 Revision on: 3/27/2019 -Goal: Resident 6 will utilize effective coping mechanisms as evidenced by remaining free from consumption of alcohol through the review date. Date Initiated: 3/27/2019; Revision on: 3/27/2019; Target Date: 07/27/2019 -Interventions: Consult with: Pastoral care, Social services, Psych services, Other: Date Initiated: 03/27/2019; Notify nurse of blood shot or glazed eyes, dilated or constricted pupils, irritability, sudden change in sleeping pattern or withdraw from social events. Date Initiated: 03/27/2019; When conflict arises, remove resident to a calm safe environment and allow to vent/share feelings. Date Initiated: 03/27/2019 Record Review of Resident 6's Health Status Notes: -5/29/19 at 3:20 PM Resident was verbally abusive to this nurse in main area at Station 1. Attempted to calm resident but behavior escalated. Incident was reported to DON and Administrator at this time. C. Interview with an anonymous resident on 6/5/19 at 1:55 PM revealed several weeks ago that Resident 6 had yelled/called the resident name to come into Resident 6's room. When the anonymous resident went to Resident 6's room, they witnessed Resident 6 naked from the waist down and showing genitals. The anonymous resident stated this had happened two times. It was revealed that several times during the last three weeks Resident 5 had offered alcohol in lieu of oral sex and showing the anonymous residents private parts to Resident 5. The anonymous resident stated Resident 5 had not touched (gender) and was not afraid of Resident 5. The anonymous resident did state that they were afraid that Resident 5 might find out that they had talked to the State Surveyors. D. Interview on 6/5/19 at 12:15 PM with the facility Administrator revealed that staff had not identifed behavioral issues with Residents 5 and 6 and had not investigated the incidents reported by an anonymous resident.",2020-03-01
3335,CHIMNEY ROCK VILLA,285260,"P O BOX A, 106 EAST 13TH STREET",BAYARD,NE,69334,2019-01-08,607,E,1,1,UIRZ11,"**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 implement their Abuse and Neglect Prevention policy in identifying, investigation, Protection, and Reporting of ongoing behavioral symptoms regarding one sampled resident (Resident 33). The failure had the potential to affect some of the facility residents from the behaviors exhibited by the resident. Facility census was 32. Findings are: Record review of Resident 33's Face Sheet revealed the resident was admitted to the facility on [DATE]. Record review of Resident 33's closed medical record revealed the facility had obtained a Nebraska Sex Offender Registry report on 4/15/2014 identifying the resident had Sex Crime Conviction(s) for Immoral Acts with a Child Felony on 7/12/1996 and Crime Sexual Assault of a Child on 12/23/1996. Record review of Resident 33's Nurses Notes revealed the following entries: - 8/10/18 at 11:33 a.m. the resident was observed for Public Sexual Acts/Disrobing and recorded: Observed resident do a playful slap to resident (Resident 13) after making a sexual innuendo . - 8/10/18 at 11:37 a.m. the resident was observed for Behavior and recorded: Resident setting in solarium with other staff members making gestures of other residents being crazy, also talking and encouraging them to try and go outside. Resident has been redirected without success and has been told that this is inappropriate and that behavior is not acceptable. Also relayed message to DON (Director of Nursing) regarding residents behavior. Also noted that when resident stood up to go to dining room that (the resident) re-buttoned pants. - 8/10/18 2:16 p.m. recorded the resident had been having increased sexual behaviors toward staff and other residents with dementia. The entry recorded the police chief came into the facility and discussed the behaviors with the resident and warned the resident that (resident) history of being a lifetime sex offender could result in charges. - 8/13/18 at 1:07 p.m. for Public Sexual Acts/Disrobing the entry recorded the resident was sitting on the couch next to a resident and was observed fastening the top button of pants. The nurse discussed inappropriateness of the behavior and resident responded the staff was harassing me. - 10/3/18 at 4:38 p.m. the staff recorded Resident 33 began yelling in the dining room in the presence of other residents. - 10/10/18 at 2:30 p.m. an incident of significantly disrupts care or living environment recorded the resident cursed aloud during a game in activities in front of other residents. - 11/9/18 at 1:47 p.m. a Behavior was recorded in which staff discussed with the Resident 33 to properly dress self and put pants on when going to the bathroom as this offends the resident's room mate. Record review of facility policy for Abuse and Neglect Prevention dated 4/1/16 revealed the following instructions regarding the facility's policy: - The policy defined Physical Injury abuse included: slapping, hitting, pinching, kicking .; Verbal Abuse: The use of oral written or gestured language that willfully includes disparaging and derogatory terms used with or to residents, their families, or within hearing distance . Sexual Abuse: Includes but is not limited to sexual harassment, sexual coercion, or sexual assault . - In the Prevention portion of the policy, the instructions read: The facility staff will identify, correct, and intervene in situations in which abuse, neglect . is more likely to occur . There will be knowledge of . Assessment, care planning and monitoring of residents with needs and behaviors that might lead to conflict or neglect; such as history of aggressive behaviors . - In the Investigation portion of the policy, the instructions read: All allegations of abuse and/or neglect will be investigated in accordance with state and federal laws . - In the Protection section of the policy, the instructions read: Residents will be protected from harm during an investigation . - In the Reporting/Response section of the policy the instructions read: Report alleged incidents as required to all local/state/federal agencies within 2 hours if the allegation results in serious bodily injury (this includes sexual abuse) and within 24 hours for all others. After conducting an internal investigation, you must submit a report of all investigation results to the state . It is the responsibility of any employee . to report any act of witnessed or suspected abuse to their supervisor or the Administrator immediately. Record review of Resident 33's care plan revealed none of the behaviors documented between 8/10/18 and 11/19/18 had been updated on the resident's care plan identifying the problem behaviors and approaches to address the problem. Record review of facility investigations of alleged abuse between 6/1/18 and 1/8/19 revealed there were no investigations initiated or completed by the facility regarding the incidents between 8/10/18 and 11/19/18 which recorded symptoms meeting definitions of types of abuse in the facility's Abuse and Neglect Prevention program. Interviews with the Administrator and DON on 1/8/19 from 10 a.m. to 10:30 a.m. confirmed Resident 33's medical record and nurses notes showed multiple incidents of behaviors between 8/10/18 and 11/19/18. The Administrator and DON confirmed that none of these recorded behaviors were identified by the facility as potential abuse, none of the incidents were reported to the State Agency, none of these incidents were investigated or forwarded to the State Agency.",2020-09-01
3337,CHIMNEY ROCK VILLA,285260,"P O BOX A, 106 EAST 13TH STREET",BAYARD,NE,69334,2019-01-08,610,E,1,1,UIRZ11,"**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 initiate and complete an investigation into Law Enforcement intervention for alleged increasing sexual behaviors exhibited by one sampled resident (Resident 33) toward facility staff and other residents with dementia. These behaviors had the potential of affecting some of the facility residents in which Resident 33 directed behaviors toward. Sample size included 15 current residents and 4 closed records. Facility census was 32. Findings are: Record review of Resident 33's closed medical record revealed the following: Review of Resident 33's Face Sheet dated 9/26/18 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 33's Nurses Notes recorded an entry on 8/10/18 at 2:16 p.m. recording: Resident Contact: Resident has been having increased sexual behaviors toward staff and other residents with dementia. Spoke with Administrator, it was decided to have the police come up and visit with (the resident) again. (Name of police officer) came up and spoke with resident regarding behavior . There was no documentation of when these alleged events occurred or the residents involved. Review of facility investigations of allegations of abuse revealed there was no investigation initiated or completed by the facility regarding the incident involving Law Enforcement intervention for Resident 33 which occurred on 8/10/18. Record review of the facility's policy for Abuse and Neglect Prevention dated 4/1/16 revealed instructions for Investigation which read: All allegations of abuse and/or neglect will be investigated . In the event that an allegation of abuse was between residents, the investigation procedure would be the same. The resident(s) in question should be immediately moved to a place of safety during the investigation . Under the heading Protection the instructions direct: Residents will be protected from harm during an investigation . Interviews with the DON and Administrator 1/8/19 from 10:00 a.m. to 10:30 a.m. confirmed on 8/10/18 the facility had contacted local Law Enforcement regarding Resident 33's increased sexual behaviors toward staff and other residents with dementia. The DON and Administrator verified the facility had not followed policies regarding initiating and completing an investigation of the alleged behaviors and ensuring that residents involved were protected during the investigation period",2020-09-01
3336,CHIMNEY ROCK VILLA,285260,"P O BOX A, 106 EAST 13TH STREET",BAYARD,NE,69334,2019-01-08,609,D,1,1,UIRZ11,"**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: 1) ensure staff reported an alleged incident of sexual abuse involving two sampled residents (Resident 33 and Resident 13) immediately to the facility administration; and 2) failed to contact the State Agency after contacting local Law Enforcement as an intervention regarding increasing sexual behaviors exhibited by one sampled resident (Resident 33). These failures could potentially have affected some of the facility residents in which Resident 33 directed the behaviors toward. Sample size was 15 current residents and 4 closed records. Facility census was 33. Findings are: [NAME] Record review of Resident 33's closed medical record revealed the following: Review of Resident 33's Face Sheet dated 9/26/18 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 33's Nurses Notes revealed the following note: - 8/10/18 at 11:33 a.m. Public Sexual Acts/Disrobing recorded Comments: Observed resident do a playful slap to resident (Resident 13) after making sexual innuendo. This nurse went and spoke with resident and advised that (Resident 33) needs to keep hands to self. Resident stated that (the resident) was just playing around. advised resident (Resident 33) that (the resident) is aware of what (the resident) is doing and the other resident (Resident 13) is not. Resident stated geez this place is no fun. Record review of facility investigations of alleged abuse involving facility residents revealed between (MONTH) of (YEAR) and (MONTH) of 2019 there were no investigations of incidents involving Resident 33 or Resident 13 completed. Record review of the facility policy for Abuse and Neglect Reporting dated 4/1/16 revealed the facility Policy Interpretation and Implementation instructions recorded: All staff members . are required to immediately report any incidents or suspected incidents of resident mistreatment, abuse, or neglect . The policy goes on to define the following types of abuse: Physical abuse: hitting, slapping, pinching, kicking . and Sexual abuse: includes--but is not limited to--sexual harassment, sexual coercion, or sexual assault. The policy heading for Procedure included instructions that The Charge Nurse or Department Head receiving the initial allegation of abuse or neglect must immediately contact the Administrator and/or Director of Nursing. Interviews with the Administrator and DON (Director of Nursing) on 1/8/19 from 10 a.m. to 10:30 a.m. verified the documentation of the incident involving Resident 33 toward Resident 13 on 8/10/18 described Resident 33 slapping Resident 13 and making sexual innuendo remarks toward the resident. The DON and Administrator confirmed this met the definitions in facility policy for physical and sexual abuse and should have been reported to the DON and Administrator immediately by the staff to begin an investigation of the incident. The Administrator and DON both confirmed they were not informed by the staff of the slapping incident or the sexual remarks made toward Resident 13 by Resident 33. B. Record review of Resident 33's Nurses Notes recorded an entry on 8/10/18 at 2:16 p.m. recording: Resident Contact: Resident has been having increased sexual behaviors toward staff and other residents with dementia. Spoke with Administrator, it was decided to have the police come up and visit with (the resident) again. (Name of police officer) came up and spoke with resident regarding behavior . There was no documentation of when these alleged events occurred or the residents involved. Review of facility incidents reported to the State Agency revealed nothing was reported to the State Agency regarding the incident involving Law Enforcement intervention for Resident 33 which occurred on 8/10/18. Record review of the facility's policy for Abuse and Neglect Reporting dated 4/1/16 revealed the following instructions in the Procedure section of the policy: In cases when Local Law Enforcement (LEA) and/or staff as alleged perpetrators, the Administrator or his/her designee will also contact within the first working day: The Nebraska Department of Health and Human Services Regulation and Licensure, Facility Investigation Program . Interviews with the DON and Administrator 1/8/19 from 10:00 a.m. to 10:30 a.m. confirmed on 8/10/18 the facility had contacted local Law Enforcement regarding Resident 33's increased sexual behaviors toward staff and other residents with dementia. The DON and Administrator verified the facility had not followed policies regarding reporting to the state agency the alleged sexual behaviors exhibited by Resident 33 involving Law Enforcement intervention.",2020-09-01
6109,"PREMIER ESTATES OF CRETE, LLC",285170,830 EAST 1ST STREET,CRETE,NE,68333,2016-06-08,157,D,1,0,L0XK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.04 C3a Based on record review and interview, the facility failed to report a change in condition for Resident 1 to their physician. The facility census was 52. Findings are: Review of Resident 1's medical record revealed Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Progress Notes dated 3/19/16 at 4:43 PM revealed Registered Nurse (RN) A noted Resident 1 to be hot to touch, had respirations that were shallow at times then strong and that resident opened eyes but did not offer speech. Review of Resident 1's Progress Notes dated 3/20/16 at 1:59 AM revealed Licensed Practical Nurse (LPN) B entered Resident 1's room on 3/19/16 at 9 PM that evening and noted Resident 1 to be having apnea (temporary pauses in breathing) [MEDICATION NAME] 35-45 seconds with a temperature of 100.0 degrees Fahrenheit and a slightly elevated pulse of 110. LPN B notified the physician and sent Resident 1 to the hospital via emergency services per the physician's orders [REDACTED].>Review of Resident 1's Progress Notes dated 3/21/16 revealed Resident 1's family member came to the facility and voiced concerns that Resident 1 had a high blood sugar reading when arriving at the hospital from the facility on 3/20/16. Review of a Disciplinary Action Record dated 3/23/16 revealed that on 3/19/16 RN A had taken Resident 1's blood sugar and gotten a result of 416 which should have been reported to Resident 1's physician. RN A further documented will continue to monitor resident but did not continue to monitor the resident.",2019-06-01
6234,HILLCREST HEALTH & REHAB,285133,1702 HILLCREST DRIVE,BELLEVUE,NE,68005,2016-05-05,225,D,1,0,5GBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.04A3 and 175 NAC 12-006.02(8) Based upon record review and interview; the facility failed to report and investigate allegations of abuse for 1 resident (Resident 2). The facility identified a census of 109. Findings are: A. Record review of Resident 2's face sheet dated 05/05/2016 revealed Resident 2 was admitted on [DATE] with the following Diagnoses: [REDACTED]. Record review of a facility Concern Form dated 02/08 revealed that Resident 2 complained to Licensed Practical Nurse (LPN) H that Nursing Assistant (NA) I was rough with cares and when Resident 2 mentioned it to NA I, Resident 2 heard NA I say vulgar terms NA I's breath. Further review of the Concern Form revealed the allegation of rough handling had not been evaluated by facility staff. Interview with RN (Registered Nurse) A on 05/05/2016 at 9:14 AM revealed that RN A was informed by LPN H, that Resident 2 reported that NA I was rough with (gender) cares. RN A stated that there was no evidence of this interview. RN A further confirmed that there was no investigation of the allegations. Interview with the DON (Director of Nursing) on 05/05/2016 at 9:46 AM revealed the DON confirmed that there was no evidence of an investigation. Record review of the facility Patient Abuse and Neglect Policy Revised 7-9-15 revealed that physical abuse was defined as damage to bodily tissue caused by nontherapeutic conduct and verbal abuse was defined as any use of oral, written or gestured language that willfully included disparaging and derogatory terms to patients or families, or within their hearing distance. The Administrator or designee will notify the appropriate agencies to report the incident.",2019-05-01
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
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
4431,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-06-14,157,D,1,0,LO8N11,"**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 a change in condition related to an increase in pain for one resident (Resident 1) of 3 residents sampled. The facility census was 61. Findings are: Review of Progress Notes dated 6/8/2017 at 1:35 AM revealed Resident 1 fell and complained of pain. Resident 1 scored the pain as a 10 on a 0 to10 scale (0 being no pain/10 being worst pain). Review of Resident 1's Medication Administration Record [REDACTED]. Review of Resident 1's MAR indicated [REDACTED]. Review of Resident 1's Pain assessment summary revealed on 6/10/2017 at 4:52 PM Resident 1's pain level was 10 and the resident was sent to the hospital and was diagnosed with [REDACTED]. Review of Resident 1's MAR indicated [REDACTED]. Review of the medical record revealed the facility did not update the physician regarding Resident 1's increased pain levels after the fall. Interview on 6/14/2017 at 11:30 AM with the MDS Coordinator (Minimum Data Set) revealed Resident 1 usually denies pain. Review of Resident 1's Progress Notes revealed Resident 1's continued increase in pain from baseline was not reported to the Physician until the resident was sent to the emergency roiagnom on [DATE] and admitted to the hospital for bilateral femur (thigh bone) fractures. Interview on 6/14/2017 at 2:00 AM with the Director of Nurses revealed that the resident did have increased pain over the course of 60 hours and the physician was not notified. Interview on 6/14/2017 at 11:35 AM with the Director of nursing revealed the physician should have been notified of the resident's increased pain levels.",2020-06-01
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
5894,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2016-08-31,157,D,1,0,F2SC11,"**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 notify and consult with one sampled resident's (Resident 4) physician prior to an anticipated discharge of the resident from the facility. Facility census was 27. Findings are: Record review of Resident 4's Physician's Discharge Summary form signed by the physician on 8/24/16 revealed the resident was admitted to the facility on [DATE] and discharged from the facility on 8/23/16 at 9:46 a.m. Record review of Resident 4's Admission Record printed on 8/30/16 revealed the resident had multiple medical [DIAGNOSES REDACTED]. Record review of Resident 4's Report of Consultation form dated 7/14/16 revealed the resident was seen by the physician for a 60 day (review)- wants d/c (discharge) orders. The physician responded with Recommendations which read (MONTH) D/C (discharge) home if can transfer to shower chair or toilet. Record review of Resident 4's Physical Therapy Plan of Care (Evaluation Only) form signed by the Physical Therapist on 7/26/16 revealed a referral for assessment to acquire wheelchair and evaluation of posture and positioning. The therapist documented: It should be noted that patient was on therapy caseload in the past year following R (right) BKA (below knee amputation) and was discharged due to unwillingness to continue or participate. Patient now expresses desire to return home and will require a w/c (wheelchair) for mobility . Record review of Resident 4's Progress Notes for (MONTH) (YEAR) revealed an entry on 8/17/16 at 11:50 a.m. the resident was found on the floor by staff. The note read: Resident states that was transferring self from bed to w/c using slide board. Resident also reports that slide board slips and causes (resident) to fall . Record review of Resident 4's Quarterly review assessment MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) dated 8/22/16 revealed the resident's Transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) ability was assessed as Extensive assistance- resident involved in activity, staff provide weight-bearing support with the support of One person physical assist. The assessment recorded the resident weight was 398 pounds. Record review of Progress Notes for Resident 4 revealed: - an entry on 8/22/16 at 5:04 p.m. documenting the resident stated wanted to go home . Resident has discharge to home per (name of physician) with the stipulation of being able to transfer self from w/c to toilet and back independently. Resident is able to perform transfer without difficulty. Resident has begun to gather belongings to leave for (name of town) tomorrow morning . Staff notified of discharge and will escort resident to home. - an entry on 8/23/16 revealed at 9:46 a.m. the resident left the facility per facility transportation for discharge to home with family member. Sent medication and medication list with resident . - an entry dated 8/24/16 at 6:50 p.m. revealed the resident went to motel instead of home . Resident now in hospital. - There were no notes in the resident's Progress Notes between 7/14/16 and the resident's discharge on 8/23/16 documenting any conversations with the physician regarding the resident's plan to return home or whether or not the physician or therapy department were in agreement the resident demonstrated the independent transfer skills recommended by the physician before discharge orders would be considered. Record review of the facility policy for Discharge/Transfer of the Resident dated 2006 revealed instructions in the policy When calling the attending physician for a discharge order, inquire whether or not the resident's medication is to be sent with the resident . Interview with the DON (Director of Nursing) on 8/31/16 at 10:45 a.m. confirmed Resident 4 requested a discharge from the facility and consulted the physician on 7/14/16 receiving a recommendation for safe independent transfers before could return home. The DON verified the resident anticipated discharge and discussed with the facility on 8/22/16 indicating the resident wished to go to a family home and requested facility transportation. Facility staff were notified of the discharge to this setting and set up transport on 8/22/16 and the resident was discharged from the facility on 8/23/16 and taken to a motel in the hometown of a family member. The DON verified the therapy department had not assessed the resident or provided consultation on the resident's safety for discharge and that the physician was not notified or consulted regarding the resident's desire to transfer until receiving a discharge summary report on 8/24/16 after the resident had already discharged from the facility. The DON agreed the resident had multiple medical issues including [MEDICAL CONDITION] activity, obesity making it difficult to mobilize or get self up if falling, diabetes, and an amputated leg and confirmed the physician was not consulted on the stability of these problems prior to discharge.",2019-08-01
2026,GOOD SAMARITAN SOCIETY - VALENTINE,285176,601 WEST 4TH STREET,VALENTINE,NE,69201,2018-05-30,580,G,1,1,DSI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.04C3a (6) Based on record reviews, observation, and interviews, the facility failed to notify the medical practitioner of: 1) condition changes for one sampled resident (Resident 18) regarding unusual behaviors and loose stools resulting in the facility holding scheduled medications. The resident's ongoing loose stools resulted in hospitalization and surgical intervention for a bowel obstruction; and 2) ongoing pain issues for one sampled resident (Resident 86). Sample size was 16 current residents. Facility census was 34. Findings are: [NAME] Record review of Resident 18's Admission Record printed on 5/25/18 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 18's Medication Record for (MONTH) of (YEAR) revealed the following: - an order for [REDACTED]. - an order for [REDACTED]. - an order for [REDACTED]. Record review of Resident 18's Complex Alert Documentation Report for (MONTH) of (YEAR) revealed documentation of the consistency of BM (Bowel movements) exhibited by the resident. The form documented the resident had Formed/Normal BMs or Soft BM's from 2/1/18 through 2/7/18. Beginning on 2/8/18 in the evening, the resident had a loose/liquid BM which continued through 2/24/18. On 2/25/18 and 2/26/18 there were no BM's recorded for the resident. Record review of Resident 18's Progress Notes for (MONTH) of (YEAR) revealed the following entries: - 2/13/18 at 7:34 a.m. the resident was sitting on edge of bed and the staff attempted to give the resident an antianxiety medication as the resident won't go to the bath house with bath aide, won't allow aide to assist to BR (bathroom). The resident questioned How do I know those (medications) are mine. The resident refused to take the medications and the nurse recorded Meds held and then offered multiple times as walked by resident room. - 2/13/18 at 8:57 a.m. the entry recorded the resident questions what is the plan for the security for me and my family . Resident still refusing to eat or take meds (medications). Contacted (name of family member) and explained situation. - 2/13/18 at 10:21 the resident's family expressed a concern with the facility Social Services Director that the resident was having more paranoia and questioned if (the doctor) had been notified. SSD (Social Services Director explained not being aware if the doctor had been notified of this morning's mood/behavior but resident had been seen on 2/6/18 . (family member) felt (the need) to contact the doctor to inform what was going on. The SSD provided the family member the clinic's office number. - 2/18/18 at 8:05 a.m. the staff held the resident's scheduled Polyethylene [MEDICATION NAME] (for constipation) due to loose stools. The staff held the resident's potassium tablets due to the resident was feeling sick. At 8:06 a.m. the staff held the resident's [MEDICATION NAME] (for constipation) due to loose stools. - 2/18/18 at 9:52 a.m. the nurse recorded: Resident reported to have had some loose stools during N[NAME] (night). Early meds given without issue. By the time breakfast was served (the resident's) demeanor changed. (The Resident) decided everyone was talking about (the resident) and was very angry. Refused food . didn't feel well. Held [MEDICATION NAME] r/t (related to) loose stools and explained this to (the resident). 'Well who make you God? How do you know what I need or why I'm here?' Several staff members attempted to visit with (the resident) and encourage to go back to room but would refuse. Asking another nurse why no one will tell (Resident 18) the truth about how (the resident's) aunt is doing. No one knows about this. After about an hour, (the resident) was speaking to a visitor and stated wanted to go to room. CNA (Nurse Aide) then ambulated to room and is resting in bed at this time. - 2/19/18 at 8:32 a.m. the nurse documented holding the resident's Polyethylene [MEDICATION NAME] due to c/o (complaints of) loose stools. - 2/19/18 at 10:45 p.m. the resident was given Tylenol for voices headache and sore throat. - 2/25/18 at 9:46 a.m. the nurse recorded Out for breakfast early and reported at table that (the resident) was hot. Cheeks flushed. Temp (resident temperature) 96.2. Ate only bites of breakfast but drank several glasses of water . - 2/25/18 at 2:32 p.m. the nurse recorded Resident refused lunch states just doesn't feel well took in sips of supplement with noon medications. Resident is flush but is afebrile (doesn't have elevated temperature). Will continue to monitor . - 2/25/18 at 2:32 p.m. the nurse recorded administering Tylenol for the resident's request for headache. - 2/26/18 at 9:38 a.m. the nurse recorded: Notified by CNA that resident stated stomach did not feel good and didn't want to get up. Observed abdomen to be distended fully; states 'Doesn't feel real good' when palpated. high abdominal sounds upper, hypo (little or no sounds) lower . The facility contacted a family member and was asked about past history of ovarian cysts or blockages in colon. (Family member) stated (the resident) has an extensive hx (history) of both and saw (the resident) last night and believes it is an ileus (intestinal obstruction)). The nurse contacted the clinic and reported the symptoms and an order was received to send the resident to the emergency room for evaluation. - 2/26/18 at 4:30 p.m. the Director of Nursing recorded a Late entry for earlier this am (morning). The nurse recorded an assessment of the resident's abdomen was done at 9:20 a.m. in which the abdomen was very distended, BS (Bowel sounds) in upper quad's (quadrants) very hyper and lower quad's very hypo to little sounds, abdomen was very firm with palpation and (Res 18) did have facial grimacing with touch. Face was very flush, warm to touch, heart was regular, lungs clear, didn't notice any [MEDICAL CONDITION] (swelling). (The Resident) report 'I don't feel good' . Review of Resident 18's Progress Notes and electronic medical record revealed the resident began developing symptoms of loose stools recorded on the BM records beginning on 2/8/18 through 2/25/18. The resident exhibited unusual paranoia and behavioral symptoms beginning on 2/13/18 which included resisting medications and assistance. The staff held medications due to loose stools on 2/18/18 and 2/19/18, and the resident continued to complain of feeling sick or requesting Tylenol for pain on 2/19/18 and 2/25/18. There was no evidence the facility contacted the medical practitioner or physician regarding these symptoms until 2/26/18. Record review of Resident 18's hospital Transfer Summary dated 2/26/18 recorded the resident was brought to the emergency room with complaints of abdominal pain. (The resident) states the abdominal pain has been going on for the past week, but has gotten worse today . A CT (computerized axial tomography- type of non-invasive test analyzing internal organs and structures) of (the resident's) abdomen shows a distal sigmoid (colon) obstruction with severe dilitation of the colon, sigmoid volvulus (twisting of the bowel upon itself). Recommend urgent surgical consultation. Interview with the DNS (Director of Nursing Services) on 5/30/18 at 9:15 a.m. confirmed Resident 18 began developing loose stools as recorded on the BM records on 2/8/18, unusual behaviors on 2/13/18, and the staff held medications for the resident on 2/18 and 2/19/18 due to loose stools. The DNS verified the resident continued with symptoms requiring Tylenol for pain and refusing meals on 2/25 due to not feeling well. The DNS verified the resident's medical practitioner or physician were not notified of the changes until 2/26/18. B. On 5/22/18 at 02:42 PM, NA-B (Nurse Aide) and NA-C entered the room of Resident #86 to assist the resident transfer from the bed to the wheel chair. During movement, Resident #86 grunted, winced, and quitely said, Ow, ow, ow. Once the resident was transferred into the wheelchair the resident stated, I know (the nurse) said 1 but it's already past 2, so. Resident #86 had been waiting for the prescribed pain medication {[MEDICATION NAME] 5/325 1 tab every 4 hours as needed for pain (a medication used mainly in the management of moderate to severe pain)} before being transferred from the bed to the wheelchair. Resident verbalized pain level at 9 out of 10 in left hip and back areas. On 5/23/18 Resident #86 reported that the prescribed pain medication ([MEDICATION NAME]) helped once it became effective, approximately 45 minutes after it was taken, and lasts for about an hour. It takes the pain from horrible to a 4 or 5 which is ok but then it comes back. In my hip and my back. On 5/29/18 a review of the resident's medical records revealed that Resident #86 was admitted on [DATE] after a repair of a left [MEDICAL CONDITION] due to a fall at home. Record review also revealed the resident was taking 1 tablet of [MEDICATION NAME] 3 to 4 times a day with documented pain ratings of 7, 8, 9, and 10 prior to taking the medication. Review of the care plan for Resident #86 revealed the resident identified a tolerable level of pain to be rated at a 4 to 5 . On 5/29/18 at 3:56 PM an interview with RN-D (Registered Nurse) confirmed that the record reflected that Resident #86 was reporting pain levels of 7, 8, 9, and 10 prior to the administration of the prescribed pain medication and that the care plan reflected that Resident #86 had identified a tolerable level of pain at a 4 or 5. RN-D also confirmed that there had been no communication with the resident's provider regarding current pain levels or pain management. On 5/30/18 at 09:45 AM an interview with the Director of Nursing and the Administrator confirmed records for Resident #86 showed pain ratings of 7, 8, 9, and 10 prior to the administration of pain medication and that the care plan reflected that Resident #86 had identified a tolerable level of pain at 4 or 5. The interview also confirmed there had been no communication with the resident's provider regarding the consistent pain levels of 7, 8, 9, and 10.",2020-09-01
5326,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-01-31,157,D,1,0,BKZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.04C3a Based on record review and interview, the facility failed to notify a physician of Resident 84's refusal to take medications. This affected 1 out of 1 resident sampled. The facility Census was 69. Findings are: Record review of the facility Medication Management policy revealed : -Discuss resident goals for medication treatment. Communicate to the physician and pharmacist, as indicated. -Notify physician and document refusal of care in the medical record -If resident declines or refuses medication, document reasons in the medical record; offer alternatives, as indicated. -Monitor for changes in condition and notify physician as indicated Record review revealed that Resident 84 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of Resident 84's MDS (The Long-Term Care Minimum Data Set (MDS): 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) with an Assessment Reference Date of 12/5/16 revealed that Resident 84 did understand and was understood. Resident 84 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 . Resident 84 had a Resident Mood Interview that had recognized that Resident 84 had feelings of hopelessness and was feeling depressed. Resident 84 had little interest or pleasure in doing things, was feeling bad about self or that Resident 84 felt like a failure and had let self and family down. It also identified that Resident 84 had feelings of hurting self in some way or would be better off dead. It was recorded as Resident 84 had the above symptoms/feelings 12 out of 14 days. It was recorded that the responsible staff or provider were informed that there was a potential for resident self harm. The MDS section regarding resident behavior recorded Resident 84 as rejecting care 1 to3 days and had verbal behaviors 1 to3 days in the assessment period. Record review of Resident 84's physician's orders [REDACTED]. -Entecavir; (a medication used to treat [MEDICAL CONDITIONS]) give one tablet one time a day by mouth (PO), -[MEDICATION NAME] Tablet ([MEDICATION NAME]); (a medication used to treat Depression) 45 milligrams (mg) one tablet one time a day PO, -[MEDICATION NAME]; (a medication used to treat the symptoms of psychotic conditions such as [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) give 5 mg two times a day (BID)PO, -Raltegravir Potassium; (a medication used to [MEDICAL CONDITION]) give 100 mg BID PO, -[MEDICATION NAME]; (a medication used to treat nerve pain) give 300 mg capsule 3 times a day PO. Record review of Resident 84's Medication Administration Record [REDACTED] -Entecavir; had been refused in (MONTH) of (YEAR) on1/3, 1/8, 1/9, 1/13, 1/14, 1/20, 1/22, 1/23, 1/24, 1/25, and 1/26. -[MEDICATION NAME] was refused in (MONTH) of (YEAR) on 1/1 thru 1/13, 1/17, 1/18, 1/20, 1/22, 1/25. -[MEDICATION NAME] was refused in (MONTH) of (YEAR) on 12/1, 12/2,12/4 thru12/10, 12/12,12/13, 12/14,12/15,12/17,12/19,12/21 thru 12/26, 12/27 thru and included 12/31. -[MEDICATION NAME] was refused in (MONTH) of (YEAR) on 11/6,11/13,11/15, 11/17, 11/18, 11/21,11/22, 11/27. -[MEDICATION NAME] was refused at least one time in (MONTH) of (YEAR) on 1/1 thru 1/7, 1/8/17, 1/9 thru and included 1/13, 1/15, 1/17 thru 1/22, and 1/25. -Resident 84 refused all but 4 doses of the PM doses of [MEDICATION NAME] for (MONTH) (YEAR). Record review of Resident 84's Progress notes and physician communications revealed there was no documentation to show the physician had been notified of Resident 84's refusal of medications. Interview on 01/26/17 at 1:20 PM with the facility Director of Nursing (DON) confirmed that Resident 84 had refused to take the medications prescribed by the physician. The DON confirmed that the standard of care was to notify the physician of medications that had been refused, by a resident 3 times. The DON was unable to provide documentation that Resident 84's physician had been notified of the refusals of these medications.",2020-01-01
5521,"SORENSEN CARE AND REHABILITATION CENTER, LLC",285107,4809 REDMAN AVENUE,OMAHA,NE,68104,2016-11-14,156,D,1,0,7EEE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.04C3a Based on record review and interview, the facility failed to notify the physician of a change in condition for one of five residents (Resident 1) sampled. The facility census was 66. Record review of the facility's Policy Notification of Change in Resident Health Status dated 10/20/16 revealed: - It was the facility's policy to ensure that notifications were made when a resident had a change in health status. Record review of a nurse's note dated 10/28/16 at 10:30 AM by Registered Nurse (RN) B revealed that Resident 1's vital signs had been recorded as; - a temperature of 97.2 Fahrenheit, - a blood pressure of 145/82, - pulse of 108, - respirator rate of 18 breaths per minute, - a oxygen saturation of 96% on room air. Resident 1 was alert and oriented, independent with transfers and ambulated with a walker. Resident 1 was independent with activities of daily living (ADL's). Resident 1 had no shortness of breath. Resident 1 did not require oxygen, and had capillary refill time of less than 3 seconds. Resident 1 had no complaints of pain and had been using the telephone and talking with family and friends. A record review of Resident 1's medical record, titled Progress Note dated 10/29/16 at 6:00 AM, written by Licensed Practical Nurse (LPN) A, revealed that Resident 1 was yelling stating having trouble breathing. The on-duty, Nursing Assistant (NA), requested that this writer report to Resident 1's room. I immediately expedited to the distressed resident room. Resident 1's oxygen saturation was 84% (Lippencott's Nursing Center states that SpO2, or pulse oximetry, is normal when in the range of 97 to 99 percent). Resident 1 presented with good color and was assisted to bed. An assessment of Resident 1's lungs revealed clear sounds in the upper lungs, bilaterally, and diminished sounds in lower lungs bilaterally. Oxygen was applied by nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory assistance), at 2 liters. Resident 1's oxygen saturation was then 91%. Resident 1 was reassured and made comfortable in bed. Resident 1 voiced no further distress, respirations were even and non-labored and skin was warm and dry to touch. Record review of Resident 1's Electronic Medical Record (EMR) Nursing Progress note dated 10/29/16 at 7:15 AM revealed that Resident 1 was found unresponsive. Resident 1 was cold to touch with nail beds cyanotic and no pulse could be obtained. An interview with LPN A on 11/03/16 at 4:40 PM revealed that Resident 1 had been under the care of LPN A for three nights. LPN A revealed that Resident 1 had called for help due to having problems breathing. LPN A confirmed that Resident 1 had called for help three times from 3:00 AM till 5:15 AM. LPN A revealed that NA C called over to the west nursing station at 5:15 AM, from the east nursing station, and said that NA-C felt the resident needed help right away and was having difficulty breathing The NA stated that Resident 1 was screaming that Resident 1 was unable to breathe. LPN A revealed at 5:15 a check of Resident 1's oxygen level had been performed and it was 84% but came up to 91% after oxygen had been applied. LPN A confirmed that Resident 1 did not have an order for [REDACTED]. LPN A confirmed that no vital signs except the oxygen saturation had been performed on Resident 1 during the three visits to Resident 1's room for respiratory distress. LPN A confirmed the inhaled medication that was administered to Resident 1 was not documented and that the time it was administered could not be recalled. LPN A confirmed that Resident 1's physician and family had not been notified of the respiratory distress episodes. Interview on 11/3/16 at 12:18 PM with the Director Of Nursing (DON), confirmed that Resident 1's physician had not been notified of the sudden onset of shortness of breath and the use of oxygen without an order.",2019-11-01
3454,LOUISVILLE CARE CENTER,285267,410 WEST 5TH STREET,LOUISVILLE,NE,68037,2017-08-31,279,E,1,1,XE3U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.04C3a(5) Based on record review and interviews, the facility failed to develop a Comprehensive Care Plan for 4 of 34 residents reviewed related to the following areas: incontinence for Resident 18, for use of an anticoagulant medication for one resident (Resident 23) and for behaviors for two residents (Residents 53 and 57). The facility census was 52. Findings are: [NAME] Record review of Resident 18's MDS dated [DATE], BIMS score of 15. Record review of Resident 18's MDS dated [DATE] revealed in Section H - Bladder and Bowel for question-Urinary Continence (H0300). Quarterly review assessment: 2 (Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding)). A record review of Resident 18's Continence assessment dated [DATE] revealed the resident was continent and had a total score of 14 out of 15. A record review of Resident 18's undated Care Plan reviewed there was no indication of urinary incontinence as an identified problem or issue. An interview with ADON on 08/31/2017 at 02:25 PM, confirmed that Resident 18 did have a decline in incontinence status and should have had an incontinence care plan in place to address it and currently does not. B. Review of resident 53's most recent MDS (Minimum Date Set: a federally mandated assessment tool used for care planning) revealed Resident 53 has a score of 2 on a 0-15 score for cognitive function. Review of Resident 53's [DIAGNOSES REDACTED]. Review of Resident 53's nurses notes dated for the month of (MONTH) (YEAR) revealed Resident 53 can become agitated and aggressive with staff and other residents. Review of Resident 53's behavior documentation dated for (MONTH) (YEAR) revealed behaviors including wandering, resisting cares, striking out at staff, kicking, cursing, and scratching. Review of Resident 53's behavior monitoring documentation dated as printed 8/30/2017 revealed no target behaviors. Interview on 08/31/2017 at 9:43 AM with the ADON (Assistant Director of Nursing) revealed behavior charting is completed by the nurse's aides and the options for behaviors are the same for all residents not specific to each residents target behaviors. Review of a page from the facility communication book revealed on 7/13/2017 entry regarding Resident 53 revealed Resident 53 had a history of [REDACTED]. Review of Resident 53's care plan received from the facility on 8/30/2017 reveals no entries regarding [MEDICAL CONDITION] medication or target behaviors to be monitored. Interview on 08/31/2017 at 9:43 AM with the ADON revealed no interventions are on the care plan for Resident 53's target behaviors related to psychoactive medications. C. Review of Resident 57's Medication Administration Record [REDACTED]. Review of a page from the staff communication book provided by ADON on 8/30/2017 revealed instructions for staff to monitor Resident 57 for non-verbal facial expressions: crying, pacing, or worried facial expressions. Interview on 8/31/2017 at 9:40 AM with the ADON revealed the non-verbal facial expressions would be considered target behaviors related to depression. Review of Resident 57's care plan revealed no target behaviors on care plan. Interview on 08/31/2017 at 9:43 AM with the ADON revealed no target behaviors are on the care plan for related to Resident 57's psychoactive medications. D. Review of [DIAGNOSES REDACTED]. Review of Resident 23's MAR indicated [REDACTED]. Review of Resident 23's care plan dated 6/15/2017 revealed no care plan goal or interventions related to monitoring of side effects of Eliquis. Interview on 08/31/2017 at 9:43 AM with the ADON revealed no interventions are on Resident 23's care plan for side effects of Eliquis and monitoring should be done due to risk of bleeding.",2020-09-01
3354,CHIMNEY ROCK VILLA,285260,"P O BOX A, 106 EAST 13TH STREET",BAYARD,NE,69334,2018-04-19,580,D,1,0,KTGP11,"**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 notify the responsible party of new physician orders [REDACTED]. The facility census was 33 with six current sampled residents and one closed record reviewed. Findings are: Review of the Face Sheet, printed 4/18/18, revealed that Resident 1 was admitted to the facility on [DATE] with an activated DPOA (Durable Power of Attorney) for healthcare. Review of the Physician Orders, dated 4/13/18, revealed that the resident's corneal abrasion was healed on the left eye and new orders to leave the bandage and contact lens in place and follow up in two weeks. Further review revealed that the orders were signed off by RN (Registered Nurse) - [NAME] Interview with the Director of Nursing on 4/19/18 at 11:00 AM confirmed that there was no documentation that the resident's DPOA was notified that the corneal ulcer was healed and the new orders received. Further interview confirmed that the nurses should have notified the DPOA of the new orders.",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
3758,GOOD SAMARITAN SOCIETY - GRAND ISLAND VILLAGE,285285,4061 TIMBERLINE STREET & 4055 TIMBERLINE STREET,GRAND ISLAND,NE,68803,2019-09-26,725,F,1,1,7E3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.04C7 Based on observations, record reviews and interviews, the facility failed to: 1) ensure the restorative nursing department was staffed to provide restorative nursing to residents as outlined by physical and occupational therapy for 4 sampled residents (Residents 28, 1, 25, and 53); 2) ensuring that grievances related to staffing are investigated with a resolution solution and follow up comments with concerned parties for concerns reported regarding staffing on the Cottonwood units, and conceders reported regarding two sampled residents (Residents 57 and 30); and 3) ensure facility direct care positions were staffed to ensure resident baths were being done according to requested schedule for two sampled residents (Residents 2 and 45). Facility census was 59. Sample size was 19 current residents. Findings are: [NAME] Record review of a facility MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) Facility Rate Report ( A report identifying potential resident problems based on MDS data) on 9/17/19 revealed the facility had 12 residents with Range of Motion (ability to move joints) limitations and were not receiving services (i.e. Restorative Nursing or formal Physical and/or Occupational Therapies). Four sampled residents were reviewed for Range of Motion limitations: - Resident 28 was observed on 9/23/19 at 3:50 p.m. with a shoulder limitation. The resident received OT (Occupational Therapy) and PT (Physical Therapy). The discharge summaries from OT on 10/18/18 and PT on 10/18/18 recommended follow up with a Restorative Nursing program. Medical record review revealed the resident was not receiving a Restorative Nursing program. - Resident 1 was observed with left sided limitations in range of motion on 9/23/19 at 4:22 p.m The resident received OT (Occupational Therapy) and PT (Physical Therapy). The discharge summaries from OT on 11/15/18 and PT on 11/21/18 recommended follow up with a Restorative Nursing program. Medical record review revealed the resident was not receiving a Restorative Nursing program. - Resident 25 was observed on 9/24/19 at 11:45 a.m. as having contractures (fixed position) of the joints and hands. The resident received PT and was discharged on [DATE]. The PT recommended follow up with a Restorative Nursing program. Medical record review revealed the resident was not receiving a Restorative Nursing program. - Resident 53's Quarterly review MDS assessment on 8/28/19 revealed the resident had Range of Motion limitations on both sides of the lower extremities and the resident was not receiving Restorative Nursing, OT, or PT services. The resident had been treated by OT and per the OT discharge summary on 7/11/19 was recommended for follow up with a Restorative Nursing Program. Medical record review revealed the resident was not receiving a Restorative Nursing Program. Interview with the interim-Director of Nursing on 9/24/19 at 9:09 a.m. confirmed the facility's restorative aide had left on a medical leave and was terminated on 7/5/19. The interim-Director of Nursing verified the position had not been replaced yet and confirmed Residents 28, 1, 25, and 53 were recommended for restorative nursing programs and their programs were not being implemented. Interview with SC on 9/25/19 at 4:45 p.m. verified the Restorative Aide for the facility was out on medical leave for a time and terminated on 7/5/19. The SC verified the position had not been filled since July. B. Record review of facility Suggestion or Concern (grievance) forms revealed the following grievances filed expressing staffing concerns. - 7/25/19 concern regarding Cottonwood unit staff filed by the SC (Staffing Coordinator). The SC concern reported returning from picking up a resident at the emergency room at 6:15 p.m. and dietary staff asked the SC where the nurses were because residents were getting up and leaving: from the dining room. Other residents reported wanting to leave. There was no staff present to pass out the trays and food remained on the counter. When the SC went to find staff one staff was giving report and another was at the nurses station on Cottonwood East. Two additional staff were in the Cottonwood West nurses station, one on the phone texting. The SC reported to nursing that they needed to help in the dining room and clocked out, unaware of what time staff arrived to assist residents in the dining room. - 8/7/19 concern reported by Resident 57 reporting there were not enough nurses. - 9/9/19- FM-1 (Family Member) for Resident 30 reported another FM-2 came to the facility at 4:30 p.m. on 9/7/19 and found Resident 30 on the floor in the bathroom. FM-2 could not find a staff member anywhere so the FM-2 had to assist the resident off the floor and help get the resident ready to take to church. The concern form indicated FM-1 was concerned staff are not present on the units. The back of these concern forms was not completed to show an investigation of the concern, resolution solutions, or follow up comments/reviewed with concerned parties. Interview with the interim-Administrator on 9/25/19 at 1:45 p.m. verified the staffing concerns expressed by the SC on 7/25/19; Resident 57 on 8/7/19; and the FM of Resident 30 on 9/9/19 had not been investigated and addressed. C. Interview with Resident 2's POA (Power of Attorney) by phone on 9/24/19 at 2:26 p.m. revealed the POA felt there was not enough staff at the facility on nights or evenings. A second interview with the POA on 9/24/19 at 4:45 p.m. revealed the family had requested the resident receive 3 baths per week. The POA reported the facility was not honoring this request. The POA expressed concerns Record review of Resident 2's bathing records for (MONTH) 2019 revealed the resident had received only 2 baths in July. Record for (MONTH) 2019 revealed the resident received only 3 baths in the month of August. D. Record review of a Suggestion or Concern (grievance) form dated 9/11/19 revealed Resident 45 reported to a therapist that the resident couldn't recall the last time the resident received a shower or bath. Record review of Resident 45's Documentation Survey Report v2 (Bathing documentation form) revealed that from 9/1/19 until the evening shift on 9/10/19, the resident had not received a bath. Interview with the interim-Director of Nursing on 9/26/19 at 7:54 a.m. confirmed that Resident 45 filed a Suggestion or Concern form regarding not receiving baths. The interim-Director of Nursing confirmed from bathing records, the resident had not received a bath from 9/1/19 until evening shift on 9/10/19. Interviews with charge nurse, LPN (Licensed Practical Nurse)-H on 9/24/19 at 11:00 a.m. revealed ideal staffing for the facility is for two nurse aides on each of the four clinical areas with two bath aides providing baths for four units. LPN-H stated that often times, the bath aide is pulled from doing baths to fill direct care floor staff positions. Record review of staff assignment sheets from 9/2/19 through 9/22/19 revealed on eight days there were no bath aides assigned, on eight days there was one bath aide assigned (for the entire facility, four clinical areas) and 5 days where two bath aides were assigned to provide baths in the four clinical areas. Interview with SC on 9/25/19 at 4:45 p.m. revealed that ideal staffing patterns for the facility are for each unit to have two nurse aides on day and evening shifts or one nurse aide and a float. The SC described night shift staffing as especially hurting and challenging. Ideally they try to have 3 nurse aides and one nurse on each half of the building. The SC verified bath aides are often pulled off their scheduled bathing assignment to fill positions on the floor. This leaves the direct care nursing staff responsible to pick up bathing. The SC reported there were currently 8 open direct care staff positions and only three had been filled by agency staff. The SC reported they had three licensed nurse position open with two being filled by agency staff. Interview with the interim- Director of Nursing on 9/26/19 at 7:54 p.m. confirmed the facility had direct care staff and licensed nurse positions that were unfilled. The DON reported agency staff were being utilized to fill some of the positions. The DON verified bath aides were often pulled to the floor rather than providing scheduled baths for residents.",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
4440,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2018-03-08,550,D,1,1,VCTE11,"**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 failed to ensure a catheter drainage bag was covered for 1 (Resident 53) of 1 sampled resident. The facility census was 54. Findings Are: Record review of the electronic medical record for Resident 53 revealed a [DIAGNOSES REDACTED]. Review of Resident 53's Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) signed on 02/20/2018 revealed Resident 53 required extensive assistance of one person with tolieting needs. Record review of Resident 53's Compressive Care Plan dated 1/28/2018 revealed the following: -Resident 53 had an indwelling catheter (a tube in the bladder that allows urine to exit the body), due to [MEDICAL CONDITION]. -Care of the Resident 53's catheter included: Position catheter bag and tubing below the level of the bladder and away from entrance room door. -Resident 53 was an extensive assist of one person with indwelling catheter care and emptying of the catheter bag. -Observation on 03/05/18 at 10:54 AM revealed Resident's 53's catheter drainage bag was visible from the hallway to be hanging from the bed frame with no bag covering the drainage bag. Observation on 03/06/18 at 3:20 PM revealed Resident 53 was asleep in bed. The catheter bag filled with urine was visible from the hallway with no bag covering the catheter bag. Interview with Director of Nursing on 03/07/18 at 6:42 AM confirmed that it was the facility's policy that all catheter drainage bags be enclosed in a coverup bag. Record Review of the Facility Policy dated 01/2013 and titled, Nursing Procedure Manual: Catheter Care revealed the following information: -#18 Position catheter and drainage bag below the level of the Resident/Patient bladder to facilitate flow of urine. Position drainage bag from view or cover with a privacy bag",2020-06-01
6302,HILLCREST HEALTH & REHAB,285133,1702 HILLCREST DRIVE,BELLEVUE,NE,68005,2016-04-27,242,D,1,0,IO6811,"**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 provide resident choices for bathing for 1 resident (Resident 9). The facility identified a census of 109 residents. Findings are: A. Record review of Resident 9's admission assessment dated [DATE] revealed that Resident 9 was asked How often do you prefer to bathe on a weekly basis? and Resident 9 answered 2-3 times a week. Record review of ADL Verification Worksheet dated 04/25/2016 revealed that for the week of 03/29/2016-04/04/2016, Resident 9 only received one bath; for the week of 04/05/2016-04/11/2016, Resident 9 only received zero baths; for the week of 04/12/2016-04/18/2016, Resident 9 only received one bath. Interview with Registered Nurse (RN G), on 04/26/2016 at 10:10 AM, confirmed that based upon documentation provided, the facility did not provide the number of baths as requested by Resident 9.",2019-04-01
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
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
3802,MITCHELL CARE CENTER,285287,1723 23RD STREET,MITCHELL,NE,69357,2018-06-19,585,E,1,0,57D211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.05 (7) Based on record reviews and interviews, the facility failed to include residents and/or personal representatives in the grievance resolution process for three sampled residents (Residents 3, 7, and 8). Sample size included four residents filing formal grievances in the last 90 days. Census was 59. Findings are: [NAME] Record review of a Grievance Form dated 6/6/18 filed by Resident 3's FM's (Family members) revealed a concern voiced by the FM's regarding emptying Resident 3's catheter leg bag and a concern staff were not providing proper peri care (toileting cleaning) for the resident. An Action Plan on the form revealed a staff meeting was completed on 6/14/18 regarding the issue. There was no Resident or Resident Family Member Signature on the form, nor was there any documentation Resident 3's FM's had been contacted about facility interventions pertaining to the concerns or to ask the FM's if the issue was resolved toward their satisfaction. Phone interview with Resident 3's FM (Family member) on 6/19/18 at 3:00 p.m. confirmed Resident 3's FM's had expressed concerns regarding the facility's care and treatment of [REDACTED]. The FM stated no one at the facility had contacted the FM or the FM's sibling or spouse regarding interventions taken to correct the problem or to ask if the issues had been resolved. B. Record review of a Grievance Form dated 5/17/18 filed by Resident 7 revealed the resident expressed a concern about the driver taking corners too fast while being transported on the facility bus. The Action Plan on the form recorded a discussion was done with the van driver who stated the driver would take corners extra slow when transporting Resident 7. There was no Resident or Resident Family Member Signature on the form, nor was there any documentation Resident 7 had been contacted about facility interventions pertaining to the concern and no documentation on the form if the resident was satisfied with the resolution. C. Record review of a Grievance Form dated 5/2/18 filed by Resident 8's FM revealed a concern regarding an incident with a staff member's response to the resident leaving the resident in a commons area without the resident's glasses which upset the resident. The form documented the Action Plan on 5/3/18 the incident happened on 4/28/18 and the facility interventions included the staff member would be assigned to another hall and since that time had no further issues. There was no Resident or Resident Family Member Signature on the form, nor was there any documentation Resident 8's FM had been contacted about facility interventions pertaining to the concerns or to ask the FM if the issue was resolved toward their satisfaction. Interview with the facility Administrator on 6/19/18 at 3:45 p.m. confirmed the facility had not ensured grievances filed by Residents 3, 7, and 8 had included follow up in the resolution process to discuss facility interventions for correction and determine if those filing the grievances were satisfied with the facility's resolution.",2020-09-01
3334,CHIMNEY ROCK VILLA,285260,"P O BOX A, 106 EAST 13TH STREET",BAYARD,NE,69334,2019-01-08,600,E,1,1,UIRZ11,"**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: 1) ensure the community was protected from one sampled resident (Resident 33) with a recorded sex offender conviction; and 2) ensure facility residents with dementia were protected from ongoing behavioral symptoms including those of a sexual nature and disrobing in public places exhibited by one sampled resident (Resident 33). This failure could potentially have affected six current residents with severe cognitive impairments (Residents 26, 22, 3, 13, 25, and 17). Facility census was 32. Findings are: [NAME] Record review of Resident 33's Face Sheet revealed the resident was admitted to the facility on [DATE]. Record review of Resident 33's closed medical record revealed the facility had obtained a Nebraska Sex Offender Registry report on 4/15/2014 identifying the resident had Sex Crime Conviction(s) for Immoral Acts with a Child Felony on 7/12/1996 and Crime Sexual Assault of a Child on 12/23/1996. Record review of Resident 33's Nurses Notes revealed the following entries: - 8/10/18 at 2:16 p.m. recorded: Resident Contact: Resident has been having increased sexual behaviors toward staff and other residents with dementia. Spoke with Administrator, it was decided to have the police come up and visit with (the resident) again. (Name of police officer) came up and spoke with resident regarding behavior. Police informed resident that (the resident) is a life time offender and this behavior is against (the resident's) probation . - an entry on 8/23/18 at 8:50 a.m. documenting a Family/Guardian Contact was made. The facility discussed that on 8/22/18 the resident went on outing to a department store and the staff could not find Resident 33. They found the resident in the bus and discovered security at the store had escorted the resident out. Security informed the staff the resident was not allowed in the store and this was the third time the store had to escort the resident out of the store. Staff reported not being aware of the restriction. Interview with the DON (Director of Nursing) and Administrator on 1/8/19 from 10:00 a.m. to 10:30 a.m. confirmed that Resident 33 had a criminal conviction of sex crimes. The DON and Administrator verified that the resident was taken to a department store for an outing by activities and that the resident would shop in the store with another resident unsupervised by staff. On 8/22/18 the Administrator and DON verified the resident was not found when the activity person was leaving the store and the resident was discovered in the van. Store security reported escorting the resident out of the store due to not being allowed to enter the facility and that this was the third time this had happened at this particular store. The Administrator and DON verified the activity staff was not aware of the sex crime conviction and that the facility had let the resident go shopping unsupervised. B. Record review of Resident 33's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) Annual assessment on 9/24/18 recorded the resident had exhibited behaviors on 1-3 days in the previous 7 days. The types of behaviors were recorded as Verbal (symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) and Other (symptoms not directed toward 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 sounds. The assessment also recorded daily resistance to care provision. Further review of this assessment revealed the resident's BIMS (Brief Interview for Mental Status, an examination testing resident memory) revealed the resident tested at a 4 (0-7 indicating severe impairment). Record review of Resident 33's Nurse's Notes revealed the following entries: - 8/10/18 at 11:33 a.m. the resident was observed for Public Sexual Acts/Disrobing and recorded: Observed resident do a playful slap to resident (Resident 13) after making a sexual innuendo . - 8/10/18 2:16 p.m. recorded the resident had been having increased sexual behaviors toward staff and other residents with dementia. The entry recorded the police chief came into the facility and discussed the behaviors with the resident and warned the resident (the resident) history of being a lifetime sex offender could result in charges. - 8/13/18 at 1:07 p.m. for Public Sexual Acts/Disrobing the entry recorded the resident was sitting on the couch next to a resident and was observed fastening the top button of pants. The nurse discussed inappropriateness of the behavior and resident responded the staff were harassing me. - 10/3/18 at 4:38 p.m. the staff recorded Resident 33 began yelling in the dining room in the presence of other residents. - 10/10/18 at 2:30 p.m. an incident of significantly disrupts care or living environment recorded the resident cursed aloud during a game in activities in front of other residents. - 11/9/18 at 1:47 p.m. a Behavior was recorded in which staff discussed with the Resident 33 to properly dress self and put pants on when going to the bathroom as this offends the resident's room mate. Record review of a Grievance Form reviewed on 11/2/18 revealed Resident 83 (Resident 33's room mate) filed a grievance form concerned about Resident 33 stopping by Resident 83's bed while being naked. Interviews with staff members: - 1/3/19 at 1:40 p.m. NA (Nurse Aide)-B. works day shift 6 a.m. to 2 p.m. described that Resident 33 would make female staff uncomfortable at times especially when bathing. The resident would say inappropriate things to the staff of a sexual nature. NA-B also said the resident would tease and egg on other residents, especially those with dementia. -1/3/19 1:45- NA-H works on all shifts. Familiar with the resident. Stated resident would be verbal and taunting toward other residents with dementia. - 1/7/19 at 1:30 p.m. NA-I and NA-J both working day shift. Described the resident as having ongoing behavioral problems. Would be rude and condescending toward other residents. Would act out in a sexual nature and make suggestive comments toward female staff. Disrobed in public. Sometimes re-directed, but at other times would get angry or not listen. - 1/8/19 at 9:20 a.m. interview with the DM (Dietary Manager). Discussed resident behaviors in dining. The DM witnessed resident smacking staff members on the bottom playfully and observing the resident unbuttoning pants in the dining room. Record review of current residents of the opposite sex of Resident 33 which were severely impaired cognitively revealed from BIMS (Brief Interview of Mental Status, a cognitive test to identify cognitive impairments with memory) scores that six residents (Residents 26, 22, 3, 13, 25, and 17) with severe cognitive impairment resided in the facility during the time Resident 33 was a resident. Record review of Resident 33's Care Plan revealed the resident's care plan was developed which included a Problem Behavior: Behavior not directed at others manifested by Refusal of cares. Further review of the resident's care plan revealed nothing updated or added to the care plan regarding ongoing behaviors directed toward others, behaviors of a sexual nature or disrobing, behaviors of disruptions in activities, cursing, or making gestures. Record review of Resident 33's counseling sessions revealed the following: - 8/20/18- Res having increased sexual behaviors, refusing to follow rules, unzipping pants in public areas, becomes angry when approached. Counselor documented- admits to errors on reports and with a smile notes Yeah I probably need to do better. - 9/26/18- having behaviors. Not resting well, continues to push residents in wheelchairs, sits in lobby unzipping pants. counselor documented, discussed concerns and res states they are all in the past denies doing them now. - 11/7/18 resident increasing behaviors with room mate yelling at resident for no reason. Walking in hallway naked and asked several times to wear pants and refuses. Counselor reported resident denies the above. stated it was a long time ago. Resident reports clearly different than what staff reported. Record review of the facility's Abuse and Neglect Prevention policy dated 4/1/16 revealed the following: - Regarding Definitions, the policy identified Physical Injury abuse Includes slapping, hitting, pinching, kicking . Regarding Verbal Abuse: The use of oral, written or gestured language that willfully includes disparaging and derogatory terms used with or to residents . or within their hearing distance . Regarding Sexual Abuse: Includes but is not limited to sexual harassment, sexual coercion, or sexual assault. - Regarding Investigation the policy directed that All allegations of abuse and/or neglect will be investigated in accordance with the state and federal laws. - Regarding Reporting/Response the policy directs that the facility will Report alleged incidents as required to all local/state/federal agencies within 2 hours if the allegation results in serious bodily injury (this includes sexual abuse) and within 24 hours for all others. After conducting an internal investigation, you must submit a report of all investigation results to the state . Record review of facility investigations of alleged abuse toward residents from (MONTH) (YEAR) through (MONTH) of 2019 revealed there were no investigations initiated or completed regarding Resident 33's behaviors of a sexual nature toward others. Record review of a Doctor's Progress Notes on 10/8/18 revealed the physician documented Nursing reports continued inappropriate and mean spirited remarks to other residents. Pt (patient or Resident 33) has been banned from (name of department store). The physician documented the resident sees a counselor and would probably benefit from low dose tranq (tranquilizing medication) such as [MEDICATION NAME], etc. The physician did not order any medication at this time. Interviews with the DON (Director of Nursing) and facility Administrator on 1/8/19 at 10:00 a.m. verified Resident 33 had multiple ongoing behavioral issues beginning shortly after re-admission to the facility in (MONTH) and continuing through the time of resident discharge on 12/20/18. The DON confirmed that there was no behavioral management plan put in place regarding the ongoing behaviors and the resident's care plan had not been updated to include these ongoing issues. When questioned about whether or not the facility had explored psychiatry consultation, the DON felt this was brought up in the past but thought the resident refused though there was nothing in the record to confirm this occurred. The DON verified the facility had not re-explored this intervention in lieu of the ongoing symptoms and physician note that resident may benefit from psychiatric medication. The DON stated the resident was seeing a counselor but verified from the counseling sessions, the resident was denying these issues occurred or stated they were long ago in the past and the behaviors continued month after month. The DON verified the interventions of speaking with the resident or discussing inappropriate behaviors with the resident were ineffective as the resident had poor cognition based on residents BIMS scores ranging from 4-6 between (MONTH) and (MONTH) of (YEAR). The Administrator verified there were no investigations initiated, completed, or forwarded to the state agency regarding Resident 33's behaviors of a sexual nature toward others.",2020-09-01
1082,EMERALD NURSING & REHAB LAKEVIEW,285106,1405 WEST HWY 34,GRAND ISLAND,NE,68801,2018-05-07,550,E,1,1,QN7C11,"**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 failed to maintain 5 residents' (Resident 11, 19, 59, 43 and 13) dignity by failing to knock, request and wait for permission to enter the residents' rooms and failing to provide a privacy current to prevent potential exposure to passers-by. This affected 5 out of 5 residents sampled. The facility identified a census of 55 at the time of survey. Findings are: [NAME] Observation of Resident 11's room on 5/02/18 at 10:56 AM revealed MA-H opened the closed door and walked in without knocking or requesting and waiting for permission to enter. Observation of Resident 11's room on 5/02/18 at 11:01 AM revealed the AC knocked on the closed door and walked in without requesting and waiting for permission to enter. B. Observation of Resident 19's room on 5/02/18 at 11:26 AM revealed an unidentified activity staff person knocked on the closed door, opened it and and walked in without requesting and waiting for permission to enter. Interview with Resident 19 on 5/2/2018 at 11:28 AM confirmed the facility staff generally enter their room without requesting and waiting for permission to enter. Observation of Resident 19's room on 5/2/2018 at 11:28 AM revealed an unidentified therapy staff person knocked on the closed door and walked in without requesting and waiting for permission to enter. Interview with Resident 19 on 5/2/2018 at 11:29 AM revealed the staff did not treat them with respect and dignity because they talked to each other without including Resident 19 while they were helping Resident 19 with cares. Interview with the facility Administrator on 5/07/18 at 10:58 AM revealed facility staff were expected to knock and request permission to enter a resident's room. Review of the facility policy Preservation of Residents' Rights dated 6/29/2016 revealed the following: The social services staff will take an active role in training employees and monitoring practice on issues regarding residents' personal privacy including knocking on doors and requesting permission to enter resident rooms. Review of the facility policy Promoting/Maintaining Resident Dignity dated 5/2017 revealed the following: all staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. When interacting with a resident, pay attention to the resident as an individual. Staff members do not talk to each other while performing a task for the resident as if the resident is not there. Conversation should be resident focused and resident centered. C. Review of Resident 59's Face Sheet dated 7-21-17 revealed [DIAGNOSES REDACTED]. During an interview with Resident 59 on 5-2-18 at 1:44 PM in the resident's room, a staff person knocked on the resident's room door. The resident replied very loudly wait just a minute. The AD (Activity Director) opened the door and entered and the AD apologized for bothering us but wanted Resident 59 to know there was an activity at 2:00 PM. Then apologized again and left the room and closed the door. Interview with Resident 59 on 05/02/18 at 1:47 PM revealed the staff knocked on the door then entered the room without waiting for me to reply all the time. D. Review of Resident 43's Face Sheet dated 2-28-17 revealed [DIAGNOSES REDACTED]. Resident 43's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 3-2-18 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 43's cognition had not impairment. Observation on 5-1-18 at 11:19 AM during an interview with the resident revealed a staff person knocked on the resident's room door and without waiting for a response from the resident, the staff person opened the door and walked in. When the staff person saw the surveyors, the staff person apologized and stated (gender) would return later. Interview on 05/3/18 at 4:43 PM with the Administrator confirmed all of the staff were to knock then wait for the resident to respond to give permission for the staff to enter the residents' rooms. E. On 05/03/18 at 10:35 AM, MA (Medication Aide)-B and NA (Nurse Aide)-C were observed in Resident 13's room providing care during which Resident 13's body was exposed. There was not a privacy curtain in front of the door. Review of the Facility's 'CLINICAL MANAGEMENT- PROMOTING/MAINTAINING RESIDENT DIGNITY; CREATED 05-17. policy revealed It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.'",2020-09-01
6061,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2016-06-09,242,D,1,0,6BDX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.05(4) Based on observations, record reviews and interviews; the facility failed to accommodate residents needs and preferences for those that smoked and/or used tobacco products upon admission to the facility. This affected 4 residents (Resident 3, 5, 1, and 4). The facility census was 135. Findings are: A. Observation of Resident 3 on 6/9/2016 at 11:00 AM revealed the resident in a wheelchair dressed appropriately, clean and well groomed. The resident was self ambulating down the hall of the facility, resident was oriented and alert. Interview with Resident 3 on 6/9/2016 at 10:30 AM revealed that they had smoked for approximately [AGE] years and the facility was aware that the resident smoked upon admission. The resident revealed being informed that the facility was smoke free and that they agreed because they had no other place to go to. The resident revealed that it was very difficult to quit smoking. The resident revealed that the facility had provided the resident with nicotine patches but the resident experienced an allergic reaction and could not continue the patch. The resident explained they were currently on [MEDICAL TREATMENT] and, due to this, they were unable to take the other medication available for smoking cessation. The resident revealed that the facility staff had informed them that if they were going to smoke they had to sign themselves out and leave the facility campus. The resident explained they signed out and crossed the street to smoke when they received cigarettes from friends and family. The resident was informed that (MONTH) 26, (YEAR) was the last time they had a cigarette because, while they were out of the facility and off campus with facility knowledge, they had fallen out of their wheelchair and hit the back of their head. The resident revealed that the Director of Nursing had now refused to let the resident leave the facility campus to smoke. Interview with the Director of Nursing (DON) on 6/9/2016 at 2:30 PM revealed the facility was a smoke free facility with no designated smoking area for residents. The DON confirmed that the facility accepted the resident knowing that the resident smoked prior to admission. The DON revealed that the resident was aware of the policy and agreed. The DON further revealed the facility had offered the resident nicotine patches and [MEDICATION NAME] gum but the resident refused. Record review of the Smoking Assessment, undated completion, listing admitted as 3/16/2016 revealed the resident was identified as currently smoking, the resident did not wish to quit smoking, smoked 3 to 4 cigarettes a day, and did have a history of smoking related incidents including burning clothing, dropping ashes on self and smoking in a non-smoking area. The document revealed the resident did exhibit signs of confusion but was able to make himself/herself understood, understood smoking policy, understood the facility's times and places to smoke with an expectation they must remain alert and able to communicate the need for help. Further review revealed the resident had no physical disability that affected their ability to hold a cigarette safely without a device and they could extinguish the cigarette safely. The assessment also revealed the resident used supplemental oxygen and could safely be without the supplemental oxygen during smoking times. The resident propelled a wheelchair independently. The assessment furthermore revealed that the facility reviewed the policy related to smoking times and storage or smoking materials with the resident and that the care plan was initiated/updated. Record review of the Care Plan, dated 1/8/2016 revealed a focus area that the resident sometimes had behaviors which included expressing displeasure because of non-smoking facility and inability to go outside and smoke. (nicotine patch was ordered but patient refused. Gum was also attempted with refusal). The Goal; which was revised on 12/28/2015, stated the resident would calm down with staff intervention and understanding. Interventions; dated 12/28/2015, included staff would offer resident something the resident liked as a diversion like sitting and talking if the resident would allow. Continue to discuss the risk and benefits of smoking, and staff would respect the resident rights and personal beliefs on smoking. Record review of the facility Reminders for New Residents 9 revealed We are a smoke free campus. Please do not smoke on the facility grounds. B. Record review of the Admission Record, revealed that Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 5 Clinical Health Status, dated 5/18/2016 revealed the resident was alert, understood others, independent for decisions, heard adequately and made self understood. Record review of a facility fax to the physician, dated 6/3/2016 revealed resident would like an order for [REDACTED]. Record review of letter/memo addressed to Facility Residents from the Facility Interim Executive Director and the Director of Nursing dated 6/3/2016, revealed the letter/memo was in reference to the Smoking and Tobacco policies. Further review revealed the facility has been a Drug free and smoke-free facility for staff and residents for a long time, and we will now set and follow those limitations with staff and residents . The letter/memo continued to state that, if the resident chose to stay at the facility after this time, the facility would offer smoking cessation or visit with the resident's physician about nicotine replacement therapy. Continued review revealed that, for those residents that did not find this acceptable, the facility would attempt to find another facility that they could move to. Interview 6/9/2016 at 2:20 PM with 2 Medication Aids (MA-A and C) and 3 Nursing Assistants (NA-B, D, E) revealed the resident chewed tobacco upon admission to the facility and this continued until 6/3/2016 when the facility Interim Executive Director, provided a letter to Facility Residents pertaining to Smoking and Tobacco Policies. They revealed that, facility staff were instructed to confiscate resident smoking and tobacco products. Interview with the Facility Interim Executive Director and Director of Nursing confirmed the facility was enforcing the facility statement that they were a smoke free facility. That now residents would not be allowed to smoke or use tobacco products. The Interim Executive Director revealed that the facility believed that a notification to the residents did not violate their rights as they already knew they should not be smoking at the facility. C. Review of the Admission Record dated as printed 6/9/16 for Resident 1 revealed an admission date of [DATE] to the facility. Further review revealed a [DIAGNOSES REDACTED]. Review of the Clinical Health Status dated 2/27/16 revealed that Resident 1 did smoke and desired to smoke. Review of the Medication Administration Record [REDACTED]. Review of a Reminder for all New Residents with no date, revealed written documentation that the facility was a smoke free campus, and to please not smoke on the facility grounds. Review of a general letter to all residents on 6/3/16 Smoking and Tobacco Policies for all facility residents revealed that all residents had to sign the forms and seek smoking cessation or the facility would look for placement elsewhere for the residents. Observation on 6/9/16 at 1:40 PM revealed that Resident 1 was seated in an oversized recliner watching television. Further observation revealed no signs of cigarettes and no observations of this resident smoking. Observation on 6/9/16 at 4:00 revealed that Resident 1 remained in the recliner watching television, no smoking observed. Interview on 6/9/16 at 1:40 PM with Resident 1 revealed that the resident had been in and out of the hospital and different nursing homes. Further interview revealed that the resident was allowed to smoke up to a week ago when the facility gave each resident a letter that revealed that the facility campus was smoke free. Continued interview revealed that, on 6/3/16, the resident signed the form and cigarettes were taken away. Further interview revealed that, upon admission, the resident was informed that the resident could not smoke on the facility campus but was unaware that the resident could not go across the street to smoke. Interview on 6/9/16 at 2:20 PM with (Medication Aides) MA - A and MA - C, and (Nursing Assistants) NA - B, D, and E revealed that Resident 1 still wanted to smoke. Further interview revealed that the resident had been asking and wanting a cigarette and to smoke. Continued interview verified that the facility had gotten the Nicotine patch for Resident 1 but that the patch had not worked. Further interview verified that last week, on 6/3/16, a letter was given to all the residents to sign as the facility was changed to a smoke free campus. Interview on 6/9/16 at 3:30 PM with the Administrator and the (Director of Nursing) DON verified that Resident 1 had smoked and desired to smoke upon admission to the facility. At time of admission the resident did agree to try smoking cessation. Continued interview confirmed that Resident 1 was no longer able to smoke on the facility grounds. Continued interview verified that the resident did have the right to smoke but not on the campus. Further interview revealed that the facility had not allowed or accommodated Resident 1 with smoking per the resident's wishes. D. Review of the Admission Record dated as printed 6/9/16 for Resident 4 revealed an admission date of [DATE] to the facility. Review of a printed letter taken to all of the facility residents revealed that the facility was now a smoke free and tobacco free campus on 6/3/16. The resident would be offered smoking cessation with an alternative that the facility would assist with finding placement elsewhere that would accommodated smoking or tobacco. Review of the Medication Administration Record [REDACTED]. Observation on 6/9/16 at 2:00 PM of Resident 4 revealed that the resident was lying on the bed crocheting. No observation of tobacco products or instances of chewing for Resident 4. Resident 4 was tearful at times during the interview. Observation on 6/9/16 at 4:00 PM of Resident 4 seated in the bed watching television. No chewing noted at this time. Interview on 6/9/16 at 2:00 PM with Resident 4 revealed that the resident did chew tobacco and had started approximately [AGE] years ago when the resident had to give up a baby for adoption. Further interview verified that the tobacco or chew assisted the resident with anxiety. Continued interview verified that a letter was given to the resident about a week ago with the smoke free, tobacco free policy. The resident did sign the facility policy but could not understand why the staff took away the chew that was in the resident's room. The resident did state the Nicotine patch had been tried but failed to take away the tobacco craving and the anxiety. Interview on 6/9/16 at 2:20 PM with MA's A and C and NA's B, D, and E verified that all residents of the facility had received a written letter that had to be signed by all residents. Further interview verified that the staff had been instructed to remove all of the chewing tobacco from Resident 4's room. Continued interview confirmed that Resident 4 still desired to chew and was upset about the policy as the facility had let the resident chew tobacco and then took it away. Interview on 6/9/16 at 3:30 PM with the Administrator and the DON verified that Resident 4 did chew tobacco upon admission to the facility. Further interview confirmed that a letter in regards to a smoke free tobacco free campus had been given to all residents on 6/3/16. Continued interview confirmed that all tobacco products had been removed from Resident 4's room by the staff upon instruction to do so with enforcement of the policy. Further interview verified that Resident 4 desired to continue chewing tobacco and the facility had not accommodated the resident with their right to chew tobacco.",2019-06-01
1187,GOOD SAMARITAN SOCIETY - AUBURN,285112,1322 U STREET,AUBURN,NE,68305,2017-09-28,223,G,1,1,7CQF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.05(9) Based on interviews and record reviews, the facility failed to ensure 1 resident (Resident 22) of 35 residents sampled was free from abuse. The facility staff identified the census at 64. A review of Resident 22's Admission Record dated 9-27-17 revealed that Resident 22 was admitted to the facility on [DATE]. A review of Resident 22's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 8-29-17 revealed a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). An interview conducted on 9-25-17 at 2:14 PM with Resident 22 revealed that Resident 22 was involved in an altercation one morning with Resident 31 where Resident 22 was hit by Resident 31. Resident 22 reported that Resident 31 also threatened to kill Resident 22 and that Resident 31 attempted to hit Resident 22 again that evening. Resident 22 reported that they did not feel safe around Resident 31 and that the resident had a lock put on their door until Resident 31 was discharged in order to ensure Resident 31 did not get in the room. An interview conducted on 9-28-17 at 9:01 AM with Resident 22 revealed that Resident 22 felt the facility staff handled resident concerns well except for the way the facility handled Resident 31. Resident 22 reported it took the facility months to do anything about Resident 31. A review of the facility's Resident to Resident investigation dated 4-25-17 revealed that Resident 31 at 7:27 AM slapped Resident 22 across the face and rammed their electric wheelchair into Resident 22's electric wheelchair. The facility staff intervened and removed Resident 31 from the area and that multiple staff heard Resident 31 say they wanted to kill Resident 22. Resident 31 was documented to have told the Social Services Director that they would beat Resident 22 down. Resident 22 and Resident 31 resided in different parts of the facility and ate in separate dining rooms. A review of a witness statements dated 4-25-17 revealed that Resident 31 was overheard saying they would kill Resident 22 or beat Resident 22 to death. An interview conducted on 9-27-17 at 9:33 AM with Licensed Practical Nurse (LPN) A revealed that Resident 22 had come to Resident 31's room and yelled at Resident 31 while LPN A was doing Resident 31's leg treatments. LPN A reported that Resident 31 attempted to stand up and go after Resident 22, but that Resident 31 ended up falling due to their feet being slippery as their dressing change was in process. LPN A reported that they spoke with Resident 31 about their temper and told Resident 31 to let it go and not go after Resident 22. LPN A reported that they asked a staff member from another hallway to follow Resident 31 to make sure Resident 31 to not go after Resident 22. LPN A reported that the staff person followed Resident 31 to Resident 22's room but the resident was not there. Resident 31 then went to the main dining with the staff person following, but the staff person was too far behind Resident 31 to keep them from hitting Resident 22. LPN A reports that Resident 31 did not eat meals in the main dining room and did not have a reason to go into the main dining room that day. LPN A reported that they did not call 911 or send Resident 31 to the emergency room . An interview conducted on 9-27-17 at 9:44 AM with the Social Services Director (SSD) revealed that both Residents 31 and 22 were placed on 15 minute checks and encouraged to stay out of each other's hallways. The SSD called the State Ombudsman and a 30 day discharge notice was issued to Resident 31. The SSD reported that they did call the local sheriff's office by non-emergency line and they said they would come to the facility if they had time. Resident 31 was not sent to the emergency room . The SSD reported that they called Resident 31's psychiatric nurse practitioner who spoke with the resident on the phone. The nurse practitioner told the SSD that Resident 31 knew what they were doing when they hit Resident 22 and was cognitively aware of his actions and his threats. The SSD reported that Resident 31 continued to verbalize threats towards Resident 22 that day. The SSD reported that a 30 day notice of discharge had been issued to Resident 31 in the past due to the resident having physical and verbal altercations with other residents, but it was not followed up. Resident remained in the facility until (MONTH) because the facility struggled to find the resident a safe discharge location because the resident refused to be transferred to another skilled nursing facility. A review of Resident 31's Admission Record dated 9-27-17 revealed Resident 31 was admitted to the facility on [DATE] and was discharged from the facility on 7-14-17. A review of Resident 31's 15 minute checks revealed no documentation that resident was checked on 4-25-17 from 1:00 PM to 2:00 PM and on 4/28/17 from 5:15 AM to 6:00 AM. A review of Resident 31's progress note date 2-10-17 at 4:45 PM revealed that Resident 31 reported to the nurse that they had hit another resident in the face because the other resident had said the wrong thing to the wrong person. The nurse checked with the other resident that confirmed they were hit in the left cheek by Resident 31. A review of Resident 31's progress note dated 2-10-17 at 7:27 PM revealed that Resident 31 approached another resident from a previous altercation and told the other resident You better shut your mouth or I'm going to shut it for you. A review of Resident 31's progress note dated 3-4-17 revealed that Resident 31 was upset related to another residents clothing and was making accusations and threats toward the other resident. A review of Resident 31's progress noted dated 3-8-17 revealed that Resident 31 met with the SSD to discuss increased behaviors toward other residents and how the behaviors were affecting other resident's safety and endangering them. The resident verbalized to the SSD that they would stop bullying and belittling other residents. The resident was issued a 30 day notice of discharge at the meeting and the State Ombudsman was notified. A review of Resident 31's progress note dated 4-26-17 revealed that the SSD spoke with the State Ombudsman regarding the incident on 4-25-17 and that an 30 day notice of discharge had been issued to the resident on 3-8-17. The Ombudsman reported that per regulation, discharge can be as soon as practical if the safety of other residents and staff are a concern. A review of Resident 31's psychiatric progress note dated 4-20-17 revealed that facility staff had called the nurse practitioner several times due to increased behaviors. Resident 31 was having outbursts, rude to staff, threatening, and had been making scenes in front of other residents. The resident stated to the nurse practitioner that When I get in a corner, I don't back down. I never have and never will. The progress note instructed the facility staff to call 911 or send the resident to the emergency department in case of an emergency. A review of Resident 31's psychiatric progress note dated 4-25-17 revealed that Resident 31 visited on the phone with the psychiatric nurse practitioner. Resident 31 admitted to hitting Resident 22 and verbalized that if Resident 22 ever came near the resident's room again the resident would kill Resident 22. Resident 31 told the nurse practitioner that they were liable to hit Resident 22 again because they do not take lip from anybody, that is just who they are and they will never let people talk to them that way. The resident refused medication changes. Resident 31 expressed understanding that assaulting and threatening other residents was unacceptable and would not be tolerated in nursing facilities. The nurse practitioner made plans to see the resident in the facility the following month. A review of Resident 31's care plan revealed an intervention dated 4-13-17 for facility staff to intervene as necessary to protect the rights and safety of others. If an increase in aggression was noted or the resident had violent or threatening behaviors, the charge nurse was to call 911 and notify the DON. An interview conducted on 9-27-17 at 9:58 AM with the Director of Nursing (DON) revealed that Resident 31 and Resident 22 were placed on 15 minute checks. The police were called, but they did not do anything. The resident was not sent to the emergency room because the management staff felt the emergency room would not have done anything for the resident. An interview conducted on 9-28-17 at 8:11 AM with the Administrator revealed that Resident 31 threatening to kill Resident 22 would have been an emergency situation and the emergency room would have been a safe place for discharge for Resident 31. An interview conducted on 9-28-17 at 10:34 AM with the DON revealed that Resident 31 was not seen again by the psychiatric nurse practitioner after the incident on 4-25-17 due to the nurse practitioner going on medical leave and no one was assigned to see their patients during the medical leave. An interview conducted on 9-28-17 at 10:54 AM with the psychiatric nurse practitioner revealed that Resident 31 had been a patient of theirs for approximately 2 years. Resident 31 acted out aggressively in order to get attention. Resident 31 had the cognitive function to know what they did was wrong. The nurse practitioner reported that they felt Resident 31 would not act out violently again, but could not say for certain that the resident would not have acted out again had a resident said something that upset Resident 31. Resident 31 was cognitively aware of their actions.",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
5712,NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER,285271,2100 CIRCLE DRIVE,SCOTTSBLUFF,NE,69361,2016-10-03,166,D,1,0,SRLF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.06B Based on observations, record reviews, and interviews; the facility failed to ensure family reported grievances related to care delivery for one sampled resident (Resident 2) were being resolved and the resolution maintained. Sample size was four current residents. Facility census was 51. Findings are: Interview with Resident 2's family members on 9/28/16 at 11:20 a.m. revealed the family had several care issues and concerns brought to the facility's administrative staff for resolution. The family members stated having consulted with the State Ombudsman who was present during meetings with the facility and also assisted with the filing of formal grievance reports. The family stated the facility had not resolved the issues to their satisfaction leading them to place a video surveillance device in the resident's room. The family stated they had not received information consistently from administration regarding measures taken to resolve their concerns. The family described having care issues dating back to when the resident was taken to the emergency room in (MONTH) of (YEAR). Issues of unresolved concerns were outlined during the interview as follows: - Hydration issues- resident had specific instructions on the provision of water for the resident outlined by the Speech Therapist. They had concerns of staff not following the directions. - Toileting being neglected. Twice the family caught the resident trying to get up due to not being toileted. They had to call the nurse's station to get response. The family requested a two hour toileting schedule be added to the care plan since (MONTH) of (YEAR) and this still hadn't been done. - 9/12/16 they met with the facility in a meeting with facility administration at the request of the State Ombudsman. They described on 9/10/16 from a video observation of the resident, they saw a staff member pulling the resident up with both hands and in the arm pit area and not using the gait belt as described in the care plan. Other video evidence observed on 9/9/16 revealed concerns with staff administering medication to the resident, stating staff kept shoving applesauce into the resident's mouth. The resident never swallowed the pill and no one else re-approached. Family described finding the same medication in the resident's chair. - Ongoing meetings and problems with medication administration, feeding the resident according to Speech Therapy recommendations, providing supplements as ordered, and safety issues related to resident transfers were brought to administrative staff's attention and not resolved as the issues remain ongoing. Phone interview with the State Ombudsman on 9/29/16 at 4:30 p.m. confirmed the Ombudsman had attended meetings and care conferences with the family regarding ongoing concerns related to Resident 2's care. The Ombudsman reported that several issues continue to be witnessed by the family and reported and they re-occur without resolution. The Ombudsman reported family describing concerns with safe transfers using a gait belt; staff failing to follow Speech Therapy recommendations for feeding and providing fluids to the resident; staff failing to place the floor mat on the floor when the resident is in bed; and failure of staff to consistently provide medications as ordered by the physician. The Ombudsman stated the facility has not maintained correction of the concerns as the family repeatedly has observed these things not being done. Record review of facility grievances files revealed Resident 2's family had written out grievances and filed them with facility administration. Review of these grievances revealed the following documents recorded on Complaint Forms: -9/16/16- facility contacted administrator by e-mail and reported video evidence of family observing the nurse aides working with the resident were not holding onto the gait belt during the transfer. Also noted the floor mat was not placed on the floor after the resident was placed in bed. Facility correction for the issue was documented Education provided. There was no documentation on the form that the family was notified of facility response to the grievance, nor evidence the grievance was resolved. - 9/6/16- family member reported no fresh water was provided the resident and resident was not toileted between 9:20 p.m. and 11:44 p.m. Also expressed a concern the resident was left in bed for an hour and a half. The grievance stated the family observed staff pulling the resident's arm while helping the resident up and that no pad was placed on the floor at night. The facility Administrator responded through e-mail dated 9/6/16, stating that the staff member in question demonstrated correct gait belt usage to the Director of Nursing and Administrator. The Administrator stated the staff said they offered the resident toileting and the resident refused. The e-mail had not addressed what was being done to assure the family that staff would use gait belts during transfers; toilet the resident routinely; or use the safety pad floor mat when the resident was in bed. There was no documented follow up communication with the family regarding if they were satisfied the concerns were resolved. -8/29/16- family member reported to the Administrator and Director of Nursing a resident eye drop packet was left in the room which was administered at 7:00 p.m. They also found a pill in resident's chair. There was no documentation of facility communicating with family about interventions to resolve. -8/21/16- family reported resident was hollering for help for half an hour before help arrived and the resident was incontinent. Later the same evening, the resident hollered for help with vision aid glasses for half an hour and the floor mat pad was not put into place until 1:00 a.m. The facility findings documented staff were educated on needs by the resident. There was no documentation on the report for a Plan of Correction/Action taken nor documentation the issue was resolved or the complainant was notified of the correction. -8/12/16- Family reported the resident was not fed the proper amount of food during the evening meal the previous night. The documentation revealed the issue was reported to the Assistant Director of Nursing who would re-educate staff. There was no documentation of follow up communication with family to see if the issue was resolved. Record review of facility Grievance and Complaint Tracking forms revealed the following documentation pertaining to grievance reports filed by Resident 2's family. - 9/7/16- complaint made was documented as Large Bruise on right arm reported on 9/7/16. There was no documentation that the grievance was given to the Department head, followed up, follow up with the complainant, or resolution. - 8/21/16- complaint made documented as: waiting 1/2 hr (hour) for help. Incontinent. There was no documentation who received the report, which department head was assigned the report, follow up completion, follow up with the complainant, or date and time resolved. - 7/14/16- complaint made documented; Aid left while feeding (Resident 2). There was no documentation on the form indicating follow up with the complainant had been done or a date and time the grievance was resolved. Record review of Resident 2's Speech Therapy SLP (speech language pathology) Discharge Summary signed by the ST (speech therapist) on 7/13/16 revealed the resident was seen in therapy from 5/26/16 through 7/13/16 and discharged for reaching the Highest Practical Level. In the summary notes the ST documented that caregivers were instructed in communication strategies, functional maintenance, and positioning maneuvers along with safe swallow techniques, safety precautions, and use of adaptive equipment. the ST documented : Swallow strategies/Positions recommended during oral intake for guided bolus/utensil placement, alternation of liquids/solids, alternation of temperatures, rate modification, and bolus size modifications. Frazier Water protocol (A Speech therapy technique protocol for residents with swallowing disorders) and general swallow techniques/precautions and upright posture during meals and 30 minutes after meals. Record review of Resident 2's Physician order [REDACTED]. The form described an order dated 7/7/16 which read: Continue pureed solids with strategies by staff of 1/2 tsp (teaspoon) size pacing between bites, alternating solids/liquids. Record review of Resident 2's Care Plan with goals through 10/17/16 revealed problems were identified on the care plan for Nutritional Risk due to dysphagia (difficulty swallowing); Dehydration/Fluid Maintenance; and ADL functionality. Further review of the Dehydration/Fluid Maintenance problem had nothing documented describing or identifying steps on using a Frazier Water Protocol recommended by the Speech Therapist. The ADL care plan did not provide instructions related to assisting resident with fluids or meals recording the resident had an order not to feed self. The Nutritional problem had not identified approaches when feeding the resident to alternate foods and fluids as directed in both the ST discharge summary and physician orders. Observations during the investigations of the families concerns from the interview revealed the following: - 9/29/16 at 1:15 p.m. NA-C was observed transferring Resident 2 from the wheelchair into bed without using a gait belt. NA-C held onto the resident's right arm during the transfer. - Meal assistance provided Resident 2 on 9/29/16 at breakfast and noon, and again at supper on 10/2/16 revealed staff members NA-G and NA-E had not followed physician orders [REDACTED]. - Medication Administration observation on 9/29/16 at 6:30 a.m. revealed a medication timing error was observed when LPN (Licensed Practical Nurse)-H administered the resident's [MEDICATION NAME] at 6:30 a.m. which was ordered for 8:00 a.m. Interview with LPN-H after the administration revealed the computer populates times automatically and LPN-H had not corrected the time. LPN-H stated the medication was ordered a week ago and had not been changed yet in the computer to ensure the medication was given before meals. Record reviews of facility 'Medication Error Reports revealed the following regarding Resident 2: - 8/12/16- the resident received [MEDICATION NAME] on 8/12/16 without a physician's orders [REDACTED]. - 9/5/16- the resident's [MEDICATION NAME] eye drops were omitted and not given though the staff member had signed off for the administration at bedtime. Record review of Resident 2's Medications Administration History documents for (MONTH) and (MONTH) of (YEAR) revealed the following: - Aspirin ordered for daily administration at bedtime was not administered on 8/1/16 due to the resident sleeping. - Prostat Supplements ordered daily were not administered between 8/12/16 through 8/14/16; on 9/12/16; and 9/19/16 due to the supplement being unavailable. - [MEDICATION NAME] eye drops ordered twice daily were not administered on 8/1/16 due to resident sleeping and on 8/23/16 due to the resident being at activities. - [MEDICATION NAME] ordered daily was administered late on 9/10/16. - Ensure Clear supplement ordered three times daily was not administered during two scheduled times 8 a.m. and 12 noon on 9/6/16 due to the supplement being unavailable. Interview with the Administrator, Director of Nursing, and facility Nurse Consultants on 10/3/16 beginning at 11:45 confirmed Resident 2's family had repeated concerns regarding medication administration, transfers with the use of a gait belt, following instructions from Speech Therapy on feeding and fluid intakes, use of a floor mat when the resident was in bed, and concerns over the resident's bruise. During the discussion, the evidence from observations of staff transfers without the use of a gait belt, the medication error pertaining to timing of the resident's [MEDICATION NAME], and failure to address Speech recommendations and physician orders [REDACTED].",2019-10-01
4863,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2018-07-12,585,E,1,0,PP9911,"**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 concerns regarding ongoing issues related to assistance with bed making, the provision of bathing, the use of special TED hose (special elastic hose to reduce swelling and prevent blood clots) and dietary requests for one sampled resident (Resident 2). The bed-making issue also was expressed as ongoing concerns by two sampled residents Residents (5 and 7). Facility census was 27. Sample included 7 current residents. [NAME] Record review of Resident 2's Admission Record printed on 7/12/18 revealed the resident's initial admitted at the facility was 12/21/2016. The current admitted was recorded on the form as 5/31/2018. Among the resident's medical [DIAGNOSES REDACTED]. Phone interview with Resident 2's POA (Power of Attorney for finance and healthcare) on 7/12/18 from 11:15 a.m. through 11:45 a.m. revealed the POA had written formal grievances at the facility regarding bed making, provision of baths, applying TED hose, and requesting dietary preferences. The POA stated though the facility had done some interventions, the issues remain and are not consistently done by staff as expressed by the POA and other family. The POA stated bed making is just not getting done consistently, several times when family comes in the resident's bed is not made. The POA expressed that Resident 2 due to dementia will often resist bathing, but can go several days without a bath. The POA stated since returning from the hospital, the resident was supposed to have TED hose on due to blood clots and the family has noted during visits this is not always getting done. The POA stated having issues with dietary for over a month regarding the resident getting pork after family has told the staff the resident does not like pork except bacon. In addition, staff do not cut up the resident's meat. Family has also requested that chocolate milk be provided at every meal to add calories to the resident's diet and the family visits at mealtimes identified this was not always being done. The POA reiterated that though the facility has done some interventions such as educating staff, the issues continue to be ongoing and not done consistently. Interview with another FM (Family Member) for Resident 2 on 7/12/18 from 1:30 p.m. to 1:45 p.m. revealed the family had ongoing concerns related to the resident's bed not being made and TED hose were not always applied to the resident's legs to prevent swelling. Record 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: -The resident was discharged to the hospital on [DATE]. - The resident returned to the facility on [DATE]. - The resident was readmitted to hospital on [DATE]. - The resident returned from the hospital on [DATE]. Significant Change MDS dated [DATE] along with a PPS (Preferred Payment Source MDS required assessment required for Medicare Part A recipients) assessment dated [DATE] revealed Resident 2 required Extensive Assistance (Resident involved, staff provide weight bearing) with the assistance of two or more staff for Transfers (moving between surfaces, bed-to chair, chair to bed). Further review of the assessments revealed the Activity did not occur regarding bathing for the reference periods 6/16/12 through 6/18 and 6/19 through 6/25/18. Record review of facility bath records revealed Resident 2 was in the hospital and no bathing was recorded between the resident's return on 5/31/18 through 6/8/18 when the resident was discharged to the hospital. When the resident returned, the records revealed bathing done 6/15/18, 6/23/18 (eight days apart), 7/4/18 (11 days apart), and 7/7/18. An untitled form dated 2/18/18 documented staff interviewing Resident 2 about how many times a week the resident would like to shower or bathe. The document recorded the resident preferred a shower once a week. Record review of Resident 2's Care plan printed on 7/12/18 revealed the following: - A Focus Problem initiated on 12/28/16 revealed the resident had an ADL (Activities of Daily Living, performance of daily tasks) Deficit related to dementia. Interventions for the problem were contradictory. A revised problem on 7/11/18 instructed staff to provide assistance with bathing/showering 3 x (three times) weekly and as necessary. While another intervention for this problem read Bathing: (Resident 2) would like to have a shower twice a week. - Another intervention in the Focus problem for ADL's initiated on 3/30/2017 instructed staff to Make (Resident 2 s) bed promptly in the morning. - A Focus problem initiated on 6/11/18 revealed the resident had a [MEDICAL CONDITIONS] r/t (related to) [MEDICAL CONDITION], immobility. Review of the interventions for this problem revealed no directions for applying and removing TED hose. - A Focus problem initiated on 1/30/18 identified the resident had a nutritional problem related to dementia, Diabetes type 2, [MEDICAL CONDITION] (swelling), and obesity. There were interventions in the resident's care plan regarding the resident's dislike of pork except for bacon, request for chocolate milk at every meal, and assistance from staff for cutting up meats. Record review of Grievance/Concern forms filed by Resident 2's POA revealed the following: - 5/20/18 the POA filed a grievance complaint expressing concern the resident's bed is never made The grievance stated family requested bed be made and staff refused to do so. The facility responded with a customer service meeting with staff on 6/4/18. - 5/31/18 through 6/3/18 the POA filed a grievance reporting the resident continues to receive pork for meals even though dietary was told the resident does not like pork except bacon. The grievance recorded the resident was supposed to get chocolate milk and wasn't and that staff were not cutting the resident's meat up at meals. - 6/4/18 The POA again reported resident not getting chocolate milk and was still receiving pork at meals. Again reported meats not being cut up for the resident. - 6/25/18- POA reported dietary still not cutting up food. Resident's hair is greasy and smelly, bed is not being made consistently. Review by facility revealed resident receiving a bath a week and described bed making was inconsistent especially on weekends. Described that Dietary would cut resident's food. Record review of Resident 2's physician orders [REDACTED]. Documentation by the orthopedic physician on 7/2/18 ordered the facility to measure the resident for thigh high TED hose with instructions to apply in the morning and remove in the evening. Interview with the Administrator on 7/12/18 at 2:10 p.m. confirmed the POA and family of Resident 2 had brought up concerns with bathing, bed making, meal preferences, and application of TED hose. The Administrator verified Resident 2's care plan had conflicting information regarding bathing. The care plan instructed staff to ensure the resident's bed was made but there had been problems in getting this done, especially on weekends. The Administrator verified the family and POA had ongoing concerns written in three separate grievances over the dietary requests of no pork, adding chocolate milk to every meal, and cutting up meats and the Administrator confirmed none of these issues were added to the care plan. The Administrator explained having meetings and doing some audits but agreed the family continued to have complaints in these areas. B. Interview with Resident 5 on 7/12/18 at 10:00 a.m. revealed the resident had been a long-term resident at the facility since 2012. The resident described the facility staff were inconsistent with making resident beds and on those occasions the resident makes own bed. Interview with Resident 7 on 7/12/18 at 10:15 a.m. revealed the resident had been at the facility for about seven months. The resident reported there are times when the bed has not been made by the staff and the resident will not have enough blankets on the bed and will sleep on just the mattress.",2020-03-01
4102,CARL T CURTIS HEALTH EDUCATION CENTER NURSING HOME,28A065,"PO BOX 250, 100 INDIAN HILLS DRIVE",MACY,NE,68039,2017-10-16,520,D,1,1,FXJ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.07 Based on record review and interview, the facility failed to have an effective quality assurance program as evidenced by deficiencies related to identification and implement of treatment for [REDACTED]. The facility had a total census of 17. Findings are: [NAME] The following deficiencies were cited during this survey: -F314 for failure to identify and implement a treatment for [REDACTED].>-F325 for failure to implement interventions for weight loss -F323 for failure to ensure hot water temperatures were maintained to prevent potential scalds B. A review of the facility policy dated 10/26/11 and titled Quality Assessment and Assurance revealed the following: -The committee will meet on a quarterly basis. They will identify whether issues are present that may affect the quality of care and services delivered to the residents. -The committee will develop plans of correction or action to correct identified quality deficiencies, including monitoring the effect of implemented changes and revising the action plans as needed. -Departments will have identified areas that will need to be addressed prior to the quality assessment meetings. C. In an interview on 10/16/17 at 10:40 AM, Registered Nurse G reported that Registered Nurse G will be taking over quality assurance and stated Registered Nurse G has been to one meeting. Registered Nurse G reported being unaware of anything being monitored for quality assurance. D. In an interview on 10/16/17 at 11:42 AM, the Director of Nursing reported that the Director of Nursing had not been to a quality assurance meeting yet. The Director of Nursing was uncertain if the facility was tracking or trending anything at this time.",2020-09-01
5719,NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER,285271,2100 CIRCLE DRIVE,SCOTTSBLUFF,NE,69361,2016-10-03,520,E,1,0,SRLF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.07C (4) Based on observations, record reviews, and interviews; the facility failed to re-evaluate prior plans of correction to correct and maintain correction for previously cited deficient practice related to: medication errors, provision of medications per standards of practice, and resolution of resident and/or family grievances. The failure resulted in repeat deficiencies affecting eight sampled residents (Residents 2, 8, 9, 10, 11, 12, 13, and 14). Sample size included thirteen current residents and one closed record review. Facility census was 51. Findings are: Record review of previous complaint and annual survey deficiencies for the facility revealed the following: 2/14/16- annual survey cited the facility for medication error rates exceeding 5% and failure of facility staff to compare medication labels with medication administration records per facility policy and standard of practice. 4/25/16- complaint survey cited facility failure to resolve grievances for both the Resident Council and individual grievances. 6/6/16- complaint survey cited facility for a significant medication error pertaining to liquid narcotic doses being miscalculated by administering personnel resulting in the death of the resident. In addition, the facility was cited for not administering medications at the time ordered by the physician. Observations, record reviews, and interviews during the complaint investigation conducted on 9/28/16 through 10/3/16 revealed deficient practice cited for repeat violations. The investigation and citations were as follows: - Failure to resolve family grievances for ongoing concerns related to care planning and repeated failure of staff to transfer one sampled resident (Resident 2) with a gait belt according to facility policy and care plan directions. (Refer to F166 and F280). - Repeat issue with miscalculation of a liquid narcotic medication administered to one sampled resident (Resident 11). The facility's plan of correction from the citation on 6/6/16 related to this failure indicated the facility revised their policy to ensure two nurse's checked dosages for accuracy. Interview with the Director of Nursing and facility Nurse Consultants on 10/3/16 at 1145 confirmed this was not done resulting in Resident 11 being given double the ordered dose. (Refer to F333). - An additional significant medication error was cited for two sampled residents. Resident 2 was administered a medication ordered for Resident 9. This resulted in Resident 2 being given an antihypertensive medication not ordered for the resident. Resident 2 was already receiving two antihypertensive medication doses daily. Resident 9 had a [DIAGNOSES REDACTED]. (Refer to F333). - Another significant medication error was cited for one sampled resident (Resident 10) when an order to continue a [MEDICATION NAME] dose was entered into the record to discontinue rather than continue the medication. This resulted in the resident not receiving the medication for a two week period. (Refer to F333). - Record reviews, and interviews revealed the facility staff administering medications were documenting the administration of these medications outside the ordered time frame. The facility policy and standard of practice required all medications to be recorded immediately after administration. This affected seven sampled residents (Residents 2, 8, 9, 10, 12, 13, and 14). (Refer to F425). In addition, the documentation and interviews confirmed these same residents (Residents 2, 8, 9, 10, 12, 13, and 14) were not administered some of their medications within the ordered time frames; experienced omissions of some of their ordered medications; and were not administered some of their ordered medications due to the medications being unavailable at the facility. (Refer to F425). - Observations, record reviews, and interviews revealed some of the medications administered to Resident 8 failed to include label directions with current physician orders [REDACTED]. (Refer to F431). Interview with the facility Director of Nursing, Administrator, Nurse Consultants, and facility Chief Executive Officer on 10/3/16 at 12 noon confirmed the facility had ongoing issues with medication errors and failure to follow current standards and facility policies regarding the administration of medications. The interview also confirmed ongoing concerns regarding Resident 2 had not been resolved to family and state ombudsman satisfaction that resolution had been achieved. Observations during the investigation revealed grievance issues regarding Resident 2's care planning and safe transfers with a gait belt were confirmed as ongoing.",2019-10-01
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
4869,"ARBOR CARE CENTERS-VALHAVEN, LLC",285117,300 WEST MEIGS STREET,VALLEY,NE,68064,2017-03-21,314,G,1,0,LPBJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09 Based on observation, record review, and interview; the facility failed to implement interventions to prevent the development and aide in healing of a pressure sore for 1 of 3 residents reviewed (Resident 3). The facility census was 46. Findings are: Review of Resident 3's medical record revealed Resident 3 had a [DIAGNOSES REDACTED]. Review of Resident 3's care plan dated 11/01/2016 revealed Resident 3 was at risk for pressure ulcer/skin breakdown related to Resident 3 required assistance with bed mobility. The intervention was to offload feet with Prevalon Boots (a padded boot to relieve pressure) both feet when in bed. Review of Resident 3's Weekly Wound Assessment sheet dated 3/13/2017 revealed Resident 3 developed a pressure ulcer on the right foot on the bunion area of the great toe. The wound was described as a Stage 3 ( full thickness tissue loss) blister and the interventions will be heel boots at all times. Review of Resident 3's care plan dated 3/14/2017 revealed a revision that Resident 3 was to have Prevalon boots on at all times. Observation on 3/16/2017 at 12:45 PM revealed Resident 3 sitting in a tilt n space wheelchair. Resident 3's feet were exposed with no covering on Resident 3's feet, a pillow on the foot rests of the wheelchair and the area of the wound resting on the pillow. No Prevalon boots were observed on resident feet or in the room. Observation on 3/16/2017 at 1:10 PM revealed Resident 3 in bed. There were no Prevalon boots on Resident 3's feet and the open area was resting directly on the mattress of the bed. Observation on 3/20/2017 at 3:00 PM revealed Resident 3 lying in bed. There were no Prevalon boots on Resident 3. There was a cushioned ring on Resident 3's ankle but the ring did not hold the foot from touching the mattress . Interview on 3/20/2017 at 3:05 PM with NA-A (Nurse Aide ) revealed NA-A thought the Prevalon boots had been discontinued and were not being used. Review of Resident 3's Weekly Wound assessment dated [DATE] revealed the Pressure Ulcer on Resident 3's right toe measured 1.3 centimeters (cm) in length. Review of Resident 3's Weekly Wound assessment dated [DATE] revealed the Pressure Ulcer on Resident 3's right toe measured 3.9 cm in length. Interview on 3/20/2017 at 4:15 PM with the Assistant Director of Nursing revealed the Prevalon boots had not been discontinued and that the Prevalon boots should be on at all times. The cushioned ring was not sufficient to provide pressure relief. Not having the Prevalon boot on put Resident 3 at increased risk for additional skin breakdown and a size increase in the current pressure ulcer.",2020-03-01
4925,"PREMIER ESTATES OF WEST POINT, LLC",285158,960 PROSPECT ROAD,WEST POINT,NE,68788,2018-06-12,684,D,1,1,ELDP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09 Based on observations, interviews, and record reviews; the facility failed to follow practitioner's orders for daily weights and pain management for 1 resident (Resident 187) and to evaluate causal factors and monitor bruising for Resident 34. The sample size was 22 and the facility census was 39. Findings are: [NAME] Review of Resident 187's admission orders [REDACTED]. The following orders were identified: -daily weight and notify practitioner if the resident's weight is up 2-3 pounds (lb.) overnight or if up 4-5 lbs. in 5 days; and -[MEDICATION NAME] HCI (medication used to stimulate central nervous system and prescribed to assist with pain management) 5 milligrams (mg) give 2.5 mg two times a day for pain. Review of Resident 187's Weights and Vitals Summary Sheet (form used to document a resident's weight, blood pressure, respiration, temperature and pulse) for (MONTH) (YEAR) revealed the resident's weight was 269 pounds (lbs.) on 6/4/18 and on 6/6/18 the resident's weight was 268 pounds. Further review of the resident's medical record revealed [REDACTED]. Review of Resident 187's Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. During an interview with the Director of Nursing (DON) on 6/7/18 at 1:20 PM the DON confirmed daily weights had not been obtained for Resident 187 and the resident had not received the [MEDICATION NAME] HCI 2.5 mg twice a day as the medication had not been available from the pharmacy. B. Review of the Policy titled Skin Care & Wound Management Documentation dated 6/2015 included the following related to documentation of wounds other that pressure ulcers: -The purpose of the policy was to document the status of skin impairments that require measurements or dimensions to indicate healing; and -The Licensed Nurse completes wound documentation on admission if skin issues are identified, upon identification of skin impairments, and weekly until the area is healed. C. Review of Resident 34's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/23/18 revealed the resident was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toilet use and hygiene. Review of Resident 34's Care Plan dated 5/21/18 indicated the resident was at risk for pressure ulcers and other skin impairments. Nursing interventions included: -Monitor/document/report to physician as needed any changes in skin status, including appearance, color, wound healing, signs/symptoms of infection, wound size; -When transferring the resident using the EZ stand (sit-to-stand mechanical lift), assure the resident is gripping the hand bars and tucks elbows in towards the body to prevent injuries to the arms and fingers (initiated 9/7/17); and -Skin inspection weekly. Observe for redness, open areas, scratches, cuts, bruises, and any changes, and document in the skin book. During interview on 6/6/17 at 9:56 AM, Resident 34 pointed out dark purple bruises on both hands and forearms and reported they occurred during mechanical lift transfers when arms and hands were hit on the doorframe of the bathroom door. During observation on 6/11/18 from 9:26 AM until 9:39 AM, Nursing Assistant (NA)-H and NA-B transferred Resident 34 from the wheelchair to the toilet using the sit-to-stand mechanical lift. The resident had a large dark purple bruise on the right elbow, and scattered dark purple bruises on bilateral forearms and hands. Resident 34 did not support self well in the lift and was transferred in a slouched position with elbows extended upward and to the sides. During the transfer, NA-H placed hands over the resident's elbows when passing through the threshold of the bathroom door and commented I whacked one the other day and felt bad about it. During interview on 6/11/18 at 2:38 AM, Registered Nurses (RN)-K verified staff were to report anything out of the norm to the charge nurse, including redness, breakdown, and bruising. If the resident was unable to tell them how it happened, they attempted to determine the cause. They documented weekly in the skin book but were currently transferring to an electronic system for skin documentation. RN-K verified Resident 34 was not doing well with the sit-to-stand lift and that she slouches in the sling. There was no evidence in the medical record that the facility identified the presence of bruising on Resident 34's forearms and hands; monitored and documented the healing of the bruises; and/or re-evaluated the use of the sit-to-stand mechanical lift as a cause of the injuries. During interview on 6/12/18 at 9:00 AM, the Nurse Consultant verified there was no documentation related to bruising for Resident 24.",2020-03-01
3283,COMMUNITY MEMORIAL HEALTH CENTER,285257,"P O BOX 340, 1015 F STREET",BURWELL,NE,68823,2018-09-25,684,E,1,1,E7OB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09 Based on observations, interviews, and record revieww, the facility failed to follow practitioner's orders regarding: 1) tube feedings (tube inserted through the abdomen that delivers nutrients directly to the stomach) and administration of blood pressure medication for Resident 24; 2) placement of an orthotic device (support, brace or splint) for management of Resident 4's hand contractures (a limitation in range of motion and defined as a condition of fixed high resistance to passive stretch of a muscle); and 3) provision of thickened liquids (dietary modification of liquids to prevent choking for individuals with swallowing problems) for Resident 21. The sample size was 4 and the facility census was 50. Findings are: [NAME] Review of Resident 24's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/27/18 revealed the resident had [DIAGNOSES REDACTED]. The assessment identified the resident was on a mechanically altered diet (modification of food consistency which allows improved oral intake) and the resident received 25 percent (%) or less of total calories through tube feeding. Review of Resident 24's current Care Plan with revision date of 3/5/18 revealed the resident was at risk for complications related to a recent stroke. The resident required use of a tube feeding due to insufficient caloric intakes and dysphagia. Review of a physician order [REDACTED]. Review of Resident 24's Meal Intake Detail Report dated 9/1/18 through 9/23/18 revealed for the noon meal the resident consumed less than 50% of the meal on the following dates: 9/6/18, 9/7/18, 9/9/18, 9/13/18, 9/18/18 and 9/20/18 (a total of 6 out of 23 days). Review of Resident 24's Treatment Administration Record (TAR) dated 9/2018 revealed the resident received the bolus tube feeding after the noon meal on 9/6/18 and on 9/18/18 (2 out of 23 days). Further review of the resident's TAR revealed no bolus tube feeding was administered on 9/7/18, 9/9/18, 9/13/18 and on 9/20/18 even though the resident's intake for the noon meal was documented as less than 50%. Review of Resident 24's Meal Intake Detail Report dated 9/1/18 through 9/23/18 for the evening meal revealed the resident ate less than 50% of the meal on 9/3/18, 9/7/18, 9/8/18, 9/10/18, 9/12/18, 9/20/18 and 9/21/18 (7 out of 23 days). Review of Resident 24's TAR dated 9/2018 revealed the resident received a bolus tube feeding after the evening meal on 9/3 (a total of 1 out of 23 days). Further review of the resident's TAR revealed no bolus tube feeding was provided on 9/7, 9/8, 9/10, 9/12, 9/20 and 9/21 even though the resident's intake for the evening meal was less than 50%. Review of Resident 24's physician orders [REDACTED]. The order indicated a blood pressure was to be obtained prior to administration of the medication and if the resident's systolic blood pressure (the top number of a blood pressure reading which measures the pressure in a blood vessel when the heart beats) was less than 120, then the medication should not be given. Review of Resident 24's MAR indicated [REDACTED] -9/1 the resident's blood pressure was 116/71; -9/19 the resident's blood pressure was 118/73; and -9/21 the resident's blood pressure was 112/60. Further review of the resident's MAR indicated [REDACTED]. During an interview with the Director of Nursing (DON) on 9/24/18 at 3:45 PM, the DON confirmed Resident 24's practitioner's orders had not been followed regarding the resident's bolus tube feeding and administration of [MEDICATION NAME]. B. Review of Resident 4's MDS dated [DATE] revealed a [DIAGNOSES REDACTED]. Review of Resident 4's TAR dated 9/1/18 through 9/17/18 revealed a physician's orders [REDACTED]. There was documentation that indicated the treatment was provided at 9:00 AM, 1:00 PM, 7:00 PM and 9:00 PM daily except on 3 occasions when the resident was out of the facility. During observations on 9/18/18 at 2:37 PM, on 9/19/18 at 10:51 AM, 1:21 PM and 2:12 PM, and on 9/20/18 at 10:33 AM, Resident 4 was observed in the room with hands tightly fisted and no braces and/or washcloths in the palms of the hands. Review of Resident 4's TAR dated 9/18/18 at 9:00 AM through 9/20/18 at 9:00 AM revealed documentation that the treatment to wash hands after meals and bedtime and use a brace/washcloth daily 4 times a day was provided at 9:00 AM, 1:00 PM, 7:00 PM and 9:00 PM daily. During interviews on 9/20/18, the following was revealed related to Resident 4's contracted hands: -7:15 AM - Nursing Assistant (NA)-E indicated they used to put an orthotic device in the hands, but this was no longer being done. NA-E further verified this with Resident 4 at that time; -7:44 AM until 9:47 AM - Licensed Practical Nurse (LPN)-C indicated they try the best they can to clean the hands but are unable to get anything placed in the palms; -10:10 AM to 10:15 AM - NA-G verified they used to place something in the palms of the hands but was unaware if this was currently being done; and -10:47 AM - LPN-H verified ordering the orthotic devices with the OT, and that they were currently supposed to be placed in the hands but was not sure what they are doing with this. The following were observed on 9/24/18 related to Resident 4's contracted hands: -9:15 AM - in room with hands tightly fisted and no braces and/or washcloths in the palms of the hands. The orthotic devices were stored in a cup on top of a table in the room; and -3:30 PM - in room with hands tightly fisted and no braces and/or washcloths in the palms of the hands. C. Review of Resident 21's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. Review of Resident 21's current Care Plan (undated) revealed the resident had physician's orders [REDACTED]. Observation of the breakfast meal on 9/20/18 at 8:22 AM revealed Resident 21 was served nectar thickened liquids which consisted of juice, water and milk. The resident drank the nectar thickened liquids without difficulty. Observations on 9/20/18 at 11:15 AM revealed Resident 21 was seated in the resident's room. A water pitcher and a glass of water were observed on the dresser. The water in both the pitcher and the glass had not been thickened. Interview with Nursing Assistant (NA)-F on 9/20/18 at 11:30 AM revealed the water served to Resident 21 in the resident's room was not usually thickened. NA-F was observed to give Resident 21 a sip of water (which had not been thickened) from the glass at the bedside on 9/20/18 at 11:30 AM. The resident took a small sip and then coughed several times before refusing to take another drink. Interview with the DON on 9/20/18 at 11:52 AM confirmed Resident 21 was to receive only nectar thickened liquids.",2020-09-01
4432,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-06-14,309,D,1,0,LO8N11,"**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 complete an assessment after a fall and failed to provide monitoring of the resident's condition to determine causal factors of increased pain post fall for 1 resident (Resident 1) of 3 residents sampled. Facility census was 61. Findings are: [NAME] Review of Resident 1's Nurses notes revealed Resident 1 fell on [DATE] at 1:35 AM and experienced increased pain. Review of Resident 1's Nurses notes dated 6/8/2017 at 1:35 AM revealed Nurse A did not assess Resident 1 for Range of Motion (ROM: ability to move arms and legs). Review of the facility policy dated 6/2015 titled Clinical Change in Condition Management revealed the following Daily observations: - Physical assessment - Mobility - Comfort level Interview on 6/14/2017 at 1:30 AM with the Director of Nursing (DON) revealed Nurse A should have completed a full assessment of Resident 1 at the time of the fall and documentation should have been completed every shift to include range of motion and comfort levels. Interview on 6/14/2017 at 10:00 AM with the DON revealed if assessments had been done at the time and following Resident 1's fall, Resident 1 would have received more timely transfer to the hospital. B. Review of Resident 1's medical record revealed a fax to Resident 1's physician sent at 2:45 AM to notify the physician of the fall and a response to the fax notification with orders to monitor. Review of the facility policy dated 4/2013 titled Fall Risk Reduction and Management revealed the nursing staff to evaluate and document on the residents clinical condition once per shift at least 72 hours post fall to include: -Vital signs -Physical status and pain level -Communication with physician -Condition of trunk and extremities to assess joint for changing normal range of motion. -Presence of pain including precipitating factors Review of Resident 1's Progress Notes revealed the resident remained in the facility for 60 hours after the fall before being admitted to the hospital. Review of the Progress Notes dated 6/9/2017 revealed no documentation of an assessment of Resident 1's ROM or pain level per facility policy. Interview on 6/14/2017 at 2:00 AM with the DON revealed no evidence in the medical record that Resident 1 was assessed once a shift after the fall to determine the cause of Resident 1's increase in pain after the fall.",2020-06-01
2868,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2018-01-02,684,D,1,1,51KH11,"**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 ensure the coordination of care between the facility and the hospice provider organization for 1 resident on Hospice care Resident 36. The facility census was 66. Findings are: Review of Resident 36's paper medical record revealed Resident 36 was admitted on hospice care starting on 11/2/2017. Review of Resident 36's [DIAGNOSES REDACTED]. Review of Resident 36's paper chart revealed no care plan from the hospice provider related to the hospice care that was to be provided for Resident 36 and no documentation of nursing assistant cares from the hospice organization was available to insure communication between agencies. Review of the hospice contract dated 11/2016, Article 3 revealed Hospice and the facility shall develop a process to exchange information regarding the development and updating of the Plan of Care (P[NAME]) to insure the resident receives necessary and appropriate care and services. Review of the hospice care plan for Resident 36 marked with a date faxed to the facility on [DATE] revealed the facility care plan did not incorporate all the elements of the hospice care plan and no hospice plan was attached to the facility care plan for Resident 36. Interview on 12/27/2017 at 10:30 AM with the Director of Nursing (DON) revealed the facility did not have copies of the hospice care plan or the documentation of care provided by hospice staff prior to 12/26/2017 and the facility care plan did was incorporated into the facility care plan.",2020-09-01
1767,PLUM CREEK CARE CENTER,285159,1505 NORTH ADAMS STREET,LEXINGTON,NE,68850,2019-07-01,656,E,1,0,C70G11,"**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 care plan interventions to prevent a fall with injury. This involved 3 of 3 sampled residents (Residents 1, 2, 3). Findings are: [NAME] Review of the Intake Information revealed an incident on 6/19/2019 for Resident 1 was transferring to commode via slide board with 1 assist and ankle brace on per care plan. Resident 1 lost balance and was lowered to the floor. Resident 1 complained of discomfort to hip and foot. Swelling and redness noted later in day. Dr. observed the resident the following day and X-ray was taken. Cat Scan was completed which identified a fracture of ankle. Resident currently transfers with full lift. Review of Resident 1's care plan revealed an admission date of [DATE]. Review of Resident 1's care plan revealed the admission [DIAGNOSES REDACTED]. Review of Resident 1's care plan with an entry dated 11/21/2018 the resident needed extensive assist of 1 staff with slide board transfers with use of gait belt. Review of Resident 1's care plan revealed an entry dated 2/6/2019 staff of 2 assist to transfer the resident with use of gait belt and walker. The care plan addressed two different transfers to be used. Observation on 7/1/2019 at 10:25 AM found Nurse Aide C (NA-C) performed a transfer using the slide board and a gait belt from the wheelchair to the commode then back to the wheelchair. Nurse Aide C pulled on the gait belt to move the resident along the slide board. Interview with NA-C on 7/1/2019 at 10:25 AM revealed using the slide board was the preference of Resident 1. Interview with the DON on 7/1/2019 at 3:00 PM revealed the care plan addressed to transfer with two people and walker. Also an entry of extensive assist of 1 staff with slide board transfers with use of a gait belt. B. Review of the Intake Information for Resident 2 revealed the resident had slipped through the lift blanket during a transfer. Sent to the hospital for a [DIAGNOSES REDACTED]. Review of Resident 3's Medication Administration Report revealed the resident was admitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident 3's care plan dated 5/1/2019 revealed staff were to utilize a total lift for all transfers with 2 assist. Further review of the care plan did not reflect the type of lifter sheet that was to be used. Also the care plan did not address the lifter sheet legs were not to be crossed due to the resident's fracture. Observation of a full body transfer on 7/1/2019 at 1:10 PM performed by NA-A and NA-B. The full body lift was performed with out crossing the legs of the lift sheet. Interview with the DON on 7/1/2019 at 3:00 PM confirmed the care plan had not been updated to address the type of lifter sheet to be used. C. Review of Resident 3's care plan revealed admission to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident 3's care plan dated 11/16/16 revealed Resident 1 was to have a call light within reach. Observation of a full body transfer for Resident 3 on 7/1/2019 at 10:00 AM by NA-A and NA-B revealed the proper size lift was used. Once the resident was placed in the bed, the lifter sheet was removed. The staff did not give the resident the call light to notify staff if a need arose. Interview with the DON on 7/1/2019 at 3:00 PM confirmed the care plan did address the call light should be in reach was important even if the resident probably would not use the call light.",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
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
5560,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2016-12-06,280,D,1,0,OL0511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09C1b Based on observation, record review, and interviews, the facility failed to revise the care plan for one sampled resident (Resident 1) to include information related to the resident's most recent fall, causal factors related to the fall, and new interventions following the fall resulting in hospitalization . Sample size was five residents. Facility census was 30. Findings are: Record review of Resident 1's Admission Record printed on 12/6/16 revealed the resident was admitted to the facility on [DATE]. Observation of Resident 1 on 12/6/16 at 11:40 a.m. revealed the resident had a healing scabbed linear area from above the left eyebrow extending to the middle of the forehead. Interview with Resident 1 on 12/6/16 at 11:45 a.m. revealed the resident recalled having fallen in the room resulting in a head injury which required stitches in the emergency room . The resident stated having lost balance and falling and the injury resulted in an overnight stay at the hospital. Record review of Resident 1's Progress Notes revealed an entry recorded on 10/25/16 at 12:23 a.m. The entry documented the resident was discovered on the floor at 6:45 p.m. and sustained a laceration on the left side of the forehead which was bleeding profusely. The resident's physician was notified at 7:00 p.m. and the resident was transported to the emergency room by ambulance. The entry recorded at 11:50 p.m. a hospital nurse notified the facility the resident would be kept overnight due to a new [DIAGNOSES REDACTED]. Record review of Nurses Notes entries on 10/26/16 revealed the resident returned from the hospital with new orders including [MEDICATION NAME] (heart medication), and Eliquis (a medication to prevent clotting and used for [MEDICAL CONDITION] treatment). Record review of Resident 1's current care plan revealed a Focus problem initiated 9/5/14, with a Target date (for goals) through 11/30/16, regarding Impaired Cardiovascular status. The problem did not identify the new [DIAGNOSES REDACTED]. Another Focus problem initiated on 10/19/12, with a target date of 11/30/16, identified the resident was At risk for falls. the problem identified a fall occurring on 8/25/16 but failed to record any information of the fall with injury which occurred on 10/25/16. Interview with the DON (Director of Nursing) on 12/6/16 at 2:00 p.m. verified Resident 1 fell in the resident's room on 10/25/16 resulting in overnight hospitalization related to a [MEDICAL CONDITION] and new [DIAGNOSES REDACTED].",2019-11-01
4297,OGLALA SIOUX LAKOTA NURSING HOME,2.8e+301,"7835 ELDERS DRIVE, STATE HIGHWAY 87",RUSHVILLE,NE,69360,2017-11-16,280,E,1,1,XK2J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09C1c Based on Record reviews, Observations, and Interviews, the facility failed to update care plans identifying concerns for: 1) One sampled resident's (Resident 12) falls and risk for dehydration; 2) one sampled resident's (Resident 8) aggression toward a specific resident; 3) one sampled resident's (Resident 15) changes in activities; 4) one sampled resident's (Resident 30) specialized diet; 5) one sampled resident's (Resident 13) risk for bruising and increase in incontinent episodes; and 6) one resident's (Resident 5) catheter removal. Sample size included 14 current residents. Facility census was 29. Findings are: [NAME] Record review of Resident 12's Admission Record printed on 11/14/17 revealed the resident was admitted tot he facility on 2/6/17. Record review of Resident 12's Progress Notes revealed the following entries: -10/12/17 at 8:10 a.m. the entry described that a nurse aide entered the room and the resident was discovered on the floor and bleeding from the head. The resident was assessed and assisted and transported to the emergency room for the laceration. - 10/25/17 at 11:33 a.m. the entry described the resident was found on the floor in the room. The resident was assessed and assisted and transferred to the emergency room for evaluation. Record review of Resident 12's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) revealed the resident had an MDS assessment compelted for a Significant Change in Status on 8/18/17. Further review of the assessment revealed the facility assessed the resident as having exhibited Dehydration during the reference period (8/12-8/18/17). Review of the Care Area Assessment Summary (a form identifying concerns based on the MDS assessment on 8/18/17) revealed the resident triggered a concern item for Dehydraiont/Fluid Maintenance and recorded the facility would update the care plan regarding this concern. Record review of Resident 12's care plan with the last revision completed on 10/12/17 revealed there were no care plan problems identified to describe the resident's falls on 10/12 and 10/25/17, nor were there any interventions developed to identify methods to reduce the risk of repeat falls. Further review of the care plan revealed no problem identified for concerns with dehydration or methods to address this concern. Interview with the DON (Director of Nursing) on 11/16/17 at 10:34 a.m. confirmed Resident 12's falls on 10/12/17 and 10/25/17 were not updated on the care plan to identify the risk and interventions to reduce the risk of falling. The DON stated there was a period of time when Resident 12 lost a significant amount of weight and was not drinking fluids either and verified the MDS recorded resident dehydration during the assessment on 8/18/17. The DON confirmed dehydration concerns were not updated on the resident's care plan nore were there methods described to address this concern. B. Record review of Resident 8's Admission Record printed on 11/14/17 revealed the resident was admitted to the facility on [DATE]. Record review of a facility investigation report of an incident involving Resident 8 and Resident 12, dated 5/22/17 revealed a statement by Staff-F,a witness who saw the incident. Staff F wrote an account of the event on 5/22/17 and described around 5 or 5:15 p.m. the staff member heard someone talking loud in the dining room. Staff F witnessed Resident 8 striking Resident 12 in the face while Resident 12 raised arms to defend self. Staff F intervened and stepped in between the residents and instructed Resident 8 to return to the resident's table. Resident 8 continued threatening Resident 12 but did back away. Staff F reported the incident to nursing. Record review of Resident 8's Progress Notes revealed an entry dated 9/2/17 at 7:23 p.m. The nurse documented confronting Resident 8 about a verbal altercation with Resident 12. Resident 8 denied fault in the altercation but stated Resident 8 would beat up Resident 12 . The nurse attempted to calm Resident 8 but the resident yelled at the nurse stating What am I supposed to do? Wait till (Resident 12) hits me. Resident 8 described not wanting to turn (resident's) back on Resident 12. The note described staff were aware the two resident's don't get along. Resident 8's family member was described as calling the facility at 7:26 p.m. and yelling at the nurse about the tension between Resident 8 and Resident 12. The nurse notified the Director of Nursing and Administrator of the issue. Observations of Resident 8 and 12 from 11/13/17 through 11/16/17 revealed the residents were separated in the dining room with seating at opposite ends of the dining room. In addition, their room proximities were separated as they reside on different halls. Interviews with staff providing direct care to Resident 8 revealed the following: - NA (Nurse Aide)-E on 11/14/17 at 10:30 a.m. - described being aware that Resident 8 did not like or get along with Resident 12. NA-E stated that after the incidents, the residents were moved to different tables in the dining room and Resident 12 was transferred to another wing away from Resident 8. - NA-G on 11/15/17 at 2:30 p.m. - described being aware that Resident 8 did not like or get along with Resident 12. NA-E stated that after the incidents, the residents were moved to different tables in the dining room and Resident 12 was transferred to another wing away from Resident 8. Record review of Resident 8's care plan initiated in (MONTH) of (YEAR) revealed there was nothing on the resident's care plan updated to identify Resident 8's dislike of one specific resident (Resident 12) resulting in altercations. The care plan does not identify interventions to prevent these specific altercations. The care plan did not describe any interventions about keeping them apart in the dining room or keeping them on different clinical areas of the building. Interview with the DON on 11/16/17 at 10:20 a.m. confirmed Resident 8's care plan was not individualized or developed to identify the specific altercations and threats toward Resident 12 nor interventions to prevent further altercations between the residents. C. Record review of Resident 15's Admission Record printed on 11/15/17 revealed the resident was admitted to the facility on [DATE]. Interview and observation of Resident 15 on 11/13/17 at 2:37 a.m. revealed the resident was awake in the room and in bed. The lights were off and there was no activity as there was no television, radio, or other methods of activity for the resident. During the interview with the resident the resident was asked about activities and replied that the resident does attend some activity events. When asked if the activity program met the resident's interests, the resident replied no, and described that the resident would prefer to have a television or radio in the room to pass the time. Record review of Resident 15's Progress Notes revealed an entry recorded by the Social Services Director on 9/21/17 at 10:37 a.m. The Social Services Director described that the television is always turned off, since (Resident 15) will hear something from the TV and imagines something happened to (a family member) or someone else in the family. This is from the news or violent movies. Record review of the Resident 15's care plan, revised on 9/29/17 revealed activity interventions of one on one activities. The care plan had not been updated to identify the delusional events precipitating removal of radio and television for the resident, nor did the care plan identify methods of substituting in room activity for the loss of the radio or television. Interview with the facility Activity Director on 11/16/17 at 11:32 a.m. confirmed the resident's television was removed from the room due to the television was causing the resident delusional events. The Activity Director stated the resident does come out for church, musical performers, and pow-wows. The staff plan is to read to the resident a minimum of twice a week and provide one on one sounds, spas, and relaxing events. The Activity Director confirmed the resident's care plan was not updated to reflect the loss of radio and television, reason for the removal, or methods of substituting in-room activities for the loss of the radio or television. D. Record review of Resident 30's Admission Record printed on 11/14/17 revealed the resident was admitted to the facility on [DATE] and was diagnosed with [REDACTED]. Record review of Resident 30's Medication Review Report (a form listing physician's orders [REDACTED]. Record review of Resident 30's Care plan initiated on 10/24/17 revealed a problem for risk of complications related to [MEDICAL TREATMENT] for end stage [MEDICAL CONDITION] was revised on 11/13/17. The problem did not identify the specified renal diet ordered, nor did the care plan identify individual components of what a renal diet consists of. Interview with the DON on 11/16/17 at 10:20 a.m. confirmed the Resident 30's diet was changed to a renal diet on 11/8/17. The DON confirmed the specified therapeutic renal diet was not updated on the care plan and the care plan did not identify individualized components of this diet on the care plan. E. Record review of Resident 24's Admission Record printed on 11/14/17 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 24's MDS assessments revealed an admission MDS assessment was done on 6/27/17 and a quarterly assessment was done on 9/26/17. Comparisons of the records revealed the resident's urinary incontinence status had declined from continent (no episodes of incontinence) in (MONTH) to Occasionally incontinent (7 or less episodes of incontinence over a seven day period). Record review of a facility Orders-Administration Note dated 11/13/17 at 3:23 p.m. recorded during the resident's weekly skin check, the nurse discovered a bruise to the right inner forearm and recorded the Res (resident) propels self around facility and does not see very well so has been noted to bump into things at times. Interviews with direct care staff familiar with Resident 24's care revealed the following: -NA-E on 11/15/17 at 11:20 a.m. described working primarily evening shift but does cover day shift. NA-E described resident does use the call light but doesn't always recognize when the resident needs to use the toilet and does have incontinent episodes. Resident wears a pullup brief and staff assist with toileting or cleaning up after incontinence. - NA-G on 11/15/17 at 2:30 p.m. described working day shift. Stated res does use a pullup and does have incontinent episodes. Staff assist the resident in cleaning up after incontinence. NA-G described resident as able to self propel in wheelchair but does bump into things. Record review of Resident 24's care plan initiated in (MONTH) of (YEAR) and revised on 9/29/17 revealed the resident does require assistance for toileting and identified the resident had vision deficit and required a walker or wheelchair to attend activities. There was nothing on the resident's care plan addressing a risk for injuries associated with bumping into things when mobilizing. The care plan also was not updated to identify the resident's change involving incontinent episodes and interventions to address the resident's incontinence. Interview with the DON on 11/16/17 at 10:30 a.m. verified Resident 24's propensity to bump into things resulting in injury, nor the resident's incontinence and methods to address the incontinence were not updated on the resident's care plan. Example F. Record review of resident 5's MDS (Minimal Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) revealed that the facility did a MDS admission assessment on 7/27/2017 which was a quarterly and a significant change on 8/30/2017 Resident 5 did not have a indwelling catheter. 11/13/2017 2:30 PM Interview with MDS Coordinator when asked if resident 5 had a catheter they did not. 11/13/2017 12:44 PM Dining Room observation of resident 5 did not have a indwelling catheter. 11/14/2017 12:22 PM Observation of dining room resident 5 did not have a indwelling catheter. Review the resident 5's care plan it is documented that they have a indwelling catheter. 11/16/2017 11:58 AM interview with the DON confirmed that resident 5 has it documented in the care plan that they have a indwelling catheter and resident 5 does not have a indwelling catheter per observation and hasn't had one for several months and the care plan has not been updated to indicate that.",2020-09-01
6428,GOLDEN OURS CONVALESCENT HOME,2.8e+200,902 CENTRAL AVENUE,GRANT,NE,69140,2016-03-22,280,E,1,0,KC2W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09C1c Based on interviews, observation and record reviews the facility failed to review and revise the care plans of 4 sampled residents (Resident 1, 3, 4 and 5) identified at risk for falls to reduce the risks for further falls. The facility census was 32. Findings: A. Review of the Admission Face Sheet for Resident 1 revealed an admission date of [DATE] to the facility. Further review revealed [DIAGNOSES REDACTED]. Review of the Fall Incident Report for Resident 1 dated 2/28/16 at 3:55 PM revealed that the resident did have a fall in front of a chair in the resident's room. Further review revealed that resident was confused and no injuries were noted at the time. Review of the Care Plan for Resident 1 dated 1/6/16 revealed a problem: Falls/history of falls, and fall score of 20 (10 or higher at risk for falls). Further review of revealed no written documentation of a fall or fall interventions revised after the fall on 2/28/16 to prevent further falls of the same nature. Interview on 3/22/16 at 4:30 PM with NA (Nurse Aide) - A revealed that fall interventions were passed off during shift changes by the charge nurse, the NA's leaving the shift, and was also written on the report sheets. Further interview reveled that Resident 1 had a fall recently but used to walk prior to the fall using a walker. Interview on 3/22/16 at 5:30 PM with the Administrator and the (DON) Director of Nursing verified that Resident 1 did have a fall on 2/28/16 with no injuries identified at the time. Further interview confirmed that on 3/3/16, Resident 1 had been sent to the physician's office for an x-ray for complaints of pain and a possible non-displaced pelvic fracture was noted at the time. Further interview confirmed that the care plan for Resident had not been reviewed or revised to reflect the resident's care following the fall with the possible fracture. Continued interview verified that Resident 1's care plan should have been updated after the fall with interventions to prevent further falls of the same nature. B. Review of the Admission Face Sheet for Resident 3 revealed an admission date of [DATE] to the facility. Further review revealed a [DIAGNOSES REDACTED]. Review of the Fall Incident Report dated 1/18/16 for Resident 3 revealed a fall while attempting to get up and go to the bathroom. Further review revealed that the resident was cognitively impaired. Review of the Care Plan for Resident 3 dated 8/3/15 revealed a problem of Falls/[MEDICAL CONDITION] drug use, history of falls, and fall score of 22. Interventions included remind to use call light, wear boots on feet at night, monitor for side effects of med's (medications), sleep in high-low bed and keep in low position. Further review of the care plan revealed no written interventions after the fall on 1/18/16 to prevent further falls of the same nature. Interview on 3/22/16 at 4:00 PM with NA - A revealed that Resident 3 was a sit to stand lift to transfer to the wheelchair and then, once up, was able to propel self in the wheelchair. Further interview revealed that the resident did have a high/low bed and a mat for the floor. Interview on 3/22/16 at 5:15 PM with the Administrator and the DON verified that Resident 3 did have a fall on 1/18/16. Further interview verified that the fall had not been identified on the care plan and interventions had not been written to prevent further falls of the same nature. Continued interview verified that, after all resident falls, the resident's fall interventions were to be reviewed and revised to prevent further occurrences. C. Review of the Admissions Face Sheet for Resident 4 revealed an admission date of [DATE] to the facility. Further review revealed [DIAGNOSES REDACTED]. Review of a written facility report sent to the State Agency dated 11/1/15 revealed an incident on 10/28/15 for Resident 4 of a fall in the resident's room. The resident was found on the floor with hip pain. The resident was sent to the emergency room and noted to have a pelvic fracture. Review of the Interdisciplinary Notes for Resident 4 dated dated 10/30/15 revealed that the resident had returned to the facility. Review of the Care Plan for Resident 4 with the report date of 9/2/15 revealed a problem of Falls/history of falls with a fall score of 15. Further review revealed written documentation of a fall on 10/28/15 with a fractured pelvis. Further review revealed no written documentation of the care plan interventions updated after the return of the resident to the facility. Observation on 3/22/16 at 2:45 PM of Resident 4's room revealed that the resident was not present. Further observation revealed that the resident did have a high/low bed, floor mat, bedside commode, and a grab bar on the bed. Interview on 3/22/16 at 3:55 PM with (Registered Nurse) RN - B revealed that Resident 4 did have a fall at the end of last year with a fracture to the pelvis. Interview on 3/22/16 at 5:30 PM with the Administrator and the DON verified that Resident 4 did have a fall with a fracture on 11/28/15. Further interview confirmed that the care plan for Resident 4 had not been updated to reflect new interventions to prevent further falls of the same nature after returning to the facility on [DATE]. Continued interview verified that all resident care plans were to be updated after falls to prevent further falls from occurring. D. Review of the Admissions Face Sheet for Resident 5 revealed an admission date of [DATE] to the facility. Further review revealed a [DIAGNOSES REDACTED]. Review of the Fall Incident Reports for Resident 5 revealed a fall on 3/1/16 in which the resident was attempting to sit down in the wheelchair and the wheelchair brakes were not locked. This caused the wheelchair to roll back and the resident ended up on the floor. Further review revealed a fall on 3/12/16 in which the resident leaned forward in the wheelchair, tipped the wheelchair over and fell on the floor with minor abrasions. Review of the Care Plan dated 12/11/14 for Resident 5 revealed a problem of of falls/history of falls, history of [MEDICAL CONDITION], and a fall score of 17. Further review revealed fall interventions included a bed mat, ambulate with 2 assist and gait belt, blood pressure med's and monitor for side effects, offer to take to bathroom, walk, staff to use wheelchair for mobility. Interview on 3/22/16 at 5:15 PM with the Administrator and the DON verified that Resident 5 had falls on 3/1/16 and 3/12/16. Further interview verified that the resident's care plan had not been updated with interventions following the falls on 3/1/16 and 3/12/16 to prevent further recurrences. Continued interview confirmed that the care plan interventions were to be updated after all falls with current interventions to prevent for recurrences.",2019-03-01
4164,REGIONAL WEST GARDEN COUNTY NURSING HOME,2.8e+181,1100 WEST 2ND,OSHKOSH,NE,69154,2017-09-14,280,D,1,1,D2LP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09C1c Based on observations, record reviews, and interviews, the facility failed to update one sampled resident's (Resident 2) care plan to include the current method of transfer. Sample size was eight current residents. Facility census was 27. Findings are: Record review of Resident 2's Resident Face Sheet printed on 9/13/17 revealed the resident was admitted to the facility on [DATE] and had a latest return to the facility on [DATE]. Observation on 9/12/17 at 1:30 p.m. revealed NA (Nurse Aide)-D and NA-E were assisting Resident 2 with a transfer from the resident's wheelchair to chair. Further observation revealed the staff utilized a sit to stand mechanical lift for the transfer. Record review of Resident 2's Care Plan revised on 6/7/17 revealed the resident was identified with a problem for risk for falls r/t (related to). gait instability, history of falls, noncompliance with safe practice regarding transfers. The Care plan was updated to record the resident was admitted through the emergency room to the hospital on [DATE] and readmitted to the nursing home on 9/7/17. Further review of approaches regarding the resident's risk for falls revealed the care plan had not been updated to include the current method of transferring the resident. Interview with RA (Restorative Aide)-F on 9/13/17 at 3:15 p.m. revealed Resident 2 had been on a restorative program for cognition and a walking program to meals. RA-F reported the resident sustained [REDACTED]. RA-F stated the resident's ability to transfer between surfaces had changed due to the fracture and the resident was now being transferred with a sit to stand lift. Interview with the DON (Director of Nursing) on 9/14/17 at 8:40 a.m. confirmed Resident 2 was being transferred by pivot transfer and ambulation prior to falling and fracturing a hip on 8/26/17. The DON verified upon return, the method of safe transfer of the resident was changed to include the use of a mechanical sit to stand lift. The DON confirmed the resident's care plan had not been updated to identify the change and current method of transfer for the resident.",2020-09-01
4864,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2018-07-12,657,D,1,0,PP9911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09C1c Based on observations, record reviews, and interviews, the facility failed to update one sampled resident's (Resident 2) care plan to include the intervention of TED hose to prevent blood clotting; dietary preferences expressed by the resident and family; and ensure the resident's bathing needs were non-contradictory. Sample size was seven current residents. Facility census was 27. Findings are: Record review of Resident 2's Admission Record printed on 7/12/18 revealed the resident's initial admitted at the facility was 12/21/2016. The current admitted was recorded on the form as 5/31/2018. Among the resident's medical [DIAGNOSES REDACTED]. Phone interview with Resident 2's POA (Power of Attorney for finance and healthcare) on 7/12/18 from 11:15 a.m. through 11:45 a.m. revealed the POA had written formal grievances at the facility regarding bed making, provision of baths, applying TED hose, and requesting dietary preferences. The POA expressed that Resident 2 due to dementia will often resist bathing, but can go several days without a bath. The POA stated since returning from the hospital, the resident was supposed to have TED hose on due to blood clots and the family has noted during visits this is not always getting done. The POA stated having issues with dietary for over a month regarding the resident getting pork after family has told the staff the resident does not like pork except bacon. In addition, staff do not cut up the resident's meat. Family has also requested that chocolate milk be provided at every meal to add calories to the resident's diet and the family visits at mealtimes identified this was not always being done. The POA reiterated that though the facility has done some interventions such as educating staff, the issues continue to be ongoing and not done consistently. Interview with another FM (Family Member) for Resident 2 on 7/12/18 from 1:30 p.m. to 1:45 p.m. revealed the family had ongoing concerns TED hose were not always applied to the resident's legs to prevent swelling. An untitled form dated 2/18/18 documented staff interviewing Resident 2 about how many times a week the resident would like to shower or bathe. The document recorded the resident preferred a shower once a week. Record review of Resident 2's Care plan printed on 7/12/18 revealed the following: - A Focus Problem initiated on 12/28/16 revealed the resident had an ADL (Activities of Daily Living, performance of daily tasks) Deficit related to dementia. Interventions for the problem were contradictory. A revised problem on 7/11/18 instructed staff to provide assistance with bathing/showering 3 x (three times) weekly and as necessary. While another intervention for this problem read Bathing: (Resident 2) would like to have a shower twice a week. - A Focus problem initiated on 6/11/18 revealed the resident had a [MEDICAL CONDITIONS] r/t (related to) [MEDICAL CONDITION], immobility. Review of the interventions for this problem revealed no directions for applying and removing TED hose. - A Focus problem initiated on 1/30/18 identified the resident had a nutritional problem related to dementia, Diabetes type 2, [MEDICAL CONDITION] (swelling), and obesity. There were interventions in the resident's care plan regarding the resident's dislike of pork except for bacon, request for chocolate milk at every meal, and assistance from staff for cutting up meats. Record review of Grievance/Concern forms filed by Resident 2's POA revealed the following: - 5/31/18 through 6/3/18 the POA filed a grievance reporting the resident continues to receive pork for meals even though dietary was told the resident does not like pork except bacon. The grievance recorded the resident was supposed to get chocolate milk and wasn't and that staff were not cutting the resident's meat up at meals. - 6/4/18 The POA again reported resident not getting chocolate milk and was still receiving pork at meals. Again reported meats not being cut up for the resident. - 6/25/18- POA reported dietary still not cutting up food. Resident's hair is greasy and smelly. Described that Dietary would cut resident's food. Record review of Resident 2's physician orders [REDACTED]. Documentation by the orthopedic physician on 7/2/18 ordered the facility to measure the resident for thigh high TED hose with instructions to apply in the morning and remove in the evening. Interview with the Administrator on 7/12/18 at 2:10 p.m. confirmed Resident 2's family had ongoing concerns regarding the application of TED hose and verified this intervention was not updated on the resident's care plan related to [MEDICAL CONDITION]. The Administrator confirmed the ongoing family concerns regarding dietary preferences had not been updated on the care plan to include chocolate milk at meals, assistance cutting up meats, and dislike of pork products except bacon. The Administrator verified the resident's care plan was contradictory regarding the number of baths the resident should have per week and needed updating to clarify the intervention.",2020-03-01
2497,PIONEER MANOR NURSING HOME,285212,"P O BOX 310, 318 N 3RD STREET",HAY SPRINGS,NE,69347,2018-08-07,657,D,1,0,9WZ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09C1c Based on observations, record reviews, and interviews, the facility failed to update the care plan for one sampled resident (Resident 1) to prevent contradictory information regarding safe transfers. Sample size was 3 current residents. Facility census was 51. Findings are: Record review of Resident 1's undated Resident Face Sheet revealed the resident was admitted to the facility on [DATE] with a latest return date of 7/23/2018. Observation of Resident 1 on 8/7/18 at 1130 revealed NA (Nurse Aide)-D and NA-E assisted the resident with transfer from bed to wheelchair with a mechanical lift device and sling. Further observation revealed the resident had a splint/immobilizer on the left leg from ankle to mid thigh in which NA-D stated was in place from a fracture. Interview with NA-D on 8/7/18 revealed NA-D was employed at the facility providing direct care for residents for about three years and was familiar with Resident 1's care. NA-D described Resident 1 as slowly declining in self care ability over the past few months. Prior to this, the resident was transferring between surfaces and to the toilet with the help of one staff member. In June, the resident was lowered to the floor and staff discovered the resident's knees buckled more often. The transfers were changed to have two persons transferring the resident. A pivot wheel was also used when the resident was able and NA-D described a week when staff tried using a sit to stand lift but discontinued this after the resident was unable to follow safe directions and hold on properly. Interviews with Restorative Aides RA-F on 8/7/18 at 10:28 a.m. and RA-G on 8/7/18 at 10:50 a.m. revealed both staff members worked in Restorative Nursing and were familiar with Resident 1's program. Both staff members described the resident as being on a walk to dine program about two to three times per week. The resident would other times decline walking. Both described the resident as having more difficulty walking and knees buckling or giving out during walking or transfers. Both described after the incident in (MONTH) when the resident was lowered to the floor, the resident was transferred with the assistance of two staff members. Record review of Resident 1's care plan related to safe transfer approaches revealed the following: - Problem dated 7/24/18 for Fractures revealed the resident sustained [REDACTED]. The care plan recorded the resident was to now be transferred with a mechanical lift. - Problem dated 6/6/2018 for Falls documented the resident was lowered to the floor in the bathroom. An approach for the problem also dated 6/6/18 revealed the resident was to be transferred with the assistance of two staff members. - Problem dated 12/10/2017 for Falls documented the resident was lowered to the floor by staff. An approach for the problem also dated 12/10/2017 recorded Staff will transfer with pivot disk during times when (the resident) is feeling weak. - Problem dated 6/14/2018 identified Res (Resident 1) is unable to dress/undress, groom, toilet, bathe, or transfer independently R/T (Related to) weakness. The approach toward the problem also dated 6/14/2018 provided instructions for Direct care staff will know (Resident 1's) routine and will allow (the resident) to dictate her cares as much as possible- (Resident 1) requires assist of 1-2 (staff) for dressing, grooming, transferring, bathing, and toileting. Interview with the Administrator on 8/7/18 at 11:45 a.m. reviewed the resident's care plan and discussed inconsistencies and ambiguous approaches as to how the resident was to be properly transferred as there were instructions for a pivot disk without specifying how the direct care staff were to identify when to use the pivot disk. The 6/14/18 update indicated staff could use 1 or 2 staff members when toileting and transferring but provided no clear cut instructions on how to determine when to use one or two. There was no updated information on the care plan when the pivot disk was discontinued and there was nothing on the resident's care plan about a trial use of a sit to stand lift described as being attempted and unsuccessful.",2020-09-01
6192,REGIONAL WEST GARDEN COUNTY NURSING HOME,2.8e+181,1100 WEST 2ND,OSHKOSH,NE,69154,2016-06-14,280,E,1,0,BN0W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09C1c Based on observations, record reviews, and interviews; the facility failed to update resident care plans to reflect current interventions to address transfer assistance and fall prevention for four current residents (Residents 1, 2, 5, and 7). Facility census was 30. Findings are: A. Record review of Resident 1's Admission Record revealed the resident was admitted to the facility on [DATE]. Record review of a physician's follow up hospital stay dated 5/3/16 revealed the resident was being seen in follow up from a hospitalization for a cervical fracture. Observation on 6/14/16 at 9:15 a.m. revealed Resident 1 seated in a wheelchair and requesting assistance to lie down. NA (Nurse Aide)-C and NA-D responded to the request and assisted the resident with transfer from the wheelchair to the bed. During the transfer, NA-C and NA-D utilized a mechanical sling lift for the transfer. Record review of Resident 1's Care Plan dated 3/9/16 revealed a problem identified for Falls with an approach, dated 12/9/15, to Transfer (resident) with 2x (two staff) assistance, transfer belt, and pivot disc. Notes from the Care Conference Report attached to the care plan on 3/9/16 read: (Resident 1) transfers well with 2x assist using pivot disc. Interview with LPN (Licensed Practical Nurse)-E and NA-C on 6/14/16 at 2:00 p.m. revealed that Resident 1 had fallen sustaining a cervical fracture on 4/28/16. Prior to the hospitalization for this fracture, the resident was transferring with two assist and a pivot disc. Following the injury, the safe and comfortable method of transfer was determined to be with the use of a mechanical sling lift. Interview with RN (Registered Nurse)-A on 6/14/16 at 2:15 p.m. confirmed Resident 1's care plan had not been updated to reflect the current method of transferring the resident following a fall in (MONTH) of (YEAR). B. Review of the Admission Record dated as printed 9/3/13 for Resident 2 revealed that the resident was admitted to the facility on [DATE]. Further review revealed [DIAGNOSES REDACTED]. Review of the Care Plan for Resident 2 dated 10/21/15 revealed a problem of At risk for falls . Further review revealed an entry on 5/29/16 of a fall with an intervention of continue with current approaches including a TABS alarm (an alarm attached to the resident and chair that will alarm when the connection is broken)and lap buddy. Continued review revealed that the TABS alarm intervention was dated 10/21/15 and lap buddy was dated 3/31/16 indicating both interventions were in place prior to the fall. Further review revealed no entries for a change in interventions on 5/29/16 to prevent further recurrence of falls. Observation on 6/14/16 at 11:20 AM revealed that Resident 2 was able to ambulate with assist of two (Nursing Assistants) NA - D and NA - F using a gait belt. Continued observation revealed that the resident was returned to the wheelchair and the TABS alarm was placed on the resident. Further observation revealed that there was no lap buddy in place. Observation on 6/14/16 at 12:15 PM revealed Resident 2 in the dining room with the tabs alarm in place. Interview on 6/14/16 at 11:25 AM with LPN - E verified that Resident 2 was a high risk for falls. Interview on 6/14/16 at 12:45 PM with RN - A confirmed that Resident 2 had falls and was a high risk for falls. Further interview confirmed that the care plan interventions had not been updated or changed after the documented fall on 5/29/16. Continued interview verified that the lap buddy and the TABS alarm were in place prior to the fall and were not new interventions to prevent further recurrence of falls. C. Review of the Admission Record for Resident 5 dated as printed on 6/16/15 revealed that the resident was admitted to the facility on [DATE]. Review of the Accident or Incident Report for Resident 5 dated 4/2/16 revealed a fall at 6:00 AM that day. Further review revealed no injuries from the fall. Review of the Care Plan dated 8/11/15 for Resident 5 revealed a problem of Falls, resident has fallen recently and is at risk for future falls . Continued review revealed no identified fall on 4/2/16 and no change in fall interventions after the fall on 4/2/16 to prevent further fall recurrences. Observation on 6/14/16 at 11:55 AM revealed Resident 5 ambulating independently using a front wheeled walker to the dining room to eat. Further observation revealed that the the resident was unsteady on feet. Interview on 6/14/16 at 10:00 AM with Resident 5 revealed that the resident was able to get up out of the chair and walk with the use of the wheeled walker. Interview on 6/14/16 at 11:00 AM with NA (Nursing Assistant) - D and NA - F verified that Resident 5 walked independently with the wheeled walker. Further interview verified that Resident 5 was a high risk for falls. Interview with RN - A on 6/14/16 at 12:30 PM verified that Resident 5 was a high risk for falls, had previous falls, and had an unsteady gait. Further interview confirmed that the fall had not been identified on the care plan and there was no change in the fall interventions to prevent for reoccurrences. D. Review of the Admission Record dated as printed on 11/18/15 for Resident 7 revealed an admission date of [DATE] to the facility. Review of the Accident or Incident Report for Resident 7 dated 4/23/16 revealed a fall in the hallway by the Activity door with a laceration on the right eyebrow. Further review revealed additional falls on 5/19/16, 5/25/16 and 6/5/16 with no injuries. Observation on 6/14/16 at 11:00 AM of toileting provided to Resident 7 revealed that NA - F used a sit to stand to transfer the resident to the commode. Review of the Care Plan dated 12/9/15 for Resident 7 revealed a problem of Falls-resident is at risk for falls and fall related injuries . Continued review revealed that the falls had not been identified on the care plan for 4/23/16, 5/19/16, 5/25/16 and 6/5/16. Continued review of the care plan revealed that one of the interventions for falls was that the resident ambulated about the facility with a front wheel walker. Continued review revealed no written documentation of the resident changed to a sit to stand for transfers. Interview on 6/14/16 at 11:00 AM with NA - F verified that Resident 7 was to be transferred using the sit to stand lift. The resident had weakness and had refused recently to ambulate. Further interview revealed that the resident was a high risk for falls and had falls in the past. Interview on 6/14/16 at 12:15 PM with RN - A verified that Resident 7 was a sit to stand transfer. Further interview revealed that the resident used to ambulate but had refused recently. Resident 7 was changed to a sit to stand transfer. Continued interview confirmed that the resident had several falls and was at high risk for falls. Further interview verified that the falls on 4/23/15, 5/19/16, 5/25/16 and 6/5/16 had not been identified on the resident's care plan and the fall interventions had not been reviewed or changed to prevent further falls from reoccurring.",2019-06-01
5713,NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER,285271,2100 CIRCLE DRIVE,SCOTTSBLUFF,NE,69361,2016-10-03,280,D,1,0,SRLF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09C1c Based on observations, record reviews, and interviews; the facility failed to: 1) Update the resident's care plan to include the use of a metal grab bar attached to the bed; 2) Update the care plan to include toileting and repositioning of the resident as requested by the resident's family during care conferences; and 3) update the care plan to include physician orders [REDACTED]. The violations affected one sampled resident (Resident 2). Sample size was four current residents. Facility census was 51. Findings are: A. Observations of Resident 2 from the initial tour of the facility on 9/28/16 throughout the survey concluding on 10/3/16 revealed a metal grab bar device was attached to the right side of the resident's bed which was positioned against the wall. Record review of Resident 2's Care Plan with goal target dates through 10/17/16 revealed the metal grab bar device was not included in any of the resident problems or approaches recorded on the resident's care plan. Interview with the Director of Nursing, facility Nurse Consultants, and Administrator on 10/2/16 beginning at 11:45 a.m. confirmed the grab bar device attached to Resident 2's bed was not included in the resident's care plan. B. Interview with Resident 2's family members on 9/28/16 at 11:20 a.m. revealed concerns with the facility not listening to family requests that two hour toileting and repositioning be added to the care plan. The family stated following an emergency room visit in (MONTH) of (YEAR), the family requested a toileting and repositioning schedule be added to the care plan to ensure these task were being done. Since that time, the family stated they attend care conferences and discuss this request every time but the facility has not gotten it added. The family stated concerns that it has been hit and miss with regard to the facility checking the resident every two hours based on their observations while in the facility and when monitoring the video camera they placed in the room. Phone interview with the State Ombudsman on 9/29/16 at 4:30 p.m. revealed the Ombudsman had attended care conference meetings with the family at their request. The Ombudsman confirmed that family members requested the two hour repositioning and toileting schedule be included in the resident's care plan at each meeting the Ombudsman attended. Record review of Resident 2's Physician order [REDACTED]. with Special instructions if resident sleeping between 10 p.m. and 5 a.m. allow the resident to sleep and don't awaken the resident. Record review of Resident 2's Quarterly review MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessment completed on 7/18/16 revealed the following items observed/assessed in the previous 7 day period: - The resident's BIMS (Brief Interview of Mental Status, a test to assess resident memory capabilities) scored a 6 (0-7=severe cognitive impairment). - The resident required Extensive Assist (Resident involved in activity, staff provide weight bearing support) for Toilet Use (how resident uses the toilet room . transfers on/off toilet, cleanses self after elimination .). - The MDS recorded the resident had not had a trial of a toileting program (including scheduled toileting, prompted voiding, or bladder training) since urinary incontinence was noted in the facility. - The MDS recorded the resident was Frequently Incontinent (Incontinent of urine during seven or more episodes in the previous seven days. Record review of Resident 2's Care plan with goal target dates through 10/17/16 revealed Problems for Urinary Incontinence; Risk for developing pressure ulcers; and ADL (Activities of Daily Living functionality were added to the care plan. Further review of the care plan revealed there was nothing recorded on the care plan in the problems or approaches directing staff to reposition or toilet the resident every two hours as requested by the family. An interview with the Administrator was conducted on 10/3/16 beginning at 11:45 a.m. The Administrator reviewed Resident 2's Care plan with target dates through 10/17/16 and confirmed there were no instructions in the resident's identified problems or approaches directing staff to reposition or toilet the resident every two hours as requested by the family. The Administrator verified the physician order [REDACTED]. C. Interview with Resident 2's family members on 9/28/16 at 11:20 a.m. revealed the family had ongoing concerns with the resident's care involving the resident's assistance at meals. The family stated due to turnover of staff, the facility was not consistent in providing care as directed by the Speech Therapist. The family stated the resident had difficulty swallowing and risk for aspirating food requiring pureed food and thickened liquids to be served at meals. The family stated witnessing meals when staff feeding the resident had not been informed of special instructions from the Speech Therapist and didn't follow the instructions. Record review of Resident 2's Speech Therapy SLP (speech language pathology) Discharge Summary signed by the ST (speech therapist) on 7/13/16 revealed the resident was seen in therapy from 5/26/16 through 7/13/16 and discharged for reaching the Highest Practical Level. In the summary notes the ST documented that caregivers were instructed in communication strategies, functional maintenance, and positioning maneuvers along with safe swallow techniques, safety precautions, and use of adaptive equipment. the ST documented : Swallow strategies/Positions recommended during oral intake for guided bolus/utensil placement, alternation of liquids/solids, alternation of temperatures, rate modification, and bolus size modifications. Frazier Water protocol (A Speech therapy technique protocol for residents with swallowing disorders) and general swallow techniques/precautions and upright posture during meals and 30 minutes after meals. Record review of Resident 2's Physician order [REDACTED]. The form described an order dated 7/7/16 which read: Continue pureed solids with strategies by staff of 1/2 tsp (teaspoon) size pacing between bites, alternating solids/liquids. Observations of Resident 2 being assisted in the dining room revealed the resident was assisted by NA-G during breakfast and noon meals on 9/29/16 and NA-E during the supper meal on 10/2/16. All of the observations revealed the resident received pureed foods in separate bowls with small sized spoons. The liquids were provided and thickened. Observations of both NA-G and NA-E revealed the staff provided a drink of liquid prior to beginning the pureed food intake. Throughout the meals, both NA-G and NA-E gave the resident five to ten bites of food before liquids were offered again. Record review of Resident 2's Care Plan with goals through 10/17/16 revealed problems were identified on the care plan for Nutritional Risk due to dysphagia (difficulty swallowing); Dehydration/Fluid Maintenance; and ADL functionality. Further review of the Dehydration/Fluid Maintenance problem had nothing documented describing or identifying steps on using a Frazier Water Protocol recommended by the Speech Therapist. The ADL care plan did not provide instructions related to assisting resident with fluids or meals recording the resident had an order not to feed self. The Nutritional problem had not identified approaches when feeding the resident to alternate foods and fluids as directed in both the ST discharge summary and physician orders. Interview with the Director of Nursing, Administrator, and facility Nurse Consultants verified specific instructions from the ST recommendations and physician orders [REDACTED].",2019-10-01
5896,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2016-08-31,284,J,1,0,F2SC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09C2 Based on observations, interviews, and record reviews; the facility failed to develop a post-discharge plan for one sampled resident (Resident 4) including: 1) involvement of the physician; 2) determination of safety capabilities and consultation with therapy to meet physician recommended discharge requirements; and 3) pre-assess the safety of the discharge environment and acceptance of discharge by the resident's family. The facility additionally failed by aiding the resident to transport and remain in a setting incapable of meeting the resident's safety needs. The failure resulted in Immediate Jeopardy of the resident's safety and led to a resident fall and fracture culminating in hospitalization . Facility census was 27. Findings are: Record review of Resident 4's Admission Record printed on 8/30/16 revealed the resident was initially admitted to the facility on [DATE]. Among medical [DIAGNOSES REDACTED]. Record review of Resident 4's Quarterly review assessment MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) dated 8/22/16 revealed the following: - The resident's Functional Status for Transfer- how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position was recorded as Extensive assistance- resident involved in activity, staff provide weight-bearing support at a minimum of three times during a seven day period. The Support provided for the activity was One person physical assist. - The resident's Functional Status for walking in and out of room was recorded as Activity did not occur. - The resident's Functional Status for Locomotion off unit- how resident moves to and returns from off-unit locations (e.g. areas set aside for dining, activities, or treatments) . how resident moves to and from distant areas on the floor. If in wheelchair, self sufficiency once in chair. The item recorded the resident received Extensive Assistance for the activity with the assistance of one staff. - Active Medical [DIAGNOSES REDACTED]. - The resident experienced pain over the last five days Frequently and rated the worst pain at 8 on a pain scale of 0-10 with 0=no pain and 10= very severe pain. - The resident experienced one fall since the prior assessment. - The resident's weight was recorded as 398 pounds. - The resident had not received any Occupational therapy since 1/6/16 and had not received any Physical Therapy since 7/26/16. Record review of Resident 4's care conference on 6/2/16 revealed the resident was invited to the conference and had not attended. The Discharge Plans for the resident at the conference were recorded as Long term. Record review of Resident 4's Care Plan initiated on 5/24/16 revealed the resident's discharge plan was recorded as I would like to make plans to discharge to a skilled nursing facility closer to my home. Further review of the care plan revealed a focus problem with Physical functioning deficit related to: Mobility Impairment, self care impairment, r/t (related to) [MEDICAL CONDITION] and recent BKA (Below Knee Amputation). The problem was initiated 5/24/16 and identified Transfer assistance of 2 staff with gait belt, extensive assist regarding interventions for the problem. Record review of a Report of Consultation with the resident's physician on 7/14/16 revealed the purpose of the visit was: 60 day- wants d/c (discharge) orders. The physician documented under Recommendations that the resident (MONTH) d/c home if can transfer to shower chair or toilet. Record review of the facility's Progress Notes for (MONTH) (YEAR) revealed the following entries: - 8/17/16 recorded at 3:10 p.m.- At 1150 (11:50 a.m.) Resident is found on floor by CNA (Nurse Aide). Resident states was transferring self from bed to w/c (wheelchair) using slide board. Resident also reports that slide board slips and causes to fall . Resident is helped up off floor via Maxi-lift and an assist of 4 onto bed . - 8/22/16 recorded at 5:04 p.m.- . (resident) stated wanted to go home . Resident has discharge to home orders per (name of physician) with the stipulation of being able to transfer self from w/c to toilet and back independently. Resident is able to perform transfer without difficulty. Resident has begun to gather belongings to leave for (name of town) tomorrow morning . Staff notified of discharge and will escort resident to home. - 8/23/16 recorded at 9:46 a.m.- Resident left facility via (facility) transportation for d/c, to be d/c to home with (family member), sent medication and medication list with resident. Resident left with w/c which will be brought back by staff, left with belongings . resident refused vital signs to be taken at this time, no questions or concerns. - 8/24/16 recorded at 6:50 p.m.- Resident went to motel instead of home. Concerned about how (resident) would get food/water and cook. Reported having family/friends/money for these things. Resident now in hospital. Discussed with DON (Director of Nursing) today. Interview with the SSD (Social Service Director) on 8/30/16 at 1:35 p.m. and Staff-B (facility van driver) on 8/31/16 at 9:35 a.m. revealed Resident 4 requested a discharge to the home of a family member and requested facility transportation to the home. The residence was in a town over two hours away. The facility provided van for transport and the SSD and Staff-B assisted the resident during the transport. They stopped at a medical supply vendor on the way and picked up a new wheelchair for the resident. The SSD stated when arriving at the town, the resident stated the family member would be sleeping and requested staff help the resident check into the motel where the resident would wait until the family member got off night shift work and would take the resident to the home. The SSD stated they assisted the resident with check in as the resident was unable to get inside the lobby due to the resident's size of wheelchair and inability to walk. Both staff then assisted the resident to the motel room. Staff-B stated the resident's wheelchair was too big for the resident to get through the door of the motel room and both the SSD and Staff-B stated the resident was unable to use a prosthetic leg to stand and transfer and requested use of a slide board which the facility brought along. Staff-B stated the resident used the slide board and staff placed one wheelchair inside the room in the doorway and the resident wheeled the other one outside the doorway and transferred into the wheelchair in the motel room with the aid of the sliding board. The resident requested they leave the slide board and the staff complied. The SSD stated they asked the resident if there were any other needs and resident stated no and the SSD and Staff-B left the resident and returned to the facility. Interview with the motel owner on 8/29/16 at 12:51 p.m. revealed the owner was in the office when Resident 4 arrived at the motel on 8/24/16 after lunch. The owner stated the facility staff came in and requested check in for the resident as the resident was wheelchair bound and oversized and unable to get into the office. The owner told the staff the motel was not equipped for handicapped individuals and the facility staff proceeded with the check in anyway. The owner stated later in the night the owner received a call from Resident 4 who stated having fallen and experiencing pain and felt this was not going to work. The owner stated Resident 4 requested transfer to a nursing home. The owner instructed the resident to contact family. Telephone interview with Resident 4's family member (identified by facility as the family member to which the resident requested discharge to) on 8/29/16 at 11:45 a.m. The family member stated not having any knowledge of the resident's intent to discharge to the family member's home and heard nothing of what happened until being notified by Resident 4 by phone while at work on the night shift on 8/24/16. Resident 4 called the family member at work and reported having been dropped off at the motel by the facility staff. Resident 4 stated having fallen and that the resident's back was hurting. The family member then planned to go to the motel at end of shift and assist. The family member stated when arriving, Resident 4 was in pain and unable to be moved without help and an ambulance was called. The family member stated it took six responders to assist the resident into the ambulance for transport to the hospital. Further interview with the family member revealed the family member was unable to provide care for Resident 4 due to the resident's size and amputated leg. The family member stated the home was not equipped for handicapped accessibility and stated if the resident were to fall, there would be no way to get the resident off the floor without extensive assistance of several persons. Observation of Resident 4's motel room conducted with the motel owner on 8/29/16 at noon revealed one entry/exit door into the room. The room was not handicapped accessible regarding the doorway size entering the room. The entry door measured 32 inches and the bathroom door entry measured 28 inches. Both of these were confirmed by the owner. There were no grab bars or assistive devices inside the room or bathroom. The telephone to the room was located across from the bed behind the television. The only water source in the room was in the bathroom. Interview with an EMT (Emergency Medical Technician) on 8/29/16 at 11:44 a.m. revealed the EMT responded to the call at the motel involving Resident 4 on 8/24/16. The EMT stated having arrived sometime between 5 a.m. and 5:30 a.m. on 8/24/16 . The resident was lying on the bed and was stoic and complaining of significant back pain. The resident stated having fallen sometime during the night. The EMT stated due to the resident's size and amputation, six personnel were required along with the use of the slide board to get the resident onto the transfer cot where the resident was transported to the hospital. Record review of Resident 4's hospital documents revealed the following: -Patient Registration Form from the hospital revealed the resident was admitted to the hospital on [DATE] at 10:10 a.m. -History and Physical Report on 8/24/16 revealed documentation the resident was released from the nursing home yesterday and fell last night at the (name of motel) hurting (the resident's) back. They waited until this morning, then called the ambulance, hurts in the high lumbar spine. (Resident 4) has had back pain before, but this was different and that it was more severe . (Resident 4) is a very poor historian. Seems to be slow mentally . The physical report assessed that the resident had an amputation on the right side below the knee. The Assessment recorded: New L1 (area of the lumbar spine) compression fracture intractable pain. - Radiology Report dated 8/24/16: Findings recorded: There appears to be loss of height at the L1 level consistent with a mild compression fracture. The fracture was not apparent on the previous study . - Hematology report on 8/24/16 revealed the resident's [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] disorders) toxicology report discovered a reading of 32.6 ug/ml (micrograms of medication per milliliter of blood) and recorded the result as H (Higher than normal with normal range for the medication between 10 and 20 ug/ml). Observation of Resident 4 in the hospital on [DATE] at 12:15 p.m. revealed the resident was in a hospital bed and had an amputated right leg below the knee. Interview with Resident 4 on 8/29/16 at 12:15 p.m. verified the resident requested discharge to a family member's home on 8/22/16 and the facility discharged the resident and assisted with the transfer on 8/23/16. The resident verified directing staff to transport the resident to a motel instead of the family member's home and that the staff honored the request and assisted the resident checking in to the motel and then into the motel room. The resident stated after being left, the resident was uncertain if this would work out and requested the motel owner to get the resident to a nursing home. The resident was told to contact family member by the motel owner. Resident 4 stated having fallen and was in a lot of pain. After the family member arrived, the resident was taken to the hospital by ambulance. The resident confirmed the family member was not consulted regarding the discharge by Resident 4 or the facility prior to the discharge. Interview with facility NA (Nurse Aide)-C on 8/30/16 at 11:15 a.m. revealed NA-C worked with Resident 4 in assisting with the resident's daily needs. NA-C stated transferring the resident was problematic due to the resident's size and amputated leg. NA-C stated the resident had not used the prosthetic leg and refused transfers with a mechanical lift. NA-C was aware staff had been injured during transfer of the resident resulting in a Physical Therapy review. After the review, the resident began transferring from the w/c to the bed with the use of a slide board but for safety reasons, staff still needed to be present during these transfers to ensure a safe transfer. Resident did not always comply with this or use the call light. Interview with the facility PT (Physical Therapist) on 8/30/16 at 11:30 a.m. revealed the PT had worked with Resident 4 when admitted following a [MEDICAL CONDITION]. The resident was discharged from therapy in (MONTH) of (YEAR) due to lack of progress and refusal to continue. The resident was again seen 7/26/16 for a wheelchair evaluation. The PT recalled the resident being seen due to size and transfer problems, staff were getting injured with transfers. A transfer board was initiated and resident was transferring with this when discharged . The PT verified therapy was not consulted after 7/26/16 to assess the resident's transfer ability and safety to return to a home setting. The PT stated the evaluation would determine if the resident could safely transfer between surfaces, evaluate the home setting to determine if doorways could accommodate size and wheelchair size, evaluate if steps were there, evaluate how the resident would get in and out of bed and mobilize from room to room. Other consideration would be how the resident would get in and out of the home. Record review of Resident 4's therapy documentation revealed the following: -PT Therapist Progress & Discharge summary signed on 1/6/16 revealed the resident was discharged as a Long term resident due to a plateau in progress and lack of motivation to participate and assist with transfers. Pt (patient or Resident 4) is unable to ambulate and cannot stand for greater than 10 seconds due to a fear of falling/walking . PT has encouraged and educated the pt to participate and assist more with transfer in order for the pt to return to prior living environment . - OT (Occupational Therapy)- Therapist Progress & Discharge Summary signed on 1/7/16 revealed documentation the resident was morbidly obese individual with a BKA who has been struggling to make progress over past several weeks. Pt is now at 372 pounds with a goal of 350 pounds in order to be a candidate for a prosthesis . - Physical Therapy Plan of Care (Evaluation Only) dated 7/26/16- revealed therapy was referred to assess and acquire a wheelchair and evaluation of posture and positioning. The therapist documented resident was on therapy case in past year following a Right BKA and was discharged due to unwillingness to continue or participate. The resident returned for the evaluation expressing desire to return home and will require a w/c for mobility. The resident was discharged to the Skilled Nursing Facility with plans to return home, however was unable to fully indicate home environment and location. Record review of facility policies regarding transfers and discharges revealed the following: an updated policy of - Transfers and Discharges number SS-705. The Purpose of the policy read: Transfers and discharges should be handled appropriately to assure proper notification and assistance to residents and family in accordance with federal and state specific regulations. - Discharge/Transfer of the Resident procedure number CLIN1300-320 dated 1/26/15 revealed the procedure purpose was To provide safe departure from the facility and to provide sufficient information for after care of the resident. The Procedure included: Explain discharge procedure and reason to resident and give copy of Transfer & Discharge notice as required. Include resident representatives. Further instructions in the policy included: The attending physician is required to write a discharge order . When calling the attending physician for a discharge order, inquire whether or not the resident's medication is to be sent with the resident . include instructions for post discharge care and explain to the resident and/or representative . Interview with the facility DON (Director of Nursing) on 8/31/16 at 1:30 p.m. verified Resident 4 had multiple co-morbidities regarding the resident's medical status. Among these were Diabetes with Diabetic [MEDICAL CONDITION] and pain, [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION], Chronic embolism/[MEDICAL CONDITION] history, and amputation of the right leg below the knee. The DON verified the resident had fallen five days prior to discharge using a transfer board independently, but was deemed by facility as independent to return to a home setting. The DON could not recall who specifically cleared the resident as safe for discharge and self transfers but said the administrative team discussed this. The DON confirmed the resident requested to go to a family member's home and the facility assisted with the transport without contacting the family member or determining if the family member's home could accommodate the special safety needs for the resident. The DON confirmed the physician nor the therapy department were consulted prior to the resident's discharge, regarding the discharge to determine if the resident had met the discharge safe transfer recommendation or if the resident was medically stable for discharge. The DON verified there was no documentation supporting whether the facility discussed diabetic needs, safety with [MEDICAL CONDITION] medications and monitoring labs, or any discussions regarding other medical needs with the resident or family. The DON verified the resident had a [MEDICAL CONDITION] disorder history and received daily doses of [MEDICATION NAME] for the [DIAGNOSES REDACTED]. The DON confirmed the family member was not consulted to assure the facility that the discharge to the family member's home would be safe and the resident's needs would be met. The DON confirmed the facility aided in the transport of the resident to a motel room which was not handicapped accessible without access to water or bathroom facilities and doorways capable of allowing the resident to exit the room in an emergency. Prior to the survey team exit on 8/31/16, the facility's Quality Assurance team convened and developed a plan of action to prevent re-occurrence of the violation and implement immediate changes regarding resident discharges. The plan included identifying all residents with active discharge plans and validating the environment being sent for discharge was safe before implementing the discharge. The plan provided education of facility transportation aides and the Social Service Director immediately and education to all staff on duty regarding discharge policy implementation. In addition the facility plan included assurance the physician or other interdisciplinary team members including therapy were notified of planned discharges and involved in consultation prior to the discharges. Due to these measures, the Immediate Jeopardy was abated and scope and severity lowered to a G.",2019-08-01
2031,GOOD SAMARITAN SOCIETY - VALENTINE,285176,601 WEST 4TH STREET,VALENTINE,NE,69201,2018-05-30,684,G,1,1,DSI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D Based on observation, record reviews, and interviews, the facility failed to: 1) provide follow up assessments of one sampled resident's (Resident 18) ongoing condition changes and bowel elimination changes. The resident's ongoing loose stools and condition resulted in hospitalization and surgical intervention for a bowel obstruction; and 2) provide follow up assessments for one sampled resident (Resident 32) with an abnormal low blood pressure reading. Sample size was 16 current residents. Facility census was 34. Findings are: [NAME] Record review of Resident 18's Admission Record printed on 5/25/18 revealed the resident was admitted to the facility on [DATE]. Observation of Resident 18 on 5/30/18 at 8:57 a.m. revealed the resident had a [MEDICAL CONDITION] (opening of the colon onto the abdominal surface to allow feces to pass through) for bowel elimination of feces. Interview with Resident 18 on 5/30/18 at 8:57 a.m. revealed the resident was hospitalized for [REDACTED]. Record review of Resident 18's Medication Record for (MONTH) of (YEAR) revealed the following: - an order for [REDACTED]. - an order for [REDACTED]. - an order for [REDACTED]. Record review of Resident 18's Complex Alert Documentation Report for (MONTH) of (YEAR) revealed documentation of the consistency of BM (Bowel movements) exhibited by the resident. The form documented the resident had Formed/Normal BMs or Soft BM's from 2/1/18 through 2/7/18. Beginning on 2/8/18 in the evening, the resident had a loose/liquid BM which continued through 2/24/18. On 2/25/18 and 2/26/18 there were no BM's recorded for the resident. Record review of Resident 18's Progress Notes for (MONTH) of (YEAR) revealed the following entries: - 2/13/18 at 7:34 a.m. the resident was sitting on edge of bed and the staff attempted to give the resident an anti-anxiety medication as the resident won't go to the bath house with bath aide, won't allow aide to assist to BR (bathroom). The resident questioned How do I know those (medications) are mine. The resident refused to take the medications and the nurse recorded Meds held and then offered multiple times as walked by resident room. - 2/13/18 at 8:57 a.m. the entry recorded the resident questions what is the plan for the security for me and my family . Resident still refusing to eat or take meds (medications). Contacted (name of family member) and explained situation. - 2/13/18 at 10:21 the resident's family expressed a concern with the facility Social Services Director that the resident was having more paranoia and questioned if (the doctor) had been notified. SSD (Social Services Director explained not being aware if the doctor had been notified of this morning's mood/behavior but resident had been seen on 2/6/18 . (family member) felt (the need) to contact the doctor to inform what was going on. The SSD provided the family member the clinic's office number. - 2/18/18 at 8:05 a.m. the staff held the resident's scheduled Polyethylene [MEDICATION NAME] (for constipation) due to loose stools. The staff held the resident's potassium tablets due to the resident was feeling sick. At 8:06 a.m. the staff held the resident's [MEDICATION NAME] (for constipation) due to loose stools. - 2/18/18 at 9:52 a.m. the nurse recorded: Resident reported to have had some loose stools during N[NAME] (night). Early meds given without issue. By the time breakfast was served (the resident's) demeanor changed. (The Resident) decided everyone was talking about (the resident) and was very angry. Refused food . didn't feel well. Held [MEDICATION NAME] r/t (related to) loose stools and explained this to (the resident). 'Well who make you God? How do you know what I need or why I'm here?' Several staff members attempted to visit with (the resident) and encourage to go back to room but would refuse. Asking another nurse why no one will tell (Resident 18) the truth about how (the resident's) aunt is doing. No one knows about this. After about an hour, (the resident) was speaking to a visitor and stated wanted to go to room. CNA (Nurse Aide) then ambulated to room and is resting in bed at this time. - 2/19/18 at 8:32 a.m. the nurse documented holding the resident's Polyethylene [MEDICATION NAME] due to c/o (complaints of) loose stools. - 2/19/18 at 10:45 p.m. the resident was given Tylenol for voices headache and sore throat. - 2/25/18 at 9:46 a.m. the nurse recorded Out for breakfast early and reported at table that (the resident) was hot. Cheeks flushed. Temp (resident temperature) 96.2. Ate only bites of breakfast but drank several glasses of water . - 2/25/18 at 2:32 p.m. the nurse recorded Resident refused lunch states just doesn't feel well took in sips of supplement with noon medications. Resident is flush but is afebrile (doesn't have elevated temperature). Will continue to monitor . - 2/25/18 at 2:32 p.m. the nurse recorded administering Tylenol for the resident's request for headache. - 2/26/18 at 9:38 a.m. the nurse recorded: Notified by CNA that resident stated stomach did not feel good and didn't want to get up. Observed abdomen to be distended fully; states 'Doesn't feel real good' when palpated. high abdominal sounds upper, hypo (little or no sounds) lower . The facility contacted a family member and was asked about past history of ovarian cysts or blockages in colon. (Family member) stated (the resident) has an extensive hx (history) of both and saw (the resident) last night and believes it is an ileus (intestinal obstruction)). The nurse contacted the clinic and reported the symptoms and an order was received to send the resident to the emergency room for evaluation. - 2/26/18 at 4:30 p.m. the Director of Nursing recorded a Late entry for earlier this am (morning). The nurse recorded an assessment of the resident's abdomen was done at 9:20 a.m. in which the abdomen was very distended, BS (Bowel sounds) in upper quad's (quadrants) very hyper and lower quad's very hypo to little sounds, abdomen was very firm with palpation and (Res 18) did have facial grimacing with touch. Face was very flush, warm to touch, heart was regular, lungs clear, didn't notice any [MEDICAL CONDITION] (swelling). (The Resident) report 'I don't feel good' . Review of Resident 18's Progress Notes and electronic medical record revealed the resident began developing symptoms of loose stools recorded on the BM records beginning on 2/8/18 through 2/25/18. The resident exhibited unusual paranoia and behavioral symptoms beginning on 2/13/18 which included resisting medications and assistance. The staff held medications due to loose stools on 2/18/18 and 2/19/18, and the resident continued to complain of feeling sick or requesting Tylenol for pain on 2/19/18 and 2/25/18. There was no ongoing assessments or follow up documented regarding the resident's condition related to the continuing loose stools and behavior changes until the symptoms became sever on 2/26/18. Record review of Resident 18's hospital Transfer Summary dated 2/26/18 recorded the resident was brought to the emergency room with complaints of abdominal pain. (The resident) states the abdominal pain has been going on for the past week, but has gotten worse today . A CT (computerized axial tomography- type of non-invasive test analyzing internal organs and structures) of (the resident's) abdomen shows a distal sigmoid (colon) obstruction with severe dilatation of the colon, sigmoid volvulus (twisting of the bowel upon itself). Recommend urgent surgical consultation. Record review of Resident 18's hospital History and Physical dated 2/26/18 revealed the resident was sent in because of abdominal pain. Patient is in a lot of pain, is a little bit confused right now and is unable to give a clear history. Most of the information was obtained from transfer papers from (another hospital). Patient had apparently been having abdominal pain for about a week or so which is ultimately what prompted (the resident) to come to the Emergency Department for further workup and management there. CT scan imaging showed evidence of a distal sigmoid obstruction with severe dilation of the colon with a suspicion for a sigmoid volvulus. Hence (the resident) was transferred here for evaluation by our surgical team and for possible intervention. Further review of the physical revealed Past Surgical History which identified none was documented, although on (the resident's) abdomen there seems to be a previous exploratory laparotomy (surgical opening of the abdomen) surgical incision site. Record review of Resident 18's Discharge Transfer Instruction Summary form from the hospital signed by the MD on 3/5/18 revealed the resident was diagnosed with [REDACTED]. Interview with the DNS (Director of Nursing Services) on 5/30/18 at 9:15 a.m. confirmed Resident 18 began developing loose stools as recorded on the BM records on 2/8/18, unusual behaviors on 2/13/18, and the staff held medications for the resident on 2/18 and 2/19/18 due to loose stools. The DNS verified the resident continued with symptoms requiring Tylenol for pain and refusing meals on 2/25 due to not feeling well. The DNS verified the resident's medical practitioner or physician were not notified of the changes until 2/26/18 and there were no ongoing physical assessments by the staff regarding the resident's condition presenting with ongoing symptoms of loose stools, pain, abdominal assessments, bowel sounds, and confusion/paranoia. B. Review of the Admission Record, printed 5/24/18, revealed that Resident 32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the electronic Blood Pressure Summary revealed that on 5/16/18 at 1:10 PM, the resident's blood pressure was 84/54. Review of the Progress Notes, dated 5/16/18, revealed no documentation including an assessment of the resident's condition related to the low blood pressure or follow up blood pressure readings. Interview with the Director of Nursing on 5/29/18 at 2:30 PM confirmed that the resident's blood pressure reading on 5/16/18 was abnormally low. Further interview confirmed that there was no documentation in the medical record of an assessment of the resident's condition or follow up blood pressure readings. The Director of Nursing also confirmed that the nurses should have completed an assessment of the resident and follow up blood pressures to ensure that the resident's condition was stable or to determine the need for possible medical attention.",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
5898,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2016-08-31,329,D,1,0,F2SC11,"**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 a lab test monitoring the therapeutic drug level for one sampled resident (Resident 4) was obtained and reviewed as ordered by the physician. Facility census was 27. Findings are: Record review of Resident 4's Admission Record printed on 8/30/16 revealed the resident was admitted to the facility on [DATE] and recorded a medical [DIAGNOSES REDACTED]. Record review of Resident 4's Order Summary Report dated 7/14/16 revealed the facility received a medication order for [MEDICATION NAME] Sodium (a medication used to treat [MEDICAL CONDITION] activity) Extended Release Capsules with instructions to administer 300 milligrams every morning and 500 milligrams every evening. The original order date for the medication was recorded on the form as 11/13/2015. Record review of a Clinical Pharmacist Letter to Physician Services with a Recommendation Date of 6/8/16 revealed a recommendation for the physician to Please consider ordering a [MEDICATION NAME] level (blood test to examine the level of medication in the blood stream to determine dosing) and CBC (Complete Blood Count) now and every 6 months. The physician responded documenting acceptance of the recommendation with orders to Please revise orders as suggested (by the pharmacist) above. The physician signed the order on 6/14/16. Record review of Resident 4's chart revealed a CBC was collected and analyzed on 7/1/16 but there was no record of a [MEDICATION NAME] level collected between 6/14/16 and the resident's discharge from the facility on 8/23/16 Record review of a hospital History and Physical Report dated 8/24/16 revealed Resident 4 was admitted to the hospital following a fall resulting in back pain. Further review of hospital documents revealed the resident was admitted to the hospital and a [MEDICATION NAME] level was ordered. Record review of the Toxicology Report revealed on 8/24/16 the resident's [MEDICATION NAME] level was obtained and tested resulting in a reading of 32.6 ug/ml (micrograms of medication per milliliter of blood) and recorded the result as H (Higher than normal with normal range for the medication between 10 and 20 ug/ml). Interview with the Director of Nursing on 8/31/16 at 10:45 a.m. confirmed the facility received a physician order [REDACTED].",2019-08-01
5727,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2016-09-07,309,D,1,0,IKT911,"**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 monitor and assess the progress and/or symptoms and explore causal factors or medical [DIAGNOSES REDACTED]. The sample size included eight current residents and two closed record reviews. Facility census was 101. Findings are: Record review of Resident 7's Face Sheet dated 5/16/16 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 7's Admission Nursing Evaluation dated 5/14/16 revealed a section entitled Skin Condition. Review of this section revealed the assessment nurse identified 10 different areas of abnormality and plotted the location of the abnormalities on a body diagram. Review of the site 10 on the form revealed the area of abnormality was circled below the resident's neck, extending to both armpits and down the back just above the resident's bottom. The documentation for site 10 read: Many scabs over the whole area of (the resident's) back. Pinpoint in size. Record review of Resident 7's Non Pressure Skin Record observed and documented on 5/14/16 revealed additional documentation of the resident's skin condition on the site location documented Back. The Condition was described as: Other:Scabs. There were no measurements or identification of how many scabs were noted, the documentation for Measurements read: Many small scabs. Progress Notes for the Initial Evaluation read: Many scabs intact over the whole area of (the resident's) back. The site of the skin condition was identified on a posterior body diagram where the entire back of the resident was circled from the shoulders to the resident's bottom. Record review of Resident 7's closed medical record revealed no further documentation regarding the condition of the resident's back. Phone interviews were conducted with two of Resident 7's family members on 9/7/16 at 11:30 a.m. and 12:20 p.m. Both family members reported the resident resided at the facility until 6/14/16. Following discharge on 6/14/16 the family opted to take the resident home on hospice services. The family noted [MEDICAL CONDITION] all over the resident's back and hospice evaluation of the [MEDICAL CONDITION] revealed the resident had contracted scabies which was confirmed by medical [DIAGNOSES REDACTED]. The family was concerned that nothing was reported regarding anything going on with the resident's skin condition of the back and that the facility had an outbreak of scabies. Record review of the infection control Scabies Intervention and Study record, undated, revealed the Infection Control Nurse, RN (Registered Nurse)-A investigated an outbreak of scabies in the facility in (MONTH) of (YEAR). The report revealed three residents (not including Resident 7) on different units were diagnosed with [REDACTED]. The report revealed Resident 7's family contacted facility reporting Resident 7 had scabies. the report regarding Resident 7 revealed the resident revealed no documentation related to the skin condition related to the resident's back. Interview with RN-A at 12:45 p.m. confirmed RN-A investigated a facility scabies outbreak in (MONTH) involving three residents diagnosed with [REDACTED]. RN-A recalled being told by the family of Resident 7 they suspected scabies but said they had not had a [DIAGNOSES REDACTED]. The resident was seen by several medical practitioners and hospitalized on ce (5/19-5/22/16). RN-A confirmed on admission to the facility on [DATE] assessments identified scabs all over the resident's back and that there was nothing in the medical record identifying further examination of the abnormality. Interview with the DON (Director of Nursing) on 9/7/16 at 2:30 p.m. confirmed Resident 7 was admitted to the facility on [DATE] and assessed with [REDACTED]. The DON confirmed there was no further documentation related to the condition of the resident's back, whether these scabs improved or deteriorated, possible causal factors for the condition, assessment of symptoms, or requests for consultation regarding [MEDICAL CONDITION] or abnormalities of skin on the resident's back between admitted on 5/14/16 and discharge on 6/14/16. Phone interview with the Hospice RN on 9/8/16 at 9:15 a.m. confirmed the Hospice RN assumed care for Resident 7 upon discharge to home on 6/14/16. The Hospice RN described an initial assessment describing multiple [MEDICAL CONDITION] on the resident's back extending to the resident's flan. The Hospice RN stated the [MEDICAL CONDITION] were consistent with scabies which was confirmed by medical [DIAGNOSES REDACTED]. The Hospice RN stated that three family members also contracted scabies from contact with the resident.",2019-09-01
3754,GOOD SAMARITAN SOCIETY - GRAND ISLAND VILLAGE,285285,4061 TIMBERLINE STREET & 4055 TIMBERLINE STREET,GRAND ISLAND,NE,68803,2019-09-26,677,D,1,1,7E3P11,"**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 provide a minimum of weekly bathing for 2 sampled residents (Residents 2, and 45). Facility census was 59. Sample size included 19 current residents. Findings are: [NAME] Record review of Resident 2's MDS (Minimum Data Set a federally mandated comprehensive assessment tool utilized to develop resident care plans) records revealed the resident had a Quarterly Review assessment completed on 06/11/19. Review of this assessment revealed the resident was admitted to the facility on [DATE] the assessment recorded the resident required one person physical assistance with bathing. Family Interview on 09/24/19 at 2:02 p.m. Resident 2's POA (Power of Attorney) reported that Hospice was providing a sponge bath to Resident 2 and then the facility was only showering the resident 1 X a week. The POA reported the facility was to be showering the Resident 2 X a week and then Hospice would provide a sponge bath 1 X a week. POA reported the facility is not doing what is requested from the family and that is that the resident is to have a total of 3 bathes 2 provided by the facility and one by hospice. Family Interview on 09/24/19 at 4:45 p.m. Resident 2's daughter who is not the POA reported that the resident is not getting the 3 bathes a week as requested by the family and sometimes Resident 2 does not even get a bath during the week. Record review Good Samaritan Society - Grand Island Village bathing record for Resident 2 for the month of July-2019 verified that Resident 2 was only bathed on (MONTH) 23, 2019, and on (MONTH) 27, 2019. This made it a total of 2 bathes for the month of (MONTH) and there were no other baths provided to Resident 2 during the Month of July. Resident 2 is not receiving the 3 bathes a week as requested by family. Record review Good Samaritan Society - Grand Island Village bathing record for Resident 2 for the month of August-2019 verified that Resident 2 was only bathed on (MONTH) 3, 2019, (MONTH) 10, 2019, and on (MONTH) 24, 2019. This made it a total of 3 baths for the month of (MONTH) and there were no other baths provided to Resident 2 during the Month of August. Resident 2 is not receiving the 3 bathes a week as requested by family. Record review Good Samaritan Society - Grand Island Village bathing record for Resident 2 for the month of September-2019 verified that Resident 2 was bathed on 09/03/19, 09/06/19, 09/10/19, 09/13/19, 09/14/19, 09/17/19, 09/20/19 and 09/24/19. This bathing schedule identified that on the week of (MONTH) 8th through (MONTH) 14th did Resident 2 receive 3 baths. Staff interview on 09/25/19 at 11:35 am LPN (Licensed Practical Nurse)-H confirmed that Resident 2 is only bathed 2 X a week. LPN-H verified Resident 2 is showered 1 X a week by nursing staff and a sponge bath provided 1 X a week by Hospice Care. Family interview on 09/25/19 at 2:07 p.m. POA confirmed having discussed the preference of Resident 2 getting 3 bathes a week. POA reported having told the care plan team that the facility was to provide 2 bathes a week and Hospice was to provide 1 bath a week which consisted of a sponge bath. POA verified the care plan is not reflective of the choice of having the resident bathed 3 X a week as requested by the family. Staff interview on 09/26/19 at 10:36 p.m. Administrator and Director of Nursing verified that Resident 2 was not receiving 3 baths a week as requested by the family and confirmed there were times when the resident had not even received a bath during the week. B. Record review of Resident 45's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) revealed an Admission assessment was completed on 7/5/19. The MDS records revealed the resident was admitted to the facility on [DATE]. The assessment recorded the resident did not resist cares and required Total Dependence: with two or more persons physically assisting the resident to bathe. Record review of a Suggestion or Concern (grievance) form dated 9/11/19 revealed Resident 45 reported to a therapist that the resident couldn't recall the last time the resident received a shower or bath. Record review of Resident 45's Documentation Survey Report v2 (Bathing documentation form) revealed that from 9/1/19 until the evening shift on 9/10/19, the resident had not received a bath. Interview with the interim-Director of Nursing on 9/26/19 at 7:54 a.m. confirmed that Resident 45 filed a Suggestion or Concern form regarding not receiving baths. The interim-Director of Nursing confirmed from bathing records, the resident had not received a bath from 9/1/19 until evening shift on 9/10/19.",2020-09-01
1353,HILLCREST HEALTH & REHAB,285133,1702 HILLCREST DRIVE,BELLEVUE,NE,68005,2017-08-02,329,D,1,1,YKIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D Based upon record review and interviews; the facility failed to ensure that the resident was receiving an antibiotic that was shown to be an effective treatment for [REDACTED]. The facility census was identified as 110. FINDINGS ARE: [NAME] Record review of Resident 62's urinalysis (a lab test to see if there are any abnormalities in a urine sample) results dated 07/19/2017 revealed that there were abnormal results for bacteria as many were observed when the reference range is none - few seen. Also noted was Specimen forwarded for Culture and Sensitivity. (A culture is a test to find germs (such as bacteria or a fungus) that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection). Record review of Resident 62's urine culture results dated 07/23/2017 revealed that there were two different bacteria found-Escherichia coli and [MEDICATION NAME] faecium VRE. The sensitivity analysis revealed that [MEDICATION NAME]/[MEDICATION NAME] (also known as the antibiotic medication Bactrim or [MEDICATION NAME]) was resistant to the Escherichia coli. The only medications that were found to be susceptible (effective) to the [MEDICATION NAME] faecium VRE were [MEDICATION NAME], Linezolid and [MEDICATION NAME]. Record review of a physician telephone order dated 7/31/2017 revealed an order [MEDICATION NAME] DS by mouth twice a day for 7 days for the [DIAGNOSES REDACTED]. Interview with the DON (Director of Nursing) on 08/01/2017 at 01:05 PM, revealed that Resident 62 had an order for [REDACTED].",2020-09-01
4478,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2019-04-01,676,D,1,1,OJJK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D1b Based on observation, record review and interview; the facility failed to have a restorative program (a nurse guided exercise program to prevent decline) for 1 resident (Resident 33) of 3 residents reviewed. The facility census was 52. Findings are: Review of Resident 33's MDS dated [DATE] revealed Resident 33 required limited assistance with bed mobility and transfers. Review of Resident 33's MDS (Minimum Data Set: a federally mandated assessment tool used for care planning) dated 12/17/2018 revealed Resident 33 had a decline in bed mobility and transfer and required extensive assist with transfers. Review of Resident 33's care plan lists the following problems: Deconditioning, prefers to be independent and a history of falls. Observation 03/28/19 2:08 PM of Diane NA assisting resident 33 with a transfer revealed Resident 33 was able to transfer from the wheelchair to the bed with limited assistance. Interview on 03/28/19 at 2:16 PM with the Director of Nursing (DON) revealed Resident 33 sometimes requires more assistance than at other times. Review of Resident 33's care plan revealed Resident 33 does not have a restorative exercise plan to maintain ability or prevent decline. Interview on 04/01/19 at 7:00 AM with the DON revealed Resident 33 had no restorative program.",2020-06-01
5461,GOOD SAMARITAN SOCIETY - WOOD RIVER,285198,1401 EAST STREET,WOOD RIVER,NE,68883,2017-03-22,314,D,1,1,HUVK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D2a-b Based on observation, record review, and interview; the facility failed to prevent a pressure ulcer from occurring and failed to provide ongoing monitoring for one Resident (78) of one sampled. The facility census was 59. Findings are: Review of Resident 78's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/3/17 upon Resident's admission revealed Resident 78 was admitted on [DATE]. Resident 78 had no pressure ulcers but was at risk. Review of Resident 78's Braden Scale for Predicting Pressure Sore Risk (Admission/Readmission) dated 1/29/17 revealed Resident 78 was at High Risk of developing a pressure sore. Review of Resident 78's Progress Notes dated 1/28/17 and 1/29/17 revealed both heels were reddened and staff provided pressure relief with pillows. Further review of Resident 78's Progress Notes revealed sporadic follow documentation of Resident 78's heels. There was no further documentation of Resident 78's heels until 2/6/17 when a note was faxed to the physician regarding heels being red with bruising. A Progress Note on 2/6/17 further revealed, Heel protectors are to be on, heels are getting sore and are at risk for breakdown. Will continue to monitor. Review of Resident 78's Care Area Assessments (CAA's - A more in-depth assessment following a comprehensive MDS to aid in the development of a resident-specific care plan based on identified problems, needs, and strengths) for Pressure Ulcers dated 2/7/17 revealed, Resident has no current skin integrity issues but is at an increased risk r/t (related to) factors that include but are not limited to - incontinence and decreased mobility. Other risk factors included immobility, poor nutrition, pain, newly admitted , functional limitation in range of motion. The care plan consideration for the same CAA revealed, will proceed to careplan to monitor for any skin integrity issues and treat accordingly. Review of Resident 78's Careplan revealed no problem or interventions were developed until 02/07/2017 after the development of the reddened heels that occurred on 1/28/17. The problem statement identified, Date initiated: 2/7/17. The resident has actual impairment to skin integrity to bilateral posterior heels evidenced by pressure from mattress while in bed. Fragile skin related to disease process. Interventions included: Resident needs protection for the feet, have heel protectors on at all times (Initiated 2/7/17). Further follow up documentation of Resident 78's heels occurred in the Progress Notes only on the dates as follows: - 2/10/17 Resident has a stage one non open pressure area on both heals about .8 cm in diameter stage 1 pressure area. Heel protectors are on and resident heels and lower legs up on pillows away from mattress. - 2/22/17 skin areas to heels and back area remains very dry but no redness and no open areas. Heel protectors and leg elevations while in bed is helping. - 3/10/17 revealed Heel protectors on at all times except when bathing. Every shift for pressure to heels - not on at this time. - 3/15/17 Progress Note reveals has shoes on for response to heel protectors on at all times except when bathing - every shift for pressure to heels. Interview with the Assistant Director of Nursing (ADON) on 3/15/17 at 3:00 PM revealed there was no wound documentation to date in Resident 78's medical record. No assessments of pressure ulcer(s) were noted in the medical record until 3/16/17 after the pressure ulcer was brought to the ADON's attention. Review of Resident 78's Wound Data Collection dated 3/16/17 revealed, Initial data collection: Right heel. Length 1.7; width 1.5. Dry, scabbed over. No dressing, ulcer is dry and scabbed. Wound margins [DIAGNOSES REDACTED]tous- reddened. No undermining/tunneling. Red, dry and flaky. Review of Resident 78's Wound Data Collection dated 3/16/17 revealed, Initial Data Collection:Left heel. Length 1.7; width 1.4; dry and scabbed over. No dressing present. Surrounding area is dry, red and flaky. Review of Resident 78's Skin Observation - V 2 signed 3/16/17 revealed, left heel Old pressure sore intact skin very dry Left heel wear heel protectors while in and out of bed. Pressure ulcer was not present upon admission. Unstageable with scabbed over skin. Observations of Resident 78 from 3/15/17 to 3/22/17 revealed Resident 78 did not have heel protectors on at all times as follows: -3/15/17 at 10:00 AM Resident 78 was in bed with heels elevated but not offloaded and gripper socks were on but no heel protectors. -3/22/17 at 9:20 AM Resident 78 was up in the wheelchair out in the dining room with only gripper socks on while resting feet on the wheelchair pedals. -3/22/2017 at 11:00 AM Resident 78 was observed in hallway with the Physical Therapy Assistant (PTA) using both heels to propel self while in the wheelchair. Resident 78 had gripper socks on both feet and propelled self 75 feet on the carpeted floor. Interview with Registered Nurse (RN) C on 3/21/2017 at 2:15 PM revealed the pressure ulcers remained to both heels at this time. Review of the facility's Pressure Ulcer Practice Guidelines revised 9/16 revealed residents should have an initial risk assessment followed by preventative interventions to be addressed on the care plan. Ongoing skin assessments should be completed daily and if a wound is identified it should be documented on the Wound Data Collection and reflect changes fro a shift - to shift perspective. At a minimum, weekly documentation is recommended to provide a review of the pressure ulcer/wound.",2020-01-01
2872,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2018-01-02,690,D,1,1,51KH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D3 (6) Based on observation, record review and interviews; the facility failed to ensure that residents were free of indwelling catheters without a clinical [DIAGNOSES REDACTED]. Findings are: Review of Resident 23's Comprehensive care plan dated revised 11/27/2017 revealed Resident 23 has a problem statement of : Alteration in elimination related to foley catheter placement, Resident 23 prefers to have a catheter, due to taking high doses of [MEDICATION NAME](diuretic). Review of Resident 23's medical [DIAGNOSES REDACTED]. Review of NP/PA progress note dated 1/17/2017 revealed Resident 23 was refusing afternoon diuretic and states Resident 23 does not attend activities due to her incontinence. [DIAGNOSES REDACTED]. Review of Care plan dated 11/06/2017 revealed Resident 23 has a foley catheter per her preference. Interview on 12/28/2017 at 10:15 AM with the Facility Consultant revealed Resident 23 had a trial removal of the catheter in (MONTH) (YEAR) but was incontinent, refused diuretic medication and Resident 23 insisted the catheter was replaced. An order was obtain to reinsert Resident 23's catheter. No further attempts have been made in the past 12 months to provide services to decrease incontinence with a goal to remove the catheter and [DIAGNOSES REDACTED].",2020-09-01
3803,MITCHELL CARE CENTER,285287,1723 23RD STREET,MITCHELL,NE,69357,2018-06-19,690,D,1,0,57D211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D3 Based on observation, record review and interview, the facility failed to change an indwelling urinary catheter (tubing inserted into the bladder to empty urine) according to practitioner's orders for one sampled resident (Resident 4). Sample size included 3 residents with indwelling catheters. Facility census was 49. Findings are: Record review of Resident 4's Admission Record printed on 6/19/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Observation of Resident 4 on 6/19/18 at 8:45 a.m. revealed the resident had an indwelling urinary catheter draining clear yellow urine into a drainage bag. Record review of Resident 4's Treatment Administration Records for (MONTH) and (MONTH) of (YEAR) revealed orders to Change (the resident's) catheter . every day shift starting on the 28th and ending on the 28th of every month for infection control related to Other Retention of Urine Further review of the document revealed documentation on the 28th which indicated the treatment was held with directions to See Progress Notes and recorded Other/See Progress Notes regarding documentation of why the treatment was not completed as ordered. Further review of the document revealed no catheter change documented as being completed in (MONTH) and no change of catheter was documented until the scheduled change on (MONTH) 28th, (YEAR). Record review of Resident 4's Progress Notes revealed two entries regarding the treatment order for the resident's catheter change. They read: - 4/28/18 at 9:39 a.m. the entry revealed the catheter change was not done due to No catheter bags available at facility, pending delivery of supplies for cath (catheter) change. - 4/28/18 at 2:53 p.m. the entry revealed the catheter change was not done due to No catheter bags available at facility, pending delivery of supplies for monthly cath change. There was no further documentation in the progress notes indicating a catheter change was done in (MONTH) as scheduled. Interview with LPN (Licensed Practical Nurse)-A, the facility's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) Coordinator on 6/19/18 at 2:35 p.m. confirmed Resident 4's medical practitioner ordered urinary catheter changes monthly specified on the 28th of each month. LPN-A verified the resident's scheduled catheter change on 4/28/18 was not done due to lack of catheter bags being available and that there was no documentation that the resident's catheter was changed as ordered for the month of April.",2020-09-01
2680,HERITAGE OF EMERSON,285222,607 NEBRASKA STREET,EMERSON,NE,68733,2017-08-31,315,D,1,1,AEM711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D3(6) Based on interview, and record review, the facility failed to have justification of catheter use for one of 2 residents (Resident 33). The facility census was 30. Findings are: Record review of the facility Bowel and Bladder Management Standard revealed: * A resident who has a catheter ( a tube that is inserted into the bladder to drain urine by gravity to a collection bag), or is incontinent of bladder will be identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible, this included the prevention of urinary tract infections. Any resident with an indwelling Foley catheter must have an approved [DIAGNOSES REDACTED]. Record review of the facility Face Sheet for Resident 36 revealed admission to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident 36's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated (MONTH) 16, (YEAR) revealed that Resident 36 was occasionally incontinent of urine. Record review of Resident 36's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated (MONTH) 06, (YEAR) revealed that Resident 36 had a change to Always continent. Record review of Nursing Progress Note dated 6/25/17 at 3:10 PM revealed Resident 36 was alert and oriented, continued on skilled care with Occupational and Physical Therapy, transferred with assist of 2, requires assist of 2 with cares and was continent of bowel and bladder. Resident 36 used a commode when up in wheel chair and requested the bedpan when in bed. Record review of Nursing Progress Note dated 6/25/17 at 2:51 PM revealed that Resident 36 was alert and oriented. Denies concerns. Resident 36 transferred with 2 assist and the sit-stand. Resident was able to voice when needed the restroom. Record review of Nursing Progress Note dated 6/26/17 revealed that a fax was received from Resident 36's primary provider with regards to fax sent earlier in the day for wound care contamination. The new order was for a foley catheter to be placed due to Stage II Pressure Ulcer to Coccyx. Resident 36 was aware of the new orders. Record review of Bladder Assessment form dated 8/8/17 revealed that Resident 36's Bowel and Bladder Summary confirmed that the medical justification for indwelling foley catheter was Stage II Pressure Ulcer. Record review of Physician Visit/Communication form, dated 8/22/17, revealed a physician order [REDACTED]. Interview with Director of Nursing on 08/29/17 confirmed that Resident 36 did have a Stage II Pressure Ulcer. The DON confirmed that Resident 36 was voiding large amount of urine on the bed pan, causing wound dressing to become wet/contaminated with urine. The DON confirmed that Resident 36 was continent of urine prior to placement of the foley catheter. The DON confirmed that a Stage II Pressure Ulcer was not an approved indication for use of a foley catheter. Record review of Resident 36's plan of care with target date of 9/25/17 revealed that Resident has a indwelling catheter related to contamination of stage 2 Pressure Ulcer with urine.",2020-09-01
4439,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-10-10,309,E,1,0,H84311,"**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 protect residents from a resident (Resident 2) with behaviors. This had the potential to affect 35 cognitively impaired residents. The facility census is 61. Findings are: Review of Resident 2 [DIAGNOSES REDACTED]. Review of Resident 2 Care plan dated revised on 8/28/2017 revealed Resident 2 has behaviors of wandering, physical and verbal aggression and making sexual innuendo. Interview on 10/10/2017 at 11:20 PM with the Director of Nursing revealed that Resident 2 was identified as a resident that wanders into other resident rooms. Review of Resident 2 progress notes dated 9/14/2017 revealed Resident 2 was found in Resident 1's room and attempted to touch Resident 1's foot and Resident 2 has had an increase in sexual comments toward staff and other residents and was difficult to redirect. Review of a hand written statement by Nursing Assistant (NA)-A revealed NA-A observed Resident 2 in Resident 1's room with a hand up the covers of Resident 1 from the foot of the bed. NA-A removed resident 1 from the room at which time Resident 2 made a sexual comment to NA-[NAME] Review of Resident 2's care plan revealed no additional interventions were put in place as a result of the Resident 2 wandering into other resident rooms or increased sexual behaviors. Interview on 10/10/2017 at 10:30 AM with the Administrator revealed no interventions were put in place to prevent any similar incident from occurring in the future. Interview on 9/14/2017 at 10:30 PM with the Director of Nursing 35 residents are cognitively impaired and non-interviewable.",2020-06-01
5335,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2017-01-31,319,D,1,0,BKZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D5 Based on record review and interview, the facility failed to provide psychiatric services as stated in comprehensive plan of care, for 1 of 5 residents sampled (Resident 84). The facility census was 69. Findings are: Record review revealed that Resident 84 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Record review of Resident 84's Plan of care originating on 10/4/16 for behaviors related to the [DIAGNOSES REDACTED]. Record review of Resident 84's Plan of care originating on 10/4/16 for behaviors revealed a new intervention dated 1/9/17 for a Psychiatric evaluation. Record review of Resident 84's progress notes revealed the following increased behavior towards others: Progress note dated 1/5/2016 at 7:00 PM revealed that Resident 84 had run over another resident's foot, with his wheelchair. When the other Resident alerted Resident 84 that his foot had been run over, the nurse revealed that Resident 84 made hand gestures to the resident and then preceded to strike the other resident in the arm three times. Progress note dated 1/8/2017 at 3:15 PM, by the Social Services Director (SSD) revealed that the SSD had observed Resident 84 making obscene hand gestures to a staff member and began calling that staff member names. The SSD removed Resident 84 from the situation and talked with Resident 84. Progress note dated 1/17/2017 at 1:27 PM revealed that, Resident 84 had been yelling with another resident, followed by ramming the wheelchair into the other resident's legs making contact, and other resident RH yelling. Staff then attempted to intervene, and Resident 84 attempted to ram into the staff member with the wheel chair. The Assistant Director of Nursing (ADON) had then intervened and informed Resident 84 that those actions were inappropriate. Progress note dated 1/21/2017 at 6:48 PM revealed that a resident had been parked in a wheel chair near a wall. Resident 84 had been going down the hall and asked the other resident to move. When the other resident had replied that there was room for Resident 84 to get by Resident 84 then raised a right hand, made a fist and hit the other Resident in the back. The Director of Nursing (DON) was notified of Resident 84's behaviors. Record review of Resident 84's Medication Administration Review revealed that Resident 84 had been refusing the resident's antidepressant and antipsychotic medication most of the months of (MONTH) and January. Interview with the DON and ADON on 1/26/17 at 1:20 PM confirmed that Resident 84 was having increased behaviors. The DON confirmed that after a resident to resident altercation a new intervention was written to Resident 84's comprehensive care plan, for a Psychiatric evaluation. The DON confirmed that a Psychiatric appointment had not been made for Resident 84 upon admission to the facility, when medications were refused, or when behaviors had increased.",2020-01-01
3342,CHIMNEY ROCK VILLA,285260,"P O BOX A, 106 EAST 13TH STREET",BAYARD,NE,69334,2019-01-08,740,E,1,1,UIRZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D5 Based on record reviews and interviews, the facility failed to develop a behavioral management plan and/or seek additional mental health psychiatric consultation for one sampled resident (Resident 33) with ongoing behavioral symptoms directed toward other residents and staff. These behaviors were directed toward some of the other residents in the facility. Sample size included 15 current residents and 4 closed records. Facility census was 32. Findings are: Record review of Resident 33's closed medical record revealed the following records: Record review of Resident 33's Face Sheet revealed the resident was admitted to the facility on [DATE]. Record review of Resident 33's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) Annual assessment on 9/24/18 recorded the resident had exhibited behaviors on 1-3 days in the previous 7 days. The types of behaviors were recorded as Verbal (symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) and Other (symptoms not directed toward 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 sounds. The assessment also recorded daily resistance to care provision. Further review of this assessment revealed the resident's BIMS (Brief Interview for Mental Status, an examination testing resident memory) revealed the resident tested at a 4 (0-7 indicating severe impairment). Record review of Resident 33's Nurse's Notes revealed the following entries: - 7/25/18 at 6:31 p.m. Behavior recorded the resident was observed transferring another resident to a wheelchair without staff assistance. Explained this could result in injury to the resident and/or self. - 8/3/18 at 4:02 p.m. Behavior recorded speaking with Resident 33 about chewing on cigars and other residents complaining the resident spits them out on the floor after chewing on them. Described the resident should only chew on cigars in the resident's room . Now resident continues to chew on cigars out in the solarium, redirected twice this afternoon . Outcome was unchanged. - 8/10/18 at 11:33 a.m. the resident was observed for Public Sexual Acts/Disrobing and recorded: Observed resident do a playful slap to resident (Resident 13) after making a sexual innuendo . - 8/10/18 at 11:37 a.m. the resident was observed Screaming/Disruptive Sounds and recorded the resident was making other gestures of residents being crazy and encouraging them to try to go outside. The resident was redirected without success. - 8/10/18 2:16 p.m. recorded the resident had been having increased sexual behaviors toward staff and other residents with dementia. The entry recorded the police chief came into the facility and discussed the behaviors with the resident and warned the resident (the residents) history of being a lifetime sex offender could result in charges. - 8/13/18 at 1:07 p.m. for Public Sexual Acts/Disrobing the entry recorded the resident was sitting on the couch next to a resident and was observed fastening the top button of pants. The nurse discussed inappropriateness of the behavior and resident responded the staff was harassing me. - 8/23/18 at 8:50 a.m. a Family/Guardian Contact was made. The facility discussed that on 8/22/18 the resident went on outing to a department store and the staff could not find Resident 33. They found the resident in the bus and discovered security at the store had escorted the resident out. Security informed the staff the resident was not allowed in the store and this was the third time the store had to escort the resident out of the store. Staff reported not being aware of the restriction. - 10/3/18 at 4:38 p.m. the staff recorded Resident 33 began yelling in the dining room in the presence of other residents. - 10/10/18 at 2:30 p.m. an incident of significantly disrupts care or living environment recorded the resident cursed aloud during a game in activities in front of other residents. -11/9/18 at 1:47 p.m. a Behavior was recorded in which staff discussed with the Resident 33 to properly dress self and put pants on when going to the bathroom as this offends the resident's room mate. Record review of a Grievance Form reviewed on 11/2/18 revealed Resident 83 (Resident 33's room mate) filed a grievance form concerned about Resident 33 stopping by Resident 83's bed while being naked. Record review of a Doctor's Progress Notes on 10/8/18 revealed the physician documented Nursing reports continued inappropriate and mean spirited remarks to other residents. Pt (patient or Resident 33) has been banned from (name of department store). The physician documented the resident sees a counselor and would probably benefit from low dose tranq (tranquilizing medication) such as [MEDICATION NAME], etc. The physician did not order any medication at this time. Record review of a correspondence between the DON (Director of Nursing) and Resident 33's mental health counselor dated 10/8/18. The DON recorded the resident was displaying increased behaviors and described it was brought to the facility's attention the resident was not allowed in a department store as the resident is banned from numerous places. Resident now lost cigar privileges d/t (due to) spitting them out on the floor throughout the facility. Resident has been being inappropriate toward other residents, calling them fat, being rude if they sit at the table the resident sits at during meals. Resident has been denied trips to the pumpkin patch due to criminal past. Interviews with staff members: - 1/3/19 at 1:40 p.m. NA (Nurse Aide)-B. works day shift 6 a.m. to 2 p.m. described that Resident 33 would make female staff uncomfortable at times especially when bathing. The resident would say inappropriate things to the staff of a sexual nature. NA-B also said the resident would tease and egg on other residents, especially those with dementia. -1/3/19 1:45- NA-H works on all shifts. Familiar with the resident. Stated resident would be verbal and taunting toward other residents with dementia. - 1/7/19 at 1:30 p.m. NA-I and NA-J both working day shift. Described the resident as having ongoing behavioral problems. Would be rude and condescending toward other residents. Would act out in a sexual nature and make suggestive comments toward female staff. Disrobed in public. Sometimes re-directed, but at other times would get angry or not listen. - 1/8/19 at 9:20 a.m. interview with the DM (Dietary Manager). Discussed resident behaviors in dining. The DM witnessed resident smacking staff members on the bottom playfully and observing the resident unbuttoning pants in the dining room. Record review of Resident 33's Care Plan revealed the resident's care plan was developed which included a Problem Behavior: Behavior not directed at others manifested by Refusal of cares. Further review of the resident's care plan revealed nothing updated or added to the care plan regarding ongoing behaviors directed toward others, behaviors of a sexual nature or disrobing, behaviors of disruptions in activities, cursing, or making gestures. Record review of Resident 33's counseling sessions revealed the following: - 8/20/18- Res having increased sexual behaviors, refusing to follow rules, unzipping pants in public areas, becomes angry when approached. Counselor documented- admits to errors on reports and with a smile notes Yeah I probably need to do better. - 9/26/18- having behaviors. Not resting well, continues to push residents in wheelchairs, sits in lobby unzipping pants. counselor documented, discussed concerns and res states they are all in the past denies doing them now. - 10/9/18 having increased behaviors, making rude comments, calling others fat. Counselor documented he admits to the concerns that staff report. Unfortunately (the resident) doesn't show any interest in changing. Just kind of 'laughs it off'. - 10/31/18- Resident behaviors continues. Increased since last visit. Makes rude comments, calling names, not following facility rules in regards to cigars. Counselor recorded: We've tried working together for two months and today was first time (the resident) showed desire to improve behavior. Will meet together next week to assure improving. - 11/7/18 resident increasing behaviors with room mate yelling at (the resident) for no reason. Walking in hallway naked and asked several times to wear pants and refuses. Counselor reported resident denies the above. stated it was a long time ago. (The resident) reports clearly different than what staff reported. Interviews with the DON (Director of Nursing) and facility Administrator on 1/8/19 at 10:00 a.m. verified Resident 33 had multiple ongoing behavioral issues beginning shortly after re-admission to the facility in (MONTH) and continuing through the time of (the resident) discharge on 12/20/18. The DON confirmed that there was no behavioral management plan put in place regarding the ongoing behaviors and the resident's care plan had not been updated to include these ongoing issues. When questioned about whether or not the facility had explored psychiatry consultation, the DON felt this was brought up in the past but thought the resident refused though there was nothing in the record to confirm this occurred. The DON verified the facility had not re-explored this intervention in lieu of the ongoing symptoms and physician note that resident may benefit from psychiatric medication. The DON stated the resident was seeing a counselor but verified from the counseling sessions, the resident was denying these issues occurred or stated they were long ago in the past and the behaviors continued month after month. The DON verified the interventions of speaking with the resident or discussing inappropriate behaviors with the resident were ineffective as the resident had poor cognition based on (the resident) BIMS scores ranging from 4-6 between (MONTH) and (MONTH) of (YEAR).",2020-09-01
5550,"WAUSA CARE AND REHABILITATION CENTER, LLC",285111,703 SOUTH VIVIAN,WAUSA,NE,68786,2018-03-14,745,D,1,0,1GWJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D5a Based on observations, record reviews, and interviews, the facility failed to provide Social Services hours to meet Resident 2's needs related to language barrier and behaviors. The sample size was Sample size was 6 and the facility census was 19. Findings are: [NAME] Interview with the Interim Administrator 3/14/18 at 8:30 AM revealed the facility Social Service Director (SSD) was also licensed as a Nursing Assistance. Due to concerns with staffing, the SSD was frequently placed on the nursing schedule. B. Record review of the nursing schedule as worked revealed the SSD had been working as a Nurse Aide on 2/2/18, 2/19/18, 2/21/18, 2/22/18, 2/27/18, 2/28/17, and on 3/1/18. C. Review of Resident 2's Minimum Data Set (MDS-a federally mandated comprehensive tool used for care plans) dated 12/15/17 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The following was also identified related to Resident 2: -usually understood (difficulty with communicating some words or finishing thoughts but was able if prompted or given time); -usually understands (misses some part/intent of message but comprehends most conversations); -short and long term memory loss with severely impaired decision making skills; -physical behaviors directed at others; -verbal behaviors directed at others; and -extensive staff assistance required for dressing, toileting, personal hygiene and bathing. Review of Resident 2's current Care Plan dated 12/27/17 revealed the resident had a language barrier as the resident was unable to speak and/or understand English. In addition, the resident had limited physical mobility, poor safety awareness, behaviors and impaired communication skills related to a motor vehicle accident with a [MEDICAL CONDITION] (TBI- external trauma to the head or violent movement of the head resulting in memory loss, difficulties with communication and emotional disturbances).The following Social Service interventions were identified: -provide a translator as needed to assist with communicating with the resident; -anticipate and meet the resident's needs; -ensure a safe environment and avoid isolation; and -assist to develop appropriate methods with coping and interacting. Review of the resident's Nursing Progress Notes revealed the following: -12/10/17 at 7:35 PM, the resident was offered an evening snack. The resident threw a water glass and a water pitcher at the staff. The resident's room door was then closed to isolate the resident. -12/17/17 at 5:29 PM, the resident was yelling angrily in Spanish and refused to allow staff in the resident's room. -12/20/17 at 3:51 PM, the resident saw staff in the corridor outside of the resident's room. The resident started to holler and threw a water pitcher and then a dish of ice cream at the staff. The resident continued to yell with hands in the air. -12/23/17 at 8:15 PM, the resident was heard loudly pounding on the wall next to the resident's bed. -12/25/17 at 4:28 PM, the resident was yelling and pounding on the wall next to the resident's bed. -12/25/17 at 3:40 AM, the resident had been sleeping in bed and suddenly started to yelp, yell and scream. -1/6/18 at 1:18 AM, the staff heard a banging noise and found the resident lying on bed, hollering out incoherently and hitting wall with the resident's fist. -1/12/18 at 10:52 AM, the resident was heard yelling and was found in the resident's room with a broken bedside table. -1/30/18 at 1:16 PM, the resident was alone in the resident's room, crying and holding stomach. -2/6/18 at 9:28 PM, the resident had been banging on the wall next to the resident's bed numerous times throughout the shift. D. During an interview on 3/14/18 at 2:00 PM, the Interim Administrator verified Resident 2 had ongoing behaviors as well as a language barrier related to the resident's inability to speak English. The Interim Administrator indicated the SSD had been available in the past to assist with developing behavior modification programs for new admissions and also to assist with contacting interpreters, however now the SSD was expected to cover open hours on the Nursing schedule and was able to complete these tasks.",2019-11-01
2866,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2018-01-02,679,D,1,1,51KH11,"**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 activities to meet resident interest for Resident 36 and 49. Findings are: [NAME] Observation on 12/21/2017 at 10:00 AM revealed resident sleeping and not engaged in any type of activity to provide visual or auditory stimulation. Resident remains sleeping at 10:30 AM. Son visited at 12:05 PM and resident observed to be more alert and cheerful. Review of residents medical record revealed resident has had no activities or 1:1 visits since 12/18/2017 and no other activities documented in the past 30 days. Review of Resident 36's IDT-care plan review dated 11/21/2017 revealed resident enjoys wathcing sports on TV, reading and conversing about her past. Continue to engage resident and encourage participation in actifities of choice. Observation on 12/26/2017 at 10:00 AM revealed Resident 36 not in activity. No radio or TV on in room. Curtains closed. Observation on 12/26/2017 at 11:20 AM revealed Resident 36 remains in bed with room dark. Resident stated I don't like my curtains closed. . Interview on 12/26/2017 at 11:20 AM with the Activity Director(AD) revealed all activities are documented in the electronic medical record . B. Observation on 12/20/17 at 1:23 PM revealed Resident 49 in bed with gown on. Lights out in room. Review of residents admission activity assessment dated [DATE] revealed resident likes group activities, exercise, television, cards. Review of the electronic medical record revealed no documentation of activities for the past 30 days. Observation on 12/26/2017 at 11:15 AM Resident 49 in bed Hospital gown on. Lights in room off. No self initiated activity at this time. Interview on 12/27/2017 at 10:30 AM with the administrator revealed if Resident 49 was offered and refuses to attend activities it should be documented as a refusal in the medical record.",2020-09-01
3793,MITCHELL CARE CENTER,285287,1723 23RD STREET,MITCHELL,NE,69357,2019-02-11,679,D,1,1,TCU511,"**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 Identify an individualized activity program including specific types of activities and responses to the activities provided for two sampled residents (Residents 8 and 13) with severe cognitive impairments. Sample size included 21 current residents. Facility census was 48. Findings are: [NAME] Record review of Resident 8's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) Annual assessment revealed the resident was admitted to the facility on [DATE] and had a date of birth recorded as 8/5/1974. The MDS revealed the resident was evaluated by Level II PASRR (Pre-Admission Screening and Resident Review, an assessment for those diagnosed with [REDACTED]. Further review of the MDS revealed Staff Assessment of Daily and Activity Preferences had recorded listening to music as an activity preference. Record review of Resident 8's PASRR II evaluation dated 9/9/2016 and signed by the psychologist reviewer on 9/10/16 revealed the resident was diagnosed with [REDACTED]. Among the Service Recommendations on the form was an evaluation to: increase in stimulation/environmental enhancements. The Rationale for service decision portion of the assessment revealed the resident (MONTH) enjoy gentle one to one activities involving music or soft toys. Observations of Resident 8 during hourly rounds throughout the survey revealed the following: - Between 8:00 a.m. and noon on 2/5/19 the resident was observed in the room on top of the bed looking out the window and rocking back and forth. The resident did not come out of the room all morning and had not been attended to by activity staff or attend activities. The resident was assisted to the dining room for the noon meal and returned to the room in the afternoon. From 1:30 p.m. to 4:00 p.m. the resident remained in the room atop the bed with a television on tuned to Animal Planet. - 2/6/19 at 7:10 a.m. the resident was up in the wheelchair dressed and self propelled behind the nurses' station and was fidgeting with the telephone. The resident was brought to the dining room for breakfast. After breakfast the resident returned to the room by staff and was laying down in bed. The television was not on. The resident remained in the room until lunch time and was brought to the Dining Room. After lunch, the resident spent the afternoon sleeping in bed from 2:00 p.m. to 4:00 p.m. with the television on to Animal Planet. - 2/7/19- the resident was out for breakfast. At 10:30 a.m. the resident was independently mobilizing the wheelchair up and down the 100 hall. The resident was not observed attending any activities in group or in room. After lunch, the resident was observed sleeping in bed all afternoon with the television on to Disney. There are stuffed animals on a bedside table but not within the resident's reach. Record review of Resident 8's care plan with target goal dates through 2/26/2019 revealed among the resident's Focus problems the [DIAGNOSES REDACTED]. I like to hold people hands . I like to spend my time when up just moving myself around in my wheelchair. Has had an increase in behaviors . Among the Interventions/tasks for the resident was: encourage 1:1 (one on one) with our strength based program . It is ok to have the TV on while I am in room. The channels I prefer Disney, Sesame Street, Animated shows . Music will help improve my mood. I will watch them exercise and listen to the music being offered . No other activity interventions or descriptions of the resident's activity program were included in the resident's care plan. Record review of Resident 8's Activity therapy Service Record revealed the following: - (MONTH) 2019 was in ball therapy twice, had a visitor once, and attended one on one twice. - (MONTH) (YEAR) revealed attended ball therapy twice, visitors twice, and one on one three times. - (MONTH) (YEAR)- attended ball therapy twice, visitors twice, and one on one three times. - (MONTH) (YEAR) attended ball therapy three times and snacks/baking once. - (MONTH) (YEAR)- attended evening activity once, ball therapy once, one on one once. - (MONTH) (YEAR)- Attended ball therapy three times and games once. Interviews with direct care staff revealed the following: - MA (Medication Aide)-F an evening shift employee on 02/07/19 at 03:24 p.m. MA-F was a two year employee working all halls in building as assigned. NA-F described Resident 8's routine in evening as being put in the room after supper. The resident liked to watch out the window and staff will put the television on to Disney or an animal show. Does not go to group activities. When on shift in the late afternoon, the resident naps often. - NA (Nurse Aide)-G a long term day shift employee on 02/11/19 11:07 a.m. NA-G stated the resident does not attend any group activities, stays in room except for meals and/or will come out in the wheel chair and go up and down hall independently. Record review of Activity Progress Notes for Resident 8 revealed no documentation since 10/31/17. This notation recorded: resident doesn't attend activities is one on one, enjoys wheeling around in wc (wheelchair). Will hold hands and want too (sic) 'walk' with you . TV in room. Interview with the AD (Activity Director) on 2/11/19 at 1:55 p.m. verified the Activity Department had not recorded any quarterly progress notes regarding the Resident 8's activity program, what the one on one program entailed, or defined what the care plan strength based program was, nor were there any responses to the one on one program and other activities by the resident. The AD confirmed that attendance records for the resident may not be accurate as if things such as music, family/visitor visits, and other things occur when activity staff are not present, the activity does not always get recorded. The AD verified that the resident's intellectual disorder limits what can be done as the resident doesn't tolerate groups or does not like being outside. The AD verified the program for Resident 8 is not well defined as to what activities are being offered or provided. B. Record review of Resident 13's MDS records revealed a Significant Change in status assessment was completed on 9/5/2018. The assessment revealed the resident was admitted to the facility on [DATE]. The resident was assessed as rarely/never understood with regard to the resident's cognitive ability. Record review of Resident 13's care plan with Target Date goals through 3/4/2019 revealed among the Focus problems for the resident documented Cognition is severely impaired, can speak English and primarily speaks Spanish . mild depression, having increased agitation . carries a baby doll around, believes it to be (the resident's) baby. Enjoys visits form family that visit often . Among the Interventions/tasks on the care plan were to: invite and remind when activities are and what they are . when seems upset make sure has baby doll as this will help calm down. No other activity interventions or descriptions of the activity program were included in the resident's care plan. Hourly observations of the resident throughout the survey revealed the following: - 2/5/19 9:27 a.m. the resident was in the room asleep on the bed. At noon, the resident was brought out by staff in a tilt/space wheelchair for the meal. After lunch returned to the room and put back in bed. From 1:41 to 4:00 p.m. the resident remained in the room in bed. The television was on. - 2/6/19 at 7:30 a.m. the staff provided wound cares and morning cares. At 8 a.m. the resident was transported to the dining room for the meal and returned to the room at 9 a.m. From 9 till noon, the resident remained in bed, no television or music, a baby doll was in the chair by the bed. The resident was up for lunch then returned to bed after lunch, remained in bed 1:00 p.m. to 4:00 p.m. with no television or music. - 2/7/19 8 a.m. the resident was up for breakfast in the tilt/space wheelchair. Returned to room [ROOM NUMBER] a.m. and placed in bed for the remainder of the morning. No television or radio on. Res out for lunch at noon, returned to room and placed in bed all afternoon between 1 p.m. and 4 p.m. No observed one on one activities or visitors throughout these days. Record review of Resident 13's Activity Therapy Service Record forms revealed the following: - (MONTH) 2019 the resident attended nail personal care activity once and a one on one activity once. - (MONTH) (YEAR)- The resident attended music activity once. Catholic mass once, and an intergenerational activity once. - (MONTH) (YEAR)- the resident attended one Bible study and two night events. - (MONTH) (YEAR)- The resident attended Nail/personal care activity once. - (MONTH) (YEAR)- The resident attended one night event, one music activity, ball therapy once, puzzles/crafts once, visitors once, and Bible study once. - (MONTH) (YEAR)- The resident attended two music activities, one baking activity, ball therapy once, one on one once, and Bible Study three times. Record review of Resident 13's Activity Progress notes revealed no entries in the resident's notes since 8/26/18. Review of this note revealed activities attempted on three days to have one on one activities with the resident which were unsuccessful unable to communicate with (the resident). Threading and fold towels, however was successful in making tortillas will cont. (continue) to work with resident too (sic) find some items of interest. Interview with the AD on 2/11/19 at 1:55 p.m. verified the Activities Department had not documented any progress notes for Resident 13 regarding the resident's activity program, what was being done for activities, and the resident's response to the activities attempted or provided since (MONTH) of (YEAR). The AD described the resident had developed a pressure wound and was now being laid down after meals to alleviate pressure. The AD said family visits are not always documented and that the activity attendance may not be accurate as when activity staff are not here some activities the resident attends may not be recorded. The AD verified nothing new had been developed in the resident's Captivity program since the resident's daily routine had changed due to the pressure injury.",2020-09-01
1428,LIFE CARE CENTER OF OMAHA,285137,6032 VILLE DE SANTE DRIVE,OMAHA,NE,68104,2018-01-30,693,D,1,0,Z0EK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D6 Based on observation, record review and interview; the facility failed to provide care according to standard of practice for tube feedings (Delivery of nutrients through a tube directly into the stomach for 1 of 3 residents, Resident 3. The facility census was 85. Findings are: Interview on 1/29/2018 at 11:00 AM with the Director of Nursing (DON) revealed Resident 3 had just completed a tube feeding. Observation on 1/29/2018 at 11:30 AM revealed Resident 3 in bed with the head of the bed elevated less than 30 degrees. Observation on 1/29/2018 at 12: 50 PM revealed Resident 3 remained at less than a 30 degree angle in bed. Review of Resident 3s comprehensive care plan(a tool used to define the care the resident is to receive) dated 9/27/2017 revealed an intervention related to the tube feeding of Keep Head of bed elevated at least 30 degrees while administering bolus feeding and at least 1 hour after infusion complete. Interview on 1/29/2018 at 2:30 PM with the DON revealed the Head of the bed should remain elevated to prevent the potential for aspiration. Observation on 1/29/2018 at 3:20 PM revealed LPN-C preparing to give Resident 3 a scheduled tube feeding. Nurse accessed tube and began tube feeding without checking for residual (amount of fluid remaining in the stomach). Review of undated facility policy titled Tube feeding Administration revealed: Verify proper positioning of feeding tube using a syringe aspirate gastric fluid. Review of Resident 3's physician orders [REDACTED]. If residual is greater than 90 hold tube feeding. Interview on 1/30/2018 at 2:30 PM with the DON revealed the residual should have been checked prior to starting the feeding.",2020-09-01
5317,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-01-23,514,D,1,0,5YZX12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D6 Based on record review and interviews, the facility failed to provide [MEDICAL CONDITION] suctioning documentation to show the suctioning was completed for one resident (Resident 4). The facility census was 96. Findings are: Review of Resident 4's Admission Record revealed Resident 4 was admitted on [DATE] to the facility after having a [MEDICAL CONDITION] (an opening into the wind pipe for breathing) placed. Review of the Resident 4's Discharge Summary dated 11/1/016 from the hospital revealed Resident 4 was admitted to the hospital after experiencing an apneic (absence of breathing) episode and a plugged [MEDICAL CONDITION] from mucous build up. Review of Resident 4 progress notes revealed Resident 4 returned to the facility on [DATE]. Review of the residents Treatment Administration Record (TAR) dated 11/2016 revealed an order dated 11/11/2016 for Resident 4 to be suctioned every 2 hours. The TAR revealed that on the following dates Resident 4 was not suctioned as ordered: - 11/14/16 2 times - 11/15/16 8 times - 11/16/16 4 times. - 11/17/16 9 times, - 11/20/16 3 times, - 11/21/16 7 times, - 11/22/16 5 times, - 11/23/16 2 times, - 11/26/16 5 times, - 11/27/16 7 times - 11/29/16 5 times, - 11/30/16 5 times. Interview with Registered Nurse (RN)-C revealed that if blanks are on the TAR this would indicate the treatment was not completed. Review of the TAR dated (MONTH) (YEAR) revealed the resident had an order to suction [MEDICAL CONDITION] twice daily on the day shift and the night shift. The TAR indicates that the suctioning was not completed on the day shift for 9 of 28 days in the month on the following days: 2/4, 2/5, 2/9, 2/10, 2/11, 2/19, 2/23 and 2/27. Interview on 3/14/2017 at 1:00 PM with the Director of Nursing revealed no further documentation was available to indicate the suctioning was completed",2020-01-01
5462,GOOD SAMARITAN SOCIETY - WOOD RIVER,285198,1401 EAST STREET,WOOD RIVER,NE,68883,2017-03-22,323,K,1,1,HUVK11,"**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 2 residents (Residents 30 and 42) of 2 sampled were supervised during a whirlpool bath and failed to protect 1 resident (Resident 84) from an accident while being transported in the facility van which had the potential to affect 42 residents. The facility also failed to ensure chemicals were secured to protect residents on the SCU (Special Care Unit) from potential ingestion, skin irritation or eye irritation which had the potential to affect 11 of the 18 residents on the SCU. The facility census was 59. Findings are: [NAME] Observation on 3/22/2017 at 11:58 AM revealed Resident 42 was in the bathhouse in the whirlpool tub filled with water unattended. Interview on 3/22/2017 at 11:58 AM with ED (Executive Director) revealed the resident was in the whirlpool tub alone without supervision. Interview on 3/22/2017 at 12:37 PM with NA (Nursing Assistant) K revealed Resident 42 was left alone in the whirlpool bath as NA K went out for break. NA K went on to say the other NA's had instructed NA K it was ok for Resident 42 to be left unattended while in the whirlpool tub. Interview on 3/22/2017 at 12:10 PM with Nurse BB revealed Nurse BB was not sure if the resident had been assessed to be in the whirlpool alone. Nurse BB revealed Resident 42 did not get left in the bathroom alone due to being a fall risk. Interview with Nurse CC revealed NA K did not notify Nurse CC of Resident 42 being left in the bath house alone before taking a break. Nurse CC further stated Resident 42 was not safe to be left alone in the whirlpool. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1/6/17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 8 out of 15 which indicated Resident 42 had moderate cognition problems. Resident 42 required limited to extensive assist with mobility tasks and bathing. Review of Resident 42's Care Area Assessments (CAA's - A more in-depth assessment to aid in the development of a resident-specific care plan based on identified problems, needs, and strengths) for Activities of Daily Living (ADLs) dated 1/12/17 revealed, Resident needs assistance with all ADLs recently had a fall that resulted in a fracture. Review of Resident 42's CAAs for Falls dated 1/12/17 revealed, Resident had a recent fall that resulted in a fracture to right second metatarsal (toe ) is at an increased risk for further falls r/t (related to) factors that include but are not limited to weakness and needs assistance with all ADLs Review of Resident 42's Care Plan dated 12/23/15 revealed Resident 42 had impaired cognitive function related to Alzheimer's disease and hallucinations/delusions. Further review of Resident 42's Care Plan revised 1/6/17 revealed Resident 42 required assistance of 1 staff with bathing. Resident 42's Care Plan did not state that Resident 42 was safe to be in the whirlpool unattended. Resident 42's Care Plan revised 6/12/14 further stated Resident 42 was at risk for falls related to impulsivity and needed reminders to wait for assistance from staff. Interview with NA M on 3/22/17 at 1:28 PM revealed NA M had left Resident 42 in the whirlpool alone because NA M was told by administrative staff that it was care planned for Resident 42 to be able to sit in the whirlpool alone. Further interview with NA M revealed it was common practice to leave Resident 30 unattended in the whirlpool and that staff usually left and took their 30 minute break or went to do their charting for the day. Interview with Medication Aide (MA) X on 3/22/17 at 1:43 PM revealed MA X had left Resident 30 unattended in the whirlpool when providing baths. Review of Resident 30's MDS dated [DATE] revealed Resident 30 had a BIMS of 9 out of 15 indicating moderate cognitive impairment and had a [DIAGNOSES REDACTED]. Review of Resident 30's Care Plan dated 10/26/15 revealed Resident 30 preferred a whirlpool and requested time to soak, but bath aide must remain in bath house with resident. Review of Resident 30's Progress Notes dated 3/18/17 revealed Resident 30 was found on the floor after feeling light headed while getting ready for bed. Further review of Resident 30's Progress Notes revealed episodes of confusion documented on 3/18/17 and 2/15/17. Review of the facility's procedure for bathing revised 3/17 revealed, 5. Do not leave resident unattended. Resident may be unattended during bath per his/her request and if assessed by the interdisciplinary team to be safe/independent. Interview with the ED on 3/22/17 at 2:30 PM confirmed that neither Resident 42 nor 30 had been assessed to be safe to be left unattended in the whirlpool tub. The Immediate Jeopardy was abated to an [NAME] level on 3/22/17 at 3:30 PM when the ED stated all staff who had the potential to assist residents with bathing had been educated to not leave any residents alone while in the whirlpool tub. B) Review of the undated census sheet for Resident 84 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed a BIMS score of 15 which indicated Resident 84 had no cognition problems. Resident 84 was independent with setup help only with bed mobility. The resident did not walk and required extensive assistance of one staff person for transfers, dressing, toileting, and personal hygiene. Review of the Progress Notes dated 5-6-16 revealed Resident 84 was picked up by the facility van from the Dialysis Unit to be transported back to the facility. The employee who drove the van failed to secure the front wheels of the wheelchair prior to leaving and, when the van crossed over an intersection, the resident's wheelchair tipped over backwards with the resident in it. The resident hit the back of the resident's head on the back wall of the bus. The resident was assessed for injury by the staff person then called 911 to assist with lifting the resident and to transfer to the hospital for an evaluation. A CXR (chest x-ray) and CT scan of the head were completed, both were negative. The resident returned to the facility. Review of the physician progress notes [REDACTED]. Review of the facility investigation report revealed the interventions initiated were: 1) Signs were made and posted into each of the facility vehicles (van and bus) with instructions to follow prior to the staff being able to drive the vehicle. The instructions revealed: -strap down and tighten all four latches to the wheelchair -put the seatbelt around the resident -attempt to move the wheelchair and ensure that it is secure 2) The van driver involved was educated. Observation on 3-21-17 at 10:22 AM of Staff J revealed a resident in a wheelchair was loaded into the van and a 4 point wheelchair harness and seatbelt was applied. The driver made sure the wheelchair was secure. Observation inside the van revealed the absence of a sign posted with instructions on wheelchair/seatbelt application. Observation on 3-21-17 at 12:10 PM accompanied by Staff J of the facility bus revealed the absence of a sign posted with instructions to the driver on the wheelchair/seatbelt application. Interview on 3-21-17 at 12:10 PM with Staff J confirmed there were no signs in either vehicle and Staff J revealed there never had been. Interview on 3-21-17 at 12:35 PM with the SW (Social Worker) revealed the signs were made at the time of the incident by the SW. The SW thought either the ADM (Administrator) or the DON (Director of Nursing) had posted them in the vehicles. Interview on 3-21-17 at 2:20 PM with the DON confirmed the DON did not post the signs and confirmed no education was provided to any of the other staff who drove the van or bus after the incident. Review of the policy Before Operating a Vehicle with Wheelchair Lifts, Wheelchair Securement Systems and/or Seat Belt Systems dated 5/2013 revealed a Vehicle Knowledge Checklist form (GSS: Good Samaritan Society #655) should be completed prior to a driver transporting resident in a wheelchair. A Transporting Residents in Wheelchair Checklist (GSS #359) shall be satisfactorily completed prior to a staff person driving and annually thereafter. Interview on 3-21-17 at 2:22 PM with the Administrator confirmed there were 4 staff trained to drive the van/bus to transport residents and per the policy the competencies should be completed annually. The ADM confirmed last van competencies completed on the staff were in (YEAR) and not done in (YEAR) or yet in (YEAR). Review of personnel files revealed : 1) Staff J last competency on driving the facility van/bus was completed 12-28-15. 2) SW last competency on driving the facility van/bus was completed 12-29-15. 3) DON last competency on driving the facility van/bus was completed 5-26-15. 4) Staff K last competency on driving the facility van/bus was completed 1-20-17. C) Observation on 3-8-17 at 08:50 AM on the SCU (Special Care Unit) revealed the Dirty Utility room door, located by the Bath House, was shut but not secured/locked. When the door was gently pushed, it opened. Observation inside the room revealed a spray bottle of Virex, a disinfectant cleaner, on top of the counter. Observation on 3-8-17 at 8:50 AM on the SCU in the Bath House revealed the door to the room was wide open and no staff was in view of the door. In the Bath House was a cabinet with the doors wide open and a spray bottle of Virex sat on the shelf. Interview on 3-8-17 at 8:50 AM with Staff X revealed Staff X had been giving baths this morning before breakfast, then stopped to assist at the breakfast time and was back to start to give baths again. Observation were conducted on 3-8-17 at 8:52 AM of a cupboard in the SCU in the DR (dining room) above the hand wash sink. The cupboard had locks on both cabinet doors but the doors were unlocked. The cupboard contained a full bottle of Wax Glue-Max. The DR contained 14 residents sitting around at various chairs and wheelchairs. One resident, Resident 82, was wandering in the halls. At 8:55 AM, Resident 82 entered into the Bath House, as the door was wide open and was beside the cabinet which held the Virex. Staff P came out of the room directly across from the Bath House and redirected the Resident 82 out of the Bath House and shut the door. Observation on 3-8-17 at 11:45 AM on the SCU revealed the Utility Room located by the Bath House. The door was shut but not secured/locked. Inside on the counter was the bottle of Virex disinfectant. In a cupboard on the bottom shelf, there was several Isolyser LTS spill kit packets. On the packets was 'Precaution: Not for Internal Use.' Observation of the bathhouse next door revealed the door was shut but the door was not secured and, with a gentle push on the door, the door opened. Inside the room, the cabinet that had previously been opened was secured shut with a padlock. Observed on top of the cabinet was a clear basket full of fingernail polish and a full bottle of fingernail polish remover. Observation on 3-8-17 at 11:50 AM revealed the Staff GG exit the Dirty Utility room and shut the door but did not pull it shut to ensure the door was secured. At 11:51 AM, a gentle push on the door opened the door. No residents were in the hallway wandering at this time. Observation on 3-8-17 at 12:25 PM revealed the cupboard in the SCU DR above the hand wash sink had unlocked cabinet doors. The cabinet had been cleaned and the Wax Glue-Max was gone. Observation on 3-8-17 at 12:39 PM revealed the door to Bath House was open about 12 inches and no staff was in sight of the room. Observation on 3-8-17 at 1:50 PM revealed the door to the Bath House was open about 1/2 inch. Inside the room was the basket at head height of fingernail polish and full bottle of fingernail remover. The whirlpool on the bottom right side had a door with a lock on it. The door opened and inside was the whirlpool disinfectant concentrate hooked up to the hose to the tub. The door was not locked. Observation on 3-9-17 at 10:30 AM revealed the Dirty Utility room door was shut but not latched secure. With a gentle push on the door, the door opened and observation revealed a bottle of Virex disinfectant spray on the counter. Observation on 3-9-17 at 10:38 AM revealed Resident 6 in the Dining Room in the SCU, which was located 1 room away from the Bath House and Dirty Utility room. Resident 6 was exit seeking with attempts to push open the exit door to the courtyard door several times At 3-9-17 at 1:45 PM, Resident 6 was across the hall from the Bath House rummaging through some dresser drawers in the resident room. Review of the MSDA (Material Safety Data) sheets of the chemicals observed revealed they were classified as harmful for oral consumption, skin corrosion/irritation, and serious eye damage/eye irritation. Interview on 3-9-17 at 4:00 PM with the ED (Executive Director) revealed the expectation was to have the doors shut and secured at all times when a staff was not in the room when chemicals are in the room. Interview with the SW (Social Worker) on 3-22-17 at 3:30 PM revealed 11 residents who live on the SCU rummaged and were independent with locomotion.",2020-01-01
2498,PIONEER MANOR NURSING HOME,285212,"P O BOX 310, 318 N 3RD STREET",HAY SPRINGS,NE,69347,2018-08-07,689,G,1,0,9WZ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D7 Based on observations, interviews, and record reviews, the facility failed to identify and implement safe transfer interventions to prevent falls for 3 sampled residents (Residents 1, 2, and 3). The failure resulted in major injuries requiring medical attention for 2 of the sampled residents (Residents 1 and 3). Sample size was 3. Facility census was 51. Findings are: [NAME] Record review of Resident 1's undated Resident Face Sheet revealed the resident was admitted to the facility on [DATE] with a latest return date of 7/23/2018. Observation of Resident 1 on 8/7/18 at 1130 revealed NA (Nurse Aide)-D and NA-E assisted the resident with transfer from bed to wheelchair with a mechanical lift device and sling. Further observation revealed the resident had a splint/immobilizer on the left leg from ankle to mid thigh in which NA-D stated was in place from a fracture. Record review of Resident Progress Notes for Resident 1 revealed the following entries: - 6/6/18 at 5:55 a.m. the resident was attempting to sit on toilet missed hand rail lost balance. CNA (Nurse Aide) had hold of (the resident) as (the resident) grabbed wall rail and lowered self to floor . -Entries following this incident on 6/6/18 between 6/8/18 through 7/18/18 recorded the resident was receiving the assistance of two staff for toileting and transfers. - Entry on 7/18/2018 at 3:48 a.m. recorded 0320 (3:20 a.m.) CNA summoned me (charge nurse) to room, resident on floor by bed L) (left) leg twisted could feel large lump on bottom side of leg stabilized leg activated EMS (Emergency Medical Services-ambulance) . CNA reports (the resident) went to turn and just fell . Left per ambulance 0347 (3:47 a.m.). Record review of a facility investigation report for a Fall with major injury dated 7/23/18 revealed the facility investigated an incident involving Resident 1 on 7/18/18 which recorded the resident was transported to the hospital for a potential broken leg. The investigation concluded the resident's leg seemed to break during transfer of the resident who just quit bearing weight mid-transfer. Record review of a Hospital H & P (History and Physical) report dated 7/18/18 and a hospital x-ray report dated 7/18/18 revealed the following regarding Resident 1's arrival at the hospital: - The H & P recorded the resident arrived at the emergency room via rescue unit following a fall this morning. The resident presented with bruising and swelling of the left lower leg resulting in further examination. - The x-ray report findings revealed [MEDICATION NAME] (cross-wise) fractures of the proximal (nearest point of attachment) tibia (larger shin bone) and fibular (smaller shin bone) shafts are identified with mild impaction. Interview with NA-D on 8/7/18 revealed NA-D was employed at the facility providing direct care for residents for about three years and was familiar with Resident 1's care. NA-D described Resident 1 was slowly declining in self care ability over the past few months. Prior to this, the resident was transferring between surfaces and to the toilet with the help of one staff member. In June, the resident was lowered to the floor and staff discovered the resident's knees buckled more often. The transfers were changed to have two persons transferring the resident. A pivot wheel was also used when the resident was able and NA-D described a week when staff tried using a sit to stand lift but discontinued this after the resident was unable to follow safe directions and hold on properly. At the time of the resident's fall and fracture on 7/18/18, NA-D stated the staff were supposed to be transferring the resident with two persons. Interviews with Restorative Aides RA-F on 8/7/18 at 10:28 a.m. and RA-G on 8/7/18 at 10:50 a.m. revealed both staff members worked in Restorative Nursing and were familiar with Resident 1's program. Both staff members described the resident as being on a walk to dine program about two to three times per week. The resident would other times decline walking. Both described the resident as having more difficulty walking and knees buckling or giving out during walking or transfers. Both described after the incident in (MONTH) when the resident was lowered to the floor, the resident was transferred with the assistance of two staff members. Both stated at the time of the resident's fall and fracture on 7/18/18 the resident was a two person assist with transfers. Record review of Resident 1's Care plan document revealed a problem for Falls was recorded on 6/6/18 with further problem of Res (Resident 1) lowered to the floor in the bathroom. The goal with a target date of 9/19/2018 for the problem was Res will not sustain a serious injury if a fall occurs. The approach to meet the goal for the problem instructed staff to transfer the resident with the assistance of two staff. Interview with the Administrator on 8/7/18 at 11:45 a.m. confirmed Resident 1 fell during a transfer on 7/18/18 at 3:20 a.m. and was transferred to the hospital and diagnosed with [REDACTED]. plan. B. Review of the Resident Face Sheet, printed 8/7/18, revealed that Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that the resident was readmitted on [DATE] post [MEDICAL CONDITION] surgery. Review of the Care Plan History, printed on 8/7/18 and goal date 9/11/18, revealed the following including: - 10/13/14 Cognitive Loss and Dementia; - 4/12//17 Fractured Right Hip; - 12/12/17 Resident on the ground in the staff parking lot, looking for four wheeler, approach listed - Wanderguard (alarm device to notify staff when the resident leaves the building) applied; - 1/4/18 Resident needs help with activities of daily living related to poor eyesight and knee pain and extensive assistance of one with dressing and toileting; - 1/17/18 Resident on the floor in room, approach listed - staff will try to keep the resident's door open and check on the resident frequently; - 2/19/18 Resident stated fell in room, approach listed - staff will offer assistance with toileting more frequently; - 4/2/18 Resident on the floor in room by the bed, approach listed - staff will check on resident frequently throughout the day and night; - 4/16/18 Resident was found sitting on the floor in room, attempted to get in the wheelchair and sat on the floor, approach listed - keep the resident's wheelchair near the bed at night; - 6/11/18 Resident was found on the ground outside, approach listed - sent to the hospital per ambulance for evaluation. Review of the Resident Progress Notes revealed the following including: - 6/11/18 at 11:45 AM the resident was found outside on the ground outside of the courtyard fence. The resident complained of left hip pain and was sent to the hospital per ambulance for evaluation. The hospital reported that the resident had a [MEDICAL CONDITION] and would have surgery to repair it; - 6/15/18 the resident returned to the facility post surgical repair of the left [MEDICAL CONDITION]; - 6/27/18 at 12:33 AM the resident was agitated and attempting to climb out of bed; - 7/5/18 at 10:31 PM the resident self transferred to bed this afternoon; - 7/20/18 at 10:45 AM transferred self from the wheelchair to the bed; - 7/27/18 at 10:16 PM resident was found on the floor between the commode and the wheelchair at 7:20 PM, no injuries noted: - 7/30/18 at 5:30 PM the resident transferred self to the commode this afternoon, reminded not to get up without assistance. Observations on 8/7/18 at 10:00 AM revealed the resident seated in a wheelchair in room with a blanket over head, grab bar on the bed and a call light and U shaped pillow on the bed. Observations on 8/7/18 at 10:45 AM revealed the resident standing by the window air conditioner and then sat on the arm of the recliner. The resident stated trying to shut this off, it's cold. Call light activated to call for assistance with the resident and no one responded. At 10:50 AM called the nurse, LPN (Licensed Practical Nurse) - B in the hallway a few doors down at the medication cart for assistance to position the resident in a safe place. LPN - B offered to assist the resident to the bathroom and the resident declined. LPN - B reminded the resident to use the call light for help and assisted the resident to sit in the recliner. LPN - B placed a blanket on the resident's lap and legs and attached the call light to the arm of the recliner. Interview with LPN - B, Charge Nurse, on 8/7/18 at 10:50 AM revealed that the resident was at risk for falls because vision was bad. LPN - B stated that fall prevention interventions were to toilet the resident every two hours, use the U shaped pillow on the bed, keep the floor clear, place the resident at the nurses station or in an activity and check the Wanderguard every shift because the resident liked to go outside. LPN - B stated that the resident required assistance with two staff for safe transfers. Interview with RN (Registered Nurse) - C, Assistant Director of Nursing, on 8/7/18 at 11:30 AM revealed that the resident was considered a high risk for falls. RN - C confirmed that the resident had a history of [REDACTED]. Further interview confirmed that the resident had poor vision and hearing and was increasingly confused. RN - C confirmed that fall interventions in place were not effective to prevent or to reduce the risk for falls and injuries. C. Review of the Resident Face Sheet, printed 8/7/18, revealed that Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan History, printed 8/7/18 and goal date 10/12/18, revealed the following including: - Diagnoses: [REDACTED]. - 5/3/18 Fall Risk: Increased fall risk related to knee pain; - 7/6/18 Unwitnessed fall, resident on the floor near the bed, approaches listed - have call light in reach and remind resident to call for assistance; - 7/12/18 Resident on the floor in room next to the bed, stated was transferring from the wheelchair to the bed, approaches listed - Blood Pressures monitored and fluids encouraged due to complaints of dizziness. Review of the Resident Progress Notes included the following: - 7/12/18 at 10:00 PM Resident found on the floor next to the bed, confusion noted, no injuries noted, reminded resident to not transfer without assistance; - 7/15/18 at 9:47 PM Resident found transferring self into the bathroom, call light was not on, reminded to use the call light for assistance; - 7/19/18 9:59 PM Resident self transferred to the bathroom; - 7/21/18 at 1:15 AM Resident found on the floor, trying to stand and fell , no injuries; - 7/23/18 at 1:45 AM Resident self transfers; - 7/25/18 at 4:05 PM Resident self transfers at times to the bathroom, encouraged to ring for assistance; - 7/26/18 at 10:32 PM Resident had no signs or symptoms of pain. The Director of Nursing and the Provider were notified and will notify family in the morning; - 7/27/18 at 2:51 AM Will notify family of fall in the morning, encouraged resident multiple times per shift to use the call light; 5:57 AM Notified family of fall last night and the residents complaints of right leg and left shoulder pain; 1:00 PM Resident continues to complain of left shoulder pain, routine medications administered; - 7/28/18 at 2:49 AM Encouraged resident to use the call light for all needs; Resident complains of left shoulder pain; - 7/29/18 at 1:45 AM Resident found attempting to get out of bed; - 7/29/18 at 9:17 PM Resident transfers self to the bathroom at tunes, encouraged to ring for assistance; - 7/30/18 at 1:50 AM Resident complained of left shoulder pain and Tylenol was administered; - 7/30/18 at 2:02 PM Resident complained of left shoulder pain. Family requests no doctor's appointment and x rays, continue to monitor and treat with pain medications; - 7/31/18 1:08 PM Resident complained of left shoulder pain this morning and scheduled pain medications given. Resident is needing a little more assistance from staff because of the sore shoulder. Observations on 8/7/18 at 11:00 AM revealed the resident seated in the wheelchair in room. The resident stated Having some shoulder pain and indicated the left shoulder. The resident stated I must have slept on it wrong last night. Interview with LPN - B, Charge Nurse, on 8/7/18 at 11:00 AM revealed that the resident was at risk for falls, tries to transfer self and falls, required one staff assistance with transfers. LPN - B stated that the resident was encouraged to call for assistance with transfers. Further interview confirmed that the resident had ongoing left shoulder pain, probably from a fall, and the resident was monitored and pain medication was administered. Interview with RN - C, Assistant Director of Nursing, on 8/7/18 at 11:10 AM revealed that the resident was considered a high risk for falls and had recurrent falls when transfers self. RN - C stated that the resident had physical and mental declines, required extensive assistance of one staff member for activities of daily living, including transfers. Further interview confirmed that care plan interventions were not effective to prevent of to reduce the risk for falls and injuries.",2020-09-01
3149,IMPERIAL MANOR NURSING HOME,285252,"P O BOX 757, 933 GRANT STREET",IMPERIAL,NE,69033,2019-08-26,689,E,1,0,94T611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D7 Based on record reviews and interviews, the facility failed to ensure that 1) staff assisted one sampled resident (Resident 3), identified at risk for falls, with toileting at the Senior Center and 2) a plan was in place to monitor three sampled residents (Residents 1, 2 and 7), identified at risk for elopement at the Senior Center. The facility census was 35 with eight sampled residents who required assist with toileting and three residents at risk for elopement who attended meals at the Senior Center. Findings are: [NAME] Review of the facility list of residents who attended meals at the Senior Center revealed that Resident 3 attended on 7/16/19 and 7/23/19. Review of the resident's Care Plan, goal date 10/24/19, revealed that the resident was at risk for falls related to muscle weakness, abnormal gait and mobility and history of falls. Further review revealed that the resident required assistance with safe toileting. Review of the facility report, not dated, revealed that the resident needed to use the bathroom at the Senior Center and staff allowed a volunteer to assist the resident. Interview with NA (Nursing Assistant) - A on 8/26/19 at 2:50 PM confirmed that a volunteer assisted the resident to the bathroom at the Senior Center. Interview with the DON (Director of Nursing) on 8/26/19 at 3:00 PM confirmed that only staff members were to assist residents with cares, including toileting, while at the Senior Center to ensure the safety of the residents. B. Interview with the DON on 8/26/19 at 2:30 PM revealed that Residents 1, 2 and 7 attended meals at the Senior Center and were at risk for elopement. Interview with NA - C on 8/26/19 at 2:45 PM revealed that Resident 7 attempted to leave the Senior Center unaccompanied by staff. Interview with an employee at the Senior Center, who requested to remain anonymous, on 8/26/19 at 5:15 PM revealed that other residents attempted to leave the Senior Center and volunteers saw them and directed them back to the group. Review of Resident 1's Care Plan, goal date 10/10/19, revealed that the resident had increased wandering and stated was going home and a Wanderguard (alarm device which activates door alarms when opened) was placed on the resident. Review of Resident 2's Care Plan, goal date 10/24/19, revealed that the resident was at risk for elopement related to [MEDICAL CONDITION] and history of attempting to leave the facility unattended. Further review revealed that a Wanderguard alarm was place on the resident. Review of Resident 7's Care Plan, goal date 9/10/19, revealed that the resident was at risk for elopement as evidenced by attempts to leave the facility unattended. Further review revealed that a Wanderguard was placed on the resident. Interview with the DON on 8/26/19 at 4:00 PM confirmed that there was no documentation that a plan was in place to monitor these residents with exit seeking behaviors to reduce the risk for elopement and potential injuries.",2020-09-01
5282,BLUE VALLEY LUTHERAN CARE HOME,2.8e+280,"P O BOX 166, 755 SOUTH 3RD STREET",HEBRON,NE,68370,2017-10-12,323,E,1,1,QF6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D7a Based on observation, interview and record review; the facility failed to evaluate causal factors and implement preventative fall interventions for three (Residents 38, 24 and 5) of 20 sampled residents. The facility census was 36. Findings are: [NAME] Review of Resident 5's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated 8/9/17 revealed Resident 5 had intact cognition, required only supervision for walking and transfers and had no falls since the previous assessment. Review of Resident 5's Fall Risk assessment dated [DATE] revealed Resident 5 was at risk of falls with a score of 80. Review of Resident 5's Care Plan dated 1/10/14 revealed Resident 5 had a potential for falls. Interventions included keeping pathways clear, checking on resident frequently while in room or restroom, encouraging walker use, encouraging to ask for assistant and to pause before attempting to transfer or make position changes. Staff were also to encourage Resident 5 to move feet completely, to turn body instead of twisting, making sure shoes were tied, and proper footwear was being used. Further review of Resident 5's Care Plan revealed the last updated intervention was on 8/19/17 and re-stated that staff were to remind Resident 5 to call for help with bathroom duties. Review of the facility's computer incident logs for August, (MONTH) and (MONTH) (YEAR) revealed Resident 5 had a fall on 8/19/17, 9/6/17, 9/20/17 and 9/28/17. Interview with the Director of Nursing (DON) on 10/12/17 at 12:45 PM revealed the nurse caring for the resident at the time of the fall was responsible for evaluating the falls for causal factors and revising interventions to prevent further falls. The DON went on to say that the relevant documentation should be found in the progress notes, unusual occurrence report or on the care plan. Review of Resident 5's Progress notes, unusual occurrence logs and care plan revealed no documentation of investigated causal factors and no revised interventions after 8/19/17. B. Review of Resident 24's MDS dated [DATE] revealed Resident 24 had severely impaired cognition, required extensive assist with all mobility tasks and had a history of [REDACTED]. Review of the facility's computerized incident logs for August, (MONTH) and (MONTH) revealed Resident 24 had a fall with bruises and a laceration on 5/14/17 and falls without injuries on 8/7/17 and 9/19/17. Review of Resident 24's Care plan revised on 8/24/17 revealed no new fall interventions after the fall with injury on 5/14/17 or the fall on 9/19/17. The last care plan intervention was dated 8/24/17 and stated staff were to encourage staff to lay resident down after meals for rest periods in bed. C. Review of Resident 38's MDS dated [DATE] revealed Resident 38 had severe cognitive impairment, required limited assistance with mobility tasks and had a history of [REDACTED]. Review of the facility's computerized incident logs revealed Resident 38 had falls on 7/19/17, 8/14/17 and 9/25/17. Review of Resident 38's Care Plan dated 1/17/17 revealed Resident had a potential for falls. Interventions included encouraging good body alignment, encouraging rest periods and reminding Resident 38 to wear proper foot wear. There was not revised intervention after the falls in (MONTH) or September. The last revised intervention was on 8/14/17 and stated staff were to encourage resident to watch placement of own feet before attempting to sit in a chair. Interview with the DON on 10/12/17 at 12:47 PM revealed Resident 38 had severe cognitive impairment and was very forgetful. The DON went on to confirm that there was no documented evidence of causal factors or revision of interventions for falls stated above.",2020-02-01
4479,"PREMIER ESTATES OF FREMONT, LLC",285103,2550 NORTH NYE AVENUE,FREMONT,NE,68025,2019-04-01,689,D,1,1,OJJK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D7a Based on observation, record review and interviews; the facility failed to implement interventions to prevent falls for Resident 21 and failed to implement interventions to prevent unsupervised smoking for Resident 30. The facility census was 52. Findings are: [NAME] Review of Resident 24's Health Status Note dated 3/25/2019 revealed Resident 24 was sitting by the nurses station, tilted back in her w/c, Resident 24 leaned forward and fell out of the w/c, hitting head on the floor and received a large hematoma on the left side of forehead. Resident 24 was taken to room and returned to chair in lounge area. Observation at 03/25/19 at 11:04 AM revealed Resident 24 at the nurse's station in the wheelchair that Resident 24 had fallen out of earlier. Review of Resident 24's care plan revealed Resident 24 is at risk for injury related to anticipated falls. Fall interventions in place. Resident 24 has poor safety awareness, and staff are to anticipate Resident 24's needs. Review of Resident 24's Health Status Note dated 3/26/2019 revealed the Director of nursing (DON) visited with Hospice nurse regarding different wheelchair options as the current chair sits high and Resident 24 leans forward, if chair was lower Resident 24 would have less distance to fall. Review of Resident 24's progress notes dated 2/22/2019 12:18 revealed Resident 24 fell on [DATE]. Resident 24 tends to fidget with items on the table at meal time. Resident 24 was taken to the table prior to lunch by the CNA staff and was set up at the table prior to the meal service starting or nursing staff presence. The intervention initiated was to not take Resident 24 to the dining room until nursing staff are in the dining room monitoring Resident 24. Observation on 3/25/2019 at 12:30 PM revealed Resident 24 was in the dining room area prior to the meal service. No staff were at the table or near Resident 24. Resident 24 stood up from the chair and took a step away from the chair. No staff were in the immediate area. Nurse Consultant (NC) Z was alerted to assist Resident 24. Interview on 3/25/2019 at 12:45 PM with NC-Z revealed staff should have followed Resident 24 care plan and monitored Resident 24 while in the dining room to prevent the potential for falls. Observation on 4/1/2019 at 6:30 AM revealed Resident 24 remains in the tilt n space chair that Resident 24 has fallen from previously. B. Interview on 03/25/19 at 9:45 AM with Resident 30 revealed Resident 30 is restricted from smoking due to smoking outside of the designated smoking times. Review of Resident 30's care plan revealed 30 is a smoker and wishes to continue to smoke while a resident at the facility. Resident 30 has a history of giving other residents smoking materials and is on supervised smoking. Review of Resident 30's progress notes dated 3/13/2019 revealed Resident 30 was seen smoking in the courtyard outside of the designated supervised smoking times. The Social Services Director and the Administrator advised Resident 30 that Resident 30's smoking privileges were suspended temporarily. Review of Resident 30's progress note dated 3/17/2019 revealed Resident 30 was found in the courtyard smoking without supervision. The Administrator informed Resident 30 that Resident 30 had permanently lost his smoking privileges for not following the policy. Review of Resident 30's Behavior Note dated 3/25/2019 at 18:30 Resident 30 was observed going out to courtyard after attending supper. Observed attempting to remove cigarette butts from ashtray, then picking up cigarette butt from ground and attempting to light it with cigarette lighter. Interview on 3/26/2019 at 2:00 PM with Licensed Practical Nurse (LPN)-R revealed the staff do not monitor the resident on a routine bases. Review of Resident 30's health status note dated 3/26/2019 at 12:36 PM revealed Staff witnessed Resident 30 walking around in courtyard and smoking. Review of Resident 30's Interdisciplinary Team (IDT) note dated 3/26/2019 revealed the Team met today to review Resident 30's continued noncompliance with the smoking policies. During the review, it was noted Resident 30 has been more noncompliant with the smoking policy than before. The IDT set up for the Ombudsmen to meet with the facility administrator and Resident 30 to go over the smoking policy and to re-instate Resident smoking privileges with the understanding that further noncompliance may lead to further action by the facility per policy. Resident 30 was re-evaluated for smoking safety and the care plan was reviewed and updated. Interview on 03/28/19 at 6:58 AM with the Director of Nursing (DON) revealed Resident 30 is monitored when outside by office staff. Office staff are able to h ear resident leaving the building and can check on Resident 30 when outside during non-smoking times. Random observations are done but not routine checks. Review of Resident 30's IDT Focus Note dated 03/28/19 at 06:58 AM Resident was witnessed smoking outside of scheduled times this morning. SW called this resident legal guardian and talked to her about his non-compliance. SW spoke to resident about the loss of his smoking privilege. Review of Resident 30 Progress notes and care plan revealed no intervention to monitor Resident 30 for unsupervised smoking on a routine basis over the weekend when office staff not available. Interview on 04/01/19 at 9:08 AM with the Administrator revealed no interventions were put in place to further monitor Resident 30 between smoke breaks when office staff are not on campus.",2020-06-01
4865,"SIDNEY CARE AND REHABILITATION CENTER, LLC",285113,1435 TOLEDO STREET,SIDNEY,NE,69162,2018-07-12,689,G,1,0,PP9911,"**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) Put measures in place to ensure the resident's bed was made for one sampled resident (Resident 2). The failure resulted in the resident attempting to retrieve a blanket and falling resulting in fractures to the humerus and hip; and 2) identify and implement interventions to prevent re-occurring falls with injuries resulting in stitches and a fractured sacrum. Sample size was 7 current residents. Facility census was 27. Findings are: [NAME] Record review of Resident 2's Admission Record printed on 7/12/18 revealed the resident was initially admitted to the facility on [DATE] with a most current admission date of [DATE]. Further review of the document revealed among the resident's medical [DIAGNOSES REDACTED]. Phone interview with Resident 2's POA (Power of Attorney for healthcare and financial) on 7/12/18 from 11:15 a.m. through 11:45 a.m. revealed the POA was concerned regarding an incident that resulted in Resident 2 sustaining a [MEDICAL CONDITION] and arm. The POA described visiting the resident and taking the resident out to supper on 5/20/18. The family noted prior to taking the resident out that the bed had not been made. The POA made a request for the charge nurse to come see that the bed was not made and the charge nurse refused to come look. Before leaving the facility after taking the resident out, the POA and family noted the bed had still not been made and filled out a grievance form and slid it under the Administrator's door. Later in the evening around 8:15 p.m. the POA phoned the resident and asked if the bed had been made. The resident reported being in the recliner and the bed was not made yet. After this phone call, the POA phoned the facility and spoke with the night time charge nurse. The POA stated that the resident had a favorite red blanket and the family noted it to be in the closet. The POA described that staff needed to retrieve this blanket and make the resident's bed or else the resident would get up in the middle of the night looking for it. The POA described receiving a phone call from the night charge nurse around 3:30 in the morning in which the facility reported the resident had fallen by tripping over a phone cord. Later staff told the POA the resident tripped over a table. The staff reported the resident was getting up from the recliner to get a blanket. The POA felt if the staff had merely made the bed and retrieved the blanket that they requested the resident be given, the fall would likely have been prevented. The POA described the resident being discharged to the hospital and treated at another hospital for the [MEDICAL CONDITION] and arm. Record review of Resident 2's Progress Notes revealed the following entries: - 5/21/18 at 9:03 p.m. the nurse recorded the resident often forgets walker and has to be reminded to use it. Gait at those times is lurching and wobbly . Res in lobby this afternoon with 6 blankets and 2 pillows piled on (the resident's) rollator walker seat along with a heavy coat and plastic bag full of numerous personal belongings . Attempts to return blankets to room and make bed and offers to assist with putting items back in room all met with increased agitation and refusal as res (resident) is insistent in leaving. Niece (POA) called to inform staff (POA) was going to take res out to supper. OOF (out of facility) at 1735 (5:35 p.m.) to dinner. Ret'd (returned) at approx (approximately) 1930 (7:30 p.m.) without incident. (POA) then came out of room and voiced irritation that res bed not made. This nurse advised it was made earlier in the day but res tore it apart and refused to allow staff to remake it at that time . Assured bed would be made before res went to bed . advised staff to tend to bed once family departs with pets . - 5/21/18 at 3:20 a.m. the charge nurse recorded hearing the resident yelling for help and upon opening the door observed res on right side on the floor in front of the recliner, head was under the wooden chair to the right of the resident's recliner and small wooden table was knocked on the side between the recliner and the resident. Resident stated fell . Complained of right hip pain and the ambulance service was contacted at 3:25 a.m. The charge nurse contacted the PO[NAME] The ambulance arrived at 3:40 a.m. and the resident left per ambulance at 3:55 a.m. - 5/21/18 at 4:36 a.m. the POA contacted the charge nurse who recorded the POA reported the resident had a broken humerus (long bone between the shoulder and elbow) and a broken hip. Record review of a Hospital History and Physical Final Report on 5/21/18 recorded the resident had a history of [REDACTED]. Was found to have a right femur fracture along with a right humerus fracture as well. Family reported the resident was in usual state of health until later in the evening, after going to bed, the resident woke up and tried to grab a blanket; however, slipped and fell resulting in the fractures. Hospital x-ray reports dated 5/21/18 at 4:27 a.m. revealed the resident sustained [REDACTED]. Facility investigation report of Resident 2's 5/21/18 fractures was completed on 5/24/18. The documented outcome of the investigation recorded the resident appears to have been sleeping in (the resident's) recliner dressed in a bra and underwear at the time of the incident. It is believed that (Resident 2) tripped over the small wooden table next to (the resident's) recliner while getting up to get a blanket. The investigation included measures to prevent reoccurrence that included checking the resident frequently in night to encourage to sleep in bed. Ensure enough blankets are placed. Education was also provided that beds should be made every day. Interview with the Administrator on 7/12/18 verified Resident 2 fell and received two fractures, one to the humerus and the other to the hip on 5/21/18. The Administrator verified the family had filed a formal grievance on 5/20/18 regarding the resident's bed not being made during a visit the evening prior to the fall. A discussion of the events documented was done with the Administrator who agreed the resident removed blankets earlier in the day and resisted to having them taken back to the room. The documentation revealed the bed was not made even after the resident went out for supper and the family complained it was not made at the time they left and after later calling the resident. The documentation showed the resident fell from the recliner getting a blanket drawing a reasonable conclusion the bed probably was not made at the time of the fall. The Administrator agreed with these events and the likely conclusion the resident's bed was not made resulting in a fall from the recliner. B. Review of the Admission Record, printed 7/12/18, revealed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan, goal date 8/6/18, revealed that the resident was at risk for falls related to history of falls, poor safety awareness and unsteady gait. Further review revealed that the resident had behaviors including frequently refuses cares and medications and required assistance of one with transfers. Interventions included chair tender (alarm) in recliner and wheelchair, encourage resident to ask for assistance when attempting to transfer, keep call light within reach, make sure all staff are aware of high fall risk and what needs to be done to ensure safety, provide appropriate footwear, provide one on one care and attention when increased restlessness raises risk for falls, visual checks every 15 minutes for safety and increase positive interactions with staff and provide consistent staffing assignments with staff members familiar to the resident. Review of the facility Investigation Report, dated 6/29/18, revealed that on 6/24/18 at 6:20 AM the nurse was attempting to help resident back into room to the chair and the resident was combative and tried to hit the nurse. The resident slipped and fell to the floor landing on the right hip, shoulder and head. The resident had a laceration to the right side of the forehead above the eye which measured approximately 10 cm. (centimeters). The resident was transported to the hospital for evaluation and treatment and received 11 stitches to the forehead. Review of the facility Investigation Report, dated 6/29/18, revealed that on 6/25/18 at 7:20 AM the staff observed that the alarm was sounding and the resident was out of the recliner ambulating to the bathroom with an unsteady gait and balance with involuntary body movements of the arms and shoulder. The resident lost balance and fell on to the floor on left hip. Further review revealed that the resident did not initially appear to have any injury, however, the resident began to complain of pain several hours later and was transferred to the hospital emergency room . The resident was found to have a sacral fracture and a urinary tract infection. The resident was admitted overnight for pain management and received intravenous hydration and potassium supplement. Review of the Progress Notes revealed the following including: - 6/9/18 at 2:28 AM the resident has been in and out of the room several times this night as well as going to the toilet; - 6/9/18 at 11:59 PM the resident has been very agitated this shift, continuously getting out of the recliner, walking into the hallway and cursing at staff when attempts made redirect the resident; - 6/14/18 at 3:19 AM the resident was in and out of the recliner several times; - 6/17/18 at 2:29 PM the resident was in and out of recliner several times setting off the chair alarm; - 6/19/18 at 5:48 PM the resident got out of the chair several times, setting off the chair alarm; - 6/24/18 at 5:30 AM the resident was found on the floor by the nursing assistant, alarm sounding, found sitting on the floor in front of the recliner. The resident had a 1.5 cm. skin tear to the right elbow; - 6/24/18 at 6:15 AM the nurse heard to alarm and the resident was coming out of the room, the resident tried to hit the nurse, lost balance and fell on to the right hip, shoulder and head. The nurse was not able to catch the resident, noticed blood from a wound on the forehead. Emergency Medical Services was called and the resident was transported to the emergency for evaluation and treatment; - 6/25/18 at 7:20 AM no documentation of the resident's fall in the room as stated in the Investigation Report; - 6/25/18 at 1:26 PM the resident was admitted to the hospital for pain control: - 6/25/18 at 3:04 PM the emergency department reported that the resident had a sacral fracture and would be admitted over night for pain control; - 6/26/18 at 1:40 PM the resident was readmitted to the facility; - 6/27/18 at 2:26 PM the resident was treated at the hospital after a fall resulting in a sacral fracture, also had a urinary tract infection. The resident was to be NWB (no weight bearing) but was noncompliant and transfers independently despite repeated education to ring for assistance; - 6/28/18 at 5:58 PM the resident continues to be noncompliant with NWB status and continues to get up independently, attempts to educate regarding safety ineffective, chair alarm and call light in place; - 7/4/18 at 9:39 PM another resident reported to the nurse that the resident fell . The resident was found on the floor in front of the dresser. The other resident stated that the resident had been attempting to walk out into the hallway, holding a blanket, turned and lost balance an fell , no injuries were documented; - 7/5/18 at 7:12 PM the resident continues to self-transfer, a new physician order [REDACTED]. - 7/7/18 at 9:10 PM the resident frequently gets up unassisted and wanders in the room and into the hallway; - 7/11/18 at 12:31 PM the resident continues to have full boy jerking motions which makes it very unsafe for the resident to self-transfer, although the resident continues to do so. Observations on 7/12/18 at 9:50 AM revealed the resident seated in the recliner with legs over the side of the recliner, confused and restless, alarm and call light in place. Further observations at 1:30 PM revealed the resident seated in the recliner with legs over the edge, trying to get up unassisted, the alarm sounded and staff responded and assisted the resident to the bathroom. Interview with the Administrator and the Director of Nursing on 7/12/18 at 11:45 AM confirmed that interventions in place to prevent recurrent falls and injuries was not effective.",2020-03-01
1960,WILBER CARE CENTER,285172,611 NORTH MAIN,WILBER,NE,68465,2018-08-30,689,G,1,1,FIS811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D7b Based on observation record review and interview, the facility failed to identify causal factors and implement individualized interventions to prevent reoccurrence of falls and injury for three of three sampled residents involved in falls, (Residents 2, 18, and 43). The facility census was 48. Findings are: [NAME] On 8/29/2019 at 11:44 AM interview with MDS (Material Data Set, a comprehensive assessment tool use to complete care plan for residents) Coordinator confirmed that multiple interventions were the same in Resident 43's care plans for falls. MDS Coordinator and DON (Director of Nurses) confirmed that on dates 1/2/18 and 12/29/17 assessments did not have causal factors documented for Resident 43. On 8/29/18 at 11:00 interview with DON and Administrator revealed that they are not able to staff the special care unit with 2 care givers and the staff should be calling for help if they are in a room with resident for extended periods of time. On 08/27/18 at 10:01 AM an observation of resident 43 had been ambulating in the hallway wondering back and forth. The Certified Medication Aide (CMA) B was in the bathroom giving a bath to Resident 5. Therapy Staff Member came out of a room and took Resident 2 off the unit and the door alarm sounded. The CMA B that was with Resident 5 in the bath house came to the door of the bath house to see what set the alarm off, leaving Resident 5 unattended in the bath tub. House Keeping Staff Member A was left in the resident area to monitor residents while the CMA B was in the bath house, the Housekeeper A had mopped floor and had been attempting to keep Resident 43 off the wet floor. Resident 43 was able to get to the wet floor nearly slipped and almost fell . The Housekeeper A was able to steady Resident 43. Resident 43 had been in room [ROOM NUMBER] and room [ROOM NUMBER] without supervision. Record review of Fall Investigation/Occurrence Report dated 6/16/18 at 4:15 PM revealed Resident 43 fell in day room. Resident 43 had fallen over the feet of another resident. Resident 43 was ambulating independently with shoes and was continent of urine. The resident had an injury requiring sutures. Record review of Progress notes dated 6/16/18 at 9:15 PM revealed at 4:15 PM the resident walked around in living area and tripped over another resident's feet. Resident 43 fell and put hand out to catch self. This resulted in a 8 cm laceration on the residents chin which required sutures. Record review of Care Plan interventions dated 6/17/18 for the fall on 6/16/18 revealed an intervention to monitor closely when ambulating. Record review of Fall Investigation/Occurrence Report dated 6/17/18 at 5:10 PM revealed Resident 43 had a fall in the activity room. Resident 43 tripped on a walker. Resident 43 was alert but disoriented, ambulated independently without a device with shoes on and was continent. The root cause was object in the way. Record review of Care Plan interventions dated 6/18/18 for fall on 6/17/18 revealed walk with Resident 43 as much as allowed by resident and monitor for safety. Record review of Progress note dated 6/17/18 8:41 PM Revealed Resident 43 had a fall by tripping over a walker and falling on buttocks without injury. Record review of Fall Investigation/Occurrence Report dated 6/21/18 6:00 AM revealed Resident 43 had a fall to the floor in the dining area while ambulating independently with shoes. Resident 43 was alert but confused and was continent. The root cause was unsteady gait and questioning shoes sticking to floor. Record review of Fall Investigation/Occurrence Report dated 7/6/18 0840 AM revealed Resident 43 had a fall in the lounge of the Special Care unit. There were no factors noted. Resident 43 had an injury of a bruise to the left cheek bone. The root cause had Unknown and Questioned poor gait. Record review of Progress note dated 7/6/18 at 4:15 PM revealed Resident 43 was observed on floor at 08:40 AM. Resident 43 was laying on the left side in front of television in the lounge area. At 11:00 AM an area bruising had been noticed on the right cheek and measured 3 cm x 3 cm. Record review of Care Plan interventions dated 7/6/18 revealed to encourage rest periods after breakfast. B. Record review dated 12/9/17 MDS section C revealed BIMS (Brief Interview for Mental Status) an assessment tool for cognition status, Resident 2 scored 09 indicating moderate impairment. On 8/9/18 MDS (Material Data Set) an assessment used to develop a comprehensive care plan, Section C BIMS score was 04 indicating severe impairment. Record review of Resident 2's progress notes revealed the following: - Fall on 12/18/2018: no Injury - Fall on 1/3/2018: no Injury Fall investigation dated 12/18/17 at 3:35 AM revealed that there were no factors observed at the time of fall. Resident 2 was bare foot, alert but confused. Resident 2 had a bed alarm that had been used, unknown if the alarm had been sounding. Resident 2 was incontinent. No injury. The box with what appears to be the root cause is blank. Record review of Progress noted dated 1/3/18 at 0247 Observed on floor in Special Care Unit in dining area. Had back toward chair. By the time this nurse got to him, he managed to get himself up and into the dining room chair. Is uncooperative and agitated at the time. When asked what happened he states I know but I'm not telling anyone. Neuro checks started but refused to participate in most things asked. When returned to do next set of neuro checks, was more cooperative and joking with staff again. At that time when asked what happened states, I don't remember. Blood pressure elevated first set but back down to normal range with second Blood pressure taken. Denies any pain. No injury noted. Record review of Fall Investigation/Occurrence Report dated 1/11/18 0410 Factors: Resident slipped, Lost Strength/Appeared to get weak, rolled out of bed, alert but disoriented, bare feet, and incontinent. Medications were: anti-anxiety/anti-psychotic, antidepressant, narcotic, hypoglycemic. Root cause: I am not sure anymore. He gets on the floor then gets up then next time he is unable to get up. Intervention: sit in doorway and remind him to stay in bed, and pull tabs. Review of Care Plan dated 6/7/17 the intervention of Sit in doorway and remind him to stay in bed was not located in the care plan. Record review revealed that Resident 2 had 19 falls since (MONTH) of (YEAR) and Resident 43 had 17 falls since (MONTH) of (YEAR). C. A review of a PHYSICIAN UPDATE AND ORDER SHEET, faxed to Resident 18's Primary Care Physician on 2/9/18, revealed the resident had an observed fall. The resident had lost balance and fell , while trying to pick up toilet riser from the floor. The Nursing Update documented Full AROM (Active Range of Motion)-will monitor. The document did not include information related to the interventions in place to prevent reoccurrence. A review of the facility's Incident logs, revealed Resident 18 was involved in the following occurrences: on 3/26/18 and 4/2/18, the resident was found on the floor by recliner; on 4/8/18 the resident was lowered to the floor from wheelchair; on 5/17/18 the resident was observed on the floor in the bathroom. Observations on 08/27/18 9:21 AM-10:30 AM, revealed Resident 18 seated in a recliner in the resident's room. The chair was in a reclined position and a personal safety alarm was noted to be attached to the back of the chair and Resident 18's blouse at the right shoulder area. The controller for the electric recliner/lift chair was noted to be resting on the floor next to Resident 18's chair. The call light was within the resident's reach, however, Resident 18 was noted to be calling out, requesting a drink of water. An unidentified Nursing Staff member entered the Resident's room and was overheard to report that the water pitcher was empty, and that staff would refill the pitcher as soon as possible. The staff member left Resident 18's room without offering to assist the resident with an immediate drink of water. Resident 18 appeared restless and uncomfortable, frequently attempting to reposition causing the safety alarm to sound. LPN (Licensed Practical Nurse)-D was noted to step into Resident 18's room, picked the control for the electric recliner up off the floor and gave the controller to the resident, step back out of the Resident's room, and directed Nursing Assistants to assist the resident out of the recliner. Staff were overheard to reply it will be a minute. A few minutes later, Resident 18 was overheard calling out for help. A Nursing Assistant who was walking by in hallway, immediately entered the room to assist Resident 18, closing the door to the resident's room. An observation on 08/27/18 at 11:02 AM revealed, Resident 18 seated in a wheelchair (w/c), with a long amount of oxygen tubing wrapped around self and in the resident's lap. A personal safety alarm was in place to the back of the w/c and attached to the resident's clothing at right shoulder area. An interview on 8/29/18 at 8:38 AM with Registered Nurse (RN)-C, revealed Resident 18 exhibited fluctuating levels of confusion/forgetfulness which may be related to the Resident's respiratory status or illness. The RN explained that Resident 18's respiratory concerns exacerbate quickly, and the resident was recently treated for [REDACTED]. RN-C reported that Resident 18 was safe to have control of the lift recliner, and confirmed that a personal safety alarm was in use to alert staff of attempted unassisted transfers. A review of the Care Plan for Resident 18 revealed Problem(s) with Start Date of 05/10/2017 including a self-care deficit related to: [MEDICAL CONDITION] (a chronic respiratory disease), back pain, weakness, dementia with anxiety, and inability to stay on track to complete task at hand; very poor safety awareness and being very impulsive. This indicates a high risk for falls. Interventions implemented on 5/10/17 included: Restorative program (a program that helps residents maintain any progress they've made during therapy treatments, enabling them to function at a high capacity) as outlined, 3-5 times per week; Keep my pain under control, this will help decrease my chances of falling; Keep room clean and free of clutter and call light within reach at all times; Please give me frequent reminders about things like locking my wheelchair brakes, using call light, etc; Remind me frequently that I need to call for help, and not attempt to do things on my own; At this time I need one staff to help me with transfers, ambulation, locomotion, dressing, bathing and toilet use. With encouragement and supervision, I believe I can do these things on my own. If I can not stand safely then I will need to transfer with the EZ Stand (a mechanical device used by staff to assist residents to transfer from one surface to another); Due to my lung conditions, I do have good and bad days so please be aware of this and give me more assistance as I need; I am able to ambulate (walk) with my walker and one staff assistance but often refuse to do this. Please encourage me to continue ambulating and to wheel myself short distances; When having increased anxiety remind me of safe strategies. I have a tendency to forget what is safe for me. I do have a very compulsive personality. I like to drink coffee and like to have my things within my reach so I don't have to try and get up to reach them. When I am at an activity and seem to get more anxious or and trying to pay attention to what everyone else is doing, I will tend to not always pay attention to where I am going with my w/c. Remind to watch for others. Further review of the Care Plan revealed no documented evidence that safety interventions had been reviewed or updated following the fall for Resident 18, on 2/9/18. The documentation indicated: on 3/27/18 the resident Slid from chair due to playing with controls. Monitor frequently and remind to not play with controls. Consider using regular recliner instead of lift chair; on 4/2/18 fell from recliner. No injuries. Monitor frequently. Remind on how to use control frequently and ask (gender) to call for help if is not sure; on 4/8/18 Slid out of wheelchair. Offer recliner or bed when sleeping in chair; and on 5/18/18 Fall taking self to bathroom. Offer to assist resident to bathroom many times through our shift. The document did not contain information related to the personal safety alarm noted to be in use. A review of MDS (a mandatory comprehensive assessment tool used for care planning) information for Resident 18 indicated a declining BIMS (Brief Interview for mental status) score. For an annual assessment dated [DATE] the BIMS score was 10 (scores of 8-12 indicates moderately impaired) and for a quarterly assessment dated [DATE] the Resident's score was 8. A review of an undated facility policy titled Fall Prevention and Management Program revealed the Program Objectives included: a. To improve and maintain a resident's optimal functional level and quality of life b. To identify and reduce or eliminate environmental risk factors for residents c. To identify and reduce or eliminate risk factors for residents d. To reduce the frequency of falls e. To reduce the severity of injuries from falls f. To ensure best practice interventions for residents who have fallen g. To monitor and track trends related to resident falls. An interview, on 08/30/18 at 08:30 AM, with the DON (Director of Nursing) revealed that the facility had not implemented true safety interventions for a resident who exhibited signs of dementia. Resident 18 would need more than repeated reminders and monitoring in order to prevent the potential for reoccurrence or injury during a fall.",2020-09-01
6397,TABITHA NURSING CENTER AT CRETE,285283,1800 EAST 13TH STREET,CRETE,NE,68333,2016-03-23,323,G,1,0,FUXK11,"**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 failed to assess and address the causal factors for falls, in an effort to prevent injuries from occurring, for two residents (Residents 1 and 3). The facility's census was 41. Findings are: A. Review of Resident 3's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 1/18/16 revealed Resident 3 had moderately impaired cognition, required extensive assistance with transfers and ambulation and was unable to stabilize without assistance when going from a seated to standing position. Review of Resident 3's Care Plan dated 12/14/15 revealed Resident 3 had a history of [REDACTED]. Approaches staff were to implement in an effort to prevent falls included adding lighting to the resident's room/bathroom, assisting Resident 3 with ambulation and with toileting as needed and using alarms to the chair at all times to alert staff when Resident 3 was getting up unattended. Review of Resident 3's Departmental Notes revealed on 3/4/16 Resident 3 had been confused throughout the shift. At 2:57 PM Resident 3 was found on the floor in front of the recliner which was in the highest position and the alarm had not activated as it had pulled free of Resident 3's clothing. Resident 3 complained of head pain and was transferred to the hospital for further evaluation. Review of the facility's internal investigation dated 3/8/16 revealed Resident 3 was attempting to ambulate to the restroom without asking for assistance. Care plan interventions to prevent further falls were to 1) Place call light within reach and instruct on call light usage. 2) Pain medications as needed for comfort. 3) Participate in therapies as recommended by physician. 4) Continued use of Alarms. 5) Assess for toileting need and schedule if appropriate. Injuries that resulted from the fall included , Right Tibia Fracture (lower leg), C-Spine Fracture (Cervical Spine or neck fracture) and laceration to the left side of the forehead. Interview with Nursing Assistant (NA) A and Licensed Practical Nurse (LPN) B on 3/22/16 at 3:35 PM revealed Resident 3's recliner had electronic controls and Resident 3 often used those controls to raise to a standing position. NA A went on to state that the facility initiated the use of the alarms to alert staff when Resident 3 was raising self to a standing position so they could intervene before Resident 3 began to attempt independent ambulation. NA A stated Resident 3 would raise self to a standing position all the time. Interview with the Director of Nursing (DON) on 3/22/16 at 3:51 PM revealed that Resident 3 had not been assessed to determine if Resident 3 was safe to operate the electric controls of the lift chair. The DON further confirmed the change in interventions after Resident 3's fall did not address the use of the lift chair. Review of the facility's Policy and Procedure for Fall Risk and Post Fall Assessments dated 1/6/14 revealed if a client (resident) falls the plan of care should be updated to include any causal factors and what changes need to be made to prevent a similar occurrence in the future. B. Review of Resident 1's Minimum (MDS) data set [DATE] revealed Resident 1 had severely impaired cognition, required extensive assistance with transfer, had poor balance and had one fall since admission to the facility. Review of Resident 1's Departmental Notes revealed on 1/8/16 Resident 1 was found on the floor in front of the lift chair. The lift chair was noted to be raised about half way to the standing position. The remote for the chair was noted to be between the recliner and Resident 1's right thigh. Review of Resident 1's Department Notes dated 1/16/16 revealed Resident 1 was found on the floor in front of the recliner and appeared to have slid from the chair as it was in the elevated position. Resident 1 voices that this is what occurred. Review of Resident 1's Care Plan, updated 2/1/16, revealed Resident 1 was at risk of further falls and interventions included using a slip cushion with the lift chair and pinning the electric recliner remote on the outside of the chair for safety. Observation of Resident 1 on 3/23/16 at 11:45 AM revealed Resident 1 reclined in the lift chair with the controls to the lift chair hanging freely to the right side of Resident 1. Resident 1 was moving Resident 1's legs back and forth in the chair. Resident 1 was sitting on an incontinent pad and an alarm sensor. No slip cushion was noted. Observation of Resident 1 on 3/23/16 at 12:50 PM revealed Resident 1 now lying in the bed. Observation of the lift chair revealed the electric controls were still hanging freely and not pinned on the outside as care planned. Further observation confirmed the only items in the lift chair were an incontinent pad and an alarm sensor. Interview with LPN B on 3/23/16 at 3:36 PM revealed a non slip pad would be a piece of dycem (a pad made of polymer material that has non slipping properties.) LPN B was unsure why the dycem was not in place on Resident 1's chair. LPN B was further unaware that the controls for the lift chair were to be pinned onto the chair for safety.",2019-03-01
6251,"CALLAWAY GOOD LIFE CENTER, INC",285200,"PO BOX 250, 600 WEST KIMBALL STREET",CALLAWAY,NE,68825,2016-05-04,323,G,1,0,VB9F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D7b Based on record and interview, the facility failed to prevent an accident as the staff walked away leaving the resident sitting on the edge of the wheelchair for one sampled resident (Resident 15). The failure resulted in a resident fall requiring medical attention for suture repair to the forehead. Facility census was 34. Findings are: Review of the facility accident and investigation report revealed Resident 15's fall was 4/16/16 at 7:45 PM. LPN-A (Licensed Practical Nurse) noted the resident sitting at the edge of the wheelchair (w/c). The nurse left the resident's room to get assistance to reposition the resident and when the nurse returned to the room the resident had fallen face down on the floor. A laceration was noted to the forehead measuring 6 cm. (centimeters). The resident was sent to the emergency room where the forehead was sutured. Review of the facility form entitled Resident Incident Report revealed Resident 15 was admitted to the facility on [DATE]. Review of the [DIAGNOSES REDACTED]. Review of Resident 15's MDS (Minimun Data Set; a federally mandated comprehensive assessment tool used care planning) dated 4/20/16, revealed the resident's cognition was scored 3 out of 15. The bed mobility was extensive assist of two person. Transfer was extensive assist of two persons. The resident fell in the last month prior to admission and had fallen in the last 2-6 months prior to admission. No fractures were related to a fall in the last 6 months. Interview with the Administrator on 5/4/2016 at 2:19 PM revealed LPN-A had gone into the room and the resident was on the edge of the wheelchair so the LPN left the room to get help and when the LPN came back to the room the resident was face down on the floor. The Administrator revealed the topic of resident safety was discussed in the nurses meeting. Interview with LPN-A on 5/4/2016 at 2:55 PM revealed on 4/16/2016 the nurse entered Resident 15's room to find the resident was sitting on the edge of the wheelchair. The nurse told the resident to not move or fall. The nurse left the room to get help to assist in moving the resident and was gone about 5 minutes. Upon return to the resident's room, LPN A found the resident on the floor with a lot of blood. LPN-A did not turn on the call light and did not call out for help from the room. Also LPN-A did not attempt to move the resident back in the wheelchair. Review of Resident 15's care plan, dated 2/17/16, revealed a history of falls and multiple falls since admission and prior to admit. The resident slid down in the recliner, rolled out of bed, and had falls in trying to toilet independently. Interventions were as follow: -Monitor for changed in condition may warrant increased supervision/assistance and notify the physician, -Uses a wheelchair for long distance mobility, ensure slipper socks when not wearing shoes, recliner was changed for a better fit, -Encourage resident to use call light for assist, reeducate resident to ask for assist for all ambulation and transfers, if awake at night encourage to stay in bed or offer to bring her to TV room, -Continue hourly rounds, keep BR door closed while the resident was awake, -If awake while in bed offer toileting or to get up in w/c. Assist with 2 staff member for all transfers and weight bearing tasks, -Refer to restorative nursing program, offer to transfer resident to recliner or bed ASAP (as soon as possible) after meals to prevent the resident from trying to transfer self or slipping out of wheelchair, utilize horse shoe pillow when in bed, -Requires 2 assist for dressing, grooming, bathing and weight bearing tasks, 1 person assist with bathing, transfer with mechanical lift. Review of the facility documentation for education on resident safety revealed no documentation on staff education on resident safety.",2019-05-01
6276,SIDNEY REGIONAL MEDICAL CENTER-EXTENDED CARE,285290,549 KELLER DRIVE,SIDNEY,NE,69162,2016-05-03,323,G,1,0,1C5K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D7b Based on record reviews and interview, the facility failed to implement fall prevention interventions for one sampled resident (Resident 5) during toileting. The failure resulted in a resident fall requiring medical attention for suture repair and subarachnoid space (space between vascular membranes) bleeding. Facility census was 50. Findings are: Record review of an undated Resident Master Information form for Resident 5 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 5's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) records revealed the resident was assessed for a Significant change in status MDS dated [DATE]. Review of this MDS revealed the following assessed items pertaining to the resident: - BIMS (Brief Interview for Mental Status- a test of memory) score for the resident was recorded as zero (0-7 score=severe cognitive impairment). - The resident had not resisted or rejected cares provided by the staff. - The resident received extensive assistance (resident performed part of the activity but received help for weight bearing support or full staff performance during part of the activity) for transfers and toileting. - The resident's Balance during transitions and walking recorded when the resident was moving on and off the toilet the resident was not steady, only able to stabilize with human assistance. - Among the resident's active medical [DIAGNOSES REDACTED]. - The assessment identified the resident had fallen in the last 2-6 months prior to this assessment. Record review of Resident 5's Long Term Care Plan printed on 4/15/16 revealed a Safety problem was identified with an original date of 3/22/16 and reviewed on 4/12/16. The problem identified Resident 5 at Risk for fall related injury R/T (related to) weakness, lethargy, and condition. The Interventions to address the problem included directions for the staff to Staff will stay with (Resident 5) in the bathroom. Record review of the facility fall risk assessments for Resident 5 revealed the following: - 3/12/16: The resident's Morse Fall Risk Score was 80 (46+ points indicated High Risk) and the resident's Conley score was 7 (10 or more points indicating High Risk). The Conley assessment recorded the resident had a history of [REDACTED]. - 4/1/16: The resident's Morse Fall Risk Score was 65 and the Conley score was 7. The Conley assessment recorded the resident had a history of [REDACTED]. - 4/13/16: the resident's Morse Fall Risk Score remained 65 and the Conley score remained 7. The Conley assessment identified risk factors for history of falls in last 3 months, impaired judgment, impaired gait, and incontinence. Record review of facility Progress Notes for Resident 5 revealed an entry recorded at 8:28 a.m. on 4/13/16 entitled post fall team meeting notes. The entry recorded the resident was found on the floor in the bathroom on the right side and identified the resident's POA (Power of Attorney) was present in the room when the nurse arrived. The note recorded the resident hit head against the bathroom door. The nurse recorded a laceration on the lower resident's forearm measured 11.5 centimeters by 12 centimeters and the lower forearm had a skin tear measuring 2 by 3 centimeters. The resident also exhibited a hematoma to the back of the head measuring 5 by 2 centimeters. The entry recorded the resident was sent to the emergency room at 7:50 a.m. following the incident and assessment by staff. Record review of the hospital Emergency Department Provider Documentation dated 4/13/16 at 8:06 a.m. revealed the Chief Complaint: Patient presents from nursing home, (resident) was in the bathroom this morning and fell backward and hit (the resident's) head . has a quite significant skin tear on (resident's) right forearm as well. The provider recorded in the Physical Exam that the laceration to the right forearm was sutured and dressed and ,measured 15 centimeters in total area and a second laceration measured 3 centimeters into the fat layer. The provider recorded Head Common Findings There is a 2 cm (centimeter) in diameter hematoma over the occipital (back of the head) area. In addition, the provider documented a diagnostic CT scan (Computerized Tomography test, combining x-ray images with the aid of a computer to generate cross-sectional views and images of internal organs and body structures) which revealed the resident sustained [REDACTED]. Record review of the facility's Investigative Report for the incident dated 4/13/16 involving Resident 5 revealed the incident occurred at approximately 7:00 a.m. on 4/13/16. The investigation recorded the resident was found in the bathroom on the floor and was assessed with [REDACTED]. Documentation in the conclusion portion of the investigation revealed NA (Nurse Aide)-A and NA-B assisted the resident to the restroom and onto the toilet and both were called away to assist other residents leaving Resident 5 alone in the restroom. Interview with the DON (Director of Nursing) on 5/3/16 at 12:30 p.m. confirmed Resident 5 fell on [DATE] in the bathroom sustaining injuries to the forearm and head which required medical treatment and sutures. The DON confirmed the resident was identified as a fall risk prior to the incident and the resident's care plan instructed staff to remain with the resident in the bathroom when toileting. The DON verified the resident's fall prevention interventions were not implemented by the staff resulting in the fall with injury.",2019-05-01
1620,GOOD SHEPHERD LUTHERAN HOME,285148,2242 WRIGHT STREET,BLAIR,NE,68008,2017-06-01,323,G,1,0,BXIN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D7b Based upon record review and interviews, and observations the facility failed to identify causal factors following a resident fall. This affected 3 of 4 residents reviewed (Resident 2, 3, and 4). The facility census was identified as 72. FINDINGS ARE: [NAME] Record review of Resident 2's Admission Record, dated 06/01/2017, revealed Resident 2 was admitted with some of the following medical Diagnoses: [REDACTED]. A record review of Resident 2's nursing progress notes dated 4/28/2017 revealed Resident 2 was sitting in (gender) wheel chair near the med cart by nurses' station and was observed moving a straight back chair about. LPN A (Licensed Practical Nurse A) noted this and moved the chair from in front of the resident back to where the chair was originally placed and informed Resident 2 that staff would be along shortly to assist resident into bed. LPN A then went to give another resident medication. After LPN A returned to the med cart and began setting up meds for another resident when LPN A heard a thud. LPN A turned to observe Resident 2 lying on the floor in a prone position with glasses on and a laceration to the left side of Resident 2's forehead. A record review of Resident 2's MDS (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/or Medicaid-certified long-term care facility) dated 03/10/2017 revealed a BIMS Score (Brief Interview for Mental Status-a screening tool that aids in detecting cognitive impairment) score of 3, (score of three indicates the resident has severe cognitive impairment). A record review of Resident 2's Quarterly Morse Fall Scale (MFS: a rapid and simple method of assessing a patient's likelihood of falling) dated 03/04/2017 revealed a score of 75 (A score of 45 and higher indicates high risk). A record review of Resident 2's MFS dated 04/28/2017 revealed a post fall score of 55. It further revealed that the resident was one to Overestimates or forgets limits. A record review of Physician communication form dated 4/28/2017 revealed the following: FYI: Resident had a unwitnessed fall out of W/chair (wheelchair) onto floor (carpeted) landing in a prone position with laceration to the left forehead. Resident transported by ambulance to ER (emergency room ) for evaluation. resident sustained [REDACTED]. Patient returned with order for triple antibiotic ointment, we applied Steri-strips, Telfa and Kerlex. A record review of Resident 2's Care Plan dated 03/18/2014 revealed Resident 2 was at risk for falls related to poor safety awareness, weakness and unsteady gait. Interventions included that Resident 2 used a chair and bed electronic alarm. The facility was to ensure the device was in place as needed. A record review of Resident 2's Care Plan dated 04/29/2017 for Resident 2 revealed the following: I fell out of my chair while trying to stand up. I have a skin tear to my left elbow. The care plan had the following interventions: Continue interventions on the at-risk plan. Nursing to apply treatment as directed by MD. An interview with the DON (Director of Nursing) revealed that the resident did not have any causal factors identified on the fall facility incident report. The DON also confirmed there were no interventions to prevent this type of fall from occurring again. A record review of Resident 2's Fall Scene Investigation Report dated 05/02/2017 revealed under the root cause area Chair in wrong position and medication review? There was no documentation under the sections of describe initial interventions to prevent future falls. An interview with the Assistant Director of Nursing (ADON) on 06/01/2017 at 1:45 PM revealed that the resident was in a Tilt-N-Space wheel chair. There was no documentation to identify interventions to prevent the same situation from occurring again. B. Record review of Resident 3's Admission Record dated 06/01/2017 revealed Resident 3 was admitted with some of the following medical Diagnoses: [REDACTED]. A record review of Resident 3's nursing progress notes dated 5/12/2017 revealed a staff member alerted nursing that they heard a loud crash in Resident 3's room. Resident 3 was observed sitting on buttocks and leaning toward left side. ROM (Range of Motion) was WNL (Within Normal Limits) to all extremities. Voices c/o (complaint of) pain in left elbow/wrist but able to move them on (gender) own. Assisted into standing position with assist of two staff and gait belt without incident and placed into wheel chair. A record review of Resident 3's MDS dated [DATE] revealed a BIMS Score of 11(a score of 11 indicates moderate cognitive impairment). Observations on 06/01/2017 from 07:57 AM - 08:22 AM revealed Resident 3 was in the bathroom alone. Upon exiting the bathroom Resident 3 said that Resident 3 was closing the door to walk back to bed with Resident 3's walker. Resident 3 was wearing slippers. An interview with Resident 3 on 06/01/2017 at 08:25 AM revealed that Resident 3 blacked out and had fallen both at the facility and at home. The resident stated that (gender) was hard of hearing. Resident 3 stated that (gender) does use and push the call light button, but staff are not fast enough. Interview with Medication Aide B (MA B) at 08:30 AM revelaed that the staff checked on Resident 3 every 2 hours or so. Staff were to keep Resident 3's slippers near and remind Resident 3 to use (gender's) walker. The staff also makes sure Resident 3's floor and room were free from clutter. MA B stated that Resident 3 can be up and ambulatory independently. If staff does assist, they do use a gait belt. A record review of Resident 3's Quarterly MFS dated 03/28/2017 revealed a score of 90. It further revealed that Resident 3 had Impaired gait and was one to Overestimates or forgets limits. A record review of the Un-Witnessed Fall Incident Report dated 05/12/2017 revealed Resident 3's statement was I was walking to the bathroom by myself like I always do and lost my balance. It further revealed under the section Predisposing Physiological Factors: Gait imbalance and Weakness/Fainted. Under the section Predisposing Situation Factors: Improper foot wear, ambulating without Assist and during Transfer. In the section other info: wears loose slippers, refuses to wear tennis shoes. A record review of a Physician communication form dated 5/12/2017 revealed the following: patient was ambulating to bathroom without walker and lost (gender) balance. Observed sitting on buttocks leaning to left side. Noted a 3 x 2 purple bruise to lost posterior hand and 2 x 2.5cm bruise to left elbow (small scattered busies around left elbow as well.) ROM is WNL. Denies hitting head. Refusing to see doctor or allow ice pack to site. FYI. A record review of a Confirmation of Physician Visit dated 05/12/2017 revealed under the Reason for Visit was that the resident fell this AM and had increased edema (swelling) and pain. Under the physician progress notes [REDACTED]. A record review of Resident 3's Care Plan dated 5/16/2017 revealed the resident had a fall in the resident's room on 5/12/2017. Under interventions: I have poor safety awareness. Please check on me frequently during your shifts to encourage assistance so I don't try to toilet independently. The DON confirmed that the resident did not have any causal factors identified on the fall facility incident report. A record review of Resident 2's Fall Scene Investigation Report dated 05/16/2017 revealed that the Root Cause section was blank. C. Record review of Resident 4's Admission Record dated 06/01/2017 revealed Resident 4 was admitted with some of the following medical Diagnoses: [REDACTED]. The first symptoms of this disorder include varying degrees of weakness or tingling sensations in the legs). A record review of Resident 4's nursing progress notes dated 5/22/2017 revealed a staff member was assisting the resident to the bathroom. The resident stated their legs were giving out so the resident was lowered to the floor. During this time, the resident's head grazed against the door. A record review of Resident 4's MDS dated [DATE] revealed a BIMS Score of 13. A score of 13 indicates the resident is cognitively intact. Interview with LPN C at 09:10 AM revealed the fall of Resident 4 was a freak occurrence so the staff have been keeping a good eye on (gender) with no other interventions. Observation and interview with Resident 4 at 09:22 AM revealed Resident 4 stated that (gender) had one fall some time back, but did not remember any of the particulars including. A record review of Resident 4's Quarterly MFS dated 03/05/2017 revealed a score of 90. It further revealed that Resident 4 had Impaired gait and was one to Overestimates or forgets limits. A record review of the Witnessed Fall Incident Report dated 05/22/2017 revealed the following: Lowered to the floor by MA D and Resident 4's statement was stated hit head on door. A record review of Resident 4's Care Plan dated 6/16/2016 revealed: the focus: I am weak and have multiple falls at home. Intervention: I will let you know if my legs are giving out on me. A record review of Resident 4's Fall Scene Investigation Report, dated 05/31/2017, revealed under the Root Cause section: Weakness. Under the section: Describe initial interventions to prevent future falls: resident communicating with staff when his legs can no longer hold him. Under summary of meeting: Just discharged from therapy services. Under the sections conclusion and additional care plan/nurse aide assignment updates, there was no documentation noted. An interview with the ADON on 06/01/2017 at 1:45 PM stated that weakness was a new issue for Resident 4 and the facility had not identified the cause of the weakness.",2020-09-01
5715,NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER,285271,2100 CIRCLE DRIVE,SCOTTSBLUFF,NE,69361,2016-10-03,325,D,1,0,SRLF11,"**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 provide nutritional supplementation as ordered by the physician for two sampled residents (Residents 9 and 2). Sample size was three current residents. Facility census was 51. Findings are: A. Record review of Resident 9's Resident Face Sheet revealed the resident was admitted to the facility on [DATE] with a latest return date recorded as 12/10/2015. Further review of the face sheet revealed the resident was diagnosed with [REDACTED]. Record review of Resident 9's Medications Administration History forms for (MONTH) and (MONTH) of (YEAR) revealed an order starting on 12/24/2015 for [MEDICATION NAME] (nutritional supplement for nutritional support with residents diagnosed with [REDACTED]. B. Record review of Resident 2's Resident Face Sheet revealed the resident was admitted to the facility on [DATE] with a latest return date recorded as 5/23/2016. Further review of the face sheet revealed the resident had a medical [DIAGNOSES REDACTED]. Record review of Resident 2's Medications Administration History forms for (MONTH) and (MONTH) of (YEAR) revealed the resident had orders for nutritional supplementation including: Ensure Plus ordered on [DATE] with instructions to administer the medication twice daily at morning and afternoon snacks. The resident also had orders for ProStat Protein supplement with instructions to administer the supplement once a day with an order date of 6/9/2016. Further review of the administration forms revealed the following omissions of the Ensure supplement in (MONTH) and (MONTH) of (YEAR):: - The supplement was not administered on 8/1/16 in the afternoon due to resident at an activity and out for a walk. - The supplement was not administered in the afternoon on 8/2/16 due to the resident sleeping. -The ensure was not administered on 8/10/16 in the morning due to: waiting on shipment -The supplement was not administered on 8/11/16 in the morning due to: Resident unavailable. - The supplement was not administered on 8/26/16 and 8/29/16 due to the supplement being unavailable. - The supplement was not administered on 8/30/16 in the afternoon due to resident sleeping soundly. - The supplement was not administered in the morning on 9/2/16 due to the resident sleeping. Further review of the administration forms revealed the following omissions of the Prostat supplement in (MONTH) and (MONTH) of (YEAR): - The supplement was not given on 8/12; 8/13; and 8/14/16 due to waiting on pharmacy. - The supplement was not administered on 9/12/16 and 9/19/16 due to the supplement being unavailable. Interview with the Administrator, Director of Nursing, and facility Nurse Consultants on 10/3/16 beginning at 11:45 a.m. confirmed Residents 9 and 2 received physician orders [REDACTED].",2019-10-01
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
6305,HILLCREST HEALTH & REHAB,285133,1702 HILLCREST DRIVE,BELLEVUE,NE,68005,2016-04-27,333,D,1,0,IO6811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.10D Based on interview and record review; the facility failed to ensure that one resident (Resident 4) was free of significant medication errors. The facility census was identified at 109. Findings are: A. Record review of Resident 4's Face Sheet, dated 04/27/2016, revealed that Resident 4 was admitted on [DATE] for the following medical [DIAGNOSES REDACTED]. Record review of Resident 4's Medication Administration Record [REDACTED]. Record review of Resident 4's Preoperative Surgery Instruction sheet dated 11/19/2015 revealed instructions to do not take blood thinner medications within 7 days prior to your surgery. Surgery was scheduled on 12/1/2015. Staff noted this and both medications were discontinued on 11/24/2015. Record review of nursing progress notes dated 11/24/2015, revealed that Resident 4's POA (Power of attorney) canceled the scheduled surgery and that the nursing staff had notified the pharmacy to restart both medications. Record review of Resident 4's (MAR) for the month of (MONTH) revealed that Resident 4 was not receiving either Aspirin [MEDICATION NAME] coated 81 mg by mouth daily and Eliquis 2.5 mg by mouth twice a day as previously ordered on [DATE]. Record review of the physician orders [REDACTED]. Interview with RN G and RN E on 04/26/2016 at 1:30 PM, confirmed that these medications were discontinued and not restarted. When RN G was asked what the expectations for follow-up was; RN G stated the expectation of the staff was that the staff would report on to the oncoming shifts that the medication needs to be restarted and that they should continue to follow-up until the medication is restarted. RN G confirmed that the resident probably should have been on an anticoagulant due to the [MEDICAL CONDITION] condition and was not. Based on this resident's condition and the length that Resident 4 had gone without the anticoagulant medication, RN G considers this to be a significant medication error.",2019-04-01
2927,KEYSTONE RIDGE POST ACUTE NURSING AND REHAB,285238,7501 KEYSTONE DRIVE,OMAHA,NE,68134,2018-07-02,759,D,1,0,EO8U11,"**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 residents received medications as ordered with a 5% or less error rate for 3 residents ( Resident 104, 108, and 112). Observation of 26 medication administered revealed 3 medication errors resulting in an error rate of 11.50%. The facility census was 54. Findings are: [NAME] Observation on 6/27/2018 at 8:00 PM of eye drop medication administration for Resident 104 by Licensed Practical Nurse (LPN)-C revealed LPN-C administered 1 drop of [MEDICATION NAME] solution for [MEDICAL CONDITION] (high eye pressure) medication in each eye. Review of Resident 104 medical record revealed no signed order from the physician for the eye drops. Interview on 6/27/2018 at 8:15 PM with Consultant-D revealed no order for the medication could be located in the medical record. B. Observation on 6/28/2018 at 7:30 AM revealed LPN-A checked Resident 108's blood sugar and stated that she was not going to get any insulin because Resident 108's blood sugar was too low. Interview at 8:00 AM with LPN-A revealed each resident should have an order for [REDACTED]. Interview at 8:00 AM with LPN-A revealed Resident 108 does not have an order to not give insulin based on Resident 108's blood sugar level. C. Observation on 6/28/2018 at 8:30 AM revealed LPN-E gave Resident 112 one Vitamin [NAME] capsule from a bubble pack with the label that said 200 units give 1 capsule. Review of Resident 112's MAR revealed an order for [REDACTED]. Review of the signed physician order [REDACTED]. Interview on 6/28/2018 at 1:00 PM with LPN [NAME] revealed LPN [NAME] had not noticed the difference in the label and the MAR and that she had not compared them before dispensing and the order should have been clarified.",2020-09-01
3764,GOOD SAMARITAN SOCIETY - GRAND ISLAND VILLAGE,285285,4061 TIMBERLINE STREET & 4055 TIMBERLINE STREET,GRAND ISLAND,NE,68803,2019-09-26,760,D,1,1,7E3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.10D Based on observations, interviews, and record review, the facility failed to ensure that one sampled resident (Resident 39) and on non-sampled resident (Resident 46) were free of significant medication errors because the nurse administering their insulin failed to prime the insulin pens before giving the injections. Facility census was 59. Sample size was 19 residents. Findings are: On 9/24/19 at 7:45 AM, observed LPN (Licensed Practical Nurse)-D administer [MEDICATION NAME] 70/30 insulin (a combination of insulin [MEDICATION NAME] and insulin regular, an intermediate-acting and a short-acting insulin; https://www.drugs.com/[MEDICATION NAME]-30.html) to Resident 46. LPN-D removed the insulin pen from a locked cabinet in the resident's room, rolled the pen to mix the insulins, attached the needle, and administered 40 units of insulin to the resident. LPN-D did not prime the insulin pen before administering the medication. After leaving the resident's room, LPN-D opened the electronic Treatment Record for Resident 46 and verified that the correct dose had been administered before signing the record. On 9/24/19 at 8:02 AM, LPN-D prepared oral medications for Resident 39. After administering the oral medications, LPN-D removed an insulin pen from a locked cabinet in the resident's room. This pen was labeled [MEDICATION NAME]70/30. LPN-D was asked about the dose to be administered and about the facility policy regarding priming insulin pens. LPN-D responded that the dose was written on the label and stated that they were unaware of any policy related to priming insulin pens. LPN-D then administered 20 units of insulin to the resident. After leaving Resident 39's room, LPN-D signed out all the oral medications which had been given on the electronic Medication Record. LPN-D then opened the electronic Treatment Record and verified that the correct dose of insulin had been given before signing for the insulin administration. At that time, LPN-D was again asked about priming insulin pens to ensure the full dose of insulin was given, and the nurse repeated that they were unaware of any policy regarding this. Review of the facility's Policy and Procedure Insulin Pens revised 3/18 revealed under Procedure 10. Turn the dosage knob to '2' units to prime the pen. 11. Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears. 12. Dial in the ordered dose of units. Review of the facility's Policy and Procedure Medication Administration last revised 10/17 revealed under Procedure 5. Dosage of high-risk medications (e.g. liquid narcotics, insulin) should be double checked with another nurse prior to administration. Locations that do not have two licensed nurses on the same shift should create a process to calculate and post the dosage so that a nurse working alone may compare during administration On 9/26/19 at 10:35 AM, an interview with the DON (Director of Nursing) and the facility's Administrator verified that the facility policy required the nurse to prime insulin pens to ensure that the correct dose of insulin was administered. The DON also clarified that LPN-D was an agency nurse and had now been educated regarding the correct procedure for insulin administration.",2020-09-01
3763,GOOD SAMARITAN SOCIETY - GRAND ISLAND VILLAGE,285285,4061 TIMBERLINE STREET & 4055 TIMBERLINE STREET,GRAND ISLAND,NE,68803,2019-09-26,759,D,1,1,7E3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.10D Based on observations, interviews, and record reviews the facility failed to ensure that medications were administered accurately for one sampled resident (Resident 39) and two non-sampled residents (Residents 23 and 46) which resulted in a medication error rate of 14.29%. Facility census was 59. Sample size was 19 residents. Findings are: On 9/24/19 at 7:45 AM observed LPN (Licensed Practical Nurse)-D administer [MEDICATION NAME] 70/30 insulin (a combination of insulin [MEDICATION NAME] and insulin regular, an intermediate-acting and a short-acting insulin; https://www.drugs.com/[MEDICATION NAME]-30.html) to Resident 46. LPN-D removed the insulin pen from a locked cabinet in the resident's room, rolled the pen to mix the insulins, attached the needle, and administered 40 units of insulin to the resident. LPN-D did not prime the insulin pen before administering the medication. After leaving the resident's room, LPN-D opened the electronic Treatment Record for Resident 46 and verified that the correct dose had been administered before signing the record. On 9/24/19 at 8:02 AM, LPN-D prepared oral medications for Resident 39. Among the medications administered was ASA (aspirin) 81 mg. The electronic Medication Record indicated that this should be ASA 81 mg EC ([MEDICATION NAME] Coated, coated with a material that permits transit through the stomach to the small intestine before the medication is released; https://www.rxlist.com/script/main/art.asp?articlekey=3254). However, the medication in the card which was used for Resident 39 was chewable aspirin rather than [MEDICATION NAME] coated. After administering the oral medications, LPN-D removed an insulin pen from a locked cabinet in the resident's room. This pen was labeled [MEDICATION NAME] 70/30. LPN-D was asked about the dose to be administered and about the facility policy regarding priming insulin pens. LPN-D responded that the dose was written on the label and stated that they were unaware of any policy related to priming insulin pens. LPN-D then administered 20 units of insulin to the resident. After leaving the Resident 39's room, LPN-D signed out all the oral medications which had been given on the electronic Medication Record. When asked about the chewable aspirin, LPN-D replied that the dose was correct and that the pharmacy had provided the medication so it was the right form to use. LPN-D then opened the electronic Treatment Record and verified that the correct dose of insulin had been given before signing for the insulin administration. At that time, LPN-D was again asked about priming insulin pens to ensure the full dose of insulin was given, and the nurse repeated that they were unaware of any policy regarding this. Review of the facility's Policy and Procedure Insulin Pens revised 3/18 revealed under Procedure 10. Turn the dosage knob to '2' units to prime the pen. 11. Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears. 12. Dial in the ordered dose of units. Review of the Care Plan for Resident 39 revealed a history of GI (Gastrointestinal) bleed but did not specify the use of [MEDICATION NAME] coated aspirin. Review of the facility's Policy and Procedure Medication Errors under Medication Error Types listed Wrong Form of Medication The adminstration of a medication in a dosage form different from the one that was ordered by the prescriber. On 9/26/19 at 7:45 AM, LPN-H was administering medications to Resident 23. After administering the resident's oral medications and applying a topical gel, LPN-H administered [MEDICATION NAME] eye drops to the resident placing one drop in each eye. LPN-H then replaced the topical gel and the eye drops in the medication cart before signing out the medications which had been administered. When the nurse was signing the Medication Record for Resident 23, they were asked how many drops of [MEDICATION NAME] had been administered. LPN-H verified that only 1 drop had been placed in each eye and acknowledged the need to provide two drops in each eye based on the Medication Record. LPN-H then administered a second drop in each of Resident 23's eyes as ordered. The resident questioned the nurse asking why they were receiving more eye drops than usual this morning and was told this was for dry eyes. Observation of 28 opportunities for errors during medication administration by three nurses revealed a total of four errors which resulted in an error rate of 14.29%. On 9/26/19 at 10:35 AM, an interview with the DON (Director of Nursing) and the facility's Administrator verified that the facility policy required the nurse to prime insulin pens to ensure that the correct dose of insulin was administered. The DON also clarified that LPN-D was an agency nurse and had now been educated regarding the correct procedure for insulin administration.",2020-09-01