cms_NE: 11264

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
11264 AINSWORTH CARE CENTER, LLC 285142 143 NORTH FULLERTON STREET AINSWORTH NE 69210 2014-12-02 241 E 0 1 ZQ0211 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(21) Based on observations, staff interview and record review; the facility failed to ensure residents were treated with respect and dignity related to: 1) transporting Resident 9 to the bathing room and prolonged wait time to receive meal service; 2) positioning Resident 29's urinary catheter drainage bag to prevent visual exposure; and 3) prolonged wait time to receive meal service and soiled clothing/equipment for Resident 15. Facility census was 33. Findings are: A. Review of Resident 9's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/3/14 revealed [DIAGNOSES REDACTED]. The same MDS indicated the resident had moderate cognitive impairment, was dependent upon staff for transfers and personal hygiene and required extensive assistance with eating. Review of Resident 9's Care Plan dated 10/9/14 revealed the resident wore a wig and removed it when napping/sleeping during the day and at night. The Care Plan indicated a goal to provide the resident with dignity and respect. The intervention indicated the privacy curtain was to be closed when the resident was napping/sleeping to provide privacy and dignity. In addition, the Care Plan indicated Resident 9's family requested the resident not be taken to the dining room "too early" in the morning. The Care Plan indicated the resident was to remain in room until "shortly before breakfast is served." On 11/19/14 at 7:18 AM, Resident 9 was observed seated in a shower chair (a chair on wheels which allows the resident to be rolled into the shower while seated). Nursing Assistant (NA)-B pulled Resident 9 backwards with 1 hand and with the other hand pushed the resident's wheelchair through the Wing 1 corridor while en-route to the bathing room. Resident 9 was not wearing the wig, was dressed in a hospital gown and covered with a torn frayed blanket. The resident's bare legs and feet dangled below the blanket. The resident's wig was lying in the seat of the wheelchair. At 7:41 on 11/19/14, NA-B was observed to wheel Resident 9 out of the bathing room and into the dining room. Resident 9 was not served the breakfast meal until 8:35 AM (53 minutes later). On 11/20/14 Resident 9 was observed seated at the table in the dining room waiting to be served the breakfast meal from 7:11 AM until 10:03 AM (2 hours and 52 minutes later). B. Review of Resident 29's MDS dated [DATE] identified a [DIAGNOSES REDACTED]. Review of Resident 29's Care Plan with revision date of 9/14/14 revealed the resident had a supra-pubic urinary catheter (tube inserted into the bladder through a hole in the stomach to drain urine from the bladder) with an intervention to store the urinary catheter drainage bag inside a protective dignity pouch. Observations of Resident 29 revealed the following: -11/19/14 from 8:23 AM to 9:06 AM- the resident was observed seated in a wheelchair in the Dining Room. A urinary catheter drainage bag was observed attached to the wheelchair frame. The urinary catheter drainage bag was stored in a dignity pouch, but the pouch had bunched around the tubing and the top of the drainage bag. The drainage bag contained dark yellow urine which was visible to any other residents and/or visitors seated in the Dining Room. -11/24/14 at 5:38 PM- the resident was observed seated in a wheelchair in the dining room. A urinary catheter drainage bag was observed attached to the frame of the wheelchair. The lower 5 inches of the urinary catheter drainage bag was uncovered and dark yellow urine was visible to any residents and/or visitors seated or passing through the Dining Room. -11/25/14 from 7:01 AM to 8:02 AM- the resident was observed seated in a recliner. The foot rest of the recliner was elevated and the resident's urinary catheter drainage bag was observed uncovered and attached to the framework under the foot rest. The catheter bag and 300 cubic centimeters (CC) of dark yellow urine were visible from the doorway of the resident's room. -12/1/14 from 6:40 AM to 7:50 AM- the resident's urinary catheter drainage bag was uncovered and lying directly on the floor in the entrance of the resident's room. The catheter bag contained 350 cc of dark yellow urine and was visible from the hallway and the entrance of the resident's room. During an interview on 12/2/14 from 8:30 AM to 8:45 AM, the Director of Nursing verified Resident 29's supra-pubic urinary catheter drainage bag should have been kept covered at all times to maintain the resident's dignity. C. The following was observed during Resident 15's breakfast meal on 11/20/14: - The resident sat in the wheelchair at the dining room table with no food or fluids from 6:55 AM until 7:48 AM. - At 7:48 AM (53 minutes after first observed in the dining room) the resident was served water, juice and nutritional supplement. The resident retrieved and drank the fluids independently. - At 9:21 AM the resident sat with head down and eyes closed, still awaiting service of the breakfast meal. The resident had consumed 100% of the nutritional supplement and juice, and 50% of the water. - At 9:54 AM (2 hours and 59 minutes after the resident was first observed in the dining room awaiting service of the meal) the resident was served a piece of toast with jelly and ate independently. During observation of incontinent care for Resident 15 on 11/24/14 from 1:12 PM until 1:25 PM, NA-D and NA-E transferred the resident from wheelchair to toilet. The resident's sweatshirt and pants were soiled with food splatter. There was a sheet of clear plastic beneath the cushion in the seat of the wheelchair that extended out the side of the chair and was heavily soiled with food spillage. The tire of the wheelchair on the same side was splattered as well. Without cleaning the sheet of clear plastic, NA-E replaced it beneath the wheelchair cushion so it no longer extended out the side of the chair and was no longer visible. Following incontinent care, Resident 15 was transferred to bed. The resident's soiled clothing was not changed, and the resident was left to rest in bed. During interview on 12/1/14 at 10:18 AM, the Director of Nurses verified the clear plastic sheet beneath Resident 15's wheelchair cushion was used to keep the cushion from sliding. The DON further verified staff should have changed the resident's soiled clothing prior to laying the resident in bed to rest. 2015-07-01