cms_NE: 2917

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.

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
2917 KEYSTONE RIDGE POST ACUTE NURSING AND REHAB 285238 7501 KEYSTONE DRIVE OMAHA NE 68134 2018-06-14 689 I 1 0 BBR311 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.18E3 Based on observation, interview, and record review, the facility failed to protect 1 (Resident 4) of 4 sampled residents from a hot liquid burn and the facility failed to ensure that water temperatures did not present a potential scald hazard This practice had the potential to affect 37 residents who consume hot liquids, 55 residents who take baths in the facility and 32 residents of the facility who utilized the bathroom sinks in resident rooms. The facility had a total census of 57 residents. Findings are: [NAME] Resident 4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations on 6/13/18 at 11:45 AM revealed multiple fluid filled blisters to Resident 4's lower left arm. A review of a Skin Ulcer Non-Pressure assessment dated [DATE] revealed the following: -Chin burn, two areas in close proximity, measuring 3 cm (centimeter) in length x 2 cm in width. -Chest/left breast burn, multiple areas measured as one 22 cm in length x 16.5 cm in width. -Left arm burn, multiple areas, measured as one 16.6 cm in length x 6.2 cm in width. A review of a 6/13/18 at 6:30 AM Progress Note revealed a staff member was called to the resident's room and multiple areas were found. A review of Resident 4's Hot Liquid Safety assessment dated [DATE] revealed Resident 4 required staff set up for drinking hot liquids. Recommendations were cool beverages prior to handling/drinking. Educate resident/caregivers of hot liquids as a causative factor to prevent skin injury. Resident 4 requires a 2 handle cup and lid for hot liquids. In an interview on 6/11/18 at 10:14 AM, the Director of Nursing reported an investigation had been completed the following week due to a burn on Resident 1's foot. From that investigation, it was discovered the coffee was very hot and the coffee pot was to be replaced. Staff were provided education regarding the hot coffee. A review of the In-Service Training Report dated 6/8/18 revealed training was provided to 7 staff members that coffee had to be cooled down and hot liquids needed to be temped at 140 degrees F or lower before giving to resident. In an interview on 6/13/18 at 11:12 AM, Administrator and Director reported second [MEDICAL CONDITION] been discovered on Resident 4 that morning and the Director of Nursing had been notified at 9 AM. The Administrator reported coffee temperatures were to be checked and cooled before giving to resident. The investigation was being completed at that time and the coffee machine had been locked to prevent its use. In an interview on 6/13/18 at 12:32 PM, Dietary Aide A reported attending the in-service last week and adding ice cubes to the coffee it is too hot. Dietary Aide A reported that Dietary Aide A did not check the temperature of the coffee but could tell if the coffee was hot by feeling the bottom of the cup. In an interviews on 6/13/18 at 12:35 PM, the Administrator reported coffee was found to be 168 to 170 degrees F when coming out of the coffee machine. The Administrator had expected staff to record the temperatures of the coffee after being cooled and before service to resident but that was not being done. According to the Administrator, the current coffee machine was going to be removed and replaced with the coffee machine that the facility had previously used. B. Observations on 6/11/18 at 10:38 AM revealed a hot water temperature of 145 degrees F (Fahrenheit) in the shower on the Medical Center floor of the facility. Observations on 6/11/18 at 10:44 AM revealed a hot water temperature of 122 degrees F in the whirlpool on the Medical Center floor of the facility. Observation on 6/11/18 at 10:50 AM revealed a hot water temperature of 116 degrees F in the whirlpool and 116.6 F in the shower on the Garden level. Observations on 6/11/18 at 1:32 PM revealed a hot water temperature of 133 degrees F in the whirlpool on the Medical Center floor of the facility. In an interview on 6/11/18 at 1:32 PM, the Maintenance Director reported the water heater had been adjusted down and the water line just needed to be emptied. Observations on 6/11/18 at 1:58 PM revealed a hot water temperature of 130.2 degrees F in the bathroom sink for room [ROOM NUMBER]. Observations on 6/11/18 between 3:52 and 4:16 PM revealed the following hot water temperatures: -bathroom sink in room [ROOM NUMBER]-121.4 degrees F -bathroom sink in room [ROOM NUMBER]-125.7 degrees F -bathroom sink in room [ROOM NUMBER]-122.5 degrees F -Medical Center shower-120.2 degrees F A review of water temperature log from 6/5/17 to 6/8/18 revealed checks of hot water temperature had been checked on garden tub, medical center tub on 6/8/18, 8/25/17, and 7/27/18 In an interview on 6/11/18 at 10:52 AM, the Maintenance Director reported water temperatures are not to exceed 120 F in bathing fixture and facility water temperatures usually are between 108-110 degrees F in the facility. In an interview on 6/11/18 at 11 AM, the Director of Nursing reported all baths in the facility had been stopped. In an interview on 6/11/18 at 4:17 PM, the Administrator reported the facility was getting bids for repair of the water mixing valve. In a telephone interview on 6/11/18 at 4:34 PM, the facility Outside Contracted Plumber reported one mixing valve had been determined to be in need of repair. The hot water had been rerouted to go through the other mixing valve. The Outside Contracted Plumber reported the water temperature had been set between 115-117 F and the water temperature in the sinks and bathing areas would decrease once the water in the pipes was used. A review of 30 minute water temperature checks completed between 5:30 PM on 6/11/18 and 9 AM on 6/12/18 revealed 90 of 144 water temperatures were greater than 121 degrees F in bathing fixtures and resident bathroom sinks. In an interview on 6/12/18 at 10:19 AM, the Administrator reported signs stating not to use sink were being put on sinks with high water temperatures. In an interview on 6/12/18 at 11 AM, the Regional Director reported the hot water in the building had been shut off until one of the mixing valves could be repaired. A review of Center for Medicare and Medicaid Services guidelines effective 11/28/17 for temperatures revealed for the following: -Temperatures of 120 degrees F can cause a third degree burn within 5 minutes -Temperature of 133 degrees F can cause a third degree burn within 15 seconds -Temperature of 140 degrees F can cause a third degree burn within 5 seconds -Temperature of 148 degrees F can cause a third degree burn within 2 seconds 2020-09-01