cms_NE: 5887

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
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