cms_NE: 6026

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
6026 ROCK COUNTY HOSPITAL LONG TERM CARE 2.8e+279 100 EAST SOUTH STREET BASSETT NE 68714 2016-12-14 223 E 0 1 K1OV11 **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 residents were protected from potential abuse for 3 residents (Resident 4, 9, and 17). The sample size was 23 and the facility census was 28. Findings are: A. Review of the facility policy titled Abuse Reporting and Investigation (revision date 1/18/16) revealed the following: -Sexual abuse was defined as sexual harassment, sexual coercion or sexual assault; -In all case of alleged abuse, neglect or misappropriation of property, the facility would intervene in the situation, report the situation to the proper authorities, investigate the allegation and prevent abuse, neglect and misappropriation while the investigation was in process; -The facility would have documented evidence allegations of abuse/neglect/misappropriation were investigated; and -Results of investigations of potential abuse/neglect/misappropriation of property were to be submitted to the State agency within 5 working days. B. Review of a Progress Note dated 9/10/16 at 6:20 PM revealed Resident 4 returned from an outing and it was reported the resident fell in the bathroom while out of the building. The resident had a hematoma (an abnormal collection of blood outside of the blood vessel) measuring 6 centimeters (cm) by 6cm. The hematoma was light purple in color and had a superficial split measuring 2cm by 2cm. The physician ordered a computed tomography (CT- uses x-rays to make images of parts of the body) scan of the head. Review of the facility investigations of potential abuse/neglect from 1/10/16 through 12/14/16 revealed no evidence Resident 4's fall with injury requiring medical treatment was reported to the State agency and there was no evidence an investigation was completed. Interview with the Director of Nursing (DON) on 12/14/16 at 10:53 AM confirmed the fall was not investigated or reported. The DON stated the incident happened while the resident was out of the facility and was unaware that it should have been investigated and reported. C. Review of Resident 4's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 7/6/16 revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 4's Progress Notes revealed the following: - On 7/3/16 at 3:29 AM Resident's 4 and 9 were found in Resident 4's room with the door closed. When a staff member entered the room Resident's 4 and 9 were observed touching each other with clothing in disarray. Both residents were instructed to go to the activity room if they wanted to visit. Resident 9 then left the room. - On 8/1/16 at 3:09 PM it was reported to the facility that Resident 4 and Resident 9 were kissing in the dining room. Resident 4's family felt the resident's cognition had diminished and the resident would not have formerly acted in this manner. During an interview on 12/14/16 at 9:35 AM Nursing Assistant-K revealed Resident 4 was fond of Resident 9 and Resident 9 would try to get Resident 4's attention by going back and forth slowly in the hallway. Resident 4 would then try follow Resident 9 into the resident's room. During an interview on 12/14/16 at 10:37 AM the Social Services Director (SSD) confirmed Resident 9 would slowly go past Resident 4's room in the resident wheelchair and then Resident 4 would try to get up and follow Resident 9. The SSD felt Resident 4 wouldn't have been involved in such an activity if it was not for the resident's dementia. The SSD revealed the facility had not completed an investigation other than what was documented in the progress notes. During an interview on 12/14/16 at 10:53 AM the DON confirmed the incidents between Resident's 4 and 9 had not been investigated or reported. The DON stated they just tried to keep Resident 4 and Resident 9 separated the best they could. D. Review of Resident 9's MDS's dated 6/22/16 and 9/14/16 revealed the resident was cognitively intact. Review of Resident 9's Progress Notes revealed: - On 8/1/16 at 5:05 PM Resident 9 entered the SSD's office upset regarding allegations of Resident 9 and Resident 4 kissing in the dining room. Resident 9 denied the allegations and stated Resident 4 just went overboard. Resident 9 was instructed to keep away from Resident 4. - On 11/16/16 at 5:38 AM after supper Resident 9 sat next to Resident 17 in the activity room. A staff member observed Resident 9 holding Resident 17's hand and moving it against Resident 9's leg. When Resident 9 saw the staff member Resident 9 let go of Resident 17's hand. - On 11/16/16 at 1:50 PM the SSD spoke with Resident 9 regarding the incident with Resident 17. Resident 9 denied the allegations. Resident 9 stated Resident 17 grabbed Resident 9's hand and wouldn't let go. Review of the facility investigations of potential abuse/neglect from 1/10/16 through 12/14/16 revealed no evidence the incidents between Resident 9 and Resident's 4 and 17 were reported to the State agency and there was no evidence investigations were completed to ensure the residents were free from potential abuse. 2019-07-01