cms_NE: 6423

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
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