cms_NE: 8311

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
8311 HENDERSON CARE CENTER 2.8e+174 1621 FRONT STREET HENDERSON NE 68371 2014-02-27 323 L 0 1 WOMQ11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 AND 12-006.09D7a Based on observation, interview, and record review; the facility failed to ensure one resident (Resident 18) was not left unattended while bathing in a whirlpool tub with water and failed to maintain the whirlpool tub bath belt free from rips, frayed areas, and peeling plastic pieces with rough edges affecting 37 out of 38 residents. The facility census was 38. Findings are: A. During the initial tour of the facility on 2/25/14 at 8:35 am, the facility bath house door was unlocked. There was no staff member in attendance and Resident 18 was in the whirlpool tub with water, Resident 18 was leaning forward. There was a bath belt around the resident's waist and between the resident's legs. The bath belt was loosely applied and had frayed edges. Approximately one minute later a staff member entered the bath house carrying clothing. B. Interview with BA (Bath Aide) A 2/25/14 at 8:37 am revealed that the staff member never left residents alone in the whirlpool. The BA A stated that the resident lived nearby and just went down the hall to get the resident's clothing. Interview with the DON on 2/25/14 at 9:35 am and revealed that Bath Aide A was the only staff member that bathed residents. There was only one resident that preferred showers. Interview with BA A on 2/27/14 at 9:45 am revealed that with Resident 18 (gender) always used the T- strap bath belt (belt through the legs). BA A stated the staff did not bring the resident's clothing with the resident. The BA stated unsure why left the bath house to get the clothing. BA A stated that the bath belts were the original bath belts that came with the whirlpool tub two years ago. If the BA had any trouble with the tub the BA would report it to the Maintenance department. Interview with Resident 18 on 2/26/14 at 9:05 am revealed that the resident stated that (gender) was left alone in the whirlpool tub once in a while when the resident forgot her clothing. The resident stated that the resident's room was close by and BA A would leave and get the clothing if forgotten. C. Review of Resident 18's Annual MDS (Minimum Data Set: a federally mandated comprehensive data collection tool used for care planning) dated 10/13/13 revealed that the resident's BIMS (Brief Interview for Mental Status) was a 10 (8-12 moderate cognitive impairment). The resident did not have any behaviors. The resident required extensive assistance with activities of daily living which included: transfers, bed mobility, walking in room, locomotion, dressing toilet use, personal hygiene, and bathing. The resident required hands on assistance with correction of all balance. The resident had limited range of motion in the upper and lower extremities on one side. The resident received restorative nursing program for active range of motion. Review of Resident 18's Quarterly MDS dated [DATE] revealed that the residents BIMS was a 10. The resident had a total mood score of 10. The resident did not have any behaviors. The resident required extensive assistance with activities of daily living which included: transfers, bed mobility, locomotion, dressing toilet use, personal hygiene, and bathing. The resident was non-ambulatory. The resident's balance activity required assistance from staff. The resident had limited range of motion in the upper and lower extremities on one side. The resident receive restorative nursing program for active range of motion. The resident had not fallen in the past three months. Review of Resident 18's Care Plan dated 2/4/10 and revised on 1/14/14 revealed that the resident had a self-care deficit related to hyponatremia (low levels of sodium in the bloodstream) and a mild stroke. The resident experienced weakness, fatigue, left sided weakness and an unsteady gait and balance. The resident's goal was to receive the necessary assistance needed to complete ADL (Activities of Daily Living) tasks to allow participation. The resident's interventions included: one to two physical assistance with ADLS; provide two staff assists with transfers using a gait belt; twice weekly whirlpool baths. Review of Resident 18's Fall Risk Assessment and Intervention dated 1/15/14 revealed that the resident had a score of 14. A score of 7+ was a higher risk. D. Observation of Resident 18's transfer from bed to chair on 2/27/14 at 10:35 am revealed NA (Nurses Aides) B and C assisted the resident from a lying position to a seated position on the edge of the bed. The resident required assistance to maintain seated balance. A gait belt was applied around the resident's waist. The resident was assisted to a standing position with extensive assistance of the two NAs and a pivot transfer was done. The resident was unable to move the resident's left foot. E. Interview on 2/25/14 at 8:55 am with the DON (Director of Nursing) revealed that the resident had a CVA - Cerbral Vascular accident (stroke) and was flaccid (weakness) on the resident's left side. The resident required 2 staff assistance with activities of daily living. The resident had poor balance from the resident's CVA. Interview with DON and ADM (Administrator) on 2/25/14 at 11:15 am revealed it had been reported to SS (Social Services) that BA A had left a resident unattended in the whirlpool tub. The staff member had received re-education on the bathing policy and procedure to never leave a resident unattended in the whirlpool. Observation of Resident 11 on 2/27/14 at 9:25 am Bath Aide A attached a ripped, frayed, peeling rough waist bath belt around the resident and lifted the resident approximately four feet up with the lift and lowered the resident into the Superior Aqua Aire Whirlpool Tub. The Bath Aide did not put the strap on between the resident's legs. The Bath Aide did not leave the resident alone during the observation. F. Interview with the DON and ADM on 2/27/14 at 10 am revealed that they acknowledged the peeling plastic, ripped edges, and frayed edges of the bath belt. The DON stated that a bath belt was ordered on [DATE] when it was reported it was frayed. The DON stated that the bath belt had not been on any checklist to monitor when worn for replacement. G. Review of the Facility Bathing Policy dated as revised on 5/2012 revealed that the bath aide was always to ensure the residents were attended to while in the bath. Review of the Penner Superior Aqua Aire whirlpool tub manual stated Daily Safety Checklist Penner Transfer Perform the following safety checks for the Penner Transfer: 1. Seat Belt- Check this is to insure the parts are secure and not missing. WARNING If during the safety checks you find parts are missing are excessively worn, do not function properly, do not operate the equipment until the maintenance department has taken the appropriate corrective action. H. The immediate jeopardy was abated to an E 2/27/14 when the facility provided information that the bath aide had been re-educated to not leave residents unattended in the whirlpool tub. The other nursing staff attended an in-service on 2/26/14 and were educated to not leave residents in the whirlpool unattended. The DON had an additional belt that was on the top of the chair switched to the waist. The DON had ordered a new whirlpool bath belt on 2/25/14 that had not arrived yet on 2/27/14. 2017-09-01