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| Link | rowid | facility_name | facility_id | address ▼ | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4072 | 4072 | ROCK COUNTY HOSPITAL LONG TERM CARE | 285304 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2019-04-10 | 600 | D | 0 | 1 | 8X4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].02(8) Based on record review and interview, the facility failed to ensure residents were protected from potential abuse for 2 residents (Residents 1 and 23). The sample size was 2 and the facility census was 22. Findings are: [NAME] Review of the facility policy titled Abuse Reporting and Investigation (revision date ,[DATE]) revealed sexual abuse was defined as sexual harassment, sexual coercion or sexual assault. The policy further identified the following tips for the prevention of abuse: -observation of resident behaviors and reactions/interactions with other residents; -educate staff on care needs of the residents; and -assess, monitor and develop appropriate plans of care for residents with inappropriate sexual behavior whether behavior is toward the staff, or other residents. B. Review of Resident 1's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated [DATE] revealed [DIAGNOSES REDACTED]. The assessment indicated the resident was cognitively intact, however the resident had episodes of hallucinations and delusions. The assessment further indicated the resident had behaviors which included verbal behaviors directed at others, rejection of cares and wandering. The resident's behaviors were worse than behaviors identified with the previous assessment. Review of a Nursing Progress Note dated [DATE] at 4:07 AM revealed the resident had been making confused statements the previous evening shift regarding a deceased resident. Resident 1 indicated the resident had not really passed away and was just setting there knitting. Review of a Nursing Progress Note dated [DATE] at 8:11 AM revealed Resident 1 was making confused statements regarding Resident 23. Review of a Nursing Progress Note dated [DATE] at 8:26 AM revealed the resident was making confused statements. The resident indicated to the Bath Aide the resident felt the resident needed something … | 2020-09-01 |
| 4073 | 4073 | ROCK COUNTY HOSPITAL LONG TERM CARE | 285304 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2019-04-10 | 684 | D | 0 | 1 | 8X4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER ,[DATE].09A Based on record review and interview, the facility failed to assure an initial nursing assessment was completed for Resident 32 upon admission to the facility, and that the resident was routinely monitored to determine care and treatment needs. The sample size was 1 and the facility census was 22. Findings are: [NAME] Review of the facility policy titled Admissions (LTC-Long Term Care), Last Approved ,[DATE], revealed that upon admission to the facility, the nurse must record the following data in the nurses's notes: -Date and time of the resident's admission; -Age, sex, race and marital status; -The name of the person accompanying the resident and his/her relationship to the resident; -From where the resident was admitted ; -Reason for admission; -Current vital signs and condition of resident upon admission; -The time the physician's orders were received and verified; -Description of any lab work; -Acute conditions; -Presence of a catheter, dressings, etcetera; -The time dietary was notified of the diet order; -Complete the nursing assessment; -A brief description of any disabilities; -Any known allergies [REDACTED].>-Prosthesis required; -Weight and height of the resident;; and -Signature and title of the person recording the data. B. Initial documentation in Resident 32's Medical Record was completed on the Clinical Weights and Vitals form dated [DATE] from 1:30 PM until 1:59 PM and included the resident's weight, height, blood pressure (BP), temperature (T), pulse (P), respirations (R) and oxygen (O2) saturation (a measure of the amount of oxygen in the bloodstream). Review of Progress Notes indicated the first entry related to Resident 32's admission to the facility was completed by the Social Services Director (SSD) on [DATE] at 5:11 PM and revealed the resident was admitted to the facility at 10:50 AM (2 hours and 40 minutes prior to documentation of the resident's weight and vital signs) that mor… | 2020-09-01 |
| 4074 | 4074 | ROCK COUNTY HOSPITAL LONG TERM CARE | 285304 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2019-04-10 | 686 | D | 0 | 1 | 8X4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility failed to provide care and treatment to assure healing of Resident 7's pressure ulcers. The sample size was 1 and the census was 22. Findings are: Review of Resident 7's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/25/19 revealed the following: -cognition was severely impaired; -required extensive staff assistance with transfers, eating, bed mobility, dressing, toilet use and personal hygiene; -always incontinent of bowel and bladder; and -the resident had a Stage I (skin is not opened but appears reddened) and a Stage II (partial thickness skin loss that presents as an abrasion, blister or shallow crater) pressure ulcers. Review of a Skin Observation Tool dated 1/13/19 at 1:24 PM revealed the resident had a Stage II pressure ulcer to the resident's coccyx which measured 2 centimeters (cm) by 2 cm. Review of a Physician order [REDACTED]. Review of a Skin Observation Tool dated 1/19/19 (6 days later) at 6:39 PM revealed the resident had a Stage II pressure ulcer to the coccyx which measured 2.2 cm by 2 cm. The area was assessed and then left open to the area with [MEDICATION NAME] (barrier cream used to protect skin from wetness, urine or feces) ointment applied. Review of a Skin Observation Tool dated 1/22/19 at 1:27 PM revealed the resident's Stage II pressure ulcer was unchanged and measured 2.2 cm by 2 cm. Review of a Skin Observation Tool dated 1/31/19 (9 days since the previous assessment) at 9:12 AM revealed the pressure ulcer to the resident's coccyx measured 2 cm by 2 cm but was now only a reddened area. Review of a Skin Observation Tool dated 2/3/19 at 10:33 AM revealed the pressure ulcer to the resident's coccyx was unchanged and continued to be identified as a reddened area which measured 2 cm by 2 cm. Review of a Skin Observation Tool dated 2/6/19 at 5:20 AM rev… | 2020-09-01 |
| 4075 | 4075 | ROCK COUNTY HOSPITAL LONG TERM CARE | 285304 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2019-04-10 | 689 | D | 0 | 1 | 8X4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Numbers 175 NAC 12-006.09D7 Based on observations, record review and interview, the facility failed to assure a safe environment was provided for residents identified at risk for falls as fall prevention interventions were not implemented, revised and/or new interventions developed to prevent ongoing falls for 2 (Residents 3 and 18) of 4 sampled residents. Facility census was 22. Findings are: [NAME] Review of Resident 18's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/30/19 revealed [DIAGNOSES REDACTED]. The same assessment indicated the resident's cognition was moderately impaired, the resident required extensive staff assistance with toileting, transfers, dressing and personal hygiene and indicated the resident was frequently incontinent of bowel and bladder. The resident had 1 fall with a minor injury and 2 falls without any injury since the previous assessment. Review of a Nursing Progress Note dated 10/18/18 at 6:30 PM revealed the resident was heard calling for help. Upon entering the resident's room, the resident was found lying on the floor next to the resident's bed. When the resident was asked what had happened, the resident pointed to the heating unit on the wall and stated, I stepped up on that thing and it spun me around. review of the resident's medical record revealed [REDACTED]. Review of a Nursing Progress Note dated 12/3/18 at 8:10 PM revealed the resident was found seated on the floor of the resident's room, positioned next to the resident's trash receptacle. The resident had removed the resident's disposable, urinary incontinence brief and the brief was now located in the trash receptacle. While pointing to the trash receptacle, the resident indicated I was going to sit down on this, but it didn't hold me up. The resident was assisted to the bathroom. No injuries were noted. Review of a Falls Intervention Report dated 12/3/18 revealed the resid… | 2020-09-01 |
| 6021 | 6021 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2015-12-10 | 225 | D | 0 | 1 | 77700000000000.0 | **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 report and/or investigate potential allegations of abuse for 2 residents (Residents 14 and 18). The facility census was 28. Findings are: A. Review of the facility Abuse Reporting and Investigation policy (revision date 8/2010) included the following: -In all cases of alleged abuse/neglect the facility was to intervene in the situation, report the situation to the proper authorities, investigate the allegation and prevent abuse/neglect while the investigation was in process. Documented evidence the facility intervened, reported, prevented abuse/neglect and completed an investigation was to be completed. -The abuse reporting procedure was to be initiated when an accident with significant injury occurred and resulted in the resident needing immediate medical attention. B. Review of an Incident Report dated 1/2/15 at 6:40 AM revealed Resident 14 was assisted to the toilet by a staff member. Documentation indicated the staff member turned to get something and the resident was discovered lying on the floor with their head under the sink and feet pointing towards the door of the bathroom. The resident sustained [REDACTED]. Review of Progress Notes revealed a late entry dated 1/2/15 at 6:40 AM which indicated Resident 14 was discovered lying on the bathroom floor. The resident complained of back pain and had a 1.5 centimeter (cm) laceration on the back of the head. The resident was transported to the emergency room for treatment. Documentation further indicated the resident returned from the emergency room at 10:00 AM that day after the laceration had been sutured (stitched). Review of the facility investigations of potential abuse/neglect from 1/1/15 through 12/10/15 revealed no report had been filed with the State Agency regarding Resident 14's fall on 1/2/15 which resulted in the need for immediate medical attention. There was no evidence … | 2019-07-01 |
| 6022 | 6022 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2015-12-10 | 242 | D | 0 | 1 | 77700000000000.0 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(4) Based on record review and interview, the facility failed to accommodate residents' individual preferences related to frequency of baths for Residents 13 and 18. The facility census was 28. Findings are: A. During interviews conducted on 12/8/15 from 10:03 AM until 10:59 AM the following was revealed: -Resident 13 indicated would like a bath every day but had never been asked bath preference and was never given a choice. -Resident 18's family member indicated the resident received 2 baths weekly but should receive baths more often due to incontinence. B. Review of the Bath Schedule (not dated) indicated Residents 13 and 18 received baths 2 times weekly on Tuesday and Friday. C. During interview on 12/9/15 at 10:26 AM, Resident 13 verified 2 baths weekly were currently provided. The resident indicated preference for a daily bath, but would be satisfied with 3 baths weekly. D. During interviews on 12/10/15 from 6:45 AM until 8:24 AM, the following was revealed: -Nursing Assistant (NA)-K worked as a Bath Aide 4 days a week. No routine baths were provided on Wednesday or the weekend. There was a 2 bath a week rule in the facility, and some residents' baths were scheduled on Monday and Thursday, and the others on Tuesday and Friday. -The Director of Nursing (DON) indicated residents received 2 baths weekly but they would try to accommodate residents if they asked for more. The DON further indicated it was the responsibility of the Social Services Director (SSD) to evaluate residents' preferences for bath choice upon admission. -Interview with the SSD indicated residents received 2 baths weekly, and this information was related to residents and/or family members on admission. The SSD further indicated there was no further discussion with residents and/or family members related to bath frequency. | 2019-07-01 |
| 6023 | 6023 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2015-12-10 | 248 | D | 0 | 1 | 77700000000000.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D5b Based on observation, record review and interview; the facility failed to provide individualized activities for 1 resident (Resident 18). The facility staff identified a census of 28. Findings are: Review of Resident 18's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/25/15 identified [DIAGNOSES REDACTED]. The assessment further indicated the resident had severe cognitive impairment, displayed no behaviors and required total staff assistance with activities of daily living, which included mobility out of the resident's room. Review of Resident 18's Care Plan with revision date 11/25/15 revealed the resident was dependent on staff to be brought out to activities. The Care Plan further revealed the resident liked bright things, math, puzzles, going outside, markers, coloring books and games. Interventions included: -Remind the resident of activities each day. -Visit with the resident 1:1 and play bounce the ball with the resident. -Take the resident outside when the weather permits. -Read short stories to the resident. -Assist with doing simple math problems or spelling words. Review of Resident 18's Activity Participation Review dated 11/25/15 revealed the resident's activity preferences included playing Bingo, coming to music events and watching other residents during arts and crafts activities. Record review of Resident 18's activity attendance record for (MONTH) (YEAR) revealed Resident 18 had attended 7 activities in the month. Review of Resident 18's activity attendance record from 12/1/15 to 12/7/15 revealed the resident attended 2 activities. During stage 1 of the survey, Resident 18 was not observed to be involved in activities. Observations on 12/8/15 revealed from 2:00 PM to 3:00 PM, Bingo was held in the facility dining room. Observations of Resident 18 on 12/8/15 from 2:00 PM to 3:00 PM, revealed the resident was seated in a w… | 2019-07-01 |
| 6024 | 6024 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2015-12-10 | 329 | D | 0 | 1 | 77700000000000.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were free from the use of psychoactive medications (drugs that can alter consciousness, mood and thoughts) as: 1) Resident 14 received [MEDICATION NAME] (psychoactive medication) in excess of the recommended daily dose without evidence to support the rational for the dosage; and 2) gradual dose reductions (GDR-a dose of medication is slowly decreased) of psychoactive medications were not attempted for Resident 14 and 7. There was no evidence to indicate why GDR's were clinically contraindicated. The facility census was 28. Findings are: A. Review of physician's orders [REDACTED]. -Quetiapine [MEDICATION NAME] ([MEDICATION NAME]) 125 milligrams (mg) at bedtime since 3/12/13 and 25 mg 2 times daily since 7/11/13 (a total of 175 mg daily). -ABH cream (a topical medication that consists of 1 mg of [MEDICATION NAME]-which is used for anxiety, 12.5 mg of [MEDICATION NAME]-an [MEDICATION NAME] and .5 mg of [MEDICATION NAME]-a psychoactive) 3 times daily since 6/19/14. There was no evidence in the medical record to indicate why Resident 14's [MEDICATION NAME] dose (which was above the daily recommended dosage) was clinically appropriate. Review of Resident 14's Mood and Behavior sheet (form used to document adverse moods and behaviors) for 6/2015 revealed the following: -No adverse moods or behaviors were displayed from 6/1/15 through 6/22/15. -on the day shift on 6/23/15, the resident was short tempered, made negative statements and resisted activities of daily living. Review of a Consultation Report dated 6/24/15 from the Registered Pharmacist (RP) to Resident 14's Healthcare Practitioner (HCP) revealed a request for the HCP to review the concurrent use of ABH cream and [MEDICATION NAME] and to provide documentation why a GDR was contraindicated. The HCP declined to order a GDR of the ABH cream or [MEDICATION NAME] but provided no documentation to indicate why this was cl… | 2019-07-01 |
| 6025 | 6025 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2016-12-14 | 176 | E | 0 | 1 | K1OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.10A1 Based on observation, record review and interview; the facility failed to assess 3 residents (Resident 26, 28 and 30)) to determine if the residents could safely administer prescription medications which were kept at the bedside. The sample size was 23 and the facility census was 28. Findings are: A. Review of the facility policy/procedure for Self-Administration of Medication by Residents (undated) revealed the following was to be completed if a resident self-administered medication: -An assessment was to be conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out the responsibility of self-administering medications; -The interdisciplinary team determines the resident's ability to self-administer medications by means of a cognitive and skill assessment; and -The results of the interdisciplinary team assessment are recorded on a Medication Self-Administration assessment form, which was to be placed in the resident's health care medical record. B. Review of Resident 26's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/26/16 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was cognitively intact but the resident's vision was impaired and the resident was only able to read material with large print. Review of Physician's Orders dated 05/05/15 revealed Resident 26 had an order for [REDACTED].>-[MEDICATION NAME] (medication used to reduce itching, redness and swelling associated with many skin conditions) lotion as needed twice daily; and -Anti-itch cream for [MEDICAL CONDITION] (a general term that describes an inflammation of the skin) to affected areas four times a day as needed. On 12/14/16 at 7:50 AM, a container of [MEDICATION NAME] and 1 tube of Anti-itch cream were observed sitting on top of a bedside table in Resident 26's room. Review of Resident 26's medical r… | 2019-07-01 |
| 6026 | 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 wa… | 2019-07-01 |
| 6027 | 6027 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2016-12-14 | 225 | 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 report and investigate potential allegations of abuse/neglect for 4 residents (Residents 11, 17, 9 and 4). 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: -Verbal abuse was defined as the use of oral, written or gestured language including disparaging and derogatory terms to the residents or within their hearing distance; -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 Resident 11's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/22/16 revealed the resident was cognitively intact (able to maintain attention, orientation and register/recall information) with [DIAGNOSES REDACTED]. Review of Resident 11's Progress Notes dated 9/23/16 at 10:17 AM revealed the resident became upset when a Nursing Assistant (NA) encouraged the resident to ambulate and the resident began screaming .No I'm not going to walk, I hate you? I don't want you in here! Review of Resident 11's Progress Notes dated 9/23/16 at 12:40 PM revealed the Social Services Director (SSD) visited with the resident and the resident voiced not wanting the female NAs to assist the resident that day. Docume… | 2019-07-01 |
| 6028 | 6028 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2016-12-14 | 280 | E | 0 | 1 | K1OV11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1b Based on record review and interview; the facility failed to revise the Care Plan for 1 sampled resident (Resident 26) related to fall prevention interventions. The sample size was 23 and the facility census was 28. Findings are: Review of Resident 26's Progress Notes dated 6/3/16 at 4:20 AM revealed the resident was sleeping on the edge of the bed and rolled off, landing on knees. Review of Resident 26's current Care Plan (undated) revealed a Temporary Problem List dated 6/13/16 which indicated the resident rolled out of bed and interventions were to remind the resident to call for assistance and the bed was placed in the low position. Review of Resident 26's Progress Notes dated 10/13/16 at 5:21 AM revealed the resident slid out of bed. Documentation further indicated the bed was in the lowest position and the call light was in reach. The resident was reminded to call for assistance. There was no evidence potential causal factors were assessed and additional interventions for the prevention of falls were not developed. Interview with the Director of Nurses on 12/14/16 at 1:15 PM confirmed Resident 26's Care Plan was not revised to address additional interventions to prevent the resident from falling out of bed. | 2019-07-01 |
| 6029 | 6029 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2016-12-14 | 282 | D | 1 | 1 | K1OV11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on observations, record review and interview; the facility failed to implement Care Plan interventions for the prevention of falls for 1 resident (Resident 26). The sample size was 23 and the facility census was 28. Findings are: Review of Resident 26's Progress Notes dated 12/9/16 at 9:22 AM revealed a staff member attempted to wheel the resident out of the dining room and the resident's .shoes stuck to floor and under wheelchair and fell forward on knees. Review of Resident 26's current Care Plan (undated) revealed a Temporary Problem List dated 12/9/16 which identified the resident's fall from the wheelchair on 12/9/16. The intervention to prevent another fall from the wheelchair was to Make sure feet are up. Resident 26 was observed seated in a wheelchair in the dining room at 11:24 AM on 12/13/16. The resident's feet were positioned directly on the floor. The wheelchair foot pedals were stored in a bag hanging on the back of the wheelchair. At 12:11 PM on 12/13/16, Registered Nurse (RN)-B was observed to wheel Resident 26 out of the dining room and down the corridor to the resident's room. RN-B did not reattach the wheelchair foot pedals and Resident 26's feet were observed to slide along the floor while being transported to the room. At 2:22 PM on 12/13/16, an Activity Volunteer was observed to wheel Resident 26 from the resident's room, down the corridor and into the dining room. The wheelchair foot pedals were not in use and the resident's feet were observed to slide along the floor while being transported into the dining room. Interview with the Director of Nurses on 12/14/16 at 1:15 PM confirmed foot pedals were to be used when staff were transporting Resident 26 in the wheelchair. | 2019-07-01 |
| 6030 | 6030 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2016-12-14 | 315 | D | 0 | 1 | K1OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on record review and interview, the facility failed to provide care and services to improve urinary continence for Resident 4. The sample size was 23 and the facility census was 28. Findings are: 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 always continent of urine. Review of Resident 4's MDS dated [DATE] revealed the resident had occasional urinary incontinence. During an interview on 12/14/16 at 9:35 AM, Nursing Assistant-K confirmed Resident 4 had occasional urinary incontinence. During an interview on 12/14/16 at 1:39 PM, the MDS Coordinator confirmed Resident 4 had a decline in urinary incontinence. Further interview revealed the facility did not assess the type of the urinary incontinence and did not put interventions in place to improve the resident's urinary incontinence. The MDS Coordinator stated they just tried to take the resident to the bathroom a little more often. | 2019-07-01 |
| 6031 | 6031 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2016-12-14 | 323 | E | 1 | 1 | K1OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record review and interview; the facility failed to assess causal factors and develop, revise and implement interventions for the prevention of falls for 4 residents (Residents 26, 17, 29 and 4). The sample size was 23 and the facility census was 28. Findings are: A. Review of Resident 26's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/26/16 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was cognitively intact (able to maintain attention, orientation and register/recall information) and the resident had 1 fall with no injury since the last assessment. Review of Resident 26's Progress Notes dated 6/3/16 at 4:20 AM revealed the resident was sleeping on the edge of the bed and rolled off, landing on knees. Review of Resident 26's Progress Notes dated 6/11/16 at 1:07 PM revealed the resident was found on the floor at the foot of the bed. Documentation indicated the resident fell while going to get a magazine. Review of Resident 26's current Care Plan (undated) revealed a Temporary Problem List which identified the following: -6/11/16-the resident had a fall and the intervention was to remind the resident to call for assistance. -6/13/16-the resident rolled out of bed and interventions were to remind the resident to call for assistance and the bed was placed in the low position. Review of Resident 26's Progress Notes dated 10/13/16 at 5:21 AM revealed the resident slid out of bed. Documentation further indicated the bed was in the lowest position and the call light was in reach. The resident was reminded to call for assistance. There was no evidence potential causal factors were assessed and additional interventions for the prevention of falls were not developed. Review of Resident 26's Progress Notes dated 12/9/16 at 9:22 AM revealed a staff member attempted to wheel the resident out of the din… | 2019-07-01 |
| 6032 | 6032 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2016-12-14 | 329 | E | 0 | 1 | K1OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview; the facility failed to assure Residents 1, 4 and 8 were free from the use of unnecessary medications as: 1) monitoring for the effectiveness and continued need for use of medications were not completed for Resident 8 and 4; 2) target behaviors were not identified and/or monitored for the continued use of a psychoactive medication (drugs that alter consciousness, mood and thought) for Resident 1; and 3) no clinical rationale was identified related to failure to follow the Consultant Pharmacist's recommendation regarding use of [MEDICATION NAME] (medication used to treat acid reflux and stomach problems) for Resident 1. The sample size was 23 and the census was 28. Findings are: A. Review of Resident 8's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 09/21/16 revealed [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of Resident 8's medical record from 02/01/16 through 12/13/16 revealed no evidence the resident's blood pressure was obtained and/or the results were recorded prior to the administration of [MEDICATION NAME] and [MEDICATION NAME]. During an interview on 12/13/16 at 2:00 PM Licensed Practical Nurse (LPN)-C confirmed staff were to complete a blood pressure and then to document the results on the resident's Medication Administration Record [REDACTED]. LPN-C further identified there was no evidence in the resident's medical record to indicate the resident's blood pressure was obtained and/or the results were documented on the resident's MAR from 02/01/16 though 12/13/16. B. Review of Resident 3's current Medication Administration Record [REDACTED]. If the blood sugar was over 400 the resident was to receive 8 units of [MEDICATION NAME] insulin. The blood sugar level then needed to be rechecked 2 hours later, and the physician was to be contacted if the blood sugar was still h… | 2019-07-01 |
| 6033 | 6033 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2016-12-14 | 441 | E | 0 | 1 | K1OV11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observations, record review and interviews: the facility failed to prevent the potential for cross contamination related to: 1) disinfection of reusable resident equipment which had the potential to affect 13 (Residents 3, 4, 5, 7, 8, 9, 11, 12, 15, 20, 22, 26 and 28) out of 23 residents sampled; 2) washing hands at appropriate intervals during the provision of treatments for 2 (Residents 3 and 12) out of 23 sampled residents and; 3) storage and disinfection of respiratory equipment for 5 (Residents 8, 17, 25, 26 and 30) out of 23 sampled residents. The facility census was 28. Findings are: A. Review of facility policy entitled Blood Glucose Monitoring (method of determining a resident's blood glucose level with use of a glucometer) undated, revealed the following identified procedure: -Wash hands. -Put on clean gloves. -Turn on the glucometer and insert a test strip. -Cleanse the resident's finger with alcohol and let dry. -Obtain a drop of blood from the resident's finger and complete test. -After completion of test, remove gloves and wash hands. B. Review of facility policy entitled Hand Washing with revision date 07/2016 revealed the staff were required to wash their hands or to use an alcohol based hand rub after each direct resident contact for which hand hygiene was indicated by accepted standards of practice. Staff was required to wash their hands before putting on gloves, after removing soiled gloves and after handling any item(s) considered dirty or soiled. C. Review of facility policy entitled Infection Control-Environmental Services with revision date 9/2016 identified all reusable resident equipment was to be cleaned with an approved germicide (a substance or other agent that destroys harmful microorganisms; an antiseptic) between each resident use. D. On 12/13/16 from 11:05 AM to 11:25 AM, Registered Nurse RN-D was observed to check blood sugar levels on Residents 3 and 12. RN-D removed a zippered case from a drawer inside the medication cart. RN… | 2019-07-01 |
| 6034 | 6034 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2017-11-14 | 323 | D | 1 | 0 | SRMC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on record review and interview; the facility failed to assure residents identified at risk for falls were protected from injuries as causal factors were not assessed and fall prevention interventions were not revised and/or new interventions developed following ongoing falls for 2 residents (Residents 3 and 8). The facility census was 21 and sample size was 11. Findings are: A. Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/30/17 revealed [DIAGNOSES REDACTED]. The MDS identified the following: -cognition was severely impaired; -required extensive staff assistance with transfers, bed mobility and toileting; -balance was unsteady during transfers and required physical assist to stabilize; -frequently incontinent of bladder; and -history of falls. Review of a Nursing Progress Note dated 3/5/17 at 8:05 PM revealed the resident was discovered on the floor of the resident's room. The resident's TABs alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) had been removed. An intervention was identified for staff to check the resident hourly and to anticipate the resident's needs. Further review revealed no causal factors were identified. Review of a Nursing Progress Note dated 5/1/17 at 3:11 PM revealed the resident was found on the floor at the foot of the resident's bed. Review of a Nursing Progress Note dated 5/5/17 at 5:00 PM revealed staff heard Resident 3's TABs alarm sounding and found the resident on the floor, next to the roommate's bed. review of the resident's medical record revealed [REDACTED]. In addition, fall prevention interventions were not revised and/or new interventions … | 2019-07-01 |
| 6035 | 6035 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2018-02-13 | 580 | D | 0 | 1 | 8O9O11 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.04C3a (6) Based on observation, record review, and interview; the facility failed to notify Resident 4's physician of a change in condition. The sample size was 14 and the facility census was 23. Findings are: Review of the facility policy titled Notifying Clinicians of Changes in Resident's Condition/Status with a revision date of 08/2017 revealed the resident's physician would be notified when there was a significant change in the resident's physical, mental, or emotional state or if there was a need to alter the resident's treatment significantly. All notifications would be made as soon as possible, but not to exceed 24 hours. Review of a Progress Note dated 2/5/18 revealed Resident 4 had a decline over the weekend. Resident 4 normally needed 1 assist with activities of daily living, but over the weekend required 2 assist. The physician was notified and encouraged the staff to report any other abnormal behaviors, fever, or physical decline. Observations of Resident 4 revealed the following: - On 2/12/18 at 9:08 AM, the resident was seated in the dining room in the resident's wheel chair with a sling that was used with the full body mechanical lift underneath the resident. - On 2/13/18 at 7:19 AM, the resident was seated in the resident's wheel chair with a sling that was used with the full body mechanical lift underneath the resident. Interview with Nursing Assistant-E on 2/13/18 at 11:07 AM revealed Resident 4 had been a 1 assist with transfers. Then 2 weekends ago (February 3rd and 4th) the resident required 2 assist with transfers and over the last weekend (February 10th and 11th) the resident had a drastic change in condition and needed a full body mechanical lift for transfers. Review of Resident 4's Progress Notes dated 2/5/18 through 2/13/18 revealed no evidence to indicate the resident's physician had been notified of the continued decline in condition. Interviews with the Director of Nursing on 2/13/18 at 12:01 PM and 12:05 PM confirmed Resident 4 had another… | 2019-07-01 |
| 6036 | 6036 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2018-02-13 | 600 | D | 0 | 1 | 8O9O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05(9) Based on record review and interview: the facility failed to protect Resident 74 after an allegation of potential abuse and/or neglect. The sample size was 14 and the facility census was 23. Findings are: A. Review of the facility policy Abuse, Neglect and Exploitation (revised 12/2017) revealed the following definition of abuse and neglect: -Abuse means the willful infliction of injury, unreasonable confinement, intimidation and punishment with resulting harm, pain or mental anguish. -Mental abuse includes but is not limited to, humiliation, harassment, threats of punishment or depravation. -Neglect means the failure of the facility, its employees or service providers to provide goods and services that are necessary to avoid physical harm, pain, mental anguish or emotional distress. -Mistreatment means inappropriate treatment or exploitation of a resident. Further review revealed in response to allegations of abuse, neglect, exploitation or mistreatment, the facility must prevent further potential abuse and/or neglect and assure the resident's safety. B. Review of Resident 19's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/23/18 revealed the resident was cognitively intact with [DIAGNOSES REDACTED]. The assessment indicated the resident required extensive to total staff assistance with transfers, toileting and dressing. During an interview on 2/8/18 at 9:26 AM, Resident 74 identified an incident in which Nurse Aide (NA)-B was assisting the resident with morning cares. Resident 74 indicated a need to use the bathroom. NA-B refused to assist Resident 74 with toileting needs. NA-B told the resident the resident needed to get dressed while lying in bed and could not get up until dressed. Resident 74 continued to ask NA-B to take the resident to the bathroom, until Resident 74 was incontinent of urine in the resident's bed. Resident 74 furth… | 2019-07-01 |
| 6037 | 6037 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2018-02-13 | 609 | D | 0 | 1 | 8O9O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on interview and record review, the facility staff failed to report an allegation of potential abuse and/or neglect to the state agency within the required time frame for Resident 74. The sample size was 14 and facility census was 23. Findings are: A. Review of the facility policy Abuse/Neglect and Exploitation (revised 12/2017) revealed in response to allegations of abuse, neglect, exploitation or mistreatment, the facility must assure allegations are reported immediately, but not later than 2 hours after the allegation is made if bodily injury or not later than 24 hours if events do not result in serious bodily injury. B. Review of Resident 19's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/23/18 revealed the resident was cognitively intact with [DIAGNOSES REDACTED]. The assessment indicated the resident required extensive to total staff assistance with transfers, toileting and dressing. During an interview on 2/8/18 at 9:26 AM, Resident 74 identified an incident in which Nurse Aide (NA)-B was assisting the resident with morning cares. Resident 74 indicated a need to use the bathroom. NA-B refused to assist Resident 74 with toileting needs. NA-B told the resident the resident needed to get dressed while lying in bed and could not get up until dressed. Resident 74 continued to ask NA-B to take the resident to the bathroom, until Resident 74 was incontinent of urine in the resident's bed. Resident 74 further identified the incident had been reported to the facility Social Service Director (SSD). Review of facility investigations for the last 6 months revealed no evidence Resident 74's allegation of potential abuse and/or neglect had been reported to the state agency. Interview with the SSD on 2/12/18 at 3:50 PM confirmed Resident 74's allegation of potential abuse and/or neglect involving NA-B had not been reported to the state ag… | 2019-07-01 |
| 6038 | 6038 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2018-02-13 | 610 | D | 0 | 1 | 8O9O11 | **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 investigate an allegation of potential abuse and/or neglect for Resident 74. The sample size was 14 and the facility census was 23. Findings are: A. Review of the facility policy Abuse/Neglect and Exploitation (revised 12/2017) revealed in response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: - assure allegations are reported immediately, but not later than 2 hours after the allegation is made if bodily injury or not later than 24 hours if events do not result in serious bodily injury; - conduct an investigation, preventing further potential abuse and/or neglect while the investigation is in the process; and - report the results of the investigation to the state agency within 5 working days of the incident. B. Review of Resident 19's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/23/18 revealed the resident was cognitively intact with [DIAGNOSES REDACTED]. The assessment indicated the resident required extensive to total staff assistance with transfers, toileting and dressing. During an interview on 2/8/18 at 9:26 AM, Resident 74 identified an incident in which Nurse Aide (NA)-B was assisting the resident with morning cares. Resident 74 indicated a need to use the bathroom. NA-B refused to assist Resident 74 with toileting needs. NA-B told the resident the resident needed to get dressed while lying in bed and could not get up until dressed. Resident 74 continued to ask NA-B to take the resident to the bathroom, until Resident 74 was incontinent of urine in the resident's bed. Resident 74 further identified the incident had been reported to the facility Social Service Director (SSD). Review of Resident 74's medical record revealed no evidence an investigation had been conducted regarding allegations of potential abuse and/or neglect involving… | 2019-07-01 |
| 6039 | 6039 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2018-02-13 | 692 | D | 0 | 1 | 8O9O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8 Based on record review and interview; the facility failed to develop weight loss interventions to prevent ongoing weight loss for Resident 19 and to ensure assessed nutritional interventions for the prevention of weight loss were implemented for Resident 8. The sample size was 14 and the facility census was 23. Findings are: A. Review of a facility policy titled Unintended Weight Loss (revised 01/2013) revealed the following weight loss prevention strategies to be implemented in an attempt to improve the weight status of residents: -evaluate the diet orders for residents who do not seem to be thriving; -food preferences to be considered; -assess the size and frequency of meals; -offer food such as fortified puddings, cereal or custards; -give nutritional supplements; and -offer snacks between meals. B. Review of Resident 19's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/28/18 revealed [DIAGNOSES REDACTED].). In addition, the assessment identified the resident had coughing or choking during meals or when swallowing medications. Review of Resident 19's Weights and Vitals Summary Sheet (form used to document a resident's weight, blood pressure, respiration, temperature and pulse) revealed the resident's weight on 1/16/18 was 199 lbs. Review of a Nutrition/Dietary Note dated 1/17/18 at 9:17 AM revealed the resident was alert and able to eat meals independently. The resident was identified as having a mechanically soft diet with small portions. Review of Resident 19's current Care Plan dated 1/28/18 revealed the resident was at nutritional risk due to difficulty with swallowing and loss of appetite from [MEDICAL CONDITION] treatments for Hodgkin's [MEDICAL CONDITION] (cancer of the immune system). Interventions included the following: -encourage resident to drink extra fluids with and between meals; -offer snacks between meals; -offer choices… | 2019-07-01 |
| 6040 | 6040 | ROCK COUNTY HOSPITAL LONG TERM CARE | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2018-02-26 | 689 | G | 1 | 0 | RFUP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observations, record review and interview; the facility failed to assure residents identified at risk for falls were protected from ongoing falls and injury as fall prevention interventions were not implemented for 2 residents (Residents 1 and 4) of 7 sampled residents. The facility census was 24. Findings are: A. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/18/17 revealed [DIAGNOSES REDACTED]. The MDS identified the following: -cognition was severely impaired; -required extensive staff assistance with transfers, bed mobility and toileting; -balance was unsteady during transfers and required physical assist to stabilize; -frequently incontinent of bladder; and -history of falls. A review of Resident 1's Care Area Worksheet (a worksheet used for care plan development) dated 10/18/17 revealed the resident was at risk for falls due to unsteadiness with the need for staff assistance to stabilize, a history of falls with major injury, difficulty focusing and forgetfulness regarding physical limitations. A plan was identified to assist the resident as needed with cares, to encourage continued involvement with the Restorative Program and not to leave the resident alone when toileting. Review of a Morse Fall Scale (assessment used to determine a resident's risk for falling) dated 1/9/18 revealed the resident was at high risk for falls. Review of MDS dated [DATE] revealed no change in assessment of the resident's risk for falls. Review of Resident 1's current Care Plan (revision date 1/11/18) revealed the resident had short and long term memory loss with poor decision making skills. The care plan further identified the resident was at high risk for falls, required extensive staff assistance with cares, was frequently incontinent of bladder and had a history of [REDACTED]. Review of a Nursing Progress Note dated… | 2019-07-01 |
| 7516 | 7516 | ROCK COUNTY HOSPITAL LTC | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2014-09-04 | 157 | D | 0 | 1 | TE6J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.04C3a (6) Based on record review and interviews, the facility failed to notify the family/responsible party and the medical practitioner regarding the presence of bruising to Resident 27's face. Facility census was 28. Findings are: Review of facility policy titled Skin Assessment with revision date 5/14/14 revealed staff were to immediately report bruises to the charge nurse and to the physician. Bruises were to be documented in the Progress Notes, on a skin integrity sheet and on the Treatment Administration Record (TAR). Staff were to check skin condition daily and to chart size and coloration weekly until the bruising was healed. Review of Resident 27's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/20/14 indicated the resident had a BIMS (Brief Interview for Mental Status-an assessment used to determine mental faculty) score of 13 (a score of 13-15 indicated the resident was cognitively intact). The MDS further indicated the resident had [DIAGNOSES REDACTED]. Review of Resident 27's Care Plan with revision date of 8/20/14 indicated the resident required limited to extensive staff assistance with dressing, transfers and toileting and was occasionally incontinent of urine. Resident 27's Care Plan indicated the resident was at risk for skin breakdown and had a pressure reduction mattress to bed and a pressure reduction cushion to the resident's chair. During observation on 9/2/14 at 1:51 PM, Resident 27 was noted to have dark purplish bruise to the resident's left upper cheek underneath of the resident's eyelid. During interview at this time, the resident was unable to identify how the bruising occurred. Review of Resident 27's Progress Note dated 8/31/14 revealed a 2 centimeter (cm) by 2 cm bruise was noted under the resident's left eye. The resident denied any complaint of pain associated with the bruise. Review of Resident 27's medical re… | 2018-03-01 |
| 7517 | 7517 | ROCK COUNTY HOSPITAL LTC | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2014-09-04 | 164 | E | 0 | 1 | TE6J11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(20) Based on observation and staff interview; the facility failed to ensure medical record confidentiality for 3 residents (Residents 21, 5 and 14). Medication Administration Records (MAR-records maintained for each individual resident that lists their medications, allergies and other personal information) were left open and information was exposed when the medication carts were not attended. Facility census was 28. Finding area: A. During observations on 9/3/14, Licensed Practical Nurse (LPN)-F left the medication cart unattended in the corridor adjacent to the dining room at 7:30 AM. The notebook containing MAR's was on top of the cart and open, exposing information on Resident 21. LPN-F returned to the medication cart at 7:36 AM (6 minutes). At 7:40 AM, LPN-F exited the area and left the notebook of MAR's open and exposing information on Resident 21. LPN-F did not return to the medication cart until 7:52 AM (12 minutes.) B. The medication cart was left unattended in the corridor adjacent to the dining room from 8:28 AM until 8:31 AM (3 minutes). The notebook containing MAR's was on top of the cart and open, exposing information on Resident 5. During this time, Resident 7 exited the dining room, stood next to the medication cart and had the opportunity to have a clear view of Resident 5's MAR. C. The medication cart was left unattended in the corridor outside the Social Services office on 9/3/14 from 11:06 AM until 11:10 AM (4 minutes). The notebook containing MAR's was on top of the cart and open, exposing information on Resident 14. D. Interview with LPN-K on 9/4/14 at 9:00 AM and with the Director of Nurses on 9/4/14 at 9:35 AM revealed nursing staff were to shield the MAR indicated [REDACTED]. | 2018-03-01 |
| 7518 | 7518 | ROCK COUNTY HOSPITAL LTC | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2014-09-04 | 226 | D | 0 | 1 | TE6J11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(7) Based on record review and staff interview; the facility failed to complete an investigation in regards to Resident 5's missing property and develop a plan to prevent further loss of residents property. Facility census was 28. Findings are: Record review of Internal Missing Property Investigations, dated 2/4/14, revealed Resident 5 informed an unidentified nurse aide (NA) of missing money. The report further revealed the Social Services Director (SSD) interviewed Resident 5 who stated approximately $200 was missing. The facility verified the money had been withdrawn by the resident from the Resident Trust Account on 1/30/14. A search of the resident's room revealed some money to be found, but not the entire missing amount. The report further stated laundry personnel was interviewed as well as the resident's child. On 2/5/14, an unidentified charge nurse reported to SSD that Resident 5 was overheard asking an unidentified NA if the NA had taken the resident's money. The report read that the SSD interviewed the unidentified NA as well as the resident who stated (gender) was joking when (gender) asked the NA about taking the money. The report then stated that the SSD believed the money was an accusation of theft and an investigation would be underway. No further investigation was included in the report. During an interview with the SSD, on 9/3/14 at 9:45 AM, it was verified that no interventions were put into place to protect Resident 5 from further misappropriation of property, including money. The SSD went on to state that no follow up was done with the resident after the money was discovered to be missing. During an interview with the Administrator, on 9/4/14 at 8:00 AM, it was verified the police were not called and no additional interviews were completed during the investigation, leaving the investigation incomplete. | 2018-03-01 |
| 7519 | 7519 | ROCK COUNTY HOSPITAL LTC | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2014-09-04 | 309 | D | 0 | 1 | TE6J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2 Based on observations, record review, and resident and staff interviews; the facility failed to assess and/or monitor the presence of bruising on Resident 27's face for cause, extent and healing. Facility census was 28. Findings are: Review of facility policy titled Skin Assessment with revision date 5/14/14 revealed staff were to immediately report bruises to the charge nurse and to the physician. Bruises were to be documented in the Progress Notes, on a skin integrity sheet and on the Treatment Administration Record (TAR). Staff were to check skin condition daily and to chart size and coloration weekly until the bruising was healed. Review of Resident 27's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/20/14 indicated the resident had a BIMS (Brief Interview for Mental Status-an assessment used to determine mental faculty) score of 13 (a score of 13-15 indicated the resident was cognitively intact). The MDS further indicated the resident had [DIAGNOSES REDACTED]. Review of Resident 27's Care Plan with revision date of 8/20/14 indicated the resident required limited to extensive staff assistance with dressing, transfers and toileting and was occasionally incontinent of urine. Resident 27's Care Plan indicated the resident was at risk for skin breakdown and had a pressure reduction mattress to bed and a pressure reduction cushion to the resident's chair. During observation on 9/2/14 at 1:51 PM, Resident 27 was noted to have dark purplish bruise to the resident s left upper cheek underneath of the resident's eyelid. During interview at this time, the resident was unable to identify how the bruising occurred. Review of Resident 27's Progress Note dated 8/31/14 revealed a 2 centimeter (cm) by 2 cm bruise was noted under the resident's left eye. The resident denied any complaint of pain associated with the bruise. Review of Resident 27's medic… | 2018-03-01 |
| 7520 | 7520 | ROCK COUNTY HOSPITAL LTC | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2014-09-04 | 441 | E | 0 | 1 | TE6J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D, 175 NAC 12-006.17B Based on observations, record review and staff interview; facility staff failed to perform hand hygiene during the provision of care and/or treatments in a manner to prevent cross contamination for 4 residents (Residents 12, 16, 21 and 6). Facility census was 28. Findings are: A. Review of facility policy entitled Hand-washing with revision date of 3/09 revealed staff were required to wash their hands or to use an alcohol-based hand rub after each direct resident contact for which hand-washing was indicated by accepted standards of practice. The policy indicated staff were to wash hands before putting on and after taking off gloves and after handling any item considered soiled. B. Nursing Assistant (NA)-C and A were observed to provide Resident 12's incontinent care on 9/3/14 from 8:21 AM to 8:32 AM. NA-A put on clean gloves and removed Resident 12's disposable incontinent brief which was soiled with urine. NA-A provided the resident's perineal hygiene and removed soiled gloves. Without washing or cleansing hands, NA-A adjusted the resident's clothing, positioned the resident in bed with pillows and pinned the resident's call light to a blanket covering the resident before washing hands in the bathroom sink. C. NA-A was observed to assist Resident 16 to the toilet on 9/3/14 from 9:40 AM until 9:54 AM. NA-A put on clean gloves and proceeded to remove the resident's disposable incontinent brief. NA-A indicated the resident's brief was soiled with urine. NA-A provided the resident's perineal hygiene and removed soiled gloves. NA-A placed a clean disposable incontinent brief on the resident, adjusted the resident's slacks, transferred the resident into a wheelchair, opened up the window blinds and made the resident's bed before washing hands and leaving the resident's room. D. During an interview on 9/3/14 from 10:00 AM to 10:12 AM, NA-A indicated staff were trained to wash hands o… | 2018-03-01 |
| 8769 | 8769 | ROCK COUNTY HOSPITAL LTC | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2013-07-18 | 323 | E | 0 | 1 | X10Z11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E4 Based on observations, record review and staff interview; the facility failed to secure chemicals in the Central Bath whirlpool room, the Soiled Utility Room and the Activity Room, and on the housekeeping cart, to ensure hazardous chemicals were not accessible to wandering residents (Residents 16, 20, 2 and 17). Facility census was 23. Findings are: A. Review of Material Safety Data Sheets (MSDS) revealed the following: - Lysol Brand III Disinfectant Spray dated 12/3/07 - Eye and skin irritant. May cause stomach distress, nausea or vomiting. May cause irritation if inhaled. - PDI Sani-Cloth Plus Germicidal Disposable Cloth dated 6/7/10 - Causes moderate eye irritation. Prolonged or repeated skin exposure may cause drying, defatting and dermatitis. Symptoms may include headache, dizziness, tiredness, nausea and vomiting. - Barbicide dated 10/23/12 - Irritating to skin and eyes. Causes a burning sensation, watering or redness of the eyes. Prolonged inhalation exposure may cause nausea, dizziness or disorientation. - Clorox Bleach Disinfecting Wipes dated 6/16/10 - Liquid causes moderate eye irritation. First aid included the following: For eye contact, rinse slowly and gently with water for 15 to 20 minutes; call doctor if irritation persists. For skin contact, rinse with plenty of water; call doctor if irritation persists. For inhalation, remove to fresh air; call doctor if breathing problems develop. For ingestion, drink a glass full of water; call doctor or poison control center. - Penner Whirlpool Disinfectant Cleaner dated 7/20/07 - May cause eye irritation and skin irritation with prolonged exposure. Can be harmful if swallowed or if spray mist is inhaled. Signs and symptoms of exposure included the following: If in eyes; a burning sensation, watering or redness. If on skin; redness, irritation or burning sensation with prolonged exposure. If spray mist is inhaled; possible irritation and/or burning sensation. If swallowed; possible gastrointestinal irritation or… | 2017-03-01 |
| 10523 | 10523 | ROCK COUNTY HOSPITAL LTC | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2012-04-18 | 280 | D | 0 | 1 | VXY711 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on observations, record reviews, staff and resident interviews; the facility failed to revise Resident 15's Comprehensive Care Plan (CCP) to address the resident's verbally and physically aggressive behaviors toward Residents 10, 17 and 18. Facility census was 26. Findings are: A. Review of Resident 15's Nurse's Notes dated 1/20/12 at 7:30 PM revealed Resident 15 hits out @ (at) other resident and Uses cuss words to other resident. Review of Resident 15's Nurse's Notes dated 1/25/12 at 7:30 PM indicated Resident 15 had a hold of another resident's arm. Documentation further indicated Resident 15 raised arm to hit the other resident when a nursing assistant intervened. Resident 15 stated I'm going to hit (other resident) because I can. Review of Resident 15's Nurse's Notes dated 4/7/12 at 7:00 AM revealed Resident 15 hit Resident 10 on the back of the head with an open hand 3 times before a staff member intervened. Review of Resident 15's Nurse's Notes dated 4/7/12 at 8:00 AM revealed Resident 15 grabbed Resident 18's wrist and caused a scratch on Resident 18's wrist. B. On 4/17/12 at 8:20 AM, Resident 15 was observed to exit the dining room independently following the breakfast meal. Resident 15 proceeded to walk down the corridor and enter Resident 10's room. Resident 10 was not in the room at that time although the roommate (Resident 24) was present. Nursing Assistant (NA) F was alerted to Resident 15's presence in Resident 10's room and NA-F encouraged Resident 15 to exit the room. Interview with Resident 24 on 4/17/12 at 8:20 AM revealed Resident 15 did wander into this room about every day however, Resident 24 did not feel threatened by this behavior. C. Review of Resident 15's current Comprehensive Care Plan (CCP) dated 3/30/12 revealed aggressive behaviors toward other residents was not addressed. There were no interventions for the prevention of further altercations. Interview with the DON and Social Services Director (SSD) on 4/17/12 from 2:50 PM unti… | 2016-01-01 |
| 10524 | 10524 | ROCK COUNTY HOSPITAL LTC | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2012-04-18 | 309 | E | 0 | 1 | VXY711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175NAC 12-006.02(8) Based on observations, record reviews, staff and resident interviews; the facility failed to implement policies to protect 3 residents (Residents 10, 17 and 18) from verbal and physical abuse by Resident 15. Interventions to prevent reoccurrence were not developed. Facility census was 26. Findings are: A. Review of the Abuse Policy (revision date 8/10) for resident to resident abuse revealed the facility was to Take steps to protect resident(s) and Take steps to prevent reoccurrence and document . B. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/12/11 indicated [DIAGNOSES REDACTED]. The MDS's dated 10/12/11, 1/4/12 and 3/28/12 indicated the resident had short and long term memory problems and delusions. The 3/28/12 MDS indicated the resident displayed physical and verbal behavioral symptoms directed toward others, other behavioral symptoms and rejection of care 1 to 3 days per week in addition to wandering behaviors 4 to 6 days per week. C. Review of Nurse's Notes dated 1/20/12 at 7:30 PM revealed Resident 15 hits out @ (at) other resident and Uses cuss words to other resident. Review of Nurse's Notes dated 1/25/12 at 7:30 PM indicated Resident 15 had a hold of another resident's arm. Documentation further indicated Resident 15 raised arm to hit the other resident when a nursing assistant intervened. Resident 15 stated I'm going to hit (other resident) because I can. Review of Nurse's Notes dated 4/7/12 at 7:00 AM revealed Resident 15 hit Resident 10 on the back of the head with an open hand 3 times before a staff member intervened. Review of Nurse's Notes dated 4/7/12 at 8:00 AM revealed Resident 15 grabbed Resident 18's wrist and caused a scratch on Resident 18's wrist. D. Review of Resident 15's current Comprehensive Care Plan (CCP) dated 3/30/12 revealed aggressive behaviors toward other residents was not addr… | 2016-01-01 |
| 10525 | 10525 | ROCK COUNTY HOSPITAL LTC | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2012-04-18 | 323 | E | 0 | 1 | VXY711 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E1 Based on observations and staff interview, the facility failed to protect residents from potential hazards as the stove located in the Activity room was not secured. 15 residents who were identified as confused and at risk for wandering had access to the stove burners (Residents 37, 15, 25, 30, 7, 31, 20, 9, 36, 16, 2, 14, 10, 28 and 4. Findings are: Observations on 4/15/12 at 10:36 AM revealed the stove in the Activity room was not secured. The stove top burners were encased by 2 decorative metal covers. Covers were easily removed and the stove knobs were accessible. Interview with the Activity Director on 4/16/12 from 8:40 AM until 8:50 AM revealed the stove was used infrequently; however it was not kept secured and was accessible to any residents who were confused or at risk for wandering. During an interview on 4/18/12 from 8:50 AM until 8:55 AM, the Director of Nursing identified Residents 37, 15, 25, 30, 7, 31, 20, 9, 36, 16, 2, 14, 10, 28, and 4 as confused and or at risk for wandering. | 2016-01-01 |
| 12286 | 12286 | ROCK COUNTY HOSPITAL LTC | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2011-01-31 | 244 | B | 0 | 1 | DTVN11 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.06 Based on review of Resident Council Minutes, confidential interview and staff interviews the facility failed to honor the residents' choice regarding a vote taken for dining room seating arrangements. There was no documentation to indicate why the residents' choice was not honored. Facility census was 27. Findings are: A. Review of the Resident Council Minutes dated 5/24/10 revealed the Social Services Director (SSD) asked residents to voice their opinions on the dining room arrangement per Administrator's request. 7 residents voted to have the dining room return to the original arrangement with the horseshoe tables (tables that are shaped like a horseshoe and provide access for a staff member to assist 3 to 4 residents with eating at 1 time) in a small dining area adjacent to the main dining room. 5 residents voted to have the dining room stay the way it currently was with the horseshoe tables in the main dining room. 4 residents voiced not caring how the dining room was arranged. Review of the 6/28/10 Resident Council Minutes revealed that issues from the previous month (5/24/10) had been resolved. Review of the 7/26/10 Resident Council Minutes revealed 1 resident, "Voiced that residents voted on the dining room arrangement, but no decision had been made". Resident stated, "Why were we asked to vote if our vote didn't count?" The minutes to this meeting did not contain a response to the resident's question. Review of the 8/30/10, 9/27/10, 10/25/10, 11/29/10/, 12/27/10/ and 1/31/11 Resident Council Minutes revealed the issue of the dining room arrangement had not been discussed with the residents. B. During confidential family interview the concern regarding assisted residents eating in the main dining room was voiced. The family member voiced concern for residents being assisted to eat and were asked to open their mouth or swallow in front of other residents. C. Interview with the Administrator on 1/31/11 from 3:55 PM until 4:00 PM revealed the residents did not rec… | 2014-09-01 |
| 12287 | 12287 | ROCK COUNTY HOSPITAL LTC | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2011-01-31 | 253 | E | 0 | 1 | DTVN11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B Based on observation and staff interviews, the facility failed to provide maintenance services as needed to ensure that the doors to the resident ' s room were safe and free from hazards as the surface of the bottom of the doors to 9 of 14 rooms were splintered with rough and gouged edges. This had the potential to affect 18 residents out of a facility census of 27. Findings are: A. During environmental tour on 1/31/11 from 10:00 AM until 10:45 AM it was observed that resident ' s rooms 102, 106, 105, 107, 109, 111, 113, 114, and 115 had rough and splintered edges to the surface of the bottom of the doors. B. During interview 1/31/11 from 10:20 AM until 10:30 AM the Maintenance Supervisor reported being unaware of the condition of the doors and that residents rooms were inspected annually for concerns. Maintenance Supervisor did verify that the doors identified were in need of repair. C. Interview with Administrator 1/31/11 from 2:50 PM until 2:55 PM confirmed that the resident ' s rooms were inspected once a year and no plan was in place at this time to replace or repair the identified resident room doors. | 2014-09-01 |
| 12288 | 12288 | ROCK COUNTY HOSPITAL LTC | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2011-01-31 | 356 | C | 0 | 1 | DTVN11 | Based on observations, review of nurse staffing postings, and staff interview the facility failed to post the daily nurse staffing information in a prominent place that was accessible as well as visible to the residents and any visitors. The staffing information was not posted in a timely manner on two out of the three days of the survey and review of staff postings from 1/13/11 through 1/30/11 indicated that information had not been filled in completely. Facility census was 27. Findings are: A. During the initial tour on entrance to the facility 1/26/11 at 9:30 AM it was observed that the form used for staff posting was on display in a plastic sleeve posted on the wall behind the nurse ' s station but no information was listed on the form. Interview with Charge Nurse E regarding daily staffing information posting from 10:00 -10:05 AM revealed that " we normally post it about 10:00 AM. " Staffing information was then completed and posted by this nurse. B. On 1/27/11 the nurse staffing information was not posted when checked at the following times; 6:50 AM, 7:30 AM, 8:10 AM, 8:40 AM, 9:15 AM, 10:30 AM, 11:00 AM, and 12:30 PM. C. Review of nurse staffing data postings from 1/11/11 through 1/30/11 revealed that on the following dates the resident census was not completed for the 2:00 PM to 10:00 PM shift, 1/12/11. 1/20/11, 1/22/11 and 1/28/11 and resident census was not completed for the 10:00 PM to 6:00 AM shift on 1/17/11, 1/18/11, and 1/29/11. In addition staffing hours were not completed for the 6:00 AM to 2:00 PM shift on 1/20/11, and hours were not posted for the 2:00 PM to 10:00 PM shift for the dates of /12/11 and 1/20/11 D. On 1/26/11 and 1/31/11 the nurse staffing information was posted in a plastic sleeve located behind the nurse ' s station. The information was printed in small print with a pencil on letter sized paper which made the information inaccessible and not visible to residents and visitors. | 2014-09-01 |
| 12289 | 12289 | ROCK COUNTY HOSPITAL LTC | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2011-01-31 | 371 | F | 0 | 1 | DTVN11 | LICENSURE REFERENCE NUMBER: 175 NAC-12-006.11e Based on observations and staff interview the facility failed to use sanitary techniques when cleaning and storing dishes and utensils that came in direct contact with food items as wet dishes and/or storage containers were stacked and stored in cabinets, utensils were not stored with the handles readily assessable, and breakfast cereals were stored in open boxes; and holes were observed in cabinet floors. Facility census was 27. All 27 residents received their meals from the kitchen. Findings are: A. During the sanitation tour of the kitchen on 1/31/11 from 11:30 AM until 12:05 PM the following issues were identified: -14 food storage containers, 6 lids, 4 large juice containers, a coffee carafe, 6 beverage glasses, a large roaster and lid, 2 steam table pans, and 3 dinner plate covers were stacked and stored wet in kitchen cabinets. -23 dishers (serving scoops), 6 spoodles, large serving spoons and pancake turners and a pizza cutter were stored in disarray in 2 cabinet drawers. The handles were not easily assessable to enable the utensil to be picked up without contaminating the food contact portion of the utensil. -3 boxes of breakfast cereals and 1 box of pancake mix were stored open in a cabinet which provided a source for contamination. -The wire grid under the water and ice dispenser contained a lime build-up. The lime deposit was removable when scraped. -The floor of the vegetable sink in the kitchen contained a 9 inch by 9 inch hole. The drain pipe for the sink was cut off approx 6 inches above the hole. The hole provided a source for rodents to enter the kitchen contaminating food and equipment. -The floor of the ice machine cabinet in the dining room contained a 3 inch by 9 inch hole. The hole in the cabinet floor provided a source for rodents to enter the kitchen and/or dining room contaminating food and equipment. -The shelf above the burners and the griddle on the kitchen range contained a greasy food residue indicating lack of routine cleaning. B. Inte… | 2014-09-01 |
| 12290 | 12290 | ROCK COUNTY HOSPITAL LTC | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2011-01-31 | 372 | F | 0 | 1 | DTVN11 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.11e Based on observations and staff interview the facility failed to properly store garbage while meal service was in progress as a large uncovered receptacle full of garbage sat adjacent to the steam table during serving of the noon meal on 1/31/11. This provided a source of cross contamination. 27 residents eat out of this kitchen. Facility census was 27. Findings are: A. During observation of the preparation and serving of the noon meal on 1/31/11 from 11:05 AM until 1:10 PM, Dietary Cook F had the large garbage receptacle which was full of refuse sitting next to the range and steam table. The garbage receptacle was uncovered and refuse was observed sticking above the top of the receptacle. During serving of the noon meal from 12:00 PM until 1:00 PM the garbage receptacle sat approximately 1 inch from the side of the steam table. The pans of food in the steam table were uncovered during the serving of the meal. This practice provided the opportunity for cross contamination of the food and refuse. B. Interview with the Dietary Manager on 1/31/11 from 1:00 PM to 1:05 PM revealed the garbage receptacle was to have the lid on and not be placed by the range and or steam table next to food items. C. Review of the 7/1/2007 version of the "Food Code", based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food sanitation practices, revealed the following: -5-501.113: "Receptacles and waste handling units for refuse, recyclables, shall be kept covered inside the food establishment if the receptacles and units contain food residue and are not in continuous use, or after they are filled. | 2014-09-01 |
| 3589 | 3589 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2020-02-25 | 554 | D | 0 | 1 | 1MXF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.10A1 Based on observation, record review and interview, the facility failed to ensure that 1 (Resident 197) of 1 sampled resident was evaluated to self-administer medications. The facility census was 208. Findings are: Observation on 02/20/20 at 9:10 AM revealed that Resident 197 was eating breakfast in Unit 1 Dining Room. A medication cup with [MEDICATION NAME] (a medication that can treat occasional constipation) was sitting next to a glass of orange juice. Resident 197 poured the [MEDICATION NAME] into glass of juice. Interview on 02/20/20 9:43 AM with Medication Aide F revealed that Resident 197 wanted to take pills in his room and take [MEDICATION NAME] out at the table, to be poured into the juice. Interview with Resident 197 on 2/20/20 at 12:10 PM revealed that some nurses leave the medication at the table and some nurses mix the medication in the juice. Observation on 02/20/20 at 12:36 PM of Resident 197 [MEDICATION NAME] eye drops (a liquid medication used to reduce eye redness) and Nasal Spray (medication that goes locally in the nose to help with allergies and dry air) in the bedside cabinet. Interview on 02/20/20 at 12:38 PM of Resident 197, confirmed does own eye drops and nasal spray. Record review of Resident 197's EMAR (electronic medication administration record) revealed Resident 197 had an order for [REDACTED]. The EMAR did not reveal an order for [REDACTED]. Record review of of Self-Administration of Medications Evaluation completed on 10/27/19, revealed Resident was not appropriate to self-administer any medications, eye drops, or nasal sprays, based on the evaluation. Interview on 02/20/20 at 2:56 PM with LPN (Licensed Practical Nurse) [NAME] confirmed that Resident 197 did not have an order for [REDACTED]. Interview with DON (Director of Nursing) on 02/20/20 at 3:15 PM confirmed that the expectation is not to have medications left at the dining room tables or in resident rooms a… | 2020-09-01 |
| 3590 | 3590 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2020-02-25 | 561 | D | 0 | 1 | 1MXF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.05(4) Based on interviews and record review, the facility failed to provide resident's baths per the resident preference for 4 residents (Resident 57, 165, 178 and 603) of a sample of 36 residents. The facility census was 208. Findings are: [NAME] An interview on 02/18/20 at12:40 PM with Resident 57 revealed; Resident 57 wanted 2 baths per week. Resident 57 reported the bath aide quit and they had not replaced the bath aide. Resident 57 reported itching when the baths were farther apart. Record review of Annual MDS (Minimal Data Set-a Federally mandated assessment used to create a comprehensive plan of care) dated 12/02/19 revealed; Section C Cognition revealed; Resident 57 had a BIMS (Brief Interview of Mental Status- conducted to evaluate mental status) of 15 indicating no impairment, Section F 0400 Preferences for Customary Routine and Activities revealed; while in the facility how important was it to you to choose to take a tub bath, shower, bed bath or sponge bath, the response was somewhat important. Section G 0120 Bathing Resident 57 required total dependence of 2 person assist. Record review of Social History Observation dated 08/16/14 revealed; Resident 57 preferred showers in the AM three times per week. Record review of Baseline Care Plan dated 12/23/19 revealed; no documentation of bathing preferences. Record review of PN (Progress Note) dated 02/17/2020 at 11:11 AM Focus: Resident was alert and orientated x 3. This morning resident had complaints of not getting a shower again and was very upset and said, I just may call state on this matter, this was the 7th day in a row and last week was the same and this seems to continue as we don't have a bath aide again to help me, I heard that someone was doing baths today but I guess I'm not that important to be on that list. This was said to this nurse and other staff members as well. Record review of Grievance log dated 02/17/20 revealed; Residen… | 2020-09-01 |
| 3591 | 3591 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2020-02-25 | 580 | G | 0 | 1 | 1MXF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review, observation, and interviews, the facility failed to notify the physician of change of condition for 1 of 36 sampled residents, Resident 76 related to recurrent episodes of epistaxis (nose bleeds) resulting in transfer to the ER for treatment . The facility census was 208. Findings are: Resident #74 Notification of Change An observation on 02/18/20 at 01:43 PM revealed Resident 76 to be sitting up in wheelchair with nose bleed occurring, call light was on due resident needing more washcloths. MA-M (Medication Aide) brought more washcloths, MA-M leaned head out of door and stated you know they have a nose bleed right? LPN-K (Licensed Practical Nurse), answered yes. Nurse did not come in to assess Resident 76 at that time. Resident stated this was 3rd nose bleed of the day. Resident 76 was noted to wear oxygen continuously at 4 l/m, (liters per minute) with no humidity (provides moisture to nasal cavity). A record review of medications revealed Resident 76 taking Xeralto ( medication which thins the blood and reduces the risk of blood clots forming). A record review on 02/19/20 of Resident 76's Progress Notes for 02/18/2020 revealed no assessment documentation in place regarding nose bleeds and no documentation of physician notification. An observation on 02/19/20 at 11:58 AM revealed Resident 76 to be lying in bed with washcloth to face due to another epistaxis episode. LPN-K entered room and informed Resident 76 of plan to get a fax out to MD today. An interview on 02/19/20 at 02:10 PM with LPN-K, revealed that this nurse was Medication Nurse on 02/18/2020 7-3 shift, and confirmed they were aware of nose bleeds on 02/18/2020. Record review of Resident 76's Progress Notes dated 02/19/2020 as follows: 02/19/2020 03:28 PM Humidifier added to oxygen concentrator at this time 02/19/2020 05:41 PM Resident has two nose bleeds today. Water added to 02. Fax out for an order for … | 2020-09-01 |
| 3592 | 3592 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2020-02-25 | 623 | D | 0 | 1 | 1MXF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(5) Based on record review and interview, the facility failed to provide written reason for transfer to the resident and resident's representative. This affected 1 resident (Resident 131) of 5 residents reviewed. The facility census was 208. Findings are: Review of Resident 131's Progress Note dated 1/27/20 at 11:16 AM revealed Resident 131 was sent to the emergency room for evaluation per the resident representative's request after the resident fell . Review of Resident 131's Progress Note dated 1/27/20 at 5:23 PM revealed the resident was admitted to the hospital on [DATE]. Review of Resident 131's Progress Note dated 2/5/20 at 3:19 PM revealed Resident 131 was sent to the emergency room for evaluation due to the resident feeling cool and clammy, having diarrhea, and complaints of abdominal pain. Review of Resident 131's Progress Note dated 2/5/20 at 4:40 PM revealed the resident was admitted to the hospital on [DATE]. Review of Resident 131's medical record revealed an absence of documentation related to written notice of the reason for transfer to the hospital provided to the resident and resident's representative for the hospitalized from [DATE] - 1/29/20 and 2/5/20 - 2/11/20. Interview on 2/20/20 at 4:17 PM with the SSD (Social Services Director) revealed the facility did not provide Resident 131 or the resident's representative a written notice of transfer to the hospital. | 2020-09-01 |
| 3593 | 3593 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2020-02-25 | 641 | D | 0 | 1 | 1MXF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006-09.B Based on record review and interview, the facility failed to ensure that the MDS (the Long Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and or Medicaid-certified long term care facility) was accurately coded to reflect the wound status for1 resident (Resident 73) of 36 sampled (Resident 73). The facility census was 208. Findings are: Record review of Hospital Patient Treatment Update dated 1/13/20 revealed; The Wagner Grade III ulcer (a [MEDICAL CONDITION]) on the left 5th Metatarsal head had been present for 2 months. The ulcer was thought to be related to diabetes. Record review of ulcer left 5th metatarsal head revealed; The Wagner Grade II ulcer located on the left 5th metatarsal head Record review of Significant Change MDS dated [DATE] Section M revealed; Resident 73 had a pressure ulcer/scare over a bony prominence stage III full thickness tissue loss, non-stagable. Pressure reductions treatments Pressure reducing device for bed and chair. Nutrition and hydration, Pressure injury care, Applications of ointments and medications. The MDS had not reflected documentation of a diabetic wound. An interview on 02/24/20 10:04 AM with MDS Coordinator S revealed; Resident 73 had a diabetic pressure wound and it was not coded on the MDS. A correction would be done to reflect Resident 73's diabetic wound. | 2020-09-01 |
| 3594 | 3594 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2020-02-25 | 657 | D | 0 | 1 | 1MXF11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1b Based on record review, observation, and interview; the facility failed to develop the Comprehensive Care Plan related to communication for 1 resident (Resident 131) of 36 residents reviewed. The facility census was 208. Findings are: Review of Resident 131's Progress Note dated 2/18/20 at 9:21 AM revealed Resident 131 was Spanish speaking and there was a language barrier. Observation on 2/20/20 at 8:50 AM revealed Resident 131 was in the Station 1 dining room with a family member. Resident 131 spoke to the family member in Spanish, the family member got up and went over to speak to SSW-G (Social Services Worker), and then SSW-G went to the resident's side and spoke to Resident 131 in Spanish. SSW-G then spoke to a NA and the NA took Resident 131 back to the resident's room. Interview on 2/24/20 at 1:27 PM with LPN-H (Licensed Practical Nurse) revealed Resident 131's family member was present often and would translate to Spanish as needed so staff could communicate with the resident. LPN-H revealed if the resident's family is not present, LPN-H would utilize staff for translating, or would point/use hand gestures to communicate. Interview on 2/24/20 at 2:09 PM with UM-C (Unit Manager) revealed Resident 131 is primarily Spanish speaking so staff would try to find staff or the resident's family to translate. UM-C revealed if no one was available to translate they have picture cards hanging on the wall in the resident's room that cover general needs. UM-C revealed some staff have also used translation apps available on cell phones to communicate. Observation on 2/24/20 at 3:01 PM revealed Resident 131 did have communication cards hanging on the wall in the resident's room. Review of Resident 131's Care Plan related to Activities dated 2/19/20 revealed staff would invite Resident 131 to activities, utilizing assistance from Spanish speaking staff if needed. The Care Plan did not include other documentation related to communication with the resident. Interview on 2/24/20… | 2020-09-01 |
| 3595 | 3595 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2020-02-25 | 676 | D | 0 | 1 | 1MXF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1 Based on record review and interview, the facility failed to ensure restorative services were provided as directed by therapy for 1 resident (Resident 98) of 2 residents reviewed. The facility census was 208. Findings are: Interview on 2/18/20 at 1:53 PM with Resident 98 revealed the resident did not always receive restorative services because the Restorative Aide (RA) was reassigned to cover when there weren't enough Nurse Aides (NA). Review of Resident 98's Face Sheet dated 2/19/20 revealed [DIAGNOSES REDACTED]. Review of Resident 98's Care Plan dated 12/31/19 revealed Resident 98 is at risk for decreased ADL (Activities of Daily Living) participation related to [DIAGNOSES REDACTED], dysphagia (swallowing difficulty), weakness, gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints), wheelchair dependence, diarrhea, [MEDICAL CONDITION] (swelling), high blood pressure, and obesity. Interventions included participation in a restorative plan as written by nursing and/or therapy. Review of Resident 98's Restorative Communication dated 12/20/19 revealed the goal was ROM (range of motion)/prevent loss of mobility 3 times per week. The suggested approaches revealed passive ROM to bilateral upper and lower extremities. Review of Resident 98's Restorative Detail Report dated 6/4/19 - 2/19/20 revealed resident was receiving therapy 11/12/19 - 12/20/19. Resident 98 received restorative as follows: - 12/24/19 - 1/1/20, 1/3/20 - 1/7/20, 1/8/20, 1/10/20 - 1/15/20, 1/17/20 - 1/21/20, 1/24/20 - 1/28/20, 1/29/20 - 2/5/20, 2/7/20 - 2/12/20 Resident 98 received restorative 3 times per week for 1 of 8 weeks since therapy ended 12/20/19. Interview on 2/24/20 at 1:03 PM with RA-B confirmed Resident 98 was supposed to receive restorative services 3 times per week, but was not receiving all sessions. RA-B revealed Resident 98 had complained about not receiving restorative but did not… | 2020-09-01 |
| 3596 | 3596 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2020-02-25 | 761 | D | 0 | 1 | 1MXF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.12E7 Based on observation, interview, and record review, the facility failed to ensure an Insulin label was updated for 1 (Resident 32) of 1 sampled resident. The facility census was 208. Findings are: Record Review of Physician order [REDACTED]. Observation with RN L on 02/24/20 at 11:40 AM revealed an order on the ETAR (Electronic Treatment Administration Record) dated 02/12/22 was to inject 22 units (basic measure of insulin) of Humalog (Insulin [MEDICATION NAME] a fast-acting insulin) Insulin (a hormone that works by lowering levels of sugar in the blood) subcutaneously (applied under the skin) twice daily before lunch and supper to Resident 32. Record review of Insulin label on 02/24/20 revealed 7 units before Lunch and 9 units before Dinner. Interview with RN L on 02/24/20 at 11:40 AM revealed Resident 32 received insulin from the Veterans Administration. RN L confirmed insulin was drawn up to match the ETAR (Electronic Treatment Administration Record) not the label on the Insulin box. Interview with Unit Manager C on 02/24/20 at 12:00PM confirmed label on the Insulin box dated 01/29/20 did not match the current order in the ETAR. | 2020-09-01 |
| 3597 | 3597 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2020-02-25 | 804 | E | 0 | 1 | 1MXF11 | Licensure Reference 175 NAC 12-006.11D Based on observations and interviews, the facility failed to ensure that foods were served at a comfortable temperature according to resident preference as evidenced by reports of cold food. This had the potential to affect 49 residents that ate food in the Station 1 dining room. The facility census was 208. Findings are: [NAME] Observation of temperature checks at end of meal service performed by dietary staff server N with dining room manager (DRM) present in Station 1 dining room on 02/19/20 at 1255 PM revealed the following temperatures: Chicken 115, puree green beans 120, soup 120, gravy 120. Dietary staff server N prepared a tray with the DRM present, a cover was placed on the plate and the tray was taken to a table to sample. The green beans were cold to taste. The Dietary Manager (DM) also sampled the food. Observation at the end of meal service with DRM present on Station 1 on 02/20/20 at 0855 AM revealed dietary staff server O prepared a sample tray with DRM present. The plate was covered, placed on tray and taken to a table to test the palatability. The temperature was checked by the DRM and revealed the scrambled egg temperature was 110. The food was tasted and revealed that the scrambled eggs, oatmeal and corn beef hash were not warm to taste. Interview on 2/20/20 at 855 AM with the DRM confirmed that the scrambled eggs, oatmeal, and corn beef hash were not warm to taste. B) Interview on 2/18/20 at 1:36 with Resident 98 revealed the resident received room trays for meals, and the food was usually cold when it is served. Resident 98 revealed occasionally the food would be served warm, but would be cold within a few bites. Review of Resident 98's Care Plan dated 1/9/20 revealed the resident was at a stable weight and received a diabetic/heart healthy diet (a low salt, low fat diet with restricted carbohydrates) with thin consistency liquids. Interview on 2/24/20 at 12:29 PM with Resident 98 revealed the noon meal served consisted of an egg roll, chicken, and rice.… | 2020-09-01 |
| 3598 | 3598 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2020-02-25 | 812 | F | 0 | 1 | 1MXF11 | Licensure Reference 175 NAC12-12.006.11E. Based on observations and interviews, the facility failed to maintain equipment in the kitchen in good and clean condition, failed to ensure food items were stored off the floor and in sealed packages, and failed to ensure ready to eat foods were not touched with soiled gloves. This had the potential to affect 205 out of 208 residents that ate food that was prepared in the facility kitchen. The facility failed to ensure food temperatures were maintained at a level to prevent the potential for food borne illness, this had the potential to affect 49 residents that ate in the Station 1 dining room. The facility failed to ensure staff did not contaminate food serving surfaces and resident's food when served, this had the potential to affect 23 residents served in Station 3 dining room. The facility census was 208. Findings are: [NAME] Observation during the initial kitchen tour performed in the kitchen and storage areas on 02/18/20 at 7:45 AM with Dietary Manager (DM) present revealed 3 containers of cheese in the refrigerator that were not dated with the open date. A box of frozen hamburger was on the floor in the freezer, the box was open. A package of buns was open in storage room with several buns damaged in the package. Observation of the vent hood revealed grease splatters and grease smears on hood. Interview with the DM on 2/18/20 at 8:00 AM confirmed that the hamburger should not be on the floor in the freezer and the package of buns in the storage room were damaged and should not be left open. B. Sanitation observation performed in the kitchen on 2/24/20 at 2:30 PM revealed several bugs in the light fixture above a cart storage area, the hood above the broiler range with grease splatters and smears and that part of the hood covering appeared to be falling down. Observation also revealed there was paint peeling on the wall above the splash board that is directly above the puree prep table. Interview on 2/24/20 at 2:45 PM with DM confirmed that the vent cover was broke… | 2020-09-01 |
| 3599 | 3599 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2020-02-25 | 842 | D | 0 | 1 | 1MXF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.16C1 Based on record review, observation, and interviews, the facility failed to maintain accurate documentation for 2 of 36 sampled residents, Resident 76 related to sores in the mouth and Resident 74 related to fluid restriction. The facility census was 208. Findings as follows: [NAME] Resident #76 An interview on 02/18/20 at 02:25 PM with Resident 76 revealed inability to wear dentures due to sores in mouth. Resident 76 stated they can't wear dentures, and the nurses are aware. Record review of Progress Note for Resident 76 dated 02/11/2020 through 02/20/2020 revealed no documentation related to oral sores or not wearing dentures. Interview with Unit Manager, (UM-D), on 02/20/20 at 01:30 PM revealed an order was obtained on 02/19/2020 for Ambesol (a topical oral pain medication). UM-D reported that Resident 76 did not normally wear dentures and when in, dentures did not seem ill fitting. An observation of lunch at 11:30 on 02/20/2020 revealed Resident 76 eating a salad with no facial grimacing or prolonged chewing. An interview with Resident 76 at 11:40 on 02/20/2020, denied difficulty eating salad and stated mouth is feeling better. Record review of Progress Note dated 02/21/2020 by the Transport Scheduler reveals the following information: 02/21/2020 10:22 AM Spoke with resident about recent comments that were made regarding sores in mouth and dentures not fitting properly Resident 76 stated that there are no sores in her mouth at this time but have had sores in the past. Resident 76 states that top denture fits perfect but feels that they may not be putting enough denture glue on the bottom because they seem to move around a lot. I did ask Resident 76 if it would be okay to get them set up for a dental appointment to have the bottom adjusted. Resident 76 stated that would be fine. An interview completed on 02/24/2020 at 10:30 AM with UM-D did confirm that Resident 76 did have sore present on rig… | 2020-09-01 |
| 3600 | 3600 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2020-02-25 | 880 | E | 0 | 1 | 1MXF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006-17B and 12-006.17D Based on observation, interview and record review; the facility failed to ensure [NAME] hand hygiene was completed and gloves were donned prior to placing a dressing for 1 resident (Resident 73), B. failed to ensue staff performed hand hygiene after glove removal for 1 resident (Resident 130), C. and failed to ensure supplies were stored off the floor in 5 resident rooms (Rooms 107, 109, 125, 213, and 217). The sample size was 36 and the facility census was 208. Findings are: An observation on 02/24/20 at 10:25 AM of wound care for Resident 73 revealed; LPN R completed hand hygiene for 20 seconds and donned gloves, the Prevalon boot (the boot was turned inside out and used for positioning of the foot), dressing and Therabond were removed, the Therabond was rinsed under tap water. LPN R doffed gloves and completed hand hygiene with hand sanitizer. LPN donned gloves. LPN R washed the wound bed with one cloth, rinsed with a new cloth and dried with a new cloth all in a dabbing motion. The wound had a small amount of red drainage during the wound care. LPN R then applied a clean dressing to the wound [MEDICATION NAME]. No hand hygiene or glove change was completed prior to the new dressing placement. An interview on 02/24/20 10:38 AM with the Staff Development Coordinator confirmed LPN R should have removed gloves and completed hand hygiene prior to the new dressing being placed. Record review of the Handwashing/Hand Hygiene dated 04/2012 revealed; Employees must wash their hands for at least Twenty (20) seconds using Antimicrobial or non-antimicrobial soap and water under the following conditions: a. When coming on duty; b. When hands are visibly soiled (hand washing with soap and water); c. Before and after direct resident care (for which hand hygiene is indicated by acceptable professional practice); d. Before and after performing any invasive procedure e. Before and after entering i… | 2020-09-01 |
| 3601 | 3601 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2017-10-19 | 241 | E | 0 | 1 | YFYL11 | Licensure Reference Number 175 NAC 12-006.05(21) Based on observation and interview, the facility failed to ensure lift slings were not visible when residents were seated in the 100 and 200 hall dining area on first floor to maintain resident dignity. This had the potential to effect 5 (Residents 3, 69, 88, 102, and 278) of 12 residents that required a full lift with a sling for transfers and ate in the 100 and 200 hall dining area on the first floor. The facility census was 231. Findings are: Observation on 10/16/2017 at 09:09 AM, 10/18/217 at 8:21 AM and 10/18/17 at 12:08 PM revealed 5 (Residents 3, 69, 88, 102, and 278) residents in the 100 and 200 hall dining area on the first floor seated in wheelchairs with full lift slings under the residents. The upper backs and straps of the lift slings were exposed and in plain sight. Record review of the most recent Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) for cognitive ability revealed the following information for those residents: Res 102: MDS 9/18/17: severely cognitively impaired Res 3: MDS 8/14/17: severely cognitively impaired. Res 88: MDS 9/13/17: severely cognitively impaired Res 278: MDS 9/20/17: severely cognitively impaired Res 69: MDS 7/24/17: Moderately cognitively impaired Interview on 10/18/2017 at 12:13:57 PM with Nurse Consultant (NC) confirmed that Residents 3, 69, 88, 102, and 278 required full lift transfers and that the slings were exposed and in plain sight. The NC confirmed that this was a dignity issue to have the slings exposed while in the dining room and could cause embarrassment for those residents. Interview on 10/18/2017 at 1:00:35 PM with the Director of Nursing confirmed that there were a total of 12 residents that require a full lift with slings for transfers and ate in the 100 and 200 hall dining areas. A total of 83 residents ate in the 100 and 200 unit dining area. | 2020-09-01 |
| 3602 | 3602 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2017-10-19 | 371 | E | 0 | 1 | YFYL11 | Licensure Reference Number 175 NAC 12-006.11E Based on observation and record review, the facility failed to ensure that direct food contact with contaminated gloves did not occur to prevent the potential for foodborne illness. This had the potential to effect 88 residents that received a regular diet from dining rooms 1, 2, and 3. The facility census was 231. Findings Are: [NAME] On 10/18/17 at 12:10 PM Staff A and Staff D were observed serving lunch from the serving area on the 300 hall dining room. On 10/18/17 at 12:20 PM Staff A was observed to leave the immediate serving area and go to the sink approximately 10 feet away, washed hands and then return to the serving area. Prior to entering the serving area Staff A stopped, opened a lower cupboard door with bare hands, took a box containing gloves out set it on the counter, Staff A then was observed to take out two gloves and put them on, Staff A then opened the cupboard with a gloved hand and put the box of gloves back into the cupboard and re-entered the serving area and continued to serve lunch. Between 12:25 PM and 12:34 PM Staff A was observed to pick up a 12 pack container of burger buns with the gloved hands, open the bag and take out a bun and place the bun on a plate, put a piece of chicken on the bun and sent the sandwich out to the residents a total of 6 times. Staff A was also observed to pick up a dinner role from a pan in the serving area to serve to a resident with the same gloved hands. On 10/18/17 at 12:40 PM observed Staff B serving lunch to the residents in hall 200 dining room. At 12:44 PM Staff B was observed to take a bun out of a plastic hamburger bun bag with gloved hands, put on a residents plate and served it to the resident. At 12:48 PM Staff B left the cooking area, when Staff B returned the staff stopped at a hand wash sink and washed hands, then just before entering the immediate serving area Staff B stopped and opened a lower cupboard and got a box of gloves, took out 2 gloves then returned the box of gloves to the cupboard and p… | 2020-09-01 |
| 3603 | 3603 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2018-12-04 | 655 | D | 0 | 1 | ESLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 132-006.091a Based on interviews, record reviews and observation, the facility failed to develop an Baseline care plan addressing Urinary Tract Infection, Pneumonia, incontinence, mobility, pain, and fall risk/history of fall with fracture for Resident 155 This had the potential to affect 1 resident, Resident 155. The facility census was 217. Findings are: Interview on 11/27/18 at 03:57 PM with Resident 155 revealed the resident had been incontinent of urine since a fall with [MEDICAL CONDITION] and complained of pain from the placement of the bed pan. Record review of MDS (Minimum Data Set- a comprehensive assessment tool used to develop a resident care plan) 5 day Admission assessment dated [DATE] revealed: 1. Section A, admitted was 10/5/18. 2. Section C, Cognition revealed Resident 155 BIMS (Brief Interview for Mental Status an assessment used to determine memory loss) score was 15 indicated Resident 155 was cognitively intact. 3. Section G, Functional Status revealed Resident 155 required extensive assist of 2 person for bed mobility, transfers, dressing, toilet use, bathing, and personal hygiene. 4. Section H, Bowel and Bladder revealed Resident 155 was incontinent of bladder frequently (7 or more episodes of incontinence). 5. Section I [DIAGNOSES REDACTED]. Record review of Baseline Care Plan dated 10/05/18 revealed; 1. The significant [DIAGNOSES REDACTED]. 2. The Care Plan participants (may be in person or through documentation or interview) were the Resident, SSR (Social Services Representative), DON (Director of Nurses)/Nurse manager, MDS, Professional Nurse with responsibility for the resident, Nutritional services, Activities, Nursing Assistant, Physician, Other. 3. Resident 155 was a full code. 4. Resident 155 was to remain in LTC (Long-term Care) at the time of the assessment- maybe reevaluated if condition changed or Resident 155 chose to initiate a discharge plan. 5. The facility was to notif… | 2020-09-01 |
| 3604 | 3604 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2018-12-04 | 656 | D | 0 | 1 | ESLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.04C3a(5) Based on record reviews, interviews and an observation, the facility failed to develop an CCP (Comprehensive Care Plan) to ensure the provision of quality care for; A) Cognitive loss, ADL (Activities of Daily Living) to include Mobility, Urinary Incontinence, Falls and History of Falls with Fracture, Dehydration, Dental, Pressure Ulcer, [MEDICAL CONDITION] Drug Use, Infection, and Pain. This had the potential to affect 1 resident, Resident 155. B.) A CCP was not developed related to Restorative Services for Resident 182 that reflected the current care needs This had the potential to affect one resident, Resident 182. C.) The facility failed to develop a Comprehensive Care Plan for the use of a catheter for Resident 195. The facility census was 217. Findings are: Interview on 11/27/18 at 03:57 PM with Resident 155 revealed the resident had been incontinent of urine since a fall with [MEDICAL CONDITION] and pain from the placement of the bed pan. Record review of MDS (Minimum Data Set- a comprehensive assessment tool used to develop a resident care plan) 5 day Admission assessment dated [DATE] revealed: 1. Section A, Identification Information revealed Resident 155's admitted was 10/5/18. 2. Section C, Cognition revealed a BIMS (Brief Interview for Mental Status an assessment used to determine memory loss) score was 15, indicated Resident 155 was cognitively intact, without long or short term memory problems 3. Section G, Functional Status revealed Resident 155 required extensive assist of 2 person for bed mobility, transfers, Dressing, toilet use, bathing, and Personal hygiene. 4. Section H, Bowel and Bladder revealed that Resident 155 was incontinent of bladder frequently (7 or more episodes of incontinence). 5. Section I [DIAGNOSES REDACTED]. 6. Section V 0200, CAA (Care Area Assessment) revealed the areas that triggered to be care planned included: Cognitive loss, ADL (Activities of Daily Li… | 2020-09-01 |
| 3605 | 3605 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2018-12-04 | 688 | D | 1 | 1 | ESLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 12-006.09D4 Based on interviews and record reviews the facility failed to implement a specific Nursing Restorative Program care and treatment plan to improve or maintain range of motion for 1 resident (Resident 95). The facility census was 217. Findings are: An interview on 11/27/18 at 04:13 PM with Resident 95 reported a decline in function since admission. Resident 95 reported upon admission was able to transfer alone. Resident 95 reported inability to transfer unattended, related to weakness from [MEDICAL TREATMENT] and leg muscle loss. Resident 95 confirmed had not been on an exercise program since discharge from Therapy Services. Observation on 11/27/18 at 04:13 PM of Resident 95 self-propelling in a wheel chair. Record review of Therapy service revealed the last date of service was on 11/19/18. A note dated 11/19/18 revealed that Resident 95 had responded well to therapeutic interventions and had achieved functional independence levels that should have allowed safe discharge to a Functional Maintenance Program with Restorative Nurse Supervision/assistance. An interview on 11/29/18 at 02:18 PM with DON (Director of Nurses) confirmed that Resident 95 had not started on a Functional Maintenance Program per Therapy recommendations. An interview on 11/29/18 at 02:27 PM with the DON confirmed that the Therapy Department had not written a restorative program for resident 95. | 2020-09-01 |
| 3606 | 3606 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2018-12-04 | 761 | F | 0 | 1 | ESLD11 | Licensure Reference Number 12-006.12E1 Based on observation, interview and record review; the facility failed to ensure that medications were stored in labeled containers in accordance with facility policy. This had the potential to effect all the residents in the facility. The facility census was 217. Findings are: An observation on 11/29/18 at 08:54 AM of Medication Cart A, on station 2 revealed; in a medication cup, in the top drawer were 2 clear capsules, the medications were not labeled. An interview on 11/29/18 at 08:54 AM with Staff Member D CMA (Certified Medication Aide) confirmed that the medication were not in a labeled container related to the medication being kept in a locked refrigerator. Record review of Storage Policy revised in (MONTH) of (YEAR) revealed; Drugs and Biological's shall be stored in the packaging containers or other dispensing systems in which they are received. | 2020-09-01 |
| 3607 | 3607 | LANCASTER REHABILITATION CENTER | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2018-12-04 | 812 | F | 1 | 1 | ESLD11 | > Licensure Reference Number 175 NAC 12-006.11E Based on observations and interviews, the facility failed to ensure that foods were fresh, foods were discarded on or before the expiration date, bread containers were dated, floors were maintained in a clean manner in the walk in refrigerator, freezer and dry food storage area in the facility kitchen, fluid spills were wiped up in the reach in refrigerator, soiled rags were not left in the reach in refrigerator and food carts did not contain soiled dried on food and liquid particles and the facility failed to ensure hair nets full contained all hair during meal service and food preparation in accordance with food code guidelines. This had the ability to affect all residents that ate foods prepared in the facility kitchen. The facility census was 217. Findings are: Observation on 11/26/18 between 8:15 AM and 8:30 AM with the Director of Food Service (DFS) identified the following sanitation issues in the facility: - A box which contained several black, slimy bananas on a shelf in the dry storage room. - Four wilted and slimy cabbage heads in a bag on a shelf in the walk in cooler. - Two bags of wilted, brown discolored parsley dated with an expiration date of 10/18/18 on a shelf in the walk in cooler. - Dried on food and liquids spills and food particles on the floor walk in cooler, freezer and the dry storage area. - A soiled wet rag left on the shelf in the reach in refrigerator. - A dust covered and black particles on a fan in the soiled dish area. The fan faced the clean dish area and blew on the clean dishes. - A dust covered and black particles present on a fan above the food tray line. The fan faced the tray line and blew on the trays being prepared for service. - Food storage/transport carts had dried on food and liquid spills present Interview on 11/26/18 at 8:30 AM with the DFS confirmed the observations that some foods were not fresh, had not been discarded on or before the expiration date, food and liquid spills were present in the walk in cooler, freeze… | 2020-09-01 |
| 4704 | 4704 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2016-07-26 | 280 | D | 0 | 1 | OEW511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on observation, record review, and interviews; the facility failed to 1) update the Care Plan to reflect Resident 126's non-weight bearing status, change in transfer status, and new skin impairment on right leg; and 2) failed to revise one resident's (Resident 171) care plan related to nutritional supplement and denture status. The facility census was 222. Findings are: [NAME] Review of Resident 126's undated face sheet revealed the admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of the MDS (Minimum data Set, a federally mandated comprehensive assessment tool used for care planning) dated 2-5-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 14 which indicated Resident 126 had no cognitive impairment. Resident 126 required total dependence of 2 staff with transfer, toileting, and bathing. The resident required limited assistance of 2 staff with locomotion on and off the unit, dressing and personal hygiene. Resident 126 did not walk. The resident was assessed at risk for pressure ulcers but did not have any at the time of the assessment. Review of the Physician orders [REDACTED]. Review of the Therapy To Nursing Communication form dated 2-1-16 revealed the OT (Occupational Therapist) and the PT (Physical Therapist) recommended the staff use the Hoyer (full body lift) lift for all transfers. Review of Resident 126's Care Plan revealed a problem dated 2-1-16 of a fractured right femur with the intervention of the resident required 2 staff assist with transfers. The resident's non-weight bearing status on the right leg and the change in the transfer technique to a full body lift initiated on 2-1-16 by the Physical Therapist were not listed on the Care Plan. B. Review of Resident 126's Skin Condition Record revealed resident developed a 10 x 1.0 cm (centimeter) blister on the right inner thigh on 2… | 2020-04-01 |
| 4705 | 4705 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2016-07-26 | 332 | D | 0 | 1 | OEW511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.10E Based on observation, record reviews, and interviews; the facility failed to ensure a medication error rate of less than 5%. Observation of 30 medications administered revealed 2 errors resulting in an error rate of 6.66 %. The errors affected 1 resident (Resident 110). The facility census was 222. Findings are: [NAME] Observation on 7-21-16 at 9:51 AM revealed LPN-A (Licensed Practical Nurse) administered the medication [MEDICATION NAME]/[MEDICATION NAME] (antiParkinson agent) 25/100 mg (milligram) to Resident 110 per [DEVICE] (gastrostomy tube, a flexible tube surgically inserted through the abdomen into the stomach for administering liquid food and fluids). Review of the Physician orders signed 7-11-16 revealed [MEDICATION NAME]/[MEDICATION NAME] 25/100 mg per [DEVICE] to be given at 08:00 AM and 12:00 PM. Review of Resident 110's TAR (Treatment Administration Record) revealed the [MEDICATION NAME]/[MEDICATION NAME] 25/100 mg was scheduled for 08:00 AM and 12:00 PM and LPN-A had initialed the 08:00 AM dose on 7-21-16 as administered. Review of the facility policy titled Medication Administration dated 11-3-14 revealed medications are to be administered within 60 minutes of the scheduled time. Interview on 7-25-16 at 12:02 PM with the DON (Director of Nursing) revealed the DON reviewed Resident 110's TAR and confirmed the 08:00 dose was given at 9:56 AM and therefore was not within the 60 minute window time frame as per policy. Review of the [NAME]'s Drug Guide for Nurses Thirteenth Edition revealed the medication [MEDICATION NAME]/[MEDICATION NAME] should be taken on a routine schedule. B. Observation on 7-21-16 at 9:51 AM revealed LPN-A prepared medications to be administered to Resident 110 per [DEVICE]. Resident 110 was on a continuous flow of enteral formula (liquid nutrition). LPN-A disconnected the formula and entered the [DEVICE] and started administering the medications without first pe… | 2020-04-01 |
| 4706 | 4706 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2016-07-26 | 431 | E | 0 | 1 | OEW511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].12E4 Based on observation, record review, and interviews; the facility failed to ensure expired glucose test strips were not available for residents use on Units 1,2, and 3. This affected 24 (Residents 13, 35, 42, 59, 92, 117, 152, 183, 192, 229, 240, 244, 266, 275, 290, 298, 304, 336, 340, 386, 398, 401, 402, and 403) out of 129 residents. The facility census was 222. Findings are: [NAME] Review of the Assure Platinum glucose strip bottle package insert revealed when the bottle was first opened, it was to be dated and the strips were only good for 90 days from the date opened. B. Observation on [DATE] at 3:29 PM revealed the Assure Platinum glucose strip bottle on the 100 unit nurse treatment cart. The bottle was without a date when the bottle was opened or a 90 day expiration date from when the bottle was opened. Interview on [DATE] at 3:29 PM with LPN-A (Licensed Practical Nurse) confirmed the Assure Platinum glucose strip bottle was not dated when opened or a 90 day expiration date written on the bottle. LPN-A revealed LPN-A was not aware the glucose strips were to be dated when opened. Interview on [DATE] at 3:33 PM with UM-B (Unit Manager) confirmed it was not the unit's practice to date the glucose strip bottles when opened and to be used only for 90 days. C. Observation on [DATE] at 3:40 PM revealed the Assure Platinum glucose strip bottle on the 200 unit nurse treatment cart. The bottle was without a date when the bottle was opened or a 90 day expiration date from when the bottle was opened. Interview on [DATE] at 3:40 PM with LPN-C confirmed the Assure Platinum glucose strip bottle was not dated when opened or a 90 day expiration date wrote on the bottle. LPN-C revealed LPN-C was not aware the glucose strips were to be dated when opened. D. Observation on [DATE] at 3:50 PM revealed the Assure Platinum glucose strip bottle on the 300 unit nurse treatment cart. The bottle was without a date w… | 2020-04-01 |
| 5648 | 5648 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2016-11-22 | 176 | D | 1 | 0 | FLP211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(16) Based on observation, record review and interviews; the facility failed to ensure the safety of one resident (Resident 100) out of 43 residents on the dementia unit to self-administer medications. The facility census was 221. Findings are: Observed on 11-22-16 at 7:12 AM Resident 100 sat in a chair in the solarium of the secured dementia unit with two [MEDICATION NAME] HFA Inhaler units (an aerosol medication used to treat [MEDICATION NAME] of the lungs and open up the airways) in the resident's hands and no staff within sight. Interview on 11-22-16 at 7:20 AM with LPN-A (Licensed Practical Nurse) revealed Resident 100 self-administered the [MEDICATION NAME] HFA inhaler and the resident kept the inhaler in the pants pocket. LPN-A revealed the resident lived on the dementia unit because the resident wandered and hallucinated. Review of Resident 100's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 10-13-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 3 which indicated severely impaired cognition. Resident 100 exhibited the behaviors of hallucinations and delusions. Resident 100 required supervision of 1 staff with bed mobility, transfers, walking, locomotion on the unit, dressing, and toileting. The resident required extensive assistance of 1 with locomotion off the unit. Interview on 11-22-16 at 12:11 PM with the SW-C (Social Work Manager) revealed the process in the facility when a resident requested to self-administer a medication was the Interdisciplinary Team reviewed the request to ensure the resident's cognition level and safety ability. A Physician's order would be obtained, a self-administration assessment would be completed and the resident's ability to self-administer the medication would be placed on the Care Plan. Review of the Physician orde… | 2019-11-01 |
| 5649 | 5649 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2016-11-22 | 425 | D | 1 | 0 | FLP211 | > Based on observation and interview, the facility failed to ensure a medication had a pharmacy label on the medication for identification of the resident and direction instructions for one resident (Resident 100) out of 43 residents sampled. The facility census was 221. Findings are: Observation on 11-22-16 at at 1:30 PM of the Ventolin HFA inhaler for Resident 100 was kept in Resident 100's pant's pocket for the resident to self-administer. The inhaler did not have a pharmacy label with the resident's name and directions on often to administer the medication. Interview on 11-22-16 at 1:45 PM with UNM (Unit Nurse Manager) confirmed the Ventolin HFA inhaler did not have a pharmacy label on it with instructions for the resident to read and should have. | 2019-11-01 |
| 6640 | 6640 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2015-06-17 | 272 | D | 0 | 1 | J4S611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on observation, record review, and interview; the facility failed to comprehensively assess the dental status of 2 residents (Resident 220 and Resident 28). Facility census was 221. Findings are: A. Review of Resident 220's Admission Record revealed Resident 220 was admitted to the facility on [DATE] with readmission on 02/15/2013 with [DIAGNOSES REDACTED]. Interview with Resident 220 on 06/11/2015 at 8:26 AM revealed that Resident 220 stated, no upper teeth, had dentures but didn't fit, so threw them away, bottom teeth ok. Observation of Resident 220 on 06/11/2015 at 8:35 AM revealed that Resident 220 did not have upper dentures. Resident 220 did not have any upper teeth at all. Review of the annual Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) with a reference assessment date of 05/15/15 revealed the Oral/Dental Status for Resident 220 was that the resident had no dental concerns. Review of the Comprehensive Care Plan (CCP) dated 02/11/2015 revealed Resident 220's lower partial denture was not fitting correctly. The facility was to set up a new dental appointment for adjustment for 02/05/2015. The Dentist was in the process of making new upper dentures for the resident. Record review of a Progress Note dated 04/25/2014 revealed Resident 220 returned from a dental appointment and said that the resident threw away upper denture and felt that Resident 220 was doing just fine without it. A call was placed to the resident's Power of Attorney (POA). The POA stated that the POA did not wish to replace the denture now as Resident 220 was eating fine and denied problems. Record review was a Consultation/Clinic Referral Form dated 02/02/2015 revealed Resident 220 had a dental appointment. An adjustment was made to the lower partial. Interview with the Corporate Consultant Registered Nurse on 06/17/2015 at 10:55 AM confirmed that Resident 220's MDS … | 2018-12-01 |
| 6641 | 6641 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2015-06-17 | 323 | E | 0 | 1 | J4S611 | LICENSURE REFERENCE 175 NAC 12-006.18E4 and 12-006.18E Based on observations, interviews, and record review; the facility 1) failed to ensure one housekeeping cart containing hazardous chemicals was locked and; 2) failed to ensure that one treatment cart and one medication cart was locked. The facility census was 221. Findings are: A. On 6/10/15 at 8:55 AM during the initial facility tour, there was an unlocked housekeeping cart on Station 1 Hallway B that contained the following: -One full bottle of glass cleaner. -One full bottle of cleaner with label unreadable. -One and one-half bottles of restroom cleaner. -One full bottle of foul odor eliminator. -Two bottles of Lime-Off Descaler. -Housekeeper A was not in sight of the cart. The housekeeper was visiting with a resident residing in Room 130-B. Interview with Housekeeper A on 6/10/15 at 9:15 AM identified the product without the label as a product that the housekeeper used to clean the dining room tables, resident night stands and window sills. The housekeeper stated that the housekeeping cart should be locked and produced a key to lock the cart from the housekeeper's pocket. Housekeeper A stated that gloves were to be worn with the product without the label. Review of the updated MSDS (Material Safety Data Sheet) information for the Restroom Floor and Surface Disinfectant Cleaner, revealed that the product was corrosive and caused irreversible eye damage and skin burns. The product was harmful or fatal if swallowed. Review of the MSDS information for the Virex II revealed that it was used as a disinfectant. It was labeled as corrosive and caused skin and eye burns. Virex II was harmful or fatal if swallowed. Virex II was a combustible liquid and vapor. Review of the MSDS information for the Good Sense Odor Eliminator revealed that the product could be mildly irritating to the eyes. Review of the MSDS information for the Glance Glass and Multi-purpose Cleaner revealed that it was it was mildly irritating to the eyes and skin. B. Observation of the Station 1 T… | 2018-12-01 |
| 9652 | 9652 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2013-03-20 | 174 | D | 0 | 1 | ZJLW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.05(14) Based on observation, resident and staff interviews, review of resident records and regulations identifying Resident Rights: the facility failed to ensure that three (Resident 50, 224 and 276) residents were provided a private area for telephone conversations. The facility census was 219. FINDINGS ARE: A: INTERVIEW with Resident 224 on 03/18/2013 in residents room revealed: -Does not have privacy when talking to spouse on the phone; -Has to use the phone at the nurses station and everyone can hear that is around the station; -Sometimes I like to say I love you but that is private to my (spouse); -Is not aware of any other place for residents to speak on the phone in private. REVIEW of the MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning) completed as a Quarterly review and dated 12/04/2012 revealed: -BIMS (Brief Interview for Mental Status) scored 14 out of 15; -Independent with locomotion/ambulation on the unit; -[DIAGNOSES REDACTED]. INTERVIEW: SOCIAL WORKER C (SSW), on 03/19/2013 at 9:50 AM in the Dining Room, for Station 4 revealed: -Facility land lines are available in the conference room by elevators or the SSW office for Station 4: -If residents do not have their own cell phone they can call from pay phones or from the nurses stations; -Station 3 (Skilled Service/rehab) has a landline phone in each resident private room. INTERVIEW with RN B on 03/19/2013 at 10:10 AM, at the Nurses Station 5/Secured Unit for memory and behaviors revealed: -Residents can use phone at nurses station or can purchase their own; -Resident 224 used the desk phone at the nurses station when on Station 5. B: OBSERVATION on 03/20/2013 at 11:55 AM at Station 4 Nurses Station: -Resident 50 sitting in a wheelchair on the exterior side of the nurses station talking on the station phone; -Numerous nursing staff are in and around the nursing station area within hearing di… | 2016-07-01 |
| 9653 | 9653 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2013-03-20 | 241 | D | 0 | 1 | ZJLW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: NAC 175 12-006.05(21) Based on resident and staff interviews, observation of resident bathing care area and review of records: the facility failed to ensure dignity and maintain visual privacy for one (Resident 224) resident during bathing in the bath house. The facility census was 219. FINDINGS ARE: REVIEW of MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning) dated 12/04/2012 as a Quarterly Review for Resident 224 revealed: -Is able to make self understood and can understand others; -Cognition assessed with [REDACTED]. -Requires physical help from staff for bathing; -[DIAGNOSES REDACTED]. INTERVIEW with Resident 224 on 03/18/2013 in resident room revealed: -There is no privacy in the bath house (.resident tells staff to close the curtain) there is another resident taking a tub bath next to shower staff being used by Resident 224; -Other people coming in and out of the bath house. INTERVIEW with NA L on 03/19/2013 at 1:30 PM revealed: -Showered once a week per resident choice and requires some assistance with activity; -Divider curtains closed but staff will open door to bring other residents in to bathe or ask questions; -Entrance door is locked with a key code and only staff can open with a touch pad code; -There is a sign on the front of the bath house door (to the public) in use -Minimum bathing provided at least once for each resident and facility would like two baths given; -This Resident 224 will only take one shower and then bathe at home when on pass with spouse to own home. -INTERVIEW with NA M, Bath Aide for Station 4, on 03/19/2013 at 11:00 AM in the Bath House revealed: -Resident 224 opted for one shower a week; -save for last because Resident takes time and is very particular about the routine; -Bath aide sets up shampoo, washes back and the resident does the rest; - Showers on Wednesdays once a week. -There is a lot of disruption with staff coming in for… | 2016-07-01 |
| 9654 | 9654 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2013-03-20 | 309 | G | 0 | 1 | ZJLW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, interview, and record review; the facility failed to ensure that one resident (Resident 276) received the care and services to alleviate the resident's dental pain from a resident sample size of 47. The facility census was 219. Findings are: Review of Resident 276's History and Physical dated 4/11/12 revealed that the resident had a [DIAGNOSES REDACTED]. Review of Resident 276's Significant Change MDS (Minimum Data Set: a federally mandated comprehensive tool used for care planning) dated 10/1/12 revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 14 (cognitively intact). The resident had a mood score of 3 and did not display behaviors. The resident required extensive to total assistance with bed mobility, transfers, toilet use, dressing, and personal hygiene. The resident was non-ambulatory and had impaired balance. The resident had constant pain rated at a six. The resident was on antipsychotic, antidepressant, and anticoagulant medications. Review of Resident 276's Quarterly MDS dated [DATE] revealed that the resident had a BIMS score of 15 (cognitively intact). The resident had a mood score of 10. The resident had delusions and was verbally abusive one to three days out of seven. The resident had occasional pain rated at a three. Review of Resident 276's Pain assessment dated [DATE] revealed that the resident's pain was described as: aching, sharp, nagging, tingling in the resident's left shoulder, left hip and teeth. The resident rated the pain as a five. The resident's pain was worse in the morning. The pain was helped with [MEDICATION NAME]/ APAP (narcotic pain medication) 5/325 mg (milligrams) 1 to 2 tablets every 4 hours prn (as needed) for pain and [MEDICATION NAME] (medication to treat nerve pain) 150 mg three times daily, repositioning, decreasing activity. The resident's pain did cause [MEDICAL CONDITION] and difficulty to concentra… | 2016-07-01 |
| 9655 | 9655 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2013-03-20 | 315 | D | 0 | 1 | ZJLW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.D3 (1) Based on observation, interview, and record review the facility failed to ensure that perineal care was provided for one resident (Resident 217) in a manner to prevent the potential for urinary tract infections [MEDICAL CONDITION] from a resident sample size of 47. The facility census was 219. Findings are: Review of Resident 217's Hospital Discharge Summary dated 10/11/13 revealed [DIAGNOSES REDACTED]. Review of Resident 217's Bowel and Bladder Assessment Check List dated 10/22/12 revealed that the resident's risks included pain, decreased mobility. The resident denied incontinence. The resident was on a diuretic and was rarely incontinent and a bladder program was not needed. Review of Resident 217's Admission MDS (Minimum Data Set: a federally mandated comprehensive tool used for care planning) dated 10/3/13 revealed that the resident had short term memory issues. The resident had modified independence with decision making skills. The resident had a mood score of 2. The resident required extensive assistance with transfers, toilet use, dressing and personal hygiene. A toileting program was tried and no improvement was seen. The resident remained occasionally incontinent or urine and continent of bowel. Review of Resident 217's 1/9/13 Quarterly MDS revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 9 (moderate cognitive impairment). The resident had a mood score of 1. The resident required extensive assistance with transfers, toilet use, and dressing. The resident required total assistance with personal hygiene. The resident was not on a toileting plan and was frequently incontinent of urine and continent of bowel. Review of Resident 217's Care Plan dated 11/17/12 revealed that the resident was at risk for infection related to recent urinary tract infection with occasional urinary incontinence. The resident's goal was to be kept comfortable. Care plan intervent… | 2016-07-01 |
| 9656 | 9656 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2013-03-20 | 431 | E | 0 | 1 | ZJLW11 | Based on observation, interview, and record review the facility failed to ensure one of five medication refrigerators were maintained a temperature to store medications according to the manufacturer's directions. This affected 10 resident's receiving insulin via pen mechanisms. The facility census was 219. Findings are: Observation of Station 2 medication refrigerator on 3/21/13 at 10 am - 10: 20 am revealed: -The freezer contained a thick layer approximately one inch of frost. The thermometer was stuck down with the face of the thermometer in the accumulation of frost. The freezer temperature was negative 10 degrees F (Fahrenheit). -The top shelf of the refrigerator contained plastic holders with boxes of insulin pins. The refrigerator thermometer had ice on it and was in a holder with the insulin. The thermometer registered 22 degrees F. There were four boxes of Novolog 3 ml (milliliter) pens belonging to three residents that were stuck to the plastic holder and were wet and icy. There were two boxes of Humulin 70/30 insulin pens for 1 resident that contained ice on the boxes. Three residents had Humalog Kwik insulin pens that also had ice on them. Seven boxes of Lantus Solostar insulin pens were on the second shelf close to the top of the refrigerator and did have some ice in the plastic holder. The Lantus Solo Star insulin label stated store 36-46 degrees F. Interview with LPN (Licensed Practical Nurse) E on 3/21/13 at 10:20 am acknowledged that the refrigerator thermometer was 22 degrees F and that there was ice on the insulin pen boxes. The LPN stated that the refrigerator was checked daily. Review of the facility's Fridge Med Room Record for Med Room for 3/6/13 - 3/20/13 revealed that the refrigerator was checked daily at 3 pm. The refrigerator temperature range was 38 - 42 degrees F. The freezer temperature was negative 4 to negative 11 F. | 2016-07-01 |
| 11167 | 11167 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2012-03-05 | 253 | E | 1 | 1 | CKRL11 | Based on observation and interview, the facility failed to provide maintenance, repair and housekeeping to Resident Areas, Bathing Area, Resident's bed and Resident Rooms related to: 1. Repair ripped and peeled wall paper in the 300 hallway; 2. Repair broken, cracked, and chipped floor tiles and door finishes in Bathing area 221; 3. Repair chipped and splintered beds board in Room 136 and 409; and 4. Clean lighting fixtures in Rooms 105, 130, 131, 132, 136, and 409. Facility census was 222. Findings are: During the Stage 2 of the QIS (Quality Indicator Survey) Survey, an environmental observation tour was conducted with the Administrator, Director of Maintenance, Housekeeping District Manager and Housekeeping Supervisor on 03/01/12 beginning at 08.05 AM. During the tour, the following issues were identified regarding maintenance, repair and housekeeping of the facility: A. Resident Areas observations revealed: ? Wallpapers at the bottom part of the right side wall leading towards the nurses' station at 300 hallway peeling off exposing scuffed walls. These made the structures uncleanable. B. 221 Bathing area observation revealed: ? Floor tiles in front of the exit from the whirlpool tub and leading towards the shower cracked and chipped. ? 3 x 3 centimeters chip on the main door exposing scuffed wooden door frame. C. Resident Rooms observations revealed: ? Covering on Resident's bed footboard at Room 136 bed A (Resident 75) peeled off exposing scuffed wooden frame. ? Duct tape used to hold foam on toilet safety guard in Room 409 bathroom (Resident 34 and 226) peeling off its edges exposing adhesive parts of the tape. ? Resident rooms observed to have collections of grayish powdery material removable by finger swipes on the top of lighting fixtures in Room 105 (Resident 47 and 186), 130 (Resident 26 and 86), 131 (Resident 22 and 103), 132 (Resident 13 and 211), 136 (Resident 75 and 277), and 409 (Resident 34 and 226). The Administrator, Director of Maintenance, Housekeeping District Manager and Housekeeping Supervi… | 2015-08-01 |
| 11168 | 11168 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2012-03-05 | 323 | E | 1 | 1 | CKRL11 | Based on observation and interview, the facility failed to protect residents from potential accidents in Resident Areas and Resident Rooms related to: 1. Splintered handrails in the 400 and 500 hallway; 2. Splintered bed footboard; and 3. Trip hazard. Facility census was 222. Findings are: During the Stage 2 of the QIS (Quality Indicator Survey) Survey, an environmental observation tour was conducted with the Administrator, Director of Maintenance, Housekeeping District Manager and Housekeeping Supervisor on 03/01/12 beginning at 08.05 AM. During the tour, the following issues were identified as potential for causing accidents in the facility: A. Resident Areas observations revealed handrails at the hallways of 400 and 500 wing of the facility had splinters which could stick residents as they used them. B. Resident Rooms observations revealed: ? Resident's bed footboard at Room 136 bed A (Resident 75) had cracked and peeled covering with pointy and sharp edges which could inflict skin tears. ? Resident's bed in Room 239 bed A (Resident 210) was customized with approximately 15 cm (centimeters) outward extension below the bed footboard at ankle high made of unfinished woods. Observation on this part showed splinters and cracks from knocks and bumps. The Administrator, Director of Maintenance, Housekeeping District Manager and Housekeeping Supervisor verified the observations during interview (on 03/01/12) throughout the tour starting at 8:05 a.m. | 2015-08-01 |
| 11169 | 11169 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2012-03-05 | 371 | F | 1 | 1 | CKRL11 | Licensure Reference Number 175 NAC 12-006.11E Based on observation, staff interview and record review; the facility failed to: -Follow the hand washing techniques to prevent the spread of food borne illness for the facility's residents. - Ensure that the Quat sanitizing solution was at the manufacturer's recommended strength to maintain a clean prep table surface. -Follow the food code book recommendations for the thawing of meat. The facility census was 222. Findings are: A. Kitchen observations of Dietary Aide (DA) A preparing toast and plating the poached eggs on resident trays and DA B working on the tray prep line on 3/1/2012 at 7:28 AM revealed: -Dietary Aide (DA) A with gloved hands (right hand with disposable glove and left hand with cloth glove) was placing toast on the resident trays. Between the time of placing toast on the resident trays DA A was handling cooking utensils and the kitchen towel from the prep area without changing gloves. -While reaching for the cereal bowls, DA A fingers touched the inside of the bowl. The bowl was then filled with hot cereal. -DA A handled an empty bowl with the unchanged gloved hands, dipped the bowl into a container holding the dry cereal, and placed it on a resident tray. -It was noted that the plastic lids used to cover the cereal bowl were placed on the dirty wood surface in front of the steam cart pan before using. Also a towel that was used to wipe cereal from the edges of the bowl was laying on the tray with clean plastic lids. B. Observation of DA B at 7:45 AM on 3/1/12 revealed that, while placing clean utensils wrapped in a napkin and menus on the resident trays, 2 menus were dropped to the floor. DA B picked the menus off the floor and placed them back on the tray. Without washing hands, DA B continued to place the clean wrapped utensils on the resident trays. C. Review of the 6/15/05 Kitchen Handwashing Policy revealed, "Hand washing is an integral part of an effective infection control program. The purpose is to reduce the risk of food borne illness and … | 2015-08-01 |
| 11170 | 11170 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2012-03-05 | 282 | D | 1 | 1 | CKRL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on record review and staff interview, the facility failed to follow the Care Plan (CP) for one resident (Resident 98) related to providing a nutritional supplement if the resident refused meals. The facility census was 222 and the sample size was 43. Findings are: Resident 98 had the following [DIAGNOSES REDACTED]. Review of the 11/23/11 and the 2/15/12 MDS (Minimum Data Set-a federally mandated comprehensive assessment tool used for care planning) identified Resident 98 as having a BIMS (Brief Interview for Mental Status-a test to evaluate cognition.) of 2 which indicated severe cognitive impairment. Also that Resident 98 required extensive one person assistance with eating, bed mobility, toileting and dressing. The Physician Fax dated 1/12/12, stated "May we have an order for [REDACTED]. The faciltiy received an order for [REDACTED]. Review of Resident 98's Meal Consumption documentation and the Medication Administration Record [REDACTED] -Refused dinner on 2/3/12, lunch on 2/8/12, dinner on 2/16/12, dinner on 2/23/12. -Ensure Chocolate Liquid provided only on 2/22/12. Interview with Licensed Practical Nurse (LPN) K on 3/5/12 at 12:15PM revealed, "Before 2/22/12 the person that fed (Resident 98) would have to let us (The Medication Nurse) know if the meal was refused. Then on 2/22/12 we put it on the MAR indicated [REDACTED]." | 2015-08-01 |
| 11965 | 11965 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2011-08-17 | 514 | D | 1 | 0 | CT7T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.16B Based on review of the medical record and staff interview; the facility failed to ensure that the medical record for 1 (Resident 3) of 3 sampled residents was complete with accurate documentation identifying provision of care, nursing assessments and interventions provided during an identified change of condition/decline. Facility census was 222 with 3 sampled residents. Findings are: Review of the medical record for Resident 3 on 08/16/2011 at 2:30PM revealed: -Medicare Daily Skilled Nursing Notes did not address an event that led to a decline/change in condition for Resident 3 or the nursing care/monitoring of Resident 3; -Doctor's Orders and Progress Notes: Resident 3 demonstrated behaviors by yelling and stating "feeling like before (gender) went to the hospital.....like having a stroke". The date and time of this event is identified in the Doctors Orders and Progress Notes as 06/29/2011 at 04:55AM by phone call to primary physician; -Physician order [REDACTED]. -One narrative entry on 06/28/2011 without a time is entered by the night nurse. Interview by phone with CNA D on 08/17/2011 at 08:10 reveals; The House Supervisor arranged for a staff member to sit with Resident 3. This did have a calming effect and there was no further yelling. Review of the Behavior Monitoring/Intervention Record reveals: Last entry in written on 06/27/2011 during the evening shift relating to transferring from chair to bed with the use of a mechanical life and/or a recliner brought from home. Interview with the Director of Nursing and the Assistant Director of Nursing on 08/17/2011 at 09:00 AM revealed: -Nursing assessment for Resident 3 for a change in condition occurring on 06/29/2011 during the night shift did not appear in the form used for narrative documentation of resident condition and service on 06/29/2011; -There is one narrative entry on 06/28/2011 and a check box assessment done but no specific time is… | 2014-12-01 |
| 12275 | 12275 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2011-05-09 | 281 | D | 1 | 0 | 29O411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.04C3a Based on record review and staff interview; the facility failed to notify the physician/healthcare practitioners that a once a month administration of inhalation medication, prescribed for immunosuppress of organ transplants, was not administered to Resident 1. The facility census was 219 residents. Sample size was 6 Findings are: Review of closed medical records [REDACTED] -Admission of the facility on 02/06/201; -Past medical history included: liver transplant, July 2010 and remains on chronic immunosuppression, chronic [MEDICAL CONDITIONS], asthma, [MEDICAL CONDITION] hypertension and multiple banding's with [MEDICAL CONDITION] varices; -Physician order, 02/08/2011 "[MEDICATION NAME] 300mg vial respiratory (IH inhalation) treatment to be given monthly at Lancaster Manor while (patient) resides there"..; -Faxed communication, 02/09/2011, to transplant center in Omaha "...has to have [MEDICATION NAME] before [MEDICATION NAME] respiratory treatment"; -Review of the February Medication Administration Record [REDACTED] -Review of the Doctor's Orders and Progress Notes for 02/08/2011 revealed: fax communication with Pharmacy Provider to have medication delivered to the facility (02/08/2011); -Discharge to home was on 02/18/2011. Interview with the Director of Nursing on 05/09/2011 revealed: The medication was not identified as given in the record at the time of discharge to home on 02/18/2011. Staff acknowledged that the medication was not given but there had been attempts to coordinate administration with respiratory therapy services, pharmacy service and the transplant team in Omaha as evidenced in the written record on 02/08/2011 and 02/09/2011. Resident 1's length of stay was 02/06/2011 to 02/18/2011. There was no alternative plan identified to ensure administer this medication. There is no information that identifies that the physician or transplant team was notified that this medication was … | 2014-09-01 |
| 12276 | 12276 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2011-05-09 | 157 | D | 1 | 0 | 29O411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09 Based on record review and staff interview; the facility failed to ensure the administration of one medication as ordered by healthcare practitioners for 1 of 6 resident records reviewed. The facility census was 219 residents. Sample size was 6. Findings are: Review of closed medical records [REDACTED] -Admission of the facility on 02/06/201; -Past medical history included: liver transplant, July 2010 and remains on chronic immunosuppression, chronic [MEDICAL CONDITIONS], asthma, [MEDICAL CONDITION] hypertension and multiple banding's with [MEDICAL CONDITION] varices; -Physician order, 02/08/2011 "[MEDICATION NAME] 300mg vial respiratory (IH inhalation) treatment to be given monthly at Lancaster Manor while (patient) resides there"..; -Faxed communication, 02/09/2011, to transplant center in Omaha "...has to have [MEDICATION NAME] before [MEDICATION NAME] respiratory treatment"; -Review of the February Medication Administration Record [REDACTED] -Review of the Doctor's Orders and Progress Notes for 02/08/2011 revealed: fax communication with Pharmacy Provider to have medication delivered to the facility (02/08/2011); -Discharge to home was on 02/18/2011. Interview with the Director of Nursing on 05/09/2011 revealed: The medication was not identified as given in the record at the time of discharge to home on 02/18/2011. Staff acknowledged that the medication was not given but there had been attempts to coordinate administration with respiratory therapy services, pharmacy service and the transplant team in Omaha as evidenced in the written record on 02/08/2011 and 02/09/2011. Resident 1's length of stay was 02/06/2011 to 02/18/2011. There was no alternative plan identified to ensure administer this medication. There is no information that identifies that the physician or transplant team was notified that this medication was not administered or to identify other alternatives to ensure administration … | 2014-09-01 |
| 12348 | 12348 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2011-01-19 | 280 | D | 1 | 1 | VFG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on observation, record review and interview; the facility failed to review and revise care plan interventions for 2 residents (Residents 56 and 148) regarding activities; and for 1 resident (Resident 260) regarding nutritional status. The facility census at the time of survey was 221 residents. The sample size was 35 residents. Findings are: A. A review of Resident 56's CARE PLAN (undated) revealed that the resident was identified as spending the majority of the time during the day in bed, and was Catholic. Approaches included inviting to Rosary and mass; offering drinks with a sippy cup; having staff/volunteers take the resident to and from Mass/rosary; providing Rosary beads; and working with nursing so that the resident was available for group activities. Review of Resident 56's ACTIVITY ASSESSMENT with a review date of 12/7/2010; revealed that the resident was Catholic and used to work on the railroad. The resident was identified as having poor short and long term memory with a short attention span at times. The resident needed a pureed diet with thickened drinks. The residents' past interests included hunting and fishing. The resident was identified as preferring large group activities; leisure activities; small group and one-one activities with limited participation due to laying down in the afternoons. Family and friends visit weekly. Current activity interests include: music; dance; outdoors; cards; bingo with assistance; sensory stimulation; reality orientation; one to one; pet therapy; socialization with peers and staff; sports; spiritual; entertainment; intergenerational; educational; reading large print; community outings; resident council; gender related activities; TV with assistance; favorite programs include football, basketball; game shows and news. This assessment was initially completed 8/2009 and was dated as being reviewed for accuracy on 12/7/2010. A review of the res… | 2014-08-01 |
| 12349 | 12349 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2011-01-19 | 279 | D | 1 | 1 | VFG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09C Based on observation of residents, interview with staff and record review; the facility failed to develop comprehensive care plan goals and interventions regarding 1) the provision of oxygen therapy for 1 resident (Resident 110); 2) [MEDICAL TREATMENT] care and services for 1 resident (Resident 143); 3) hospice services for 1 resident (Resident 258); and 4) regarding pain management for 1 residents (Residents 98). Findings are: A. Review of the Comprehensive Care Plan for Resident 258 on 01/19/2011 revealed; -Identified Hospice service initiated: 11/13/2010 for "end stage heart" with plan to invite Resident, family and hospice to all care plan reviews; spiritual support will be provided by personal pastor and St. Elizabeth chaplain. Interview and observation of Resident 258 on 01/18/2011 in resident room revealed: -A medication was provided on a regular basis and that there was medication to take at other times. The pain did increase at times it depended on what activity the resident was or had been doing; -The resident was currently taking an antibiotic for a "cough" and had a respiratory illness. Interview with the Nursing Station 2 Manager on 01/19/2011 revealed: -Hospice service was initiated on 11/15/2010; -No Hospice contract or individualized Plan of Care for Hospice Service could be located in the medical records or provided by the staff. - A Hospice Nurse visited on 01/08/2011 to discuss medication therapy for pain control for routine administrations and which medications should be given on a as needed basis, use of other medications for congestive heart and kidney failure. Other alternative treatments (non-pharmacological) were were ordered that included: topical creams for muscle pain, heat and massage. Plan included assessment for hydration. This information is found in the Progress notes for physician/nurse communications with orders; -Review of the current care plan for Resident 258 with the Nurse Manager did … | 2014-08-01 |
| 12350 | 12350 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2011-01-19 | 441 | F | 1 | 1 | VFG211 | Based on observation, record review, and interview; the facility failed to ensure that staff followed accepted infection control practices. This had the ability to affect all residents residing in the facility. The facility census was 321 with a total of 35 sampled residents. Observation of Medication administration on Unit 5 by Medication Aide (MA) L on 1/12/11 at 7:15 AM; revealed no use of hand sanitizer or hand washing after giving medication to 5 residents. Observation of one of these incidents was the resident dropped a pill on the floor and MA L picked up the pill off the floor and took it back to dispose of it at the medication cart. MA L then got out a pill to replace it from the bubble pack and took the pill in the medication cup back into the resident room and gave it to the resident. At no time was washing hands observed or use of hand sanitizer. Observation of medication pass on Unit 4 dining room by MA L on 1/19/11 at 8:00AM; revealed this MA delivering medication to three residents without washing hands or applying hand sanitizer. Observation on Unit 2 of Licensed Practical Nurse (LPN) L on 1/19/11 at 9:20AM; revealed this LPN L holding a dirty clothing protector in hand and putting it in bag of soiled clothing protectors. This LPN L then got two clean gloves from a box and without use of hand sanitizer or handwashing then touched Resident 234 on the shoulders and assisted to push this resident in the wheelchair to own room. No hand sanitizer or handwashing observed with this event. Observation on Facility Tour of the Housekeeping Manager (CA) on 1/19/11 at 12:05PM; revealed CA picking up unidentifiable pieces off the floor on units 2, and 3 with no evidence of washing hands or use of hand sanitizer. Further observation of CA revealed that on Unit 1 this CA put a clean clothing protector on a resident and then put hands on this residents shoulders. Interview with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) on 1/19/10 at 10:15AM; revealed that handwashing was reviewed in t… | 2014-08-01 |
| 12942 | 12942 | LANCASTER MANOR | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2010-10-27 | 332 | E | 78PJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.10D Based on observation and record review, the facility failed to have a medication error rate of less than 5%5 percent during onsite medication administration observations. A total of 40 medications were observed with 3 errors resulting in a 7.5 % error rate. The facility census was 239. Findings are: Observations during morning medication pass on 10/27/10 at 9:45 AM revealed Medication Aide (MA) A administer the following medications to Resident 3: [MEDICATION NAME] (laxative) 3 mg (milligrams) , [MEDICATION NAME] Sodium (stool softener) 100 mg , [MEDICATION NAME] (multivitamin) one tab, [MEDICATION NAME] (a steroid spray for allergies [REDACTED]. Review of Resident 3's October Routine Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The [MEDICATION NAME] and [MEDICATION NAME] were to be given at 0800 AM. Further Review of Resident 3's October Routine Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observations during morning medication pass on 10/27/10 at 10:00 AM revealed Medication Aide (MA) A administer the following medications to Resident 4: [MEDICATION NAME] (an antidepressant)150 mg and [MEDICATION NAME] 300 mg, [MEDICATION NAME] (an antipsychotic) 100 mg, [MEDICATION NAME] (to treat high cholesterol) 600 MG, [MEDICATION NAME] (an antidepressant) 20 mg, Vitamin D 1,000 units, [MEDICATION NAME] (to treat high blood pressure) 1 mg and Tylenol (for pain) 325 mg. Review of Resident 4's October Routine Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observations during noon medication pass on 10/27/10 at 12:30 PM revealed Medication Aide (MA) A administer the following medication to Resident 5: [MEDICATION NAME] (an antipsychotic) 4 mg. Review of Resident 5's October Routine Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the sa… | 2014-02-01 | ||
| 934 | 934 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-07-03 | 657 | E | 1 | 0 | 5XJ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on interview and record review, the facility staff failed to review and revise 3 residents' care plans after falls to prevent further falls and potential injury. This affected 3 of 4 residents whose care plans were reviewed during the survey process (Residents 1, 3, and 4). The facility identified a census of 22 at the time of survey. Findings are: [NAME] Review of Resident 1's quarterly MDS (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 6/11/2019 revealed an admission date of [DATE]. Resident 1 had no falls since prior assessment. Review of Resident 1's Fall reports revealed Resident 1 had falls documented on 3/2/2019 and 6/19/2019. Review of Resident 1's Care Plan dated 3/15/2018 revealed no documentation of interventions implemented to prevent further falls and injuries after Resident 1 fell on [DATE] and 6/19/2019. Interventions were added to the care plan on 6/25/2019, 6 days after Resident 1 fell on [DATE]. B. Review of Resident 3's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 3 required extensive assistance with transfers. Resident 3 had 1 fall with injury since the prior assessment. Review of Resident 3's Fall report revealed documentation Resident 3 had a fall on 3/1/2019. Review of Resident 3's Care Plan dated 12/7/2018 revealed no documentation of interventions implemented to prevent further falls and injuries after Resident 3 fell on [DATE]. C. Review of Resident 4's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 4 was rarely/never understood. Staff assessment for mental status revealed Resident 4 had short tern and long term memory problems and Resident 4 had moderately impaired cognitive skills for daily decision making. Resident 4 required limited assistance of 1 staff person for transfers. Resident had 2 falls with no injury since prior assessment. Review of Resident 4's Fall repor… | 2020-09-01 |
| 935 | 935 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2017-08-22 | 371 | F | 0 | 1 | GG8P11 | Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview and record review; the facility failed to utilize a facial hair restraint to prevent the potential for hair contact with food and failed to change gloves during food preparation in a manner to prevent the potential for food borne illness. This had the potential to affect 32 residents that ate food prepared in the facility kitchen. The facility census was 32. Findings are: [NAME] Observation on 08/16/2017 between 11:00:40 AM and 11:10 AM during the initial tour of the kitchen revealed Dietary Aide (DA) A had a goatee beard and mustache with no facial hair restraint in place during food preparation of the lunch meal. B. Observation on 08/16/2017 at 12:01:37 PM revealed DA A served lunch with no facial hair restraint in place. C. Observation on 08/21/2017 at 10:31:12 revealed DA A was in the food preparation area of the facility kitchen with no facial hair restraint in place. D. Record review of the 7/1/07 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: - 2.402.1(A) Food employees shall wear hair restraints such as beard restraints that are designed and worn effectively to keep hair from contacting exposed food, clean equipment, utensils and linens. E. Observation on 8/21/17 between 11:00 AM and 11:15 AM during food preparation revealed Cook B removed a box of ground beef patties from the freezer. Cook B washed hands and donned gloves. [NAME] removed 2 frozen ground beef patties from a bag and placed them on a pan. Cook B placed the meat soiled bag on top of the plastic wrap container. It remained in that position for the entire observation. Cook B repeated the process of removing the individual ground beef patties and placed them on the pan until the pan was full. With meat soiled gloves, Cook B touched the oven door handle and opened the oven door, placed the pan in the oven and closed the oven… | 2020-09-01 |
| 936 | 936 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2018-09-05 | 637 | D | 0 | 1 | Y9XX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B1(2) Based on observation, interview, and record review; the facility staff failed to complete a SCSA (Significant Change in Status Assessment) MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) when Resident 8 was admitted to Hospice (care designed to give supportive care to people in the final phase of a terminal illness). This affected 1 of 16 residents whose MDS assessments were reviewed during the survey process. The facility identified a census of 22 at the time of survey. Findings are: Review of Resident 8's Annual MDS dated [DATE] revealed Resident 8 was admitted to the facility on [DATE]. Resident 8 had a terminal prognosis and received Hospice care during the assessment period. Observation of Resident 8's room on 8/30/18 at 3:59 PM revealed a Hospice aide was sitting in the Resident 8's room. Interview with the unidentified Hospice aide at this time revealed they provided Resident 8 Hospice care twice a week. Interview with NA-A (Nurse Aide) on 9/04/18 at 1:34 PM revealed Resident 8 received Hospice services. Review of Resident 8's Hospice Certification and Plan of Care dated 9/18/2017 revealed a start of Care Date of 9/14/2017. Review of Resident 8's MDS assessments revealed the following assessments were completed: 6/15/2018 Annual 3/15/2018 Quarterly 12/18/2017 Quarterly 9/18/2017 Quarterly 6/15/2017 Annual There was no documentation a SCSA MDS was completed after Resident 8 was admitted to Hospice on 9/14/2017. Review of the Centers for Medicare and Medicaid RAI (Resident Assessment Instrument) 3.0 manual revealed the following: A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD (Assessment Reference Date) must be within 14 days from the effective date of the hospice el… | 2020-09-01 |
| 937 | 937 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2018-09-05 | 641 | E | 0 | 1 | Y9XX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09b Based on interview and record review, the facility staff failed to code the MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) to reflect the PASRR (Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) requirement. This affected 3 of 3 sampled residents (Residents 10, 21, and 1). The facility identified a census of 22 at the time of survey. Findings are: [NAME] Review of Resident 10's annual MDS dated [DATE] revealed a response to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?in section A1500 PASRR was marked No. Resident 10 had an active [DIAGNOSES REDACTED]. Resident 10's admitted was 1/31/2011. Review of the Ascend Nebraska Level 1 PASRR Screening Instructions revised 11/25/2015 revealed the following: The federal definition for mental illness is designed to include individuals with a potential for and history of episodic changes in treatment and service needs. Federal guidelines include a three component definition that includes: [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Anxiety disorder may require further evaluation through PASRR depending upon their extent and severity. Review of Resident 10's [DIAGNOSES REDACTED]. Resident #21 B. Review of Resident 21's annual MDS dated [DATE] revealed a response to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?in section A1500 PASRR was marked No. Resident 21 had an active [DIAGNOSES REDACTED]. Resident 21's admitted was 9/14/2015. Review of the Ascend Nebraska Level 1 PASRR Screening Instructions revised 11/25/2015 revealed the following: The … | 2020-09-01 |
| 938 | 938 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2018-09-05 | 727 | F | 0 | 1 | Y9XX11 | Licensure Reference Number 175 NAC 12-006.04C1 Based on record review and interview, the facility failed to provide 8 hours of RN (Registered Nurse) coverage for every 24 hour period. This had the potential to affect all the residents at the facility. The facility census was 22. Findings are: Record review of the facility nursing staff schedule revealed that the nursing staff schedule did not reflect 8 hour RN coverage on the following dates: (MONTH) 5, (MONTH) 18, (MONTH) 25, (MONTH) 1 and (MONTH) 2. Interview (MONTH) 4th, (YEAR) at 11:30 AM with the DON (Director of Nursing) confirmed there was no RN coverage on those dates. | 2020-09-01 |
| 939 | 939 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2018-09-05 | 812 | F | 1 | 1 | Y9XX11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview, and record review; the facility staff failed to serve food in a manner to prevent potential cross contamination; failed to maintain cookware and dishes to prevent potential cross contamination; and failed to keep kitchen surfaces clean. This had the potential to affect all of the facility residents. The facility identified a census of 22 at the time of survey. Findings are: [NAME] Initial tour of the kitchen on 8/29/18 at 9:44 AM revealed the following: Mixing bowls, plate warmers and lids for room trays were stored on bottom shelves upright and uncovered. Plates were uncovered in the rack by the steam table. Refrigerator and freezer doors were visibly soiled with smears of white and brown material. A window air conditioner was blowing back behind the stove over the sink; the front cover had gray debris on it. B. Observation of evening meal service on 8/30/2018 at 5:30 PM revealed Cook-B wearing gloves. Cook-B grabbed the handles of 2 carts and wheeled them over to where the steam table was. At 5:37 PM Cook-B touched the buns for the riblet sandwiches with the same gloved hands that they had touched the cart handles with and the handles of the utensils. Cook-B did not change gloves. Cook-B then picked up trays off the bottom shelf of the food prep table and continued to serve. Cook-B also handled the diet cards. Cook-B then touched the ham sandwiches with the same gloved hands. At 5:42 PM Cook-B opened the cupboard door and got plastic cups out and put them on the condiment cart. Cook-B then grabbed more trays off the shelf. At 5:43 PM Cook-B put their fingers in the ramekins then put corn in them using the same gloved hands. Cook-B then served the corn to the residents. At 5:46 PM Cook-B got more trays off the shelf then continued to serve touching the buns with the same gloved hands and putting fingers in the ramekins. At 5:50 PM Cook-B got more trays and proceeded to touch the buns and put fingers inside the ramekins with the same… | 2020-09-01 |
| 940 | 940 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 582 | E | 0 | 1 | DGFB11 | Based on record review and interview, the facility failed to ensure that residents were provided a Notice of Medicare Non coverage for 3 (Resident 8, Resident 124, and Resident 125) of 3 sampled residents. The facility census at the time of the survey was 21. Finds are: [NAME] Record review of Resident 8's Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) dated 9/1/19 resident was notified of discharge from skilled services but did not receive the required Notice of Medicare Non Coverage (NOMNC). B. Record review of Resident 124's Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) dated 6/22/19 resident was notified of discharge from skilled services but did not receive the required Notice of Medicare Non Coverage (NOMNC). C. Record review of Resident 125's Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) dated 5/28/19 resident was notified of discharge from skilled services but did not receive the required Notice of Medicare Non Coverage (NOMNC). An interview on 10/16/19 at 4:29 PM with the DON (Director of Nursing) revealed the DON issues the denial letters for SNFABN and NOMNC. The DON stated that Resident 8, Resident 124, and Resident 125 did not initiate their discharges and that each one had days remaining for Medicare A Services. The DON confirmed that the NOMNC letters were not given to Resident 8, Resident 124 or Resident 125. | 2020-09-01 |
| 941 | 941 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 584 | D | 1 | 1 | DGFB11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-007.04D Based on observation and interview the facility failed to ensure the vents in the bathroom were free from dirt and dust for 2 (Resident 10 and Resident 15) of 16 sampled residents. The census at the time of the survey was 21. Findings Are: [NAME] Observation on 10/10/19 at 8:40 AM of the bathroom for Resident 10 revealed that the ceiling vent was covered with a fuzzy gray debris that rained down when touched with a piece of toilet tissue. B. Observation on 10/10/19 at 8:43 AM of the bathroom for Resident 15 revealed that the ceiling vent was covered with a fuzzy gray debris that rained down when touched with a piece of toilet tissue. An interview on 10/16/19 at 5:28 PM with the HS (Housekeeping Supervisor) confirmed that the bathroom vents for Resident 10 and Resident 15 were covered with a fuzzy gray debris. | 2020-09-01 |
| 942 | 942 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 602 | D | 1 | 1 | DGFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 12-006.05(9) Based on interview and record review, the facility failed to protect residents from potential misappropriation by failing to conduct reference checks, a criminal background check, and licensure certification verification checks for RN-B (Registered Nurse) who subsequently diverted medications from the facility residents. This affected 2 of 21 residents in the facility (Resident 1 and 17) who received medication. The facility identified a census of 21 at the time of survey. Findings are: Review of the facility report Misappropriation dated 9/15/2019 revealed the current facility DON (Director of Nursing) and other nursing staff suspected there were medications missing from the medication cart that had belonged to Resident 1 and Resident 17. The report contained documentation of discrepancies in the amount of medications that were sent to the facility from the pharmacy for Residents 1 and 17, the amount of the medication that was administered to the residents, and the amount remaining in the supply. The facility discovered that 86 tablets of [MEDICATION NAME] (a narcotic like pain reliever) for Resident 17, 32 tablets of [MEDICATION NAME] (antianxiety medication) for Residents 1 and 17, and 51 tablets of [MEDICATION NAME] (an opioid or narcotic pain reliever) that were slated for destruction had potentially been diverted from the facility and residents' medication supply. Review of the facility report of the investigation into drug diversion dated 9/17/2019 revealed documentation RN-B (the DON at the time of the incident) was confronted about the missing medications. RN-B admitted to diverting the mediations from the facility medication cart for their own use including [MEDICATION NAME] and [MEDICATION NAME]. RN-B was suspended then terminated from the facility. Interview with the facility administrator on 10/16/19 at 4:46 PM confirmed the medications belonging to Resident 1 and Resident 17 were diverte… | 2020-09-01 |
| 943 | 943 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 606 | D | 1 | 1 | DGFB11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3d Based on interview and record review, the facility failed to maintain 3 of 6 personnel files with evidence the NA (Nurse Aide) registry was checked for adverse findings prior to employment for the HS (Housekeeping Supervisor) and DA-C (Dietary Aide), failed to ensure staff working did not have a criminal conviction involving misappropriation on their record prior to employment, failed to ensure personnel files contained evidence that prospective employees had not been found guilty of abuse, neglect, exploitation or misappropriation, failed to ensure reference checks were completed for RN-B, and failed to check licensure certification verification status for RN-B prior to employment. The facility identified a census of 21 at the time of survey. Findings are: [NAME] Review of RN-B's General Orientation Checklist revealed a hire date of 2/4/2019. Review of RN-B's Separation Acton Form dated 9/17/2019 revealed their last day worked was 9/13/2019. Review of the personnel file for RN-B revealed their date of hire was 2/4/2019 and their day of separation (termination date) was 9/17/2019. RN-B's last day worked was listed as 9/13/2019. There was no documentation a criminal background check, reference checks, or nursing licensure check was completed upon hire. RN-B's employment application was also missing from the file. Review of the document Employment Profile Form dated and signed by RN-B on 1/24/2019 revealed documentation RN-B had a conviction 2010/2011 of misdemeanor attempt to possess narcotics. There was documentation the form had been faxed to the criminal background check company, but there was no documentation of the results of the criminal background check. Interview with the facility Administrator on 10/15/19 at 10:08 AM revealed they could not find the criminal background check for RN-B. The administrator revealed the criminal background check had been completed but they did not have access to the results because the company would not release it. The administ… | 2020-09-01 |
| 944 | 944 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 607 | E | 1 | 1 | DGFB11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3b Based on interview and record review, the facility staff failed to follow the facility policy for screening 3 of 6 employees RN-B (Registered Nurse), HS (Housekeeping Supervisor), and DA-C (Dietary Aide) for abuse, neglect, and misappropriation prior to employment. This had the potential to affect all of the facility residents. The facility identified a census of 21 at the time of survey. Findings are: [NAME] Review of RN-B's General Orientation Checklist revealed a hire date of 2/4/2019. Review of RN-B's Separation Acton Form dated 9/17/2019 revealed their last day worked was 9/13/2019. Review of the personnel file for RN-B revealed their date of hire was 2/4/2019 and their day of separation (termination date) was 9/17/2019. RN-B's last day worked was listed as 9/13/2019. There was no documentation a criminal background check, reference checks, or nursing licensure check was completed upon hire. RN-B's employment application was also missing from the file. Review of the document Employment Profile Form dated and signed by RN-B on 1/24/2019 revealed documentation RN-B had a conviction 2010/2011 of misdemeanor attempt to possess narcotics. There was documentation the form had been faxed to the criminal background check company, but there was no documentation of the results of the criminal background check. Interview with the facility Administrator on 10/15/19 at 10:08 AM revealed they could not find the criminal background check for RN-B. The administrator revealed the criminal background check had been completed but they did not have access to the results because the company would not release it. The administrator confirmed they didn't have any way of knowing what the results were of the criminal background check. The administrator confirmed it should have been completed/results available so they could act on it. Interview with the facility Administrator on 10/15/19 at 11:23 AM revealed the BOM (Business Office Manager) had a misunderstanding about completing the … | 2020-09-01 |
| 945 | 945 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 657 | D | 0 | 1 | DGFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on interview and record review, the facility failed to include 2 residents and their responsible party in planning their care (Residents 3 and 13). This affected 2 of 14 residents whose care plans were reviewed during the survey process. The facility identified a census of 21 at the time of survey. Findings are: Interview with Resident 3 on 10/09/19 at 2:43 PM revealed they had not been invited to a care plan meeting nor had been involved in the planning of their care. Review of Resident 3's quarterly MDS (MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) revealed an admission date of [DATE]. Resident 3 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated moderate cognitive impairment. Review of Resident 3's Care Plan dated 1/27/2019 revealed no documentation Resident 3 had participated in their care plan meeting. Review of Resident 3's Progress Notes revealed no documentation Resident 3 or their responsible party was invited to the care plan meeting. B. Interview with Resident 13 on 10/10/19 at 11:33 AM revealed they had not had a care plan meeting for 6-7 months. Review of Resident 13's annual MDS dated [DATE] revealed an admission date of [DATE]. Resident 13 had a BIMS score of 12. Interview with Resident 13's responsible party on 10/16/19 at 2:00 PM confirmed they have not had a care plan meeting for quite some time. They had one set up after the first of the year and the facility canceled it for some reason; they were unable to have it. Resident 13's responsible party said the facility staff had tried to schedule it on a Friday and the responsible party said they were here every Wednesday and Saturday and they had told the facility staff they would like to have the meeting when they were here. I am here. We could have the meeting. Review of Resident 13's Progress Notes revealed no documentation Resident 13 or their resp… | 2020-09-01 |
| 946 | 946 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 688 | D | 0 | 1 | DGFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D4 Based on observation, interview, and record review; the facility failed to offer a restorative nursing program to Resident 13 to restore or prevent further contractures. This affected 1 of 2 residents reviewed for restorative care. The facility identified a census of 21 at the time of survey. Findings are: Review of Resident 13's annual MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 8/16/2019 revealed an admission date of [DATE]. Resident 13 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated moderate cognitive impairment. Resident 13 required extensive assistance from 2 staff for bed mobility and Resident 13 was dependent upon staff for transfer and locomotion. No therapy or nursing restorative minutes were documented. Resident 13 had a functional limitation in range of motion on one side both upper and lower extremity. Interview with Resident 13 on 10/10/19 at 11:36 AM revealed they only had use of their right arm and leg. Resident 13 revealed the facility had not offered a restorative nursing program. Observation of Resident 13 on 10/15/19 at 10:00 AM, 10/16/2019 at 7:59 AM, and 10/16/2019 at 2:00 PM revealed both of Resident 13's hands had contractures (permanent shortening of tissue, such as muscle, tendon or skin, as a result of disuse, injury or disease. Contracture leads to the inability to straighten joints fully and to permanent deformity and disability). Resident 13's left hand was misshapen: it was curled over and their thumb was sticking out of the opposite side of their hand through their fingers. Resident 13's right hand was misshapen and fixed in a bent manner without the ability to perform spontaneous movement. Interview with the DON (Director of Nursing) on 10/16/19 at 10:03 AM revealed at one time Resident 13 was receiving a restorative nursing program for range of motion but they were refusing it. The … | 2020-09-01 |
| 947 | 947 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 689 | D | 0 | 1 | DGFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E43-8-17 Based on observation, record review, and interview; the facility failed to ensure hazardous/poisonous chemicals in the housekeeping close were stored to prevent accidental ingestion, inhalation or consumption by one wandering resident (Resident 11) out of one wandering resident on the unit. The facility census at the time of the survey was 21. Findings Are: Observation on 10/09/19 at 11:42 AM the housekeeping storage room was left unlocked. No staff were observed in the hallway. Chemicals inside the unlocked storage room were: -Multi-Surface Peroxide, an agent according to the MSDS (Material Safety Data Sheet) was harmful if swallowed or came into contact with the skin. Causes [MEDICAL CONDITION] eye damage. Avoid breathing dust/fume/gas/mist/vapors/spray. -Kling Toilet Bowl and Urinal Cleaner, an agent according to the MSDS was dangerous causing [MEDICAL CONDITION] eye damage. If swallowed immediately call a Poison Center or a Physician. Review of Resident 11's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used in care planning) dated 8/8/19 revealed that wandering behavior occurred daily. Behavior of pacing and rummaging were observed. Review of Resident 11's Progress Notes revealed documentation of Resident 11 wandering the hallways and not being easily redirected. An interview on 10/9/19 at 11:42 AM with the HS (House Supervisor) revealed that the door was unlocked and residents could have wandered into the room. The HS confirmed that harmful and dangerous chemicals were being stored in the storage room. | 2020-09-01 |
| 948 | 948 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 700 | D | 1 | 1 | DGFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B Based on observations, interviews, and record reviews; the facility failed to assess Resident 11 and Resident 21 for the use of bed rails. This affected 2 of 2 sampled residents. The facility census at the time of the survey was 21. Findings are: [NAME] Observation of Resident 11's bed on 10/9/19 at 10:51 AM revealed a bed rail in the raised position with a 13.5 gap between the head of the bed and the rail. There was greater than a 4 gap between the mattress and the bed rail. A closed fist could be placed between the mattress and the rail. An interview on 10/9/19 at 11:20 AM with the ADM (Administrator) revealed that the bed in the room to the right should have been appropriate for Resident 11 just in case Resident 11 wanted to lay in the bed. 10/09/19 11:51 AM Interview with RN-A (Registered Nurse) revealed that the bed in room [ROOM NUMBER] on the right side of the room had a space between the mattress and the bed rail of greater than 4. Review of the Side Rail Assessment for Resident 11 revealed the only assessment completed was dated 10/9/19. B. Observation of Resident 21's bed on 10/9/19 at 10:59 AM revealed a side rail on the exit side of the bed with no cover over the rail and a 7 gap in the rail. A head could easily fit into this space. 10/09/19 11:51 AM Interview with RN-A (Registered Nurse) revealed that the side rail in room [ROOM NUMBER] on the exit side of the bed had a space that Resident 21 could have put Resident 21's head through the opening. An interview on 10/09/19 at 11:55 AM with the MS (Maintenance Supervisor) revealed that the side rail did not belong to the facility. The maintenance man was informed by RN- A (Registered Nurse) that the rail needed to be remove immediately. The MS then slid the rail off of the bed which had been attached to a wooden board and place under the mattress. Review of the Side Rail Assessment for Resident 21 revealed the only assessment completed… | 2020-09-01 |
| 949 | 949 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 909 | E | 1 | 1 | DGFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B3 Based on observation, interview, and record review; the facility staff failed to have a program in place to ensure residents' beds were maintained to prevent a potential entrapment hazard for Residents 3, 5, 20, 22, 11, and 21. This affected 6 of 16 residents' beds evaluated during the survey process. The facility identified a census of 21 at the time of survey. Findings are: [NAME] Observation of Resident 3's bed on 10/09/19 at 11:49 AM revealed the bed was up against the wall and the mattress was not secured to the bed. The mattress could be slid off the bed frame creating a gap between the wall and the bed that created a potential entrapment hazard. B. Observation of Resident 5's bed on 10/09/19 at 11:48 AM revealed the bed was up against the wall. The mattress was not secured to the bed and could be slid off the bed frame creating a gap between the wall and the bed and a potential entrapment hazard for Resident 5. C. Observation of Resident 20's bed on 10/09/19 at 11:50 AM revealed the mattress was not secured to the bed and could be slid off the creating a gap between the wall and the bed creating a potential entrapment hazard. Resident 20's bed was up against the wall. There are mattress stops on the bed but the mattress did not fit into the stops as the mattress was too big for the bed. D. Observation of Resident 22's bed on 10/09/19 at 11:45 AM revealed Resident 22's bed was against the wall. The mattress was not secured to the bed and could be slid off the bed frame creating a gap between the wall and the bed and a potential entrapment hazard. Interview with RN-A (Registered Nurse) 10/09/19 at 3:03 PM confirmed the facility should have a program in place to ensure the beds did not create a potential entrapment hazard for the residents. Interview with the facility Administrator on 10/09/19 at 5:10 PM confirmed the beds could potentially create an entrapment hazard for the residents and … | 2020-09-01 |
| 950 | 950 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 921 | F | 1 | 1 | DGFB11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18 Based on observation and interview, the facility failed to ensure a clean dining environment for all the residents, eating in the main dining room, due to fuzzy gray matter on the blades of the ceiling fans. This had the potential to affect all 21 residents in the main dining room. The census at the time of the survey was 21. Findings Are: Observation on 10/09/19 at 10:30 AM of the dining room revealed that the lighting fixtures in the main dining room which consisted of units in the center of the dining room with fans. The blades of these 3 fans had gray fuzzy debris on the fan blades. Resident tables were placed close to and below the fans. An interview and tour of the dining room on 10/16/19 at 5:28 PM with the HS (Housekeeping Supervisor) revealed the fans in the dining room were covered with gray fuzzy debris. | 2020-09-01 |
| 5045 | 5045 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2016-06-30 | 253 | E | 0 | 1 | 76NZ11 | Licensure Reference Number: 175 NAC 12-006.18B3 Based on interview and observation; the facility failed to: 1) ensure a resident room did not have a strong ammonia odor for Resident 27; 2) clean the resident room windows and screens for three residents (Residents 14, 11, 30); 3) cover a light bulb in the resident bathroom affecting two residents (Resident 22 and 32); 4) fix the marred closet door for Resident 22; and 5) paint over a water stain on the wall in Resident 20's room. This had the potential to affect 7 of 27 residents. The Facility census was 27 residents at the time of the survey. Findings are: [NAME] Tour of the room occupied by Resident 27 on 6/27/16 at 2:35 PM revealed the wall behind the recliner was marred. The room had a strong ammonia odor in the bathroom and room. Tour of the room occupied by Resident 27 on 6/28/16 at 3:45 PM found the resident's room had a strong ammonia odor. Tour of the room occupied by Resident 27 on 06/29/2016 at 2:50 PM found the resident's room had a strong ammonia odor. B. Tour of the room occupied by Resident 14 on 6/27/16 at 2:56 PM revealed the window screen had a gray/white debris. C. Tour of the room occupied by Resident 17 on 6/28/16 at 8:39 AM revealed the room window was covered with a white film. D. Tour of the room occupied by Resident 30 on 6/28/16 at 8:42 AM revealed the room window was covered with a white film and the window screen was covered with a while/gray debris E. Tour of the room occupied by Resident 22 on 6/28/16 at 9:36 AM revealed the closet door was marred, the bathroom light bulb was not covered and the window screen was covered with a white/gray debris. F. Tour of the room occupied by Resident 32 on 6/28/16 at 10:04 AM revealed the bathroom light bulb was not covered. [NAME] Tour of the room occupied by Resident 20 on 6/28/16 at 10:04 AM revealed a water stain on the wall near the window and the wall was marred near the garbage can. H. Tour of the room occupied by Resident 32 on 6/28/16 at 10:05 AM revealed the window screen had a gray/white… | 2020-02-01 |
| 5046 | 5046 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2016-06-30 | 323 | D | 0 | 1 | 76NZ11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, interview, and record review; the facility staff failed to evaluate a transfer method to prevent potential injury for Resident 18. The facility census was 27 at the time of survey. Findings are: Review of Resident 18's quarterly MDS (Minimum Data Set-a comprehensive resident assessment tool used to develop a resident's care plan) dated 5/5/2016 revealed that Resident 18 required extensive assistance from 2 staff for transfers and had severely impaired decision making skills. Resident 18's weight was 111 pounds. Observation of staff transferring Resident 18 on 6/28/2016 at 5:29 PM revealed NA-F (Nursing Assistant) and NA-G picked Resident 18 up by the underarms and placed Resident 18 in a wheelchair. Resident 18's legs were drawn up and Resident 18 was hanging in the air by the underarms. Observation of staff transferring Resident 18 on 06/29/2016 at 12:58 PM revealed MA-A and NA-B picked Resident 18 up by the underarms out of the wheelchair and placed Resident 18 on a mattress on the floor. Resident 18's legs were drawn up and Resident 18 was hanging in the air by the underarms. Interview with the PTA (Physical Therapy Assistant) on 6/30/2016 on 8:22 AM revealed they had not been consulted to assist nursing staff with evaluating Resident 18 for an effective transfer method. The PTA confirmed that transferring Resident 18 using the underarms was not the best method to transfer and that the joints in the legs and the arms should have been supported. The PTA revealed that either a cradle lift (a type of lifting technique that supports the back and the legs of the resident) or a mechanical lift transfer would have been a better choice for transferring Resident 18. Interview with NA-C on 6/30/2016 at 8:33 AM revealed the nursing staff had not been trained to transfer Resident 18. Interview with the DON (Director of Nursing) on 06/30/2016 at 12:06 PM revealed they had not consulted with therapy to determine the most effective and safe transfer method… | 2020-02-01 |
| 5047 | 5047 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2016-06-30 | 329 | D | 0 | 1 | 76NZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 12-006.09D Based on interview and record review, the facility failed to ensure that Resident 22's medication regimen was free from the use of antipsychotic medication (medication used to treat behavior disorders). Facility census was 27 at the time of survey. Findings are: Review of Resident 22's Order Summary Report dated 6/12/2016 revealed that Resident 22 had an order for [REDACTED]. Review of Resident 22's MDS (Minimum Data Set-a comprehensive assessment tool used for developing a resident's care plan) dated 5/5/2016 revealed that Resident 22's admitted to the facility was 12/7/2013 and that Resident 22 had received antipsychotic medication every day during the 7 day look back period for the assessment. Review of Resident 22's MAR (Medication Administration Record) for (MONTH) (YEAR) revealed documentation that Resident 22 had received [MEDICATION NAME] 0.5 mg every day. Review of Resident 22's chart including the pharmacy review records and progress notes revealed no documentation that a GDR (Gradual Dose Reduction) had been attempted annually for the antipsychotic medication. Interview with the DON (Director of Nursing) on 6/30/2016 at 12:05 PM revealed there was no documentation in Resident 22's chart that a GDR had been attempted annually for the antipsychotic medication. Interview with the RP (Registered Pharmacist) on 7/5/2016 at 10:10 AM revealed there was no record that a GDR attempt had been requested annually for the antipsychotic Resident 22 was receiving. Review of the facility policy Antipsychotic Medication Review dated 3/6/2016 revealed to ensure that the Pharmacy Consultant had reviewed the medication program at least monthly and made recommendations for dose reductions, as appropriate. | 2020-02-01 |
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CREATE TABLE [cms_NE] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );