cms_NE
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 268 | 268 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2019-03-05 | 578 | E | 0 | 1 | MX7V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** [NAME] Based on record review and interview, the facility failed to ensure that the residents advanced directives were included in the Comprehensive Care Plan. This had the potential to effect all Residents in the facility. The facility census was 35. Record review of Resident #5s medical chart revealed, a Durable Power of Attorney dated [DATE], a Declaration of Living Will dated [DATE] and a Declaration of Intent for Life Sustaining Measures dated [DATE]. Record review also revealed a Comprehensive Care Plan dated [DATE] with no documentation of advanced directives. Record review of Resident #8s medical chart revealed, a Nebraska Power of Attorney for Health Care dated [DATE] and a Declaration of Intent for Life Sustaining Measures dated [DATE]. Record review also revealed a Comprehensive Care Plan dated [DATE] with no documentation of Advanced Directives. Record review of Resident #10s medical chart revealed. A Durable Power of Attorney dated [DATE] a Power of Attorney for Health Care dated [DATE] and a Living Will dated [DATE] and a Declaration of Intent for Life Sustaining Measures dated [DATE], Record review also revealed a Comprehensive Care Plan dated [DATE] with no documentation of Advanced Directives. On [DATE] at 1:48 PM an interview with the MDS Coordinator revealed that they do not put advanced directives on care plans. B. Record review of the Care Plan with a goal target date of [DATE] revealed; Advanced Directives were not addressed in the Comprehensive care plan. Record review of the Advanced Directives dated [DATE] revealed; Resident 28's preference was not to have CPR (Cardiopulmonary Resuscitation a medical procedure involving repeated compression of a residents chest performed in an attempt to restore circulation and breathing of a person who has had a [MEDICAL CONDITION]) initiated if the heart stopped. Resident 28's preference was to have nutrition and hydration provided through a tube which would be inserted into the nos… | 2020-09-01 |
| 269 | 269 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2019-03-05 | 584 | E | 0 | 1 | MX7V11 | Licensure and Reference Number 175 NAC 12-006.18A(1) Based on observation, interview and record review the facility failed to ensure the vent fans in the resident restrooms were free of dust, this had the potential to affect 4 resident rooms, rooms numbered; 502, 503, 505, and 508, and the facility had 28 rooms. The facility census was 35. On 03/05/19 at 10:25 AM an observation revealed a brown fuzzy substance on the restroom vents in room #s 502, 503, 505, and 508. On 03/05/19 at 10:25 AM an interview with the Maintenance Director, confirmed the vents in the resident restrooms in rooms; 502. 503, 505, and 508 were covered in a brown fuzzy substance. On 03/05/19 at 10:27 AM an interview with the housekeeper on 500 hall confirmed the vents were covered with a brown fuzzy substance and should be cleaned, the housekeeper also revealed the vents are cleaned once or twice a year. On 03/05/19 at 12:00 PM an interview with Administrator / Housekeeping Director revealed; there is no routine cleaning schedule for the resident restroom vent fans, and the vent fans should be cleaned when dirty. | 2020-09-01 |
| 270 | 270 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2019-03-05 | 641 | D | 0 | 1 | MX7V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview the facility failed to ensure that the MDS (The Long-term 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 resident in a Medicare or Medicaid-certified long term care facility) was accurately coded to reflect the Swallowing/Nutritional Status for weight loss for one resident (Resident 25)of 2 sampled residents. The facility census was 35. Findings are: Record review of Resident 25 weights revealed; on 08/13/2018 at 11:46AM was 169.4 lbs. (Pounds) and on 02/21/2019 at 11:12AM Resident 25 weighed 150.2 lbs. and had a weight loss of 11.33% in 6 months. Record review of MDS (Minimum Data Set- an assessment used to develop a person centered comprehensive plan of care for the resident) Annual assessment dated [DATE] revealed; Section K Swallowing/Nutrition Status revealed; Resident 25 had no loss of 5% or more in the last month or loss of 10 % or more in the last 6 months. Record review of Progress note from Dietary dated 02/19/2019 at 12:51PM Revealed; o Resident's 25's current weight was149.lbs. , had stabilized, same as 30 days, but remained 10% below weight 180 days ago. Record review of Nutritional assessment dated [DATE] at 10:26AM Resident 25 had a decrease of 22 lbs. or 13% weight loss in 90 days. Interview with Dietary Manager on 03/04/19 at 03:12 PM confirmed that the MDS dated [DATE] was coded incorrectly for Section K and Resident 25 had an 11 percent weight loss in 180 days. | 2020-09-01 |
| 271 | 271 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2019-03-05 | 689 | E | 0 | 1 | MX7V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006 18.E4 Based on observation, record review and interview; the facility failed to ensure chemicals were secured to prevent the potential for accidental exposure for 2 residents( Residents 87 and 34) identified as self mobile with wandering behaviors. The facility failed to ensure hot equipment was not accessible to residents with cognitive impairment. This had the potential to affect 5 residents( Residents #15, 17, 22, 23, and 186) of 7 residents that reside on the memory care unit. The facility census was 35. Findings are: [NAME] Observation on 03/04/19 at 02:25 PM reveled one utility room on the 200 hall that was unlocked. The under the sink cabinet was unlocked and contained the following chemicals: - Empty 409 Cleaning container. - One gallon of Bleach. - One 32 ounce bottle of Lime -A- Way. - Spray Disinfectant cleaner 8 ounce bottle. - Spray Bathroom cleaner and Disinfectant 450 ml bottle - Aerosol Stainless Steel cleaner can - Aerosol Garage Door Lube can. - Mop bucket with mop and dirty water also noticed in cleaning closet. Observation on 03/04/19 at 2:30 P.M. Revealed a clean linen closet on the 200 hall that was unlocked. The top shelf had a full container of Germicide wipes in plain site. Interview on 03/04/19 at 3:25 P.M. with the facility Administrator, confirmed that the 200 hall utility room was unlocked and the lock on the cabinet under the sink was not working. The Administrator confirmed the cabinet contained chemicals which could be considered hazards to residents that had exhibited wandering behavior as they could open the cabinet and have immediate access to chemicals. The Administrator agreed mop bucket and dirty water should not be in an unlocked room. The Administrator confirmed that all chemicals should be kept in a locked cabinet. Interview on 03/04/19 at 3:27 P.M. with the Administrator confirmed that the 200 hall clean linen closet contained Germicidal wipes on top shelf in … | 2020-09-01 |
| 272 | 272 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2019-03-05 | 700 | D | 0 | 1 | MX7V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B Based on observations, record reviews, and interviews, the facility failed to review the risks and benefits of bed rails to the resident and/or legal representative, failed to obtain consent to use bed rails, failed to attempt to use other alternatives prior to installing the bed rail, and failed to assess the resident for risk of entrapment from bed rails prior to installation on one resident (Resident 2) out of 1 resident sampled. The facility census was 35. Findings are: Record review of Resident 2's undated Face Sheet revealed the [DIAGNOSES REDACTED]. Review of Resident 2's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 2-27-19 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 11 which indicated Resident 2 had moderate impairment of cognition. The resident required extensive of assist of two staff with bed mobility, transfers, dressing, and toileting. The resident did not walk during the assessment period. Observation on 2-27-18 at 3:30 PM of Resident 2's bed revealed the bed had a bed rail on the outside edge at the HOB (head of bed) only. The other side of the bed was against the wall and did not have a bedrail. The mattress on the bed had a gap between the uncompressed mattress and the bedrail which measured 3.5 inches. Review of Resident 2's Careplan dated 12-17-18 revealed the resident had an assist handle on the right side of the bed to help the resident with transfers and repositioning. Review of the medical record revealed absence of a bedrail assessment and absence of a consent form. Interview on 2/28/19 at 2:44 PM with the DON (Director of Nursing) confirmed the facility did not complete siderail/bedrail assessments on residents with siderails or assist bars and therefore Resident 2 did not have a bedrail assessment completed. The DON confirmed the… | 2020-09-01 |
| 273 | 273 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2019-03-05 | 756 | D | 0 | 1 | MX7V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 174 NAC 12-006.12B Based on record review and interview, the facility failed to ensure the drug allergies [REDACTED]. The facility census was 35. Findings are: Review of undated Face Sheet revealed the resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. Review of the electronic medical record on the undated Face Sheet revealed the allergies [REDACTED]. Review of the paper chart revealed an allergy sticker across the front of the resident's medical record with the allergy sticker listed cephalosporins, latanoprost, [MEDICATION NAME], and [MEDICATION NAME] (pain medication). Interview on 03/05/19 at 11:50 AM with the MDS-C (Minimum Data Set Coordinator) confirmed the electronic medical record list of cephalosporins, lantaprost, [MEDICATION NAME], and [MEDICATION NAME] would be the current list of allergies [REDACTED]. MDS-C reviewed the most recent H/P (history and physical) and the H/P did not list the [MEDICATION NAME] as an allergy. MDS-C could not explain where the [MEDICATION NAME] allergy came from. Later in the day on 3-5-19, MDS-C provided 2 forms, the Admission Notification and Clarification form dated 08/27/15 which listed Resident 1's allergies [REDACTED]. Interview on 03/05/19 at 2:06 PM with MDS-C revealed MDS-C attempted to enter [MEDICATION NAME] into the electronic medical record but the program would not accept it. When MDS-C entered it as ketoralac (the generic name for [MEDICATION NAME]) the program accepted it so the MDS-C felt the discrepency resulted from a glitch in the computer system. | 2020-09-01 |
| 274 | 274 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2019-03-05 | 770 | E | 0 | 1 | MX7V11 | **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 glucose (blood sugar) test strips were not expired for 3 residents (Residents 1, 88, and 30) out of 3 sampled. The facility census was 35. Findings are: Observation on [DATE] at 12:08 PM revealed RN-E (Registered Nurse) performed a blood glucose check using the Assure Platinum test strips on Resident 88. Review on [DATE] at 3:07 PM of the Assure Platinum test strip bottle for Resident 88 revealed the bottle was opened and did not have an opened date documented on the bottle. Review of Residents 1 and 30's glucose test strip bottles revealed the bottles were opened and also did not have a date the bottles were opened documented on the bottles. Review of the Assure Platinum Test Strips instructional insert revealed to date the bottle and use within 3 months, or the manufacturer expiration date on the bottle, whichever comes first. Interview on [DATE] at 3:08 PM with LPN-J (Licensed Practical Nurse) revealed the manufacturer's expiration date listed on the bottle was the expiration date the facility used. Residents 1, 30, and 88 had manufacturer expiration dates listed as [DATE]. LPN-J revealed the date the test strip bottles were opened were documented in the control book log, but staff only review that log anytime a new bottle was opened and therefore the nurse using the test strips would not know the date the bottle was opened since it was not documented on the bottle. LPN-J denied knowledge of the instructions listed on the bottle stating the test strips expired 90 days after the bottle was opened. | 2020-09-01 |
| 275 | 275 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2019-03-05 | 812 | F | 0 | 1 | MX7V11 | Licensure Reference Number 175 NAC 12-006.11 E Based on observation and interview, the facility failed to maintain equipment in a clean, sanitary manner to prevent the potential for food borne illness as evidenced by: air ventilation and ceiling ventilation systems covers with reddish substance that resembled rust and a fuzzy gray substance that resembled dust present, peeled paint on the ceiling near lights, peeled and missing non-slip black tile floor surfaces, fuzzy gray substance present on the fan that blew air toward the clean dish area, fuzzy gray substance on the ventilation fans in the walk in cooler. The facility staff failed to ensure that hair restraints fully enclosed all hair in a manner to prevent potential contact with food. This had the potential to affect 34 residents that ate food prepared in the facility kitchen. The facility census was 35. Findings are: [NAME] Equipment: Observation on 03/04/19 between 10:45 AM and 11:25 AM with the DM revealed the following concerns with sanitation of equipment and surfaces: - Return air ventilation system covers for the air conditioner had a reddish substance that resembled rust and a fuzzy gray substance that resembled dust present on the exterior of the covers. - Ceiling ventilation system covers had a reddish substance that resembled rust and a fuzzy gray substance that resembled dust present on the exterior of the covers. - Paint on the ceiling surrounding the light fixtures was peeled and missing in places in the food preparation area and above the stove. - Non-skid black floor tiles were peeled off and absent in front of the stove and dish wash area which created a non-cleanable surface. - Small white fan above the clean dish area had a fuzzy gray substance present. The fan blew air toward the clean dish area. - Walk in refrigerator had a fuzzy gray substance present on the ventilation system fans. Interview on 03/04/19 at 11:25 AM with the DM confirmed the concerns with sanitation of the air conditioning ventilation system covers, the ceiling ventila… | 2020-09-01 |
| 276 | 276 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2019-03-05 | 880 | F | 0 | 1 | MX7V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 174 NAC 12-006.17 Based on observation, record review, and Inteview, the facility failed to ensure that hand hygiene and gloving during resident care procedures were performed in a manner to prevent the potential cross contamination for 3 residents (Residents 1, 5, and 88) out of 3 residents sampled; and failed to store clean linens inches above the floor in the linen storage closets in halls 100 and 300. This had the potential to affect all residents in the facility. the facility failed to ensure that hand hygiene and gloving during resident care procedure's were performed in a manner to prevent the potential cross contamination for residents # 5, 1, and 88. and failed to store clean linens 6 inches above floor in the linen storage closets in hall 100 and 300 this had the potential to affect all residents in the facility. The facility census was 35. Findings are: [NAME] Review of Resident 1's undated Face Sheet revealed Resident 1 was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 2-13-19 revealed the resident had a stage 2 pressure ulcer (per the MDS manual: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). ) Interview on 3-4-19 at 2:56 PM with the MDS-C (MDS Coordinator) revealed the resident's pressure ulcer on the heel began on 8-24-18. The resident had been evaluated by the Physician several times at a wound clinic and the wound was healing but very slowly. Observation on 03/04/19 at 10:09 AM revealed RN-E (Registered Nurse) performed wound care to Resident 1's left heel pressure ulcer in the resident's room while the resident was in bed. RN-E had brought wound supplies into the room on a cart from the medication supply room. RN-E entered the resident's room, then washed the top of the cart with a disinfectant … | 2020-09-01 |
| 277 | 277 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2019-03-05 | 909 | F | 0 | 1 | MX7V11 | LICENSURE REFERENCE NUMBER 174 NAC 12-006.18B3 Based on observation, record review, and interview, the facility failed to implement a process designed for routine preventative maintenance to inspect all bed frames, matresses, and bed rails as part of a regular maintenance program for possible areas of entrapment. This had the potential to affect all residents. Facility census was 35. Findings are: Observation on 02/27/19 at 3:30 PM revealed Resident 2's bed was up against the wall with a positioning bar on the outside edge of the bed. There was a large gap between the mattress and the bar. Observation on 02/28/19 at 2:55 PM with the DON (Director of Nursing) confirmed the head of the bed frame device to hold the mattress in place was absent from this bed. Interview on 02/28/19 at 2:18 PM with the (MS) Maintenance Supervisor revealed the beds in the facility had a mattress securing device on the head and foot of the beds. MS revealed the facility used positioning bars on some of the resident beds and had one resident who used siderails. MS confirmed the Maintenance Department did not contduct routine inspection of all bed frames, mattresses, and bedrails for preventative maintenance. MS revealed the beds were checked only when the nursing staff reported problems like a frayed cord on the controls or something broken. Interview on 02/28/19 at 2:49 PM with the ADM (Administrator) confirmed the facility did not perform regular inspection of all bed frames, mattresses, and bedrails to identify areas of entrapment. | 2020-09-01 |
| 278 | 278 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2016-10-13 | 225 | D | 0 | 1 | MH0511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report fractures as potential instances of abuse/neglect for two residents (Residents 8 and 35). The facility census was 39. Findings are: Review of the facility's incident log from 10/5/15 through 10/11/16, revealed that Resident 35 was found on 10/22/15, to have a fractured ankle from a fall. Further review of the incident log revealed that Resident 8 suffered a [MEDICAL CONDITION] after a fall from a bath board on 5/24/16. On 10/11/16 at 2:30 PM, the Social Services Director (SSD) was interviewed about reporting requirements. The SSD stated that the facility had not been reporting fractures as potential instances of neglect to the state agency, which included Residents 8 and 35. | 2020-09-01 |
| 5508 | 5508 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2016-11-09 | 323 | D | 1 | 0 | MINW11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, interview and record review; the facility failed to implement interventions to prevent the potential for falls for one of three sampled residents (Resident 1). The facility census was 40. Findings are: Review of Resident 1's care plan revealed a problem related that the resident was at high risk for falls. The problem start date was 5/6/14. According to the care plan the resident had a fall on 10/20/16 resulting in a fracture. The stated interventions to prevent falls included an intervention dated 12/21/15 that the resident should wear gripper socks at night and an intervention dated 10/20/16 that the bathroom light should be on at night. Review of the Event Report dated 10/20/16 revealed that just prior to the fall on 10/20/16 at 3:50 AM, Resident 1 was walking to the bathroom with the lights off. On 11/9/16 at 4:25 AM, observation was made of Resident 1 in bed. The resident did not have gripper socks on and the bathroom light was not on. At 4:40 AM on 11/9/16, Nursing Assistant A (NA A) confirmed that Resident 1 was not wearing gripper socks and that the bathroom light was not on. NA A stated not being aware if the bathroom light being left on was an intervention or not for Resident 1. Interview on 11/9/16 at 7:55AM with the Director of Nursing confirmed that gripper socks and the bathroom light being left on at night were care planned interventions for Resident 1 and should have been in place. | 2019-11-01 |
| 6292 | 6292 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2015-10-13 | 157 | D | 0 | 1 | RHXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a Based on record review and interview, the facility staff failed to notify the physician of abnormal bleeding for one resident (Resident 42) using anticoagulants. The facility census was 43. Findings are: Record review of Resident 42's Physician order [REDACTED]. Record review of Resident 42's Progress Notes dated 5/26/2015 at 01:50 AM revealed that Resident 42 had 1x7 cm (centimeter) blue bruise to right wrist. Record review of Resident 42's Progress Notes dated 5/27/2015 at 00:45 AM revealed that Resident 42 had a large, soft, light brown BM (bowel movement) with 'a considerable amount of bright red blood noted'. Record review of Resident 42's Progress Notes dated 5/27/2015 at 21:52 PM revealed that Resident 42 again had large amount of blood in the stool. Record review of Resident 42's Progress Notes dated 5/28/2015 at 9:30 AM revealed the bruise to Resident 42's right wrist had increased in size to 11 x 4.5cm. Further record review of the Progress Notes and the physician's notes from 5/26/2015 to 5/31/2015 revealed that none of these episodes were reported to the resident's physician. Record review of the facility's undated Policy and Procedure for [MEDICATION NAME] revealed The nurse shall contact the physician when .severe or spontaneous bruising .bloody or tarry stools. Interview with LPN (Licensed Practical Nurse) A on 10/13/2015 at 6:15 PM revealed that, if a resident was taking an anticoagulant, that resident would be monitored for bruising, nose bleeds, bloody gums, blood in urine. LPN A continued on to say that, if any of these symptoms would occur, the physician would be notified. Interview with RN (Registered Nurse) B on 10/13/2015 at 6:20 PM revealed a resident taking an anticoagulant should be monitored for any signs and symptoms of bleeding such as blood in urine or stool, or any increase in confusion. RN B further stated, if these signs occurred, that the physician would be noti… | 2019-04-01 |
| 6293 | 6293 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2015-10-13 | 241 | E | 0 | 1 | RHXH11 | Licensure Reference Number: 175 NAC 12-006.05 (21) Based on observation and interview, the facility failed to protect the dignity and privacy of three residents (Residents 6, 53 and 10) by posting individualized care instructions in an area easily visualized by visitors. Findings are: A. Observation of Resident 53's room on 10/7/15 at 12:16 PM and again on 10/13/15 at 10:55 AM revealed a sign dated 1/2/2015 posted on the wall above Resident 53's bed. Further review of the sign revealed four detailed instructions for positioning Resident 53 in the wheel chair and was signed Therapy. Interview with the Director of Rehabilitation (DOR) on 10/13/15 at 2:50 PM revealed therapy placed signs in the residents' rooms to ensure staff provided positioning and application of devices, if needed, appropriately. The DOR could not say whether or not the resident or resident's family member had been asked for permission prior to posting the sign. B. Observation of Resident 6's room on 10/13/15 at 11:10 AM revealed an undated sign above Resident 6's bed that read, Please elevate (Resident 6's) head and feet when in bed. This makes (gender) more comfortable and decreases (Resident 6's) crying. Thank you! During the same observation a second sign was noted hanging on the inside of the open bathroom door. This sign was dated 1/7/15 and titled Techniques for working with (Resident 6) with a handwritten signature from a therapist. The sign went on to explain how to transfer, move, re-direct behaviors and approach Resident 6. Interview with the Director of Rehabilitation on 10/13/15 at 2:52 PM revealed the DOR had placed the sign on the bathroom door and that the family had not been asked for permission. Interview with the Director of Nursing (DON) on 10/13/15 at 4:45 PM revealed that, before posting any signs regarding the residents, the residents or resident's families were to be asked for permission. The DON went on to say that, if residents or their families had been asked, for it would be documented in the care plan notes. Further … | 2019-04-01 |
| 7673 | 7673 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2014-11-10 | 241 | D | 0 | 1 | 2C8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number NAC 12-006.05 (21) Based on observation, interview and record review; the facility failed to ensure the dignity of two residents (Residents 21 and 24) related to positioning and hygiene. The facility census was 43. Findings are: A. Record review of the Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 7/30/14 revealed that Resident 21 required extensive to total dependence on 1-2 person physical assist and was severely cognitively impaired. Observation on 11/05/2014 at 1:05 PM of Resident 21's legs were dangling unsupported from elevated foot rests on wheelchair. A staff member came along and put feet up on foot rest. At 1:14 PM Resident 21's feet had slid off the foot pedals and legs were dangling. Observation on 11/06/2014 at 9:20 AM of Resident 21 sitting in common area, tilted slightly back in wheelchair. Resident 21's feet were on foot pedals, a gait belt was tied around the wheelchair leg mechanism to support ankles so that legs did not dangle. In an interview on 11/06/2014 at 11:50 AM with the Restorative Aide revealed the facility provides wheelchairs to most residents. The Restorative Aide also stated that maintenance does repairs to wheelchairs and if the problem is bigger than that the Restorative Aide talks to the OT (Occupational Therapist) and the resident may be put on the therapy case load. In an interview on 11/06/2014 11:41 AM with the OT revealed that the OT gets involved when wheelchairs are ill-fitting or not meeting resident needs. The OT stated that the OT always looks at residents for positioning and if the wheelchair is appropriate for the resident. The OT also stated that if possible the facility tries to reuse wheelchair parts to meet resident needs and that had not been a problem getting equipment needed for resident wheelchairs. In an interview on 11/10/14 at 9:22 AM with LPN (Licensed Practical Nurse) M revealed that LPN M did not fi… | 2018-01-01 |
| 7674 | 7674 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2014-11-10 | 253 | E | 0 | 1 | 2C8X11 | Licensure Reference Number: 175 NAC 12-006.18B3 Based on observation and interview, the facility failed to keep the caulking around the base of the toilets clean and in good repair in 8 resident rooms. The facility had 35 resident rooms with toilets designated for resident use. Findings are: During the environmental tour on 11/10/14 at 10:10 AM observation of resident rooms and bathrooms revealed the caulking at the base of the toilets in rooms 104, 106, 109, 202, 204, 303, 307 and 308 to be separated from the base of the toilet and contain a heavy build up of black substance between the caulking and the toilet base. Interview with Maintenance Supervisor (MS) on 11/10/14 at 10:15 AM confirmed the above findings and revealed that maintenance employees did not routinely audit resident use areas for needed repairs. MS continued to report that replacing caulking around the base of the toilets was an easy task to complete. | 2018-01-01 |
| 7675 | 7675 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2014-11-10 | 315 | D | 0 | 1 | 2C8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D3 Based on observation, interview and record review; the facility failed to assess causal factors and implement interventions to minimize urinary incontinence for one resident (Resident 53). Facility census 43. Findings are: Record review of Resident 53's Admission MDS (Minimum Data Set: A federally mandated assessment used for care planning purposes) dated 7/1/14 showed the resident had short term and long term memory problem. Cognitive skills for daily decision making was severely impaired and toilet use was totally dependent with the use of two staff. Resident 53 was not on an urinary toileting program and was frequently incontinent of urine Record review of Resident 53's Quarterly MDS dated [DATE] revealed that Resident 53 was totally dependent for toilet use, was not on a toileting program and was always incontinent of urine. Observation on 11/05/2014 at 3:22 PM with MA-A (Medication Aide) and NA-B (Nurse Aide) revealed NA-B and MA-A took off Resident 53's wet incontinent brief and performed perineal care to Resident 53. Resident 53 was not offered the use of the toilet or urinal. Observation on 11/06/2014 at 9:50 AM with MA-C and NA-D revealed MA-C and NA-D took off Resident 53's wet incontinent brief and performed perineal care to Resident 53. Resident 53 was not offered the use of the toilet or urinal. Interview on 11/6/2014 at 9:55 AM with MA-C revealed sometimes they hold the urinal for Resident 53 and a lot of the time the resident had already been incontinent. Interview on 11/06/2014 at 2:33 PM with the DON (Director of Nursing) revealed that before residents were admitted to the facility, the DON would call the facility that the new resident was coming from and got a verbal report of the incontinent resident's needs. The DON would also ask about incontinent products used by the resident so the facility could have the products ready when the resident arrived. The DON revealed that the … | 2018-01-01 |
| 7676 | 7676 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2014-11-10 | 318 | D | 0 | 1 | 2C8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D4 Based on record review, observation and interview; the facility failed to identify the need for and implement ROM (range of motion) for one resident with contractures (Resident 35) and failed to ensure ROM was implemented as needed and recommended for one resident with contractures (Resident 8). The facility had a census of 43 residents. Findings are: A. Review of Resident 35's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 10/8/14 revealed Resident 35 had severely impaired cognition, required total assistance for mobility and ADL (activities of daily living) tasks and had an impairment of range of motion on both sides to upper and lower extremities. Review of Resident 35's care plan dated 11/12/13 revealed Resident 35 required a mechanical lift to transfer and had chronic pain. There was no notation to the plan of care regarding range of motion. Review of an Observation Report for Resident 35 dated 4/18/14 revealed Resident 35 had a contracture. The area on the same form indicating whether or not a splint was used or range of motion services provided was left blank. Review of Resident 35's Progress Notes dated 10/14/14 and written by Restorative Aide (RA) E revealed, receives no therapy or restorative at this time. Observation of Resident 35 on 11/5/14 at 1:39 PM revealed Resident 35 lying on the left side with knees flexed up to chest with a pillow between them. Observation of Resident 35 on 11/6/14 at 10:48 AM during the provision of cares revealed Resident 35 was unable to straighten either leg or arm. Nursing Assistant (NA) F during the provision of cares replied that Resident 35 was rolled in bed as a unit as (Resident 35) was getting more and more contracted. Interview with the RA E on 11/6/14 at approximately 9:20 AM revealed that Resident 35 was not receiving any range of motion exercises. RA E further explained that residents are… | 2018-01-01 |
| 7677 | 7677 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2014-11-10 | 323 | D | 0 | 1 | 2C8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D7b Based on record review and interview, the facility failed to identify causal factors of falls and identify preventative interventions to prevent the potential for further falls for one resident (Resident 23). The facility census was 43. Findings are: Review of Resident 23's Fall Risk assessment dated [DATE] revealed Resident 23 was not a fall risk. The following Fall Risk assessment for Resident 23 dated 10/21/14 Resident 23 was not at risk for falls. Review of Resident 23's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 10/29/14 revealed Resident 23 had a cognitive impairment, a [DIAGNOSES REDACTED]. Review of Resident 23's Care Plan revised on 11/4/14 revealed Resident 23 was at risk for falls and staff were to ensure the bed was locked with a revision in August 2014 to encourage resident to feel for the chair before sitting. Another revision dated 11/4/14 was made to monitor (Resident 23) for falls and implement new interventions should a fall occur. Review of Resident 23's Event Reports revealed Resident 23 fell on [DATE] with complaints of dizziness. Two additional falls occurred on 8/17/14 and 8/2/14 where Resident 23 was found leaning against a wall and sustained a skin tear and missed a chair in the dining room and sustained a fracture to the 5th digit of left hand. Interview with the Director of Nursing (DON) on 11/10/2014 at 10:32 AM revealed that after a resident falls a report is completed and forwarded to the DON or the MDS nurse coordinator. Whichever nurse gets the report ensures the family and physician have been notified and that a revision to fall interventions is made to the plan of care. When questioned on what might be causing the increase in falls for Resident 23 the DON replied that after the most recent fall a Urinary Analysis (UA) was conducted to rule out a Urinary Tract Infection (UTI) due to the resident's comp… | 2018-01-01 |
| 7678 | 7678 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2014-11-10 | 371 | E | 0 | 1 | 2C8X11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation and interview, the facility failed to ensure food was prepared and served in a sanitary manner. This failure increased the risk of bacterial growth and therefore posed a food safety risk to the residents. The facility census was 43. Findings are: Observation of the noon meal preparation and service on 11-06-2014 beginning at 10:29 am revealed the following: -Dietary Employee (DE) N obtained an uncovered thermometer from a coffee cup that had pens, pencils and scissors in it and checked the temperature of the puree without sanitizing the thermometer. After use, the thermometer was sanitized with alcohol, then placed directly on the countertop where other equipment had been. The thermometer was then used to test another food temperature. -DE N obtained serving utensils from a drawer by touching the serving ends of both the ladle and tongs with an un-gloved hand. These utensils where then placed in containers of food on the steam table. -The Nebraska Food Code (4-904.11) states .Sanitized utensils shall be handled, displayed, and dispensed so that contamination of food- and lip-contact surfaces is prevented. | 2018-01-01 |
| 7679 | 7679 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2014-11-10 | 441 | E | 0 | 1 | 2C8X11 | Licensure Reference Number: 175 NAC 12-006.17 Based on observation, interview and record review; the facility failed to ensure the arm bike was sanitized between resident use for one resident (Resident 8) and failed to ensure mechanical lifts were sanitized between resident use for two residents (Residents 35 and 40). This had the potential to effect three residents who utilized the arm bike and 14 residents who required the use of the mechanical lift. The facility had a census of 43 residents. Findings are: A. Observation of Resident 8 completing exercises using the arm bike in the therapy room on 11/6/14 at 9:20 AM revealed the pedals of the arm bike had been padded and the padding was secured to the pedal with numerous wraps of a clear plastic tape. Interview with Restorative Aide (RA) E on 11/6/14 at 9:20 AM revealed that the padding on the pedals was changed once in a while and sanitized. Review of an undated listing of current residents provided by the RA revealed three residents (Resident 8, 57, and 31) were currently using the arm bike for exercise. B. Observation on 11/5/14 at 1:35 PM revealed Nursing Assistant (NA) H and I transfer Resident 40 from a wheelchair to a recliner using a mechanical lift. The lift was not sanitized before or after use. Observation on 11/6/14 at 10:45 AM revealed Nursing Assistant (NA) F and NA G transfer Resident 35 to bed using a mechanical lift. The lift was not sanitized before or after use and there were no sanitizing wipes noted in the vicinity of the lift. Interview with NA G on 11/06/14 at 2:22 PM revealed the mechanical lifts were cleaned once daily on the night shift but that NA G tried to sanitize them more often especially if the resident had just finished wiping themselves after using the toilet or had a cold. Interview with LPN M on 11/6/14 at 2:25 PM revealed that night shift was responsible for cleaning the mechanical lifts. Review of an undated wheelchair cleaning list provided by the Director of Nursing revealed mechanical lifts were scheduled to be cleaned w… | 2018-01-01 |
| 7680 | 7680 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2014-11-10 | 504 | D | 0 | 1 | 2C8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09 Based on record review and interview, the facility failed to obtain a PT and INR ([MEDICATION NAME] and International Normalized Ratio - blood tests done to determine the clotting tendency of blood) as ordered for one Resident (Resident 35). The facility had a census of 43 residents. Findings are: Review of Resident 35's October - November 2014 Medication Administration Record [REDACTED]. Review of Resident 35's Individual INR Log completed by the physician's assistant last revealed the last INR drawn was on 10/14/14 and was to be rechecked on Monday (10/20/14). Review an another Individual INR log for Resident 35 completed by the facility nursing staff revealed the last INR was drawn on 10/14/14 and was to be rechecked in one month. Review of the laboratory testing and results revealed no further PT/INR testing since 10/14/14. Interview with the Licensed Practical Nurse (LPN) M on 11/06/2014 at 10:38 AM revealed that the health chare practitioner used the 1st log to document any new orders based on the results of the PT/INR testing and the 2nd INR log was used for the nurses to transcribe the orders and keep record. LPN M further reported that the nurse transcribed the order onto the 2nd log with the wrong time frame for follow up testing and the PT/INR test got missed. | 2018-01-01 |
| 9023 | 9023 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2014-01-15 | 226 | D | 0 | 1 | WBLH11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3 AND 12-006.04A3b Based on record review and interview, the facility failed to ensure that direct care staff were screened for registry and background checks for 3 of 5 personel files (Registered Nurse C, Nursing Assistant D, and Licensed Practical Nurse E) reviewed. The facility census was 41. Findings are: Review of employee file for RN (Registered Nurse)-C revealed a hire date of 11/29/13. No results were documented for the Criminal Background check which was authorized by RN-C on 11/29/13. A copy of the RN license was present in file but there was no documentation related to a licensure/registry check. The Adult and Child Abuse and Neglect Registry check request, which were authorized by RN-C on 11/29/13, had a fax confirmation dated 1/14/14 and No report Found document received from the DHHS-CPS Central Register on 1/14/14. Review of employee file for NA (Nursing Assistant)-D revealed a hire date of 12/4/13. There were no results documented for the Criminal Background check which was authorized by NA-D on 12/4/13. The Adult and Child Abuse and Neglect Registry check request, which were authorized by NA-D on 12/4/13, had a fax confirmation dated 1/14/14 and No report Found document received from the DHHS-CPS Central Register on 1/14/14. Review of employee file for LPN (Licensed Practical Nurse)-E revealed a hire date of 8/16/13. There was no copy of LPN licensure and no documentation of a licensure/registry check present in file. During an interview on 1/14/14 at 2:10 PM the Administrator confirmed the above findings. An interview on 1/15/14 at 3:15 PM with the Director of Nursing revealed that all 5 of the employees that were reviewed have worked as direct care staff since their hire dates. | 2016-11-01 |
| 9024 | 9024 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2014-01-15 | 318 | D | 0 | 1 | WBLH11 | Based on observation, record review and interview; the facility failed to prevent the potential for a decrease in range of motion for one resident, Resident 10. The facility census was 41. Findings are: Review of Resident 10's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 12/4/13 revealed that this resident was totally dependent for all activities of daily living and had limited range of motion to bilateral upper and lower extremities. Review of Resident 10's care plan, updated on 12/10/13, revealed that the resident was receiving restorative exercises three times per week. Observation was made of Nursing Assistant-A (NA-A) demonstrating range of motion exercises on Resident 10 at 12:37 PM on 1/14/14. The resident did not shows signs of resisting the exercises or have verbal or non-verbal indicators of pain. NA-A stated that the restorative program for this resident consisted of passive range of motion to the resident's neck and shoulders. When asked if Resident 10 had limitations in the knees, NA-A stated, Not very much but demonstrated that the resident's knees did show limited range of motion. Review of Physical Therapy Discharge Summary, dated 10/31/12, revealed that the long term goal was met on 10/31/12 of, Restorative program will be established to bi-lateral lower extremity passive range of motion to hips, knees, and ankles in all planes for prevention of contractures . An interview was conducted with the Restorative Coordinator, Nursing Assistant-B, (NA-B) on 1/14/14 at 3:22 PM, related to Resident 10's range of motion. NA-B confirmed that the MDS did indicate lower extremity limitations but that the current program only included range of motion to the resident's neck and shoulders. NA-B stated that the lower extremities could be added to the program and acknowledged that it would help prevent the contractures from worsening. | 2016-11-01 |
| 9025 | 9025 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2014-01-15 | 323 | E | 0 | 1 | WBLH11 | Licensure Reference Number 175 NAC 12-006.18E3a and 12-006.09D7b Based on observation, interview, and record review; the facility failed to protect residents from the potential for accidents related to high water temperatures in 5 of 35 resident room sinks, (Rooms 202, 205, 204, 301, and 307); and related to falls for 1 resident, Resident 55. The facility census was 41. Findings are: A) On 1/9/2014 at 3:42 PM during resident observations, using a state issued Cooper thermometer, it was observed the water temperature in room 302 was 121 degrees. On 1/13/14 at 10 AM, during an interview with the Maintanence Director, it was acknowledged, that the temperatures had been high in some resident restroom sinks. Also revealed, on 1/10/14 it was discovered that the thermostat on the hot water heater that supply's water to the 100-200 and 300 halls, had a faulty digital thermostat, and that was the cause of the high water temperatures. On 1/9/14 at 10:20 AM the following observations were made of water temperatures in resident rooms: Room 202-128.6 degrees Fahrenheit Room 204-127.9 Room 205-129.2 room 301-127.6 B) Review of Nurses Notes for Resident 55 and facility incident report dated 10/19/13 at 3:00 PM revealed that Resident 55 was found outside by the fountain on all fours. Resident 55 reported that (gender) just wanted to sit in the sun, when (gender) sat down, the chair went over backwards. Resident 55 did complain of back pain and was noted to have a slightly reddened area across upper back. The resident also reported hitting head during the fall. Review of Resident 55's care plan dated 8/6/13-10/29/13, revealed no documentation related to a fall on 10/19/13 or any new interventions added related to falls. Further review of the care plan revealed Resident 55's Fall Assessment equaled 12 which is a high risk for falls and a BIMS (Brief Interview for Mental Status) score of 6 out of a possible 15, indicating severe cognitive impairment. During an interview with the Director of Nursing (DON) on 1/14/14 at 3:45 PM, the … | 2016-11-01 |
| 9821 | 9821 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2013-05-28 | 281 | D | 1 | 0 | C6NT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.04C1 (3) Based on interview and record review, the facility failed to assess one resident (Resident 4) for a change in condition after an unwitnessed fall with potential head injury. Facility census was 40. Findings are: Resident 4's care plan dated 2-19-13 stated (gender) is at risk for potential bleeding due to use of [MEDICATION NAME] (an anticoagulant) and aspirin (also used as an anticoagulant). Resident 4's care plan also revealed Resident 4 has had a series of six falls in May and April of 2013. Review of an undated typed facility investigation revealed the following: -Resident 4 fell on [DATE] at approximately 2:30 pm in a public restroom at the facility. Several employees heard the fall and responded immediately. Restroom door was locked, key was obtained quickly and door was opened. Resident 4 was found lying at an angle up against a wall with head positioned partially on the floor and partially on the wall behind the bathroom door. -Registered Nurse (RN) C's written statement of events from the same report as above revealed Resident 4's color was gray, (gender) was slow to respond and eyes were rolled back in head; Resident 4's hand grip was strong. Range of motion was normal for this resident. Resident 4 denied injury. Resident 4's vital signs were taken. - RN C reported to Licensed Practical Nurse (LPN) E that Resident 4 hit (gender's) head. LPN E then asked Resident 4 if (gender) hit head and Resident 4 denied hitting Resident 4's head. -Resident 4 was transferred to a wheelchair and taken to the living room in front of the skilled nurses' desk. LPN E's documentation of incidents revealed resident was joking and talking during time in living room. Resident 4 ambulated to the dining room at approximately 5:00 pm without difficulty; a gait belt and front wheeled walker was used. -At 5:30 pm Resident 4 had a coffee ground like emesis in in the dining room; LPN E was notified and transferre… | 2016-05-01 |
| 10544 | 10544 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2012-09-27 | 332 | E | 0 | 1 | YX3V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, staff interview, and record review the facility failed to ensure that medication errors of 5% or greater did not occur. Observations of 52 medications administered to 10 residents, revealed 6 medication errors that affected three residents (Residents 39, 36, and Resident 64. This showed a medication error rate of 11.53%. The resident sample size was 30 and the facility census was 40. Findings are: A. Observation of Resident 39 medication administration on 9/26/12 at 7:05 am revealed: -MA (Medication Aide) A compared the resident's medication cassette to the MAR (Medication Administration Record) before placing the resident's medication into the medication cup. -Review of the medication cassette labels stated Baby Aspirin 81 mg (milligrams) BID (twice daily) with meals .Carvedilol 12.5 mg give 1/2 tablet 6.25 mg BID with meals . -The resident was seated in the TV lounge. The resident had not been served breakfast. Review of Resident 39's physician's orders [REDACTED]. The residents [MEDICATION NAME] (Carvedilol) 12.5 mg 1/2 6.25 mg BID was to be given with meals. Review of the Nursing 2012 Drug Handbook stated that [MEDICATION NAME] should be given with food. Aspiring should be given with food, milk, antacid, or large glass of water to reduce gastrointestinal effects of the medication. B. Interview with MA A on 9/26/12 at 7:10 am revealed that breakfast began around 8 am. C. Observation of Resident 36 medication administration on 9/26/12 at 7:15 am revealed: -MA A compared the resident's medication cassette to the MAR before placing the resident's medication into the medication cup. -Review of the medication cassette labels revealed Aspirin 325 mg with breakfast, [MEDICATION NAME] 200 mg daily with breakfast, and Calcium 600 mg with Vitamin D3 400 IU BID with meals. -The resident was seated in the TV lounge. The resident had not been served breakfast. Review of Resident 36's phy… | 2015-12-01 |
| 11373 | 11373 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2012-02-28 | 225 | D | 1 | 0 | OZWV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews; the facility failed to report an injury of unknown origin for one sampled resident (Resident 1). The facility also failed to document a full investigation of this incident for Resident 1. The facility census was 38. The sample size was 4. Findings are: Part A REPORTING: LICENSURE REFERENCE NUMBER 12-006.02(8) Review of Resident 1's History and Physical dated February 6, 2012 revealed a history of Severe Dementia, [MEDICAL CONDITION], Type 2 Diabetes, Hypertension and [MEDICAL CONDITION]. Review of Resident 1's Minimum Data Set (MDS - a federally mandated comprehensive assessment tool used for care planning) dated 2/1/12 revealed the resident had short and long term memory problems and required extensive assist to transfer and dress. Review of an accident report dated Friday, 2/3/12 revealed that NA (Nursing Assistant) A noticed a 15 cm (centimeter) x 10 cm bruise on the Resident 1's right shoulder area. The resident was noted to flinch with movement. The charge nurse was notified and then notified the administrator. The physician was notified on 2/3/12 and orders were received for: sling at all times, ice, pain medicine, and for an x ray to be completed on Monday 2/6/12. A mobile x ray was not taken immediately due to the snow storm that weekend per interview with the Assistant Director of Nursing. Results of the x ray of the right arm on Monday 2/6/12 showed an acute humerus fracture. The resident was then ordered to have a shoulder immobilizer placed on at all times. Interview with the Administrator on 2/28/12 at 10:00 AM revealed that no injuries of unknown origin or accident with serious injury had been reported to the state health agency after 1/1/12. Review of the facility's Abuse Policy defined an injury of unknown origin as, "An injury should be classified as an injury of unknown source when both of the following conditions are met: 1) The source of the injury was not observed by any person or th… | 2015-06-01 |
| 11732 | 11732 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2011-08-24 | 225 | D | 0 | 1 | 0WOU11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (9) Based on resident and staff interview the facility failed to investigate and report an allegation of missing money for 1 resident (Resident 55) from a sample of 28. The facility census was 39. Findings are: Interview with Resident 55 on 8/22/11 at 3:55 PM revealed, " I am missing $60.00 that I won in a pool. I put it in my dresser drawer and the next day it was gone, someone took it from my drawer. I talked to some staff but not the front administrative staff." Interview with the Social Services Director (SSD) on 8/23/11 at 1:20 PM inquiring if the facility had any investigations related to missing items. The SSD stated, "I just use a form for lost articles, we look into it and try to find them." When asked if the facility calls the report into the State Agency or APS, the SSD stated, "No, we don't." Inquired if there was any mention of Resident 55 missing some money that was won in a pool. The SSD stated, "I remember something about the that. I'll check with the team (The group that investigates allegations.)" Interview with the SSD on 8/24/11 at 8:10 AM, "I remember I called (Resident 55's) family and asked if (Resident 55) mentioned anything about missing the money. The family stated that (Resident 55) did mention it, but was kind of embarrassed because the money was won in a pool. I don't know why I didn't follow up on the investigation, I guess I just didn't." The facility lacked the completion of an investigation and the reporting of the allegation to the State Agency or APS related to the missing $60.00. | 2015-01-01 |
| 11733 | 11733 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2011-08-24 | 323 | E | 0 | 1 | 0WOU11 | Based on observation, staff interview and review of the facility documents, the facility failed to ensure that hazardous chemicals, disposable razors, scissors, and a blanket warming unit were not accessible to 6 confused and independently mobile residents. The census of the facility was 39 residents and the sample size at the time of the survey was 28 residents. Findings included: 1. During initial tour of the facility on 08/22/11 at 8:40 AM, the door to the 200 hall bath house was observed unlocked and standing open unattended by the staff. A cabinet next to the tub was found unlocked with a pair of scissors, a package of 10 disposable razors, a 19 ounce can of Lysol aerosol disinfectant, 1/3 full which indicated "hazardous to humans and domestic animals," and a 16 ounce bottle of Oasis 499 germicidal, non-acid cleaner. The 200 hall bath house also contained a metal blanket warmer that registered on the outside of the blanket warmer the internal air temperature at 159 degrees Farenheit before opening the door of the blanket warmer. After opening the non-secured door to the blanket warmer, the inside metal shelves and metal walls of the warmer were hot to touch to the human hand without pulling the hand away instinctively. The temperature of the internal metal wall of the warmer registered on the thermometer at 150.7 degrees Farenheit and continued to climb upwards. An interview on 08/22/11 at 8:41 AM with Certified Nurse Aide (CNA) A, confirmed the bath house door was never locked and always open unless the staff was giving a resident a bath. CNA A confirmed the warmer did not have a lock and was never locked. CNA A then confirmed the cabinet with the razors, scissors, and chemicals was not locked and should be locked when the bath house was unattended by staff. An interview on 08/22/11 at 8:45 AM with Licensed Practical Nurse (LPN) A confirmed the bath house was always unlocked with no lock on the warmer unit housed within the bath house. LPN A was notified regarding the concern for the unsecured sharps (sciss… | 2015-01-01 |
| 12912 | 12912 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2010-08-09 | 278 | E | P8NF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.09B Based on observation, interview, and record review, the facility failed to ensure that Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) assessments were coded accurately on Residents 4, 8, and 9. The facility census at the time of survey was 41 residents. The sample size was 11 residents. Findings are: A. A record review of Resident 4's MDS dated [DATE] revealed that the nursing rehabilitation/restorative care (nursing interventions that promote the resident's ability to adapt and adjust to living independently and safely as possible) was provided for eating or swallowing to this resident on three out of seven days and nursing rehabilitation/restorative care was provided for communication on five out of seven days. A record review of Resident 4's NURSING RESTORATIVE PROGRAM for 7/28/2010 revealed that Resident 4 was not on a restorative program for eating or swallowing and was not on a restorative program for communication at that time. An interview with the Restorative Aide (RA) A on 8/5/2010 at 2:20PM revealed that Resident 4 was not on a restorative program for nursing to receive eating, swallowing, or communication services. RA A stated that Resident 4 was receiving physical therapy, occupational therapy, and speech/language therapy at this time and thought that this section meant it was to be counted for speech/language therapy services received at this time. B. A record review of Resident 8's MDS dated [DATE] revealed that the nursing rehabilitation/restorative care was provided for splint/brace assistance on seven out of seven days and that dressing or grooming assistance was provided on three out of seven days. A record review of Resident 8's NURSING RESTORATIVE PROGRAM for 7/2010 revealed that Resident 8 was not on a nursing restorative program for dressing assistance, grooming assistance, or splint/brace assistance. A record review of Resid… | 2014-02-01 | ||
| 4017 | 4017 | SANDHILLS CARE CENTER | 285298 | 143 N FULLERTON STREET | AINSWORTH | NE | 69210 | 2018-02-13 | 688 | D | 0 | 1 | WVL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D4 Based on observation, record review and interview; the facility failed to provide restorative therapy for Resident 4's contracture (abnormal shortening of muscle tissue making it highly resistant to stretching and eventually causing permanent disability) as recommended by the Occupational Therapist (OT). Total sample size was 18 and the facility census was 20. Findings are: Review of Resident 4's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/24/18 revealed the following: -[DIAGNOSES REDACTED]. -intact cognition; -required extensive assistance with activities of daily living (ADL); -had functional limitation in Range of Motion (ROM-the full movement potential of a joint) on one side including the upper and lower extremities; and -received ROM restorative therapy 4 times in the past 7 calendar days. Review of the current Care Plan dated 11/17/17 indicated Resident 4 had a self-care deficit related to [MEDICAL CONDITION] on the left side. Nursing interventions included the following: -extensive assistance of 1 or 2 for bed mobility, transferring, moving on and off the unit, dressing, toileting, and with personal hygiene tasks; and -participate in RT (Restorative Therapy) for stretching of upper and lower left extremities and strengthening of upper and lower right extremities with the goal of being able to continue to self-propel the wheelchair. Review of OT Progress Notes included the following related to Resident 4: -11/15/17 at 4:06 PM - evaluated and found to require skilled services to improve strength and activity tolerance for improved safety when using the sit-to-stand mechanical lift for transfers, and for ADL tasks; -11/20/17 at 10:29 AM - provided PROM (Passive Range Of Motion-the joints are moved through their full ROM by another individual when the resident is unable to move independently) to the left spastic ([DIAGNOSES REDACTED… | 2020-09-01 |
| 4018 | 4018 | SANDHILLS CARE CENTER | 285298 | 143 N FULLERTON STREET | AINSWORTH | NE | 69210 | 2018-02-13 | 689 | E | 0 | 1 | WVL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on observations, record review and interview, the facility failed to identify causal factors and develop additional interventions for the prevention of falls for Residents 10, 5 and 22. The sample size was 18 and the facility census was 20. Findings are: [NAME] Review of Resident 10's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/10/18 revealed [DIAGNOSES REDACTED]. The MDS further indicated Resident 10 had: -severe cognitive impairment; -extensive assistance with transfers and toileting; -frequent urine incontinence; -no toileting program such as scheduled toileting, prompted voiding (urination) or bladder training; and -experienced 2 or more falls with no injury since the previous assessment. Review of the current Care Plan (undated) revealed Resident 10 was at high risk for falls. Interventions (and the dates the interventions were initiated) included the following: -Pressure alarm (A device which alerts the caregiver when a resident moves from a certain position. The resident sits or lies on a pad which sounds an alarm when the resident attempts to rise) placed in the bed and chair-5/24/17 and 9/25/17; -Fall mats placed on both sides of the bed-5/24/17 and 9/25/17; -Move walker out of reach as a reminder to use the call light and wait for assistance-9/25/17; -Call light within reach-10/26/17; -Participation in Physical Therapy-10/4/17, 10/26/17 and 11/8/17; -Participation in restorative therapy-9/25/17; and -Bed placed in lowest position when resident lying in bed-5/24/17 and 9/25/17. Review of Progress Notes from 10/1/17 through 2/10/18 revealed Resident 10 had 7 falls with 4 of the falls occurring between 1:30 AM and 5:13 AM. Review of Resident 10's Progress Notes dated 10/9/17 at 1:47 AM revealed the resident was found lying on the fall mat at 1:30 AM. The resident voiced looking for the keys. There was no evidence additiona… | 2020-09-01 |
| 4019 | 4019 | SANDHILLS CARE CENTER | 285298 | 143 N FULLERTON STREET | AINSWORTH | NE | 69210 | 2018-02-13 | 690 | D | 0 | 1 | WVL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(2) Based on record review and interview; the facility failed to develop interventions to address Resident 10's urine incontinence. The sample size was 18 and the facility census was 20. Findings are: Review of Resident 10's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/10/18 revealed [DIAGNOSES REDACTED]. The MDS further indicated Resident 10 had: -severe cognitive impairment; -extensive assistance with transfers and toileting; -frequent urine incontinence; and -no toileting program such as scheduled toileting, prompted voiding (urination) or bladder training. Review of Resident 10's Continence Evaluation dated 11/17/17 revealed the resident: -used the toilet an average of 6 times per day; -was incontinent of urine at least once daily; -used at least 3 incontinent products in 24 hours; -had to rush to the bathroom upon feeling the urge to urinate; -leaked urine on the way to the bathroom and experienced dribbling of urine after passing urine; -required 1 person to assist with getting in and out of bed/chair; -was able to use the toilet or commode; and -was motivated to be continent. Further review of Resident 10's Continence Evaluation dated 11/17/17 revealed treatment options were Personal Hygiene and use of Incontinence Product. There was no evidence Resident 10 was assessed for a bladder retraining program, toileting program or a scheduled toileting plan. Interview with the Director of Nurses on 2/13/18 at 10:05 AM confirmed Resident 10 was incontinent of urine and there was no evidence the resident was assessed for a bladder retraining program, toileting program or scheduled toileting plan. | 2020-09-01 |
| 4020 | 4020 | SANDHILLS CARE CENTER | 285298 | 143 N FULLERTON STREET | AINSWORTH | NE | 69210 | 2018-02-13 | 761 | E | 0 | 1 | WVL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1 Based on observation, record review and interview; the facility failed to provide safe storage of drugs and biologicals as medication carts were left unlocked and unattended, and medications were left on top of the medication/treatment cart unattended. The total sample size was 18 and the facility census was 20. Findings are: [NAME] Review of the facility policy titled Storage of Medications and dated 2001 included the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; and -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. B. During observation of the Medication Pass by Licensed Practical Nurse (LPN)-C on 2/12/18, the following was observed: -the medication cart was parked in the corridor directly across from the nurses' station, and the treatment cart was positioned directly to the left of the medication cart; -11:59 AM - prepared [MEDICATION NAME] (a type of laxative) for Resident 9 and left the medication cart unlocked and unattended to administer the medication in the dining room; -12:02 PM - prepared [MEDICATION NAME] Insulin for Resident 7 and left the medication cart unlocked and unattended to administer the injection in the resident's room; -a bottle of [MEDICATION NAME] powder (an anti-fungal antibiotic used to treat skin infections caused by yeast) labeled for Resident 9 was observed on top of the treatment cart and unattended; -12:05 PM - prepared [MEDICATION NAME] powder (a laxative) for Resident 1, locked the medication cart, but left the container of [M… | 2020-09-01 |
| 4021 | 4021 | SANDHILLS CARE CENTER | 285298 | 143 N FULLERTON STREET | AINSWORTH | NE | 69210 | 2019-05-08 | 684 | D | 0 | 1 | E1DY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2 Based on record review and interview, the facility failed to provide treatment and monitoring to ensure wound healing for 2 (Residents 4 and 22) of 2 sampled residents. The facility census was 23. Findings are: [NAME] Review of the facility policy titled Wound Care with revision date 10/2010 revealed the following information was to be documented when assessing a resident's wound: -the type of wound care provided; -the date and the time the wound care was provided; -any change in the resident's condition; -all assessment data (wound bed color, size, and drainage); and -how the resident tolerated the procedure. The following procedure was also identified for the care of wounds to promote healing: -wash and dry hands thoroughly; -put on clean gloves. Wear sterile gloves whenever physically touching the wound; -use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from containers; -pour solutions directly onto dressings; -removes gloves; and -wash and dry hands thoroughly after removal of soiled gloves. B. Review of Resident 4's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/22/19 revealed [DIAGNOSES REDACTED]. Review of a Physical Therapy Progress Note dated 1/24/19 at 3:37 PM revealed the resident demonstrated with severe serous (thin, watery drainage which usually has a clear to yellowish or brownish appearance) drainage and a very large lower leg wound that presented as a circumferential wound that was 25 centimeters (cm) long and 28 cm wide. The wound extended to the top of the resident's right foot. Review of Resident 4's current Care Plan dated 1/31/19 revealed the resident had a venous stasis ulcer to the resident's right lower leg. The care plan indicated the ulcer caused the resident to have pain constantly. Review of a Nursing Progress Note dated 3/3/19 at 1:48 PM revealed the resident's … | 2020-09-01 |
| 4022 | 4022 | SANDHILLS CARE CENTER | 285298 | 143 N FULLERTON STREET | AINSWORTH | NE | 69210 | 2019-05-08 | 692 | D | 0 | 1 | E1DY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on record review and interview; the facility failed to implement current nutritional interventions and to revise and/or develop additional interventions as needed for the prevention of weight loss for 2 (Residents 12 and 19) of 2 sampled residents for the prevention of weight loss. The facility census was 23. Findings are: [NAME] Review of Resident 12's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/6/19 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS identified the resident had severe cognitive impairment, required supervision with eating and had a weight of 107 pounds. Review of a Nutritional Progress Note by the Dietary Manager (DM) dated 3/29/19 at 9:43 AM revealed the resident's initial nutritional assessment was completed and indicated the resident was malnourished. The resident was started on an 8 ounce House Supplement (drink with added protein and calories) once a day and as needed. Review of the Weights and Vitals Summary form (a document used to record the resident's weights) revealed Resident 12's weight on 3/27/19 was 106 pounds. Further review revealed the resident's weight on 4/9/19 was 109 pounds (up 3 pounds in 1 week). Review of the resident's current Care Plan dated 4/9/19 revealed the resident was at nutritional risk due to [DIAGNOSES REDACTED]. The resident was identified as having a poor appetite with a history of a 15-20 pound weight loss over the last 2 years. Nutritional interventions included the following: -Provide and serve supplements as ordered. House Supplement once daily and as needed if the resident consumed less than 50% of prior meal. -Serve regular diet as order. -Registered Dietician (RD) to evaluate and make recommendations as needed. Review of a Nutrition/Dietary Progress Note by the RD dated 4/9/19 at 10:41 AM revealed the resident had been admitted from home wi… | 2020-09-01 |
| 4023 | 4023 | SANDHILLS CARE CENTER | 285298 | 143 N FULLERTON STREET | AINSWORTH | NE | 69210 | 2019-05-08 | 880 | E | 0 | 1 | E1DY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12.006.17D Based on observations, record review and interview: the facility failed to prevent potential cross contamination between residents as staff failed to: 1) provide care and management of 1 (Resident 17) of 1 sampled resident's indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage)to prevent ongoing infections; 2) provide care and treatment of [REDACTED]. This failure had the potential to affect 3 (Residents 2, 5 and 21) who also received routine blood glucose testing. The facility census was 23. Findings are: [NAME] Review of a facility Policy titled Hand washing/Hand Hygiene with revision date 8/15 the policy identified the facility considered hand hygiene as the primary means to prevent the spread of infections. The policy indicated hand washing or use of an alcohol based hand rub was required for the following situations: -before and after coming on duty; -before and after direct contact with residents; -before preparing or handing medications; -before donning gloves; -before handling clean or soiled dressings; -before moving from a contaminated body site to a clean body site during resident cares; -after handling used dressings or contaminated equipment; and -after the removal of soiled gloves. B. Review of a facility Policy titled Catheter Care, Urinary with revision date 9/14 revealed the purpose of the policy was to prevent catheter associated urinary tract infections. Steps in the procedure included the following: -wash and dry hands thoroughly; -put on gloves; -cleanse the catheter from the insertion site to approximately 4 inches outward of the catheter tubing; -remove soiled gloves and discard; and -wash and dry hands thoroughly. The policy further identified the following regarding infection control: -maintain clean technique when handling or manipulating the catheter, tubing and the drainage bag; -assure … | 2020-09-01 |
| 4024 | 4024 | SANDHILLS CARE CENTER | 285298 | 143 N FULLERTON STREET | AINSWORTH | NE | 69210 | 2018-10-01 | 689 | D | 1 | 0 | LLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, record review and interview, the facility failed to implement fall prevention interventions for 1 (Resident 26) of 3 sampled residents with a history of falls. The facility census was 20. Findings are: Review of Resident 26's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/26/18 revealed a [DIAGNOSES REDACTED]. Review of Progress Notes dated 4/2/18 at 4:05 PM revealed Resident 26 was found on the floor in front of the recliner in the resident's room. The resident stated .that chair just threw me out. Review of a Post Fall assessment dated [DATE] revealed Resident 26 fell at 4:00 PM that day when the resident attempted to get up from the recliner to go to the bathroom. An intervention to prevent further falls was placement of non-skid tape on the floor in front of the recliner. Review of Progress Notes dated 6/9/18 at 11:30 AM revealed at 10:50 AM, Resident 26 was found sitting on the floor and the resident stated the chair threw the resident out. Documentation further indicated staff intervened when the resident was found during room checks to be standing between the footrest and the chair. Review of a Post Fall assessment dated [DATE] revealed Resident 26 fell that day. The resident stated, That damn chair threw me out. Documentation further indicated Restorative Therapy (RT) would assess the resident's chair for placement of sandbags (additional weight placed at the base behind the recliner to prevent the chair from tipping forward). Review of Resident 26's current Care Plan (undated) included the following fall prevention interventions: -place non-skid tape on the floor in front of the recliner to prevent the resident from slipping and falling; and -RT will evaluate the recliner in regards to putting sandbags down to prevent the chair from leaning forward. If sandbags will work, RT will leave the sandbags on the f… | 2020-09-01 |
| 4025 | 4025 | SANDHILLS CARE CENTER | 285298 | 143 N FULLERTON STREET | AINSWORTH | NE | 69210 | 2019-10-09 | 609 | D | 1 | 0 | Y6PW11 | > Licensure Reference Number 1[AGE] NAC 12-006.02 (8) Based on record review and interviews, the facility failed to report allegations of potential abuse and/or neglect for 2 (Residents 3 and 5) of 8 residents sampled. The facility staff identified a census of 21. The findings are: A. Review of the facility's Abuse Prevention Policy and Procedure with a revision date of 7/2017 revealed all reports of resident abuse, neglect and misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) were to be promptly reported to local, state, and federal agencies as defined by current regulations and thoroughly investigated by facility management. The policy identified the following regarding reporting: -all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation would be reported to the Administrator or his/her designee and to the State licensing/certification agency responsible for surveying/licensing the facility; -an alleged violation of abuse, neglect exploitation or mistreatment should be reported immediately or no later than 2 hours if the alleged violation involved abuse or had resulted in bodily injury or 24 hours if the alleged violation did not involve abuse and had not resulted in serious bodily injury; and -the Administrator, or his/her designee would provide the appropriate agencies with a written report of the findings of the investigation within 5 working days of the occurrence of the incident. B. Record review of a facility investigation dated 9/1/19 at 5:00 PM revealed a visitor identified concerns with how Nursing Assistant (NA)-E had spoken to and provided assistance to Resident 5. The visitor indicated NA-E stated Resident 5 never does what I ask and is always difficult. NA-E was assisting Resident 5 to eat and NA-E stated I don't even know what this stuff is referring to the food NA-E was assisting the resident to eat. The visitor indicated the resident's nose was draining at the time of the ob… | 2020-09-01 |
| 4026 | 4026 | SANDHILLS CARE CENTER | 285298 | 143 N FULLERTON STREET | AINSWORTH | NE | 69210 | 2019-10-09 | 689 | E | 1 | 0 | Y6PW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.09D7b Based on observations, record review, and interview; the facility failed to identify causal factors, develop new interventions and/or revise current interventions, and failed to implement interventions for the prevention of further falls for 3 (Residents 1, 2 and 3) of 8 sampled residents. The facility census was 21. Findings are: A. Review of Resident 2's current Care Plan with a review date of 8/28/19 revealed the resident was at high risk for falls related to cognitive impairment and generalized weakness. Further review revealed the resident had fallen on 5/15/19, 6/13/19, 6/19/19, 8/19/19, 9/26/19, and 10/7/19. The following fall prevention interventions were identified. - Place pancake light at the resident's side so when the resident got up the call light and fall mat would alarm, - the physician was consulted regarding the resident's urinary frequency, - the resident had a medication change due to urinary frequency, - staffing was assessed, - a bed/chair alarm was initiated, - a bolster pillow placed on the resident's side when sleeping, - a scoop mattress was placed on the resident's bed, - the resident was not to be left in the dining room unsupervised, and - staff would offer the bathroom when the resident got up in the morning, before and after every meal, before and after every activity, and before going to bed at night. Review of Resident 2's Post Fall assessment dated [DATE] revealed the resident fell at 5:25 AM in the resident's room. Further review revealed the resident was trying to go to the bathroom. The root cause analysis identified the problem was the resident was attempting to go to the restroom due to the need to urinate as the resident had not been up during the night. The fall intervention did not address the causal factor and the report did identify when the resident was last taken to the bathroom. Review of Resident 2's Post Fall assessment dated [DATE] revealed … | 2020-09-01 |
| 11239 | 11239 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 226 | C | 0 | 1 | G3Q011 | F 226 LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on observations, record review and staff interview the facility failed to protect all residents from potential abuse/neglect. The facility failed to re-educate a staff member who was accused of neglect of Resident 16 before allowing the staff member to return to work. Facility census was 34. Findings are: On 8/6/12 at 11:00 AM the Administrator indicated an allegation of neglect involving Resident 16 and Nursing Assistant (NA) M had been reported to the State Agency that morning. The Administrator stated NA-M had been suspended until the investigation was completed. Review of the written investigation for this allegation dated 8/8/12 revealed NA-M was placed on extended probation and was to be re-educated regarding facility abuse and neglect policy. Additional staff training was to be done with all staff regarding abuse and neglect recognition and reporting. On 8/8/12 at 5:30 PM the suspended employee NA-M was observed working the 2:00 PM to 10:00 PM shift. Interview with the Director of Nursing (DON) on 8/9/12 from 10:20 AM until 10:30 AM, revealed DON thought the investigation was completed; however the interventions for re-education of the suspended employee and other staff members had not been completed. The DON stated the suspended employee was informed on 8/8/12 while working the evening shift of the need for the DON to visit with employee regarding the incident. Interview with the Administrator on 8/9/12 from 10:30 AM until 10:35 AM, revealed the suspended employee should not have returned to work until the interventions were in place to prevent further neglect of residents. | 2015-07-01 |
| 11240 | 11240 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 242 | D | 0 | 1 | G3Q011 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(4) Based on record review, staff and resident interviews, the facility failed to afford Residents 20 and 22 their choice regarding the number of baths they received per week. Facility census was 34. Findings are: A. When asked about choosing how many times a week the resident received a bath, Resident 20 stated during interview on 8/7/12 from 11:23 AM until 11:40 AM, "I would like to choose. I would choose to take more. I would like it (bath) 3 times a week." The resident stated the bath aide was informed of this request; however the resident indicated 1 whirlpool bath was provided weekly. Review of the Bath/Shower Schedule revealed Resident 20 was scheduled to receive 2 baths per week on Tuesdays and Fridays. Review of documentation of baths provided for Resident 20 revealed the resident did not receive a bath for 8 or 9 days on the following dates: -4/24/12 until 5/2/12 (8 days) -5/9/12 until 5/18/12 (9 days) -5/29/12 until 6/6/12 (8 days) -6/19/12 until 6/28/12 (9 days) -7/10/12 until 7/19/12 (9 days) Interview with Nursing Assistant (NA) J on 8/9/12 from 7:25 AM until 7:30 AM revealed Resident 20 was scheduled for 2 baths per week. NA-J indicated Resident 20 did not always receive 2 baths per week. NA-J was aware the resident desired more baths per week. B. Resident 22 stated during interview on 8/6/12 from 2:00 PM until 2:20 PM that no choice was provided regarding how many times a week a bath was provided. The resident stated 1 bath a week was provided and "sometimes" 2 baths a week were provided. The resident's choice was to receive 2 baths per week. Review of the Bath/Shower Schedule revealed Resident 22 was scheduled to receive 2 baths per week on Tuesdays and Fridays. Review of documentation of baths provided for Resident 22 revealed the resident did not receive a bath for 8 to 10 days on the following dates: -4/25/12 until 5/5/12 (10 days) -5/8/12 until 5/17/12 (9 days) -5/17/12 until 5/29/12 (8 days) -5/29/12 until 6/8/12 (10 days) -6/19/12 until 6/28/12 (9… | 2015-07-01 |
| 11241 | 11241 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 280 | D | 0 | 1 | G3Q011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on record review, observations and staff interviews; the facility failed to revise Resident 3's Care Plan following falls. Facility census was 34. Findings are: Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/11/12 revealed [DIAGNOSES REDACTED]. The MDS indicated the resident had short term memory problems and had 1 fall in the past 3 months with no injury. Review of the MDS dated [DATE] revealed the resident continued to have short term memory problems and no falls since the last assessment. Review of an Event Report dated 1/23/12 at 2:09 PM revealed at 1:45 PM the resident lost balance while ambulating with the aid of a walker and a nursing assistant. The resident fell backwards and slid to the floor. Documentation further indicated measures taken following the fall were the "use of gait belt (a belt placed around a resident's waist to assist with transferring the resident from one position to another by providing support for the resident and a safe hand hold for the caregiver) during transfers". Review of the current Care Plan dated 5/10/12 revealed the resident had a potential for injury as a result of poor safety awareness. The Care Plan specified a goal for the resident to remain free from injury. There was no documentation to indicate the intervention of using a gait belt during transfers was added to the Care Plan. On 8/6/12 from 4:05 PM until 4:10 PM, Nursing Assistant (NA) C was observed to transfer Resident 3 out of a wheelchair and into bed. The resident required extensive assistance and no gait belt was used during the transfer. Review of an Event Report dated 7/21/12 at 12:27 AM revealed the resident was heard screaming and crying at 11:40 PM (on 7/20/12). Documentation further indicated the resident was confused. The resident was assisted to the bathroom, placed on the toilet and instructed to us… | 2015-07-01 |
| 11242 | 11242 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 309 | D | 0 | 1 | G3Q011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on record review, observations and staff interviews, the facility failed to reposition Residents 10 and 15 every 2 hours in accordance with the facility's standard of practice. These residents were unable to reposition themselves. Facility census was 34. Findings are: A. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/25/12 revealed [DIAGNOSES REDACTED]. The MDS dated [DATE], 4/18/12 and 7/19/12 indicated the resident had short and long term memory problems, was totally dependent with bed mobility, and was on a turning/repositioning program. Review of Resident 15's current Care Plan dated 7/12/12 revealed the resident was limited in bed mobility. Interventions were to turn and reposition the resident frequently. Resident 15 was observed seated in a wheelchair without benefit of repositioning on 8/8/12 at 6:50 AM, 8:00 AM, 9:22 AM, 10:34 AM, 11:00 AM, 12:00 PM, 12:50 PM and 1:50 PM (7 hours). On 8/8/12 at 1:50 PM, Nursing Assistants (NA) G and H were observed to transfer the resident from the wheelchair into bed. Interviews with NA-H and NA-A at this time revealed NA-H had gotten the resident out of bed that morning. NA-H and NA-G were unaware if the resident had been repositioned since that time. NA-G stated the resident was usually laid down for a while between the breakfast and noon meal, but did not know if this had been done on this day. NA-H and NA-G proceeded to check the resident's disposable incontinent brief. The resident ' s slacks and disposable incontinent brief were saturated with urine (which indicated the resident had not been checked for incontinence and repositioned in a timely manner). B. Review of Resident 10's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS dated [DATE], 3/21/12 and 6/21/12 indicated the resident had short and long term memory problems, was totally dependent with be… | 2015-07-01 |
| 11243 | 11243 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 323 | D | 0 | 1 | G3Q011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review, observations and staff interview; the facility failed to implement interventions for the prevention of falls for Resident 3. Facility census was 34. Findings are: Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/11/12 revealed [DIAGNOSES REDACTED]. The MDS indicated the resident had short term memory problems and had 1 fall in the past 3 months with no injury. Review of the MDS dated [DATE] revealed the resident continued to have short term memory problems and no falls since the last assessment. Review of an Event Report dated 1/23/12 at 2:09 PM revealed at 1:45 PM the resident lost balance while ambulating with the aid of a walker and a nursing assistant. The resident fell backwards and slid to the floor. Documentation further indicated measures taken following the fall were the "use of gait belt (a belt placed around a resident's waist to assist with transferring the resident from one position to another by providing support for the resident and a safe hand hold for the caregiver) during transfers". Review of the current Care Plan dated 5/10/12 revealed the resident had a potential for injury as a result of poor safety awareness. The Care Plan specified a goal for the resident to remain free from injury. Interventions included the following: give resident verbal reminders not to ambulate/transfer without assistance, keep bed in lowest position with brakes locked, fall prevention program, provide an environment free of clutter, provide with safety device/appliance wheeled walker and wheelchair and use of a tabs alarm (A pull-string is attached to the resident's garment and sounds an alarm if the resident attempts to rise out of a chair or bed) at all times. There was no documentation to indicate the intervention of using a gait belt during transfers was added to the Care Plan. On 8/6/12 from 4:… | 2015-07-01 |
| 11244 | 11244 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 371 | F | 0 | 1 | G3Q011 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.11e Based on observations, staff interview and record review; the facility failed to ensure dishes and utensils were cleaned under sanitary conditions and food was served in a sanitary manner and at safe temperatures. Facility staff did not maintain and operate the dishwashing machine according to manufacturer ' s instructions. In addition, facility staff did not wash hands and change gloves during meal service according to facility policy. A poached egg and a glass of milk were served to Resident 35 at an unsafe temperature. Facility census was 34. Findings are: A. Review of facility policy titled; "Food Preparation and Service" (revised November 2010) Cooking and Holding Temperatures and Times and Food Service/Distribution" revealed the following: -The "danger zone" for food temperatures is between 41 degrees and 135 degrees Fahrenheit (F). This temperature range promotes the rapid growth of pathogenic microorganisms that cause food borne illness. Food temperatures must be maintained at 40 degrees F or below or at 136 degrees F and above. -Potentially hazardous foods include meats, poultry, cut melon, eggs, milk, yogurt and cottage cheese. -Gloves must be worn when handling food directly. However, gloves can become contaminated and/or soiled and must be changed between tasks. B. During observation of the noon meal in the Assisted Dining Room on 8/6/12 from 11:50 AM until 12:34 PM, the Dietary Manager (DM) put on gloves and dished up plates of food from the steam table. The DM placed a plate of food in front of Resident 8 and offered to cut the chicken off of the bone. With gloved hands, the DM picked up the resident's fork and cut the chicken off of the bone. The DM did not remove gloves, returned to the steam table and proceeded to dish up plates of food for other residents. C. Observation of the breakfast meal in the Assisted Dining Room on 8/8/12 revealed the following: -At 8:00 A.M., the Dietary Cook (DC)-K placed a bowl of hot cereal and a plate with a poached egg … | 2015-07-01 |
| 11245 | 11245 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 441 | D | 0 | 1 | G3Q011 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observations, staff interview and record review; the facility failed to ensure respiratory equipment was stored and maintained in a sanitary manner to prevent cross contamination. Oxygen tubing with nasal cannula and a nebulizer machine with mask and tubing for Residents 34 and 35 were observed lying on the floor, in a trash receptacle and in Resident 34 ' s recliner. Facility census was 34. Findings are: Review of the Infection Control Policy titled; " Department (Respiratory Therapy) -Prevention of Infection " (revised October 2010) revealed the following: -Keep the oxygen cannula and tubing in a plastic bag when not in use. -Store Nebulizer equipment in a plastic bag, marked with date and the resident ' s name, between uses. Observations on 8/6/12 at 12:04 PM, 8/7/12 at 4:30 PM and 8/8/12 at 9:00 AM, revealed Resident 34 ' s nebulizer machine, tubing and mask were lying uncovered in the seat of Resident 34 ' s recliner. In addition the oxygen tubing and cannula to Resident 34 ' s oxygen concentrator were uncovered and were observed lying directly on the floor. Observation on 8/6/12 at 11:55 AM revealed the tubing and cannula to Resident 35 ' s oxygen concentrator were uncovered and tubing was draped across a trash receptacle at the resident ' s bedside. 2 cleansing cloths covered with feces were in the trash receptacle. The cannula was lying across the resident ' s water pitcher on the bedside table. On 8/7/12 at 9:00 AM, Resident 35 ' s oxygen tubing and cannula were again uncovered with the tubing lying directly on the floor and the cannula resting inside the bedside trash receptacle. Interview with the Administrator on 8/9/12 from 9:00 to 9:45 AM, revealed the nebulizer and oxygen equipment should be cleaned and stored according to facility policy. | 2015-07-01 |
| 11246 | 11246 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-11-20 | 323 | G | 1 | 0 | R4Z111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE: 175 NAC 12-006.09D7 Based on observation, record review and staff interview; the facility failed to assess Resident 1who was identified with a history of falls. Assessments were not completed to identify causal factors and additional interventions were not developed to protect residents from further falls with injury. The facility had a census of 35. Findings are: A. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/16/12 revealed resident had short and long term memory loss with severely impaired decision making skills. Identified [DIAGNOSES REDACTED]. The MDS reflected Resident 1 required extensive assist of 2 staff with bed mobility and total assist of 1 staff with transfers and dressing. Assessment further revealed Resident 1 had a history of [REDACTED]. Review of Resident 1's Care Plan dated 6/15/12 reflected the resident had potential for injury related to restlessness, poor balance and due to unawareness of safety hazards. Care Plan interventions included: -3/17/11 Fall assessment every quarter and prn (as needed). -3/17/11 TABS alarm (a 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) at all times. -3/3/11 Give verbal reminders not to ambulate or transfer without assistance. -3/17/11 Provide proper, well maintained footwear. -3/17/11 Keep call light within reach at all times. -3/17/11 Provide with a clutter free environment. -3/17/11 Keep personal items and frequently used items within reach. -3/17/11 Keep bed in lowest position (mattress on floor with mat at bedside) -3/17/11 Encourage resident to participate in restorative program. -3/17/11 Assure the floor is free of glare, liquids, and foreign objects. -3/17/… | 2015-07-01 |
| 11247 | 11247 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-05-02 | 312 | E | 1 | 0 | L4W811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observations, record review and staff interview; the facility failed to provide toileting assistance and personal hygiene for 4 residents (Residents 5, 9, 7 and 1) who required assistance with activities of daily living. Facility census was 24. Findings are: A. Review of Resident 5's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/4/13 indicated the resident was totally dependent with toileting and personal hygiene. Nursing Assistant (NA)-A and NA-B were observed to assist Resident 5 to the toilet on 5/1/13 from 2:18 PM until 2:41 PM. The resident's disposable incontinent brief and slacks were saturated with urine. Following toileting, NA-B assisted Resident 5 to stand. NA-B cleansed the resident's buttock and rectal area. NA-B did not cleanse the resident's frontal perineal area and inner groin/thighs. The resident's hands were not washed upon completion of care. Interview with NA-B on 5/1/13 from 2:18 PM until 2:41 PM revealed NA's were "about an hour late" in assisting Resident 5 to the toilet and the resident was last toileted approximately 11:30 AM or 11:45 AM (which indicated the resident had not been toileted for approximately 2 hours 33 minutes to 2 hours 48 minutes. B. Review of Resident 9's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. NA-A and NA-B were observed to assist Resident 9 to the toilet on 5/1/13 from 3:20 PM until 3:30 PM. The resident's disposable incontinent brief was wet with urine. Upon completion of toileting, NA-B did not cleanse the resident's frontal perineal area and inner groins/thighs. The resident's hands were not washed upon completion of care. C. Review of Resident 7's MDS dated [DATE] and 5/2/13 indicated the resident was totally dependent with toileting and personal hygiene. NA-A and NA-B were observed to assist Resident 7 to the toilet on 5/1/13 from 3:40 PM until 4:05 PM. The resident's di… | 2015-07-01 |
| 11248 | 11248 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-05-02 | 353 | E | 1 | 0 | L4W811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observations, record review and staff interviews; the facility failed to provide sufficient nursing staff to meet resident's needs related to: 1) failure to provide personal hygiene and toileting assistance for Residents 5, 9, 7 and 1 who required assistance with activities of daily living; 2) concerns regarding shortage of nursing staff on duty voiced during 2 of 3 confidential family interviews; 3) concerns regarding insufficient staffing voiced during 2 confidential resident interviews and; 4) failure to ensure the number of staff on duty was in accordance with the planned staffing pattern on 4/27/13. Findings are: A. Review of Resident 5's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/4/13 indicated the resident was totally dependent with toileting and personal hygiene. Nursing Assistant (NA)-A and NA-B were observed to assist Resident 5 to the toilet on 5/1/13 from 2:18 PM until 2:41 PM. The resident's disposable incontinent brief and slacks were saturated with urine. Following toileting, NA-B assisted Resident 5 to stand. NA-B cleansed the resident's buttock and rectal area. NA-B did not cleanse the resident's frontal perineal area and inner groin/thighs. The resident's hands were not washed upon completion of care. Interview with NA-B on 5/1/13 from 2:18 PM until 2:41 PM revealed NA's were "about an hour late" in assisting Resident 5 to the toilet and the resident was last toileted approximately 11:30 AM or 11:45 AM (which indicated the resident had not been toileted for approximately 2 hours 33 minutes to 2 hours 48 minutes. B. Review of Resident 9's MDS dated [DATE] indicated the resident was totally dependent with toileting and personal hygiene. NA-A and NA-B were observed to assist Resident 9 to the toilet on 5/1/13 from 3:20 PM until 3:30 PM. The resident's disposable incontinent brief was wet with urine. Upon completi… | 2015-07-01 |
| 11249 | 11249 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 226 | D | 1 | 1 | 320W11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on record review and staff interview, the facility failed to report, investigate and protect Resident 5 following an injury of unknown origin. Facility census was 27. Findings Are: Review of Abuse-Allegation and Reporting Policy/Procedure revised 06/13 revealed the following: - "The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress" . - "Report any knowledge of all alleged violations involving mistreatment, neglect or abuse immediately to a Supervisor or Administrator or in his/her absence, to his/her designee. Bruises, cuts, skin tears or other injury of unknown origin will be investigated and reported as potential resident abuse" . - "During the investigation process, the facility must prevent further physical abuse, mistreatment or verbal aggression ....ensure increased monitoring of at risk residents" . Review of Resident 5's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 9/22/13 revealed Resident 5 had severely impaired cognitive functioning and required total assist for toilet use, personal hygiene, dressing, bed mobility and transferring. Review of Resident 5's medical record revealed a progress note written on 11/5/13 at 2:54 PM stating, "Noted bruise to upper sternum. Resident cannot verbalize how (resident) received the bruise. 3.5 centimeter (cm) by 3 cm. Two small dots just to the bottom left and bottom right also noted. Resident denies any pain related to bruises. Will continue to monitor" . During an interview with the Director of Nursing (DON) on 11/12/13 at 11:28 AM the DON was unaware of Resident 5's bruising. DON stated staff would look to see if an investigation had been done on the bruising. Interview with DON on 11/12/13 at 12:19 PM revealed an investigation was begun on 11/12/13 and the nurse was working on the investigation currently. Interview with DON on 11/12/13 at 4:3… | 2015-07-01 |
| 11250 | 11250 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 253 | E | 0 | 1 | 320W11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A1 Based on observations and staff interview; the facility failed to maintain clean ventilation systems in the bathrooms of 11 resident rooms (Resident Rooms 105, 106, 107, 108, 109, 112, 113, 114, 119, 121 and 124). Facility census was 27. Findings are: During the environmental tour of the facility on 11/7/13 from 9:15 AM until 10:21 AM and accompanied by the Maintenance Supervisor, bathroom vents and/or ventilation ducts were heavily coated with dust and lint in Resident Rooms 105, 106, 107, 108, 109, 112, 113, 114, 119, 121 and 124. During interview on 11/7/13 from 9:15 AM until 10:21 AM, the Maintenance Supervisor verified there was a build-up of dust and lint in the bathroom ventilation system, and that the system was in need of cleaning. | 2015-07-01 |
| 11251 | 11251 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 280 | E | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews; the facility failed to review and revise Care Plans related to fall interventions for Residents 27, 15 and 23. In addition, Resident 15's Care Plan was not revised for prevention and treatment of [REDACTED]. A. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for Care Planning) dated 10/16/13 indicated [DIAGNOSES REDACTED]. The assessment indicated Resident 15 was at risk for pressure sore development and had a history of [REDACTED]. The MDS further indicated Resident 15 was at risk for falls and the resident had sustained 1 fall without injury and 2 falls with injury since the previous assessment. Review of Care Plan dated 11/1/13 revealed Resident 15 had a history of [REDACTED]. Interventions included the following: -9/25/12 Tab 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) on at all times -10/17/12 pressure pad alarm (an electronic pressure sensitive sensor pad designed for use in chairs or beds which will alarm if a resident tries to get up without assistance) on at all times -12/13/12 may put mattress on floor for resident to sleep on per resident's request -7/25/13 may use tilt-n-space wheelchair -10/30/13 ensure Tabs alarm cord length is adjusted to proper length -may use sit-to-stand mechanical lift for transfers -bolsters to resident's bed and fall mat on floor next to bed -keep bed in lowest position with brakes locked -observe resident frequently and place in supervised areas when out of bed In addition Resident 15's Care Plan indicated the resident was at risk for pressure sores. Interventions included the following: -keep heels elevated. -keep feet and heels moisturized -keep heels prot… | 2015-07-01 |
| 11252 | 11252 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 282 | E | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on observations, record review and staff interview; the facility failed to implement Care Plan interventions for Resident 36 regarding prevention of agitated behaviors, Resident 15 regarding prevention of falls and pressure sores, and Resident 24 regarding toileting assistance. Facility census was 27. Findings are: A. Review of Resident 36's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/18/13 identified [DIAGNOSES REDACTED]. The same MDS indicated the resident had severely impaired cognitive functioning and displayed adverse behavioral symptoms on a daily basis. Review of current Care Plan dated 9/11/13 revealed the resident displayed behaviors of crying, being tearful and having "outbursts" with a goal for the resident to exhibit fewer behaviors in the next 90 days. Interventions included the following: -"Outbursts; intervene if necessary and remove to quite (quiet) area ..." -"When I become socially inappropriate/disruptive, move resident to a quiet, calm environment ..." Resident 36 was observed seated at a table in the dining room on 11/6/13 at 3:15 PM while a group activity was in progress. The television at the end of the dining room was also on which caused additional noise in the area. The resident had an anxious expression and talked in a loud voice about getting some popcorn for a sibling. No attempts were made to move the resident to a quieter area. At 3:40 PM, the resident remained seated at a table in the dining room and was speaking in a loud shrill voice. Other residents were seated in the dining room and continued to participate in the group activity. At 3:41 PM, Licensed Practical Nurse (LPN) D stated the resident was going to receive a dose of prn (as needed) [MEDICATION NAME] (medication used for anxiety). LPN-D commented the [MEDICATION NAME] "really does work" in decreasing the resident's anxiety and agitation. L… | 2015-07-01 |
| 11253 | 11253 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 312 | E | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observations, record review, staff and resident interview; the facility failed to provide toileting and bathing assistance for Residents 9, 13 and 24 who required assistance with activities of daily living. Facility census was 27. Findings are: A. Resident 9 stated during interview on 11/6/13 at 8:58 AM that "...bath supposedly set up for once a week. Haven't had a bath for nearly 2 weeks now. Maybe they forgot about me." Review of Resident 9's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/24/13 revealed the resident required physical help with personal hygiene and part of bathing activity. Review of Resident 9's Shower/Bath record (a form used to record provision of each resident ' s shower/bath) revealed the resident received a bath on 10/11/13 and 10/18/13. Documentation indicated the resident did not receive another bath until 11/1/13 (14 days later). A confidential staff interview stated, "When we are short on the floor they pull the bath aide to the floor and the baths don't get done." The DON verified during interview on 11/13/13 at 7:30 AM that there was no evidence to indicate Resident 9 received a bath between 10/18/13 and 11/1/13. B. Review of Resident 24's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The same assessment indicated the resident required total staff assistance with bed mobility and transfers and extensive staff assistance with toileting and that the resident was frequently incontinent of bladder and occasionally incontinent of bowel. Review of Resident 24's Care Plan dated 9/10/13 indicated the resident did not always wait for staff to provide assistance with toileting and was at risk for falls. Interventions included the following: -Staff to assist with toileting, may use the sit- to-stand mechanical lift as needed -Answer the resident's call light promptly -Report signs and symptoms of urinary tra… | 2015-07-01 |
| 11254 | 11254 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 314 | D | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observations, record review and staff interview; the facility failed to consistently implement assessed interventions for the prevention of pressure sores and to revise interventions as needed to promote healing of pressure sores for 1 resident (Resident 15). Facility census was 27. Findings are: Review of facility policy titled "Pressure Sore Prevention and Monitoring Guidelines" (revised 10/12) revealed the following: Upon identifying a pressure sore the licensed nurse will perform the following procedures -Ensure pressure sore identification, goals and interventions are addressed on the resident's Care Plan. -Notify the Dietary Manager upon identifying a pressure sore and Dietary Manager will notify the Registered Dietician for recommendations. -The Interdisciplinary Team will meet at least weekly and as needed to make recommendations and will conduct weekly wound rounds on all pressure sores not responding to current treatment orders. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for Care Planning) dated 10/16/13 indicated [DIAGNOSES REDACTED]. The MDS further indicated Resident 15 was at risk for pressure sore development and had a history of [REDACTED]. Review of Resident 15's physician orders [REDACTED]. The physician orders [REDACTED]. Review of Resident 15's Braden Scale For Predicting Pressure Sore Risk dated 10/15/13 indicated a total score of 14 (score of 13-14 indicated moderate risk). Review of Progress Notes dated 10/20/13 revealed Resident 15 had a red area noted to left heel. The note indicated staff was to keep the resident's legs propped up on pillows while in bed to reduce pressure to left heel. Review of "Event Report" dated 11/1/13 revealed a Hospice Nurse had informed facility staff of an intact blister to Resident 15's left lateral heel. This report indicated the area surrounding the blister was intact, slig… | 2015-07-01 |
| 11255 | 11255 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 323 | E | 1 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Numbers 175 NAC 12-006.09D7 and 175 NAC 12-006.184 Based on observations, record review and staff interviews; the facility failed to assure Residents 15 and 23 were protected from falls as fall intervention measures were not consistently provided and the facility failed to identify causal factors and revise interventions to prevent ongoing falls for Resident 15. In addition, the facility failed to secure hazardous chemicals in resident rooms and the beauty shop which allowed access to 7 residents who were identified at risk for wandering. Facility census was 27. Findings are: A. Review of Resident 15' s Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for Care Planning) dated 10/16/13 indicated [DIAGNOSES REDACTED]. The MDS further indicated Resident 15 was at risk for falls and the resident had sustained 1 fall without injury and 2 falls with injury since the previous assessment. Review of Care Plan dated 11/1/13 revealed Resident 15 had a history of [REDACTED]. Interventions included the following: -9/25/12 Tab 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) on at all times -10/17/12 pressure pad alarm (an electronic pressure sensitive sensor pad designed for use in chairs or beds which will alarm if a resident tries to get up without assistance) on at all times -12/13/12 may put mattress on floor for resident to sleep on per resident's request -7/25/13 may use tilt-n-space wheelchair -10/30/13 ensure Tabs alarm cord length is adjusted to proper length -may use sit-to-stand mechanical lift for transfers -bolsters to resident's bed and fall mat on floor next to bed -keep bed in lowest position with brakes locked -observe resident frequently and place in supervis… | 2015-07-01 |
| 11256 | 11256 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 353 | E | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observations, record review, staff and resident interviews; the facility failed to provide sufficient nursing staff to meet resident's needs related to: 1) 5 of 10 resident interviews voiced concerns regarding lack of staff; 2) provision of baths in accordance with bath schedules for Residents 24, 9 and 1 who required assistance with bathing/personal hygiene; and 3) provision of toileting assistance for Residents 13 and 24 who required assistance with toileting. Facility census was 27. Findings are: A. 4 confidential resident interviews revealed the following comments when asked, "Do you feel there is enough staff available to make sure you get the care and assistance you need without having to wait a long time?" -Confidential interview on 11/5/13 at 3:26 PM-"Not really. If you call them and they are someplace else it takes a while." The resident further stated 2 baths were to be provided per week but "...about once a month only gets1bath during the week." -Confidential interview on 11/5/13 at 4:12 PM-"There is a little bit of shortage on that. Weekend is the worst." -Confidential interview on 11/6/13 at 8:57 AM-"No, we turn on the call light and then we have to wait and wait until someone comes to help you. Mostly in the morning when I want to get up out of bed. Sunday I had to wait quite a while to get into the bathroom." -Confidential interview on 11/6/13 at 9:02 AM-Resident voiced not enough staff as "have to wait for call lights." B. Interview with Resident 9 on 11/6/13 at 8:58 AM revealed the resident had concerns about staffing. The resident stated, "...bath supposedly set up for once a week. Haven't had a bath for nearly 2 weeks now. Maybe they forgot about me." Review of Resident 9's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/24/13 revealed the resident required physical help with personal hygiene and part of bathing … | 2015-07-01 |
| 11257 | 11257 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 441 | E | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B and 175 NAC 12- D Based on observations, record review and staff interview; the facility failed to assure staff members washed hands at appropriate intervals, and that the mechanical sit/stand lift was cleaned between each resident use, during the provision of nursing cares for Residents 15 and 5. This provided the potential for cross contamination between 7 residents ( Residents 19, 24, 38, 15, 26, 1 and 5) who were identified as requiring use of the mechanical sit/stand lift for transfers. Facility census was 27. Findings are: A. Review of facility policy titled Handwashing/Hand Hygiene with a revision date of June 2010 revealed the following: - "Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: ... c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); ... h. Before and after assisting a resident with personal care (e.g., oral care, bathing); ... l. Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident); ... n. Before and after assisting a resident with toileting (hand washing with soap and water); ... r. After handling soiled or used linens, dressings, bedpans, catheters and urinals; ... s. After handling soiled equipment or utensils; ...u. After removing gloves or aprons; and v. After completing duty." - "If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for all the following situations: a. Before and after direct contact with residents; b. Before donning sterile gloves; ... g. After contact with a resident's intact skin; h. After handling used dressings, contaminated equipment, etc.; i. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident;… | 2015-07-01 |
| 11258 | 11258 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 520 | F | 1 | 1 | 320W11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interview; the facility failed to assure an effective Quality Assurance program was in place to correct previously cited deficiencies regarding sufficient staffing, accidents and activities of daily living (ADL) care. Facility census was 27. Findings are: Review of facility deficiency statement from the Quality Indicator Survey (QIS) completed on 5/24/11 revealed the facility was cited for failure to implement interventions for the preventions of falls. Review of facility deficiency statement from QIS completed on 8/9/12 revealed the facility was cited for failure to implement interventions for the prevention of falls. Review of facility deficiency statement from a complaint survey completed on 11/20/12 revealed the facility was cited for failure to assess 1 resident with a history of falls. Review of facility deficiency statement from a complaint survey completed 5/2/13 revealed the facility was cited for failure to provide toileting assistance and personal hygiene for residents and failure to provide sufficient nursing staff to meet residents needs. Review of the preliminary citations for the current survey revealed these deficiencies were not corrected. Review of the facility's policy "Monthly Quality Assurance Meeting Policy and Procedure" (revised 6/13) revealed the following: - "Purpose: To ensure appropriate follow-up and ongoing tracking of identified environmental and quality of care issues by the facility Quality Assurance team. To develop and implement plans of corrective action for identified trends and/or deficient practices. To ensure the provision of the highest possible quality of care to facility residents" . - "Policy: If a trend is identified, the Quality Assurance Committee will develop a Plan of Action, appoint a team leader and project a target date of completion" . - "Possibly Quality Assurance areas and trends may be identified through Focused Rounds, Resident Counsel Meeting, Consultant Reports, Grand Rounds by… | 2015-07-01 |
| 11259 | 11259 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-05-15 | 164 | E | 1 | 0 | C4V911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(20) Based on observation and staff interview; the facility failed to ensure medical record confidentiality for 14 residents (Residents 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15). Medication and treatment administration records were left open and information was exposed when the medication/treatment carts were not attended. In addition, resident care information was lying on top of the Nurses Station desk and was accessible to anyone passing by. Facility census was 29. Findings are: A. During observations on 5/15/14, Registered Nurse (RN)-B left the medication cart unattended in the hallway with the Medication Administration Record [REDACTED]. B. During observations on 5/15/14, RN-B left the treatment cart unattended in the hallway with the Treatment Administration Record (TAR-a record maintained for each individual resident that lists their treatments, allergies and other personal information) on top of the cart and open, exposing information on Resident 8 from 6:59 AM until 7:05 AM, 7:13 AM until 7:21 AM and 7:27 AM until 7:33 AM. C. The desk of the Nurses Station located adjacent to the dining room was unattended on 5/15/14 from 7:37 AM until 7:45 AM. The following items and documents were lying on top of the desk and within view of anyone passing by: -an empty box of [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]) prefilled syringes labeled with Resident 9's name and instructions for use -an empty bubble pack (a packaging system for medication administration) of [MEDICATION NAME] (an antibiotic) labeled with Resident 10's name and instructions for use -a form titled "REPORT FOR HALLS ONE AND THREE" which identified 10 residents (Residents 1, 11, 12, 13, 8, 14, 2, 15, 3 and 9) by name and included details of their personal care such as urine output, bowel movements, and/or behaviors of wandering/exit seeking, touching, crying and hitting. D. During observations on 5/15/14… | 2015-07-01 |
| 11260 | 11260 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-05-15 | 226 | D | 1 | 0 | C4V911 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and staff interview; the facility failed to immediately report an allegation of potential abuse to the Stage Agency. This involved 2 residents (Resident 1 and 2). Facility census was 29. Findings are: Review of facility Abuse Allegation and Reporting Policy and Procedure (revision date 6/13) revealed: "The facility must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator." The procedure further identified "The Administrator will assure immediate notification of proper authorities in compliance with regulatory/licensing requirements that an allegation has been made and a facility investigation is underway. State specific reporting requirements and timeframes pertaining to the reporting and submission of preliminary reports will be observed ..." Interview with the Director of Nurses (DON) on 5/14/14 at 11:30 AM revealed the DON received a report on 4/27/14 regarding verbal abuse of Resident 1 and Resident 2 by Licensed Practical Nurse(LPN)-J and Nursing Assistant(NA)- K which occurred on 4/26/14. The DON indicated LPN-J and NA-K were placed on administrative leave until an investigation was completed. Review of facility investigation records dated 5/1/14 regarding potential verbal abuse of Residents 1 and 2 revealed the allegations were not reported to the State Agency until 4/30/14 (3 days after the facility was made aware of the incident). During interview on 5/15/14 at 2:00 PM the DON verified the facility did not immediately report the allegation of potential verbal abuse involving Residents 1 and 2 to the State Agency. | 2015-07-01 |
| 11261 | 11261 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-05-15 | 318 | D | 1 | 0 | C4V911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D4 Based on record review and staff interview; the facility failed to provide range of motion (ROM) exercises in accordance with physician's orders [REDACTED]. Facility census was 29. Findings are: A. Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/17/14 indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The same MDS indicated the resident required extensive to total assistance with activities of daily living (ADL), and had functional limitation of ROM in upper and lower extremities on both sides. Review of physician's orders [REDACTED]. Review of Resident 3's Care Plan dated 3/13/14 revealed a problem in ADL function and rehabilitation potential, with a goal to provide a "satisfying" restorative program that met the resident's needs. Nursing interventions included assessing health issues that could result in a lack of or reduced participation in the restorative program, adapting the restorative program to meet the resident ' s current abilities, praising involvement and offering encouragement. Review of Restorative Flowsheets (a form used to document when Restorative Therapy (RT) exercises were provided) indicated Resident 3 was to receive AAROM to upper and lower extremities every day, and documentation revealed the following: - During 3/2014, the resident received AAROM 3 times weekly for a total of 12 times. - During 4/2014, the resident received AAROM 3-4 times weekly for a total of 13 times. - From 5/1/14 until 5/14/14, the resident received AAROM 1 time weekly for a total of 2 times. B. Review of Resident 2's MDS dated [DATE] indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The same MDS indicated the resident required extensive to total assistance with ADL's, and had functional limitation of ROM in lower extremities on both sides. Review of Resident 2's Care Plan dated 4/15/… | 2015-07-01 |
| 11262 | 11262 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-05-15 | 373 | E | 1 | 0 | C4V911 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C7b Based on record review and staff interview; the facility failed to ensure staff members who assisted residents to eat had completed a State-approved training course in feeding techniques. Facility census was 29. Findings are: Review of Resident 4's Progress Notes dated 1/7/14 at 12:35 PM revealed the Administrator fed Resident 4 a couple of bites of the breakfast meal until a nursing assistant returned to feed the resident the rest of the meal. Interview with the Administrator on 5/14/14 at 11:30 AM revealed the Administrator had on occasion provided feeding assistance to residents. The Administrator verified the facility did not provide a State-approved training course in feeding techniques (also known as a paid feeding assistant program) and the Administrator had not been trained to assist and feed residents. Interview with the Social Services Director (SSD) on 5/15/14 at 1:07 PM revealed the SSD provided residents with feeding assistance at times. The SSD verified a State-approved training course in feeding techniques had not been completed. | 2015-07-01 |
| 11263 | 11263 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 157 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review, staff interview and observation; the facility failed to ensure physicians were notified regarding significant weight loss for Residents 9 and 15, and development of pressure ulcers for Resident 38, 10 and 19. Facility census was 33. Findings are: A. Review of facility policy for weight loss titled "Weight" (revision date 8/2013) revealed weight loss or gain was to be calculated every time a resident was weighed. Significant weight losses were identified as 5 percent (%) in 1 month, 7.5% in 3 months and 10% in 6 months. The policy further specified the physician was to be notified regarding significant weight variances. B. Review of Resident 9's Weight Variance Reports from 10/3/14 through 11/17/14 and Weight and Vital Signs Monitoring Record from 10/3/14 through 11/19/14 revealed the following weights: -10/3/14-117.8 pounds -10/10/14-117 pounds -10/24/14-116.8 pounds -11/3/14-116.8 pounds -11/5/14-110 pounds -11/10/14-106.6 pounds (an 8 percent significant weight loss in 1 month) Review of Resident 9's medical record revealed no evidence to indicate the physician was notified of the significant weight loss. C. Review of Resident 10's Admission and Weekly Skin Integrity Action Tool for 9/2014, 10/2014 and 11/2014 revealed the following: -9/14/14-"red/purple area above coccyx, no open areas noted" -9/21/14-"red/purple area remains. No open sore" -9/28/14-"no new skin issues" -10/5/14-"no new skin issues" -10/12/14-"No new skin issues" -There was no documentation on 10/19/14 and 10/26/14 -11/2/14-"no new skin issues" -There was no documentation on 11/9/14 -11/16/14-"No new skin issues" On 11/19/14 at 4:32 PM, NA-C commented Resident 10 had a "little schiff" (a small open area) on the "backside" (coccyx area) which had been reported to the Director of Nurses earlier that day. A small Stage 2 pressure sore (partial thickness skin loss that presents as an abrasion, blister o… | 2015-07-01 |
| 11264 | 11264 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 241 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(21) Based on observations, staff interview and record review; the facility failed to ensure residents were treated with respect and dignity related to: 1) transporting Resident 9 to the bathing room and prolonged wait time to receive meal service; 2) positioning Resident 29's urinary catheter drainage bag to prevent visual exposure; and 3) prolonged wait time to receive meal service and soiled clothing/equipment for Resident 15. Facility census was 33. Findings are: A. Review of Resident 9's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/3/14 revealed [DIAGNOSES REDACTED]. The same MDS indicated the resident had moderate cognitive impairment, was dependent upon staff for transfers and personal hygiene and required extensive assistance with eating. Review of Resident 9's Care Plan dated 10/9/14 revealed the resident wore a wig and removed it when napping/sleeping during the day and at night. The Care Plan indicated a goal to provide the resident with dignity and respect. The intervention indicated the privacy curtain was to be closed when the resident was napping/sleeping to provide privacy and dignity. In addition, the Care Plan indicated Resident 9's family requested the resident not be taken to the dining room "too early" in the morning. The Care Plan indicated the resident was to remain in room until "shortly before breakfast is served." On 11/19/14 at 7:18 AM, Resident 9 was observed seated in a shower chair (a chair on wheels which allows the resident to be rolled into the shower while seated). Nursing Assistant (NA)-B pulled Resident 9 backwards with 1 hand and with the other hand pushed the resident's wheelchair through the Wing 1 corridor while en-route to the bathing room. Resident 9 was not wearing the wig, was dressed in a hospital gown and covered with a torn frayed blanket. The resident's bare legs and feet dangled below the bl… | 2015-07-01 |
| 11265 | 11265 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 258 | C | 0 | 1 | ZQ0211 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A(3) Based on observations, confidential resident interviews and staff interview; the facility failed to ensure comfortable noise levels related to an audible chime alarm in the corridor of Wing 1 which sounded repeatedly. This had the potential to affect the comfort of all residents as the noise could be heard throughout the Wing 1 corridor and extended into the dining room area. Facility census was 33. Findings are: A. On 11/19/14 at 6:56 AM, a motion alarm (an alarm activated by movement) was observed positioned on the ceiling in the corridor outside of Resident 40's room. The motion alarm sounded an audible chime alarm each time Resident 40 entered or exited the room and whenever anyone passed by in the corridor. The audible chime alarm sounded repeatedly between 6:56 AM and 8:37 AM as residents and staff passed by in the corridor. The sound from the audible chime alarm was heard throughout the Wing 1 corridor and extended into the dining room area. At 9:45 AM, Resident 40 repeatedly walked in and out of the room triggering the audible chime alarm. B. 2 confidential resident interviews conducted on 11/19/14 between 10:48 AM and 11:31 AM indicated they were able to hear the audible chime alarm. 1 resident stated "I hear it and try not to pay attention to it. I don't complain". Another resident stated the audible chime alarm had started recently and "It's a nuisance". C. The audible chime alarm in the corridor of Wing 1 sounded repeatedly on 11/20/14 between 8:35 AM and 9:30 AM as staff and residents walked by Resident 40's room. The sound was heard throughout the Wing 1 corridor and extended into the dining room area. D. Interview with the Director of Nurses (DON) on 11/25/14 at 8:40 AM revealed the audible chime alarm was placed outside Resident 40's room in an effort to monitor the resident's whereabouts. The DON verified the audible chime alarm needed to be re-set as it sounded when anyone passed by in the corridor. | 2015-07-01 |
| 11266 | 11266 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 279 | D | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04c3a(5) Based on observations, record review and staff interview; the facility failed to develop a plan of care to address the need for turning and repositioning for Resident 15 who was assessed to be at risk for the development of pressure ulcers. Facility census was 33. Findings are: Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/23/14 revealed the resident was admitted with [DIAGNOSES REDACTED]. The MDS further indicated Resident 15 required extensive to total assistance with bed mobility and transfers. Review of the Braden Scale For Prediction of Pressure Ulcer Risk dated 10/23/14 revealed Resident 15 was at high risk for the development of pressure ulcers and nursing interventions included pressure reducing devices in the chair and bed, and a turning and repositioning program. During observations of Resident 15 were noted on 11/20/14: - The resident was seated in wheelchair at the dining room table for the breakfast meal at 6:55 AM, 7:44 AM, 7:48 AM, 8:09 AM, 8:39 AM, 9:21 AM, 9:42 AM, 10:07 AM, and 10:12 AM when the resident was wheeled to the activity room. - The resident remained in wheelchair for an activity from 10:12 AM until 10:34 AM when the resident was returned to room. - The resident remained seated in wheelchair from 10:34 AM until 11:30 AM when Nursing Assistant (NA)-G was observed to wheel the resident from room to the dining room. During interview on 11/20/14 at 11:30 AM, NA-G verified Resident 15 was not toileted or repositioned prior to being wheeled to the dining room for the noon meal. (The resident was observed seated in wheelchair without repositioning for 4 hours and 35 minutes.) The following observations of Resident 15 were noted on 11/24/14: - The resident was seated in wheelchair at the dining room table for the breakfast meal from 9:15 AM until 10:00 AM when the resident was wheeled to t… | 2015-07-01 |
| 11267 | 11267 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 280 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on observations, record review and staff interviews; the facility failed to review and revise Care Plans related to the treatment of [REDACTED]. Facility census was 33. Findings are: A. Review of facility policy titled "Pressure Sore Prevention and Monitoring Guidelines" (revised 6/13) revealed the goal of the facility was to maintain skin integrity. If a resident developed a pressure sore, the resident was to receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Upon identifying a pressure sore the licensed nurse was to ensure pressure sores were identified with goals and interventions to be addressed on the resident's Care Plan. B. Review of Resident 38's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/14/14 revealed resident 38 was admitted on [DATE] with [DIAGNOSES REDACTED]. -Two Stage 2 pressure sores (The staging system is a method of summarizing certain characteristics of pressure sores, including the extent of tissue damage. Stage 2 refers to partial thickness skin loss that presents as an abrasion, blister or shallow crater). -Two Stage 3 pressure sores (full thickness skin loss with damage to subcutaneous (under the skin) tissue). -One unstageable pressure sore (unstageable refers to a full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (dead tissue) in the wound bed). -One unstageable pressure sore with suspected deep tissue injury (pressure related injury to subcutaneous tissue). Review of Resident 38's "Wound Assessment Tool" dated 10/8/14 revealed Resident 38 had a 9.5 centimeter (cm) by 5.7 cm pressure sore with 10 cm depth to gluteal sacral area (lower back above buttock crease) and a 4 cm by 3.7 cm pressure sore with 3 cm depth to left [MEDICATION NAME] area (upper back). Review of Resident 38's "Weekly Pres… | 2015-07-01 |
| 11268 | 11268 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 282 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on observations, record review and staff interview; the facility failed to implement Care Plan interventions related to activities of daily living, repositioning, nutrition, pressure sores and management of urinary catheters for Residents 9, 15, 10, 17 and 29. Facility census was 33. Findings are: A. Review of Resident 29's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/3/14 identified [DIAGNOSES REDACTED]. Review of Resident 29's Care Plan with revision date of 9/14/14 identified the resident had a supra-pubic catheter (tube inserted into the resident's bladder through a small hole in the stomach to drain urine from the bladder). Resident 29's Care Plan further identified the resident was at risk for urinary tract infections and skin breakdown and listed the following interventions: -Do not allow drainage bag to touch the floor or the surface of the bed. -Use principles of infection control and standard precautions (procedures designed by the Centers for Disease Control and Prevention (CDC) to prevent the spread of known and unknown sources of infections. It applies to blood; body fluids, excretions, and secretions of the skin; and oral mucosa) when doing any treatments or catheter care. -Store catheter drainage bag inside a protective dignity pouch. -Perform catheter care per facility policy. During an observation on 11/19/14 at 4:30 PM, Resident 29 was seated in a recliner in the resident's room. The resident's supra-pubic urinary catheter drainage bag was hung on the outside of a trash receptacle next to the resident's recliner. The trash receptacle contained soiled Kleenex and crumpled papers. The bottom of the drainage bag rested directly on the floor next to the trash receptacle. During an observation on 11/20/14 at 7:45 AM, Resident 29 was seated in a recliner in the resident's room with foot rest elevated. The resident's supr… | 2015-07-01 |
| 11269 | 11269 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 309 | H | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2 Based on observations, record review and staff interview; the facility failed to provide care and treatment to promote healing of wounds for Residents 17, 28, and 35. Facility census was 33. Findings are: A. Review of facility policy for Actual Impaired Skin Integrity (no date indicated) revealed residents with impaired skin integrity as a result of pressure ulcers, vascular ulcers, rashes, skin tears, surgical sites and diabetic/neuropathic ulcers were to receive interventions which included the following: -Medications and treatments as ordered -Encouragement and assistance to turn and reposition every 1 - 2 hours -Measure/assess wound and skin check every week -Notify physician of signs and symptoms of impaired skin integrity -Notify physician as needed for lack of response to treatment if no improvement noted within 2-4 weeks as indicated/appropriate -Monitor status of surrounding skin every day and notify physician as needed of noted impairment -Monitor for signs/symptoms of infection or other complication and notify physician as needed B. Review of Resident 17's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/27/14 indicated the resident was admitted to the facility 2/19/14 with [DIAGNOSES REDACTED]. Review of Resident 17's Treatment Flowsheet (a record of treatments provided by nursing) for 2/2014 revealed a physician's order dated 2/19/14 for saline wet-to-dry dressings (A gauze pad soaked in saline and placed on the surface of a wound bed, followed by a dry dressing pad placed on top of the wet dressing) to left lateral ankle BID (2 times daily) at 10:00 AM and 10:00 PM. Documentation revealed the 10:00 AM dressing change to Resident 17's ankle was not documented from 2/19/14 to 2/25/14 (6 of 13 dressing changes in 7 days). Review or Resident 17's Care Plan dated 2/25/14 indicated the resident had an open wound to the left lateral… | 2015-07-01 |
| 11270 | 11270 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 312 | D | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observations, record review and staff interview; the facility failed to provide toileting assistance for Resident 38 and feeding assistance for Resident 9 who both required assistance with activities of daily living. Facility census was 33. Findings are: A. Review of Resident 38's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/14/14 indicated [DIAGNOSES REDACTED]. Observations of Resident 38 on 11/17/14 revealed the following: -At 7:01 AM, the resident's call light was on and the resident was lying in bed. The resident indicated the call light had been turned on as the resident needed to use the bathroom. -At 7:15 AM, (14 minutes later) The Registered Nurse (RN) Consultant entered Resident 38's room, turned off the call light and told the resident help was coming, before exiting the resident's room. -At 7:22 AM, (21 minutes after call light was first turned on) Resident 38 turned the call light back on stating, "They still haven't taken me to the bathroom". -At 7:39 AM, (38 minutes after the call light was first turned on) Nursing Assistant (NA)-M entered the resident's room and turned off the resident's call light, NA-M indicated an additional staff member was needed to help the resident and NA-M exited the resident's room. -At 7:52 AM, (51 minutes after Resident 38 initially turned on the call light to seek assist with toileting) NA-A entered the resident's room, closed the door and turned off the resident's call light. During an interview on 11/17/14 from 8:05 AM to 8:12 AM, NA-A confirmed Resident 38 was not taken to the bathroom until the call light was turned off at 7:52 AM. In addition, NA-A verified Resident 38 was incontinent of urine by the time the resident was assisted to the bathroom. B. Review of Resident 9's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. At 7:41 AM on 11/19/14, NA-B was observed to wheel Resident… | 2015-07-01 |
| 11271 | 11271 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 314 | H | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observations, record review and staff interviews; the facility failed to identify the presence of pressure sores and/or to provide identified interventions for the prevention and treatment of [REDACTED]. Facility census was 33. Findings are: A. Review of facility policy titled "Pressure Sore Prevention and Monitoring Guidelines" (revised 6/13) revealed the goal of the facility was to maintain skin integrity. If a resident developed a pressure sore, the resident was to receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Upon identifying a pressure sore the licensed nurse was to perform the following procedures: -Notify the physician for orders to treat each pressure sore identified. -Notify resident's responsible party and physician regarding change in condition. -Ensure pressure sores are identified with goals and interventions to be addressed on the resident's Care Plan. -Schedule weekly head to toe skin assessments. -Notify the Dietary Manager and the Registered Dietician for recommendations to ensure adequate caloric and protein needs as applicable. -All pressure sores will be assessed weekly. B. Review of facility policy titled "Dressing-Non-sterile Treatment" (revised 6/13) revealed the policy of the facility was to perform treatments and dressing changes per physician orders. The licensed nurse was to follow the following procedure: -Review physician treatment orders. -Prepare clean field. -Create a barrier for dressing supplies and place on the clean field. -Wash hands. -Apply clean gloves -Remove soiled dressing and place in a biohazard container. -Remove gloves and wash hands. -Apply clean gloves. -Clean wound per physician order. Clean wound from the center to the outer borders using a circular motion (area of most contamination to the area of the least). Ensure you do not contaminate the wound bed. -Remove … | 2015-07-01 |
| 11272 | 11272 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 315 | G | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D3 (1) Based on observations, record review and staff interview: the facility failed to provide catheter care and to provide treatment and handling of a urinary catheter drainage bag in a manner to prevent recurrent urinary tract infections for 1 resident (Resident 29). Facility census was 33. Findings are: A. Review of facility policy titled "Urinary/ Catheter Care" (revised 2/2012) indicated the purpose of catheter care was to minimize the risk of catheter-associated urinary tract infection and its related problems. The policy identified the following procedures: -Wash hands and apply gloves. -Cleanse the catheter insertion site daily with soap and water. Cleanse the proximal third of the catheter with soap and water, washing away from the insertion site and manipulating the catheter as little as possible. -Apply a sterile 4 x 4 to catheter insertion site as ordered or as indicated. -Remove gloves and wash hands. B. Review of Resident 29's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/3/14 identified [DIAGNOSES REDACTED]. Review of Resident 29's Care Plan with revision date of 9/14/14 revealed the resident had drainage from the insertion site of a supra pubic catheter (tube inserted into the bladder through a small hole in the stomach to drain urine from the bladder) with a goal for the area to be without drainage and to heal. An intervention was identified to wash the insertion site BID (twice a day) with soap and water and to apply [MEDICATION NAME] (topical antibiotic use to treat/prevent infections and to promote healing) as needed followed by a dressing. Resident 29's Care Plan further identified the resident was at risk for urinary tract infections and skin breakdown related to indwelling supra-pubic urinary catheter and listed the following interventions: -Monitor site for signs and symptoms of infection every shift. -Change dressin… | 2015-07-01 |
| 11273 | 11273 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 323 | K | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record review and staff interviews; the facility failed to assure residents were free of injury from hot liquid spills. Resident 28 was not assessed for risk of hot liquid spills and sustained a burn after spilling coffee. In addition, hot water temperatures were not monitored to ensure residents who received showers were protected from potential burn injury. This affected 23 residents (Resident 35, 10, 12, 4, 17, 6, 34, 28, 37, 33, 1, 29, 15, 9, 18, 40, 36, 23, 2, 24, 39, 43, and 38). Facility census was 33. Findings are: A. Review of facility Hot Beverage Safety Guideline policy (revision date 4/2013) revealed residents were to be assessed using the Hot Beverage Safety Evaluation upon admission, quarterly and as needed to determine ability to independently consume hot beverages safely. Staff were to ensure supervision and assistance was provided as identified by the Hot Beverage Safety Evaluation and witnessed unsafe practices associated with the consumption of hot beverages were to be reported to the Nursing Department Manager/Designee with interventions implemented as required. B. Review of Resident 28's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/18/14 revealed [DIAGNOSES REDACTED]. Review of a facsimile (fax) dated 11/21/14 at 7:52 PM revealed Resident 28's physician was notified of a "...burn from hot coffee." The resident spilled coffee and sustained reddened skin areas on the inner left thigh from groin to knee and a 3 centimeter (cm) area on the left inner foot. Documentation further indicated that 45 minutes later the redness to the resident's inner thigh had decreased to "...mid inner thigh approx. (approximately) 5 cm" and the reddened area to the foot had " ...decreased as well." Review of Resident 28's medical record revealed no evidence to indicate a Hot Beverage Safety Evaluation was completed unt… | 2015-07-01 |
| 11274 | 11274 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 325 | H | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observations, record review and staff interview; the facility failed to evaluate significant weight losses for Residents 15 and 9, and gradual weight loss for Resident 10. Interventions for the prevention of weight loss were not developed and/or revised to prevent further loss of weight. Facility census was 33. Findings are: A. Review of the facility Weight Policy (Revised 08/13) included the following: 1. All residents will be weighed monthly. 2. The charge nurse will notify the Dietary Manager (DM) and Director of Nursing (DON) of weight variances. 3. Weight variance: Calculate weight loss or gain every time a resident is weighed. Significant weight variance must be brought to the attention of the Registered Dietician (RD). (Significant weight loss/gain was defined as 5% (percent) in 1 month, 7.5% in 3 months, and 10% in 6 months.) 4. RD or designee will review information, discuss with resident and document on the medical record. 5. The physician will be called by the charge nurse regarding significant weight variances. B. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/23/14 indicated the resident was admitted with [DIAGNOSES REDACTED]. The MDS further revealed the resident had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making, and required extensive assistance with eating. Review of Resident 15's Care Plan dated 2/2/13 indicated the resident had a history of [REDACTED]. Interventions included to offer ice cream if not eating the meal provided; provide 2 Cal (a high calorie nutritional supplement) 4 ounces TID (3 times daily) between meals; encourage, provide cues, and/or assist with oral intake of food and fluids although resident not always receptive to this; monitor and record weight weekly; notify physician and family of significant weight cha… | 2015-07-01 |
| 11275 | 11275 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 353 | F | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observations, record reviews and confidential resident and family interviews; the facility failed to provide nursing staff to meet resident's needs related to: 1) 9 of 12 resident interviews and 2 of 5 family interviews voiced concerns regarding lack of staff; 2) provision of toileting assistance and prompt response to call light for Resident 38; 3) provision of repositioning for Resident 15 and Resident 10 and; 4) provision of repositioning and feeding assistance/meal service for Resident 9. Facility census was 33. Finding are: A. Nine residents voiced concerns regarding insufficient nursing staff during confidential interviews conducted on 11/18/14 from 2:29 PM until 11/19/14 at 11:38 AM. Comments included the following: -"Call light response-as a rule 20 minutes to maybe an hour." -"Very understaffed. Sometimes have to wait quite a while. 20 minutes or more to have help after we push our call lights." -"They don't have enough staff, sometimes (waits) 15 to 20 minutes". -"Not enough staff...Have had to wait ? hour to an hour." -"Always short of help here." -"When you ring the bell, it takes forever for them to come to you. Typically I have to wait ? hour to 45 minutes to have my call light answered." -"Sometimes I feel like it takes up to 45 minutes to an hour to get help." -"One time I waited so long I forgot what I wanted." -"They just don't have enough help. If you have to go to the bathroom usually takes 15 minutes or more to get someone to help you." B. Two family members voiced concerns regarding insufficient nursing staff during confidential interviews conducted on 11/24/14 from 1:43 PM until 4:27 PM. Comments included the following: -"...it takes so long for staff to come and get (resident) to the bathroom" and they "complain daily when (resident's) care is delayed." -"There is not enough staff here to take care of the residents." C. Observations of Resident 38 on 11/17/14 revea… | 2015-07-01 |
| 11276 | 11276 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 356 | C | 0 | 1 | ZQ0211 | Based on observations and staff interview; the facility failed to post and retain the required daily nurse staffing information. This had the potential to affect all residents, family members and visitors. Facility census was 33. Findings are: Observations during entrance tour of the facility on 11/18/14 at 12:00 noon revealed the nurse staffing information was not posted. During interview on 11/18/14 at 12:15 PM, the Director of Nursing (DON) verified the nurse staffing information was not posted. Interview with the DON at 7:35 AM on 12/2/14 revealed nurse staffing information had not been posted since the end of 7/2014. The DON further indicated nurse staffing information had not been retained since that time. Therefore, nurse staffing records were not maintained for 18 months as required. | 2015-07-01 |
| 11277 | 11277 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 364 | F | 0 | 1 | ZQ0211 | Licensure Reference: 175 NAC 12-006.11D Based on observations, record review and resident/staff interviews; the facility failed to provide food at temperatures palatable to residents. This practice had the potential to affect all facility residents. Facility census was 33. Findings are: A. Confidential resident interviews conducted on 11/18/14 through 11/19/14 revealed 5 residents responded "No" when asked if food was served at the proper temperature. B. Observations on 11/24/14 revealed the following: -12:13 PM- The Dietary Manager (DM) served Resident 33 an uncovered plate consisting of cooked cabbage, mashed potatoes with butter and a chicken breast. Resident 33 took a bite of the mashed potatoes and indicated the food was not hot enough. -1215 PM- The DM completed temperature checks on the lunch plate served to Resident 33. The following temperatures were measured; cooked cabbage 138 degrees F (Fahrenheit), mashed potatoes with butter 139 degrees and chicken breast 128 degrees F. C. During an interview on 11/24/14 from 12:30 PM to 12:38 PM, the DM identified all food should be at least 140 degrees F when served to the residents. The DM indicated the cook was to complete food temperatures before meal service and temperatures were to be documented on a "Food Temperature Record ". The DM further identified meal temperatures were routinely checked after the meal service but were never documented. D. Review of the facility "Food Temperature Records" from 11/1/14 to 11/30/14 revealed missing documentation of meal temperatures on 11/6/14, 11/10/14, 11/17/14, 11/18/14, 11/24/14, 11/26/14, 11/27/14 and 11/29/14 (meal temperatures were not documented for all food items served on 8 out of 30 days in November). E. During an interview on 12/1/14 from 9:00 AM to 9:12 AM, the DM indicated no further "Food Temperature Records" were available for review. The DM indicated food temperatures were routinely checked but had not been documented. | 2015-07-01 |
| 11278 | 11278 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 371 | F | 0 | 1 | ZQ0211 | Licensure Reference: 175 NAC 12-006.11E Based on observations, record review and staff interview; the facility failed to 1) ensure food items were labeled and dated, 2) maintain kitchen equipment, food contact/non-contact surfaces, floors, walls, light fixtures, and ceiling vents in a clean and sanitary manner, 3) ensure food and bottled water were not stored directly on the floor and 4) ensure hand-washing and glove changes were completed during meal preparation and service to prevent potential cross contamination of food. These practices had the potential to affect all of the facility residents. Facility census was 33. Findings are: During the initial kitchen tour with the Dietary Manager (DM) on 11/18/14 from 11:00 AM to 11:30 AM the following were observed: -The edges of all of the kitchen counters had surfaces completely worn away with bare wood visible making the surfaces not easily cleanable. -The kitchen floor was soiled throughout with dust, dirt and food crumbs; including under the steam table and a 2 compartment food preparation sink, between the refrigerator/freezer and the stove and in front and underneath of the dishwashing area. In addition, the kitchen floor had 2 approximately 6 inch slits in the flooring between the stove and the refrigerator and the floor had several black and gray colored stains underneath of the 2 compartment sink and the dishwashing area. -The kitchen counter immediately to the left of the steam table; contained a sealed plastic bag with biscuits, a metal cake pan with a Rice Krispy dessert covered with a plastic wrap and a metal cake pan with a chocolate dessert covered with a plastic wrap. Further observations revealed neither the plastic bag nor the metal cake pans were labeled or contained a date as to when the foods were originally prepared. -The kitchen counter immediately to the right of the 2 compartment food preparation sink had no available open space and was packed with several baking products including opened containers of salt, baking soda, baking powder and cor… | 2015-07-01 |
| 11279 | 11279 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 387 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview; the facility failed to ensure physician visits were conducted as required for 3 (Residents 36, 34 and 40) of 4 residents reviewed. Facility census was 33. Findings are: A. Review of facility policy for Physician Services (revision date 6/2013) revealed the physician was to see each facility resident at least every 30 days for the first 90 days after admission and at least every 60 days thereafter. B. Review of Resident 34's Admitting Physician order [REDACTED]. Review of Resident 34's medical record revealed no evidence to indicate the resident was seen by the physician since 9/3/14. During interview on 12/2/14 at 10:15 AM, the Director of Nurses (DON) verified Resident 34 had not been seen by the physician for the 30 day and 60 day visits and was last seen by the attending physician on 9/3/14. C. Review of Resident 36's Referral Form dated 9/29/14 revealed the resident was admitted on [DATE] and was seen by the physician on 9/29/14. Review of Resident 36's medical record revealed no evidence to indicate the resident was seen by the physician between 9/29/14 and 11/19/14. Review of Resident 36's Referral Form dated 11/19/14 revealed the resident was seen by the physician on that day. During interview on 12/2/14 at 9:25 AM, the DON verified Resident 36 had not been seen by the physician between 9/29/14 and 11/19/14. The DON indicated the resident should have been seen by the physician on 10/22/14 when the physician was in the facility. D. Review of Resident 40's Care Plan revealed the resident was admitted to the facility on [DATE]. Review of Resident 40's medical record revealed no evidence to indicate the resident had been seen by the physician since admission to the facility on [DATE]. During interview on 12/2/14 at 12:00 noon, the DON verified Resident 40 had not been seen by the physician since 10/22/14. | 2015-07-01 |
| 11280 | 11280 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 388 | D | 0 | 1 | ZQ0211 | Based on record review and staff interview; the facility failed to assure Resident 12's physician and nurse practitioner conducted alternate visits. Resident 12 was seen by the nurse practitioner on 3 consecutive 60 day visits. Facility census was 33. Findings are: Review of facility policy for Physician Services (revision date 6/2013) revealed the physician was to see each facility resident at least every 30 days for the first 90 days after admission and at least every 60 days thereafter. After the initial visit following admission, a qualified nurse practitioner or physician assistant may make every other required visit. Review of Referral Forms dated 4/1/14, 6/2/14 and 8/4/14 revealed Resident 12 was seen by the nurse practitioner on those days. There was no evidence in Resident 12's medical record to indicate the resident was seen by the physician until 9/11/14. Review of a Referral Form dated 9/11/14 revealed the resident was seen by the physician on that day. The Director of Nurses (DON) indicated during interview on 12/2/14 at 11:40 AM that Resident 12's physician was reminded recently of the need to alternate visits with the nurse practitioner. The DON verified during interview on 12/2/14 at 12:00 noon that Resident 12's physician and nurse practitioner had not conducted alternate visits. | 2015-07-01 |
| 11281 | 11281 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 441 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B, 12-006.17D Based on observations, record review and staff interviews; facility staff failed to utilize hand-washing and gloving techniques to prevent cross contamination during the provision of toileting cares for Residents 2 and 19, during a treatment for [REDACTED]. In addition, facility staff failed to handle Resident 29's urinary catheter drainage bag in a manner to prevent cross contamination. Facility census was 33. Findings are: A. Review of facility policy titled "Dressing-Non-sterile Treatment" (revised 6/13) revealed the facility staff was to perform treatments and dressing changes per physician orders. The licensed nurse was to follow the following procedure: -Review physician treatment orders. -Prepare clean field. -Create a barrier for dressing supplies and place on the clean field. -Wash hands. -Apply clean gloves -Remove soiled dressing and place in a biohazard container. -Remove gloves and wash hands. -Apply clean gloves. -Clean wound per physician order. Clean wound from the center to the outer borders using a circular motion (area of most contamination to the area of the least). Ensure you do not contaminate the wound bed. -Remove gloves and wash hands. -Apply clean gloves. -Apply dressing as ordered. -Remove gloves and wash hands. B. Review of facility policy titled "Urinary/ Catheter Care" (revised 2/12) indicated the purpose of catheter care was to minimize the risk of catheter-associated urinary tract infection and its related problems. The policy identified the following procedures: -Wash hands and apply gloves. -Cleanse the catheter insertion site daily with soap and water. Cleanse the proximal third of the catheter with soap and water, washing away from the insertion site and manipulating the catheter as little as possible. -Apply a sterile 4 x 4 to catheter insertion site as ordered or as indicated. -Remove gloves and wash hands. C. Review of facility policy titled "Pers… | 2015-07-01 |
| 11282 | 11282 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 490 | F | 0 | 1 | ZQ0211 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on record reviews and staff interviews; Facility Administration failed to maintain a system to prevent non-compliance with Federal and State regulations related to assuring residents were protected from injury due to hot liquid spills and hot water temperatures in resident care areas. In addition, Facility Administration failed to assure correction of previously cited deficiencies was maintained. This had the potential to affect all residents within the facility. The facility census was 33. Findings are: A. Interview with the Director of Nurses on 11/25/14 at 8:50 AM revealed Hot Beverage Safety Evaluations were completed on all residents on 11/24/14 (which was 3 days after Resident 28 sustained a burn from a hot liquid spill). The DON further indicated 3 residents were identified at risk for hot liquid spills and the intervention was to place lids on cups of hot liquids. Interview with the Dietary Manager (DM) on 11/25/14 at 9:30 AM revealed interventions for prevention of hot liquid spills were not implemented at the breakfast meal on 11/25/14 for 2 of 3 residents who were identified at risk for hot liquid spills. B. Interview with the Registered Nurse Consultant (RNC) on 11/19/14 at 2:13 PM revealed hourly monitoring of hot water temperatures was in progress due to hot water temperatures throughout the facility in excess of 130 degrees Fahrenheit. The RNC indicated all staff were educated regarding excess hot water temperatures and a log was placed in the shower room for staff to monitor and document water temperatures before all showers/baths. Review of facility shower/bath schedules from 11/20/14 through 12/1/14 revealed no documentation to indicate hot water temperatures were checked/monitored prior to provision of showers for 38 residents. This was verified during interview with the staff member who provided showers/baths during that time frame. C. The following deficient practices were cited during the previous Quality Indicator Survey (QIS) completed 11/… | 2015-07-01 |
| 11283 | 11283 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 497 | F | 0 | 1 | ZQ0211 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.04B2a Based on record review and staff interview; the facility failed to ensure annual employee performance evaluations were completed for 6 of 6 personnel records reviewed. The facility census was 33. Findings are: Review of personnel files for Nursing Assistants (NA) A, B, C, H, E and N revealed the following: -NA-A was hired on 7/15/10 with no evidence that a performance evaluation had ever been completed. -NA-B was hired on 2/7/14 with no evidence of a completed performance evaluation. -NA-C was hired on 10/22/13 with no evidence that a performance evaluation had ever been completed. -NA-H was hired on 8/1/13 with no evidence that a performance evaluation had ever been completed. -NA-E was hired on 9/16/13 with no evidence that a performance evaluation had ever been completed. -NA-N was hired on 3/24/14 with no evidence of a completed performance evaluation. During an interview on 12/2/14 from 11:45 AM to 12:00 PM, the Director of Nursing verified performance evaluations were to be completed annually but was unaware when evaluations were last completed. | 2015-07-01 |
| 11284 | 11284 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 520 | H | 0 | 1 | ZQ0211 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on observations, record review and staff interview; the facility Quality Assurance (QA) Committee failed to maintain correction of previously cited deficiencies regarding accident prevention, infection control, Care Plan revision and implementation, timely assistance for residents who require assist with activities of daily living, treatment and care of pressure sores, QA and staffing. This failure had the potential to affect the well-being of all residents. Facility census was 33. Findings are: A. Record review of the Quality Assurance policy and procedures (undated) revealed the purpose of the program was to ensure appropriate follow-up and ongoing tracking of identified environmental and quality of care issues. The policy further indicated the QA Committee was to develop and implement plans of corrective action for identified trends and/or deficient practices. The following areas were to be addressed monthly by the QA Committee: -Infection Control -Skin Integrity -Safety/Environment -Resident Assessment -Quality of Care B. Review of facility deficiency statement from the Quality Indicator Survey (QIS) completed 11/13/13 and QIS completed 12/2/14 revealed repeated facility noncompliance with the following Federal (F) tags: -F 323-Failure to prevent accidents -F 280-Failure to revise resident Care Plans -F 282 Failure to implement assessed Care Plan interventions -F 312 Failure to provide timely assistance for residents who required toileting and feeding assistance. -F 441-Failure of staff to remove gloves and wash hands during toileting cares, dressing changes and catheter cares in a manner to prevent cross contamination. F 520-Failure to maintain correction of previously cited deficiencies through the QA program. C. Interview with the Administrator on 12/2/14 from 7:45 AM to 8:01 AM revealed the QA Committee had discussed issues regarding infection control practices and current facility pressure ulcers at the last QA meeting on 10/22/14. However, there was no… | 2015-07-01 |
| 11775 | 11775 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 241 | E | 1 | 1 | 6TPT11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(21) Based on observations and staff interview, the facility failed to assure all residents were treated in a dignified manner as Residents 7, 22 and 23 were fed meals while seated next to the bird aviary which was soiled with bird droppings and feathers. Facility census was 38. Findings are: A. The interior glass surface of the bird aviary, located in the main dining room, was observed to be soiled with dried bird droppings on 5/17/11 at 11:50 AM and 5/18/11 at 6:45 AM and 9:00 AM. From 9:00 AM until 9:07 AM on 5/18/11, Residents 7, 22 and 23 were observed seated at the dining room table adjacent to the bird aviary. The residents had just finished eating the breakfast meal. Resident ' s 22 and 23 sat facing the soiled glass of the bird aviary. Resident 7 was seated in a wheelchair which was placed sideways next to the bird aviary. The wheels of Resident 7 ' s wheelchair were touching the glass of the bird aviary. B. At 10:20 AM on 5/19/11 the interior glass surface of the bird aviary was observed to remain soiled with dried bird droppings and there was an accumulation of bird feathers on the floor. The Administrator verified during interview at this time that the bird aviary was in need of cleaning and a pleasant dignified dining experience was not provided for residents. The Administrator indicated there were plans to remove the bird aviary from the dining room at some point. | 2015-01-01 |
| 11776 | 11776 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 253 | E | 1 | 1 | 6TPT11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A Based on observations and staff interview, the facility failed to assure the facility was free from odors and failed to maintain walls, doors/door jams, closet doors, dresser drawers, floors and the bird aviary in clean condition and/or good repair. This affected 15 (Rooms 1, 2, 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 21, 22 and 25) out of 21 occupied resident rooms and 3 residents (Residents 7, 22 and 23) who ate their meals while seated next to the bird aviary located in the main dining room. Facility census was 38. Findings are: A. The interior glass surface of the bird aviary, located in the main dining room, was observed to be soiled with dried bird droppings on 5/17/11 at 11:50 AM and 5/18/11 at 6:45 AM and 9:00 AM. At 9:00 AM on 5/18/11, Residents 7, 22 and 23 were observed seated at the dining room table adjacent to the bird aviary. Resident ' s 22 and 23 sat facing the soiled glass of the bird aviary. Resident 7 was seated in a wheelchair which was placed sideways next to the bird aviary. The wheels of Resident 7 ' s wheelchair were touching the glass of the bird aviary. B. At 10:20 AM on 5/19/11 the interior glass surface of the bird aviary was observed to remain soiled with dried bird droppings and there was an accumulation of bird feathers on the floor. Interview with the Maintenance Supervisor at this time revealed the bird aviary was not on a routine cleaning schedule and the last time it had been cleaned might have been in December 2010. C. The following was observed during environmental tour of the facility with the Administrator and Maintenance Supervisor on 5/19/11 from 10:20 AM until 11:10 AM: -Room 1-Bathroom walls were paint chipped and gouged below the sink and beneath the call light system. -Room 2-There was duct tape holding the vinyl covering in place on the bottom edge of the door to the room. -Room 3-There was a strip of red tape on the floor between the resident ' s beds. The tape was torn and frayed and did not present a smooth easily cleanable… | 2015-01-01 |
| 11777 | 11777 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 323 | D | 1 | 1 | 6TPT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E4 Based on observations, record review and staff interviews the facility failed to assure Resident 38 was protected from falls, as fall prevention measures were not consistently provided. The sensor alarm was not in place on one occasion and the floor mat to be used in the resident's room was not used throughout the days of the survey. Facility census was 38. Findings are: Review of Resident 38's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for Care Planning) dated 5/12/11 identified an admission date of [DATE] with current [DIAGNOSES REDACTED]. The MDS identified Resident 38 required extensive assist of 2 staff for all transfers, bed mobility, dressing, toileting and bathing. This assessment reflected the resident had a history of [REDACTED]. Review of Care Plan dated 5/6/11 reflected the resident was a fall risk due to weakness and surgical repair of right hip fracture. Care Plan interventions included; -High/low bed -Mat on the floor -Sensor alarms -Call light in place and resident educated to use it Review of Resident Progress Notes dated 5/12/11 at 3:49 AM indicated Resident 38's bed alarm went off and resident was found sitting beside the bed on the floor. The bed had been in the lowest position. Resident 38 stated that resident was going to the bathroom and forgot to call. 2 staff assisted resident back into bed. The bed alarm was changed to immediate ring instead of a 2 second delayed ring. Staff reminded Resident 38 to use the call light to call for help. During observation of Resident 38 on 5/18/11 at 1:18 PM resident was seated in a wheelchair next to the bed in the resident ' s room. No fall mat was noted on the floor. Resident was observed 5/18/11 at 2:30 PM asleep on resident ' s bed. No fall mat was noted on floor. At 3:21 PM on 5/18/11 Resident 38 was seated in a wheelchair in the Activity Room and no sensor alarm was noted to wheelchair. During obs… | 2015-01-01 |
| 11778 | 11778 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 329 | D | 1 | 1 | 6TPT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview; the facility failed to assure drug regimens were free from unnecessary drugs for Residents 6 and 30. The facility failed to monitor behaviors on Resident 6 whose drug regimen included [MEDICATION NAME] (a medication used to treat anxiety). Furthermore, the facility failed to routinely monitor Resident 30 ' s blood pressure to evaluate use of [MEDICATION NAME] (a medication used to treat hypertension). Facility census was 38. Findings are: A. Review of Resident 6 ' s Face Sheet with an admission date of [DATE] indicated [DIAGNOSES REDACTED]. Review of Resident 6 ' s Current physician's order [REDACTED].? tablet (0.25 mg) 3 times daily (TID). There was no documentation in the electronic medical record to indicate what resident behaviors were targeted for use of [MEDICATION NAME], nor was there documentation of behavior monitoring. Observations on 5/18/11 at 2:10 PM and 3:30 PM and 5/19/11 at 7:50 AM and 9:00 AM revealed Resident 6 seated in the recliner in room with eyes closed. During interview on 5/23/11 from 10:00 AM to 10:05 AM, Licensed Practical Nurse (LPN) - A verified there was no behavior monitoring documentation in the medical record. LPN - A revealed Resident 6 was administered [MEDICATION NAME] for " restlessness " . Observations on 5/23/11 at 10:15 AM, 1:30 PM and 3:15 PM revealed Resident 6 seated in the recliner in room with eyes closed. During interview on 5/23/11 from 3:30 PM to 4:15 PM, the Director of Nursing and the Administrator verified Resident 6 did not exhibit signs of restlessness or anxiety. B. Review of Resident 30 ' s Face Sheet with an admission date of [DATE] indicated [DIAGNOSES REDACTED]. Review of Resident 30 ' s Medications Flowsheet dated 5/11 indicated Resident 30 had a physician's order [REDACTED]. Review of the Vitals Report dated 11/1/10 through 5/24/11 revealed Resident 30 ' s blood pressure (BP) was not measured during the month of 11/10. It furt… | 2015-01-01 |
| 11779 | 11779 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 356 | C | 0 | 1 | 6TPT11 | Based on observations and staff interview, the facility failed to post Nurse Staffing information on a daily basis. In addition, the facility failed to maintain the Nurse Staffing information for a minimum of 18 months as required. This potentially affected all 38 residents who currently resided in the facility. Findings are: A. Observations on 5/17/11 at 9:45 AM, 5/18/11 at 7:00AM and 1:20 PM, and 5/19/11 at 6:20 AM and 10:00 AM revealed the Nurse Staffing information was not posted. B. Interview with the Director of Nursing on 5/19/11 from 10:00 AM until 10:12 AM revealed the facility had not been posting the Nurse Staffing information and there were no past records to indicate the information had been completed and maintained. | 2015-01-01 |
| 11780 | 11780 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 516 | F | 0 | 1 | 6TPT11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.16C Based on observations and staff interview, the facility failed to assure confidentiality of resident records as resident medical record information could be easily obtained from the shredding machine storage container which was located in the sunroom (an area readily accessible to residents, visitors and staff members). This had the potential to affect all 38 residents currently residing in the facility. Findings are: A. On 5/19/11 at 11:00 AM, the shredding machine storage container was observed in the sunroom of the facility. The sunroom was located in a public area and available for use by residents, visitors and staff members. The shredding machine storage container was full of papers, including discarded confidential medical records, which could easily be removed from an open slot on the container. B. The Administrator verified during interview on 5/19/11 from 11:15 AM until 11:20 AM that the shredding machine storage container needed to be emptied. The Administrator stated the facility had a contract with a paper shredding service. The Administrator was not sure when the contract service had last emptied the container. C. Observations on 5/23/11 at 2:44 PM and 3:30 PM and 5/24/11 at 6:45 AM revealed the shredding machine storage container remained full of papers, including discarded confidential medical record information which could easily be removed. | 2015-01-01 |
| 2299 | 2299 | GOOD SAMARITAN SOCIETY - ALBION | 285197 | P O BOX 271, 1222 SOUTH 7TH STREET | ALBION | NE | 68620 | 2018-01-24 | 689 | D | 0 | 1 | QYYQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview, the facility failed to determine causal factors and develop new interventions for the prevention of falls for Resident 42. The facility census was 52 and the sample size was 13. Findings are: Review of Resident 42's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 12/8/17 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had moderate cognitive impairment and had no falls since the previous assessment. Review of Resident 42's Care Plan dated 9/6/17 revealed the resident was at risk for falls, was able to complete toileting tasks independently and was resistive with staff assistance with toileting. The Care Plan further indicated the resident did not like staff to accompany the resident into the bathroom and extensive assistance with perineal care and clothing changes was required at times due to incontinence. Review of a Risk Management Report dated 1/19/18 revealed Resident 42 was found on the floor that day at 12:00 midnight. Documentation further indicated the intervention to prevent another fall was to place a Dycem (a non-slip material placed in the seat of a chair to prevent sliding) between the wheelchair seat and cushion. Review of a Risk Management Report dated 1/13/18 revealed Resident 42 was found sitting on the floor between the bed and the wheelchair at 11:15 AM that day. The resident stated, I was going to go to the bathroom. Documentation indicated the resident was last toileted at 9:30 AM. The intervention to prevent further falls was to request a therapy evaluation (screening) due to the resident's weakness of the lower legs. Review of the Nursing Communications For Therapy Screening (a form used to request a therapy evaluation) dated 1/15/18 (2 days after the resident's fall) revealed Resident 42 had 2 falls in a 4 day period. Documentation on the same form by the Physi… | 2020-09-01 |
| 2300 | 2300 | GOOD SAMARITAN SOCIETY - ALBION | 285197 | P O BOX 271, 1222 SOUTH 7TH STREET | ALBION | NE | 68620 | 2018-01-24 | 690 | D | 0 | 1 | QYYQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(1)(2) Based on record review and interview, the facility failed 1) to provide care and services for catheter management for Resident 24 and 2) to assess a decline in bowel and bladder continence for Resident 154 and develop a plan to prevent further decline. The sample size was 13 and the facility census was 52. Findings are: [NAME] Review of Resident 154's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/11/17 revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. The MDS further indicated the resident was cognitively intact, required extensive assistance for toilet use, and was always continent of bowels and bladder. Review of Resident 154's Care Plan dated 8/1/17 indicated the resident was occasionally incontinent of urine and the nursing intervention was to use a pull-up (an adult incontinent brief). The Care Plan further indicated Resident 154 had a deficit in performance of activities of daily living. Nursing interventions related to toilet use included extensive assistance of 1 with perineal hygiene upon arising, the resident uses the toilet independently throughout the remainder of the day, and the resident requested assistance with toileting at times. Review of the MDS dated [DATE] revealed Resident 154 continued to require extensive assistance for toilet use, was occasionally incontinent of bowel and bladder (this indicated a decline in continence status), and no toileting program (including scheduled toileting, prompted voiding, or bladder training) had been attempted. There was no evidence a Bowel and Bladder Assessment was completed to evaluate causal factors related to the resident's decline in continence status, or that the resident's Care Plan was reviewed and revised to include interventions to manage the incontinence and prevent further decline. During interview on 1/24/18 at 11:15 AM, Medication Aide… | 2020-09-01 |
| 2301 | 2301 | GOOD SAMARITAN SOCIETY - ALBION | 285197 | P O BOX 271, 1222 SOUTH 7TH STREET | ALBION | NE | 68620 | 2019-04-03 | 609 | D | 1 | 1 | 8Y0Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure reference number 175 NAC 12-006.02(8) Based on observation, interview, and record review; the facility failed to investigate and report alleged neglect for Resident 21 and failed to investigate and report an incident of potential neglect for Resident 56. The sample size was 5 and the facility census was 53. Findings are: [NAME] Review of the facility policy Abuse and Neglect with a revision date of 11/2016 revealed the facility would ensure all incidents of alleged or suspected abuse/neglect were promptly investigated and reported. B. Review of a Grievance Form dated 3/15/19 revealed Resident 21 had developed [MEDICAL CONDITION] and was treated in the hospital. The reporting family member felt this could have been prevented with better washing and drying of the resident's foot. The family member felt this was neglect. Review of the facility self-reports from 3/2019 to 4/2019 revealed no evidence the alleged neglect had been reported to the State Agency. An observation of resident care was completed on 4/2/19 at 7:30 AM with Licensed Practical Nurse (LPN)-B and Medication Aide (MA)-C. Resident 21 had just gotten out of the bath tub. LPN-B gave the resident morning medications and MA-C went to apply the dressing to the resident's right foot. MA-C placed dry gauze between the resident's toes (as ordered). MA-C spread the resident's toes gently and revealed open areas between the 2nd and 3rd toes and the 3rd and 4th toes. The area between the resident's toes was still wet when the gauze pads were placed and the resident complained of pain during the treatment. During an interview on 4/2/19 at 7:30 AM, MA-C stated either MA-C or MA-E were usually assigned baths on the 200 wing. MA-C stated the resident had a lot of pain when the resident's feet were cleaned. MA-C stated when cleaning and drying between the resident's toes MA-C would do the best I can but it was difficulty to get between the toes dry due to the resident moving and pain … | 2020-09-01 |
| 2302 | 2302 | GOOD SAMARITAN SOCIETY - ALBION | 285197 | P O BOX 271, 1222 SOUTH 7TH STREET | ALBION | NE | 68620 | 2019-04-03 | 678 | E | 0 | 1 | 8Y0Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure reference number 175 NAC ,[DATE].02(1) Based on interview and record review, the facility failed to ensure a Cardiopulmonary Resuscitation (CPR) certified staff member was available for the residents at all times. This had the ability to affect all residents that had a Resuscitate order (indicating CPR should be initiated if needed). The sample size was 7 and the facility census was 53. Findings are: Review of the facility Cardiopulmonary Resuscitation policy with a revision date of ,[DATE] revealed: - The purpose of the policy was to ensure all licensed nursing staff members were certified in CPR and to ensure CPR was available to residents at all times. - Each facility would assign an employee responsible to ensure all licensed nurses had a current CPR certification. Review of the facility Advanced Directives dated [DATE] revealed 7 residents (Residents 35, 25, 2, 40, 24, 52, and 36) had a resuscitate order. Review of the undated list CPR certification and expiration provided by the facility did not identify the Transportation Aides as being CPR certified. Further review revealed Licensed Practical Nurse (LPN)-A's and LPN-K's CPR certifications had expired ,[DATE]. During an interview with the Director of Nursing (DON) on [DATE] at 10:15 AM, the DON confirmed LPN-A and LPN-K did not have a current CPR certification. During an interview with the Human Resources Coordinator on [DATE] at 10:22 AM, the Human Resources Coordinator confirmed 3 of the Transportation Aides (Transportation Aides G, H, and I) did not have a current CPR certification. | 2020-09-01 |
| 2303 | 2303 | GOOD SAMARITAN SOCIETY - ALBION | 285197 | P O BOX 271, 1222 SOUTH 7TH STREET | ALBION | NE | 68620 | 2019-04-03 | 684 | G | 0 | 1 | 8Y0Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review, the facility failed to assure Resident 56's highest level of well-being related to lack of monitoring and physician notification related to abnormal vital signs. The sample size was 1 and the facility census was 53. Findings are: Review of the facility's procedure titled Change in Condition Evaluation with a revision date of 5/2016 revealed the purpose of the procedure was to improve communication between nurses and a provider when nursing was monitoring a change in condition, to enhance the nursing evaluation of and documentation of a resident who had a change in condition, to provide a standard format to collect pertinent clinical data prior to contacting the provider when there was a change in condition, and to standardize shift to shift communication about a resident's change in condition. Further review revealed nursing judgment should be used when determining the urgency of contacting the provider. Review of the hospital Discharge Documentation dated 3/14/19 revealed Resident 56 was hospitalized for [REDACTED]. The hospital discharge education stated help should be sought right away if the resident had shortness of breath and it continued to get worse. Review of Resident 56's Weights and Vitals Summary revealed on 3/14/19 at 12:24 PM the resident's oxygen level was 91 percent (%) (with a normal range of 90-100%) upon return from the hospital. Review of Resident 56's Progress Notes dated 3/14/19 revealed: - At 2:30 PM, the resident was given a nebulizer treatment for [REDACTED]. - From 5:23 PM to 5:25 PM, the resident's vital signs were taken. The resident's blood pressure was 70/40 (with low blood pressure being below 90/60) and the resident was light headed with standing. The resident respiratory rate was 32 (with a normal rate being between 12 and 20). The resident's oxygen level was 73% (there was no evidence to indicate the physician or family was not… | 2020-09-01 |
| 2304 | 2304 | GOOD SAMARITAN SOCIETY - ALBION | 285197 | P O BOX 271, 1222 SOUTH 7TH STREET | ALBION | NE | 68620 | 2019-04-03 | 689 | D | 1 | 1 | 8Y0Z11 | **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 1 (Resident 29) of 3 sampled residents. Facility census was 53. Findings are: Review of Resident 29's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/28/18 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The same assessment indicated the resident's cognition was severely impaired and the resident had a behavior of wandering which occurred on a daily basis and placed the resident at risk for getting into a potentially dangerous place. In addition, the assessment indicated the resident required extensive staff assistance with toilet use and dressing. Review of an Incident Report dated 11/25/18 at 5:35 AM revealed staff heard a noise and found the resident kneeling on the floor next to the resident's bed. The resident indicated I am trying to get on the bed. The report identified the resident had removed gripper socks and was barefoot. The resident was provided re-education on use of the call light system to seek staff assistance and about wearing appropriate footwear. Review of an Incident Report dated 12/10/18 at 7:10 AM revealed the resident was found sitting on the floor in the resident's bathroom. The resident had been incontinent of urine on the floor, slipped and fell . Review of a Fall Screen Huddle Worksheet (form used to assess a resident's fall to determine causal factors and to assist with the development of new interventions for fall prevention) revealed the resident had not been toileted since 12:36 AM (6 hours and 34 minutes). The resident had gotten up independently to go to the bathroom, was incontinent and slipped and f… | 2020-09-01 |
| 6128 | 6128 | GOOD SAMARITAN SOCIETY - ALBION | 285197 | P O BOX 271, 1222 SOUTH 7TH STREET | ALBION | NE | 68620 | 2015-08-12 | 221 | D | 0 | 1 | 2LSH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(8) Based on observation, record review and interview; the facility failed to assess the use of a seat belt alarm (a belt attached at the sides of a wheelchair with a velcro closure that is secured around the waist of the seated resident; when the velcro closure is released, an alarm sounds to alert staff the resident has removed the seat belt in an attempt to stand up from the wheelchair) as a potential physical restraint (if the resident is not capable of intentionally removing the seat belt, it is considered a physical restraint) for Resident 50. Facility census was 55. Findings are: A. Review of the facility Procedure for Physical Restraints, issued 2/2013, revealed the following: - A physical restraint is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's own body. - Physical restraints may include, but are not limited to, using devices in conjunction with a chair such as trays, tables or belts, that prevent a resident from rising. - Remove easily was defined as The manual method, device, material or equipment . can be removed intentionally by the resident in the same manner as it was applied by the staff. - Anytime a device, material or equipment is attached or placed adjacent to the resident's body, a determination will be made by a licensed nurse as to whether it is or could be a restraint for the individual resident. - If the device, material or equipment cannot be removed easily by the resident and restricts freedom of movement or normal access to one's own body, then it is a restraint. - If the device, material or equipment is not a restraint for this resident, then the steps taken to make this decision must be documented, and it must be reviewed with a significant change in condition and quarterly in conjunction with t… | 2019-06-01 |
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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 );