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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 12644 | 12644 | TABITHA NURSING HOME | 285057 | 4720 RANDOLPH STREET | LINCOLN | NE | 68510 | 2010-11-18 | 309 | D | 9F1411 | **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 interviews the facility failed to ensure that documented interventions were in place to promote wound healing on 1 of 31 residents. (Resident 8 ). The facility census was 199. Findings are: A. Review of Resident 8 ' s Record of admitted d 8/5/10 revealed that Resident 8 had the [DIAGNOSES REDACTED]. Review of Resident 8 ' s MDS (Minimum Data Set- a federally mandated comprehensive assessment tolls used for care planning) dated 10/23/10 revealed that Resident 8 had modified independence-some difficulty with decision making in new situations. Resident 8 needed extensive assistance with two person physical assist for activities of daily living. Review of Resident 8 ' s All Wounds Info Detail Report dated 11/15/10 revealed that Resident 8 had a wound on the upper outer thigh and lower buttocks, stage 2, which was being treated with [MEDICATION NAME] tx(treatment) twice a day and prn(as needed). The date of onset was 11/9/10. Review of Resident 8's care plan dated 11/10 revealed that the original date of the problems identified was 8/5/10. On 8/5/10 the care plan identified that Resident 8 was at risk for skin breakdown due to weakness from a fever, a recent fall and [MEDICAL CONDITION] (body system infection). Three of the interventions identified on the care plan were: - the Atmos pressure reducing air mattress - Resident 8 was to be repositioned every 2 hours and PRN (as needed) and - Resident 8 was supposed to have a Gel cushion on the wheelchair and or in the recliner. Interview with UM (Unit Manager) A on 11/15/10 at 9:00am revealed that Resident 8's wound was not a pressure sore and that the left lower buttocks skin had been caught in the toilet seat which caused the wound. The wound was pea sized and superficial in depth. Observations of Resident 8 throughout the survey from 11/15/10 to 11/18/10 revealed that Resident 8 was up in the wheelchair fr… | 2014-04-01 | ||
| 12645 | 12645 | TABITHA NURSING HOME | 285057 | 4720 RANDOLPH STREET | LINCOLN | NE | 68510 | 2010-11-18 | 441 | E | 9F1411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175NAC 12-006.17 Based on observations, interviews and record review; the facility failed to disinfect contaminated equipment and the floor, and failed to follow their infection control policy to protect 3 out of 31 residents. (Residents 22, 20 and Resident 4). The facility census was 199. Findings are: A. Review of Resident 22 ' s Record of admitted d 3/22/10 revealed that Resident 22 had the [DIAGNOSES REDACTED]. Review of Resident 22 ' s MDS (Minimum Data Set - a federally mandated comprehensive assessment tool used for care planning.) dated 9/23/10 revealed that Resident 22 was moderately impaired with daily decision making and needed extensive assistance with the physical assist of two people for activities of daily living. Observation on 11/16/10 at 4:00pm of RA (Resident Assistant) C and LPN (Licensed Practical Nurse) B providing toileting and perineal care for Resident 22 revealed that RA C and LPN B closed the door, placed a gait belt around Resident 22 ' s waist and applied gloves. As RA C and LPN B transferred Resident 22 from the wheelchair to the toilet that Resident 22 ' s slacks, and pull up brief were saturated with urine. The wheelchair seat, the wheelchair seat pressure alarm and Dicem (square of material to prevent the resident from sliding out of wheelchair) were also urine soaked. After RA C and LPN B stood Resident 22 over the toilet RA C they pulled down Resident 22 ' s pants and brief and sat Resident 22 on the toilet. RA C placed the soaked slacks in a plastic bag and placed the soaked brief in the lined trash can. LPN B changed gloves and got clean slacks. RA C put on a new pull up brief and pulled it up to Resident 22 ' s knees. RA C stated " there is urine on the floor. " RA C grabbed some paper towels laid them on the floor and with the right foot proceeded to make circular motions with the paper towels to wipe up the urine off of the floor which was between Resident 22 ' s feet. RA C re… | 2014-04-01 | ||
| 12646 | 12646 | TABITHA NURSING HOME | 285057 | 4720 RANDOLPH STREET | LINCOLN | NE | 68510 | 2010-11-18 | 166 | D | 9F1411 | Licensure Reference Number 175 NAC 12-006.06B Based on staff interview, confidential Resident Interviews, Group Interviews, and Grievances, the facility had not resolved the concern of call lights being in reach and the timely answering of the call lights for 5 confidential interviews. The resident sample was 31 and the facility census was 199. Findings are: Review of 2 of 6 Grievances received by the facility in 2010 revealed: -In September, a resident, and family voiced a concern that the residents call light was not always in reach. -In November, another resident voiced a concern that the call light was on and not answered for at least 30 minutes. During the Group Interview on 11/17/10 at 10:30 AM, 4 of 11 residents present stated: -"My call light has been on up to an hour at times. It is especially bad at staff change and meal times. My call light averages a 15-30 minute wait most of the time." - "My call light is on a minimum of 15 minutes most times. Resident B agreed that at staff change and meal times are the worst. - " I feel the weekends are bad, they don't know us and it takes longer." - "I agree that the weekends are worse because we have different staff here." During a confidential individual interview on 11/17/10 the resident stated that "Sometimes you have to wait for help, they are all busy." Interview with the Administrator and Director of Nurses on 11/17/10 at 4:00 PM revealed, "We have been working on the call light issue. The residents have talked about it in Resident Council on occasion and the grievances identified a problem. We feel we are making progress though." | 2014-04-01 | ||
| 12647 | 12647 | NEBRASKA SKILLED NURSING & REHAB | 285058 | 7410 MERCY ROAD | OMAHA | NE | 68124 | 2010-12-22 | 328 | E | XNFV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D6 Based on observation, record review and interview; the facility staff failed to have an extra cannula available for use in the residents' room for 2 (Resident 1 and 3) of 3 sampled residents. The facility staff identified a census of 117. Findings are: A. Record review of an Admission and Discharge Summary sheet dated 12/09/2010 revealed Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's Minimum Data Set ( MDS,a federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 7/16/2010 revealed the facility staff assessed the following about the resident: -Resident 1's short and long term memory was ok. -Decision making was moderately impaired. -Required total assistance with bed mobility, transfers, dressing, eating and personal hygiene. Resident 1 was identified with having Oxygen Therapy, Ostomy care, Suctioning and [MEDICAL CONDITION] care. Observation on 12/21/2010 at 1:20 PM revealed Resident 1 was in bed connected to oxygen and a feeding pump. Other equipment in the room observed was a suction machine, an Ambu bag [MEDICAL CONDITION], an obturator (device to guide insertion of an outer cannula) and extra tubing. An extra cannula was not observed in Resident 1's room. Observation on 12/21/2010 at 1:45 PM revealed the Director of Nursing (DON) was not able to locate an extra cannula in Resident 1's room. The DON confirmed a spare cannula was not in Resident 1's room. When asked if a spare cannula should be in Resident 1's room, the DON stated "yes". Record review of the facility policy and procedure for Tracheotomy Care dated 10/02/2008 an undated information sheet provided as part of the policy and procedure per the DON revealed the following: -External Tube Site Care: #3. Have available at all times at the patient's bed side a replacement ET (external tube or cann… | 2014-04-01 | ||
| 12648 | 12648 | NEBRASKA SKILLED NURSING & REHAB | 285058 | 7410 MERCY ROAD | OMAHA | NE | 68124 | 2010-12-22 | 279 | D | XNFV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006C(2)(3) Based on record review and interview; the facility staff failed to develop a Comprehensive Care Plan (CCP) of [MEDICAL CONDITION] care and services for 3 (Resident 1, 2 and 3) of 3 sampled residents. The facility staff identified a census of 117. A. Record review of an Admission and Discharge Summary sheet dated 12/09/2010 revealed Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's Minimum Data Set ( MDS,a federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 7/16/2010 revealed the facility staff assessed the following about the resident: Resident 1 was identified with having Oxygen Therapy, Ostomy care, Suctioning and [MEDICAL CONDITION] care. Record review of Resident 1's CCP dated 7/14/2010 revealed the facility staff identified Resident 1 had "alteration in breathing related to [MEDICAL CONDITION] (and) Trach". Resident 1's CCP did not identify the size of the cannula, what types of equipment must be kept in the residents room, and the need to have a spare cannula in the residents room. An interview was conducted with the Director of Nursing (DON) on 12/21/2010 at 2:05 PM. During the interview Resident 1's CCP was reviewed with the DON. When asked if the size of the cannula, the need for an extra cannula and the equipment for [MEDICAL CONDITION] care and services was identified on the CCP, the DON stated "no". When asked if these items should be on the CCP, the DON stated "yes". B. Record review of History and Physical sheet dated 11/22/2010 revealed Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 2's Minimum Data Set ( MDS,a federally mandated comprehensive assessment tool used for care planning) dated 11/23/2010, revealed the facility staff assessed the following about the resident: Resident 2 was … | 2014-04-01 | ||
| 12649 | 12649 | HIGHLAND PARK CARE CENTER | 285063 | P O BOX 950, 1633 SWEETWATER | ALLIANCE | NE | 69301 | 2011-04-11 | 241 | E | 8W6H11 | Licensure Reference Number 175 NAC 12-006.05 (21) Based on record reviews, observations in the dining room, and staff interviews; the facility failed to promote dignity 1) while assisting 3 residents to eat at an assistance table (Resident 37, Resident 4, and Resident 9) and while administering medications for 1 resident (Resident 30); and 2) failed to evaluate 3 residents sitting alone at tables during meal service (Resident 25, Resident 5, and Resident 15). The facility census was 45. Findings are: 1. Observation on 4/5/11 at 12:00 PM revealed NA (Nursing Assistant) - J standing to assist Resident 37 to eat a couple of bites of food at an assist table in the dining room. Further observation revealed NA -J moved to Resident 4, seated at the same table and, while standing next to the resident, assisted the resident to eat a bite of food. NA - J then, while standing, assisted Resident 9, also seated at the same table, to eat a bite of food. Further observations revealed that the residents had to lift their heads up and lean towards the NA to be fed the bites of food. Observation on 4/7/11 at 12:15 PM in the dining room, revealed LPN (Licensed Practical Nurse) A prepared medications for Resident 30 and administered several bites of the medication to the resident while standing next to the resident. Interview on 4/11/11 at 3:30 PM with the DON (Director of Nursing) confirmed that the staff were to sit next to the residents while assisting the residents to eat and to take medications to promote the resident's dignity and comfort. 2. Observation on 4/5/11 at 12:00 PM in the main dining room revealed Resident 37, Resident 4, and Resident 9 seated at dining room tables alone during the meal service. Observation on 4/7/11 at 12:00 PM revealed the same residents seated alone again at the dining room tables for the meal service. Review of the "Care Plan" for Resident 37, Resident 4, and Resident 9 revealed no care plan to indicate a need or preference to eat alone at a table in the dining room. Interviews on 4/11/11 at 1:0… | 2014-04-01 | ||
| 12650 | 12650 | HIGHLAND PARK CARE CENTER | 285063 | P O BOX 950, 1633 SWEETWATER | ALLIANCE | NE | 69301 | 2011-04-11 | 279 | D | 8W6H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C1b Based on record reviews and staff interview, the facility failed to develop the care plan to address functional limitations in range of motion for 1 sampled resident (Resident 5). The facility census was 45 with a Stage 2 survey sample of 27 residents. Findings are: Review of the "Face Sheet" revealed that Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 3/17/11, revealed that the resident had functional limitations in range of motion, on 1 side, involving the upper extremity and the lower extremity. Review of the "Care Plan", with a goal date of 6/23/11, revealed no care plan to address the resident's functional limitations in range of motion. Interview on 4/11/11 at 1:40 PM with the DON (Director of Nursing) confirmed that a care plan should have been developed to address the resident's functional limitations in range of motion. | 2014-04-01 | ||
| 12651 | 12651 | HIGHLAND PARK CARE CENTER | 285063 | P O BOX 950, 1633 SWEETWATER | ALLIANCE | NE | 69301 | 2011-04-11 | 280 | D | 8W6H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09C1c Based on record reviews and staff interviews; the facility failed to update the care plan for 1) care interventions following a fall with injury for 1 sampled resident (Resident 25); and 2) routine hypnotic use for 1 sampled resident (Resident 7). The facility census was 45 and the Stage 2 survey sample was 27 residents. Findings are: A. Review of the "Face Sheet" revealed that Resident 25 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the "Interdisciplinary Progress Notes", dated 4/4/11, revealed that at, 7:00 AM, the resident was found sitting on the bathroom floor. Further review revealed that the resident complained of increased pain around the left ankle and the top of the foot. Swelling was noted at the ankles. The physician was notified and an x ray was ordered. Review of the x ray report of the left ankle, dated 4/4/11, revealed an irregularity at the tip of the medial malleolus which may relate to acute or chronic injury, smoothly marginated periosteal reaction of the lateral malleolus, and diffuse soft tissue swelling. Review of the "Telephone Orders", dated 4/5/11, revealed orders for no weight bearing at the left ankle for 1 week or so, keep the left ankle wrapped and in stabilizer, and elevate when not at meals. Review of the "Care Plan", goal date 4/21/11, revealed a problems including the following: - Potential for alteration in comfort, chronic pain related to [MEDICAL CONDITION] joint changes in hips and spine. Approaches included 4/4/11 - increased pain at the left ankle and foot with swelling, placed on no weight bearing status,and keep left leg wrapped; - Requires assist with activities of daily living related to weakness and short of breath. Approaches included - assist resident with transfers and ambulation with a gait belt and 1 assist. Further review revealed no approaches to include the use of a sit/stand mechanical lift for transfers, the… | 2014-04-01 | ||
| 12652 | 12652 | HIGHLAND PARK CARE CENTER | 285063 | P O BOX 950, 1633 SWEETWATER | ALLIANCE | NE | 69301 | 2011-04-11 | 309 | D | 8W6H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on observations, record reviews, and staff interview; the facility failed to 1) assess and provide care for 1 sampled resident (Resident 25) to manage left ankle pain; and 2) assess heart rate prior to administration of "[MEDICATION NAME]" for 1 sampled resident (Resident 67). The facility census was 45 and the Stage 2 survey sample size was 27 residents. Findings are: A. Review of the "Face Sheet" revealed that Resident 25 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 1/13/11, revealed that the resident was moderately impaired with cognitive skills for daily decision making, did not resist cares, required extensive assistance with 1 person physical assist with transfers and locomotion on the unit, did not ambulate in the room or hallways, was on scheduled pain medications, and experienced severe pain in the past 5 days. Review of the "Interdisciplinary Progress Notes", dated 4/4/11, revealed that, at 7:00 AM, the resident was found sitting on the bathroom floor. Further review revealed that the resident complained of increased pain around the left ankle and the top of the foot. Swelling was noted at the ankles. The physician was notified and an x ray was ordered. Review of the x ray report of the left ankle, dated 4/4/11, revealed an irregularity at the tip of the medical malleolus which may relate to acute or chronic injury, smoothly marginated periosteal reaction of the lateral malleolus, and diffuse soft tissue swelling. Review of the "Telephone Orders", dated 4/5/11, revealed orders for no weight bearing at the left ankle for 1 week or so, elevate left foot when not at meals, ice to left ankle as needed, keep the ankle wrapped at in stabilizer, and physical therapy to evaluate and treat. Review of the "Care Plan", goal date 4/21/11, revealed a prob… | 2014-04-01 | ||
| 12653 | 12653 | HIGHLAND PARK CARE CENTER | 285063 | P O BOX 950, 1633 SWEETWATER | ALLIANCE | NE | 69301 | 2011-04-11 | 314 | G | 8W6H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D2a 175 NAC 12-006.09D2b Based on observations, record review, and staff interviews; the facility failed to provide interventions to prevent the development of pressure sores for a resident identified at risk for the development of pressure sores, failed to provide care including treatments as ordered by the physician, and failed to provide pressure relief to promote healing of a pressure sore for 1 sampled resident (Resident 67). The facility census was 45 and the Stage 2 survey sample size was 27 residents. Findings are: Review of the "Face Sheet" revealed that Resident 67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the "Admission Nursing Evaluation", dated 1/13/11, revealed that the resident had no pressure ulcers, was lethargic, was confused at times, did not resist cares, and required assistance with 2 people for bed mobility, transfers, toileting, personal hygiene, and bathing. Review of the "Braden Scale - For Predicting Pressure Sore Risk", dated 1/13/11 revealed a score of "18" and on 1/20/11 a score of "14". According to the form, a score of "15-18" was mild risk and a score of "13-14" was moderate risk. Review of the "Interdisciplinary Progress Notes", dated 1/16/11, revealed that 2 areas were noted on the right buttock that were reddened area with superficial skin impairment. The right was circular with a diameter of 4 cm. (centimeters) and no bleeding. Left area measured 4.75 cm. x 4 cm. with loose skin covering the area which was reddened and irregular and with evidence of deep red areas underneath the loose impaired skin. "[MEDICATION NAME]" was applied. Review of the treatment record for January 2011 revealed an order, dated 1/16/11, to monitor pressure ulcer on left and right buttocks and apply "[MEDICATION NAME]" until resolved. Review of the "Pressure Ulcer Record", dated 1/17/11, revealed that the bath aide reported fluid filled blisters on the res… | 2014-04-01 | ||
| 12654 | 12654 | HIGHLAND PARK CARE CENTER | 285063 | P O BOX 950, 1633 SWEETWATER | ALLIANCE | NE | 69301 | 2011-04-11 | 318 | D | 8W6H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D4 Based on observations, record review, and staff interviews; the facility failed to provide an exercise program to maintain functional range of motion or to prevent a decline for 1 sampled resident (Resident 5). Sample size was 27. The facility census was 45 residents and the Stage 2 survey sample was 27 residents. Findings are: Review of the "Face Sheet" revealed that Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 3/17/11, revealed that the resident had functional limitations in range of motion, on 1 side effecting the upper extremities and the lower extremities. Review of the "Care Plan", goal date 6/23/11, revealed a problem of potential for injury related to history of falls, right [MEDICAL CONDITION], and [MEDICAL CONDITION]. Further review revealed no care plan to address the resident's limitations in range of motion of the upper and lower extremities. Observation on 4/6/11 at 3:05 PM revealed the resident seated in the wheelchair in the room with the right foot supported on a footrest and the right arm supported on a pillow. Further observation revealed the resident transported self in the wheelchair around the room. Observation on 4/7/11 at 1:00 PM revealed the resident propelled self in the wheelchair in the hallway with the fight foot supported on the footrest. Interview on 4/4/11 at 3:50 PM with LPN (Licensed Practical Nurse) - E, Unit Coordinator, revealed that the resident had contractures at the right shoulder and the right foot secondary to a stroke. Further interview revealed that the resident was not on a restorative exercise program and did not utlilize splints to manage the contractures. Interview on 4/11/11 at 1:40 PM with the DON (Director of Nursing) confirmed that there were no restorative nursing notes in the record regarding t… | 2014-04-01 | ||
| 12655 | 12655 | HIGHLAND PARK CARE CENTER | 285063 | P O BOX 950, 1633 SWEETWATER | ALLIANCE | NE | 69301 | 2011-04-11 | 323 | D | 8W6H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7 Based on observation, record review, and staff interviews; the facility failed to provide care interventions to prevent a fall with injury for 1 sampled resident (Resident 25). The facility census was 45 and the Stage 2 survey sample was 27. Findings are: Review of the "Face Sheet" revealed that Resident 25 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 1/13/11, revealed that the resident was moderately impaired with cognitive skills for daily decision making, did not resist cares, required extensive assistance with 1 person physical assist with transfers and locomotion on the unit, and did not ambulate in the room or hallways. Review of the "Care Plan", goal date 4/21/11, revealed a problem - potential for injury due to falls related to shortness of breath, impaired balance, current medications, and [DIAGNOSES REDACTED]. Review of the "Interdisciplinary Progress Notes", dated 4/4/11, revealed that, at 7:00 AM, the resident was found sitting on the bathroom floor. Further review revealed that the resident complained of increased pain around the left ankle and the top of the foot, swelling was noted at the ankles, the physician was notified, and an x ray was ordered. Interview on 4/11/11 at 2:00 PM with the DON (Director of Nursing) and the Administrator revealed that the fall investigation determined that the staff left the resident unattended in the bathroom when the fall occurred. Further interview confirmed that the staff were to implement the care plan approaches to reduce the risk for falls and injury. | 2014-04-01 | ||
| 12656 | 12656 | HIGHLAND PARK CARE CENTER | 285063 | P O BOX 950, 1633 SWEETWATER | ALLIANCE | NE | 69301 | 2011-04-11 | 333 | D | 8W6H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.10D Based on observations, record reviews, and interviews, the facility failed to administer medications before meals as specified by the manufacturer for 2 sampled residents (Residents 34 and 52). Sample size was 27. Facility census was 45. Findings are: A. Observation of Resident 34 receiving medications delivered by LPN (Licensed Practical Nurse)-B on 4/7/11 at 7:44 a.m. revealed Resident 34 receiving [MEDICATION NAME] 20 mg (milligrams) during the breakfast meal. Further observation of Resident 34 at the time of the medication being delivered, revealed Resident 34 had consumed over half of the breakfast meal before taking the [MEDICATION NAME]. Review of Resident 34's "MAR (Medication Administration Record)" for April of 2011 revealed Resident 34's order "[MEDICATION NAME] ([MEDICATION NAME]) 20mg" was ordered originally on 12/24/09 for "[MEDICAL CONDITION] Reflux". Scheduled time of administration on the MAR indicated [REDACTED] Review of Resident 34's "Physician Orders" form, signed on 3/21/11 by the medical practitioner, revealed the order for "[MEDICATION NAME] 20 mg" twice daily had been recertified with an original order date of 12/24/09. The order form revealed a [DIAGNOSES REDACTED]. B. Observation of medication administration to Resident 52 on 4/7/11 at at 7:38 a.m. revealed LPN-A was administering medications to Resident 52 during the breakfast meal. The label instructions on the medication container included instructions to administer "30 minutes" before meals. Observation of the task revealed Resident 52 received [MEDICATION NAME] 20 mg. Further observation of the resident revealed Resident 52 had consumed one half of the breakfast meal at the time the [MEDICATION NAME] was administered. Review of Resident 52's "MAR for April of 2011 revealed Resident 34's order "[MEDICATION NAME] 20mg" was ordered originally on 4/28/10. Scheduled time of administration on the MAR indicated [REDACTED]… | 2014-04-01 | ||
| 12657 | 12657 | HIGHLAND PARK CARE CENTER | 285063 | P O BOX 950, 1633 SWEETWATER | ALLIANCE | NE | 69301 | 2011-04-11 | 371 | F | 8W6H11 | Licensure Reference Number 175 NAC 12-006.11E Based on observations in the kitchen and staff interviews, the facility failed to follow handwashing procedures when preparing and serving food. This practice had the potential to affect all residents in the facility. The facility census was 45. Findings are: Observation in the kitchen on 4/7/11 at 7:45 AM revealed Cook - M dropped several cornflakes on the floor. Cook M picked up the cornflakes from the floor with bare hands and deposited the cornflakes in the trash container. Cook M returned to the food preparation table to handle parts of the food processor. Cook - M did not wash hands after picking up the cornflakes from the floor and before continuing food preparation task. Further observation revealed Cook - M washed hands after already performing food preparation tasks and then turned the faucet off with clean hands. Observation in the kitchen on 4/7/11 at 8:00 AM revealed Cook - N washed hands at the sink and turned off the faucet with clean hands. Interview on 4/7/11 at 8:10 AM with the Dietary Manager confirmed that the staff were to follow the handwashing procedures which included handwashing after picking up items off of the floor and before continuing food preparation. Further interview confirmed that the staff were to turn the faucet off with a paper towel to reduce the risk of cross contamination of bacteria to food items. Review of the facility policy and procedure "Hand Washing" revealed the following: "Clean hands and exposed portions of arms (or surrogate prosthetic devices) immediately before engaging in food preparation including working with exposed food. . . . When to Wash Hands: . . . During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. . . . How to Wash Hands: . . .Dry hands with paper towel. Turn the faucet off with the towel. . . .". Reference: Review of the 7/1/2007 version of the "Food Code", based on the United States Food and Drug Administration Food Code … | 2014-04-01 | ||
| 12658 | 12658 | HIGHLAND PARK CARE CENTER | 285063 | P O BOX 950, 1633 SWEETWATER | ALLIANCE | NE | 69301 | 2011-04-11 | 425 | D | 8W6H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.12A Based on record review and staff interview; the facility failed to provide routinely scheduled eye medication for 1 sampled resident (Resident 25). The facility census was 45 and the Stage 2 survey sample was 27. Findings are: Review of Resident 25's "Treatment" sheet, dated March 2011, revealed an order for [REDACTED]. Interview on 4/4/11 at 3:37 PM with the DON (Director of Nursing) confirmed that the medications were to be available in the facility for the nurses to administer to the residents as ordered by the physician. | 2014-04-01 | ||
| 12659 | 12659 | HIGHLAND PARK CARE CENTER | 285063 | P O BOX 950, 1633 SWEETWATER | ALLIANCE | NE | 69301 | 2011-04-11 | 514 | E | 8W6H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to complete documentation on records in the medical records for 4 sampled residents (Residents 67, 25, 63, and 28) including routine medications administered, response to medications administered as needed, and ensure clinical assessment forms were documented accurately. The facility census was 45 and the Stage 2 sample was 27 residents. Findings are: LICENSURE REFERENCE NUMBER: 175 NAC 12-006.16B A. Review of Resident 67's "Medication Administration Record", dated March 2011, revealed: - No documentation that the routine dose of "[MEDICATION NAME]" and "[MEDICATION NAME]" was administered as ordered on [DATE] at bedtime. - No documentation that "[MEDICATION NAME]" was administered as ordered on [DATE] at 5:30 PM. - No documentation that the air mattress pressure was checked on the day shift on 3/1/11 and 3/2/11 of on the night shift on 3/3/11, 3/16/11, and 3/17/11. Review of the "Pain Flow Sheet" revealed no documentation of the intensity level of pain after pain medication was administered for right foot pain on 3/22/11 and 3/28/11. B. Review of Resident 25's "Medication Administration Record", dated April 2011, revealed no documentation of the resident's response to medication administered for pain on 4/5/11 and on 4/9/11. Review of the "Pain Flow Sheet" revealed no documentation on the intensity level of pain after intervention on 4/6/11 when "[MEDICATION NAME]" was administered for left ankle pain rated at "8" on the pain scale of "0-10". Review of the "Medication Administration Record", dated March 2011, revealed no documentation that the "Oxygen" saturation was checked as indicated on the night shift on 3/16/11, 3/17/11, and 3/27/11. C. Review of Resident 63's "Pain Flow Sheet" revealed no documentation of the resident's response to pain medication administered on 4/1/11 and 4/6/11 and no documentation of the resident's response to medication given for gas pains on 4/2/11, 4/4/… | 2014-04-01 | ||
| 12660 | 12660 | THE AMBASSADOR LINCOLN | 285066 | 4405 NORMAL BLVD | LINCOLN | NE | 68506 | 2010-12-09 | 279 | D | BMMD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C1b Based on record reviews and staff interviews, the facility failed to develop a care plan to address hand contractures for Resident 180. The facility census was 80. Findings are: Review of the "Record of Admission" revealed that Resident 180 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 11/24/10, revealed that the resident had functional limitations in range of motion at upper extremities (shoulder, elbow, wrist, hand). Review of the Plan of Care, goal date 2/22/11, revealed that the resident was at risk for skin impairment due to limited/decreased mobility and contractured hands. Further review revealed no care plan to address interventions to prevent further decrease range of motion. Interview on 12/9/10 at 2:30 PM with the DON (Director of Nursing) and the ADON (Assistant Director of Nursing) confirmed that the resident had contractures involving both hands and a care plan was not developed to address interventions to prevent further decrease in range of motion. | 2014-04-01 | ||
| 12661 | 12661 | THE AMBASSADOR LINCOLN | 285066 | 4405 NORMAL BLVD | LINCOLN | NE | 68506 | 2010-12-09 | 282 | D | BMMD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on to observations, record reviews, and staff interviews; the facility failed to: 1) ensure that qualified nursing staff implemented care plan interventions for oral care and oral suctioning for Resident 20 and 2) failed to ensure safety interventions were followed to prevent falls for Resident 50. The facility census was 80. Findings are: A. Review of the "Record of Admission" revealed that Resident 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 10/1/10 revealed that the resident was dependent with 1 or 2 plus persons physical assist with activities of daily living. Review of the "Plan of Care", goal date 12/10, revealed that the staff were to provide oral suctioning with routine morning cares, with bed baths, and with brushing teeth. Observation on 12/9/10 at 7:50 AM revealed NA (Nursing Assistant) A suctioned the resident's mouth secretions with [MEDICATION NAME] suctioning. Interview on 12/9/10 at 7:50 AM with NA- A revealed that this was the only resident on the unit who he/she suctioned. Interview on 12/9/10 at 2:30 PM with the DON (Director of Nursing) confirmed that nursing assistants provided routine oral care for the resident which included oral suctioning as care planned. Further interview confirmed that the facility policy and procedure stated that oral suctioning was to be done by the respiratory therapist or licensed nurses and that nursing assistants could remove oral secretions with oral swabs or cloths. Review of the facility policy and procedure "Suctioning - Oropharyngeal", dated 1/1/09, revealed the following: "Policy Statement - To remove secretions from the oropharynx that interfere with normal respiration, and that the patient cannot remove with a spontaneous cough.". "Procedure - 1. Wash hands. 2. Apply gloves. 3. Turn on suction… | 2014-04-01 | ||
| 12662 | 12662 | THE AMBASSADOR LINCOLN | 285066 | 4405 NORMAL BLVD | LINCOLN | NE | 68506 | 2010-12-09 | 318 | D | BMMD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D4 Based on record reviews and staff interviews, the facility failed to provide care to manage hand contractures for Resident 180. Facility census is 80. Findings are: Review of the "Record of Admission" revealed that Resident 180 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 11/24/10, revealed that the resident had functional limitations in range of motion at upper extremities (shoulder, elbow, wrist, hand). Further review revealed that the resident did not receive any physical therapy or restorative nursing programs. Interview on 12/8/10 at 10:15 AM with the ADON (Assistant Director of Nursing) revealed that the resident had contractures at both hands and the resident was not on a physical therapy program or a nursing restorative program. Interview on 12/9/10 at 2:30 PM with the DON, (Director of Nursing) and the ADON confirmed that no interventions were in place, such as passive range of motion exercises or splints, to prevent further decline in ROM to the resident's hands. | 2014-04-01 | ||
| 12663 | 12663 | THE AMBASSADOR LINCOLN | 285066 | 4405 NORMAL BLVD | LINCOLN | NE | 68506 | 2010-12-09 | 371 | E | BMMD11 | Licensure Reference Number 175 NAC 12-006.11D Based on observations and staff interviews, the facility failed to ensure that staff 1) passed drinks to the residents in the dining room without touching the rim of the glasses, 2) changed disposable gloves after contact with residents in the dining room, and 3) passed food on clean trays in the dining room. The facility census was 80. Findings are: A. Observation on 12/6/10 at 12:00 PM in the main dining room revealed DA (Dietary Assistant) E and NA (Nursing Assistant) F passing glasses of juice and water to residents wearing gloves and by touching the rims of the glasses at tables 10, 11, and 4. Further observation revealed NA- F wearing gloves, passing meal tray to a resident at table 11 removed the dishes of food from the tray, moved the resident's wheelchair closer to the table by touching the wheelchair handles, touched the resident's shoulder, and touched the resident's wheelchair armrests. NA - F returned the tray to the serving window, picked up another tray of food for another resident at table 2, and served that resident, wearing the same gloves. Further observation during the meal service revealed other staff members wearing disposable gloves without changing the gloves between resident contacts. Observation on 12/8/10 at 12:10 PM in the main dining room revealed NA - G passing drinks to the residents by touching the rims of the glasses at tables 19 and 13. Further observation revealed NA- H, wearing gloves, pushed a resident's wheelchair up to table 11, touched the resident's wheelchair armrests, picked up the resident's silverware, and cut the resident's meat and buttered the bread for the resident. NA- H patted the resident's arm and then, without removing the disposable gloves, continued to serve a meal tray to another resident. Interview on 12/9/10 at 2:30 PM with the ADON (Assistant Director of Nursing) and also the Infection Control Nurse, and the DON (Director of Nursing) confirmed that the staff were to pass drinks to the residents without touchi… | 2014-04-01 | ||
| 12664 | 12664 | THE AMBASSADOR LINCOLN | 285066 | 4405 NORMAL BLVD | LINCOLN | NE | 68506 | 2010-12-09 | 441 | D | BMMD11 | Licensure Reference Number 175 NAC 12-006.17B Based on observations and staff interview, the facility failed to ensure that an open container of water was stored off of the floor to reduce the risk of cross contamination for Resident 20. The facility census was 80. Findings are: Observations on 12/7/10 at 11:00 AM and on 12/9/10 at 7:45 AM revealed an open plastic gallon container of drinking water on the floor in Resident 20's room. Interview on 12/9/10 at 7:45 AM with CRT (Certified Respiratory Therapist) D confirmed that the container of water should not be on the floor and placed the open container and an unopened gallon of water in the resident's closet. Further interview revealed that the water was used for oral cares for the resident. Interview on 12/9/10 at 3:00 PM with the ADON (Assistant Director of Nursing) and Infection Control Nurse confirmed that the containers of water should not be stored on the floor to reduce the risk of cross contamination. | 2014-04-01 | ||
| 12665 | 12665 | THE AMBASSADOR LINCOLN | 285066 | 4405 NORMAL BLVD | LINCOLN | NE | 68506 | 2010-12-09 | 164 | D | BMMD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05 (21) Based on record reviews, observations and staff interview; the facility failed to provide privacy during catheter care for Resident 169 and during tracheotomy care for Resident 20. The facility census was 80. Findings are: A. Review of the "Record of Admission" revealed that Resident 169 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 10/24/10, revealed that the resident required extensive assistance with 2 plus persons physical assist with toilet use including management of the indwelling catheter. Observation on 12/9/10 at 7:30 AM revealed the resident in bed as NA (Nursing Assistant) A and NA- B provided catheter care. Further observation revealed that NA B removed the top linens from the resident, exposing the resident from the waist down and NA-B and NA- A provided catheter care without any attempt to cover or drape the resident during the procedure. B. Review of the "Record of Admission" revealed that Resident 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS, dated [DATE], revealed that the resident was dependent with one to two plus persons physical assist with activities of daily living. Observation on 12/9/10 at 7:45 AM revealed CRT (Certified Respiratory Therapist) D suctioned the resident's tracheotomy tube. Further observation revealed that the resident's door to the main hallway remained open during the procedure and other residents and staff were in the hallway and could observe the care. Interview on 12/9/10 at 10:40 AM with the DON (Director of Nursing) confirmed that the staff were to provide privacy during cares for the residents. | 2014-04-01 | ||
| 12666 | 12666 | THE AMBASSADOR LINCOLN | 285066 | 4405 NORMAL BLVD | LINCOLN | NE | 68506 | 2010-12-09 | 356 | C | BMMD11 | Based on observations and staff interview, the facility failed to include the resident census on the daily nursing staff posting. The facility census was 80. Findings are: Observation on 12/6/10 at 8:30 AM, during the initial tour of the facility, revealed the daily staff posting form at the front nurses' station. Further observation revealed that the section for the total resident census was blank. Observations on 12/7/10 at 1:30 PM, on 12/8/10 at 8:30 AM, and on 12/9/10 at 9:00 revealed no resident census posted on the form. Interview on 12/9/10 at 10:40 AM with the DON (Director of Nursing) confirmed that the resident census was not posted as required. | 2014-04-01 | ||
| 12667 | 12667 | MATNEY'S COLONIAL MANOR | 285082 | 3200 G STREET | SOUTH SIOUX CITY | NE | 68776 | 2011-01-27 | 280 | D | HE0G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, record review and staff interviews; the facility failed to revise the care plan problems and interventions to promote skin healing for Resident 1. The survey consisted of 6 sampled residents from a facility census of 52. Findings are: Resident 1 was admitted to the facility on [DATE] according to Resident 1's medical record face sheet. Medical [DIAGNOSES REDACTED]. Record review of Resident 1's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning), Medicare readmission/return assessment dated and signed as completed on 11-10-2010, revealed that the resident was assessed with [REDACTED]. -Resident 1 received a score of 4 out of a total score of 15 on the BIMS (Brief Interview for Mental Status), - Resident 1 received a score of 2 in Section C1300, for the areas of Inattention and Disorganized Thinking, indicating the " Behavior present, fluctuates (comes and goes, changes in severity), however, this was not a change from resident's baseline, - Resident 1 used a wheelchair for mobility, - Resident 1 was documented as "Frequently incontinent" of urine and "Occasionally incontinent" of bowel (Section H), - Resident 1 was recorded in Section K for height of 60 inches and weight of 186 pounds, - Resident 1 was considered a risk of developing pressure ulcers under Section M0150, - Resident 1 had "2" Stage 2 ulcers (Section M0300). Review of Resident 1's Wound/Skin Records revealed that Resident 1 had [MEDICAL CONDITION] cm Site B wound, marked as "Healed" on 10-27-10 pictured to be on the left posterior leg/lower buttock, on the inner and upper aspect near the perineal region. Subsequent weekly documentation for Site B included: - 11-5-10; 1 x 1cm. No exudates. Intervention requested (see orders below) - 11-10-10; 4 x 1.5cm. No exudate. - 11-17-10; 4 x 1.5cm. Sanguinous exudate (bloody drainage). - 11-24-10; 3.2 x 1.2cm. With serosang dra… | 2014-04-01 | ||
| 12668 | 12668 | MATNEY'S COLONIAL MANOR | 285082 | 3200 G STREET | SOUTH SIOUX CITY | NE | 68776 | 2011-01-27 | 279 | D | HE0G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC-12-006.04Ca5 Based on observation, interview and chart review, the facility staff failed to develop a comprehensive care plan for skin care for Resident 5. The facility census was 52. The sample size was 6. Resident 5 was admitted to the facility on [DATE]. Record review of Resident 5's MDS (Minimum Data Set - A federally mandated comprehensive assessment tool used for care planning) dated 10/26/2010, revealed Resident 5 has the following diagnoses; Diabetes Mellitus type 2, Heart Failure, Hypertension, Gastroeso phageal Reflux Disease, [MEDICAL CONDITION], Anxiety Disorder and Depression , Obesity, Arterial Disease and frequently incontinent. Resident 5 had a foley catheter. It also stated Resident 5 had shortness of breath with exertion and at rest, had frequent pain, and had a fracture from a fall within the past 2 months and had limited mobility. Skin assessment records dated from November 2010 thru January 2011 indicated Resident 5 had two open areas on admission and continued to have two open areas. Observation of Resident 5 revealed two stage 2 (skin anomalies are measured in stages with 2 being beyond the surface but not into the muscle) wounds on the buttocks. The facility used a tool called Norton Plus Pressure Ulcer Scale to determine if a resident was at high risk for skin breakdown, based on mental function, mobility, physical activity, incontinence, lab values and [DIAGNOSES REDACTED]. Resident 5 was assessed on 10/26/2010 and had a score of 10. On the Norton Scale , 10 or less was high risk. The assessment was repeated on 1/11/2011 and Resident 5 scored 11 which was a moderate risk for breakdown. The care-plan initiated for Resident 5 addressed the following problems; accepting placement at the facility, mood (sadness),social interaction, Assistance with daily living activity, therapeutic diet, anticoagulant therapy, indwelling catheter, pain, hypertensive crisis, allergies [REDACTED]. In an … | 2014-04-01 | ||
| 12669 | 12669 | ALEGENT HEALTH IMMANUEL FONTENELLE HOME | 285085 | 6809 N 68TH PLAZA | OMAHA | NE | 68152 | 2010-03-03 | 332 | D | 9OFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 12-006.10D Based on observation, record review and interview: the facility staff failed to ensure a medication error rate of 5 percent or less. A total of 45 opportunities were observed with 3 medication errors which gave an error rate of 6.66 percent. The survey consisted of 24 sampled and 6 non-sampled residents. The facility staff identified a census of 152. Findings are: Record review of a Resident Face Sheet dated 10/15/2009 revealed that Resident 4 was admitted to the facility on [DATE]. Record review of Resident 4's Physician order [REDACTED]. that the resident's physician had ordered medication including [MEDICATION NAME] ( antiemetic) 10 mg (milligrams) before meals and at bed time by a tube. Resident 4 had a gastrostomy tube in place. (a tube placed into the stomach usually through the abdomen). Record review of an physician's orders [REDACTED]. Observation on 2/25/2010 at 12:30 PM of a medication administration revealed that Certified Medication Assistant (CMA) G administered the [MEDICATION NAME] and [MEDICATION NAME] to Resident 4. When asked if Resident 4 had eaten lunch, CMA G stated "yes". When asked if the medication identified above was to be given before meals, CMA G stated ''yes". CMA G confirmed that the medications had been given after the meal and not before as ordered. Record review of a Face Sheet dated 3/01/2010 revealed that Resident 25 was admitted to the facility on [DATE]. Record review of a transfer sheet dated 6/16/09 revealed that Resident 25's Physician had ordered Asprin 81 mg a day. Observation on 3/01/2010 at 7:10 AM revealed Licensed Practical Nurse (LPN) H prepared Resident 25 medications. Observation at this time revealed the Asprin was [MEDICATION NAME] coated. LPN G placed the Asprin in a small package with several other medications and crushed those medication. LPN H placed the crushed medications into apple sauce and administered them to Resident 25. An interview on 3/02/… | 2014-04-01 | ||
| 12670 | 12670 | ALEGENT HEALTH IMMANUEL FONTENELLE HOME | 285085 | 6809 N 68TH PLAZA | OMAHA | NE | 68152 | 2010-03-03 | 280 | D | 9OFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 12-006.09C1c Based on record review and interview; the facility staff failed to revise Comprehensive Care Plans to include specific interventions to address [MEDICAL CONDITION] for 1 (Resident 18) of 24 sampled residents. The facility census was 152. Findings are: Record review of Resident 7's Admission Face Sheet showed an admission date of 2/5/10. Record review of an Admission History and Physical dated 1/29/10 revealed [DIAGNOSES REDACTED]. Record review of Resident 7's Skilled Admission Note by the Nursing Home Network dated 2/8/10 revealed that a Short Geriatric Depression Scale assessment for Resident 7 had been completed on that date. The score for Resident 7 was 3 out of 5 possible points with "yes" answers given to the questions " Do you often feel helpless" and "Do you feel pretty worthless the way you are now". Documentation was present on the form that Resident 7 indicated that those feelings were related to the recent illness. Record review of an E.A.C. H. ( A facility process initiated each time a resident makes a suicidal statement or gesture) document dated 2/10/10 revealed that Resident 7 had made the comment " I don't know if life is worth living". Record review of the E.A.C.H Process for the incident dated 2/10/10 revealed that, after this comment was made by Resident 7, the facility followed their process as required. Record review of an E.A.C.H. document dated 2/11/10 revealed that Resident 7 made another suicidal statement to facility staff. Record review of the E.A.C.H Process for the incident dated 2/11/10 revealed that, after this comment was made by Resident 7, the facility followed their process as required. Record review of Resident 7's Comprehensive Care Plan (CCP) dated 2/18/10 revealed that the E.A.C.H. process was done on 2/10/10 and 2/11/10 and that Resident 7 was sent to the emergency room after the 2/11/10 incident. The CCP did not contain any specific interventions related to the … | 2014-04-01 | ||
| 12671 | 12671 | ALEGENT HEALTH IMMANUEL FONTENELLE HOME | 285085 | 6809 N 68TH PLAZA | OMAHA | NE | 68152 | 2010-03-03 | 441 | E | 9OFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F441 LICENSURE REFERENCE NUMBER-12-006.17B-Prevention of Cross-Contamination LICENSURE REFERENCE NUMBER-12-006.17D -Hand washing Based on observation, record review and interview the nursing staff failed to follow infection control practices during the provision of treatment and services related to hand washing and gloving during personal hygiene cares for incontinent residents, administering fluids per Gastrostomy tube, handling and transporting soiled linens and disinfecting the glucose meter. The total samples of 24 residents within the nursing facility census of 152 were reviewed. Findings are: A. Review of the Alegent Health Skills Demonstration, revised 01/06/10, requires Hand Washing, Item 3. Lathers all surfaces of fingers, hands and wrists, producing friction for at least 20 seconds; And Item 4. Can state that the minimum length of time to wash hands is 20 seconds. B. Review of GLOVE INFORMATION HEALTH CARE WORKERS, Occupational safety and Health Administration updated Blood borne pathogens Standard, effective April 2001: in part states: *it is crucial for Health Care Worker ' s (HCW ' s) to wash hands following glove removal when hands are visibly soiled. Hands should also be washed when the integrity of the gloves has been compromised (torn, etc.) during use. In the absence of visible (or any perceived) contamination of hands, hand hygiene with alcohol hand rubs is appropriate, following glove removal. Gloves should also be changed any time the healthcare worker switches from contaminated to clean tasks. C. On 3/2/2010, from 8:15 to 9:10 A.M., observation of both NA (Nurse Aide) F and E during the provision of personal hygiene cares for Resident 1 revealed both NA (Nurse Aide) F and E contaminated their hand gloves with stool while attempting to remove the resident ' s brief. NA-F commented, " I ' m contaminated " and held both hands up off the resident. While NA-E continued to hold the resident over by the buttock covered with sto… | 2014-04-01 | ||
| 12672 | 12672 | ALEGENT HEALTH IMMANUEL FONTENELLE HOME | 285085 | 6809 N 68TH PLAZA | OMAHA | NE | 68152 | 2010-03-03 | 281 | D | 9OFY11 | LICENSURE REFERENCE NAC 175 12-006.10B1 Based on interview and observation and record review, the Facility staff failed to document medications after administration for 2 residents (Resident 7 and Resident 29).These observations were made during the survey that occurred from February 25, 2010 to March 3, 2010. The facility census was 152 and the sample size was 24 plus 6 non-sampled residents. Findings are: A. Observation was on March 2, 2010 at 08:!0 AM of LPN K preparing insulin for Resident 29. When finished drawing insulin into the syringe, LPN K was observed initialing the MAR. (Medication Administration Record). Review of the facility ' s Skills Demonstration Document of Medication Administration, item #13 states, " Meds charted immediately after given " . In an interview with LPN K done at the time of the initialing, LPN K admitted to initialing the medication prior to giving, stating that it was known that was not a correct procedure and this is not the way LPN K normally charts medications. B. On 03/01/2010 at 4:05 P.M. observation of the LPN (License Practical Nurse) Nurse-A revealed the nurse charted the medications for Resident 7 at the time the medications were prepared instead of documenting the medications as given following the administration of the medications. During the discussion of the administration and documentation of medications with LPN Nurse-A, the nurse confirmed that medications are to be charted after the administration of the medications. C. Review of the ALEGENT HEALTH I Skills Demonstration, MEDICATION ADMINISTRATION, last revised 04/08, has documented under item 13. Meds charted immediately after given. | 2014-04-01 | ||
| 12673 | 12673 | ALEGENT HEALTH IMMANUEL FONTENELLE HOME | 285085 | 6809 N 68TH PLAZA | OMAHA | NE | 68152 | 2010-03-03 | 322 | D | 9OFY11 | LICENSURE REFERENCE NUMBER 12-006.09D6(1) Based on observation, interview and the policy for Skills Demonstration the faculty failed to ensure cleansing of the equipment for administration of fluids through a Gastrostomy tube for 1 (Resident 7) resident. The total samples of 24 residents within the nursing facility census of 152 were reviewed. Findings are: On 03/01/2010, 4:05 P.M., observation during the administration of Resident 7 ' s water flush per Gastrostomy tube, revealed the LPN (License Practical Nurse) Nurse-A prepared the graduate with 200cc (Centimeters) water; placed the graduate and the syringe on the resident ' s bed linens. Upon completion of the water flush through the Gastrostomy tube, LPN-A separated the syringe, placed the barrel and plunger into the graduate and returned the equipment, without rinsing, to Resident 7 ' s bedside table. On 03/01/2010, following the Gastrostomy tube water flush for Resident 7, an interview with LPN-A revealed " it didn ' t occur to me to rinse it " . Review of the ALEGENT HEALTH Senior Health Services Skills Demonstration, MEDICATION ADMINISTRATION VIA GASTROINTESTINAL TUBE, last revised 12/08, has documented under item 21. Rinses graduate and syringe (separate barrel and plunger) and sets in clean area to dry. | 2014-04-01 | ||
| 12674 | 12674 | GOLDEN LIVINGCENTER - OMAHA | 285097 | 5505 GROVER STREET | OMAHA | NE | 68106 | 2010-05-18 | 371 | F | E8GK11 | LICENSURE REFERENCE NUMBER 12-006.11E Based on observation, record review and interview; the facility staff failed to prepare food under sanitary conditions as evidenced by hand washing practices during 2 food preparation observations. This had the potential to affect all residents that ate food prepared from the facility kitchen. The facility census at the time of survey was 106. Findings are: Record review of a facility dietary Policy and Procedure for Hand washing dated 2002 revealed a policy that hands were to be washed upon entering the dietary department, during food preparation, after touching bare human body parts such as the face, after handling any soiled or contaminated equipment, cleaning cloths, utensils, soiled aprons, after obtaining food supplies for preparation, after signing invoices for food delivery, after handling raw foods and before handling cooked or ready to eat foods. Observation on 5/13/10 between 7:02 AM and 7:50 AM during breakfast preparation revealed Cook I went to the griddle and proceeded to break eggs onto the griddle to make fried eggs. Cook I then rinsed hands in a bucket with sanitizer solution, touched pants and pulled them up and put bare hands on hips. Cook I turned the fried eggs over with a spatula and then turned and signed a grocery invoice. Cook I then repeated the process of making fried eggs and turned them over with a spatula. Cook I put the soiled spatula into the small sink. Cook I removed a pan of fried bacon from the oven, picked the soiled spatula out of the small sink and used it to remove the bacon from the pan. Cook I then washed the counters with a sanitizer solution cloth. Cook I did not at any time wash hands during the food preparation observation. Observation on 5/13/10 between 9:30 AM and 10:35 AM during lunch preparation revealed Cook I prepared Pureed Ham. Cook I took the meat soiled puree machine to the dirty dish area and rinsed the equipment with water. Cook I did not immerse the equipment in sanitizer solution or wash hands before returning to th… | 2014-04-01 | ||
| 12675 | 12675 | GOLDEN LIVINGCENTER - OMAHA | 285097 | 5505 GROVER STREET | OMAHA | NE | 68106 | 2010-05-18 | 441 | D | E8GK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 12.006.17D Based on observations, interviews and policy review; the facility failed to follow facility policy for providing hand washing hygiene during personal cares and medication pass for Residents 3, 23, and 24. The facility census was 106 and the sample size was 22 plus 2 un-sampled resident. Findings are: A. Review of the facility policy titled Hand Washing Procedure 430 dated 2006 included the following information: ? General Instructions: Wash hands before and after resident contact and wash hands when soiled. ? Procedure item 7. Rub hands briskly using sufficient lather and friction for fifteen seconds, pay special attention to area between fingers. On May 13 at 09:47 AM, Licensed Practical Nurse A (LPN A) entered the room of Resident 3 to give assistance with personal cares. Upon entering the room, LPN A washed hands for 3 seconds using no soap and no friction. Gloves were donned after drying hands with a paper towel. LPN A then helped reposition Resident 3. In an interview conducted later that same day, LPN A stated the hand-washing time should have been 15 seconds. B. On May 13, LPN A was observed during the 9AM medication pass, preparing medications for Resident 23. While at the medication cart, no hand -sanitizing was done prior to preparing [MEDICATION NAME] in a syringe, for a subcutaneous injection. The RN Nurse Consultant kept the [MEDICATION NAME] back for a short time while the orders were verified. Meanwhile, LPN A went to Resident 23 ' s room to give the other medications. Upon entering the room, hands were washed for 3 seconds before donning gloves. No soap or friction was used. LPN A then administered eye drops for Resident 23. C. On May 13, 2010 at 11:45 AM, LPN B was observed preparing insulin for Resident 24. No hand-washing or hand -sanitizing was done prior to preparing the syringes with insulin. The Resident was found in Physical Therapy and LPN B went to that department to administer the shot… | 2014-04-01 | ||
| 12676 | 12676 | GOLDEN LIVINGCENTER - PLATTSMOUTH | 285104 | 602 SOUTH 18TH STREET | PLATTSMOUTH | NE | 68048 | 2011-01-26 | 469 | F | 1FRU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A (4) Based on observation, interview, and record review the facility failed to maintain the environment pest free for the facility's 95 residents. Findings are: Interview with the Director of Environmental Services on 1/26/11 at 8:05 AM revealed that the facility's has a contracted monthly pest control service unless there is a pest problem and then the pest control company will come out the next day to treat the problem. The Director stated that occasionally the building has fruit flies. Interview with Resident 8 on 1/26/11 at 11:35 AM stated that the resident was tired of "bugs" being in the resident's food and drinks in the main dining room. Observation conducted in the main dining room on 1/26/11 at 11:37 AM revealed that fruit flies alive and dead were in the East windowsills, on the dining room floor, and on the dining room tables. Interview with the Interim Executive Director on 1/26/11 at 11:40 AM revealed that the fruit flies were a reoccurrence that the facility was trying to treat. Interview with Resident 9 on 1/26/11 at 11:50 AM revealed that the resident had to kill bugs off the table. The resident demonstrated by hitting the dining room table. Observation conducted of the kitchen on 1/26/11 at 11:55 AM with the Interim Executive Director and Corporate Nurse revealed that fruit flies were located throughout the kitchen in the windowsills; on the dishwasher; food prep table; kitchen floor; and in the 2 compartment sink. Two fruit flies were beneath the saran wrap and were on the apple crisp dessert that was dished up and ready to serve. Review of the pest control records revealed that the pest control company had been in the facility on 1/17/11, but there was no documentation that any treatment was done for fruit fly treatment. The pest company had treated for [REDACTED]. | 2014-04-01 | ||
| 12677 | 12677 | GOLDEN LIVINGCENTER - GRAND ISLAND LAKEVIEW | 285106 | 1405 WEST HWY 34 | GRAND ISLAND | NE | 68801 | 2010-12-13 | 309 | D | JOJD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09D Based on record review and staff interview, the facility failed to assess impaired skin integrity for 1 (Resident 100) of 4 sampled residents. The facility had a census of 77 residents and a sample size of 4. Findings are: Resident 100 was admitted to the facility on [DATE] according to the Admission Record on the medical record. The following [DIAGNOSES REDACTED]. Review of the Hospital Anatomical Drawing dated 11/23/2010 for Resident 100 showed bruises under both arms in the arm pit area, the inner thighs, the right knee, and the inner right ankle. Review of the history and physical examination [REDACTED]. Review of the facility medical record for Resident 100 found no documentation of any assessment of the bruises. Review of the facility form entitled Verification of Investigation dated 11/23/2010 at 10:00 AM indicated RN-B (Registered Nurse) stated "the inner thighs had a large areas of skin that were discolored brown in color". RN-B stated "the aides wanted the nurses to look at the resident's bottom because the rectum was too large". Review of the Facility Progress Notes found no documentation the rectum was assessed. Interview with LPN-R on 12/8/2010 at 2:30 PM confirmed the bruises were not assessed and documented. Interview with the DON (Director of Nurses) on 12/3/2010 at 10:30 AM confirmed the chart contained no documentation that the bruises were assessed and documented. Review of the facility form entitled Clinical Guideline: Skin Integrity, with revised date of 2/25/2010, indicated the following: -All residents will be assessed/observed for risk of skin breakdown within 24 hours of admission-quarterly and as necessitated by change in condition. -Assessment/Observation was to be completed within the first twenty-four hours of admission/quarterly/significant change of condition. -Residents will be observed by the CNA (Certified Nurse Aide) daily for reddened/open areas, [MEDICAL CONDITION] of… | 2014-04-01 | ||
| 12678 | 12678 | GOLDEN LIVINGCENTER - GRAND ISLAND LAKEVIEW | 285106 | 1405 WEST HWY 34 | GRAND ISLAND | NE | 68801 | 2010-12-13 | 226 | G | JOJD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure 2 allegations of abuse toward 2 residents (Residents 11 and 21) by a nurse were reported immediately to the facility administrator in accordance with the facility's abuse policy. The failure to report the first abusive incident enabled the second abusive incident to occur. The facility census was 77 and the survey sample size was 4. Findings are: A. Review of the facility's 7/1/10 policy titled "Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property" revealed: - "Policy: It is the policy of the Company to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws with involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident property, are reported immediately to the Executive Director (hereinafter "ED") of the facility". - "Reporting: Any employee who suspects an alleged violation shall immediately notify the ED or his/her designee". B. Review of an ADMISSION RECORD dated 11/20/10 revealed Resident 11 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of a VERIFICATION OF INVESTIGATION dated 11/29/10 revealed: - "DATE/TIME OF OCCURRENCE 11/21/2010 2-10 shift"; - DESCRIPTION OF EVENT/ALLEGATION was "Reported by nursing staff that (Registered Nurse (RN)-J) had been rough handling resident (Resident 11) when placing in (gender) wheelchair. Also reported that (RN-J) had been using profanity when working with resident"; - "DATE REPORTED 11/21/2010". "TIME REPORTED 2200" (10:00 PM) to the Administrator. During an interview on 12/8/10 at 2:50 PM, Nurses Aide (NA)-K revealed Registered Nurse (RN)-J, on 11/21/10 at about 4:00 PM, had picked u… | 2014-04-01 | ||
| 12679 | 12679 | GOLDEN LIVINGCENTER - GRAND ISLAND LAKEVIEW | 285106 | 1405 WEST HWY 34 | GRAND ISLAND | NE | 68801 | 2010-12-13 | 223 | G | JOJD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.05(9) Based on record review and interviews; the facility failed to protect 3 residents (Residents 100, 21 and 11) from staff to resident coercion and physical abuse. Staff members forced the residents to receive care at a time and manner against resident wishes. The facility census was 77 residents at the time of the complaint investigation with 4 residents selected for sampled review. Findings are: A. Review of the facility's staff training materials on abuse and neglect revealed the following definition of physical abuse and staff responsibility: PREVENTING RESIDENT ABUSE - Your responsibility: to protect all residents from any form of abuse. Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Interview with the ED (Executive Director) on 12/8/10 at 10:00 AM confirmed that all staff were trained with the PREVENTING RESIDENT ABUSE training materials when hired by the facility. Record review confirmed that RN-J (Registered Nurse) signed acknowledgment of receiving the PREVENTING RESIDENT ABUSE training on 6/1/10. B. According to the undated RECORD OF ADMISSION, Resident 21 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident 21 resided on the secured memory support unit of the facility. Review of the CARE PLAN revealed that the facility identified Resident 21 as being forgetful and having limited functional abilities. The following were the planned interventions starting on 9/1/10: Help me maintain my dignity. Help me with reminders and cues as needed. Please allow me to do what I am capable of doing, at my own pace in my own way even if it doesn't make sense to you. Please help me make safe choices. Please remember that I am an adult and treat me accordingly. Please speak to me in my reality. Review of an 11/29/10 INVESTIGATIVE FINDINGS of an allegation of staff to resident abuse tha… | 2014-04-01 | ||
| 12680 | 12680 | GOLDEN LIVINGCENTER - SCHUYLER | 285110 | 2023 COLFAX STREET | SCHUYLER | NE | 68661 | 2010-07-12 | 242 | E | L8LX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.05 (4) Based on observation and interview, the facility failed to honor food preferences for eight residents (Residents 1, 11, 14, 15, 16, 17, 18 and 19) and failed to honor preferred seating arrangements in the dining room for five residents (Residents 14, 15, 16, 17 and 18). Sample size was 13 plus 8 non sampled residents. The facility census was 49. Findings are: A. Review of Resident 11's undated record of admission revealed that Resident 11 was admitted to the facility on [DATE]. Observation of the noon meal on 7/6/10 revealed that Resident 11 was served a plate with spinach. Resident 11 was overheard saying," I don't like spinach. I have told them that. I can't even stand to smell it." Interview with Resident 11 on 7/12/10 at 11:30 AM revealed, "I have told them (facility staff) repeatedly since I got here that I can't stand the smell of spinach but they keep serving it to me." Interview with the RD on 7/12/10 at 11:45 AM revealed that all food preferences are to be entered into the computer system and will then appear on the dietary cards as indicated. When requesting a list of preferences for Resident 11 the RD revealed that spinach was not listed on the system as a dislike for Resident 11 but that the RD would enter it now. When asked if the RD was previously aware that Resident 11 did not like spinach the RD replied, "yes". B) Review of the Resident Council minutes of June 1st, 2010 revealed a note which had been added to the minutes which read: " Had a short meeting with most of the residents on June 28th, 2010 after golden stretchers, about all the tables with assisted eating residents were moved by the windows and the residents by the windows moved by the kitchen. The reason was : to let the air conditioning on high until serving meal, then on low during the meal, but turned back up when the assisted eating residents are done eating and taken out of the dining room." This addition to the… | 2014-04-01 | ||
| 12681 | 12681 | GOLDEN LIVINGCENTER - SCHUYLER | 285110 | 2023 COLFAX STREET | SCHUYLER | NE | 68661 | 2010-07-12 | 311 | D | L8LX11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 D1b Based on observation, interview and record review the facility failed to consistently implement an individualized toileting plan for 2 residents, Residents 5 and 6. The facility census was 49 with 13 sampled and 8 non-sampled residents. A) Review of Resident 5's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 5/17/10 indicated that Resident 5 required assistance of 2 persons to transfer to the toilet. During the initial tour of the facility on 7/6/10 at 10 AM the Assistant Director of Nursing (ADON) stated that Resident 5 was incontinent and transferred via a Sara Lift (a mechanical devise used to lift residents to a standing position) with 2 persons assisting. Observation of cares on Resident 5 on 7/7/10 at 11:15 AM revealed the resident being transferred from a recliner to the bed via the Sara Lift. After being transferred to the bed by Nursing Assistants A and B Resident 5's incontinent briefs were changed and Resident 5 was again transferred via the Sara Lift from the bed to the wheel chair and escorted to the dining room. Resident 5 was not offered the opportunity to be placed on the toilet or a bedside commode. Review of Resident 5's Comprehensive Care Plan revealed a problem of, "Needs assistance with ADLs (Activities of Daily Living) ....Requires 2 assist with transfers, dressing and toileting." An entry dated 12/07/09 "Harder time transferring and at times needs sit to stand lift." One of the (undated) interventions for this problem states, "Functional incontinence program and requires to be toileted upon request...upon getting up in the morning 6-8:30 AM and after breakfast 9:30 to 10:30 AM, prior to supper 3-5PM at HS (bedtime)..." Review of Resident 5's record did not reveal documentation that an individualized toileting assessment had been completed. On 7/08/10 at 9:45 AM Nursing Assistant B was interviewed. When asked what the toileting program was for Resident 5 Nursing Assistant B stated reside… | 2014-04-01 | ||
| 12682 | 12682 | GOLDEN LIVINGCENTER - SCHUYLER | 285110 | 2023 COLFAX STREET | SCHUYLER | NE | 68661 | 2010-07-12 | 253 | E | L8LX11 | Licensure Reference Number 175 NAC 12-007.18B3 Based on observations and interviews, the facility failed to maintain wheelchairs to assure safe, cleanable surfaces for 3 residents (Resident 5, 12, 21). Sample size was 13 plus 8 non-sampled residents. The facility census was 49. Findings are: A. Observation of Resident 5's wheelchair on 7/7/2010 at 8:30 am revealed the covering on the left armrest was cracked and non-cleanable. Observation of Resident 12 ' s wheelchair on 7/7/2010 at 8:30 am revealed both the right and the left wheelchair armrest were cracked, creating a non-cleanable surface. Observation of Resident 21 ' s wheelchair on 7/7/2010 at 8:30 am revealed the plastic frame of the left armrest was broken creating potential for injury. Interview with the maintenance supervisor at final meeting on 7/12/2010 at 3:00 pm reported that he was in charge of maintaining the wheelchairs and he only knew about them needed repair when the staff reported it to him. He stated that staff had notified him of Resident 5's wheelchair needing repair on 7/12/2010. | 2014-04-01 | ||
| 12683 | 12683 | GOLDEN LIVINGCENTER - FULLERTON | 285115 | P O BOX 648, 202 NORTH ESTHER | FULLERTON | NE | 68638 | 2010-09-15 | 285 | D | 8W2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to assure that an approval was obtained on a Pre-admission Screening and Resident Review (PASSR- a screening tool used to determine appropriate placement) for one resident (Resident 11). Sample size was 15. Facility census was 71. Record review revealed that Resident 11had the following Diagnosis: [REDACTED]. Resident 11was admitted to the hospital on [DATE] and a PASSR was completed on 10/01/09 that indicated a denial of admission to a Nursing Facility (NF). No additional PASSR was done to obtain approval of resident 11's admission to the NF on 10/08/09. Interview with Lisa SSD (Social Services Designee) on 9/15/10 at 3:00 P.M. revealed that a PASSR should have been completed prior to Resident 11's admission that indicated NF level of care was appropriate and that it had not been done. | 2014-04-01 | ||
| 12684 | 12684 | GOLDEN LIVINGCENTER - FULLERTON | 285115 | P O BOX 648, 202 NORTH ESTHER | FULLERTON | NE | 68638 | 2010-09-15 | 315 | D | 8W2Y11 | **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 formulate and implement an individualized toileting plan in order to maintain one resident's (Resident 5) bowel and bladder function. Sample size was 15 and the facility census was 71. Findings are: Review of Resident 5's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 1/26/10 revealed Resident 5 was occasionally incontinent of bowel and frequently incontinent of urine. Review of a later MDS for Resident 5 dated 8/15/10 revealed Resident 5 was frequently incontinent of both urine and bowel. Further review of the same MDS also revealed Resident 5 required assistance with all toileting tasks and was on a scheduled toileting plan. Review of Resident 5's Bowel and Bladder assessment dated [DATE] revealed, "Incont (incontinent of bladder) and continent of bowels. Toilet per schedule. Resident will be included in the following Restorative Program: Scheduled defecation program. Treatment Program: Scheduled toileting/ habit training." No further assessments of bowel and bladder function were observed for Resident 5. Review of Resident 5's Resident Assessment Protocol summary dated 8/6/10 revealed, "Incont of b/b (bowel and bladder). Toileting schedule per care plan." Review of Resident 5's Care Plan dated 8/6/10 revealed, "Toilet schedule ac/pc/hs (before and after meals and at bedtime) and demands on rounds at noc (night) and prn (as needed)." Review of the facility's policy and procedure titled, "Incontinence Management/Bladder Function Guideline" and dated March '07 revealed, "The purpose of a bladder management program is to: Manage urinary incontinence, restore or maintain as much normal bladder function as possible...Scheduled Toileting - schedule the residents toileting at regular intervals to increase continent episodes per habit such as upon arising, before and after… | 2014-04-01 | ||
| 12685 | 12685 | GOLDEN LIVINGCENTER - FULLERTON | 285115 | P O BOX 648, 202 NORTH ESTHER | FULLERTON | NE | 68638 | 2010-09-15 | 465 | F | 8W2Y11 | Licensure Reference Number: 175 NAC 12-006.18A Based on observation and interview, the facility failed to maintain two wooden benches to be free of splintered surfaces. This had the potential of effecting both residents and visitors who utilized the outdoor benches. The facility census was 71. Findings are: During environmental tour with the Maintenance Supervisor (MS) on 9/15/10 from 10:10 AM to 11:20 AM the following observations were made: -One wooden bench in the courtyard had peeling finish and a splintered surface to the touch. -One wooden bench in the front of the facility was noted to have a splintered surface to the touch. Throughout the survey four residents were observed utilizing both benches as seating areas at different times. Interview with the MS during the environmental tour revealed that a number of residents utilized the benches and that wooden benches were difficult to maintain. | 2014-04-01 | ||
| 12686 | 12686 | GOLDEN LIVINGCENTER - FULLERTON | 285115 | P O BOX 648, 202 NORTH ESTHER | FULLERTON | NE | 68638 | 2010-09-15 | 253 | E | 8W2Y11 | Licensure Reference Number: 175 NAC 12-006.18A (1) Based on observation and interview, the facility failed to maintain both whirlpool rooms in a sanitary and comfortable manner. This had the potential of effecting all residents who utilized the whirlpool tubs. The facility census was 71. Findings are: During observation of a whirlpool bath in the South unit on 9/14/10 at 2:30 PM a chip was noted on the back right corner of the tub. Further observation revealed a buildup of a brownish substance on the floor around the base of the tub. Interview with Nursing Assistant E during the whirlpool bath revealed that "about half" of the residents utilized the whirlpool tubs. During environmental tour with the Maintenance Supervisor (MS) on 9/15/10 from 10:10 AM to 11:20 AM the following observations were made: -The bath house on the South unit was noted to have a buildup of black and brown substance between the floor tiles, around the toilet and around the whirlpool tub. -The bath house on the North unit was noted to have a buildup of brown and black substances between the floor tiles and around the toilet. Interview with the District Manager for environmental services on 9/15/10 at 1:00 PM revealed that an industrial strength cleanser and steel brush would remove the buildup on the floor and around the tubs. | 2014-04-01 | ||
| 12687 | 12687 | GOLDEN LIVINGCENTER - BROKEN BOW | 285120 | 224 EAST SOUTH E STREET | BROKEN BOW | NE | 68822 | 2011-01-04 | 364 | E | 45IC11 | REFERENCE NUMBER: 175 NAC 12-006.11D Based on record review, meal observations, and interviews with residents and family members, the facility failed to serve food that were palatable to residents. This had the potential to affect the meal enjoyment and food intake for 7 residents (Residents 46, 59, 02, 45, 48, 26, and 05) that had expressed food palatability concerns and for 6 residents (Residents 31, 32, 34, 35, 38, and 41) that received a pureed diet on the Special Care Unit. The facility census was 61 and the survey sample size was 13. Findings are: A. Review of Resident Council meeting minutes revealed: - 12/17/10 "Pizza - too dry" and "Kitchen is out of everything ... example diet jelly, ranch dressing". 6 residents attended the meeting; Residents 46, 59, 02, 45, 48, and 26. B. Review of the GRIEVANCE TRACKING LOG revealed: - 12/17/10 from Resident Council: "Kitchen is out of everything. Example: diet jelly, ranch dressing. Do not always get what is asked for"; - 10/6/10 from Resident 46: "Food does not taste good"; C. Observation on 1/3/10 from 12:10 PM - 12:30 PM revealed individual packets of salad dressing were served with lettuce salad. Observations revealed French dressing served at the start of meal service, then was substituted for Italian dressing when the kitchen ran out of French dressing. At 12:15 PM, Dietary Aide (DA) - D poured Ranch dressing into 3 small bowls. The Ranch dressing was not served. Observations of nursing staff, serving the plated lunch to residents, revealed residents were not asked their preference of salad dressings. D. During an interview 1/3/11 at 1:45 PM, Resident 05 revealed (gender) did not eat the lettuce salad because the resident only liked Dorothy Lynch salad dressing and "they gave me Italian". Resident 05 stated that the facility had a French dressing that tasted close to Dorothy Lynch, "I would eat that", but wasn't given a choice of salad dressing. E. During an interview on 1/4/11 at 10:50 AM, Resident 45 revealed the pork chops were always tough, sometimes "you … | 2014-04-01 | ||
| 12688 | 12688 | GOLDEN LIVINGCENTER - BROKEN BOW | 285120 | 224 EAST SOUTH E STREET | BROKEN BOW | NE | 68822 | 2011-01-04 | 309 | D | 45IC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D Based on observation, record review and staff interviews; the facility staff failed to assess and evaluate pain management for 1 resident (Resident 34) of 13 sampled residents. In addition, the facility failed to implement interventions for provision of extra protein to promote healing of skin issues for 1 (Resident 05) of 13 sampled residents. The facility identified a census of 61 residents. Findings are: A. Observation of personnel cares on 1/3/2011 at 11:20 AM for Resident 34 found the resident expressed pain in the right arm by facial grimacing and resisted to move the right arm during the cares. Observation of personnel cares on 1/3/2010 at 2:15 PM for Resident 34 found the resident expressed pain in the right arm by facial grimacing and resisted to move the right arm during the cares. Record review of the ADMISSION RECORD found Resident 34 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the MDS (Minimum Data Set; a federally mandated comprehensive assessment tool used for care planning) dated 10/14/2010, indicated the following resident information: -The resident was non interviewable. -The resident experienced severe cognitive impairment. -The resident was total dependent on staff for transfers, dressing, eating, personal hygiene and bathing. Review of the Health Practitioner ' s Orders, signed on 9/28/2010 found the following orders: -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. Review of the facility form entitled Progress Notes found no documentation that Resident 34 had been assessed for pain in the right arm. Review of the MAR (Medication Administration Record), dated 1/1/2011 to 1/31/2011, found documentation that Resident 34 had received [MEDICATION NAME] 5-500 mg ? tabled at 0800… | 2014-04-01 | ||
| 12689 | 12689 | GOLDEN LIVINGCENTER - BROKEN BOW | 285120 | 224 EAST SOUTH E STREET | BROKEN BOW | NE | 68822 | 2011-01-04 | 325 | D | 45IC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D8a Based on record review, observations, and interviews with Resident 05 and staff, the facility failed to ensure 2 residents (Residents 05 and 23) received the therapeutic diet for increased protein as ordered by the physician. This failure had the potential to affect the nutritional status of the residents. The facility census was 61 and the survey sample size was 13. Findings are: A. Resident 05 was admitted to the facility 4/14/2010 according to the ADMISSION RECORD on the medical record. The following [DIAGNOSES REDACTED]. Resident 05 was also observed to have a large Stage IV pressure sore on the coccyx area. Review of Resident 05's physician's orders [REDACTED]. B. Observation of the noon meal on 1/3/2011 between 12:15 PM and 1:00 PM revealed that Resident 05 received a bowl of beef stew, salad with dressing, slice of bread, cup of ice cream, 8 oz (ounces) of lemonade and water and a cup of coffee. Resident 05 ate 100% of the stew and the cup of ice cream and drank the glass of lemonade but did not consume the salad or the slice of bread. Resident 05 was not served the hot chocolate with Pro Pass nor was the resident served any extra protein. At 1:00 PM, Resident 05 approached the dietary service window and requested a sandwich. The sandwich was served with 2 slices of bread, 3 slices of cold meat and a slice of cheese. Resident 05 consumed 100% of the sandwich. C. Observation on 1/4/2011 at 8:32 AM of the breakfast meal revealed that Resident 05 was not served any hot chocolate with the Pro Pass mixed in to aid in healing of the pressure sore. D. Interview on 1/4/2011 at 9:45 AM with Resident 05 revealed that the resident was not served hot chocolate with meals. Resident 05 stated that (gender) could get hot chocolate if (gender) asked for it but does not get served the hot chocolate on a regular basis. E. Interview on 1/4/2011 at 10:10 AM with LPN (Licensed Practical Nurse) L revealed tha… | 2014-04-01 | ||
| 12690 | 12690 | GOLDEN LIVINGCENTER - BROKEN BOW | 285120 | 224 EAST SOUTH E STREET | BROKEN BOW | NE | 68822 | 2011-01-04 | 254 | D | 45IC11 | Licensure Reference: 175 NAC 12-006.18C Based on observation, record review and interview, the facility failed to provide clean bed linens for 3 sampled residents and failed to provide bed linens in good repair for 1 of the 3 sampled residents with soiled bed linens. The facility had a census of 61 and a complaint sample of 13. A. A random observation was made on 1/3/11 at 11:50 AM of bed linens revealed the following beds made with soiled linens: Resident 40's bedspread and top sheet were lifted to check the sheets for cleanliness, there were brown smears noted on the bottom sheet. The bedding had the odor of feces. Resident 44's bedspread and top sheet were lifted to check the sheets for cleanliness, there were brown stains noted on the bottom sheet. The bedding had the odor of feces. Resident 53's bedspread and top sheet were lifted to check the sheets for cleanliness, there were brownish stains on the bottom sheet. The bottom sheet was thread bare and had torn areas of the sheet. The mattress pad could be seen thru the threads of the bottom sheet. Interview with the Director of Nursing on 1/5/11 at 3:00 PM confirmed that the facility policy was to do a complete change of bed linens for each resident on their bath day and as needed when soiled. Review of the record of the dates of the most recent bed linen change for the fore-mentioned residents revealed: Resident 40's bed was last changed on 12/31/10 Resident 44's bed was last changed on 12/29/10 Resident 53's bed was last changed on 1/2/11. | 2014-04-01 | ||
| 12691 | 12691 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2011-01-12 | 323 | D | 8GEM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, interview, and record review the facility failed to follow facility procedure to prevent a fall for 1 resident (Resident 2) from a bath chair and failed to implement a process to ensure that the integrity of bath safety straps were monitored for 4 of 4 available bath chairs in the facility's 2 bath houses. The facility census was 80. Findings are: Review of Resident 2's History and Physical dated 4/10/10 revealed that the resident had the following Diagnoses: [REDACTED]. Review of Resident 2's MDS (Minimum Data Set: a federally mandated comprehensive tool used for care planning) dated 8/27/10 revealed that the resident did not have any memory impairment and had modified independence in new situations only. The resident did not have any communication difficulties. The resident did not have any behavioral symptoms in the past 7 days. The resident required extensive assistance with transfers, dressing, and toileting. The resident required physical help with bathing. The resident's balance was unsteady while sitting, but was able to rebalance self without physical support. The resident had function limitation in range of motion in the resident's arms, legs and feet. Review of Resident 2's Care Plan dated 11/12/10 revealed that the resident was at high risk for falls related to peripheral neuropathy of all extremities. The resident fell on [DATE] while being transported from bath tub in the bathhouse. The resident fell after a syncopal episode after safety belt gave out. The safety arms were not in place at the time of the fall. The resident had a contusion to the head. The resident's goals were: to have less occurrences of falls if possible weekly and all safety devices for bath in place whenever resident bath i.e. safety belt and safety bar at all times. Interventions included: call light usable and in reach; bed in the lowest position with wheels locked; floor mat by bed; fall… | 2014-04-01 | ||
| 12692 | 12692 | MAPLE CREST CARE CENTER | 285149 | 2824 NORTH 66TH AVENUE | OMAHA | NE | 68104 | 2011-01-28 | 332 | D | 2OBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review and interview; the facility failed to ensure a medication error rate of 5% or less. Observations of 40 medications revealed 4 errors for 1 (Resident 1) of 13 sampled residents. The resulting error rate was 10 %. The facility staff identified a census of 120. Findings are: Record review of a Admission Record dated 11/11/2010 revealed Resident 1 was admitted to the facility on [DATE]. Record review of a physician's orders [REDACTED]. times a day. Observation on 1/27/2011 at 6:02 AM revealed Licensed Practical Nurse (LPN) C prepared to administer Resident 1's medications. Observation during the preparation revealed Ducosate Sodium was not available and half (500 mg) of the dose of Vitamin C was available for administration. LPN C took the available medication and gave them to Resident 1. The Potassium was given with out food. LPN C asked Resident 1 if (gender) had the [MEDICATION NAME] Inhaler. Resident 1 stated yes, took 2 puffs without spacing out the puffs and had a drink of water. LPN C did not attempt to cue Resident 1 on the process for using the inhaler. An interview with LPN C was conducted on 1/27/2010 at 6:10 AM. During the interview, LPN C confirmed the Ducosate Sodium and half the dose of Vitamin C were not available to be given to Resident 1. LPN C confirmed Resident 1 did not correctly use the [MEDICATION NAME] inhaler and should have waited 2 minutes in-between puffs and that the Potassium was not given with food. According to the Nursing 2011 Drug Handbook by Lippincott Williams and Wilkins, page 1398 titled Patient Teaching, instructed the patient be told to take Potassium "...with or after meals with a full glass of water or fruit juice to lessen GI stress". | 2014-04-01 | ||
| 12693 | 12693 | MAPLE CREST CARE CENTER | 285149 | 2824 NORTH 66TH AVENUE | OMAHA | NE | 68104 | 2011-01-28 | 333 | D | 2OBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on record review and interview; the facility staff failed to ensure 1 (Resident 12) of 13 sampled residents were free of significant medication errors. The facility staff identified a census of 120. Findings are: Record review of a Medication Incident / Error report dated 11/27/2010 revealed Resident 12 had received 50 units of [MEDICATION NAME]at 1700 ( 5 PM). Record review of Resident 12's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of Interdisciplinary Progress Notes dated 1/27 (2010) revealed Resident 12 was "cool,clammy. BS ( blood sugar) 55. juice with sugar given". Record review of a Doctor's Orders and progress Notes dated 11/27/2010 revealed the Physician was informed of the medication error. The resident's Physicians gave orders for the facility staff to follow to monitor the resident every 1/2 hour until 10:00 PM that night. An interview with Registered Nurse (RN) D was conducted on 1/27/2011 at 2:27 PM. During the interview, the Medication Incident / Error report was reviewed with RN D. RN D confirmed that the error was a significant error. | 2014-04-01 | ||
| 12694 | 12694 | MAPLE CREST CARE CENTER | 285149 | 2824 NORTH 66TH AVENUE | OMAHA | NE | 68104 | 2011-01-28 | 353 | D | 2OBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C7 Based on observation, record review and interview; the facility failed to ensure sufficient staff were provided to ensure toileting needs and transfers were met for 1 (Resident 1) and failed to ensure sufficent staff were assigned to transfer 1 (Resident 6) off the floor. The survey sample was 13 Residents. The facility staff identified a census of 120. Findings are: Record review of a Admission Record sheet date 11/11/2010 revealed Resident 1 was admitted to the facility on [DATE]. Record review of Resident 1's Minimum Data Set ( A federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 11/23/2010 revealed the facility staff assessed the following about the resident: -Resident 1 required limited assistance when walking in the room. -Required extensive assistance with transfers, dressing, toilet use and personal hygiene. -Occasionally incontinent of bladder. [DIAGNOSES REDACTED]. An interview on 1/26/2011 at 11:00 AM was conducted with Resident 1. During the interview, Resident 1 stated " it takes them a long time to answer my call light. They don't have enough staff. In the night they are very slow". Observation on 1/27/2011 at 4:33 AM revealed Resident 1 had turned on the call light for assistance. Observation on 1/27/2011 at 4:50 AM revealed Nursing Assistant (NA) E entered Resident 1's room and turned the call light off. Further observation revealed that as NA E exited Resident 1's room, Resident 1 turned the call light back on. An interview with NA E was conducted at 4:51 AM on 1/27/2011. During the interview, NA E was asked what Resident 1 was needing. NA E stated that Resident 1 had wanted to get out of bed and had informed Resident 1 to wait until Resident 1's assigned NA was able to assist. NA E stated that if Resident 1 "needed the bed pan.. I would of helped". NA E reported that hall Resident 1 lived on was " not (gender)". When asked i… | 2014-04-01 | ||
| 12695 | 12695 | MAPLE CREST CARE CENTER | 285149 | 2824 NORTH 66TH AVENUE | OMAHA | NE | 68104 | 2011-01-28 | 312 | D | 2OBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D1c Based on observation and interview; the facility staff failed to answer a call light in a timely manner for 1 (Resident 1) of 13 sampled resident. The facility staff identified a census of 120. Findings are: Record review of a Admission Record sheet date 11/11/2010 revealed Resident 1 was admitted to the facility on [DATE]. Record review of Resident 1's Minimum Data Set ( A federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 11/23/2010 revealed the facility staff assessed the following about the resident: -Resident 1 required limited assistance when walking in the room. -Required extensive assistance with transfers, dressing, toilet use and personal hygiene. -Occasionally incontinent of bladder. [DIAGNOSES REDACTED]. An interview on 1/26/2011 at 11:00 AM was conducted with Resident 1. During the interview, Resident 1 stated " it takes them a long time to answer my call light. They don't have enough staff. In the night they are very slow". Observation on 1/27/2011 at 4:33 AM revealed Resident 1 had turned on the call light for assistance. Observation on 1/27/2011 at 4:50 AM revealed Nursing Assistant (NA) E entered Resident 1's room and turned the call light off. Further observation revealed that as NA E exited Resident 1's room, Resident 1 turned the call light back on. An interview with NA E was conducted at 4:51 AM on 1/27/2011. During the interview, NA E was asked what Resident 1 was needing. NA E stated that Resident 1 had wanted to get out of bed and had informed Resident 1 to wait until Resident 1's assigned NA was able to assist. NA E stated that if Resident 1 "needed the bed pan.. I would of helped". NA E reported the hall Resident 1 lived on was " not (gender)". Observation on 1/27/2011 at 4:58 AM revealed NA F entered Resident 1's room. Observation at this time revealed Resident 1 was visibly upset and stated ' I needed to use the … | 2014-04-01 | ||
| 12696 | 12696 | MAPLE CREST CARE CENTER | 285149 | 2824 NORTH 66TH AVENUE | OMAHA | NE | 68104 | 2011-01-28 | 315 | D | 2OBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure reference: 175 NAC 12-006.09D3 Based on record review and interview, the facility failed to ensure catheter was changed in accordance with physician's order [REDACTED]. The facility had a total census of 120 residents. Findings are: Resident 13 was admitted to the facility on [DATE] according to admission orders [REDACTED]. A review of Resident 13 ' s care plan included a problem dated 12/8/10 of Resident 13 ' s need for a indwelling catheter due to inability to control urination. Interventions for Resident 13 included change each month. A review of Resident 13 ' s Doctor Referral Form dated 12/17/10 revealed a catheter was placed in Resident 13s suprapubic site on that date with an order to change tube on a monthly basis. A review of Resident 13 ' s Interdisciplinary Progress Notes revealed Resident 13 ' s suprapubic catheter was replaced on 1/26/11. In an interview on 1/27/11 at 3 PM, the DON (Director of Nursing) confirmed the catheter change had gone over by a week. The DON reported being aware of the catheter was not changed and directed a nurse to complete the catheter change. | 2014-04-01 | ||
| 12697 | 12697 | MAPLE CREST CARE CENTER | 285149 | 2824 NORTH 66TH AVENUE | OMAHA | NE | 68104 | 2011-01-28 | 441 | D | 2OBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure reference 175 NAC 12-006.17A Based on observations, record review, and interview, the facility failed to follow facility infection control procedure related to isolation of 1 (Resident 4) of 13 sampled residents. The facility had a total census of 120 residents. Findings are: A. Resident 4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations at 2:23 PM on 1/26/11 revealed a box of masks located next to Resident 4 ' s room door. A review of Resident 4 ' s physician's order [REDACTED]. Observations at 8:45 AM on 1/27/11 revealed Resident 4 eating breakfast in the Peterson Hall dining room without a mask on. Resident 4 ' s room door had a sign indicated individuals entering Resident 4 ' s door are to wear a mask. Observations at 12:35 PM on 1/27/11 revealed Resident 4 eating lunch in the Peterson Hall dining room without a mask on. Resident 4 was seated at a table with two other residents. In an interview on 1/27/11 at 12:50 PM, RN A reported Resident 4 had a history of [REDACTED]. RN A reported Resident 4 is to eat meals in Resident 4 ' s room. In an interview at 2:30 PM on 1/27/11, Infection Control RN B reported Resident 4 has a history of respiratory MRSA and cultures had been ordered. RN B reported Resident 4 had been placed in isolation pending results of the cultures. RN B confirmed Resident 4 needed to wear a mask when out of Resident 4 ' s room and meals are to be served in Resident 4 ' s room. | 2014-04-01 | ||
| 12698 | 12698 | MAPLE CREST CARE CENTER | 285149 | 2824 NORTH 66TH AVENUE | OMAHA | NE | 68104 | 2011-01-28 | 514 | D | 2OBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.16 B(2) Based on record review and interview, the facility failed to document completion of skin treatments for 1 (Resident 3), failed to document oxygen saturation levels for 1 (Resident 9) and failed to document medications and treatment completed for 2 (Resident 1 and 2 )of 13 sampled residents. The facility had a total census of 120 residents. Findings are: A. Resident 3 was admitted to the facility on [DATE] according to admission information. A review of Resident 3 ' s 1/11 MAR (Medication Administration Record) revealed [DIAGNOSES REDACTED]. A review of Resident 3 ' s physician orders [REDACTED]. A review of Resident 3 ' s 1/11 treatment record revealed triple antibiotic ointment treatment is listed with times of 7 AM -3 PM shift, 3 PM-11 PM shift, and 11 PM-7 AM shift. The treatment sheet was not signed off indicating any treatment was provided on 1/21/11, 1/22/11, and 1/23/11. The treatment record was signed off indicating the treatment was given for the 7 AM-3 PM shift and the 11 PM-7 AM only on 1/24/11 and 1/25/11. In an interview on 1/27/11 at 3:11 PM, the RN Clinical Nurse Manager D confirmed there was no documentation of the treatment being completed from 1/21-1/23/11 and no documentation of treatment being done three times per day on 1/24/11 and 1/25/11. B. Resident 9 was admitted to the facility on [DATE] according to admission information. A review of Resident 9 ' s care plan revealed [DIAGNOSES REDACTED]. A review of Resident 9 ' s physician orders [REDACTED]. A review of a review of Resident 3 ' s Interdisciplinary Progress Note dated 1/13/11 revealed Resident 3 was readmitted to the facility on [DATE] at 4 PM. A review of Resident 3 ' s 1/11 treatment record revealed order for oxygen saturation levels to be checked each shift was listed with times the following times: 7 AM-3 PM, 3 PM-11PM, and 11 PM-7 AM. The oxygen saturation level was listed one time on 1/13/11. The oxygen satura… | 2014-04-01 | ||
| 12699 | 12699 | MAPLE CREST CARE CENTER | 285149 | 2824 NORTH 66TH AVENUE | OMAHA | NE | 68104 | 2011-01-28 | 502 | D | 2OBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure reference: 175 NAC 12-006.15 Based on record review and interview, the facility failed to obtain lab tests in a timely manner for 1 (Resident 11) of 13 sampled residents. The facility had a total census of 120 residents. Findings are: A. Resident 11 was admitted to the facility on [DATE]. A review of Resident 11 ' s physician orders [REDACTED]. An Interdisciplinary Progress Note for Resident 11 dated 1/7/11 at 11:30 PM reported the nurse was unable to catch urine for a urinalysis and would pass that on to the night shift. A review of Interdisciplinary Progress Notes from 1/7/11 though 1/11/11 did not reveal any other entries regarding attempts to obtain a urine sample. A review of urinalysis results for Resident 11 revealed urine sample was collected on 1/12/11 and results were noted by the facility on 1/15/11. In an interview on 1/27/11 at 2:50 PM, the Director of Nursing reported the facility tries to get labs done within 24 hours of receiving in the physician order. | 2014-04-01 | ||
| 12700 | 12700 | GOOD SAMARITAN SOCIETY - ARAPAHOE | 285175 | P O BOX 448, 601 MAIN STREET | ARAPAHOE | NE | 68922 | 2010-09-01 | 225 | E | 3PJX11 | Licensure Reference: 12-006.02(8) Based on record review and interview, the facility failed to report 4 allegations of abuse by Residents 62, 63, 72 and 76 to the State Agency. The facility census was 30. Findings are: A review of the grievances and abuse investigations provided by the facility revealed the following 'Suggestion or Concern' forms: 10/13 & 14/2009 Two employees reported that Resident 76 was either fearful of a staff member (10/13 concern) or was upset with a staff member (10/14 concern) due to the staff member telling the resident that s/he used the call light too much. One of the employee reports stated that the resident claimed the staff member was "nose to nose" when s/he told Resident 76 to 'stay off the call light.' An investigation was started on 10/15/2009. The administrator signed that the investigation was reviewed on 10/20/2009. 3/30/2010 An LPN wrote a note that Resident 72 had told a family member that bruises on the arms were caused by an evening staff member (description was included) that was rough with the resident. An investigation was started on 3/30/2010 and signed as reviewed by the Administrator on 4/7/2010. 5/17/2010 The Administrator filled out a Suggestion or Concern form that stated Resident 62 complained about the way a specific nurse treated the resident when responding to a call light. The next night the resident did not use the call light to request any assistance because of the nurse's treatment. An investigation was started, and the Administrator, Director of Nursing Services, and the Social worker all signed that the investigation was reviewed on 5/20/2010. 7/14/2010 The Administrator completed a Suggestion or Concern form that stated Resident 63 complained that a named staff member "bangs me around, I don't like it" and that the resident reported yelling at the staff member for that reason on 7/13/2010. An investigation was started that day and the Administrator signed that the investigation was reviewed on 7/14/2010. A resident interview was noted on the back side… | 2014-04-01 | ||
| 12701 | 12701 | GOOD SAMARITAN SOCIETY - ARAPAHOE | 285175 | P O BOX 448, 601 MAIN STREET | ARAPAHOE | NE | 68922 | 2010-09-01 | 329 | E | 3PJX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure monitoring for the indications for use/efficacy of the medications and gradual dose reductions or clinical rationale for not attempting dose reductions were done for 3 of 10 sampled residents. (Residents 39, 62, and 69) The facility census was 30. Findings are: A. A review if Resident 39's record revealed a face sheet (a cover sheet to a multipage document that contains demographic information, preferences, contact information, and limited medical information) dated 12/05/2008 that showed the resident was admitted to the facility on [DATE]. A sheet entitled Cumulative [DIAGNOSES REDACTED]. A review of Resident 39's MDSs (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 4/25/2010 and 7/25/2010 revealed the resident had short and long term memory difficulties and was moderately impaired in cognitive skills for daily decision making. The MDSs also revealed the resident had taken an antidepressant and an anti-anxiety medication every day for the 7 days preceding each assessment. A review of Resident 39's Care Plan dated 9/29/2010 revealed a concern that the resident was at risk for impaired skin integrity related to the [MEDICAL CONDITION], and OCD with scratching and picking to the scalp and needed assist with transfers causing stage II [MEDICAL CONDITION] to the arms, shoulders, face, hips, and scalp. An approach to the goal of not developing any pressure ulcers and healing the open areas by 10/28/2010 was a medication adjustment on 12/15/2008 to increase the [MEDICATION NAME] to 15 mg (milligrams) from 10 mg three times per day. Another concern on the Care Plan for Resident 39 was an alteration in thought process related to a [DIAGNOSES REDACTED]. An approach to the goal that Resident 39 would be oriented to name 75% of the time was an approach Medications as ordered: Monitor for side effects - [MEDICATION NAME]: dizziness, fatigue, and dry… | 2014-04-01 | ||
| 12702 | 12702 | GOOD SAMARITAN SOCIETY - ARAPAHOE | 285175 | P O BOX 448, 601 MAIN STREET | ARAPAHOE | NE | 68922 | 2010-09-01 | 253 | E | 3PJX11 | STATE LICENSURE REFERENCE NUMBER: 175 NAC 12-006.18 Based on observation, staff interview and record review; the facility failed to 1) ensure the bathroom vents in the resident bathrooms were clean for 7 of 30 residents (Rooms 44, 43, 81, 42, 74, 58, and 72) and a vent in the "A" hall had a grey debris, 2) ensure the filters in the beauty shop hair dryers were free of grey debris for the 2 hair dryers, 3) enure the molding under the heaters were unclean and not painted for 11 of 30 residents (Rooms 43, 46, 38, 84, 83, 82, 41, 81, 45, 44), 4) ensure the doors to resident rooms were not marred for 5 of 30 residents (Rooms 62, 70, 76, 50, 46), and 5) ensure the hole in the wall was fixed in the bathroom in room 43. The facility census was 30 and the survey sample size was 10. Findings are: A. Observation during the facility tour on 8/30/10 from 9:30 AM to 10:20 AM found vents in the resident bathrooms with grey debris in the following bathrooms: -Bathroom between rooms 44 and 43, -Bathroom in room 81, -Bathroom in room 42, -Bathroom in room 74, -Bathroom in room 58, -Bathroom in room 72. Interview with the Maintenance Director on 8/30/2010 at 9:35 AM confirmed the debris on the vents in the bathrooms. The Maintenance Director stated "I try to clean the vents 1 time a month but don't always get it done". B. Observation of the beauty shop on 8/30/2010 at 10:00 AM found a grey debris on the filters of the # 1 and # 2 hair dryers. Interview with Beautician A on 8/31/2010 at 1:00 PM revealed the beautician tired to check the filter monthly and clean it if needed. Interview with Beautician B on 9/1/2010 at 11:00 AM revealed the beautician did not clean the hair dryers that was not the job of the beautician there was a person that cleaned the room. C. Observation of resident rooms on 8/30/2010 between 9:30 AM and 10:20 AM found the molding under the heaters was unclean and not painted in rooms 43, 46, 38, 84, 83, 82, 41, 81 and 45. Interview with the Maintenance Director on 8/30/2010 at 10:15 AM revealed the molding needed… | 2014-04-01 | ||
| 12703 | 12703 | GOOD SAMARITAN SOCIETY - ARAPAHOE | 285175 | P O BOX 448, 601 MAIN STREET | ARAPAHOE | NE | 68922 | 2010-09-01 | 371 | E | 3PJX11 | STATE LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observations and staff interview the facility staff failed to remove jewelry while working in the kitchen. The mixer contained a white substance toward the back of the mixer that had not been cleaned. The sink contained an area toward the back of the sink that was green in color and a non cleanable surface. Mayo and relish was stored in the walk in fridge that had no open date that labeled the opening of the containers and no expirations dates on the containers. The sample size was 10. The facility census was 30. Findings are: A. Observation of the staff on 8/30/2010 at 9:10 AM found Cook-C served the breakfast then stated to prepare the noon meal with rings on the left hand with a stone. Observation of Dietary Aide D on 8/31/2010 at 4:30 PM preparing for the evening meal with a ring on the left hand with a rough surface. Interview with the Dietary Manager on 8/31/2010 at 10:45 AM confirmed the jewelry on the staff fingers and stated they were not to wear rings in the kitchen. Review of the 7/1/07 version of the "Food Code", based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: - statute 2-303.11 Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. B. Observation of the kitchen found a white debris on the underside of the mixer on 8/30/2010 at 9:10 AM and 8/31/2010 at 10:20 AM. Interview with the Dietary Manager on 8/31/2010 at 10:45 AM confirmed the white debris on the underside of the mixer. Review of the 7/1/07 version of the "Food Code", based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: -statue 4-002.11 Equipment food-contact surfaces and utensils shall be cleaned an any time during the operations when conta… | 2014-04-01 | ||
| 12704 | 12704 | GOOD SAMARITAN SOCIETY - ATKINSON | 285177 | 409 NEELY STREET | ATKINSON | NE | 68713 | 2010-07-21 | 323 | E | O8E211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E1 Based on observations, record review and staff interview; the facility failed to assure the environment was free from safety hazards as Resident 34's side rail (A side rail is a barrier extending upward at the side edges of the bed. It can be located on either one or both sides of the bed and extends either a partial distance or the entire length of the bed. The side rails can be used by the resident to assist with transfers, turning, and bed mobility.) use was not assessed as a potential risk for injury. In addition, the medication room door was left open and the area was not monitored for 10 minutes on 7/19/10 which allowed access to 10 residents of the facility who were at risk for wandering. A box of medications was sitting on a shelf in the medication room. Total sample size was 12 and facility census was 47. Findings are: A. Review of Resident 34 ' s Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/9/09 indicated [DIAGNOSES REDACTED]. The same MDS indicated the resident had short-term memory problems and moderately impaired cognitive skills for daily decision-making, required total assistance with transfers and bed mobility, and used a type of side rail daily. Review of the Bed Rail/Side Rail/Assist Bar Screening Tool dated 10/3/09 revealed side rails and/or other devices were not indicated for Resident 34. Review of a Resident/Visitor Incident Report dated 10/25/09 revealed Resident 34 had been restless while in bed and got left hand caught " between Assist bar & (and) mattress " . The form indicated Resident 34 sustained a 3 centimeter (cm) by 5 cm bruise to the left wrist with a 1 cm skin tear at the center of the bruise. The form indicated the facility initiated use of a U-shaped pillow (a pillow in the shape of a U with long sides that can be draped around the resident and used to position the resident in bed) since the resident … | 2014-04-01 | ||
| 12705 | 12705 | GOOD SAMARITAN SOCIETY - ATKINSON | 285177 | 409 NEELY STREET | ATKINSON | NE | 68713 | 2010-07-21 | 281 | E | O8E211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12.006.09D2b Based on observations, record reviews, review of policies/procedures related to skin care, and staff interviews; the facility failed to provide care in accordance with nursing standards of practice as pressure ulcers and other skin conditions were not monitored in accordance with facility policies/procedures for Residents 28, 33 and 34. Total sample size was 12 and facility census was 47. Findings are: A. Review of the Pressure Ulcer Practice Guidelines revised 3/08 indicated the following: 1. " If during the skin observation areas are identified, then ...documentation is recommended ...on the Wound Flow Sheet (GSS#487) or on the Interdisciplinary Progress Notes (GSS#239) as appropriate. " and 2. " At a minimum, weekly documentation is recommended to provide a review of the wound. Weekly documentation should include the date observed and " : - " Location with staging/depth description for non pressure wounds " - " Measurements (length, width, depth and the presence location and any extent of undermining, tunneling or sinus tract.) " - " Presence, type, color, odor, appearance and approximate amount of any exudates (drainage) " - " Presence, nature, and frequency of pain " - " Wound bed characteristics " - " Description of wound edges and surrounding skin as appropriate " B. Review of Resident 28 ' s Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/16/09 indicated [DIAGNOSES REDACTED]. Review of Wound Flow Sheets dated 5/28/10 and 6/30/10 revealed Resident 28 developed a Stage 2 (The staging system is a method of characterizing pressure ulcers, including the extent of tissue damage. A Stage 2 pressure ulcer involves partial thickness skin loss and presents clinically as an abrasion, blister, or shallow crater.) pressure ulcer on the " left center coccyx " (tailbone). Documentation on the same forms indicated the pressure ulcer was monitored … | 2014-04-01 | ||
| 12706 | 12706 | GOOD SAMARITAN SOCIETY - ATKINSON | 285177 | 409 NEELY STREET | ATKINSON | NE | 68713 | 2010-07-21 | 157 | E | O8E211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE Reference Number 175 NAC 12-006.04C3a(6) Based on observation and record review; the facility failed to notify residents' physicians and/or family of problems with skin breakdown and/or weight loss for 4 of 12 residents reviewed (Residents 28, 33, 34 and 35). Total sample size was 12 and facility census was 47. Findings are: A. Review of Resident 28's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/16/09 indicated [DIAGNOSES REDACTED]. Review of the Weight Record dated 6/21/10 through 7/20/10 indicated Resident 28 weighed 113.7 lb on 4/21/10 and 99 lb on 7/18/10. This indicated a 12.9% significant weight loss in 3 months. There was no documentation in the medical record to indicate the resident's physician and/or family had been notified of this significant weight loss. Review of a Resident/Visitor Incident Report dated 7/8/10 indicated Resident 28 had an open area on the right buttock that was described as a skin tear measuring 0.5 centimeter (cm) in diameter. There was no documentation in the medical record to indicate the resident's physician had been notified of the development of this skin problem. During observation on 7/19/10 from 1:50 PM to 2:10 PM, Registered Nurse (RN)-M provided treatment to a pressure ulcer on Resident 28's coccyx. A second pressure ulcer was observed directly above the rectum. RN-M placed an Alginate [MEDICATION NAME] dressing (a dressing used to treat pressure ulcers) over the entire area, covering both pressure ulcers. Review of the resident's medical record indicated the resident's physician was not notified of the presence of a second pressure ulcer until 7/20/10 at 9:30 AM. Review of Interdisciplinary Progress Notes dated 6/6/10 at 12:00 PM indicated a pressure ulcer was observed on Resident 28's right buttock. Review of a Wound Flow Sheet dated 6/6/10 revealed a Stage 2 pressure ulcer (A Stage 2 pressure ulcer involves partial thickness skin… | 2014-04-01 | ||
| 12707 | 12707 | GOOD SAMARITAN SOCIETY - ATKINSON | 285177 | 409 NEELY STREET | ATKINSON | NE | 68713 | 2010-07-21 | 314 | G | O8E211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2 Based on observations, record review, review of policies and procedures, family and staff interviews; the facility failed to provide treatment and services to prevent development of pressure ulcers and promote healing of existing ulcers for 2 of 12 sampled residents (Residents 14 and 28). Sample size was 12. Facility census was 47. Findings are: A. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's Minimum Data Set (MDS - a federally mandated comprehensive assessment tool used for care planning) dated 3/17/10 revealed [DIAGNOSES REDACTED]. The same MDS further identified the resident had fallen and had a fracture. The Resident Assessment Protocol dated 3/11/10 identified Resident 14 was admitted with a splint on the fractured right ulna. Review of the Comprehensive Care Plan dated 3/17/10 revealed no documentation that the fractured ulna was in a splint and no interventions for care of the splint were identified. Review of the Braden scale (a measurement that identifies risk of skin breakdown) dated 3/19/10 revealed the resident was at risk to develop pressure ulcers. Review of the 2/10 and 3/10 Treatment Records revealed no orders/instructions for nursing staff to check Resident 14's splint to the fractured ulna. Review of the Clinic Referral form dated 4/16/10 (48 days after admission to the facility) revealed the physician documented, "Fractured R (right) elbow. Open sore to R elbow when splint removed. Foul odor noted". At this visit the physician ordered the splint to be removed every other day, change dressing to right elbow and to wash and moisturize the skin. Review of the Interdisciplinary Progress Notes (IPN) dated 4/16/10 at 3:00 PM revealed the following documentation after the facility received a phone call from the Physician's Assistant (PA) at the Doctor's office: The PA asked, "If the facility staff had been removing the splint et (and) this writer stated… | 2014-04-01 | ||
| 12708 | 12708 | GOOD SAMARITAN SOCIETY - ATKINSON | 285177 | 409 NEELY STREET | ATKINSON | NE | 68713 | 2010-07-21 | 325 | E | O8E211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8, 12.006.09D8b Based on observations, record reviews, review of facility policies/procedures related to weight loss, and staff, resident and family interviews; the facility failed to develop and/or implement interventions to maintain weight and prevent weight loss for 4 of 12 residents (Residents 14, 22, 28 and 34). Total sample size was 12 and facility census was 47. Findings are: A. Review of the facility Procedure for Weight and Height revised 11/09 indicated a significant weight change is defined as " five percent in 30 days, 7.5 percent in 90 days and 10 percent in 180 days " . The Procedure further indicated if a resident ' s weight varied by more than 3 pounds (lb) from the previous weight, the resident would be reweighed within 24 hours and the second weight would be documented. B. Review of Resident 28 ' s Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/16/09 indicated [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated the resident had short-term memory problems and moderately impaired cognitive skills for daily decision-making (decisions poor; cues/supervision required), required extensive assistance with eating, and weighed 125 lb. Review of a Registered Dietician (RD) progress note dated 12/3/09 indicated Resident 28 had " severe " weight loss and meal intakes were less than 25 percent (%). The RD revealed the resident was receiving 8 ounces (oz) Carnation Instant Breakfast (CIB-nourishment used to increase caloric intake) 3 times daily (TID) and acceptance varied from 0% to 75%. The RD indicated the resident was assisted to eat and meals were fortified (a method used to add caloric value to the diet). The MDS dated [DATE] indicated the resident had long-term and short-term memory problems and moderately impaired cognitive skills for daily decision-making, had a problem chewing foods, and required total assistance with eating. … | 2014-04-01 | ||
| 12709 | 12709 | GOOD SAMARITAN SOCIETY - ATKINSON | 285177 | 409 NEELY STREET | ATKINSON | NE | 68713 | 2010-07-21 | 329 | D | O8E211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 329 LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D Based on observations and record review the facility failed to assure 1 of 12 sampled residents (Resident 35) was free from unnecessary drugs, as a psychoactive medication (a drug that acts primarily upon the central nervous system to alter brain function, resulting in temporary changes in perception, mood, consciousness and behavior) [MEDICATION NAME] IM (an injection given into the muscle) was given in excess of the daily recommended dosage of 2 mg. There was no explanation or documentation to indicate why a lower dosage was not attempted. Resident 35 became lethargic, unable to ambulate and feed self. Total sample size was 12. Facility census was 47. Findings are: A. Review of the Interdisciplinary Progress Notes (IPN) dated 7/9/10 at 9:45 AM revealed Resident 35 was admitted from the hospital to the facility with [DIAGNOSES REDACTED]. IPN further noted Resident 35 walked with assistance to the dining room for the noon meal and independently ate 75% of the food and drank 240 cc of fluids. IPN documentation at 8:00 PM on 7/9/10 identified Resident 35 was yelling, and combative. After attempting interventions of toileting, offering fluids and repositioning in a chair without success, the licensed nurse called the physician for medication to calm the resident. The physician ordered [MEDICATION NAME] 10 mg IM. Resident 35 received the [MEDICATION NAME] 10 mg IM at 8:00 PM. On 7/10/10 at 9:00 AM, IPN documented, "Res. (resident) very sleepy this AM-arouses some-responds with word or two. Keeps eyes closed-took only bite/two of AM meal-sleepy". The IPN further documented the physician was called and updated regarding Resident 35's condition. The physician ordered [MEDICATION NAME] 5 mg IM every 8 hours as needed for increased behaviors. IPN documentation on 7/14/10 at 6:45 AM indicated Resident 35 became combative and belligerent. After interventions were attempted without success the physicia… | 2014-04-01 | ||
| 12710 | 12710 | COLONIAL MANOR OF RANDOLPH | 285183 | P O BOX 67, 811 SOUTH MAIN STREET | RANDOLPH | NE | 68771 | 2010-09-02 | 225 | D | DGBS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record reviews, observations and staff interview, the facility failed to report to the State Agency and/or investigate 2 situations of potential abuse/neglect. This involved Resident 2 ' s elopement (when a cognitively impaired resident leaves the facility unattended and without staff knowledge) and Resident 23 ' s ingestion of alcohol hand sanitizer. Total sample size was 10 and facility census was 35. Findings are: A. Review of Resident 2 ' s Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/7/10 revealed [DIAGNOSES REDACTED]. The 7/7/10 MDS indicated the resident had short term and long term memory problems with severely impaired cognitive skills for daily decision making. This MDS further indicated Resident 2 had behaviors of wandering (movement with no rational purpose, seemingly oblivious to needs or safety). Review of Interdisciplinary Progress Notes dated 8/8/10 at 10:30 AM indicated Resident 2 was " Found outside in chair - Very hot color pale (no) verbal response. Back of bilat (bilateral) arms pink. Assisted into W/C (wheelchair) & (and) brought back into NH (nursing home). " Documentation further indicated the resident ' s temperature was 101.7 degrees Fahrenheit and cold packs were applied to the resident ' s lower arms, head and face. There was no documentation to indicate the facility reported Resident 2 ' s elopement and there was no evidence to indicate an investigation had been conducted. During interview on 9/1/10 from 2:45 PM until 3:30 PM, the Director of Nurses (DON) indicated Resident 2 had gone outside without staff knowledge for no more than 15 to 20 minutes. The DON verified the State Agency was not notified of Resident 2 ' s elopement and an investigation was not completed. B. Review of Resident 23 ' s MDS dated [DATE] indicated [DIAGNOSES REDACTED]. The same MDS indicated the resident had short-term and l… | 2014-04-01 | ||
| 12711 | 12711 | COLONIAL MANOR OF RANDOLPH | 285183 | P O BOX 67, 811 SOUTH MAIN STREET | RANDOLPH | NE | 68771 | 2010-09-02 | 279 | E | DGBS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on record reviews and staff interview; the facility failed to develop comprehensive care plans that addressed individual needs of residents and specific interventions for 5 of 10 residents reviewed (Residents 2, 12, 23, 24 and 35). Facility census was 35. Findings are: A. Review of Resident 24 ' s Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/17/10 indicated [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE] revealed Resident 24 was at high risk for falls. Review of a Change in Condition Report-Post Falls/Trauma form dated 11/13/09 revealed Resident 24 fell while ambulating to the dining room with walker. Documentation on the same form indicated the resident would continue to receive restorative therapy, gait would be monitored, and resident would be reminded to request assistance if feeling weak. Review of the Fall Risk assessment dated [DATE] revealed Resident 24 was at high risk for falls. Review of the Resident Care Plan with a team conference date of 11/25/09 indicated falls were not addressed on the care plan and there were no interventions in place to prevent falls. Review of Change in Condition Report-Post Falls/Trauma forms dated 12/23/09 and 1/5/10 revealed Resident 24 fell in room and while ambulating in the hallway respectively. Documentation on the same forms indicated the resident would be reminded to go slowly when first getting up and when walking. Review of the Fall Risk assessment dated [DATE] revealed Resident 24 was not at high risk for falls. Review of a Change in Condition Report-Post Falls/Trauma form dated 3/10/10 at 5:15 AM revealed Resident 24 was found on the floor next to bed and a body alarm was applied to be used at all times. Documentation on the same form indicated the resident " does not remember to call for assist " . Review of a Change in Condition Report-Post Falls/Trauma form da… | 2014-04-01 | ||
| 12712 | 12712 | COLONIAL MANOR OF RANDOLPH | 285183 | P O BOX 67, 811 SOUTH MAIN STREET | RANDOLPH | NE | 68771 | 2010-09-02 | 323 | E | DGBS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record reviews, observations and staff interview; the facility failed to develop and implement interventions to provide a safe environment for Resident 2 who eloped (when a cognitively impaired resident leaves the facility unattended and without staff knowledge), Resident 24 who was at risk for falls and Resident 23 who ingested alcohol hand sanitizer. Total sample size was 10 and facility census was 35. Findings are: A. Review of Resident 2 ' s Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/7/10 revealed [DIAGNOSES REDACTED]. The 7/7/10 MDS indicated the resident had short term and long term memory problems with severely impaired cognitive skills for daily decision making. This MDS further indicated Resident 2 had behaviors of wandering (movement with no rational purpose, seemingly oblivious to needs or safety). Review of Resident 2 ' s Elopement assessment dated [DATE] revealed the resident was at risk for elopement. Review of the Resident Care Plan dated 7/15/10 revealed Resident 2 was to wear a wanderguard (a bracelet worn by the resident and sounds an alarm if the resident comes within a certain distance of the door). Review of Interdisciplinary Progress Notes dated 8/8/10 at 10:30 AM indicated Resident 2 was " Found outside in chair - Very hot color pale (no) verbal response. Back of bilat (bilateral) arms pink. Assisted into W/C (wheelchair) & (and) brought back into NH (nursing home). " Documentation further indicated the resident ' s temperature was 101.7 degrees and cold packs were applied to the resident ' s lower arms, head and face. Review of Interdisciplinary Progress Notes dated 8/8/10 at 10:48 AM revealed the resident ' s temperature was 98.7 degrees with no further ill effects documented following the resident ' s unsupervised time outdoors. Resident 2 was observed wandering in corridor of the Center Hall on 9/1/1… | 2014-04-01 | ||
| 12713 | 12713 | COLONIAL MANOR OF RANDOLPH | 285183 | P O BOX 67, 811 SOUTH MAIN STREET | RANDOLPH | NE | 68771 | 2010-09-02 | 329 | D | DGBS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure all residents were free from unnecessary drugs as Resident 12 was started on [MEDICATION NAME] (a psychoactive medication that acts primarily on the central nervous system to alter brain function, resulting in temporary changes in perception, mood, consciousness and behavior) without indication for use. In addition, a gradual dose reduction had not been attempted. Total sample size was 10 and facility census was 35. Findings are: Review of Resident 12 ' s Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/16/09 revealed [DIAGNOSES REDACTED]. MDSs dated 9/16/09, 12/8/09, 3/25/10 and 8/18/10 indicated the resident had no short term or long term memory problems and displayed behaviors of making negative statements. Review of the Behavior/Intervention Monthly flow Record dated 1/10 revealed the resident was monitored for negative comments. Documentation indicated the resident voiced negative comments on 1 day during the month of 1/10. Review of Interdisciplinary Progress Notes (IPN ' s) dated 2/6/10 for the 7:00 AM to 3:00 PM shift revealed documentation that Resident 12 made " rude comments " to other residents and visitors. Review of IPN ' s revealed no further documentation to indicate Resident 12 displayed rude behaviors or made negative comments on 2/7/10 and 2/8/10. IPN documentation dated 2/9/10 at 1:00 PM indicated Resident 12 was seen by the physician " ...for behaviors ... " Review of physician's order [REDACTED]. Review of Behavior/Intervention Monthly Flow Records for 3/10 through 8/10 revealed Resident 12 voiced negative comments a total of 6 times in 6 months. There was no documentation to indicate the facility reassessed Resident 12 ' s continued need for [MEDICATION NAME]. The DON verified during interview on 9/2/10 from 2:10 PM until 2:50 PM that Resident 12 had not been assessed for a possible dose redu… | 2014-04-01 | ||
| 12714 | 12714 | GOOD SAMARITAN SOCIETY - ST LUKE'S VILLAGE | 285192 | 2201 EAST 32ND STREET | KEARNEY | NE | 68847 | 2011-01-19 | 157 | D | EPLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.04C3a(6) Based on record review and staff interview, the facility failed 1) to notify the physician and Legal Representative of elevated temperatures and bleeding for Resident 03; 2) to notify the Physician of the refusal of pain medication for Resident 47. The sample size was 13 residents. The facility census was 51 residents. Findings are: A. Record review of the FACE SHEET and [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set; a federally mandated comprehensive assessment tool used for care planning) with an assessment reference date of 12/29/2010 revealed the following information about the resident: -The resident ' s ability to hear was adequate. -The resident was able to understand others and was able to make self understood. -The resident had no memory problems. -The resident had a feeling of being down, depressed, or hopeless. -The resident had tired feeling or having little energy. -The resident was an extensive assist of two person physical assist for bed mobility and toilet use. -The resident was an extensive assist of one person physical assist for locomotion on and off the unit, dressing, and bathing. -The resident was totally dependent of two person physical assist for transfers. -The resident had an indwelling catheter. -The resident was occasionally incontinent of bowel. -The resident fed self with some set up assistance. Record review of the INTERDISCIPLINARY PROGRESS NOTES for Resident 3 found the following information about the resident: -On 1/1/2011 at 0800 (8:00 AM) a note that the resident had minimal bloody mucous vaginal discharge. No documentation the doctor or family were not notified at that time. -On 1/3/2011 at 1400 (2:00 PM) a note that the resident had minimal amount of blood tinged mucous vaginal drainage, No documentation to verify the doctor and family were notified at that time. -1/4/2011 at 0700 (7:00 AM) recorded a temperature of 99.8 degrees Fahrenheit. N… | 2014-04-01 | ||
| 12715 | 12715 | GOOD SAMARITAN SOCIETY - ST LUKE'S VILLAGE | 285192 | 2201 EAST 32ND STREET | KEARNEY | NE | 68847 | 2011-01-19 | 284 | D | EPLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LINCENSURE REFERENCE NUMBER: 175 NAC 12-006.09C3a Based on record review and staff interviews, the facility failed to provide written documentation of the resident's medical condition that required a transfer to the hospital to ensure the resident's needs could be met by the receiving facility for Resident 3. The sample size was 13 records. The facility census was 51. Findings are: Record review of the FACE SHEET and [DIAGNOSES REDACTED]. Review of the IPN (Interdisciplinary Progress Notes), dated 1/12/2011 at 11:00 AM documented that Resident 3 was sent to the ER (emergency room ). Further review of the IPN dated 1/12/2011 at 3:00 PM revealed an entry that Resident 3 was admitted to the hospital. Record review of the IPN for Resident 3 found the following information about the resident's medical condition preceding the hospital transfer on 1/12/2011: -On 1/1/2011 at 0800 (8:00 AM), a note the resident had bloody mucous vaginal discharge. -On 1/3/2011 at 1400 (2:00 PM), a note the resident had blood tinged mucous vaginal drainage. -On 1/4/2011 at 0700 (7:00 AM), a recorded temperature of 99.8 degrees Fahrenheit. -On 1/4/2011 at 2000 (8:00 PM), a recorded temperature of 100.0 degrees Fahrenheit. -On 1/4/2011 at 2000 the resident had a liquid brown stool with scant blood noted. -On 1/5/2011 at 0200 (2:00 AM), a recorded temperature of 100.2 degrees Fahrenheit. -On 1/5/2011 at 0400 (4:00 AM), a recorded temperature of 100.0 degrees Fahrenheit. -On 1/5/2011 at 2330 (11:30 PM) a recorded temperature of 100.5 degrees Fahrenheit. -On 1/7/2011 at 1330 (1:30 PM), a recorded temperature of 99.7 degrees Fahrenheit. -On 17/2011 at 1330 documentation the resident had blood clots in the mouth. -On 1/8/2011 at 0340 (3:40 AM), a recorded temperature of 101.1 degrees Fahrenheit. -On 1/9/2011 at 0315 (3:15 AM), a recorded temperature of 100.5 degrees Fahrenheit. -On 1/12/2011 at 0140 (1:49 AM), a recorded temperature of 100.9 degrees Fahrenheit. -On 1-12-2011 … | 2014-04-01 | ||
| 12716 | 12716 | GOOD SAMARITAN SOCIETY - ST LUKE'S VILLAGE | 285192 | 2201 EAST 32ND STREET | KEARNEY | NE | 68847 | 2011-01-19 | 309 | G | EPLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09 Based on record review and staff interview, the facility failed to: 1) assess deterioration of medical status on 1/12/11; 2) assess elevated temperatures; 3) assess the cause of vaginal/rectal bleeding; 4) assess the effectiveness of pain relief medications; and 5) assess tolerance of catheter change. The facility census was 51 at the time of the survey and the survey sample size was 13. This affected Resident 3. Findings are: A. According to the medical file for Resident 3 the FACE SHEET and [DIAGNOSES REDACTED]. Record review of the IPN (Interdisciplinary Progress Notes) and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -On 1/1/2011 at 11:30 AM [MEDICATION NAME] 5/325 mg (milligrams) 1 tablet given per the MAR for back pain with no assessment of the intensity of the pain or the effectiveness of pain medication. -On 1/1/11 at 11:00 PM [MEDICATION NAME] 5/325 mg 2 tablets given per the MAR for back pain with no assessment of the effectiveness of pain medication. -On 1/3/11 at 5:20 PM [MEDICATION NAME] 5/325 mg 2 tablets given per the MAR for leg pain with no assessment of the effectiveness of pain medication. -On 1/5/11 at 11:20 AM [MEDICATION NAME] 5/325 mg 2 tablet given per the MAR for leg pain with no assessment of the effectiveness of pain medication. B. Record review of the IPN (Interdisciplinary Progress Notes) and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. -On 1/5/2011 at 2:00 AM, a recorded temperature of 100.2 degrees Fahrenheit and at 4:00 AM a recorded temperature of 100.0 degrees Fahrenheit with no follow up temperature taken until 11:30 PM at which time it was documented at 100.5 degrees Fahrenheit. -On 1/7/2011 at 1:30 PM, documentation showed the resident had blood clots in the mouth with no further assessment of the mouth documented in the medical record. -On 1/9/2011 at 3:15 AM, a recorded temperatu… | 2014-04-01 | ||
| 12717 | 12717 | GOOD SAMARITAN SOCIETY - ST LUKE'S VILLAGE | 285192 | 2201 EAST 32ND STREET | KEARNEY | NE | 68847 | 2011-03-14 | 325 | D | EPLO12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D8 Based on record reveiw, interview, and observation; the facility failed to increase a nutritional supplement as ordered by the physician for a resident (Resident 6) with known weight loss. Facility census was 44. Sample size was 11. Resident 06 was admitted to the facility on [DATE] according to the FACE SHEET on the medical record. The following [DIAGNOSES REDACTED]. In addition, review of the current signed physician's orders [REDACTED]. Review of Resident 06's physician's orders [REDACTED]. Observation on 3/10/2011 at 12:04 PM revealed that Resident 06 had been served 60 cc of [MEDICATION NAME] for lunch. Interview on 3/10/2011 at 12:04 PM with DA (Dietary Aide) D confirmed that 60 cc of [MEDICATION NAME] had been served to Resident 06 at the noon meal. Review on 3/10/2011 of the facility supplement list that had been updated on 3/10/2011 revealed that Resident 06 was still receiving 60 cc of [MEDICATION NAME] at meals. Review on 3/10/2011 of the DIET ORDER NOTIFICATION from nursing to dietary concerning Resident 06's increase of [MEDICATION NAME] from 60 cc to 120 cc TID did not reveal any documentation that the Dietary department had been notified of the increase of the [MEDICATION NAME] as ordered by physician on 2/28/2011. Review of Resident 06's comprehensive care plan dated 2/1/2011 revealed that [MEDICATION NAME] was to be administered as ordered with a date of 3/10/2011 documented; however, the amount was not specified to ensure that the correct amount was given to the resident as ordered by the physician on 2/28/2011. | 2014-04-01 | ||
| 12718 | 12718 | GOOD SAMARITAN SOCIETY - SCRIBNER | 285196 | 815 LOGAN STREET | SCRIBNER | NE | 68057 | 2011-01-06 | 323 | D | NPJV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 2 residents (Resident 1 and 3). Sample size was 3 residents. Facility census was 42. Findings are: A. Review of Resident 1's Discharge summary from the hospital dated 12/13/2010 revealed a [DIAGNOSES REDACTED]. Review of Resident 1's Falls Data Collection Tool undated and unsigned entry revealed resident score of 20 with a score of 12 or more indicating high risk was completed. Review of Daily Skilled note dated 12/13/2010 revealed an entry for the evening shift that a TABS alarm (a device to alert staff of resident rising) was placed on Resident 1's wheelchair and bed. Daily Skilled note dated 12/14/2010 at 23:00 (11:00 pm) revealed a motion alarm is in place. Review of Resident 1's Resident/Visitor Incident report dated 12/18/10 at 2050 revealed resident 1 was found on the floor and was complaining of Right hip pain. No mention of motion sensor alarm (a device to alert staff of resident rising) in place at time of fall. Review of the facility investigation dated 12/20/2010 revealed the nursing assistant was not aware the resident was to have a motion sensor alarm(a device to alert staff of resident rising) in place because it was not in view at the time Resident 1 was assisted to bed. Review of Resident 1's Comprehensive Care Plan dated 12/17/2010 revealed a problem statement of "Mobility Impairment R/T (related to): Dementia m/b (manifested by) history of falls". No mention of Alarms used as an intervention. During an interview with NA-A on 1/6/2011 at 2:30 PM, when asked how the nursing assistance are aware of the interventions on each residents care plan, NA-A revealed that the nursing assistance have hand held computer devices that they can view the care plan interventions for each resident. Interview with Care Plan coordinator on 1/6/2011 at 4:10 PM reve… | 2014-04-01 | ||
| 12719 | 12719 | COUNTRYSIDE HOME | 285207 | 703 NORTH MAIN STREET | MADISON | NE | 68748 | 2010-09-29 | 166 | F | C99211 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.06B Based on observations, record review, staff and resident interviews; the facility failed to resolve grievances related to resident complaints that foods were not always served at palatable temperatures, and call light response by staff was not always prompt. Total sample size was 15 and facility census was 63. Findings are: A. Review of a Grievance/Complaint Report dated 6/4/10 indicated a resident received a room tray at supper on 6/3/10. The plate did not have an insulating cover on it, and the food was cold. Comments and recommendations regarding this complaint were that " all room trays had lids " and " Discussed at In-Service " . Review of Resident Council meeting minutes dated 6/8/10 indicated food was " sometimes cold " and chicken strips were " not always hot " . Review of Grievance/Complaint Reports dated 6/9/10 and 6/18/10 revealed resident complaints that soup was served cold and residents were returning it to the kitchen to be re-heated. Comments and recommendations regarding these complaints included " posted note to make sure soup hot " , instructions to take temperatures of the soup, and re-education of staff. Review of the Resident Council meeting minutes dated 7/13/10 indicated there was no follow-up to the 6/8/10 complaint of cold food temperatures. Review of Grievance/Complaint Reports dated 7/20/10 and 8/4/10 revealed resident complaints of " cool " chicken, resident disappointment when served food that is not " warm enough to enjoy " , vegetables being cold " so does not eat them " , and soup sent back to the kitchen 3 times and " still too cool " . Recommendations in regard to these complaints were to post a reminder to dietary staff to take the temperature of all food items before service, and re-education of staff to make sure the plate warmer is turned on. Review of Resident Council meeting minutes dated 8/10/10 revealed resident complaints that the mashed potatoes and vegetables were served cold and the Administrator was " going to check the … | 2014-04-01 | ||
| 12720 | 12720 | COUNTRYSIDE HOME | 285207 | 703 NORTH MAIN STREET | MADISON | NE | 68748 | 2010-09-29 | 371 | F | C99211 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observations, record review and staff interviews; the facility failed to sanitize pots, pans and cooking utensils that were washed in the 3 compartment sink (a cleaning system consisting of 3 sinks side by side; 1 used for washing, 1 used for rinsing, and the third used to sanitize), and dietary staff did not test water used to clean eating and food preparation surfaces in the dining room to assure the proper concentration of disinfectant and adequate sanitization. Furthermore, the ledges on the range hood were coated with grease and sticky residue. Total sample size was 15. The facility census was 63, and 61 of these residents were served meals from the facility kitchen. Findings are: A. During observation of preparation of the noon meal on 9/27/10 from 10:25 AM to 11:25 AM the following was observed: -Dietary Aide (DA)-R was observed washing dishes in the 3 compartment sink. Observation revealed pots, pans and a variety of cooking utensils were soaking in sanitizing solution. The sanitizing solution in the sink was steaming. Soap and disinfectant dispensers were attached to the 3 compartment sink system. Interview with DA-R at this time indicated the solution used for sanitization was checked every time the sink was filled for dishwashing to assure the concentration of disinfectant was adequate for sanitization. DA-R then prepared a sanitizing solution (used to clean and sanitize eating and food preparation surfaces when soiled) in a bucket with water from the 3 compartment sink, carried the bucket into the dining room, and set the bucket on top of a utility cart for later use. The sanitizing solution in the bucket was covered with soap suds. Upon request, DA-R returned to the kitchen to obtain a chemical test strip (a thin strip of paper that turns colors when immersed in a sanitizing solution, different colors indicating a different concentration of disinfectant in the solution) to test the concentration of disinfectant in the sanitizing solution in the b… | 2014-04-01 | ||
| 12721 | 12721 | COUNTRYSIDE HOME | 285207 | 703 NORTH MAIN STREET | MADISON | NE | 68748 | 2010-09-29 | 314 | G | C99211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2 Based on observations, record review, review of pressure ulcer policies and procedures and staff interview; the facility failed to provide treatment and services to prevent development of pressure ulcers and promote healing of existing ulcers for 3 of 15 sampled residents (Residents 40, 32 and 55). Sample size was 15. Facility census was 63. Findings are: A. Review of Resident 55's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/18/10 revealed [DIAGNOSES REDACTED]. The same MDS further identified the resident had short and long term memory problems with moderately impaired cognitive skills for decision making; required extensive assistance with bed mobility and/or transfer; was on a turning/repositioning program and had a Stage 3 pressure ulcer (full thickness of skin loss, exposing subcutaneous tissues and presents as a deep crater). Review of the facility policy and procedure dated 2001 for the Prevention of Pressure Ulcers revealed the resident's position should be changed every 2 hours when in bed and every hour when in a chair. The policy further stated that when a resident was in a chair, a gel or air cushion for pressure relief was indicated. Review of the 3/3/10 Braden scale (a measurement that identified risk of skin breakdown) revealed Resident 55 was at high risk to develop pressure ulcers. Review of Resident 55's Care Plan dated 3/24/10 revealed nursing staff were to provide assistance with bed mobility and encourage resident to reposition every 2 hours. The Care Plan further stated a pressure relieving mattress was applied to the resident's bed and a pressure relieving cushion was placed in the resident ' s wheelchair. Review of the E-Z Graph Wound Assessment Worksheet (a graph system that measures the size and depth of wounds) dated 7/7/10 revealed Resident 55 had a Stage 3 pressure ulcer to the left (L) hip which measured 3.7… | 2014-04-01 | ||
| 12722 | 12722 | WEDGEWOOD CARE CENTER | 285221 | 800 STOEGER DRIVE | GRAND ISLAND | NE | 68803 | 2010-12-07 | 157 | G | 291811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.04C3a(6) Based on record review, staff interviews and family interviews, the facility failed to immediately notify physicians and legal representative when an accident with injury and significant change of condition occurred. Also the facility failed to ensure follow-up assessment for treatment and obtaining physicians orders which delayed treatment for 1 of 3 sampled residents (Resident 16). The facility had a census of 74 residents. The sample size was 3 residents. Findings are: Resident 16 was admitted to the facility on [DATE] according to the ADMISSION RECORD on the medical record. The following [DIAGNOSES REDACTED]. A. Record review of the facility form entitled Medical Daily Skilled Nursing Notes for Resident 16, dated 12/4/2010 between 6 PM to 10 PM, found documentation that stated while @ (at) supper tonight the resident pulled the supper plate off on the lap and L (left) lower forearm (between the elbow and the back of the hand). Area on underside of forearm was red with 2-3 blisters. On top of the left forearm was an L-shaped 43 cm (centimeter) X 5.0 cm pinkish red area and on L upper thigh a light pink area that measured 0.8 X 3.0 cm. The area was cleansed with a skin prep and Vaseline gauze with non-adherent dressing was applied with conform bandage to the blisters and the thigh left open to air. Record review of Resident 16's medical file found no documentation that the facility staff had notified the legal representative or the physician of the burn the resident had experienced on 12/4/2010. Review of a facility form dated 12/5/2010 with a heading to the physician found a written description that read the resident pulled the supper plate off the table onto the lap. The resident had sustained 1 small light pink burn to the upper left thigh that measured 0.8 x 3.0 cm that was left open to the air. The inner aspect of the left lower forearm had an area that measured 3.0 x 10.0 cm and ligh… | 2014-04-01 | ||
| 12723 | 12723 | WEDGEWOOD CARE CENTER | 285221 | 800 STOEGER DRIVE | GRAND ISLAND | NE | 68803 | 2010-12-07 | 226 | D | 291811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure an incident of possible neglect regarding 1 resident's (Resident 16) burned arm was reported to the facility administrator and the appropriate state agencies in accordance with the facility's abuse policy. The facility census was 74 and the survey sample size was 3. Findings are: Review of an ADMISSION RECORD revealed Resident 16 was admitted to the facility on [DATE]. Review of a [DIAGNOSES REDACTED]. Review of an ADMISSION SAFETY ASSESSMENT AND PLAN OF CARE dated 11/22/10 revealed Resident 16 was at risk [MEDICAL CONDITION] to confusion/dementia and [MEDICAL CONDITION]. Approaches to care included "supervision prior to serving hot liquids" and "keep hot liquids out of reach of resident". Review of an ADMISSION PLAN OF CARE dated 11/22/10 revealed Resident 16 was unable to feed self and required the assistance of 1 staff with ADL's (activities of daily living). Review of Resident 16's "Medical Daily Skilled Nursing Notes" documented on 12/4/10 revealed Resident 16 had an area on the underside of the left forearm which was reddened with 2-3 blisters present; on the top of the left forearm was a L-shaped 43 cm (centimeter) by 5.0 cm pinkish red area; and on the left upper thigh was a 0.8 cm by 3.0 light pinkish area. Review of a SUSPECTED ABUSE REPORTING TOOL dated 12/6/10 revealed: - Administrator was notified at 9:00 AM on 12/6/10; - Adult Protective Services (APS) was notified at 10:35 AM on 12/6/10; - Resident 16 was served hot food items for supper without staff supervision as documented from 3 staff interviews. During an interview on 12/6/10 at 7:10 PM, it was revealed the Administrator received notification of the 12/4/10 burn to Resident 16 during "stand up" report at 9:00 AM on 12/6/10. The Administrator revealed the state agency, APS, was called and notified "today" (12/6/10). Review of the facility's 6/26/05 Abuse and Neglect Policy revealed: - "I. THE LONG TE… | 2014-04-01 | ||
| 12724 | 12724 | WEDGEWOOD CARE CENTER | 285221 | 800 STOEGER DRIVE | GRAND ISLAND | NE | 68803 | 2010-12-07 | 309 | G | 291811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC12-006.09D Based on record review and staff interview, the facility failed to assess an injury sustained from hot food being spilled on bare skin and then provide follow-up care for treatment of [REDACTED]. The facility had a census of 74 residents and a sample of 3. Findings are: Resident 16 was admitted to the facility on [DATE] according to the ADMISSION RECORD on the medical record. The following [DIAGNOSES REDACTED]. Review of Resident 16's MEDICARE DAILY SKILLED NURSING NOTES dated 12/4/2010 between 6 PM to 10 PM revealed the following entry by LPN (Licensed Practical Nurse) A: "While @ (at) supper tonight resident pulled supper plate off on lap and L) (left) lower forearm. Area on underside of forearm red c (with) 2-3 blisters. On top an L-shaped 43 cm (centimeter) x (by) 5.0 cm Pinkish-red and on L (arrow pointing up) thigh, a light pink area 0.8 x 3.0 cm. Area cleansed et (and) thigh left open to air and arm, skin prep applied to blisters and Vaseline gauze c non-adherent dressing and conform bandage. Denies pain when asked and no S/S (signs or symptoms) noted". Review of the facility policy and procedure titled treatment of [REDACTED]. Treatment: a. Immerse the burned skin in cool water until the pain subsides. Apply dry sterile gauze as a protective bandage. DO NOT use an antiseptic preparation ointment, sprays or home remedy on a severe burn. DO NOT break blisters or remove tissue. b. If the arms or legs are affected, keep them elevated. c. A physician must evaluate all second and third degree burns. d. Assess the need for a Tetanus immunization. e. Instruct the employee to report any signs or symptoms of infection. Redness, swelling, drainage, or fever is signs of infection. Seek medical attention immediately." Interview on 12/6/2010 at 6:35 PM with LPN A revealed that at the end of the 2 PM to 10 PM shift, LPN A had charted that the resident had received a burn from spilled food at the evening meal. LP… | 2014-04-01 | ||
| 12725 | 12725 | WEDGEWOOD CARE CENTER | 285221 | 800 STOEGER DRIVE | GRAND ISLAND | NE | 68803 | 2010-12-07 | 323 | G | 291811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE: 175 NAC 12-006.09D7a Based on record review, observation and staff interview, the facility failed to ensure the safety of residents needing assistance with eating from receiving burns from hot spilled foods. This failure resulted in burns with resultant blisters forming on Resident 16's left lower forearm. The facility had a census of 74 residents and a sample of 3 residents was reviewed. Findings are: Resident 16 was admitted to the facility on [DATE] according to the ADMISSION RECORD on the medical record. The following [DIAGNOSES REDACTED]. Review of Resident 16's MEDICARE DAILY SKILLED NURSING NOTES dated 12/4/2010 between 6 PM to 10 PM revealed the following entry by LPN (Licensed Practical Nurse) A: "While @ (at) supper tonight resident pulled supper plate off on lap and L) (left) lower forearm. Area on underside of forearm red c (with) 2-3 blisters. On top an L-shaped 43 cm (centimeter) x (by) 5.0 cm Pinkish-red and on L (arrow pointing up) thigh, a light pink area 0.8 x 3.0 cm. Area cleansed et (and) thigh left open to air and arm, skin prep applied to blisters and Vaseline gauze c non-adherent dressing and conform bandage. Denies pain when asked and no S/S (signs or symptoms) noted". Review of the Taber's Cyclopedic Medical Dictionary (20th edition), burns are classified as: - First degree: damage is limited to the outer layer of the skin and is marked by redness, tenderness and mild pain - Second degree: burn that damages partial thickness of the epidermal and some dermal tissues. The burn is painful and red; blisters form and the wounds may heal with a scar. - Third degree: burn that extends through the full thickness of the skin and subcutaneous tissues beneath the dermis. The burn is painless because it destroys nerves in the skin. Scar formation and contractures are likely complications. Observation on 12/6/2010 at 4:46 PM revealed that Resident 16 had the following areas noted on the left inner forearm: a l… | 2014-04-01 | ||
| 12726 | 12726 | SKYVIEW AT BRIDGEPORT | 285224 | 505 O STREET | BRIDGEPORT | NE | 69336 | 2011-07-28 | 315 | D | DMKP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D3 (6) Based on record reviews, observations, and staff interview; the facility failed to ensure that a supporting [DIAGNOSES REDACTED]. The facility census was 30 and the Stage 2 sample was 9 residents. Findings are: A. Review of the "Face Sheet" revealed that Resident 41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission physician orders, dated 7/15/11, revealed "Foley" secondary to weakness and limited weight bearing. Review of the "Catheter Assessment", dated 7/15/11, revealed that the resident had an indwelling catheter, was expected to have the catheter longer that 14 days, and the [DIAGNOSES REDACTED]. Observation on 7/21/11 at 10:50 AM revealed the resident seated in the wheelchair at activities with the catheter positioned properly under the wheelchair. Interview on 7/25/11 at 2:45 PM with the DON (Director of Nursing) confirmed that there was no physician [DIAGNOSES REDACTED]. B. Review of the "Face Sheet" revealed that Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician History and Physical Exam", dated 1/21/11, revealed [DIAGNOSES REDACTED]. Observation on 7/21/11 at 10:45 AM revealed the resident seated in the wheelchair with the catheter positioned properly under the chair. Review of the "Physician Orders", signed 6/13/11, revealed an order to cleanse the suprapubic catheter site with soap and water, change the dressing every shift, and change the catheter monthly. Review of the "Catheter Assessment", dated 1/14/11, revealed that the resident had an indwelling catheter for terminal illness or severe impairments, which make positioning or clothing changes painful. Interview on 7/25/11 at 2:00 PM with the DON confirmed that there was no supporting [DIAGNOSES REDACTED]. Further interview confirmed that the resident did not have a terminal illness or severe impairment and did not have pain with clothin… | 2014-04-01 | ||
| 12727 | 12727 | SKYVIEW AT BRIDGEPORT | 285224 | 505 O STREET | BRIDGEPORT | NE | 69336 | 2011-07-28 | 280 | D | DMKP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C1c Based on record reviews and staff interview, the facility failed to update the care plan to address significant weight loss for 1 current sampled resident (Resident 7). The facility census was 30 and the Stage 2 sample was 9 residents. Findings are: Review of the "Face Sheet" revealed that Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the "Physician Orders", dated 6/9/11, revealed that the resident was on comfort cares, had considerable weight loss in the last 6 months, especially in the last 2 months, was not eating well, and was experiencing progressive worsening of mental status. Review of the "Care Plan", goal date 11/5/11, revealed a care plan which stated potential for weight loss and the goal was to maintain normal BMI (Body Mass Index). Review of the "Nutrition Risk Review", dated 7/15/11, revealed that that the resident weighed 103 pounds, diet order was liberal geriatric diet, power pack meals, 1 ounce of protein to meals, and eats 46% of meals. Overall comments included down in weight from 116 pounds, family wants comfort care only at this time. Further review of the "Care Plan" revealed no care plan to address the actual significant weight loss. Interview on 7/25/11 at 2:20 PM with the DON (Director of Nursing) confirmed that the care plan should have included the resident's actual significant weight loss and interventions to promote nutrition with comfort care. | 2014-04-01 | ||
| 12728 | 12728 | SKYVIEW AT BRIDGEPORT | 285224 | 505 O STREET | BRIDGEPORT | NE | 69336 | 2011-07-28 | 329 | D | DMKP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure monitoring was done for indications for use and/or efficacy of benzodiazepine medications and an [MEDICATION NAME] medication for Resident 39. The facility census was 30 and the stage 2 survey sample included 24 residents. Findings are: A review of Resident 39's face sheet (a cover sheet to a multipage document that contains demographic information, preferences, contact information, and limited medical information) dated 5/05/11 and located in the resident's chart, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. - [MEDICATION NAME] (generic name: [MEDICATION NAME], an antianxiety benzodiazepine medication) 0.25 mg (milligrams) at bedtime as needed for anxiety; prescribed 5/18/11. ([MEDICATION NAME] was prescribed nightly from 4/27/11 to 5/18/11) -[MEDICATION NAME] (generic name: [MEDICATION NAME], a sedative/hypnotic benzodiazepine medication) 30 mg at bedtime as needed for [MEDICAL CONDITION]; prescribed 5/19/11. ([MEDICATION NAME] was prescribed nightly 4/23/11 to 5/19/11 and then reduced to 15mg on 7/13/11) -Tylenol PM (a combination of [MEDICATION NAME] (an [MEDICATION NAME] and antipyretic) and [MEDICATION NAME][MEDICATION NAME] (an [MEDICATION NAME], often used for its sedative properties as a sleep aid)) 500mg at bedtime; prescribed 5/27/11. A review of Resident 39's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the July 2011 MAR indicated [REDACTED] A review of Resident 39's record revealed Sleep Evaluations completed on 7/4/11 and 7/18/11. The first Sleep Evaluation listed the resident ' s specific complaint as difficulty falling asleep and difficulty staying asleep. The 7/18/11 Sleep Evaluation listed the resident ' s specific complaint as difficulty staying asleep. Further review of Resident 39's record revealed a Sleep/Activity… | 2014-04-01 | ||
| 12729 | 12729 | SKYVIEW AT BRIDGEPORT | 285224 | 505 O STREET | BRIDGEPORT | NE | 69336 | 2011-07-28 | 371 | F | DMKP11 | Licensure Reference Number 175 NAC 12-006.11 E Based on observations and staff interviews, the facility failed to ensure that 2 mixers used in the kitchen were free from paint chips and peeling. The facility census was 30 and this failure had the potential to effect all residents. Findings are: Observation on 7/21/11 at 11:00 AM revealed two mixers in the kitchen with paint peeling and paint chipped from the surface of the machines. Interview with Cook - A confirmed that both mixers were routinely used for food preparation. Interview on 7/21/11 at 11:15 AM with the DM (Dietary Manager) confirmed that the mixers needed to be refinished to reduce the risk of accidental food contamination from the peeling and chipped paint. Review of the 7/1/2007 version of the "Food Code", based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: 4-601.11 Equipment, Food Contact surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. | 2014-04-01 | ||
| 12730 | 12730 | SKYVIEW AT BRIDGEPORT | 285224 | 505 O STREET | BRIDGEPORT | NE | 69336 | 2011-07-28 | 428 | D | DMKP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12-006.12B Based on interview and record review, the facility failed to ensure the consulting pharmacist identified the medication regime irregularity of the use of dual benzodiazepines in conjunction with a antihistamine at bedtime for Resident 39. Findings are: A review of Resident 39's face sheet (a cover sheet to a multipage document that contains demographic information, preferences, contact information, and limited medical information) dated 5/05/11 and located in the resident's chart, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. - Xanax (an antianxiety benzodiazepine medication) 0.25 mg (milligrams) at bedtime as needed for anxiety; prescribed 5/18/11. (Xanax was prescribed nightly from 4/27/11 to 5/18/11) -Restoril (a sedative/hypnotic benzodiazepine medication) 30 mg at bedtime as needed for insomnia; prescribed 5/19/11. (Restoril was prescribed nightly 4/23/11 to 5/19/11 and then reduced to 15mg on 7/13/11) -Tylenol PM (a combination of acetaminophen (an analgesic and antipyretic) and diphenhydramine (an antihistamine, often used for its sedative properties as a sleep aid) 500mg at bedtime; prescribed 5/27/11. A review of Resident 39's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the July 2011 MAR indicated [REDACTED] A review of the Consulting Pharmacist's Monthly Medication Regime Review sheet revealed the following: -5/5/2011 A recommendation for lab tests of a potassium level and thyroid stimulating hormone level. -6/14/11 No irregularities noted. -7/7/11 A recommendation for a gradual dose reduction for the Restoril. In an interview on 7/26/2011 at 4:45PM, the Consulting Pharmacist stated he/she was looking for medications that could be gradually reduced and/or medications that might be contra-indicated for that resident. The Consulting Pharmacist stated he/s… | 2014-04-01 | ||
| 12731 | 12731 | SKYVIEW AT BRIDGEPORT | 285224 | 505 O STREET | BRIDGEPORT | NE | 69336 | 2011-07-28 | 431 | E | DMKP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC ,[DATE].12 E4; 175 NAC ,[DATE].12E7 Based on observation, interview and record review, the facility failed to ensure (A) medications in the medication cart were labeled; and (B) that insulin was not available for resident use past the manufacturer's storage instructions. Findings are: 175 NAC ,[DATE].12E7 A) A review of the ,[DATE] hall Medication Cart with Med Aide (MA)-B, on [DATE] at 10:50AM, revealed two brown 1 milliliter syringes, with a blue ball-like cap. Neither syringe was labeled as to the contents of the syringe, or to whom the syringe was prescribed. In an interview on [DATE] at 10:53AM, MA-B stated the syringes were for Resident 21 and that they contained a topical cream for nausea. A review of the policy titled Storage of Medications, provided by the facility, revealed the following: -Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. At 11:05 on [DATE], MA-B brought out a brown bag of syringes from the fridge in the medication room and stated 'all these are labeled.' The Infection Control Nurse stated in response to seeing the labeled syringes, ' since the others weren't labeled, we have no idea how old they are and they need to be destroyed.' 175 NAC ,[DATE].12E4 B) During the review of the ,[DATE] hall Medication Cart on [DATE] with MA-B, a vial of Lantus insulin for Resident 6 was observed to have had an open date of [DATE] written on the box. There was no other Lantus observed in the med cart for Resident 6. In an interview at 10:55AM, MA-B stated "it's over a month old." According to the Lantus manufacturer website ( ) Open (In-Use) Vial:Opened vials, whether or not refrigerated, must be used within 28 days after the first use. They must be discarded if not used within 28 days. If refrigeration is not possible, the open vial can be kept unrefrigerated for up to 28 days away from direct heat and ligh… | 2014-04-01 | ||
| 12732 | 12732 | SKYVIEW AT BRIDGEPORT | 285224 | 505 O STREET | BRIDGEPORT | NE | 69336 | 2011-07-28 | 441 | D | DMKP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12-006.17 and 175 NAC 12-006.18C Based on observation, interview and record review, the facility failed to ensure A) clean laundry was handled in a manner to prevent cross contamination and B) that wound care was completed with techniques to prevent contamination for one resident. (Resident 40) The facility census was 30 and the stage 2 survey sample included 24 residents. Findings are: 175 NAC 12-006.18C A) During the stage 1 room observations on 7/20/2011 at 12:05PM, Laundry Aide-C (LA) was observed to enter room [ROOM NUMBER] with clothing on hangers over his/her left arm, held tight to his/her T-shirt. LA-C hung the clothes in the closet and exited the room. Moments later, LA-C re-entered room [ROOM NUMBER] with a stack of folded clothing held against his/her T-shirt with the left arm. In an interview while LA-C was putting the folded clothes in the drawer, LA-C stated "I do it all. I wash it, fold it and deliver it." In an interview on 7/21/2011 at 1:15PM, the Infection Control Nurse stated staff are not to hold clean clothes against their clothing. On 7/25/2011 at 9:20AM, LA-C was observed in the Laundry Room folding clean clothes, washers could be heard running. During an interview at that time, LA-C stated he/she had just started a load of towels. When asked if LA-C wore a covering when washing clothes, LA-C pointed to two gowns hanging on the wall just inside the dirty side door, and stated he/she wore one when sorting the clothes in the morning, but not when he/she was doing the laundry after that. A review of the facility provided policy titled Linen Handling revealed: -Clean Linen should be handled carefully. Hold it away from your body or uniform. If clean linen should come into contact with anything that is contaminated (the floor, another resident, etc.) place it directly into a soiled linen hamper so that it can be rewashed. 175 NAC 12-006.17 B) A review of Resident 40's record revealed the residen… | 2014-04-01 | ||
| 12733 | 12733 | SKYVIEW AT BRIDGEPORT | 285224 | 505 O STREET | BRIDGEPORT | NE | 69336 | 2011-07-28 | 514 | E | DMKP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.16B (2) Based on record reviews and staff interview, the facility failed to ensure that the nurses accurately documented routine medications administered to the residents for 3 current sampled residents (Resident 7, Resident 37, and Resident 41) and failed to ensure that the resident's response to as needed medications administered was documented for 1 current sampled resident (Resident 41). The facility census was 30 residents and the Stage 2 sample was 9 residents. Findings are: A. Review of Resident 7's MAR (Medication Administration Record), dated July 2011, revealed no documentation that the routine dose of "[MEDICATION NAME]" was administered on 7/17/11 and the routine doses of "[MEDICATION NAME]" on 7/17/11 and 7/21/11. B. Review of Resident 37's MAR, dated July 2011, revealed no documentation that the routine dose of "Calcium with Vitamin D" was administered on 7/20/11. C. Review of Resident 41's MAR, dated July 2011 revealed that the routine doses of "Calcium with Vitamin D" and "[MEDICATION NAME]" were not signed as administered on 7/20/11. Further review revealed that the site of "Insulin" administered was not documented on 7/19/11 and blood pressures were not documented 2 times a day as directed from 7/15/11 through 7/21/11. Review of the resident's MAR indicated [MEDICATION NAME]" for agitation/anxiety on 7/17/11 at 8:30 PM and on 7/21/11 at 10:25 AM with no documentation of the results or the resident's response to the medication. Interview on 7/25/11 at 3:00 PM with the DON (Director of Nursing) confirmed that the nurses were to document routine medications, vital signs, and the results of as needed medications administered to ensure accurate medical records and to reduce the risk of medication errors. | 2014-04-01 | ||
| 12734 | 12734 | SKYVIEW AT BRIDGEPORT | 285224 | 505 O STREET | BRIDGEPORT | NE | 69336 | 2011-07-28 | 283 | D | DMKP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC ,[DATE].09C3 Based on record reviews and staff interview, the facility failed to complete discharge summaries for 2 closed records reviewed (Resident 8 and Resident 20). The facility census was 30 and the Admission Sample was 6 residents. Findings are: A. Review of the "Face Sheet" revealed that Resident 8 was admitted to the facility on [DATE]. Review of the "Physician's Progress Notes" revealed that the resident was discharged from the facility to a private residence on [DATE]. Review of the closed medical record revealed no discharge summary. B. Review of the "Record of Death" revealed that Resident 20 was admitted to the facility on [DATE] and expired on [DATE]. Review of the closed medical record revealed no discharge summary. Interview on [DATE] at 8:00 AM with the DON (Director of Nursing) confirmed that the discharge summaries were not completed for these residents. | 2014-04-01 | ||
| 12735 | 12735 | BROOKEFIELD PARK | 285226 | 1405 HERITAGE DRIVE | ST PAUL | NE | 68873 | 2010-06-02 | 166 | E | CCHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.05(7) Based on observations, record review, and interviews with staff and residents; the facility failed to resolve a grievance voiced by 19 residents (Residents 07, 08, 09, 11, 13, 14, 18, 20, 21, 23, 24, 26, 27, 31, 32, 34, 35, 37, and 39) that meals were served late. This failure had the potential to affect the quality of life for residents living in the facility. The facility census was 41 and the survey sample was 11. Findings are: A. Review of an 10/2008 COMPLAINT/GRIEVANCE POLICY AND PROCEDURE revealed: - "Our facility addresses and investigates all complaints and grievances expressed to the facility. This process provides feedback and follows up on action to address any oral or written complaint/grievance from a resident or resident's representative"; - "5. The designated person will also be responsible to complete the last section (Resolution) on complaint/Grievance Report Form and see to informing the results to the complainant within 5-7 days of the initial onset of the report"; - "8. The Administrator is responsible for maintaining compliance with the Complaint/Grievance process". B. Information provided by the facility and confirmed by the Dietary Manager (DM) revealed that meal service for breakfast was scheduled to begin at 7:45 AM, lunch at 12:00 PM, and supper at 5:45 PM. C. Observations of meal services throughout the survey revealed: - 5/26/10 = lunch service began at 12:20 PM. At 12:45 PM, 9 residents (Residents 03, 10, 11, 19, 21, 24, 30, 37, and 39) had not been served when dietary ran out of the main entree, beef tips in gravy. The DM prepared an additional entree and lunch service resumed at 1:10 PM. The last resident (Resident 10) was served at 1:23 PM. - 5/26/10 at 1:12 PM, Resident 24 was served lunch 15 minutes after everyone else at the table had been served. 2 of Resident 24's tablemates finished eating and had left the dining room. - 5/26/10 at 1:14 PM, Resident 37 was … | 2014-04-01 | ||
| 12736 | 12736 | BROOKEFIELD PARK | 285226 | 1405 HERITAGE DRIVE | ST PAUL | NE | 68873 | 2010-06-02 | 371 | E | CCHB11 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.11E Based on observations, document review, and staff interview; the facility failed to maintain the temperatures of cold foods at the time of meal service for 5 residents (Residents 03, 04, 26, 27, and 32) that received extra protein with meals, as well as residents that chose the alternate entree offered. This failure increased the risk that bacterial growth and food borne illness could occur which could pose a food safety risk to the residents. The facility census was 41 and the survey sample size was 11. Findings are: Review of the facility's COMPLETE INFORMATION ON ALL RESIDENTS list revealed Residents 03, 04, 26, 27, and 32 were to receive extra protein at lunch. A. Observation on 5/26/10 from 12:15 - 1:23 PM revealed Cook-J gave a sliced, hard-boiled egg to Residents 03, 04, 26, 27, and 32 for lunch. Observation on 5/26/10 at 1:23 PM, after the last resident was served lunch, the temperature of the hard-boiled eggs, taken by Cook-J with a probe thermometer, was 43.5 degrees F (Fahrenheit). During an interview on 5/26/10 at 12:35 PM, Cook-J revealed hard-boiled eggs were given to residents that received extra protein with lunch. B. Observation on 5/27/10 from 12:13 - 1:23 PM revealed Cook-J added a tablespoonful of grated cheddar cheese to the peas served to Residents 03, 04, 26, 27, and 32 for lunch. The cheese was in a container approximately 8 " (inches) tall and was set on top of ice in another container. The ice was not around the container of cheese. Further observation revealed egg salad sandwiches available and were requested by at least 2 residents as an alternative to the main entree. The cold food items were in container set on ice next to the steam table. Observation on 5/27/10 at 1:13 PM, after the last resident was served lunch, Cook-J took temperatures of the cold food items with a probe thermometer and got the following results: egg salad sandwiches = 43 degrees F and cheddar cheese = 56 degrees F. During an interview on 5/27/10 at 1:23 PM, Cook-J s… | 2014-04-01 | ||
| 12737 | 12737 | BROOKEFIELD PARK | 285226 | 1405 HERITAGE DRIVE | ST PAUL | NE | 68873 | 2010-06-02 | 225 | D | CCHB11 | Based on record review and staff interview, the facility failed to ensure that all staff immediately notified Administration of allegations of abuse for 1 incident involving 2 staff members. The facility census was 41 at the time of the annual survey/complaint investigation and the survey sample size was 11. Findings are: A. Review of the facility policy and procedure concerning ABUSE AND NEGLECT PREVENTION STANDARD dated 4/2009 revealed the following definition of verbal abuse: " The use of oral, written or gestured language that willfully includes disparaging and derogatory terms used with or to residents, their families or within their hearing distance, regardless of their age, ability to comprehend or disability. Examples of verbal abuse include but are not limited to: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again " . B. Further review of the facility policy and procedure concerning ABUSE AND NEGLECT PREVENTION STANDARD dated 4/2009 revealed the following under REPORTING/RESPONSE: " It is the responsibility of any employee, visitor or resident to report any act of witnessed or suspected abuse to their supervisor or the Administrator immediately " . C. Review of the facility abuse investigations for the past 9 months revealed that on 9/29/2009, allegations of verbal abuse were reported to the SSD (Social Service Designee) of the facility. Documentation on the ABUSE/NEGLECT INVESTIGATION REPORT dated 9/29/2009 revealed that NA (Nursing Assistant) J had been caring for Resident 15. Resident 15 had become combative/resistant with cares and NA J had told Resident 15 that " If you ' f_____g ' hit me again, I ' ll knock you out " . According to documentation on the ABUSE/NEGLECT INVESTIGATION REPORT, the incident had been witnessed by NA A approximately 2 weeks prior to being reported. D. Interview on 6/1/2010 at 10:00 AM with the SSD revealed that NA J and NA A had been working with Resident 15 when the incident occurred.… | 2014-04-01 | ||
| 12738 | 12738 | BROOKEFIELD PARK | 285226 | 1405 HERITAGE DRIVE | ST PAUL | NE | 68873 | 2010-06-02 | 441 | D | CCHB11 | LICENSURE REFERENCE 175NAC 12-006.17D Based on observation and record review, the facility failed to ensure that nursing personnel performed hand hygiene/glove changing as required during provision of incontinent cares for 1 (Resident 16) resident. The facility census was 41 at the time of the survey and the survey sample size was 11. Findings are: A. Review of the facility policy and procedure concerning BLOODBORNE PATHOGEN PROGRAM EXPOSURE CONTROL PLAN METHODOLOGIES dated 6/30/2008 revealed the following: " precautions must be consistently used against contact with blood and body fluids when dealing with all residents ....All staff members must routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with blood or other body fluids of any residents is anticipated. Gloves must be worn for touching blood and body fluids, mucous membranes, or non-intact skin of all residents, for handling items or surfaces soiled with blood or body fluids ....Gloves must be changed after contact with each resident ....Hands must be washed immediately after gloves are removed " . B. Review of the facility policy and procedure titled PROCEDURE FOR HANDWASHING, undated, revealed that handwashing should occur " before and after each resident contact, after touching a resident or handling his or her belongings and after contact with any body fluids " . C. During observation on 5/27/2010 at 11:45 AM of incontinent cares for Resident 16 revealed the following lack of appropriate glove changing and handwashing: NA (Nursing Assistant) D and NA B entered Resident 16 ' s room to provide incontinent cares and get the resident up for lunch. NA D and NA B put on gloves. There was no handwashing performed by NA D and NA B prior to putting on the disposable gloves. NA D provided the incontinent care, using a disposable wipe. NA D washed the mons pubis and then wiped down over the labia, smearing feces on the disposable glove. NA D got more periwipes out of the package, touching the outside of the pac… | 2014-04-01 | ||
| 12739 | 12739 | BROOKEFIELD PARK | 285226 | 1405 HERITAGE DRIVE | ST PAUL | NE | 68873 | 2010-06-02 | 281 | D | CCHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09 Based on record review and staff interview, the facility failed to ensure that laboratory work was drawn as ordered by the physician for 2 (Resident 32 and 22) of 11 residents reviewed. The facility census was 41 at the time of the survey and the survey sample size was 11. Findings are: A. Resident 32 was admitted to the facility on [DATE] according to the FACE SHEET on the medical record. The following [DIAGNOSES REDACTED]. Review of Resident 32 ' s admission orders [REDACTED]. Review of Resident 32 ' s laboratory results section of the medical record revealed no evidence that the H/H and INR had been drawn every week for 4 weeks as ordered by the physician on 4/9/2010. Interview on 6/1/2010 at 11:00 AM with the DON (Director of Nursing) revealed that Resident 32 had an H/H and INR performed on 5/4/2010 and the ordered lab work had not been done every week as ordered by the physician on 4/9/2010. B. Resident 22 was admitted to the facility on [DATE] according to the FACE SHEET on the medical record. The following [DIAGNOSES REDACTED]. Review of Resident 22 ' s admission orders [REDACTED]. Review of Resident 22 ' s laboratory results section of the medical record revealed no evidence that the PT/INR had been performed as ordered on [DATE]. Interview on 6/1/2010 at 10:56 AM with the DON confirmed that the PT/INR was not performed on 4/27/2010 as ordered by the physician. | 2014-04-01 | ||
| 12740 | 12740 | HERITAGE CROSSINGS | 285230 | 501 NORTH 13TH STREET | GENEVA | NE | 68361 | 2010-08-20 | 272 | D | 9E5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 12-006.09B Based on observation, interview, and record review: the facility failed to ensure that one resident (Resident 13) had an accurate assessment of functional range of motion and one resident (Resident 56) had an accurate assessment of dental condition. Facility census was 48. Sample size was 28. Findings are: A. A review of Resident 13's MINIMUM DATA SET (MDS: a federally mandated comprehensive assessment tool used for care planning) with an assessment reference date of 7/6/2010 revealed that the resident had [DIAGNOSES REDACTED]. The resident had also been identified as having a functional limitation of range of motion with partial loss in both arms, including shoulder or elbow. No other limitations had been identified. A review of Resident 13's RECERTIFICATION OF TERMINAL ILLNESS for hospice services dated 5/18/10 revealed that it was noted that the resident had "drop foot noted to bilateral feet". A review of Resident 13's hospice NURSING ASSESSMENT UPDATE dated 7/9/10 revealed that the resident had been evaluated as having an overall loss in range of motion and contractures marked with a written note "feet inward". An interview with the MDS Coordinator on 8/19/10 at 12:05pm revealed that the Restorative Coordinator did assessments for range of motion, and indicated that the resident's Hospice nurse did come to the quarterly care plan meeting and it was expected that any issues regarding foot drop, contractures or declining range of motion would be discussed at that time. An interview with the Restorative Coordinator Licensed Practical Nurse Z on 8/18/10 at 12:25pm confirmed that (staff) had not assessed Resident 13 as having any issues with range of motion in feet. B. Interview with the Director of Nursing (DON) and Observation of range of motion to ankles and feet for Resident 13 on 08/20/10 at 2:30PM in the Resident's room revealed: -Surveyor requested director of Nursing to assess presence of function and po… | 2014-04-01 | ||
| 12741 | 12741 | HERITAGE CROSSINGS | 285230 | 501 NORTH 13TH STREET | GENEVA | NE | 68361 | 2010-08-20 | 315 | D | 9E5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D3 Based on observations, record review and staff interview; the facility failed to 1.) complete a Bladder Assessment to ensure that 1 resident (Resident 17) to maintain bladder function at the highest level from a resident sample size of 28. The facility census was 48. Findings are: Review of Resident 17' MDS (Minimum Data Set, a federally mandated assessment used for care planning)) dated 5/18/10/10 revealed the resident had short-term memory impairment with moderately impaired with daily decision making skills. The resident was able to communicate the resident's needs. The resident required extensive assist with bed mobility, transfers, dressing, and personal hygiene, and toileting. The resident was continent of bowel and frequently incontinent of bladder. The resident was on a scheduled toileting plan and wore pads/ briefs. Review of Resident 17's 5/25/10 RAP (Resident Assessment Protocol Worksheet) revealed that the resident's was frequently incontinent of urine with contributing factors of decision making ability; diuretics and mobility. The resident was currently on a toileting schedule with recent changes made. Review of Resident 17's Care Plan dated 6/10/05 revealed that the resident had functional incontinence. The resident had a decline in ability to self transfers. The resident was frequently incontinent of urine and usually continent of bowels. The resident was toileted before and after meals; or activities, HS (at bedtimes) and prn (as needed). The resident wore incontinent products for protection. The resident was to be encouraged to use the bathroom on a routine schedule. Review of Resident 17's Bladder assessment dated [DATE] revealed that the resident had normal urine; on diuretics and laxatives, was usually continent; and had not change in incontinence. Review of Resident 17's Bowel and Bladder Progress Notes revealed: -On 11/16/09, the resident was frequently incontinent of urin… | 2014-04-01 | ||
| 12742 | 12742 | HERITAGE CROSSINGS | 285230 | 501 NORTH 13TH STREET | GENEVA | NE | 68361 | 2010-08-20 | 428 | E | 9E5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 12-006.12b Based on interview and record review, the facility failed to ensure that drug irregularities identified by the pharmacist were reported to 2 resident's physician (Resident 27 and 17) and that potential side effects and monitoring concerns with medications were identified and reported for 1 resident (Resident 56) . The resident sample size was 28 and the facility census was 48. Findings are: A. A review of Resident 27's admission orders [REDACTED]. A review of the Plavix product information sheet undated, revealed the following : Drug Interactions- CYP2C19 inhibitor (e.g. omeprazole) :Avoid concomitant use Warning and Precautions-Reduced effectiveness in impaired CYP2C19 function: Avoid concomitant use with drugs that inhibit CYP2C19 (e.g. omeprazole). A review of Resident 27's monthly CONSULTANT PHARMACIST REPORT dated 7/26/10 revealed no irregularities had been noted regarding the resident's drug regimen. Further review of the consulting pharmacist's COMMENTS dated 7/26/10 revealed that the pharmacist had identified that the combined used of omeprazole and Plavix may result in decreased Plavix effectiveness. No further documentation was found in Resident 27's clinical record indicating that the resident's physician had been notified of the information regarding the combined use of Plavix and Prilosec. An interview with the Director of Nursing (DON) on 8/20/10 at 9:35am indicated that the consulting pharmacist's COMMENTS information was not sent to Resident 27's physician by the facility and was unsure if the pharmacist contacted the physician personally regarding that information. An interview with the facility Consultant Pharmacist on 8/20/10 at 9:50am indicated that possible issues related to the combined use of Plavix and Priolsec did not have to be reported to the resident's physician. The pharmacist revealed that the use of Plavix/Prilosec was not a "significant irregularity" and "I think the doctor knows … | 2014-04-01 | ||
| 12743 | 12743 | HERITAGE CROSSINGS | 285230 | 501 NORTH 13TH STREET | GENEVA | NE | 68361 | 2010-08-20 | 441 | D | 9E5K11 | LICENSURE REFERENCE NUMBER 12-006.17B Based on observation, record review and interview; the facility failed to ensure that staff changed gloves and washed hands preventing the potential for cross-contamination for 1 resident (Resident 35). The facility census was 48 residents. The sample size was 28 residents. Findings are: Observation of Resident 35 on 8/18/2010 from 10:27 - 10:53AM, revealed: Registered Nurse (RN) B washed hands in the resident bathroom for 30 seconds, used a paper towel to shut off the water faucet and then put gloves on. RN B assisted resident into the bathroom, and helped the resident lower pants and sit on the toilet, wearing the same pair of gloves. RN B was then observed taking the gloves off and putting on a new pair of gloves without washing hands. RN B then left the resident in the bathroom. After the resident voided in the toilet, RN B entered the residents' bathroom and provided pericare to the resident, swiping from the front to the back, multiple times using 3 different wipes. RN B then removed the dressings on Resident 35's buttock without removing or changing gloves. After the dressings were removed, RN B instructed the resident to ambulate out of the bathroom while RN B removed gloves and washed hands. Interview with RN B on 8/18/2010 at 2:55PM revealed that RN B "should have taken gloves off" prior to removing the dressings from Resident 25's buttocks. Interview with the facility Director of Nursing (DON) on 8/19/2010 at 11:50AM, revealed that RN B should have taken off the gloves after pericare had been provided to the resident and hands should have been washed and new gloves applied prior to removing the old dressings. A review of the facility HANDWASHING POLICY AND PROCEDURE dated 11/2005; revealed that "gloves are not a substitute for handwashing, after removing gloves you still need to wash your hands". | 2014-04-01 |
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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 );