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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2264 | 2264 | ELMS HEALTH CARE CENTER | 285191 | P O BOX 628, 410 BALL PARK ROAD | PONCA | NE | 68770 | 2017-11-06 | 151 | D | 0 | 1 | PNZ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.02(4) Based on interview and record review, the facility interfered with Resident 5's ability to exercise resident rights. The sample size was 30 and the facility census was 42. Findings are: Review of the facility policy titled Federal Rights of Residents dated 2014 revealed the resident had the right to choose activities, schedules, and health care according to the resident's interests, assessment, and plan of care. The resident had the right to make choices about aspects of the resident's life in the facility that were significant to the resident. Further review revealed the resident had the right to be free of interference from the facility in exercising the resident's rights. Review of Resident 5's Care Plan with a revision date of 9/29/17 revealed the resident had a [DIAGNOSES REDACTED]. Further review identified the following interventions/approaches for working with the resident: - Encourage oral fluids; - Avoid overstimulation; - Convey an attitude of acceptance towards the resident; - When the resident becomes socially inappropriate/disruptive provide comfort measures for basic needs (pain, hunger, toileting, or too hot or cold); - Help the resident keep the same daily routine; - Respect the resident's right to make decisions; and - Make sure the resident has coffee every morning. Review of a Resident Progress Note dated 8/15/17 revealed Resident 5 had hit a staff member in the resident's room. Resident 5's breakfast ice privileges and breakfast coffee privileges were revoked. Privileges were restored at lunch until Resident 5 stated See, I told you I would have coffee. Privilege were then revoked for lunch. At supper the resident's privileges were restored. Interview with the Director of Nursing on 11/2/17 at 1:27 PM confirmed Resident 5 was not on a behavior modification program, and ice and coffee shouldn't have been taken away as a result of the resident's behaviors. Further interview c… | 2020-09-01 |
| 6868 | 6868 | OMAHA NURSING AND REHABILITATION CENTER | 285240 | 4835 SOUTH 49TH STREET | OMAHA | NE | 68117 | 2015-09-03 | 151 | D | 1 | 0 | IFVV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(4) Based on record review and interview; the facility staff failed to ensure 1 resident (Resident 2) was able to exercise their right for a request to go to the hospital. The facility staff identified a census of 60. Findings are: Record review of a Discharge Order Sheet dated 6-19-2015 revealed Resident 2 was admitted to the facility with the [DIAGNOSES REDACTED]. Record review of Resident 2's Progress Note (PN) dated 6-21-2015 revealed Resident 2 had complained of being nauseated with pain to the upper gastric area. According to the PN dated 6-21-2015, Resident 2 also had [MEDICAL CONDITION] . and stools are very dark and tarry. A call was placed to an on call physician who order several laboratory work. Record review of Resident 2's PN dated 6-22-2015 revealed Resident 2 continued to complain of being nauseated, not feeling well and wanted to go to the hospital. Further review of Resident 2's PN dated 6-22-2015 revealed Resident 2's family member had call the facility and wanted Resident 2 sent to the hospital. A interview was conducted with the Assistant Director Of Nursing (ADON) on 9-3-2015 at 9:00 AM. During the interview, review of Resident 2's PN dated 6-22-2015 were reviewed with the ADON. When asked if Resident 2 should have been sent to the hospital as requested, the ADON stated yes. | 2018-09-01 |
| 7685 | 7685 | SCOTTSBLUFF CARE AND REHABILITATION CENTER, LLC | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2015-01-21 | 151 | E | 1 | 0 | RQVT11 | Licensure Reference Number 175 NAC 12-006.05(4) Based on interviews and record reviews, the facility failed to ensure that five sampled residents (Resident 2, 12, 1, 5, and 10) were allowed to make choices for the number of baths received per week. Facility census was 124. Findings are: A. Interview with Resident 2 on 1/21/15 at 2:00 PM revealed that resident did not get to choose the number of baths desired per week. Further interview revealed that resident was to be scheduled for 2 baths per week and had received a bath 12/9/14 then 9 days later on 12/16/14, then 8 days later on 12/24/14, then 6 days later on 12/30/14 then 6 days later on 1/5/15, then 8 days later on 1/13/15, and 7 days later on 1/20/15. Further interview revealed that resident preferred to have 2 baths a week. Review of the Bathing Schedule for Resident 2 dated 1/12/15 revealed that resident was scheduled for 2 baths a week. Review of the Bathing Type Detail Report, dated as printed 1/21/14 for Resident 2 revealed written documentation that the resident had received one bath every 7 to 9 days from December 2014 through January 20th 2015. B. Interview with Resident 12 revealed that resident did not get to choose the number of baths desired per week. Further interview revealed that resident was to be scheduled for 2 baths per week and had received a bath 12/11/14 then 3 days later on 12/14/14, then 5 days later on 12/19/14, then 10 days later on 12/29/14, then 9 days later on 1/6/15, then 2 days later on 1/8/15, then 7 days later on 1/15/14. Further interview revealed that Resident 2 preferred at least 3 baths a week or at the minimum the 2 baths per week as desired. Review of the Bathing Schedule dated 1/12/15 revealed that Resident 12 was scheduled for baths on Tuesdays and Thursdays. Review of the Bathing Type Detail Report, dated as printed 1/21/14 for Resident 12 revealed written documentation that the resident had received baths every 6 to 9 days from December 2014 through January 20th 2015. Interview with the Social Worker on 1/21/15 at 4… | 2018-01-01 |
| 8948 | 8948 | DUNKLAU GARDENS | 285119 | 450 EAST 23RD STREET | FREMONT | NE | 68025 | 2013-08-26 | 151 | D | 0 | 1 | 67UX11 | Licensure Reference Number: 175 NAC 12-006.05(6) Based on record reviews and interviews the facility failed to honor the resident ' s right to file complaints without fear of retaliation for one sampled resident (Resident 68). The facility census was 87. Findings are: -- An interview with the Administrator on 8-22-13 at 10:45 am revealed Resident 68 had reported incidents of missing money. The Administrator reported an interview with Resident 68 and family was conducted regarding the safe keeping of money. The Administrator stated failure to follow the facility ' s policy regarding safe keeping of money put both the facility and resident at risk. Review of a letter dated 8-13-12 that was sent to Resident 68 and family revealed actions to be taken to ensure the Resident ' s money is inventoried and kept safe as well as what will and will not be reimbursed per facility policy. The last action listed stated If continued incidence and resident non-compliance are reported, facility will be forced to give a 30 day notice of discharge and evaluate alternative facilities and discharge. -An interview with Resident 68 on 8-26-13 at 10:38 revealed Resident 68 will get a 30 day notice to find a new place if missing money is reported again. Resident 68 reported not wanting to move so Resident 68 now keeps money in a lock box which is in the Resident ' s room. Review of an E-mail dated 8/15/12 from the Facility Administrator to the facility's DON (Director of Nursing) RE: follow up with (with) Resident 68 and family member revealed the Administrator reviewed the expectations and provided strategies to protect Resident 68's monies. Resident 68 had not been compliant with these expectations which placed (gender) resources and the facility at risk. The Administrator stated Resident 68 was of sound mind and the expectation would be that Resident 68 would follow the strategies provided to keep resources safe and Resident 68 acknowledged understanding. The correspondence stated Resident 68 would be given a 30 day notice of discharge… | 2016-12-01 |
| 9637 | 9637 | BRIGHTON GARDENS OF OMAHA | 285274 | 9220 WESTERN AVENUE | OMAHA | NE | 68114 | 2013-04-02 | 151 | D | 0 | 1 | PQE811 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.05(2) Based on record review and interviews, the facility failed to inform a resident (Resident 54) of the rules of the facility. Facility census was 41. Sample size was 33. Findings are: Brief interview for Mental Status was completed for Resident 54 on 03/05/2013. Results indicated the resident score was 12/15. Interview with Resident 54 on 04/01/13 at 1:00 PM revealed that the resident was unaware of any rules that the facility had. The resident stated that the facility did not discuss rules of the facility on admission to the facility or did not discuss rules at the resident council meetings. Interview with Resident 2 on 04/02/2013 at 10:10 AM revealed that the facility activities director did discuss some of the rules of the facility at the monthly Resident Council Meeting. Interview held with Resident 114 on 04/02/2013 at 11:05 AM revealed that the rules of the facility were given to each resident or their representative on admission to the facility. The resident had attended one Resident Council Meeting since admission and rules were discussed at the resident council meeting. This was a violation to Licensure Reference number 12-006.05(2) for 1 of 3 sampled residents. The facility census was 41. | 2016-07-01 |
| 10823 | 10823 | MILLER MEMORIAL CARE CENTER, LLC | 2.8e+296 | P O BOX 428, 589 VINCENT AVENUE | CHAPPELL | NE | 69129 | 2012-11-20 | 151 | D | 1 | 0 | GJND11 | Licensure Reference Number 175 NAC 12-006.05 Based on record reviews and staff interview, the facility failed to honor the resident's right to choose to not participate in a group activity for one current sampled resident (Resident 1). The facility census was 22 and the sample was 6 current residents. Findings are: Review of the Abuse, Neglect or Misappropriation investigation document, dated 7/31/12, revealed that on 7/29/12 at 6:45 PM the charge nurse told Resident 1, when leaving the dining room, to go to the solarium to watch television with the other residents. The resident stated didn't want to go and the charge nurse said that the resident needed to to to get our of room and participate in the activity. The charge nurse asked an aide to assist the resident to the solarium, the resident did not physically resist but verbally cursed at the staff. Review of the Care Plan, dated 7/9/12, revealed that the resident has shown little interest in pursuing group or individual activities. Approaches included provide an activity calendar and ensure that the resident was aware of the planned activities each day. Review of the Interdisciplinary Progress Notes, dated 7/28/12, revealed that a resident interview was completed on 6/28/12 by the activity director. The interview indicated that the resident did little activities and liked to stay in room and watch television. Interview on 11/20/12 at 4:15 PM with the Director of Nursing confirmed that the staff did not allow the resident to exercise the right to not participate in the activity program. | 2015-11-01 |
| 11581 | 11581 | ARBOR MANOR | 285103 | 2550 NORTH NYE AVENUE | FREMONT | NE | 68025 | 2012-01-31 | 151 | D | 1 | 0 | FO7O11 | Licensure Reference number: 175 NAC 12-006.05(6) Findings are: Based on record review and interview the facility failed to obtain consent of responsible party prior to changing an insurance provider for 1 Resident (Resident 1). Sample size was 6. Facility Census was 114. Interview on 1/31/2012 at 9:40 AM with Resident 1's POA (Power of Attorney) revealed the resident was initially signed but for Part D prescription coverage with a Provider (insurance company), the POA revealed a letter received from a different provider (insurance company) stating the resident coverage was now under that provider for Part D coverage. POA revealed that the family was not aware of or give consent for the change in providers. Review of the financial record for Resident 1 revealed a letter dated 9/29/2011 stating that the provider initially chosen by the family began coverage on 11/1/2011 for Resident 1. A photocopy of Resident 1's insurance cards filed in the business office revealed a card for Part D insurance from the provider (insurance company) Resident 1 was changed to with a date of 2012. Interview with the business office manager revealed the facility had changed "a few" residents to another provider (insurance company) for Part D insurance in the recent months and confirmed that Resident 1 was one of them. The Business office manager confirmed Resident 1's POA did come to the office and ask why the provider had been changed and confirmed Resident 1's POA should have been consulted prior to the change. Interview with SS (Social Service) A revealed that she had not spoken to Resident 1 or Resident 1's POA regarding the change of insurance carriers. | 2015-05-01 |
| 27 | 27 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2016-09-21 | 152 | D | 0 | 1 | 7TIB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview; the facility staff failed to obtain permission from a guardian on a behavioral modification plan to restrict privileges for 1 (Resident 7) of 1 resident sampled. The facility staff identified a census of 236. Findings are: Record review of an undated Social History sheet revealed Resident 7 had a had a Guardian to manager Resident 7's care. Record review of Resident 7's Comprehensive Care Plan (CCP) dated 6-04-2009 revealed the following: -Restrict (Resident 7) to the unit if Resident 7's blood sugars are equal or greater to 225. -If Resident 7 refuses to get up for breakfast or drinks a Glytol (supplement type of liquid), Resident 7 was to remain on the unit until the following meal for observation. -If refuses to get up for lunch or drink a [MEDICATION NAME], Resident 7 is to remain on the neighborhood until the following meal. -If verbally or physically abusive with staff or peers and unable to direct, Resident 7 was to remain on the neighborhood for 24 hours. -If resident must have a breathing treatment after smoking, there would be no smoking allowed for the remainder of the day. Review of Resident 7's medical record revealed there was no evidence that Resident 7's Guardian had given permission for the restriction of privileges. On 9-19-2016 at 9:09 AM an interview was conducted with Registered Nurse (RN) B. During the interview RN B confirmed Resident 7 had a behavioral modification plan that restricted privileges. During the interview, RN B reported that the behavioral modification plan had not been discussed with the Guardian and there was not any evidence any other staff had spoke to the guardian about the behavioral modification plan. The facility was not able to provide any evidence of the Guardian giving permission for the behavioral modification plan at the time of exit from the facility. | 2020-09-01 |
| 7549 | 7549 | GOOD SAMARITAN SOCIETY - ALLIANCE | 285174 | P O BOX 970, 1016 EAST 6TH STREET | ALLIANCE | NE | 69301 | 2015-06-25 | 152 | D | 1 | 0 | P4MK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to obtain guardianship and resident approval prior to removing snack items, possessed by the resident, from the resident's room for one sampled resident (Resident 3). Facility census was 45. Findings are: Record review of Resident 3's Admission Record printed on 6/23/15 revealed the resident was admitted to the facility on ,[DATE]//2006. Review of Resident 3's electronic medical record revealed an Order Appointing Guardian document filed with the county court on 4/8/14 appointing the resident's family member as the resident's guardian. This document granted the guardian powers including Protecting the personal effects of the ward; along with Giving necessary consent, approval, or releases on behalf of the ward. Record review of a Suggestion or Concern (formal grievance) form dated 6/9/15 revealed Resident 3's guardian reported a concern that the DON (Director of Nursing) went into (Resident 3's) room and removed pkg (package) of cookies from the snack cart and also removed full cans of pop as if (Resident 3) had no right to possess (the resident's) items . The DON admitted at the meeting (the DON) did this . Interview with Resident 3's guardian on 6/23/15 between 4:30 p.m. and 5:30 p.m. confirmed having filed a formal grievance related to the facility removing snack items from the resident's room without receiving prior permission from the guardian. The removed items included three cans of lemon lime twist soft drinks and six packages of cookies. The guardian stated never directing the facility to remove any food items from the resident's room and said the IDON (Interim Director of Nursing) removed the items while the resident was not in the room. After the items were removed, the Interim Administrator notified the guardian of what was done. Interview with the IDON on 6/25/15 at 10:30 a.m. confirmed the IDON went into Resident 3's room while the resident was not in the room and remov… | 2018-02-01 |
| 11009 | 11009 | GOOD SAMARITAN SOCIETY - ALLIANCE | 285174 | P O BOX 970, 1016 EAST 6TH STREET | ALLIANCE | NE | 69301 | 2012-08-02 | 153 | D | 0 | 1 | 94LI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.05 (18) Based on record review and interviews, the facility failed to honor the legal representative request to examine a list of resident medications for one sampled resident (Resident 44). Sample size was 15 current residents and 2 closed records. Facility census was 48. Findings are: Review of Resident 44's closed medical record revealed from a discharge summary dated 4/25/12 that Resident 44 was admitted to the facility on [DATE] and discharged from the facility on 4/19/12. The discharge summary revealed the resident's family member entered the facility on 4/19/12 and signed forms for discharge AMA (Against Medical Advice). Phone interview with Resident 44's legal guardian, FM (Family Member)-A on 8/2/12 at 8:35 a.m. revealed FM-A obtained guardianship of Resident 44 in April of 2012 and notified the facility of this legal guardianship. FM-A stated notifying the facility at the time that FM-A wished to discharge the resident to a private home. FM-A also stated requesting from the facility a list of medications and that the facility did not want to honor (FM-A's) guardianship.they refused to provide FM-A a list of Resident 44's medications after the request was made. FM-A stated that the requested medication list was not provided and that the facility wouldn't provide them even after the medical offices requested a list. Review of Resident 44's closed record revealed a court document dated 4/17/12 and faxed to the facility on [DATE] at 11:09 a.m. The document, signed by the county judge and filed by the clerk of the court, appointed FM-A as temporary guardian of (Resident 44) with full power and authority to take and have custody of such person and the care and management of his/her property and affairs. Specifically you may: A. Select a place of abode within or without this state; B. Arrange for medical care of Resident 44 including but not limited to, signing any medical authorizations, providin… | 2015-09-01 |
| 5767 | 5767 | THE AMBASSADOR NEBRASKA CITY | 285126 | 1800 14TH AVENUE | NEBRASKA CITY | NE | 68410 | 2016-01-28 | 154 | D | 0 | 1 | IJ8P11 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.05 (4) Based on record review and interviews, the facility failed to notify and inform one resident (Resident 7) of a medication change and reason for a blood draw. The facility census was 47. Findings are: An interview with Resident 7 on 01/25/2016 at 2:01 PM revealed the following: When asked, Do staff include you in decisions about your medicine, therapy, or other treatments? The Resident answered No. When asked for an example, Resident 7 stated, I had a lab draw this morning and when I asked what it was for, the staff didn't tell me why it was being done. So my family member had to go ask the staff at the desk why my blood was drawn. Record review of Resident 7's care plan meeting notes from 11/4/2015 revealed that Resident 7 asked about a pink pill? that was new in the past week and was given between 6 and 7 am. There was also a note that the facility would check about the new pill. There was no other notes pertained to the new pill. Interview with the MDS (Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) Coordinator on 01/27/2016 at 12:04 PM revealed that (gender) had no documentation of the follow-up to the care plan note dated 11/04/2015. Interview with Registered Nurse E (RN E) on 01/27/2016 at 12:40 PM revealed that RN E confirmed that Resident 7 was cognitively able to ask about new medication. RN E further reported that it would have been RN E who completed the education with Resident 7 and Resident 7's family. RN E reported that RN E was not sure if RN E had completed the education and notification of the change with Resident 7 and Resident 7's family. An interview on 01/27/2016 at 12:27 PM interview with RN D revealed that RN D was not able to find any evidence of follow-up to the care plan meeting notes or the notification of Resident 7 or Resident 7's family concerning the medication change. | 2019-09-01 |
| 6285 | 6285 | GOLDEN OURS CONVALESCENT HOME | 2.8e+200 | 902 CENTRAL AVENUE | GRANT | NE | 69140 | 2016-08-24 | 154 | D | 0 | 1 | BYW711 | Licensure Reference Number 175 NAC 12-006.05(4) Based on interviews and record review, the facility failed to include two sampled residents (Resident's 17 and 15) in care planning meetings where decisions of medicine, therapy and/or other treatments affecting the resident were discussed. The facility census was 38. Findings are: Interview with Resident 15 on 8/23/2016 at 2:00 PM revealed staff did not include the resident in decisions about medicine, therapy or other treatments. The resident revealed they were not invited to their care plan meetings and revealed no one in their family attended either. Record review of Annual Note dated 4/26/2016 reveals the resident is alert and oriented and other items pertaining to the the residents behaviors and cognitive abilities but does not list the resident as being in attendance of this meeting. Record review of Annual Note date 7/20/2016 reveals the resident as alert and oriented and other issues pertaining to the residents behaviors, cognitive abilities and best interest but does not list the resident as being in attendance of this meeting. Interview with the the Social Service Director (SSD) on 08/23/2016 at 2:20:05 PM revealed the resident has been asked to come to the meetings but that was not documented. SSD confirmed that they list who is in attendance at the meetings and if the resident was not listed they probably did not attend. Interview with Resident 17 on 8/22/2016 at 3:00 PM revealed the resident was not included in decisions about medicine, therapy or other treatments. The resident revealed they were not included in attending their care plans. Record reviews of the care planning notes have been reviewed for 4/6/2016, 6/29/16, did not include documentation that the resident had been invited to the care plan. The Quarterly CCP Review dated 4/6/2016 reveals the resident as alert and oriented as does the Quarterly MDS Note dated 6/29/2016. The care plan notes discuss issues relevant to the care of the resident but the resident was not included in the decisions… | 2019-05-01 |
| 12132 | 12132 | CALLAWAY GOOD LIFE CENTER, INC | 285200 | PO BOX 250, 600 WEST KIMBALL STREET | CALLAWAY | NE | 68825 | 2011-05-09 | 154 | D | 1 | 1 | U5HQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.05(4) Based on record review, resident interview and staff interview; the facility failed to inform 1 (Resident 15) of 10 residents reviewed of administration of a laxative when it affected the care, treatment and well-being of the resident. The facility census was 23 at the time of the survey and the survey sample size was 10. Findings are: Resident 15 was admitted to the facility on [DATE] according to the FACE SHEET on the medical record. The following [DIAGNOSES REDACTED]. Review of the facility investigative file revealed that an investigation was performed on 2/23/2011 concerning administration of [MEDICATION NAME] (laxative) without Resident 15's knowledge or at the request of Resident 15. The investigation revealed that on 2/23/2011, Resident 15 requested [MEDICATION NAME] for loose stools and was informed that the reason for the loose stools was due to the [MEDICATION NAME] that had been administered on 2/22/2011. Resident 15 was very upset that (gender) had not been consulted or informed for the need of the laxative and that it had been administered in the juice on 2/22/2011 without (gender) knowledge. Interview on 5/9/2011 at 9:40 AM with LPN (Licensed Practical Nurse) C revealed that (gender) was the charge nurse on 2/22/2011. LPN C stated that Resident 15 had not had a bowel movement between 2/18/2011 and 2/22/2011 and (gender) did not want the resident to experience a bowel obstruction. LPN C stated that (gender) talked to the DON (Director of Nursing) and (gender) said to give the [MEDICATION NAME] to Resident 15. LPN C stated that the [MEDICATION NAME] was mixed in the juice and given to Resident 15 without informing the resident that it had been added to the juice. Interview on 5/9/2011 at 10:12 AM with Resident 15 revealed that (gender) had not been consulted for the need of the laxative on 2/22/2011 and did not feel constipated. Resident 15 stated that the plan was for the resident to ask … | 2014-10-01 |
| 1484 | 1484 | PREMIER ESTATES OF PIERCE, LLC | 285139 | P O BOX 189, 515 EAST MAIN STREET | PIERCE | NE | 68767 | 2017-10-11 | 155 | D | 1 | 1 | 3PT811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC ,[DATE].05(4) Based on interview and record review, the facility failed to ensure Resident 1's code status (choice for or against Cardio-Pulmonary Resuscitation-CPR) was reviewed following a change in condition and conflicting orders. The sample size was 24 and the facility census was 31. Findings are: Review of the facility policy titled Advanced Directives/DNRO Log dated ,[DATE] indicated code status forms would be completed upon admission, reviewed and updated quarterly, and review and updated with a change in condition. Review of a Progress Note dated [DATE] revealed Resident 1 had a change in condition and a change in condition form was in progress/completed. Review of the Physician's Transfer Orders from the hospital dated [DATE] listed Resident 1's code status as a Do not Resuscitate (indicting CPR would not be initiated). Review of Resident 1's Order Summary Report dated [DATE] signed by the resident's physician listed the resident's code status as a full-code (indicating CPR would be initiated). Review of a Progress Note dated [DATE] revealed Licensed Practical Nurse-M initiated CPR on Resident 1. Review of Resident 1's Medical Record revealed no evidence to indicate the resident's code status was reviewed and/or updated following an identified change of condition on [DATE] or following the resident's conflicting code status orders on [DATE]. During an interview on [DATE] at 8:50 AM the Director of Nursing (DON) confirmed CPR was initiated on Resident 1 on [DATE]. Further interview confirmed there was no evidence to indicate the resident's code status had been reviewed and/or update (if applicable). | 2020-09-01 |
| 1734 | 1734 | PREMIER ESTATES OF PAWNEE, LLC | 285157 | P O BOX 513, 438 12TH STREET | PAWNEE CITY | NE | 68420 | 2017-05-11 | 155 | E | 1 | 1 | MMVU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC ,[DATE].05(4) Based on interview and record review, the facility failed to ensure staff who provided resident transportation services were certified to perform CPR (Cardiopulmonary Resuscitation). This failure had the potential to affect eight residents (Resident 2, 27, 29, 47, 25, 19, 32, and 9) out of a sample of 8 whose Advanced Directive indicated CPR was requested. The facility census was 40. Findings are An interview on [DATE] at 9:23 AM with Transportation Aide-E revealed the staff member assisted with providing transportation for the facility's residents on a part time basis and that there were two other staff members who shared the responsibility of providing residents with needed transportation (Staff D and F). The Transportation Aide reported that (gender) CPR certification had expired. An interview on [DATE] at 2:38 PM with Transportation Aide-D revealed the staff member did assist with resident transportation and was not CPR certified. An interview on [DATE] at 9:12 AM with the Administrator revealed none of the three staff members (Staff Members D, E, and F) who provided resident transportation services were certified to perform CPR. A review of an Order Listing Report for Advanced Directive dated [DATE] revealed the facility had eight residents whose Advanced Directive was for CPR/Full Code. A review of a facility form titled CLINICAL SERVICES-EMERGENCY CARE/CPR dated ,[DATE] revealed the facility had staff available 24 hours per day who were certified to perform Heart Saver CPR as defined by the American Heart Association. | 2020-09-01 |
| 1789 | 1789 | PLUM CREEK CARE CENTER | 285159 | 1505 NORTH ADAMS STREET | LEXINGTON | NE | 68850 | 2016-11-21 | 155 | E | 0 | 1 | 2V8U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC ,[DATE].05 (4) Based on interview, and record review; the facility failed to ensure staff were trained and certified to provide CPR (cardiopulmonary resuscitation- a procedure to support and maintain breathing and circulation for person who has stopped breathing (respiratory arrest) and/or whose heart had stopped ([MEDICAL CONDITION])) for residents who requested CPR. This had the potential to affect the 6 residents (Residents 2, 31, 8, 53, 25 and 54) in the facility who requested CPR. The facility identified a census of 36 at the time of survey. Findings are: Interview with the DON (Director of Nursing) on [DATE] at 2:17 PM revealed there was not a staff person in the building 24 hours a day 7 days a week that was CPR certified. The DON did not produce a list of staff that were certified in CPR. Review of the resident medical record for residents revealed 6 residents (Residents 2, 31, 8, 53, 25 and 54) had requested CPR. | 2020-09-01 |
| 4492 | 4492 | MIDWEST COVENANT HOME | 285062 | P O BOX 367, 615 EAST 9TH STREET | STROMSBURG | NE | 68666 | 2016-06-30 | 155 | D | 0 | 1 | ER4L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05 (4) Based on record review, observation, and interview; the facility failed to ensure residents were allowed choices related to the use of personal safety alarms. This violation had the potential to effect one resident (Resident 45). The facility census was 39. Findings are: A review of the medical record for Resident 45 revealed INTERDISCIPLINARY PROGRESS NOTES (IPN) including: -a note dated 1/24/16 at 8:52 PM indicated Resident 45's family member did not want the resident to be wearing a TABS (a personal safety alarm which attaches to the persons clothing to alert staff to a possible unassisted transfer) alarm during the day time, the family member had detached the alarm from the resident while in the facility and did not reattach it prior to leaving. Resident 45 was upset when the alarm was replaced by staff, documentation indicated was ok with it after explanation and understands why the alarm was needed. -a note dated 1/24/16 at 10:17 PM revealed Resident 45's alarm was noted to be disconnected from the resident upon an LPN's (Licensed Practical Nurse) entrance into the resident's room to answer the call light. Resident 45 stated my daughter doesn't want me to have those alarms on, I'm supposed to be walking so I can go home The resident was assisted to the bathroom with walker, gait was unsteady. Resident 45 was reminded to put call light on when finished, and was compliant with the reminder. The documentation indicated Resident 45 was assisted back to the chair, and the TABS was placed on resident without incident or complaint from the resident. -notes dated 1/26/16 at 11:27 and 11:28 PM revealed that scheduled/ordered treatments for Resident 45 were held due to the Resident's mood. The documentation indicated Resident 45 was angry, agitated, and believes staff was lying to (gender) about having to wear alarms. -a note dated 1/28/16 at 1:54 PM indicated Resident 45's functional ability was: … | 2020-04-01 |
| 4562 | 4562 | AZRIA HEALTH SUTHERLAND | 285141 | P O BOX 307, 333 MAPLE STREET | SUTHERLAND | NE | 69165 | 2016-08-10 | 155 | E | 0 | 1 | KY2M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC ,[DATE].05 (4) Based on interviews and record reviews, the facility failed to ensure that two transportation drivers (Drivers D and E) obtained current certification in CPR (Cardiopulmonary Resuscitation) - artificial heart and respiratory procedure in the event of a [MEDICAL CONDITIONS]. The failure had the potential of affecting 5 sampled residents (Residents 33, 34, 5, 36, and 54) requesting full codes, transported by the two sampled drivers. Facility census was 43. Findings are: Interview on [DATE] at 9:04 AM with the Administrator revealed that there were 5 sampled residents (Residents 33, 34, 5, 36, and 54) that were requesting to have full CPR. Review of the CPR certifications revealed that van drivers D and [NAME] did not have written documentation of current CPR certifications. Interview on [DATE] at 9:10 AM with the Administrator verified that the van drivers D and [NAME] did not hold current certification and were responsible for transportation of 5 sampled residents (Residents 33, 34, 5, 36, and 54 who had requested full CPR. Interview on [DATE] at 11:30 AM confirmed that the two van drivers (Drivers D and E) did not have current CPR certification and there were 5 sampled residents(Residents 33, 34, 5, 36, and 54) with wishes of full CPR. Further interview confirmed that the van drivers (Drivers D and E) should have had CPR certification to apply CPR to residents (Residents 33, 34, 5, 36, and 54) in case of a [MEDICAL CONDITION] of any of the 5 sampled residents while in transport. | 2020-04-01 |
| 4601 | 4601 | CALLAWAY GOOD LIFE CENTER, INC | 285200 | PO BOX 250, 600 WEST KIMBALL STREET | CALLAWAY | NE | 68825 | 2016-09-22 | 155 | E | 0 | 1 | SRTA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC ,[DATE].05 (4) Based on observation, interview, and record review; the facility failed to ensure staff were trained and certified to provide CPR (cardiopulmonary resuscitation- a procedure to support and maintain breathing and circulation for person who has stopped breathing (respiratory arrest) and/or whose heart has stopped (cardiac arrest)) for residents who requested it. This had the potential to affect the 5 residents in the facility who requested CPR: Residents 11, 31, 28, 12, and 45. The facility identified a census of 25 at the time of survey. Findings are: Review of the current facility staff CPR certification information revealed that the Office Manager, Food Service Supervisor, Social Services Director, Activities Director, Transportation Aide and the DON (Director of Nursing) were CPR certified. The HIM (Health Information Manager), RN-B (Registered Nurse), LPN-C (Licensed Practical Nurse), and LPN-D had expired CPR certification and no other staff were listed as currently CPR certified. Interview with the DON (Director of Nursing) on [DATE] at 12:12 PM revealed there was not a staff person in the building 24 hours a day 7 days a week that was CPR certified. Review of the facility Resident User Defined Fields list revealed 5 residents (Residents 11, 31, 28, 12, and 45 ) had requested CPR. Interview with the DON on [DATE] at 1:21 PM confirmed that RN-B, LPN-C, and LPN-D had expired CPR certification and the HIM had expired certification for teaching the CPR classes. Review of the facility policy Emergency Procedure-Cardiopulmonary Resuscitation revised (MONTH) 2011 revealed that if an individual was found unresponsive and not breathing normally, a licensed staff member who was certified in CPR/BLS (Basic Life Support) shall initiate CPR. Interview with HIM on [DATE] at 1:46 PM confirmed that the HIM, RN-B, LPN-C, and LPN-D had expired CPR certification and none of the nurses or the aides were CPR… | 2020-04-01 |
| 4671 | 4671 | CHIMNEY ROCK VILLA | 285260 | P O BOX A, 106 EAST 13TH STREET | BAYARD | NE | 69334 | 2017-01-05 | 155 | E | 0 | 1 | W1HN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure one staff member transporting residents to appointments and activities was certified in administering CPR (Cardio-Pulmonary Resuscitation). The failure had the potential of affecting fourteen current residents (Residents 5, 9, 10, 17, 21, 23, 25, 26, 30, 36, 39, 40. 43, and 48.) with advance directives requesting CPR administration in the event of [MEDICAL CONDITION]. Sample size was a review of all facility residents' advance directives. Facility census was 36. Findings are: Record review of of Staff-B's employee file revealed a certification card confirming the employee obtained a CPR credential certification through the American Heart Association on [DATE]. Further review of the card revealed the certification expired in (MONTH) of (YEAR). Record review of a facility tracking form entitled Code Status and Advance Directives dated [DATE] revealed 14 current residents (Residents 5, 9, 10, 17, 21, 23, 25, 26, 30, 36, 39, 40. 43, and 48.) were identified with advance directives requesting CPR initiation in the event of [MEDICAL CONDITION]. Interview with the Administrator on [DATE] at 1:15 p.m. confirmed Staff-B was utilized by the facility to transport residents to appointments and activities per the facility van. The Administrator verified Staff-B's CPR certification credential expired in (MONTH) of (YEAR) and Staff-B had not renewed the certification. | 2020-04-01 |
| 4826 | 4826 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2017-10-04 | 155 | G | 1 | 0 | VJ5811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Federal Tag F155 Based on record review and interviews, the facility failed to follow the resident's advance directives to perform CPR (Cardiopulmonary Resuscitation). This affected one sampled resident (Resident 4). Facility census was 17. Findings are: Review of the Nursing Progress Note, dated [DATE], for Resident 4; identified that on [DATE] at 7:39 PM, MA(Medication Aide)-B called the LPN (Licensed Practical Nurse)-D to Resident 4's room. The resident was non-responsive and the resident's breath was short and pursed, and the nail bed was cyanotic. LPN-D went to the nurse's station and called 911. While on the phone with 911, MA-B called LPN-D back to the resident's room. When LPN-D went back to the room, the resident's body went limp and non-responsive. LPN-D was holding the resident in the bed with LPN-D's legs so that the resident would not fall out of the bed. The paramedics arrived and transferred the resident to the gurney for transport to the hospital. The paramedics left with the resident at approximately 8:20 PM. The resident's physician called the facility and asked for the signed advanced directive and LPN-D was unable to locate one in the resident's chart. At 11:10 PM, a hospital employee called the facility to inform them that the resident was transferred to another medical center in Colorado. Review of the facility document, titled Admit/Discharge To/From Report, identified that Resident 4 passed away on (MONTH) 22, (YEAR). Review of the facility policy, titled Cardiopulmonary Resuscitation (CPR) - Basic Life Support, dated ,[DATE], stated that Unless a decision not to initiate CPR has previously been made by the resident/patient, CPR will be initiated for any resident/patient who experiences a cardiopulmonary arrest while in the facility. If a decision (code status) has not been established and documented, CPR will be initiated. Interview on [DATE] at 2:25 PM with RN (Registered Nurse)-A revealed that if a resident was fo… | 2020-03-01 |
| 5520 | 5520 | SORENSEN CARE AND REHABILITATION CENTER, LLC | 285107 | 4809 REDMAN AVENUE | OMAHA | NE | 68104 | 2016-11-14 | 155 | D | 1 | 0 | 7EEE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview; the facility failed to ensure that an Advanced Directive (information about the residents wishes for end of life care) had been formulated for Resident 4 and Resident 3. Sample size was two. The census was 66. Findings are: [NAME] Record review of the facility Policy and Procedure for Advance Directives dated [DATE] revealed that the resident had a right to execute or refuse to execute an advance directive which stipulates how the decisions regarding his/her medical care will be made. The procedure revealed that prior to or upon admission, family members, and or legal representatives were informed and provided written materials governing their legal rights pertaining to medical decisions upon admission to the facility. These rights included the right to formulate an advanced medical directives such as a living will, Power of attorney for Health Care, Do not resuscitate or health care surrogate. The procedure identifies that prior to or upon admission to the facility, the admissions Coordinator or Social Services Designee ascertains the presence of any existing advance directives and a copy is placed under the advance directive tab in the medical record. Prior to or on admission, the Social services designee will provide written information to the resident/legal representative concerning right to make decisions regarding medical care including the right to accept /refuse medical /surgical treatment and the right to formulate advance directives. Record review of Resident 4's Face Sheet dated [DATE] revealed that Resident 4 had been admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 4's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) dated [DATE] and quarterly MDS dated [DATE] revealed that Resident 4 had a cognitive score of ,[DATE] which indicated that Resident 4 was independent with cognitive decision making. I… | 2019-11-01 |
| 5536 | 5536 | WAUSA CARE AND REHABILITATION CENTER, LLC | 285111 | 703 SOUTH VIVIAN | WAUSA | NE | 68786 | 2016-03-10 | 155 | D | 0 | 1 | T3NP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC ,[DATE].05 (4) Based on record reviews and interviews, the facility failed to ensure the transport driver obtained current certification in CPR (Cardiopulmonary Resuscitation- artificial heart and respiratory procedures in the event of a [MEDICAL CONDITIONS]). This failure had the potential of affecting 1 resident (Resident 5) who requested CPR and who was transported by the transport driver. Facility census was 25. Findings are: Review of the facility policies and procedures for Advanced Directives-CPR with revision date [DATE] revealed all licensed nursing staff and facility van-drivers were to be CPR certified. Licensed nursing staff certification was to be obtained within 90 days of hire. Van drivers were to be CPR certified upon hire. Record review of the facility Active Employee Roster revealed the Maintenance Specialist was listed among active employees. Record review of the Maintenance Specialist's employee file revealed no documentation regarding CPR course completion or certification. Interview on [DATE] from 9:30 AM to 9:45 AM with the facility Administrator confirmed that the Maintenance Specialist routinely transports residents to and from appointments as scheduled. The Administrator verified the Maintenance Specialist had not been certified in CPR or completed a CPR course. Interview with the facility Director of Nursing on [DATE] at 10:05 AM verified one current resident (Resident 5) requested full code (CPR initiation in the event they quit breathing or their heart stops beating) directives and confirmed that Resident 5 had been transported to appointments by the Maintenance Specialist. Review of Residents 5's medical records verified the resident requested full code status regarding advanced directives. | 2019-11-01 |
| 6471 | 6471 | BELLE TERRACE | 285237 | 1133 NORTH THIRD ST | TECUMSEH | NE | 68450 | 2016-02-24 | 155 | D | 1 | 0 | TIKE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC ,[DATE].05(4) Based on interview and record review, the facility failed to follow the cardiopulmonary resuscitation (CPR) directive for one resident (Resident 2) and failed to immediately initiate CPR for one resident (Resident 3). The facility census was 43. Findings are: A. Review of Resident 2's Cardio [MEDICAL CONDITION] Resuscitation (CPR) Form dated [DATE] revealed that in the event of cardiac and/or respiratory arrest Resident 2 wanted CPR initiated. Further review of the same form revealed Resident 2's physician had signed an order for [REDACTED]. Review of Resident 2's Nurses Notes dated [DATE] revealed at 6:15 AM, LPN (Licensed Practical Nurse) A had performed a visual check of Resident 2 and respirations were noted to be even and shallow with oxygen intact. Nurses Notes at 7:30 AM revealed, Observed resident (with) no respirations pulseless, breathless, pupils fixed. DON (Director of Nursing) notified. PCP (Primary Care Physician) called. At 7:35 AM, the APRN (Advanced Practitioner Registered Nurse) had called and given an order to release the body to the mortuary and notify the county coroner of the death. Interview with the DON on [DATE] at 11:40 AM revealed LPN A no longer was employed at the facility and confirmed that LPN A had not initiated CPR for Resident 2 when found to be absent of all vital signs. The DON further explained that by the time the DON arrived at the facility the APRN had been called and had given orders to release Resident 2 to the mortuary. The DON further stated that after this occurred that all licensed nursing personal were educated on performing CPR when a resident elected to have CPR performed. Review of the agenda for a Charge Nurse Meeting dated [DATE] revealed the DON reviewed the meaning of a Code Status and that a resident's desire to have CPR should be respected and followed. B. Review of Resident 3's Cardio [MEDICAL CONDITION] Resuscitation (CPR) Form dated [… | 2019-02-01 |
| 6577 | 6577 | PLATTSMOUTH CARE AND REHABILITATION CENTER, LLC | 285104 | 602 SOUTH 18TH STREET | PLATTSMOUTH | NE | 68048 | 2015-12-03 | 155 | J | 1 | 0 | YK8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC ,[DATE].05(4) Based on interview and record review, the facility failed to follow the cardiopulmonary resuscitation (CPR) directive for one resident (Resident 1). The facility census was 100. Findings are: Review of Resident 1's Resuscitation Orders dated [DATE] revealed that in the event of cardiac and/or respiratory arrest Resident 1 wanted CPR initiated. Review of Resident 1's Nurses Notes, dated [DATE], revealed that the resident was found at 7:05 PM with no vitals or respiration. CPR was initiated and 911 was called, Director of Nursing (DON) was notified. During an interview with Licensed Practical Nurse A (LPN A) on [DATE] at 2:40 PM, LPN A revealed that, on the evening shift of [DATE], LPN A came up to the nurses station on the central unit while LPN B and Registered Nurse C (RN C) were having a discussion that Resident 1 had died and that they were unsure of Resident 1's CPR status. LPN A informed them that Resident 1's directive was to initiate CPR and that 911 needed to be called. LPN A stated that LPN A got the crash cart (a mobile cart carrying medical equipment used for resuscitation) and went to Resident 1's room but didn't have the key to turn the oxygen tank on and had to go back to get it. LPN A said that this all took about 5 minutes. LPN B was interviewed by telephone on [DATE] at 2:10 PM. LPN B said that on [DATE] after supper, RN C came to the nurses station and told LPN B that Resident 1 had died . LPN B said that, We kinda thought (Resident 1) was a no code. LPN B said it was ,[DATE] minutes before CPR was started on Resident 1. On [DATE] at 5:31 PM, RN C was interviewed by telephone. RN C stated that RN C found Resident 1 in room and unresponsive at 7:05 PM. RN C went to the nurses station and called LPN B and checked the resident's chart for the code status. Asked how long from the time Resident 1 was found unresponsive until CPR was initiated, RN C said, about 10 minutes. Review … | 2018-12-01 |
| 6609 | 6609 | PIONEER MANOR NURSING HOME | 285212 | P O BOX 310, 318 N 3RD STREET | HAY SPRINGS | NE | 69347 | 2015-07-29 | 155 | E | 0 | 1 | MDY311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC ,[DATE].05(4) Based on interviews and record reviews, the facility failed to ensure that 10 sampled employees ( Employee C, D, E, F, G, H, I, J, K and L) responsible for resident transportation and 8 sampled employee (M, N, O, P, Q, R, S and T) responsible for supervision of residents during the evening and night shifts maintained up to date CPR (Cardiopulmonary Resuscitation-artificial heart and respiratory procedure in the the event of a [MEDICAL CONDITION] or [MEDICAL CONDITION]). This failure had the potential of affecting 6 sampled residents (Resident 58, 62, 48, 34, 18 and 7) requesting CPR who were transported by the transportation employees and cared for on the floor by the the 8 sampled employees (Employee M, N, O, P, Q, R, S, and T). Facility census was 50. Findings are: Interview with the Director of Nursing (DON) on [DATE] at 1:00 PM revealed that a list of employees responsible for transportation and providing supervision and cares in the nursing facility could not be found. Interview with the Administrator Assistant on [DATE] at 9:25 AM revealed that the facility did not have up to date CPR certifications for the transportation staff or the staff providing supervision and cares to the residents in the facility. Review of the facility list of employees that provided transportation for the residents included: 10 employees (Employee C, D, E, F, G, H, I, J, K, and L). Further review revealed a list of 8 employees (Employee M, N, O, P, Q, R, S and T) responsible for supervision and cares provided to the residents at the facility. Review of a facility list, Advanced Directives and Code Status Report, dated as printed on [DATE] revealed a list of 6 residents(Resident 58, 62, 48, 34, 18 and 7) who had requested full CPR. Interview with the Administrator and the DON on [DATE] at 2:30 PM verified that the employees responsible for resident transportation and the employees responsible for supervision and … | 2018-12-01 |
| 6781 | 6781 | HEMINGFORD COMMUNITY CARE CENTER | 285265 | P O BOX 307, 605 DONALD AVENUE | HEMINGFORD | NE | 69348 | 2015-04-22 | 155 | E | 0 | 1 | 46IN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC ,[DATE].05 (4) Based on record review and interviews, the facility failed to ensure staff assigned to transport residents obtained current CPR (Cardiopulmonary Resuscitation- a procedure to resuscitate a person in cardiac or respiratory arrest) certification. This failure had the potential of affecting six current residents (Residents 8, 10, 13, 18, 25, and 32), requesting CPR in the event of cardiac or respiratory arrest. Facility census was 27. Findings are: Record review of facility staff members assigned to transport residents to appointments outside of the facility revealed two of the staff members (MA (medication aide)-A and Staff-B)) who transported residents to appointments had not obtained current CPR certification. Interview LPN (Licensed Practical Nurse)-C on [DATE] at 2:20 p.m. revealed that six current residents requested full code (CPR initiation in event of cardiac or respiratory arrest) status. LPN-C stated the residents requesting full code status were Residents 8, 10, 13, 18, 25, and 32. Interview on [DATE] at 9:18 a.m. with the facility administrator confirmed MA-A and Staff-B transported residents outside the facility for appointments and had not obtained current CPR certifications. | 2018-10-01 |
| 6926 | 6926 | PREMIER ESTATES OF KENESAW, LLC | 285166 | P O BOX 10, 100 WEST ELM AVENUE | KENESAW | NE | 68956 | 2015-03-26 | 155 | E | 0 | 1 | S4T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC ,[DATE].05 (4) Based on record reviews and interviews, the facility failed to ensure the transport driver obtained current certification in CPR (Cardiopulmonary Resuscitation- artificial heart and respiratory procedures in the event of a [MEDICAL CONDITIONS]). This failure had the potential of affecting four sampled residents (Residents 9, 15, 20, and 65) requesting CPR who were transported by the transport driver. Facility census was 48. Findings are: Record review of the facility Active Employee Roster revealed Staff-F was listed among active employees with the job title listed as Driver. Record review of Staff-F's employee file revealed the staff member completed an American Red Cross course for CPR for the Professional Rescuer and the Healthcare Provider on [DATE]. The document recorded the certificate is valid for 2 year(s) from completion date. Further review of Staff-F's employee file revealed no other documentation of CPR course completion or certification. Interview on [DATE] at 12:20 p.m. with Staff-F and the facility Administrator confirmed that Staff-F routinely transports residents to and from appointments as scheduled. Staff-F and the Administrator verified Staff-F had not been certified in CPR or completed a CPR course since the American Red Course certificate expired on [DATE]. Interview with the facility LPN/ADON (Licensed Practical Nurse/Assistant Director of Nursing)-A, on [DATE] at 2:05 p.m. verified eight current residents requested full code (CPR initiation in the event they quit breathing or their heart stops beating) directives and confirmed that four of these residents (Residents 9, 15, 20, and 65) were routinely transported to appointments by Staff-F. Record review of Residents 9, 15, 20, and 65 verified from these resident medical records, the residents requested full code status regarding advanced directives. | 2018-08-01 |
| 7140 | 7140 | INDIAN HILLS HEALTHCARE COMMUNITY | 285091 | 1720 NORTH SPRUCE | OGALLALA | NE | 69153 | 2015-05-20 | 155 | D | 0 | 1 | RGZC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC ,[DATE].05 (4) Based on record reviews and staff interviews, the facility failed to ensure that two sampled transport drivers and four sampled nurses obtained current certification in CPR (Cardiopulmonary Resuscitation - artificial heart and respiratory procedure in the event of a [MEDICAL CONDITIONS]). This failure had the potential to affect two sampled residents (Resident 30 and Resident 22) who requested CPR in the event of a respiratory or [MEDICAL CONDITION]. The facility census was 43. Findings are: Interview on [DATE] at 9:36 AM with the Business Office Manager revealed that two employees (Staff H and Staff I) were responsible to transport residents in the facility van. Review of the employee files revealed that Staff H and Staff I did not have current CPR certification. Further interview on [DATE] at 9:36 AM with the Business Office manager revealed that there was no documentation of current CPR certification in the employee files for RN (Registered Nurse) - K, RN - L, LPN (Licensed Practical Nurse) - M, and LPN - N who work on the night shift. Interview on [DATE] at 10:00 AM with the DON (Director of Nursing) revealed that two residents (Resident 30 and Resident 22) requested CPR in the event of a respiratory or [MEDICAL CONDITION]. Interview on [DATE] at 12:00 PM with the Administrator confirmed that the facility transport drivers and the night nurses needed to be certified in CPR to accommodate the residents' requests for CPR in the event of a respiratory or [MEDICAL CONDITION]. | 2018-05-01 |
| 7342 | 7342 | HERITAGE ESTATES | 285071 | 2325 LODGE DRIVE | GERING | NE | 69341 | 2015-04-06 | 155 | E | 0 | 1 | IR6111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC ,[DATE].05(4) Based on interviews and record reviews, the facility failed to ensure that two sampled transport drivers obtained current certification in CPR (Cardiopulmonary Resuscitation-artificial heart and respiratory procedure in the event of a [MEDICAL CONDITIONS]. This failure had the potential of affecting 10 sampled residents (Residents 117, 49, 94, 53, 80, 127, 31, 5, 55 and 92) requesting CPR who were transported by the transportation driver. Facility census was 83. Findings are: Interview with the (People Development Coordinator) PDC - C on [DATE] at 10:00 AM revealed that two employees (Staff D and E) were responsible for transporting residents. Further review revealed that Staff D and E did not have current CPR certifications. Interview on [DATE] at 10:10 AM with the Life Enrichment Coordinator revealed that Staff E routinely transported residents and Staff D also transported residents when needed. Review of a facility printed lists of employees for CPR certification verification revealed that two employees (Staff D and E) responsible for transportation did not have current CPR certification for transportation purposes. Interview with the Director of Nursing on [DATE] at 9:50 AM revealed that the facility census was 83 and out of the 83 there were 10 residents (Residents 117, 49, 94, 53, 80, 127, 31, 5, 55, and 92) that were routinely transported that had requested CPR if needed. Interview on [DATE] at 9:00 AM with the Administrator verified that two employees (Staff D and E) were responsible for the routine transportation of Residents 117, 49, 94, 53, 80, 127, 31, 5, 55, and 92) and did not have current CPR certifications. Further interview confirmed that CPR certifications should have been current with staff members responsible for transportation of residents requesting CPR. | 2018-04-01 |
| 7379 | 7379 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2015-05-06 | 155 | E | 0 | 1 | D1MH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC ,[DATE].05(4) Based on interviews and record reviews, the facility failed to ensure that two sampled facility transportation drivers obtained current certification in CPR (Cardiopulmonary Resuscitation-artificial heart and respiratory procedure in the event of a [MEDICAL CONDITION]/[MEDICAL CONDITION]). This failure had the potential of affecting 6 sampled residents (Residents 31, 45, 29, 44, 34, and 33) requesting CPR who were transported by the transportation driver. Facility census was 33 Findings are: Interview with the Administrator on [DATE] at 9:00 AM revealed that the last CPR course was held on [DATE]. Further interview revealed confirmation by the Administrator, of no further instructional classes for CPR were administered at the facility since [DATE]. Review of the American Heart Association-Cardiopulmonary Resuscitation record dated [DATE], revealed that there was no written documentation to support that the Activities Director or the Van Driver for the facility had current CPR certifications. Interview with the Activities Coordinator on [DATE] at 10:00 AM revealed that the Van Driver was the main person responsible for transporting residents in the facility van. Further interview confirmed that the Activities Coordinator was also responsible for transportation of residents on occasions. Review of Resuscitation Orders for Resident 31, 45, 29, 44, 34, and 33 revealed that orders were present for each of these residents. Interview on [DATE] at 3:00 PM with the Interim Director of Nursing revealed that Resident 31, 45, 29, 44, 34, and 33 had written documentation of wishes for a full CPR code status and that the residents were transported in the facility van by the Van Driver and the Activities Coordinator. Interview on [DATE] at 11:30 AM with the Administrator verified that the Van Driver and the Activities Coordinator were responsible to transport Resident 31, 45, 29, 44, 34, and 33 in the facilit… | 2018-04-01 |
| 8046 | 8046 | GOOD SAMARITAN SOCIETY - SCRIBNER | 285196 | 815 LOGAN STREET | SCRIBNER | NE | 68057 | 2016-08-24 | 155 | F | 0 | 1 | XS7811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview; the facility failed to ensure staff members providing transportation to residents were trained and certified to administer CPR (Cardiopulmonary Resuscitation) if needed. This failure had the potential to affect all of the residents residing in the facility. The facility census was 36. Findings are: An observation on [DATE] at 4:05 PM revealed Van Driver A assisting a resident in a w/c (wheelchair) off of the facility van and into the facility. No other staff were observed to be in or around the van as it returned and was unloaded at the facility. An interview on [DATE] at 11:00 AM with the Administrator revealed the three staff members (Staff A, B, and C) who have been driving the facility van while transporting residents were not CPR certified. A review of the Facility's Policy & Procedure for CARDIOPULMONARY RESUSCITATION (CPR) revised ,[DATE] indicated the facility was responsible to have CPR available at all times. | 2017-11-01 |
| 8274 | 8274 | GOOD SAMARITAN SOCIETY - OSCEOLA | 285193 | 600 CENTER DRIVE | OSCEOLA | NE | 68651 | 2014-05-19 | 155 | E | 0 | 1 | B86K11 | Licensure Reference Number: 175 NAC 12-006.05 Based on record review and interview the facility failed to ensure Resident choices were honored, related to morning wake up times for one Resident (Resident 21). Facility census was 36 and sample size was 30. Finding are: Interview conducted on 5/15/14 at 12:58 PM with Resident 21's family member revealed that the facility woke the resident up fairly early in the morning approximately at 6:00 AM. The family member revealed that the resident did not voice concern for getting up so early in the morning to the facility; however the resident had expressed concern to family member regarding getting up too early. The family member revealed that the Resident's wake-up times were too early in the morning. The family member stated (gender) had informed the facility the resident's wake-up time is too early. Interview conducted on 5/13/14 at 2:47 PM with Nurse Aid-M (NA-M) revealed that Resident 21 was bathed at 6:15 AM-6:30 AM. NA-M stated it seemed to work to get (gender) up first thing in the morning. Review of care plan dated 3/4/14 revealed that Resident 21 would like to sleep in until 7:00 AM. | 2017-09-01 |
| 9103 | 9103 | HUNTINGTON PARK CARE CENTER | 285251 | 1507 GOLD COAST ROAD | PAPILLION | NE | 68046 | 2015-04-02 | 155 | E | 1 | 1 | BX8K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].05(4) Based on record review and interview; the facility staff failed to educate Agency Pool Staff on the facility CardioPulmonary Resuscitation (CPR) Policy and Procedures. The facility provided a list on [DATE] of 25 residents residing in the facility who were identified as wanting CPR. The facility staff identified a census of 85. Findings are: Record review of an undated Orientation Checklist for Temporary Staffing agencies revealed there was not an area that identified the facility policy and procedures for conducting CPR in the facility. An interview with Registered Nurse (RN) E was conducted on [DATE] at 11:12 AM. During the interview, RN E reported that (gender) was an Agency Nurse. When asked if (gender) had been educated on the facility Policy and Procedure for CPR, RN R stated no. On [DATE] at 8:40 AM an interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed the facility did not have an orientation to the facility CPR process for Agency Pool staff. | 2016-11-01 |
| 11152 | 11152 | CALLAWAY GOOD LIFE CENTER, INC | 285200 | PO BOX 250, 600 WEST KIMBALL STREET | CALLAWAY | NE | 68825 | 2012-04-16 | 155 | D | 1 | 0 | 10KC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE: NAC 175 12.006.05 (4). Based on observation, record review and interview, the facility failed to allow the resident/legal representative the informed right to refuse care and treatment interventions by failing to explain consequences and to provide options to the care and treatment. The facility had a census of 22 and a complaint investigation sample of 5. This affected Resident 2. A. Review of the facility handbook of RESIDENT ' S BILL OF RIGHTS FOR SKILLED NURSING FACILITIES (revised 1/07) revealed that residents had the right to refuse treatment. B. According to the 10/10/08 FACE SHEET Resident 2 was admitted to the facility on [DATE]. The FACE SHEET documented that Resident 2 had a power of attorney for healthcare decisions (the resident ' s spouse). The following [DIAGNOSES REDACTED]. Review of the IPN (INTERDISCIPLINARY PROGRESS NOTES) dated 1/11/12 revealed that the facility informed the legal representative of Resident 2 that Resident 2 had risk factors for skin breakdown and the facility was recommending the resident be removed from the double bed and placed in a smaller bed that could be fitted with a pressure relieving mattress. The legal representative did not want the resident to be placed in the smaller bed. According to the NOTE the legal representative reported that the staff would not listen to the wishes of the legal representative. The legal representative reported that the skin was observed earlier that morning and there were no signs of skin breakdown. Review of the 1/12/12 physician progress notes [REDACTED]. The NOTES documented that the resident was accompanied to the appointment by the legal representative . The NOTES documented that Resident 2 was in a double bed to allow the resident room to move in bed without falling out. The legal representative was aware of the risks of skin breakdown but knew the resident didn ' t have any breakdown as of 1/12/12. The legal representative explained to the p… | 2015-08-01 |
| 11652 | 11652 | OAKLAND HEIGHTS | 285281 | 207 SOUTH ENGDAHL AVENUE | OAKLAND | NE | 68045 | 2011-11-10 | 155 | J | 1 | 0 | U8LG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC ,[DATE].09D Based on record reviews, observations, and staff interviews, the facility failed to provide CPR (Cardiopulmonary Resuscitation) in accordance with the resident's signed and documented advanced directive for 1 (Resident 1) of 7 sampled residents as a result Resident 1 passed away at the facility without receiving CPR. In addition, the facility failed to provide education to staff and clarify the facility CPR policy following the incident to prevent possible reoccurrence in order to protect 6 other residents of the facility who had requested CPR. The facility had a total census of 31 residents. Findings are: A. Resident 1 was admitted to the facility on [DATE] according to the Face Sheet. History and Physical for Resident 1 dated [DATE] listed the following [DIAGNOSES REDACTED]. A review of Resident 1's CPR/No CPR form revealed Resident 1 had marked CPR as the choice that Resident 1 wanted the facility to follow and had signed the form on [DATE]. Observation of Resident 1's medical record on [DATE] revealed Resident 1's medical record had a lime green dot on the chart indicating Resident 1 wanted CPR. A review of Resident CPR Status list maintained in facility medication room identified Resident 1 as wanting CPR. Resident 1's name had been crossed off the list. B. Undated facility policy titled "Cardiopulmonary Resuscitation (CPR) stated the following: "CPR or No CPR will be performed according to the resident's wishes. Procedure: 1. The Administration, or designee, will have the resident or resident representative sign the CPR determination form upon admission. 2. The licensed nurse will inform the physician by sending the form to the doctor. 3. The chart will be marked with a green sticker, when CPR is to be done. The resident's name, outside of the resident's room, will be underlined as an indication the resident wants to have CPR. 4. When sudden [MEDICAL CONDITION] is witnessed, on a resident w… | 2015-03-01 |
| 158 | 158 | RIVER CITY NURSING AND REHABILITATION | 285058 | 7410 MERCY ROAD | OMAHA | NE | 68124 | 2017-07-12 | 156 | E | 0 | 1 | 0ROU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide notices of non-coverage of Medicare services for 3 (12,165, 16) and failed to provide a list of services not covered by Medicaid for 2 residents (Resident 122 and 47). Findings are: The facility Policy and Procedure titled When to Deliver the Notice of Medicare Non-Coverage CMS (NOMNC), undated, revealed that: A Medicare provider or health plan must deliver a completed copy of the Notice of Medicare Non-Coverage to beneficiaries/enrollees receiving covered skilled nursing. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Providers must deliver the NOMNC to all beneficiaries eligible for the expedited determination process. A NOMNC must be delivered even if the beneficiary agrees with the termination of services. The Provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. A) Record review of Admission Record for Resident 12 revealed that, Resident 12 was admitted to the facility on [DATE] with Medicare services. Record review of Resident 12's Electronic Medical Record revealed that Resident 12 services changed from Medicare to Private pay. Record review revealed the facility did not have documentation of NOMNC or SNF Denial Letter for services. Interview with facility Business Office Manager (BOM) on 7/11/17 at 2:23 PM confirmed that the facility failed to provide Resident 12 with NOMNC and Denial Letter. The BOM confirmed that there was no documentation of Resident 12 being provided notice of when Medicare Services would end. B) Record review of Admission Record for Resident 16 revealed that Resident 16 was admitted to the facility on [DATE] with Medicare services provided Record review of NOMNC,… | 2020-09-01 |
| 1069 | 1069 | EMERALD NURSING & REHAB LAKEVIEW | 285106 | 1405 WEST HWY 34 | GRAND ISLAND | NE | 68801 | 2017-04-12 | 156 | F | 0 | 1 | G7JM11 | Licensure Reference Number 175 NAC 12-006.05(1) Based on record review and interview; the facility failed to ensure that Residents 2, 3 and 85 were offered the option to have the Fiscal Intermediary review the medical record prior to the end of Medicare Part A for services rendered for 3 Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) reviewed. The facility census was 60. Findings are: [NAME] During the review of the facility Liability Notices processes, record review of Resident 2's SNFABN dated 11/9/16 revealed that no boxes had been selected by the resident or the responsible party to indicate resident choice whether or not to have the medical record reviewed by the Fiscal Intermediary. B. During the review of the facility Liability Notices processes, record review of Resident 3's SNFABN dated 3/8/17 revealed that no boxes had been selected by the resident or the responsible party to indicate resident choice whether or not to have the medical record reviewed by the Fiscal Intermediary. C. During the review of the facility Liability Notices processes, record review of Resident 85's SNFABN dated 2/7/17 revealed that no boxes had been selected by the resident or the responsible party to indicate resident choice whether or not to have the medical record reviewed by the Fiscal Intermediary. D. Interview on 4/10/17 at 9:20 AM with the MDS (The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and/or Medicaid-certified long-term care facility.) Coordinator confirmed that Residents 2, 3 and 85's SNFABN letters did not indicate resident choice as to whether or not they wished to have the medical record reviewed by the Fiscal Intermediary. The MDS Coordinator confirmed that the facility staff went over the letters with the residents but did not ensure that a choice had been selected whether or not to have had the medical record reviewed by the Fiscal Inter… | 2020-09-01 |
| 1156 | 1156 | PRESTIGE CARE CENTER OF NEBRASKA CITY | 285109 | 1420 NORTH 10TH STREET | NEBRASKA CITY | NE | 68410 | 2017-05-02 | 156 | D | 0 | 1 | 4KPH11 | Based upon record review and interviews, the facility failed to provide a listing of covered and non-covered Medicaid charges to one resident (Resident 54 ). The facility census was 43. Findings are: [NAME] During an interview with the POA (Power of Attorney ) of Resident 54, on 04/19/2017 09:50 AM, Resident 54's POA was asked the question- Is the Resident on Medicaid and if so, did the staff give her/him (or you) a list of services and items that you would and would not be charged for? The POA answered Resident 54 was on Medicaid and that (gender) didn't know if (gender) received the list of covered items and non-covered items. A review of the admission papers for Resident 54's revealed that there was no document that showed what items or costs Medicaid covered and what costs Medicaid did not cover. An interview with SSD (Social Services Director) on 04/25/2017 at 2:15 PM, confirmed Resident 54's admission packet did not have a list of services covered and not covered by Medicaid. | 2020-09-01 |
| 1347 | 1347 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2017-08-02 | 156 | D | 1 | 1 | YKIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide a cost listing of what Medicaid would and would not cover upon admission. This effected 2 residents (Resident 161 and 285 ). The facility census was 110. Findings are: [NAME] Record review of Resident 161's Face Sheet, dated 7/27/17, revealed that, Resident 161 was admitted to the facility on [DATE]. Record review of Resident 161's Census History, dated 7/27/17, revealed that Resident 161 became Medicaid eligible on 5/1/2016 . Interview on 7/26/17 at 3: 40 PM with Resident 161's family revealed that staff did not provide a list of services and items that would and would not be charged for when Resident 161 became eligible for Medicaid. Interview with the facility business office, Staff Member I, on 7/27/17 at 3:10 PM confirmed that there was not a form provided to Resident 161's family upon eligibility for Medicare. Interview with the facility Administrator on 7/27/17 at 3:11 PM confirmed that the facility did not provide information to Resident 161's family regarding Medicaid coverage and charges. B. Record review of Resident 285's Face Sheet, dated 7/27/17, revealed that, Resident 161 was admitted to the facility on [DATE]. Record review of Resident 161's Census History, dated 7/27/17, revealed that Resident 161 became Medicaid eligible on 7/22/16. Interview on 7/26/17 at 2:45 PM with Resident 285's family revealed that staff did not provide a list of services and items that would and would not be charged for when became eligible for Medicaid. Interview with the facility business office, Staff Member I, on 7/27/17 at 3:10 PM confirmed that there was not a form provided to Resident 285's family upon eligibility for Medicare. Interview with the facility Administrator on 7/27/17 at 3:11 PM confirmed that the facility did not provide information to Resident 285's family regarding Medicaid coverage and charges. | 2020-09-01 |
| 1580 | 1580 | AZRIA HEALTH GRETNA | 285146 | 700 HIGHWAY 6 | GRETNA | NE | 68028 | 2017-01-30 | 156 | D | 0 | 1 | PGG811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.05(1) Based on record review and interview, the facility failed to provide a list of services and items covered and not covered by Medicaid for two residents (Resident 27 and 44). The facility census was 50. Findings are: [NAME] In a telephone interview, with a family member of Resident 27, on 01/18/2017 at 3:11 PM revealed that when asked, If the resident is on Medicaid did the staff give her/him (or you) a list of services and items that you would and would not be charged for? The answer was No. In a telephone interview, with a family member of Resident 44, on 01/18/2017 at 3:30 PM revealed that when asked, If the resident is on Medicaid, did the staff give her/him (or you) a list of services and items that you would and would not be charged for? The answer was No. A record review of Resident 27's checklist form has nothing written on it except Resident 27's name. A record review of Resident 44's checklist form has nothing written on it except Resident 44's name, date completed (4/10/14) and a medical record number. A record review of General SNF Admission Package: Policies and Procedures, dated 05/12/2011 revealed in section 5.2 step 5) Place the admission checklist on top of each package. As you are completing the package materials, you must also be signing and dating each section assist is completed. An interview with Director of Social Services (DSS) on 01/19/2017 at 2:08 PM revealed that DSS has a premade admission packet of information; that includes an information sheet that contains a list of what is covered and not covered by Medicaid. It is included as part of every admission packet, even if the new resident was not Medicaid. Each packet has an admission checklist with the new resident's name and the Medicaid covered items form is one of the forms on the checklist. The DSS also stated that the DSS assisted Resident 27 with (gender) Medicaid application and that the DSS didn't re-share the… | 2020-09-01 |
| 1771 | 1771 | PLUM CREEK CARE CENTER | 285159 | 1505 NORTH ADAMS STREET | LEXINGTON | NE | 68850 | 2017-10-19 | 156 | E | 0 | 1 | 2BUM11 | Based on record review and interviews, the facility failed to ensure that the resident rights were discussed at the resident council meetings. This had the potential to affect 14 sampled residents (Residents 18, 23, 40, 29, 43, 6, 26, 15, 27, 13, 38, 2, 1, and 19) that resided in the facility. The facility census was 37. Findings are: Interview on 10/19/2017 at 10:00 AM with Resident 18 revealed that the only resident right that was discussed at the resident council meetings was abuse/neglect and respect and dignity. The facility staff did not discuss any other resident rights with the residents that attended the resident council meetings. Review of the facility's resident council minutes from (MONTH) (YEAR) to (MONTH) (YEAR) identified that the only resident rights that were discussed at the resident council meetings were abuse/neglect and respect and dignity. None of the other resident rights were discussed at the resident council meetings. Review of the facility policy, titled, RESIDENT COUNCIL MEETINGS AND RESIDENT CONCERNS, dated (MONTH) 2014; stated that Staff will read and review with the Resident Council bullet points from the Resident Bill of Rights at each monthly meeting. Interview on 10/19/2017 at 10:33 AM with the SSD (Social Service Director) confirmed that the only resident right that was discussed at the monthly resident council meetings was abuse/neglect and respect and dignity. The SSD stated that they were only trained to discuss the abuse/neglect and respect and dignity rights and was unaware that they were to discuss the other resident rights at the monthly resident council meetings. | 2020-09-01 |
| 2414 | 2414 | COMMUNITY PRIDE CARE CENTER | 285208 | 901 SOUTH 4TH STREET | BATTLE CREEK | NE | 68715 | 2017-03-30 | 156 | C | 0 | 1 | N3I911 | Based on record review and interview, the facility failed to assure the residents were informed of where to find information on how to file a complaint with the state agency. This had the potential to affect all residents in the facility. The facility staff identified the resident census as 43. Survey sample size was 26 . The findings are: A review of the Resident Council Minutes dated 9/23/16, 11/18/16, 12/23/16, 2/17/17, and 3/24/17 revealed the state agency information was not reviewed at the resident council meetings. An interview conducted on 3/28/17 at 11:00 AM with Resident 45 revealed that the residents were not made aware of the state agency contact information in order to file a complaint if needed. An interview conducted on 3/28/17 at 1:10 PM with the Social Services Director (SSD) revealed the state agency contact information was given to residents upon request or when a resident and/or family member filed a grievance with the facility. The SSD reported the residents were not given this information at any of the Resident Council meetings or during the admission process. | 2020-09-01 |
| 2964 | 2964 | RIDGECREST REHABILITATION CENTER | 285239 | 3110 SCOTT CIRCLE | OMAHA | NE | 68112 | 2017-10-11 | 156 | E | 0 | 1 | 09Y611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide notice of non-coverage from Medicare A two calendar days prior to the end of Medicare A services to 3 residents (Residents 27, 34, 68) of 3 residents sampled. The facility staff identified the census at 65. Findings are: [NAME] A review of Resident 27's Face Sheet dated 10-11-17 revealed that Resident 27 was readmitted to the facility on [DATE]. A review of Resident 27's undated Notice of Medicare Non-Coverage revealed that the resident's Medicare Part A services were to end on 5-22-17. The notice was signed by the resident's representative on 5-24-17. An interview conducted on 10-11-17 at 9:25 AM with the Social Services Director (SSD) revealed that the SSD believed the notice was mailed to the resident's representative through regular first class mail at least 3 days prior to the end of services, but did know when the representative received the notice. The SSD was unable to provide evidence of when the notice was mailed. B. A review of Resident 68's Face Sheet dated 10-11-17 revealed that Resident 68 was admitted to the facility 12-22-16. A review of Resident 68's undated Notice of Medicare Non-Coverage revealed that the resident's Medicare Part A services were to end on 7-28-17. The notice was signed by the resident's financial representative on 7-28-17. A review of Resident 68's Progress Notes revealed a note dated 7/27/17 that revealed the resident's family member was given the Notice of Medicare Non-Coverage. C. A review of Resident 34's Face Sheet dated 10-11-17 revealed Resident 34 was admitted to the facility on [DATE]. A review of Resident 34's undated Notice of Medicare Non-Coverage revealed that the resident's Medicare Part A services were to end on 5-22-17. The notice was signed by the resident's financial representative on 5-26-17. A review of Resident 34's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) date… | 2020-09-01 |
| 3001 | 3001 | OMAHA NURSING AND REHABILITATION CENTER | 285240 | 4835 SOUTH 49TH STREET | OMAHA | NE | 68117 | 2017-08-22 | 156 | D | 0 | 1 | LWTC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a list of services not covered by Medicaid to 1 resident (Resident 69) of 1 resident sampled. The facility staff identified the resident census as 65. Findings are: A review of Resident 69's Admission Record dated 8-21-17 revealed Resident 69 was admitted to the facility on [DATE] and was receiving Medicaid services. An interview conducted on 8-16-17 at 3:08 PM with Resident 69's spouse revealed that Resident 69 had been receiving Medicaid services for approximately one month. Resident 69's spouse reported they were the financial representative for the resident and had not received a list of services not covered by Medicaid. A review of Resident 69's medical record revealed no documentation that a list of services not covered by Medicaid had been given to the resident or their spouse. A review of the facility's Resident Admission Packet dated 3-17-15 revealed no list of services not covered by Medicaid was present in packet. An interview conducted on 8-22-17 at 1:02 PM with the Business Office Manager revealed that the facility did not have a list of services not covered by Medicaid. The Business Office Manager reported they talk to the resident of financial representative about the services that Medicaid will not cover, but did not have documentation to show this had been discussed with Resident 69's spouse. | 2020-09-01 |
| 3437 | 3437 | GATEWAY SENIOR LIVING | 285266 | 225 NORTH 56TH STREET | LINCOLN | NE | 68504 | 2016-09-19 | 156 | E | 0 | 1 | PZWF11 | Based on record review and interview the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (also known as a waiver of liability, a notice that is given to residents when a provider or supplier offers a service or item they believe Medicare will not cover) for three of three sample residents (Res 121, 122, & 183). Facility census was 56. Findings are: On 09/15/2016 at 11:19 AM an interview with Social Services D revealed, the facility was not giving residents whose Medicare services were ending the SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice) until last Thursday 9/8/16. Record review revealed there was no SNFABN for three sampled residents. | 2020-09-01 |
| 3468 | 3468 | PAPILLION MANOR | 285268 | 610 SOUTH POLK STREET | PAPILLION | NE | 68046 | 2017-03-29 | 156 | D | 0 | 1 | COVY11 | Based on interview and record review, the facility failed to provide a list of services and items that would and would not be charged once Resident 5 became eligible for medicaid. Sample size was 1 and the facility census was 76. Findings are: Interview on 3/27/17 at 9:45 AM with Resident 5's family member, responsible for financial's, revealed that information of items covered and items not covered was not provided upon Resident 5's eligibility for Medicaid. Resident 5's family member revealed that it was a long process and that the Medicaid had just started, and that they were not provided with information regarding Medicaid covered and non covered items. Interview with the facility Social Services Director (SSD), on 03/29/2017 1:52:25 PM, revealed that Resident 5's family was assisted with the Medicaid application process. The SSD confirmed that Resident 5's family did not receive a review of Medicaid covered and non covered items, and it was not reviewed with resident or family, when the resident became eligible for Medicaid. The SSD confirmed that the facility did not have a policy to provide regarding this process. | 2020-09-01 |
| 3615 | 3615 | BROOKESTONE MEADOWS REHABILITATION AND CARE CENTER | 285276 | 600 BROOKESTONE MEADOWS PLAZA | ELKHORN | NE | 68022 | 2016-12-01 | 156 | D | 0 | 1 | 809811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a list of services and items that would and would not be charged once Resident 161 became eligible for medicaid. Sample size was 1 and the facility census was 121. Findings are: Interview on 11/29/16 at 8:54 AM with Resident 161's Power of Attorney (POA) revealed that information of items covered and items not covered was not provided upon Resident 161's eligibility for Medicaid. Record review of Resident 161's Electronic Medical Record (EMR) revealed that Resident 161 was admitted to the facility on [DATE] with Medicare as the payment source. Record review of Resident 161's EMR revealed eligibility of Medicaid began on 10/01/16. Interview on 12/01/2016 at 10:23:40 AM with the facility Business Office Manager (BOM) that review of Medicaid covered and non covered items was not reviewed with resident or family when the resident became eligible for Medicaid. It was reviewed at admission but no other time. Interview on 12/01/2016 at 1:17:41 PM with the facility Administrator revealed that the facility did provide information upon application for Medicaid. The facility did not provide Resident 161's POA a list of items covered and not covered upon Medicaid eligibility. | 2020-09-01 |
| 3624 | 3624 | SUTTON COMMUNITY HOME, INC. | 285277 | 1106 NORTH SAUNDERS | SUTTON | NE | 68979 | 2017-08-31 | 156 | F | 0 | 1 | VZOT11 | Based on record review and interview; the facility failed to provide a written notice to the Medicare Beneficiary explaining the right to file an expedited appeal upon termination of all Medicare covered services. This affected 3 (Residents 1, 6 and 13) of 3 residents reviewed. The facility census was 25. Findings are: Record review of a Survey and Certification letter dated 1/9/09 from the Center for Medicare and Medicaid Services revealed that the Skilled Nursing Facility (SNF) must provide a written notice (QIO Letter) to the Medicare Beneficiary explaining the right to file an expedited appeal to the Quality Improvement Organization (QIO) upon termination of all Medicare covered services. The notice informed the beneficiary of their right to an expedited review of a service termination. The SNF must issue this notice when there was a termination of Medicare Part A services for coverage reasons. Record review of a Determination on Continued Stay Letter for Resident 1 dated 5/1/17 revealed that Medicare Part A services were discontinued on 5/3/17. Record review of a Determination on Continued Stay Letter for Resident 6 dated 7/24/17 revealed that Medicare Part A services were discontinued on 7/28/17. Record review of a Determination on Continued Stay Letter for Resident 13 dated 7/24/17/17 revealed that Medicare Part A services were discontinued on 7/28/17. Record review during the Liability Notices and Beneficiary Appeal Review revealed that Residents 1, 6 and 13 did not receive an expedited appeal notice upon termination of Medicare A services. Interview on 08/29/2017 at 1:55:39 PM with the facility Social Worker revealed that a liability notice was provided to residents and responsible parties upon completion of Medicare services but that there were no other letters that were given in regards to a request for an expedited appeal. Interview on 08/30/2017 at 8:39:24 AM with the facility Administrator revealed that the facility had not issued any expedited appeal notices to the residents and confirmed that Resi… | 2020-09-01 |
| 3666 | 3666 | THE LIGHTHOUSE AT LAKESIDE VILLAGE | 285280 | 17600 ARBOR STREET | OMAHA | NE | 68130 | 2017-06-15 | 156 | E | 0 | 1 | AZ9A11 | Licensure Reference Numbers: 175 NAC 12-006.05(1) Based upon record review and interview; the facility failed to provide the liability and appeals notices for 4 residents (Residents 34, 21, 16 and 15) of 5 residents reviewed. The facility census was 30. Findings are: [NAME] A facility provided an undated list of residents who were discharged from Medicare A to a different payer source over the last six months with 6 names. One of the six was excluded as the resident was discharged to home on the date of the notice. Of the other five residents, Residents 15, 16, 21, 29 and 34; only Resident 29's file had the required Notice of Medicare Non-Coverage (NOMNC) and Intermediary Determination of Noncoverage and Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) forms signed and dated 48 hours prior to the end of services. An interview with the Director of Social Services and Admissions (DSS&A) on 06/13/2017 at 4:20 PM reveled the following: a search of the discharge files was conducted and (gender) was not able to locate the SNFABN and NOMNC letters for the following residents- Residents 34, 21, 16 and 15. The DSS&A stated that the process is for (gender) to fill out the both SNFABN and NOMNC letters and inform the resident or POA (Power of Attorney) of the ending of services 72 hours prior and obtain signatures. The DSS&A does not make any copies of these letters and does not know where the original documents are currently located as (gender) has not locate them. A record review of the policy Medicare Compliance: Expedited Review, Denial Letter, Appeals Process, Consolidated Billing-HDGR dated (MONTH) 2009, revised (MONTH) 2013 revealed that in section Expedited Review, step 10-Place a copy of the signed notice in the resident's medical file. In the section Denial/ABN Letters step one-skilled nursing facility, according to the CMS Medicare provider agreement, furnishes a beneficiary with a denial letter: (b) Upon discharge from skilled services appropriate. An interview with the Director of Nursing (DON) on 0… | 2020-09-01 |
| 4545 | 4545 | THE AMBASSADOR OMAHA | 285127 | 1540 NORTH 72ND STREET | OMAHA | NE | 68114 | 2016-12-13 | 156 | D | 0 | 1 | R06911 | Based on record review and interview, the facility failed to provide the correct advance beneficiary non-coverage notice to inform the resident or responsible party of the potential liability for payment and the right to request a standard claim appeal be sent to the fiscal intermediary for a payment decision for one (Resident 49) of three sampled residents. The facility had a total census of 92 residents. Findings are: Record review of a Centers for Medicare and Medicaid Services Survey and Certification letter 09/20 revealed that the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services when limitation of liability applies. The SNF's responsibility to provide notice can be fulfilled by use of either the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or one of 5 uniform Denial Letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e., demand bill) submitted to Medicare Record review revealed Resident 49 was issued a Notice of Medicare Non-coverage (NOMNC) which stated Medicare probably will not pay for your current skilled nursing services after 10/7/16 and the Medicare part B Therapy Threshold Notification. Both notices were signed on 10/5/16. In an interview on 12/12/16 at 11:35 AM, the Director of Customer Relations confirmed Resident 49 should have been issued the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and was not. | 2020-04-01 |
| 4572 | 4572 | WISNER CARE CENTER | 285151 | 1105 9TH STREET | WISNER | NE | 68791 | 2016-08-24 | 156 | E | 0 | 1 | 1DYH11 | Based on record review and interview, the facility failed to complete liability notices as required for 3 residents (Resident's 25, 23, and 30). The facility census was 35. Findings are: [NAME] Review of the facility's Medicare Demand Bill process revealed 3 (Residents 25, 23, and 30) of 3 resident files reviewed had not identified whether or not the resident and/or their responsible party wanted their bill to be submitted for a Medicare decision. During an interview on 8/24/16 at 1:18 PM, the Director of Nursing confirmed the forms for Resident's 25, 23, and 30 did not indicate whether the resident and/or their responsible party did or did not want their bill to be submitted for a Medicare decision. B. Further review of the facility's Medicare Demand Bill process revealed 3 (Residents 25, 23, and 30) of 3 resident files reviewed had not been informed of the contact information for the Quality Improvement Organization (QIO: the state agency that processes expedited reviews of Medicare denials). During an interview on 8/24/16 at 11:45 AM, Licensed Practical Nurse-A confirmed the forms for Resident's 25, 23, and 30 did not include the QIO address. | 2020-04-01 |
| 4625 | 4625 | BELLE TERRACE | 285237 | 1133 NORTH THIRD ST | TECUMSEH | NE | 68450 | 2017-01-19 | 156 | E | 0 | 1 | RCWF11 | Based on record review and interview, the facility failed to issue the correct advanced beneficiary non-coverage notice to inform the resident or responsible party of the potential liability for payment and the right to request a standard claim appeal be sent to the fiscal intermediary for a payment decision for 3 residents (Resident 22, 36, and 40). The facility had total census of 43 residents. Findings are: [NAME] Record review of a Centers for Medicare and Medicaid Services Survey and Certification letter 09/20 revealed that the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services when limitation of liability applies. The SNF's responsibility to provide notice can be fulfilled by use of either the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or one of 5 uniform Denial Letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e., demand bill) submitted to Medicare. B. Record review revealed Resident 36 was issued an Advance Beneficiary Notice of Non-Coverage (ABN) dated 11/23/16 which stated Resident 36 would be discharged from all therapies on 11/27/16. The notice was signed on 11/25/16. C. Record review revealed Resident 40 was issued an Advance Beneficiary Notice of Non-Coverage (ABN) dated which stated Resident 40 would be discharged from all occupational therapy on 3/3/16. The notice was signed on 3/8/16. Documentation on Notice of Medicare Non-Coverage stated Resident 40 ' s family member was notified of non-coverage by telephone on 2/29/16. D. Record review revealed Resident 22 was issued an Advance Beneficiary Notice of Non-coverage (ABN) dated 11/21/16 which stated Resident 22 would be discharged from all therapies on 11/25/16. The notice was signed on 11/28/16. Notice of Medicare Non-Coverage stated Resident 22 ' s family member was notified of non-coverage by telephone on 11/21/16. E. In an interview on 1/11/17 at 2:31 PM, Licensed Practical Nurse Social Worker confirmed th… | 2020-04-01 |
| 4720 | 4720 | OLD MILL REHABILITATION (OMAHA TCU) | 285289 | 1131 PAPILLION PARKWAY | OMAHA | NE | 68154 | 2016-05-09 | 156 | E | 0 | 1 | 5T6711 | Based on record review and interview, the facility staff failed to issue a required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of potential liability for Medicare non-coverage (called a Medicare Denial Letter/Demand Bill request) for 3 (Residents 96, 141 and 144) residents reviewed. The facility census was 40. Findings are: Record review of a Centers for Medicare and Medicaid Services Survey and Certification letter 09-20 revealed that the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services when limitation of liability applies. The SNF's responsibility to provide notice can be fulfilled by use of either the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or one of 5 uniform Denial Letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e., demand bill) submitted to Medicare. Issuing the Notice to Medicare Provider Non-coverage to a beneficiary only conveys notice to the beneficiary of the right to an expedited review of a service termination and does not fulfill the providers ' obligation to advise the beneficiary of potential liability of payment. The provider must still issue the SNFABN or a Denial Letter to address liability of payment. Review of the facility's Medicare Demand Bill process revealed that 3 (Residents 96, 141 and 144) residents files reviewed had not been informed of the right to submit a Demand Bill to Medicare through the standard claim appeal and had not been issued a SNFABN or a Denial Letter to address liability of payment. Review of the resident files revealed the following: - Resident 96: Medicare services ended 11/23/15. The resident was not issued a SNFABN and was only provided with an expedited appeal notice (a way to request a quick decision by Medicare). - Resident 141: Medicare services ended 04/27/16. The resident was not issued a SNFABN and was only provided with an expedited appeal notice. - Resident 144: Medicare services ended 11/24/… | 2020-04-01 |
| 4743 | 4743 | SORENSEN CARE AND REHABILITATION CENTER, LLC | 285107 | 4809 REDMAN AVENUE | OMAHA | NE | 68104 | 2017-06-15 | 156 | D | 1 | 1 | F9RW11 | > No state equivalent Based on interview and record review, the facility failed to provide a list of services and items that would and would not be charged when Medicaid eligible, for 2 Residents (Resident 56 and 87). The sample size was 5. The facility census was 67. Findings are: [NAME] Interview with Resident 55's family member (responsible party), on 06/15/2017 at 12:37 PM revealed that the facility did not provide information, upon admission to the facility, to the family member regarding services and items that would and would not be charged for Resident 55, who was Medicaid eligible. Interview with Business Office Manager (BOM), on 6/15/17 at 12:51 PM confirmed that the facility did not provide a written statement to Resident 55's family member (responsible party), to review Medicaid covered and non covered items, and it was not reviewed with resident or family. Interview on 6/15/217 at 2:36 PM, with the facility Regional Vice President of Operations, confirmed that the facility did not have a form to provide to Medicaid eligible residents, to inform them of the services and items that would and would not be charged for. B. Interview with Resident 56's family member on 6/13/17 at 11:05 AM revealed that the facility did not provide information, upon admission to the facility, to the family member regarding services and items that would and would not be charged for Resident 55, who was Medicaid eligible. Interview with BOM, on 6/15/17 at 12:51 PM confirmed that the facility did not provide a written statement to Resident 55's family member (responsible party), to review Medicaid covered and non covered items, and it was not reviewed with resident or family Interview on 6/15/217 at 2:36 PM, with the facility Regional Vice President of Operations, confirmed that the facility did not have a form to provide to Medicaid eligible residents, to inform them of the services and items that would and would not be charged for. | 2020-03-01 |
| 4789 | 4789 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2016-05-11 | 156 | E | 0 | 1 | LW9411 | Based on record reviews and interview, the facility failed to 1) issue the notice of Medicare A noncoverage for one sampled resident (Resident 7) and 2) include the reason for Medicare A noncoverage for two sampled residents (Resident 4 and 34). The facility census was 31. Findings are: [NAME] Review of the SNF (Skilled Nursing Facility) Determination on Continued Stay for Resident 7 revealed that on 5/6/16 the resident would no longer qualify for Medicare services. Further review revealed no documentation that the resident received information on the appeal process. B. Review of the Notice of Medicare Non-Coverage revealed that Resident 4's coverage for skilled nursing would end on 3/12/16. Further review revealed no signature on the SNF Determination on Continued Stay which included the reason for non coverage. C. Review of the Notice of Medicare Non-Coverage revealed that Resident 34 skilled nursing services would end on 1/29/16. Further review reveled no information regarding the reason the resident's Medicare coverage would end. Interview on 5/10/16 at 3:53 PM with the Social Services Director confirmed that the residents were to receive notices of Medicare non coverage when their Medicare benefits were ending. Further interview confirmed that the notices were to include the information of the appeal process and the reason for non coverage. | 2020-03-01 |
| 5128 | 5128 | MT CARMEL HOME- KEENS MEMORIAL | 285216 | 412 WEST 18TH STREET | KEARNEY | NE | 68845 | 2016-05-02 | 156 | C | 0 | 1 | WQ7E11 | Licensure Reference Number 175 NAC 12-006.06C Based on observations, interviews, and record review; the facility failed to ensure that 1) the Resident Council Representative was informed of the location of the Ombudsman information and phone number and, 2) the Ombudsman information and phone number were accessible to the residents at the facility. This had the potential to affect 67 of the facility identified census of 67. Findings were: Observation on 05/02/2016 at 1:50 PM of the facility entrance and reception desk area that was identified by the facility as the location for the posting of the state Ombudsman information and phone number revealed that no Ombudsman information was observed. Interview revealed that the Resident Council Representative was unsure if the Ombudsman information and numbers were posted and available to all facility residents. Further interview with the facility Resident Council Representative on 05/02/2016 at 3:45 PM revealed that the resident was unfamiliar with the name Ombudsman and unaware of the location of the Ombudsman information. Review of the Resident Council Minutes from (MONTH) (YEAR) through (MONTH) (YEAR) revealed no written documentation to support that the resident council members had been informed about the location of the Ombudsman information or telephone number. Observation of the facility on 5/2/2016 at 4:11 PM revealed no posting of the Ombudsman information. Interview with the SSD (Social Services Director) on 5/2/2016 at 4:11 PM confirmed the Ombudsman information was not posted where the facility residents could have access to it. Interview with the facility Administrator on 5/2/2016 at 4:14 PM revealed the Ombudsman information had been removed from the wall about 2 weeks ago because the maintenance department was painting. The Administrator confirmed that the Ombudsman information was not posted in a location accessible to the facility residents. | 2020-02-01 |
| 5433 | 5433 | PREMIER ESTATES OF PAWNEE, LLC | 285157 | P O BOX 513, 438 12TH STREET | PAWNEE CITY | NE | 68420 | 2016-04-27 | 156 | E | 0 | 1 | 3FQM11 | Based on record review and interview; the facility failed to issue liability notices to inform the resident or responsible party of the right to an expedited appeal to the Quality Improvement Organization (QIO) for Resident 11, 12, and 24. The facility also failed to provide the notice for potential liability for payment for non-covered services, the right to have a claim submitted to Medicare, and the right to request a standard claim appeal to be sent to the fiscal intermediary for a payment decision for Resident 11, 12 and 24. The facility census was 36. Findings are: Review of the Centers for Medicare and Medicaid Services Survey and Certification letter 09/20 revealed a Skilled Nursing Facility (SNF) must issue a Notice of Medicare Provider Non-coverage when there is a termination of all Medicare Part A services for coverage reasons to inform the beneficiary of the right to an expedited review of a service termination. If after issuing the Notice of Medicare Provider Non-coverage, the SNF expects the beneficiary to remain in the facility in a non-covered stay, either the SNF Advanced Beneficiary Notice (SNFABN) or 1 of 5 uniform Denial Letters must be issued to inform the beneficiary of potential liability for the non-covered stay. The SNFABN and the Denial Letters inform the beneficiary of his/her right to have a claim submitted to Medicare and advises them of the standard claim appeal rights that apply if the claim is denied by Medicare. Review of liability notices for Resident 11 revealed that a Notice of Medicare Non-coverage was signed on 1-13-2016 for Medicare A services ending on 1-13-2016. Further review revealed that the name and number of the QIO was not given. Review of liability notices for Resident 12 revealed that a Notice of Medicare Non-coverage was signed on 3-1-2016 for Medicare A services ending on 3-2-2016. Further review revealed that the name and number of the QIO was not given. Review of liability notices for Resident 24 revealed that a Notice of Medicare Non-coverage was signed on 3-8… | 2020-01-01 |
| 5521 | 5521 | SORENSEN CARE AND REHABILITATION CENTER, LLC | 285107 | 4809 REDMAN AVENUE | OMAHA | NE | 68104 | 2016-11-14 | 156 | D | 1 | 0 | 7EEE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.04C3a Based on record review and interview, the facility failed to notify the physician of a change in condition for one of five residents (Resident 1) sampled. The facility census was 66. Record review of the facility's Policy Notification of Change in Resident Health Status dated 10/20/16 revealed: - It was the facility's policy to ensure that notifications were made when a resident had a change in health status. Record review of a nurse's note dated 10/28/16 at 10:30 AM by Registered Nurse (RN) B revealed that Resident 1's vital signs had been recorded as; - a temperature of 97.2 Fahrenheit, - a blood pressure of 145/82, - pulse of 108, - respirator rate of 18 breaths per minute, - a oxygen saturation of 96% on room air. Resident 1 was alert and oriented, independent with transfers and ambulated with a walker. Resident 1 was independent with activities of daily living (ADL's). Resident 1 had no shortness of breath. Resident 1 did not require oxygen, and had capillary refill time of less than 3 seconds. Resident 1 had no complaints of pain and had been using the telephone and talking with family and friends. A record review of Resident 1's medical record, titled Progress Note dated 10/29/16 at 6:00 AM, written by Licensed Practical Nurse (LPN) A, revealed that Resident 1 was yelling stating having trouble breathing. The on-duty, Nursing Assistant (NA), requested that this writer report to Resident 1's room. I immediately expedited to the distressed resident room. Resident 1's oxygen saturation was 84% (Lippencott's Nursing Center states that SpO2, or pulse oximetry, is normal when in the range of 97 to 99 percent). Resident 1 presented with good color and was assisted to bed. An assessment of Resident 1's lungs revealed clear sounds in the upper lungs, bilaterally, and diminished sounds in lower lungs bilaterally. Oxygen was applied by nasal cannula (a device used to deliver supplemental oxygen o… | 2019-11-01 |
| 5709 | 5709 | PAPILLION MANOR | 285268 | 610 SOUTH POLK STREET | PAPILLION | NE | 68046 | 2016-02-17 | 156 | D | 0 | 1 | 9ENN11 | Based on record review and interview, the facility failed to issue either the standard SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice) or one of the 5 uniform Denial Letters) to 3 sampled residents (Resident 1, 108, and 123). The facility had a total census of 86 residents. Findings are: A. Record review of a Centers for Medicare and Medicaid Services Survey and Certification letter 09/20 revealed that the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services when limitation of liability applies. The SNF's responsibility to provide notice can be fulfilled by use of either the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or one of 5 uniform Denial Letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e., demand bill) submitted to Medicare. B. A review of Determination on Continued Stay dated 1/15/16 issued to Resident 1 revealed Resident 1's Medicare benefits would end on 1/17/16. The notice stated the following You are being placed in a section of the facility that is not certified for Medicare. Ordinarily, services furnished in a non-certified bed are not payable under Medicare. C. A review of Determination on Continued Stay dated 2/1/16 issued to Resident 108 revealed Resident 108's Medicare benefits would end on 2/4/16. The notice stated the following You are being placed in a section of the facility that is not certified for Medicare. Ordinarily, services furnished in a non-certified bed are not payable under Medicare. D. A review of Determination on Continued Stay dated 12/21/15 issued to Resident 123 revealed Resident 123's Medicare benefits would end on 12/29/15. The notice stated the following You are being placed in a section of the facility that is not certified for Medicare. Ordinarily, services furnished in a non-certified bed are not payable under Medicare. E. In an interview on 2/17/16 at 11:41 AM, Social Worker A confirmed that the Determination on Continu… | 2019-10-01 |
| 5728 | 5728 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2016-09-20 | 156 | E | 1 | 0 | TD4511 | > Licensure Reference Number 175 NAC 12-006.05(1) Based on record review and interview; the facility failed to ensure 1 sampled resident (Resident 16) was provided the complete liability and appeals notices when Medicare benefits were being denied. The facility census was 114. Findings are: Review of Resident 16's files revealed the facility failed to provide documentation to support they had provided the appropriate liability and appeal notices for 1 Resident 16. On 9/19/2016 at 10:00 AM, the Minimum Data Set (MDS) Coordinator revealed in an interview that the facility was unable to locate Resident 16's file and, therefore, there was no supporting documentation that the resident was given a liability notice when Medicare services were ending. | 2019-09-01 |
| 5775 | 5775 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2015-06-03 | 156 | E | 0 | 1 | EJB611 | Based on record review and interview, the facility failed to issue the correct advanced beneficiary non-coverage notice to inform the resident or responsible party of the potential liability for payment and the right to request a standard claim appeal be sent to the fiscal intermediary for a payment decision for 4 residents (Resident 12, 585, 587, and 586). The facility had total census of 83 residents. Findings are: A. Record review of a Centers for Medicare and Medicaid Services Survey and Certification letter 09/20 revealed that the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services when limitation of liability applies. The SNF ' s responsibility to provide notice can be fulfilled by use of either the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or one of 5 uniform Denial Letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e., demand bill) submitted to Medicare B. Record review revealed Resident 12 was issued an Advance Beneficiary Notice of Noncoverage (ABN) which stated Medicare may not pay for room and board, medications and supplies due to Resident 12 having no skilled needs. The notice was signed on 5/4/15. C. Record review revealed Resident 585 was issued an Advance Beneficiary Notice of Noncoverage (ABN) which stated Medicare may not pay for room and board, medications and supplies due to Resident 585 having no skilled needs. The notice was signed on 11/19/14. D. Record review revealed Resident 586 was issued an Advance Beneficiary Notice of Noncoverage (ABN) which stated Medicare may not pay for room and board, medications and supplies due to Resident 586 having no skilled needs. The notice was signed 11/5/14. E. Record review revealed Resident 587 was issued an Advance Beneficiary Notice of Noncoverage (ABN) which stated Medicare may not pay for room and board, medications and supplies due to Resident 587 having no skilled needs. The notice was signed on 11/24/14. F. … | 2019-09-01 |
| 5995 | 5995 | HOOPER CARE CENTER | 285229 | 400 EAST BIRCHWOOD DRIVE | HOOPER | NE | 68031 | 2015-12-03 | 156 | C | 0 | 1 | D8VH11 | Licensure Reference Number 175 NAC 12-006.05(1) Based on record review , interview and observation; the facility staff failed to ensure that residents and responsible parties were informed of charges for beauty shop services for 40 residents that resided in the facility. The facility census was 40. Findings are: Record review of Resident Policies, dated 01/12/11 related to Barber and Beauty Shops revealed that the basic fees for the barber and beauty shop were posted in the beauty shop. Observation on 12/2/15 at 11:00 AM revealed no posted list of charges for the barber and beauty services in the beauty shop. Interview on 12/2/15 at 10:47 AM with the facility Business Office Manager revealed that residents and responsible parties were not given anything in writing related to the charges for the beauty shop services. Interview with the facility Beauty Shop Operator on 12/2/15 at 10:50 AM revealed that the beauty shop operator had not given the families or residents any information related to the cost for barber and beauty shop services and confirmed that the costs had never been posted in the beauty shop. | 2019-07-01 |
| 6007 | 6007 | HERITAGE CARE CENTER | 285262 | P O BOX 667, 909 17TH STREET | FAIRBURY | NE | 68352 | 2015-09-28 | 156 | D | 0 | 1 | DDPI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview; the facility failed to issue liability notices to inform the resident or responsible party of the right to request a standard claim appeal to be sent to the fiscal intermediary for a payment decision for 1 resident (Resident 30) of three resident files reviewed. The facility census was 54. Findings are: Review of the facility's Medicare Meeting - Tracking Log dated 7/2/15 revealed Resident 30 was admitted on [DATE] and had utilized 30 days of Medicare A benefits for rehabilitation (therapy) services. Review of Resident 30's Interdisciplinary Progress Note dated 7/6/15 revealed, call placed to (family member) . Informed that Med A (Medicare A) ending due to Dr. (physician) not signing cert (certification) and .has met max potential. Review of a notice signed as completed on 7/6/15 titled, Voluntary Notice of Medicare or Insurance Non-Coverage revealed the service of Skilled Care would no longer be covered by Medicare for Resident 30 as of 7/8/15. The form went on to state that Resident 30's benefits were reviewed on 7/2/15 and to expect Medicare and/or Insurance may not pay for services listed below beginning on 7/8/15 due to Care not ordered or certified by a physician. The last paragraph of the letter informed recipients that the notice did not serve as an official medicare decision and the recipient may call the 1-800 number listed if they had questions. Interview with the Administrator on 9/24/15 at 11:18 AM revealed Resident 30's responsible party was not given a letter explaining their rights to appeal the non-coverage decision. The Administrator further explained the corporate office's policy was to issue the Voluntary Notice so that the resident or responsible party at least received some type of notice. The Administrator then confirmed that the Voluntary Notice did not notify the resident or responsible party of their right to appeal the decision. | 2019-07-01 |
| 6071 | 6071 | SORENSEN CARE AND REHABILITATION CENTER, LLC | 285107 | 4809 REDMAN AVENUE | OMAHA | NE | 68104 | 2015-06-02 | 156 | D | 0 | 1 | 0MYE11 | Licensure Reference Number 175 NAC 12-006.05(1) Based on record review and interview; the facility failed to ensure that residents were offered the option to have the Fiscal Intermediary review the medical record prior to the facility ceasing billing Medicare Part A for services rendered to residents for 2 (Residents 34 and 22) Medicare Determination on Continued Stay Letters reviewed. The facility census was 63. Findings are: A. Record review of a facility Flow Chart for Denial Letters dated (MONTH) (YEAR) revealed directions to ensure appropriate sections of the denial notices are complete or the denial notice is considered invalid. B. Record review of Resident 34 Medicare Determination on Continued Stay letters reviewed during the review of the facility Demand Billing processes revealed that no boxes had been selected by the resident or the responsible party to indicate resident choice whether or not to have had the medical record reviewed by the Fiscal Intermediary. Record review of Resident 34's Skilled Nursing Facility (SNF) Determination on Continued Stay letter dated 12/30/14 request for Medicare Intermediary Review section revealed that no box had been checked to indicate a choice to have bill submitted or not for a Medicare decision. C. Record review of Resident 22 Medicare Determination on Continued Stay letters reviewed during the review of the facility Demand Billing processes revealed that no boxes had been selected by the resident or the responsible party to indicate resident choice whether or not to have had the medical record reviewed by the Fiscal Intermediary. Record review of Resident 22's SNF Determination of Continued Stay letter dated 12/30/14 request for Medicare Intermediary Review section revealed that no box had been checked to indicate a choice to have bill submitted or not for a Medicare decision. D. Interview on 6/2/15 at 8:07 AM with the facility Director of Nursing verified that Residents 34 and 22's Medicare Determination on Continued Stay Letters did not indicate resident choice … | 2019-06-01 |
| 6095 | 6095 | BLUE HILL CARE CENTER | 285144 | 414 NORTH WILLSON | BLUE HILL | NE | 68930 | 2015-08-03 | 156 | C | 0 | 1 | IVKP11 | Based on record review and staff interview, the facility failed to provide Medicare denial notices for three residents (Residents 27, 19, and 21) using the correct expedited process forms and giving the beneficiaries the notice to request a Medicare demand bill. The facility census was 34. Findings are: A. Review of Resident 21's Social Service IDPN (Interdisciplinary Note) on 7/29/15 at 12:32 revealed that, on 4/9/15, the resident's family (no name) was notified that the resident no longer qualified for Medicare A and would be returning to the resident's former payer source. A message was left on the family member's answering machine. Interview on 7/29/15 at 9:44 AM with the Administrator revealed that there was no copies of Resident 21's forms in the facility. The forms had not been sent certified and the family had not returned the forms. The resident no longer resided in the building. B. Review of Resident 27's Medicare Expedited Letter issued on 6/8/15 revealed the wrong form was used. The family member was notified by phone on 6/8/15. C. Review of Resident 22's Expedited Letter revealed that the resident's Medicare A benefits were ending on 2/17/15. Resident 22 signed the Expedited letter on 2/16/15. The resident was given the wrong form and not the 48 hours the notice required. Resident 22 received a Skilled Nursing Facility Non Coverage Notice dated 2/13/15 and the notice was not signed until 2/16/15 when the Expedited Letter was signed. D. On 7/29/15 at 3:32 PM, an interview with the Administrator revealed that the Administrator acknowledged that Residents 27 and 22 were not given a 48 hour notice when they were denied from Medicare A. | 2019-06-01 |
| 6131 | 6131 | CLOVERLODGE CARE CENTER | 285201 | 301 NORTH 13TH STREET | ST EDWARD | NE | 68660 | 2015-11-24 | 156 | E | 0 | 1 | 4ZFX11 | Based on record review and interview, the facility failed to issue a liability notice to inform the resident or responsible party of the potential liability for payment and the right to request a standard claim appeal be sent to the Fiscal Intermediary (FI) for a payment decision for 1 resident (Resident 30). In addition, the option to have the FI review the medical record prior to the facility ceasing to bill Medicare Part A for services rendered was not identified for 3 residents (Residents 39, 28 and 1). The facility census was 39. Findings are: A. Review of the Centers for Medicare and Medicaid Services Survey and Certification letter 09/20 revealed a Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment of non-covered services when limitation of liability applies. The SNF's responsibility to provide notice can be fulfilled by use of either the SNF Advanced Beneficiary Notice (SNFABN) or 1 of 5 uniform Denial letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e., demand bill) submitted to Medicare. B. Review of Resident 30's Interdisciplinary Progress Notes dated 5/28/15 at 3:45 PM indicated notice was given to the resident's responsible party that the resident's Medicare Part A services were to be discontinued on 5/31/15. There was no evidence in Resident 30's medical record to indicate a SNFABN or Denial letter was provided to the resident or the responsible party. There was no evidence to indicate the resident/responsible party was provided the option to choose to have the medical record reviewed by the FI. C. Review of Resident 39's Determination on Continued Stay (Denial letter) dated 9/8/15 revealed no option was selected by the resident or responsible party to indicate their choice of whether or not to have the medical record reviewed by the FI. D. Review of Resident 28's Determination on Continued Stay dated 9/15/15 revealed no option was selected by the resident or responsible party to indicate their choice of… | 2019-06-01 |
| 6198 | 6198 | REGENCY SQUARE CARE CENTER | 285076 | 3501 DAKOTA AVENUE | SOUTH SIOUX CITY | NE | 68776 | 2015-11-05 | 156 | D | 0 | 1 | WMVL11 | Licensure Reference Number 175 NAC 12-006.05(1) Based on record review and interview; the facility failed to ensure that Resident 60 and 70 were offered the option to have the Fiscal Intermediary review the medical record prior to the end of Medicare Part A for services rendered for 2 Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) reviewed. The facility census was 59. Findings are: A. During the review of the facility Demand Billing processes, record review of Resident 60's SNFABN dated 5/11/15 revealed that no boxes had been selected by the resident or the responsible party to indicate resident choice whether or not to have the medical record reviewed by the Fiscal Intermediary. B. During the review of the facility Demand Billing processes, record review of Resident 70's SNFABN dated 5/14/15 revealed that no boxes had been selected by the resident or the responsible party to indicate resident choice whether or not to have the medical record reviewed by the Fiscal Intermediary. C. Interview on 11/4/15 at 4:12 PM with the facility Director of Resident Accounts (DRA) confirmed that Residents 60 and 70's SNFABN letters did not indicate resident choice as to whether or not they wished to have the medical record reviewed by the Fiscal Intermediary. The DRA confirmed that the facility staff went over the letters with the residents but did not ensure that a choice had been selected whether or not to have had the medical record reviewed by the Fiscal Intermediary. | 2019-05-01 |
| 6236 | 6236 | NORTH PLATTE CARE CENTER, LLC | 285165 | 2900 WEST E STREET | NORTH PLATTE | NE | 69101 | 2015-12-10 | 156 | F | 0 | 1 | JGHO11 | Licensure Reference Number 175 NAC 12-006.06C Based on observations, interviews and record reviews; the facility failed to ensure 1) that the Resident Council President was informed of the State Agency and the Ombudsman phone number and, 2) the the information containing the phone numbers for the State Agency and the Ombudsman were accessible to residents at the facility. The facility census was 49. Findings are: Observation on 12/9/15 at 10:00 AM revealed that the posted information containing the State Agency phone number and the Ombudsman phone number were posted at the end of an employee hallway. Further observation revealed that hallway was not accessible to residents of the facility. Review of the Resident Council Minutes from (MONTH) (YEAR) through (MONTH) (YEAR) revealed no written documentation to support that the resident council members had be instructed about the State Agency complaint reporting number or the Ombudsman number. Interview on 12/8/15 at 9:00 AM with the Resident Council President revealed that the president was not aware of a State Agency report number and was not aware of who the Ombudsman was. Further interview revealed that the president was not sure if the numbers were posted and available to all facility residents. Interview on 12/9/15 at 10:30 AM with the Activities Coordinator verified that the State Agency posting and the Ombudsman information was not accessible to the residents at the facility and should have been in a place and area that all residents could read. Further interview confirmed that the residents had not been told about the State Agency number for reporting complaints or the Ombudsman number. Interview on 12/10/15 at 9:45 AM with the Administrator verified that all of the facility residents should have been aware of the State Agency complaint number and the Ombudsman number. Further interview confirmed that the posting containing the information was not available for the residents at the facility and should have been. | 2019-05-01 |
| 6327 | 6327 | BIRCHWOOD MANOR | 285247 | 1120 WALNUT ST | NORTH BEND | NE | 68649 | 2017-02-02 | 156 | D | 0 | 1 | VXND11 | Based on record review and interview, the facility failed to issue the correct advanced beneficiary non-coverage notice to inform the resident or responsible party of the potential liability for payment and the right to request a standard claim appeal be sent to the fiscal intermediary for a payment decision for 3 residents (Resident 17, 26 and 49). The facility had total census of 47 residents. Findings are: A. Record review of a Centers for Medicare and Medicaid Services Survey and Certification letter 09/20 revealed that the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services when limitation of liability applies. The SNF's responsibility to provide notice can be fulfilled by use of either the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or one of 5 uniform Denial Letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e., demand bill) submitted to Medicare. B. Record review revealed Resident 17 was issued a Notice of Medicare Non-Coverage signed 11/02/16 which stated Resident 17's medicare coverage would end on 11/08/16. C. Record review revealed Resident 26 was issued a Notice of Medicare Non-Coverage signed 1/12/17 which stated Resident 26's medicare coverage would end on 1/16/17. D. Record review revealed Resident 49 was issued a Notice of Medicare Non-Coverage signed with an unreadable date which stated Resident 49's medicare coverage would end on 1/03/17. E. In an interview on 2/02/17 at 9:54 AM with the Social Service Director (SSD) confirmed that neither a SNFABN or one of the five uniform denial letters were given to Residents 17,26 and 49 because the SSD was unaware these forms should be given. | 2019-04-01 |
| 6429 | 6429 | GENOA COMMUNITY HOSPITAL/LTC | 2.8e+272 | P O BOX 310, 606/706 EWING AVENUE | GENOA | NE | 68640 | 2015-07-01 | 156 | F | 0 | 1 | 3TSL11 | Based on observation, record review and interview; the facility failed to ensure residents were given information about how to report care concerns to the State Agency, which had the potential to affect all residents. The facility census was 24 Findings are: Observations during the annual survey on 6/25, 6/29, 6/30 and 7/1/15 revealed no posting of the contact information for the State Agency for residents and the public to be able to call and report care concerns. A review of the facility admission packet did not reveal any contact information for the State Agency. On 6/30/15 at 5:23 PM the Social Service Designee confirmed the contact information was not posted or otherwise being provided to residents of the facility. | 2019-03-01 |
| 6502 | 6502 | OMAHA METRO CARE AND REHABILITATION CENTER, LLC | 285097 | 5505 GROVER STREET | OMAHA | NE | 68106 | 2015-04-01 | 156 | D | 0 | 1 | 0RLK11 | Based on record review and interview the facility staff failed to issue a skilled nursing facility advanced beneficiary notice (SNFABN) of potential liability for Medicare non-coverage (called a Medicare Denial Letter) for 3 (Residents 8, 21 and 110) residents reviewed. The facility census was 88. Findings are: Record review of three residents reviewed for the provision of notices of potential liability and non-coverage by Medicare revealed the following information: - Resident 8: Medicare services ended 10/12/14. The resident was not issued a SNFABN and was only provided with an expedited appeal notice (a way to request a quick decision by Medicare). - Resident 21: Medicare services ended 10/30/14. The resident was not issued a SNFABN and was only provided with an expedited appeal notice. - Resident 110: Medicare services ended 12/11/14. The resident was not issued a SNFABN and was only provided with an expedited appeal notice. Interview on 03/30/15 at 11:02:24 AM with Registered Nurse Assessment Coordinator (RNAC) F confirmed that Residents #8, 21 and 110 were not issued an SNFABN after Medicare services were discontinued. RNAC F stated that the facility did not have a policy related to Medicare denial letters. | 2019-01-01 |
| 6772 | 6772 | MOTHER HULL HOME | 285254 | 125 EAST 23RD STREET | KEARNEY | NE | 68847 | 2015-07-23 | 156 | F | 0 | 1 | PYGC11 | Based on interview and record review, the facility failed to educate the resident on their rights to file a complaint to the State Agency. The facility census was 48 at the time of the survey. This had the potential to affect all residents. Findings are: Interview with Resident 5 (Resident Council Representative) on 7/23/2015 at 1:06 PM revealed the residents had not been given information on how to formally make a complaint to the State about the care they were receiving. Interview with the Administrator on 7/23/2015 at 3:00 PM revealed the resident council had not been meeting until requested by a resident. The Administrator revealed they only had minutes of the Resident Council Minutes for May, (MONTH) and (MONTH) of (YEAR). Record review revealed the the facility had minutes of resident council minutes dated May, (MONTH) and (MONTH) (YEAR). | 2018-10-01 |
| 6808 | 6808 | FRANKLIN CARE AND REHABILITATION CENTER, LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2015-07-01 | 156 | F | 0 | 1 | BPRX11 | Based on observation and resident interview, the facility failed to educate the residents on the location of the posted Ombudsman's information. The Facility census was 26 at the time of the survey. This had the potential to affect all residents. Findings are: Interview on 07/01/2015 at 1:49 PM with the resident council president (Resident 7) revealed the residents were unaware of the location of the Ombudsman (a government official appointed to report and receive grievances). Observation on 07/01/2015 at 1:55 PM revealed the Ombudsman information was posted 74 inches off of the floor in the entry way of the building. Interview on 7/1/2015 at 3:45 PM with the Administrator revealed the Ombudsman information was located in the entry way of the building. | 2018-09-01 |
| 6969 | 6969 | TABITHA NURSING HOME | 285057 | 4720 RANDOLPH STREET | LINCOLN | NE | 68510 | 2015-03-23 | 156 | D | 0 | 1 | TARJ11 | Based on record review and interview; the facility failed to issue liability notices to inform the resident or responsible party of potential liability for payment and the right to request a standard claim appeal be sent to the fiscal intermediary for payment decision for 3 (Resident 387, 397 and 284) resident files reviewed. The facility staff identified a census of 208. Findings are: A. Record review of a Centers for Medicare and Medicaid Services Survey and Certification letter dated 09/20 revealed the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services when limitation of liability applies. The SNF's responsibility to provide notice can be fulfilled buy use of either the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or one of 5 uniform Denial letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e.,demand bill) submitted to Medicare. Issuing the Notice to Medicare Provider Non-coverage to a beneficiary only conveys notice to the beneficiary of the right to an expedited review of service termination and does not fulfill the provider's obligation to advise the beneficiary of potential liability of payment. The provider must still issue the SNFANBN or Denial Letter to address liability of payment. B. Record review of Resident 387's Notice of Medicare Non-coverage Quality Improvement Organization (QIO) request (a request for an expedited appeal) revealed Medicare services ended on 11-23-2014. Resident 387 was not issued a Medicare Denial of Benefits SNFABN liability notice. C. Record review of Resident 397's Notice of Medicare Non-coverage Quality Improvement Organization (QIO) request (a request for an expedited appeal) revealed Medicare services ended on 10-01-2014. Resident 397 was not issued a Medicare Denial of Benefits SNFABN liability notice. D. Record review of Resident 284's Notice of Medicare Non-coverage Quality Improvement Organization (QIO) request (a request for an exped… | 2018-07-01 |
| 7141 | 7141 | INDIAN HILLS HEALTHCARE COMMUNITY | 285091 | 1720 NORTH SPRUCE | OGALLALA | NE | 69153 | 2015-05-20 | 156 | D | 0 | 1 | RGZC11 | Based on record reviews and staff interview, the facility failed to ensure that the reason for discontinuing Medicare coverage was included as required on the Notice of Medicare Non-Coverage for one sampled resident (Resident 56). The facility census was 43. Findings are: Review of Resident 56's Notice of Medicare Non-Coverage, signed on 4/16/15 by the Resident's Representative, revealed no reason listed for discontinuing the Medicare Part A coverage on 4/22/15. Interview on 5/20/15 at 8:46 AM with the Business Office Manager confirmed that there was no documentation, as required, of the reason that the Medicare Part A coverage was discontinued as of 4/22/15. | 2018-05-01 |
| 7216 | 7216 | LIFE CARE CENTER OF OMAHA | 285137 | 6032 VILLE DE SANTE DRIVE | OMAHA | NE | 68104 | 2014-10-30 | 156 | D | 0 | 1 | K3JZ11 | Based on record review and interview, the facility failed to provide liability notices after discontinuation of Medicare benefits for 3 residents (Residents 1, 90 and 135). The facility staff identified a facility census of 97. Findings are: A. Record review of a Centers for Medicare and Medicaid Services Survey and Certification letter 09/20 revealed that the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services with limitation of liability applies. The SNF's responsibility to provide notice can be fulfilled by use of either the Skilled nursing Facility Advanced Beneficiary notice (SNFABN) or one of the 5 uniform Denial Letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e demand bill) submitted to Medicare. Issuing the Notice to Medicare Provider Non-coverage to a beneficiary only conveys notice to the beneficiary of the right to an expedited review of a service termination and does not fulfill the provider's obligation to advise the beneficiary of the potential liability of payment. The provider must still issue the SNFABN or a Denial Letter to address liability of payment. B. Record review of Resident 1's Notice of Medicare Non-Coverage dated 09/17/2014 revealed Medicare services ended on 9/20/2014. Resident 1's Responsible party was not issued a Medicare Denial of Benefits SNFABN liability notice. C. Record review of Resident 90's Notice of Medicare Non-Coverage dated 04/28/2014 revealed Medicare services ended on 05/01/2014. Resident 1's Responsible party was not issued a Medicare Denial of Benefits SNFABN liability notice. D. Record review of Resident 135's Notice of Medicare Non-Coverage dated 05/13/2014 revealed Medicare services ended on 05/17/2014. Resident 1's Responsible party was not issued a Medicare Denial of Benefits SNFABN liability notice. E. Interview with the facility Administrator on 10/30/2014 at 11:30 AM revealed that the Notice of Medicare Non-coverage were issued and not th… | 2018-05-01 |
| 7272 | 7272 | GOOD SAMARITAN SOCIETY - RAVENNA | 285202 | 411 WEST GENOA | RAVENNA | NE | 68869 | 2015-03-11 | 156 | E | 0 | 1 | IJQR11 | LICENSURE REFERNCE NUMBER 175 NAC 12-006.05 Based on staff and confidential resident interview, observations and record review; the facility failed to post contact information for Department of Health and Human Services (DHHS) and Resident Rights in an area easily accessible to residents and visitors. Furthermore, the facility failed to review Resident Rights with residents during their stay. Facility census was 38. Findings are: A. During a confidential resident interview on 3/11/15 at 10:31 AM it was revealed Resident Rights were not reviewed with residents. The resident went on to state that they were uncertain where the Resident Rights were posted in the building. The resident stated they were unsure of how to formally complain to DHHS about their care or where this information was posted. B. Observations of the facility revealed the Resident Rights and DHHS contact information to be posted on a bulletin board outside of the activity room, located down a hallway leading to the staff breakroom. The Resident Rights were printed in small print, making it difficult to read. The contact information for DHHS was posted 5 feet from the floor. This information was not accessible to residents and/or visitors in a wheelchair. C. Record review of Resident Council Meeting Minutes dated August 14-January 15 revealed the following Resident Rights were reviewed: - August: Comfortable room temperatures and food substitutes - September: Comfortable room temperatures and food substitutes - October: Life Safety - November: Services included in Medicare of Medicaid Payment - December: No right was reviewed - January: Safe, clean, comfortable and home-like Environment Review of Resident's Bill of Rights for Skilled Nursing Facilities (undated) which is provided to residents upon admission did not include rights of comfortable room temperatures and food substitutes. D. During an interview with the Social Services Director (SSD) on 3/11/15 at 1:34 PM it was verified the print of the Resident Rights hanging on the bulletin board was… | 2018-05-01 |
| 7521 | 7521 | ST JANE DE CHANTAL LONG TERM CARE SERVICES | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2014-09-24 | 156 | F | 0 | 1 | 1E3U11 | Based on observation and interviews, the facility failed to post the contact information for the State survey and certification agency, the protection and advocacy network and the Medicaid fraud control unit. This had the potential to affect all the residents of the facility. The facility had a census of 113. Findings are: Observation on 9/14/17 at 4:40 PM revealed that facility had postings with contact information for the local and state ombudsman. A Tour of the facility during the same time revealed no other contact information was posted. Interview with Resident 37 on 9/23/14 at 1:45 PM revealed that Resident 37 did not know that residents had the right to complain formally to the State about the care they are receiving and did not know how to contact the State to make such a complaint. Interview with Social Worker K on 9/23/14 at 3:40 PM revealed Social Worker K was able to only find postings with contact information for the local and state ombudsman. | 2018-02-01 |
| 7586 | 7586 | GOOD SAMARITAN SOCIETY - ALLIANCE | 285174 | P O BOX 970, 1016 EAST 6TH STREET | ALLIANCE | NE | 69301 | 2017-05-23 | 156 | D | 0 | 1 | M19B11 | Based on record review and interview, the facility failed to issue a required beneficiary non - coverage notice to inform the resident or the resident's responsible party of the potential liability for payment and the right to request an appeal to the fiscal intermediary for a payment decision for one sampled resident (Resident 20). The facility census was 37 with three residents sampled for review of the payment liability notice. Findings are: Review of the sampled list of Medicare beneficiaries discharged in the last six months revealed Resident 20 was discharged from Medicare benefits. Interview with the Social Services Director on 5/22/17 at 10:50 AM revealed that Resident 20 was discharged from skilled services on 3/8/17 and then discharged from the facility on 3/16/17. Further interview revealed there was no documentation that the resident's representative was issued the required liability and appeal notices. | 2018-02-01 |
| 7605 | 7605 | HILLCREST CARE CENTER | 285178 | 702 CEDAR AVENUE | LAUREL | NE | 68745 | 2014-07-23 | 156 | D | 0 | 1 | 9RA811 | Based on record review and staff interview; the facility failed to provide Residents 11 and 20 and/or their responsible party of the needed information to complete an expedited claim appeal. Facility census was 25. Findings are: Review of the facility's Medicare Demand Bill process revealed 2 (Residents 11 and 20) of 3 resident files reviewed had not been informed of the contact information for the Quality Improvement Organization (QIO: the state agency that processes expedited reviews of Medicare denials). During an interview with the Administrator on 7/23/14 at 1:50 PM, it was verified the QIO contact information was not on the form provided to the residents. | 2018-02-01 |
| 7733 | 7733 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2014-05-15 | 156 | D | 0 | 1 | 2Z8011 | Based on record review and interview, the facility failed to have the resident or resident representative sign the Skilled Nursing Facility Determination on Continued Stay or the Notice of Medicare Non-Coverage for three residents (Residents 7, 70 and 85). In addition, the facility failed to ensure that each resident was issued both the Skilled Nursing Facility Determination on Continued Stay and Notice of Medicare Non-Coverage for two residents (Resident 7 and 70). The facility census was 71. Findings Are: Review of Resident 7's Notice of Medicare Non-Coverage dated April 5, 2013 revealed there was no signature indicating Resident 7 received the notice. No letter of notification for Skilled Nursing Facility Determination on Continued Stay was on file. Record review of Resident 70's Skilled Nursing Facility Determination of Continued Stay dated 11/18/2013 revealed no markings indicating if there was a request for Medicare Fiscal Intermediacy Review and no signature for Verification of Receipt of Notice. There was no Notice of Medicare Non-Coverage stating if they requested an expedited review for this ending medicare stay. Record Review of Resident 85's Skilled Nursing Facility Determination of Continued Stay dated 9/9/2013 did not have a signature on the Verification of Receipt of Notice. There was no signature on the Notice of Medicare Non-Coverage stating if they requested an expedited review for this ending medicare stay. The Skilled Nursing Facility Advanced Beneficiary Notice had no signature. Interview with SSD (Social Services Director) on 5/14/14 at 11:25 AM stated that the Notice of Non-Coverage for Resident 7 and Resident 85 were not signed. The SSD further stated that the Skilled Nursing Facility Determination of Continued Stay for resident 85 and Resident 70 were not signed and the Advanced Beneficiary Notice was not signed for Resident 85. Review of the Facility ABN (Advanced Beneficiary Notice) Policy and Procedure dated 10/20/05 revealed the Notice to Medicare Provider Non-coverage does not fulfil… | 2018-01-01 |
| 7758 | 7758 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2014-05-12 | 156 | C | 0 | 1 | 7XFG11 | LICENSURE REFERENCE NUMBER NAC 12-006.06C Based on resident and staff interviews, record review and observations, the facility failed to make the ombudsman's information readily available to residents and/or responsible parties. The census was 37. Findings Are: A. During an interview on 5/7/14 at 2:00 PM the Resident Council president voiced that it was not known where the ombudsman's information was posted and/or who the ombudsmen was. During confidential interviews on 5/7/14 at 2:19 PM and 5/8/14 at 9:54 AM, 2 residents stated they were unaware of who the ombudsmen was or where the ombudsman's information was posted. During an interview with the Activity Director, Social Services Director and the Administrator, on 5/8/14 from 10:48 AM until 11:27 AM, it was revealed the ombudsmen visits the facility every 3 months, but staff were unaware if the ombudsmen spoke with residents during these visits. Review of the Resident Council Meeting Minutes from November 2012 through April 2014, revealed staff did not inform residents of who the ombudsman was or where the information for the ombudsman could be found. Observations on 5/8/14 at 11:38 AM revealed a sign measuring 8 inches x 10 inches posted in the hallway next to the activity room in an enclosed case, approximately 5 foot above the floor, inaccessible to residents in wheelchairs, with information on how to contact the ombudsman. | 2018-01-01 |
| 7789 | 7789 | BLUE VALLEY LUTHERAN NURSING HOME | 285259 | P O BOX 166, 220 PARK AVENUE | HEBRON | NE | 68370 | 2014-07-01 | 156 | D | 0 | 1 | T6OC11 | Based on interview and record review, the facility failed to provide a list of covered and non-covered items and services for Medicare and Medicaid charges for one resident (Resident 12) on admission. The facility census was 41. Findings are: Interview with Resident 12 family member on 6/25/14 at 12:42 PM revealed that the family member did not remember receiving a list of covered and non-covered services and item charges for Medicaid. The resident was admitted to the facility with Medicaid services. Review of the facility Admission Packet on 6/26/14 failed to provide the written information of the covered and non-covered items and services charges for Medicare and Medicaid. Interview on 6/26/14 at 10:51 AM with the Social Service Director (SSD) acknowledged that the Admission Packet did not contain a written list of non-covered and covered items and services for Medicare and Medicaid. The SSD did stated that the SSD did verbally state some of the covered and non-covered charged, but there was not a written list. | 2018-01-01 |
| 7885 | 7885 | FALLS CITY HEALTHCARE COMMUNITY | 285114 | 2800 TOWLE STREET | FALLS CITY | NE | 68355 | 2014-09-10 | 156 | E | 0 | 1 | 5IE211 | Licensure Reference Number 175 NAC 12.006.06C Based on observation and interview, the facility failed to ensure that residents knew how to contact the state and local ombudsman and the state department of health to file complaints about care received. The facility census was 48. Findings: Observed on 9/3/14 that postings of ombudsman and state department of health contact information were outside the social service office on the 600 hall, a hall that is not along a destination, like to the dining room, for the majority of residents. The bottom of the postings was approximately 4 feet above the floor, not easily visible from seated (wheelchair) position. Interview with Resident 15 on 9/3/14 at 3 PM revealed that the resident was unaware of how to contact the ombudsman or the state department of health and did not recall this information being shared at Resident Council meetings. Resident 15 had been observed earlier on 9/3/14 to walk the halls of the facility and aware of the day to day activities of the facility yet was unaware of the postings for the ombudsman and state department of health outside the social service office. Interview with Activities Director (AD) on 9/9/14 at 5:07 PM revealed that the AD assists with Resident Council meetings and confirmed that information on how to contact the ombudsman and the state department of health should be announced at meetings. The AD stated that residents are told to bring complaints or concerns to Social Services, Director of Nursing or Administrator and are not given the information to contact the state until they are not satisfied with facility resolutions. Review of Resident Council minutes for the past year reveal no notification or discussion about how to contact the local and state ombudsman or the state department of health. | 2017-12-01 |
| 7917 | 7917 | CROWELL MEMORIAL HOME | 285210 | 245 SOUTH 22ND STREET | BLAIR | NE | 68008 | 2014-09-17 | 156 | D | 0 | 1 | QMIV11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(1) Based on record review and interview; the facility failed to ensure that residents were offered the option to have the Fiscal Intermediary review the medical record prior to the facility ceasing billing Medicare Part A for services rendered to residents for two residents (Residents 78 and 79). The facility census was 64. Findings are: Record review of Facility Determination of Non-Coverage Letters for 2 residents (Residents 78 and 79). Facility Determination of Non-Coverage Letters reviewed during the review of the facility Demand Billing processes revealed that no boxes had been selected by the resident or the responsible party to indicate resident choice whether or not to have had the medical record reviewed by the Fiscal Intermediary. Record review of Resident 78's Facility Determination of Non-Coverage Letter dated 5/13/14 Request for Medicare Intermediary Review section revealed that no box had been checked to indicate a choice to have bill submitted or not for a Medicare decision. Record review of Resident 79's Facility Determination of Non-Coverage Letter dated 5/06/14 Request for Medicare Intermediary Review section revealed that no box had been checked to indicate a choice to have bill submitted or not for a Medicare decision. Interview on 8/16/12 at 11:37 AM with the facility Medicare Coordinator (MC) verified that Residents 78 and 79's Medicare Determination of Non-Coverage Letters did not indicate resident choice as to whether or not they wished to have had the medical record reviewed by the Fiscal Intermediary. The MC confirmed that the facility sent the letters to the resident or the responsible party but did not follow up with the resident or responsible party to ensure that a choice had been selected whether or not to have had the medical record reviewed by the Fiscal Intermediary. | 2017-12-01 |
| 7929 | 7929 | LOUISVILLE CARE CENTER | 285267 | 410 WEST 5TH STREET | LOUISVILLE | NE | 68037 | 2014-05-05 | 156 | C | 0 | 1 | WLGK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC ,[DATE].05 (4) Based on record review and interview, the facility failed to ensure residents were informed of changes in the facility's policy and procedures for CPR (Cardiopulmonary Resuscitation - Using rescue breathing and chest compressions to help a person whose breathing and heartbeat have stopped) which had the potential to impact all of the resident's or their legal representatives' decisions regarding their CPR status. The facility census was 58. Findings are: Interview with LPN (Licensed Practical Nurse) C on [DATE] at 3:03 PM revealed residents are asked their preference for the initiation of CPR if needed upon admission and an advance directive form is signed and placed in the residents chart. Review of a blank undated form titled Advanced Directives revealed, Do Not Resuscitate - What would you want us to do in the event facility staff find you without a heart beat and/or not breathing? (First option) I want facility staff to begin CPR and/or call 911. (Second option) I want the facility staff NOT to begin CPR. Residents and/or their responsible parties are to check which option they prefer and sign their names. Interview with the Director of Nursing Services on [DATE] at 3:30 PM revealed the facility had changed their policy and procedure for CPR to reflect that CPR would not be initiated if obvious signs of death were present when the need for CPR was identified. Review of the facility's policy titled, CPR/No CPR status and revised on [DATE] revealed the following, In the event of cardiac and/or respiratory arrest, a yes to CPR would then initiate the following: CPR will start immediately and a call to 911 will be placed A nurse is not expected to perform resuscitation on an individual when obvious signs of death are present. Obvious signs of death include lividity (bluish colored tissue) or pooling of blood in dependent body parts, cooling of the body following death, hardening of muscles or… | 2017-12-01 |
| 8012 | 8012 | HILLTOP ESTATES | 285163 | P O BOX 429, 2520 AVENUE M | GOTHENBURG | NE | 69138 | 2014-09-16 | 156 | D | 0 | 1 | N5FF11 | Based on interview and record review, the facility failed to present the Centers for Medicare and Medicaid SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice) to one resident (Resident 22) or their financially responsible parties when their Medicare A services ended and the resident remained in the facility. The facility census was 46 at the time of the survey. Findings are: Review of the facility's Medicare Demand Bill process revealed 1 (Resident 22) of 3 resident files reviewed had not been informed of the contact information for the Quality Improvement Organization (QIO: the state agency that processes expedited reviews of Medicare denials). Interview with FSM-B (Financial Service Manager) on 9/16/2014 at 1:52 PM revealed the facility failed to provide appropriate liability and appeal notice to Resident 22. | 2017-11-01 |
| 8070 | 8070 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2014-10-02 | 156 | D | 0 | 1 | 30CN11 | Based on interview and record review, the facility failed to issue the right to request a standard claim appeal be sent to the fiscal intermediary for a payment decision (Medicare A Denial Letter) for one resident (Resident 83) and two residents (Residents 3 and 42) were not given the required 48 hour notice timeframe. The facility census was 73. Findings are: A. Record review of a Centers for Medicare and Medicaid Services Survey and Certification letter 09/20 revealed that the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services when limitation of liability applies. The SNF's responsibility to provide notice can be fulfilled by use of either the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or one of 5 uniform Denial Letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e. Demand bill) submitted to Medicare. Issuing the Notice to Medicare Provider Non-coverage to a beneficiary only conveys notice to the beneficiary of the right to an expedited review of a service termination and does not fulfill the provider's obligation to advise the beneficiary of potential liability of payment. The provider must still issue the SNFABN or a Denial Letter to address liability of payment. B. Review of the Centers for Medicare and Medicaid Services Survey and Certification Instruction Manual 70.3.3 Timely Delivery of SNFABN stated that the SNF must notify the beneficiary well enough in advance to all the beneficiary to make other arrangements. Last minute deliveries of the SNFABN would be considered untimely, regardless of the SNF's intentions. C. Review of the Notice of Medicare Non-Coverage stated the beneficiary must receive the Notice of Medicare Non-Coverage of services two days before the termination of services for timely delivery to occur. D. Review of Resident 3's Medicare Non-Coverage Quality Improvement Organization (QIO) notice was dated that services would end on 9/17/14. The resident re… | 2017-11-01 |
| 8116 | 8116 | NEBRASKA SKILLED NURSING & REHAB | 285058 | 7410 MERCY ROAD | OMAHA | NE | 68124 | 2014-06-17 | 156 | D | 0 | 1 | USL111 | Based on record review and interview; the facility staff failed to provide notice of potential liability after discontinuation of Medicare benefits for 3 (Resident 29, 183 and 51). The facility staff identified a census of 111. A. Record review of a Centers for Medicare and Medicaid Services Survey and Certification letter 09/20 revealed that the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services with limitation of liability applies. The SNF's responsibility to provide notice can be fulfilled by use of either the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or one of 5 uniform Denial Letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e. demand bill) submitted to Medicare. Issuing the Notice to Medicare Provider Non-coverage to a beneficiary only conveys notice to the beneficiary of the right to an expedited review of a service termination and does not fulfill the provider's obligation to advise the beneficiary of potential liability of payment. The provider must still issue the SNFABN or a Denial Letter to address liability of payment. B. Record review of Resident 29's Notice of Medicare Non-Coverage revealed Medicare services ended on 1-23-2014. Resident 26/Responsible party was not issue a Medicare Denial of Benefits SNF ABN liability notice. C. B. Record review of Resident 183's Notice of Medicare Non-Coverage revealed Medicare services ended on 4-18-2014. Resident 26/ Responsible party was not issue a Medicare Denial of Benefits SNF ABN liability notice. D. Record review of Resident 51's Notice of Medicare Non-Coverage revealed Medicare services ended on 3-10-2014. Resident 51 was not issue a Medicare Denial of Benefits SNF ABN liability notice. On 6-16-2014 at 11:54 AM an interview was conducted with the Social Services Director (SSD). During the interview, Resident's 29, 183 and 51's Notice of Medicare Non-coverage Notices were reviewed with the SSD. The SSD confirmed were… | 2017-10-01 |
| 8469 | 8469 | GREELEY CARE HOME | 285286 | 201 E O'CONNOR AVENUE | GREELEY | NE | 68842 | 2013-12-12 | 156 | E | 0 | 1 | W7NN11 | Based on record review and interview, the facility failed to ensure three residents, Residents 9, 15, and 27 were provided the complete liability and appeals notices when Medicare benefits were being denied. The facility census was 19 and 18 residents were taken on sample. Findings are: Review of Resident 9 and 15's files revealed that while a notice was given it did not include a date that Medicare services would be ending and did not include the resident's right to appeal the decision. On 12/11/13 at 3:49 PM the Facility Consultant stated in an interview that the facility was unable to locate Resident 27's file and therefore there was no supporting documentation that the resident was given a liability notice when Medicare services were ending. The Facility Consultant also confirmed at this time that the incorrect/incomplete forms were given to Residents 9 and 15. | 2017-06-01 |
| 9084 | 9084 | SOUTH HAVEN LIVING CENTER | 285231 | 1400 MARK DRIVE | WAHOO | NE | 68066 | 2013-05-21 | 156 | B | 0 | 1 | K9A011 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(1) Based on record review and interview; the facility staff failed to inform the resident and/or responsible party of the potential liability of payment and the right to request a standard claim appeal (i.e. demand bill) be submitted to Medicare for two ( Residents 22 and 91) of nine resident's files reviewed. One resident (Resident 27) was issued notice of non-coverage 26 days early. The facility census was 76. Findings are: Record review of a Centers for Medicare and Medicaid Services Survey and Certification letter 09-20 revealed that the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services when limitation of liability applies. The SNF's responsibility to provide notice can be fulfilled by use of either the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or one of 5 uniform Denial Letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e. demand bill) submitted to Medicare. Issuing the Notice to Medicare Provider Non-coverage to a beneficiary only conveys notice to the beneficiary of the right to an expedited review of a service termination and does not fulfill the providers obligation to advise the beneficiary of potential liability of payment. The provider must still issue the SNFABN or a Denial Letter to address liability of payment. Review of the facility's Medicare Demand Bill process revealed that two (Residents 22 and 91) of nine residents files reviewed had not been informed of the right to submit a Demand Bill to Medicare through the standard claim appeal and had not been issued a SNFABN or a Denial Letter to address liability of payment. Resident 27 was issued appropriate notice however the notice issued to the resident 26 days prior to the end of service. Interview on 05/20/13 at 11.30AM with the facility Administrator confirmed that SNFABN liability notices should have been issued to Resident 22 and 91and this had not been done. … | 2016-11-01 |
| 9104 | 9104 | HUNTINGTON PARK CARE CENTER | 285251 | 1507 GOLD COAST ROAD | PAPILLION | NE | 68046 | 2015-04-02 | 156 | F | 1 | 1 | BX8K11 | Based on record review and interview; the facility staff failed to provide education on Resident Rights. This had the potential to affect all residents in the facility. The facility staff identified a census of 85. In an Interview with Resident 86 on 04/01/2015 at 10:00 AM revealed Resident Rights had not been reviewed at Resident Council Meeting since Resident 86 had been at the facility. Record review of Resident Council Meeting notes dated 04/09/2014 revealed Social Services reviewed Resident Rights; these will be reviewed at the meeting every 6 months going forward . Interview with Social Services Director on 04/02/2015 at 8:42 AM revealed that Residents Rights are to be reviewed with residents twice yearly at Resident Council Meeting as voted on by the Resident Council in April on 2014. Social Service Director also revealed there was no documentation that this had occurred. | 2016-11-01 |
| 9410 | 9410 | NEBRASKA SKILLED NURSING & REHAB | 285058 | 7410 MERCY ROAD | OMAHA | NE | 68124 | 2013-02-25 | 156 | D | 0 | 1 | XPOS11 | Based on record review and interview, the facility failed to provide notice of potential liability after discontinuation of Medicare benefits for 3 (Resident 10, 158, and 268) of 35 sampled residents. The facility had a total census of 120 residents. Findings are: A. Record review of a Centers for Medicare and Medicaid Services Survey and Certification letter 09/20 revealed that the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services when limitation of liability applies. The SNF's responsibility to provide notice can be fulfilled by use of either the Skilled Nursing Facility Advanced Beneficiary Notice ( SNFABN) or one of 5 uniform Denial Letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e.,demand bill) submitted to Medicare. Issuing the Notice to Medicare Provider Non-coverage to a beneficiary only conveys notice to the beneficiary of the right to an expedited review of a service termination and does not fulfill the providers ' obligation to advise the beneficiary of potential liability of payment. The provider must still issue the SNFABN or a Denial Letter to address liability of payment. B. Record review of Resident 10 ' s Notice of Medicare Non-coverage revealed that Medicare services ended 2/15/13. Resident 10 was not issued a Medicare Denial of Benefits SNF ABN liability notice. C. Record review of Resident 158 ' s Notice of Medicare Non-coverage revealed that Medicare services ended 2/14/13. Resident 158 was not issued a Medicare Denial of Benefits SNF ABN liability notice. D. Record review of Resident 268 ' s Notice of Medicare Non-coverage revealed that Medicare services ended 1/5/13. Resident 268 was not issued a Medicare Denial of Benefits SNF ABN liability notice. E. In an interview on 2/21/13 at 8:28 AM, Social Worker A reported residents were only issued a Notice of Medicare Non-Coverage and not issued a SNFABN. | 2016-07-01 |
| 9540 | 9540 | LEGACY GARDEN REHABILITATION & LIVING CENTER | 285186 | 200 VALLEY VIEW DRIVE | PENDER | NE | 68047 | 2013-03-04 | 156 | D | 0 | 1 | BOXW11 | Based on record review and interview; the facility staff failed to ensure that 1 (Resident 31) of 3 resident liability notice records reviewed were offered a choice to request a Medicare Intermediary review upon discontinuation of skilled Medicare services. The sample size was 28 from a facility census of 32. Findings are: Record review of a Centers for Medicare and Medicaid Services Survey and Certification letter dated 09/20 revealed that the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services when limitation of liability applies. The SNF's responsibility to provide notice can be fulfilled by use of either the Skilled Nursing Facility Advanced Beneficiary Notice ( SNFABN) or one of 5 uniform Denial Letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e.,demand bill) submitted to Medicare. Record review of Resident 31's Determination of Continued Stay liability notice dated 7/2/12 revealed that the choice whether or not to request a Medicare Intermediary Review had not been identified or marked. Interview on 2/17/13 at 10:56 AM with the Business Office Manager (BOM) confirmed that the choice wether or not to request a Medicare Intermediary Review had not been checked and that no follow up had been done to determine if the Resident 31 wanted to request a Medicare Intermediary review. The BOM confirmed that the facility did not have a policy related to Medicare Determination on Continued Stay letters or Demand Billing. | 2016-07-01 |
| 9585 | 9585 | SUNRISE HEIGHTS OF WAUNETA | 285220 | PO BOX 520, 427 LEGION STREET | WAUNETA | NE | 69045 | 2013-09-25 | 156 | D | 0 | 1 | LPTG11 | Licensure Reference Number 175 NAC 12-006.06C Based on interviews and record review, the facility failed to ensure that two sampled residents (Residents 13 and 22) were educated on the location of the telephone numbers and information on reporting for the State Department of Investigations and the State Ombudsman. Facility census was 31. Findings are: Interview on 9/24/13 at 4:00 PM revealed that Resident 13 did not know the location of the Ombudsman or the Department of Investigations contact numbers or how to file a complaint. Interview on 9/24/13 at 10:00 AM revealed that Resident 22 did not know the location of the Ombudsman or the Department of Investigation contact numbers or how to file a complaint. Review of the Resident Council Meeting notes for the months of January 2013 through August 2013, revealed that there was no written documentation to indicate that Residents 13 and 14 had been instructed on the location of the contact numbers for the State Department of Investigations or the State Ombudsman. Interview on 9/25/13 at 10:15 AM with the Director of Nursing (DON) revealed that the State Ombudsman had been at the facility but had not visited with the Residents 13 and 14. Further interview revealed that the contact numbers for the Ombudsman and the Department of Investigations had not been reviewed at Resident Council Meetings. Interview on 9/25/13 at 3:00 PM with the Administrator and the DON confirmed that Residents 13 and 22 had not been educated on the contact numbers for the State Ombudsman and the Department of Investigations or how to file a complaint. Further interview confirmed that Residents 13 and 22 should have been educated on the location of the telephone numbers for the State Ombudsman and the Department of Health and instructed on how to file a complaint. | 2016-07-01 |
| 9638 | 9638 | BRIGHTON GARDENS OF OMAHA | 285274 | 9220 WESTERN AVENUE | OMAHA | NE | 68114 | 2013-04-02 | 156 | D | 0 | 1 | PQE811 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.06C Based on interview, the facility failed to inform the resident about the right to file a complaint with the State Survey agency. The facility sample was 33 with a census of 41. This was in violation to Licensure Reference Number 12-006.06C. Findings are: Interview with Resident 54 on 04/01/2013 at 1:00 PM revealed the facility failed to inform the resident of the right to file a complaint with the state survey agency and the manner in which that could be done. The resident stated that no information had been given to the resident to report a complaint to the state agency. The resident was not aware of a phone number posted in the facility where the state agency could be reached. . | 2016-07-01 |
| 9687 | 9687 | PIONEER MEMORIAL COMMUNITY HOSPITAL | 2.8e+176 | P O BOX 578, 206 NW 4TH STREET | MULLEN | NE | 69152 | 2013-08-21 | 156 | E | 0 | 1 | UESZ11 | Licensure Reference Number 175 NAC 12-006.06C Based on resident interview, staff interview, and record review; the facility failed to ensure that the Representative of the Resident Council (Resident 7) was aware of the procedures to: 1) file a complaint with the State Investigations Division and; 2) contact the Long Term Care Ombudsman. Facility census was 26. Findings are: Interview on 8/20/13 at 10:00 AM revealed that Resident 7 was not aware of the location of reporting information or the phone number to file a report with the State Investigations Division. Further interview revealed that Resident 7 was not aware of the location of the Long Term Care Ombudsman information or the phone number to reach the Ombudsman. Interview on 8/21/13 at 10:00 AM with the Activities Director revealed that the information for reporting a complaint to the State Investigations Division, the Long Term Care Ombudsman information and, the contact phone numbers had not been addressed with Resident 7. Review of Resident Council Meeting notes for months of April, May, June, and July of 2013 did not contain written information to indicate that residents educated on location of the information for filing complaints or contacting the ombudsman. Further review revealed that Resident 7 attended meetings on those dates. Interview on 8/21/13 at 10:20 AM with the Activities Director confirmed that the information on reporting complaints to the State and the Ombudsman information and phone numbers should have been discussed with residents. | 2016-07-01 |
| 9921 | 9921 | GOLDEN LIVINGCENTER - WAUSA | 285111 | 703 SOUTH VIVIAN | WAUSA | NE | 68786 | 2012-09-20 | 156 | C | 0 | 1 | BQ8V11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.06C Based on observations and staff interview the facility failed to post phone numbers and addresses on how to contact the Ombudsman (an advocate for residents) and/or information needed to submit a complaint to the State Agency in a prominent place. Facility census was 24. Findings are: During the environmental tour conducted on 9/20/12 from 9:20 AM until 10:30 AM, the phone numbers for the Ombudsman and/or information to submit a complaint to the State Agency were not posted in a prominent place. This information was placed in a notebook, on a table by the front entrance. The notebook identified the contents included Resident Information and Survey Inspection Results . Interview with the Administrator on 9/20/12 from 9:30 AM until 9:35 AM verified the information was in a notebook and not posted in a prominent place and readily visible to residents, employees and the public. | 2016-04-01 |
| 9968 | 9968 | THE REHABILITATION CENTER OF OMAHA LLC | 285218 | 910 SOUTH 40TH STREET | OMAHA | NE | 68105 | 2013-01-23 | 156 | E | 0 | 1 | O26211 | Based on record review and interview; the facility failed to issue liability notices timely and inform the resident /or responsible party of the potential liability of payment and the right to request a standard claim appeal be sent to the fiscal intermediary for a payment decision for 3 ( Residents 21, 42 and 25) of 4 resident files reviewed. The sample size was 52 and the census was 50. Findings are: A. Record review of a Centers for Medicare and Medicaid Services Survey and Certification letter 09/20 revealed that the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services when limitation of liability applies. The SNF's responsibility to provide notice can be fulfilled by use of either the Skilled Nursing Facility Advanced Beneficiary Notice ( SNFABN) or one of 5 uniform Denial Letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e.,demand bill) submitted to Medicare. Issuing the Notice to Medicare Provider Non-coverage to a beneficiary only conveys notice to the beneficiary of the right to an expedited review of a service termination and does not fulfill the providers obligation to advise the beneficiary of potential liability of payment. The provider must still issue the SNFABN or a Denial Letter to address liability of payment. B. Record review of Resident 21's Medicare Denial of Benefits notice dated 9/6/12 revealed that Resident 21 had not received advance notice of the denial of benefits and that services would end on 9/6/12. The notice was issued the same day of discharge on 9/6/12 with no advance notice given to the resident. C. Record review of Resident 42's Medicare Denial of Benefits notice dated 12/6/12 revealed that Resident 42 had not received advance notice of the denial of benefits and that services would end on 12/6/12. The notice revealed that services ended 12/6/12 but the notice was not signed by the resident until 12/14/12. Review of the Medicare Intermediary Review section reve… | 2016-04-01 |
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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 );