cms_NE
Data source: Big Local News · About: big-local-datasette
12,996 rows sorted by facility_name
This data as json, copyable, CSV (advanced)
| Link | rowid | facility_name ▼ | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11239 | 11239 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 226 | C | 0 | 1 | G3Q011 | F 226 LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on observations, record review and staff interview the facility failed to protect all residents from potential abuse/neglect. The facility failed to re-educate a staff member who was accused of neglect of Resident 16 before allowing the staff member to return to work. Facility census was 34. Findings are: On 8/6/12 at 11:00 AM the Administrator indicated an allegation of neglect involving Resident 16 and Nursing Assistant (NA) M had been reported to the State Agency that morning. The Administrator stated NA-M had been suspended until the investigation was completed. Review of the written investigation for this allegation dated 8/8/12 revealed NA-M was placed on extended probation and was to be re-educated regarding facility abuse and neglect policy. Additional staff training was to be done with all staff regarding abuse and neglect recognition and reporting. On 8/8/12 at 5:30 PM the suspended employee NA-M was observed working the 2:00 PM to 10:00 PM shift. Interview with the Director of Nursing (DON) on 8/9/12 from 10:20 AM until 10:30 AM, revealed DON thought the investigation was completed; however the interventions for re-education of the suspended employee and other staff members had not been completed. The DON stated the suspended employee was informed on 8/8/12 while working the evening shift of the need for the DON to visit with employee regarding the incident. Interview with the Administrator on 8/9/12 from 10:30 AM until 10:35 AM, revealed the suspended employee should not have returned to work until the interventions were in place to prevent further neglect of residents. | 2015-07-01 |
| 11240 | 11240 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 242 | D | 0 | 1 | G3Q011 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(4) Based on record review, staff and resident interviews, the facility failed to afford Residents 20 and 22 their choice regarding the number of baths they received per week. Facility census was 34. Findings are: A. When asked about choosing how many times a week the resident received a bath, Resident 20 stated during interview on 8/7/12 from 11:23 AM until 11:40 AM, "I would like to choose. I would choose to take more. I would like it (bath) 3 times a week." The resident stated the bath aide was informed of this request; however the resident indicated 1 whirlpool bath was provided weekly. Review of the Bath/Shower Schedule revealed Resident 20 was scheduled to receive 2 baths per week on Tuesdays and Fridays. Review of documentation of baths provided for Resident 20 revealed the resident did not receive a bath for 8 or 9 days on the following dates: -4/24/12 until 5/2/12 (8 days) -5/9/12 until 5/18/12 (9 days) -5/29/12 until 6/6/12 (8 days) -6/19/12 until 6/28/12 (9 days) -7/10/12 until 7/19/12 (9 days) Interview with Nursing Assistant (NA) J on 8/9/12 from 7:25 AM until 7:30 AM revealed Resident 20 was scheduled for 2 baths per week. NA-J indicated Resident 20 did not always receive 2 baths per week. NA-J was aware the resident desired more baths per week. B. Resident 22 stated during interview on 8/6/12 from 2:00 PM until 2:20 PM that no choice was provided regarding how many times a week a bath was provided. The resident stated 1 bath a week was provided and "sometimes" 2 baths a week were provided. The resident's choice was to receive 2 baths per week. Review of the Bath/Shower Schedule revealed Resident 22 was scheduled to receive 2 baths per week on Tuesdays and Fridays. Review of documentation of baths provided for Resident 22 revealed the resident did not receive a bath for 8 to 10 days on the following dates: -4/25/12 until 5/5/12 (10 days) -5/8/12 until 5/17/12 (9 days) -5/17/12 until 5/29/12 (8 days) -5/29/12 until 6/8/12 (10 days) -6/19/12 until 6/28/12 (9… | 2015-07-01 |
| 11241 | 11241 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 280 | D | 0 | 1 | G3Q011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on record review, observations and staff interviews; the facility failed to revise Resident 3's Care Plan following falls. Facility census was 34. Findings are: Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/11/12 revealed [DIAGNOSES REDACTED]. The MDS indicated the resident had short term memory problems and had 1 fall in the past 3 months with no injury. Review of the MDS dated [DATE] revealed the resident continued to have short term memory problems and no falls since the last assessment. Review of an Event Report dated 1/23/12 at 2:09 PM revealed at 1:45 PM the resident lost balance while ambulating with the aid of a walker and a nursing assistant. The resident fell backwards and slid to the floor. Documentation further indicated measures taken following the fall were the "use of gait belt (a belt placed around a resident's waist to assist with transferring the resident from one position to another by providing support for the resident and a safe hand hold for the caregiver) during transfers". Review of the current Care Plan dated 5/10/12 revealed the resident had a potential for injury as a result of poor safety awareness. The Care Plan specified a goal for the resident to remain free from injury. There was no documentation to indicate the intervention of using a gait belt during transfers was added to the Care Plan. On 8/6/12 from 4:05 PM until 4:10 PM, Nursing Assistant (NA) C was observed to transfer Resident 3 out of a wheelchair and into bed. The resident required extensive assistance and no gait belt was used during the transfer. Review of an Event Report dated 7/21/12 at 12:27 AM revealed the resident was heard screaming and crying at 11:40 PM (on 7/20/12). Documentation further indicated the resident was confused. The resident was assisted to the bathroom, placed on the toilet and instructed to us… | 2015-07-01 |
| 11242 | 11242 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 309 | D | 0 | 1 | G3Q011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on record review, observations and staff interviews, the facility failed to reposition Residents 10 and 15 every 2 hours in accordance with the facility's standard of practice. These residents were unable to reposition themselves. Facility census was 34. Findings are: A. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/25/12 revealed [DIAGNOSES REDACTED]. The MDS dated [DATE], 4/18/12 and 7/19/12 indicated the resident had short and long term memory problems, was totally dependent with bed mobility, and was on a turning/repositioning program. Review of Resident 15's current Care Plan dated 7/12/12 revealed the resident was limited in bed mobility. Interventions were to turn and reposition the resident frequently. Resident 15 was observed seated in a wheelchair without benefit of repositioning on 8/8/12 at 6:50 AM, 8:00 AM, 9:22 AM, 10:34 AM, 11:00 AM, 12:00 PM, 12:50 PM and 1:50 PM (7 hours). On 8/8/12 at 1:50 PM, Nursing Assistants (NA) G and H were observed to transfer the resident from the wheelchair into bed. Interviews with NA-H and NA-A at this time revealed NA-H had gotten the resident out of bed that morning. NA-H and NA-G were unaware if the resident had been repositioned since that time. NA-G stated the resident was usually laid down for a while between the breakfast and noon meal, but did not know if this had been done on this day. NA-H and NA-G proceeded to check the resident's disposable incontinent brief. The resident ' s slacks and disposable incontinent brief were saturated with urine (which indicated the resident had not been checked for incontinence and repositioned in a timely manner). B. Review of Resident 10's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS dated [DATE], 3/21/12 and 6/21/12 indicated the resident had short and long term memory problems, was totally dependent with be… | 2015-07-01 |
| 11243 | 11243 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 323 | D | 0 | 1 | G3Q011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review, observations and staff interview; the facility failed to implement interventions for the prevention of falls for Resident 3. Facility census was 34. Findings are: Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/11/12 revealed [DIAGNOSES REDACTED]. The MDS indicated the resident had short term memory problems and had 1 fall in the past 3 months with no injury. Review of the MDS dated [DATE] revealed the resident continued to have short term memory problems and no falls since the last assessment. Review of an Event Report dated 1/23/12 at 2:09 PM revealed at 1:45 PM the resident lost balance while ambulating with the aid of a walker and a nursing assistant. The resident fell backwards and slid to the floor. Documentation further indicated measures taken following the fall were the "use of gait belt (a belt placed around a resident's waist to assist with transferring the resident from one position to another by providing support for the resident and a safe hand hold for the caregiver) during transfers". Review of the current Care Plan dated 5/10/12 revealed the resident had a potential for injury as a result of poor safety awareness. The Care Plan specified a goal for the resident to remain free from injury. Interventions included the following: give resident verbal reminders not to ambulate/transfer without assistance, keep bed in lowest position with brakes locked, fall prevention program, provide an environment free of clutter, provide with safety device/appliance wheeled walker and wheelchair and use of a tabs alarm (A pull-string is attached to the resident's garment and sounds an alarm if the resident attempts to rise out of a chair or bed) at all times. There was no documentation to indicate the intervention of using a gait belt during transfers was added to the Care Plan. On 8/6/12 from 4:… | 2015-07-01 |
| 11244 | 11244 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 371 | F | 0 | 1 | G3Q011 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.11e Based on observations, staff interview and record review; the facility failed to ensure dishes and utensils were cleaned under sanitary conditions and food was served in a sanitary manner and at safe temperatures. Facility staff did not maintain and operate the dishwashing machine according to manufacturer ' s instructions. In addition, facility staff did not wash hands and change gloves during meal service according to facility policy. A poached egg and a glass of milk were served to Resident 35 at an unsafe temperature. Facility census was 34. Findings are: A. Review of facility policy titled; "Food Preparation and Service" (revised November 2010) Cooking and Holding Temperatures and Times and Food Service/Distribution" revealed the following: -The "danger zone" for food temperatures is between 41 degrees and 135 degrees Fahrenheit (F). This temperature range promotes the rapid growth of pathogenic microorganisms that cause food borne illness. Food temperatures must be maintained at 40 degrees F or below or at 136 degrees F and above. -Potentially hazardous foods include meats, poultry, cut melon, eggs, milk, yogurt and cottage cheese. -Gloves must be worn when handling food directly. However, gloves can become contaminated and/or soiled and must be changed between tasks. B. During observation of the noon meal in the Assisted Dining Room on 8/6/12 from 11:50 AM until 12:34 PM, the Dietary Manager (DM) put on gloves and dished up plates of food from the steam table. The DM placed a plate of food in front of Resident 8 and offered to cut the chicken off of the bone. With gloved hands, the DM picked up the resident's fork and cut the chicken off of the bone. The DM did not remove gloves, returned to the steam table and proceeded to dish up plates of food for other residents. C. Observation of the breakfast meal in the Assisted Dining Room on 8/8/12 revealed the following: -At 8:00 A.M., the Dietary Cook (DC)-K placed a bowl of hot cereal and a plate with a poached egg … | 2015-07-01 |
| 11245 | 11245 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 441 | D | 0 | 1 | G3Q011 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observations, staff interview and record review; the facility failed to ensure respiratory equipment was stored and maintained in a sanitary manner to prevent cross contamination. Oxygen tubing with nasal cannula and a nebulizer machine with mask and tubing for Residents 34 and 35 were observed lying on the floor, in a trash receptacle and in Resident 34 ' s recliner. Facility census was 34. Findings are: Review of the Infection Control Policy titled; " Department (Respiratory Therapy) -Prevention of Infection " (revised October 2010) revealed the following: -Keep the oxygen cannula and tubing in a plastic bag when not in use. -Store Nebulizer equipment in a plastic bag, marked with date and the resident ' s name, between uses. Observations on 8/6/12 at 12:04 PM, 8/7/12 at 4:30 PM and 8/8/12 at 9:00 AM, revealed Resident 34 ' s nebulizer machine, tubing and mask were lying uncovered in the seat of Resident 34 ' s recliner. In addition the oxygen tubing and cannula to Resident 34 ' s oxygen concentrator were uncovered and were observed lying directly on the floor. Observation on 8/6/12 at 11:55 AM revealed the tubing and cannula to Resident 35 ' s oxygen concentrator were uncovered and tubing was draped across a trash receptacle at the resident ' s bedside. 2 cleansing cloths covered with feces were in the trash receptacle. The cannula was lying across the resident ' s water pitcher on the bedside table. On 8/7/12 at 9:00 AM, Resident 35 ' s oxygen tubing and cannula were again uncovered with the tubing lying directly on the floor and the cannula resting inside the bedside trash receptacle. Interview with the Administrator on 8/9/12 from 9:00 to 9:45 AM, revealed the nebulizer and oxygen equipment should be cleaned and stored according to facility policy. | 2015-07-01 |
| 11246 | 11246 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-11-20 | 323 | G | 1 | 0 | R4Z111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE: 175 NAC 12-006.09D7 Based on observation, record review and staff interview; the facility failed to assess Resident 1who was identified with a history of falls. Assessments were not completed to identify causal factors and additional interventions were not developed to protect residents from further falls with injury. The facility had a census of 35. Findings are: A. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/16/12 revealed resident had short and long term memory loss with severely impaired decision making skills. Identified [DIAGNOSES REDACTED]. The MDS reflected Resident 1 required extensive assist of 2 staff with bed mobility and total assist of 1 staff with transfers and dressing. Assessment further revealed Resident 1 had a history of [REDACTED]. Review of Resident 1's Care Plan dated 6/15/12 reflected the resident had potential for injury related to restlessness, poor balance and due to unawareness of safety hazards. Care Plan interventions included: -3/17/11 Fall assessment every quarter and prn (as needed). -3/17/11 TABS alarm (a personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) at all times. -3/3/11 Give verbal reminders not to ambulate or transfer without assistance. -3/17/11 Provide proper, well maintained footwear. -3/17/11 Keep call light within reach at all times. -3/17/11 Provide with a clutter free environment. -3/17/11 Keep personal items and frequently used items within reach. -3/17/11 Keep bed in lowest position (mattress on floor with mat at bedside) -3/17/11 Encourage resident to participate in restorative program. -3/17/11 Assure the floor is free of glare, liquids, and foreign objects. -3/17/… | 2015-07-01 |
| 11247 | 11247 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-05-02 | 312 | E | 1 | 0 | L4W811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observations, record review and staff interview; the facility failed to provide toileting assistance and personal hygiene for 4 residents (Residents 5, 9, 7 and 1) who required assistance with activities of daily living. Facility census was 24. Findings are: A. Review of Resident 5's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/4/13 indicated the resident was totally dependent with toileting and personal hygiene. Nursing Assistant (NA)-A and NA-B were observed to assist Resident 5 to the toilet on 5/1/13 from 2:18 PM until 2:41 PM. The resident's disposable incontinent brief and slacks were saturated with urine. Following toileting, NA-B assisted Resident 5 to stand. NA-B cleansed the resident's buttock and rectal area. NA-B did not cleanse the resident's frontal perineal area and inner groin/thighs. The resident's hands were not washed upon completion of care. Interview with NA-B on 5/1/13 from 2:18 PM until 2:41 PM revealed NA's were "about an hour late" in assisting Resident 5 to the toilet and the resident was last toileted approximately 11:30 AM or 11:45 AM (which indicated the resident had not been toileted for approximately 2 hours 33 minutes to 2 hours 48 minutes. B. Review of Resident 9's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. NA-A and NA-B were observed to assist Resident 9 to the toilet on 5/1/13 from 3:20 PM until 3:30 PM. The resident's disposable incontinent brief was wet with urine. Upon completion of toileting, NA-B did not cleanse the resident's frontal perineal area and inner groins/thighs. The resident's hands were not washed upon completion of care. C. Review of Resident 7's MDS dated [DATE] and 5/2/13 indicated the resident was totally dependent with toileting and personal hygiene. NA-A and NA-B were observed to assist Resident 7 to the toilet on 5/1/13 from 3:40 PM until 4:05 PM. The resident's di… | 2015-07-01 |
| 11248 | 11248 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-05-02 | 353 | E | 1 | 0 | L4W811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observations, record review and staff interviews; the facility failed to provide sufficient nursing staff to meet resident's needs related to: 1) failure to provide personal hygiene and toileting assistance for Residents 5, 9, 7 and 1 who required assistance with activities of daily living; 2) concerns regarding shortage of nursing staff on duty voiced during 2 of 3 confidential family interviews; 3) concerns regarding insufficient staffing voiced during 2 confidential resident interviews and; 4) failure to ensure the number of staff on duty was in accordance with the planned staffing pattern on 4/27/13. Findings are: A. Review of Resident 5's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/4/13 indicated the resident was totally dependent with toileting and personal hygiene. Nursing Assistant (NA)-A and NA-B were observed to assist Resident 5 to the toilet on 5/1/13 from 2:18 PM until 2:41 PM. The resident's disposable incontinent brief and slacks were saturated with urine. Following toileting, NA-B assisted Resident 5 to stand. NA-B cleansed the resident's buttock and rectal area. NA-B did not cleanse the resident's frontal perineal area and inner groin/thighs. The resident's hands were not washed upon completion of care. Interview with NA-B on 5/1/13 from 2:18 PM until 2:41 PM revealed NA's were "about an hour late" in assisting Resident 5 to the toilet and the resident was last toileted approximately 11:30 AM or 11:45 AM (which indicated the resident had not been toileted for approximately 2 hours 33 minutes to 2 hours 48 minutes. B. Review of Resident 9's MDS dated [DATE] indicated the resident was totally dependent with toileting and personal hygiene. NA-A and NA-B were observed to assist Resident 9 to the toilet on 5/1/13 from 3:20 PM until 3:30 PM. The resident's disposable incontinent brief was wet with urine. Upon completi… | 2015-07-01 |
| 11249 | 11249 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 226 | D | 1 | 1 | 320W11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on record review and staff interview, the facility failed to report, investigate and protect Resident 5 following an injury of unknown origin. Facility census was 27. Findings Are: Review of Abuse-Allegation and Reporting Policy/Procedure revised 06/13 revealed the following: - "The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress" . - "Report any knowledge of all alleged violations involving mistreatment, neglect or abuse immediately to a Supervisor or Administrator or in his/her absence, to his/her designee. Bruises, cuts, skin tears or other injury of unknown origin will be investigated and reported as potential resident abuse" . - "During the investigation process, the facility must prevent further physical abuse, mistreatment or verbal aggression ....ensure increased monitoring of at risk residents" . Review of Resident 5's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 9/22/13 revealed Resident 5 had severely impaired cognitive functioning and required total assist for toilet use, personal hygiene, dressing, bed mobility and transferring. Review of Resident 5's medical record revealed a progress note written on 11/5/13 at 2:54 PM stating, "Noted bruise to upper sternum. Resident cannot verbalize how (resident) received the bruise. 3.5 centimeter (cm) by 3 cm. Two small dots just to the bottom left and bottom right also noted. Resident denies any pain related to bruises. Will continue to monitor" . During an interview with the Director of Nursing (DON) on 11/12/13 at 11:28 AM the DON was unaware of Resident 5's bruising. DON stated staff would look to see if an investigation had been done on the bruising. Interview with DON on 11/12/13 at 12:19 PM revealed an investigation was begun on 11/12/13 and the nurse was working on the investigation currently. Interview with DON on 11/12/13 at 4:3… | 2015-07-01 |
| 11250 | 11250 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 253 | E | 0 | 1 | 320W11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A1 Based on observations and staff interview; the facility failed to maintain clean ventilation systems in the bathrooms of 11 resident rooms (Resident Rooms 105, 106, 107, 108, 109, 112, 113, 114, 119, 121 and 124). Facility census was 27. Findings are: During the environmental tour of the facility on 11/7/13 from 9:15 AM until 10:21 AM and accompanied by the Maintenance Supervisor, bathroom vents and/or ventilation ducts were heavily coated with dust and lint in Resident Rooms 105, 106, 107, 108, 109, 112, 113, 114, 119, 121 and 124. During interview on 11/7/13 from 9:15 AM until 10:21 AM, the Maintenance Supervisor verified there was a build-up of dust and lint in the bathroom ventilation system, and that the system was in need of cleaning. | 2015-07-01 |
| 11251 | 11251 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 280 | E | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews; the facility failed to review and revise Care Plans related to fall interventions for Residents 27, 15 and 23. In addition, Resident 15's Care Plan was not revised for prevention and treatment of [REDACTED]. A. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for Care Planning) dated 10/16/13 indicated [DIAGNOSES REDACTED]. The assessment indicated Resident 15 was at risk for pressure sore development and had a history of [REDACTED]. The MDS further indicated Resident 15 was at risk for falls and the resident had sustained 1 fall without injury and 2 falls with injury since the previous assessment. Review of Care Plan dated 11/1/13 revealed Resident 15 had a history of [REDACTED]. Interventions included the following: -9/25/12 Tab alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) on at all times -10/17/12 pressure pad alarm (an electronic pressure sensitive sensor pad designed for use in chairs or beds which will alarm if a resident tries to get up without assistance) on at all times -12/13/12 may put mattress on floor for resident to sleep on per resident's request -7/25/13 may use tilt-n-space wheelchair -10/30/13 ensure Tabs alarm cord length is adjusted to proper length -may use sit-to-stand mechanical lift for transfers -bolsters to resident's bed and fall mat on floor next to bed -keep bed in lowest position with brakes locked -observe resident frequently and place in supervised areas when out of bed In addition Resident 15's Care Plan indicated the resident was at risk for pressure sores. Interventions included the following: -keep heels elevated. -keep feet and heels moisturized -keep heels prot… | 2015-07-01 |
| 11252 | 11252 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 282 | E | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on observations, record review and staff interview; the facility failed to implement Care Plan interventions for Resident 36 regarding prevention of agitated behaviors, Resident 15 regarding prevention of falls and pressure sores, and Resident 24 regarding toileting assistance. Facility census was 27. Findings are: A. Review of Resident 36's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/18/13 identified [DIAGNOSES REDACTED]. The same MDS indicated the resident had severely impaired cognitive functioning and displayed adverse behavioral symptoms on a daily basis. Review of current Care Plan dated 9/11/13 revealed the resident displayed behaviors of crying, being tearful and having "outbursts" with a goal for the resident to exhibit fewer behaviors in the next 90 days. Interventions included the following: -"Outbursts; intervene if necessary and remove to quite (quiet) area ..." -"When I become socially inappropriate/disruptive, move resident to a quiet, calm environment ..." Resident 36 was observed seated at a table in the dining room on 11/6/13 at 3:15 PM while a group activity was in progress. The television at the end of the dining room was also on which caused additional noise in the area. The resident had an anxious expression and talked in a loud voice about getting some popcorn for a sibling. No attempts were made to move the resident to a quieter area. At 3:40 PM, the resident remained seated at a table in the dining room and was speaking in a loud shrill voice. Other residents were seated in the dining room and continued to participate in the group activity. At 3:41 PM, Licensed Practical Nurse (LPN) D stated the resident was going to receive a dose of prn (as needed) [MEDICATION NAME] (medication used for anxiety). LPN-D commented the [MEDICATION NAME] "really does work" in decreasing the resident's anxiety and agitation. L… | 2015-07-01 |
| 11253 | 11253 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 312 | E | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observations, record review, staff and resident interview; the facility failed to provide toileting and bathing assistance for Residents 9, 13 and 24 who required assistance with activities of daily living. Facility census was 27. Findings are: A. Resident 9 stated during interview on 11/6/13 at 8:58 AM that "...bath supposedly set up for once a week. Haven't had a bath for nearly 2 weeks now. Maybe they forgot about me." Review of Resident 9's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/24/13 revealed the resident required physical help with personal hygiene and part of bathing activity. Review of Resident 9's Shower/Bath record (a form used to record provision of each resident ' s shower/bath) revealed the resident received a bath on 10/11/13 and 10/18/13. Documentation indicated the resident did not receive another bath until 11/1/13 (14 days later). A confidential staff interview stated, "When we are short on the floor they pull the bath aide to the floor and the baths don't get done." The DON verified during interview on 11/13/13 at 7:30 AM that there was no evidence to indicate Resident 9 received a bath between 10/18/13 and 11/1/13. B. Review of Resident 24's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The same assessment indicated the resident required total staff assistance with bed mobility and transfers and extensive staff assistance with toileting and that the resident was frequently incontinent of bladder and occasionally incontinent of bowel. Review of Resident 24's Care Plan dated 9/10/13 indicated the resident did not always wait for staff to provide assistance with toileting and was at risk for falls. Interventions included the following: -Staff to assist with toileting, may use the sit- to-stand mechanical lift as needed -Answer the resident's call light promptly -Report signs and symptoms of urinary tra… | 2015-07-01 |
| 11254 | 11254 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 314 | D | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observations, record review and staff interview; the facility failed to consistently implement assessed interventions for the prevention of pressure sores and to revise interventions as needed to promote healing of pressure sores for 1 resident (Resident 15). Facility census was 27. Findings are: Review of facility policy titled "Pressure Sore Prevention and Monitoring Guidelines" (revised 10/12) revealed the following: Upon identifying a pressure sore the licensed nurse will perform the following procedures -Ensure pressure sore identification, goals and interventions are addressed on the resident's Care Plan. -Notify the Dietary Manager upon identifying a pressure sore and Dietary Manager will notify the Registered Dietician for recommendations. -The Interdisciplinary Team will meet at least weekly and as needed to make recommendations and will conduct weekly wound rounds on all pressure sores not responding to current treatment orders. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for Care Planning) dated 10/16/13 indicated [DIAGNOSES REDACTED]. The MDS further indicated Resident 15 was at risk for pressure sore development and had a history of [REDACTED]. Review of Resident 15's physician orders [REDACTED]. The physician orders [REDACTED]. Review of Resident 15's Braden Scale For Predicting Pressure Sore Risk dated 10/15/13 indicated a total score of 14 (score of 13-14 indicated moderate risk). Review of Progress Notes dated 10/20/13 revealed Resident 15 had a red area noted to left heel. The note indicated staff was to keep the resident's legs propped up on pillows while in bed to reduce pressure to left heel. Review of "Event Report" dated 11/1/13 revealed a Hospice Nurse had informed facility staff of an intact blister to Resident 15's left lateral heel. This report indicated the area surrounding the blister was intact, slig… | 2015-07-01 |
| 11255 | 11255 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 323 | E | 1 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Numbers 175 NAC 12-006.09D7 and 175 NAC 12-006.184 Based on observations, record review and staff interviews; the facility failed to assure Residents 15 and 23 were protected from falls as fall intervention measures were not consistently provided and the facility failed to identify causal factors and revise interventions to prevent ongoing falls for Resident 15. In addition, the facility failed to secure hazardous chemicals in resident rooms and the beauty shop which allowed access to 7 residents who were identified at risk for wandering. Facility census was 27. Findings are: A. Review of Resident 15' s Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for Care Planning) dated 10/16/13 indicated [DIAGNOSES REDACTED]. The MDS further indicated Resident 15 was at risk for falls and the resident had sustained 1 fall without injury and 2 falls with injury since the previous assessment. Review of Care Plan dated 11/1/13 revealed Resident 15 had a history of [REDACTED]. Interventions included the following: -9/25/12 Tab alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) on at all times -10/17/12 pressure pad alarm (an electronic pressure sensitive sensor pad designed for use in chairs or beds which will alarm if a resident tries to get up without assistance) on at all times -12/13/12 may put mattress on floor for resident to sleep on per resident's request -7/25/13 may use tilt-n-space wheelchair -10/30/13 ensure Tabs alarm cord length is adjusted to proper length -may use sit-to-stand mechanical lift for transfers -bolsters to resident's bed and fall mat on floor next to bed -keep bed in lowest position with brakes locked -observe resident frequently and place in supervis… | 2015-07-01 |
| 11256 | 11256 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 353 | E | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observations, record review, staff and resident interviews; the facility failed to provide sufficient nursing staff to meet resident's needs related to: 1) 5 of 10 resident interviews voiced concerns regarding lack of staff; 2) provision of baths in accordance with bath schedules for Residents 24, 9 and 1 who required assistance with bathing/personal hygiene; and 3) provision of toileting assistance for Residents 13 and 24 who required assistance with toileting. Facility census was 27. Findings are: A. 4 confidential resident interviews revealed the following comments when asked, "Do you feel there is enough staff available to make sure you get the care and assistance you need without having to wait a long time?" -Confidential interview on 11/5/13 at 3:26 PM-"Not really. If you call them and they are someplace else it takes a while." The resident further stated 2 baths were to be provided per week but "...about once a month only gets1bath during the week." -Confidential interview on 11/5/13 at 4:12 PM-"There is a little bit of shortage on that. Weekend is the worst." -Confidential interview on 11/6/13 at 8:57 AM-"No, we turn on the call light and then we have to wait and wait until someone comes to help you. Mostly in the morning when I want to get up out of bed. Sunday I had to wait quite a while to get into the bathroom." -Confidential interview on 11/6/13 at 9:02 AM-Resident voiced not enough staff as "have to wait for call lights." B. Interview with Resident 9 on 11/6/13 at 8:58 AM revealed the resident had concerns about staffing. The resident stated, "...bath supposedly set up for once a week. Haven't had a bath for nearly 2 weeks now. Maybe they forgot about me." Review of Resident 9's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/24/13 revealed the resident required physical help with personal hygiene and part of bathing … | 2015-07-01 |
| 11257 | 11257 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 441 | E | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B and 175 NAC 12- D Based on observations, record review and staff interview; the facility failed to assure staff members washed hands at appropriate intervals, and that the mechanical sit/stand lift was cleaned between each resident use, during the provision of nursing cares for Residents 15 and 5. This provided the potential for cross contamination between 7 residents ( Residents 19, 24, 38, 15, 26, 1 and 5) who were identified as requiring use of the mechanical sit/stand lift for transfers. Facility census was 27. Findings are: A. Review of facility policy titled Handwashing/Hand Hygiene with a revision date of June 2010 revealed the following: - "Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: ... c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); ... h. Before and after assisting a resident with personal care (e.g., oral care, bathing); ... l. Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident); ... n. Before and after assisting a resident with toileting (hand washing with soap and water); ... r. After handling soiled or used linens, dressings, bedpans, catheters and urinals; ... s. After handling soiled equipment or utensils; ...u. After removing gloves or aprons; and v. After completing duty." - "If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for all the following situations: a. Before and after direct contact with residents; b. Before donning sterile gloves; ... g. After contact with a resident's intact skin; h. After handling used dressings, contaminated equipment, etc.; i. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident;… | 2015-07-01 |
| 11258 | 11258 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 520 | F | 1 | 1 | 320W11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interview; the facility failed to assure an effective Quality Assurance program was in place to correct previously cited deficiencies regarding sufficient staffing, accidents and activities of daily living (ADL) care. Facility census was 27. Findings are: Review of facility deficiency statement from the Quality Indicator Survey (QIS) completed on 5/24/11 revealed the facility was cited for failure to implement interventions for the preventions of falls. Review of facility deficiency statement from QIS completed on 8/9/12 revealed the facility was cited for failure to implement interventions for the prevention of falls. Review of facility deficiency statement from a complaint survey completed on 11/20/12 revealed the facility was cited for failure to assess 1 resident with a history of falls. Review of facility deficiency statement from a complaint survey completed 5/2/13 revealed the facility was cited for failure to provide toileting assistance and personal hygiene for residents and failure to provide sufficient nursing staff to meet residents needs. Review of the preliminary citations for the current survey revealed these deficiencies were not corrected. Review of the facility's policy "Monthly Quality Assurance Meeting Policy and Procedure" (revised 6/13) revealed the following: - "Purpose: To ensure appropriate follow-up and ongoing tracking of identified environmental and quality of care issues by the facility Quality Assurance team. To develop and implement plans of corrective action for identified trends and/or deficient practices. To ensure the provision of the highest possible quality of care to facility residents" . - "Policy: If a trend is identified, the Quality Assurance Committee will develop a Plan of Action, appoint a team leader and project a target date of completion" . - "Possibly Quality Assurance areas and trends may be identified through Focused Rounds, Resident Counsel Meeting, Consultant Reports, Grand Rounds by… | 2015-07-01 |
| 11259 | 11259 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-05-15 | 164 | E | 1 | 0 | C4V911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(20) Based on observation and staff interview; the facility failed to ensure medical record confidentiality for 14 residents (Residents 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15). Medication and treatment administration records were left open and information was exposed when the medication/treatment carts were not attended. In addition, resident care information was lying on top of the Nurses Station desk and was accessible to anyone passing by. Facility census was 29. Findings are: A. During observations on 5/15/14, Registered Nurse (RN)-B left the medication cart unattended in the hallway with the Medication Administration Record [REDACTED]. B. During observations on 5/15/14, RN-B left the treatment cart unattended in the hallway with the Treatment Administration Record (TAR-a record maintained for each individual resident that lists their treatments, allergies and other personal information) on top of the cart and open, exposing information on Resident 8 from 6:59 AM until 7:05 AM, 7:13 AM until 7:21 AM and 7:27 AM until 7:33 AM. C. The desk of the Nurses Station located adjacent to the dining room was unattended on 5/15/14 from 7:37 AM until 7:45 AM. The following items and documents were lying on top of the desk and within view of anyone passing by: -an empty box of [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]) prefilled syringes labeled with Resident 9's name and instructions for use -an empty bubble pack (a packaging system for medication administration) of [MEDICATION NAME] (an antibiotic) labeled with Resident 10's name and instructions for use -a form titled "REPORT FOR HALLS ONE AND THREE" which identified 10 residents (Residents 1, 11, 12, 13, 8, 14, 2, 15, 3 and 9) by name and included details of their personal care such as urine output, bowel movements, and/or behaviors of wandering/exit seeking, touching, crying and hitting. D. During observations on 5/15/14… | 2015-07-01 |
| 11260 | 11260 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-05-15 | 226 | D | 1 | 0 | C4V911 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and staff interview; the facility failed to immediately report an allegation of potential abuse to the Stage Agency. This involved 2 residents (Resident 1 and 2). Facility census was 29. Findings are: Review of facility Abuse Allegation and Reporting Policy and Procedure (revision date 6/13) revealed: "The facility must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator." The procedure further identified "The Administrator will assure immediate notification of proper authorities in compliance with regulatory/licensing requirements that an allegation has been made and a facility investigation is underway. State specific reporting requirements and timeframes pertaining to the reporting and submission of preliminary reports will be observed ..." Interview with the Director of Nurses (DON) on 5/14/14 at 11:30 AM revealed the DON received a report on 4/27/14 regarding verbal abuse of Resident 1 and Resident 2 by Licensed Practical Nurse(LPN)-J and Nursing Assistant(NA)- K which occurred on 4/26/14. The DON indicated LPN-J and NA-K were placed on administrative leave until an investigation was completed. Review of facility investigation records dated 5/1/14 regarding potential verbal abuse of Residents 1 and 2 revealed the allegations were not reported to the State Agency until 4/30/14 (3 days after the facility was made aware of the incident). During interview on 5/15/14 at 2:00 PM the DON verified the facility did not immediately report the allegation of potential verbal abuse involving Residents 1 and 2 to the State Agency. | 2015-07-01 |
| 11261 | 11261 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-05-15 | 318 | D | 1 | 0 | C4V911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D4 Based on record review and staff interview; the facility failed to provide range of motion (ROM) exercises in accordance with physician's orders [REDACTED]. Facility census was 29. Findings are: A. Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/17/14 indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The same MDS indicated the resident required extensive to total assistance with activities of daily living (ADL), and had functional limitation of ROM in upper and lower extremities on both sides. Review of physician's orders [REDACTED]. Review of Resident 3's Care Plan dated 3/13/14 revealed a problem in ADL function and rehabilitation potential, with a goal to provide a "satisfying" restorative program that met the resident's needs. Nursing interventions included assessing health issues that could result in a lack of or reduced participation in the restorative program, adapting the restorative program to meet the resident ' s current abilities, praising involvement and offering encouragement. Review of Restorative Flowsheets (a form used to document when Restorative Therapy (RT) exercises were provided) indicated Resident 3 was to receive AAROM to upper and lower extremities every day, and documentation revealed the following: - During 3/2014, the resident received AAROM 3 times weekly for a total of 12 times. - During 4/2014, the resident received AAROM 3-4 times weekly for a total of 13 times. - From 5/1/14 until 5/14/14, the resident received AAROM 1 time weekly for a total of 2 times. B. Review of Resident 2's MDS dated [DATE] indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The same MDS indicated the resident required extensive to total assistance with ADL's, and had functional limitation of ROM in lower extremities on both sides. Review of Resident 2's Care Plan dated 4/15/… | 2015-07-01 |
| 11262 | 11262 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-05-15 | 373 | E | 1 | 0 | C4V911 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C7b Based on record review and staff interview; the facility failed to ensure staff members who assisted residents to eat had completed a State-approved training course in feeding techniques. Facility census was 29. Findings are: Review of Resident 4's Progress Notes dated 1/7/14 at 12:35 PM revealed the Administrator fed Resident 4 a couple of bites of the breakfast meal until a nursing assistant returned to feed the resident the rest of the meal. Interview with the Administrator on 5/14/14 at 11:30 AM revealed the Administrator had on occasion provided feeding assistance to residents. The Administrator verified the facility did not provide a State-approved training course in feeding techniques (also known as a paid feeding assistant program) and the Administrator had not been trained to assist and feed residents. Interview with the Social Services Director (SSD) on 5/15/14 at 1:07 PM revealed the SSD provided residents with feeding assistance at times. The SSD verified a State-approved training course in feeding techniques had not been completed. | 2015-07-01 |
| 11263 | 11263 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 157 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review, staff interview and observation; the facility failed to ensure physicians were notified regarding significant weight loss for Residents 9 and 15, and development of pressure ulcers for Resident 38, 10 and 19. Facility census was 33. Findings are: A. Review of facility policy for weight loss titled "Weight" (revision date 8/2013) revealed weight loss or gain was to be calculated every time a resident was weighed. Significant weight losses were identified as 5 percent (%) in 1 month, 7.5% in 3 months and 10% in 6 months. The policy further specified the physician was to be notified regarding significant weight variances. B. Review of Resident 9's Weight Variance Reports from 10/3/14 through 11/17/14 and Weight and Vital Signs Monitoring Record from 10/3/14 through 11/19/14 revealed the following weights: -10/3/14-117.8 pounds -10/10/14-117 pounds -10/24/14-116.8 pounds -11/3/14-116.8 pounds -11/5/14-110 pounds -11/10/14-106.6 pounds (an 8 percent significant weight loss in 1 month) Review of Resident 9's medical record revealed no evidence to indicate the physician was notified of the significant weight loss. C. Review of Resident 10's Admission and Weekly Skin Integrity Action Tool for 9/2014, 10/2014 and 11/2014 revealed the following: -9/14/14-"red/purple area above coccyx, no open areas noted" -9/21/14-"red/purple area remains. No open sore" -9/28/14-"no new skin issues" -10/5/14-"no new skin issues" -10/12/14-"No new skin issues" -There was no documentation on 10/19/14 and 10/26/14 -11/2/14-"no new skin issues" -There was no documentation on 11/9/14 -11/16/14-"No new skin issues" On 11/19/14 at 4:32 PM, NA-C commented Resident 10 had a "little schiff" (a small open area) on the "backside" (coccyx area) which had been reported to the Director of Nurses earlier that day. A small Stage 2 pressure sore (partial thickness skin loss that presents as an abrasion, blister o… | 2015-07-01 |
| 11264 | 11264 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 241 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(21) Based on observations, staff interview and record review; the facility failed to ensure residents were treated with respect and dignity related to: 1) transporting Resident 9 to the bathing room and prolonged wait time to receive meal service; 2) positioning Resident 29's urinary catheter drainage bag to prevent visual exposure; and 3) prolonged wait time to receive meal service and soiled clothing/equipment for Resident 15. Facility census was 33. Findings are: A. Review of Resident 9's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/3/14 revealed [DIAGNOSES REDACTED]. The same MDS indicated the resident had moderate cognitive impairment, was dependent upon staff for transfers and personal hygiene and required extensive assistance with eating. Review of Resident 9's Care Plan dated 10/9/14 revealed the resident wore a wig and removed it when napping/sleeping during the day and at night. The Care Plan indicated a goal to provide the resident with dignity and respect. The intervention indicated the privacy curtain was to be closed when the resident was napping/sleeping to provide privacy and dignity. In addition, the Care Plan indicated Resident 9's family requested the resident not be taken to the dining room "too early" in the morning. The Care Plan indicated the resident was to remain in room until "shortly before breakfast is served." On 11/19/14 at 7:18 AM, Resident 9 was observed seated in a shower chair (a chair on wheels which allows the resident to be rolled into the shower while seated). Nursing Assistant (NA)-B pulled Resident 9 backwards with 1 hand and with the other hand pushed the resident's wheelchair through the Wing 1 corridor while en-route to the bathing room. Resident 9 was not wearing the wig, was dressed in a hospital gown and covered with a torn frayed blanket. The resident's bare legs and feet dangled below the bl… | 2015-07-01 |
| 11265 | 11265 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 258 | C | 0 | 1 | ZQ0211 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A(3) Based on observations, confidential resident interviews and staff interview; the facility failed to ensure comfortable noise levels related to an audible chime alarm in the corridor of Wing 1 which sounded repeatedly. This had the potential to affect the comfort of all residents as the noise could be heard throughout the Wing 1 corridor and extended into the dining room area. Facility census was 33. Findings are: A. On 11/19/14 at 6:56 AM, a motion alarm (an alarm activated by movement) was observed positioned on the ceiling in the corridor outside of Resident 40's room. The motion alarm sounded an audible chime alarm each time Resident 40 entered or exited the room and whenever anyone passed by in the corridor. The audible chime alarm sounded repeatedly between 6:56 AM and 8:37 AM as residents and staff passed by in the corridor. The sound from the audible chime alarm was heard throughout the Wing 1 corridor and extended into the dining room area. At 9:45 AM, Resident 40 repeatedly walked in and out of the room triggering the audible chime alarm. B. 2 confidential resident interviews conducted on 11/19/14 between 10:48 AM and 11:31 AM indicated they were able to hear the audible chime alarm. 1 resident stated "I hear it and try not to pay attention to it. I don't complain". Another resident stated the audible chime alarm had started recently and "It's a nuisance". C. The audible chime alarm in the corridor of Wing 1 sounded repeatedly on 11/20/14 between 8:35 AM and 9:30 AM as staff and residents walked by Resident 40's room. The sound was heard throughout the Wing 1 corridor and extended into the dining room area. D. Interview with the Director of Nurses (DON) on 11/25/14 at 8:40 AM revealed the audible chime alarm was placed outside Resident 40's room in an effort to monitor the resident's whereabouts. The DON verified the audible chime alarm needed to be re-set as it sounded when anyone passed by in the corridor. | 2015-07-01 |
| 11266 | 11266 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 279 | D | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04c3a(5) Based on observations, record review and staff interview; the facility failed to develop a plan of care to address the need for turning and repositioning for Resident 15 who was assessed to be at risk for the development of pressure ulcers. Facility census was 33. Findings are: Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/23/14 revealed the resident was admitted with [DIAGNOSES REDACTED]. The MDS further indicated Resident 15 required extensive to total assistance with bed mobility and transfers. Review of the Braden Scale For Prediction of Pressure Ulcer Risk dated 10/23/14 revealed Resident 15 was at high risk for the development of pressure ulcers and nursing interventions included pressure reducing devices in the chair and bed, and a turning and repositioning program. During observations of Resident 15 were noted on 11/20/14: - The resident was seated in wheelchair at the dining room table for the breakfast meal at 6:55 AM, 7:44 AM, 7:48 AM, 8:09 AM, 8:39 AM, 9:21 AM, 9:42 AM, 10:07 AM, and 10:12 AM when the resident was wheeled to the activity room. - The resident remained in wheelchair for an activity from 10:12 AM until 10:34 AM when the resident was returned to room. - The resident remained seated in wheelchair from 10:34 AM until 11:30 AM when Nursing Assistant (NA)-G was observed to wheel the resident from room to the dining room. During interview on 11/20/14 at 11:30 AM, NA-G verified Resident 15 was not toileted or repositioned prior to being wheeled to the dining room for the noon meal. (The resident was observed seated in wheelchair without repositioning for 4 hours and 35 minutes.) The following observations of Resident 15 were noted on 11/24/14: - The resident was seated in wheelchair at the dining room table for the breakfast meal from 9:15 AM until 10:00 AM when the resident was wheeled to t… | 2015-07-01 |
| 11267 | 11267 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 280 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on observations, record review and staff interviews; the facility failed to review and revise Care Plans related to the treatment of [REDACTED]. Facility census was 33. Findings are: A. Review of facility policy titled "Pressure Sore Prevention and Monitoring Guidelines" (revised 6/13) revealed the goal of the facility was to maintain skin integrity. If a resident developed a pressure sore, the resident was to receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Upon identifying a pressure sore the licensed nurse was to ensure pressure sores were identified with goals and interventions to be addressed on the resident's Care Plan. B. Review of Resident 38's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/14/14 revealed resident 38 was admitted on [DATE] with [DIAGNOSES REDACTED]. -Two Stage 2 pressure sores (The staging system is a method of summarizing certain characteristics of pressure sores, including the extent of tissue damage. Stage 2 refers to partial thickness skin loss that presents as an abrasion, blister or shallow crater). -Two Stage 3 pressure sores (full thickness skin loss with damage to subcutaneous (under the skin) tissue). -One unstageable pressure sore (unstageable refers to a full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (dead tissue) in the wound bed). -One unstageable pressure sore with suspected deep tissue injury (pressure related injury to subcutaneous tissue). Review of Resident 38's "Wound Assessment Tool" dated 10/8/14 revealed Resident 38 had a 9.5 centimeter (cm) by 5.7 cm pressure sore with 10 cm depth to gluteal sacral area (lower back above buttock crease) and a 4 cm by 3.7 cm pressure sore with 3 cm depth to left [MEDICATION NAME] area (upper back). Review of Resident 38's "Weekly Pres… | 2015-07-01 |
| 11268 | 11268 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 282 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on observations, record review and staff interview; the facility failed to implement Care Plan interventions related to activities of daily living, repositioning, nutrition, pressure sores and management of urinary catheters for Residents 9, 15, 10, 17 and 29. Facility census was 33. Findings are: A. Review of Resident 29's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/3/14 identified [DIAGNOSES REDACTED]. Review of Resident 29's Care Plan with revision date of 9/14/14 identified the resident had a supra-pubic catheter (tube inserted into the resident's bladder through a small hole in the stomach to drain urine from the bladder). Resident 29's Care Plan further identified the resident was at risk for urinary tract infections and skin breakdown and listed the following interventions: -Do not allow drainage bag to touch the floor or the surface of the bed. -Use principles of infection control and standard precautions (procedures designed by the Centers for Disease Control and Prevention (CDC) to prevent the spread of known and unknown sources of infections. It applies to blood; body fluids, excretions, and secretions of the skin; and oral mucosa) when doing any treatments or catheter care. -Store catheter drainage bag inside a protective dignity pouch. -Perform catheter care per facility policy. During an observation on 11/19/14 at 4:30 PM, Resident 29 was seated in a recliner in the resident's room. The resident's supra-pubic urinary catheter drainage bag was hung on the outside of a trash receptacle next to the resident's recliner. The trash receptacle contained soiled Kleenex and crumpled papers. The bottom of the drainage bag rested directly on the floor next to the trash receptacle. During an observation on 11/20/14 at 7:45 AM, Resident 29 was seated in a recliner in the resident's room with foot rest elevated. The resident's supr… | 2015-07-01 |
| 11269 | 11269 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 309 | H | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2 Based on observations, record review and staff interview; the facility failed to provide care and treatment to promote healing of wounds for Residents 17, 28, and 35. Facility census was 33. Findings are: A. Review of facility policy for Actual Impaired Skin Integrity (no date indicated) revealed residents with impaired skin integrity as a result of pressure ulcers, vascular ulcers, rashes, skin tears, surgical sites and diabetic/neuropathic ulcers were to receive interventions which included the following: -Medications and treatments as ordered -Encouragement and assistance to turn and reposition every 1 - 2 hours -Measure/assess wound and skin check every week -Notify physician of signs and symptoms of impaired skin integrity -Notify physician as needed for lack of response to treatment if no improvement noted within 2-4 weeks as indicated/appropriate -Monitor status of surrounding skin every day and notify physician as needed of noted impairment -Monitor for signs/symptoms of infection or other complication and notify physician as needed B. Review of Resident 17's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/27/14 indicated the resident was admitted to the facility 2/19/14 with [DIAGNOSES REDACTED]. Review of Resident 17's Treatment Flowsheet (a record of treatments provided by nursing) for 2/2014 revealed a physician's order dated 2/19/14 for saline wet-to-dry dressings (A gauze pad soaked in saline and placed on the surface of a wound bed, followed by a dry dressing pad placed on top of the wet dressing) to left lateral ankle BID (2 times daily) at 10:00 AM and 10:00 PM. Documentation revealed the 10:00 AM dressing change to Resident 17's ankle was not documented from 2/19/14 to 2/25/14 (6 of 13 dressing changes in 7 days). Review or Resident 17's Care Plan dated 2/25/14 indicated the resident had an open wound to the left lateral… | 2015-07-01 |
| 11270 | 11270 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 312 | D | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observations, record review and staff interview; the facility failed to provide toileting assistance for Resident 38 and feeding assistance for Resident 9 who both required assistance with activities of daily living. Facility census was 33. Findings are: A. Review of Resident 38's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/14/14 indicated [DIAGNOSES REDACTED]. Observations of Resident 38 on 11/17/14 revealed the following: -At 7:01 AM, the resident's call light was on and the resident was lying in bed. The resident indicated the call light had been turned on as the resident needed to use the bathroom. -At 7:15 AM, (14 minutes later) The Registered Nurse (RN) Consultant entered Resident 38's room, turned off the call light and told the resident help was coming, before exiting the resident's room. -At 7:22 AM, (21 minutes after call light was first turned on) Resident 38 turned the call light back on stating, "They still haven't taken me to the bathroom". -At 7:39 AM, (38 minutes after the call light was first turned on) Nursing Assistant (NA)-M entered the resident's room and turned off the resident's call light, NA-M indicated an additional staff member was needed to help the resident and NA-M exited the resident's room. -At 7:52 AM, (51 minutes after Resident 38 initially turned on the call light to seek assist with toileting) NA-A entered the resident's room, closed the door and turned off the resident's call light. During an interview on 11/17/14 from 8:05 AM to 8:12 AM, NA-A confirmed Resident 38 was not taken to the bathroom until the call light was turned off at 7:52 AM. In addition, NA-A verified Resident 38 was incontinent of urine by the time the resident was assisted to the bathroom. B. Review of Resident 9's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. At 7:41 AM on 11/19/14, NA-B was observed to wheel Resident… | 2015-07-01 |
| 11271 | 11271 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 314 | H | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observations, record review and staff interviews; the facility failed to identify the presence of pressure sores and/or to provide identified interventions for the prevention and treatment of [REDACTED]. Facility census was 33. Findings are: A. Review of facility policy titled "Pressure Sore Prevention and Monitoring Guidelines" (revised 6/13) revealed the goal of the facility was to maintain skin integrity. If a resident developed a pressure sore, the resident was to receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Upon identifying a pressure sore the licensed nurse was to perform the following procedures: -Notify the physician for orders to treat each pressure sore identified. -Notify resident's responsible party and physician regarding change in condition. -Ensure pressure sores are identified with goals and interventions to be addressed on the resident's Care Plan. -Schedule weekly head to toe skin assessments. -Notify the Dietary Manager and the Registered Dietician for recommendations to ensure adequate caloric and protein needs as applicable. -All pressure sores will be assessed weekly. B. Review of facility policy titled "Dressing-Non-sterile Treatment" (revised 6/13) revealed the policy of the facility was to perform treatments and dressing changes per physician orders. The licensed nurse was to follow the following procedure: -Review physician treatment orders. -Prepare clean field. -Create a barrier for dressing supplies and place on the clean field. -Wash hands. -Apply clean gloves -Remove soiled dressing and place in a biohazard container. -Remove gloves and wash hands. -Apply clean gloves. -Clean wound per physician order. Clean wound from the center to the outer borders using a circular motion (area of most contamination to the area of the least). Ensure you do not contaminate the wound bed. -Remove … | 2015-07-01 |
| 11272 | 11272 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 315 | G | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D3 (1) Based on observations, record review and staff interview: the facility failed to provide catheter care and to provide treatment and handling of a urinary catheter drainage bag in a manner to prevent recurrent urinary tract infections for 1 resident (Resident 29). Facility census was 33. Findings are: A. Review of facility policy titled "Urinary/ Catheter Care" (revised 2/2012) indicated the purpose of catheter care was to minimize the risk of catheter-associated urinary tract infection and its related problems. The policy identified the following procedures: -Wash hands and apply gloves. -Cleanse the catheter insertion site daily with soap and water. Cleanse the proximal third of the catheter with soap and water, washing away from the insertion site and manipulating the catheter as little as possible. -Apply a sterile 4 x 4 to catheter insertion site as ordered or as indicated. -Remove gloves and wash hands. B. Review of Resident 29's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/3/14 identified [DIAGNOSES REDACTED]. Review of Resident 29's Care Plan with revision date of 9/14/14 revealed the resident had drainage from the insertion site of a supra pubic catheter (tube inserted into the bladder through a small hole in the stomach to drain urine from the bladder) with a goal for the area to be without drainage and to heal. An intervention was identified to wash the insertion site BID (twice a day) with soap and water and to apply [MEDICATION NAME] (topical antibiotic use to treat/prevent infections and to promote healing) as needed followed by a dressing. Resident 29's Care Plan further identified the resident was at risk for urinary tract infections and skin breakdown related to indwelling supra-pubic urinary catheter and listed the following interventions: -Monitor site for signs and symptoms of infection every shift. -Change dressin… | 2015-07-01 |
| 11273 | 11273 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 323 | K | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record review and staff interviews; the facility failed to assure residents were free of injury from hot liquid spills. Resident 28 was not assessed for risk of hot liquid spills and sustained a burn after spilling coffee. In addition, hot water temperatures were not monitored to ensure residents who received showers were protected from potential burn injury. This affected 23 residents (Resident 35, 10, 12, 4, 17, 6, 34, 28, 37, 33, 1, 29, 15, 9, 18, 40, 36, 23, 2, 24, 39, 43, and 38). Facility census was 33. Findings are: A. Review of facility Hot Beverage Safety Guideline policy (revision date 4/2013) revealed residents were to be assessed using the Hot Beverage Safety Evaluation upon admission, quarterly and as needed to determine ability to independently consume hot beverages safely. Staff were to ensure supervision and assistance was provided as identified by the Hot Beverage Safety Evaluation and witnessed unsafe practices associated with the consumption of hot beverages were to be reported to the Nursing Department Manager/Designee with interventions implemented as required. B. Review of Resident 28's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/18/14 revealed [DIAGNOSES REDACTED]. Review of a facsimile (fax) dated 11/21/14 at 7:52 PM revealed Resident 28's physician was notified of a "...burn from hot coffee." The resident spilled coffee and sustained reddened skin areas on the inner left thigh from groin to knee and a 3 centimeter (cm) area on the left inner foot. Documentation further indicated that 45 minutes later the redness to the resident's inner thigh had decreased to "...mid inner thigh approx. (approximately) 5 cm" and the reddened area to the foot had " ...decreased as well." Review of Resident 28's medical record revealed no evidence to indicate a Hot Beverage Safety Evaluation was completed unt… | 2015-07-01 |
| 11274 | 11274 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 325 | H | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observations, record review and staff interview; the facility failed to evaluate significant weight losses for Residents 15 and 9, and gradual weight loss for Resident 10. Interventions for the prevention of weight loss were not developed and/or revised to prevent further loss of weight. Facility census was 33. Findings are: A. Review of the facility Weight Policy (Revised 08/13) included the following: 1. All residents will be weighed monthly. 2. The charge nurse will notify the Dietary Manager (DM) and Director of Nursing (DON) of weight variances. 3. Weight variance: Calculate weight loss or gain every time a resident is weighed. Significant weight variance must be brought to the attention of the Registered Dietician (RD). (Significant weight loss/gain was defined as 5% (percent) in 1 month, 7.5% in 3 months, and 10% in 6 months.) 4. RD or designee will review information, discuss with resident and document on the medical record. 5. The physician will be called by the charge nurse regarding significant weight variances. B. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/23/14 indicated the resident was admitted with [DIAGNOSES REDACTED]. The MDS further revealed the resident had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making, and required extensive assistance with eating. Review of Resident 15's Care Plan dated 2/2/13 indicated the resident had a history of [REDACTED]. Interventions included to offer ice cream if not eating the meal provided; provide 2 Cal (a high calorie nutritional supplement) 4 ounces TID (3 times daily) between meals; encourage, provide cues, and/or assist with oral intake of food and fluids although resident not always receptive to this; monitor and record weight weekly; notify physician and family of significant weight cha… | 2015-07-01 |
| 11275 | 11275 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 353 | F | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observations, record reviews and confidential resident and family interviews; the facility failed to provide nursing staff to meet resident's needs related to: 1) 9 of 12 resident interviews and 2 of 5 family interviews voiced concerns regarding lack of staff; 2) provision of toileting assistance and prompt response to call light for Resident 38; 3) provision of repositioning for Resident 15 and Resident 10 and; 4) provision of repositioning and feeding assistance/meal service for Resident 9. Facility census was 33. Finding are: A. Nine residents voiced concerns regarding insufficient nursing staff during confidential interviews conducted on 11/18/14 from 2:29 PM until 11/19/14 at 11:38 AM. Comments included the following: -"Call light response-as a rule 20 minutes to maybe an hour." -"Very understaffed. Sometimes have to wait quite a while. 20 minutes or more to have help after we push our call lights." -"They don't have enough staff, sometimes (waits) 15 to 20 minutes". -"Not enough staff...Have had to wait ? hour to an hour." -"Always short of help here." -"When you ring the bell, it takes forever for them to come to you. Typically I have to wait ? hour to 45 minutes to have my call light answered." -"Sometimes I feel like it takes up to 45 minutes to an hour to get help." -"One time I waited so long I forgot what I wanted." -"They just don't have enough help. If you have to go to the bathroom usually takes 15 minutes or more to get someone to help you." B. Two family members voiced concerns regarding insufficient nursing staff during confidential interviews conducted on 11/24/14 from 1:43 PM until 4:27 PM. Comments included the following: -"...it takes so long for staff to come and get (resident) to the bathroom" and they "complain daily when (resident's) care is delayed." -"There is not enough staff here to take care of the residents." C. Observations of Resident 38 on 11/17/14 revea… | 2015-07-01 |
| 11276 | 11276 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 356 | C | 0 | 1 | ZQ0211 | Based on observations and staff interview; the facility failed to post and retain the required daily nurse staffing information. This had the potential to affect all residents, family members and visitors. Facility census was 33. Findings are: Observations during entrance tour of the facility on 11/18/14 at 12:00 noon revealed the nurse staffing information was not posted. During interview on 11/18/14 at 12:15 PM, the Director of Nursing (DON) verified the nurse staffing information was not posted. Interview with the DON at 7:35 AM on 12/2/14 revealed nurse staffing information had not been posted since the end of 7/2014. The DON further indicated nurse staffing information had not been retained since that time. Therefore, nurse staffing records were not maintained for 18 months as required. | 2015-07-01 |
| 11277 | 11277 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 364 | F | 0 | 1 | ZQ0211 | Licensure Reference: 175 NAC 12-006.11D Based on observations, record review and resident/staff interviews; the facility failed to provide food at temperatures palatable to residents. This practice had the potential to affect all facility residents. Facility census was 33. Findings are: A. Confidential resident interviews conducted on 11/18/14 through 11/19/14 revealed 5 residents responded "No" when asked if food was served at the proper temperature. B. Observations on 11/24/14 revealed the following: -12:13 PM- The Dietary Manager (DM) served Resident 33 an uncovered plate consisting of cooked cabbage, mashed potatoes with butter and a chicken breast. Resident 33 took a bite of the mashed potatoes and indicated the food was not hot enough. -1215 PM- The DM completed temperature checks on the lunch plate served to Resident 33. The following temperatures were measured; cooked cabbage 138 degrees F (Fahrenheit), mashed potatoes with butter 139 degrees and chicken breast 128 degrees F. C. During an interview on 11/24/14 from 12:30 PM to 12:38 PM, the DM identified all food should be at least 140 degrees F when served to the residents. The DM indicated the cook was to complete food temperatures before meal service and temperatures were to be documented on a "Food Temperature Record ". The DM further identified meal temperatures were routinely checked after the meal service but were never documented. D. Review of the facility "Food Temperature Records" from 11/1/14 to 11/30/14 revealed missing documentation of meal temperatures on 11/6/14, 11/10/14, 11/17/14, 11/18/14, 11/24/14, 11/26/14, 11/27/14 and 11/29/14 (meal temperatures were not documented for all food items served on 8 out of 30 days in November). E. During an interview on 12/1/14 from 9:00 AM to 9:12 AM, the DM indicated no further "Food Temperature Records" were available for review. The DM indicated food temperatures were routinely checked but had not been documented. | 2015-07-01 |
| 11278 | 11278 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 371 | F | 0 | 1 | ZQ0211 | Licensure Reference: 175 NAC 12-006.11E Based on observations, record review and staff interview; the facility failed to 1) ensure food items were labeled and dated, 2) maintain kitchen equipment, food contact/non-contact surfaces, floors, walls, light fixtures, and ceiling vents in a clean and sanitary manner, 3) ensure food and bottled water were not stored directly on the floor and 4) ensure hand-washing and glove changes were completed during meal preparation and service to prevent potential cross contamination of food. These practices had the potential to affect all of the facility residents. Facility census was 33. Findings are: During the initial kitchen tour with the Dietary Manager (DM) on 11/18/14 from 11:00 AM to 11:30 AM the following were observed: -The edges of all of the kitchen counters had surfaces completely worn away with bare wood visible making the surfaces not easily cleanable. -The kitchen floor was soiled throughout with dust, dirt and food crumbs; including under the steam table and a 2 compartment food preparation sink, between the refrigerator/freezer and the stove and in front and underneath of the dishwashing area. In addition, the kitchen floor had 2 approximately 6 inch slits in the flooring between the stove and the refrigerator and the floor had several black and gray colored stains underneath of the 2 compartment sink and the dishwashing area. -The kitchen counter immediately to the left of the steam table; contained a sealed plastic bag with biscuits, a metal cake pan with a Rice Krispy dessert covered with a plastic wrap and a metal cake pan with a chocolate dessert covered with a plastic wrap. Further observations revealed neither the plastic bag nor the metal cake pans were labeled or contained a date as to when the foods were originally prepared. -The kitchen counter immediately to the right of the 2 compartment food preparation sink had no available open space and was packed with several baking products including opened containers of salt, baking soda, baking powder and cor… | 2015-07-01 |
| 11279 | 11279 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 387 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview; the facility failed to ensure physician visits were conducted as required for 3 (Residents 36, 34 and 40) of 4 residents reviewed. Facility census was 33. Findings are: A. Review of facility policy for Physician Services (revision date 6/2013) revealed the physician was to see each facility resident at least every 30 days for the first 90 days after admission and at least every 60 days thereafter. B. Review of Resident 34's Admitting Physician order [REDACTED]. Review of Resident 34's medical record revealed no evidence to indicate the resident was seen by the physician since 9/3/14. During interview on 12/2/14 at 10:15 AM, the Director of Nurses (DON) verified Resident 34 had not been seen by the physician for the 30 day and 60 day visits and was last seen by the attending physician on 9/3/14. C. Review of Resident 36's Referral Form dated 9/29/14 revealed the resident was admitted on [DATE] and was seen by the physician on 9/29/14. Review of Resident 36's medical record revealed no evidence to indicate the resident was seen by the physician between 9/29/14 and 11/19/14. Review of Resident 36's Referral Form dated 11/19/14 revealed the resident was seen by the physician on that day. During interview on 12/2/14 at 9:25 AM, the DON verified Resident 36 had not been seen by the physician between 9/29/14 and 11/19/14. The DON indicated the resident should have been seen by the physician on 10/22/14 when the physician was in the facility. D. Review of Resident 40's Care Plan revealed the resident was admitted to the facility on [DATE]. Review of Resident 40's medical record revealed no evidence to indicate the resident had been seen by the physician since admission to the facility on [DATE]. During interview on 12/2/14 at 12:00 noon, the DON verified Resident 40 had not been seen by the physician since 10/22/14. | 2015-07-01 |
| 11280 | 11280 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 388 | D | 0 | 1 | ZQ0211 | Based on record review and staff interview; the facility failed to assure Resident 12's physician and nurse practitioner conducted alternate visits. Resident 12 was seen by the nurse practitioner on 3 consecutive 60 day visits. Facility census was 33. Findings are: Review of facility policy for Physician Services (revision date 6/2013) revealed the physician was to see each facility resident at least every 30 days for the first 90 days after admission and at least every 60 days thereafter. After the initial visit following admission, a qualified nurse practitioner or physician assistant may make every other required visit. Review of Referral Forms dated 4/1/14, 6/2/14 and 8/4/14 revealed Resident 12 was seen by the nurse practitioner on those days. There was no evidence in Resident 12's medical record to indicate the resident was seen by the physician until 9/11/14. Review of a Referral Form dated 9/11/14 revealed the resident was seen by the physician on that day. The Director of Nurses (DON) indicated during interview on 12/2/14 at 11:40 AM that Resident 12's physician was reminded recently of the need to alternate visits with the nurse practitioner. The DON verified during interview on 12/2/14 at 12:00 noon that Resident 12's physician and nurse practitioner had not conducted alternate visits. | 2015-07-01 |
| 11281 | 11281 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 441 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B, 12-006.17D Based on observations, record review and staff interviews; facility staff failed to utilize hand-washing and gloving techniques to prevent cross contamination during the provision of toileting cares for Residents 2 and 19, during a treatment for [REDACTED]. In addition, facility staff failed to handle Resident 29's urinary catheter drainage bag in a manner to prevent cross contamination. Facility census was 33. Findings are: A. Review of facility policy titled "Dressing-Non-sterile Treatment" (revised 6/13) revealed the facility staff was to perform treatments and dressing changes per physician orders. The licensed nurse was to follow the following procedure: -Review physician treatment orders. -Prepare clean field. -Create a barrier for dressing supplies and place on the clean field. -Wash hands. -Apply clean gloves -Remove soiled dressing and place in a biohazard container. -Remove gloves and wash hands. -Apply clean gloves. -Clean wound per physician order. Clean wound from the center to the outer borders using a circular motion (area of most contamination to the area of the least). Ensure you do not contaminate the wound bed. -Remove gloves and wash hands. -Apply clean gloves. -Apply dressing as ordered. -Remove gloves and wash hands. B. Review of facility policy titled "Urinary/ Catheter Care" (revised 2/12) indicated the purpose of catheter care was to minimize the risk of catheter-associated urinary tract infection and its related problems. The policy identified the following procedures: -Wash hands and apply gloves. -Cleanse the catheter insertion site daily with soap and water. Cleanse the proximal third of the catheter with soap and water, washing away from the insertion site and manipulating the catheter as little as possible. -Apply a sterile 4 x 4 to catheter insertion site as ordered or as indicated. -Remove gloves and wash hands. C. Review of facility policy titled "Pers… | 2015-07-01 |
| 11282 | 11282 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 490 | F | 0 | 1 | ZQ0211 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on record reviews and staff interviews; Facility Administration failed to maintain a system to prevent non-compliance with Federal and State regulations related to assuring residents were protected from injury due to hot liquid spills and hot water temperatures in resident care areas. In addition, Facility Administration failed to assure correction of previously cited deficiencies was maintained. This had the potential to affect all residents within the facility. The facility census was 33. Findings are: A. Interview with the Director of Nurses on 11/25/14 at 8:50 AM revealed Hot Beverage Safety Evaluations were completed on all residents on 11/24/14 (which was 3 days after Resident 28 sustained a burn from a hot liquid spill). The DON further indicated 3 residents were identified at risk for hot liquid spills and the intervention was to place lids on cups of hot liquids. Interview with the Dietary Manager (DM) on 11/25/14 at 9:30 AM revealed interventions for prevention of hot liquid spills were not implemented at the breakfast meal on 11/25/14 for 2 of 3 residents who were identified at risk for hot liquid spills. B. Interview with the Registered Nurse Consultant (RNC) on 11/19/14 at 2:13 PM revealed hourly monitoring of hot water temperatures was in progress due to hot water temperatures throughout the facility in excess of 130 degrees Fahrenheit. The RNC indicated all staff were educated regarding excess hot water temperatures and a log was placed in the shower room for staff to monitor and document water temperatures before all showers/baths. Review of facility shower/bath schedules from 11/20/14 through 12/1/14 revealed no documentation to indicate hot water temperatures were checked/monitored prior to provision of showers for 38 residents. This was verified during interview with the staff member who provided showers/baths during that time frame. C. The following deficient practices were cited during the previous Quality Indicator Survey (QIS) completed 11/… | 2015-07-01 |
| 11283 | 11283 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 497 | F | 0 | 1 | ZQ0211 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.04B2a Based on record review and staff interview; the facility failed to ensure annual employee performance evaluations were completed for 6 of 6 personnel records reviewed. The facility census was 33. Findings are: Review of personnel files for Nursing Assistants (NA) A, B, C, H, E and N revealed the following: -NA-A was hired on 7/15/10 with no evidence that a performance evaluation had ever been completed. -NA-B was hired on 2/7/14 with no evidence of a completed performance evaluation. -NA-C was hired on 10/22/13 with no evidence that a performance evaluation had ever been completed. -NA-H was hired on 8/1/13 with no evidence that a performance evaluation had ever been completed. -NA-E was hired on 9/16/13 with no evidence that a performance evaluation had ever been completed. -NA-N was hired on 3/24/14 with no evidence of a completed performance evaluation. During an interview on 12/2/14 from 11:45 AM to 12:00 PM, the Director of Nursing verified performance evaluations were to be completed annually but was unaware when evaluations were last completed. | 2015-07-01 |
| 11284 | 11284 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 520 | H | 0 | 1 | ZQ0211 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on observations, record review and staff interview; the facility Quality Assurance (QA) Committee failed to maintain correction of previously cited deficiencies regarding accident prevention, infection control, Care Plan revision and implementation, timely assistance for residents who require assist with activities of daily living, treatment and care of pressure sores, QA and staffing. This failure had the potential to affect the well-being of all residents. Facility census was 33. Findings are: A. Record review of the Quality Assurance policy and procedures (undated) revealed the purpose of the program was to ensure appropriate follow-up and ongoing tracking of identified environmental and quality of care issues. The policy further indicated the QA Committee was to develop and implement plans of corrective action for identified trends and/or deficient practices. The following areas were to be addressed monthly by the QA Committee: -Infection Control -Skin Integrity -Safety/Environment -Resident Assessment -Quality of Care B. Review of facility deficiency statement from the Quality Indicator Survey (QIS) completed 11/13/13 and QIS completed 12/2/14 revealed repeated facility noncompliance with the following Federal (F) tags: -F 323-Failure to prevent accidents -F 280-Failure to revise resident Care Plans -F 282 Failure to implement assessed Care Plan interventions -F 312 Failure to provide timely assistance for residents who required toileting and feeding assistance. -F 441-Failure of staff to remove gloves and wash hands during toileting cares, dressing changes and catheter cares in a manner to prevent cross contamination. F 520-Failure to maintain correction of previously cited deficiencies through the QA program. C. Interview with the Administrator on 12/2/14 from 7:45 AM to 8:01 AM revealed the QA Committee had discussed issues regarding infection control practices and current facility pressure ulcers at the last QA meeting on 10/22/14. However, there was no… | 2015-07-01 |
| 11775 | 11775 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 241 | E | 1 | 1 | 6TPT11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(21) Based on observations and staff interview, the facility failed to assure all residents were treated in a dignified manner as Residents 7, 22 and 23 were fed meals while seated next to the bird aviary which was soiled with bird droppings and feathers. Facility census was 38. Findings are: A. The interior glass surface of the bird aviary, located in the main dining room, was observed to be soiled with dried bird droppings on 5/17/11 at 11:50 AM and 5/18/11 at 6:45 AM and 9:00 AM. From 9:00 AM until 9:07 AM on 5/18/11, Residents 7, 22 and 23 were observed seated at the dining room table adjacent to the bird aviary. The residents had just finished eating the breakfast meal. Resident ' s 22 and 23 sat facing the soiled glass of the bird aviary. Resident 7 was seated in a wheelchair which was placed sideways next to the bird aviary. The wheels of Resident 7 ' s wheelchair were touching the glass of the bird aviary. B. At 10:20 AM on 5/19/11 the interior glass surface of the bird aviary was observed to remain soiled with dried bird droppings and there was an accumulation of bird feathers on the floor. The Administrator verified during interview at this time that the bird aviary was in need of cleaning and a pleasant dignified dining experience was not provided for residents. The Administrator indicated there were plans to remove the bird aviary from the dining room at some point. | 2015-01-01 |
| 11776 | 11776 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 253 | E | 1 | 1 | 6TPT11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A Based on observations and staff interview, the facility failed to assure the facility was free from odors and failed to maintain walls, doors/door jams, closet doors, dresser drawers, floors and the bird aviary in clean condition and/or good repair. This affected 15 (Rooms 1, 2, 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 21, 22 and 25) out of 21 occupied resident rooms and 3 residents (Residents 7, 22 and 23) who ate their meals while seated next to the bird aviary located in the main dining room. Facility census was 38. Findings are: A. The interior glass surface of the bird aviary, located in the main dining room, was observed to be soiled with dried bird droppings on 5/17/11 at 11:50 AM and 5/18/11 at 6:45 AM and 9:00 AM. At 9:00 AM on 5/18/11, Residents 7, 22 and 23 were observed seated at the dining room table adjacent to the bird aviary. Resident ' s 22 and 23 sat facing the soiled glass of the bird aviary. Resident 7 was seated in a wheelchair which was placed sideways next to the bird aviary. The wheels of Resident 7 ' s wheelchair were touching the glass of the bird aviary. B. At 10:20 AM on 5/19/11 the interior glass surface of the bird aviary was observed to remain soiled with dried bird droppings and there was an accumulation of bird feathers on the floor. Interview with the Maintenance Supervisor at this time revealed the bird aviary was not on a routine cleaning schedule and the last time it had been cleaned might have been in December 2010. C. The following was observed during environmental tour of the facility with the Administrator and Maintenance Supervisor on 5/19/11 from 10:20 AM until 11:10 AM: -Room 1-Bathroom walls were paint chipped and gouged below the sink and beneath the call light system. -Room 2-There was duct tape holding the vinyl covering in place on the bottom edge of the door to the room. -Room 3-There was a strip of red tape on the floor between the resident ' s beds. The tape was torn and frayed and did not present a smooth easily cleanable… | 2015-01-01 |
| 11777 | 11777 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 323 | D | 1 | 1 | 6TPT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E4 Based on observations, record review and staff interviews the facility failed to assure Resident 38 was protected from falls, as fall prevention measures were not consistently provided. The sensor alarm was not in place on one occasion and the floor mat to be used in the resident's room was not used throughout the days of the survey. Facility census was 38. Findings are: Review of Resident 38's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for Care Planning) dated 5/12/11 identified an admission date of [DATE] with current [DIAGNOSES REDACTED]. The MDS identified Resident 38 required extensive assist of 2 staff for all transfers, bed mobility, dressing, toileting and bathing. This assessment reflected the resident had a history of [REDACTED]. Review of Care Plan dated 5/6/11 reflected the resident was a fall risk due to weakness and surgical repair of right hip fracture. Care Plan interventions included; -High/low bed -Mat on the floor -Sensor alarms -Call light in place and resident educated to use it Review of Resident Progress Notes dated 5/12/11 at 3:49 AM indicated Resident 38's bed alarm went off and resident was found sitting beside the bed on the floor. The bed had been in the lowest position. Resident 38 stated that resident was going to the bathroom and forgot to call. 2 staff assisted resident back into bed. The bed alarm was changed to immediate ring instead of a 2 second delayed ring. Staff reminded Resident 38 to use the call light to call for help. During observation of Resident 38 on 5/18/11 at 1:18 PM resident was seated in a wheelchair next to the bed in the resident ' s room. No fall mat was noted on the floor. Resident was observed 5/18/11 at 2:30 PM asleep on resident ' s bed. No fall mat was noted on floor. At 3:21 PM on 5/18/11 Resident 38 was seated in a wheelchair in the Activity Room and no sensor alarm was noted to wheelchair. During obs… | 2015-01-01 |
| 11778 | 11778 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 329 | D | 1 | 1 | 6TPT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview; the facility failed to assure drug regimens were free from unnecessary drugs for Residents 6 and 30. The facility failed to monitor behaviors on Resident 6 whose drug regimen included [MEDICATION NAME] (a medication used to treat anxiety). Furthermore, the facility failed to routinely monitor Resident 30 ' s blood pressure to evaluate use of [MEDICATION NAME] (a medication used to treat hypertension). Facility census was 38. Findings are: A. Review of Resident 6 ' s Face Sheet with an admission date of [DATE] indicated [DIAGNOSES REDACTED]. Review of Resident 6 ' s Current physician's order [REDACTED].? tablet (0.25 mg) 3 times daily (TID). There was no documentation in the electronic medical record to indicate what resident behaviors were targeted for use of [MEDICATION NAME], nor was there documentation of behavior monitoring. Observations on 5/18/11 at 2:10 PM and 3:30 PM and 5/19/11 at 7:50 AM and 9:00 AM revealed Resident 6 seated in the recliner in room with eyes closed. During interview on 5/23/11 from 10:00 AM to 10:05 AM, Licensed Practical Nurse (LPN) - A verified there was no behavior monitoring documentation in the medical record. LPN - A revealed Resident 6 was administered [MEDICATION NAME] for " restlessness " . Observations on 5/23/11 at 10:15 AM, 1:30 PM and 3:15 PM revealed Resident 6 seated in the recliner in room with eyes closed. During interview on 5/23/11 from 3:30 PM to 4:15 PM, the Director of Nursing and the Administrator verified Resident 6 did not exhibit signs of restlessness or anxiety. B. Review of Resident 30 ' s Face Sheet with an admission date of [DATE] indicated [DIAGNOSES REDACTED]. Review of Resident 30 ' s Medications Flowsheet dated 5/11 indicated Resident 30 had a physician's order [REDACTED]. Review of the Vitals Report dated 11/1/10 through 5/24/11 revealed Resident 30 ' s blood pressure (BP) was not measured during the month of 11/10. It furt… | 2015-01-01 |
| 11779 | 11779 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 356 | C | 0 | 1 | 6TPT11 | Based on observations and staff interview, the facility failed to post Nurse Staffing information on a daily basis. In addition, the facility failed to maintain the Nurse Staffing information for a minimum of 18 months as required. This potentially affected all 38 residents who currently resided in the facility. Findings are: A. Observations on 5/17/11 at 9:45 AM, 5/18/11 at 7:00AM and 1:20 PM, and 5/19/11 at 6:20 AM and 10:00 AM revealed the Nurse Staffing information was not posted. B. Interview with the Director of Nursing on 5/19/11 from 10:00 AM until 10:12 AM revealed the facility had not been posting the Nurse Staffing information and there were no past records to indicate the information had been completed and maintained. | 2015-01-01 |
| 11780 | 11780 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 516 | F | 0 | 1 | 6TPT11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.16C Based on observations and staff interview, the facility failed to assure confidentiality of resident records as resident medical record information could be easily obtained from the shredding machine storage container which was located in the sunroom (an area readily accessible to residents, visitors and staff members). This had the potential to affect all 38 residents currently residing in the facility. Findings are: A. On 5/19/11 at 11:00 AM, the shredding machine storage container was observed in the sunroom of the facility. The sunroom was located in a public area and available for use by residents, visitors and staff members. The shredding machine storage container was full of papers, including discarded confidential medical records, which could easily be removed from an open slot on the container. B. The Administrator verified during interview on 5/19/11 from 11:15 AM until 11:20 AM that the shredding machine storage container needed to be emptied. The Administrator stated the facility had a contract with a paper shredding service. The Administrator was not sure when the contract service had last emptied the container. C. Observations on 5/23/11 at 2:44 PM and 3:30 PM and 5/24/11 at 6:45 AM revealed the shredding machine storage container remained full of papers, including discarded confidential medical record information which could easily be removed. | 2015-01-01 |
| 12669 | 12669 | ALEGENT HEALTH IMMANUEL FONTENELLE HOME | 285085 | 6809 N 68TH PLAZA | OMAHA | NE | 68152 | 2010-03-03 | 332 | D | 9OFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 12-006.10D Based on observation, record review and interview: the facility staff failed to ensure a medication error rate of 5 percent or less. A total of 45 opportunities were observed with 3 medication errors which gave an error rate of 6.66 percent. The survey consisted of 24 sampled and 6 non-sampled residents. The facility staff identified a census of 152. Findings are: Record review of a Resident Face Sheet dated 10/15/2009 revealed that Resident 4 was admitted to the facility on [DATE]. Record review of Resident 4's Physician order [REDACTED]. that the resident's physician had ordered medication including [MEDICATION NAME] ( antiemetic) 10 mg (milligrams) before meals and at bed time by a tube. Resident 4 had a gastrostomy tube in place. (a tube placed into the stomach usually through the abdomen). Record review of an physician's orders [REDACTED]. Observation on 2/25/2010 at 12:30 PM of a medication administration revealed that Certified Medication Assistant (CMA) G administered the [MEDICATION NAME] and [MEDICATION NAME] to Resident 4. When asked if Resident 4 had eaten lunch, CMA G stated "yes". When asked if the medication identified above was to be given before meals, CMA G stated ''yes". CMA G confirmed that the medications had been given after the meal and not before as ordered. Record review of a Face Sheet dated 3/01/2010 revealed that Resident 25 was admitted to the facility on [DATE]. Record review of a transfer sheet dated 6/16/09 revealed that Resident 25's Physician had ordered Asprin 81 mg a day. Observation on 3/01/2010 at 7:10 AM revealed Licensed Practical Nurse (LPN) H prepared Resident 25 medications. Observation at this time revealed the Asprin was [MEDICATION NAME] coated. LPN G placed the Asprin in a small package with several other medications and crushed those medication. LPN H placed the crushed medications into apple sauce and administered them to Resident 25. An interview on 3/02/… | 2014-04-01 | ||
| 12670 | 12670 | ALEGENT HEALTH IMMANUEL FONTENELLE HOME | 285085 | 6809 N 68TH PLAZA | OMAHA | NE | 68152 | 2010-03-03 | 280 | D | 9OFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 12-006.09C1c Based on record review and interview; the facility staff failed to revise Comprehensive Care Plans to include specific interventions to address [MEDICAL CONDITION] for 1 (Resident 18) of 24 sampled residents. The facility census was 152. Findings are: Record review of Resident 7's Admission Face Sheet showed an admission date of 2/5/10. Record review of an Admission History and Physical dated 1/29/10 revealed [DIAGNOSES REDACTED]. Record review of Resident 7's Skilled Admission Note by the Nursing Home Network dated 2/8/10 revealed that a Short Geriatric Depression Scale assessment for Resident 7 had been completed on that date. The score for Resident 7 was 3 out of 5 possible points with "yes" answers given to the questions " Do you often feel helpless" and "Do you feel pretty worthless the way you are now". Documentation was present on the form that Resident 7 indicated that those feelings were related to the recent illness. Record review of an E.A.C. H. ( A facility process initiated each time a resident makes a suicidal statement or gesture) document dated 2/10/10 revealed that Resident 7 had made the comment " I don't know if life is worth living". Record review of the E.A.C.H Process for the incident dated 2/10/10 revealed that, after this comment was made by Resident 7, the facility followed their process as required. Record review of an E.A.C.H. document dated 2/11/10 revealed that Resident 7 made another suicidal statement to facility staff. Record review of the E.A.C.H Process for the incident dated 2/11/10 revealed that, after this comment was made by Resident 7, the facility followed their process as required. Record review of Resident 7's Comprehensive Care Plan (CCP) dated 2/18/10 revealed that the E.A.C.H. process was done on 2/10/10 and 2/11/10 and that Resident 7 was sent to the emergency room after the 2/11/10 incident. The CCP did not contain any specific interventions related to the … | 2014-04-01 | ||
| 12671 | 12671 | ALEGENT HEALTH IMMANUEL FONTENELLE HOME | 285085 | 6809 N 68TH PLAZA | OMAHA | NE | 68152 | 2010-03-03 | 441 | E | 9OFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F441 LICENSURE REFERENCE NUMBER-12-006.17B-Prevention of Cross-Contamination LICENSURE REFERENCE NUMBER-12-006.17D -Hand washing Based on observation, record review and interview the nursing staff failed to follow infection control practices during the provision of treatment and services related to hand washing and gloving during personal hygiene cares for incontinent residents, administering fluids per Gastrostomy tube, handling and transporting soiled linens and disinfecting the glucose meter. The total samples of 24 residents within the nursing facility census of 152 were reviewed. Findings are: A. Review of the Alegent Health Skills Demonstration, revised 01/06/10, requires Hand Washing, Item 3. Lathers all surfaces of fingers, hands and wrists, producing friction for at least 20 seconds; And Item 4. Can state that the minimum length of time to wash hands is 20 seconds. B. Review of GLOVE INFORMATION HEALTH CARE WORKERS, Occupational safety and Health Administration updated Blood borne pathogens Standard, effective April 2001: in part states: *it is crucial for Health Care Worker ' s (HCW ' s) to wash hands following glove removal when hands are visibly soiled. Hands should also be washed when the integrity of the gloves has been compromised (torn, etc.) during use. In the absence of visible (or any perceived) contamination of hands, hand hygiene with alcohol hand rubs is appropriate, following glove removal. Gloves should also be changed any time the healthcare worker switches from contaminated to clean tasks. C. On 3/2/2010, from 8:15 to 9:10 A.M., observation of both NA (Nurse Aide) F and E during the provision of personal hygiene cares for Resident 1 revealed both NA (Nurse Aide) F and E contaminated their hand gloves with stool while attempting to remove the resident ' s brief. NA-F commented, " I ' m contaminated " and held both hands up off the resident. While NA-E continued to hold the resident over by the buttock covered with sto… | 2014-04-01 | ||
| 12672 | 12672 | ALEGENT HEALTH IMMANUEL FONTENELLE HOME | 285085 | 6809 N 68TH PLAZA | OMAHA | NE | 68152 | 2010-03-03 | 281 | D | 9OFY11 | LICENSURE REFERENCE NAC 175 12-006.10B1 Based on interview and observation and record review, the Facility staff failed to document medications after administration for 2 residents (Resident 7 and Resident 29).These observations were made during the survey that occurred from February 25, 2010 to March 3, 2010. The facility census was 152 and the sample size was 24 plus 6 non-sampled residents. Findings are: A. Observation was on March 2, 2010 at 08:!0 AM of LPN K preparing insulin for Resident 29. When finished drawing insulin into the syringe, LPN K was observed initialing the MAR. (Medication Administration Record). Review of the facility ' s Skills Demonstration Document of Medication Administration, item #13 states, " Meds charted immediately after given " . In an interview with LPN K done at the time of the initialing, LPN K admitted to initialing the medication prior to giving, stating that it was known that was not a correct procedure and this is not the way LPN K normally charts medications. B. On 03/01/2010 at 4:05 P.M. observation of the LPN (License Practical Nurse) Nurse-A revealed the nurse charted the medications for Resident 7 at the time the medications were prepared instead of documenting the medications as given following the administration of the medications. During the discussion of the administration and documentation of medications with LPN Nurse-A, the nurse confirmed that medications are to be charted after the administration of the medications. C. Review of the ALEGENT HEALTH I Skills Demonstration, MEDICATION ADMINISTRATION, last revised 04/08, has documented under item 13. Meds charted immediately after given. | 2014-04-01 | ||
| 12673 | 12673 | ALEGENT HEALTH IMMANUEL FONTENELLE HOME | 285085 | 6809 N 68TH PLAZA | OMAHA | NE | 68152 | 2010-03-03 | 322 | D | 9OFY11 | LICENSURE REFERENCE NUMBER 12-006.09D6(1) Based on observation, interview and the policy for Skills Demonstration the faculty failed to ensure cleansing of the equipment for administration of fluids through a Gastrostomy tube for 1 (Resident 7) resident. The total samples of 24 residents within the nursing facility census of 152 were reviewed. Findings are: On 03/01/2010, 4:05 P.M., observation during the administration of Resident 7 ' s water flush per Gastrostomy tube, revealed the LPN (License Practical Nurse) Nurse-A prepared the graduate with 200cc (Centimeters) water; placed the graduate and the syringe on the resident ' s bed linens. Upon completion of the water flush through the Gastrostomy tube, LPN-A separated the syringe, placed the barrel and plunger into the graduate and returned the equipment, without rinsing, to Resident 7 ' s bedside table. On 03/01/2010, following the Gastrostomy tube water flush for Resident 7, an interview with LPN-A revealed " it didn ' t occur to me to rinse it " . Review of the ALEGENT HEALTH Senior Health Services Skills Demonstration, MEDICATION ADMINISTRATION VIA GASTROINTESTINAL TUBE, last revised 12/08, has documented under item 21. Rinses graduate and syringe (separate barrel and plunger) and sets in clean area to dry. | 2014-04-01 | ||
| 2237 | 2237 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2019-02-26 | 609 | D | 0 | 1 | 1UP111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report to the State agency an allegation of potential abuse and/or neglect related to a hot liquid spill that resulted in injury for Resident 19. 3 residents were reviewed for abuse, and the total facility census was 32. Findings are: [NAME] Review of the facility policy titled Abuse, Neglect, and Misappropriation of Resident Property (not dated) included the following related to reporting of potential abuse and/or neglect: -allegations are reported in accordance with Federal and State law; and -all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later that 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials in accordance with State law. B. Review of Resident 19's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/25/18 included the following: -[DIAGNOSES REDACTED]. -severely impaired cognition; and -required extensive assistance with eating. Review of Progress Notes dated 8/3/18 at 2:40 PM revealed Resident 19 spilled coffee at the lunch meal. Staff were present at the time. The area was assessed and the skin observed to be pink. Ice was applied. The area was reassessed at 2:00 PM and the skin remained red and cold from ice, and tender to touch. The ice was removed in order to assess whether the redness was related to the ice or a potential burn. Review of a Skin Occurrence assessment dated [DATE] at 6:15 PM revealed the following related to Resident 19: -had a burn on the right inner thigh measuring 0.7cm (centimeters) x (by) … | 2020-09-01 |
| 2238 | 2238 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2019-02-26 | 689 | E | 0 | 1 | 1UP111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, record review and interview; the facility failed to evaluate and implement interventions for the prevention of hot liquid spills for 3 of 3 residents (Residents 4, 19 and 29) who were reviewed related to a history of hot liquid spills. The total facility census was 32. Findings are: [NAME] Review of the facility policy titled Hot Liquids Assessment, Revised 2/25/19, included that following: -to identify and protect residents who are at risk for burning themselves while drinking hot liquids; -residents will be identified by utilizing a Hot Liquids Risk Assessment tool; -assess all residents on admission, annually and with a significant change; -residents considered At Risk (score of 6-9 on the assessment) will wear a long vinyl insulated clothing protector and/or have a lidded cup; -residents considered High Risk (score of 10 or greater) will wear a long vinyl insulated clothing protector, use a cup with a lid and have added either 1/4 cup cold water/broth to hot liquids or have their hot liquid food (soup/hot cereal) dished up and set aside in the kitchen until it reaches 145 degrees or less before it is served to the resident; -staff will notify the DON (Director of Nursing)/Administrator immediately of any hot liquid spills so a State report can be filed; -monitor skin for 4 days following hot liquid spills, whether injury occurs or not; and -if injury occurs a weekly skin occurrence will be created and initiated, and monitoring will continue until the area is resolved. B. Review of Resident 19's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/25/18 included the following: -[DIAGNOSES REDACTED]. -severely impaired cognition; and -required extensive assistance with eating. Review of Resident 19's Care Plan dated 6/18/18 revealed the resident was at risk for hot liquid spills/burns, and lids for coffee cups and vinyl … | 2020-09-01 |
| 2239 | 2239 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2019-02-26 | 880 | E | 0 | 1 | 1UP111 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observations, record review and interview; the facility failed to ensure hand hygiene and/or gloving was provided when indicated during the completion of blood glucose testing for Resident 10 and with administration of an eye drop for Resident 25. This had the potential to put 8 residents (Residents 25, 15, 19, 23, 1, 8, 29 and 12) who received routine eye drops and 5 residents (Residents 10, 32, 29, 12 and 18) who received routine blood glucose testing at increased risk for potential cross contamination. The total sample size was 21 and the facility census was 32. Findings are: [NAME] Review of the facility policy titled Standard Precautions (undated) revealed standard precautions included the following practices: -hand hygiene refers to hand-washing with soap or using an alcohol based hand rub; -hands were to be washed with soap and water whenever visibly soiled with dirt, blood or body fluids, or after direct or indirect contact with such; -wear gloves when anticipated direct contact with blood, body fluids, mucous membranes, non-intact skin and potentially infected material; -change gloves as necessary during the care of a resident to prevent cross contamination from one body site to another; and -remove gloves promptly after use, before touching non-contaminated items and environmental surfaces and before going to another resident and wash hands immediately to avoid transfer of microorganisms. B. During an observation of blood glucose testing on 2/21/19 at 11:30 AM, the following was observed: -Registered Nurse (RN)-D gathered supplies at the medication cart in the corridor, then entered Resident 10's room and set up supplies on a table. Without washing hands, RN-D donned gloves and proceeded to perform blood glucose testing; -RN-D removed disposable gloves and without performing hand hygiene, gathered supplies and returned to the medication cart; -still without completing hand hygiene, RN-D donned a clean pair of gloves and proceeded to cleanse the gluco… | 2020-09-01 |
| 2240 | 2240 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2016-09-08 | 280 | D | 0 | 1 | QVJK11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on observations, record review and interview; the facility failed to revise Care Plans following a resident to resident altercation involving Residents 1 and 13. The sample size was 20 and the facility census was 44. Findings include: [NAME] Review of Progress Notes dated 4/7/16 at 11:00 AM revealed a verbal confrontation was noted between Resident 1 and Resident 13 who were roommates. Documentation indicated Resident 13 reported being hit by Resident 1. Resident 13 was observed to have .a red mark to neck and shoulder area. Review of a facility investigation of potential abuse/neglect dated 4/11/16 revealed that on 4/7/16 at 11:00 AM, Resident 1 was seated in a wheelchair in the doorway of the room. Resident 1 was positioned directly behind Resident 13 who was also seated in a wheelchair. Staff responded after hearing yelling and Resident 13 reported being hit by Resident 1. Resident 1 voiced a need to use the bathroom and indicated Resident 13 was in the way. Resident 13 was noted to have a reddened area on the right side of the shoulder/neck. Documentation further indicated preventative measures put in place to prevent reoccurrence were to remind Resident 1 to use the call light for assistance and Resident 13 was removed from the room for lunch. B. Review of Resident 1's previous Care Plan (revision date 2/11/16) revealed the altercation with the roommate (Resident 13) on 4/7/16 was identified and the interventions were: -Staff to monitor and; -Roommate encouraged to spend time in the commons area (public sitting area of facility). Review of Resident 1's current Care Plan (revision dates 5/12/16 and 8/5/16) revealed the altercation with the roommate on 4/7/16 was not identified and there were no interventions to prevent a reoccurrence. C. Review of Resident 13's previous Care Plan (revision date 2/26/16) revealed the altercation with the roommate (Resident 1) on 4/7/16 was identified. The intervention to prevent a reoccurrence was to encourage Resident 13 t… | 2020-09-01 |
| 2241 | 2241 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2016-09-08 | 309 | D | 0 | 1 | QVJK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observations, record review and interview; the facility failed to develop interventions to: 1) address Resident 1's adverse behaviors toward Resident 13 and; 2) address Resident 27's positioning. The sample size was 20 and the facility census was 44. Findings include: [NAME] Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/4/16 revealed [DIAGNOSES REDACTED]. Review of Progress Notes dated 4/7/16 at 11:00 AM revealed a verbal confrontation was noted between Resident 1 and Resident 13 who were roommates. Documentation indicated Resident 13 reported being hit by Resident 1. Resident 13 was observed to have .a red mark to neck and shoulder area. Review of a facility investigation of potential abuse/neglect dated 4/11/16 revealed on 4/7/16 at 11:00 AM, Resident 1 was seated in a wheelchair in the doorway of the room. Resident 1 was positioned directly behind Resident 13 who was also seated in a wheelchair. Staff responded after hearing yelling and Resident 13 reported being hit by Resident 1. Resident 1 voiced a need to use the bathroom and indicated Resident 13 was in the way. Resident 13 was noted to have a reddened area on the right side of the shoulder/neck. Documentation further indicated preventative measures put in place to prevent reoccurrence were to remind Resident 1 to use the call light for assistance and Resident 13 was removed from the room for lunch. Review of Resident 1's previous Care Plan (revision date 2/11/16) revealed the altercation with the roommate on 4/7/16 was identified and the interventions were: -Staff to monitor and; -Roommate encouraged to spend time in the commons area (public sitting area of facility). Observations on 8/31/16 revealed the following: -Resident 1 and Resident 13 were roommates; -1:35 PM-Resident 1 and Resident 13 were seated in wheelchairs on opposite sides of the room… | 2020-09-01 |
| 2242 | 2242 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2016-09-08 | 315 | D | 0 | 1 | QVJK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on interview and record review, the facility failed to implement interventions to prevent further decline in bladder function and/or improve current bladder function for Resident 48. The sample size was 20 and the facility census was 44. Findings are: Review of the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/18/16 revealed Resident 48 was admitted on [DATE], and was always continent of urine. Review of the MDS dated [DATE] revealed Resident 48 was occasionally incontinent of urine (meaning less than 7 episodes of incontinence during the 7 day assessment period). Review of Resident 48's Bowel and Bladder Program Screener (a tool used to review a residents bowel and bladder status and identify their ability for retraining) dated 7/13/16 revealed Resident 48 was incontinent of urine at least daily, and was a good candidate for retraining. Review or Resident 48's undated Care Plan revealed no interventions to prevent further decline in bladder function and/or improve current bladder function. Interview with Nursing Assistant-C on 9/8/16 at 10:01 AM revealed Resident 48 had an increase in bladder incontinence. Further interview revealed Resident 48 was toileted on a routine schedule that was consistent for all residents that required assistance with toileting. Interview with Licensed Practical Nurse-A on 9/8/16 at 10:08 AM, confirmed Resident 48 did not have a bladder retraining program. Interview with Registered Nurse -F on 9/8/16 at 10:28 AM confirmed Resident 48 had an increase in bladder incontinence. | 2020-09-01 |
| 2243 | 2243 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2016-09-08 | 323 | D | 0 | 1 | QVJK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on record review and interview, the facility failed to assess causal factors and to develop and/or revise interventions for the prevention of falls for 1 resident (Resident 35). The sample size was 20 and the facility census was 44. Findings are: Review of Resident 35's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/13/16 indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident 35's current Care Plan with revision date 6/23/16 indicated the resident was at risk for falls related to impaired safety awareness and a history of frequent falls. Nursing interventions included: -Be sure the resident's call light was within reach at all times and to provide prompt response to all requests for assistance. -Ensure the resident has appropriate footwear when out of bed (black rubber soled lace up shoes). -Pin alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) to the resident's recliner, bed and wheelchair. -Low bed with a defined edge mattress. -Toilet the resident after meals. -Lift chair recliner. Review of Incident/Accident Report dated 6/26/16 at 3:45 PM revealed the resident was found lying on the floor of the resident's room. The resident's personal alarm was in place and was alarming at the time of the fall. Review of the Post Fall Assessment completed 6/26/16 at 3:45 PM revealed the resident had been seated in a lift recliner in the resident's room prior to the fall. The fall was unwitnessed and the resident was unable to identify the reason for the fall. A new intervention was identified to assess use of the recliner to determine if a different recliner should be implemented … | 2020-09-01 |
| 2244 | 2244 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2017-12-14 | 684 | D | 0 | 1 | MZNW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observation, interview, and record review; the facility failed to assess causal factors and develop interventions to 1) prevent ongoing bruising/skin tears for Resident 37, and 2) prevent ongoing skin tears for Resident 17. The sample size was 15 and the facility census was 42. [NAME] Review of Resident 17's current Care Plan with a review date of 10/23/17 revealed the resident was at risk for impaired skin integrity related to impaired mobility. Observation of Resident 17 on 12/12/17 at 9:49 AM revealed a skin tear to the right hand with steri-strips (surgical tape strips used to close small wounds) in place and a skin tear to the left forearm with steri-strips in place. Review of Resident 17's Skin Occurrence Assessments from 8/31/17 through 12/9/17 revealed the following: - On 8/31/17, the resident had a skin tear to the middle finger of the left hand caused by the resident's dresser. No new interventions were identified. - On 10/27/17, the resident had a deep slit between the 4th and 5th toes on the left foot. No causal factors or new interventions were identified. - On 11/9/17, the resident had a skin tear to the left lateral forearm. No causal factors or new interventions were identified. - On 12/4/17, the resident had a skin tear to the back of the right hand from the grab bar in the bathroom. No new interventions were identified. - On 12/9/17, the resident had a skin tear to the left forearm from bumping into a railing. No new interventions were identified. During an interview on 12/14/17 at 11:40 AM the Director of Nursing (DON) confirmed causal factors were not assessed for skin tears and/or bruising, and interventions were not put in place to prevent potential recurrence. B. Review of Resident 37's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/22/17 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident h… | 2020-09-01 |
| 2245 | 2245 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2017-12-14 | 689 | D | 0 | 1 | MZNW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record review and interview; the facility failed to ensure Resident 16 was safe to be outside without staff supervision. The facility census was 42 and the sample size was 15. Findings are: Review of Resident 16's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/11/17 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had modified independence with cognitive skills for daily decision making and displayed episodes of disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Review of Resident 16's Care Plan dated 4/20/17 revealed the use of a Wanderguard (a bracelet worn by the resident and sounds an alarm if the resident comes within a certain distance of the exit door). Review of a Wandering Risk assessment dated [DATE] revealed Resident 16 was at moderate risk for wandering. Review of Resident 16's Progress Notes dated 11/16/17 at 11:53 AM revealed the resident was at moderate risk for wandering per the assessment completed 11/16/17 following a recent room change. Documentation indicated the following: -no increased confusion or attempts to exit the facility had been noticed; -the Wanderguard was discontinued; and -staff would continue to monitor for exit seeking behaviors. Review of Progress Notes dated 12/6/17 at 10:21 AM revealed Resident 16 was .attempting to enter the Assisted portion (assisted living) of the facility today-to this time has attempted 3 times and each time was either redirected or pushed to (resident's) room by staff. There was no evidence to indicate Resident 16's attempt to exit the facility was assessed. On 12/11/17 at 10:30 AM, Resident 16 was observed seated in a wheelchair and was attempting to re-enter the facility from outside through the front door. The resident was unable to co… | 2020-09-01 |
| 6309 | 6309 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2015-07-08 | 205 | D | 0 | 1 | KV0V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview; the facility failed to provide written notification of bed hold options for Residents 28 and 22 who were discharged from the facility for hospitalization . Facility census was 41. Findings are: A. Review of the facility's undated Bed Hold Policy revealed that in the event of temporary absence from the facility, Medicare does not allow for Bed Hold payment, and therefore, Medicare residents must pay privately for Bed Hold. B. Review of Resident 28's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/30/15 indicated the resident was admitted with [DIAGNOSES REDACTED]. Review of Social Services (SS) Progress Notes dated 12/5/14 at 4:04 PM revealed Resident 28 was admitted to the facility for skilled nursing services and therapies with Medicare as the payment source. Review of SS Progress Notes dated 2/26/15 at 4:54 PM indicated staff from another facility visited to evaluate Resident 28 for possible transfer to their facility. Documentation revealed Resident 28 changed (resident's) mind about wanting to leave at this time, but that the visiting facility would accept the resident if there were changes in the future. Review of Resident 28's Nursing Progress Notes dated 2/27/15 revealed the following: - At 9:35 AM, the physician called, was updated on lab results and current condition, and ordered transfer to the hospital. - At 9:58 AM, the resident was transferred to the hospital by rescue unit. There was no documentation in the medical record to indicate written notification of the Bed Hold Policy was presented to the resident and/or responsible party, or that a decision was made related to holding the bed until the resident returned from the hospital. C. Review of Resident 22's Nursing Progress Notes on 5/14/15 revealed the following: - 6:40 AM - receiving Medicare payments for skilled services of therapy, wound care and management of pain; - 11:02 AM - o… | 2019-04-01 |
| 6310 | 6310 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2015-07-08 | 221 | D | 0 | 1 | KV0V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(8) Based on observations, record review and interviews; the facility failed to protect Resident 53 from the use of physical restraints as a fully reclined tilt-in-space wheelchair (wheelchair which allows for manual recline of resident at various degrees to assist with positioning) was implemented following falls and was used without [DIAGNOSES REDACTED]. Furthermore, the physical restraint was used without evidence of monitoring and without plans for reduction or elimination of the physical restraint. Facility census was 41. Findings are: Review of the Restraint Management Policy (revised 2/20/11) revealed the following: -Physical restraints were defined as any device, method or drug that hinders or restricts a resident from any action, mental or physical. -Restraints were used only when authorized in writing by a physician for a specified and limited time period. -When restraints were ordered, the order would be incorporated in the Care Plan, along with the mechanism for monitoring and controlling their use. -It was expected that, for those residents whose Care Plans indicate the need for restraints, the facility would engage in a systematic and gradual process towards reducing restraints. -During the time a restraint was in place, the restraint was periodically removed and the resident assisted with change of position, range of motion and/or stretching. Review of Resident 53's Minimum Data Set (MDS-a comprehensive assessment tool used for care planning) dated 5/13/15 revealed diagnoses of dementia and [MEDICAL CONDITION]. The same MDS indicated the resident's cognitive status was severely impaired and the resident required extensive staff assistance with activities of daily living. Review of Resident 53's Care Plan with revision date 5/21/15 revealed the resident was at risk for falls due to resistance with cares and impaired safety awareness. Further review of Resident 53's Care Plan revealed a… | 2019-04-01 |
| 6311 | 6311 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2015-07-08 | 279 | D | 0 | 1 | KV0V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on observations, record review and staff interview; the facility failed to develop a Care Plan that addressed use of a tilt-in-space wheelchair (wheelchair which allows for manual recline of resident at various degrees to assist with positioning) as a restraint for Resident 53. Facility census was 41. Findings are: Review of Resident 53's Minimum Data Set (MDS-a comprehensive assessment tool used for care planning) dated 5/13/15 revealed [DIAGNOSES REDACTED]. The same MDS indicated the resident's cognitive status was severely impaired and the resident required extensive staff assistance with activities of daily living. Review of Resident 53's Care Plan with revision date 5/21/15 revealed the resident was at risk for falls due to resistance with cares and impaired safety awareness with an intervention dated 5/28/15 to position the resident in the wheelchair when increased restlessness noted. Observations of the Resident 53 on the following dates and times revealed the resident sitting in the tilt-in-space wheelchair fully reclined, without foot rests, and attempting to get out of the chair: - 7/7/15 at 7:12 AM, 11:00 AM to 12:02 PM, and 1:12 PM to 3:00 PM; - 7/8/15 at 8:50 AM to 9:35 AM; and - 7/8/15 at 10 :00 AM to 10:25 AM. During interview on 7/8/15 from 10:24 AM to 10:35 AM, the Director of Nursing (DON) verified when Resident 53 was fully reclined in the tilt-in-space wheelchair, without the foot pedals, the chair prevented the resident from rising and therefore should be considered a restraint. The DON further verified the resident's Care Plan did not address use of the tilt-in-space wheelchair as a restraint. Furthermore, no interventions were developed for the monitoring or reassessment of the tilt-in-space wheelchair for reduction or elimination. | 2019-04-01 |
| 6312 | 6312 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2015-07-08 | 371 | F | 0 | 1 | KV0V11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review and interviews; the facility failed to prevent the potential for food borne illness as staff failed to follow the manufacturer's recommendations for safe usage of the dishwashing machine and temperatures were not monitored in accordance with facility policy. These practice had the potential to affect all facility residents. Facility census was 41. Findings are: Review of Policy/Procedure for Dish Machine Temperature Log (undated) revealed facility staff were to monitor and record dish machine temperatures during wash and rinse cycle at each meal to assure proper sanitizing of dishes. Observation of the dish room during the initial tour of the kitchen on 6/30/15 from 2:10 PM to 2:35 PM, revealed the facility's dish machine was a low temperature dishwasher and utilized chemical sanitation to clean dishware. Review of the manufacturer's recommendations, which were posted on the front of the dish machine revealed the water temperature during the wash cycle was to be a minimum of 120 degrees Fahrenheit (F). Review of the facility Dishwasher Temperature Log dated 6/1/15 through 6/30/15 revealed the following: -Breakfast wash temperature of 110 degrees F on 6/16/15 and 115 degrees F on 6/18/15. No wash temperatures were recorded 6/1/15 through 6/15/15, 6/17/15, 6/19/15 through 6/27/15 and on 6/30/15. (12 out of 30 days) -No lunch wash temperatures were recorded 6/1/15 through 6/17/15, 6/19/15 through 6/27/15 and 6/30/15. (27 out of 30 days) -Dinner wash temperature was 115 degrees F on 6/29/15. There was no documentation of wash temperatures 6/1/15 through 6/28/15. (28 out of 29 days). -Further review of temperature log from 6/1/15 through 6/30/15 revealed no documentation at any meal of rinse temperatures. Interview with the Dietary Manager (DM) on 6/30/15 at 2:30 PM, verified staff were to monitor and record wash and rinse cycle temperatures of the dish machine before every meal. The DM verified the wash and rinse cycle temperatures were… | 2019-04-01 |
| 6607 | 6607 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2015-12-28 | 225 | D | 1 | 0 | FEDO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to report and/or investigate a potential allegation of abuse and/or neglect for 1 resident (Resident 2). The facility census was 41. Findings are: A. Review of the facility Abuse Reporting and Investigation policy (revision date 2/11/12) included the following: -In all cases of alleged abuse/neglect the facility was to intervene in the situation, report the situation to the proper authorities, investigate the allegation and prevent abuse/neglect while the investigation was in process. -The abuse reporting procedure was to be initiated when an accident with significant injury occurred and resulted in the resident needing immediate medical attention. B. Review of Nursing Progress Noted dated 10/7/15 at 10:55 AM revealed Resident 2 had been seated on a couch next to the Nurse's Station. Documentation indicated Resident 2 stood up unassisted and was heard by staff shuffling feet and then falling. The resident sustained [REDACTED]. Review of Nursing Progress Note dated 10/7/15 at 11:40 AM revealed Resident 2 was seen at the physician clinic and received 6 sutures to the laceration above the resident's left eye. Review of the facility investigations of potential abuse/neglect from 7/8/15 through 12/28/15 revealed no report had been filed with the State Agency regarding Resident 2's fall on 10/7/15 which resulted in the need for immediate medical attention. There was no evidence to indicate an investigation had been completed or submitted to the State Agency. Interview with the Administrator on 12/28/15 at 12:00 PM confirmed Resident 2's fall with injury on 10/7/15 was not reported to the State Agency and an investigation had not been completed. | 2018-12-01 |
| 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 |
| 7759 | 7759 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2014-05-12 | 250 | D | 0 | 1 | 7XFG11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.04E3 Based on record review and staff interview; the facility failed to determine Resident 12's and/or the resident's Power of Attorney's (POA-someone who is either appointed or chosen to provide assistance in executing another individual's health decisions) wishes for dental services. Facility census was 37. Findings are: Record review of Resident 12's Admission Records dated 7/28/06 revealed the POA at that time wanted Resident 12 to have routine dental appointments. Further review of the Medical Record revealed POA paperwork signed 8/31/07 appointing a different individual as Resident 12's POA. During an interview with the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) Coordinator and Social Services Director (SSD) on 5/8/14 from 9:40 AM until 9:55 AM it was revealed the POA had been contacted in 12/12 via telephone call with no answer and in 2/13 by letter with no response. The MDS coordinator went on to state that the facility was unsure of how to handle Resident 12's dental status as the POA had not responded to the facility's attempts to contact the POA. The SSD stated that in addition to trying to contact the POA with dental concerns message had been left in regards to clothing and personal belonging issues. The SSD revealed the possible need of a change in POA to meet the residents ' needs had not been discussed. There was no documentation in Resident 12 ' s Medical Record to indicate when Resident 12 had last had a dental appointment. Review of Resident 12's Progress Notes dated from 3/21/14 through 5/5/14 revealed the facility had attempted to contact Resident 12's POA due to varying issues on 6 occasions with no response from the POA. | 2018-01-01 |
| 7760 | 7760 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2014-05-12 | 329 | D | 0 | 1 | 7XFG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview; the facility failed to assure Resident 15's medication regimen was free from unnecessary medications as the resident was receiving [MEDICATION NAME] (an antipsychotic medication that acts on the central nervous system to alter brain function) in a dosage above the recommended daily dose threshold. In addition, Resident 15's [MEDICATION NAME] dosage was increased on 2 occasions with no indication why the increased dosage was needed. Facility census was 37. Findings are: A. Review of facility policy for Antipsychotic Medication Use dated 3/14/14 indicated .All antipsychotic medications will be used within the dosage guidelines listed in F 329 (Federal Guidelines), or clinical justification will be documented for dosages that exceed the listed guidelines for more than 48 hours. B. Review of Resident 15's Care Plan revised 2/25/14 included [DIAGNOSES REDACTED]. The Care Plan further indicated the resident's target behaviors were screaming/yelling, hitting, hallucinations/delusions/paranoia. Review of Resident 15's physician's orders [REDACTED]. Review of Progress Notes revealed the following 4 entries regarding Resident 15's behaviors: -9/17/13 at 1:02 AM- .returns from supper per w/c (wheelchair). Calling out in loud humming sound. Very agitated, face red. Fluids offered and relaxes somewhat . -9/17/13 at 9:16 AM-Resident yelling loudly in dining room. Staff assist resident with breakfast and (resident) does quite (quiet) down. -9/21/13 at 2:33 PM-resident has been very loud today-at meals low pitched droning noise is constant only decreasing when (resident) has food or fluid in (resident) mouth . and when resident in room the sound .continues and at times takes on the nature of a loud roar . -9/22/13 at 6:25 PM-resident has been making loud droning noise for much of this day-at times noise becomes very loud and resident may say words or call out . Review of Resident 15's physician's orders [REDACTED].… | 2018-01-01 |
| 7761 | 7761 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2014-05-12 | 334 | D | 0 | 1 | 7XFG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview; the facility failed to provide pneumococcal vaccination in accordance with documented consent by Resident 37's authorized representative, and to provide education related to the benefits and side effects of the pneumococcal vaccine to Resident 33 who refused the vaccination. Facility census was 37. Findings are: A. Review of the facility policy titled Pneumococcal Vaccine (not dated) included the following: - Prior to or upon admission, residents would be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, would be offered the vaccination within 30 days of admission unless medically contraindicated or the resident had already been vaccinated. - Before receiving the vaccination, the resident or legal representative would receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine, and provision of such education would be documented in the resident's medical record. - Residents/representatives had the right to refuse the vaccination, and if refused, appropriate entries would be documented in the resident's medical record indicating the date of the refusal. - For residents who received the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination would be documented in the resident's medical record. B. Review of Resident 33's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/19/14 indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The MDS indicated the resident was cognitively intact related to short-term and long-term memory and memory recall, and had modified independence for daily decision making (some difficulty in new situations only). Review of a Pneumococcal Immunization Informed Consent form dated 9/12/11 revealed Resident 33 gave the facility permission to administer the vaccination. Re… | 2018-01-01 |
| 7762 | 7762 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2014-05-12 | 371 | F | 0 | 1 | 7XFG11 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.11E Based on observations, staff interview and record review; the facility failed to ensure staff washed hands and changed gloves at appropriate intervals during the meal service to prevent the potential contamination of food. Facility census was 37. Findings are: A. Review of facility Policy entitled Glove Use in Dietary Department (revision date of 5/12) revealed employees should wash hands thoroughly before and after wearing or changing gloves, change disposable gloves between tasks and not wear them continuously, and not use food contact gloves for nonfood tasks. B. During observations of the noon meal on 5/7/14 from 11:40 AM to 11:58 AM Dietary Cook (DC)-M picked up buttered bread, sandwich slices and unpackaged crackers with gloved hands. During the meal service, DC-M touched various kitchen surfaces including the residents' dietary cards, dishes, utensils and the refrigerator door handle, and without changing gloves or washing hands returned to handling the bread, sandwiches and crackers. From 11:59 AM to 12:09 PM, without changing gloves or washing hands, DC-M used a hand mixer to liquefy food items in coffee cups, took the temperature of the food items, and documented the temperatures on a food temperature log. DC-M returned to serving bread slices, sandwiches and crackers without first changing gloves or washing hands. C. Review of the 3/8/2012 version of the Food Code based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices revealed the following: -single use gloves shall be discarded when interruption occurs in the operation. -hand washing shall be completed before donning gloves for working with food. D. During an interview on 5/8/14 from 9:30 AM to 9:45 AM, the Dietary Manager confirmed DC-M should have washed hands and changed gloves before directly handling food items and when changing tasks during the meal service. | 2018-01-01 |
| 7763 | 7763 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2014-05-12 | 412 | D | 0 | 1 | 7XFG11 | LICENSURE REFERNCE NUMBER NAC 12-006.14 Based on observations, record review and staff interview; the facility failed to provide dental services as needed for Resident 12. Facility census was 37. Findings are: A. Review of Resident 12's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/30/13 revealed the resident had obvious broken teeth. Review of Resident 12's Admission Record, dated 7/28/06, revealed that the resident's Power of Attorney (POA-someone who is either appointed or chosen to provide assistance in executing another individual's health decisions) wished for the resident to receive routine dental check-ups. Review of Resident 12's current Care Plan, initiated 12/11/12 and reviewed 4/22/14, revealed the resident had chipped and broken teeth and staff were to coordinate arrangements for dental care as needed and/or ordered. Observations of Resident 12 on 5/6/14 at 9:21 AM revealed the resident had missing teeth on both the upper and lower front jaw. During an interview with the MDS coordinator on 5/8/14 at 9:40 AM, it was revealed the MDS coordinator had tried several times to contact the POA regarding Resident 12's broken/missing teeth and need to see a dentist with no response. It was also revealed a letter had been sent to the POA asking for a decision on how to handle Resident 12's dental status with no response. Furthermore, the MDS coordinator was not able to verify when Resident 12 had last received dental care. | 2018-01-01 |
| 9295 | 9295 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2013-03-28 | 323 | E | 0 | 1 | UVQR11 | Licensure Reference Number: 175 NAC 12-006.184 Based on observations, record reviews, and staff interviews; the facility failed to secure potentially hazardous chemicals which had the potential of access for 13 (Residents 51, 5, 22, 13, 20, 28, 52, 26, 23, 12, 1, 67, and 68) out of 46 sampled residents identified as mobile, cognitively impaired and at risk for wandering. The facility had a total census of 46. Findings are: A. Observations during the initial facility tour conducted on 3/19/13 at 10:10 AM to 10:40 AM revealed an unlocked storage room labeled Oxygen Storage. Observation of the unlocked storage area revealed 2 unsecured cupboards containing 3 bottles of HBV Quat Disinfectant Cleaner, 1 bottle of Stain Blaster A Cleaner and a gallon container of Clorox Bleach. Observations of the Oxygen Storage room revealed the following: -On 3/20/13 at 9:35 AM, 12:55 PM and 2:45 PM the storage room was unlocked. Unsecured cupboards in the room contained 3 bottles of HBV Quat Disinfectant Cleaner, 1 bottle of Stain Blaster A Cleaner and a gallon container of Clorox Bleach. -On 3/21/13 at 7:44 AM the storage room was unsecured with 3 bottles of HBV Quat Disinfectant Cleaner, 1 bottle of Stain Blaster A Cleaner and a gallon bottle of Clorox Bleach stored in unlocked cupboards. During an interview on 3/21/13 from 8:05 AM to 5:20 AM, the Administrator confirmed the Oxygen Storage room was to be locked at all times and potentially hazardous chemicals should not have been left unsecured. B. Observations of the facility house-keeping cart revealed the following: -On 3/20/13 from 8:00 AM to 8:12 AM the housekeeping cart was observed unsupervised in the 300 wing corridor. The bottom shelf of the cart contained an aerosol container of Ocean Breeze Scent Air Freshener, one bottle of Stain Blaster A, one bottle of Humidifier Bacteriostatic Treatment and one bottle containing HBV Quat Disinfectant Cleaner. -On 3/21/13 from 7:39 AM to 7:54 AM and from 10:50 AM to 11:00 AM, the housekeeping cart was observed unsupervised in the 100… | 2016-09-01 |
| 9296 | 9296 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2013-03-28 | 329 | E | 0 | 1 | UVQR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on record review and staff interview; the facility failed to assure 3 residents (Residents 2, 3 and 24) were free from the use of unnecessary drugs. Psychoactive medications (medications that act primarily on the central nervous system to alter brain function, resulting in temporary changes in perception, mood and behavior) were used without adequate indication for use and /or documentation to support dosages used above daily recommendations. In addition, gradual dose reductions (GDR) were not attempted and there was no documentation to indicate why GDR were clinically contraindicated. Sample size was 33 and facility census was 46. Findings are: A. A review of Resident 2's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/9/13 revealed [DIAGNOSES REDACTED]. The MDS further indicated Resident 2 exhibited no behaviors. Review of Physician Admission/Monthly Orders dated 7/30/12 indicated an order for [REDACTED]. Review of Behavior Summary reports from 12/1/12 through 3/26/13 revealed the resident displayed no adverse behaviors. Review of the Chronological Record of Medication Regimen Review for Resident 2 revealed on 1/9/13 the Consultant Pharmacist recommended a GDR of the [MEDICATION NAME]. There was no documentation in the medical record to indicate a GDR of [MEDICATION NAME] had been attempted. There was no documentation to indicate why a GDR was clinically contraindicated. During an interview on 3/27/13 from 9:20 AM to 9:35 AM, Nursing Assistant (NA)-M verified adverse behaviors were not exhibited by Resident 2. During an interview on 3/27/13 from 10:00 AM to 10:11 AM the Director of Nursing (DON) confirmed the Consultant Pharmacist had recommended a GDR of the [MEDICATION NAME] for Resident 2 and no GDR had been attempted. Furthermore the DON verified adverse behaviors were not exhibited by Resident 2. B. Review of Resident 3's MDS da… | 2016-09-01 |
| 9297 | 9297 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2013-03-28 | 428 | D | 0 | 1 | UVQR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.12B5 Based on record review and staff interview; the Consultant Registered Pharmacist (RP) failed to identify and/or report a potential drug irregularity related to duplicate drug therapy for Resident 24 who was receiving Risperdal (a medication used to treat psychotic symptoms by changing the actions of chemicals in the brain) and Seroquel (another type of medication used to treat psychotic symptoms). In addition, the RP failed to identify Resident 24's Seroquel was above the daily recommended dose. Total sample size was 33 and facility census was 46. Findings are: Review of Resident 24's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/3/12 revealed [DIAGNOSES REDACTED]. The MDS indicated the resident had hallucinations and delusions. Review of Resident 24's MDS dated [DATE] also revealed the resident had hallucinations and delusions. The same MDS further indicated the resident displayed adverse physical and verbal behaviors and rejected care 1 to 3 days per week. Review of a Nursing Home Progress Note dated 8/7/12 revealed Resident 24's physician ordered Risperdal 2 milligrams (mg) twice daily and Seroquel 100 mg 3 times daily. (According to Transmittal 274 Appendix PP-Guidance to Surveyors, the recommended daily dose threshold for Seroquel should not exceed 150 mg daily. Resident 24's Seroquel dose was 2 times above the recommended dosage). Review of the Chronological Record of Medication Regimen Review dated 8/10/12 through 3/9/13 revealed the RP failed to identify the concurrent use of Risperdal and Seroquel. The RP did not identify the Seroquel dose was above daily recommendations. Review of Resident 24's Medication Administration Record [REDACTED]. During interview on 3/27/13 from 1:05 PM until 1:10 PM, the Director of Nursing indicted the RP was aware Resident 24 was receiving Risperdal but the RP was not aware the resident was also rec… | 2016-09-01 |
| 9298 | 9298 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2013-03-28 | 431 | E | 0 | 1 | UVQR11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.121 Based on observations, staff interviews and record review; the facility failed to assure medications were stored and secured at all times in accordance with facility policy and to prevent access from unauthorized persons. Observations revealed unlocked medication carts were not under direct observation of the persons administering the medications and medications were left unsecured during the medication pass. This had the potential to affect 13 residents (Resident 15, 1, 12, 23, 26, 52, 68, 67, 28, 20, 13, 22 and 5) identified as mobile, cognitively impaired and at risk for wandering. Facility census was 46. Findings are: A. Review of the facility policy for Storage of Medications (revised 4/07) included the following; Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biological shall be locked when not in use and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. B. During observations on 3/25/13 from 11:35 AM to 11:48 AM, Registered Nurse (RN) - F and Licensed Practical Nurse (LPN) - E parked 2 medication carts in the dining room by the entrance of the chapel area as residents and staff were entering and exiting the room for the breakfast meal. RN-F and LPN-E left the medication carts unlocked, unattended and not under direct supervision as they crossed the dining room to administer medications to residents. C. On 3/26/13 from 7:56 AM to 8:15 AM, RN-N parked a medication cart in the dining room by the entrance of the chapel area as staff and residents were entering and exiting the area for the breakfast meal. The medication cart was unlocked and a drawer containing numerous medication cassettes was stored on the top of the medication cart. RN-N left the medication cart and medication cassettes unlocked, unattended and not in direct supervision while administering medications to the residents in the dining room. D. Interv… | 2016-09-01 |
| 9299 | 9299 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2013-03-28 | 441 | E | 0 | 1 | UVQR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.17 Based on observations, record review and staff interviews; the facility failed to practice infection control techniques to prevent cross contamination and the spread of infection during the provision of cares for Residents 3, 66, 10, and 48; indwelling urinary catheter cares for Residents 66 and 33; and wound care for Residents 5 and 47. Blood glucose monitoring meters (machines used to determine a resident's blood sugar level from a small sample of the resident's blood) were not cleaned in accordance with facility policy, providing a source of cross contamination which had the potential to affect 13 residents (Residents 63, 53, 8, 21, 40, 47, 6, 68, 33, 34, 31, 18 and 55) identified as routinely using the meters. In addition the mechanical sit-to-stand lift was not routinely sanitized between resident uses, which had the potential to affect 15 residents (Residents 2, 10, 23, 27, 7, 29, 25, 48, 40, 1, 18, 20, 3, 32, and 39) who were identified as using the mechanical sit-to-stand lift on a routine basis. Facility census was 46 and sample size was 33. Findings are: A. Review of the facility policy titled Hand-washing/Hand Hygiene dated 11/13/12 indicated employees must wash their hands before and after direct contact with residents; before and after performing any invasive procedure such as finger-stick blood sampling; before and after assisting a resident with personal care; after coming in contact with a resident's intact skin; before and after assisting a resident with toileting; after contact with a resident's mucous membranes and body fluids or excretions; after handling soiled or used linens, dressings, bedpans, catheters and urinals; after handling soiled equipment or utensils; and after removing gloves. The policy further indicated hand hygiene is always the final step after removing and disposing of personal protective equipment and the use of gloves does not replace hand-washing/hand hygie… | 2016-09-01 |
| 11027 | 11027 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | PO BOX 130, 706 JAMES STREET | VERDIGRE | NE | 68783 | 2011-12-19 | 280 | D | 0 | 1 | ULX411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on record reviews and staff interview; the facility failed to revise Comprehensive Care Plans (CCP) following Resident 26 and 49 ' s falls. Facility census was 42. Findings are: Review of Resident 49 ' s MDS dated [DATE] indicated [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated the resident ' s cognition was intact and extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene was required. Review of Resident 49 ' s current Care Plan revealed the resident was at risk for falls. Interventions included the following: Be sure the oxygen tubing is out of way prior to ambulating, needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night, personal items within reach, use of chair/bed electronic silent alarms (A silent alarm is a device which consists of a pad placed beneath the resident which triggers an alarm if the resident should attempt to rise. The alarm is not audible in the resident ' s room but does sound on a pager which is carried by staff members and alerts the staff member that the resident is attempting to get up without assistance), anticipate and meet the resident ' s needs, be sure the call light is within reach, encourage the resident to use the call light and prompt response to all requests for assistance. Review of Nurse ' s Notes dated 11/20/11 at 1:10 PM revealed the following documentation: staff enter rm (room) to answer light & (and) resident is seated in easy chair & tells staff (resident) fell in bathroom . Documentation further indicated the resident got a little dizzy , sat down faster than expected and the resident ' s back bumped into the toilet tank. The resident stated I couldn ' t ' t wait for staff to get there. Review of a Report of Incident/Accident form dated 11/20/11 revealed Resident 49 reported falling agai… | 2015-09-01 |
| 11028 | 11028 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | PO BOX 130, 706 JAMES STREET | VERDIGRE | NE | 68783 | 2011-12-19 | 323 | D | 0 | 1 | ULX411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b(3)(4) Based on record review and staff interview; the facility failed to initiate new interventions for the prevention of falls for Residents 26 and 49 who had a history of [REDACTED]. Findings are: A. Review of the [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/11/11 indicated Resident 26 had severely impaired cognition, required extensive 2 person physical assistance with transfers, and had 1 fall with injury since the previous assessment. Review of the Care Plan with a review date of 5/23/11 indicated Resident 26 was at risk for falls due to decreased cognition, unsteady gait, incontinence, a history of falls, and extensive medication use that included antipsychotic and antidepressant medications. Nursing interventions included to assure the resident ' s call light and frequently used objects were within reach; use of non-skid foot wear; reminders to the resident to call when needing assistance; extensive assistance with toileting; assistance of 1 to 2 with transfers; if transferring poorly, use stand-up lift (a mechanical lift used to transfer residents in a standing position); chair and wheelchair alarms (alarm devices attached to the resident ' s chair/wheelchair that sound an alarm to alert staff when the resident attempts to leave the chair/wheelchair unattended) in place and functional; and bathroom door alarm (an alarm attached to the bathroom door that sounds an alarm to alert staff when the bathroom door is opened). Review of Nurse ' s Notes dated 6/5/11 at 6:40 PM indicated Resident 26 ' s bathroom door alarm sounded. When staff answered the alarm, the resident was found on the floor in the bathroom and the resident ' s wheelchair was just outside the bathroom door. There was no documentation in the medical record to indicate causal factors leading to the fall were investigated, or that add… | 2015-09-01 |
| 11029 | 11029 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | PO BOX 130, 706 JAMES STREET | VERDIGRE | NE | 68783 | 2011-12-19 | 441 | E | 0 | 1 | ULX411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 D Based on observations, staff interviews and record review; the facility failed to utilize infection control techniques during the cleaning of Resident 49 ' s indwelling urinary catheter bag and for the cleaning of a mechanical lift following use on Resident 26. In addition, staff failed to remove gloves and/or wash hands when providing personal hygiene for Resident 42. Facility census was 42. Findings are: A. Review of the facility's policy for Hand washing (undated) and for Perineal Care dated 10/2011 revealed the staff should wash their hands for 20 seconds before applying gloves and after removing gloves. -Review of Resident 42's Minimum Data Sets (MDS, a federally mandated comprehensive assessment tool used for care planning) dated 10/26/11 identified [DIAGNOSES REDACTED]. The MDS reflected Resident 42 required limited assist with personal hygiene, bathing and toileting and extensive assist with dressing. The MDS also identified Resident 42 was occasionally incontinent of bladder. -Review of Resident 42's Care Plan dated 8/10/11 identified interventions for one staff to assist with toileting, transfers, and personal hygiene. -Nursing Assistant (NA)-B was observed providing cares for Resident 42 on 12/14/11 from 8:20 AM to 8:30 AM. NA-B assisted Resident 42 onto the toilet and donned gloves but did not wash hands prior to direct resident contact. After Resident 42 finished on the toilet, NA-B cleansed the resident ' s perineal area and buttocks with a pre-moistened cleansing cloth and applied a barrier cream to the resident ' s buttocks. NA-B did not remove soiled gloves and assisted the resident with adjusting incontinence brief and clothing. NA-B then removed soiled gloves but failed to wash hands. NA-B proceeded to position the resident in bed, removed the resident ' s glasses and positioned the resident ' s call light. NA-B removed the trash can liner from the bathroom trash and left the r… | 2015-09-01 |
| 934 | 934 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-07-03 | 657 | E | 1 | 0 | 5XJ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on interview and record review, the facility staff failed to review and revise 3 residents' care plans after falls to prevent further falls and potential injury. This affected 3 of 4 residents whose care plans were reviewed during the survey process (Residents 1, 3, and 4). The facility identified a census of 22 at the time of survey. Findings are: [NAME] Review of Resident 1's quarterly MDS (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 6/11/2019 revealed an admission date of [DATE]. Resident 1 had no falls since prior assessment. Review of Resident 1's Fall reports revealed Resident 1 had falls documented on 3/2/2019 and 6/19/2019. Review of Resident 1's Care Plan dated 3/15/2018 revealed no documentation of interventions implemented to prevent further falls and injuries after Resident 1 fell on [DATE] and 6/19/2019. Interventions were added to the care plan on 6/25/2019, 6 days after Resident 1 fell on [DATE]. B. Review of Resident 3's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 3 required extensive assistance with transfers. Resident 3 had 1 fall with injury since the prior assessment. Review of Resident 3's Fall report revealed documentation Resident 3 had a fall on 3/1/2019. Review of Resident 3's Care Plan dated 12/7/2018 revealed no documentation of interventions implemented to prevent further falls and injuries after Resident 3 fell on [DATE]. C. Review of Resident 4's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 4 was rarely/never understood. Staff assessment for mental status revealed Resident 4 had short tern and long term memory problems and Resident 4 had moderately impaired cognitive skills for daily decision making. Resident 4 required limited assistance of 1 staff person for transfers. Resident had 2 falls with no injury since prior assessment. Review of Resident 4's Fall repor… | 2020-09-01 |
| 935 | 935 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2017-08-22 | 371 | F | 0 | 1 | GG8P11 | Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview and record review; the facility failed to utilize a facial hair restraint to prevent the potential for hair contact with food and failed to change gloves during food preparation in a manner to prevent the potential for food borne illness. This had the potential to affect 32 residents that ate food prepared in the facility kitchen. The facility census was 32. Findings are: [NAME] Observation on 08/16/2017 between 11:00:40 AM and 11:10 AM during the initial tour of the kitchen revealed Dietary Aide (DA) A had a goatee beard and mustache with no facial hair restraint in place during food preparation of the lunch meal. B. Observation on 08/16/2017 at 12:01:37 PM revealed DA A served lunch with no facial hair restraint in place. C. Observation on 08/21/2017 at 10:31:12 revealed DA A was in the food preparation area of the facility kitchen with no facial hair restraint in place. D. Record review of the 7/1/07 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: - 2.402.1(A) Food employees shall wear hair restraints such as beard restraints that are designed and worn effectively to keep hair from contacting exposed food, clean equipment, utensils and linens. E. Observation on 8/21/17 between 11:00 AM and 11:15 AM during food preparation revealed Cook B removed a box of ground beef patties from the freezer. Cook B washed hands and donned gloves. [NAME] removed 2 frozen ground beef patties from a bag and placed them on a pan. Cook B placed the meat soiled bag on top of the plastic wrap container. It remained in that position for the entire observation. Cook B repeated the process of removing the individual ground beef patties and placed them on the pan until the pan was full. With meat soiled gloves, Cook B touched the oven door handle and opened the oven door, placed the pan in the oven and closed the oven… | 2020-09-01 |
| 936 | 936 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2018-09-05 | 637 | D | 0 | 1 | Y9XX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B1(2) Based on observation, interview, and record review; the facility staff failed to complete a SCSA (Significant Change in Status Assessment) MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) when Resident 8 was admitted to Hospice (care designed to give supportive care to people in the final phase of a terminal illness). This affected 1 of 16 residents whose MDS assessments were reviewed during the survey process. The facility identified a census of 22 at the time of survey. Findings are: Review of Resident 8's Annual MDS dated [DATE] revealed Resident 8 was admitted to the facility on [DATE]. Resident 8 had a terminal prognosis and received Hospice care during the assessment period. Observation of Resident 8's room on 8/30/18 at 3:59 PM revealed a Hospice aide was sitting in the Resident 8's room. Interview with the unidentified Hospice aide at this time revealed they provided Resident 8 Hospice care twice a week. Interview with NA-A (Nurse Aide) on 9/04/18 at 1:34 PM revealed Resident 8 received Hospice services. Review of Resident 8's Hospice Certification and Plan of Care dated 9/18/2017 revealed a start of Care Date of 9/14/2017. Review of Resident 8's MDS assessments revealed the following assessments were completed: 6/15/2018 Annual 3/15/2018 Quarterly 12/18/2017 Quarterly 9/18/2017 Quarterly 6/15/2017 Annual There was no documentation a SCSA MDS was completed after Resident 8 was admitted to Hospice on 9/14/2017. Review of the Centers for Medicare and Medicaid RAI (Resident Assessment Instrument) 3.0 manual revealed the following: A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD (Assessment Reference Date) must be within 14 days from the effective date of the hospice el… | 2020-09-01 |
| 937 | 937 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2018-09-05 | 641 | E | 0 | 1 | Y9XX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09b Based on interview and record review, the facility staff failed to code the MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) to reflect the PASRR (Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) requirement. This affected 3 of 3 sampled residents (Residents 10, 21, and 1). The facility identified a census of 22 at the time of survey. Findings are: [NAME] Review of Resident 10's annual MDS dated [DATE] revealed a response to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?in section A1500 PASRR was marked No. Resident 10 had an active [DIAGNOSES REDACTED]. Resident 10's admitted was 1/31/2011. Review of the Ascend Nebraska Level 1 PASRR Screening Instructions revised 11/25/2015 revealed the following: The federal definition for mental illness is designed to include individuals with a potential for and history of episodic changes in treatment and service needs. Federal guidelines include a three component definition that includes: [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Anxiety disorder may require further evaluation through PASRR depending upon their extent and severity. Review of Resident 10's [DIAGNOSES REDACTED]. Resident #21 B. Review of Resident 21's annual MDS dated [DATE] revealed a response to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?in section A1500 PASRR was marked No. Resident 21 had an active [DIAGNOSES REDACTED]. Resident 21's admitted was 9/14/2015. Review of the Ascend Nebraska Level 1 PASRR Screening Instructions revised 11/25/2015 revealed the following: The … | 2020-09-01 |
| 938 | 938 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2018-09-05 | 727 | F | 0 | 1 | Y9XX11 | Licensure Reference Number 175 NAC 12-006.04C1 Based on record review and interview, the facility failed to provide 8 hours of RN (Registered Nurse) coverage for every 24 hour period. This had the potential to affect all the residents at the facility. The facility census was 22. Findings are: Record review of the facility nursing staff schedule revealed that the nursing staff schedule did not reflect 8 hour RN coverage on the following dates: (MONTH) 5, (MONTH) 18, (MONTH) 25, (MONTH) 1 and (MONTH) 2. Interview (MONTH) 4th, (YEAR) at 11:30 AM with the DON (Director of Nursing) confirmed there was no RN coverage on those dates. | 2020-09-01 |
| 939 | 939 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2018-09-05 | 812 | F | 1 | 1 | Y9XX11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview, and record review; the facility staff failed to serve food in a manner to prevent potential cross contamination; failed to maintain cookware and dishes to prevent potential cross contamination; and failed to keep kitchen surfaces clean. This had the potential to affect all of the facility residents. The facility identified a census of 22 at the time of survey. Findings are: [NAME] Initial tour of the kitchen on 8/29/18 at 9:44 AM revealed the following: Mixing bowls, plate warmers and lids for room trays were stored on bottom shelves upright and uncovered. Plates were uncovered in the rack by the steam table. Refrigerator and freezer doors were visibly soiled with smears of white and brown material. A window air conditioner was blowing back behind the stove over the sink; the front cover had gray debris on it. B. Observation of evening meal service on 8/30/2018 at 5:30 PM revealed Cook-B wearing gloves. Cook-B grabbed the handles of 2 carts and wheeled them over to where the steam table was. At 5:37 PM Cook-B touched the buns for the riblet sandwiches with the same gloved hands that they had touched the cart handles with and the handles of the utensils. Cook-B did not change gloves. Cook-B then picked up trays off the bottom shelf of the food prep table and continued to serve. Cook-B also handled the diet cards. Cook-B then touched the ham sandwiches with the same gloved hands. At 5:42 PM Cook-B opened the cupboard door and got plastic cups out and put them on the condiment cart. Cook-B then grabbed more trays off the shelf. At 5:43 PM Cook-B put their fingers in the ramekins then put corn in them using the same gloved hands. Cook-B then served the corn to the residents. At 5:46 PM Cook-B got more trays off the shelf then continued to serve touching the buns with the same gloved hands and putting fingers in the ramekins. At 5:50 PM Cook-B got more trays and proceeded to touch the buns and put fingers inside the ramekins with the same… | 2020-09-01 |
| 940 | 940 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 582 | E | 0 | 1 | DGFB11 | Based on record review and interview, the facility failed to ensure that residents were provided a Notice of Medicare Non coverage for 3 (Resident 8, Resident 124, and Resident 125) of 3 sampled residents. The facility census at the time of the survey was 21. Finds are: [NAME] Record review of Resident 8's Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) dated 9/1/19 resident was notified of discharge from skilled services but did not receive the required Notice of Medicare Non Coverage (NOMNC). B. Record review of Resident 124's Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) dated 6/22/19 resident was notified of discharge from skilled services but did not receive the required Notice of Medicare Non Coverage (NOMNC). C. Record review of Resident 125's Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) dated 5/28/19 resident was notified of discharge from skilled services but did not receive the required Notice of Medicare Non Coverage (NOMNC). An interview on 10/16/19 at 4:29 PM with the DON (Director of Nursing) revealed the DON issues the denial letters for SNFABN and NOMNC. The DON stated that Resident 8, Resident 124, and Resident 125 did not initiate their discharges and that each one had days remaining for Medicare A Services. The DON confirmed that the NOMNC letters were not given to Resident 8, Resident 124 or Resident 125. | 2020-09-01 |
| 941 | 941 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 584 | D | 1 | 1 | DGFB11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-007.04D Based on observation and interview the facility failed to ensure the vents in the bathroom were free from dirt and dust for 2 (Resident 10 and Resident 15) of 16 sampled residents. The census at the time of the survey was 21. Findings Are: [NAME] Observation on 10/10/19 at 8:40 AM of the bathroom for Resident 10 revealed that the ceiling vent was covered with a fuzzy gray debris that rained down when touched with a piece of toilet tissue. B. Observation on 10/10/19 at 8:43 AM of the bathroom for Resident 15 revealed that the ceiling vent was covered with a fuzzy gray debris that rained down when touched with a piece of toilet tissue. An interview on 10/16/19 at 5:28 PM with the HS (Housekeeping Supervisor) confirmed that the bathroom vents for Resident 10 and Resident 15 were covered with a fuzzy gray debris. | 2020-09-01 |
| 942 | 942 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 602 | D | 1 | 1 | DGFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 12-006.05(9) Based on interview and record review, the facility failed to protect residents from potential misappropriation by failing to conduct reference checks, a criminal background check, and licensure certification verification checks for RN-B (Registered Nurse) who subsequently diverted medications from the facility residents. This affected 2 of 21 residents in the facility (Resident 1 and 17) who received medication. The facility identified a census of 21 at the time of survey. Findings are: Review of the facility report Misappropriation dated 9/15/2019 revealed the current facility DON (Director of Nursing) and other nursing staff suspected there were medications missing from the medication cart that had belonged to Resident 1 and Resident 17. The report contained documentation of discrepancies in the amount of medications that were sent to the facility from the pharmacy for Residents 1 and 17, the amount of the medication that was administered to the residents, and the amount remaining in the supply. The facility discovered that 86 tablets of [MEDICATION NAME] (a narcotic like pain reliever) for Resident 17, 32 tablets of [MEDICATION NAME] (antianxiety medication) for Residents 1 and 17, and 51 tablets of [MEDICATION NAME] (an opioid or narcotic pain reliever) that were slated for destruction had potentially been diverted from the facility and residents' medication supply. Review of the facility report of the investigation into drug diversion dated 9/17/2019 revealed documentation RN-B (the DON at the time of the incident) was confronted about the missing medications. RN-B admitted to diverting the mediations from the facility medication cart for their own use including [MEDICATION NAME] and [MEDICATION NAME]. RN-B was suspended then terminated from the facility. Interview with the facility administrator on 10/16/19 at 4:46 PM confirmed the medications belonging to Resident 1 and Resident 17 were diverte… | 2020-09-01 |
| 943 | 943 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 606 | D | 1 | 1 | DGFB11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3d Based on interview and record review, the facility failed to maintain 3 of 6 personnel files with evidence the NA (Nurse Aide) registry was checked for adverse findings prior to employment for the HS (Housekeeping Supervisor) and DA-C (Dietary Aide), failed to ensure staff working did not have a criminal conviction involving misappropriation on their record prior to employment, failed to ensure personnel files contained evidence that prospective employees had not been found guilty of abuse, neglect, exploitation or misappropriation, failed to ensure reference checks were completed for RN-B, and failed to check licensure certification verification status for RN-B prior to employment. The facility identified a census of 21 at the time of survey. Findings are: [NAME] Review of RN-B's General Orientation Checklist revealed a hire date of 2/4/2019. Review of RN-B's Separation Acton Form dated 9/17/2019 revealed their last day worked was 9/13/2019. Review of the personnel file for RN-B revealed their date of hire was 2/4/2019 and their day of separation (termination date) was 9/17/2019. RN-B's last day worked was listed as 9/13/2019. There was no documentation a criminal background check, reference checks, or nursing licensure check was completed upon hire. RN-B's employment application was also missing from the file. Review of the document Employment Profile Form dated and signed by RN-B on 1/24/2019 revealed documentation RN-B had a conviction 2010/2011 of misdemeanor attempt to possess narcotics. There was documentation the form had been faxed to the criminal background check company, but there was no documentation of the results of the criminal background check. Interview with the facility Administrator on 10/15/19 at 10:08 AM revealed they could not find the criminal background check for RN-B. The administrator revealed the criminal background check had been completed but they did not have access to the results because the company would not release it. The administ… | 2020-09-01 |
| 944 | 944 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 607 | E | 1 | 1 | DGFB11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3b Based on interview and record review, the facility staff failed to follow the facility policy for screening 3 of 6 employees RN-B (Registered Nurse), HS (Housekeeping Supervisor), and DA-C (Dietary Aide) for abuse, neglect, and misappropriation prior to employment. This had the potential to affect all of the facility residents. The facility identified a census of 21 at the time of survey. Findings are: [NAME] Review of RN-B's General Orientation Checklist revealed a hire date of 2/4/2019. Review of RN-B's Separation Acton Form dated 9/17/2019 revealed their last day worked was 9/13/2019. Review of the personnel file for RN-B revealed their date of hire was 2/4/2019 and their day of separation (termination date) was 9/17/2019. RN-B's last day worked was listed as 9/13/2019. There was no documentation a criminal background check, reference checks, or nursing licensure check was completed upon hire. RN-B's employment application was also missing from the file. Review of the document Employment Profile Form dated and signed by RN-B on 1/24/2019 revealed documentation RN-B had a conviction 2010/2011 of misdemeanor attempt to possess narcotics. There was documentation the form had been faxed to the criminal background check company, but there was no documentation of the results of the criminal background check. Interview with the facility Administrator on 10/15/19 at 10:08 AM revealed they could not find the criminal background check for RN-B. The administrator revealed the criminal background check had been completed but they did not have access to the results because the company would not release it. The administrator confirmed they didn't have any way of knowing what the results were of the criminal background check. The administrator confirmed it should have been completed/results available so they could act on it. Interview with the facility Administrator on 10/15/19 at 11:23 AM revealed the BOM (Business Office Manager) had a misunderstanding about completing the … | 2020-09-01 |
| 945 | 945 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 657 | D | 0 | 1 | DGFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on interview and record review, the facility failed to include 2 residents and their responsible party in planning their care (Residents 3 and 13). This affected 2 of 14 residents whose care plans were reviewed during the survey process. The facility identified a census of 21 at the time of survey. Findings are: Interview with Resident 3 on 10/09/19 at 2:43 PM revealed they had not been invited to a care plan meeting nor had been involved in the planning of their care. Review of Resident 3's quarterly MDS (MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) revealed an admission date of [DATE]. Resident 3 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated moderate cognitive impairment. Review of Resident 3's Care Plan dated 1/27/2019 revealed no documentation Resident 3 had participated in their care plan meeting. Review of Resident 3's Progress Notes revealed no documentation Resident 3 or their responsible party was invited to the care plan meeting. B. Interview with Resident 13 on 10/10/19 at 11:33 AM revealed they had not had a care plan meeting for 6-7 months. Review of Resident 13's annual MDS dated [DATE] revealed an admission date of [DATE]. Resident 13 had a BIMS score of 12. Interview with Resident 13's responsible party on 10/16/19 at 2:00 PM confirmed they have not had a care plan meeting for quite some time. They had one set up after the first of the year and the facility canceled it for some reason; they were unable to have it. Resident 13's responsible party said the facility staff had tried to schedule it on a Friday and the responsible party said they were here every Wednesday and Saturday and they had told the facility staff they would like to have the meeting when they were here. I am here. We could have the meeting. Review of Resident 13's Progress Notes revealed no documentation Resident 13 or their resp… | 2020-09-01 |
| 946 | 946 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 688 | D | 0 | 1 | DGFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D4 Based on observation, interview, and record review; the facility failed to offer a restorative nursing program to Resident 13 to restore or prevent further contractures. This affected 1 of 2 residents reviewed for restorative care. The facility identified a census of 21 at the time of survey. Findings are: Review of Resident 13's annual MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 8/16/2019 revealed an admission date of [DATE]. Resident 13 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated moderate cognitive impairment. Resident 13 required extensive assistance from 2 staff for bed mobility and Resident 13 was dependent upon staff for transfer and locomotion. No therapy or nursing restorative minutes were documented. Resident 13 had a functional limitation in range of motion on one side both upper and lower extremity. Interview with Resident 13 on 10/10/19 at 11:36 AM revealed they only had use of their right arm and leg. Resident 13 revealed the facility had not offered a restorative nursing program. Observation of Resident 13 on 10/15/19 at 10:00 AM, 10/16/2019 at 7:59 AM, and 10/16/2019 at 2:00 PM revealed both of Resident 13's hands had contractures (permanent shortening of tissue, such as muscle, tendon or skin, as a result of disuse, injury or disease. Contracture leads to the inability to straighten joints fully and to permanent deformity and disability). Resident 13's left hand was misshapen: it was curled over and their thumb was sticking out of the opposite side of their hand through their fingers. Resident 13's right hand was misshapen and fixed in a bent manner without the ability to perform spontaneous movement. Interview with the DON (Director of Nursing) on 10/16/19 at 10:03 AM revealed at one time Resident 13 was receiving a restorative nursing program for range of motion but they were refusing it. The … | 2020-09-01 |
| 947 | 947 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 689 | D | 0 | 1 | DGFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E43-8-17 Based on observation, record review, and interview; the facility failed to ensure hazardous/poisonous chemicals in the housekeeping close were stored to prevent accidental ingestion, inhalation or consumption by one wandering resident (Resident 11) out of one wandering resident on the unit. The facility census at the time of the survey was 21. Findings Are: Observation on 10/09/19 at 11:42 AM the housekeeping storage room was left unlocked. No staff were observed in the hallway. Chemicals inside the unlocked storage room were: -Multi-Surface Peroxide, an agent according to the MSDS (Material Safety Data Sheet) was harmful if swallowed or came into contact with the skin. Causes [MEDICAL CONDITION] eye damage. Avoid breathing dust/fume/gas/mist/vapors/spray. -Kling Toilet Bowl and Urinal Cleaner, an agent according to the MSDS was dangerous causing [MEDICAL CONDITION] eye damage. If swallowed immediately call a Poison Center or a Physician. Review of Resident 11's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used in care planning) dated 8/8/19 revealed that wandering behavior occurred daily. Behavior of pacing and rummaging were observed. Review of Resident 11's Progress Notes revealed documentation of Resident 11 wandering the hallways and not being easily redirected. An interview on 10/9/19 at 11:42 AM with the HS (House Supervisor) revealed that the door was unlocked and residents could have wandered into the room. The HS confirmed that harmful and dangerous chemicals were being stored in the storage room. | 2020-09-01 |
| 948 | 948 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 700 | D | 1 | 1 | DGFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B Based on observations, interviews, and record reviews; the facility failed to assess Resident 11 and Resident 21 for the use of bed rails. This affected 2 of 2 sampled residents. The facility census at the time of the survey was 21. Findings are: [NAME] Observation of Resident 11's bed on 10/9/19 at 10:51 AM revealed a bed rail in the raised position with a 13.5 gap between the head of the bed and the rail. There was greater than a 4 gap between the mattress and the bed rail. A closed fist could be placed between the mattress and the rail. An interview on 10/9/19 at 11:20 AM with the ADM (Administrator) revealed that the bed in the room to the right should have been appropriate for Resident 11 just in case Resident 11 wanted to lay in the bed. 10/09/19 11:51 AM Interview with RN-A (Registered Nurse) revealed that the bed in room [ROOM NUMBER] on the right side of the room had a space between the mattress and the bed rail of greater than 4. Review of the Side Rail Assessment for Resident 11 revealed the only assessment completed was dated 10/9/19. B. Observation of Resident 21's bed on 10/9/19 at 10:59 AM revealed a side rail on the exit side of the bed with no cover over the rail and a 7 gap in the rail. A head could easily fit into this space. 10/09/19 11:51 AM Interview with RN-A (Registered Nurse) revealed that the side rail in room [ROOM NUMBER] on the exit side of the bed had a space that Resident 21 could have put Resident 21's head through the opening. An interview on 10/09/19 at 11:55 AM with the MS (Maintenance Supervisor) revealed that the side rail did not belong to the facility. The maintenance man was informed by RN- A (Registered Nurse) that the rail needed to be remove immediately. The MS then slid the rail off of the bed which had been attached to a wooden board and place under the mattress. Review of the Side Rail Assessment for Resident 21 revealed the only assessment completed… | 2020-09-01 |
Advanced export
JSON shape: default, array, newline-delimited
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 );