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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text ▼ | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6989 | 6989 | NEBRASKA CITY CARE AND REHABILITATION CENTER, LLC | 285109 | 1420 NORTH 10TH STREET | NEBRASKA CITY | NE | 68410 | 2014-12-11 | 248 | D | 0 | 1 | 9RWM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -LICENSURE REFERENCE NUMBER: NAC 12-006.09D5b Based on observation, record review and staff interview; the facility failed to provide individualized activities for two residents (Resident 55 and 53). The facility identified a census of 50 residents. Findings are: A. A records review of the care plan dated 6/17/2013 for Resident 55 revealed Resident 55 was admitted on [DATE] for the following diagnoses- Unspecified after Cataract, Urinary Frequency, Acute pain due to trauma, [MEDICAL CONDITION], Dementia condition classified elsewhere without behavioral disturbance, swelling of limb, unspecified [MEDICAL CONDITIONS], Obstructive chronic [MEDICAL CONDITION] with exacerbation, other vitamin B 12 deficiency [MEDICAL CONDITION], unspecified essential hypertension, unspecified vitamin D deficiency. A records review of the Resident 55's MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning) dated 09/15/2014, revealed the facility assessed the following about the resident: Resident 55 has a BIMS (Brief Interview for Mental Status) score of 00, (BIMS is used to determine a resident's cognitive understanding. A BIMS score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment.) Resident 55 is assessed as having Inattention and Disorganized Thinking. Preferences for Customary Routine and Activities has the following marked: Reading books, newspapers or magazines, listening to music, Being around animals such as pets, Keeping up with the news, Doing things with groups of people, Participating in favorite activities, Spending time outdoors, Participating in religious activities or practices. Total dependence in bed mobility and transfers. Mobility is by wheelchair A records review of Recreation Services assessment dated [DATE] Resident 55, revealed Resident 55's activity preferences are- Independent, 1:1, with friends and family, small groups, out of room… | 2018-07-01 |
| 1426 | 1426 | LIFE CARE CENTER OF OMAHA | 285137 | 6032 VILLE DE SANTE DRIVE | OMAHA | NE | 68104 | 2017-01-11 | 431 | E | 0 | 1 | N57P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC ,[DATE] 12E Based on observation, interview and record review; the facility failed to ensure that medications were kept secure in the medication storage room on the South nurses unit, and failed to ensure that outdated medications and unlabeled medications were not available for resident use. The facility identified a census 85. Findings are: [NAME] An observation on [DATE] 07:55 AM the medication storage room door was propped open with a full garbage bag, with no nursing staff present in the area. A housekeeper appeared shortly after the observation of the door was made and entered the open area. This observation revealed that medications were present on the counter. The medications included: Carvedilol 12.5 mg - a drug used to treat heart failure and hypertension Atrovastatin Calcium 10 a drug used as a lipid-lowering agent and for prevention of events associated with cardiovascular disease Eliqus 2.5 mg a drug used to inhibit blood clotting and reduce the risk of heart attack and blood clots. Levothyroxine 25 mcg. a drug used to increase thyroid levels Protonix 40 mg a drug used to treat various gastric disorders such as ulcers Diltiazem 24 hour 300 mg a drug used to treat hypertension and chest pain, and treat irregular heart rhythm Alprazolam 0.25 mg a drug that is a Controlled substance used to treat anxiety Januvia 100 mg a drug used to treat diabetes and control blood sugar levels Carvedilol 12.5 mg a drug used to treat high blood pressure and heart failure Namenda 14 mg a drug used to treat memory loss Lasix 20 mg a drug used treat heart failure and decrease swelling Escitalopram 20 mg a drug used to treat depression and anxiety Alprazolam 0.5 mg a drug that is a Controlled substance used to treat anxiety Metromidazole 500 mg a drug used to treat infections Levocetirizine 5 mg a drug uses to treat allergies [REDACTED]. ADON K confirmed that nursing staff are to be present when the door is open. ADON K confirmed the housekeepi… | 2020-09-01 |
| 1407 | 1407 | LIFE CARE CENTER OF ELKHORN | 285134 | 20275 HOPPER STREET | ELKHORN | NE | 68022 | 2016-11-07 | 431 | F | 0 | 1 | 6P3W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC ,[DATE].12E1 Based on observation, record review and interview; the facility failed to ensure that medications were maintained at the required temperatures, failed to ensure outdated medications were not available for resident use, and failed to ensure medications were dated when they were opened. This had the potential to affect all the residents that reside in the facility. The facility census was 95. Findings are: Record review of the facility policy for Medication Administration revised ,[DATE] revealed that medications that require refrigeration should be stored at temperature of 36 to 46 degree Fahrenheit (F). Medications that are out dated, contaminated or deteriorated are immediately removed from stock. Medications that are multi-dose are to be labeled with a date open date, this date provides expiration date of medication, based on manufacturer recommendations outlined in the table in this policy. [NAME] Observation on [DATE] at 8:10 AM revealed that the temperature control record on the south medication storage refrigerator had temperatures below the recommended storage temperature for medication. Record review of the Temperature Log revealed that the log has Required Temperature ,[DATE] degree F posted on the top of the log, it also states Notify Maintenance Immediately if Variation of Temperature. The temperatures readings were 30 degrees on ,[DATE] ,[DATE], Temperatures read 32 degrees on ,[DATE]/,,[DATE],,[DATE],,[DATE], ,[DATE] of (YEAR). The temperature log revealed no temperatures were logged on the temperature log for the following dates ,[DATE],,[DATE], ,[DATE],,[DATE],,[DATE],,[DATE], ,[DATE], ,[DATE] ,[DATE], ,[DATE],,[DATE], ,[DATE],,[DATE],,[DATE] of (YEAR). Medications present in this refrigerator included insulin and albuterol (for respiratory treatments). Observation on [DATE] at 8:30 AM of the North medication refrigerator revealed that the facility had not documented the temperature of the medication refrig… | 2020-09-01 |
| 4487 | 4487 | AZRIA HEALTH AT MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2016-05-17 | 279 | D | 0 | 1 | Z8DT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.04C3a(5) Based on record review and interview, the facility staff failed to develop a comprehensive care plan related to the care and use of an Intravenous (IV) device for Resident 6 and to address bathing refusals for Resident 42. Facility census was 134. Findings Are: Physician order [REDACTED]. The order also said to place a Peripherally Inserted Central Catheter ( PICC) line (a catheter placed into a vein and extends to the heart). Record Review revealed that the PICC line was placed in Resident 6's left arm by a contracted agency on 5-2-16. Record review revealed that the comprehensive care plan was updated on 5/2/16 to include the infection and the intervention of the antibiotic IV medication. The comprehensive care plan did not contain care needed for the PICC line. Interview with Registered Nurse (RN) B on 5/16/16 at 3:30 PM confirmed that no comprehensive plan of care was developed for Resident 6's PICC line. B. Interview on 5/16/16 at 4:58 PM with Nursing Assistant (NA) C revealed that Resident 42 often refused a bed bath. NA C revealed that when Resident 42 would refuse a bath, most staff would mark it as refused. NA C stated if encouraged Resident 42 would then permit bathing. Interview with NA D on 5/17/16 at 8:16 AM revealed that Resident 42 would need encouragement to have any hygiene care performed, that you would have to talk the resident into it. NA D revealed that a pillow case was to be placed under the abdominal folds and breasts, after drying, but the resident didn't like it very much and would refuse it. Record review of Resident 42's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 4/9/16 revealed a Brief Interview for Mental Status (BIMS) score of 10 ( 8 to 12 is moderately impaired). Resident 42 required extensive extensive assist of one person for personal hygiene and bathing. Record Review of the form titled Resident Bathing Type by Day Chart for… | 2020-04-01 |
| 11641 | 11641 | MAPLE CREST CARE CENTER | 285149 | 2824 NORTH 66TH AVENUE | OMAHA | NE | 68104 | 2011-11-08 | 157 | D | 1 | 0 | MU3W12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to notify resident's physician of critical lab value for 1 (Resident 2) of 14 sampled residents. The facility had a total census of 124 residents. Findings are: A. Resident 2 was admitted to the facility on [DATE] according to Admission Record. Hospital Discharge Summary dated 9/30/11 listed [DIAGNOSES REDACTED]. A review of Resident 2's Care Plan revealed a focus area dated 10/23/11 related Resident 2's pressure ulcer-left ischeal buttock, right hip and history of [MEDICAL CONDITION] in left elbow. Resident 2's Care Plan listed the following intervention "Obtain and monitor lab/diagnostic work with regards to IV medications as ordered. Report results to MD (Medical Doctor)-infectious disease, and to the Pharm D (Doctor of pharmacy) who preps (Resident 2's) IV (intravenous) meds; ensure that new orders are followed per Pharm D orders. A review of Resident 2's 10/11 MAR (Medication Administration Record) revealed a physician's orders [REDACTED]. A review of laboratory results dated [DATE] for Resident 2 revealed a [MEDICATION NAME] Trough of 17.2 which was identified as a critical result. The reference range for the [MEDICATION NAME] Trough was listed as 5-10 micrograms/milliliter. Documentation on the laboratory results report stated results were called to VNA (Visiting Nurses Association) and directions received to continue same dose of [MEDICATION NAME]. Case Communication Report from facility pharmacy dated 10/17/11 stated the following: "Spoke with (RN F) RN/Maplecrest. Dose given at 0900 this am, trough drawn around 0800. Trough result=17.2. Will plan to continue same dose unless we hear otherwise from MD (Medical Doctor). They do not have any more doses. Will send enough to get through next Mondays labs." In interviews on 11/8/11 at 10:40 AM and 12:10 PM, RN (Registered Nurse) Unit Manager E reported [MEDICATION NAME] trough lab reports are faxed to the VN… | 2015-03-01 |
| 10739 | 10739 | MT CARMEL HOME- KEENS MEMORIAL | 285216 | 412 WEST 18TH STREET | KEARNEY | NE | 68847 | 2012-11-20 | 157 | D | 1 | 0 | PO3011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.04C3a6 Based on interview and record review the facility failed to notify the physician of a resident having an open area. The facility had a census of 74 and a complaint investigation sample of 6. This failure affected Resident 01.Findings are:According to the undated ADMISSION & DISCHARGE SUMMARY Resident 01 was admitted to the facility on [DATE]. The following [DIAGNOSES REDACTED]. Review of a 10/25/12 ACCIDENT/INCIDENT REPORT revealed that a nursing assistant reported to the charge nurse that Resident 01 had an open area on the left side of the middle abdomen at 7:00 PM. The nurse assessed the area to be a 1 centimeter round open area that was draining. Review of the 10/26/12 NURSES NOTES confirmed that the open area was red and warm to touch. The nurse documented cleansing the area and applying a dressing at 7:15 PM on 10/26/12. Review of the NURSE'S NOTES dated 10/27/12 at 9:30 AM revealed that the nurse noted the abdominal open area to be reddened and the dressing was changed. Review of the NURSE ' S NOTES confirmed that the physician was notified of the open area on 10/27/12 at 2:00 PM (43 hours after the staff first documented the open area). The physician prescribed Keflex 500 miligrams twice daily to treat the open area. Interview on 11/20/12 at 2:20 PM with the DON (Directror Of Nursing) revealed that the expectation was for the nurse to report the open area to the doctor as soon as the nurse became aware of it or the very next morning at the latest. The physican should have been consulted for a treatment plan as soon as possible. The DON reported that the physician notification in the situation with the open area on Resident 01 was tardy. | 2015-11-01 |
| 4416 | 4416 | SCHUYLER CARE AND REHABILITATION CENTER, LLC | 285110 | 2023 COLFAX STREET | SCHUYLER | NE | 68661 | 2018-07-18 | 604 | D | 0 | 1 | NXEG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.05 (8) Based on observation, record review and interview; the facility failed to use a restraint for the least time possible; failed to provide monitoring and evaluation for continued use of a physical restraint; and failed to develop and implement interventions for the restraint for 1 resident (Resident 3) Census was 28 and sample size was 13. Interview on 7/12/18 at 08:07 AM with Resident 3 revealed that the resident was reluctant to get up related to the alarm going off. Resident 3 stated, If I get up the alarm goes off. Observation on 7/12/18 at 08:07 AM of revealed a safety alarm on the bed of Resident 3. Interview on 7/16/18 at 10:09 AM with the Director of Nurses (DON) confirmed that the resident had 2 falls on 12/30/17. The DON confirmed that the alarm was a restraint if the resident felt that they were unable to get up related to the alarm going off. Interview with a staff member on 07/16/18 at 10:10 AM revelaed that the resident was thinking the resident could walk and tried to maneuver out of bed. The resident was bed ridden. Record review of Resident 3's MDS (Minimum Data Set) revealed the resident was at risk for falls related to new environment balance problems. The resident had 2 falls on 12/30/17. Intervention initiated on12/30/17 was a Bed alarm. The MDS dated ,[DATE] and 7/2018 revealed no falls since last assessment. The nurses note dated 7/5/2018 by the Intradisciplinary Care Plan Team revealed; no recent falls, refuses floot mat, and refuses the bed in the low position. | 2020-07-01 |
| 11784 | 11784 | MAPLE CREST CARE CENTER | 285149 | 2824 NORTH 66TH AVENUE | OMAHA | NE | 68104 | 2011-09-12 | 309 | D | 1 | 0 | MU3W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09 Based on record review and interviews, the facility failed to assess effectiveness of pain management for 1 (Resident 9) of 10 sampled residents. The facility had a total census of 124 residents. Findings are: Resident 9 was admitted to the facility on [DATE] according to admission record. Resident 9's 8/29/11 history and physical included a [DIAGNOSES REDACTED]. Occurrence Report for Resident 9 dated 8/28/11 at 11:15 PM stated "Dr. White' called; noted res outside of room in hallway laying flat on (gender) back." The Occurrence Report stated Resident 9 complained of right hip pain. A review of physician orders [REDACTED]. Radiology Report dated 8/29/11 for Resident 9 stated Resident had an acute right [MEDICAL CONDITION]. A review of physician's orders [REDACTED]. A review of Resident 9's MAR (Medication Administration Record) revealed physician orders [REDACTED]. According to back side of 8/11 MAR, Resident 9 was administered Tylenol 650 mg orally for complaint of right hip pain at 3 AM on 8/29/11. The section of Resident 9's MAR for results or response was not completed. Nurse's Notes dated 8/28/11 at 5 AM stated the following: "Still sore and hurts." In an interview on 9/8/11 at 7:45 AM, RN D reported not wanting to sedate the resident. A review of Nurse's Notes and Resident 9's MAR indicated [REDACTED]. Nurse's Note dated 8/28/11 at 12:39 PM stated Resident 9 received pain medication from ambulance crew prior to departing the facility for transport to hospital. In an interview on 9/12/11 between 11:45-11:55 AM, the DON reported expecting residents pain be reevaluated to see if another pain medication is needed and to contact the resident's physician if needed. | 2015-01-01 |
| 12349 | 12349 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2011-01-19 | 279 | D | 1 | 1 | VFG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09C Based on observation of residents, interview with staff and record review; the facility failed to develop comprehensive care plan goals and interventions regarding 1) the provision of oxygen therapy for 1 resident (Resident 110); 2) [MEDICAL TREATMENT] care and services for 1 resident (Resident 143); 3) hospice services for 1 resident (Resident 258); and 4) regarding pain management for 1 residents (Residents 98). Findings are: A. Review of the Comprehensive Care Plan for Resident 258 on 01/19/2011 revealed; -Identified Hospice service initiated: 11/13/2010 for "end stage heart" with plan to invite Resident, family and hospice to all care plan reviews; spiritual support will be provided by personal pastor and St. Elizabeth chaplain. Interview and observation of Resident 258 on 01/18/2011 in resident room revealed: -A medication was provided on a regular basis and that there was medication to take at other times. The pain did increase at times it depended on what activity the resident was or had been doing; -The resident was currently taking an antibiotic for a "cough" and had a respiratory illness. Interview with the Nursing Station 2 Manager on 01/19/2011 revealed: -Hospice service was initiated on 11/15/2010; -No Hospice contract or individualized Plan of Care for Hospice Service could be located in the medical records or provided by the staff. - A Hospice Nurse visited on 01/08/2011 to discuss medication therapy for pain control for routine administrations and which medications should be given on a as needed basis, use of other medications for congestive heart and kidney failure. Other alternative treatments (non-pharmacological) were were ordered that included: topical creams for muscle pain, heat and massage. Plan included assessment for hydration. This information is found in the Progress notes for physician/nurse communications with orders; -Review of the current care plan for Resident 258 with the Nurse Manager did … | 2014-08-01 |
| 1958 | 1958 | WILBER CARE CENTER | 285172 | 611 NORTH MAIN | WILBER | NE | 68465 | 2018-08-30 | 655 | D | 0 | 1 | FIS811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09C1a Based on record review and interview, the facility failed to ensure that the base line care plan was accurate for Resident 36. Facility sample size was 24. The facility census was 48. Record review revealed that the resident was admitted on with 5/17/18 complicated urinary tract infection. The Baseline Care Plan did not address the UTI (Urinary Tract Infection) or risk of UTI. Record review of Medication Administration Record [REDACTED]. Record review of Care plan Baseline had not addressed the UTI or the risk of UTI. On 08/28/18 at 02:04 PM, interview with DON (Director of Nurses) confirmed that the admitting [DIAGNOSES REDACTED]. | 2020-09-01 |
| 4346 | 4346 | BCP MILFORD, LLC | 285132 | 1100 WEST 1ST STREET | MILFORD | NE | 68405 | 2017-04-24 | 318 | D | 0 | 1 | 3QPH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09D4 Based on observations, record review and interview, the facility failed to provide range of motion and application of splint device to prevent further decline in range of motion for 1 (Resident 23) of 3 sampled residents. The facility had a total census of 45 residents. Findings are: Resident 23 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations on 4/18/17 at 10:38 AM revealed Resident 23's hand was contracted into a fist with no splint device in place. Observations on 4/20/17 at 10:04 AM revealed Resident 23's left hand was contracted in to a fist with no splint device in place. A review of MDS (Minimum Data Set; a comprehensive assessment used for care planning) dated 4/15/17 revealed Resident 23 had functional limitation of range of motion on both sides of upper and lower extremities. A review of Resident 23's Care Plan revealed a problem dated 2/17/12 related to activities of daily living. Resident 23 was noted to have contractures to all extremities, trunk and neck. Approaches for this problem included receiving range of motion during dressing and other daily cares by nursing staff; encourage resident to consider splints for hands to prevent further contractures, nursing staff unable to provide range of motion to lower extremities due to contractures of extension, and praise resident when participates in exercise or range of motion. A review of Occupational Therapy Discharge Summary dated 8/29/16 indicated that Resident 23 met goal of increasing right shoulder flexion and extension all joints/all planes. Discharge summary identified Resident 23 had reached maximum potential was being referred to restorative nursing program/functional maintenance program. Occupational Therapy Note dated 8/29/16 stated Resident 23 requesting something to open hand up. Resident 23 was given choices and selected palm contracture guard device. A review of Restorative Nursing Care Record for 10/2016 revealed Re… | 2020-08-01 |
| 10825 | 10825 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2012-10-09 | 309 | D | 1 | 0 | 48UM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09D5 Based on observations, interviews, and record review; the facility failed to ensure a medical evaluation was completed for adverse behaviors for 1 (Resident 1) of 4 sampled residents. The facility had a total census of 240 residents. Findings are: Resident 1 was admitted to the facility on [DATE] according to Resident 1's care plan. Admission history and physical dated 8/20/12 listed a [DIAGNOSES REDACTED]. A review of Nurse's Notes for Resident 1 dated 9/22/12 revealed Resident 1 was observed standing over Resident 3 touching Resident 3 on buttocks and pubic region. According to the facility investigation summary dated 9/25/12, Resident 3 was fully clothed. According to the facility investigation completed 9/26/12, the following interventions were put in place in response to the incident: -Both residents were placed on 15 minute checks; -Care plans were reviewed and Resident 1's care plan was up dated; -Geriatric Psychiatric service was notified. The facility investigative report stated both residents were followed by the Geriatric Psychiatric Service. A review of the facility investigative summary dated 9/26/12 revealed Resident 1 was observed to take a hold of Resident 2's hand while Resident 2 was walking with family member. Resident 1 stated Resident 1 would marry either one of them and pulled Resident 1's penis out of pants with other hand and shook it. According to the facility investigation completed 9/28/12, the following interventions were put in place in response to the incident: -Resident 1 was continued on 15 minute checks -On 9/26/12, Resident 1 was moved to a room closer to the nurses' station and away from Resident 2's room. -Geriatric Psychiatric Services was notified of the incident. The facility investigative report stated both residents were followed by the Geriatric Psychiatric Service. -Staff were to use 1:1 supervision intermittently to help calm resident behaviors. Observations on 10/3/12 at 8:13 AM… | 2015-10-01 |
| 12386 | 12386 | GOLDEN LIVINGCENTER - GRAND ISLAND PARK PLACE | 285105 | 610 NORTH DARR AVENUE | GRAND ISLAND | NE | 68803 | 2010-09-23 | 248 | D | 1 | 1 | E49Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09D5b The facility failed to ensure that an ongoing program of meaningful activities was developed and provided for 2 residents (Residents 57 and 62). The facility census was 56 residents. The sample size was 26 residents. Findings are: A. A review of Resident 57's Initial Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 4/3/2008 revealed that Resident 57 was born on 5/9/1959; had previously resided at a MR/DD (Mental [MEDICAL CONDITION]/Developmentally Disabled) facility prior to admission to the nursing home; and had a customary routine that included being involved in group activities. Activity preferences at that time included: crafts/art; exercise/sports; music; reading; spiritual activities; and television. A review of Resident 57's most recent Annual MDS Assessment was completed on 5/6/2010. At that time, Resident 57's activity interests were documented as crafts/art; exercise/sports; music; reading; spiritual activities; and television. A review of Resident 57's CARE PLAN (5/30/2010) revealed that Resident 57 had been identified as responding well to "being outdoors and playing catch with a ball...able to kick a ball with instructions,,,responds well to in room activities...can give high five and able to hold hands". Interventions included: being seated near the activity leader or volunteer for assistance and using sensory materials during 1:1 visits. A review of Resident 57's RECREATION PARTICIPATION RECORDS revealed the following: - June 2010 - Resident 57 participated in "music" activities on 6 out of 30 days during the month; and participated in "Fit & Fun" on 1 day during the month. - July 2010 - Resident 57 participated in "movies" one day during the month; "music" activities 3 days during the month; "sensory/relaxing" activities 5 days during the month; "entertainment" once during the month; went outdoors twice during the month; had 2 documented 1:1 visits dur… | 2014-07-01 |
| 11666 | 11666 | GOOD SAMARITAN SOCIETY - MILLARD | 285098 | 12856 DEAUVILLE DRIVE | OMAHA | NE | 68137 | 2011-10-20 | 323 | D | 1 | 0 | HIJ811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09D7 Based on observations, interviews, and record review, the facility failed to place Secure Guard bracelet (elopement prevention device) on resident in accordance with manufacturer's instructions for 1 (Resident 5) of 13 sampled and 2 non-sampled residents, failed to monitor function of Secure Guard bracelet on a daily basis in accordance with manufacturer's instructions and facility policy for 1 (Resident 4) of 13 sampled and 2 non sampled residents, and facility to implement assessed interventions to prevent falls for 1 (Resident 2) of 13 sampled and d2 non-sampled residents. The facility had a total census of 102 residents. Findings are: A. Resident 5 was admitted to the facility on [DATE] according to face sheet. Resident 5's Cumulative [DIAGNOSES REDACTED]. Resident 5's Care Plan included a problem dated 7/7/11 related to being at risk for elopement. The following Plans and Approaches were listed for Resident 5: -Take a picture of resident and keep in Medication Administration Record -Label all clothing with name -Secure guard transmitter to left wrist check placement each shift and functioning every day expiration May 2014 -Provide appropriate activities 1:1 if wandering -Notify family, medical doctor and Director of Nursing, Administrator of any elopement -Discuss possible move to a dementia unit with family. A Secure Guard transmitter/bracelet emits a radio frequency which triggers an alarm and/or locks the door when a resident wearing the bracelet approaches a monitored exit door. Incident Report dated 7/9/11 stated Resident 5 was found standing in front of the front door. The facility investigative report stated Resident 5 ". . . exited out of front door of the building and was standing in front of the door." The investigative report stated ". . .if resident had arm that had secure guard attached was raised more than 6 inches from the door handle the secure guard system did not function. Staff placed an additional … | 2015-02-01 |
| 11631 | 11631 | MAPLE CREST CARE CENTER | 285149 | 2824 NORTH 66TH AVENUE | OMAHA | NE | 68104 | 2011-09-12 | 323 | G | 1 | 0 | MU3W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09D7 Based on record review, observations, and interviews, the facility failed to implement care planned fall alarm interventions to prevent falls for 1 (Resident 9) of 10 sampled residents. The facility had a total census of 124 residents. Findings are: Resident 9 was admitted to the facility on [DATE] according to admission record. Resident 9's 8/29/11 history and physical included a [DIAGNOSES REDACTED]. Resident 9's care plan included a problem dated 7/12/11 of potential risk for falls. Interventions listed included use of a bed alarm when in bed. Occurrence Report for Resident 9 dated 8/28/11 at 11:15 PM stated "Dr. White' called; noted res outside of room in hallway laying flat on (gender) back." On occurrence checklist alarm and alarm activated were both checked no. In an interview on 9/8/11 at 7:45 AM, RN D reported Resident 9's bed alarm was on Resident 9's bed and not attached to Resident 9 when Resident 9 was found on floor in hallway. Radiology Report dated 8/29/11 for Resident 9 stated Resident had an acute right hip fracture. A review of acute care plan dated 8/29/11 for Resident 9 revealed Resident 9 was to have bed and chair alarms and floor mats down when in bed. Observations of Resident 9 in wheelchair in room at 7:45 AM on 9/8/11, in wheelchair in dining room at 8:05 AM and in wheelchair in resident lounge at 9 AM revealed Resident 9's chair alarm was not hooked up. In an interview on 9/12/11 at 11:45 AM, the DON (Director of Nursing) confirmed Resident 9 was to have sit stand alarm in place. | 2015-03-01 |
| 6152 | 6152 | BEAVER CITY MANOR | 285269 | P O BOX 70, 905 FLOYD STREET | BEAVER CITY | NE | 68926 | 2016-02-11 | 431 | D | 0 | 1 | Q2NL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.12E4 Based on observation, record review and interviews; the facility failed to ensure a discontinued medication was not available for resident use for Resident 10. The facility census was 21. Findings are: Observation of the medication administration by LPN (Licensed Practical Nurse)-G for Resident 10 on 02/09/2016 at 7:01 AM revealed LPN-G took a tube of Triamcinolone Cream 0.1% (a steroid cream used to treat skin inflammation) from the medication cart drawer. Interview with LPN-G on 02/09/2016 at 7:01 AM revealed Resident 10 had been receiving the Triamcinolone Cream 0.1% routinely and was currently receiving it quite regularly on a PRN (as needed) basis. Observation on 02/09/2016 at 7:02 AM revealed LPN-G reviewed the electronic MAR (medication administration record) and then said that the Triamcinolone Cream 0.1% had been discontinued and there was not a PRN order. LPN-G placed the medication back into the medication cart drawer. Record review revealed the medication had been ordered on [DATE] and was to be given for 2 weeks. Observation of the medication cart storage on 2/11/2016 at 5:05 PM revealed Resident 10's discontinued Triamcinolone Cream 0.1% was in the medication cart drawer. Interview with LPN-H on 2/11/2016 at 5:06 PM confirmed that the Triamcinolone Cream 0.1% order was discontinued and there was no PRN order. LPN-H confirmed the discontinued medication was still in the medication cart and available for Resident 10's use. Interview with DON (Director of Nursing) and NHA (Nursing Home Administrator) on 2/11/2016 at 5:30 PM revealed that their expectations were that all discontinued medications would be removed by the nurse from the medication/treatment cart at the time the order was received. | 2019-06-01 |
| 11681 | 11681 | LIFE CARE CENTER OF OMAHA | 285137 | 6032 VILLE DE SANTE DRIVE | OMAHA | NE | 68104 | 2011-10-17 | 411 | D | 1 | 0 | 6KY011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.14 Based record review and interview, the facility failed to arrange routine dental services for 2 (Residents 3 and 5) of 9 sampled and 3 non-sampled residents. The facility had a total census of 104 residents. Findings are: A. Resident 5 was admitted to the facility on [DATE] according to the Face Sheet. According to Diagnosis/History, Resident 5 has a [DIAGNOSES REDACTED]. A review of Resident 5's medical record did not reveal any evidence of Resident 5 being provided or refusing routine dental services. In an interview at 10/17/11 on 11:25 AM, Social Worker A reported there was no documentation of Resident 5 being seen by a dentist since admission to the facility. In an interview on 10/17/11 at 11:34 AM, Resident 5 confirmed Resident 5 had not seen a dentist since admission to the facility. Undated facility policy stated the following: "Residents are provided with routine and emergency dental care when needed." Interviews with Social Worker A and Social Worker E at 10/17/11 at 10:07 AM revealed dental services are offered to residents and family members at a meeting held within 72 hours of admission. They reported the facility did not have a mechanism for tracking resident dental visits. B. Record review of a Face sheet dated 9/23/2011 revealed Resident 3 re-admitted to the facility on [DATE]. Record review of a Oral Assessment Form dated 6/24/2011 revealed the assessment did not identify Resident 3 with missing teeth. The sections of the assessment form identified as upper and lower had an area to be marked if the resident had missing teeth. These sections of the assessment were left blank. Record review of Oral Assessment Form dated 9/13/2011 revealed Resident 3 was assessed to have missing teeth to both, the upper and lower sections. An interview on 10/17/2011 at 10:15 AM was conducted with the Social Service Director (SSD). During the interview, the SSD was asked if Resident 3 had been seen by the Dentist, the SSD stated… | 2015-02-01 |
| 1425 | 1425 | LIFE CARE CENTER OF OMAHA | 285137 | 6032 VILLE DE SANTE DRIVE | OMAHA | NE | 68104 | 2017-01-11 | 325 | D | 0 | 1 | N57P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12.006.09D Based on interview, record review, and observation; the facility failed to evaluate the diet needs and provide the correct diet for one of one resident reviewed (Resident 141) related to [MEDICAL CONDITION] requiring [MEDICAL TREATMENT] and Diabetes. The facility census was 85. Findings are: Record review of Resident 141 medical record, revealed that Resident 141 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 141's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated 11/16/2016 revealed that, Resident 141's cognitive status score was 15 out of 15. Interview with Resident 141 revealed that with the [DIAGNOSES REDACTED]. Resident 141 revealed that prior education, to the diet that should be followed, was received, and that the diet being provided makes it difficult to follow the restrictions that Resident 141 had followed at the hospital and at home. Resident 141 revealed that it included limiting foods high in potassium, sugar, carbohydrates and phosphorus. Resident 141 revealed that family had provided food items, to maintain the diet restrictions. Record review of Resident 141's Physician order [REDACTED]. Record review of Resident 141 ' 2 Physician order [REDACTED]. Potassium is a nutrient that is critical to the function of nerve and muscle cells, including those in your heart. Your blood potassium level is normally 3.6 to 5.2 millimoles per liter (mmol/L).(* mayoclinic) and required 15 grams of [MEDICATION NAME] in 60 ml of [MEDICATION NAME] by mouth on Sunday (12/4/16) evening and to recheck potassium level on 12/5/16. ([MEDICATION NAME]/[MEDICATION NAME] drug to remove the potassium from the system by way of the gastric system). Record review of lab values, for Resident 141, from the [MEDICAL TREATMENT] center, performed on 11/28/16 revealed that Resident 141's Potassium was 6.4 mmol/L. Record review of Resident 141's Lab performed … | 2020-09-01 |
| 9545 | 9545 | GOOD SAMARITAN SOCIETY - SUPERIOR | 285187 | 1710 IDAHO STREET | SUPERIOR | NE | 68978 | 2013-01-31 | 278 | D | 0 | 1 | OXQ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC Licensure Reference Number: 12-006.09B Based on record review and interviews, the facility failed to accurately code MDS (Minimum Data Set, a federally mandated comprehensive tool utilized to develop resident care plans) for one sampled resident (Resident 40). Facility census was 63. Findings are: Record review of an MDS revealed the most recent assessment of ADL (Activities of Daily Living) Assistance as Limited assistance, staff provide guided maneuvering of limbs or other non-weight bearing assistance. The previous assessment as Independent and no assistance. Record review of Care Plan dated 12/26/12 revealed that resident had a problem identified as Self Care Deficit r/t (related to) Diabetes, [MEDICATION NAME] Degeneration, Diabetic [MEDICAL CONDITION], Arthritis, and was either independent or supervised with ADL's, needs limited assist with bathing. Further record review revealed that interventions were identified as the resident was independent with AM cares and dressing, may need occasional supervision and/or set-up assistance and was independent with PM cares and undressing, may need occasional supervision and/or set-up assistance. Interview on 1/31/13 with MA (Medication Aide) - I at 9:15 AM revealed that resident had not had any decline in ADL's, and was independent in dressing. Interview with MDS Coordinator at 9:30 AM on 1/31/13 confirmed that the resident had not had any significant changes or declines. Further interview revealed that the MDS Coordinator did see the MDS was incorrectly coded. | 2016-07-01 |
| 147 | 147 | TABITHA NURSING HOME | 285057 | 4720 RANDOLPH STREET | LINCOLN | NE | 68510 | 2019-10-22 | 661 | D | 0 | 1 | J64C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 661 Based on record review and interview the facility failed to ensure a recapitulation of stay was completed for 1 resident (Resident 125) of 1 resident reviewed for discharge to Long-term Care. The facility census was 162. Findings are: The facility failed to ensure a recapitulation of stay was completed for one resident (Resident 125). Record review of the Recapitulation of stay IDT summary revealed; that the document was not completed. Information on the IDT summary included; 1. Resident 125 had a fall with right hip repair, 2. The admission dx was fracture of unspecified part of neck of right femur. 3. The discharge date was 9 to a SNF (Skilled Nursing Facility). 4. Resident 125 had no complications during stay, 5. The equipment that would be needed was a manual wheelchair and Resident 125 had no teeth. 6. Resident 125'sCognition had not been completed 7. Resident 125's Communication was documented that (gender) was able to make needs known. 8. Resident 125's Dietary needs had not been completed 9. Resident 125's Activity needs had not been completed. 10. Resident 125's vitals had been recorded. 11. Resident 125's ambulation, Transfer, ADL(Activities of Daily Living) status had not been completed. 12. Resident 125's Skin integrity had not been completed. 13. Resident 125 was continent of bowel and bladder. 14. Resident 125's Medications were on the order summary report. 15. Resident 125's Post Discharge Plan of Care revealed; follow up physician appointments. Record review of Lab Corp revealed an order dated 9 for IV [MEDICATION NAME] for 7 days and had been diagnosed with [REDACTED]. Record review of 14 day MDS dated 9 revealed; 1. Section C Cognition revealed Resident 125 had a BIMS (Brief Interview for Mental Status an interview to determine memory loss) score was 12 indicated moderately impaired cognition. 2. Section G revealed; Resident 125 required extensive assist of 2 person with the following ADL's bed mobility, transfers, toile… | 2020-09-01 |
| 1970 | 1970 | WILBER CARE CENTER | 285172 | 611 NORTH MAIN | WILBER | NE | 68465 | 2019-12-17 | 759 | D | 0 | 1 | Q3K311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 759 LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review and interview the facility failed to ensure a medication rate of less than 5%. The medication error rate was 7.69% resulting from 2 errors of 26 opportunities. The facility census was 48. Findings are: [NAME] An observation on 12/16/19 at 12:05PM of medication administration by LPN (Licensed Practical Nurse B for Resident 41. The [MEDICATION NAME] 25mcg(micrograms), Aspirin 325mg(milligrams), Vitamin D3 1000 units, and [MEDICATION NAME] 5mg were crushed and added to pudding. [MEDICATION NAME] 125mg Sprinkles 2 capsules were opened with gloved hands and added to the pudding. The medication was administered while Resident 41 was eating the noon meal. Record review of Resident 41's physician orders [REDACTED].>[MEDICATION NAME] tablet; 25 mcg; amount: 25 mcg; oral Once a Day at 09:30. [MEDICATION NAME] tablet, delayed release (DR/EC); 125 mg; amount: 2 caps; oral Three Times A Day 10:00AM, 4:00PM, and 8:00PM. [MEDICATION NAME] chloride tablet; 5 mg; amount: 5 mg; oral Twice A Day 10:00 - 1PM 7:00 - 9:00PM. Aspirin (OTC) tablet; 325 mg; amount: 325 mg; oral Once A Day 10:00 - 1:00PM [MEDICATION NAME] (vitamin D3) (OTC) capsule; 1,000 unit; amount: 1,000 unit; oral Once A Day 10:00 - 1:00PM. An interview on 12/17/19 12:49 PM with DON (Director of Nurses) confirmed; the [MEDICATION NAME] should be given on an empty stomach. B. An observation on 12/16/19 at 12:27PM of medication administration by MA (Medication Aide) C for Resident 21. [MEDICATION NAME] 1 tsp (teaspoon) was added to 5.5 ounces of Cranberry Juice and mixed. Record review of Resident 21's physician order [REDACTED].>An interview on 12/17/19 12:49 PM with the DON confirmed; that the [MEDICATION NAME] for Resident 21 had not been given per the physician order. | 2020-09-01 |
| 11599 | 11599 | MID-NEBRASKA LUTHERAN HOME | 285213 | 109 NORTH 2ND STREET | NEWMAN GROVE | NE | 68758 | 2011-07-13 | 309 | D | 0 | 1 | J4GR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ;LICENSURE REFERENCE NUMBER 175 NAC 12-006-09 Based on observations, record review and staff interviews, the facility failed to provide interventions to meet the individualized needs of Resident 24 with wheelchair positioning. Resident 24 was observed sitting in the wheelchair with head, neck and shoulders slumped forward. Facility census was 30. Findings are: Review of Resident 24 ' s Minimum Date Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/13/11 identified [DIAGNOSES REDACTED]. This MDS reflected Resident 24 required extensive assist with bed mobility, transfers, ambulation, dressing, toileting, personal hygiene and eating. The resident was also identified as having functional limitations to bilateral upper and lower extremities. Review of the Comprehensive Care Plan dated 6/13/11 indicated Resident 24 required assistance with all cares. The care plan indicated Resident 24 " cries to return to bed soon after the resident is gotten up in the chair. " Nursing approaches included placing resident in the wheelchair for meals and to get resident up only a short time before meals, then to return the resident to bed as quickly as possible after the meal. Resident 24 was observed sitting in a wheelchair in the dining room on 7/7/11 at 7:33 AM, 7/11/11 at 8:10 AM and 12:00 PM, 7/12/11 at 7:20 AM and 1:06 PM, and 7/13/11 at 8:15 AM with head, neck and shoulders slumped forward. No interventions were used to assist the resident to maintain an upright posture or to prevent the resident from slumping forward. During an interview 7/7/11 from 8:15 AM to 8:20 AM in the dining room NA-D (Nursing Assistant D) was observed feeding Resident 24 and stated " different positioning would probably help, we haven ' t tried anything that I know of. " During interview on 7/11/11 from 3:20 PM to 3:30 PM with RN-C (Registered Nurse C) and Director of Nursing (DON), the DON verified Resident 24 had poor positioning when sit… | 2015-04-01 |
| 3924 | 3924 | HILLCREST COUNTRY ESTATES-COTTAGES | 285293 | 6082 GRAND LODGE AVENUE | PAPILLION | NE | 68133 | 2018-07-18 | 770 | D | 1 | 1 | NCIW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 175 NAC 12-006.09 Based on interview and record review, the facility failed to obtain physician order to discontinue previously ordered lab for 1 (Resident 78) of 1 sampled residents. The facility had a total census of 46 residents. Findings are: Resident 78 was admitted to the facility on [DATE] and discharged on [DATE] according to Face Sheet. A review of Care Plan Report for Resident 78 revealed a [DIAGNOSES REDACTED]. A review of Resident 78's physician orders revealed an order for [REDACTED].>A review of Clinical Notes dated 6/7/18 revealed Resident 78's physician had discontinued order for urinalysis. A review of Resident 78's physician orders revealed an order dated 6/13/18 to change Foley catheter and bag. A urinalysis and culture and sensitivity was to be obtained from the new bag. A review of Resident 78's Clinical Notes dated 6/13/18 at 7 PM revealed no clean Foley bag could be found after calling several cottages. A message was left with Director of Nursing that a new bag needed to be obtained and a specimen sent in the morning. A review of Resident 78's physician orders did not reveal any orders to discontinue the order for the urinalysis on 6/6/18 or 6/13/18. In an interview on 7/17/18 at 9:46 AM, Physician B verified that orders for urinalysis on 6/6/18 had been discontinued due to Resident 78 not showing signs or symptoms of a urinary tract infection and the urinalysis on 6/13/18 had been discontinued due to moving up Resident 78's appointment with the urologist. In an interview 7/17/18 at 11:33 AM, Regional Director of Clinical Services confirmed there was no physician order to discontinue orders for urinalysis on 6/6/18 or 6/13/18. | 2020-09-01 |
| 4424 | 4424 | SCHUYLER CARE AND REHABILITATION CENTER, LLC | 285110 | 2023 COLFAX STREET | SCHUYLER | NE | 68661 | 2018-07-18 | 880 | E | 1 | 1 | NXEG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 175 NAC 12.006.17 175 NAC 12.006.17B 175 NAC 12.006.17D Infection Prevention and Control Based on observations, record review, and interview; the facility failed to ensure interventions were in place to prevent cross contamination related to resident care supplies being stored together affecting 4 residents; and related to not doing hand hygiene to prevent cross contamination for 2 residents. This had the potential to affect Resident 22, 24, 1, 23, 11 and 18. Sample size was 13. Facility census was 28. Observation on 07/16/18 at 03:09 PM revealed Perineal Care was provided to Resident 22 by NA A and B (Nurse Aides). It was noted that no hand washing was done upon entry to the room. Both nurse aides donned gloves and gathered the supplies. Nurse Aide B had done perineal-care to the front with a wet wipe then retrieved the trash bin and set it next to the bed and continued the perineal care without change of gloves nor hand sanitization. Perineal-care was done to the buttocks and anal area. Nurse aide B changed gloves without hand sanitization and applied cream to the buttocks bilateral. Nurse aide A applied cream to the front perineal area. Gloves removed by Nurse Aide B and put in the trash can, the liner was removed and Nurse Aide B left the room. Nurse Aide A removed gloves and put them in the trash, entered hall way where Nurse Aide A then touched other residents without evidence of hand sanitization. Interview on 07/17/18 at 02:41PM with the Assistant Director of Nursing revealed that there were no competencies for Nurse Aide [NAME] Record review on 07/17/18 at 02:41 PM revealed Perineal Care Policy and Perineal-care Audit that the staff was to gather the supplies prior to the start of the care, after washing the resident, gloves were to be removed and hand hygiene performed. The audit read that the staff were to clean up the work area, dispose of soiled linen in the trash bag, remove gloves and perform hand hygiene before leaving the r… | 2020-07-01 |
| 4069 | 4069 | HILLCREST MILLARD | 285302 | 13225 WESTWOOD LANE | OMAHA | NE | 68144 | 2019-09-25 | 725 | E | 1 | 0 | EL7411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 725 Licensure reference 12-006.04C Based on observations, interviews, and record reviews, the facility failed to ensure sufficient numbers of nursing staff to provide bathing assistance to 3 (Residents 8, 9, 10 and 14) of 6 current sampled residents, failed to answer call lights in a timely manner for 3 (Resident 8, 11, and 14) of 6 current sampled residents and in 3 of 5 confidential interviews residents reported concerns about staffing and ability to get call light answered. The facility had a total census of 65 residents. Findings are: [NAME] In confidential interviews conducted on 9/23/19 between 11 AM-2 PM and on 9/25/19 between 10:55-11:29 AM, 3 of 5 sampled residents reported concerns related to staffing and ability to get call lights answered. Comments included the following: -weekend staffing is a nightmare -resident reported waiting for an hour for assistance then getting self ready for bed -not uncommon to wait 20 minutes to get call lights answered -resident reported taking self to bathroom when was non-weight bearing -delay in answering call lights B. A review of Device Monitoring Records revealed the following: -Resident 14 had 25 call lights on for greater than 15 minutes out of 128 between 9/14/19-9/25/19 with one call light on for 62 minutes and 15 seconds -Resident 8 had 26 call lights on for greater than 15 minutes out of 96 between 9/13/19-9/23/19 with one call light on for 65 minutes and 58 seconds -Resident 11 had 17 call lights on for greater than 15 minutes out of 171 between 9/13/19-9/25/19 with one call light on for 47 minutes and 23 seconds In an interview on 9/24/19 at 2:38 PM, the Director of Nursing reported the goal is to have call lights answered within 15 minutes. In an interview on 9/23/19 at 3:15 PM, the Administrator reported that the facility has working on improving call light times by changing the escalation of call lights to nurse and management pagers, encouraging nurses to answer pages and implement… | 2020-09-01 |
| 5310 | 5310 | RIVER CITY NURSING AND REHABILITATION | 285058 | 7410 MERCY ROAD | OMAHA | NE | 68124 | 2017-01-23 | 225 | D | 1 | 0 | 5YZX12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Record review and interview the facility failed to complete a thorough investigation for 1 of 3 residents reviewed (Resident 4) related to an allegation of neglect. The facility census was 96 Findings are: Review of Resident 4 Admission Record dated 8/25/2016 revealed Resident 4 had the following Diagnosis: [REDACTED]. The facility investigation states the resident had an apneic(absence of breathing) episode on 11/1/2016 and staff were able to suction Resident 4's [MEDICAL CONDITION] and remove the obstruction and send Resident 4 to the hospital for further treatment. Review of the facility investigation revealed on 11/3/2016 the complainant voiced concerns regarding the need for Resident 4 to have been suctioned more often prior to Resident 4's hospitalization . Review of the facility investigation revealed a summary of the event that resulted in Resident 4 being transfered to the hospital on [DATE], however, did not address the care of Resident 4's [MEDICAL CONDITION] prior to the event. Review of Resident 4's progress note dated 11/1/2016 revealed no documentation of Resident 4's condition prior to or during the event requiring transfer to the hospital. Review of Resident 4s Treatment Administration Record (TAR) dated for (MONTH) (YEAR) revealed no suctioning or [MEDICAL CONDITION] site care was completed on the following dates: - 10/8/16 - 10/9/16 - 10/13/16 - 10/15/16 - 10/19/16 - 10/20/16 - 10/23/16 - 10/24/16 - 10/29/16 Interview with the Administrator revealed the Treatment Administration Record (TAR) had not been looked at during the investigation to determine if suctioning was completed as ordered and that should have been reviewed to determine the outcome of the concern voiced by the complainant. | 2020-01-01 |
| 1386 | 1386 | LIFE CARE CENTER OF ELKHORN | 285134 | 20275 HOPPER STREET | ELKHORN | NE | 68022 | 2018-05-17 | 609 | D | 1 | 0 | 69JP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Record review and interview, the facility failed to report a fall resulting in a significant injury for 1 of 3 residents reviewed (Resident 1) to the state agency within 2 hours. The facility census was 95. Findings Are: [NAME] Review of Resident 1's progress notes revealed Resident 1 fell on [DATE] at 10:00 PM. Resident 1 did not initially complain of pain however, on 4/29/2018 Resident 1 did report increased pain. Review of Resident 1 progress notes revealed Resident 1 complained of leg pain and an x-ray was completed. The results of the x-ray was called to the facility at 9:00 PM indicating a fractured femur. Review of the facility VOI (Verification of Investigation) dated 5/3/3018 revealed the state agency was notified of the fall resulting in a significant injury on 4/30/2018 at 6:45 AM. Review of the facility policy dated 2/2018 titled Protection of Residents: Reducing the Threat of Abuse and Neglect revealed all events resulting in serious bodily injury are to be reported to the state agency within 2 hours. Interview with the VP Vice President) of clinical services revealed a report was called within 2 hours of the time the facility is aware of a significant injury. | 2020-09-01 |
| 1086 | 1086 | EMERALD NURSING & REHAB LAKEVIEW | 285106 | 1405 WEST HWY 34 | GRAND ISLAND | NE | 68801 | 2018-05-07 | 625 | D | 1 | 1 | QN7C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility staff failed to issue notice of bed hold for 3 of 3 sampled residents's legal representative when Resident 22, Resident 33, and Resident 49 were transferred to the hospital. The facility identified a census of 55 at the time of survey. Findings are: [NAME] Review of Resident 22's Discharge Tracking and Entry records revealed Resident 22 was hospitalized [DATE] to 9/17/2017; 9/29/2017 to 10/2/2017; 10/6/2017 to 10/24/2017; 11/18/2017 to 11/21/2017; and 1/12/2018 to 1/13/2018. Record review of Resident 22's admission and discharge records revealed no documentation Resident 22's legal representative was given written notice of the facility's bed hold policy at the time Resident 22 was transferred from the facility to the hospital. Interview with the AC (Admission Coordinator) on 5/07/18 at 3:51 PM confirmed there was no documentation Resident 22's legal representative had been issued notice of the facility bed hold policy when Resident 22 was transferred to the hospital. The AC confirmed the bed hold notices had not been issued. Review of the undated facility policy Bed Hold Policy and Notification revealed the following: it is our policy to inform residents/legal representatives upon admission and after leaving the facility for hospitalization , observation or therapeutic leave of our bed hold policy and notification. Each resident/legal representative will be informed by of the facility's bed hold policy and notification upon admission to to the facility and/or when a resident leaves for hospitalization , observation or therapeutic leave. Before the resident may be transferred to a hospital or for a therapeutic leave, the facility is required to provide the facility's bed hold policy to the resident or legal representative. B. Review of the Progress Notes for Resident 33 dated 1/10/17 revealed the resident was a direct admission from a Physician Office visit to the hospital. The documentation… | 2020-09-01 |
| 1986 | 1986 | FLORENCE HOME | 285173 | 7915 NORTH 30TH STREET | OMAHA | NE | 68112 | 2017-12-06 | 578 | E | 1 | 1 | CVPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure the wishes for CPR (Cardiopulmonary Resuscitation) for 4 residents (Resident 13, 60, 32, 72) of 25 residents sampled were communicated to the nursing staff. The facility staff identified the facility census at 68. The findings are: [NAME] An interview conducted on [DATE] at 12:18 with Licensed Practical Nurse (LPN) A revealed that if a resident was unexpectedly found to not be breathing or without a heartbeat, the nursing staff would check their report sheets if they had one or for a blue dot on the spine of the resident's chart to see if the resident was to receive CPR. The residents that were supposed to receive CPR would have a blue dot on the spine of their chart. LPN A reported they would also look for a blue dot on the door, but that the dots on the door were not always up to date. Resident 72 was the only resident that had received CPR in the past 3 months and the resident expired after arriving to the hospital. A review of Resident 72's Face Sheet dated [DATE] revealed that the resident was admitted to the facility on [DATE] and that the resident was listed as no for resuscitate. A review of Resident 72's Resuscitate Policy form dated [DATE] revealed that Resident 72 had elected to not receive CPR if found to be without a heartbeat. A review of Resident 72's nurse's note dated [DATE] revealed that the resident was found without a pulse and not breathing and that CPR was started and maintained until the ambulance squad arrived and took the resident to the hospital. At the hospital, the resident was declared deceased . An interview conducted on [DATE] at 2:12 PM with the Social Services Director (SSD) revealed that the process for communicating CPR wishes was the responsibility of Admissions on admission or Social Services if the resident chose to change their CPR status after admission. The SSD reported that in (MONTH) (YEAR), the Social Services and Admissions depar… | 2020-09-01 |
| 2373 | 2373 | GOOD SAMARITAN SOCIETY - BEATRICE | 285203 | 401 S 22ND STREET | BEATRICE | NE | 68310 | 2017-09-13 | 323 | D | 1 | 1 | 9PTJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to investigate ongoing falls for 1 of 3 residents reviewed for Accidents (Resident #94) in order to determine if identified interventions were implemented and/or effective and to develop new interventions to prevent recurrence. Findings are: Resident #94 was deceased and not available for interview or observation. According to the [DATE] Summary of Skilled Services admission note, Resident #94 was admitted to the facility due to a history of falls, required two staff assistance with transfers and required a lot of assistance pulling himself into an upright position. The Care Conference note, dated [DATE], revealed the resident's spouse indicated that (resident) had a lot of falls at home as the resident did not use the walker. The Falls Tool, dated [DATE], identified the resident was at low risk for falls. The Physical Device and Restraint Assessment, dated [DATE], indicated an assist grab bar on the bed would be appropriate as it would make the resident able to repo(sition) and sit up by self. Review of Nursing Progress Notes between the resident's admission on [DATE] and death on [DATE] revealed he experienced 19 falls. Review of the Fall Scene Huddle Worksheets and Investigation forms, completed after each fall, revealed staff documented sometimes conflicting information, or lacked the details necessary to assess the cause of each fall and to develop new interventions to prevent recurrence. In addition, the facility failed to identify potential trends related to the grab bar as a risk factor for injury with falls. For example: According to a nurse progress note, dated [DATE] 0133, residents call light was on, staff went to answer his light, staff turned on the light and saw him lying on the floor with his head between the hand rail and bed. staff removed the hand rail and bed . Review of the Fall Scene Huddle Worksheet, dated [DATE], indicated the resident fell at 12:35 a.m. This … | 2020-09-01 |
| 1347 | 1347 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2017-08-02 | 156 | D | 1 | 1 | YKIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide a cost listing of what Medicaid would and would not cover upon admission. This effected 2 residents (Resident 161 and 285 ). The facility census was 110. Findings are: [NAME] Record review of Resident 161's Face Sheet, dated 7/27/17, revealed that, Resident 161 was admitted to the facility on [DATE]. Record review of Resident 161's Census History, dated 7/27/17, revealed that Resident 161 became Medicaid eligible on 5/1/2016 . Interview on 7/26/17 at 3: 40 PM with Resident 161's family revealed that staff did not provide a list of services and items that would and would not be charged for when Resident 161 became eligible for Medicaid. Interview with the facility business office, Staff Member I, on 7/27/17 at 3:10 PM confirmed that there was not a form provided to Resident 161's family upon eligibility for Medicare. Interview with the facility Administrator on 7/27/17 at 3:11 PM confirmed that the facility did not provide information to Resident 161's family regarding Medicaid coverage and charges. B. Record review of Resident 285's Face Sheet, dated 7/27/17, revealed that, Resident 161 was admitted to the facility on [DATE]. Record review of Resident 161's Census History, dated 7/27/17, revealed that Resident 161 became Medicaid eligible on 7/22/16. Interview on 7/26/17 at 2:45 PM with Resident 285's family revealed that staff did not provide a list of services and items that would and would not be charged for when became eligible for Medicaid. Interview with the facility business office, Staff Member I, on 7/27/17 at 3:10 PM confirmed that there was not a form provided to Resident 285's family upon eligibility for Medicare. Interview with the facility Administrator on 7/27/17 at 3:11 PM confirmed that the facility did not provide information to Resident 285's family regarding Medicaid coverage and charges. | 2020-09-01 |
| 3416 | 3416 | WESTFIELD QUALITY CARE OF AURORA | 285263 | PO BOX 166, 1313 1ST STREET | AURORA | NE | 68818 | 2019-11-13 | 712 | D | 1 | 0 | P0CC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility staff failed to ensure Resident 2 was seen by their physician/medical provider or physician delegate (physician delegate: physician assistant, nurse practitioner, or clinical nurse specialist) every 60 days. This affected 1 of 3 sampled residents. The facility identified a census of 64 at the time of survey. Findings are: Review of Resident 2's Admission Record revealed an admission date of [DATE]. Review of Resident 2's Clinical Health Records revealed Resident 2 was seen by a physician/medical provider on 6/5/19, 6/18/19, 6/24/19, and 8/26/2019. Resident 2 was seen by an optometrist/ophthalmologist (eye doctor) on 10/9/2019. There was no documentation Resident 2 had been seen by their physician/medical provider since (MONTH) 26, 2019. Review of Resident 2's Progress Notes revealed no documentation Resident 2 had been seen by their physician/medical provider since (MONTH) 26, 2019. Interview with the BOM (Business Office Manager) on 11/13/2019 at 2:45 PM revealed that some residents only wanted to be seen by their physician annually. The residents and/or responsible parties were to sign a Physician Visit Form which indicated they only wanted to see their physician/medical provider annually. The BOM confirmed Resident 2's appointment in (MONTH) was an eye Dr. appointment, not with their physician/medical provider. Requested documentation that Resident 2 refused to be seen by their physician/medical provider every 60 days. Review of Resident 2's medical record revealed no documentation Resident 2 or their responsible party had declined to see their physician/medical provider every 60 days. Interview with the BOM on 11/14/2019 at 3:35 PM confirmed they could not find Resident 2's Physician Visit Form which would have indicated Resident 2's preference of when they wanted to see their medical provider. Review of the facility policy Physician Visits and Physician Delegation dated (YEAR) revealed… | 2020-09-01 |
| 736 | 736 | EMERALD NURSING & REHAB COZAD | 285093 | 318 WEST 18TH STREET | COZAD | NE | 69130 | 2018-02-07 | 625 | D | 1 | 0 | Y9LY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility staff failed to notify the legal representative for Resident 1 and Resident 3 of the facility Bed Hold policy at the time of discharge. This affected 2 of 3 sampled residents. The facility identified a census of 58 at the time of discharge. Findings are: [NAME] Review of Resident 1's Discharge Tracking Form dated 1/11/2018 revealed Resident 1 was admitted to the facility on [DATE] and discharged from the facility to the hospital on [DATE]. Interview with Resident 1's legal representative on 2/7/2018 at 12:12 PM revealed the facility had not given Resident 1's legal representative notice of Bed Hold when Resident 1 was transferred to the hospital. Review of Resident 1's medical record revealed no documentation Resident 1's legal representative had been given notice of Bed Hold upon discharge to the hospital. B. Review of Resident 3's Discharge Tracking Form dated 12/26/2017 revealed Resident 3 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Review of Resident 3's medical record revealed no documentation Resident 3's legal representative had been given notice of Bed Hold when Resident 3 was transferred to the hospital. Interview with the DON (Director of Nursing) on 2/7/2018 at 3:59 PM confirmed there was no written documentation the legal representatives for Resident 1 or Resident 3 were given notice of Bed Hold. Interview with the interim SSD (Social Services Director) on 2/7/2018 at 4:05 PM confirmed the facility residents and/or legal representatives were to be issued the facility Bed Hold policy at the time of transfer and/or discharge. Review of the undated facility policy Bed Hold Policy and Notification revealed the following: It is our policy to inform residents/legal representatives upon admission and after leaving the facility for hospitalization , observation or therapeutic leave of our bed hold policy and notification. Each resident/legal represen… | 2020-09-01 |
| 3421 | 3421 | WESTFIELD QUALITY CARE OF AURORA | 285263 | PO BOX 166, 1313 1ST STREET | AURORA | NE | 68818 | 2019-11-13 | 842 | D | 1 | 0 | P0CC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review; the facility failed to ensure meal intakes were documented. This affected 2 of 3 sampled residents (Residents 3 and 4). The facility identified a census of 64 at the time of survey. Findings are: Resident 3 [NAME] Review of Amount Eaten by Resident 3 revealed that Resident 3 had 2 meals on 10//17/19; 2 meals on 10/24/19 and 2 meals on 10/29/19 there was no documentation of refusals for a meal. Review of PN (Progress Notes) for Resident 3 revealed: PN dated: 10/18/19 at 8:46 PM Resident very upset about supper. States resident was tired of sitting in the dining room for long periods of time waiting for residents food. States staff don't feed resident in a timely manner. States that resident can't transfer by self anymore to bed or bathroom and that upsets resident. Tried to comfort and talk with resident regarding the meals. Informed resident that meals are rotated with who staff serve first and that do to staffing. 400 hall and those that need assistance need to come first. Resident 4 B. Review of Amount eaten by Resident 4 revealed that Resident 4 had 2 meals recorded on 11/7/19; 1 meal on 11/8/19; 2 meals on 11/9/19; and 2 meals on 11/10/19 there was only one documentation of a meal not received for Resident 4. Review of PN ( Progress Notes) for Resident 4 revealed there was no documentation stating resident refused meals. There was a documentation of the following. PN dated: 11/7/19 at 9:13 PM Resident did not receive room tray at supper do to staff error. Spouse went outside of facility and bought resident supper. Dietary and staff educated on this and the responsibilities of room trays. Dietary states resident was on a long term list for room trays and staff are aware of that. An interview on 11/13/19 at 11:10 AM with LPN-A (Licensed Practical Nurse) revealed the Charge Nurse documents in the progress notes if the resident refused a meal. Also the staff can document that the Resident refused the me… | 2020-09-01 |
| 4052 | 4052 | HILLCREST FIRETHORN | 285300 | 8601 FIRETHORN LANE | LINCOLN | NE | 68520 | 2018-06-14 | 698 | D | 1 | 0 | U8OO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation and record review the facility: 1) failed to assess residents before and after [MEDICAL TREATMENT] treatments, 2) failed to ensure orders were in place for [MEDICAL TREATMENT] care related to the infusion site, 3) failed to give medications as ordered to ensure absorption of the medications occurred prior to [MEDICAL TREATMENT], and 4) failed to coordinate care with the [MEDICAL TREATMENT] Provider for the continuation of care related to the residents [MEDICAL TREATMENT] needs. This had the potential to affect 2 residents (Resident 46 and 41) out of 2 sampled residents. The facility census was 30. Findings are: An observation on 6/13/18 at 8:33 AM of Resident 41 revealed the resident eating breakfast in the resident's room. The Resident reported had not received any of scheduled morning medications. Blood Glucose level had not been checked this am, and that the assessment was usually completed late. Yesterday's lunch time check was completed at 2:00 PM. The Resident had already been to therapy, and went on to report that the scheduled dressing change had not been completed, and planned on leaving the facility for [MEDICAL TREATMENT] about 10:00 AM. A review of the Medication Administration Record [REDACTED]. The medications were scheduled to be given 6:00-9:30 AM and the documentation did not indicate they had been administered as of 9:30 AM on 6/13/18. Further review of MAR for Resident 41, revealed [MEDICATION NAME] is ordered 800mg Tablet 3 times daily with meals, was held on 5/23/18 at noon and 5/24/18 morning and noon dose. The signed physician orders [REDACTED]. The order for [MEDICATION NAME] was on the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The dose on (MONTH) 12, at 9:14 AM and 2:16 PM was documented not available. Per Nursing Drug Handbook (YEAR), [MEDICATION NAME] is a polymeric [MEDICATION NAME] binder and is to be given with meals. The drug may bind with other medication and decr… | 2020-09-01 |
| 3656 | 3656 | RIDGEWOOD REHABILITATION & CARE CENTER | 285279 | 624 PINEWOOD AVENUE | SEWARD | NE | 68434 | 2018-06-05 | 744 | D | 1 | 1 | RVGM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation, and record review; the facility failed to ensure that psychosocial needs were met for residents with dementia. This failure had the potential to affect one resident, Resident 32. The facility census was 73. Findings are An interview on 5/30/18 at 11:00 AM with Resident 32's Family Member revealed Resident 32 had recently been moved out of a room in the Facility's SCU (Special Care Unit) for Memory Care, into a room within the general population of the facility. The Family Member reported the dependent resident had resided in the SCU since being admitted to the facility, and had been included in all of the scheduled social and recreational activities offered while residing in the SCU. The Family Member went on to report since being moved, Resident 32 spent an increased amount of time alone in the resident's room; and it seemed as if the staff assigned to the current living area did not know the resident, so therefore the staff were unable to anticipate Resident 32's care needs. A review of an undated Care Plan (CP) for Resident 32 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the CP revealed a CP Focus initiated on 4/20/17 and revised on 1/6/18 that indicated the resident experienced cognitive impairment due to [DIAGNOSES REDACTED]. Resident 32 had a history of [REDACTED]. Resident 32 triggered for a high elopement risk however IDT (interdisciplinary team) reviewed and did not feel the resident was at risk at this time. Interventions included Resident to reside in secure memory support unit, which was initiated on 4/20/17 and had not been revised. On 06/04/18 at 10:35 AM, an interview with the DON (Director of Nursing) revealed the facility was unable to locate documentation related to the decision to relocate Resident 32 from the Memory Care Unit into the General Population. The DON reported knowledge that the team felt the resident no longer fit in… | 2020-09-01 |
| 1644 | 1644 | MAPLE CREST HEALTH CENTER | 285149 | 2824 NORTH 66TH AVENUE | OMAHA | NE | 68104 | 2018-12-18 | 609 | D | 1 | 1 | 864P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to ensure investigation of possible abuse were submitted to state survey agency within 5 working days for 2 (Residents 70 and 441) of 8 sampled residents. The facility had a total census of 138. Findings are: [NAME] Resident 441 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Adult of Protective Service reported dated 11/16/18 revealed a facility self-report regarding Resident 441's hair being cut. The report stated that Resident 441's family had not wanted Resident 441's haircut. A review of facility State Reportable Log investigations did not include report regarding Resident 441's hair being cut. In an interview on 12/13/18 at 1:30 PM, Social Worker A confirmed an investigation of Resident 441's hair being cut being cut was not submitted to the state agency. A review of facility policy titled Abuse Investigations revised (MONTH) 2006 revealed results of all investigations and reports shall be faxed or emailed to the state survey and certification agency within 5 days of notification of allegations. B. Record Review of Progress Notes dated 11/21/2018 for Resident 70 revealed: a call was placed to the state agency to report a fracture to the right 4th finger that showed on the x-ray after Resident 70 presented with a cyst to the knuckle. The nurse practitioner asked for a re-read of the x-ray and it was determined that it was not a fracture, but results of Uric Acid eating at the resident's joint. DON placed another call to the state agency to update with the current findings. Interview conducted on 12/17/2018 at 04:00 PM with the DON confirmed the call was placed to the state agency, but an investigation had not been completed or reported to the state agency within the 5 working days. | 2020-09-01 |
| 4747 | 4747 | SORENSEN CARE AND REHABILITATION CENTER, LLC | 285107 | 4809 REDMAN AVENUE | OMAHA | NE | 68104 | 2017-06-15 | 280 | D | 1 | 1 | F9RW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to ensure the responsible party was involved in the care planning process for 1 resident (Resident 87) of 3 residents sampled. The facility staff identified the census at 68. The findings are: An review of Resident 87's Admission Record dated 6/15/17 revealed the resident was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. A review of Resident 87's most recent Minimum Date Set (MDS: A federally mandated comprehensive assessment tool used for care planning) their Brief Interview for Mental Status (BIMS) score was 5 out of 15 indicating severe cognitive impairment. An interview conducted on 6/12/17 at 4:32 PM with Resident 87's responsible party revealed that the responsible party had not been notified of care plan meetings and had not been included in the care planning process for Resident 87. A review of Resident 87's progress notes since admission revealed no documentation regarding a care plan meeting or that the responsible party was notified of a care plan meeting. An interview conducted on 6/14/17 at 3:29 PM with the Social Services Director revealed that they documented care plan meetings in the progress notes on the computer, but would look for other documentation. A review of an untitled form used to document care plan meetings, supplied by the Social Services Director, dated 4-20-17 revealed the care plan meeting was attended by social services and activities representatives only. The area to document if a letter was sent to the responsible party was left blank. The area to document if a letter was given to the resident was left blank. | 2020-03-01 |
| 1159 | 1159 | PRESTIGE CARE CENTER OF NEBRASKA CITY | 285109 | 1420 NORTH 10TH STREET | NEBRASKA CITY | NE | 68410 | 2017-05-02 | 323 | E | 1 | 1 | 4KPH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to monitor interventions when a resident was identified at risk of elopement and failed to implement interventions to prevent future elopements for 3 of 3 Residents (Residents 44, 51, and 68). The facility census was 43. Findings are: [NAME] Review of resident census revealed Resident 68 was admitted on [DATE] and discharged on [DATE]. Review of the resident's care plan revealed a care plan for elopement related to anger at placement in living center. Intervention included that the resident wore a wanderguard bracelet (A device used to alert staff if a residents wearing one is too close to the doors). Staff were to check for placement and functioning every shift and as needed and change every 90 days and as needed. Review of the facility investigation revealed Resident 68 left the faciity on [DATE] without the staff knowledge and Resident 68 did have a wanderguard in place. Although Resident 68 did not score as an elopement risk on the assessment. Resident 68 did have poor safety awareness. Review of a Social Service Note dated 11/25/2016 at 4:57 PM revealed a Nursing Assistant (NA) noticed that the resident was outside of the facility. The NA came in to ask the staff if the resident was to be outside. The Charge nurse stated that Resident 68 was not. When asked what resident was doing, the resident stated that the alarms did not sound. Review of progress note dated 10/24/2016 at 5:08 PM revealed Resident 68 did have a wanderguard on at that time. Interview on 4/20/2017 at 3:30 PM with the administrator revealed the wanderguard checks were documented on the TAR (Treatment Administration Record). Resident 68 did have a wanderguard on at the time of leaving the facility and it did not sound the alarm. Review of the TAR dated for (MONTH) (YEAR) revealed no documentation of wanderguard checks for Resident 68. 04/25/2017 12:04:52 PM, interview with Health DON (Director of Nursing) revea… | 2020-09-01 |
| 75 | 75 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 761 | E | 1 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review the facility failed to ensure insulin (a medication used to treat diabetes mellitus) was dated when opened This had the potential to affect 2 residents (Resident 34, and 277). The facility failed to provide safe storage of drugs and biologicals as medications were left unlocked and unattended, and medications were left on top of the medication carts. This had the potential to affect all the residents on the 100, 200, 300, 400, and 500 halls. The facility failed to ensure a vial of insulin was labeled updated with the current administration information for 1 resident (Resident 62 and 79). The facility census was 123. Findings are: [NAME] An observation 9 at 07:10 AM Medication administration RN V prepared medications for administration for Resident 79. 1. Acidophilus 500 Million per 2 caps per day (from a stock medication bottle)-take 2 capsules per gastric tube 2. Vitamin B -1 tablet 100mg daily gastric tube 3. Vitamin C 1000mg daily 4. Folic Acid 1 mg daily every afternoon (on the card) - in the EMAR (Electronic Medical Record) the order reflected that the medication was to be given at 0700AM. 5. Modafnil 100mg 1 tab in am. 6. Ocean Nasal Spray 0.65% amount 2 sprays per nasal - The nasal spray was given 2 sprays per nostril. Record review of an order dated 06/13/18 revealed; a standing order that read, (MONTH) change the time of daily medications for compliance with taking medications, to avoid interaction with other medications unless contraindicated by manufacturer or specific time ordered by physician. Order dated 6/13/18 revealed that the medication Folic Acid 1mg was to be given in the afternoon. An interview with the DON on 09/25/19 confirmed that the labels were not the same, there was a standing order to change the times of the medication administration times. B. An observation on 09/2/519 at 12:50 PM of medication administration for Resident 227 revealed; the Humalog Pen was opened… | 2020-09-01 |
| 4070 | 4070 | HILLCREST MILLARD | 285302 | 13225 WESTWOOD LANE | OMAHA | NE | 68144 | 2019-09-25 | 761 | D | 1 | 0 | EL7411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review the facility failed to ensure the medication cart was locked and supervised, the facility failed to ensure medications were not left at bedside for Resident 7, the facility failed to ensure that nebulizer treatment was given for Resident 11. The facility census was 63 Findings: 09/24/19 record review of Medication Policy-Medications are documented as administered after the medication Aide/nurse has assured the guest consumed the medication- During administration of medications, the medication cart/medications cabinet will be kept closed and locked when out of sight of the medication team member. No medications can be left on top of Medication cart or medications cabinet in rooms without team member that is administering medications within sight of the medications. [NAME] Observation during Medication Pass on 09/24/19 at 7:50AM with RN E, revealed medication for Resident 7 was in medication cup on bedside table. Interview with Resident 7 revealed that she had not taken her medications left at bedside last night, she had forgotten. Interview with RN11 passing medications agreed that medication should not have been left at bedside. Record Review of MAR (Medication Administration Record) for Resident 7 for 09/23/19 revealed medications were charted as taken. B. 09/24/19 7:55AM Observation during Medication Pass with RN E, revealed breathing treatment (nebulizer) contained liquid in the container for Resident 11 Interview with Resident 11 revealed that he had not taken his breathing treatment last night and was wondering if he could take it now. Interview with RN [NAME] agreed that the treatment should have been observed as having been completed Record Review of Resident 11 MAR (medication administration Record) IPRAT-ALBUT 0.5-3mg/3ml inhale 1 vial via nebulizer 4 times /day. C .09/24/19 10:15AM Observation , Medication cart was sitting in doorway of room [ROOM NUMBER], medication pack with medi… | 2020-09-01 |
| 2175 | 2175 | LEGACY GARDEN REHABILITATION & LIVING CENTER | 285186 | 200 VALLEY VIEW DRIVE | PENDER | NE | 68047 | 2018-10-04 | 880 | F | 1 | 1 | JIFC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review; the facility staff failed to perform hand hygiene for care/treatment of [REDACTED]. The facility census was 34. Findings are: Observation on 10/04/18 at 1:10 PM during wound care observation for Resident 5 revealed two NA's (Nurse Aides F and G) came in to assist with the procedure. NA G did not use hand sanitizer nor did hand washing prior to application of gloves before care for Resident 5. Record review of Infection Control policy dated 01/2018 revealed staff members were to use either antimicrobial soap and water or alcohol based hand rub before performing resident care procedures. Record review of the facility's Hand Hygiene Policy dated 01/2018 revealed staff members were to use either antimicrobial soap and water or alcohol based hand rub between resident contact. | 2020-09-01 |
| 97 | 97 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2018-09-17 | 580 | D | 1 | 1 | XOYL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview: the facility failed to notify the physician of the presence of a pressure ulcer (a localized injury to the skin/underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and /or friction) to obtain treatment orders at the time of admission to promote healing of a pressure ulcer for 1 (Resident 105) of 5 residents reviewed with pressure ulcers. The facility census was 126. Findings are: Record review of a facility Policy and Procedure for Skin and Wound Management standard dated revised (MONTH) (YEAR) revealed the following policies: - A resident having pressure sores receives necessary treatment and services to promote healing and prevent infection: Pressure Ulcer Skin Condition: - Initial identification of a new pressure ulcer will include an assessment and measurement of the wound. Documentation of findings, assessment results and notification of the physician and family will be made in the residents clinical record. Treatment: - The treatment plan will be specific for each individual resident as directed by the physician. Appropriate treatment will address length, width, depth, odor, drainage, pain, wound bed and surrounding skin. Evidence of slough, necrotic tissue or infection should be communicated to the physician and treated accordingly. Record review of Resident 105's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/18 revealed that Resident 105 was admitted to the facility on [DATE] with 1 unhealed pressure sore that was unstageable due to coverage of the wound bed by slough (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and /or eschar) and/or eschar (thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissues that has lost its usual physical properties and biological activity. Eschar may be lose or firmly adhered to … | 2020-09-01 |
| 5520 | 5520 | SORENSEN CARE AND REHABILITATION CENTER, LLC | 285107 | 4809 REDMAN AVENUE | OMAHA | NE | 68104 | 2016-11-14 | 155 | D | 1 | 0 | 7EEE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview; the facility failed to ensure that an Advanced Directive (information about the residents wishes for end of life care) had been formulated for Resident 4 and Resident 3. Sample size was two. The census was 66. Findings are: [NAME] Record review of the facility Policy and Procedure for Advance Directives dated [DATE] revealed that the resident had a right to execute or refuse to execute an advance directive which stipulates how the decisions regarding his/her medical care will be made. The procedure revealed that prior to or upon admission, family members, and or legal representatives were informed and provided written materials governing their legal rights pertaining to medical decisions upon admission to the facility. These rights included the right to formulate an advanced medical directives such as a living will, Power of attorney for Health Care, Do not resuscitate or health care surrogate. The procedure identifies that prior to or upon admission to the facility, the admissions Coordinator or Social Services Designee ascertains the presence of any existing advance directives and a copy is placed under the advance directive tab in the medical record. Prior to or on admission, the Social services designee will provide written information to the resident/legal representative concerning right to make decisions regarding medical care including the right to accept /refuse medical /surgical treatment and the right to formulate advance directives. Record review of Resident 4's Face Sheet dated [DATE] revealed that Resident 4 had been admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 4's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) dated [DATE] and quarterly MDS dated [DATE] revealed that Resident 4 had a cognitive score of ,[DATE] which indicated that Resident 4 was independent with cognitive decision making. I… | 2019-11-01 |
| 5857 | 5857 | ST. JOSEPH VILLA NURSING CENTER | 285078 | 2305 SOUTH 10TH STREET | OMAHA | NE | 68108 | 2016-08-10 | 441 | D | 1 | 0 | 142711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview; the facility staff failed to wash hands and changes gloves to prevent potential cross contamination during the provision of personal cares for 2 residents (Resident 1 and 3). The facility staff identified a census of 164. Findings are: A. Record review of an undated Resident Face Sheet revealed Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 8-05-2016 revealed the facility staff assessed the following about the resident: -Short and long term memory problem with severely impaired cognition. -Required total assistance with bed mobility, transfers, locomotion, dressing, eating, personal hygiene. -Required extensive assistance with toilet use. -Always incontinent of bowel and bladder. -Had indicators of pain or possible pain with possible pain observed 3 to 4 times out of 5 days. -Other [DIAGNOSES REDACTED]. Observation on 8-09-2016 at 7:56 AM of personal care revealed Nursing Assistant (NA) E and NA G washed hands and donned gloves. Resident 1 was observed to have a splinting device to the right leg. NA E and NA G unfastened the adult briefs Resident 1 was wearing. NA G, using a white washcloth wiped the resident's groin folds revealing brown stains on the wash cloth. NA G without changing gloves and hand washing, obtained another wash cloth and wiped down the vaginal area. Resident 1 was then positioned onto the left laying position. NA G without changing the soiled gloves cleansed in between each buttock. NA G without changing the soiled gloves obtained a clean adult brief and placed it onto Resident 1. An interview with NA G was conducted on 8-09-2016 at 10:13 AM. During the interview, NA G confirmed the soiled gloves had not been changed and should have been. B. Record review of Resident… | 2019-08-01 |
| 3403 | 3403 | WESTFIELD QUALITY CARE OF AURORA | 285263 | PO BOX 166, 1313 1ST STREET | AURORA | NE | 68818 | 2019-05-14 | 695 | D | 1 | 0 | V7OX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interviews, the facility failed to obtain an order for [REDACTED]. Findings are: Record review of Resident 36's Admission Record dated 5-7-19 revealed date of admission 7-9-18 with [DIAGNOSES REDACTED]. Review of Resident 36's admission MDS dated [DATE] revealed the resident used oxygen while 'not' a resident and 'while' a resident. The MDS also revealed the resident had a [DIAGNOSES REDACTED]. Observation on 5/06/19 at 10:00 AM of Resident 36's room revealed the oxygen concentrator turned on but the tubing was no where near the resident who was on the opposite side of the bed. Inteview with NA-F (Nurse Aide) revealed the resident only wore oxygen when in bed at night time. Record review on 5/06/19 at 10:26 AM of undated Physician orders [REDACTED]. Review of (MONTH) and (MONTH) TARS/MARS (treatment / medication administration records) revealed absence of an order for [REDACTED]. Review of current order summary report dated (MONTH) 7, 2019 revealed absence of an oxygen order for Resident 36. Interview on 5/07/19 at 4:30 PM with LPN-G (Licensed Practical Nurse) revealed the Oxygen orders were not documented on the TAR or MAR. LPN-G confirmed when a resident had an order for [REDACTED]. LPN-G reviewed Resident 36's medical record and confirmed the absence of an oxygen order but confirmed the resident had used oxygen per nasal cannula via concentrator at night time only since admission last July. Interview on 5-7-109 at 4:33 PM with RN-H (Registered Nurse) reviewed the medical record of Resident 36 and confirmed the resident had been on oxygen and the facility the resident transferred from and the transfer papers revealed the resident was to be on oxygen 1-5 liters per nasal cannula at bedtime. RN-H confirmed after reviewing the facility's admission orders [REDACTED]. Review of Resident 36's admission orders [REDACTED] | 2020-09-01 |
| 5409 | 5409 | SORENSEN CARE AND REHABILITATION CENTER, LLC | 285107 | 4809 REDMAN AVENUE | OMAHA | NE | 68104 | 2017-01-25 | 323 | D | 1 | 0 | TUGY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interviews; the facility failed to ensure residents were transferred in a safe manner for 1 of 3 residents reviewed (Resident 2). The facility census was 86. Review of Resident 2 ' s medical [DIAGNOSES REDACTED]. Review of Resident 2 ' s progress notes dated 10/31/2016 revealed Resident 2 fell on [DATE] while being transferred to the toilet. Review of Resident 2 ' s care plan dated 10/31/2016 revealed a new intervention stated that staff were to transfer Resident 2 with the sit to stand lift (a mechanical device to assist resident to stand) at all times. Interview on 1/25/2017 at 2:10 PM with NA-B revealed that Resident 2 only needed a little assistance to transfer. Observation on 1/25/2017 at 2:15 PM revealed Nursing Assistant (NA)-A and NA-B entered Resident 2 ' s room to transfer Resident 2 to the toilet. NA-A pushed Resident 2 into the bathroom in the wheelchair. While standing behind Resident 2 without a gait belt (a device used to assist in stabilizing resident) or using a sit to stand lift. NA-A leaned over the back of the wheelchair, instructed Resident 2 to hold on to safety bars and to pivot onto the toilet. Interview on 1/25/2017 at 2:25 PM with the Director of Nursing (DON) revealed Resident 2 is only to be transferred with the sit to stand lift with all straps secured. DON confirmed transferring Resident 2 without the use of the sit to stand lift was not a safe transfer. | 2020-01-01 |
| 161 | 161 | RIVER CITY NURSING AND REHABILITATION | 285058 | 7410 MERCY ROAD | OMAHA | NE | 68124 | 2017-07-12 | 225 | D | 1 | 1 | 0ROU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interviews; the facility failed to report and investigate allegations of potential abuse for 5 of 5 residents reviewed Residents 48, 53, 148, 117, and 50. The facility census was 72. [NAME] Review of Resident 117's progress notes revealed on 7/8/2017 friends of Resident 117 voiced concern Resident 117 was being abused. The Assistant Director of Nursing (ADON) was notified. Interview on 7/10/2017 at 11:09 AM with the ADON revealed the staff had reported the allegation of abuse to the ADON on 7/8/2017, however, no report was called to the state agency and an investigation was not started for 2 days. Review of the facility policy titled Abuse Prevention, Intervention, Investigation and crime reporting policy dated (MONTH) (YEAR), revealed all allegations of abuse are to be reported to the state agency immediately but not later than 2 hours after the allegation is made. Interview on 7/11/2017 at 8:53 AM with the Director of Nursing (DON) revealed the facility should have reported the allegation of abuse in the regulatory timeframe. B. A review of Resident 50's Admission Record dated 7/11/17 revealed Resident 50 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Resident 50's medical record revealed a progress note dated 6/9/17 that revealed Resident 50 had yelled at a resident from another unit that they did not belong on Resident 50's unit and to leave. The author of the note documented that Resident 50 became agitated and continued yelling and that the other resident felt threatened and chose to leave. When the other resident got up to leave, Resident 50 walked towards the other resident calling them profane names. An interview conducted on 7/11/17 at 10:35 AM with the Director of Nursing revealed that the incident should have been investigated as suspected abuse and reported to the state agency. C) Interview with Resident 48 on 7/5/17 at 9:30 AM revealed that there was a… | 2020-09-01 |
| 3321 | 3321 | BLUE VALLEY LUTHERAN NURSING HOME | 285259 | P O BOX 166, 220 PARK AVENUE | HEBRON | NE | 68370 | 2017-08-08 | 314 | D | 1 | 0 | 2H1K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record reviews, and interviews; the facility failed to initiate preventative pressure ulcer interventions on 2 (Resident 100 and 112) out of 4 residents sampled. Resident census was 46. Findings are: A Review of Resident 112's undated face sheet revealed an admitted 11 18 12. Review of the undated [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) for Resident 112 dated 5 18 17 revealed the resident had moderately impaired cognition. The resident required extensive assist of 2 staff with transfers, dressing, and toileting. The resident required extensive assist of 1 staff for locomotion and eating. Interview on 08 07 17 at 11:00 AM with the Administrator revealed Resident 112 had facility acquired pressure ulcers on the resident's toes caused by the resident's shoes. Review of the PN (Progress Notes) dated 07 10 17 revealed the resident went to the Physician's clinic to be seen for the open/reddened sores on the 2nd and 3rd toes. The resident returned with new orders to treat the pressure ulcers. Review of Resident 112's Careplan revealed absence of any pressure ulcer interventions . Review of the last annual MDS dated 09 10 16 CAA's (Care Area Assessment) revealed the risk for pressure ulcers was triggered. Review of the CAA worksheet revealed the decision was to care plan the risk for pressure ulcers and therefore put interventions into place to help prevent pressure ulcers. Review of Resident 112's Kardex revealed absence of any documentation that the resident had pressure ulcers or any pressure ulcer interventions . Interview on 08 07 17 at 3:50 with the DS (Dietary Supervisor) revealed the DS was not aware Resident 112 had any pressure ulcers or was at risk for pressure ulcers. The DS revealed when a resident initially had a pressure ulcer, the DS would be informed then the DS would notify the RD (Registered Di… | 2020-09-01 |
| 5754 | 5754 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2016-09-20 | 441 | E | 1 | 0 | TD4511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations and interviews, the facility failed to ensure that 1) the whirlpool chair in the 300 wing bathing room (which was used for routine bathing for 13 residents) and the whirlpool chair in the Special Care Unit bathing room (which was used for routine bathing for 36 residents) were cleaned and free of a buildup of whitish gray material on the metal surfaces which created a rough surface that had the potential to harbor bacteria, 2) towel bars used in semiprivate bathrooms were labeled so that the residents or staff could identify which hand towels and washcloths belonged to which resident for 10 sampled residents (Residents 107 and 91 in room [ROOM NUMBER], 104 and 162 in room [ROOM NUMBER], 77 and 13 in room [ROOM NUMBER], 76 and 28 in room [ROOM NUMBER] and 121 and 132 in room [ROOM NUMBER]), 3) bathroom call light strings with a buildup of brownish, black and gray colored material were replaced for four sampled residents (Residents 30 and 7 in room [ROOM NUMBER] and 104 and 162 in room [ROOM NUMBER]), 4) bathroom light pull strings with a buildup of brownish, black and gray colored material were replaced for four sampled residents (Residents 2 and 45 room [ROOM NUMBER] and 125 and 66 in room [ROOM NUMBER]), 5) torn vinyl covered calf pads were replaced for one sampled resident (Resident 54), 5) four plastic gallon containers of distilled water were not stored on the floor in the 300 wing medication room and 6) hand washing was performed after removing disposable gloves during cares and before continuing with other tasks for two sampled residents (Residents 88 and 52) to reduce the risk of cross contamination. The facility census was 114. Findings are: Licensure Reference Number 175 NAC 12-006.17B A. Observations of the 300 wing bathing room and the SCU (Special Care Unit) bathing room on 9/12/16 at 11:30 AM, during the environment tour with the Administrator, Maintenance Director and Housekeeping Supervisor, revealed tha… | 2019-09-01 |
| 6387 | 6387 | NORTH PLATTE CARE CENTER, LLC | 285165 | 2900 WEST E STREET | NORTH PLATTE | NE | 69101 | 2016-03-02 | 367 | E | 1 | 0 | BM4911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews and record reviews; the facility failed to ensure that evening snacks were offered to four sampled insulin dependent diabetic residents (Resident 1, 6, 8 and 9). The facility census was 47. Findings are: A. Observations on 3/1/16 at 7:30 PM and 8:10 PM revealed MA (Medication Aide) - B passed snacks to several residents. Interview on 3/1/16 at 8:15 PM with MA - B revealed that snacks were offered to residents but there was no list of residents who needed a snack because they were diabetic. Further interview revealed there was no documentation of which residents were offered or accepted the snacks. B. Review of Resident 1's Routine Medications, dated (MONTH) (YEAR), revealed that the resident had a [DIAGNOSES REDACTED]. Further review revealed no documentation that the resident received an evening snack. Interview with the resident's family member on 3/1/16 at 7:45 PM revealed that the resident did not always receive a bedtime snack. C. Review of Resident 6's Routine Medications, dated (MONTH) (YEAR), revealed that the resident had a [DIAGNOSES REDACTED]. Further review revealed no documentation that the resident received an evening snack. Interview with the resident on 3/2/16 at 9:15 AM revealed that evening snacks were not always offered. D. Review of Resident 8's Routine Medications, dated (MONTH) (YEAR), revealed that the resident had a [DIAGNOSES REDACTED]. Further review revealed no documentation that the resident received an evening snack. Interview with the resident on 3/2/16 at 9:30 AM revealed that was not always offered an evening snack. E. Review of Resident 9's Routine Medications, dated (MONTH) (YEAR), revealed that the resident had a [DIAGNOSES REDACTED]. Further review revealed no documentation that the resident received an evening snack. Interview on 3/2/16 at 3:30 PM with the DON (Director of Nursing) confirmed that there was no documentation that evening snacks were offered to diabetic res… | 2019-03-01 |
| 2165 | 2165 | LEGACY GARDEN REHABILITATION & LIVING CENTER | 285186 | 200 VALLEY VIEW DRIVE | PENDER | NE | 68047 | 2017-07-20 | 329 | D | 1 | 1 | E93U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, and record reviews; the facility failed to implement non pharmacological interventions prior to administering a [MEDICAL CONDITION] medication for 2 residents (Residents 28 and 7) of the 5 residents sampled. The facility staff identified the resident census at 31. [NAME] Review of Resident 7's undated Face Sheet revealed that Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 7's Medication Administration Record [REDACTED]. A review of Resident 7's Progress Note dated [DATE] at 2:11 AM revealed Resident 7 was confused with rambling speech and was yelling out for their deceased spouse; resident was given [MEDICATION NAME] 1mg and [MEDICATION NAME] 1mg as needed. No non-pharmacological interventions were documented in the progress note. Resident 7 was documented as having rested quietly after the [MEDICATION NAME] and [MEDICATION NAME] was given. A review of Resident 7's [MEDICAL CONDITION] Drug Use Care Plan dated [DATE] revealed a goal for the resident to be prescribed the lowest effective dose of medications. The approaches included to have staff attempt to redirect the resident with non-medication interventions and to monitor and document mood and behaviors. An interview conducted on [DATE] at 3:09 PM with the Director Of Nursing (DON) confirmed that Resident 7 received on [DATE] [MEDICATION NAME] 1mg as scheduled at 8:00 PM, [MEDICATION NAME] 1mg as needed at 8:29 PM, and [MEDICATION NAME] 1mg as needed at 8:29 PM. The DON confirmed there was no non-pharmacological interventions documented as completed prior to the administration of the as needed [MEDICATION NAME] and [MEDICATION NAME]. The DON reported that the resident had been having behaviors of acting out aggressively towards staff and that numerous staff had refused to take care of the resident. The DON reported that Resident 7's family wanted the resident to remain in the facility and that the only w… | 2020-09-01 |
| 912 | 912 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2017-08-22 | 323 | H | 1 | 1 | 2T4P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review and interviews; the facility failed to ensure that 1) interventions were in place to prevent recurrent falls and a subsequent fractured finger for one current sampled resident (Resident 26) and 2) oxygen concentrators were turned off when not in use to reduce the risk of fires for five current sampled residents (Residents 25, 66, 40, 15 and 71). The facility census was 107 with 22 current sampled residents. Findings are: Licensure Reference Number: 175 NAC 12-006.09D7b (3) [NAME] Review of the Admission Record, printed 8/9/17, revealed that Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that the resident also had [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 11/3/17, revealed that the resident was at risk for falls related to poor safety awareness and self-determination related to transfers. Further review revealed that the resident fell getting out of the wheelchair on 4/24/17, slid self out of the wheelchair to the floor on 6/29/17 and had an unwitnessed fall out of the wheelchair on 7/25/17. Review of the Progress Notes, dated 7/25/17 at 1:49 PM, revealed that the resident was found to be on the floor next to the wheelchair in the dining room and no injuries were noted. Further review revealed at 2:09 PM, bruising which measured 5 cm. (centimeters) by 2 cm. was noted on the 3rd digit. At 6:14 PM, swelling was noted at the finger. On 7/27/17 at 2:45 PM, an x ray showed that the resident had a fractured right third finger and orders for a splint were received. Observations on 8/9/17 at 7:40 AM revealed the resident resting in bed and a splint in place at the right third finger. Review of the Treatment Administration Record, dated (MONTH) (YEAR), revealed an order, dated 7/26/17, for Epsom salt treatment two times a day for swelling and bruising of the right hand. Review of the Medication Administration Record, dated (MONTH) (YEAR), reveal… | 2020-09-01 |
| 2490 | 2490 | PIONEER MANOR NURSING HOME | 285212 | P O BOX 310, 318 N 3RD STREET | HAY SPRINGS | NE | 69347 | 2019-02-13 | 689 | G | 1 | 0 | U39J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interview; the facility failed to ensure that 1) interventions were in place to prevent an elopement and resulting injuries from the facility for one current sampled resident (Resident 4) with multiple attempts to leave the facility unattended, 2) identify causal factors to reduce the risk for further injuries related to skin injuries for one current sampled resident (Resident 2) and falls for two current sampled residents (Residents 7 and 8) and one closed record (Resident 6). The facility census was 51 with nine current sampled residents and one closed record reviewed. Findings are: Licensure Reference Number 175 NAC 12-006.097 [NAME] Review of the Resident Face Sheet, printed 2/11/19, revealed that Resident 4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, printed 2/12/19, revealed that the resident was a higher risk for elopement related to confusion and frequent wandering. Approaches, dated 1/31/19, included wanderguard device in place on the wheelchair, charge nurse will check functioning of the device two times a day and replace as needed. Further review revealed that the resident had moderate impaired cognition and was not able to make good decisions, had impaired vision and communication, significant memory loss and poor judgement regarding safety with transfers and required assistance for transfers. Review of the Resident Progress Notes revealed the following including: - 12/16/18 at 7:50 PM Resident opened the door at the end of the west hall and set the alarm off, did not exit; 9:32 PM Resident continued exit seeking between 7:40 PM and 8:30 PM, activity caused alarms to sound repeatedly and redirection was not successful; - 12/19/18 at at 2:48 PM Resident opened the west door in the main dining room and attempted to go outside, redirected to the assistance dining room; 6:28 PM Resident exit seeking throughout the day, wanderguard alarm alerte… | 2020-09-01 |
| 6688 | 6688 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2015-11-09 | 279 | D | 1 | 1 | HZ1311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews: the facility failed to: 1) identify and develop interventions to address one sampled resident's (Resident 32) assistance with activities of daily living (ADL's); and 2) identify and develop interventions to address one samples resident's (Resident 16) non-pressure related skin condition. Facility census was 72. Finding are: A. Interview with LPN (Licensed Practical Nurse)-N on 11/4/15 at 9:35 AM revealed Resident 32 had been declining in the ability to complete ADL's for several months. Observations of Resident 32 at 10:05 AM revealed two staff members LPN-N and MA (Medication Aide)-A transferring the resident using a hoyer lift to transfer resident from recliner to bed. Record review of Resident 32's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care planning) assessments revealed a significant change in Resident 32's functional status. The MDS revealed Resident 32 required extensive assist for bed mobility, transfer, dressing, toilet use and personal hygiene. Record review of Resident 32's Care Plan printed on 11/2/15 with goal dates through 1/28/16 revealed there were no problems, goals or approaches developed or identified on the care plan to address the resident's assistance needed to complete ADL's. Interview with the Director of Nursing on 11/9/15 at 3:25 PM revealed the care plan did not address the ADL's and there should have been changes made at the time when the resident had the significant change in condition. B. Observations of Resident 16 throughout the survey revealed bruises on bilateral forearms. Record review of Resident 16's Care Plan printed on 10/22/15 with goal dates through 1/21/16 revealed there was no mention of bruising on Resident 16's care plan. Interview with the Director of Nursing on 11/9/15 at 3:20 PM revealed the care plan contained no mention of the resident's bruising. Resident 16 had received [ME… | 2018-11-01 |
| 4816 | 4816 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2017-04-19 | 323 | D | 1 | 1 | HWP011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to 1) change fall interventions after a fall to reduce the risk of recurrent falls for one closed sampled resident (Resident 5) and 2) ensure that a portable oxygen cylinder was secured to reduce the risk of accidents for one sampled resident (Resident 13). The facility census was 24 with eight current sampled residents and five closed records reviewed. Findings are: Licensure Reference Number 175 NAC 12-006.09D7b [NAME] Review of the Admission Record, printed 4/18/17, revealed that Resident 5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility Investigation Report, dated 2/22/17, revealed that on 2/22/17 the resident was found on the floor in room after attempting to reach a brief package off the dresser. The immediate measures put into place to protect the resident was request staff assistance as needed .Further review revealed that the resident sustained [REDACTED]. Review of the care plan, target date 6/1/17, revealed that the resident was at risk for falls related to dizziness, history of multiple falls and impaired balance and mobility. Interventions included assistance of two staff members for transfers, bed alarm and chair alarm, and place call light and personal belongings within reach. Further review revealed no changes in interventions after the fall on 2/22/17 to reduce the risk for further falls. Interview with the Administrator on 4/19/17 at 10:15 AM confirmed that fall interventions were not changed after the fall on 2/22/17 to reduce the risk for further falls. Licensure Reference Number 175 NAC 12-006.09D1a B. Observations of Resident 5's room on 4/17/17 at 11:30 AM and at 2:15 PM revealed an unsecured portable oxygen tank leaning against the wall. Interview with the Director of Nursing on 4/17/17 at 2:15 PM confirmed that the portable oxygen tank was not secured and needed to be secured to reduce the risk of acc… | 2020-03-01 |
| 487 | 487 | HILLCREST NURSING HOME | 285080 | P O BOX 1087, 309 WEST 7TH STREET | MCCOOK | NE | 69001 | 2017-10-11 | 323 | E | 1 | 1 | T01F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to ensure that 1) fall interventions were in place to reduce the risk for falls for two current sampled residents (Residents 48 and 31), 2) oxygen concentrators were turned off while not in use to reduce the risk of accidental fires for four current sampled residents (Residents 83, 65, 5 and 48), 3) potentially hazardous chemicals were secured to reduce the risk of accidental exposure and injuries for eight current residents identified as confused and wandering (Residents 44, 49, 53, 62, 26, 100, 90 and 107) and 4) grab bars were tightly secured on beds for five sampled residents (Residents 64, 14, 86, 38 and 52). The facility census was 81 with 35 sampled residents. Findings are: Licensure Reference Number 175 NAC 12-006.09D7 [NAME] Review of the Face Sheet, printed 10/4/17, revealed that Resident 48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, printed 10/4/17, revealed that the resident had impaired physical mobility related to weakness and interventions included ambulation with a walker and staff assistance. Further review revealed that the resident was at risk for injuries due to history of falls and interventions included remind resident to ask for help when getting up. On 6/13/17, staff education do not leave alone in the bathroom was added to the care plan. Further review revealed that the resident was legally blind, had difficulty hearing and had dementia with episodes of disorientation. Review of the Departmental Notes revealed the following including: - 6/13/17 Resident noted sitting on the floor in the bathroom in front of the toilet at 7:40 AM. Resident complained of bottom hurting and no injuries noted; - 6/15/17 at 9:41 AM Care team met to discuss the resident's fall. The resident was left unattended in the room and staff education was provided not to leave the resident unattended in the bathroom. Interview w… | 2020-09-01 |
| 2614 | 2614 | WAUNETA CARE AND THERAPY CENTER | 285220 | PO BOX 520, 427 LEGION STREET | WAUNETA | NE | 69045 | 2017-07-20 | 323 | E | 1 | 1 | 3Q2711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to ensure that 1) interventions were in place to reduce the risk for falls for one sampled resident (Resident 34) and 2) chemicals were secured to reduce the risk for accidental exposure and injury for nine residents identified as confused and wandered in the facility (Residents 14, 17, 20, 26, 22 13, 21, 34 and 28). The facility census was 31 with 11 current sampled residents. Findings are: Licensure Reference Number 175 NAC 12-006.09D7b [NAME] Review of Resident 34's Departmental Notes, dated 2/5/17, revealed that at 4:20 PM, the resident was heard hollering and was found sitting on the floor. The resident stated was in my closet and my shoe slipped and I lost my balance abd (sic) fell to my right and hit my right arm. Review of the Care Plan, goal date 3/2/17, revealed a problem that the resident had a history of [REDACTED]. Approaches included Ensure that (resident) has and wears properly - fitting non-skid soled shoes for ambulation, Removed unsafe slippers and replace with closed heel slippers. and Give (resident) verbal reminders not to ambulate or transfer without assistance. Interview with the Director of Nursing on 7/19/17 at 2:20 PM confirmed that the resident was at risk for falls. Further interview confirmed that the care plan interventions were not in place to reduce the risk for falls as the resident was not wearing safe shoes at the time of the fall and did not call for assistance to transfer or ambulate. Licensure Reference Number 175 NAC 12-006.09D7a [NAME] Observations on 7/17/17 at 6:50 PM, during the initial tour of the facility, revealed an unlocked oxygen storage room across from the nurses station and resident lounge area. Further observations revealed a can of Lynx disinfectant spray on the counter. Several residents were in the hallways and in the lounge area. Interview with LPN (Licensed Practical Nurse ) - A on 7/17/17 at 6:50 PM confirmed … | 2020-09-01 |
| 5745 | 5745 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2016-09-20 | 323 | E | 1 | 0 | TD4511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to ensure that 1) interventions were in place to reduce the risk of recurrent falls for one sampled resident (Resident 132), 2) ensure potentially hazardous chemicals were secured to reduce the risk of accidental exposure and injury for two residents identified as confused and wandering in the unit (Residents 67 and 159), 3) footrests were utilized when transporting residents in wheelchairs to support the resident's feet and to reduce the risk for injuries for three sampled residents (Residents 132, 4, and 97), 4) one staff member did not transport two residents seated in wheelchairs in the hallway at the same time (Residents 7 and 124), 5) a safety assessment was completed for grab bars on the bed which contained gaps large enough for potential entrapment of limbs for one sampled resident (Resident 132) and 6) oxygen concentrators were turned off when not in use or when residents were out of the room to reduce the risk for fires for four sampled residents (Residents 2, 12, 68 and 86). The facility census was 114. Findings are: Licensure Reference Number 175 NAC 12-006.09D7 A. Review of the Admission Record, printed 9/8/16, revealed that Resident 132 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, with a goal date of 11/20/16, revealed that the resident was confused with impaired cognition, had poor vision, was incontinent of bowel and bladder and was at risk for falls related to history of falls and wandering behaviors. Further review revealed that the resident fell on [DATE], 8/16/16, 8/22/16, and 8/23/16. Interventions included encourage resident to use call light for help, frequent checks, non slip footwear, encourage and remind to toilet frequently, toileting after supper, keep resident close while in the wheelchair and keep environment fee of clutter and well lit. Review of the Progress Notes revealed the following incl… | 2019-09-01 |
| 918 | 918 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2017-08-22 | 425 | E | 1 | 1 | 2T4P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to ensure that 1) medications were available to administer for a newly admitted resident (Resident 173) closed record, 2) Medication Aides reported a discrepancy with a prescription label and the doctor's order to a nurse before administering the medication for two current sampled residents (Residents 143 and 75) and 3) medication aides checked the prescription labels with the current medication order at least three times before administration of medications to reduce the risk for errors for five sampled residents observed for medication administration (Residents 53, 19, 143, 75 and 8). The facility census was 107 with five residents sampled for observation of medication administration and three closed records reviewed. Findings are: Licensure Reference Number: 175 NAC 12-006.12A [NAME] Review of the Admission Record, printed 8/9/17, revealed that Resident 173 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MAR (Medication Administration Record), dated (MONTH) (YEAR), revealed that the evening doses of Bumetanide and Carvedilol (ordered for heart failure) and Florajen and Sennosides (ordered for bowel maintenance) were not administered. Review of the Treatment Administration Record, dated (MONTH) (YEAR), revealed that the evening treatment of [REDACTED]. Interview on 8/15/17 at 3:00 PM with LPN (Licensed Practical Nurse) - C, Unit Coordinator, confirmed that the evening doses of medications were not administered because the medications were not delivered to the facility from the pharmacy until late that evening. Licensure Reference Number: 175 NAC 12-006.10A3 B. Observations on 8/10/17 at 7:45 AM revealed MA (Medication Aide) - T prepared to administer morning medications for Resident 143. MA - T removed the medication card for Metoprolol. Further observations revealed that the prescription label had instructions to administer 25 mg. (m… | 2020-09-01 |
| 5742 | 5742 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2016-09-20 | 309 | D | 1 | 0 | TD4511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to ensure that 1) ongoing aggressive behaviors were managed to reduce the risk of physical altercations with other residents for two sampled residents (Resident 131 and 104) and 2) interventions were in place prevent skin injuries for one sampled resident (Resident 13) identified at high risk for skin injuries and ensure weekly skin assessments were completed which included measurements of skin tears to ensure healing without complications. The facility census was 114. Findings are: Licensure Reference Number 175 NAC 12-006.09D A. Review of Resident 131's Care Plan, goal date 6/30/16, revealed that the resident had [DIAGNOSES REDACTED]. Further review revealed that the resident had behaviors including crying, cursing, trying to help other residents, wandering in and out of other resident's rooms and waking them up and agitated and combative with attempts to redirect the behaviors. Interventions included medications as ordered, avoid upsetting situations or people and attempt interventions before behaviors begin such as one on one time with staff. Review of theBehavior Detail Report revealed the following including: - 6/1/16 at 9:36 AM, resident wandered in other resident's rooms and refused medications, interventions ineffective; - 9:37 AM, resident screamed at staff, interventions ineffective; - 9:45 AM, resident hit staff, cursed, screamed at staff, scratched staff, shoved staff, undressed in public, rejected cares, rejected medications, wandered in the halls; - 10:18 AM, resident hit, shoved, scratched staff, undressed in public; - 12:32 PM, resident had physical behaviors directed towards others; - 1:07 PM, resident wandered in hall, screamed at staff and others; - 3:35 PM and 8:55 PM, resident wandered in hall, redirection not effective. Review of the Progress Notes, revealed the following including: - 6/1/16 at 12:50 PM, resident was noted by staff to be holding… | 2019-09-01 |
| 5717 | 5717 | NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER | 285271 | 2100 CIRCLE DRIVE | SCOTTSBLUFF | NE | 69361 | 2016-10-03 | 425 | E | 1 | 0 | SRLF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews the facility failed to: 1) ensure that ordered medications were available for three sampled residents (Residents 8, 10, 14); 2) prevent medication omission errors involving three sampled residents (Residents 12, 13, and 14); 3) question an ordered medication provided for one sampled resident (Resident 8) which was listed among resident allergies [REDACTED]. residents (Residents 2, 8, 9, 10, 12, 13, and 14). Sample size was 12 current residents. Facility census was 51. Findings are: Licensure Reference Number: 175 NAC 12-006.12 A. Record review of Resident 8's Medications Administration History form for (MONTH) of (YEAR) revealed the following medication omissions: -an order for [REDACTED]. -a scheduled dose of Losartan, ordered to be administered at bedtime was not administered on 9/28/16 due to the medication being unavailable from the pharmacy. -Scheduled doses for the resident's Omeprazole ordered for administration twice daily were not administered on 9/22/16 at 8 p.m. and 9/23/16 at 6 a.m. due to the medication being unavailable from the pharmacy. Record review of Resident 10's Medications Administration History form for (MONTH) of (YEAR) revealed the following omission on 8/11/16 for Tramadol (pain medication) which was ordered on [DATE]. The comment for why the medication was not administered read: Drug Item unavailable. Record review of Resident 14's Medications Administration History form for (MONTH) of (YEAR) revealed an order for [REDACTED]. Licensure Reference Number: 175 NAC 12-006.12A B. Record reviews of Resident facility medication error reports revealed the following errors were investigated: - Error occurring on 8/23/16 revealed Resident 12's ordered medications for: Omeprazole, Simethicone, Levothyroxine, Hydrochlorothiazide, Losartin, and Nifadipine scheduled for 8 a.m. doses were omitted and not given. - Error occurring on 8/23/16 revealed Resident 13's ordered medic… | 2019-10-01 |
| 5302 | 5302 | BLUE VALLEY LUTHERAN CARE HOME | 2.8e+280 | P O BOX 166, 755 SOUTH 3RD STREET | HEBRON | NE | 68370 | 2019-01-02 | 604 | E | 1 | 0 | JR9H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews, the facility failed to ensure 3 (Resident 12, 100, and 23) out of 3 residents were free from physical restraints and the restraints that were being used, were used to treat medical symptoms. The facility census was 30. Findings are: [NAME] Observation of Resident 12 on 1-2-18 at 10:10 [NAME]M. revealed the resident was sitting in the wheelchair with a locked laptray, seatbelt, and wrist restraints on both wrists that prevented the resident from lifting either arm up off of the lap tray. Observations of the residents hands revealed both fingers/hands were contracted into a fist like shape. The lap tray was absent of any activity or food/drink items for the resident. Record review of Resident 12's Face Sheet dated 1-2-19 revealed the date of admission as 6-2-14 and [DIAGNOSES REDACTED]. Review of the Annual MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-12-18 revealed no restraints. Interview on 1-2-19 at 2:55 PM with NA-B (Nurse Aide) revealed Resident 12 was admitted with the seatbelt, laptray, and wrist restraints. NA-B revealed the resident had the laptray, the seatbelt, and the wrist restraints applied whenever up in the wheelchair. NA-B confirmed the resident was unable to remove the seatbelt, the laptray or the wrist restraints. NA-B confirmed the staff do not remove the restraints once applied unless they are transferring the resident back to bed. The resident was fed via a feeding tube into the stomach so did not need the hands to eat. Interview on 1-2-19 at 3:00 PM with LPN-A (Licensed Practical Nurse) revealed the resident was not able to remove the lap tray or the seatbelt. LPN-A revealed sometimes the resident by shear force may break free of the wrist restraints but was not able to remove them in the same manner they were applied. LPN-A confirmed the laptray, seatbelt, and wrist restraints were applied every time th… | 2020-02-01 |
| 4298 | 4298 | OGLALA SIOUX LAKOTA NURSING HOME | 2.8e+301 | 7835 ELDERS DRIVE, STATE HIGHWAY 87 | RUSHVILLE | NE | 69360 | 2017-11-16 | 309 | D | 1 | 1 | XK2J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews, the facility failed to ensure staff monitored one sampled resident's (Resident 30) [MEDICAL TREATMENT] port on a daily basis. Resident 30 was the only current resident receiving [MEDICAL TREATMENT] services. 14 Residents were sampled. Facility census was 29. Findings are: Record review of Resident 30's Admission Record printed on 11/14/17 revealed the resident was admitted to the facility on [DATE]. Among the resident's medical [DIAGNOSES REDACTED]. Observation of Resident 30 on 11/14/17 at 1:39 p.m. revealed the resident had a shunt to the left forearm. Interview with Resident 30 on 11/14/17 at 1:39 p.m. revealed the facility assisted transporting the resident to a [MEDICAL TREATMENT] center for treatment three times a week. Record review of Resident 30's Care Plan revealed a Focus problem revised on 11/13/17 which identified a problem of at risk for complications related to [MEDICAL TREATMENT] for the [DIAGNOSES REDACTED]. Among interventions to address the problem included directions to check the resident's shunt site daily and as needed for symptoms of infection, pain, or bleeding. Record review of Resident 30's medical record including treatment sheets, medication sheets, and progress notes revealed there was no documentation that the staff were monitoring the shunt daily for signs of bleeding or infection. Interview with the DON (Director of Nursing) on 11/16/17 at 10:27 a.m. confirmed the staff were not recording daily assessments of Resident 30's shunt site condition. | 2020-09-01 |
| 470 | 470 | HILLCREST NURSING HOME | 285080 | P O BOX 1087, 309 WEST 7TH STREET | MCCOOK | NE | 69001 | 2018-04-03 | 690 | D | 1 | 0 | 0YN711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews, the facility failed to: 1) Ensure facility staff followed up with assessments and urinary condition changes for one sampled resident (Resident 3) with a urinary catheter; and 2) ensured facility staff prevented catheter bags from potential cross-contamination during transfers for two sampled residents (Residents 3 and 1). Sample size was three current residents with urinary catheters. Facility census was 87. Findings are: [NAME] Licensure Reference Number: 175 NAC 12-006.09D3 Record review of Resident 3's Face Sheet printed on 4/3/18 revealed the resident was admitted to the facility on [DATE]. Further review of the document revealed the resident had medical [DIAGNOSES REDACTED]. Record review of a facility Investigation Report dated 3/29/18 describing an incident involving Resident 3 falling on 3/20/18. In the section entitled Describe the incident the investigation recorded the resident was noted on the floor by the wheelchair on 3/20/18 at 9:23 p.m. Further review of the description recorded: . Resident having dark, foul urine in catheter bag and had several days reported to nurse for confusion and hallucinations, so on 3/21/2018 nurse obtained an order for [REDACTED]. Record review of Resident 3's Departmental Notes between 3/6/18 through 4/3/18 printed on 4/3/18 revealed the following entries: - 3/9/18 through 3/11/18 entries revealed the resident was treated for [REDACTED]. - Between 3/11/18 through 3/20/18 there were no entries describing the resident's urinary status. - 3/20/18 at 9:23 p.m. the resident was discovered on the floor. Nothing charged about the resident's urinary status or condition. - 3/21/18 at 9:44 a.m. the entry read: Urine collected at this time via foley cath (catheter) port. Urine dark yellow, cloudy and malodorous (foul smelling). Coolected per orders for: Recent falls, increased confusion and cloudy urine. Sample sent to (clinic). - Between 3/21/18 and 3/27… | 2020-09-01 |
| 4299 | 4299 | OGLALA SIOUX LAKOTA NURSING HOME | 2.8e+301 | 7835 ELDERS DRIVE, STATE HIGHWAY 87 | RUSHVILLE | NE | 69360 | 2017-11-16 | 323 | D | 1 | 1 | XK2J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews, the facility failed to: 1) ensure oxygen concentrators were turned off when not in use and unattended for one sampled resident (Resident (Resident 2). This failure could potentially oxygenate the room resulting in increased fire hazard; and 2) identify causal factors and develop strategies to prevent re-occurrence of falling for one sampled resident (Resident 12) after a fall occurred. Sample size was 14 residents. Facility census was 29. Findings are: Licensure Reference Number: 175 NAC 12-006.09D7 [NAME] Record review of Resident 2's Admission Record printed on 11/14/17 revealed the resident was admitted to the facility on [DATE] and had medical [DIAGNOSES REDACTED]. Record review of Resident 2's Admission MDS (Minimum Data Set, a federally mandated comprehensive tool utilized to develop resident care plans) completed on 9/26/17 revealed the resident received Oxygen therapy. Observation on 11/15/17 at 9 a.m.; 10 a.m.; 11:00 a.m.; and 12 noon revealed Resident 12's oxygen concentrator was running set on two liters while the resident was out of the room and the room was unattended to. Another observation with the DON (Director of Nursing) on 11/15/17 at 12:15 p.m. revealed Resident 12's concentrator was left on and unattended. Interview with the DON during the observation on 11/15/17 at 12:15 p.m. confirmed Resident 12's oxygen concentrator was left on while unattended in the room. Licensure Reference Number: 175 NAC 12-006.09D7b B. Record review of Resident 12's Admission Record printed on 11/14/17 revealed the resident was admitted to the facility on [DATE] and had a medical [DIAGNOSES REDACTED]. Record review of Resident 12's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) revealed revealed a Significant Change in Status MDS was completed for the resident on 8/18/17. The MDS recorded the resident's cognition had decli… | 2020-09-01 |
| 4820 | 4820 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2017-04-19 | 425 | E | 1 | 1 | HWP011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews, the facility failed to: 1) obtain medications for administration as ordered for one sampled resident (Resident 26); and 2) ensure medication labels were compared to instructions on resident Medication Administration Records a minimum of three times per nursing standards of practice for medications administered to eight current residents (Residents 43, 15, 41, 10, 8, 21, 28, and 3). Sample included fifteen current residents and five closed records. Facility census was 24. Findings are: [NAME] Licensure Reference Number: 175 NAC 12-006.12A Record review of Resident 26's Admission Record printed on 4/18/17 revealed the resident was admitted to the facility initially on 12/2/2014. Among the medical diagnoes listed on the document were: Hypertension, Chronic Kidney Disease, and Chronic Obstructive Pulmonary Disease. Record review of Resident 26's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) records revealed the following: - The resident was discharged from the facility to a hospital setting on 3/1/17 and returned on 3/7/17. - The resident was discharged from the facility to a hospital setting on 3/13/17 and returned on 3/14/17. - The resident was discharged to another nursing facility on 3/31/17. Closed medical record review of Resident 26's medical physician orders [REDACTED]. The instructions read for the resident to take two tablets at 7 a.m.; and one tablet at 11 a.m.; 2 p.m.; and 6 p.m. Record review of Resident 26's Medication Administration Record [REDACTED]. Record review of Resident 26's Progress Notes (including Nurses Notes) revealed on 3/14/17 at 12:15 p.m. the resident was readmitted to the facility. Further review of the notes revealed an entry on 3/14/17 at 5:42 p.m. recording the resident's Lasix was not administered to the resident in the evening due to Product unavailable, pharmacy notified. Record review… | 2020-03-01 |
| 5714 | 5714 | NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER | 285271 | 2100 CIRCLE DRIVE | SCOTTSBLUFF | NE | 69361 | 2016-10-03 | 323 | D | 1 | 0 | SRLF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews; the facility failed to: 1) Transfer a cognitively impaired resident with balance impairments with the use of a gait belt as identified in the resident's care plan; 2) Assess the need for and safety for the use of a grab bar device attached to the resident's bed; and 3) Investigate all potential causes for a bruise of unknown origin. All of these failures affected one sampled resident (Resident 2). Sample size included four current residents. Facility census was 51. Findings are: Licensure Reference Number: 175 NAC 12-006.09D7a A. Record review of Resident 2's Resident Face Sheet printed on 9/28/16 revealed the resident was admitted to the facility on [DATE] with the latest return recorded 5/23/16. Among the resident's medical [DIAGNOSES REDACTED]. Record review of Resident 2's Quarterly review MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) completed on 7/18/16 revealed the following: - The resident's BIMS (Brief Interview of Mental Status, a test to assess resident memory capabilities) scored a 6 (0-7=severe cognitive impairment) - The resident's ability to transfer between surfaces and walk were recorded as: Extensive Assist (Resident involved in activity, staff provide weight-bearing support). - The resident's ability to move on and off the unit was recorded as: Limited Assist (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance). - The resident's ability to balance while moving from seat to standing, walking, and turning around while walking was assessed as: Not steady, only able to stabilize with staff assistance. Record review of Resident 2's Care Plan with Goal Target Dates through 10/17/2016 revealed the resident had a problem identified as falls due to a history of falling, poor judgment and reasoning, and decline in cognition. An additional prob… | 2019-10-01 |
| 6670 | 6670 | GRAND ISLAND PARK PLACE CARE AND REHABILITATION CE | 285105 | 610 NORTH DARR AVENUE | GRAND ISLAND | NE | 68803 | 2015-11-19 | 431 | D | 1 | 0 | 67D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure that one residents (Resident 8) Wound Vac (wound healing through negative pressure wound therapy) was at the prescribed level as ordered by the physician. The facility census was 54. Findings are: Review of Resident 8's Wound Clinic Visit on 10/23/15 revealed: -The resident was finished with the antibiotic. -The resident had more edema in left foot. The resident kept feet up except when eating. -The resident's Wound Vac pressure was increased to 150 mmHg (millimeters of mercury) continuously with a black sponge. The sponge was to be changed three times weekly. -The wounds were to be washed with soap and water at each dressing change. Review of Resident 8's Wound Clinic Visit dated 10/29/15 revealed: -The left foot was more swollen around the ankle. -There was an increase in serosanguinous drainage (blood and serum part of the blood leaving the body from a new wound) from a wound under the dressings. -The resident was having more pain and had medication adjustment for pain. -The resident's Wound Vac pressure remained at 150 mmHg continuously with a black sponge. -The sponge was to be changed three times weekly. -The wounds were to be washed with soap and water at each dressing change. -The resident was to remain at non-weight bearing on both feet.-The resident was to elevate both legs as much as possible. Review of Resident 8's (MONTH) (YEAR) TAR (Treatment Administration Record) revealed: -The resident's Wound Vac order on 10/23/15 for an increase in pressure from 125 to 150 mmHg was not updated. The order still read Wound Vac at 125 mm on both feet to be changed on Monday, Wednesday, and Friday to continuous suction. -The residents Wound Vac dressing change was not completed on 11/4/15. Review of Resident 8's (MONTH) (YEAR) TAR revealed: -The resident had an order for [REDACTED]. -The resident's Wound Vac order on 10/23/15 for an increase in pressure from 125 to 150 mmHg wa… | 2018-11-01 |
| 3944 | 3944 | VALLEY VIEW SENIOR VILLAGE | 285294 | 220 SOUTH 26TH STREET | ORD | NE | 68862 | 2018-03-21 | 712 | D | 1 | 1 | OLWQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure 2 (Resident 14 and 15) out of 4 residents Physician visits were completed at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. The census was 34. Findings are. [NAME] Review of Resident 14's undated Face Sheet revealed the resident was admitted on [DATE]. Review of Resident 14's Physician's PN (Progress Notes) revealed the resident had an initial Physician visit on 12-02-16. The Physician PN revealed the next 30 day Physician visit was not until 02-28-17 which was 60 days later and not the 30 days later as required. Review of Resident 15's undated Face Sheet revealed the resident was admitted on [DATE]. Review of Resident 15's Physician's PN revealed the resident had an initial Physician visit on 12-14-16. The Physician PN revealed the next 30 day Physician visit was 01-12-17. The 3rd 30 day Physician visit was absent from the medical record. Interview on 03/20/18 at 04:13 PM with MA-D (Medication Aide), who was the[NAME] Clerk, confirmed the Progress Notes were absent for the 2nd 30 day Physician visit for Resident 14 and for the 3rd 30 day Physician visit for Resident 15. B. Review of Resident 15's 60 day Physician visits revealed the resident received a 60 day visit from the Primary Care Physician in April, (MONTH) and (MONTH) (YEAR) then another visit was not documented until (MONTH) (YEAR). Interview on 03/20/18 at 04:13 PM with MA-D revealed the MA-D could not find any documentation of a 60 day Physician visit which occurred between (MONTH) (YEAR) and (MONTH) (YEAR). | 2020-09-01 |
| 4933 | 4933 | PREMIER ESTATES OF WEST POINT, LLC | 285158 | 960 PROSPECT ROAD | WEST POINT | NE | 68788 | 2018-06-12 | 757 | D | 1 | 1 | ELDP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure 2 residents (Resident 31 and 1) were free from the use of unnecessary medications as medications were given without indication for use and not in accordance with physician's orders [REDACTED]. Findings are: [NAME] Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/7/18 revealed [DIAGNOSES REDACTED]. Review of Resident 1's Medication Administration Record [REDACTED]. Further review revealed orders dated 9/28/17 for Tylenol 650 mg every 6 hours as needed for mild pain with pain rated as 1-4 on a pain scale. Review of the 5/2018 MAR indicated [REDACTED] -5/12/18 at 8:35 for pain level of 3; -5/14/18 at 7:00 PM for pain level of 4; -5/15/18 at 8:30 AM for pain level of 4; -5/18/18 at 1:44 AM for pain level of 4; -5/21/18 at 9:22 PM for pain level of 4; -5/22/18 at 11:59 PM for pain level of 4; -5/26/18 at 9:39 PM for pain level of 3; and -5/27/18 at 5:41 AM for pain level of 3. Review of the 6/2018 MAR indicated [REDACTED]. Documentation indicated the following: -6/6/18 at 8:01 AM for pain level of 3; -6/7/18 at 9:17 AM for pain level of 2; -6/8/18 at 7:24 PM for pain level of 4; -6/10/18 at 7:05 PM for pain level of 4; -6/11/18 at 8:06 AM for pain level of 4; and -6/12/18 at 7:01 AM for pain level of 3. B. Review of Resident 1's MAR indicated [REDACTED] -[MEDICATION NAME] (medication used to treat anxiety) 1 mg every 8 hours PRN for anxiety (order date 1/2/18); and -[MEDICATION NAME] 1 mg every 6 hours PRN for restlessness related to anxiety disorder (order date 5/15/18). Further review of Resident 1's MAR indicated [REDACTED] -Resident 1 received [MEDICATION NAME] 1 mg on 5/12/18 at 5:03 PM and again at 8:36 PM (3 hours and 30 minutes between doses); -No [MEDICATION NAME] was given on 5/27/18 and an order was obtained for [MEDICATION NAME] 10 mg IM (intramuscular) every 4 hours PRN for agitation/aggr… | 2020-03-01 |
| 5465 | 5465 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2017-03-22 | 334 | E | 1 | 1 | HUVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure 5 of 59 residents (Residents 82, 78, 61, 85 and 71) were offered the pneumococcal vaccinations as required. The facility census was 58. Findings are: [NAME] Review of Resident 82's electronic medical record revealed Resident 82 was admitted on [DATE] and had no documented evidence of being offered the pneumococcal vaccination. Review of Resident 82's MDS (The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a medicare and/or Medicaid-certified long-term care facility.) dated 2/8/17 revealed Resident 82's pneumococcal vaccination was not up to date and was not offered. B. Review of Resident 78's electronic medical record revealed Resident 78 was admitted on [DATE] and had no documented evidence of being offered the pnuemococcal vaccination. Review of Resident 78's MDS dated [DATE] revealed Resident 78's pneumococcal vaccination was not up to date. C. Review of Resident 61's electronic medical record revealed Resident 61 was admitted on [DATE] and had no documented evidence of being offered the pnuemococcal vaccination. Review of Resident 61's MDS dated [DATE] revealed Resident 61's pneumococcal vaccination was not up to date. D. Review of Resident 85's electronic medical record revealed Resident 85 was admitted on [DATE] and had no documented evidence of being offered the pnuemococcal vaccination. Review of Resident 85's MDS dated [DATE] revealed Resident 85's pneumococcal vaccination was not up to date and had not been offered. E. Review of Resident 71's electronic medical record revealed Resident 71 was admitted on [DATE] and had no documented evidence of being offered the pnuemococcal vaccination. Review of Resident 71's MDS dated [DATE] revealed Resident 71's pneumococcal vaccination was not up to date and had not been offered. Int… | 2020-01-01 |
| 6383 | 6383 | FULLERTON CARE AND REHABILITATION CENTER, LLC | 285115 | PO BOX 648, 202 NORTH ESTHER | FULLERTON | NE | 68638 | 2016-03-10 | 247 | E | 1 | 0 | UFFQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure Resident's Responsible Parties were notified prior to transferring residents into different rooms within the facility. This violation had the potential to affect four residents (Residents 2, 6, 8, and 11). The facility census was 70. Findings are: A review of a facility Policy/Document # SS-705 titled Transfers and Discharges with a review date of 2/26/2015 revealed the Social Services Director (SSD) would ensure systems were implemented to provide written notification to the resident and family prior to transfer. A review of the Notice of Transfer or Discharge forms for sampled residents revealed the following: -Resident 2 was moved from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on 6/26/15 and from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on 7/6/15; -Resident 6 was moved from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on 11/25/15; -Resident 8 was moved from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on 7/6/15, and from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-1 on 3/3/16; -Resident 11 was moved from room [ROOM NUMBER]-1 to room [ROOM NUMBER]-2 on 9/22/15, from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-1 on 10/22/15, and from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on 2/12/16. Further review of the forms revealed the Resident's Legal Representatives were notified by mail on the actual date of the moves and not before the moves. An interview on 3/9/16 at 2:45 PM with Social Services Assistant (SSA)-J confirmed the sampled Resident's Legal Representatives were not notified prior to the day of the resident moves. The SSA reported written notification of the resident moves were mailed out on the day of the actual transfers. | 2019-03-01 |
| 5331 | 5331 | PREMIER ESTATES OF FREMONT, LLC | 285103 | 2550 NORTH NYE AVENUE | FREMONT | NE | 68025 | 2017-01-31 | 285 | D | 1 | 0 | BKZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that a new Pre-Admission Screening and Resident Review (PASRR) was performed, according to the requirements for 1 resident (Resident 81) out of 1 sampled resident . The facility census was 69. Findings are: Record review of the facility policy titled, Pre-Admission Screening for MR/MI, dated 02/15, revealed that the facility would verify that all residents were screened prior to admission to determine whether they have a mental illness (MI) or mental [MEDICAL CONDITION]/developmental disability (MR/DD) [DIAGNOSES REDACTED]. A Level II screen was done to assist the facility in determining the types of services required to care for the resident. Record review of Resident 81's Admission Record, dated 1/30/17 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Record review of Resident 81's PASRR revealed a review date of 8/7/14 for admission to a receiving nursing facility on 4/12/14 that was not this facility. Interview with Social Service Director (SSD) on 1/30/17 at 2:57 PM revealed that Resident 81 did not have a PASRR performed upon admission to this facility. The SSD confirmed that the only PASRR present for Resident 81's record was the one provided by the transferring facility dated 8/7/14. Interview with the facility Administrator on 01/30/2017 at 3:02 PM confirmed that the facility failed to request a PASRR upon admission to the facility. | 2020-01-01 |
| 4415 | 4415 | SCHUYLER CARE AND REHABILITATION CENTER, LLC | 285110 | 2023 COLFAX STREET | SCHUYLER | NE | 68661 | 2017-06-20 | 205 | B | 1 | 0 | KY7C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure the bed hold policy was provided to residents or resident representative prior to the resident leaving the building for therapeutic leave or hospitalization . This failure had the potential to effect three sampled residents (Residents 3, 5, and 6). The facility census was 31 at the time of survey. Findings are [NAME] A review of the Census Tab in Resident 3's medical record, printed on 6/20/17, revealed the resident had one Therapeutic Leave and three Hospital Leaves from the facility from 10/29/16 thru 5/26/17. Further review of Resident 3's record revealed no documented evidence indicating the resident received information related to the facility's Bed Hold Policy, at the time of admission or with any of the resident's temporary leaves from the facility. An interview on 6/20/17 at 9:20 AM with the Social Services Director (SSD) revealed the facility's bed hold policy is gone over and signed upon admission, notification is not given at the time of hospitalization or other forms of tempore leaves from the facility. The SSD reported inability to locate a Bed Hold Policy and Notification form for Resident 3. B. An interview on 6/15/17 at 5:30 AM with Registered Nurse (RN)-A, revealed Resident 5 was out of the building on Bed Hold status related to being hosptalized on [DATE]. Review of an Investigation Report dated 6/18/17, revealed Resident 5 fell in the resident's room on 6/13/17. The fall caused the resident to be hospitalized and placed on Bed Hold status at the facility. A review of Resident 5's records revealed an undated BED HOLD POLICY AND NOTIFICATION form containing the resident's signature. Review of the Facility's form, revised 3/25/16, revealed each resident/legal representative will be informed of the facility's Bed Hold Policy and Notification upon admission to the facility and/or when a resident leaves for hospitalization , observation or therapeutic leave. Re… | 2020-07-01 |
| 1764 | 1764 | PLUM CREEK CARE CENTER | 285159 | 1505 NORTH ADAMS STREET | LEXINGTON | NE | 68850 | 2018-05-02 | 578 | D | 1 | 0 | GG8Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure the wishes for CPR (Cardiopulmonary Resuscitation) for 2 (Residents 1 and 6) out of 5 sampled residents were communicated to the nursing staff. The facility census was 36. Findings are: [NAME] Review of the nursing progress notes identified that Resident 1 was admitted to the facility for skilled care services on [DATE]. Interview on [DATE] at 1:10 PM with the MDS (Minimal Data Set) Coordinator revealed that they were unable to locate the advanced directive in the resident's medical record. Interview on [DATE] at 3:00 PM with LPN (Licensed Practical Nurse)-A revealed that Resident 1 had fallen in their room on [DATE] and became combative. LPN-A stated that the physician wanted the resident to be transferred to the hospital. LPN-A stated that there was no advanced directive in their medical record, so LPN-A had to call the resident's spouse to find out what the resident's wishes were in case something would happen to the resident. After the call, LPN-A stated that they went to the resident's room and resident became unresponsive, so LPN-A started CPR per the spouse's wishes. When the paramedics arrived, they continued the CPR on the resident during the transfer to the hospital. Resident passed away later that night. Interview on [DATE] at 3:00 PM revealed that the ADM (Administrator) had found the advanced directive for Resident 1. The form revealed that the resident had marked DNR (Do Not Resuscitate) on the form on [DATE]. The form was sent to the primary care physician who had signed the form on [DATE] and returned it to the facility. The ADM confirmed that there was no copy of the advanced directive in the resident's chart at the time of the incident on [DATE]. B. Review of the facility's list of new admissions for the past 3 months identified that Resident 6 was admitted to the facility on [DATE] and discharged on [DATE]. Interview on [DATE] at 1:10 PM with the MDS Coor… | 2020-09-01 |
| 5581 | 5581 | BROKEN BOW CARE AND REHABILITATION CENTER, LLC | 285120 | 224 EAST SOUTH E STREET | BROKEN BOW | NE | 68822 | 2018-05-17 | 645 | D | 1 | 1 | 1IGA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to have 1 resident (Resident 23) referred for a level 2 PASARR (Preadmission Screening and Resident Review) evaluation and determination prior to admission or within 30 days after admission based off of the resident's current medical [DIAGNOSES REDACTED]. The sample of residents used was 2. The facility census was 30. Findings are: [NAME] Review of Resident 23's undated Face Sheet revealed date of admission 3-22-18. The Face Sheet revealed [DIAGNOSES REDACTED]. Review of Resident 23's PASARR dated 4-7-14 revealed the resident had no serious MI (mental illness) or ID (intellectual disability). The resident did have anxiety and was on the medication [MEDICATION NAME] (an antianxiety medication). The PASARR revealed the resident did not need a level 2. Interview on 5-16-18 at 8:54 AM with the SSD (Social Service Director) revealed the resident transferred to their facility on 3-22-18 from another facility Alzheimer's unit. The SSD reviewed the resident's current medical diagnoses, medications, and behaviors and confirmed the resident should have had a review for a potential level 2 services. B. Review of Resident 21's undated Face Sheet revealed date of admission 1-17-18. The Face Sheet revealed [DIAGNOSES REDACTED]. Review on 5-15-18 at 9:04 AM of Resident 21's PASARR dated 1-17-18 revealed the resident was to be evaluated for a level 2 PASARR, however the level 2 PASARR was not in the medical record. Interview on 5-15-18 at 10:51 AM with SSD revealed the PASARR for Resident 21 was done but probably did not get filed in the chart. Interview on 5-15-18 at 2:57 PM with the SSD confirmed the facility did not have the level 2 results for Resident 21 and the SSD had to contact the State Designated Authority to obtain it. The SSD revealed the SSD called the State Designated Authority to confirm the results documented on the form which read the level 2 was halted and meant Resident 21 did not… | 2019-11-01 |
| 3954 | 3954 | VALLEY VIEW SENIOR VILLAGE | 285294 | 220 SOUTH 26TH STREET | ORD | NE | 68862 | 2018-03-21 | 838 | E | 1 | 1 | OLWQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to have an accurate facility assessment to care for the residents with pressure ulcers as competencies were not completed for licensed nursing staff showing the licensed nursing staff were competent to provide care and treatment for [REDACTED]. Findings are: Review of the Facility Assessment Tool completed by the ADM (Administrator) identified that the facility could provide care and treatment for [REDACTED]. Review of the facility's education and in service books identified that there were no competencies completed for the licensed nursing staff that were providing the care and treatment for [REDACTED]. The only competency that was found for pressure ulcer care was for a registered nurse in 2006. Interview on 3/20/18 at 8:24 AM with the DON (Director of Nursing) confirmed that any competencies for the licensed nursing staff would be in the education binder. The DON further stated that the DON was not aware that any of the licensed nursing staff had been competency trained on the care and treatment for [REDACTED]. Interview on 3/20/18 at 5:01 PM with the ADM (Administrator) confirmed that the Facility Assessment Tool identified that the facility would be able to care and treat residents with pressure ulcers. The ADM also confirmed that the facility did not have completed competencies documented for the licensed nursing staff to care and treat residents with pressure ulcers. | 2020-09-01 |
| 3719 | 3719 | GOOD SAMARITAN SOCIETY - GRAND ISLAND VILLAGE | 285285 | 4061 TIMBERLINE STREET & 4055 TIMBERLINE STREET | GRAND ISLAND | NE | 68803 | 2019-02-19 | 646 | D | 1 | 0 | XNDC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to notify the Physician of one resident (Resident 100) out of one resident sampled, change of condition. The facility census was 61. Findings are: Record review of Resident 100's Admission Record dated 2-14-19 revealed [DIAGNOSES REDACTED]. Review of Resident 100's MDS dated [DATE] revealed a BIMS of 14 which indicated the resident had no cognitive impairment. The resident required limited assistance of one staff with bed mobility, transfers, walking, locomotion, and toileting. Record review of Resident 100's PN dated 1-23-19 at 1:53 AM revealed the resident ambulated with the walker and the walker started to collapse. The resident used the resident's right hand to attempt to prevent a fall. The nurse assessed the resident and discovered the right ring finger had a slight amount of bleeding and the right middle finger had some swelling. The fingers were cleansed and wrapped with gauze and coban. The resident was assisted back into bed. The resident was adamant with refusal to go do the ER (emergency room ) to have the fingers examined during the night. PN on 1-23-19 at 7:43 AM revealed the resident's right hand was assessed and the middle finger appeared rotated at a 30-45 degree angle and bent away from body. The nurse called the on-call Physician and orders were received to send the resident to the ER to be evaluated. Record review of the Incident Report for Resident 100 dated 1-23-19 revealed the third finger assessed to be limp and possibly broken. Report was given to the oncoming shift to follow-up on the injury. Review of the Incident Report revealed absence of documentation of the Physician notified of the resident change of condition based on the nurse assessment on 1-23-19 at 1:53 AM. Review of the Hospital Physician order [REDACTED]. Interview on 2-19-19 at 3:30 PM with the DON (Director of Nursing) confirmed the Physician should have been notified 1-23-19 immediately after… | 2020-09-01 |
| 416 | 416 | ST. JOSEPH VILLA NURSING CENTER | 285078 | 2305 SOUTH 10TH STREET | OMAHA | NE | 68108 | 2018-02-12 | 625 | D | 1 | 1 | B6BN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide a copy of the bed hold policy at time of discharge to the hospital for 1(Resident 29) of five sampled residents. The facility had a total census of 170 residents. Findings are: A review of resident census record revealed Resident 29 was admitted to the facility on [DATE] with a Medicaid payer source. Resident 29 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE], discharged to the hospital on [DATE] and readmitted to the facility on [DATE], and discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. A review of Resident 29's medical record did not reveal documentation of Resident 29 being provided with a copy of the facility bed hold policy for any of the discharges to the hospital. In an interviews on 2/12/18 at 1:46 PM and 2:08 PM, Admission Coordinator reported residents are given a copy of the bed hold policy on admission but residents with a Medicaid payment source are not given a copy of the bed hold policy each time the resident is discharged to the hospital. A review of undated facility policy titled Bed Hold Policy revealed residents are to receive a copy of the bed hold policy upon admission to the facility and when the resident is transferred to an acute care hospital. | 2020-09-01 |
| 3839 | 3839 | OLD MILL REHABILITATION (OMAHA TCU) | 285289 | 1131 PAPILLION PARKWAY | OMAHA | NE | 68154 | 2018-05-07 | 625 | D | 1 | 0 | PUW011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide bed hold policy to 1 (Resident 1) of 1 sampled residents on transfer to the hospital. The facility had a total census of 41 residents. Findings are: Resident 1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Progress note dated 2/12/18 at 10:03 PM reported that Resident 1 was voiding small amount with complaint of burning and pain in kidney and bladder and Resident 1 was being transported to the hospital for evaluation. Progress note dated 2/13/18 at 7:58 AM noted that Resident 1 was admitted to the hospital and was not discharging for a while. In an interview on 5/7/18 at 8:19 AM, Social Worker G reported families are contacted when a residents is sent to the hospital. If a resident is not expected back to the facility in a couple of days, the family is asked if they can pick up the resident's personal items or if they want the facility to pack them up. Families are requested to pick up the resident's personal items in a couple of days. In an interview on 5/10/18 at 8:45 AM, the Administrator reported that residents are given information on the bed hold policy on admission. No information is given at the time that a resident is sent to the hospital regarding bed hold. A review of Admission Packet revised 1/2018 revealed the following bed hold policy: If a patient requires a hospital stay overnight, we do not hold any beds at Old Mill Rehabilitation. A new referral will need to be sent to our facility for review to see if we can meet the patient's needs. If we hold or reserve a vacant bed for you at your request and the charges for the bed are not paid by insurance or any third-party payor, you are responsible for paying our daily charges for the bed for each day we hold or reserve the bed for you. This will need to be approved and arranged with our facility administrator. | 2020-09-01 |
| 3945 | 3945 | VALLEY VIEW SENIOR VILLAGE | 285294 | 220 SOUTH 26TH STREET | ORD | NE | 68862 | 2018-03-21 | 726 | F | 1 | 1 | OLWQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide competencies for the nursing staff to care for the residents with pressure ulcers. This affected 4 sampled residents with pressure ulcers and the facility census was 34. Review of the Facility Assessment Tool completed by the ADM (Administrator) identified that the facility could provide care and treatment for [REDACTED]. Review of the facility's education and in service books identified that there were no competencies completed for the licensed nursing staff that were providing the care and treatment for [REDACTED]. The only competency that was found for pressure ulcer care was for a registered nurse in 2006. Interview on 3/20/18 at 8:24 AM with the DON (Director of Nursing) confirmed that any competencies for the licensed nursing staff would be in the education binder. The DON further stated that she was not aware that any of the licensed nursing staff had been competency trained on the care and treatment for [REDACTED]. | 2020-09-01 |
| 5580 | 5580 | BROKEN BOW CARE AND REHABILITATION CENTER, LLC | 285120 | 224 EAST SOUTH E STREET | BROKEN BOW | NE | 68822 | 2018-05-17 | 644 | D | 1 | 1 | 1IGA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to reflect 1 resident's (Resident 26) level 2 PASARR (Preadmission Screening and Resident Review) status on the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) out of 1 resident sampled. The facility census was 30. Findings are: Review of Resident 26's Face Sheet dated 2-13-18 revealed the resident's date of admission 10-13-17. The Face Sheet revealed the resident's [DIAGNOSES REDACTED]. Review of Resident 26's admission MDS dated [DATE] revealed the resident did not have a level 2 PASARR. Review of the Resident 26's admission PASARR dated 10-13-17 revealed a level 2 with the final determination results of the resident met the minimum criteria for nursing home admission and required the following services: ongoing medication review by a psychiatrist, ongoing med review by a medical doctor, and therapy by an OT/PT (Occupational Therapist/Physical Therapist). Interview on 5-16-18 at 8:08 AM with the SSD (Social Service Director) confirmed the resident had a level 2 PASARR and the admission MDS did not reflect the resident's current PASARR status and another MDS had not been done to update it. | 2019-11-01 |
| 1348 | 1348 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2017-08-02 | 225 | D | 1 | 0 | YKIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report a significant injury for Resident 3 to the state agency within the regulatory timeframe and failed to submit a completed investigation for Resident 2 to the state agency within 5 days. The facility census was 110 . Findings are: [NAME] Review of the facility report dated 5/5/2017 for Resident 3 revealed Resident 3 sustained a fall and was sent to the hospital emergency room . Resident 3 returned to the facility at 11:55 PM on 4/29/2017 with a [DIAGNOSES REDACTED]. Review of the facility report revealed a call was placed to the state agency at 2:00 PM on 4/30/2017. Review of the facility undated policy titled Reporting Allegations of Abuse/Neglect/Exploitation revealed the facility was to notify the appropriate agencies immediately: In the case of serious bodily injury, no later than 2 hours after discovery. Interview on 5/17/2017 at 11:30 AM with the Director of Nursing (DON ) revealed the incident with injury was not reported to the state agency within 2 hours. B. Review of the facility report dated 4/30/2017 for Resident 2 revealed Resident 2 sustained a head injury and was admitted to the hospital on [DATE]. Review of the facility report revealed a facsimile (fax) report dated 4/30/2017 at 3:13 PM with a result of NO ANS (Answer). Interview on 5/17/2017 at 11:20 AM with the DON revealed the report should have been resubmitted to the state agency due to the initial report not arriving. The DON stated no other confirmation reports could be found. Review of the undated facility policy titled Reporting Allegations of Abuse/Neglect/Exploitation revealed the facility should follow up with government agency to confirm the report was received and to report the results of the investigation when a final report as required by the state agency. | 2020-09-01 |
| 2286 | 2286 | GOOD SAMARITAN SOCIETY - OSCEOLA | 285193 | 600 CENTER DRIVE | OSCEOLA | NE | 68651 | 2017-08-03 | 225 | D | 1 | 1 | X4SG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report allegations of abuse. This had the potential to effect 2 of 3 residents sampled, Residents 27 and 25. Investigation: [NAME] Record review of a grievance dated 7/11/17 revealed that Resident 27 alleged that NA (Nursing Assistant) A was rough tossing things all over the place and left resident on the toilet for over 30 minutes. Record review of the MDS (Minimum Data Set, a tool for implementing standardized assessment and for facilitating care management in nursing homes) dated 6/21/17 revealed a BMS (Brief Interview for Mental Status, the level of cognitive ability among nursing home residents) of 10 (08-12 indicates moderately impaired). On 08/03/2017 at 1:06 PM, an interview with the DON (Director of Nursing) revealed, this was not reported to the state authority because, on re-interview, the resident denied the staff did anything wrong. Record review of reportable incidents provided by the facility revealed no documentation of this allegation of abuse being reported to the state authority. B. Record review of a grievance dated 9/21/16 revealed that on 9/19/16 Resident 25 alleged that gender got slapped, while rubbing left cheek. Record review of a grievance dated 9/22/16 revealed that on 9/17/16 Resident 25 alleged that a girl slapped me, while putting gender's hand to left cheek. Record review of the MDS dated [DATE] revealed a BIMs of 4 (00-07 indicates severe impairment). On 08/03/2017 at 1:10 PM, an interview with the DON reveled that, on re-interview, the resident's story kept changing and no determination could be made so this allegation of abuse was not reported to the state authority. Record review of investigation of the allegation of abuse revealed that upon receiving the allegation, all female Hispanic aides had been suspended pending investigation. An investigation was completed with no findings of abuse. Further review revealed there was no documentation that… | 2020-09-01 |
| 92 | 92 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2018-06-26 | 609 | D | 1 | 0 | 49DM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report an elopement (leaving a secure area without staff knowledge or supervision) to the state agency for Resident 4. The facility census was 131. Findings are: Interview on 6/26/2018 at 8:30 AM with the Director of Nursing (DON) revealed on 5/6/2018 Resident 4 left the building when a visitor left. Resident 4's Wanderguard braclet (a device used to alert staff a vulnerable resident is leaving a secured area) did activate the alarm however the visitor turned off the alarm and Resident 4 left the building. Review of the facility incident tracking assessment dated [DATE] revealed Resident 4 had gone outside to go home to check on the horses. The resident was confused and only oriented to person at the time staff were called to assist Resident 4. Review of the facility reports and investigations for the past 4 months revealed no report of the elopement (leaving a secure area without staff knowledge or supervision) was present for Resident 4. Review of the undated facility policy titled Abuse Investigations defines essential services as those necessary to safeguard the person including proper supervision of the vulnerable adult. Review of the undated facility policy titled Abuse Investigation revealed if there is a reason to suspect or believe conditions are present that could result in neglect the incident should be reported to the state agency immediately and an investigation completed. Interview with the DON on 6/26/2018 revealed no report was filed for Resident 4's elopement on 5/6/2018. | 2020-09-01 |
| 2684 | 2684 | HERITAGE OF EMERSON | 285222 | 607 NEBRASKA STREET | EMERSON | NE | 68733 | 2018-12-03 | 610 | D | 1 | 0 | BWYO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to submit an investigation to the State Agency within 5 working days after 1 resident (Resident 50) had a fall with injury requiring medical treatment. The sample size was 4 and the facility census was 31. Findings are: [NAME] Review of the facility policy titled Abuse and Neglect Prevention Standard (revision date 3/2017) included the following: -Any accident that resulted in serious resident injury should be reviewed for potential abuse/neglect and also must be reported to the proper agency; and -After conducting an internal investigation, a report of all investigation results must be reported to the state within five working days. B. Review of Progress Notes dated 11/11/18 at 7:20 AM revealed Resident 50 was observed sitting on the floor in front of the room door and bathroom. The resident sustained [REDACTED]. Documentation further indicated the laceration was 6 centimeters in length and required staples. The resident was to remain overnight at the hospital for observation. Review of facility investigations of potential abuse/neglect for 11/2018 revealed an investigation was not submitted to the State Agency regarding Resident 50's fall with injury on 11/11/18. Interview with the Administrator on 12/3/18 at 11:35 AM confirmed an investigation regarding Resident 50's fall with injury was not submitted to the State Agency as required. | 2020-09-01 |
| 4934 | 4934 | PREMIER ESTATES OF WEST POINT, LLC | 285158 | 960 PROSPECT ROAD | WEST POINT | NE | 68788 | 2018-06-12 | 758 | D | 1 | 1 | ELDP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to: 1) ensure there was an indication for the use of PRN (as needed) [MEDICATION NAME] (an antipsychotic drug used to alter certain chemicals in the brain to effect changes in behavior, mood and emotions); and 2) ensure PRN [MEDICATION NAME] was not prescribed for more than 14 days without an evaluation by the Healthcare Practitioner (HCP) and without a new written order for the PRN [MEDICATION NAME]. This involved 1 resident (Resident 1). The sample size was 22 and the facility census was 39. Findings are: Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/7/18 revealed [DIAGNOSES REDACTED]. The MDS further indicated the following regarding Resident 1: -short term and long term memory problems; -displayed no adverse behavioral symptoms; -received antipsychotic medication daily in the past 7 days; and -received 1 antianxiety medication and 1 opioid (a drug derived from [MEDICATION NAME] and used to alleviate pain) medication in the past 7 days. Review of Resident 1's Medication Administration Record [REDACTED]. Review of Progress Notes dated 5/27/18 at 2:31 PM revealed Resident 1 had slept very little through the night and during the day hours. The resident .appears anxious at times pacing and wandering. Staff have attempted one on one, change in location/environment, snacks and coloring. Documentation further indicated the resident was currently socializing with staff and cueing was provided to assist the resident to participate in an activity. The resident was redirected early that morning from entering other resident rooms. Review of Progress Notes dated 5/27/18 at 5:10 PM revealed Resident 1 .is wandering and restless and has been confrontational with staff and other residents today was reported by the dayshift staff. Documentation indicated the resident had several instances in the last 30 days of being… | 2020-03-01 |
| 6616 | 6616 | OMAHA NURSING AND REHABILITATION CENTER | 285240 | 4835 SOUTH 49TH STREET | OMAHA | NE | 68117 | 2015-12-07 | 309 | D | 1 | 0 | JX0E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview; the facility staff failed to evaluate respiratory status for 1 resident (Resident 1). The facility staff identified a census of 60. Findings are: Record review of an Admission Record sheet printed on 12-07-2015 revealed Resident 1 was admitted to the facility with the [DIAGNOSES REDACTED]. Record review of an Order Summary Report sheet printed on 12-07-2015 revealed Resident 1 was to have nothing by mouth (NPO). Record review of a Fax sheet noted on 9-02-2015 revealed the facility staff had notified Resident 1's physician that Resident 1 was observed drinking water and reported did not know (gender) was NPO. According to the information on the fax sheet, Resident 1 reported eating and drinking when goes out with a family member. Resident 1's physician gave an order to . try thicken liquids PO (by mouth). Record review of Resident 1's medical record revealed there was not an ongoing evaluation of Resident 1's respiratory status for the trail of the thicken liquids. An interview was conducted with the facility Director of Nursing (DON). During the interview review of the Fax sheet notes on 9-02-2015 was reviewed. When asked how often Resident 1's respiratory status should be evaluated, the DON reported every shift. The DON confirmed during the interview Resident 1's respiratory status had not been monitored every shift and should have been. | 2018-12-01 |
| 5938 | 5938 | ST. JOSEPH VILLA NURSING CENTER | 285078 | 2305 SOUTH 10TH STREET | OMAHA | NE | 68108 | 2016-07-26 | 225 | D | 1 | 0 | 10VG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to complete an investigation to determine the causal factors of an injury of unknown origin for Residents 1 and Resident 3. The facility census was 163. Findings are: A. Review of Resident 1's Care plan dated 7/8/2016 revealed Resident 1 has a [DIAGNOSES REDACTED]. Review of the Nurses Notes dated 7/4/2016 for Resident 1 revealed Resident 1 complained of pain in the left leg with no traumatic event identified. Review of the Nurses Notes dated 7/6/2016 revealed Resident 1 was admitted to the hospital with [REDACTED]. Review of the facility investigation revealed Resident 1 had not experienced a recent fall and Resident 1 could not explain how the injury occurred. The facility did not interview the staff working with Resident 1 from other shifts except the shift the pain was found on. Interview on 7/25/2016 at 3:55 PM with the Director of Nursing (DON) revealed that the only staff that were interviewed were the staff that was working at the time the injury was found. No interviews were done with the staff assigned to Resident 1 on prior shifts to determine how the injury occurred. Interview on 7/25/2016 at 4:00 PM with the DON revealed the investigation should have included the staff from the previous shift and the health care practitioner to attempt to determine the causal factors of the injury. B. Record review of a Incident/Accident Report sheet dated 4-11-2016 revealed Resident 3 was evaluated as having a bruise to the right inner leg. Record review of a Resident's Statement sheet dated 4-11-2016 revealed the resident did not know how the bruise happened. Record review of a Injuries of Unknown Source Investigation sheet dated 4-11-2016 revealed the bruise to the right inner thigh measured 14 centimeters (cm) by 5 cm and purple in color. Record review of Resident 3's medical record revealed there was not evidence that the facility staff had conducted interviews with facility staff … | 2019-07-01 |
| 1381 | 1381 | LIFE CARE CENTER OF ELKHORN | 285134 | 20275 HOPPER STREET | ELKHORN | NE | 68022 | 2018-02-27 | 758 | D | 1 | 1 | YXZR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to complete behavior monitoring for continued use of [MEDICAL CONDITION] medications for 2 residents (Residents 4 and 82) of 5 residents sampled. The facility staff identified the census at 101. The findings are: [NAME] A review of Resident 4's undated Face Sheet revealed that the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Resident 4's Medication Administration Record [REDACTED]. The resident received the medication on 2-18-18. A review of Resident 4's MAR for (MONTH) (YEAR) revealed the resident received [MEDICATION NAME] (an anti-anxiety medication) on an as needed basis for anxiety. The resident received the medication on 1-1-18, 1-11-18, 1-12-18, 1-15-18, 1-19-18, 1-24-18, 1-26-18, and 1-27-18. A review of Resident 4's Behavior/Intervention Monthly Flow Record for (MONTH) (YEAR) revealed the resident was documented as having no behavior episodes the entire month. A review of Resident 4's Behavior/Intervention Monthly Flow Record for (MONTH) (YEAR) revealed the resident's behaviors were no longer documented after 2-8-18. An interview conducted on 2-22-18 at 1:25 PM with Medication Assistant (MA) [NAME] revealed that the process for giving an as needed anti-anxiety medication was that the MA would notify the charge nurse that the resident had requested a medication or that the resident was having behaviors and the non-pharmacological interventions were not effective. The medication would be given by the MA at the direction of the charge nurse. The MA would document on the MAR indicated [REDACTED]. The charge nurse would document on the Behavior/Intervention Monthly Flow Record for that shift what the behaviors were and what was done for the resident to alleviate the behaviors. B. Record review of a Policy and Procedure for Psychopharmacological (medications used to manage behaviors) Medications dated 8/23/17 revealed the following: -… | 2020-09-01 |
| 3844 | 3844 | OLD MILL REHABILITATION (OMAHA TCU) | 285289 | 1131 PAPILLION PARKWAY | OMAHA | NE | 68154 | 2017-07-20 | 225 | E | 1 | 1 | ZXDC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to ensure all significant injuries and allegations of abuse were reported to the State Agency and investigated for 4 residents. (Residents 93, 240, 250). The facility census was 43. [NAME] Review of the facility abuse reporting policy includes material dated 8/20/2012 indicating an injury that is significant for the resident requires reporting to the state agency. Review of Resident 93's progress notes revealed Resident 93 fell on [DATE] and received a laceration requiring 7 staples in the emergency room . Review of Resident 93's progress notes on 7/16/2017 revealed Resident 93 required Extensive assist of 1 staff to ambulate to the bathroom. Review of Resident 93's progress notes dated 2/17/2017 at 2:00 AM revealed resident 93 had a change of ADL status and required Extensive assist of 2 staff to ambulate to the bathroom. Interview on 07/19/2017 at 10:27 AM with the Administrator and Director of Nursing (DON) revealed the significant injury on[NAME]O'Hara was not called to the state agency. B. Review of the facility policy titled Reporting Abuse to the Facility Management dated (MONTH) 2009 revealed verbal abuse is defined as any use of oral language that willfully includes disparaging and derogatory terms to residents or their families. Record review revealed on 6/21/2017 Resident 250 filed a concern form with the Social Worker stating a staff member was rude, derogatory and mocking Resident 250. Interview on 7/19/2017 at 10:30 AM with the DON revealed Resident 250's concern was not identified as abuse or called into the state agency as an allegation of abuse. Interview on 7/19/2017 at 10:35 AM with the Administrator revealed the staff member was not suspended and a thorough investigation was not completed. C. Review of the facility policy titled Reporting Abuse to Facility Management dated (MONTH) 2009 revealed mental abuse is defined as, but not limited to, humiliation, harassme… | 2020-09-01 |
| 1100 | 1100 | EMERALD NURSING & REHAB LAKEVIEW | 285106 | 1405 WEST HWY 34 | GRAND ISLAND | NE | 68801 | 2019-05-29 | 625 | D | 1 | 0 | X6N711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to notify the residents' legal representative of the bed hold policy for transfer to the hospital for 1 of 4 sampled residents (Resident 4). The facility census was 69. Findings Are: Review of Resident 4's Admission status revealed an admission date of [DATE] Review of Resident 4's medical [DIAGNOSES REDACTED]. Review of MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 3/6/19 revealed for Section C: Cognitive Patterns C0100 Should Brief Interview for Mental Status be conducted the answer was coded as No (Resident is rarely/never understood) C1000. Cognitive Skills for Daily Decision Making was coded as 3. Severely impaired. Review of MDS dated [DATE] a Significant Change in status MDS revealed for Section C: Cognitive Patterns C0100 Should Brief Interview for Mental Status be conducted the answer was coded as No (Resident is rarely/never understood) C1000. Cognitive Skills for Daily Decision Making was coded as 3. Severely impaired. Review of Resident 4's bed hold letter revealed that resident's name was signed on form dated 2/4/19 and then again on 5/9/19. Both letters are written with Residents name present and the Facility representative Signature. There is no documentation that the POA (Power of Attorney) was informed of the bed hold notification or who the copy of the notification letter was sent to. Review of Resident 4's Progress Notes revealed no documentation that a copy of the Bed Hold Policy had been sent to Resident 4's legal representative. Interview on 5/29/19 at 11:44 AM with DON (Director of Nursing) revealed, there is a bed hold letter sent with the resident to the hospital and copies are kept, along with the Ombudsman monthly notifications in a calendar book. Interview on 5/29/19 at 11:55 AM with ADM (Administrator) revealed that the POA (Power of Attorney) or legal representative has never been notified in wri… | 2020-09-01 |
| 3919 | 3919 | HILLCREST COUNTRY ESTATES-COTTAGES | 285293 | 6082 GRAND LODGE AVENUE | PAPILLION | NE | 68133 | 2017-05-04 | 428 | E | 1 | 1 | POAF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, and interview the pharmacy failed to identify irregularities of medication and notify the facility staff and physician of irregularities for 3 residents (55, 27, and 29) of 5 sampled. The facility census was 46. Findings are: [NAME] Record review of Resident 55's electronic medical record revealed that Resident 55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of Activities of Daily Living (ADL's), on 5/3/17 at 11:44 AM revealed that Resident 55 had multiple prescription creams present in the room for use. Record review of Resident 55's physician orders [REDACTED]. 1) Desoximetasone 0.25% apply topically two times daily as needed for rash . 2) Hydrocortisone 2.5% apply topically to back, as needed for itching.3) Mometasone Furoate 0.1% apply topically to affected areas daily as needed. 4) Triamcinolone 0/1% ointment apply to affected area's 2 to 3 times daily as needed. 5) Risamine ointment apply to buttocks twice daily. Record review of Resident 55's Monthly Pharmacy review, dated 12/2/16, revealed a request for a clinical rationale for Desoximetasone 0.25% cream, Clobetasol Propionate cream, and Mometasone Furoate cream. Record review of Resident 55's Monthly Pharmacy reviews dated 1/6/17, 2/6/17, 3/3/17 and 4/3/17 reveal no follow up on the request for clinical rationale for the above listed creams. ` Interview with Resident 55's pharmacy revealed that all the creams were the same medication but in different strengths. The Pharmacist confirmed that Resident 55 did have unnecessary medications, evidenced by the multiple creams that provide the same treatment at different strengths. B. Record review of Resident 27's physician orders [REDACTED]. Record review of Resident 27's Medication Administration Records for January, February, March, (MONTH) and (MONTH) revealed that Resident 27 had not been administered the Fluconazole in the past 5 months. Record review of Resident 27's Weekly S… | 2020-09-01 |
| 5790 | 5790 | WAYNE COUNTRYVIEW CARE AND REHABILITATION | 285135 | 811 EAST 14TH STREET | WAYNE | NE | 68787 | 2016-09-14 | 309 | D | 1 | 0 | IB0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation and interview; the facility failed to develop interventions to prevent the reoccurrence of skin breakdown and to complete cares per practitioner's orders related to the application of ted hose (compression devices worn to assist with swelling) for Resident 4. In addition, the facility failed to provide assessment and cares to promote healing of a wound for Resident 1. The sample size was 5 and the facility census was 37. Licensure Reference Number: 175 NAC 12-006.09D2c Findings are: A. Review of facility Policy and Procedure entitled Skin and Wound Monitoring and Management Care Guidelines (revised 1/2016) revealed the following: -At the time of admission or readmission to the facility, a licensed nurse was to complete a comprehensive assessment to identify risk factors related to the potential development of skin breakdown. -A comprehensive plan of care should be developed using the assessment with individualized interventions developed to meet the resident's needs. -Wounds identified after admission should be assessed and evaluated on a weekly basis by a licensed nurse. -The assessment should include but not be limited to; measurement and a description of the wound location, the nature of the wound, characteristics of the wound and any signs and/or symptoms of infection or complications of the wound. Review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 6/28/16 revealed the resident required extensive staff assistance with transfers, personal hygiene, bed mobility and toileting. The assessment further revealed the resident had [DIAGNOSES REDACTED]. The resident was identified as having Moisture Associated Skin Damage (MASD- the general term to describe inflammation, or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat or wound drainage) with interventions for a pressure reduction device t… | 2019-09-01 |
| 5486 | 5486 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2018-05-22 | 849 | D | 1 | 0 | NLW911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation and interview; the facility failed to ensure Hospice representatives were involved as part of the interdisciplinary group to update, follow and provide hospice comprehensive care plan recommendations to reflect current information and care needs for terminally ill residents. This failure had the potential to effect 2 of 4 sampled residents (Resident 10 and 23.) Facility census was 39. [NAME] Record review on 5/24/18 at 9:00 AM revealed that Resident 10 was admitted to hospice on 12/8/17. The care plan meeting was on 1/3/18 and the Hospice representative had not attended the meeting. No documentation on a follow up meeting with hospice team to create the comprehensive hospice care plan. Record review of Resident 10's Hospice care plan with the initiation date of 5/21/15. The correct Hospice admitted was 12/8/17. The care plan was not updated or revised until 2/22/18. The care plan meeting date was 1/3/18. Record review on 5/24/18 at 11:00 AM revealed the focused person centered comprehensive care plan for hospice addressed the following for Resident 10: Resident seen 4 times per month for extra companionship. Social Worker will visit 1 time a month for support of resident and family. Facility to work with nursing staff to provide maximum comfort for the resident by review date. Hospice RN (Registered Nurse) will visit 1 time a week and Hospice nurse aide will visit 2 times a week. Pastoral services will visit 2 times a month. Resident will be comfortable physically, spiritually, and emotionally and receive spiritual support and prayer from visits. There were no documented notes in the facility documentation of follow through with visits. Record review on 5/21/18 at 2:01 Care plan revealed Focus: The resident had a terminal [DIAGNOSES REDACTED]. Goal: resident's comfort will be maintained through the review date initiated on 4/17/18 target date 5/30/18. Intervention 1. Work with Aseracare to provide maximum… | 2020-01-01 |
| 3804 | 3804 | MITCHELL CARE CENTER | 285287 | 1723 23RD STREET | MITCHELL | NE | 69357 | 2018-06-19 | 758 | D | 1 | 0 | 57D211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interview, the facility failed to ensure PRN (as needed) anti-psychotic (tranquilizing medications used to control hallucinations, delusions, and behavioral aggression) medications were not extended beyond the required 14-day limitation without evaluation by a medical practitioner and documented rationale for extending the PRN for two sampled residents (Residents 2 and 6). Sample size was 3 current residents receiving anti-psychotic medications. Facility census was 49. Findings are: [NAME] Record review of Resident 2's Admission Record printed on 6/19/18 revealed the resident was admitted to the facility on [DATE] and had a medical [DIAGNOSES REDACTED]. Record review of Resident 2's Medication Review Report dated 6/4/18 signed by the resident's physician revealed the resident had orders for [MEDICATION NAME] Solution (an anti-psychotic medication) with instructions to administer 2 milligrams of the medication either by intramuscular injection or by mouth every 12 hours as needed for severe agitation. The report recorded the medication start date was 4/05/2018. Record review of Resident 2's Medication Administration Records for May, and (MONTH) of (YEAR) revealed the resident continued to have active orders for [MEDICATION NAME] 2 milligrams every 12 hours as needed. The resident was administered the medication 10 times by mouth and twice by injection in (MONTH) and was not administered the medication anytime in June. Record review of Resident 2's medical record charting and electronic chart revealed there was no re-evaluation of the use of PRN [MEDICATION NAME] beyond 14 days by the practitioner nor was there any documentation by the practitioner of a rationale to continue the PRN [MEDICATION NAME] beyond the required 14 day limit. B. Record review of Resident 6's Admission Record printed on 6/19/18 revealed the resident was admitted to the facility on [DATE]. Among the resident's [DIAGNOSES REDACTED]. Record rev… | 2020-09-01 |
| 5463 | 5463 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2017-03-22 | 329 | D | 1 | 1 | HUVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews the facility failed to trial GDR's (gradual dose reductions) and/or document the rationale or need to continue the use of psychoactive (medications used to treat depression and or other psychiatric symptoms) for 2 residents (Resident 6 and 47) out of the 5 sampled residents. The facility census was 59. Findings are: A Review of the undated census sheet for Resident 6 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1-17-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 3 which indicated Resident 6 had severe cognition impairment. Review of Resident 6's current Physician orders [REDACTED]. [MEDICATION NAME] 100mg (milligram) daily for depression [MEDICATION NAME] 5mg bid (twice a day) for dementia with behaviors ABH ([MEDICATION NAME]: an antianxiety medication, [MEDICATION NAME]: an [MEDICATION NAME]: an antipsychotic) gel TID (three times a day) and PRN (as needed) for agitation Review of Resident 6 medical record revealed no documentation of 6 month reviews of the resident's [MEDICAL CONDITION] medications and attempts to reduce the medications. No documentation was also found from the Physician documenting the clinical rationale why not to attempt a GDR. B) Review of the undated census sheet for Resident 47 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-28-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 3 which indicated Resident 47 had severe cognition impairment. Review of Resident 47's current Physician orders [REDACTED]. [MEDICAT… | 2020-01-01 |
| 5511 | 5511 | GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE | 285072 | 926 EAST E STREET | HASTINGS | NE | 68901 | 2016-12-22 | 309 | D | 1 | 0 | B6C911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to assess and treat a laceration in a manner to promote healing for one resident out of the 4 sampled residents. The facility census was 105. Findings are: Review of the undated [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 11-30-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 100 had no cognitive impairment. Resident 100 required limited assistance of one staff with bed mobility, transfers, dressing, and toileting. Review of the Incident Report dated 11-30-16 revealed Resident 100 was found on the floor at 1:40 PM with an injury of an 8 x 5 cm (centimeter) skin tear on the left lower leg on the front side. The nurse cleansed the wound and applied skin prep (a liquid film-forming dressing applied to the skin which prepared the skin for adhesives) to the skin that surrounded the wound. Next the nurse applied steri-strips (thin adhesive strips used to close open wounds) to the wound and wrapped the leg in a dry dressing. The Physician was notified of the resident's fall and of the skin tear to the leg. Review of the Physician orders [REDACTED]. Review of the (MONTH) and (MONTH) (YEAR) TAR (Treatment Administration Record) revealed no nursing orders to monitor or treat the skin tear on the left lower leg. Review of the Nursing Notes revealed no assessment of the skin tear wound to the left lower leg. Interview on 12-22-16 at 3:42 PM with the Facility Nursing (UM) Unit Manager on the unit Resident 100 resided on revealed the UM had not observed the skin tear to the resident's leg. The UM spoke to the nurse who initially assessed the wound and was informed the wound was a large skin tear. The UM revealed the UM had been informed that, for the top portion of the skin tear, the nurse w… | 2019-11-01 |
| 2499 | 2499 | PIONEER MANOR NURSING HOME | 285212 | P O BOX 310, 318 N 3RD STREET | HAY SPRINGS | NE | 69347 | 2018-08-07 | 726 | G | 1 | 0 | 9WZ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to ensure a newly hired nursing employee (Nurse Aide-A) received orientation competency demonstrations in safely transferring residents while providing direct care/transfers. The failure resulted in an improper transfer of one sampled resident (Resident 1) which resulted in a major injury requiring medical attention. Sample size was 3 current residents. Facility census was 51. Findings are: Record review of a facility investigative report entitled Fall with major injury dated 7/23/18 revealed the facility investigated an incident which occurred on 7/18/18 involving Resident 1. The report indicated non-residents involved in the incident included NA (Nurse Aide)-[NAME] The report revealed that during a transfer between surfaces Resident 1's leg seemed to break during mid transfer and the resident transported to the hospital for potential broken leg. Record review of a Hospital History and Physical dated 7/18/18 revealed the resident was seen in the emergency room after arriving via rescue unit. The resident had fallen with bruising and swelling of the left lower leg. The x-ray findings recorded on the document indicated the resident sustained [REDACTED]. Record review of Resident 1's Care Plan History report revealed a problem dated 6/6/18 indicated the resident had been lowered to the floor in the bathroom and the approach to prevent serious injury was updated on 6/6/18 directing staff to transfer the resident with 2 staff members assisting. Record review of the facility's Nursing Schedule documents between 5/27/18 and 6/23/18 revealed NA-A was working evening shifts as an orientee during scheduled days during this time frame. Record review of NA-A's employee records revealed no documentation of the resident's competency testing from orientation or indicating the employee had demonstrated competency in safely transferring residents. Interview with the Administrator on 8/7/18 at 11:4… | 2020-09-01 |
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CREATE TABLE [cms_NE] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );