cms_NE
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity ▼ | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 235 | 235 | HIGHLAND PARK CARE CENTER | 285063 | P O BOX 950, 1633 SWEETWATER | ALLIANCE | NE | 69301 | 2019-07-02 | 641 | B | 0 | 1 | TTUV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09B Based on record reviews and interviews the facility failed to ensure MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans): 1) recorded the receipt of insulin injections for one sampled resident (Resident 22); 2) recorded the receipt of an influenza vaccination administered in the facility for one sampled resident (Resident 13); and 3) record the actual dates for the receipt of influenza vaccinations for two sampled residents (Residents 33, and 51) and one non-sampled resident (Resident 23). Facility census was 60. Sample size was 25 current residents. Findings are: [NAME] Record review of Resident 22's Admission Record printed on 7/1/19 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 22's (MONTH) 2019 Medication Administration Record [REDACTED]. Record review of Resident 22's MDS assessments revealed a Quarterly review assessment was completed on 1/11/19. Examination of the assessment reveled in the medication section the resident received injections on 7 of the last 7 days but in the section for Insulin the assessment recorded the resident had not received any insulin injections over the last 7 day period. Interview with the Medical Records Coordinator, LPN (Licensed Practical Nurse)-A on 7/2/19 beginning at 11:00 a.m. confirmed Resident 22's quarterly MDS on 1/11/19 failed to record the insulin injections received by the resident during the reference period of the MDS. B. Record review of Resident 13's Admission Record printed on 7/1/19 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 13's Quarterly review MDS completed on 3/30/19 revealed in the section entitled Influenza vaccination that the resident had not received an influenza in the facility for this year's influenza season (fall of (YEAR) through winter 2019).… | 2020-09-01 |
| 685 | 685 | INDIAN HILLS MANOR | 285091 | 1720 NORTH SPRUCE | OGALLALA | NE | 69153 | 2018-04-30 | 657 | B | 0 | 1 | 9I0Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference number: 175 NAC 12-006.09C1c Based on record reviews and interview, the facility failed to include Nursing Assistant input into revision of Resident care plans for 3 sampled residents (Residents 19, 32, and 34). Sample size was 19 current residents. Facility census was 39. Findings are: [NAME] Record review of Resident 19's Admission Record printed on 4/24/18 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 19's Baseline Care Plan document signed on 1/29/18 by staff, the resident, and the resident's family members reviewing and contributing to the resident's plan of care development revealed staff included in the process were RN (Registered Nurse)-E, the Social Services Director, and a Physical Therapy Assistant. There was no documentation that a Nurse Aide was included in the care planning process for Resident 19. B. Record review of Resident 32's Admission Record printed on 4/24/18 revealed the resident was admitted on [DATE]. Record review of Resident 32's Baseline Care Plan document signed on 4/5/18 by staff, the resident, and the resident's family members reviewing and contributing to the resident's plan of care development revealed staff included in the process were RN (Registered Nurse)-E, the Social Services Director, the Activities Director, and a Physical Therapy Assistant. There was no documentation that a Nurse Aide was included in the care planning process for Resident 32. C. Record review of Resident 34's Admission Record printed on 4/24/18 revealed the resident was admitted on [DATE]. Record review of Resident 34's Baseline Care Plan document signed on 4/12/18 by staff, the resident, and the resident's family members reviewing and contributing to the resident's plan of care development revealed staff included in the process were RN (Registered Nurse)-E, the Kitchen Manager, Social Services Director, the Activities Director, and a Physical Therapy Assistant. There was no… | 2020-09-01 |
| 915 | 915 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2017-08-22 | 356 | B | 0 | 1 | 2T4P11 | Based on observation and interview, the facility failed to post the Nurse Staffing Hours as required. This failure could have the potential to affect all the residents. Census was 107 Findings are: Observation on the initial environmental tour of the facility on 8/7/2017 at 9:00 AM revealed that the facility hadn't posted the Nurse staffing hours. Interview with the DON (Director of Nursing) on 8/7/2017 at 9:45 AM confirmed that the Nurse staffing hours were not posted. | 2020-09-01 |
| 3199 | 3199 | EL DORADO MANOR NURSING HOME | 285253 | 71434 HWY 25, BOX 97 | TRENTON | NE | 69044 | 2019-11-07 | 625 | B | 0 | 1 | WR4Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide written notice of the Bed Hold Policy for 3 sampled residents (Residents 7, 21, and 27) when discharged to the hospital by the facility. Facility census was 28. Sample size was 16. Findings are: [NAME] An MDS (Minimum Data Set, a federally mandated tool used to track resident admissions and discharges) Discharge Assessment completed on 7/20/19 revealed that Resident 7 had been discharged to the hospital on [DATE]. Review of the resident's chart found Departmental Notes written by the SSD (Social Service Director) that showed the resident was sent to the hospital via ambulance on 7/20/19 and that the resident's POA (Power of Attorney) had been notified by phone at that time while a written notice was sent on 7/23/19 along with an e-mail to the state ombudsman on the same date. No mention was made of a Bed Hold Notice being provided. B. On 11/5/19 at 9:27 AM during an initial interview, Resident 21 reported a recent hospitalization due to vomiting which led to surgery. Review of the Departmental Notes written by the SSD revealed that Resident 21 was sent to the hospital for severe abdominal pain on 10/14/19. The note showed that the family was notified by phone on that date and a written notice was sent to the family on 10/15/19 to notify them of this facility initiated transfer. The state ombudsman was sent an e-mail copy of the notice on 10/16/19. No mention was made of a Bed Hold Notice being provided. C. An MDS Discharge Assessment completed on 9/8/19 showed that Resident 27 had been discharged to the hospital on that date. Departmental Notes completed by the SSD revealed that the resident had been sent to the hospital via ambulance on 9/8/19 and the family was notified by phone on that date. On 9/9/19, written notice of the facility initiated transfer was sent to the family via mail, and an e-mail was sent to notify the state ombudsman. No mention was made of a Bed Hold … | 2020-09-01 |
| 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 |
| 6481 | 6481 | CHIMNEY ROCK VILLA | 285260 | P O BOX A, 106 EAST 13TH STREET | BAYARD | NE | 69334 | 2016-01-07 | 287 | B | 0 | 1 | 2QXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to develop and transmit a discharge tracking MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to track resident admissions and discharges) within 14 days of the resident's facility discharge for one sampled resident (Resident 48). Facility census was 42. Findings are: Record review of Resident 48's closed medical record revealed from the progress notes the resident was admitted to the facility on [DATE] and discharged to home on 11/4/15. Record review of Resident 48's MDS assessments revealed an entry tracking MDS was done on 11/1/15 but there was no discharge MDS completed between 11/1/15 and 1/6/16 within 14 days of the resident's discharge from the facility. Record review of the facility's Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (an instructional manual on how to complete and transmit MDS assessments) Version 1.13 revised in (MONTH) of (YEAR) revealed the following instructions: - A discharge assessment- Return Not Anticipated Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. Must be completed within 14 days after the discharge date and Must be submitted within 14 days after the MDS completion date. | 2019-02-01 |
| 6754 | 6754 | GOOD SAMARITAN SOCIETY - OSCEOLA | 285193 | 600 CENTER DRIVE | OSCEOLA | NE | 68651 | 2015-05-11 | 278 | B | 0 | 1 | 2U1F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure the MDS (a mandatory comprehensive assessment tool used for care planning) reflected the status of the resident at the time the MDS was coded for residents (Resident 5, 8, 25 and 34, and 28). The facility census was 40. Findings are: A. A review of the RAI (Resident Assessment Instrument User's Manual) Version 3.0 Manual revealed if MDS question O0100k was answered yes for Hospice (a program which cares for terminally ill patients) Services, then question J1400 which indicates a condition or chronic disease that may result in a life expectancy of less than six months, must be answered yes also. B. A review of Resident 5's significant change MDS dated [DATE], revealed question number J1400 was marked No indicating the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months (a terminal prognosis). Question number O0100k was marked Yes, indicating the resident received Hospice services. A review of a Doctor's order dated 1/18/15, indicated to refer Resident 5 to Hospice Services. Continued review of the Orders section of the electronic medical record, revealed the resident was admitted to Hospice care effective 1/23/15. During an interview on 5/7/15 at 3:02 PM, RN (Registered Nurse)-H revealed (gender) was the RN that completed the MDS for Resident 5 dated 2/4/15. The RN reviewed the assessment and confirmed the documentation indicated Resident 5 did not have a terminal prognosis and did receive Hospice services. C. A review of an Annual MDS for Resident 8, dated 4/8/15 revealed question J1400 indicated a terminal prognosis, was answered no, and question O0100K was marked yes, indicating the resident received Hospice services. A review of a form titled Hospice Physician Admission and Standing Orders, dated 4/11/14, revealed it was ok to admit Resident 8 to Hospice. During an int… | 2018-10-01 |
| 7165 | 7165 | INDIAN HILLS HEALTHCARE COMMUNITY | 285091 | 1720 NORTH SPRUCE | OGALLALA | NE | 69153 | 2015-05-20 | 514 | B | 0 | 1 | RGZC11 | Licensure Reference Number: 175 NAC 12-006.16C3 Based on interviews and record reviews, the facility failed to provide the survey team access to computerized resident medical records when requested. This failure delayed the inspection process completion. Facility census was 43. Findings are: During an entrance conference with the facility administrator on 5/18/15 at 10:30 a.m. the survey team requested computer access and log-in information to inspect resident medical record information. The administrator provided a form with computer log-in instructions and stated a laptop computer would be provided to the team. On 5/18/15 from 10:00 a.m. through 5:00 p.m. and 5/19/15 from 7:00 a.m. through 4:00 p.m. the facility had not provided a laptop to the survey team. On 5/19/15 at 4:00 p.m. during an interview with the facility DON (Director of Nursing), the DON was reminded of the survey team's request for access to a computer. On 5/20/15 at 8:15 a.m., the DON was informed by the survey team that the team had not received a computer for access to the resident records. The DON provided a laptop to the team after this interview. The survey team entered the log-in information per the instructions provided by the administrator and the access to the records was denied by the system. The DON was informed of the inability of the survey team to log into the resident medical records. During an interview with the Administrator on 5/20/15 at 10:00 a.m., the Administrator was informed of the survey team's inability to access the computerized resident medical records from the provided log-in information and reminded of the need to inspect resident records. On 5/20/15 at 11:00 a.m., the DON provided additional log-in instructions to the survey team and resident medical records were accessed at that time. | 2018-05-01 |
| 7172 | 7172 | CENTENNIAL PARK RETIREMENT VILLAGE | 285094 | 510 CENTENNIAL CIRCLE | NORTH PLATTE | NE | 69101 | 2014-10-09 | 283 | B | 0 | 1 | CWIU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 12-006.09C3 Based on closed record reviews of five sampled residents (Residents 29, 33, 100, 106, and 111) and interviews, the facility failed to complete discharge summaries recapitulating the residents' stay in the facility. Facility census was 51. Findings are: Review of facility closed medical records [REDACTED] - Resident 29 was discharged to another skilled nursing facility on 9/25/14. - Resident 33 was discharged home on[DATE]. - Resident 100 was discharged to independent living on 5/15/14. -Resident 106 was discharged home on[DATE]. - Resident 111 was discharged to another skilled nursing facility on 7/17/14. Further review of these records revealed there was no discharge summaries included in the resident records describing the resident stays. Interview with the Director of Nursing on 10/9/14 verified the facility had not completed discharge summaries for Residents 29, 33, 100, 106, and 111 following their anticipated discharges from the facility. | 2018-05-01 |
| 8606 | 8606 | KIMBALL COUNTY MANOR | 285256 | 810 EAST 7TH STREET | KIMBALL | NE | 69145 | 2014-01-27 | 278 | B | 0 | 1 | 5TXJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09B Based on record reviews and interviews, the facility failed to accurately record resident prognosis for MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessments for one currently sampled resident (Resident 7) and three sampled closed records (Residents 10, 39, and 51) for residents receiving Hospice care. Facility census was 41. Findings are: A. MDS record review for Resident 7 revealed a Significant change in status MDS assessment dated [DATE] had coded that Resident 10 received Hospice services during the MDS reference period. Further review of the MDS revealed the facility had not coded the prognosis section of the MDS indicating the resident had a condition or chronic disease that may result in a life expectancy of less than 6 months (requires physician documentation. Review of Resident 7's Hospice Plan of Care for the certification period of 11/18/13 through 12/1/13 revealed documentation electronically signed by the physician which certified to the best of my medical knowledge given the data available, (Resident 7) has a life expectancy of six (6) months or less if the terminal illness runs its normal course . B. Review of Resident 10's closed medical record revealed the facility had completed an Admission assessment MDS dated [DATE]. Further review of the MDS revealed the facility had not coded the prognosis section of the MDS indicating the resident had a condition or chronic disease that may result in a life expectancy of less than 6 months (requires physician documentation. Review of Resident 10's Hospice Plan of Care, signed by a physician on 8/15/13, certified to the best of my medical knowledge given the data available, (Resident 7) has a life expectancy of six (6) months or less if the terminal illness runs its normal course . C. Review of Resident 39's closed medical record revealed the facility had completed an … | 2017-04-01 |
| 8743 | 8743 | NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER | 285271 | 2100 CIRCLE DRIVE | SCOTTSBLUFF | NE | 69361 | 2014-02-27 | 278 | B | 0 | 1 | 32F611 | Licensure Reference Number: 175 NAC 12-006.09C(1) Based on record reviews and interview, the facility failed to identify one sampled resident (Resident 6) as receiving Hospice services on the resident's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessment. Facility census was 44. Findings are: Record review of Resident 6's Resident Admission Record printed on 2/26/14 revealed Resident 6 was admitted to the faciliy on 11/14/2013 and had a date of birth listed as 8/22/1920. Review of Resident 6's MDS records revealed a Significant change in status MDS was completed on 2/1/14. Further review of this MDS assessment revealed the Special Treatments, Procedures, and Programs section of the MDS had not coded that the resident received Hospice services In the last 14 days of the assessment reference period. Review of Resident 6's chart revealed from the Hospice admission orders [REDACTED]. Interview with the MDS Coordinator, RN (Registered Nurse)-A on 2/27/14 at 1:30 p.m. verified that Resident 6's Significant Change MDS on 2/1/14 had not recorded the resident's hospice care which started on 1/24/14. | 2017-03-01 |
| 9084 | 9084 | SOUTH HAVEN LIVING CENTER | 285231 | 1400 MARK DRIVE | WAHOO | NE | 68066 | 2013-05-21 | 156 | B | 0 | 1 | K9A011 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(1) Based on record review and interview; the facility staff failed to inform the resident and/or responsible party of the potential liability of payment and the right to request a standard claim appeal (i.e. demand bill) be submitted to Medicare for two ( Residents 22 and 91) of nine resident's files reviewed. One resident (Resident 27) was issued notice of non-coverage 26 days early. The facility census was 76. Findings are: Record review of a Centers for Medicare and Medicaid Services Survey and Certification letter 09-20 revealed that the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services when limitation of liability applies. The SNF's responsibility to provide notice can be fulfilled by use of either the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or one of 5 uniform Denial Letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e. demand bill) submitted to Medicare. Issuing the Notice to Medicare Provider Non-coverage to a beneficiary only conveys notice to the beneficiary of the right to an expedited review of a service termination and does not fulfill the providers obligation to advise the beneficiary of potential liability of payment. The provider must still issue the SNFABN or a Denial Letter to address liability of payment. Review of the facility's Medicare Demand Bill process revealed that two (Residents 22 and 91) of nine residents files reviewed had not been informed of the right to submit a Demand Bill to Medicare through the standard claim appeal and had not been issued a SNFABN or a Denial Letter to address liability of payment. Resident 27 was issued appropriate notice however the notice issued to the resident 26 days prior to the end of service. Interview on 05/20/13 at 11.30AM with the facility Administrator confirmed that SNFABN liability notices should have been issued to Resident 22 and 91and this had not been done. … | 2016-11-01 |
| 9316 | 9316 | GOOD SAMARITAN SOCIETY - SCRIBNER | 285196 | 815 LOGAN STREET | SCRIBNER | NE | 68057 | 2013-09-18 | 514 | B | 1 | 0 | Q62C12 | Licensure Reference Number 175 NAC 12.006.16A Based on record review and staff interview the facility failed to ensure that resident's clinical record contained accurate documentation related to the checking for Wander Guard (an electronic system used to alert staff of resident attempts to leave the facility) bracelet function for two residents, Residents 2 and 3. The facility census was 59. Findings are: Review of paper documentation of Wander Guard Checks, dated 11/13/13-11/14/13, revealed a list of 15 residents that wear Wander Guard bracelets. Checks were made for placement of the bracelet and if the Wander Guard bracelet is functioning. Check marks were noted for both placement and function are documented for Residents 2 and 3 on forms dated 11/13/13. Review of paper documentation dated 11/14/13 revealed that there was no bracelet in place for Resident 2. A review of Progress Notes for Resident 2 dated 10/10/13 at 11:20 AM revealed that the Wander Guard bracelet had been removed per request of family. Review of documentation on Point Click Care (an electronic data collection system) showed that Wander Guard checks are performed daily and operational 11/01/2013 through 11/12/2013 for a third sampled resident. A review of Point Click Care data entered for Resident 3 revealed no information related to the checking of the Wander Guard bracelet for the dates of 11/1/13-11/12/13. An interview with the MDS (a mandatory comprehensive assessment tool used for care planning) Coordinator on 11/14/13 at 11:30 AM revealed that the facility ' s corporate office did not feel that Wander Guard checks were a documentable task, and the checks will no longer be documented on Point Click Care effective 11/12/13. The MDS Coordinator reported that paper documentation for the Wander Guard bracelets was to be initiated on 11/12/13, but that some of the staff has documented the checks on paper when the information was supposed to be documented on Point Click Care, so there was not documentation for some of the completed checks. | 2016-09-01 |
| 10342 | 10342 | GOLDEN LIVINGCENTER - NELIGH | 285124 | P O BOX 66, 1100 NORTH T STREET | NELIGH | NE | 68756 | 2012-02-07 | 253 | B | 0 | 1 | J0NF11 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.18A(1), 12-006.18B Based on observations and staff interview; the facility failed to maintain the environment as flooring was stained/soiled in 2 resident bathrooms on the A-wing (Rooms A2/A4 and Rooms A3/A1) and 1 resident bathroom on the B-wing (Rooms B43/B45); the vaneer on the chest of drawers in Room B43 was loose and chipped; 2 ceiling tiles above the head of Bed 1 in Room B38 were stained and warped; floor tiles were chipped and cracked at the entrance to Room C14; and window drapes were hanging loose in three rooms on the B-wing (Rooms B42, B43 and B38). Thirteen residents resided in these rooms, and total facility census was 57. Findings are: During the environmental tour on 2/7/12 from 9:00 AM until 9:55 AM and accompanied by the Administrator and Maintenance personnel, the following were observed: A. Bathroom flooring was stained and/or soiled in resident rooms A2/A4, A3/A1 and B43/B45. B. The vinyl vaneer on the chest of drawers in Room B43 Bed 2 was loose and chipped, causing the edges to be rough and jagged. C. Two ceiling tiles above the head of Bed 1 in Room B38 were brown stained and warped. D. Window drapes in Rooms B42, B43 and B38 were missing hooks, causing the drapes to hang loose. E. Floor tiles at the entrance to Room C14 were chipped, cracked and separated from the adjacent corridor tiles. F. Interview with the Administrator during the environmental tour verified the above observations. | 2016-01-01 |
| 10830 | 10830 | GOLDEN LIVINGCENTER - HARTINGTON | 285088 | P O BOX 107, 401 DARLENE STREET | HARTINGTON | NE | 68739 | 2012-03-07 | 253 | B | 0 | 1 | 5NJL11 | LICENSURE REFERENCE NUMBER 12-006.18B Based on observations, record review and staff interviews; the facility failed to maintain a clean and comfortable environment as the upholstery on dining room chairs in both the main dining room and the special care unit dining room was observed to be soiled and stained. In addition, the inside surfaces of toilets in bathrooms of resident rooms E1, E2, E3, E4, E5, E6, E7, E8, W1, W3, W4, W5, W6, W7, W8, W10, N2 and N12 were stained. This involved 26 residents occupying these rooms. Furthermore, the bird aviary, located in a lounge/activity area adjacent to the main dining room, contained an accumulation of bird feathers, and the glass of the aviary was soiled with bird droppings and unidentified splatter. Facility census was 38. Findings are: A. Review of the facility Programmed Work Schedule form dated 9/7/11 indicated chairs in the main dining room and special care unit dining room were to be cleaned monthly or as needed . (Surveyor ) On 2/28/12 from 12:00 PM until 12:42 PM, 16 of the dining room chairs in the main dining room were observed to have stains on the upholstery covering the seats of the chairs. (Surveyor ) During observations on the special care unit on 2/29/12 between 8:40 AM and 10:40 AM, 12 of the dining room chairs had visible stains and soil on the upholstery covering the seats of the chairs. During interview on 3/6/12 from 10:00 AM until 10:10 AM, the Administrator verified the dining room chairs were in need of cleaning and/or replacement. The Administrator indicated a bid had been submitted for new dining room chairs in both dining rooms; however, the bid had not been approved and needed to be resubmitted. Review of the e-mail bid revealed it was dated 5/26/11 (9 months and 9 days prior) and indicated Not sure at this time how many chairs would be needed. During observation on 3/6/12 at 1:10 PM, the upholstery on the seats of the chairs in the special care unit dining room had a brushed appearance as if they had been cleaned. Although the seats of the c… | 2015-10-01 |
| 11151 | 11151 | GOOD SAMARITAN SOCIETY - SCRIBNER | 285196 | 815 LOGAN STREET | SCRIBNER | NE | 68057 | 2013-11-14 | 514 | B | 1 | 0 | Q62C12 | Licensure Reference Number 175 NAC 12.006.16A Based on record review and staff interview the facility failed to ensure that resident's clinical record contained accurate documentation related to the checking for Wander Guard (an electronic system used to alert staff of resident attempts to leave the facility) bracelet function for two residents, Residents 2 and 3. The facility census was 59. Findings are: Review of paper documentation of Wander Guard Checks, dated 11/13/13-11/14/13, revealed a list of 15 residents that wear Wander Guard bracelets. Checks were made for placement of the bracelet and if the Wander Guard bracelet is functioning. Check marks were noted for both placement and function are documented for Residents 2 and 3 on forms dated 11/13/13. Review of paper documentation dated 11/14/13 revealed that there was no bracelet in place for Resident 2. A review of Progress Notes for Resident 2 dated 10/10/13 at 11:20 AM revealed that the Wander Guard bracelet had been removed per request of family. Review of documentation on Point Click Care (an electronic data collection system) showed that Wander Guard checks are performed daily and operational 11/01/2013 through 11/12/2013 for a third sampled resident. A review of Point Click Care data entered for Resident 3 revealed no information related to the checking of the Wander Guard bracelet for the dates of 11/1/13-11/12/13. An interview with the MDS (a mandatory comprehensive assessment tool used for care planning) Coordinator on 11/14/13 at 11:30 AM revealed that the facility ' s corporate office did not feel that Wander Guard checks were a documentable task, and the checks will no longer be documented on Point Click Care effective 11/12/13. The MDS Coordinator reported that paper documentation for the Wander Guard bracelets was to be initiated on 11/12/13, but that some of the staff has documented the checks on paper when the information was supposed to be documented on Point Click Care, so there was not documentation for some of the completed checks. | 2015-08-01 |
| 12219 | 12219 | GOLDEN LIVINGCENTER - NORFOLK | 285101 | 1900 VICKI LANE | NORFOLK | NE | 68701 | 2011-04-13 | 465 | B | 1 | 1 | J6Z911 | Licensure Reference Number 12-006.18A Based on observation and interview; the facility failed to maintain a saitary environment in the Linen Room of the ACU (Alzheimer's Care Unit) and the EAst wing Nursing Suply closet. Facility census was 52. Findings are: A. During the environmental tour with the Administrator and the Maintenance Supervisor on 4/12/11 from 1:20 p.m. until 2:40 p.m., the floor in the clean Linen Room located on the ACU, the Central Supply Storage Room and the East Wing Nursing Supply Closet contained paper scraps, cotton balls, cotton applicators, plastic spoons, plastic caps, an air mattress and dust which indicated a lack of routine cleaning. B. Interview with the Administrator on 4/12/11 at 2:40 PM revealed these areas were in need of cleaning and repair. | 2014-09-01 |
| 12286 | 12286 | ROCK COUNTY HOSPITAL LTC | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2011-01-31 | 244 | B | 0 | 1 | DTVN11 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.06 Based on review of Resident Council Minutes, confidential interview and staff interviews the facility failed to honor the residents' choice regarding a vote taken for dining room seating arrangements. There was no documentation to indicate why the residents' choice was not honored. Facility census was 27. Findings are: A. Review of the Resident Council Minutes dated 5/24/10 revealed the Social Services Director (SSD) asked residents to voice their opinions on the dining room arrangement per Administrator's request. 7 residents voted to have the dining room return to the original arrangement with the horseshoe tables (tables that are shaped like a horseshoe and provide access for a staff member to assist 3 to 4 residents with eating at 1 time) in a small dining area adjacent to the main dining room. 5 residents voted to have the dining room stay the way it currently was with the horseshoe tables in the main dining room. 4 residents voiced not caring how the dining room was arranged. Review of the 6/28/10 Resident Council Minutes revealed that issues from the previous month (5/24/10) had been resolved. Review of the 7/26/10 Resident Council Minutes revealed 1 resident, "Voiced that residents voted on the dining room arrangement, but no decision had been made". Resident stated, "Why were we asked to vote if our vote didn't count?" The minutes to this meeting did not contain a response to the resident's question. Review of the 8/30/10, 9/27/10, 10/25/10, 11/29/10/, 12/27/10/ and 1/31/11 Resident Council Minutes revealed the issue of the dining room arrangement had not been discussed with the residents. B. During confidential family interview the concern regarding assisted residents eating in the main dining room was voiced. The family member voiced concern for residents being assisted to eat and were asked to open their mouth or swallow in front of other residents. C. Interview with the Administrator on 1/31/11 from 3:55 PM until 4:00 PM revealed the residents did not rec… | 2014-09-01 |
| 12400 | 12400 | PIERCE MANOR | 285139 | P O BOX 189, 515 EAST MAIN STREET | PIERCE | NE | 68767 | 2011-02-09 | 465 | B | 1 | 1 | VZJ311 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.18 Based on observations and staff interview the facility failed to maintain a functional and sanitary environment as air return vents and utility room cabinets were soiled; the wood trim on windows in the assisted dining room was deteriorating; the laundry room floor was gouged and paint chipped and the floor grate on the water trap to the laundry machines was soiled. Facility census was 59. Findings are: A. During the environmental tour of the facility with the Administrator, Housekeeping Supervisor and the Maintenance Supervisor on 2/9/11 from 8:00 AM until 9:20 AM the following issues were identified: -The shelves inside the Utility Room cabinets contained a dried liquid and dust soil. -The grids on the air return vents in the ceilings of the 300 wing hallway and the Laundry Room contained a dust soil. -The trim on the southeast windows of the assisted dining room were moisture stained and the wood was splintered which did not provide a cleanable surface. -The water trap to the Laundry Room washers contained a buildup of lint and dried soap scum. -The painted cement floor of the Laundry Room was gouged, pitted and paint chipped which did not provide a cleanable surface. B. Interview with the Administrator and the Maintenance Supervisor on 2/9/11 from 9:15 AM until 9:20 AM verified the areas identified were in need of repair or cleaning. | 2014-07-01 |
| 12512 | 12512 | SIDNEY REGIONAL MEDICAL CENTER-EXTENDED CARE | 2.8e+294 | 645 OSAGE STREET | SIDNEY | NE | 69162 | 2012-11-01 | 167 | B | 0 | 1 | R1EN11 | Licensure Reference Number 175 NAC 12-006.08 Based on observations and staff interview, the facility failed to ensure that the survey results for the last annual survey were posted for public inspection. The facility census was 52. Findings are: Observation on 11/1/12 at 7:45 AM revealed that the annual survey, dated 9/7/11, was not available in the survey report file located in the front lobby area. Interview on 11/1/12 at 8:00 AM with the Administrator confirmed that the previous survey was removed from the file on 10/29/12 for copies and was not replaced back into the file. | 2014-07-01 |
| 12829 | 12829 | HUNTINGTON PARK CARE CENTER | 285251 | 1507 GOLD COAST ROAD | PAPILLION | NE | 68046 | 2010-03-25 | 492 | B | Y0WD11 | Based on record review and interview; the facility staff failed to complete the demand billing process to ensure that the resident or the responsible party were offered the choice whether or not to request a standard claim appeal (Demand Bill) be submitted to Medicare for 2 ( Resident 19 and 21) of 4 resident files reviewed. The resident sample size was 19 plus 2 non-sampled residents from a facility census of 88. Findings are: Record review of 2 ( Residents 19 and 21) of 4 Skilled Nursing Facility Determination on Continued Stay notification letters revealed that the choice boxes under the Request for Intermediary Review had been left blank. This indicated that the resident or responsible party had not made a decision as to whether or not to request an Intermediary Review for a Medicare decision. Interview on 3/22/10 at 11:25 AM with the Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) Coordinator confirmed that the boxes had been left blank. The MDS Coordinator confirmed that no follow-up was completed with the residents or the responsible party to ensure that they were aware of the right to request an Intermediary decision. The MDS Coordinator stated that when the letters are returned by the families or resident they come directly to the facility Medical Records department and are filed. Interview on 3/22/10 at 11:25 AM with Medical Records Staff N confirmed that the letters were not routinely reviewed to ensure that a choice had been documented in regards to the request for an Intermediary decision. Interview on 3/22/10 at 11:30 AM with the Director of Nursing revealed the expectation that facility staff should have followed up to ensure that the documentation on the letters was complete. | 2014-03-01 | ||
| 12969 | 12969 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2010-09-23 | 492 | B | ZEZV11 | Based on record review and interview; the facility staff failed to complete the demand billing process to ensure that the resident or the responsible party were offered the choice whether or not to request a standard claim appeal (Demand Bill) be submitted to Medicare for 3 ( Residents 11,17 and 19) of 4 resident files reviewed. The resident sample size was 12 plus 9 non-sampled residents from a facility census of 45. Findings are: Record review of 3 ( Residents 11, 17 and 19) of 4 Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) notification letters revealed that the choice boxes under Option 1 and Option 2 had been left blank. This indicated that the resident or responsible party had not made a decision as to whether or not to request an Intermediary Review for a Medicare decision. Interview on 9/22/10 at 8:30 AM with the Business Office Manager (BOM) confirmed that the boxes had been left blank. The BOM confirmed that no follow-up was completed with the residents or the responsible party to ensure that they were aware of the right to request an Intermediary decision. The BOM stated that when the letters are returned by the families or resident they come directly to the facility Business Office and are filed. The BOM confirmed that the letters for Residents 11, 17 and 19 were not reviewed to ensure that a choice had been documented in regards to the request for an Intermediary decision. Record review of a Policy and Procedure for Resident Demand Billing dated 05/06/08 revealed that after receipt of the signed SNFABN, the Buisness Services Coordinator would review with the beneficiary and/or responsible parties the option selected. Interview on 9/22/10 at 8:30 AM with the BOM confirmed that this was not done for Residents 11,17 and 19. | 2014-01-01 | ||
| 175 | 175 | RIVER CITY NURSING AND REHABILITATION | 285058 | 7410 MERCY ROAD | OMAHA | NE | 68124 | 2019-09-12 | 574 | C | 0 | 1 | 7GF911 | Based on observation and interview, it was determined the facility failed to ensure the contact information for the State Agency was posted in the facility, which impacted all 93 residents residing in the facility. Findings include: On 09/10/19 at 2:02 PM, all eight residents who attended the Resident Group meeting, Resident (R)7, R15, R34, R42, R49, R64, R66, and R72 stated they did not know where in the facility the State Survey Agency contact information was posted. The eight residents who attended the group stated they were not aware they could file grievances directly with the State Survey Agency but thought they could only contact the Ombudsman's office. On 09/12/19 at 3:53 PM, the Administrator stated that the facility did not have the contact information for the State Survey Agency posted and was not aware of the requirement. | 2020-09-01 |
| 404 | 404 | REGENCY SQUARE CARE CENTER | 285076 | 3501 DAKOTA AVENUE | SOUTH SIOUX CITY | NE | 68776 | 2019-02-11 | 838 | C | 0 | 1 | 5HF111 | Based on record review and interview, the facility failed to develop a comprehensive facility assessment. The facility census was 55. Findings are: Review of the facility assessment dated (MONTH) 6 (YEAR) and Reviewed with Quality Assurance Performance Improvement (QAPI) committee on (MONTH) 10 2019 revealed no information was included regarding how the facility determines the staffing needs based on resident census and acuity. Review of the Facility Assessment revealed no information was included regarding outside services that have contracts or memorandums of understanding with the facility and what services they provide to the facility during regular business hours and non-business hours. Interview on 02/11/19 at 10:59 AM with the Administrator revealed staffing level needs and how to determine staffing levels were not included in the Facility Assessment and no documentation of contracts with outside agency for services when needed were contained in the Facility Assessment. | 2020-09-01 |
| 576 | 576 | LINDEN COURT | 285083 | 4000 WEST PHILIP AVENUE | NORTH PLATTE | NE | 69101 | 2018-01-31 | 732 | C | 0 | 1 | 6FMP11 | Based on observations and interviews, the facility failed to post the daily staffing information as required. This failure prevented families, residents, and visitors from having access to the required information regarding the census and numbers of direct care staff providing care in the facility. Facility census was 119. Findings are: Observation on 1/28/18 at 2:00 p.m. revealed a Nursing Staff Information form was posted in the front entry to the facility. The date on the form was incorrectly recorded 2/26/17. The form was observed not to have recorded the facility census as required, nor was the date accurate. Observation on 1/29/18 at 7:22 a.m. revealed the Nursing Staff Information form was posted in the front entry to the facility. The form was observed not to have recorded the facility census as required, nor was the date accurate as it was incorrectly recorded 2/26/17. The form was the same form observed on 1/28/18 at 2:00 p.m. Interview with the facility Staffing Coordinator on 1/29/18 at 7:22 a.m. revealed the Staffing Coordinator completed forms for each day over the weekend and verified the posted Nursing Staff Information form was from Friday 1/26/18. The Staffing Coordinator confirmed the weekend staff failed to post the daily forms for posting, which were provided them by the Staffing Coordinator. | 2020-09-01 |
| 856 | 856 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2019-05-28 | 732 | C | 1 | 1 | 3V0011 | > Based on observation and interview, the facility failed to ensure the required direct care staffing hours were posted daily. The failure could potentially prevent all residents, families, and visitors from reviewing facility direct care staffing hours worked. Facility census was 85. Findings are: Observation on Monday 5/20/19 at 8:00 a.m. revealed the Direct Care Staffing Hours form was posted on the 100 wing bulletin board. Further examination of the document revealed the staffing hours posted were for Friday 5/17/19. Interview with the facility Administrator and Director of Nursing on 5/20/19 at 8:20 a.m. verified the bulliten board at the front entry was the area the facility posts its daily staffing hours. The Administrator and Director of Nursing verified the form posted on the bulliten board was dated 5/17/19 and the hours worked by direct care staff had not been posted since Friday 5/17/19. | 2020-09-01 |
| 881 | 881 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2018-07-10 | 732 | C | 0 | 1 | PRIL11 | Based on observations, record review and interview; the facility failed to ensure that the nurse staffing hours were posted as required. The facility census was 93 with the potential to affect residents, families and visitors with current information including the resident census and nursing staff providing care. Findings are: Observations on 7/2/18 at 8:15 AM, during the initial tour of the facility, revealed the daily Direct Care Staffing Hours posted by the front entrance office was dated 6/29/18. Interview with the Director of Nursing on 7/2/18 at 9:30 AM confirmed that the staff posting was not current as required. | 2020-09-01 |
| 1063 | 1063 | PRESTIGE CARE CENTER OF PLATTSMOUTH | 285104 | 602 SOUTH 18TH STREET | PLATTSMOUTH | NE | 68048 | 2019-08-15 | 576 | C | 0 | 1 | 3PTP11 | Licensure Reference Number: 175NAC 12-006.05 (12) Based on record review and interview the facility failed to ensure residents received mail on Saturday, affecting all residents who could potentially receive mail on the weekend, Facility census 72. Findings: Interview with Resident Council on 8/15/19 at 10;00 am ( Residents,( 37,63,33,6.31.51,20,26,60,64) Do not receive mail on Saturdays, all residents present agreed that mail is not delivered on Saturday. Interview Activity Director (AD), is responsible for delivering mail, it is not delivered on Saturday , (AD) comes in early on Mondays to deliver the mail. Record Review: Admission Packet does give the resident a choice to have assistance with opening of the mail. | 2020-09-01 |
| 1094 | 1094 | EMERALD NURSING & REHAB LAKEVIEW | 285106 | 1405 WEST HWY 34 | GRAND ISLAND | NE | 68801 | 2018-05-07 | 732 | C | 0 | 1 | QN7C11 | Based on observation, interview, and record review; the facility failed to post the nurse staffing information consistent with the SNF (skilled nursing facility) schedule. This had the potential to affect all 55 residents in the facility. Findings are: Record Review of the Resident Roster revealed the facility had a census of 55 at the time of survey. Review of the Direct Care Staffing posted at the reception desk on 5/1/2018, 5/2/2018, 5/3/2018, and 5/7/2018 revealed a census of 68. Observation of the facility resident care areas on 5/07/18 at 12:20 PM revealed there were 2 LPNs (Licensed Practical Nurse), 5 NAs (Nurse Aide) and 1 MA (Medication Aide) working in the SNF. Record review of the Direct Care Staffing posted for 5/7/2018 revealed there were 2 LPNs (16 hours), 6 CNAs (48 hours) and 3 MAs (24 hours), on day shift. Record review of the Daily Nursing Schedule for 6 AM to 2 PM for 5/7/2018 revealed there were 2 LPNs, 5 NAs and 1 MA scheduled in the SNF. Interview with the facility Scheduler (person who completed the nursing staff schedule) on 5/07/18 at 12:10 PM revealed they had been including the ALF (Assisted Living Facility) residents in the census and the ALF staffing in the hours on the Nursing Staff Posting. | 2020-09-01 |
| 1107 | 1107 | EMERALD NURSING & REHAB LAKEVIEW | 285106 | 1405 WEST HWY 34 | GRAND ISLAND | NE | 68801 | 2019-08-13 | 732 | C | 0 | 1 | FZCA11 | Based on observation and interview, the facility failed to ensure the required positng of direct care staffing was done daily. This could potentially affect all residents/families/visitors. Facility census was 71. Findings are. Observation on 8/12/19 at 2:00 p.m. revealed a Direct Care Staffing posting at the desk of the front entrance. The date on the document was recorded as 8/9/19. Interview with the Director of Nursing and Administrator on 8/12/19 at 2:35 p.m. confirmed the required staff posting document of direct care staff hours had not been posted over the weekend since Friday 8/9/19. | 2020-09-01 |
| 1222 | 1222 | ARBOR CARE CENTERS-FULLERTON LLC | 285115 | PO BOX 648, 202 NORTH ESTHER | FULLERTON | NE | 68638 | 2017-08-28 | 372 | C | 0 | 1 | 3S2F11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A Based on observation and interview, the facility failed to ensure garbage and refuse was disposed of in a manner to prevent cross contamination. The sample size was 41 and the facility census was 62. Findings are: The following was observed during the environmental tour of the facility on 8/28/17 from 9:00 AM until 9:35 AM: -2 of 7 outside garbage dumpsters did not have lids; -plastic bags of garbage/trash were overflowing from 1 of the outside garbage dumpsters without a lid; and -the lid of 1 outside garbage dumpster was open and plastic bags of garbage/trash were overflowing from the top. Interview with the Maintenance Director on 8/28/17 at 9:35 AM confirmed garbage/trash should be contained in the outside garbage dumpsters. The Maintenance Director further indicated all of the outside garbage dumpsters should have lids and the lids should be closed. | 2020-09-01 |
| 1355 | 1355 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2017-08-02 | 356 | C | 1 | 1 | YKIR11 | > Based on observations and interviews, the facility failed to ensure a current nurse staff posting was displayed for public reference. This had the potential to affect all residents in the facility. The facility staff identified the resident census at 110. The findings are: An initial tour of the facility conducted on 7/25/17 at 9:29 AM revealed a nurse staff posting on display dated 7/8/17 and 7/9/17. An observation conducted on 8/1/17 at 1:38 PM revealed a nurse staff posting on display dated 7/29/17 and 7/30/17. An interview conducted on 8/1/17 at 1:41 PM with Clinical Assistant A revealed that the nurse staff posting for 7/31/17 and 8/1/17 were not completed and they were working on them at that time. An interview conducted on 8/1/17 at 2:10 PM with Clinical Assistant A confirmed the nurse staff posting that was on display was for 7/29/17 and 7/30/17. Clinical Assistant A reported that they display the nurse staffing for the previous and not for the current day. | 2020-09-01 |
| 1396 | 1396 | LIFE CARE CENTER OF ELKHORN | 285134 | 20275 HOPPER STREET | ELKHORN | NE | 68022 | 2018-10-11 | 732 | C | 1 | 0 | PGI211 | > Based on observation, record review and interview; the facility staff failed to ensure the accuracy of the Posted Nursing Hours in the facility. This had the potential to affect all residents in the facility. The facility staff identified a census of 99. Findings are: [NAME] Record review of the Nurse Staff Posting (NSP) dated 10-03-2018 revealed the facility staff identified there were 2 Registered Nurses (RN), 5 Licensed Practical Nurse (LPN) and 12 Nursing Assistants (NA) working the day shift. Further review of the NSP revealed the facility staff identified there were 1 RN, 1 LPN and 5 NA's on the night shift with a census of 96. Record review of a Daily Assignment Sheet (DAS) of nursing staff who had worked dated 10-03-2018 revealed there were 2 RN's, 2 LPN's and 11 NA's. Further review of the DAS revealed there was 1 RN, 2 LPN's and 5NA's. B. Record review of the NSP dated 10-04-2018 revealed the facility staff documented there was 1 RN, 5 LPN's and 12 NA's working the day Shift. Record review of the DAS dated 10-04-2018 revealed 1 RN worked, 2 LPN's and 12 NA's. C. Record review of a NSP dated 10-05-2018 revealed the facility staff had documented there were 2 RN's and 5 LPN's working the day shift Record review of the DAS dated 10-05-2018 revealed there were 2 RN's and 2 LPN's working the day shift. D. Record review of a NSP dated 10-08-2018 revealed the facility staff had documented there were 4 LPN's and 10 NA's working the day shift. Review the DAS dated 10-08-2018 revealed there were 3 LPN's and 10 NA's working the day shift. E. Record review of a NSP dated 10-09-2018 revealed the facility staff had identified there were 1 RN and 6 LPN's working the day shift with 12 NA's. Record review of a DAS dated 10-09-2018 revealed the facility staff had identified there were 1 RN, 6 LPN's and 12 NA's working the day shift. F. Record review of a NSP dated 9-10-2018 revealed the facility staff documented there was 1 RN, 3 LPN's and 10 NA's working the day shift. Record review of the DAS dated 9-10-2018 revealed … | 2020-09-01 |
| 1408 | 1408 | LIFE CARE CENTER OF ELKHORN | 285134 | 20275 HOPPER STREET | ELKHORN | NE | 68022 | 2016-11-07 | 465 | C | 0 | 1 | 6P3W11 | Licensure Reference Number: 175 NAC 12-006.18A Based on observation and interview, the facility staff failed to maintain the condition of door frames and floors in the dishroom and dish storage area in the facility in accordance with the Nebraska Food Code. This had the potential to affect all residents in the facility. The facility census was 95. Findings are: Record review of the 7/1/2007 version of the food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food services sanitation practices, revealed the following: - Statute 4-601.11 Nonfood contact surfaces: Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Observation on 11/7/16 between 9:30 AM and 9:52 AM revealed the following concerns in the dirty dishroom and dish storage room in the facility kitchen: - Reddish, flaky substance that resembled rust and corrosion on the door frame of the dirty dish room. - Wax and dirt buildup on the floor in the clean dish storage area. - Broken corner guards on the doorframes on the entrance to the kitchen from the dish storage area. Interview on 11/7/16 at 9:52 AM with the Dietary Manager confirmed that those areas were dirty and in disrepair and needed to be cleaned and fixed. The DM confirmed that there were 95 residents that ate food prepared in the facility kitchen | 2020-09-01 |
| 1698 | 1698 | WISNER CARE CENTER | 285151 | 1105 9TH STREET | WISNER | NE | 68791 | 2018-12-26 | 801 | C | 1 | 1 | HQSG11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04D2a Based on record review and interview, the facility failed to ensure the Dietary Manager (DM) met the State requirements for DM qualification. This had the potential to affect food service provided to 30 residents who were served food from the kitchen. The facility census was 30. Findings are: Review of the DM personnel file revealed the following: -the DM assumed the DM position on 10/22/18; -the DM did not meet the State requirements for DM qualification; and -the DM was enrolled in a class/course starting 1/2019 to obtain the required credentials and education for the position of DM. Interview with the DM on 12/20/18 at 1:05 PM verified the DM did not have the education, credentialing or certification required for the position of DM. The DM confirmed enrollment in a class/course to obtain the required education and credentials. | 2020-09-01 |
| 2015 | 2015 | GOOD SAMARITAN SOCIETY - VALENTINE | 285176 | 601 WEST 4TH STREET | VALENTINE | NE | 69201 | 2017-03-30 | 167 | C | 0 | 1 | 02OK11 | Licensure Reference Number: 175 NAC 12-004.08 Based on interviews and observations, the facility failed to display survey inspection results (a legal document describing facility violations of state and/or federal regulations) in a manner that was accessible and identifiable for residents and/or resident representatives. The failure could prevent all residents from access to the records. Facility census was 37. Findings are: Interview with Resident 21 on 3/28/17 at 9:55 a.m. revealed Resident 21 attended Resident Council meetings. During the discussion of the resident council, Resident 21 was asked if the facility informed residents about accessing the survey inspection results, and whether or not the resident was aware where the results were located and if the resident could access the reports without assistance. Resident 21 answered not being aware of where the survey results were kept. Observations on 3/29/17 at 8:30 a.m., 3/29/17 at 12:30 p.m., and 3/30/17 at 8:35 a.m. revealed a red three-ring binder with a label attached to the spine reading: Current Survey Results was atop a call light system box attached to the wall at the entry of the dining room. The font on the label measured 1/2 inch and was obstructed by a microphone cord. The binder was placed atop the call light system box and was 65 inches above the floor. Interview with the Administrator on 3/30/17 at 8:35 a.m. verified the red three-ring binder atop the call light system box by the entry of the dining room contained the survey inspection results. The Administrator confirmed the binder was not accessible to residents in wheelchairs and was not easily identified due to the position of the binder and the obstructed label from the microphone cord. | 2020-09-01 |
| 2207 | 2207 | GOOD SAMARITAN SOCIETY - ST JOHNS | 285189 | 3410 CENTRAL AVENUE | KEARNEY | NE | 68847 | 2017-03-08 | 356 | C | 0 | 1 | OPBG11 | Based on observation, interview, and record review, the facility failed to document RN (Registered Nurse) hours on the daily nursing staff posting. This had the potential to affect all residents in the facility. The facility identified a census of 48 at the time of survey. Findings are: Observation of the Daily Nursing Staffing posted in the facility central hallway revealed no documentation of RN hours during the days of survey on 3/2/17, 3/6/17, and 3/7/17. Review of the Daily Nursing Staffing information for 3/1/17 to 3/7/17 revealed no RN hours listed on 3/7/17, 3/6/17, 3/3/17, and 3/2/17. Interview with LPN-C (Licensed Practical Nurse) on at 3/7/2017 at 4:10 PM revealed the RN hours should have been listed on the Daily Nursing Staffing information. Review of the facility policy Nursing Staff Daily Posting Requirements revised 12/15 revealed the following: Rehabilitation/skilled care locations will post daily the staffing and resident census at the beginning of each shift and update as appropriate (for each shift). The location will post the following information on a daily basis: licensed and unlicensed staff members include the following: Registered nurses. This information must be prominently displayed in a clear and readable format where residents, staff members and the public may view. | 2020-09-01 |
| 2281 | 2281 | GOOD SAMARITAN SOCIETY - ST LUKE'S VILLAGE | 285192 | 2201 EAST 32ND STREET | KEARNEY | NE | 68847 | 2019-09-12 | 732 | C | 0 | 1 | ZVME11 | Based on record reviews and interview, the facility failed to identify and record all staff members providing direct resident care along with their hours worked on the required staff posting document. The failure could potentially prevent all residents, visitors, and family members from reviewing direct care staffing on duty. Facility census was 47. Findings are: Record review of the facility's Daily Staffing documents posted daily between 8/13/19 and 9/9/19 for the day shift (6 a.m. to 2:30 p.m.) Nurse Aide numbers and hours revealed the following: - On 8/26/19 two Nurse Aides worked 16 hours. - On 8/28/19 two Nurse Aides worked 16 hours. - On 8/30/19 two Nurse Aides worked 16 hours. - On 8/31/19 two nurse aides worked 16 hours. - On 9/1/19 two nurse aides worked 16 hours. - On 9/2/19 two nurse aides worked 16 hours. - On 9/3/19 two nurse aides worked 16 hours. - On 9/4/19 two nurse aides worked 16 hours. - On 9/6/19 two nurse aides worked 16 hours. - On 9/7/19 one nurse aide worked 8 hours. - On 9/8/19 two nurse aides worked 16 hours. - On 9/9/19 one nurse aide worked 8 hours. Interview with the DNS (Director of Nursing Services) on 9/12/19 at 9:10 a.m. revealed the facility had three clinical units and staffed the day shift to include one nurse aide for each hall, a float nurse aide, and a bath aide on the day shift. Review of the Daily Staffing posted documents and comparisons with scheduled staff revealed the posted hours were not recording all staff working on the day shift. The DNS verified that Agency Nurse Aides were not included in the daily staff postings and due to this error, the daily staff postings were inaccurate. | 2020-09-01 |
| 2414 | 2414 | COMMUNITY PRIDE CARE CENTER | 285208 | 901 SOUTH 4TH STREET | BATTLE CREEK | NE | 68715 | 2017-03-30 | 156 | C | 0 | 1 | N3I911 | Based on record review and interview, the facility failed to assure the residents were informed of where to find information on how to file a complaint with the state agency. This had the potential to affect all residents in the facility. The facility staff identified the resident census as 43. Survey sample size was 26 . The findings are: A review of the Resident Council Minutes dated 9/23/16, 11/18/16, 12/23/16, 2/17/17, and 3/24/17 revealed the state agency information was not reviewed at the resident council meetings. An interview conducted on 3/28/17 at 11:00 AM with Resident 45 revealed that the residents were not made aware of the state agency contact information in order to file a complaint if needed. An interview conducted on 3/28/17 at 1:10 PM with the Social Services Director (SSD) revealed the state agency contact information was given to residents upon request or when a resident and/or family member filed a grievance with the facility. The SSD reported the residents were not given this information at any of the Resident Council meetings or during the admission process. | 2020-09-01 |
| 2415 | 2415 | COMMUNITY PRIDE CARE CENTER | 285208 | 901 SOUTH 4TH STREET | BATTLE CREEK | NE | 68715 | 2017-03-30 | 167 | C | 0 | 1 | N3I911 | Licensure Reference Number 175 NAC 12-004.08 Based on observation and interviews, the facility failed to assure the state survey results were accessible to all residents and residents were aware of the location of these results. The facility staff identified the census at 43 and sample size was 26. The findings are: An interview conducted on 3/28/17 at 11:00 AM with Resident 45 revealed the resident did not know the location of the state survey results and that the residents were not made aware of the location of the of the state survey results. An observation conducted on 3/28/17 at 11:29 AM revealed the state survey results were posted on a bulletin board near the dining room in a red folder labeled Plan of Correction. The folder hung at a level that would not have been accessible for a resident in a wheelchair . An interview conducted on 3/28/17 at 1:07 PM with the Social Services Director revealed that they thought they reviewed the location of the state survey results at the resident council meetings, but they did not document it in the minutes. An interview conducted on 3/28/17 at 1:29 PM with the Administrator confirmed the state survey results with in a folder labeled Plan of Correction and should have been labeled for state survey results. The Administrator also confirmed that the results were hung too high for the residents in the facility to reach. | 2020-09-01 |
| 2501 | 2501 | PIONEER MANOR NURSING HOME | 285212 | P O BOX 310, 318 N 3RD STREET | HAY SPRINGS | NE | 69347 | 2017-09-07 | 356 | C | 1 | 0 | KXTW11 | > Based on observation and interview, the facility failed to maintain 18 months of nursing staff posting. This had the potential to affect all 48 residents in the facility. Findings are: Observation of the facility nurses' station on 9/6/2017 at 4:45 PM revealed the nursing staff posting written on an erasable marker board. Interview with the facility Administrator on 9/6/2017 at 5:03 PM revealed the facility staff erased the nursing staff posting from the marker board daily and had there was no documentation of the previous nursing staff postings. | 2020-09-01 |
| 2627 | 2627 | WAUNETA CARE AND THERAPY CENTER | 285220 | PO BOX 520, 427 LEGION STREET | WAUNETA | NE | 69045 | 2018-08-01 | 908 | C | 0 | 1 | BO4511 | Licensure Reference Number: 175 NAC 12-006.11E Based on observations and interview, the facility failed to replace a cracked light fixture cover in the kitchen. The failure could potentially cause shattering and contaminate the food preparation area in the kitchen where meals were prepared for all the residents. Facility census was 28. Findings are: Observations on 7/30/18 at 11:00 a.m. and 8/1/18 at 11:46 a.m. revealed a fluorescent light fixture affixed to the ceiling above a three compartment sink, facility oven, and facility food preparation table in the kitchen had a jagged crack extending across one edge of the cover about three fourths of the length of the cover. Interview with the Dietary Manager on 8/1/18 at 11:57 a.m. confirmed the light fixture above the three compartment sink, facility oven, and facility food preparation table in the kitchen was damaged and needed replaced. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: 6-202.11 Light Bulbs, Protective Shielding . light bulbs shall be shielded . in areas where there is exposed food . | 2020-09-01 |
| 2900 | 2900 | KEYSTONE RIDGE POST ACUTE NURSING AND REHAB | 285238 | 7501 KEYSTONE DRIVE | OMAHA | NE | 68134 | 2019-04-22 | 732 | C | 0 | 1 | BJ6K11 | Based on record review and interview; the facility staff failed to ensure the facility Posted Nurse Staff identified the number of actual hours worked and staffing totals were completed. This had the potential to effect all residents in the facility. The facility staff identified a census of 60. Findings Are: Record review of the facility Daily Nurse Staffing Information sheets for 3-29-2019, 3-30-2019, 3-31-2019, 4-01-2019 and 4-02-2019 revealed the sections for actual hours worked and staffing totals had not been completed. On 4-10-2019 at 7:38 AM an interview was conducted with the facility Administrator. During the interview review of the Daily Nurse Staffing information sheets dated 3-29-2019, 3-30-2019, 3-31-2019, 4-01-2019 and 4-02-2019 were reviewed. The Administrator confirmed the Daily Nurse Staffing Information sheets had not been completed. | 2020-09-01 |
| 2998 | 2998 | OMAHA NURSING AND REHABILITATION CENTER | 285240 | 4835 SOUTH 49TH STREET | OMAHA | NE | 68117 | 2020-02-25 | 843 | C | 0 | 1 | 3ZNV11 | Based on record review and interview; the facility staff failed to have a transfer agreement between the facility and hospital. This had the potential to effect all residents in the facility. The facility staff identified a census of 53. Findings are: Record review of the facility agreements revealed there was no evidence of a transfer agreement between the facility and the hospital. On 2-26-2020 at 3:13 PM an interview was conducted with the Marketing Director via a phone call. During the interview, the Marketing Direct confirmed there was no agreement. | 2020-09-01 |
| 3003 | 3003 | OMAHA NURSING AND REHABILITATION CENTER | 285240 | 4835 SOUTH 49TH STREET | OMAHA | NE | 68117 | 2017-08-22 | 170 | C | 0 | 1 | LWTC11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(12) Based on record review and interview; the facility staff failed to ensure resident mail was delivered on Saturdays if delivered to the facility by the United States Postal Service (USPS). This had the potential to affect all residents in the facility. The facility staff identified a census of 65. Findings are; Record review of an Activity Policy and Procedure Manual for the subject identified a mail revealed the following information: -Policy: -It is the policy of this facility to ensure the resident's right to privacy in written communication. -Procedures: -#4, Delivery of mail or other materials to residents will be made within 24 hours of delivery by the postal service. On 8-22-2017 at 2:52 PM an interview was conducted with Resident 28. During the interview when asked if residents of the facility received mail if delivered to the facility from USPS, Resident 28 stated I'm not sure. On 8-22-2017 at 2:53 PM an interview was conducted with the facility Activity Director (AD). The AD reported during the interview that if (gender) worked Saturdays, the AD would deliver the mail. The AD further reported not knowing who delivered mail to residents when the AD was not working. On 8-22-2017 at 2:55 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported not knowing who delivered mail on Saturdays. | 2020-09-01 |
| 3057 | 3057 | PARKVIEW HOME, INC. | 285243 | 930 2ND STREET | DODGE | NE | 68633 | 2017-08-14 | 226 | C | 0 | 1 | 5HE011 | Licensure Reference Number 175 NAC 12-006.04A3b Based on record review and interview, the facility failed to ensure pre-employment Licensure Registry checks were completed for three of four nursing staff (Registered Nurse-B and Nursing Assistants C and D) personnel records reviewed. This failure had the potential to affect all of the facility's residents. The facility census was 33. Findings are A review of Personnel Files revealed no documented evidence that the facility checked the State Licensure Registry prior to employment for Registered Nurse (RN)-B, Nursing Assistant (NA)-C, and NA-D. An interview on 8/14/17 at 2:45 PM with the Administrator confirmed the facility did not check the Licensure Registry, as part of pre-employment screening for the three Nursing Staff members. The Administrator reported the facility's policy for pre-employment screening did include the Licensure Registry check and indicated the checks must have been missed somehow during the hiring process. | 2020-09-01 |
| 3099 | 3099 | COLONIAL ACRES NURSING HOME | 285248 | 1043 10TH STREET | HUMBOLDT | NE | 68376 | 2018-08-30 | 838 | C | 0 | 1 | LQR911 | Based on record review and interview the facility failed to ensure there was a facility assessment. This had to potential to affect all residents in the facility. The facility census was 33. Findings are: On 08/28/18 at 08:51 AM a record review revealed no facility assessment. On 08/28/18 at 08:52 AM the Administrator confirmed there was no facility assessment. | 2020-09-01 |
| 3172 | 3172 | EL DORADO MANOR NURSING HOME | 285253 | 71434 HWY 25, BOX 97 | TRENTON | NE | 69044 | 2018-10-25 | 732 | C | 0 | 1 | 1SXW11 | Based on observation, and interview, the facility failed to post the required nurse staffing information. This had the potential to affect all residents. Census was 28 residents. On 10/22/18 at 02:47 PM the Daily Staffing sheet was posted adjacent to the nurses station on a bulletin board. On 10/23/18 at 08:31 AM the Daily Staffing sheet was posted adjacent to the nurses station on a bulletin board. The posting was incompletely filled out. On 10/24/18 at 07:30 AM the incomplete Daily Staffing sheet dated for 10/23/18 was posted adjacent to the nurses station on a bulletin board. No posting was hung for the current date. On 10/25/18 at 07:45 AM the Daily staffing sheet that was undated was posted adjacent to the nurses station on a bulletin board. No posting was hung for the current date. On 10/24/18 at 11:30 AM an interview with the Director of Nursing confirmed that an incomplete nurse staffing sheet was posted dated 10/23/18 and that there was no posting for the current date. On 10/25/18 at 08:15 AM an interview with the Director of Nursing confirmed that an undated Daily staffing sheet was posted adjacent to the nurses station on a bulletin board and that there was no posting for the current date. On 10/25/18 at 08:15 AM an interview with the Administrator confirmed that an undated Daily staffing sheet was posted adjacent to the nurses station on a bulleting board and that were was no posting for the current date. | 2020-09-01 |
| 3310 | 3310 | BLUE VALLEY LUTHERAN NURSING HOME | 285259 | P O BOX 166, 220 PARK AVENUE | HEBRON | NE | 68370 | 2019-02-07 | 732 | C | 0 | 1 | KR9R11 | Based on observation, interview, and record review; the facility staff failed to post the nursing staff posting daily and failed to ensure it contained all of the required information in order to ensure the facility residents and visitors were informed of the status of the facility's staffing. This had the potential to affect all of the facility residents. The facility identified a census of 31 at the time of survey. Findings are: Observation of the facility 24 Hour Census and Staffing report dated 2/03/19 at 4:45 PM revealed it was on the wall in the main entrance lobby. The facility census not documented. The area where it was listed to be written was blank. Observation of the facility 24 Hour Census and Staffing report on 2/06/19 at 9:30 AM revealed it was dated yesterday, Tuesday (MONTH) 5. Review of the facility 24 Hour Census and Staffing report for Monday (MONTH) 4 and Tuesday (MONTH) 5 revealed the facility census was not documented. Observation of the 24 Hour Nursing Staff Posting on 2/07/19 at 8:57 AM revealed it was dated Tuesday (MONTH) 5. Interview with the facility Administrator on 2/07/19 at 9:00 AM confirmed the 24 Hour Nursing Staff Posting was not current and it needed to be updated daily. Interview with the DON (Director of Nursing) on 2/07/19 at 9:17 AM confirmed the nursing staff posting was supposed to be posted daily. Review of the facility policy Posting Direct Care Daily Staffing Numbers revised (MONTH) (YEAR) revealed the following: Within 2 hour of the beginning of each shift, the number of Licensed Nurses and the number of unlicensed nursing personnel directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. The information recorded on the form shall include: The resident census at the beginning of the shift for which the information is posted. | 2020-09-01 |
| 3761 | 3761 | GOOD SAMARITAN SOCIETY - GRAND ISLAND VILLAGE | 285285 | 4061 TIMBERLINE STREET & 4055 TIMBERLINE STREET | GRAND ISLAND | NE | 68803 | 2019-09-26 | 732 | C | 1 | 1 | 7E3P11 | > Based on observations, record reviews, and interviews, the facility failed to ensure the daily required staff posting numbers reflected actual staff providing direct care and included hours worked by these direct care staff. The failure could potentially affect all residents at the facility. Facility census was 59. Findings are: Observations on 9/23/19 beginning at 3 p.m. revealed the facility posted a Daily Staffing form on a bulletin board by the therapy department. Record review of staff Daily Staffing posting documents from 9/1/19 through 9/23/19 revealed postings on the night shift 10 p.m. to 6 a.m. showed no NA's or MA's providing direct care to residents on 9/19/19, and 9/8/19. The night shift postings showed only one NA or MA providing direct care to residents on 9/18; 9/17; 9/14; 9/9 (only four hours covered); and 9/4/19. Interview with the facility SC (Staffing Coordinator on 9/25/19 at 4:45 p.m. revealed the SC was responsible to post the Daily Staffing sheets. The SC verified there were no night shifts when there were no direct care staff (NA/MA) on duty and no night shifts when only one direct care staff was on duty. The SC stated that the facility uses Agency staff to supplement open positions for NA/MA's and that these staff are not captured on the daily staff posting forms and the hours these staff work are also not captured. Interview with the Interim- DON (Director of Nursing) and Interim- Administrator on 9/26/19 at 10:15 a.m. verified that staff posting requirements are to include all staffing numbers for direct care staff and their hours worked. | 2020-09-01 |
| 3908 | 3908 | HILLCREST COUNTRY ESTATES-COTTAGES | 285293 | 6082 GRAND LODGE AVENUE | PAPILLION | NE | 68133 | 2019-02-27 | 844 | C | 1 | 0 | ISYJ11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04c1C Based on record review and interview the facility failed to notify the Department in writing within five working days of a change in the Director of Nursing. Findings are: Interview conducted with the Corporate Clinical Nursing Service Nurse on 2/27/2019 at 2:20 PM revealed that the former Director of Nursing final day was 1/11/2019 and the facility had not sent in the paper to notify of the change. The facility provided a Nursing Home Licensure Renewal Application undated and unsigned with hand written change of the Director of Nursing and no evidence that it was sent to the department. | 2020-09-01 |
| 4281 | 4281 | OGLALA SIOUX LAKOTA NURSING HOME | 2.8e+301 | 7835 ELDERS DRIVE, STATE HIGHWAY 87 | RUSHVILLE | NE | 69360 | 2019-04-02 | 844 | C | 1 | 0 | 5T2K11 | > Licensure Reference Number 175 NAC 12-006.01(6) Based on record reviews and interview, the facility failed to notify the State Agency of a change in Administrator as required. The facility census was 37 with the potential to effect all of the residents. Findings are: Review of two facility Investigation Reports, dated 3/19/19, revealed that there was a change in Administrator in the facility. Interview with the Interim Administrator on 4/2/19 at 3:15 PM revealed that the former Administrator left on 3/8/19. Further interview confirmed that there was no written documentation that the State Agency was notified as required of the change in Administrator. | 2020-09-01 |
| 4414 | 4414 | SCHUYLER CARE AND REHABILITATION CENTER, LLC | 285110 | 2023 COLFAX STREET | SCHUYLER | NE | 68661 | 2016-05-11 | 356 | C | 0 | 1 | XQ5M11 | Based on record review and interview, the facility failed to ensure the posting of daily Nursing Staff Hours included documentation of the total hours worked by the Nursing staff and the current resident census. This failure had the potential to affect all of the residents residing in the facility. The fancily census was 33. A review of the facility's POLICY/D[NAME]UMENT #HR 606 NURSING STAFF HOURS last reviewed 8/14/15, revealed the posting needed to document the following information on a daily basis at the beginning of each shift: center/location name, current date, total number and actual hours worked by licensed and unlicensed staff responsible for resident care, and the resident census. A review of the Nursing hours posting dated 4/24/16 indicated the staffing hours for the Day Shift were not documented, and the total hours boxes on the form were not completed. A review of the Facility's posting of Nursing Hours dated 3/10/16-4/13/16, revealed no documentation related to the total number of hours worked by the staff. Further review revealed the forms dated 3/15/16-4/13/16 did not include documentation of a Registered Nurse (RN) working the required eight hours of every 24 hour period. An interview on 4/25/16 at 6:00 AM, with the Administrator confirmed the posting of Nursing Staff Hour reports were not complete and did not document the number of hours the nursing staff actually worked. | 2020-07-01 |
| 4485 | 4485 | AZRIA HEALTH AT MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2016-05-17 | 159 | C | 0 | 1 | Z8DT11 | Based on observation, record review and interview; the facility staff failed to ensure that Resident 120's Resident Trust funds (a petty cash fund that residents could assess for immediate needs) were available outside of posted business hours. This practice had the potential to affect 120 residents that had Resident Trust fund accounts that were managed by the facility. The facility had a total census of 134 residents. Findings are: Observation on 5/16/16 at 8:00 AM revealed a paper posted at the front reception desk which revealed the hours residents could withdraw funds from their Resident Trust accounts. The hours were listed as: Monday -Friday 8:30 AM to 4:30 PM and Sat and Sunday 10:30 AM to 3:00 PM. Interview on 5/11/16 at 10:45 AM with Resident 120 revealed that the resident had a Resident Trust account managed by the facility staff and that Resident 120 was unable to get money out whenever it was desired. Interview on 05/16/16 at 10:01 AM with the Director of Social Work (DSW) confirmed that Resident 120 had a Resident Trust account and that a total of 120 residents in the facility had Resident Trust accounts. The DSW stated that residents were encouraged to use Resident Trust accounts and could get money at the front desk when the receptionist was there. Interview on 05/17/16 at 7:51 AM with the Corporate Business Manager (CBM) revealed the residents could access their money at the front desk of the facility between 8:30 and 4:30 on the weekdays and 10:30 and 3:30 PM on weekends. The CBM stated that the hours are posted at the front reception desk. Interview on 05/17/16 at 8:46 AM with the facility Administrator confirmed that Resident Trust funds could only be accessed at those posted times. Record review of a facility Policy and Procedure for Resident Trust accounts dated 8/20/15 revealed that the care center would maintain all Resident Trust fund accounts in compliance with Federal and State regulations and with generally accepted accounting practices. | 2020-04-01 |
| 4574 | 4574 | WISNER CARE CENTER | 285151 | 1105 9TH STREET | WISNER | NE | 68791 | 2016-08-24 | 372 | C | 0 | 1 | 1DYH11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A Based on observations, record review and interview; the facility failed to dispose of garbage in a manner to prevent harboring of rodents and pests as the facility garbage dumpsters were filled over-capacity and/or lids were not in place to secure the contents. Facility census was 35. Findings are: [NAME] Review of the facility policy and procedures titled Storage and Handling of Waste Disposal, dated 6/2015, included the following: -staff will bag all garbage and store it in a leak proof, non-absorbent container with a lid; -staff will empty these containers as often as needed throughout the day into the large dumpsters located outside the North doors, behind the tool garage; -maintenance staff will empty the large dumpsters as scheduled 3 times weekly; -lids are to remain closed at all times to decrease pest control; and -staff will be educated to close the gates to the garbage enclosure when they exit after putting garbage in the dumpsters. B. The initial tour of the kitchen was completed on 8/22/16 from 8:59 AM until 9:11 AM, accompanied by the Dietary Manager (DM). The garbage dumpsters were located outside the North exit from the service hallway of the facility, and next to the maintenance shed. There were 2 garbage dumpsters located within a fenced enclosure, 1 for recyclable cardboard and the other for all other garbage. The lids on the garbage dumpster were open, and the dumpster was filled over-capacity with heaps of garbage bags. During interview on 8/22/16 from 8:59 AM until 9:11 AM, the DM verified the facility garbage dumpsters were to be emptied 3 times weekly on Monday, Wednesday and Friday, and as needed. C. During the kitchen sanitation tour on 8/24/16 from 10:30 AM to 10:59 AM, accompanied by the DM, the following was observed related to the facility garbage: -the gates to the fenced garbage enclosure were open; -the lids on the recyclable cardboard dumpster were open and exposed the cardboard that was stacked to the brim of the dumpster; and -the l… | 2020-04-01 |
| 4849 | 4849 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2018-03-06 | 732 | C | 1 | 1 | 9WK311 | > Based on record reviews and interviews, the facility failed to maintain daily posting of nursing staff with accurate posting of hours worked. This failure could prevent all residents and/or families from identifying staff on duty and hours worked as required. Facility census was 27. Findings are: Record review of facility staff posting documents revealed there was no staff posting documents available for inspection between 2/1/18 until 2/5/18. Further review revealed additional days on 2/9; 2/10; 2/11; 2/15; 2/19; and 2/25 the posting forms were also not available for inspection. Interview with the DON (Director of Nursing) on 3/1/18 at 6:45 a.m. revealed that the night nurse had been shredding posting information and verified there were no posting forms available for inspection for 2/1 until 2/5/18 and also for days 2/9; 2/10; 2/11; 2/15; 2/19; and 2/25. | 2020-03-01 |
| 4949 | 4949 | PREMIER ESTATES OF CRETE, LLC | 285170 | 830 EAST 1ST STREET | CRETE | NE | 68333 | 2017-02-21 | 356 | C | 0 | 1 | L91U11 | Based on observation and interview, the facility failed to post nurse staffing hours as required. The facility had a census of 57. Findings are: During a facility tour on 2/14/17 at 1:30 PM no nurse staffing hours were observed to be posted in the facility. A follow up observation on 2/16/17 at 3:00 PM revealed no posting of nurse staffing hours in the facility. Interview with the Director of Nursing (DON) on 02/21/2017 at 10:28 AM revealed the nursing hours were not posted in the facility but was kept in a folder in the DON's office. | 2020-03-01 |
| 5128 | 5128 | MT CARMEL HOME- KEENS MEMORIAL | 285216 | 412 WEST 18TH STREET | KEARNEY | NE | 68845 | 2016-05-02 | 156 | C | 0 | 1 | WQ7E11 | Licensure Reference Number 175 NAC 12-006.06C Based on observations, interviews, and record review; the facility failed to ensure that 1) the Resident Council Representative was informed of the location of the Ombudsman information and phone number and, 2) the Ombudsman information and phone number were accessible to the residents at the facility. This had the potential to affect 67 of the facility identified census of 67. Findings were: Observation on 05/02/2016 at 1:50 PM of the facility entrance and reception desk area that was identified by the facility as the location for the posting of the state Ombudsman information and phone number revealed that no Ombudsman information was observed. Interview revealed that the Resident Council Representative was unsure if the Ombudsman information and numbers were posted and available to all facility residents. Further interview with the facility Resident Council Representative on 05/02/2016 at 3:45 PM revealed that the resident was unfamiliar with the name Ombudsman and unaware of the location of the Ombudsman information. Review of the Resident Council Minutes from (MONTH) (YEAR) through (MONTH) (YEAR) revealed no written documentation to support that the resident council members had been informed about the location of the Ombudsman information or telephone number. Observation of the facility on 5/2/2016 at 4:11 PM revealed no posting of the Ombudsman information. Interview with the SSD (Social Services Director) on 5/2/2016 at 4:11 PM confirmed the Ombudsman information was not posted where the facility residents could have access to it. Interview with the facility Administrator on 5/2/2016 at 4:14 PM revealed the Ombudsman information had been removed from the wall about 2 weeks ago because the maintenance department was painting. The Administrator confirmed that the Ombudsman information was not posted in a location accessible to the facility residents. | 2020-02-01 |
| 5143 | 5143 | WAUNETA CARE AND THERAPY CENTER | 285220 | PO BOX 520, 427 LEGION STREET | WAUNETA | NE | 69045 | 2016-07-14 | 356 | C | 0 | 1 | DWL711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview; the facility failed to post the nurse staffing information in a clear format with complete information. This had the potential to affect all 33 residents in the facility. Findings are: Observation of the posted nurse staffing information by the front office on [DATE] at 1:23 PM revealed that it consisted of a copy of the nursing staff schedule. Hours were not differentiated by shift or staff type and the code definitions on the nursing staff schedule were not defined. Nursing staff hours were coded with D, 6p6a, PW, R, SK, Inf, APT, ,[DATE], ,[DATE], VB, ,[DATE], ,[DATE], ,[DATE], class, CPR, 10p6a. D, and OOT. The facility census was not indicated as well as the name of the facility. Nursing hours were not clearly defined by shift or discipline. Observation of the posted nurse staffing information on [DATE] at 12:52 PM revealed the nursing schedule was still posted by the front office as it was yesterday. Observation of the posted nurse staffing information on [DATE] at 8:36 AM revealed the nursing schedule was still posted by the front office as it was yesterday. Interview with the facility Administrator on [DATE] at 3:30 PM revealed that the nursing schedule was what the facility been using for the posted nurse staffing information. The administrator confirmed it did not have the date or census, and the administrator confirmed that the codes on the schedule may not have been understood by the residents and visitors. | 2020-02-01 |
| 5212 | 5212 | MOTHER HULL HOME | 285254 | 125 EAST 23RD STREET | KEARNEY | NE | 68847 | 2016-06-21 | 356 | C | 0 | 1 | R1MH11 | Based on observations and interviews, the facility failed to post nurse staffing information in a public area easily visible to residents and visitors. This had the potential to affect all residents. The facility census was 51 at the time of the survey. Findings are: [NAME] Observations found the posting of the nursing posted hours behind the nurses, desk taped to a cabinet not accessible to residents and family by location or height on the following. B. Interview with Resident 4 on 6/20/2016 at 3:15 PM revealed being unable to read the nurse staffing where it was posted. C. Interview with the DON (Director of Nurses) on 6/21/2016 at 8:40 AM revealed the form had always been there. D. Interview with the Administrator on 06/21/2016 9:10 AM revealed the nursing posting of hours needed to be moved. | 2020-02-01 |
| 5244 | 5244 | GREELEY CARE HOME | 285286 | 201 E O'CONNOR AVENUE | GREELEY | NE | 68842 | 2016-02-25 | 226 | C | 0 | 1 | ZD8411 | Licensure Reference Number 175 NAC 12-006.04A3b Based on record review and interview, the facility failed to ensure prescreening of new direct care staff included the APS/CPS (Adult Protective Services/Children's Protective Services) Central Registry Checks for five employee files reviewed. The facility census was 20. Findings are: A review of personal files for five newly hired direct care staff members (Nursing Assistant-A, Registered Nurse-B, Nursing Assistant/Medication Aide-C, Nursing Assistant/Medication Aide-D, and Registered Nurse-E) revealed no documented evidence of the facility checking the APS/CPS Central Registry. A review of the facility's ABUSE AND NEGLECT POLICY dated 8/1/13 revealed that all potential employees will be screened for history of abuse, neglect or mistreating residents. The Screening portion of the policy indicated Criminal, child abuse, adult abuse and sex offender registry background checks will be completed per state of Nebraska policy. An interview on 2/24/16 @ 4:15 PM with the Business Office Manager and Administrator revealed the facility had not been checking the APS/CPS Central Registry for newly hired employees. | 2020-02-01 |
| 5497 | 5497 | PARKVIEW HOME, INC. | 285243 | 930 2ND STREET | DODGE | NE | 68633 | 2016-05-25 | 356 | C | 0 | 1 | SF4R11 | Based on record review and interview, the facility staff failed to ensure that the total and actual number of hours worked per discipline were calculated and documented on the posted nurse staffing information. This had the ability to affect all residents that resided in the facility. The facility census was 39. Findings are: Observation on 05/23/16 at 9:30 AM of Posted Nurse Staffing information on the nurse's station window at the front of the facility did not include documentation of total or actual number of hours worked by each discipline. Record review of Nurse Staffing information for the past 30 days revealed no documentation of calculated total or actual hours of work time per discipline. Interview on 05/24/16 11:46 AM with the Director of Nursing confirmed that the total and actual number of hours worked had not been calculated or documented on the posted nurse staffing information sheets. Record review of a facility policy on Post Direct Care Daily Staffing Numbers dated 7/8/15 revealed no included information on documenting or calculating the number of hours worked total and actual hours worked. | 2020-01-01 |
| 5995 | 5995 | HOOPER CARE CENTER | 285229 | 400 EAST BIRCHWOOD DRIVE | HOOPER | NE | 68031 | 2015-12-03 | 156 | C | 0 | 1 | D8VH11 | Licensure Reference Number 175 NAC 12-006.05(1) Based on record review , interview and observation; the facility staff failed to ensure that residents and responsible parties were informed of charges for beauty shop services for 40 residents that resided in the facility. The facility census was 40. Findings are: Record review of Resident Policies, dated 01/12/11 related to Barber and Beauty Shops revealed that the basic fees for the barber and beauty shop were posted in the beauty shop. Observation on 12/2/15 at 11:00 AM revealed no posted list of charges for the barber and beauty services in the beauty shop. Interview on 12/2/15 at 10:47 AM with the facility Business Office Manager revealed that residents and responsible parties were not given anything in writing related to the charges for the beauty shop services. Interview with the facility Beauty Shop Operator on 12/2/15 at 10:50 AM revealed that the beauty shop operator had not given the families or residents any information related to the cost for barber and beauty shop services and confirmed that the costs had never been posted in the beauty shop. | 2019-07-01 |
| 6095 | 6095 | BLUE HILL CARE CENTER | 285144 | 414 NORTH WILLSON | BLUE HILL | NE | 68930 | 2015-08-03 | 156 | C | 0 | 1 | IVKP11 | Based on record review and staff interview, the facility failed to provide Medicare denial notices for three residents (Residents 27, 19, and 21) using the correct expedited process forms and giving the beneficiaries the notice to request a Medicare demand bill. The facility census was 34. Findings are: A. Review of Resident 21's Social Service IDPN (Interdisciplinary Note) on 7/29/15 at 12:32 revealed that, on 4/9/15, the resident's family (no name) was notified that the resident no longer qualified for Medicare A and would be returning to the resident's former payer source. A message was left on the family member's answering machine. Interview on 7/29/15 at 9:44 AM with the Administrator revealed that there was no copies of Resident 21's forms in the facility. The forms had not been sent certified and the family had not returned the forms. The resident no longer resided in the building. B. Review of Resident 27's Medicare Expedited Letter issued on 6/8/15 revealed the wrong form was used. The family member was notified by phone on 6/8/15. C. Review of Resident 22's Expedited Letter revealed that the resident's Medicare A benefits were ending on 2/17/15. Resident 22 signed the Expedited letter on 2/16/15. The resident was given the wrong form and not the 48 hours the notice required. Resident 22 received a Skilled Nursing Facility Non Coverage Notice dated 2/13/15 and the notice was not signed until 2/16/15 when the Expedited Letter was signed. D. On 7/29/15 at 3:32 PM, an interview with the Administrator revealed that the Administrator acknowledged that Residents 27 and 22 were not given a 48 hour notice when they were denied from Medicare A. | 2019-06-01 |
| 6099 | 6099 | BLUE HILL CARE CENTER | 285144 | 414 NORTH WILLSON | BLUE HILL | NE | 68930 | 2015-08-03 | 283 | C | 0 | 1 | IVKP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER ,[DATE].09C3a and ,[DATE].09C3 Based on record review and interview, the facility failed to complete discharge summaries including a recapitulation of the resident's stay for 5 residents (Resident 26, 47, 20, 45, and 50). The facility census was 34. Findings are: A. Review of Resident 26's closed record revealed that there was no Discharge Summary completed in the resident's record. B. Review of Resident 47's closed record revealed that there was no Discharge Summary completed in the resident's record. C. Review of Resident 20's closed record revealed that there was no Discharge Summary completed in the resident's record. D. Review of Resident 45's closed record revealed that there was no Discharge Summary completed in the resident's record. E. Review of Resident 50's closed record revealed that there was no Discharge Summary completed in the resident's record. F. Interview with the Director of Medical Records on [DATE] at 8:30 AM revealed that the facility no longer did discharge summaries when a resident discharged or expired. The Medical Record Director stated that the facility had done the discharge summaries in the past. G. Interview with the Administrator on [DATE] at 8:45 AM revealed that the administrator acknowledged that discharge summaries were to be completed when residents discharged . | 2019-06-01 |
| 6421 | 6421 | LYONS LIVING CENTER | 285301 | 1035 DIAMOND STREET | LYONS | NE | 68038 | 2018-05-10 | 732 | C | 1 | 0 | 2CLY11 | > Based on observations and interviews, the facility failed to post the daily nurse staffing information as required. This failure prevented families, residents, and visitors from having access to the required information regarding the census and numbers of direct care staff providing care in the facility. The facility census was 23. Findings are: Observation on 5/7/18 at 8:40 AM revealed the daily nurse staffing information form was posted on the wall by the entrance to the Administrator's office. The date on the form was 5/4/18. The form was observed not to have recorded the facility census and name of the facility as required. Interview with the Director of Nurses on 5/7/18 at 8:40 AM confirmed the daily nurse staffing information which was currently posted was from 5/4/18 and did not include the census and name of the facility. | 2019-03-01 |
| 6507 | 6507 | OMAHA METRO CARE AND REHABILITATION CENTER, LLC | 285097 | 5505 GROVER STREET | OMAHA | NE | 68106 | 2015-04-01 | 356 | C | 0 | 1 | 0RLK11 | Based on record review and interview; the facility staff failed to ensure that posted nurse staffing information contained all the required information and that the records were maintained for the required length of time. This had the potential to affect all residents that resided in the building. The facility census was 88. Findings are: Record review of posted nurse staffing information revealed that the posted nurse staffing information did not include the daily resident census or the actual number of hours worked by staff. Interview on 03/31/2015 at 10:25:08 AM with the facility Administrator confirmed that the posted nurse staffing information did not contain the actual number of staff hours worked or the daily resident census. The administrator confirmed that the posted nurse staffing information was not maintained or kept by the facility. | 2019-01-01 |
| 6588 | 6588 | GOOD SAMARITAN SOCIETY - SYRACUSE | 285138 | P O BOX F-1, 1622 WALNUT STREET | SYRACUSE | NE | 68446 | 2015-08-04 | 356 | C | 0 | 1 | L6CD11 | Based on observation, record review and interview; the facility staff failed to post staffing information in accordance with federal requirements. Federal requirements mandate the facility post nursing staff information on a daily basis at the beginning of each shift. This information must contain the following data: -Facility name. -Current date. -Resident census. -Facility-specifics shifts. -Categories of nursing staff. -Actual time worked for the specified categories of nursing staff. -The number of nursing staff working per shift. -Posted in a prominent place readily accessible to residents and visitors. -Maintain the posted daily nurse staffing data for minimum of 18 months. This had the potential to affect all residents in the facility. The facility staff identified a census 58. Findings are: Record review and observation of the Posted Nurse Staffing (PNS) sheets from 7-20-2015 through 8-02-2015 revealed the actual hours worked per category of nursing staff and the total number of hours worked for nursing had not been completed on the PNS sheets. An interview was conducted on 8-03-2015 at 10:01 AM with Registered Nurse (RN) A. During the interview, RN A reported (gender) was the Staffing coordinator and completed the PNS sheet. Review of the PNS sheets for 7-20-2015 through 8-02-2015 were reviewed with RN A. RN A confirmed during the interview the hours worked per category of nursing and total hours worked were not completed on the PNS sheets. | 2018-12-01 |
| 6606 | 6606 | COLONIAL MANOR OF RANDOLPH | 285183 | P O BOX 67, 811 SOUTH MAIN STREET | RANDOLPH | NE | 68771 | 2015-04-16 | 356 | C | 0 | 1 | 2J7A11 | Based on record review and staff interview; the facility failed to ensure the accuracy of the posting of nurse staffing information as it did not reflect the number of hours that staff were working in the attached Assisted Living Facility (ALF). This had the potential to affect all 39 residents that resided in the Nursing Facility (NF). Findings are: Review of nursing schedules for 4/13/15, 4/14/15 and 4/15/15 revealed 1 staff member per shift was assigned duties in both the NF and the ALF. Review of the POS [REDACTED]. Interview with Nursing Assistant (NA)-J on 4/15/15 at 7:05 AM revealed NA-J was responsible for answering call lights in the ALF when working the night shift in the NF. NA-J indicated the amount of time spent in the ALF during the night shift was approximately 10 minutes or less. Interview with Licensed Practical Nurse (LPN)-B on 4/15/15 at 7:10 AM revealed LPN-B was assigned duties in both the ALF and NF. LPN-B indicated approximately 60 minutes of the shift was spent providing care in the ALF. During interview on 4/15/15 at 3:00 PM, the Director of Nursing (DON) confirmed 1 staff member per shift was assigned duties in the ALF. The DON indicated the evening shift staff member who was assigned to duties in the ALF spent approximately 30 minutes during that shift in the ALF. The DON verified the nurse staffing information had not been adjusted to reflect the amount of time staff members spent working in the ALF. | 2018-12-01 |
| 6867 | 6867 | GOOD SAMARITAN SOCIETY - BEATRICE | 285203 | 401 S 22ND STREET | BEATRICE | NE | 68310 | 2015-08-18 | 356 | C | 0 | 1 | BEYR11 | Based on observations and interviews, the facility failed to post nurse staffing information in a public area easily visible to residents and visitors and failed to maintain 18 months of records. Findings are: During an entrance tour of facility on 8/11/15 at 9:00 AM, the nursing staff hours were not found posted. Further observations throughout the survey process from 8/11/15 and ending on 8/18/15, showed no staffing hours posted. An interview on 08/18/2015 at 12:17:09 PM with the receptionist revealed that the staff hours were posted behind the reception desk on a bulletin board. The receptionist noted that visitors usually don't use this entrance but enter through the households. The receptionist stated that staff posting was printed out each morning and the previous day's posting was shredded. Observations on 8/18/15 at 12:17 PM revealed that this bulletin board was behind the desk and was facing the receptionist. The posting was among several other papers on the bulletin board and not readily visible to visitors or residents. An interview on 08/18/2015 at 12:25 PM with the DON (Director of Nursing) revealed that staff postings were kept electronically and that it could be pulled up at any time and printed. The DON then demonstrated that the postings could only be accessed from (MONTH) 2014 to present. The DON indicated that this was when electronic postings began. Further interview with DON on 08/18/2015 at 12:40 PM revealed that hard copies were found for (MONTH) 2014 and (MONTH) 2014 but none from (MONTH) 2014 through (MONTH) 2014. | 2018-09-01 |
| 7004 | 7004 | NEBRASKA CITY CARE AND REHABILITATION CENTER, LLC | 285109 | 1420 NORTH 10TH STREET | NEBRASKA CITY | NE | 68410 | 2014-12-11 | 517 | C | 0 | 1 | 9RWM11 | LICENSURE REFERENCE NUMBER: NAC 12-006.16G3 Based on observation, record review and staff interview; the facility failed to provide current contracts or MOU (Memorandum of Understanding) for emergency water supply and places of safe evacuation. The facility identified a census of 50 residents. Findings are: A. A review of the undated Emergency Plans revealed the following: there is an unsigned and dated signature/update page. Also there were no contacts or MOUs for fresh water or with the locations mentioned as the locations to evacuate the residents of the facility. An interview with the Facility Administrator on 12/09/2014 1:12 PM revealed the following: the Facility Administrator states that (Gender) does not have any MOUs for evacuation locations or for fresh water replacement. The Facility Administrator states that (Gender) has meetings planned for the 16th of (MONTH) with the LIMMRS (Lincoln Metropolitan Medical Response System) chair-person and someone from the community council planning group. There are evacuation locations identified in the plan and water vendors identified, just no written agreements. (Gender) states that (Gender) is already attempting to get these agreements in place. On 12/09/2014 at 3:08 PM NA K did not know where to take evacuated residents. On 12/10/2014 at 5:15 AM LPN Q revealed that (Gender) did not know where to take evacuated residents. On 12/10/2014 at 5:25 AM NA R revealed that (Gender) did not know where to take evacuated residents. On 12/10/2014 at 5:40 AM NA P revealed that (Gender) did not know where to take evacuated residents. An interview with the Facility Administrator on 12/10/2014 at 3:35 PM revealed the following: The Facility Administrator states (Gender) can't find a signed and dated copy of the signature page. | 2018-07-01 |
| 7008 | 7008 | WAUSA CARE AND REHABILITATION CENTER, LLC | 285111 | 703 SOUTH VIVIAN | WAUSA | NE | 68786 | 2015-01-15 | 356 | C | 0 | 1 | E1VG11 | Based on observation and staff interview; the facility failed to post nurse staffing information in a place accessible to residents and visitors. This had the potential to affect all residents. Facility census was 21. Findings are: Observations of the Nurse Staffing Information revealed the posting was placed face down on the counter of the nurses ' station. The stand used to display the information was placed upside down on top of the posting. The information was not visible to residents and/or visitors. This was observed at the following dates and times: - 1/14/15 at 9:25 AM, 10:13 AM and 12:10 PM - 1/15/15 at 7:03 AM, 8:09 AM, 10:26 AM and 11:19 AM During an interview with Registered Nurse (RN)-E, on 1/15/14 at 12:35 PM, it was verified the staff posting was not visible to residents and/or visitors. Furthermore, RN-E stated that the information is often in this position and the stand used to place the information in a visible position was broken. | 2018-07-01 |
| 7048 | 7048 | WAKEFIELD HEALTH CARE CENTER | 285209 | 306 ASH STREET | WAKEFIELD | NE | 68784 | 2014-10-30 | 166 | C | 0 | 1 | NNRM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.06B Based on record review, staff and resident interviews; the facility failed to address and resolve Resident 20 and 15's grievances regarding adverse behaviors displayed by Residents 27 and 10. This had the potential to affect all facility residents and/or family members. Facility census was 33. Findings are: A. Review of facility policy entitled Resident Grievance Procedure (undated) revealed residents had the right to voice grievances without discrimination or reprisal and the facility was to provide a prompt effort to resolve grievances including those with respect to the behavior of other residents. The policy included the following procedure for residents and/or their responsible parties to file a grievance: -Grievance reports were to be available in the Social Service or Administrator's office. -The report should be completed within 3 days of the concern. -The written grievance was to be submitted to the Administrator. -The Administrator was to investigate the grievance report and set up a meeting to discuss grievance within 5 working days. B. Review of Resident 27's Care Plan with revision date 9/24/14 revealed the resident had severe cognitive impairment related to [DIAGNOSES REDACTED]. Resident 27's Care Plan included the following interventions: -Discourage the resident from spitting on the floor. -Offer the resident tissues as needed. -Monitor for spitting and clean up spit as needed to decrease the risk of resident slipping in the spit. During an interview on 10/27/14 at 11:23 AM, Resident 20 identified was a concern with Resident 27 spitting on the floor in the Dining Room as well as spitting on the floor outside of Resident 20's room. Resident 20 indicated staff were aware of these concerns and staff had told Resident 20 nothing could be done about Resident 27's behaviors. Review of the facility Grievance File from 11/1/13 through 10/28/14 revealed no grievances related to Resident 27'… | 2018-07-01 |
| 7070 | 7070 | CHRISTIAN HOMES HEALTH CARE CENTER | 285246 | 1923 WEST 4TH AVENUE | HOLDREGE | NE | 68949 | 2015-02-25 | 356 | C | 0 | 1 | SLH711 | Based on observation, record review, and interview; the facility failed to meet the requirement of posting nursing staff information at the start of each shift for view by all residents, family, staff, and visitors. this would affect all residents and visitors to the facility. Facility census at the time of survey was 81. Findings are: On 2/18/2015 at 10:20 AM, a document titled nursing staffing information was observed hanging on the wall by the entrance to Rose/Peony hall. The areas titled day shift and evening shift for 2/18/2015 were noted to be blank. On 2/18/2015 at 10:21 AM; Interview with SSD-C (Social Service Designee) noted that the information was blank and SSD-C stated that the information should have been filled out already. SSD-C proceeded to take the nursing staff information sheet up to the Rose/Peony nurses station to have the nurse complete it. Observation revealed that the nursing staff information document was blank for the following: - 02/19/2015 at 2:24 PM for the evening shift (2PM-10PM), - 02/19/2015 at 4:08 PM for the evening shift, - 02/24/2015 at 4:15 PM for the evening shift. | 2018-07-01 |
| 7081 | 7081 | AVERA CREIGHTON CARE CENTRE | 285284 | P O BOX 289, 1603 MAIN STREET | CREIGHTON | NE | 68729 | 2014-11-10 | 496 | C | 0 | 1 | QQVD11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3b Based on record review and staff interviews; the facility failed to verify Nursing Assistant (NA)-L was registered with the Nebraska Nurse Aide Registry before allowing NA-L to provide direct resident cares. This had the potential to affect all resident's receiving assistance with their activities of daily living. Facility census was 41. Findings are: Review of the facility Policy and Procedure entitled Protection/Prevention from Abuse/Neglect (undated) revealed all potential employees were to be screened by contacting previous employers, doing a background check and contacting the National Registry for Nursing Assistants and/or the appropriate Licensing Board. This was to be documented and kept in each employees file. Review of NA-L's employee file revealed NA-L was hired in (MONTH) of 2013 after completion of the Nurse Aide Course in South Dakota on 6/24/13. Further review of NA-L's employee file revealed NA-L's was not added to the Nebraska Nurse Aide Registry until 5/13/14. Review of the nurse staffing schedules from 6/24/13 through 5/13/14 revealed NA-L worked with residents at the facility in the capacity of direct care staff. During an interview on 11/10/14 from 9:30 AM to 9:45 AM, the Director of Nursing (DON) confirmed NA-L was hired in (MONTH) of 2013 and was placed in a Nurse Aide course associated with the facility. The class had been taught in South Dakota and the facility failed to identify NA-L was not a part of the Nebraska Nurse Aide Registry until 5/13/14. | 2018-07-01 |
| 7274 | 7274 | GOOD SAMARITAN SOCIETY - RAVENNA | 285202 | 411 WEST GENOA | RAVENNA | NE | 68869 | 2015-03-11 | 167 | C | 0 | 1 | IJQR11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 Based on confidential resident interview and observation; the facility failed to post a notice of the availability of the most recent survey results in an area noticeable to both residents and facility visitors. Facility census was 38. Findings are: During a confidential resident interview on 3/11/15 at 10:32 AM it was revealed the resident was unaware of where the survey results were posted. Observations of the facility from 10:45 AM-3:45 PM revealed the survey results to be found in a white binder placed inside a plastic bin hanging on the wall. The label that identified the binder to contain past survey results was not visible as the binder was turned backwards. There was no additional postings to inform residents and/or visitors of where the survey results were kept. | 2018-05-01 |
| 7319 | 7319 | MILLER MEMORIAL CARE CENTER, LLC | 2.8e+296 | P O BOX 428, 589 VINCENT AVENUE | CHAPPELL | NE | 69129 | 2015-01-15 | 356 | C | 0 | 1 | 1KRK11 | Based on observations and staff interview, the facility failed to ensure that daily nursing staff posting was accurate and easily accessible to the public. This had to potential to affect all residents. The facility census was 17. Findings are: Observations on 1/13/15 at 9:40 AM, during the initial tour of the facility, revealed that the daily staff posting was located on an inside wall at the nurses station which was not easy to see when standing at the nurses station counter. Further observation showed that the posting included the DON (Director of Nursing) who was not working that day. Interview on 1/15/15 at 9:30 AM with the Administrator confirmed that the staff posting was not easily accessible to the public. Further interview confirmed that the posting was not accurate on 1/13/15 as the DON did not work that day. | 2018-05-01 |
| 7560 | 7560 | GOOD SAMARITAN SOCIETY - ALLIANCE | 285174 | P O BOX 970, 1016 EAST 6TH STREET | ALLIANCE | NE | 69301 | 2015-10-20 | 356 | C | 1 | 0 | X9MJ11 | Based on record reviews and interviews, the facility failed to record evening shift direct care nursing staff members on duty and actual hours worked on the required staff posting documents utilized for public view. This posting has the potential to mislead all residents and visitors that might review the posting. Facility census was 38. Findings are: Record review of October 2015 weekend direct care nursing staff posting forms in comparison with nursing staff schedules and time card records revealed the following discrepancies: - 10/3/15 staff posting recorded one NA (Nurse Aide) worked 7.5 hours and one Medication Aide worked 7.5 hours for the 2 p.m. to 10 p.m. shift. This totaled two direct care staff working 15 hours. Comparison with time card records revealed MA (Medication Aide)-A; MA-C; MA-E; NA-B; NA-D; and NA-F all worked the evening shift for a total of 32.25 hours. - 10/10/15 staff posting recorded one NA worked 7.5 hours and one MA worked 4 hours (6p.m.-10 p.m.) for the 2 p.m. to 10 p.m. shift. This totaled two direct care staff working 11.5 hours. Comparison with time card records revealed revealed MA-H; MA-I; MA-J; and NA-G all worked the evening shift for a total of 24.5 hours. - 10/11/15 staff posting recorded three NA's worked 22.5 hours and one MA worked 4 hours (6-10 p.m.) for the 2 p.m. to 10 p.m. shift. This totaled four direct care staff for a total of 26.5 hours. Comparison with time card records revealed MA-A; MA-H; NA-B; and NA-G all worked the evening shift for a total of 23.25 hours. - 10/17/15 staff posting recorded one MA worked 7.5 hours on the 2 p.m. to 10 p.m. shift, totaling one direct care staff working 7.5 hours. Comparison with time card records revealed MA-A; MA-C ; NA-D; and NA-G all worked the evening shift for a total of 20.25 hours. - 10/18/15 staff posting recorded one MA worked 7.5 hours on the 2 p.m. to 10 p.m. shift totaling one direct care staff working 7.5 hours. Comparison with time card records revealed MA-A; MA-C; NA-B; NA-G; and NA-D all worked the evening shift … | 2018-02-01 |
| 7617 | 7617 | HILLCREST CARE CENTER | 285178 | 702 CEDAR AVENUE | LAUREL | NE | 68745 | 2014-07-23 | 356 | C | 0 | 1 | 9RA811 | Based on observations, review of Nurse Staffing Information and staff interview; the facility failed to retain and post the required staffing data. This had the potential to affect all residents in the facility. Facility census was 25. Findings are: Observations of the Nurse Staffing Information revealed the following: -7/21/14 at 6:50 AM, the census was 26. -7/22/14 from 6:50 AM until 2:45 PM, the census was 26 and the day shift (6:00 AM-2:00 PM) staff was listed. The evening staff, whom had begun the evening shift at 2:00 PM, was not listed on the dry erase board. -7/23/14 from 6:50 AM until 3:15 PM, the census was 26 and the day shift staff was listed. The evening staff, whom had begun the evening shift at 2:00 PM, was not listed on the dry erase board. During an interview with the Administrator on 7/21/14 at 7:11 AM, it was verified the actual census was 25 as 1 resident was currently in the hospital. During an interview with the Director of Nursing on 7/22/14 at 10:00 AM, it was revealed the Business Office Manager kept copies of the records reflecting the names of staff and the hours worked. During the same interview, the Business Office Manager revealed this information was not recorded outside of being written on the dry erase board daily. Therefore, the records were not kept for the required 18 months. | 2018-02-01 |
| 7758 | 7758 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2014-05-12 | 156 | C | 0 | 1 | 7XFG11 | LICENSURE REFERENCE NUMBER NAC 12-006.06C Based on resident and staff interviews, record review and observations, the facility failed to make the ombudsman's information readily available to residents and/or responsible parties. The census was 37. Findings Are: A. During an interview on 5/7/14 at 2:00 PM the Resident Council president voiced that it was not known where the ombudsman's information was posted and/or who the ombudsmen was. During confidential interviews on 5/7/14 at 2:19 PM and 5/8/14 at 9:54 AM, 2 residents stated they were unaware of who the ombudsmen was or where the ombudsman's information was posted. During an interview with the Activity Director, Social Services Director and the Administrator, on 5/8/14 from 10:48 AM until 11:27 AM, it was revealed the ombudsmen visits the facility every 3 months, but staff were unaware if the ombudsmen spoke with residents during these visits. Review of the Resident Council Meeting Minutes from November 2012 through April 2014, revealed staff did not inform residents of who the ombudsman was or where the information for the ombudsman could be found. Observations on 5/8/14 at 11:38 AM revealed a sign measuring 8 inches x 10 inches posted in the hallway next to the activity room in an enclosed case, approximately 5 foot above the floor, inaccessible to residents in wheelchairs, with information on how to contact the ombudsman. | 2018-01-01 |
| 7918 | 7918 | CROWELL MEMORIAL HOME | 285210 | 245 SOUTH 22ND STREET | BLAIR | NE | 68008 | 2014-09-17 | 170 | C | 0 | 1 | QMIV11 | Licensure Reference Number 12-006.05(12) Based on interview and record review; the facility staff failed to ensure that mail was delivered within 24 hours after the mail was delivered to the facility. This had the potential to affect all residents that resided in the facility. The facility census was 64. Findings are: Interview on 9/16/14 at 10:09 AM with the facility Resident Council President (RCP) revealed that the residents don't get mail on Saturdays or on the weekends. The RCP stated that the Activity Director sorts and delivers the mail during the week but not on weekends. Interview on 9/16/14 at 10:41 AM with the Activity Director confirmed that mail was not delivered to residents on the weekends. Record review of a facility Policy and Procedure on mail delivery revealed that mail would be delivered to the resident within 24 hours of delivery on the premises. Interview on 9/16/14 at 11:12 AM with the Associate Administrator (AA) confirmed no mail delivery to the residents on the weekends. The AA stated that the mail comes to the post office on Saturdays because it's open but we don't get it delivered here and we don't have anybody go pick it up on Saturday. Interview on 9/16/14 at 11:20 AM with the Director Of Nursing confirmed there was no mail delivery on weekends and no one from the facility goes to pick it up at the post office. Interview on 9/16/14 at 11:27 AM with the town Postmaster confirmed that the Post Office is open on Saturdays and that mail is available for pickup at the Post Office on Saturday AM. | 2017-12-01 |
| 7929 | 7929 | LOUISVILLE CARE CENTER | 285267 | 410 WEST 5TH STREET | LOUISVILLE | NE | 68037 | 2014-05-05 | 156 | C | 0 | 1 | WLGK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC ,[DATE].05 (4) Based on record review and interview, the facility failed to ensure residents were informed of changes in the facility's policy and procedures for CPR (Cardiopulmonary Resuscitation - Using rescue breathing and chest compressions to help a person whose breathing and heartbeat have stopped) which had the potential to impact all of the resident's or their legal representatives' decisions regarding their CPR status. The facility census was 58. Findings are: Interview with LPN (Licensed Practical Nurse) C on [DATE] at 3:03 PM revealed residents are asked their preference for the initiation of CPR if needed upon admission and an advance directive form is signed and placed in the residents chart. Review of a blank undated form titled Advanced Directives revealed, Do Not Resuscitate - What would you want us to do in the event facility staff find you without a heart beat and/or not breathing? (First option) I want facility staff to begin CPR and/or call 911. (Second option) I want the facility staff NOT to begin CPR. Residents and/or their responsible parties are to check which option they prefer and sign their names. Interview with the Director of Nursing Services on [DATE] at 3:30 PM revealed the facility had changed their policy and procedure for CPR to reflect that CPR would not be initiated if obvious signs of death were present when the need for CPR was identified. Review of the facility's policy titled, CPR/No CPR status and revised on [DATE] revealed the following, In the event of cardiac and/or respiratory arrest, a yes to CPR would then initiate the following: CPR will start immediately and a call to 911 will be placed A nurse is not expected to perform resuscitation on an individual when obvious signs of death are present. Obvious signs of death include lividity (bluish colored tissue) or pooling of blood in dependent body parts, cooling of the body following death, hardening of muscles or… | 2017-12-01 |
| 8067 | 8067 | SOUTH HAVEN LIVING CENTER | 285231 | 1400 MARK DRIVE | WAHOO | NE | 68066 | 2014-07-24 | 356 | C | 0 | 1 | HF2B11 | Based on observation and interview, the facility failed to post the hours for the nursing staff as required. This had the potential to affect all facility residents. The facility census was 68. Findings are: Observation during all days of the survey revealed plastic frames containing two forms. The form facing the nurses station was titled Staffing Daily Schedule and listed the names of staff members working that day organized by units and shifts. The form in the reverse side of the plastic frame was titled by the name of the unit it was posted on and was organized by shifts and job titles with a blank space for hours. None of the blank spaces for the hours had be filled in. Interview with the Administrator on 7/28/14 at 11:22 AM revealed that staff were supposed to put the hours worked on the form every shift and that it should be facing the public and not that staff when completed. | 2017-11-01 |
| 8163 | 8163 | FRANKLIN CARE AND REHABILITATION CENTER, LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2014-07-22 | 356 | C | 0 | 1 | PU0F11 | Based on observation, record review and interview, the facility failed to post the nursing staff hours to be accessible to the residents and visitors. This had the potential to affect all residents. The facility census was 25 at the time of the survey. Findings are: During an entrance tour of the facility on 7/16/2014 at 8:30 AM revealed the nursing staff hours were not posted. Tour of the facility on the following dates: -7/17, -7/21, -7/22 , found no posted nursing hours. Record review revealed the facility had no documented evidence of nursing hours being posted. Interview on 7/22/2014 at 9:37 AM with the DON (Director of Nurses) revealed the facility did not have the nursing hours posted. | 2017-10-01 |
| 8447 | 8447 | MT CARMEL HOME- KEENS MEMORIAL | 285216 | 412 WEST 18TH STREET | KEARNEY | NE | 68847 | 2014-05-07 | 356 | C | 0 | 1 | RVPT11 | Based on observation and interview, the facility failed to post the nursing staff hours to be accessible to the residents and visitors. The facility census was 68 at the time of the survey. Findings are: During an entrance tour of the facility on 4/30/2014 at 7:45 AM revealed the nursing staff hours were not found. During the survey process at the facility on 5/1/2014 did not find the nursing staff hours posted. Interview with the DON (Director of Nurses) on 5/6/2014 at 1:25 PM revealed the nursing staff hours were posted over the water fountain outside the DON's office. This area was located behind two turning card racks. The DON guessed the board was probably 5 feet off the floor. The posting of the nursing staff hours were not accessible to residents and families. | 2017-06-01 |
| 8515 | 8515 | GOOD SHEPHERD LUTHERAN HOME | 285148 | 2242 WRIGHT STREET | BLAIR | NE | 68008 | 2014-05-08 | 356 | C | 1 | 1 | 05IK11 | Based on observation and interview; the facility staff failed to post nurse staffing information in the facility. The facility census was 79. Findings are: Interview on 5/7/14 at 12:15 PM with the Assistant Administrator (AA) revealed that the facility staff used the information found at 42 Code of Federal Regulations (CFR) 483.30 related to Nursing services as their policy and procedure that should be followed. Record review of a regulation review that covered nursing services printed off of the Internet website HTTP://www.law.cornell.edu/CFR/text/42/483.30 revealed the following regulations related to nurse staffing information: (1) Data Requirements: The facility must post the following on a daily basis: Facility name. The current date. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. - Registered nurses - Licensed practical nurses or licensed vocational nurses - Certified Nurse Aides Resident census. (2) Posting requirements: (1) The facility must post the nurse staffing data specified in paragraph 1 of this section on a daily basis at the beginning of each shift. (2) Data must be posted as follows: (a) Clear and readable format. (b) In a prominent place readily accessible to residents and visitors. (3) Public access to nurse staff data. The facility must ,upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. (4) Facility data retention requirements: The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by state law, whichever is greater. Observation on 5/5/14 at 11:00 AM during the initial tour of the facility revealed no posted nurse staffing information present in the facility. Observation on 5/6/14 at 3:30 PM and 5/7/14 at 12:00 PM during the annual survey revealed no posted nurse staffing information present in the facility. Interview on 5/5/14 at 11:30 AM … | 2017-05-01 |
| 8548 | 8548 | AZRIA HEALTH MIDTOWN | 285218 | 910 SOUTH 40TH STREET | OMAHA | NE | 68105 | 2014-04-29 | 170 | C | 0 | 1 | D6XM11 | Llicensure Reference Number 175 NAC 12-006.05(12) Based on record review and interview the facility failed to deliver mail to residents on Saturday's. This had the potential to affect all of the residents in the facility. The facility census was 47. Findings are: Interview on 4/21/14 at 10:30 AM with the Resident Council President stated the mail was not delivered to the residents on Saturday's. Interview on 4/22/14 at 12:15 PM with the Administrator stated staff working Saturday's had not been informed they were to deliver the mail to the residents if any was delivered on Saturdays. He said it had been discussed after he first hired on at the facility but had not been implemented. At that time there was no policy/procedure for mail delivery. Record review on 4/28/14 at 3:00 PM revealed that a policy/procedure had been developed on 4/28/14 to ensure mail delivered to the facility on Saturday's would be passed onto the rightful resident that day. | 2017-05-01 |
| 8700 | 8700 | GOOD SAMARITAN SOCIETY - ALLIANCE | 285174 | P O BOX 970, 1016 EAST 6TH STREET | ALLIANCE | NE | 69301 | 2014-03-20 | 356 | C | 1 | 0 | 79411 | Based on record review and interviews, the facility failed to: post daily required staffing information for view by all residents, family, staff, and visitors. Facility census was 53. Findings are: During an entrance tour of the facility on 3/20/14 at 9:00 a.m. a clipboard was observed by the Health Information office. Further observation of the clipboard revealed the Daily Nursing Staffing form had been posted on the clipboard and was dated 3/5/14. The facility census was listed on 3/5/14 as 48. The Interim Director of Nursing was consulted on 3/20/14 at 9:30 a.m. following the observation and verified by interview the clipboard was the assigned place where daily facility staffing hours and facility census were posted and confirmed the posting was not current or accurate, being over two weeks old. | 2017-03-01 |
| 9142 | 9142 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2013-01-10 | 356 | C | 0 | 1 | UMQM11 | Based on observation and interview, the facility failed to post nurse staffing information in an area that was available to all residents and visitors and categorized as required by regulation. The nurse staff information was posted at the door of the Nursing office and can be viewed. The nursing office is not located in an area that is available to all residents and visitors. The information on the nurse staffing is not broken into categories for RN, LPN and CNA's as required by regulation. The categories were identified as licensed nurses and nurse aids. | 2016-10-01 |
| 9151 | 9151 | BLUE HILL CARE CENTER | 285144 | 414 NORTH WILLSON | BLUE HILL | NE | 68930 | 2013-06-19 | 170 | C | 0 | 1 | 48D811 | Licensure Reference Number: 175 NAC 12-006.05 (12) Based on record review and interviews, the facility failed to deliver mail to the residents on the weekend. This failure could potentially affect all residents of the facility. Facility census was 31. Findings are: A. Interview with the Resident Council President (Resident 20) on 6/17/13 at 9:56 AM revealed that residents were not receiving mail delivery on Saturday or Sunday. Resident 20 reported not getting the resident's Mother's Day card until after Mother's Day as a result of the mail not being delivered on the weekend. Resident 20 reported that the SSD (Social Services Director) usually delivered the mail but nobody was delivering it on the weekends (Saturdays or Sundays). B. Interview on 6/17/13 at 11:58 AM with the SSD confirmed that the SSD was responsible to pick up/deliver resident mail. The SSD revealed that the SSD had not been getting/delivering the Saturday mail to residents until Monday since sometime during the winter. The SSD reported not being aware if the facility had a policy on how mail would be delivered to residents on the weekends. C. Interview on 6/17/13 at 12:03 PM with the Office Manager confirmed that all of the facility mail (including resident mail) was delivered to a post office box at the post office. The Office Manager was not sure which facility staff had the keys to get the box open. The Office Manager reported that mail delivery was usual and customary to citizens in the community on Saturdays, therefore the facility was probably receiving mail for residents in the post office box on Saturdays. The Office Manager was not aware of the facility having any policies, procedures or schedules regarding the receipt/delivery of mail to residents on the weekends. D. Interview on 6/17/13 at 12:19 PM with the ADM (Administrator) confirmed the ADM was not sure who was responsible to pick up/deliver resident mail on the weekends. The ADM confirmed that the facility had no documentation as to how the weekend mail delivery would be handled. | 2016-10-01 |
| 9153 | 9153 | BLUE HILL CARE CENTER | 285144 | 414 NORTH WILLSON | BLUE HILL | NE | 68930 | 2013-06-19 | 225 | C | 0 | 1 | 48D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview; the facility failed to implement the Abuse/Neglect policy and procedure by failing to screen new employees prior to allowing employees to work. The facility had a census of 31. The failure to implement Abuse/Neglect prohibiting policies and procedures such as failing to screen new employees had the potential to affect all residents in the facility. Findings are: A. Review on 6/17/13 of the facility FIVE STAR ABUSE PREVENTION/PROHIBITION PROGRAM NE (dated 1/16/08) revealed: 5.1 EMPLOYEE SCREENING FOR PREVENTION OF ABUSE ALL potential employees will be screened for history of abuse, neglect or mistreatment of [REDACTED]. Department manager will complete reference checks Pre-employment criminal background check ALL prospective employees checked through the Nurse Aide Registry Licensing Boards for licensed staff APS (Adult Protective Services)/CPS (Child Protective Services) B. Review on 6/17/13 of employee screening for the DON (Director of Nursing) confirmed a date of hire of 4/22/13. Review of the KROLL CLIENT INFORMATION for the DON confirmed that the Pre-employment criminal background check was done on 4/24/13 (2 days after hire). Interview on 6/17/13 at 2:54 PM with the Office Manager confirmed that the Office Manager thought the background checks were completed by the corporate office before the date of hire. The Office Manager confirmed that the DON would have been working with all facility residents in the 2 day lapse between date of hire and the criminal background checks. C. Review on 6/17/13 of employee screening for NA-T (Nurse Aide) confirmed a date of hire of 3/5/13. Review of the credentialing information confirmed that the Nurse Aide Registry and License Information was not completed until 3/8/13. Interview on 6/17/13 at 3:03 PM with the Office Manager confirmed that the Office Manager thought the college certificate of passing the nurse aide class would suffice as proof of… | 2016-10-01 |
| 9159 | 9159 | BLUE HILL CARE CENTER | 285144 | 414 NORTH WILLSON | BLUE HILL | NE | 68930 | 2013-06-19 | 354 | C | 0 | 1 | 48D811 | LICENSURE REFERENCE 175 NAC 12-006.04C2 Based on record review and staff interview, the facility failed to ensure that a RN (Registered Nurse) was on duty in the facility for at least 8 consecutive hours a day, 7 days a week as required. The facility census was 31 at the time of the survey and the survey sample size was 31. Findings are: A. Interview on 6/17/2013 at 2:15 PM with the DON (Director of Nursing) revealed that (gender) was not aware that the facility needed RN coverage 8 hours a day, 7 days a week. The DON confirmed that there were days when no RN was in the building during the months of April, May and June 2013. B. Interview on 6/17/2013 at 2:52 PM with the DON revealed (gender) first day in the facility was 4/22/2013. Review of the facility Nursing Schedule for April 2013 revealed that there was no documented evidence that the DON was working in the month of April 2013. C. Review of the facility Nursing Schedules for April 2013 revealed that there was no RN coverage 8 hours a day, 7 days a week as required on 4/7, 11, 12, 16, 21, 22, 27 and 28/2013. D. Review of the facility Nursing Schedules for May 2013 revealed that there was no RN coverage on 5/12/2013, only 4 hours of RN coverage on 5/18/2013 and only 6 hours of RN coverage on 5/24/2013. E. Review of the facility Nursing Schedules for June 2013 revealed that there was no RN coverage 8 hours a day, 7 days a week as required on 6/1, 2, 5, 6, 8, 15 and 16/2013. F. Interview on 6/17/2013 at 2:30 PM with the Administrator revealed that facility did not always have RN coverage, 8 hours a day, 7 days a week as required. The Administrator stated that (gender) was in charge of nursing scheduling. | 2016-10-01 |
| 9537 | 9537 | GOOD SAMARITAN SOCIETY - ATKINSON | 285177 | 409 NEELY STREET | ATKINSON | NE | 68713 | 2012-12-17 | 356 | C | 0 | 1 | 0JR611 | Based on observations, record review and staff interview; the facility failed to assure nurse staffing information was posted daily. In addition, review of nurse staffing information from 12/1/12 through 12/17/12 revealed there were no records for 12/4/12, 12/7/12 and 12/17/12. Sample size was 31 and facility census was 48. Findings are: A. Observation on 12/12/12 at 7:29 AM revealed nurse staffing information was posted on the bulletin board outside the Director of Nurses (DON) office. The posting was dated 12/11/12. There was no nurse staffing information for 12/12/12. B. Observation on 12/12/12 at 9:25 AM revealed the nurse staffing information dated 12/11/12 had been removed. There was no nurse staffing information posted at 9:15 AM, 10:00 AM, 11:39 AM and 2:00 PM on 12/12/12. C. Observation on 12/13/12 at 7:50 AM revealed nurse staffing information posted on the bulletin board was dated 12/12/12. There was no nurse staffing information posted for 12/13/12. D. Observation on 12/17/12 at 9:00 AM and 11:30 AM revealed there was no nurse staffing information posted on the bulletin board. E. Review of facility nurse staffing information records from 12/1/12 through 12/17/12 revealed there were no records available for 12/4/12, 12/7/12 and 12/17/12. F. Interview with the DON on 12/17/12 from 1:59 PM until 2:02 PM revealed the nurse staffing information was supposed to be posted on the bulletin board. The DON indicated the charge nurse on the night shift was responsible for completion of the nurse staffing information. The DON verified there was no record of the nurse staffing information for 12/4/12 and 12/7/12. | 2016-07-01 |
| 9605 | 9605 | SKYVIEW AT BRIDGEPORT | 285224 | 505 O STREET | BRIDGEPORT | NE | 69336 | 2013-06-26 | 356 | C | 0 | 1 | NDZV11 | Based on observation, record review, and interview; the facility failed to post daily direct care staffing information accessible for review by residents, families, and visitors. Facility census was 36. Findings are: An entrance tour of the facility conducted on 6/24/13 at 10:45 a.m. revealed the facility posting board by the nurse's station had last posted direct care staffing of the facility on 6/22/13. A second observation of the facility posting board by the nurse's station on 6/24/13 at 3:30 p.m. revealed no postings for direct care staffing were posted since 6/22/13. Record review of facility staff posting forms revealed no forms were completed or posted for 6/23/13 and 6/24/13. Interview with the Director of Nursing on 6/25/13 at 3:00 p.m. stated the facility charge nurse's were responsible to complete and post the staffing of direct care staff each shift. The Director of Nursing stated the posting forms are posted on the posting board by the nurse's station and the original forms are kept in a plastic folder on the posting board or in the Director's office. The Director of Nursing confirmed the facility had not posted the direct care staff posting forms fro 6/23/13 or 6/24/13. | 2016-07-01 |
| 9613 | 9613 | RIDGECREST REHABILITATION CENTER | 285239 | 3110 SCOTT CIRCLE | OMAHA | NE | 68112 | 2013-05-20 | 456 | C | 0 | 1 | ZOWF11 | Licensure Reference Number 12-006.18B3 Based on observation, record review and interview; the facility staff failed to maintain a washing machine in good working condition. The facility census was 34. Findings are: Observation on 5/16/13 at 2:20 PM with the Environmental Supervisor (ES) revealed a large washer that was not operational. Interview on 5/16/13 at 2:20 PM with the ES confirmed that the large washer was broken and had been broken for some time. The ES stated that they were operating the laundry with only 1 small washer to be used for all of the residents personal items and all of the facility towels and linens. Interview on 5/20/13 at 8:30 AM with the facility Administrator (ADM) revealed that the facility staff had the large washing machine repaired in January of 2013 but that it was still not operational. The Administrator confirmed there had been no follow up since February 6th, 2013. The facility ADM stated that the large washing machine had been broken since the ADM was hired in August of 2011. Record review of a paid invoice revealed that the processor board on the washing machine had been replaced in January 2013. Record review of written estimates revealed that the last estimates received were February 6th 2013. | 2016-07-01 |
| 9626 | 9626 | IMPERIAL MANOR NURSING HOME | 285252 | P O BOX 757, 933 GRANT STREET | IMPERIAL | NE | 69033 | 2013-03-21 | 167 | C | 0 | 1 | FQV511 | Licensure Reference Number: 175 NAC 12-006.08 Based on observations and interview, the facility failed to post signage to identify the location of survey results and to direct residents and/or families to the location of the documents. Facility census was 37. Findings are: During initial tour observations conducted on 3/19/13 at 11:30 a.m. revealed the state survey results were attached to the wall by the Social Services office. The observation revealed there was no signage or posted information directing residents and/or family members to the location or identifying the documents as state survey results. Observation on 3/21/13 at 9:30 a.m. revealed the state survey results remained attached to the wall by the Social Services office without any signage or posted information directing residents and/or family members to the location or identifying the documents as state survey results. Interview with the Social Services Director on 3/21/13 at 9:30 a.m. confirmed the survey results were not identified by posting or signage to direct residents and/or family members to the location of the survey. | 2016-07-01 |
| 9631 | 9631 | IMPERIAL MANOR NURSING HOME | 285252 | P O BOX 757, 933 GRANT STREET | IMPERIAL | NE | 69033 | 2013-03-21 | 356 | C | 0 | 1 | FQV511 | Based on observations and interviews, the facility failed to post staffing information in a readable format for residents and/or family members to review. Facility Census was 37. Findings are: Observation on 3/19/13 during the facility initial tour at 11:30 a.m. the facility staffing information was observed on a bulletin board by the nurse's station. Further observation of the form revealed the form was posted six to seven feet from the floor. The form was observed to be faded with small print font unreadable beyond six to twelve inches from the board. A second observation on 3/21/13 at 9:25 a.m. revealed the staffing information was posted on the bulletin board by the nurses station at a height of six to seven feet from the floor in a faded small print font unreadable beyond six to twelve inches from the board. An interview with the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) Coordinator at the time of the observation confirmed that resident's and/or family members in wheelchairs or passing by would be unable to identify the form as staffing information. The MDS Coordinator also confirmed the form was faded and unreadable at normal walking distances. | 2016-07-01 |
| 9666 | 9666 | CARL T CURTIS HEALTH EDUCATION CENTER NURSING HOME | 28A065 | P O BOX 250 | MACY | NE | 68039 | 2013-03-04 | 356 | C | 0 | 1 | IO5F11 | Based on observation and record review, the facility staff failed to identify hours worked by Licensed Nurses or Nursing Assistants on posted nurse staff information. The practice had the potential to affect all residents. The survey sample was 19 and the facility census was 20. Findings are: A. Observation on 2-27-2013 at 2:30 PM with the facility Director of Nursing (DON) of the facility Staff posting. Observation of the staff posting revealed the information did not identify Registered Nurse hours worked, Licensed Practical Nurse hours worked or the Nursing assistant hours worked. Interview with the DON on 2-27-2013 at 2:30 PM was conducted. The DON confirmed the Nursing hours and the Nursing Assistant hours were not identified on the information sheet. | 2016-07-01 |
| 9839 | 9839 | GOOD SAMARITAN SOCIETY - BLOOMFIELD | 285156 | P O BOX 307, 300 NORTH SECOND ST | BLOOMFIELD | NE | 68718 | 2012-11-05 | 253 | C | 0 | 1 | 96V811 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A1 Based on observations and staff interview; the facility failed to maintain a functional, sanitary environment as bathroom air return vents contained a dust residue, resident room and bathroom doors had wood splintered and/or gouged, walls and heating units were rusty, paint chipped or gouged; and the caulking around sinks and toilets were cracked and stained. This affected 26 resident rooms (101, 102, 105, 106, 107, 109, 201, 202, 206, 207, 208, 209, 301, 302, 303, 306, 308, 310,400, 403). Facility census was 45. Findings are: A. During the environmental tour of the facility with the Administrator and the Maintenance Supervisor on 11/5/12 from 9:30 AM until 10:40 AM, the following issues were identified: -The air return vents contained a dust residue in Resident Bathrooms 401, 404, 409, 106, 302, and 306. -The paint chipped metal grates on the heating units contained a brown residue in Resident Rooms 402, 404, and 306. In Room 402 a grate was missing off the heating unit. -The metal cover on the heating unit in Resident Bathroom 404 was paint chipped and marred. The front corner of the cover was bent with a 2 inch sharp piece of metal protruding outward. -The wall next to the heating unit in Resident Room 400 contained a 4 inch by 3 inch hole through the sheetrock. -The wall next to the heating unit in Resident Room 403 contained a 6 inch by 6 inch hole through the sheetrock. -The window drapes in Resident Rooms 105 and 107 were gapping and off of the curtain rods. The cords to open and/or close the curtains did not work. -The caulking around the sink bowls and the base of the toilets was cracked, stained/and or missing in Resident Bathrooms 101, 106, 109, 201, 202, and 206. -The sink bowl in Resident Bathroom 208 had a rough hard paste in an approximate 3 inch area with 4 cracks from the rim to the drain of the sink bowl. -The sink faucet in Resident Bathroom 107 was corroded. The metal base of the faucet had corroded away. -The finish on the toilet seat in Resident… | 2016-05-01 |
| 9861 | 9861 | GOOD SAMARITAN SOCIETY - RAVENNA | 285202 | 411 WEST GENOA | RAVENNA | NE | 68869 | 2013-01-29 | 253 | C | 0 | 1 | 0FOG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.18A(1) 175 NAC 12-006.18B Based on observation, resident interview and staff interview, the facility failed to ensure that the facility was kept clean and in good repair as paint on walls and door frames in resident rooms was gouged, wall paper was observed to be torn in hallway and tiles did not fit together. Clean linen closets on 3 of 4 halls were observed to have dust, debris and cobwebs on the floor. In addition, medications carts were observed to have dust and debris in the corners of the drawers and were in need of cleaning. The facility census was 41 at the time of the survey and the survey sample size was 43. Findings are: A. Observations on the following dates, times and Rooms were noted: Room 218-1/17/2013 at 11:40 AM: had several holes in the wall above the wall heater. Resident 2 stated that the grill that covered the heater had fallen off the wall and had not been put back up again. Resident 2 stated that needed to have the grill replaced to cover the heater. Room 218-1/29/2013 at 10:00 AM: had gouge in the paint on the bathroom wall and the grill covering the heater was still loose and not positioned correctly over the heater. The Maintenance Man stated that (gender) was not aware that the grill was loose and needed to be reattached to the wall. Room 214-1/22/2013 at 12:18 PM: had gouges in the paint behind the bedside dresser and on the wall by the bed. Room 206-1/22/2013 at 12:22 PM: walls in the bathroom have black marks along the sides and gouges in the paint, bathroom door was splintered along the bottom and black marks were noted along the room side by the bathroom door. Room 208-1/22/2013 at 12:32 PM: wall of the bathroom had gouges out of the paint, bathroom door frame paint was chipped and had been scratched, Room 208-1/29/2013 at 9:55 AM: wall by Bed 2 had gouges and scrapes in the paint. Room 216-1/22/2013 at 3:13 PM: wall outside of the bathroom had gouges and paint off in places a… | 2016-05-01 |
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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 );