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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1500 | 1500 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2019-03-19 | 880 | D | 1 | 0 | YCLW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER175 NAC 12-006.17B. Based on observation, interview and record review; the facility failed to implement isolation precautions/procedures to prevent the spread of infection for one Resident 1, who was diagnosed with [REDACTED]. [MEDICAL CONDITION] is a contagious microorganism (spore) that has the potential to survive for 5 months on inanimate (not alive) surfaces and can be spread by person to person contact or by direct contact with contaminated objects and surfaces for example clothing, door handles, equipment, privacy curtains and faucets). This had the potential to effect 3 out of 5 residents sampled (Residents 2, 3, and 4). The facility also failed follow its Transmission Precaution: Contact Policy related to Cohorting residents with the same infectious microorganisms this had the potential to effect 2 residents (Resident 1 and 2). The facility census was 73. Findings are: [NAME] Observation with the DON (Director of Nursing) on 03/19/19 at 10:09 AM revealed; Resident 1 was lying in bed with red bag/boxes located at the foot of the bed with the privacy curtain rested against the red bag. Record review of Resident 1's Admission Record revealed; admitted d of 11/25/15 and [DIAGNOSES REDACTED]. introduction of food). Record review of Initiating Isolation Procedures Policy dated 10/01/09 revealed; the Purpose was to provide a safe environment, isolation precautions will be initiated when there is reason to believe that a resident has an infectious or communicable disease. To provide a physical, mechanical, or chemical barrier between resident and staff, other residents has an infectious or communicable disease. Record review of Transmission Precautions: Contact Policy dated 10/01/09 revealed; In addition to standard precautions, contact precautions are used for resident known or suspected to be infected or colonized with epidemiological important microorganisms that can be transmitted by direct contact with reside… | 2020-09-01 |
| 1501 | 1501 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2019-04-16 | 550 | E | 0 | 1 | 19PP11 | Licensure Reference Number 175 NAC 12-006.05(21) Based on observation and interview, the facility failed to ensure that resident's dignity was maintained during the dining experience by placing clothing protectors on residents without gaining permission. This had the potential to affect 8 residents (Resident 14, 17, 27, 40, 41, 42, 49, 58 and 65) of 13 residents that ate in the assisted dining area. The facility census was 69. Findings are: An Observation on 04/10/19 at 11:41 of Assisted dining area revealed that NA (Nursing Assistant) B, placed clothing protectors on the following residents; Resident 14, 17, 27, 40, 41, 49, 58, and 65 without asking the resident if they would like to wear one. Observation on 04/10/19 at 11:47 AM of OT D (Occupational Therapy) who donned gloves to assist Resident 14 to eat. An observation on 04/11/19 11:20 AM of NA B who applied clothing protectors to the following residents; Resident 14, 41, 42, 49, and 58 without asking the residents if they would like to wear one. An observation on 4/11/19 at 11: 45 AM of NA A who had assisted Resident 34 with meal preparation without gloves donned, picked up the residents pop can and tossed the can in the trash. NA A then retrieved food from the hot cart and took it to Resident 42. Hand washing had not been performed after tossing the pop can in the trash and prior to food delivery for Resident 42. An interview on 04/15/19 at 04:42 PM with the DON (Director of Nurses) confirmed that you need to ask permission prior to placing clothing protector on the resident and that it was to maintain a resident ' s dignity. An interview on 04/15/19 at 04:44 PM DON confirmed that the only time staff was to wear gloves is if they were touching an item that was ready to eat such as bread or a sandwich. | 2020-09-01 |
| 1502 | 1502 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2019-04-16 | 582 | D | 0 | 1 | 19PP11 | Licensure Reference Number 175 NAC 12-006.05(1) Based on record review and interview, the facility failed to ensure that 1 (Resident 70) of 3 residents reviewed for Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) were offered a choice to have a Medicare fiscal intermediary review performed to determine if Medicare would continue to pay for skilled services received. The facility census was 69. Findings are: Record review of a Facility Policy entitled Beneficiary Notices dated 12/1/18 revealed the following information: - The SNFABN allows a beneficiary who has Medicare part A coverage to make a decision about whether to receive items or services that they may have to pay for themselves or through other insurance. If the beneficiary or authorized representative requests a decision by Medicare, the facility submits the claim to Medicare for a decision. - 3. Option Boxes: There are 3 options listed on the SNFABN with corresponding check boxes. The beneficiary must check only 1 option box. If the beneficiary is physically unable to make a selection, the SNF may enter the beneficiaries selection at their request and indicate on the notice that this was done for the beneficiary. Otherwise, SNF's are not permitted to select or pre-select and option for the beneficiary. Record review of Resident 70's Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) notice dated 12/20/18 revealed that no box had been selected by the resident or the responsible party to indicate resident choice whether or not to have the medical record reviewed by the fiscal intermediary for a decision for continued coverage for skilled services. Interview on 04/11/19 at 11:16 AM with the facility Social Services Director confirmed that one of the choice boxes on Resident 70's SNFABN should have been marked to indicate their decision wether or not to have the fiscal intermediary review the denial of skilled services received. | 2020-09-01 |
| 1503 | 1503 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2019-04-16 | 584 | D | 0 | 1 | 19PP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-12-006.18A(1) Based on observation and interview, the facility failed to maintain the cleanliness of ventilation system covers in 2 resident bathrooms (resident rooms 119/121 (shared bathroom) and room [ROOM NUMBER]) , failed to maintain the cleanliness of the base of the toilet in 1 resident bathroom (resident rooms 120 / 122 (shared bathroom) and failed to ensure a cleanable surface of a fall alarm mat in room [ROOM NUMBER]. There were a total of 34 occupied resident rooms and 39 resident bathrooms in the facility. The facility census was 69. Findings are: Observation on 04/15/19 between 2:25 PM and 02:49 PM identified the following issues in the environment: - Dark brown stains surrounded the base of the toilet in the shared bathroom in rooms 119 / 121. - Gray fuzzy substance that resembled dust was present on the exterior and interior of the ventilation system cover in the ceiling of room [ROOM NUMBER] and the shared bathroom for rooms 120 / 122. Observation on 04/15/19 at 03:13 PM revealed a fall alarm mat placed and duck taped to the entrance of room [ROOM NUMBER] on the floor. There was also a fall alarm mat duct taped to the floor in front of the recliner. The edges of the duct tape were curled onto each other and there were dark particles of dust and dark grime present on the sticky side of the tape that created an unclean surface. Interview on 04/15/19 at 02:52 PM with the Maintenance Director confirmed the stains present on the base of the toilet in the shared bathroom [ROOM NUMBER] / 121 and that the ventilation covers in the shared bathroom in room [ROOM NUMBER] / 122 and room [ROOM NUMBER] were dust coated and needed cleaning. Interview on 04/15/19 at 03:17 PM with the Maintenance Director confirmed the presence of duct taped fall mats at the entrance of room [ROOM NUMBER] and in front of the recliner in room [ROOM NUMBER]. The MD confirmed that the exposed sticky sides of the duct tape were… | 2020-09-01 |
| 1504 | 1504 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2019-04-16 | 622 | D | 1 | 1 | 19PP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 Based on record review and interview, the facility failed to provide in writing to the resident's legal representative a 30 day notice in advance of the discharge from the facility for Resident 372 and failed to notify the resident and the residents representative in writing of the reason for the discharge for Resident 62 out of 2 residents sampled for discharge. The facility census was 69. Findings are: Review of Resident 372's Admission Record dated 4-11-19 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident 372's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1-4-18 revealed the resident had disorganized thinking. The resident had not had any behaviors exhibited during the assessment period in January. Resident 372 required supervision of one staff with transfers, walking, toileting and eating. Review of Resident 372' undated Care Plan revealed the discharge plan was initiated on 5-1-17 and was the resident and family wanted Resident 372 to stay in the facility long term. The resident/family was to be included in any discharge plans and kept updated of any changes during the resident's stay. This intervention was last updated 1-23-18. Social Service would visit with the resident and family to keep them updated and the resident would receive assistance for referrals to appropriate community resources as needed. This intervention was last updated 6-9-17. Review of the PN (Progress Notes) of Resident 372 revealed the resident had a history of [REDACTED]. On 3-4-18 the resident exhibited behaviors towards other residents without any injury resulted and toward staff and the facility transferred Resident 372 via an ambulance to a hospital to be evaluated. The resident was evaluated at the hospital and had not been demonstrating any behaviors at that time so the hospital wanted to send the resident back to the fac… | 2020-09-01 |
| 1505 | 1505 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2019-04-16 | 623 | D | 1 | 0 | 19PP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 Based on record review and interview, the facility failed to provide in writing to the resident's legal representative a 30 day notice in advance of the discharge from the facility for Resident 372 and failed to notify the resident and the residents representative in writing of the reason for the discharge for Resident 62 out of 2 residents sampled for discharge. The facility census was 69. Findings are: Review of Resident 372's Admission Record dated 4-11-19 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident 372's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1-4-18 revealed the resident had disorganized thinking. The resident had not had any behaviors exhibited during the assessment period in January. Resident 372 required supervision of one staff with transfers, walking, toileting and eating. Review of Resident 372' undated Care Plan revealed the discharge plan was initiated on 5-1-17 and was the resident and family wanted Resident 372 to stay in the facility long term. The resident/family was to be included in any discharge plans and kept updated of any changes during the resident's stay. This intervention was last updated 1-23-18. Social Service would visit with the resident and family to keep them updated and the resident would receive assistance for referrals to appropriate community resources as needed. This intervention was last updated 6-9-17. Review of the PN (Progress Notes) of Resident 372 revealed the resident had a history of [REDACTED]. On 3-4-18 the resident exhibited behaviors towards other residents without any injury resulted and toward staff and the facility transferred Resident 372 via an ambulance to a hospital to be evaluated. The resident was evaluated at the hospital and had not been demonstrating any behaviors at that time so the hospital wanted to send the resident back to the fac… | 2020-09-01 |
| 1506 | 1506 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2019-04-16 | 625 | D | 0 | 1 | 19PP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to send a bed hold letter with one resident, Resident 62, to the hospital on 3 different hospitalization s, failed to notify the legal representative of the bed hold policy in writing for one resident (Resident 62) with 3 hospitalization s, and failed to notify the legal representative one time for one resident, Resident 62, verbally and ask about the bed hold with a hospitalization . Residents sampled were 4. The census was 69. Findings are: Review of Resident 62's Admission Record dated 4-15-19 revealed [DIAGNOSES REDACTED]. Review of Resident 62's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 3-22-19 revealed the resident had severely impaired cognition and was dependent on one to two staff for transfers, locomotion, toileting, and personal cares. Review of Resident 62's MDS's revealed the resident discharged to an acute hospital with return anticipated on 1-14-19 and returned on 1-16-19. The resident then discharged to an acute hospital with return anticipated on 2-11-19 and returned on 2-14-19. Then again on 3-6-19 the resident discharged to an acute hospital with return anticipated and returned on 3-13-19. Review of Resident 62's PN (Progress Notes) revealed the resident had been hospitalized 3 times since (MONTH) 2019: 3-6-19, 2-11-19, and 1-14-19. Review of the PN at the time of the transfers in January, February, and (MONTH) 2019 revealed absence of documentation of a bed hold letter sent with the resident to the hospital or a written letter sent to the legal representative on all 3 hospitalization s. Further review of the PN revealed on the (MONTH) 11th hospitalization there was absence of documentation of notification to the legal representative at all to ask about the bed-hold. Review of the facility Bed-Hold policy dated 9-1-18 revealed all residents at the time of transfer, the community will notify the resident r… | 2020-09-01 |
| 1507 | 1507 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2019-04-16 | 661 | D | 0 | 1 | 19PP11 | LICENSE REFERENCE NUMBER NAC 12-006.09C3 Based on record review and interview, the facility failed to complete a discharge summary for one resident, Resident 372, out of 2 residents sampled. The census was 69. Findings are: Record review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 3-4-18 revealed the resident was discharged . Review of the progress notes dated 3-4-18 revealed Resident 372 was transferred and admitted to a hospital for an overnight observation. Record review on 4-11-19 at 1:30 PM revealed absence of a discharge summary for Resident 372. Interview on 4-11-19 with the DON (Director of Nursing) confirmed a discharge summary should have been completed in the 'Evaluations' section of the EHR (electronic health record) but confirmed the discharge summary had not been completed. | 2020-09-01 |
| 1508 | 1508 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2019-04-16 | 684 | D | 1 | 1 | 19PP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09 Based on interview, observation and record review; the facility failed to follow Provider ' s orders to promote optimal wound healing for 1 resident (Resident 3) of 4 residents reviewed for wound cares. The facility census was 69. Findings are: An interview on 04/10/19 at 09:00 AM with Resident 3 confirmed that the resident had an amputation. Resident 3 reported a bath time of 615am. Resident 3 reported that at times wound care was not completed for a lengthy time after the bath. An observation on 04/10/19 at 09:00 AM of the left leg wound open to air. Record review with the DON (Director of Nurses) revealed; that in the Month of (MONTH) 2019 omitted treatments for Resident 3's wound care were: Order: Weekly Skin Assessment every Tuesday. This treatment was omitted on (MONTH) 29, 2019. Order: [MEDICATION NAME] Ointment 500Unit/GM(Gram) apply to incision top of leg topically two times a day for surgical wound this treatment was omitted for the Day shift on the 25th and for the evening shift on the 23rd, 25th, ,and 30th. Order: Wash incision line to the left leg twice a day with soap and water, rinse and pat dry apply thin layer of [MEDICATION NAME], pack open areas with [MEDICATION NAME] gauze and cover with Xeroform gauze and wrap with Kerlix and ace wrap for compression. This treatment was omitted on the day shift on (MONTH) 25, 2019 and on the evening shift on (MONTH) 18th, 20th, 21st, 22nd, 26th, 30th, and 31st. Record review with the DON revealed that in the Month of (MONTH) 2019 omitted treatments for Resident 3's wound care were: Order: [MEDICATION NAME] Ointment 500Unit/GM apply to incision top of leg topically two times a day was omitted on the Day shift on (MONTH) 5 and the Evening shift on the 4th. Order: Wash the incision line to the left leg twice a day with soap and water rinse and pat dry. Apply thin layer of [MEDICATION NAME] pack open are with [MEDICATION NAME] gauze and cover wit… | 2020-09-01 |
| 1509 | 1509 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2019-04-16 | 686 | D | 1 | 1 | 19PP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 12-006.D2b Based on observation, record review, and interviews, the facility failed to ensure pressure ulcer treatment was followed per Physician orders [REDACTED]. The census was 69. Findings are: Review of Resident 68's Admission Record dated 4-15-19 revealed a date of admission of 7-23-18 with [DIAGNOSES REDACTED]. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling) to the sacral region. Resident 68's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 3-29-19 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated no cognitive impairment. The resident did require supervision with bed mobility and locomotion. Resident 68 was independent with transfers, personal hygiene, and eating. The resident had a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (piece of dead tissue) may be present. Often includes undermining and tunneling) and a MASD (moisture associated skin damage wound). Review of the undated Physician orders [REDACTED]. Cover the wound with an ABD (highly absorbent pad) pad BID (twice a day) and PRN (as needed) soiling. The order was initiated on 4/8/2019. Observation on 4-10-19 at 9:25 AM of the sacral wound revealed the sacral wound approximate size was 5 x 3 x 0.3 cm (centimeter) with the inferior edge having an undermined edge and the superior edge with white macerated skin above the wound. Observation on 4-10-19 at 9:25 AM of LPN-E (Licensed Practical Nurse) perform the wound treatments to the left and right ischium and sacrum. The wound treatment was also supervised by the DON (Director of Nursing). LPN-E performed the treatment to all 3 wounds and applied the [… | 2020-09-01 |
| 1510 | 1510 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2019-04-16 | 693 | D | 0 | 1 | 19PP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D6(1) Based on observation, record review, and interview, the facility failed to ensure staff checked placement prior to administering enteral nutrition for one resident with an enteral tube (a tube directly in the stomach or colon to administer nutrition and/or medications), Resident 62, out of one resident sampled. The census was 69. Findings are: Review of Resident 62's Admission Record dated 4-15-19 revealed [DIAGNOSES REDACTED]. Review of Resident 62's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 3-22-19 revealed the resident had severely impaired cognition and was dependent on one to two staff for transfers, locomotion, toileting, and personal cares. Observation on 4-10-19 at 12:05 PM revealed LPN-E (Licensed Practical Nurse) administered to Resident 62 a bolus of [MEDICATION NAME] 1.5 formula. LPN-E began by prepping the items then took the cap off of the resident's enteral tube. Next LPN-E connected the 60 cc (cubic centimeter) water filled syringe to the tube and inserted the water without first checking for placement either by auscultation or by checking gastric contents. Once the syringe was empty of the water, LPN-E filled the 60 cc syringe up with the [MEDICATION NAME] 1.5 formula. LPN-E began to let the formula drain into the resident by gravity, but when Resident 62 began to cough and the formula stopped draining, LPN-E placed the syringe plunger into the syringe and forced the remainder of the 45 cc of formula into the resident. LPN-E followed by administering another syringe of water and then capped the enteral tube off. Interview on 4-10-19 at 12:10 PM with LPN-E revealed since the resident was coughing and did not appear to be tolerating the formula, LPN-E would not administer the entire scheduled 237 ml of formula scheduled at this time but would come back soon and finish administering the formula. Review of the undated P… | 2020-09-01 |
| 1511 | 1511 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2019-04-16 | 761 | E | 0 | 1 | 19PP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1 Based on observation, record review, and interview, the facility failed to secure medications received from pharmacy for 7 residents (Resident 56, 2, 62, 35, 63, 64, and 15). The facility census was 69. Findings are: Observation on 04/15/19 at 01:10 PM of Nurse Station #1 revealed 5 sealed gray plastic bags sitting on the nurses' desk with a white receipt from the pharmacy company which listed the medications that were in each bag. There were no staff at the nurses' station or anywhere within site of the bags. While reviewing the contents listed on the reciepts, LPN-E (Licensed Practical Nurse) came up hallway of rooms 111 thought 118 and approached the nurses' station and instructed me to leave the bags along as LPN-E had already sorted them out to where they go. LPN-E then grabbed the bags and placed some of the bags on top of a medication cart directly across from Nurses Station #1 and the rest of the gray pharmacy bags LPN-E carried down the hall to Nurse Station #2 which was out of site of the remaining bags left on the medication cart across from Nurses Station #1. At 1:18 PM LPN-Z entered Nurse Station #1 area and I pointed out the gray pharmacy sacks on top of the medication cart. LPN-Z confirmed the pharmacy sacks were not to be left on top of the cart and LPN-Z removed the sacks into the medication room and secured them. Review of the pharmacy receipts that were attached to the sacks which contained the medications revealed the residents names and the names of the medications, the dosage, and the quantity. The receipts revealed. -Resident 56's Latanoprost eye drop bottle and 57 capsules of [MEDICATION NAME] 100 mg (milligram), an anti-[MEDICAL CONDITION] medication. -Resident 2's Senna 8.6 mg, a laxative medication, 60 tablets. -Resident 62's [MEDICATION NAME] 15 ml (milliliter) bottle, an antipsychotic medication. -Resident 35's Vicoza 3 ml injection for diabetes. -Resident 63's [MEDIC… | 2020-09-01 |
| 1512 | 1512 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2019-04-16 | 880 | E | 0 | 1 | 19PP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12.006.17 Based on observations, record review, and interviews, the facility 1) failed to ensure the potential of cross contamination of [MEDICAL CONDITION] ([MEDICAL CONDITION]: a bacterium that causes diarrhea and [MEDICAL CONDITION]) to other residents by not following the Standard of Practice for [MEDICAL CONDITION] precautions and used hand sanitizer for hand hygiene instead of soap and water for one resident, Resident 62, which had the potential to affect all residents; 2) failed to ensure staff did not cross contaminate while performing wound care for one resident, Resident 68, out of 4 sampled 3) failed to ensure hand hygiene was followed during meal service in the assisted dining area which had the potential to affect all 12 residents in the dining room, Residents 8, 14, 17, 34, 40, 41, 42, 49, 52, 58, 64 and 65; 4) failed to ensure staff performed medication administration without cross contamination for one resident, Resident 37, out of one sampled resident; 5) failed to ensure staff utilized PPE (personal protective equipment) prior to entering an isolation room for one resident, resident 62, out of 2 residents sampled; 6) and failed to ensure staff performed hand hygiene and/or glove procedure according to standard of practice guidelines for 3 residents, Resident 60, 62, and 68 out of 16 residents sampled. The facility census was 69. Findings are: [NAME] Review of Resident 62's Admission Record dated 4-15-19 revealed [DIAGNOSES REDACTED]. Review of Resident 62's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 3-22-19 revealed the resident had severely impaired cognition and was dependent on one to two staff for transfers, locomotion, toileting, and personal cares. Observation on 04/10/19 at 09:00 AM revealed hanging on the outside of Resident 62's room door was a bright yellow bag/container (as used with a resident in isolation) which held … | 2020-09-01 |
| 1513 | 1513 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2019-04-16 | 923 | D | 0 | 1 | 19PP11 | Licensure Reference Number 175 NAC12-007.04D Based on observation and interview, the facility failed to maintain a working ventilation system in 2 (Resident rooms 101 / 103 and 119 / 121) of 11 shared bathrooms in the facility. There were a total of 34 occupied resident rooms and 39 resident bathrooms in the facility. The facility census was 69. Findings are: Observation on 04/15/19 between 2:25 PM and 02:49 PM identified that the facility ventilation system would not draw a 1 ply square of toilet paper when placed against the surface of the ventilation cover in the bathroom ceilings in shared resident bathrooms in rooms 101 / 103 and 119 / 121. This was an indication that the ventilation system was not operational at the time of the observation. Interview on 04/15/19 at 02:52 PM with the Maintenance Director (MD) confirmed that the ventilation system on the 100 hall was not working in rooms 101 / 103 and 119 / 121. The MD confirmed that they are checked on a regular basis but that information was not documented. The MD was unable to determine a recent date when the ventilation system had been checked for operation. | 2020-09-01 |
| 1514 | 1514 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2019-05-20 | 609 | D | 1 | 0 | BUW311 | > Licensure Reference Number 12-006.02(8) Based on record review and interview, the facility failed to report an allegation of abuse to the State Agency and to complete an investigation and submit the results of the investigation for 2 residents (Residents 4 and 5 ) of 5 sampled residents. Facility Census was 7. Findings are: Record review of Progress note for Resident 1 dated 5/7/2019 by the SSD (Social Services Director) revealed; a Behavior Note: SSD was called to the dining room. Upon entry, into the dining room witnessed several residents telling Resident 1 to knock it off', and Shut up. The SSD asked Resident 1 what was going on and was told nothing. Multiple residents yelled you are a liar, you know what you said. Multiple residents stated that this resident was saying I want to grab your ass, lick it, and touch it. Resident 4 reported to the SSD that Resident 1 asked the resident to pull their zipper down so Resident 4 could see what Resident 1 had. Resident 1 was removed from dining room to eat dinner in the assist dining room where the staff could be monitor Resident 1 during dining. Resident 1 continued on 10 minute safety checks. Record review of Resident 5's Progress note dated 5/7/19 revealed; a Social Service note of the following: Reporting that multiple residents had stated that another resident was saying to Resident 5 I want to grab your ass, lick it and touch it. Resident 4 had reported that they were asked to pull Resident 1's zipper down to see what the resident had. An Interview on 5/20/9 at 1:02 PM with the SSD confirmed that the incident with Resident 1 on 5/7/19, at the dining room table was not reported to the State Agency and an investigation had not been submitted. The SSD stated, I didn't because we had been dealing with Resident 1 with the other problem and adjusting medications. The SSD reported that the facility staff had not documented any of the statements that were made from other residents at the table in regard to the incident on 5/7/19. The SSD confirmed that Resident 4 had … | 2020-09-01 |
| 1515 | 1515 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2019-06-27 | 880 | D | 1 | 0 | 86O711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.17D Based on Observation, record review and interview, the facility failed to ensure hand washing and gloving were done in a manor to prevent cross contamination. This had potential to affect 1(Resident 4) of 4 sampled resident's. The facility census was 69. Findings are: Record Review of Hand Washing Procedure dated 10/01/17 revealed section 3, step 3 rub hands together using friction for 20 (CDC guidelines) seconds. Front and back of hands, finger, in between the fingers, around the nail, cuticle and under the nails should be thoroughly cleaned. Record Review of Personal Protective Equipment Techniques dated 10/01/17 revealed Removing Gloves (sterile and Non-sterile) Step 1. Using one hand, pull cuff down over the opposite hand, turning glove inside out. Step 2. Keep glove in hand after removing. Step 3. With ungloved hand, pull cuff down over the opposite hand turning glove inside out Step 4. Continue pulling until the glove completely encloses the other glove and has its uncontaminated inner surface out. Step 5. Discard gloves in the waste receptacle. Step 6. Wash hands. Observation on 06/27/19 from 10:35AM - 11:55 AM revealed Resident 4 was lying in bed on back with heal protectors on both feet. LPN-A (Licensed Practical Nurse) and RN-B (Registered Nurse) present in room when surveyor arrived. Resident 4 gave permission to have wound care observed. LPN-A washed hands in shared restroom, applied gloves, turned the faucet on with gloved hands and wet wash clothes and placed in clear trash bag. LPN-A placed trash bag with wet wash cloths on bed and had Dimethicone (medicated ointment used to moisture skin) Ointment on the over bed table not on a barrier, over bed table was not cleaned prior to setting supplies on it. The empty trash bag was place on the foot of the bed for soiled linens. LPN-A pulled window curtain closed with gloved hands. RN-B pulled room divider curtain for privacy. LPN-A moved… | 2020-09-01 |
| 1516 | 1516 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2016-10-24 | 203 | D | 0 | 1 | W14V11 | Licensure Reference Number: 175 NAC 12-006.05(5) Based on record review and interview, the facility failed to provide a discharge notice to one (Resident 95) of 24 stage 2 sampled residents. The facility's census was 66. Findings are: Review of Resident 95's Nurses Notes dated 3/2/16 revealed Resident 95 had become increasingly agitated and was sent to the hospital via ambulance. The hospital then called the facility to notify them that resident had been admitted . Review of the Social Progress Notes dated 3/2/16 revealed the Social Service Director (SSD) informed the nurse at the hospital that Resident 95 would not be able to return to the facility due to concerns for other residents' safety. Interview with the SSD on 10/24/16 at 3:55 PM revealed the facility did have a form letter regarding discharges but that the facility had not had to issue a discharge letter in over 2 years. The SSD reported the letter was only given if the resident's having an unplanned discharged initiated by the facility. Review of the undated facility's discharge form letter revealed, State information on Transfer and Discharge .Normally any facility initiated transfer or discharge will be accompanied by a 30-day notice, however under special circumstances, such as the need for an immediate acute care hospitalization , the notice may be considerably less. Federal law requires that you be informed of your rights to appeal any facility initiated transfer or discharge A follow up interview with the SSD clarified that the notice may be considerably less indicated that even if a 30 day notice was not given, a notice should still be given to the resident or responsible party. The SSD went on to say that it was their understanding that the discharge notice could be verbal and not a written one. When asked if the SSD provided a verbal discharge notice to Resident 95, the SSD replied, No, no I didn't. | 2020-09-01 |
| 1517 | 1517 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2016-10-24 | 312 | D | 0 | 1 | W14V11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observation, interview and record review; the facility failed to ensure two dependent residents (Residents 21 and 46) out of three on sample, were shaved in a manner to maintain grooming. The facility census was 66. Findings are: [NAME] Observations of Resident 21 being unshaven were made on 10/17/16 at 2:48 PM and 10/24/16 at 8:40 AM. Review of Resident 21's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 7/15/16 revealed that Resident 21 required extensive assistance of one person to complete personal hygiene. Resident 21's Care Plan, with a problem start date of 8/25/14, also stated that the resident required extensive assistance of one staff to provide grooming related to dementia. On 10/24/16 at 8:41 AM Nursing Assistant C (NA C) was asked how often this resident was shaved and NA C stated that residents are shaved on their bath days. NA C was not sure how often Resident 21 was bathed. Review of Resident 21's Bath Detail Report for the last 60 days ending on 10/24/16, revealed the resident had been bathed once a week. On 10/24/16 at 10:03 AM Licensed Practical Nurse A (LPN A) was interviewed about how often Resident 21 was shaved and confirmed that one time per week was not enough to maintain a well groomed appearance. B. Observations of Resident 46 being unshaven were made on 10/17/16 at 2:48 PM and 10/24/16 at 8:40 AM. Review of Resident 46's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 7/8/16 revealed that Resident 46 required extensive assistance of one person to complete personal hygiene. Resident 46's Care Plan, with a problem start date of 12/3/14, also stated that the resident required extensive assistance of one staff to provide grooming related to dementia. On 10/24/16 at 8:41 AM Nursing Assistant C (NA C) was asked how often this resident was shaved and NA C stated that residents are shaved on their bath days. NA C was not sure … | 2020-09-01 |
| 1518 | 1518 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2016-10-24 | 332 | D | 0 | 1 | W14V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC: 12-006.10D Based on observation, interview, and record review; the facility failed to ensure medications were administered with less than a 5% (percent) medication error rate. Observations of 26 medication opportunities revealed 3 medication errors affecting two residents (Residents 50 and 60) for a medication error rate of 11.54%. The facility census was 66. Findings are: [NAME] Observation of a medication administration on 10/20/16 at 11:50 AM revealed Licensed Practical Nurse (LPN) A retrieving a bottle of [MEDICATION NAME] 70/30 insulin for Resident 50. LPN A used an alcohol swab to cleanse the top of the insulin vial, injected 12 units of air and withdrew 12 units of the [MEDICATION NAME] 70/30 insulin before administering it to Resident 50. LPN A did not roll the vial of [MEDICATION NAME] 70/30 insulin. A follow up observation on 10/24/16 at 11:45 AM revealed LPN A again failing to roll the vial of the [MEDICATION NAME] 70/30 insulin prior to administration to Resident 50. Interview with LPN A on 10/24/16 at 11:45 AM revealed LPN A did not roll the suspension of [MEDICATION NAME] 70/30 insulin prior to administering it to Resident 50. Review of the facility's policy for Insulin Administration dated 12/26/07 revealed, 6. Draw up appropriate dose of insulin into syringe as follows: Roll bottle of insulin. Review of the [NAME]'s Drug Guide for Nurses Thirteenth Edition revealed, Insulin Suspensions ([MEDICATION NAME] or [MEDICATION NAME] 70/30) Prior to withdrawing dose, rotate vial between palms to ensure uniform solution. B. Observation of a medication pass on 10/20/16 at 8:28 AM revealed LPN B interrupting Resident 60's breakfast meal to administer [MEDICATION NAME] 20 mg (milligrams) to Resident 60. Review of Resident 60's (MONTH) (YEAR) Medication Administration Record [REDACTED]*. Interview with the Director of Nursing (DON) on 10/24/16 at 5:30 PM confirmed [MEDICATION NAME] should be given before … | 2020-09-01 |
| 1519 | 1519 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2016-10-24 | 428 | D | 0 | 1 | W14V11 | Based on record review and interview, the facility failed to act upon the pharmacy consultant's recommendations and a physician's order for one resident (Resident 24) of five sampled in an effort to reduce the use of a hypnotic medication. Findings are: Review of Resident 24's Pharmacy Consultation Report signed by the physician on 10/12/16 revealed, (Resident 24) has received Rozerem (a sedative/hypnotic used to treat insomnia) since (MONTH) (YEAR). Please consider decreasing to PRN (as needed) insomnia only while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. Resident 24's physician replied, I accept the recommendation above, please implement as written. Review of Resident 24's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview with Licensed Practical Nurse (LPN) D on 10/24/16 at 2:08 PM revealed the recommendation and order for the reduction of the Rozerem got missed and it was filed in the medical record without ever being followed up on. | 2020-09-01 |
| 1520 | 1520 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2017-12-27 | 690 | D | 0 | 1 | HL5211 | Licensure Reference Number 175 NAC 12-006.09D3 Based on observation, interview, and record review; the facility failed to ensure a urinary catheter (a tube inserted into the bladder) drainage bag was positioned below the bladder, in order to prevent the potential for urinary tract infection. This failure had the potential to effect one resident (Resident 50), who required the use of an indwelling catheter. The facility census was 68. Findings are An observation with the Registered Nurse (RN)-C, on 12/27/17 at 10:40 AM, revealed Resident 50 had an indwelling Foley catheter in place, connected to a large drainage bag. The catheter tubing and drainage bag contained a small amount of dark brown colored urine. A full body mechanical lift was used with the assistance of two staff members to transfer Resident 50 from a wheel chair onto a bed. As the transfer equipment lifted Resident 50, Nursing Assistant (NA)-B was noted to hold the drainage bag for the catheter above the level of the resident's bladder. An interview on 12/27/17 at 11:10 AM with RN-C revealed that per Standard Practice, catheter drainage bags needed to be positioned below the resident's bladder in order to prevent backflow of urine. RN-C reported that a backflow of urine was a potential cause for urinary tract infections. The RN confirmed that the observed NA did not ensure the catheter drainage bag stayed below Resident 50's bladder while assisting the resident to transfer. A review of a Procedural Guide presented by the facility, titled URINARY CATHETER AND DRAINAGE BAG CARE, revised on 10/1/09 and approval date of 10/1/17, revealed the collection bag for the catheter was to be kept below the level of the bladder. | 2020-09-01 |
| 1521 | 1521 | AZRIA HEALTH ASHLAND | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2017-12-27 | 761 | E | 0 | 1 | HL5211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.12E1 Based on observation, interview, and record review; the facility failed to ensure insulin (a medication used to treat diabetes mellitus) was stored within the temperature range recommended by the manufacturer. This failure had the potential to effect five residents (Residents 03, 15, 50, 52, and 213). The census was 68. Findings are: On 12/27/17 at 02:30 PM an observation of the medication refrigerator in Medication room [ROOM NUMBER], revealed the thermometer read 50 degrees Fahrenheit,(F) upon opening the refrigerator door and there was no record of temperature readings of the medication refrigerator. On 12/27/17 at 02:32 PM an interview with Registered Nurse (RN)-C confirmed that the thermometer did read 50 degrees F. On 12/27/17 at 03:42 PM an observation and interview with RN- A, revealed that there were three thermometers in Medication room [ROOM NUMBER]'s refrigerator and they read 58, 56 and 50 degrees F. The contents of the refrigerator included: [MEDICATION NAME] (a short acting insulin) pens in sealed plastic bags with a labels indicating the medications were prescribed for Residents 3, 15, and 52; 2 [MEDICATION NAME] (a long acting insulin) Flex Touch Pens in a box with a label indicating the medication was prescribed for Resident 15; [MEDICATION NAME] (a long acting insulin) pens in sealed plastic bags with labels indicating the medications were prescribed for Residents 50 and 217. RN-A confirmed that none of the packaging for the 6 medications had been opened, and reported the refrigerators temperature should be around 40 degrees F. On 12/27/17 at 4:00 PM record review reveals no evidence of checking temperatures of medication refrigerators. On 12/27/17 at 4:30 PM an interview with the DON (Director of Nurses) revealed they did not have any evidence of the temperature in the medication refrigerator in Medication room [ROOM NUMBER] had been checked. On 12/27/17 at 4:35 PM a review of… | 2020-09-01 |
| 6093 | 6093 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2015-08-04 | 159 | D | 0 | 1 | J3ZL11 | Licensure Reference Number 175 NAC 12-006.16E Based on interviews and review of facility Policy and Procedure for Resident Trust Fund Accounts, the facility failed to ensure funds were available on nights and weekends for 2 residents (Residents 67 and 21). The facility census was 71 residents. Findings are: A. In an interview on 7-29-15 at 4:52 PM , Resident 21 reported money from personal fund accounts was not available on nights or weekends. B. In an interview on 7-29-15 at 3:44 PM, Resident 67 reported money from personal funds accounts was not available on night or weekends. C. In an interview on 8-3-15 at 10:15 AM, Business Office Manager reported, Residents know to come get money on Friday. Sometimes we forget to leave the money over the weekend. The Business Office Manager reported being uncomfortable leaving personal resident information regarding account balances with others over nights and weekends. D. Review of Facility Policy and Procedure Resident Trust Fund Accounts dated 3-15-12 states, Residents have the right to receive, retain and manage their own financial affairs and personal property. | 2019-06-01 |
| 6094 | 6094 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2015-08-04 | 441 | F | 0 | 1 | J3ZL11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.17A Based on observation, interview and record review; the facility failed to perform water pass procedure to prevent cross contamination of dirty to clean pitchers. This had to potential to affect all residents. The facility census was 71. Findings are: Observation on 8-3-15 at 4:24 PM during water pass by NA-A (Nursing Assistant) . revealed the staff person exiting a resident's room with a water pitcher and placing the pitcher on the top of a wheeled cart. NA A was then observed to take a different pitcher off of the top of the same cart and take the pitcher into another room. Interview of NA A on 8-3-15 at 4:26 PM revealed the staff person was placing clean and dirty pitcher together on the top of the wheeled cart. When explaining the procedure, NA A moved the dirty pitchers to one side of the cart and then touched the top of each of 3 remaining clean pitchers with the right index finger. Interview of the DON (Director of Nursing) on 8-4-15 at 8:02 AM revealed the expectation of staff would be for the staff person to take the cart around and pick up all dirty water pitchers. The dirty pitchers would then be delivered to the kitchen and a new cart would be used to deliver the clean water pitchers. NA A was new to the facility and required additional education. Review of the facility Policy and Procedure titled, Cleaning Water Pitchers and Drinking Cups dated 10-15-14 reveals staff are to clean or replace multi-use drinking utensils (cups or tumblers) at least daily. | 2019-06-01 |
| 6590 | 6590 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2015-12-16 | 312 | E | 1 | 0 | 61U611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D1c Based on record review and staff interview; the facility failed to provide bathing in accordance with bath schedules for four residents requiring assistance with bathing tasks (Residents 8, 9, 10 and 11). Facility census was 70. Findings are: A. Review of Resident 8's MDS (Minimum Data Set -a federally mandated comprehensive assessment tool used for care planning) dated 11/27/15 indicated that Resident 8 was totally dependent with assistance of one for bathing. Record review of the facility's undated bath schedules for Resident 8 revealed Resident 8 was to receive two baths per week. Record review of Resident 8's bath flow sheet (form used to record provision of each resident's shower/bath) for (MONTH) and (MONTH) (YEAR) indicated Resident 8 only received a bath on 11/2/15, 11/9/15, 11/19/15, 11/24,15 and 12/9/15 and not twice a week as scheduled. Interview with Resident 8 and Resident 8's family member on 12/16/15 at 4:20 PM revealed Resident 8 was supposed to be getting two baths per week but had only been getting one per week and wasn't sure why this was occurring. Resident 8 further stated there were days when the facility did not have enough staff working. Resident 8's family member responded that one bath per week was just not enough for Resident 8. B. Review of Resident 9's MDS dated [DATE] indicated the resident was totally dependent with assistance of one for bathing. Record review of the facility's undated bath schedules for Resident 9 revealed Resident 9 was to receive two baths per week. Record review of Resident 9's bath flow sheets for (MONTH) and (MONTH) (YEAR) indicated Resident 9 received a bath on 11/5/15, 11/10/15, 11/19/15, 12/1/15, 12/8/15 and 12/10/15 and not twice a week as scheduled. Interview with Resident 9 on 12/16/15 at 4:10 PM revealed Resident 9 was no longer getting 2 baths per week because the facility was having trouble finding staff to get both baths done. C.… | 2018-12-01 |
| 6591 | 6591 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2015-12-16 | 353 | E | 1 | 0 | 61U611 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on record review and interview, the facility failed to provide sufficient nursing staff to meet resident's needs related to not providing baths in accordance with bath schedules for Resident 8, 9, 10 and 11, who required assistance with bathing. Facility census was 70. Findings are: Interview with NA (Nursing Assistant) A on 12/15/15 at 2:15 pm revealed that residents are scheduled for 1 or 2 baths per week. NA A stated that NA A had gotten pulled from baths to work the floor about 1 time per week. NA A further stated 2 bath aides are normally scheduled for to give baths from 6 am to 2 pm on Monday through Friday. Interview with MA (Medication Aide) B on 12/15/15 at 2:30 pm revealed that the bath and restorative aides frequently get pulled to work on the floor when staffing is short and that staffing levels were frequently inadequate. Record review of the minutes from Resident Council Meetings from (MONTH) to (MONTH) (YEAR) revealed reoccurring monthly complaints that baths were not being given as scheduled. (MONTH) (YEAR) minutes revealed, (Residents) feel there should be more staffing. Interview with Resident 9 on 12/16/15 at 4:10 PM revealed Resident 9 was no longer getting 2 baths per week because the facility was having trouble finding staff to get both baths done. Interview with Resident 8 and Resident 8's family member on 12/16/15 at 4:20 PM revealed Resident 8 was supposed to be getting two baths per week but had only been getting one per week and wasn't sure why this was occurring. Resident 8 further stated there were days when the facility did not have enough staff working. Resident 8's family member responded that one bath per week was just not enough for Resident 8. Record review of the facility's undated bath schedules for Resident 8, 9, 10 and 11 revealed these residents were to receive two baths per week. Record review of Resident 8, 9, 10 and 11's bath flow sheets (form used to record provision of each resident's shower/bath) for (MONTH) and (M… | 2018-12-01 |
| 6728 | 6728 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2015-10-20 | 226 | E | 1 | 0 | 4N8U11 | Licensure Reference Number: 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to report allegations of verbal abuse to the state agencies as required for 11 unidentified resident council attendees and two identified residents (Resident 6 and 8). The facility census was 74. Findings are: A. Review of the facility's Abuse Prohibition and Prevention Program dated 10/10/08 revealed, Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Examples of verbal abuse include, but are not limited to threats of harm; saying things to frighten a resident, or conversation that would make the resident uncomfortable Any allegations involving mistreatment, neglect or abuse will be immediately reported to the Executive Director and appropriate state enforcement/regulatory agencies. B. Interview with Resident 6 on 10/8/15 at 4:40 PM revealed staff had referred to (Resident 6) using profanity and name calling. Resident 6 further revealed that both the Administrator and the Director of Nursing (DON) had been made aware of the incident. Review of a grievance dated 5/29/15 by Resident 6 revealed Resident 6 did report that staff were saying unsavory names about residents. Review of the Follow-up/Resolution revealed staff will be educated on 6/2/15 regarding these concerns. Review of the facility's Complaints/Grievance Procedure policy dated 1/1/01 revealed any grievance involving abuse should be immediately reported to the appropriate state agency. Review of the facility's internal abuse investigations revealed no investigation or report had been filed related to grievance filed by Resident 6. C. Interview with Resident 8 on 10/8/15 at 10:14 AM revealed a staff member here had insulted (Resident 8) a couple of times and (Resident 8) had reported it to both the SSD (Social Service Director) and the Administrator. Resident … | 2018-10-01 |
| 6729 | 6729 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2015-10-20 | 441 | E | 1 | 0 | 4N8U11 | Licensure Reference Number: 175 NAC 12-006.17 Based on observation, record review and interview, the facility failed to ensure dirty linens were not placed on the floor for for one resident (Resident 4), ensure that multi-use sit-to-stand lifts were maintained in a cleanable manner for (Resident 4) with the potential to effect three other residents that utilize sit-to-stands and failed to ensure staff performed hand hygiene in a manner to prevent cross contamination during cares for Residents 5 and 8. The facility had a census of 74. Findings are: A. Observation of toileting cares for Resident 4 on 10/8/15 at 3:01 PM revealed a wet washcloth and towel wadded up and thrown on the floor in the corner of Resident 4's bathroom. Nursing Assistant (NA) A and NA B performed perineal cares using a clean washcloth and towel after Resident 4 completed toileting. NA A And NA B then left the room and did not take the old washcloth and towel from the floor out of the room with them. Review of the facility's policy and procedure for Soiled Linen Handling dated 1/1/01 revealed, Place soiled linen directly into soiled hamper or linen bag. Do not place linen on floor . B. Observation of NA A and NA B assisting Resident 4 with transferring on 10/8/15 at 3:00 PM revealed the facility's sit to stand lift (a mechanical lift to assist in transferring residents from one surface to another while the resident grasps on to the handles) had black tape wound around both handles. The tape was not smoothly wrapped and was beginning to come apart from the handles in some areas. Interview with the Director of Nursing and Administrator on 10/8/15 at 4:30 PM confirmed that tape, especially unraveling tape, was not a cleanable surface. C. Observation of Licensed Practical Nurse (LPN) C on 10/8/15 at 11:55 AM revealed LPN C entered Resident 8's room to obtain Resident 8's blood glucose reading. LPN C went in to Resident 8's bathroom and performed hand hygiene for less than 10 seconds. LPN C performed the blood glucose testing with gloves on and the… | 2018-10-01 |
| 7733 | 7733 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2014-05-15 | 156 | D | 0 | 1 | 2Z8011 | Based on record review and interview, the facility failed to have the resident or resident representative sign the Skilled Nursing Facility Determination on Continued Stay or the Notice of Medicare Non-Coverage for three residents (Residents 7, 70 and 85). In addition, the facility failed to ensure that each resident was issued both the Skilled Nursing Facility Determination on Continued Stay and Notice of Medicare Non-Coverage for two residents (Resident 7 and 70). The facility census was 71. Findings Are: Review of Resident 7's Notice of Medicare Non-Coverage dated April 5, 2013 revealed there was no signature indicating Resident 7 received the notice. No letter of notification for Skilled Nursing Facility Determination on Continued Stay was on file. Record review of Resident 70's Skilled Nursing Facility Determination of Continued Stay dated 11/18/2013 revealed no markings indicating if there was a request for Medicare Fiscal Intermediacy Review and no signature for Verification of Receipt of Notice. There was no Notice of Medicare Non-Coverage stating if they requested an expedited review for this ending medicare stay. Record Review of Resident 85's Skilled Nursing Facility Determination of Continued Stay dated 9/9/2013 did not have a signature on the Verification of Receipt of Notice. There was no signature on the Notice of Medicare Non-Coverage stating if they requested an expedited review for this ending medicare stay. The Skilled Nursing Facility Advanced Beneficiary Notice had no signature. Interview with SSD (Social Services Director) on 5/14/14 at 11:25 AM stated that the Notice of Non-Coverage for Resident 7 and Resident 85 were not signed. The SSD further stated that the Skilled Nursing Facility Determination of Continued Stay for resident 85 and Resident 70 were not signed and the Advanced Beneficiary Notice was not signed for Resident 85. Review of the Facility ABN (Advanced Beneficiary Notice) Policy and Procedure dated 10/20/05 revealed the Notice to Medicare Provider Non-coverage does not fulfil… | 2018-01-01 |
| 7734 | 7734 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2014-05-15 | 241 | E | 0 | 1 | 2Z8011 | Licensure Reference Number 175 NAC 12-006.05 (21) Based on observations and interviews, the facility failed to maintain the dignity of six residents (Residents 6, 14, 39, 41, 46 and 48) during dining service related to assessment of vital signs, injection administration, standing while assisting residents with meal consumption and discussing medical care within hearing of others. The facility census was 71. Findings are: A. On 5/12/14 at 11:41 am, Resident 46 had blood glucose (sugar) checked and insulin (medication used to regulate blood sugars in diabetics) injected at his/her seat in dining room. Interview with Licensed Practical Nurse (LPN) B on 5/12/14 at 11:41 am revealed that residents come to the medication cart in the dining room for blood glucose checks and insulin so the nurse did not have to go to their rooms. On 5/14/14 at 6:05 pm Resident 6 had blood glucose checked by LPN D at the table in dining room. B. On 5/12/14 at 12:05 pm, Resident 48 spilled a glass of water before meal service. The water spilled on tablecloth, resident's lap and floor. NA (Nursing Assistant) E wiped off the tablecloth and clean water from floor. Neither NA-E or another staff member, who took Resident 48's B/P (blood pressure), addressed the resident's wet lap. After the meal was completed, Resident 48 left the dining room with pants still wet. C. Observation of the dining service on 5/12/14 at 11:50 AM revealed two NA's (Nursing Assistants) passing meal trays to approximately 13 residents on the SCU (Special Care Unit). NA (Nursing Assistant) C finished passing meal trays and began to assist Resident 41 with eating. NA C stood hovering over Resident 41 rather than sitting to assist Resident 41 throughout the meal. During the same meal NA C was overheard from across the room informing Resident 39 that Resident 39 would be going to Omaha to get new hearing aides at 12:30 PM. NA C was loud enough for all residents to overhear and Resident 24 verbally responded to NA C from across the room about Resident 39's appointment. Obser… | 2018-01-01 |
| 7735 | 7735 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2014-05-15 | 280 | D | 0 | 1 | 2Z8011 | Licensure Reference Number: 175 NAC 12-006.09C1a Based on record review, interview and observation; the facility failed to revise the plan of care for one resident (Resident 25) with suicidal ideation. The facility census was 71. Findings are: Review of Resident 25's Nurses Notes revealed the following: -3/31/14 Resident has made (increased) statement this weekend regarding .suicidal ideation. -4/29/14 Resident had a suicide attempt. Saw resident with wire clothes hanger around neck .Resident reported was trying to kill self with it. Send to hospital for evaluation. -5/2/14 Resident approaches this nurse upset and agitated .becomes angry and states I'll just kill myself call placed to physician and order received to send resident to hospital for evaluation of suicidal ideation. -5/7/14 Assessment showed concern noted left side facial drooping and slurred speech .resident transported to hospital. Review of Resident 25's Care plan dated 4/29/14 revealed Resident attempted to commit suicide using metal hanger from closet . Remove all metal hangers, picture frames and cords. Zip ties used to secure cords that can not be removed. Observation of Resident 25's room on 5/14/14 at 11:19 AM revealed Resident 25 lying in bed with the call light chord strung within reach between the bed and the wall. Follow up observations done intermittently revealed the call chord to be in the same position. Interview with Nursing Assistant (NA) on 5/14/14 at approximately 3:00 PM revealed Resident 25 would not be able to use the call light to call for help. Interview with the Administrator on 5/15/14 at 2:30 PM revealed that after Resident 25's last hospitalization (5/7/14) the facility had assessed Resident 25 to be safe with the call light chord in the room. Administrator acknowledged that this was not noted any where on the plan of care. | 2018-01-01 |
| 7736 | 7736 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2014-05-15 | 309 | D | 0 | 1 | 2Z8011 | Licensure Reference Number: 175 NAC 12-006.09D2 Based on observation, interview and record review; the facility failed to assess and implement a plan of care to address two Residents (Residents 59 and 25) with ongoing bruises. The facility census was 71. Findings are: A. Observation of Resident 59 on 5/14/14 at 11:08 AM revealed Resident 59 to have Bruising noted to both forearms. Review of Resident 59's Care Plan dated 1/13/14 revealed that Resident 59 sustained a bruise on the left forearm and on 1/17/14 the wanderguard bracelet (a bracelet worn that activates an alarm if the resident attempts to leave the facility without supervision) was identified as a possible causative factor and was discontinued. Review of Resident 59's medical record revealed no documentation of the current bruises as observed. Interview with the Assistant Director of Nursing (ADON) who also serves as the facility's wound nurse on 5/15/14 at 1:00 PM revealed that the ADON was unaware of Resident 59's bruising. A follow up interview with the ADON on 5/15/14 at 2:45 PM revealed the ADON had now seen Resident 59 and noted the bruising to Resident 59's right forearm. The ADON further reported staff are to inform the ADON of new bruises or skin tears and then the ADON ensures they are assessed for possible causative factors and updated on the plan of care for interventions to prevent further injuries from occurring. The ADON went on to say that the direct care nurses have had difficulty notifying the ADON of new bruising and skin tears. B. Observation of Resident 25 on 5/14/14 at 11:19 AM revealed four fingerprint sized bruises on Resident 25's left hand and two on left forearm. One bruise larger than fingerprint sized was noted also on Resident 25's left forearm. Review of Resident 25's daily Skin Assessments for the month of May revealed that on 5/9/14 abrasions to Resident 25's buttocks were noted and No changes in skin were noted with the last entry being 5/15/14. Review of Resident 25's Weekly Skin Checks completed by the Nursing Assista… | 2018-01-01 |
| 7737 | 7737 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2014-05-15 | 312 | D | 0 | 1 | 2Z8011 | Licensure Reference Number: 175 NAC 12-006.09D3(2) Based on observation, interview and record review; the facility failed to ensure one resident (Resident 12) was provided with care to prevent incontinent episodes. The facility census was 71. Findings are: Review of Resident 12's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 2/28/14 revealed Resident 12 had no cognitive impairments, was frequently incontinent and required extensive assistance with toileting tasks. Review of Resident 12's Care plan dated 3/10/14 revealed Resident 12 required assist to use the urinal and change incontinent products. This was to be done per request during waking hours. Resident 12 was able to make needs known. Observation of Resident 12 on 5/12/14 at 11:10 AM revealed a strong smell of urine. Resident 12 reported activating the call light early but that it was shut off by housekeeping who informed Resident 12 that Resident 12 would have to wait. A follow up observation on 5/12/14 at 11:32 AM revealed Resident 12 had not yet been assisted. At this time, Resident 12 reported that a nursing assistant informed Resident 12 to wait as the staff were busy. On 5/12/14 at 11:43 AM, staff were observed assisting Resident 12 with a change of clothing. Resident 12 on 5/12/14 at 1:58 PM revealed having to wait a long time for assistance after being incontinent and reported waiting as much as 40 minutes at times. | 2018-01-01 |
| 7738 | 7738 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2014-05-15 | 353 | G | 0 | 1 | 2Z8011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04C Based on interview and record review, the facility failed to ensure that staffing was sufficient to prevent falls from occurring for two residents (Residents 102 and 84) which resulted in an injury for Resident 102. The facility failed to have sufficient staffing in order to ensure dignity was maintained during dining for three residents (Residents 46, 48 and 6), to ensure that infection control tasks were completed related to sanitizing of mechanical lifts for four residents (Residents 12, 18, 28 and 25) and to ensure toileting to prevent incontinence was provided for one resident (Resident 12). This had the potential to effect all residents at risk of falls, who used the mechanical lifts, that required assistance with toileting and who ate in the dining rooms. The facility census was 71. Findings are: A. Observation of Resident 46 on 5/12/14 at 11:41 am revealed LPN (Licensed Practical Nurse) B checking Resident 46's having blood glucose (sugar) and injecting insulin (medication used to regulate blood sugars in diabetics) in the dining room. Observation during the same meal on 5/12/14 at 12:05 PM revealed an unknown staff member took Resident 48's blood pressure in the dining room at the table. Observation of Resident 6 on 5/14/14 at 6:05 pm revealed LPN D tested Resident 6's blood glucose at the table in the dining room. Interview with LPN B on 5/12/14 at 11:41 am revealed it could be difficult to get all the work done in the allotted time and that residents come to the medication cart in the dining room for blood glucose checks and insulin so the nurse does not have to use time to go to their rooms. B. Review of closed medical record revealed Resident 102 was in the SCU (Special Care Unit) with a [DIAGNOSES REDACTED]. The census in the SCU was 18. Review of Resident 102's Fall risk assessment dated [DATE] revealed Resident 102 was a moderate fall risk. Review of the nursing schedule from 5/12/… | 2018-01-01 |
| 7739 | 7739 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2014-05-15 | 364 | D | 0 | 1 | 2Z8011 | Licensure Reference Number 175 NAC 12-006.11D Based on observation and interview, the facility failed to ensure food was maintained at a temperature to prevent the growth of micro organisms for three residents, Residents 28,76 and 82. Findings are: A. According to facility provided information meal times for Hilton dining room were breakfast at 8:00 am, dinner at 12:00 pm and supper at 6:00 pm. B. Observation on 5/12/14 at 12:29 pm revealed Resident 76 had not received a room tray for noon meal. During an interview on 5/12/14 at 12:29 pm, Resident 76 stated food was usually cold, because he/she was at the end of the line and served last. The room tray was served at 12:52 pm. Resident 76 received the meal tray from the Hilton dining room. C. Observation of food temperatures tested by Dietary Aide M at 12:50 PM revealed the meat to be at 110 degrees and the beans to be 111 degrees. The staff did not attempt to reheat the food before serving. D. Interview with Resident 28 on 5/13/14 at 10:45 am revealed that breakfast was cold. A follow up interview on 5/19/14 at 9:44 am with Resident 28 revealed that food was still cold. | 2018-01-01 |
| 7740 | 7740 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2014-05-15 | 371 | F | 0 | 1 | 2Z8011 | Licensure Reference Number: 175 NAC 12-006.11E Based on observation and interview, the facility failed to prepare and serve food in a manner to prevent the potential for food borne illness in the kitchen and on the Special Care Unit (SCU). This had the possibility of effecting all residents who ate at the facility. The facility census was 71. Findings are: A. Observation of the evening meal service on 5-14-14 beginning at 5: 35 PM revealed the following: The cook was observed wearing gloves and serving food from the steam table in the kitchen for the Brown Derby dining room. The cook walked to the refrigerator, pulled the door open with gloves on, retrieved an item, came back to steam table and begin plating meals again without changing gloves. Three other employees had been opening the refrigerator with un-gloved hands to obtain items during the meal service. Further observation revealed the cook did not change gloves and touched surfaces of plates where food would be placed during food service. The cook was then observed pushing food carts to the Hilton dining room with the same gloved hands used in the Brown Derby dining area and then began plating food and checking temperatures of food without changing gloves. The Nebraska Food Code states If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation (3-304.15). B. Observation of the noon meal service on the Special Care Unit (SCU) on 5/12/14 at approximately 11:50 AM revealed Medication Aide (MA) K passing out beverages to residents and assisting residents with applying their clothing protectors. MA K would perform handwashing in between resident contact however each hand washing was performed for under 5 seconds. MA K then began serving food trays, pushed a resident up to the table and touched the resident on the back. MA K went directly to the sink and again washed hands for less than 5 s… | 2018-01-01 |
| 7741 | 7741 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2014-05-15 | 441 | E | 0 | 1 | 2Z8011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to provide a safe, sanitary environment by staff failing to do handwashing/sanitation for three residents (Resident 28, 25 and 71) and failing to clean and sanitize lifts after use for three residents (Residents 28, 25 and 71). This had the potential to affect 18 residents identified as using the mechanical lifts for transferring. The facility census was 71. Findings are: Licensure Reference Number 175 NAC 12-006.17D A. Observation on 5/13/14 at 10:55 am revealed NAs (Nurse Aides) F and G provide incontinent cares for Resident 28. Gloves were worn intermittently and randomly by one or both of the NAs during the transfer and provision of incontinent care. NA F randomly used hand sanitizer. Neither NA F or G washed their hands prior to or after providing cares. On 5/15/14 at 11:30 AM after cleaning up body fluid and upon entering the hall way NA G then pushed a lift used for transfering residents down the hall. NA G did not wash or sanitize hands at any time during the observation. Observation of cares provided to Resident 25 on 5/14/14 with NA C and NA L at 2:25 PM revealed neither NA C or NA L performed hand sanitizing when entering Resident 25's room prior to beginning cares or before exiting Resident 25's room after providing assistance with cares. Interview with the ADON (Assistant Director of Nursing) on 5/15/14 at 2:48 PM revealed aides should change gloves between residents, in between clean and dirty procedures and should wash hands when entering and upon leaving a residents room. Review of the facility's Hand Washing policy revised 10/1/09 revealed hand hygiene should be completed before and after each resident contact and after contact with an object (e.g. door knobs) of source where there is a concentration of microorganisms. Licensure Reference Number 175 NAC 12-006.17D B. On 5/13/14 at 10:55 AM, observation revealed NA G took the mechanical lift (a lift used t… | 2018-01-01 |
| 8507 | 8507 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2014-05-15 | 323 | E | 1 | 0 | 2Z8012 | Deficiency Text Not Available | 2017-05-01 |
| 8849 | 8849 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2013-04-18 | 253 | E | 0 | 1 | Z7S911 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B Based on observation and interview, the facility failed to provide maintenance and repair to one cabinet in the bath house and four occupied resident rooms (Room 232, 230, 103, and 112). The facility has a total of two bath houses and 49 resident rooms and the census was 75 Findings are: An environmental observation of the resident rooms with the Administrator, Maintenance Director and Nurse Consultant on 04/15/13 from 10.10AM through 11.15AM revealed the following concerns: - Room 230: The side edge of the main door was cut for fitment and no finishes used to cover the rough and splintered surface - Room 232: Bathroom door chipped, gouged and a hole visible at the lower part of the door - Room 104: Bathroom door chipped and scuffed and rust buildup at the lower part of the bathroom door metal frame - Room 112: Both the main and bathroom door had scuffs and gouges and part of the wooden decorative ventilation panel was broken with sharp edges Bath house 1: A utility cabinet in the bath house missing a laminate on the top frame and bottom parts. Uncovered parts exposed the rough wooden surfaces. The Administrator, Maintenance Director and the Nurse Consultant verified the identified concerns during the interview on 04/15/13 at 11.15AM. | 2017-01-01 |
| 8850 | 8850 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2013-04-18 | 279 | D | 0 | 1 | Z7S911 | Licensure Reference Number: 175 NAC 12-006.09C The facility failed to develop a plan of care for the management of limitations in range of motion (ROM - The full movement potential of a joint) for one resident (Resident 4) out of a facility census of 75 residents. Findings are: Interview with Licensed Practical Nurse (LPN) A on 4/10/13 at 9:39 AM revealed Resident 4 had a contracture of the left foot/ankle and that no restorative exercises were being completed because Resident 4 had been uncooperative with exercises in the past. Interview with Medication Aide (MA) B on 4/18/13 at 11 35 AM revealed Resident 4 does have contracted legs. MA B went on to report that Resident 4 attended group activities at 930 am and does get exercises at that time. Review of Resident 4's MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning) dated 2/27/13 revealed Resident 4 had limitation in ROM to both lower extremities and did not receive restorative exercises. Review of Resident 4's Care plan dated 2/25/13 revealed a problem statement for impaired mobility with an approach of PT (physical therapy)/OT (occupational therapy)/Restorative as needed. No statement regarding contractures, resident's attempt or refusal of restorative exercises or any other contracture management. Review of Resident 4's Restorative Flow sheet dated 1/7/12 revealed Resident 4 frequently refused restorative exercises and that staff are to continue to encourage group exercises and discontinue the restorative program. Interview with the Restorative Nurse on 4/18/13 at 11:45 AM revealed Resident 4 used to be on a ROM restorative program but was refusing to participate and kicked and hit staff when it was attempted and the program was discontinued in December. The Restorative Nurse continued to report Resident 4 does participate in group exercises and does well there. Review of the Activity Attendance record for the month of April for revealed Resident 4 frequently refused to attend the group activities. Interview with… | 2017-01-01 |
| 8851 | 8851 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2013-04-18 | 280 | E | 0 | 1 | Z7S911 | LICENSURE REFERENCE: 175 NAC 12-006.09C1c Based on record review and staff interview the facility failed to review and revise care plan interventions to meet the needs of two residents (Resident 80 and 14) out of a facility census of 75. Findings are: A. Review of Resident 80's Care Plan for alteration dated 9-18-12 revealed, mood and behavior r/t (related to) Alzheimer's Dementia express my needs, thoughts, and feeling appropriately to family, friends and staff .monitor me for moods and behaviors to determine cause per IDT (interdisciplinary team) and establish limits as possible or immediately if needed. Ensure that I am safe. Ensure that others are safe. The Facility incident log revealed on 3-3-13 at 7:30 pm Resident 80 was grabbed by Resident 14 on the wrist. Resident 14 then grabbed the Resident 80 back and they began pushing each other. Resident 80 voiced that the other resident slapped (gender) in the face. Residents 80 and 14 were separated without further difficulty. Facility incident log also revealed on 3-8-13 Resident 80 reached over staff members shoulder and lightly hit another resident on the cheek with closed fist. The Care Plan for Resident 80 was not updated with new interventions to keep resident safe from potential or actual harm and ensure others are safe following these incidents. B. Review of Resident 14's Care Plan dated 3-12-13 revealed .alteration in mood and behavior r/t Alzheimer's .behavioral symptoms .Interview me/responsible party re: preferences for daily schedule.Identify interventions that will help calm me such as 1:1, looking at magazines, craft with activities and walking outside in appropriate weather, snack. An additional problem, dated 5-7-12, stated Resident has physical behavioral symptoms toward others .resident will not harm others secondary to physically abusive behavior Assess whether the behavior endangers the resident and/or others. Intervene if necessary. The Care plan for resident 14 was not updated with new interventions to keep resident safe from potential or a… | 2017-01-01 |
| 8852 | 8852 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2013-04-18 | 469 | D | 0 | 1 | Z7S911 | Licensure Reference Number: 175 NAC 12-006.18A (4) Based on observation and interview, the facility failed to maintain an effective pest control program in three resident rooms (Room 230, 232 and 234). This practice had the potential to affect more than four residents (Room 234 was unoccupied). Facility census was 75 Findings are: An environmental observation tour was conducted with the Administrator, Maintenance Director and Nurse Consultant beginning at 10.10AM. During the tour, the following issues were identified regarding pest control of the facility: Resident Room observations revealed: - Room 234 (Unoccupied) and room 230 (Occupied by Resident 23 and 100): Bug nest present at the lower window frame. This cobweb like appearance filled with tiny live bugs approximately 1milimeter long and actively crawling along the window frames - Room 232 (Occupied by Resident 5 and 106): Live ants noted crawling on the bathroom floor The Administrator, Maintenance Director and the Nurse Consultant verified the identified concerns during the interview on 04/15/13 at 11.15AM. | 2017-01-01 |
| 9268 | 9268 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2013-09-17 | 309 | E | 1 | 0 | R13011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D7 Based on observation, record review and interview; the facility failed to ensure procedures were available to prevent injuries from 3 residents (Residents 1, 2 and 4) with adverse behaviors which had the potential to effect 16 residents who resided on Special Care Unit II. The facility census was 82. Findings are: A. Review of the facility's undated incident log revealed there were four separate resident to resident physical altercations that occurred in June, July and August 2013 involving Residents 1, 2 and 4. Review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 8/30/13 revealed Resident 1 had a [DIAGNOSES REDACTED]. Review of Resident 1's Careplan dated 1/9/13 revealed Resident 1 had physical behavioral symptoms toward others. On 7/10/13 punched another resident, on 8/16/13 pushed down on another residents hands, on 8/17/13 grabbed another resident and punched them. Interventions included psychiatrist visits, antipsychotic medication, attempt calming interventions, utilize 1:1 supervision and approach in a calm manner. Review of Resident 2's MDS dated [DATE] revealed Resident 2 had physically and verbally abusive behaviors and a [DIAGNOSES REDACTED]. Review of Resident 2's Careplan dated 9/17/13 revealed Resident had physical behavioral symptoms toward others, on 6/8/13 put hand up another residents skirt, on 7/5/13 Resident slapped another resident and on 8/20/13 kicked the back of another residents chair. Interventions included 1:1, activities and provide calm environment. Review of Resident 4's MDS dated [DATE] revealed Resident 4 had a [DIAGNOSES REDACTED]. Review of Resident 4's Careplan dated 4/1/13 revealed Resident 4 had physical behavioral symptoms and punched another resident on 5/27/12 and on 9/5/13. Interventions included providing 1:1 when agitated. Interview with the Assistant Director of Nursing (ADON) on… | 2016-09-01 |
| 9269 | 9269 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2013-09-17 | 353 | D | 1 | 0 | R13011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D7 Based on observation, record review and interview; the facility failed to ensure staffing was sufficient to supervise residents with adverse behaviors in an effort to prevent accidents from occurring. The facility census was 82. Findings are: Review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 8/30/13 revealed Resident 1 had a [DIAGNOSES REDACTED]. Review of Resident 1's Careplan dated 1/9/13 revealed Resident 1 had physical behavioral symptoms toward others. 7/10/13 punched another resident, 8/16/13 pushed down on another residents hands 8/17/13 grabbed another resident and punched them. Interventions included psychiatrist visits, antipsychotic medication, attempt calming interventions, utilize 1:1 supervision and approach in a calm manner. Review of faxed communication to Resident 1's physician revealed Resident 1 received an intramuscular (IM) injection of an antianxiety on 7/17/13, 7/22/13 and 8/17/13 due to combativeness and agitated symptoms. Further review of faxed communication revealed Resident 1 had verbal and physical altercations with other residents or staff on 7/10/13 and 8/16/13. Review of Resident 2's MDS dated [DATE] revealed Resident 2 had physically and verbally abusive behaviors and a [DIAGNOSES REDACTED]. Review of Resident 2's Careplan dated 9/17/13 revealed Resident has physical behavioral symptoms toward others. 6/8/13 put hand up another residents skirt. 7/5/13 Resident slapped another resident. 8/20/13 Resident kicked the back of another residents chair. Interventions included 1:1, activities, providing calm environment. Review of Resident 2's physician's orders [REDACTED]. Review of faxed communications to Resident 2's physician revealed Resident 2 was combative towards others including kicking, grabbing, punching and slapping other residents on 8/17/13 as well. Review of Resident 4's MDS dated … | 2016-09-01 |
| 10855 | 10855 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2012-01-23 | 315 | D | 0 | 1 | WBGK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(1) Based on observation, staff interview and record review the facility staff failed to provide perineal care using techniques to prevent the potential for urinary tract infections with 2 of 5 residents (Resident 75 and 20) observed receiving perineal care. The total sample was 34. The facility census was 81. Findings are: A. Resident 75 had the following [DIAGNOSES REDACTED]. The 10/22/11 MDS (Minimum Data Set- a federally mandated comprehensive assessment tool used for care planning) identified Resident 75 as having a BIMS (Brief Interview for Mental Status) score of 3 (0-7 indicates severely cognitively impaired); was always incontinent of bladder and frequently incontinent of bowels; required total two person assistance with bed mobility, toileting and transfers; required extensive to total assistance of 1 person with eating, hygiene and dressing. An observation on 1/19/12 from 3:10PM to 3:20PM revealed that Resident 75 was lying in bed on back. Nurse Aid (NA) R and NA S washed their hands and gloved, prepped supplies to provide peri care. NA R took a wet wash cloth with soap and washed front (from pubis)to back (anus) down the labia majora. NA R took another wet wash cloth and washed front to back down the labia majora rotated the cloth and washed the left groin, rotated the cloth and washed the right groin. The resident was then turned to left side with a new cloth washed the left buttock rotated the cloth and washed the right buttock, rotated the cloth and cleansed the peri rectal area front to back across rectum. The cloth was rotated and and the peri rectal area was cleansed back to front. NA R then dried the peri rectal area front to back rotated the dry cloth and dried the peri rectal area back to front. NA S then applied barrier cream and an attends (adult disposable diaper). The Administrator/RN was present during the cares and verified that there was a break in technique. B. Residen… | 2015-10-01 |
| 10856 | 10856 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2012-10-02 | 332 | E | 1 | 0 | 95I311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, staff interview, and record review, the facility failed to ensure that medication errors of 5% or greater did not occur. Observations of 51 medications administered to 18 residents, revealed 6 medication errors that affected four residents (Residents 10, 9, 11, and Resident 4). This showed a medication error rate of 11.76%. The resident sample size was 11 and the facility census was 81. Findings are: A. Observation of Resident 10's medication administration on 10/1/12 at 5:25 pm revealed the medication cassette labels stated Ziprasidone ([MEDICATION NAME]) 80 mg (milligrams) BID (twice daily) with meals. The resident was seated at the dining room table. The meal service in the Brown Derby dining room had not started. Interview with MA (Medication Aide) A on 10/1/12 at 5:30 pm revealed that Resident 10 had not started eating the resident's evening meal. Review of Resident 10's physician's orders [REDACTED]. Review of the Nursing 2012 Drug Handbook stated that [MEDICATION NAME] should be given with food. B. Observation of Resident 9's medication administration on 10/1/12 at 5:55 pm revealed: -Review of the medication cassette labels revealed that the resident was receiving [MEDICATION NAME] 250 mg BID, [MEDICATION NAME] 300 mg TID (three times daily), and Quetiapine ([MEDICATION NAME]) 50 mg at HS (bedtime). MA A crushed the medication and opened the capsule and mixed the medication powder in a bowl of beef stew steaming from the food cart. -The resident was in the resident's room and not ready for the evening meal. MA A left the dining room to enter Resident 9's room and assist in the in preparing for the meal for approximately 5 minutes. -At approximately 6 pm NA (Nurse Aide) E got the bowl containing the medication out of the steam cart. The DON (Director of Nursing) took the bowl of beef stew away from NA E and told MA A a new bowl of stew would be brought back for Resident 9… | 2015-10-01 |
| 12402 | 12402 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2011-03-29 | 247 | D | 1 | 1 | 5DBO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify residents and/ or legal responsible parties of a new roommate change for 3 residents (Residents 31, 37, and 78) from a list 12 residents identified by the facility as recently moved. The facility census was 76. Findings are: Confidential interviews conducted with residents and families revealed: -On 3/22/11 at 11:49 AM Confidential Resident Interview #1 stated that the resident was notified of a new roommate when the new roommate was being wheeled in. -On 3/22/11 at 3:06 AM Confidential Resident Interview #2 stated that the resident had one roommate when they left for a procedure and when they returned later in the day they had another roommate. They were not given notice that their roommate was changing rooms. -On 3/23/11 at 1:54 PM Confidential Resident Interview #3 stated that the resident's room was changed while the resident was out for a procedure. The resident had not been given notice that the resident was being moved to a different room. -On 3/23/11 at 2:33 PM Confidential Family Interview #1 revealed that the family member was not notified of the resident's new roommate. When the family member visited the resident the family member found out the resident has a new roommate. Review of the Recent Room Moves provided by the facility revealed conducted on 3/29/11 at 2 PM revealed: -12 residents had been identified as recently moved. -Resident 62's chart contained documentation about a room change to 113-A on 2/25/11. Review of Resident 37's medical record lacked documentation that the resident and/ or legal representative was notified about Resident 37 receiving a new roommate on 2/25/11. -Review of Resident 10's medical record reviewed that the resident's responsible party was notified of the resident's room change to room [ROOM NUMBER]-B. Review of the resident's medical record who resident in 125-A, Resident 78, revealed that the resident's medical record lacked docum… | 2014-07-01 |
| 12403 | 12403 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2011-03-29 | 280 | D | 1 | 1 | 5DBO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on record review and staff interview the facility failed to review and revise interventions on the Care Plan's for 2 residents (Resident 98 & 103). The Care Plan lacked interventions to maintain resident's current weight and prevent weight loss. The facility census was 76. The resident sample was 32. Findings are: A. Resident 103 had the following [DIAGNOSES REDACTED]. Review of a fax (facsimile) dated 2/23/11 from the ADON (Assistant Director of Nurses) to the physician stated: Wt (weight) 171.8 down 23# (pounds) in the past 3 weeks. Was hospitalized for [REDACTED]. RECOMMEND: Ensure 4oz (ounce) QID (four times a day), UTI-STAT 1 oz daily; [MEDICATION NAME] 40mg/ml (milligrams per milliliter)-take 10ml daily. Doctor noted and returned orders on 2/25/11. Review of a fax dated 3/9/11 from the dietician to the physician stated: Wt 163.2; down 20# past month. Eats 0-50%; varied fluid intakes, is on ensure 4oz qid = (equal) 500kcl (kilocalories), 18g (gram) protein, [MEDICATION NAME] started 2-25-11just for an update. The physician noted it on 3/14/11 and returned the fax. Review of Resident 103's 1/25/11 Nutrition Care Plan with problem started date of 2/3/11 revealed: -Alteration in nutrition [DIAGNOSES REDACTED].) -Problem: Will maintain current body weight of 194 # +/- 5# (plus or minus 5 pounds) through next 90 days. -Approach: RD (Registered Dietician) assessment/evaluation of caloric needs food/fluid consumption measured/documented/monitored daily. Offer snacks per choice and at HS (bedtime). Visit with Food Service Supervisor (FSS) on food/fluid choices/preferences/needs to formulate the plan. Admission weight then weight as directed. Regular diet, and supplements per RD's recommendation and MD (doctor) order. The Care Plan for Resident 103 lacked any of the new dietary approaches started on 2/25/11. B. Review of Resident 98's quarterly MDS dated [DATE] revealed that the resident had a… | 2014-07-01 |
| 12404 | 12404 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2011-03-29 | 323 | E | 1 | 1 | 5DBO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E3 Based on observation and interview; the facility staff failed to implement fall prevention measures for 1 resident (Resident 37); failed to maintain water temperatures in 1 of 2 bathhouses at a level to prevent the potential for scalds which had the potential to effect 40 residents; failed to maintain 3 resident room at a level to prevent the potential for scalds with the potential to affect 8 residents. The resident sample size was 32. The facility census was 68. Findings are: A. Review of Review of Resident 37's quarterly MDS (Minimum Data Set: a federally mandated assessment tool used for care planning) dated 3/11/11 revealed that the resident's BIMS (Brief Interview Memory Screen) had a total score of a 6 (a score of 0-7 = severe cognitive impairment). The resident did not have any delirium, behavioral, or mood issues. The resident required extensive activities of daily living assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was on a toilet program trial. The resident's active [DIAGNOSES REDACTED]. The resident had a fall since last MDS without injury. The resident was on a nursing passive and active range of motion program. The resident used a wheelchair and walker for mobility assistance. Review of Resident 37's Fall Risk assessment dated [DATE] and 3/18/11 revealed a total score of 27. A total score of 25 or greater represents that the resident was at high risk for falls. Review of Resident 37's Transfer Tool dated 12/2410 revealed that the resident required limited assist to transfer. Review of Resident 37's of Nurse's Notes revealed that the resident fell on [DATE] with no injury. The resident was found on the floor and stated that the resident was trying to look outside. Review of Resident 37's Fall Investigation Worksheet dated 2/28/11 revealed that the resident stood up out of the resident's wheelchair and fell backwards hitting the res… | 2014-07-01 |
| 12405 | 12405 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2011-03-29 | 325 | G | 1 | 1 | 5DBO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on record review and staff interview the facility failed to ensure 2 residents (Resident 98 & 103) maintained or increased their weight. The facility census was 76. The resident sample was 32. Findings are: A. Resident 103 had the following [DIAGNOSES REDACTED]. Review of the Weights Detail Report for Resident 103 revealed the following weights: 1/26/11 194.2 (Admission) 2/2/11 183.8 2/9/11 173.6 2/22/11 171.8 (Re admission) 3/2/11 163.2 3/9/11 159.6 3/16/11 159.6 An interview with the RD (Registered Dietician) on 3/28/11 at 9:35 AM regarding Resident 103 revealed, "It's a little hard to explain. (Res 103) was admitted on [DATE], I did (Resident 103's) assessment for nutrition on 2/7/11. (Gender) admit weight was 194. The weight on 1/31/11 of 183, that weight wasn't in the system that the FSS (Food Service Supervisor) gives me. Therefore I didn't see it until (Resident 103) was already in the hospital and by then the weight was 173.6 on 2/9/11. (Resident 103) returned from the hospital on [DATE]. When (Resident 103) came back we started the resident on 4 oz(ounce) Ensure QID (four times a day), [MEDICATION NAME] (medication used to stimulate the appetite)and UTI-StAT. Since we started the [MEDICATION NAME] (gender) seems to be eating better, but still losing weight. Today I have asked the doctor for some labs to be drawn a [MEDICAL CONDITION], cmp (complete metabolic profile) and a cbc (complete blood count). I will see what the doctor says." The RD verified that the resident's weight went from 194 to 173.6 before (gender) was started on a supplement because it wasn't in the system for the RD to know. The RD stated, "Yes I guess that is right. As soon as I was aware we got the interventions started." "I think (Resident 103) is eating better now with the [MEDICATION NAME]." Review of the Meal Intake Report for January, February (less hospitalized [DATE]-2/21/11) and March 2011 for Resident … | 2014-07-01 |
| 12406 | 12406 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2011-03-29 | 371 | E | 0 | 1 | 5DBO11 | Based on observation, interview, and staff interview the facility failed to ensure that the dishwashing machine was in proper working order with the potential to affect 66 of the facility's 68 residents. Findings are: Interview with DA (Dietary Aide) F on 3/28/11 at 9:30 AM stated that the facility had a low temperature dishwashing machine. The DA F stated that chemicals were used to disinfect the dishes. Observation conducted of the dishwashing machine on 3/28/11 at 9:30 AM revealed: -DA F rinsed dishes, placed the dishes on racks, and then put the dishes through the dish machine. -Over 3 loads observed the wash cycle on the dishwasher was 108-112 degrees Fahrenheit. The final rinse was 110-112 degrees Fahrenheit. -DA was asked if the temperature of the dishwasher was checked, and DA F replied it was done on the last load of the dishes. DA F stated that the water temperature for the wash and final rinse should be 120 degrees Fahrenheit. Interview with DA G on 3/28/11 at 8:30 at stated that the dishwasher water temperature should be 130 degrees Fahrenheit. DA G referred to the data plate on the dishwasher for the posted temperature of minimum wash and final rinse temperature of 120 degrees Fahrenheit. DA G stated if there was a low temperature the DA would stop doing dishes and notify the supervisor. Observation and interview with the DM (Dietary Manger) on 3-28-11 at 9:51 AM- 9:58 AM revealed that the dishmachine's chemical is automatically dispensed. Check of the chemical dilution in the dishmachine revealed that it was approximately 10 ppm (parts per million) per the DM. The DM stated that it should be around 100-150 ppm. The DM primed the dishwasher with chemicals and rechecked the chemical concentration. The chemical strip did not react and the DM stated it was 0 ppm. The DM stated that the company would be called to fix the dishmachine. Review of the posted March 2011 Dishmachine Temperature Log revealed: -There were no temperatures or strip recordings for the breakfast and lunch meals 3/11/11 and 3/15/11 -… | 2014-07-01 |
| 12407 | 12407 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2011-03-29 | 441 | E | 1 | 1 | 5DBO11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C2 Based on observation and interview, the facility failed to wash resident co-mingled sweaters in hot water temperatures or use a disinfectant product in the one household type washing machine to effectively destroy microorganisms. The facility census was 68. Findings are: Observation during the environmental tour conducted on 3/29/11 from 8:05 am through 10:05 am revealed: -A household type washing machine was on a warm wash setting cold rinse. -Laundry Aide E was in the laundry and stated that in the household type washing machine the resident's personal laundry is co-mingled and no bleach was added only the detergent to the household washer. -Review of the laundry detergent did not reveal a sanitizer or disinfectant product was contained in the detergent. -Temperature taken during the warm cycle fill of the household washing machine was 77-78 degrees Fahrenheit. Interview with Laundry and Housekeeping Supervisor on 3/29/11at approximately 10 am revealed that the only things washed in the household washing machine were resident sweaters and resident room divider curtains. This was so the items could be hung up and not wrinkle. The Laundry and Housekeeping Supervisor stated that the hot water would cause the divider curtains to wrinkle. The supervisor stated that there was no bleach added. | 2014-07-01 |
| 12408 | 12408 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2011-03-29 | 333 | D | 0 | 1 | 5DBO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 12-006.10D Based on observation, interview, and record review the facility failed to ensure that 2 residents (Residents 74 and 58) were free of significant medication errors from a total of 52 opportunities. The resident census was 68. Findings are: A. Observation of Medication Pass conducted on 3/24/11for Resident 74 revealed: - At LPN (Licensed Practical Nurse) J performed blood glucose (sugar) testing on Resident 74. The resident's blood glucose was 268. The resident's insulin vial label stated blood sugars 241-280 give 9 units of insulin. The LPN drew up [MEDICATION NAME] (rapid acting insulin) 9 units and administered the [MEDICATION NAME] sq (subcutaneously: beneath the skin) into the resident's abdomen at 11:03 AM. -The resident did not have any food or fluids other than water in the resident's room. -The LPN stated that lunch was served at 12 noon. -At 11:30 AM and 11:45 AM the resident remained in the resident's room without food and fluids other than water. The resident stated feeling fine. -At 12 PM the resident was seated in the Hilton dining room. The resident had only water and coffee and no food. -At 12:17 PM the resident was served lunch. B. Observation of Medication Pass conducted on 3/24/11for Resident 58 revealed: -At 11:10 AM LPN J performed blood glucose testing on Resident 58 and stated that the residents blood glucose was 121. The LPN drew up [MEDICATION NAME] 2 units per the instructions on the insulin vial label and administered the insulin into the resident's left abdomen at 11:13 AM. -At 11:30 AM and 11:45 AM the resident remained in the resident's room and stated feeling fine. -At 12 PM the resident was seated in the Hilton dining room. The resident had only water and coffee and no food. -At 12:16 PM the resident was served lunch. Review of the facility's Insulin Injection Administration Procedure dated 12/08 revealed that the Insulin Type Chart revealed that a rapid acting insulin analog… | 2014-07-01 |
| 12691 | 12691 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2011-01-12 | 323 | D | 8GEM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, interview, and record review the facility failed to follow facility procedure to prevent a fall for 1 resident (Resident 2) from a bath chair and failed to implement a process to ensure that the integrity of bath safety straps were monitored for 4 of 4 available bath chairs in the facility's 2 bath houses. The facility census was 80. Findings are: Review of Resident 2's History and Physical dated 4/10/10 revealed that the resident had the following Diagnoses: [REDACTED]. Review of Resident 2's MDS (Minimum Data Set: a federally mandated comprehensive tool used for care planning) dated 8/27/10 revealed that the resident did not have any memory impairment and had modified independence in new situations only. The resident did not have any communication difficulties. The resident did not have any behavioral symptoms in the past 7 days. The resident required extensive assistance with transfers, dressing, and toileting. The resident required physical help with bathing. The resident's balance was unsteady while sitting, but was able to rebalance self without physical support. The resident had function limitation in range of motion in the resident's arms, legs and feet. Review of Resident 2's Care Plan dated 11/12/10 revealed that the resident was at high risk for falls related to peripheral neuropathy of all extremities. The resident fell on [DATE] while being transported from bath tub in the bathhouse. The resident fell after a syncopal episode after safety belt gave out. The safety arms were not in place at the time of the fall. The resident had a contusion to the head. The resident's goals were: to have less occurrences of falls if possible weekly and all safety devices for bath in place whenever resident bath i.e. safety belt and safety bar at all times. Interventions included: call light usable and in reach; bed in the lowest position with wheels locked; floor mat by bed; fall… | 2014-04-01 | ||
| 1342 | 1342 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2020-01-06 | 812 | F | 0 | 1 | WRC811 | Licensure Reference Number 175 NAC 12-006.11E and 12-007.01A Based on observation, record review and interviews, the facility failed to ensure cleaning schedules were followed related to grease on cooking hood, food that was outdated were disposed of , and staff are wearing hair and restraints in the kitchen to prevent the potential for food-borne illness. The facility census was 122. Findings are: [NAME] Observation on 12/31/2019 on Kitchen tour revealed vents above cooking surface contained dust and grease. Interview on 12/31/19 at 8:23 AM with the Assistant Culinary Director (ACD) revealed the ACD agreed the vents over the cooking area and the top of the oven were not clean. Review of the facility policy titled Culinary Cleaning Policy dated 5/1/2016 revealed the following: - Each piece of equipment will have cleaning procedure and a weekly schedule for cleaning posted in the kitchen. - It is the responsibility of the culinary team to maintain the sanitation of all equipment and the kitchen as a whole. - Cleaning checklist forms are to be signed off on by the team member which has completed the task and turned into the assistant director. - The Culinary Directors will audit these procedures through cleaning check lists and visual inspections. Interview on 12/31/2019 at 8:35 AM with the Culinary Director (CD) revealed no checklists where used for the assigned staff to clean and then sign off on it. B. Observation of Kitchen sanitation on 12/30/19 8:14 AM revealed fruit cups, Salad dressing, and cake dated 21 in the refrigerator. Review of the facility policy dated 5/1/2016, titled Proper Food Storage revealed the following: - All food handlers must follow proper guidelines for food storage to ensure all products will be safe and sanitary for our residents. - Perishable foods to be discarded after 3 days. Interview on 12/30/2019 at 8:15 AM with the ACD revealed foods are considered to expire 3 days from the date on them and should have been discarded. C. Observation on 12/31/19 at 8:30 AM revealed the Dietary Ma… | 2020-09-01 |
| 1343 | 1343 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2018-05-31 | 880 | D | 1 | 0 | Y3V611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B and 175 NAC 12-006.17D Based on observation, interview, and record review, the facility staff failed to perform hand hygiene to prevent potential cross-contamination of dirty to clean wound dressings for 2 (Resident 5 and Resident 7) of 3 sampled residents. The facility staff identified a census of 119. Findings are: [NAME] A record review of the Facility policy for Non Sterile Dressing Change dated 11/27/2017 revealed; -Ensure any necessary equipment has been disinfected. -Place supplies on a clean field. -Wash hands. -Apply non-sterile gloves prior to removing old dressing. -Discard gloved with old dressing. -Complete hand hygiene and put on new gloves. -Clean wound as ordered. -Remove and discard gloves. -Perform hand hygiene. -Apply medication and/or new dressing per physician order. -Remove gloves and wash hands. A record review of the Facility policy for Hand Washing dated 11/27/2017 revealed that hand washing should last for at least 20 seconds using friction. An observation on 5/31/2018 at 8:12 am to 8:40 am of wound care provided to Resident 7 by Staff A revealed; Staff A entered Resident 7's room to complete the dressing change. Staff A went in to Resident 7's bathroom and preformed washed hands for 6 seconds. Staff A returned to Resident 7's bedside and covered the bedside table with a disposable incontinence protector. Staff A removed gloves from their scrub pants pocket, put the gloves on, scissors were removed from an open package and cleaned with an alcohol wipe. Staff A placed the scissors on the opened package on Resident 7's bed. Using the scissors, Staff A removed the old dressing and discarded the dressing and gloves. Staff A returned to Resident 7's bathroom where they prepared 2 packages of 4 inch by 4 inch gauze (4 X 4) to clean Resident 7's wound. One package was filled with soap and water while the other was filled with only water. At this time Staff A washed their hands… | 2020-09-01 |
| 1344 | 1344 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2017-08-01 | 225 | D | 1 | 0 | V28W11 | Deficiency Text Not Available | 2020-09-01 |
| 1345 | 1345 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2017-08-01 | 315 | G | 1 | 0 | V28W11 | Deficiency Text Not Available | 2020-09-01 |
| 1346 | 1346 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2017-08-01 | 332 | D | 1 | 0 | V28W11 | Deficiency Text Not Available | 2020-09-01 |
| 1347 | 1347 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2017-08-02 | 156 | D | 1 | 1 | YKIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide a cost listing of what Medicaid would and would not cover upon admission. This effected 2 residents (Resident 161 and 285 ). The facility census was 110. Findings are: [NAME] Record review of Resident 161's Face Sheet, dated 7/27/17, revealed that, Resident 161 was admitted to the facility on [DATE]. Record review of Resident 161's Census History, dated 7/27/17, revealed that Resident 161 became Medicaid eligible on 5/1/2016 . Interview on 7/26/17 at 3: 40 PM with Resident 161's family revealed that staff did not provide a list of services and items that would and would not be charged for when Resident 161 became eligible for Medicaid. Interview with the facility business office, Staff Member I, on 7/27/17 at 3:10 PM confirmed that there was not a form provided to Resident 161's family upon eligibility for Medicare. Interview with the facility Administrator on 7/27/17 at 3:11 PM confirmed that the facility did not provide information to Resident 161's family regarding Medicaid coverage and charges. B. Record review of Resident 285's Face Sheet, dated 7/27/17, revealed that, Resident 161 was admitted to the facility on [DATE]. Record review of Resident 161's Census History, dated 7/27/17, revealed that Resident 161 became Medicaid eligible on 7/22/16. Interview on 7/26/17 at 2:45 PM with Resident 285's family revealed that staff did not provide a list of services and items that would and would not be charged for when became eligible for Medicaid. Interview with the facility business office, Staff Member I, on 7/27/17 at 3:10 PM confirmed that there was not a form provided to Resident 285's family upon eligibility for Medicare. Interview with the facility Administrator on 7/27/17 at 3:11 PM confirmed that the facility did not provide information to Resident 285's family regarding Medicaid coverage and charges. | 2020-09-01 |
| 1348 | 1348 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2017-08-02 | 225 | D | 1 | 0 | YKIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report a significant injury for Resident 3 to the state agency within the regulatory timeframe and failed to submit a completed investigation for Resident 2 to the state agency within 5 days. The facility census was 110 . Findings are: [NAME] Review of the facility report dated 5/5/2017 for Resident 3 revealed Resident 3 sustained a fall and was sent to the hospital emergency room . Resident 3 returned to the facility at 11:55 PM on 4/29/2017 with a [DIAGNOSES REDACTED]. Review of the facility report revealed a call was placed to the state agency at 2:00 PM on 4/30/2017. Review of the facility undated policy titled Reporting Allegations of Abuse/Neglect/Exploitation revealed the facility was to notify the appropriate agencies immediately: In the case of serious bodily injury, no later than 2 hours after discovery. Interview on 5/17/2017 at 11:30 AM with the Director of Nursing (DON ) revealed the incident with injury was not reported to the state agency within 2 hours. B. Review of the facility report dated 4/30/2017 for Resident 2 revealed Resident 2 sustained a head injury and was admitted to the hospital on [DATE]. Review of the facility report revealed a facsimile (fax) report dated 4/30/2017 at 3:13 PM with a result of NO ANS (Answer). Interview on 5/17/2017 at 11:20 AM with the DON revealed the report should have been resubmitted to the state agency due to the initial report not arriving. The DON stated no other confirmation reports could be found. Review of the undated facility policy titled Reporting Allegations of Abuse/Neglect/Exploitation revealed the facility should follow up with government agency to confirm the report was received and to report the results of the investigation when a final report as required by the state agency. | 2020-09-01 |
| 1349 | 1349 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2017-08-02 | 242 | D | 1 | 1 | YKIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05 (4) Based on interviews and record reviews, the facility failed to ensure bathing preferences were followed for 1 resident (Resident 569) of 40 residents sampled. The facility staff identified the census at 110 . The findings are: A review of Resident 569's Face Sheet dated 7-31-17 revealed that Resident 569 was admitted to the facility on [DATE]. A review of Resident 569's Admission assessment dated [DATE] revealed that the resident was asked about bathing preferences and had requested 3 baths a week. A review of Resident 569's Care Plan dated 7-12-17 revealed that the resident was care planned as wanting 3 baths a week in the morning . An interview conducted on 7-25-17 at 3:20 PM revealed that Resident 569 did not get a choice in bathing frequency as they had only had one bath in 2 weeks. Resident 569 reported they preferred to receive 3 baths a week. An interview conducted on 8-1-17 at 8:11 AM with the Director of Nursing (DON) revealed that residents were asked about their bathing preferences during the admission assessment and then again during the comprehensive Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning). The DON reported that the resident's preferences were entered into the nurse tech care plan. An interview conducted on 8-1-17 at 8:19 AM with Nursing Assistant (NA) B revealed that Resident 569 was to get 3 baths per week on Tuesday, Thursday, and Saturdays unless the resident refused . NA B reported that, if a resident refused a bath, they would document the refusal and tell the nurse. NA B reported that, if the resident refused, they were to try again the next day. An interview conducted on 8-1-17 at 8:21 AM with the Education Specialist revealed that, if a nursing assistant charted a refusal, it would be found in the behavior charting and the nurse's documentation would be found in the progress notes. A review of Resident 569's Behav… | 2020-09-01 |
| 1350 | 1350 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2017-08-02 | 250 | D | 1 | 1 | YKIR11 | > Licensure Reference Number: 175 NAC 12-006.09D Based upon record review and interview; the facility failed to provide discharge planning for one resident (Resident 379) of three residents sampled. The facility census was identified as 110. FINDINGS ARE: [NAME] Record review of Resident 379's admission Transitional Specialist (TS) progress note dated 4/4/2017, revealed: admitted patient for post acute (inpatient hospitalization ) stay. TS discussed insurance along with discussions of LTC (long term care) verse ALF (Assisted Living Facility). (Spouse) open to either direction on how (gender) progresses. Goal to return home with (spouse) if possible. Record review of Resident 379's medical record revealed that there were no discharge planning records or charting found. During interview with the Director of Patient's Transitions (DTS) on 08/01/2017 at 1:35 PM, the DTS confirmed there was no documentation of discharge planning done by the TS who was assigned to this resident. The DTS explained that the expectations of all of the TSs are that they should meet and greet each assigned resident within 24 hours of admission and they should be seeing each of their assigned residents every 3 days thereafter to ensure that everything is on course, that the goals for discharge are on target, assist and facilitate discharge planning with all the disciplines and that these visits should be documented in the EMR (Electronic Medical Record). The DTS confirmed that discharge planning was not done with this resident. | 2020-09-01 |
| 1351 | 1351 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2017-08-02 | 253 | E | 1 | 1 | YKIR11 | > Licensure Reference Number 175 NAC 12-006.18A(1) The facility failed to maintain bathroom vents in 17 resident rooms (Rooms 5, 6, 9, 10, 81, 82, 83, 84, 86, 87, 88, 89, 93, 96, 102, 103 and 114), keep 4 resident room vents free of dust and debris (Rooms 14, 15, 16, 19), keep the carpet in the secured unit free of stains, maintain 2 resident doors (Rooms 35 & 36) and failed to maintain walls in 1 resident room (Room #14) of 40 occupied resident rooms in the facility. Findings are: Observation on 7/27/17 between 1:10 PM and 2:00 PM with the facility Administrator (ADM) and the Maintenance Director revealed the following environmental concerns in resident rooms and living areas in the facility. *Ventilation system bathroom vents not working in Rooms 5, 6, 9, 10,81, 82, 83, 84, 86, 87, 88, 89, 93, 96, 102, 103 and 114 ). *Fuzzy gray substance that resembled dust on the ventilation system covers in bathrooms of Rooms 14, 15, 16, and 19. * Carpet in dining room of secured unit with large stains. * Gouged and chipped doors in Rooms 35 and 36. * Gouged wall in Room 14. Interview on 7/27/17 at 2:00 PM with the facility ADM, and Maintenance Director confirmed the observations and confirmed that the issues had not been identified prior to the environmental tour of the facility. | 2020-09-01 |
| 1352 | 1352 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2017-08-02 | 315 | G | 1 | 1 | YKIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D3 Based on interviews and record reviews, the facility failed to evaluate urinary incontinence on admission and with a decline in continence for 2 residents (Residents 34 and 138) of 2 residents sampled and the facility failed to evaluate the use of an indwelling Foley catheter for 1 resident (Resident 62) of 3 residents sampled. The facility staff identified the resident census at 110 . The findings are: [NAME] A review of Resident 34's Face Sheet dated 8-1-17 revealed the resident was admitted to the facility on [DATE]. A review of Resident 34's comprehensive admission Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 3-7-17 revealed that the resident was not on a toileting plan, had frequent bladder incontinence, and was continent of bowel. The resident required extensive assistance with the help of 2 staff to transfer and use the toilet. A review of Resident 34's ADL (Activities of Daily Living) Verification Worksheet dated 2-28-17 to 3-7-17 revealed the resident was incontinent of 11 out of 16 times bladder elimination was documented. A review of Resident 34's MDS dated [DATE] revealed that the resident was not on a toileting plan, was always incontinent of bladder, and frequently incontinent of bowel. The resident required extensive assist of 1 staff to transfer and use the toilet. A review of Resident 34's ADL Verification Worksheet dated 5-31-17 to 6-6-17 revealed that the resident was incontinent 17 out of 17 times bladder elimination was documented. A review of Resident 34's medical record revealed no documentation of an evaluation of the resident's continence since the resident admitted to the facility. B. A review of Resident 138's Face Sheet revealed the resident was admitted to the facility on [DATE]. A review of Resident 138's comprehensive admission MDS dated [DATE] revealed the resident was not on a toileting plan and was occa… | 2020-09-01 |
| 1353 | 1353 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2017-08-02 | 329 | D | 1 | 1 | YKIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D Based upon record review and interviews; the facility failed to ensure that the resident was receiving an antibiotic that was shown to be an effective treatment for [REDACTED]. The facility census was identified as 110. FINDINGS ARE: [NAME] Record review of Resident 62's urinalysis (a lab test to see if there are any abnormalities in a urine sample) results dated 07/19/2017 revealed that there were abnormal results for bacteria as many were observed when the reference range is none - few seen. Also noted was Specimen forwarded for Culture and Sensitivity. (A culture is a test to find germs (such as bacteria or a fungus) that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection). Record review of Resident 62's urine culture results dated 07/23/2017 revealed that there were two different bacteria found-Escherichia coli and [MEDICATION NAME] faecium VRE. The sensitivity analysis revealed that [MEDICATION NAME]/[MEDICATION NAME] (also known as the antibiotic medication Bactrim or [MEDICATION NAME]) was resistant to the Escherichia coli. The only medications that were found to be susceptible (effective) to the [MEDICATION NAME] faecium VRE were [MEDICATION NAME], Linezolid and [MEDICATION NAME]. Record review of a physician telephone order dated 7/31/2017 revealed an order [MEDICATION NAME] DS by mouth twice a day for 7 days for the [DIAGNOSES REDACTED]. Interview with the DON (Director of Nursing) on 08/01/2017 at 01:05 PM, revealed that Resident 62 had an order for [REDACTED]. | 2020-09-01 |
| 1354 | 1354 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2017-08-02 | 332 | D | 1 | 1 | YKIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.10D Based on observations, record reviews, and interviews; the facility failed to ensure a medication error rate of less than 5%. Observation of 25 medications administered revealed 4 errors resulting in a medication error rate of 16%. The errors affected 2 residents (Residents 550 and 93 ) of a facility identified census of 110. [NAME] An observation conducted on 7-27-17 at 7:45 AM of Medication Assistant (MA) H's administration of medications to Resident 93 revealed MA H took 1 tablet from a card of [MEDICATION NAME] (a blood pressure medication) 50 milligrams (mg) and 1 tablet from a card of Potassium (a supplement) 20 milliequivalents and place them in a medication cup. MA H then pulled a tube of Ammonia [MEDICATION NAME] 12% Cream (a lotion used to treat dry, scaly skin), an inhaler, and a nasal spray out of the medication cart and delivered them to Resident 93's room. In Resident 93's room, MA H first gave Resident 93 the medication cup and watched the resident swallow the medications. MA H then administered Resident 93's nasal spray and inhaler. MA H then applied the Ammonia [MEDICATION NAME] 12% cream to the front and sides of Resident 93's left leg. MA H lifted the residen'ts pants up on the right leg but did not apply any cream to it. MA H then took the resident's pulse. A review of Resident 93's medical record revealed: - An order dated 7-26-17 to hold the Potassium for 3 days and - A consultation note dated 7-19-17 that addressed a wound to Resident 93's right ankle with wound care instructions that included Lachydrin (ammonia [MEDICATION NAME]) lotion once daily to surrounding dry skin. A review of Resident 93's MAR for (MONTH) (YEAR) revealed a note on the [MEDICATION NAME] to check the pulse before administering the medication. An interview conducted on 7-27-17 at 1:19 PM with the DON (Director of Nursing) confirmed the Potassium was on hold and should not have been given and the Ammo… | 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 |
| 1356 | 1356 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2018-10-04 | 554 | D | 0 | 1 | VC4411 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.10A1 Based on observation, record review and interview; the facility staff failed to evaluate 1 (Resident 45) of 43 residents ability to self-medicate. The facility staff identified a census of 114. Findings are: Observation on 10-04-2018 at 6:55 AM of wound care with Registered Nurse (RN) F revealed Resident 45 was awake in bed. Further observation revealed a plastic medication cup had multiple medications. On 10-04-2018 at 6:55 AM, RN F reported medications should have not been left with Resident 45 unattended. Review of Resident 45's medical record revealed there was not evidence the facility staff had evaluated Resident 45's ability to self-medicate. On 10-04-2018 at 7:55 AM an interview was conducted with the facility Regional Clinical Director (RCD). During the interview, the RCD reported the facility staff had not completed an evaluation of Resident 45's ability to self-medicate. | 2020-09-01 |
| 1357 | 1357 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2018-10-04 | 609 | D | 0 | 1 | VC4411 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on record review and interview, the facility failed to report a fall with injury to the required state agency within the 2 hour time frame for 1 (Resident 249) of 1 sampled resident. The facility census was 114. Finding are: Record review of the facility investigation dated 08/03/2018 revealed that Resident 249 had a fall while attempting to self-transfer on 07/27/2018 at 8:10 AM. The facility received x-ray results late the night of 07/27/2018 that revealed a non-displaced right medial tibial stress fracture. The facility notified the State Agency on 7/30/18 at 11:30 AM. Review of the facility's Policy and Procedure for Reporting Allegations of Abuse/Neglect/Exploitation dated 07/01/2018 revealed that the facility will notify appropriate agencies immediately in the case of serious bodily injury, no later than 2 hours after discovery. Interview conducted with the Administrator and Director of Nursing on 10/03/2018 at 03:20 PM confirmed that the facility had knowledge of the fracture for Resident 249 on 07/27/2018 and did not notify the state agency within the required 2 hour time frame. | 2020-09-01 |
| 1358 | 1358 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2018-10-04 | 623 | D | 0 | 1 | VC4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05(5) Based on record review and interview, the facility failed to notify the resident or responsible party and Ombudsman, in writing of discharge for 2 residents (Resident 73 and 248) of 5 resident sampled. The facility staff identified the census at 114. The findings are: [NAME] Review of Resident 248's Electronic Medical Record (EMR) progress notes revealed; Resident 248 was admitted to the hospital on (MONTH) 1st, (YEAR). An interview with the Facility's Social Worker on 10/4/2018 at 12:11 PM revealed that no information was provided to the Resident 248's responsible party or ombudsman in writing. B. Record review of Resident 73's medical record revealed Resident 73 was admitted to the facility on [DATE]. Further review of Resident 73's medical record revealed Resident 73 had been sent to the hospital on 8-15-2018. Additional review of Resident 73's medical record revealed there was not evidence the facility staff had provided a notice of discharge to Resident 73's family or had notified the facility Ombudsman. On 10-04-2018 at 9:02 AM an interview was conducted with the Director of Transition (DOT). During the interview the DOT reported the notice of transfer to the hospital was not completed for Resident 73 or representative and confirmed the facility Ombudsman had not been notified. | 2020-09-01 |
| 1359 | 1359 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2018-10-04 | 625 | D | 0 | 1 | VC4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to provide a notice of bed hold information upon transfer to the hospital for 4 (Resident 73, 79, 43 and 248) of 4 sampled residents. The facility census was 114. The findings are: [NAME] A record review of the progress notes for Resident 43 revealed that Resident 43 was transferred to the hospital on [DATE] requiring an overnight stay. Review of the medical record for Resident 43 revealed no bed hold agreement. Review of the Bed Hold Policy and Agreement dated 10/11/2017 revealed that before a transfer to the hospital the facility must provide written information to the resident or family member regarding the bed hold policy . Interview conducted with Social Services on 10/03/18 at 2:00 PM confirmed there was no bed hold notification given to Resident 43. B. Record review of Resident 73's medical record revealed Resident 73 was admitted to the facility on [DATE]. Further review of Resident 73's medical record revealed Resident 73 had been sent to the hospital on 8-15-2018. Additional review of Resident 73's medical record revealed there was not evidence the facility staff had provided a bed hold notice to Resident 73's representative. On 10-04-2018 at 9:02 AM an interview was conducted with the Director of Transition (DOT). During the interview, the DOT confirmed a bed hold notice had not been given to Resident 73's representative. C. A Review of Resident 248's Electronic Medical Record (EMR) progress notes revealed; Resident 248 was admitted to the hospital on (MONTH) 1st, (YEAR). An interview with the Facilities Social Worker on 10/4/2018 at 12:11 PM revealed that no Bed Hold was issued to Resident 248 or provided to the Ombudsman. D. Record review of a facility Bed hold Policy dated 10/11/17 revealed: - All patients will be given the bed hold policy on admission, prior to transfer or therapeutic leave from the facility. In cases of emergency, transfer notice at the time of tr… | 2020-09-01 |
| 1360 | 1360 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2018-10-04 | 744 | D | 0 | 1 | VC4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D5 Based on observation, record review and interview; the facility staff failed to implement an activity program related to the [DIAGNOSES REDACTED]. The facility staff identified a census of 114. Findings are: Record review of Resident 41's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 11-08-2017 revealed Resident 41 had the [DIAGNOSES REDACTED]. Record review of Resident 41's Resident Preferences sheet printed on 10-03-2018 revealed Resident 41 like to work with puzzles, nut, bolts, screws and sports. Record review of Resident 41's Comprehensive Care Plan (CCP) dated 11-03-2016 revealed Resident 41 had decreased interest in leisure participation due to long term care placement and cognitive decline. The goal identified for Resident 41 was to participate in activities of choice for stimulation and socialization. Interventions identified on Resident 41's CCP were to encourage groups of interest such as movies, music and Wii games. Encourage family to visit, encourage fitness groups. Observation on 10-03-2018 at 9:48 AM revealed Resident 41 was seated in a recliner in Resident 41's room. Resident 41's TV was on, however, Resident 41 was not watching the TV. Observation on 10-03-2018 at 11:08 AM revealed Resident 41 was asleep in a recliner in Resident 41's room. Record review of Resident 41's activity attendance record from 8-03-2018 to 9-23-2018 revealed Resident 41 had attended 18 activities. On 10-4-2018 at 1:25 PM an interview was conducted with the Activities Director (AD). During the interview the AD reported had not developed Resident 41's CCP related to activities for residents with the [DIAGNOSES REDACTED]. | 2020-09-01 |
| 1361 | 1361 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2018-10-04 | 759 | D | 0 | 1 | VC4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review and interview; the facility staff failed to ensure a medication error rate of less than 5%. Observations of 29 medications administered revealed 3 errors resulting in an error rate of 10.34%. The medication errors affected 3 (Resident 148, 56 and 31) of 4 residents. The facility staff identified a census of 114. Findings are: [NAME] Record review of Resident 148's physician's orders [REDACTED]. Observation on 10-03-2018 at 7:08 AM revealed Medication Assistant (MA) A prepared Resident 148's medications. Further observations revealed MA A prepared 1 capsule, or 25 mg of the [MEDICATION NAME] and administered the medications to Resident 148. On 10-03-2018 at 7:22 AM an interview was conducted with MA [NAME] During the interview MA A confirmed 25 mg of the [MEDICATION NAME] was administered and should have been 100 mg's. B. Record review of Resident 56's Physicians Orders current as of 10-03-2018 revealed orders for medications that included [MEDICATION NAME] Tears solution, 1 to 2 drops in both eyes, 3 times a day. Observation on 10-03-2018 at 7:42 AM revealed MA B prepared Resident 56's medications and administered the medications to Resident 56. MA B then obtained [MEDICATION NAME] Tear ointment and was prepared to apply the medication to Resident 56. On 10-03-2018 at 8:10 AM Registered Nurse (RN) D reviewed the physicians order and confirmed the [MEDICATION NAME] Ointment was not to be administered at this time. RN D confirmed giving the [MEDICATION NAME] Ointment at this time was an error. C. Record review of Resident 31's Physicians Orders current as of 10-03-2018 revealed there were medications orders that included Pantoprazole (medication used to decrease stomach acid) 40 mg to be administered every morning at 5:30 AM. According to Drugs.com, Pantoprazole tablets are taken by mouth, with or without food. The oral granules should be taken 30 minutes before a… | 2020-09-01 |
| 5083 | 5083 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2016-08-22 | 157 | D | 0 | 1 | Y66611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a Based on record review and interview; the facility staff failed to notify the physician of medications not being available for 2 residents (Resident 190 and 619). The facility staff identified a census of 102. Findings are; [NAME] Record review of Resident 190's Medication Administration Record [REDACTED]. According to the information on the MAR, Resident 190's family was to provided the Petroleum Jelly and the Vitamin C. Further review of Resident 190's (MONTH) (YEAR) MAR, revealed Resident 190 did not receive the Petroleum Jelly 11 times from (MONTH) 1st to the 21st and did not receive the Vitamin C 14 times as both, the Petroleum Jelly and Vitamin C were not available. An interview on 8-22-2016 at 2:55 PM was conducted with Registered Nurse (RN) [NAME] During the interview, RN A confirmed Resident 190's physician had not been notified of the Vitamin C and the Petroleum Jelly had not be available for use. B. Record review of Resident 619 MAR for (MONTH) (YEAR) revealed Resident 619 had order for medications that included [MEDICATION NAME] (is indicated for the temporary prevention of itching of the eye due to allergic [MEDICAL CONDITION]) eye drops and [MEDICATION NAME] ([MEDICATION NAME]) 200 mg to be administered twice a day. According to the information on the MAR, the resident family were to provide the medications. Record review of Resident 619's MAR for (MONTH) (YEAR) revealed the [MEDICATION NAME] was not available 25 times from (MONTH) 1st to (MONTH) 22nd and the [MEDICATION NAME] eye drops were not available 28 times. An interview on 8-22-2016 at 2:55 PM was conducted with Registered Nurse (RN) B. During the interview, RN B confirmed Resident 619's physician had not been notified that the medications Guaifensesin and [MEDICATION NAME] were not being given as ordered. | 2020-02-01 |
| 5084 | 5084 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2016-08-22 | 325 | D | 0 | 1 | Y66611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12-006.09D8b Based on observation, interview, and record review; the facility failed to evaluate significant weight loss for one resident (Resident 316). The facility had a total census of 102 residents. Findings are: Resident 316 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of weights for Resident 316 revealed Resident 316 weighed 168.80 lbs. (pounds) on 7/12/16 and 138 lbs. on 8/22/16. This reflected a weight loss of 30.8 lbs. or 18.2% of body weight in 6 weeks. Resident 316's Care Plan dated 7/11/16 to present listed a problem of being at risk for weight loss due to left [MEDICAL CONDITIONS], and diuretic therapy. Interventions for this problem included encourage oral intake, take resident to the dining room for meals at family request, dietary referral related to weight loss, regular diet with thin liquids, diuretic therapy, Magic Cup as ordered, and assess for nutrition and establish nutrient needs. Observation on 8/18/16 at 7:26 AM and 7:41 AM revealed Resident 316 in their room eating breakfast. Resident 316 received a bowl of cheerios and milk and ate all of meal. Observation on 8/18/16 at 12:37 PM revealed a magic cup supplement in the snack refrigerator on the unit for Resident 316. The supplement was dated 8/17/16. A review of the 8/2016 Treatment Administration Record revealed Resident 316 was to receive Magic Cup between 2 and 3:59 PM starting on 8/9/16. The 8/2016 Treatment Administration Record did not contain any documentation that the Magic Cup had been provided on 8/16/16 or 8/17/16. In an interview on 8/18/16 at 1:46 PM, the Director of Nursing confirmed the Magic Cup supplement dated 8/17/16 for Resident 316 was still in the supplement refrigerator on the unit and there was no documentation that Resident 316 received the supplement. A review of the Nutritional assessment dated [DATE] for Resident 316 revealed Resident 316 weighed 154.5 lbs. Resident 316 was assesse… | 2020-02-01 |
| 5085 | 5085 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2016-08-22 | 411 | D | 0 | 1 | Y66611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.14 Based on observation, record review and interview; the facility staff failed to arrange dental services for 1 resident (Resident 165). The facility staff identified a census of 102. Findings are: Record review of a Face Sheet printed on 8-22-2016 revealed Resident 165 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 165's Comprehensive Care Plan (CCP) printed on 8-22-2016 revealed problem section of the CCP identified dental as an active problem. According to the CCP, Resident 165's dental needs would be met. Interventions listed on Resident 165's CCP included Assist with oral care, and to monitor for any concerns and to assist with interventions as needed. Observation on 8-16-2016 at 12:51 PM revealed Resident 165 had multiple teeth missing. Record review of Resident 165's medical record revealed there was not evidence Resident 165 had been evaluated for dental services. On 8-19-2016 at 4:03 PM an interview was conducted with the Director of Nursing (DON). During the interview; the DON confirmed dental services had not been arranged for Resident 165. | 2020-02-01 |
| 5086 | 5086 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2016-08-22 | 428 | D | 0 | 1 | Y66611 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.12B5 Based on record review and interview; the facility pharmacist failed to identify potential irregularities due to the unavailability of medications for 2 residents (Resident 190 and 619). The facility staff identified a census of 102. Findings are: [NAME] Record review of Resident 190's Medication Administration Record [REDACTED]. According to the information on the MAR, Resident 190's family was to provided the Petroleum Jelly and the Vitamin C. Further review of Resident 190's (MONTH) (YEAR) MAR, revealed Resident 190 did not receive the Petroleum Jelly 11 times from (MONTH) 1st to the 21st and did not receive the Vitamin C 14 times as both, the Petroleum Jelly and Vitamin C were not available. Record review of Medication Regimen Review (MRR) sheet date 8-12-2016 completed by the facility Pharmacist Consultant revealed there were no irregularities noted. On 8-18-16 at 11:15 AM and interview was conducted with the Director of Nursing (DON). During the interview, review of Resident 190's MRR sheet was completed with the DON. The DON confirmed the facility Pharmacist Consultant had not identified the Petroleum Jelly and Vitamin C were not available. B. Record review of Resident 619 MAR for (MONTH) (YEAR) revealed Resident 619 had order for medications that included Zaditor (is indicated for the temporary prevention of itching of the eye due to allergic conjunctivitis) eye drops and Guaifenesin (expectorant) 200 mg to be administered twice a day. According to the information on the MAR, the resident family were to provide the medications. Record review of Resident 619's MAR for (MONTH) (YEAR) revealed the Guaifenesin was not available 25 times from (MONTH) 1st to (MONTH) 22nd and the Zaditor eye drops were not available 28 times. Record review of Medication Regimen Review (MRR) sheet date 8-11-2016 completed by the facility Pharmacist Consultant revealed were not identified the Guaifenesin and Zaditor as not being given as ordered by the physician. On 8-18-16 at 11:15 A… | 2020-02-01 |
| 5087 | 5087 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2016-08-22 | 431 | F | 0 | 1 | Y66611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC ,[DATE].12E1 Based upon observation and interview; the facility failed to ensure expired biological testing and medications were not available for use. This had the potential to effect all residents residing within the facility. Facility census was identified as 102. Findings are: On [DATE] at 12:25 PM, a check of the Winsor Medication and Lab refrigerators revealed the following: 5-Biscolox 10 mg Suppositories (a laxative) labeled as floor stock that expired on ,[DATE] 21-Microtest M4 Transport tubes (a tube used for the collection of swab samples to be sent to a lab for testing of viruses, like cold or flu.) o 19 tubes that expired on [DATE] o 2 tubes that expired on [DATE] An interview with Registered Nurse A (RN A), on [DATE] at 12:42 PM, confirmed that the above items were expired and that these expired items could have been used by any staff member with access, for any resident within the facility. | 2020-02-01 |
| 5775 | 5775 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2015-06-03 | 156 | E | 0 | 1 | EJB611 | Based on record review and interview, the facility failed to issue the correct advanced beneficiary non-coverage notice to inform the resident or responsible party of the potential liability for payment and the right to request a standard claim appeal be sent to the fiscal intermediary for a payment decision for 4 residents (Resident 12, 585, 587, and 586). The facility had total census of 83 residents. Findings are: A. Record review of a Centers for Medicare and Medicaid Services Survey and Certification letter 09/20 revealed that the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services when limitation of liability applies. The SNF ' s responsibility to provide notice can be fulfilled by use of either the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or one of 5 uniform Denial Letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e., demand bill) submitted to Medicare B. Record review revealed Resident 12 was issued an Advance Beneficiary Notice of Noncoverage (ABN) which stated Medicare may not pay for room and board, medications and supplies due to Resident 12 having no skilled needs. The notice was signed on 5/4/15. C. Record review revealed Resident 585 was issued an Advance Beneficiary Notice of Noncoverage (ABN) which stated Medicare may not pay for room and board, medications and supplies due to Resident 585 having no skilled needs. The notice was signed on 11/19/14. D. Record review revealed Resident 586 was issued an Advance Beneficiary Notice of Noncoverage (ABN) which stated Medicare may not pay for room and board, medications and supplies due to Resident 586 having no skilled needs. The notice was signed 11/5/14. E. Record review revealed Resident 587 was issued an Advance Beneficiary Notice of Noncoverage (ABN) which stated Medicare may not pay for room and board, medications and supplies due to Resident 587 having no skilled needs. The notice was signed on 11/24/14. F. … | 2019-09-01 |
| 5776 | 5776 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2015-06-03 | 242 | D | 0 | 1 | EJB611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(4) Based on record review and interview; the facility staff failed to evaluate bathing choices for 3 residents (Resident 569, 580 and 54). The facility staff identified a census of 83. Findings are: Record review of Resident 569's Comprehensive Care Plan (CCP) revealed an admission date of [DATE]. Further review of Resident 569's CCP did not identify the resident's bathing preference. On 5-28-2015 at 11:40 AM and interview was conducted with Resident 569. During the interview when asked if Resident 569 could chose how many times a week for a bath or shower, Resident 569 stated no, they assign times. Review of Resident 569's medical record did not have any evidence of the evaluation of amount of baths per week Resident 569 would like to have. An interview was conducted on 6-01-2015 at 3:25 PM with the Director of Nursing (DON). During the interview the DON confirmed that there was not any evidence Resident 569's bathing preference had been completed. B. Record review of Resident 580's Comprehensive Care Plan (CCP) revealed Resident 580 was admitted to the facility on [DATE]. Further review of Resident 580's CCP revealed no preferences in bathing for Resident 580. In an interview on 05/28/2014 at 3:51 PM Resident 580's Family Member revealed that Resident 580 was not being bathed according to past preference and would like Resident 580 to be bathed daily. The Family Member also revealed that Resident 580 was not given choices regarding bathing preference and was put on the schedule for twice weekly. Record review of Resident 580's medical record revealed no evidence that bathing preferences for Resident 580 had been identified. In an interview with the Director of Nursing (DON) on 06/01/2015 at 3:25 PM, the DON confirmed that there was no evidence that the bathing preferences had been completed for Resident 580. C. Resident 54 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. In an … | 2019-09-01 |
| 5777 | 5777 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2015-06-03 | 272 | D | 0 | 1 | EJB611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to identify significant weight loss on the Minimum Data Set (comprehensive assessment used for care planning) for one resident (Resident 539). The facility had a total census of 83 residents. Findings are: A. Resident 539 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. medical record. A review of Resident 539's Patient Vital Sign Report revealed Resident 539 weighed 173 lbs. (pounds) on 4/22/15 and 145.4 lbs. on 5/17/15 which is a weight loss of 27.6 lbs. or 15.9%. A review of Section K of Resident 539's 30 day Minimum Data Set with an assessment reference date of 5/18/15 revealed Resident 539 had a weight of 144 lbs. Resident 539 was identified as having no weight loss greater than 5% in one month. Dietary Staff Member G, who completed Section K, was interviewed on 6/3/15 at 1:44 PM. Dietary Staff Member G confirmed Resident 539 had a 15.9% weight loss between 4/22/15 and 5/17/15 and should have been coded as having a 5% weight loss or greater in the last 30 days. | 2019-09-01 |
| 5778 | 5778 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2015-06-03 | 280 | D | 0 | 1 | EJB611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure reference: 175 NAC 12-006.09C1c Based on record review and interview, the facility failed to review and revise care plan related to weight loss for one resident (Resident 539) and for straw usage for one resident (Resident 580). The facility has a total census of 83 residents. Findings are: A. Resident 539 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. medical record. A review of Resident 539's Plan of Care revealed a problem dated 5/29/15 problem related to nutritional status with a goal that Resident 539 will maintain nutritional status for the next 90 days. Interventions listed for this problem included the following: weight per order, diet per physician order, dietary assessment, and supplements as ordered. A review of Resident 539's Patient Vital Sign Report revealed Resident 539 weighed 173 lbs. (pounds) on 4/22/15 and 137.8 lbs. on 6/2/15 which is a weight loss of 35.2 lbs. or 20.3%. According to Patient Vital Sign Report, Resident 539 weights were as follows: -4/22/15 173 lbs. -4/29/15 165 lbs. -5/7/15 156 lbs. -5/14/15 146 lbs. -5/21/15 144 lbs. -5/28/15 141.6 lbs. -6/2/15 137.8 lbs. A review of Registered Dietitian Note dated 5/5/15 revealed Resident 539 admit weight was 173 lbs. and current body weight on 5/5/15 was 157 lbs. which reflected a weight loss of 16 lbs. or 9.25%. Weight loss was identified as likely due to [MEDICAL CONDITION] and diuretics. Registered Dietitian Note dated 5/5/15 reference physician progress notes [REDACTED]. Resident 539's weight was stabilizing in the 150's range after the weight loss according to Registered Dietitian note dated 5/5/15. Resident 539 was to receive one dish of protein salad with 1 package crackers for nutritional support. In an interview on 6/3/15 at 9:22 AM, the Director of Nursing confirmed Resident 539's care plan did not address Resident 539's weight loss. B. Record review of facility Face Sheet for Resident 580 revealed that Resident 580 was admitted on… | 2019-09-01 |
| 5779 | 5779 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2015-06-03 | 309 | D | 0 | 1 | EJB611 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2c Based on observation, record review and interview; the facility staff failed to identify and monitor a wound area for 1 resident (Resident 569). The facility staff identified a census of 83. Findings are: Record review of Resident 569's Care Plan (CP) printed on 6-01-2015 revealed an admitted d of 5-21-2015. Review of Resident 569's CP revealed Resident 569 was at risk for skin breakdown. The goal for the resident was to .have no skin breakdown. Observation of personal cares on 6-01-2015 at 11:43 AM with Nursing Assistant (NA) E revealed NA E positioned Resident into left side laying position and began to cleanse Resident 569's buttocks and scrotum area. Resident 569 reported to NA E the scrotum area had a sore and the nurses were aware. Observations revealed Resident 569 had an open area to the lower part of the scrotum that measured approximately 0.7 cm (centimeters). Record review of a Weekly Skin Assessment (WSA) sheet dated 5-31-2015 revealed the open area to Resident 569's scrotum had not been identified. According to the information on the WSA sheet, Resident 569's scrotum was red and was being treated. Record review of Resident 569's medical record did not contain evidence that the facility staff had identified and were monitoring the open area. On 6-02-2015 at 8:00 AM the Director of Nursing (DON) provided documentation dated 6-01-2015 that Resident 569 had 2 open areas on the scrotum. On 6-04-2015 at 9:13 AM a follow up interview via phone call was conducted with the DON. During the interview, the DON confirmed the facility was not aware Resident 569's scrotum had open areas. | 2019-09-01 |
| 5780 | 5780 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2015-06-03 | 311 | D | 0 | 1 | EJB611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 12-006.09D1b Based on observation, interview and record review; the facility failed to provide assistance with food set up and supervision with eating for one resident (Resident 580). The facility census was 83. Findings are: Record review of Resident 580's Comprehensive Care Plan (CCP) dated 05/06/2015 revealed Resident 580 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 580's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) signed and dated as complete on 05/22/2015 revealed that the facility assessed the following about Resident 580: -BIMS (Brief Interview for Mental Status) score of 10. According to the MDS manual a BIMS score of 8-12 indicates moderately impaired cognition. -Supervision and set up with eating. -Mechanically altered diet. -No natural teeth. -Working with Speech Therapy. Record review of Resident 580's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) signed and dated as complete on 05/25/2015 revealed that the facility assessed that Resident 580 was requiring supervision with one assist with eating. Interview with Resident 580's family member on 02/28/2015 at 3:57 PM revealed that Resident 580 needed help with the set up of the meal tray and since Resident 580 eats in Resident 580's room, Resident 580 does not always get the help with set up help from staff. Record review of Therapy Services, Daily Treatment Notes dated 05/29/2015 revealed Resident 580 had difficulty initiating swallow and Resident 580 would chew for an extended duration and then took the food out of Resident 580's mouth. The Daily Treatment Note also revealed that Resident 580 had no trouble initiating swallow with liquids but did have difficulty with dry swallow and solid food. In an observation of Resident 580's room on 06/01/2015 between 2:44 PM to 3:10 PM revealed a tray of food on the… | 2019-09-01 |
| 5781 | 5781 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2015-06-03 | 323 | D | 0 | 1 | EJB611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, record review and interview; the facility staff failed to implement interventions to prevent falls for 2 residents (Resident 552 and 568). The facility staff identified a census of 83. Findings are: A. Record review of a Resident Incident Reporting Form dated 5-19-2015 revealed Resident 552 was found on the floor. Record review of Resident 552's Comprehensive Care Plan (CCP) dated 4-30-2015 revealed Resident 552 was was identified at risk for falls. The goal identified for the residents was to have no falls with injury. Interventions identified on the CCP included the following: -Hi/Low bed, keep in (the) lowest position with floor mats on both sides. -Fall Alarm with staff to check placement and function every shift. -Patient will not be in room alone. Observation on 6-01-2015 at 1:06 PM revealed Resident 552's bed was in a waist high position and had 1 mat under the bed. Observation on 6-01-2015 at 2:09 PM revealed Resident bed remained at waist high and had 1 mat under the bed. Observation on 6-01-2015 at 2:22 PM with Registered Nurse (RN) A revealed Resident 552's bed was at waist high level and had 1 fall mat under the bed. RN A confirmed Resident 552's bed was not in the low position and that there was 1 fall mat under the bed. Observation on 6-02-2015 at 11:15 AM revealed Resident 552's bed was not in a low position and had 1 fall mat under the bed. Resident 552 was seated outside of the room and the personal alarm was not attached. An interview was conducted with Licensed Practical Nurse (LPN) B on 6-02-2015 at 11:17 AM. LPN B confirmed Resident 552's alarm was not attached to the resident. B. Resident 568 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident Incident Reporting Form dated 5/22/15 at 8 PM revealed Resident 568 was found on the floor. Resident 568 reported standing at bedside attempting to use the urinal when Resident… | 2019-09-01 |
| 5782 | 5782 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2015-06-03 | 329 | D | 0 | 1 | EJB611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review and interview; the facility staff failed to administer a PRN (as needed) antipsychotic medication according to the indications, failed to clarify orders for the use of a antipsychotic medication for 1 resident (Resident 552) and failed to have target behaviors for the use of a antipsychotic medication for 1 resident (Resident 560). The facility staff identified a census of 83. Findings are: A. Record review of a Face Sheet dated 4-30-2015 revealed Resident 552 was admitted to the facility on [DATE]. Record review of Resident 552's Medication Administration Record [REDACTED]. Further review of Resident 552's MAR for (MONTH) (YEAR) revealed Resident 552 had received the PRN [MEDICATION NAME] for anxiety on the following dates: -5-17-2015. -5-21-2015. -5-22-2015. -5-25-2015. Resident 552 received the PRN [MEDICATION NAME] on 5-18-2015 for restlessness and on 5-26-2015 received the medication for anxiety and agitation. B. Record review of a Physician's Progress Notes (PPN) dated 5-21-2015 revealed Resident 552's practitioner had made a weekly visit for the resident. According to the PPN dated 5-21-2015 Resident 552's [MEDICAL CONDITION] had resolved and the practitioner documented Will DC (discontinue) [MEDICATION NAME]. An interview was conducted with the Director of Nursing (DON) on 6-01-2015 at 2:02 PM. During the interview, review of the PRN [MEDICATION NAME] administration was reviewed with the DON. The DON confirmed the PRN [MEDICATION NAME] was not given correctly. The DON reported following up with the practitioner and confirmed the [MEDICATION NAME] should have been discontinued on 5-21-2015. C. Record review of Resident 560's Comprehensive Care Plan (CCP) dated 05/23/2015 revealed Resident 560 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 560's Medication Administration Record [REDACTED]. Further review of Resident 560's MA… | 2019-09-01 |
| 5783 | 5783 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2015-06-03 | 332 | D | 0 | 1 | EJB611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review and interview; the facility staff failed to ensure a medication error rate of less than 5%. Observations of 29 medications administered revealed 3 errors for 2 residents (Resident 584 and 582) with a resulting error rate of 10.34%. The facility staff identified a census of 83. Findings are: A. Record review of a physician's orders [REDACTED]. Record review of a physician/prescriber sheet dated 5-15-2015 revealed additional MEDICATION ORDERS FOR [REDACTED]. Observation on 6-02-2015 at 7:47 AM of the medication administration for Resident 584 revealed Registered Nurse (RN) C prepared all the AM medication for Resident 584. Observation of the [MEDICATION NAME] label from the pharmacy identified the dose of [MEDICATION NAME] as 500 mg with 400 mg of chond. RN C took the medications into Resident 584 room. RN C gave Resident 584 1 spray to each nostril of the [MEDICATION NAME] and administered the [MEDICATION NAME]. An interview with RN C was conducted on 6-02-2015 at 8:00 AM. RN C confirmed Resident 584 had received 1 spray to each nostril and not the 2 sprays as ordered. A follow up interview was conducted with RN C on 6-02-2015 at 11:05 AM. RN C confirmed the amount of [MEDICATION NAME] that was administered to Resident 584 was not the correct dose. B. Record review of a Current Orders sheet as of 6-01-2015 revealed Resident 582's practitioner had ordered medications that included [MEDICATION NAME] (Medication used to prevent chest pain) 60 mg every morning before breakfast. Observation on 6-2-2015 at 8:20 AM revealed RN H prepared to administer the morning medications to Resident 582. Resident 582 was in the room and beginning to eat breakfast. RN H administered the medications that included the [MEDICATION NAME] to Resident 582. An interview with RN H was conducted on 6-02-2015 at 8:22 AM. RN H confirmed Resident 582 was eating breakfast when the [MEDICATION NAM… | 2019-09-01 |
| 5784 | 5784 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2015-06-03 | 431 | E | 0 | 1 | EJB611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].12E4 Based on observation and record review; the facility staff failed to ensure out dated laboratory vials were not available for use on the Orchid and Windsor sections of the building. The had the potential to effect 16 residents on the Orchid section and 11 residents on the Windsor sections of the building. The facility staff identified a census of 83. Findings are: A. Observation of laboratory vials on [DATE] at 11:21 AM with Licensed Practical Nurse (LPN) B on the Orchid section of the building revealed there were 23 red top laboratory vials with an expiration dated of ,[DATE]. LPN B confirmed the laboratory vials were outdated and available for use for the residents. B. Observation on [DATE] at 11:25 AM with LPN E on the Windsor section of the building revealed the following outdate laboratory vials: -20 large red top vials that expired ,[DATE]. -2 Small red top vials that expired ,[DATE]. -2 blue top vials that expired on ,[DATE]. -2 purple top vials that expired on ,[DATE]. LPN E confirmed the vials were out dated and available for use at the time of the observation. | 2019-09-01 |
| 5785 | 5785 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2015-06-03 | 441 | E | 0 | 1 | EJB611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation, record review and interview; the facility staff failed to utilize handwashing and gloving techniques during personal care to prevent potential cross contamination for 2 residents (Resident 569 and 436) and failed to clean glucometers (machine used to check blood sugar levels) after use for 2 resident (Resident 79 and 582). The facility staff identified a census of 83. Findings are: A. Observation on 6-01-2015 at 11:43 AM of catheter ( tube placed into bladder to drain urine) and personal hygiene care for Resident 569 revealed Nursing Assistant (NA) F donned gloves and empted the urine collection bag into a container, dumped the urine into the toilet and rinsed out the container. NA F touched the toilet, door handles and sink with the same gloves. NA F without changing the soiled gloves completed catheter cares. NA F assisted Resident 569 into a left laying position and cleansed Resident 569 buttocks. NA F without changing the soiled gloves applied a barrier cream to the buttocks area and front peri area. NA Removed the soiled gloves and donned another pair of gloves without handwashing. NA F completed assisting Resident 569 up into a recliner after assisting with pulling up clothing. An interview with NA F was conducted on 6-01-2015 at 12:10 PM. During the interview, NA F confirmed the soiled gloves had not been changed and touch clean area on the resident. NA F stated I should have changed my gloves. B. Record review of Resident 79's Treatment Administration Record (TAR) for [DATE] revealed Resident 79 had orders to complete Accuchecks ( test used to check blood sugar levels) before meals and at bed time. Observation on 6-02-2015 at 7:40 AM of Resident 79's Accucheck revealed Registered Nurse (RN) C removed the glucometer from the medication cart and set it on top without the use of a barrier. RN C obtained the required supplies, including the glucometer,went into Resident 7… | 2019-09-01 |
| 5786 | 5786 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2015-06-03 | 520 | D | 0 | 1 | EJB611 | Licensure Reference: 175 NAC 12-006.07C Based on record review and staff interview, the facility Quality Assurance and Performance Improvement program failed to identify issues relevant to F280 and failed to ensure correction was maintained for repeat deficiencies at F280 and F329. The facility had a total census of 83 residents. Findings are: A review of facility policy titled Quality Assurance and Performance Improvement dated 1/1/2013 revealed the purpose of the quality assurance and performance improvement programs was to ensure person person-centered care. An objective of the quality assurance and performance improvement programs was to continually improve quality of care and quality of life to comply with regulatory requirements and customer satisfaction. Quality of care data collection areas include falls, falls with major injury, antipsychotic medication, pressure ulcers new or worsened, influenza vaccination and pneumococcal vaccination. A review of facility Casper Report 0003D, Provider History Profile revealed the facility was cited for F280 revision of care plan, and F329 drug regimen free from unnecessary drugs during recertification survey completed 3/31/14. The facility was cited for the same requirements during survey completed 6/3/15. In an interview on 6/3/15 at 8:27 AM, the Director of Nursing reported the Quality Assurance and Performance Improvement program was not currently reviewing urinary incontinence or care planning or development of care plans. | 2019-09-01 |
| 5787 | 5787 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2016-09-29 | 309 | D | 1 | 0 | QWZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference: 175 NAC 12-006.09D Based on record review, observation, and interview; the facility failed to ensure an effective pain management program for one of four sampled residents (Resident 6). The facility had a total census of 101 residents. Findings are: Resident 6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Pain assessment dated [DATE] revealed Resident 6 identified continuous pain at a level of 10 in the area of left hip and groin. A pain rating scale of 0 to 10 was used with levels 8-10 being severe. Resident 6's Care Plan identified a problem with pain dated 9/10/16. Interventions included pain medication scheduled with therapy times. A review of Resident 6's 9/2016 MAR (Medication Administration Record) revealed Resident 6 had orders for the following pain medications: [REDACTED]. Observations on 9/29/16 between 8:34 AM and 9:09 AM revealed Physical Therapist A was assisting Resident 6 to therapy. Resident 6 reporting having pain of a level 4 in Resident 6's left thigh. Physical Therapist A asked LPN B (Licensed Practical Nurse) if Resident 6 would be receiving any medications for pain. LPN B reported Resident 6 would be receiving pain medications and provided Resident 6 with medications. Physical Therapist A then transported Resident 6 to the therapy gym. Resident 6 continued to report pain in left thigh. Physical Therapist A utilized electrical stimulation (use of electrical stimulation for pain management) to decreased Resident 6's pain but Resident 6 continued to report pain in left thigh. Physical Therapist A modified Resident 6's therapy due to on-going reports of pain and increased heart rate. Observations on 9/29/16 at 8:28 AM of LPN B providing medications to Resident 6 revealed no medications for pain were provided. In an interview on 9/29/16 at 9:50 AM, LPN B confirmed no medications for pain were given at 8:28 AM. In an interview on 9/29/16 at 12:55 PM, LPN B reported Resi… | 2019-09-01 |
| 5788 | 5788 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2016-09-29 | 323 | D | 1 | 0 | QWZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 12-006.09D7 Based on observation, record review and interview; the facility staff failed to implement assessed interventions to prevent falls for 2 (Resident 5 and 8) of 3 residents. The facility staff identified a census of 101. Findings are: A. Record review of a Face Sheet dated 9-20-2016 revealed Resident 5 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 5's Comprehensive Care Plan (CCP) dated 9-01-2016 revealed Resident 5 had a fall. The goal for Resident 5 was to have reduced risk for falling and the interventions listed on the CCP included Increase lighting, bed in lowest position, keep bathroom door open, shoes on when up and remind the resident to ask for help. Observation on 9-29-2016 at 8:36 AM revealed Resident 5 was in bed asleep. The bed was positioned at waist level and not in the low position. Observation on 9-29-2016 at 9:40 AM revealed Resident 5 was in bed awake. The bed was positioned at waist level and not in the low position. Observation on 9-29-2016 at 4:45 PM revealed Resident 5's was in bed and the bed was at waist level. An interview was conducted Registered Nurse (RN) E on 9-29-2016 at 4:55 PM. During the interview, RN D was able to lower Resident 5's bed into the lowest position. RN E confirmed Resident 5's bed was not in the lowest position. B. Record review of Resident 8's CCP printed on 9-28-2016 revealed Resident 8 was risk for falls. Resident 8's CCP also identified Resident 8 had falls on 7-06-2016, 8-01-2016 and 9-24-2016. The goal for Resident 8 was to be able to ambulate and transfer without fall related injuries and would have the a reduced risk for fall. The interventions on Resident 8's CCP included footwear to fit properly, respond promptly to calls for assistance to use the bathroom, keep items in reach and bed in lowest position when in bed. Observation on 9-29-2016 at 3:45 PM revealed Resident 8 was in bed receiving a treat… | 2019-09-01 |
| 5789 | 5789 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2016-09-29 | 332 | D | 1 | 0 | QWZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review and interview;the facility staff failed to ensure a medication error rate of less then 5%. Observations of 30 medication administered revealed 4 errors resulting in an error rate of 13.33%. The medication errors effected 2 (Resident 5 and 6) of 3 sampled residents. The facility staff identified a census of 101. Findings are: A. Record review of Resident 5's physician's orders [REDACTED]. The directions were that resident 5 was to have 1 spray in each nostril. The instruction for use of the [MEDICATION NAME] medication was that Resident 5's pulse was to be taken prior to the administration. Observation on 9-29-2016 at 9:40 AM revealed Certified Medication Assistant (CMA) C prepared the morning medications that included the [MEDICATION NAME] and [MEDICATION NAME] and entered Resident 5's room. CMA C without obtaining a pulse gave Resident 5 the medications that were to be swallowed. CMA C then prepared to administer the nasal spray when Resident 5 reported (gender) would do the nasal spray. CMA C without cuing Resident 5 on the use of the nasal spray gave it to Resident 5. Resident 5 sprayed 2 sprays into each nostril. An interview with CMA C was conducted on 9-29-2016 at 9:50 AM. During the interview, CMA C confirmed Resident 5's pulse was not obtained prior to the administration of the [MEDICATION NAME] and Resident 5 used 2 sprays instead on one in each nostril. B. Record review of Resident 6's Medication Administration Record [REDACTED]. Observation on 9-29-2016 at 8:28 AM revealed Licensed Practical Nurse (LPN) B prepared Resident 6's medications. During the preparation LPN B reported Resident 6's Vitamin A, C and Zinc and [MEDICATION NAME] were not available to be given to Resident 6. On 9-29-2016 at 9:50 AM a follow up interview was conducted with LPN B. During the interview LPN B confirmed Resident 6 did not receive the [MEDICATION NAME] or the Vitamin A… | 2019-09-01 |
| 5906 | 5906 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2016-08-23 | 333 | D | 1 | 0 | S7DU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.10D Based on record review and interview, the facility staff failed to ensure no significant medication errors occurred as evidenced by the lack of administration of 3 doses of pain medication and failure to document the reason for the non-administration of the medications to one resident (Resident 1). The facility census was 103. Findings are: Record review of the facility Medication Provision Policy and Procedure dated 4/24/13 revealed that if a medication was not administered, a reason would be documented in the Quick Mar (the facilities electronic medical record). Record review of Resident 1's Medication Administration Record (MAR), revealed no documentation of administration of the resident's [MEDICATION NAME] (a strong pain medication) on 8/3/16 at 10:00 AM and 8:00 PM and 8/14/16 at 8 PM. Record review of Resident 1's Controlled substance administration count form revealed no medication was signed out for administration for 8/3/16 at 10:00 AM, 8/3/16 at 8:00 PM, and 8/14/16 at 8:00 PM. Record review of Resident 1's Electronic Health Record did not reveal nursing documentation for non- administration of Resident 1's [MEDICATION NAME]. Interview with RN A confirmed that when a controlled substance was administered it was documented on the Quick Mar and on the narcotic dispense sheet. RN A confirmed that It was the facility policy to document in the Quick Mar, or Electronic medical record when a medication was not administered and given a reason why. RN A confirmed that there was no evidence of administration of the 3 doses of [MEDICATION NAME] and no documentation for the reason that Resident 1's pain medication was not administered. | 2019-08-01 |
| 6234 | 6234 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2016-05-05 | 225 | D | 1 | 0 | 5GBT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.04A3 and 175 NAC 12-006.02(8) Based upon record review and interview; the facility failed to report and investigate allegations of abuse for 1 resident (Resident 2). The facility identified a census of 109. Findings are: A. Record review of Resident 2's face sheet dated 05/05/2016 revealed Resident 2 was admitted on [DATE] with the following Diagnoses: [REDACTED]. Record review of a facility Concern Form dated 02/08 revealed that Resident 2 complained to Licensed Practical Nurse (LPN) H that Nursing Assistant (NA) I was rough with cares and when Resident 2 mentioned it to NA I, Resident 2 heard NA I say vulgar terms NA I's breath. Further review of the Concern Form revealed the allegation of rough handling had not been evaluated by facility staff. Interview with RN (Registered Nurse) A on 05/05/2016 at 9:14 AM revealed that RN A was informed by LPN H, that Resident 2 reported that NA I was rough with (gender) cares. RN A stated that there was no evidence of this interview. RN A further confirmed that there was no investigation of the allegations. Interview with the DON (Director of Nursing) on 05/05/2016 at 9:46 AM revealed the DON confirmed that there was no evidence of an investigation. Record review of the facility Patient Abuse and Neglect Policy Revised 7-9-15 revealed that physical abuse was defined as damage to bodily tissue caused by nontherapeutic conduct and verbal abuse was defined as any use of oral, written or gestured language that willfully included disparaging and derogatory terms to patients or families, or within their hearing distance. The Administrator or designee will notify the appropriate agencies to report the incident. | 2019-05-01 |
| 6302 | 6302 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2016-04-27 | 242 | D | 1 | 0 | IO6811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.05 (4) Based on interview and record review; the facility failed to provide resident choices for bathing for 1 resident (Resident 9). The facility identified a census of 109 residents. Findings are: A. Record review of Resident 9's admission assessment dated [DATE] revealed that Resident 9 was asked How often do you prefer to bathe on a weekly basis? and Resident 9 answered 2-3 times a week. Record review of ADL Verification Worksheet dated 04/25/2016 revealed that for the week of 03/29/2016-04/04/2016, Resident 9 only received one bath; for the week of 04/05/2016-04/11/2016, Resident 9 only received zero baths; for the week of 04/12/2016-04/18/2016, Resident 9 only received one bath. Interview with Registered Nurse (RN G), on 04/26/2016 at 10:10 AM, confirmed that based upon documentation provided, the facility did not provide the number of baths as requested by Resident 9. | 2019-04-01 |
| 6303 | 6303 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2016-04-27 | 323 | G | 1 | 0 | IO6811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, record review and interview; the facility staff failed to implement assessed interventions to prevent falls for 2 residents (Resident 6 and Resident 9), and failed to identify and implement additional interventions for 1 resident (Resident 9). The facility staff identified a census of 109. Findings are: A. Record review of an Admission Assessment sheet printed on 4-25-2016 revealed Resident 6 was admitted to the facility on [DATE]. Record review of Resident 6's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 3-29-2016 revealed the facility staff assessed the following about Resident 6: -Short and long term memory problems. -Required supervision for personal hygiene,dressing, eating and locomotion off the unit. -Required extensive assistance with bed mobility, transfers, locomotion on the unit and toilet use. -Balance during transitions and walking was assessed as not steady, only able to stabilize with staff assistance. -[DIAGNOSES REDACTED]. -1 fall since admission to the facility. Record review of a Fall Risk Assessment sheet dated 3-17-2016 revealed Resident 6 scored a 12. According to the Fall Risk Assessment sheet dated 3-17-2016, a score of 10 or above identified that a resident should be considered high risk for potential falls. Record review of Resident 6's Care Plan (CP) printed on 4-25-2016 revealed an effective date of 3-17-2016 to present. Further review of Resident 6's CP identified Resident 6 had falls. The goal was that Resident 6 would not have any falls with injury. The intervention listed on the CP included Falling Leaf as indicated, encourage to use call light, Physical and Occupational therapy as ordered. Further review of Resident 6's CP revealed an additional problem area that Resident 6 was at risk for falls and Resident 6 will have reduced risk for falling. The goal was Reside… | 2019-04-01 |
| 6304 | 6304 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2016-04-27 | 332 | D | 1 | 0 | IO6811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review and interview; the facility staff failed to ensure a medication error rate of less than 5%. Observations of 30 medications administered revealed 2 errors resulting in an error rate of 6.66%. The errors were for 2 residents (Resident 15 and 16). The facility staff identified a census of 109. Findings are: A. Record review of a physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Observation on 4-25-2016 at 8:34 AM revealed Registered Nurse (RN) A obtained Resident 15's medications that included the [MEDICATION NAME]. RN A without explaining how to administer the medication, gave Resident 15 the [MEDICATION NAME] spray bottle. Resident 15 sprayed twice into each nostril and handed the spray bottle back to RN A. An interview with RN A was conducted on 4-25-2016 at 8:40 AM. During the interview RN A confirmed the order for the [MEDICATION NAME] was 1 spray into each nostril. RN A confirmed Resident 15 had sprayed twice into each nostril. B. Record review of a physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. a day. The instructions for use of the [MEDICATION NAME] medication was to check the pulse rate prior to administering the medication. Observation on 4-25-2016 at 8:20 AM revealed RN B obtained Resident 16's mediations including the [MEDICATION NAME]. RN B administered the medication to resident 16 without obtaining a pulse. An interview on 4-25-2016 at 8:30 AM was conducted with RN B. During the interview, RN B confirmed Resident 16's pulse had not been taken prior to administering the [MEDICATION NAME] medication. | 2019-04-01 |
| 6305 | 6305 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2016-04-27 | 333 | D | 1 | 0 | IO6811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.10D Based on interview and record review; the facility failed to ensure that one resident (Resident 4) was free of significant medication errors. The facility census was identified at 109. Findings are: A. Record review of Resident 4's Face Sheet, dated 04/27/2016, revealed that Resident 4 was admitted on [DATE] for the following medical [DIAGNOSES REDACTED]. Record review of Resident 4's Medication Administration Record [REDACTED]. Record review of Resident 4's Preoperative Surgery Instruction sheet dated 11/19/2015 revealed instructions to do not take blood thinner medications within 7 days prior to your surgery. Surgery was scheduled on 12/1/2015. Staff noted this and both medications were discontinued on 11/24/2015. Record review of nursing progress notes dated 11/24/2015, revealed that Resident 4's POA (Power of attorney) canceled the scheduled surgery and that the nursing staff had notified the pharmacy to restart both medications. Record review of Resident 4's (MAR) for the month of (MONTH) revealed that Resident 4 was not receiving either Aspirin [MEDICATION NAME] coated 81 mg by mouth daily and Eliquis 2.5 mg by mouth twice a day as previously ordered on [DATE]. Record review of the physician orders [REDACTED]. Interview with RN G and RN E on 04/26/2016 at 1:30 PM, confirmed that these medications were discontinued and not restarted. When RN G was asked what the expectations for follow-up was; RN G stated the expectation of the staff was that the staff would report on to the oncoming shifts that the medication needs to be restarted and that they should continue to follow-up until the medication is restarted. RN G confirmed that the resident probably should have been on an anticoagulant due to the [MEDICAL CONDITION] condition and was not. Based on this resident's condition and the length that Resident 4 had gone without the anticoagulant medication, RN G considers this to be a significant … | 2019-04-01 |
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CREATE TABLE [cms_NE] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );