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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2750 | 2750 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2018-02-26 | 625 | D | 0 | 1 | FST111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the legal representative of the bed hold policy for one resident (Resident 8), out of one resident sampled, when Resident 8 was sent to the hospital. The census was 50. Findings are: Review of Resident 8's PN (Progress Notes) dated 02-18-18 revealed the resident was admitted to the hospital with [REDACTED]. The family was updated. Review of Resident 8's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-07-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 2 which indicated the resident's cognition was severely impaired. Review of the medical record revealed absence of a bed hold policy notifying the legal representative of the 2-18-18 hospitalization . Interview on 2-21-18 at 11:44 AM with SS (Social Service Supervisor Certified) revealed the facility's process was to send the bed-hold policy with the resident to the hospital and document sending the bed hold policy to the hospital on the Resident Transfer Record. The nurse who sent the resident was to notify the legal representative about the bed hold policy and document the notification in the PN. The SS reviewed the PN on Resident 8 and confirmed the absence of documentation of the bed hold notification for the hospitalization on [DATE] for Resident 8. The SS denied any follow-up communication, such as a letter or phone call, was completed with the legal representative to inform of the bed hold policy. | 2020-09-01 |
| 2751 | 2751 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2018-02-26 | 812 | F | 0 | 1 | FST111 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview, and record review; the facility staff failed to maintain refrigerated items below the cold food retention limit to prevent potential food borne illness, failed to seal items in dry storage to prevent potential contamination, failed to keep cooking utensil storage areas clean, failed to contain hair to prevent potential cross contamination, and failed to perform hand hygiene during nourishment service (snack pass) to prevent potential cross contamination. This had the potential to affect all 50 residents who received food from the facility kitchen. The facility identified a census of 50 at the time of survey. Findings are: [NAME] Observation of the kitchen on 2/20/18 at 11:49 AM revealed the thermometer inside the 2 door refrigerator read 46 degrees F (Fahrenheit). Observation of the kitchen on 2/20/18 at 3:11 PM revealed the thermometer inside the 2 door refrigerator temperature read 50 degrees F. There was meat, meat salad, meat salad sandwiches, sour cream, cream cheese, eggs, butter and assorted drinks in the refrigerator. There was also bag of shredded lettuce on the top shelf that did not feel cool or chilled to the touch. Interview with the DM (Dietary Manager) on 2/20/18 at 3:11 PM revealed they did not have a policy for maintaining refrigerator temps. Interview with the facility Administrator on 2/20/18 at 3:24 PM revealed that their consultant wanted them to probe the food. The DM checked the temperature of a glass of water that was inside the refrigerator and it was 48 degrees F. The DM then checked the temperature of the butter with the facility thermometer and it was 45 degrees F. Both the Administrator and the DM confirmed the food temperatures were higher than the accepted upper temperature limit for holding cold foods. Interview with the facility Administrator at this time revealed the facility did not have a policy for maintaining the refrigerator temperatures; they followed the Food Code. Review of the Refrigerator Tem… | 2020-09-01 |
| 2752 | 2752 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2018-02-26 | 880 | F | 0 | 1 | FST111 | LICENSURE REFERENCE NUMBER 175 NAC 12.006.17 Based on observations and interviews, the facility failed to ensure hand hygiene was followed when working with one resident (Resident 249) who had signs and symptoms of Influenza like illness. The facility also failed to ensure staff followed standard precautions and failed to follow hand hygiene practices with one other resident (Resident 6) to prevent the potential for cross contamination to other residents. These had the potential to affect all residents. The census was 50. Findings are: [NAME] Interview on 2-20-18 at 12:00 PM with the ADM (Administrator) revealed since the facility had a resident with a positive Influenza A result and other residents with signs and symptoms of Influenza like symptoms, staff were to deliver all meals to the resident's rooms. The ADM revealed resident rooms with a sign on the door asking visitors to report to the Nurses' Station indicated those residents either had tested positive for the Influenza A or had signs and symptoms of the Influenza. Observation on 02-20-18 at 12:08 PM revealed two staff delivered a noon meal tray to Resident 249 in the resident's room. The resident's room had a sign on the door instructing staff to report to the Nurses' Station before entering the room. One staff stood outside the door with the room meal tray while NA-D (Nurse Aide) put gloves on and entered the resident's room. NA-D prepared the resident by assisting the resident to sit up on the side of the bed and prepared the overbed table. NA-D then obtained the meal plate, utensils, and drinks from the meal tray from the staff person on the outside of the room and returned to the resident's room to set the meal up. NA-D then removed the gloves and exited the resident's room and entered into the hallway without washing (gender) hands. Interview on 2-20-18 at 12:13 pm with NA-D revealed because Resident 249 had Influenza signs and symptoms, NA-D was not supposed to wash (gender) hands in the resident's room but had to go to a different area to wash th… | 2020-09-01 |
| 2753 | 2753 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2019-06-18 | 758 | D | 0 | 1 | CV1211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on interview and record review; the facility failed to ensure the provider documented the rationale for declining a GDR (Gradual Dose Reduction) request for antipsychotic medication (medication used for the treatment of [REDACTED]. This affected 1 of 5 sampled residents. The facility identified a census of 58 at the time of survey. Findings are: Review of Resident 46's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 5/9/2019 revealed and admission date of [DATE]. Resident 46 had a BIMS (Brief Interview for Mental Status) score of 1 which indicated severe cognitive impairment. Antipsychotic medication was received 7 days of the 7 days look back period. Antipsychotics were received on a routine basis only. No GDR had been attempted and the Physician had not documented a GDR as clinically contraindicated. Review of Resident 46's Physician Visit/Communication form dated 6/3/2019 revealed Resident 46 was admitted to the facility in (MONTH) 2019 with an order for [REDACTED]. The consultant pharmacist wrote a GDR request for the [MEDICATION NAME] with the consent of Resident 46's responsible party. The medical provider declined the GDR request by writing NO on the form. There was no rationale for declining the GDR documented on the form. Review of Resident 46's provider History & Physical and consult/progress notes for (MONTH) 2019 revealed no documentation of a rationale for declining the [MEDICATION NAME] GDR. Interview with the DON (Director of Nursing) on 6/18/19 at 12:11 PM confirmed there was no documentation of the medical provider's rationale for declining the GDR request for the Resident 46's [MEDICATION NAME]. Review of the facility policy [MEDICAL CONDITION]/Psychoactive Medication Management dated 1/2017 revealed the following: The attending physician must document in the resident record that the identified irregularity has b… | 2020-09-01 |
| 2754 | 2754 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2019-06-18 | 803 | E | 0 | 1 | CV1211 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.11A1 Based on observation, interview, and record review; the facility failed to serve the meals per menu. This affected 10 of the 58 residents who received food from the facility kitchen (Residents 7, 14, 29, 25, 23, 46, 11, 8, 4, and 2). The facility identified a census of 58 at the time of survey. Findings are: Observation of Cook-A on 6/17/2019 at 12:02 PM revealed they served a gray scoop of ground hamburger steak and a gray scoop of pureed hamburger steak to those residents indicated to receive this on their diet cards. Review of the facility Diet Spreadsheet Week 5 Day 29 revealed the noon meal for 6/17/2019 read to serve the pureed hamburger steak with 2 #10 scoops and 6 ounces of hamburger steak to residents with regular meat and ground meat. Review of the facility Scoop Sizes chart revealed a gray scoop was a 1/2 cup or 4 ounces. A #10 scoop was 3/8 of a cup or 3-4 ounces which indicated the residents should have received 6 ounces of meat, not 4. Review of the Diet Type Report dated 6/17/2019 revealed the following diet orders: Resident 7, Resident 14, Resident 29, Resident 25, Resident 23, Resident 46, Resident 10, and Resident 11 were to receive a mechanical soft diet texture. Resident 8, Resident 4, and Resident 2 were to receive a pureed diet texture. Interview with the FSS (Food Service Supervisor) on 06/17/19 revealed the following residents received a 4 ounce portion of ground hamburger steak meat: Resident 7, Resident 14, Resident 29, Resident 25, Resident 23, Resident 46, and Resident 11. These residents received a 4 ounce portion of pureed hamburger steak: Resident 8, Resident 4, and Resident 2. (Resident 10 received ground turkey in the amount listed per menu so they were not included in the sample). Observation of the kitchen on 6/17/19 at 3:12 PM with the facility Administrator revealed the scoops were all in a drawer. The Administrator verified the gray scoop was a #8. Interview with the Administrator at this time revealed they had called the facili… | 2020-09-01 |
| 5992 | 5992 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2015-08-13 | 329 | D | 0 | 1 | 3NYH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview; the facility failed to monitor the effects of a medication given for mood stabilization for one resident (Resident 26). The facility census was 49. Findings are: A review of the Medication Administration Record [REDACTED]. [DIAGNOSES REDACTED]. There was no documentation indicating Resident 26 had a [DIAGNOSES REDACTED]. A review of Davis's Drug Guide for Nurses, Fourteenth Edition, revealed [MEDICATION NAME] had therapeutic classifications of anticonvulsant (anti-[MEDICAL CONDITION]) and mood stabilizer. A review of a Psychoactive Medication (chemical substances that affect the brain functioning, causing changes in behavior, mood and consciousness) Review form for Resident 26, dated 4/21/14-5/28/15, revealed no documentation related to the use of [MEDICATION NAME] for mood stabilization. During an interview on 08/13/2015 at 1:19 PM, the Director of Nursing (DON) revealed [MEDICATION NAME] was not one of the medications the facility had been monitoring related to behavioral concerns for Resident 26. | 2019-07-01 |
| 5993 | 5993 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2015-08-13 | 428 | D | 0 | 1 | 3NYH11 | Licensure Reference Number 175 NAC 12-006.12B Based on record review and interview; the facility failed to ensure monthly pharmacy reviews included documentation related to duplicate medication (more than one medication used to treat the same condition) and possible medication interactions for two residents (Residents 6 and 26). The facility census was 49. Findings are: A. A review of the Medication Administration Record [REDACTED]. A review of the medical record for Resident 6 revealed no documentation indicating monthly pharmacy reviews were completed. B. A review of the MAR for Resident 26 dated (MONTH) (YEAR), indicated the resident received the following meds: Namenda 10 mg twice daily for Alzheimer's Disease, and an Exelon Patch 9.5 mg/24 hours for Alzheimer's Disease. Further review of the medical record for Resident 26 revealed no documentation indicating monthly pharmacy reviews were completed. C. During an interview on 08/13/2015 at 3:04 PM, the Director of Nursing (DON) revealed the Pharmacist signed off on the past months MAR indicated [REDACTED]. | 2019-07-01 |
| 5994 | 5994 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2015-08-13 | 467 | E | 0 | 1 | 3NYH11 | Based on observation, interview, and review; the facility failed to provide functioning vent fans in two resident restrooms, in Rooms 102 and 306. This had the potential to affect 4 residents (Residents 39, 44, 56 and 68). The facility census was 49. Findings are: On 08/12/2015 at 8:54 AM during an Environmental Tour with the Maintenance Director, it was observed that vent fans in resident restrooms for Rooms 102 and 306 were no functioning. On 08/12/2015 at 8:54 AM, an interview with the Maintenance Director revealed, the vent fans in the restrooms for Rooms 102 and 306 were not functioning. The roof fans for the restroom vent fans were checked every three months, with the last check being in (MONTH) (YEAR). The facility used the TELS Maintenance system (TELS is a Senior Living building management system) for routine preventative maintenance. The individual vents in the resident restrooms were checked randomly. No documentation was available to verify any vent fan maintenance checks had been completed. Record review revealed no documentation of routine maintenance checks of the resident restroom vent fans had been completed. | 2019-07-01 |
| 7286 | 7286 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2014-07-31 | 164 | D | 0 | 1 | BXOJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05 (21) Based on observations and staff interview, the facility failed to ensure that privacy was provided during personal cares for one sampled resident (Resident 41). The facility census was 59. Findings are: Review of Resident 41's Care Plan, goal date 10/25/14, revealed that the resident was admitted to the facility on [DATE] and required assistance with activities of daily living including dressing, transfers, and personal cares. Observation on 7/30/14 at 8:15 AM revealed NA (Nursing Assistant) - A and MA (Medication Aide) - B awakened the resident for morning cares. Further observation revealed that MA - B pulled the top linens off of the resident and placed them at the foot of the bed which exposed the resident from the waist down. MA - B and NA - A provided catheter care and perineal care without draping or covering the resident during the procedures. Interview on 7/30/14 at 2:30 PM with the DON (Director of Nursing) confirmed that the staff were to drape or cover the resident while performing personal cares to prevent unnecessary exposure of the resident's body and to promote privacy. | 2018-05-01 |
| 7287 | 7287 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2014-07-31 | 241 | E | 0 | 1 | BXOJ11 | Licensure Reference Number 175 NAC 12-006.05 (21) Based on observations and staff interview, the facility failed to remove the mechanical lift transfer slings for six sampled residents seated in the main dining room (Resident 41, Resident 25, Resident 33, Resident 24, Resident 11, and Resident 5). The facility census was 59. Findings are: Observations in the main dining room on 7/30/14 at 8:40 AM and at 12:15 PM revealed Resident 41, Resident 25, Resident 33, Resident 24, Resident 11, and Resident 5 seated in wheelchairs with the mechanical lift transfer slings draped on the back and the sides of the wheelchairs. Interview on 7/30/14 at 2:30 PM withe the DON (Director of Nursing) confirmed that the transfer slings should be removed or tucked into the wheelchair to promote the residents' dignity while in a public area. | 2018-05-01 |
| 7288 | 7288 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2014-07-31 | 428 | D | 0 | 1 | BXOJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview; the facility failed to ensure the pharmacist identified and reported drug irregularities related to Acetaminophen dosages that could exceed 4000 mg in a 24 hour period for 3 residents (Resident 26, 15, and 29). The facility census was 59. Findings are: A. Review of the facility's CONSULTANT PHARMACIST CONTRACT dated 9/12/1997, revealed the pharmacist will review each resident's drug regimen at least monthly and report any irregularities to the facility's administration and the attending physician. B. Review of the physician's orders [REDACTED]. Resident 26 had the potential to receive 5900 mg of Acetaminophen. Review of Resident 26's CARE PLAN and Medication Administration Record [REDACTED]. Review of the PHARMACIST DRUG REGIMEN REVIEW for 6/26/14 to 7/28/14 lacked evidence of the pharmacist's review for the potential overuse/overdose of Acetaminophen. C. The Food and Drug Administration (FDA) issued information in 2014 about the Acetaminophen drug class stating the maximum dose is 4000 mg per 24 hour period. D. Interview with the Director of Nursing on 7/31/14 at 9:30 AM revealed knowledge of the FDA's drug information to not exceed 4000 mg within 24 hours. E. Interview with MA-Y (medication aide) on 7/31/14 at 10:20 AM revealed the lack of knowledge of the Acetaminophen maximum dosing per 24 hour period. F. Review of the physician's orders [REDACTED]. - Acetaminophen 650 mg orally 3 times a day for leg/knee pain; - Norco (Acetaminophen 325 mg and Hydrocodone 5 mg) orally once a day at bedtime for leg/knee pain; - Acetaminophen 500 mg orally twice a day as needed for pain, fever, or headache; and - Lortab (Acetaminophen 325 mg and Hydrocodone 5 mg) orally every 4 hours as needed for severe pain. - Resident 15 had the potential to receive 5225 mg of Acetaminophen in a 24 hour period. Review of Resident 15's CARE PLAN dated 11/30/11 and the July 2014 Medication Administration Record [REDACTED]. Review of t… | 2018-05-01 |
| 7289 | 7289 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2014-07-31 | 441 | D | 0 | 1 | BXOJ11 | Licensure Reference Number 175 NAC 12-006.17B Based on observations and staff interview, the facility failed to ensure that 1) disposable gloves were worn while an injection was administered for one sampled resident (Resident 41), 2) a plastic graduate cylinder, used to measure urinary output, was cleaned and covered after use for one sampled resident (Resident 41), and 3) plastic gallon containers of distilled water were dated when opened and not stored on the floor for one sampled resident (Resident 6). The facility census was 59. Findings are: A. Observation on 7/29/14 at 9:00 AM revealed RN (Registered Nurse) - C administered an injection for Resident 41 without wearing gloves. B. Observations on 7/29/14 at 8:30 AM and on 7/30/14 at 7:30 AM and at 1:20 PM revealed a soiled and uncovered plastic graduated cylinder, used to measure urinary output, stored on the back of the toilet for Resident 41. C. Observations on 7/29/14 at 8:30 AM and on 7/30/14 at 7:30 AM and 1:20 PM revealed an opened gallon container of distilled water on the bedside table and on the floor under the sink for Resident 6. Further observations revealed no date on the containers when they were opened. Interview on 7/30/14 at 1:20 PM with the Infection Control Coordinator confirmed that the nurses were to wear gloves when administering injections to reduce the risk of cross contamination. Further interview confirmed that the plastic graduate cylinders were to be cleaned after use and stored in a bag in the resident's bathroom. The Infection Control Coordinator also confirmed that the distilled water containers were to be dated when opened and were not to be stored on the floor to reduce the risk of cross contamination. | 2018-05-01 |
| 8978 | 8978 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2013-05-23 | 279 | D | 0 | 1 | TKKZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09C1c Based on record review and staff interview, the facility failed to plan care for 1 resident (Resident 57) with planned weight loss. The facility had a census of 55 and this affected 1 resident. Findings are: According to the 12/12/12 FACE SHEET Resident 57 was admitted to the facility on [DATE]. The following [DIAGNOSES REDACTED]. Review of the 12/19/12 Individual Comprehensive CARE PLAN confirmed that the facility identified a goal for Resident 57 to maintain weight within 5 LBS (pounds) of 199 LBS. Review of the VITAL SIGNS AND WEIGHT RECORD revealed that Resident 57 had a 12/6/12 weight of 201.5 LBS. On 12/19/12 the recorded weight was 183 LBS. This represented a 9% reduction in weight for the 2 week period of time. The 12/19/12 recorded weight was 16 LBS below the 12/19/12 CARE PLAN goal weight of 199 LBS. Interview on 5/16/13 with the DON (Director of Nursing) confirmed that this resident had severe [MEDICAL CONDITION] when admitted to the nursing home. The resident was receiving adjustments in the prescribed diuretic and utilizing gradient compression stockings to treat the [MEDICAL CONDITION]. Interview on 5/21/13 at 9:44 AM with the RD (Registered Dietician) and the resident assessment/care plan coordinator revealed that Resident 57 was initially weighed with winter clothing and the subsequent recorded weights were taken without clothing, which accounted for some of the weight loss. The resident was also admitted with [MEDICAL CONDITION] in both ankles and the abdomen. The facility was actively assisting the resident with relief of that [MEDICAL CONDITION]. The RD reported that the plan was for the resident to have weight loss- not maintain the weight as per the CARE PLAN. The resident assessment/care plan coordinator confirmed that the CARE PLAN failed to reflect a planned weight loss for Resident 57. | 2016-12-01 |
| 8979 | 8979 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2013-05-23 | 309 | D | 0 | 1 | TKKZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09 Based on observation, record review, staff and resident interviews; the facility failed to identify, assess, and monitor an area of bruising to 1 resident (Resident 62). The facility census was 55. Findings are: Review of a FACE SHEET dated 3/19/13 revealed Resident 62 was admitted to the facility on [DATE]. Review of a History and Physical dated 5/8/13 revealed Resident 62 had [DIAGNOSES REDACTED]. Observation on 05/20/13 at 8:55 AM, revealed Resident 62 had a small bruise on the inside surface, at the base of the right index finger. Resident 62's right hand was limp. Resident 62 revealed no knowledge of how the resident got the bruise on the right index finger. Review of Resident 62's Nurses Notes revealed an entry dated 5/19/13 at 10:00 AM that stated Res (resident) has 1+ [MEDICAL CONDITION] (swelling) to (R) (right) hand & (R) ankle -[MEDICAL CONDITION]. Denies any discomfort. There was no documentation related to a bruise on Resident 62's right index finger. Review of UNUSUAL OCCURRENCE REPORTS for Resident 62 reveal no bruises on the right index finger had been documented. Observation on 5/22/13 at 8:39 AM, with the Director of Nursing (DON), revealed a dark purple bruise present on the inner surface of the base of Resident 62's right index finger, approximately 2 cm (centimeters) by 1 cm. Observation revealed Resident 62's right hand was limp and Resident 62 used the left hand to move the right. The DON revealed (gender) did not think the bruise had been reported and commented it looked new. The DON verbalized the thought that Resident 62's right hand was also swollen. Review of Resident 62's ADL (activities of daily living) Record revealed a right hand splint had been placed on in the PM and taken off in the AM, every day during the month of May 2013. During an interview on 5/22/13 at 8:58 AM, Nursing Assistant (NA) - D revealed (gender) had not removed Resident 62's right hand brace but … | 2016-12-01 |
| 10891 | 10891 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2012-03-28 | 312 | E | 0 | 1 | FMHL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D1c Based on observation, resident interview and family interview; the facility staff failed to ensure that call lights were answered to the resident satisfaction. The practice affected Residents 30, 19, 7, 52, 11. Facility census was 52. The survey sample size was 36. Findings are: A. Observation on 3/21/2012 at 11:14 AM found the call notification system sounding for room [ROOM NUMBER] (Resident 7), the call notification system was turned off at 11:26 AM--a total of 12 minutes. B. Observation on 3/21/2012 at 11:14 AM found the call notification system sounding for room [ROOM NUMBER] (Residents 30 and 19), the call notification system was turned off at 11:27 AM--a total of 13 minutes. C. Observation on 3/21/2012 at 11:30 AM found the call notification system sounding for room [ROOM NUMBER] (Residents 52 and 11), the call notification system was turned off at 11:43 AM--a total of 13 minutes. D. Observation on 3/22/2012 at 9:15 AM found the call notification system sounding for room [ROOM NUMBER] (Residents 30 and 19), the call notification system was turned off at 9:35 AM--a total of 20 minutes. E. Observation on 3/22/2012 at 1:25 PM found the call notification system sounding for room [ROOM NUMBER] (Residents 30 and 19), the call notification system was turned off at 1:38 PM--a total of 20 minutes. F. Observation on 3/22/2012 at 1:27 PM found the call notification system sounding for room [ROOM NUMBER] (Residents 52 and 11), the call notification system was turned off at 1:39 PM--a total of 12 minutes. G. Interview with the DON (Director of Nurses) on 3/22/2012 at 2:15 PM stated the expectations were for the staff to answer the call lights as soon as possible like 10 minutes was too long. We did a pole of the residents and the suggested time of desire was no more that 10 minutes. H. Interview with the Administrator on 3/27/2012 at 1:30 PM stated the expectation was for the staff to answer the call… | 2015-10-01 |
| 12257 | 12257 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2010-11-23 | 281 | E | 0 | 1 | Y4B511 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.10A2 Based on observations, record reviews, and staff interviews; the facility failed to follow standards of practice in regards to the administration of medication for 8 of 60 residents by not completing the 3 safety medication administration checks. The sample size was 15 residents and the facility census was 60. Findings are: A. Observation of the insulin administration on 11/16/2010 between 11:00 AM to 11:15 AM by LPN-A (Licensed Practical Nurse) found that LPN-A compared the insulin bottle to the MAR (Medication Administration Record), this completed the first check. LPN-A drew up the insulin in a syringe then compared the insulin bottle with the MAR,, this completed the second check. The insulin was administered then charted. The third check was not completed. Observation of the medication administration on 11/16/2010 between 11:45 AM to 12:00 PM by LPN-A found that the LPN-A took the medication card from the drawer then compared the medication card to the MAR indicated [REDACTED]. The medication cards were placed back into the drawer by LPN-A. The medication was administered to the resident. LPN-A charted the medication that was administered. The second and third checks were not completed. B. Observation of the medication administration on 11/16/2010 between 12:00 PM to 12:15 PM by RN-B (Registered Nurse) found that RN-B took the mediation card from the drawer then compared the medication card to the MAR indicated [REDACTED]. The medication cards were placed back into the drawer by RN-B. The medication was administered to the resident the RN-B charted the medication that was administered. The second and third checks were not completed. C. Observation of the medication administration on 11/23/2010 between 8:00 AM to 8:10 AM by MA-C (Medication Aide) found that MA-C took the medication card from the drawer made a comparison of the medication card to the MAR indicated [REDACTED]. The medication cards were placed back into the drawer by MA-C. The medication was admini… | 2014-09-01 |
| 12258 | 12258 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2010-11-23 | 315 | D | 0 | 1 | Y4B511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(1) Based on observation, record review, and staff interview; the facility staff failed to provide perineal care in a manner to prevent the potential for a urinary tract infection for 2 residents (Residents 45 and 58) from a resident sample size of 15. The facility census was 60. Findings are: A. Observation of perineal cares for Resident 45 on 11/18/2010 between 9:20 AM to 9:35 AM found MA-D (Medication Aide) with a gloved hand performed 3 wipes with the same spot of the wipe to clean the groin area. The resident had been incontinent of bladder and bowels per MA-D. The resident was rolled to the left side MA-D cleaned the buttock region with several wipes of the same spot of the wipe. Review of the Interdisciplinary Care Plan, dated 11/12/2010, indicated the resident was incontinent of bladder and bowel. The resident required two person assist for toilet use. Review of the Admission/Re-admission orders [REDACTED]. B. Observation of perineal cares for Resident 58 on 11/18/2010 between 1:30 PM and 1:40 PM found MA-C with a gloved hand performed 3 wipes with the same spot of the moistened wipe to clean the groin area. The resident had been incontinent of urine per MA-C. Review of the Interdisciplinary Care Plan, dated 11/5/2010, indicated the resident was incontinent of the bladder. Review of the Admission Nursing Evaluation dated 11/5/2010, indicated the resident was admitted to the facility with the following [DIAGNOSES REDACTED]. Interview with the DON (Director of Nurses) on 11/22/2010 at 2:15 PM revealed the expectation was for the staff to use a different spot of the wipes to clean the residents. Review of the facility form entitled Perineal Care, with a revised date of September 2005) stated to not reuse the same washcloth during personal cares. | 2014-09-01 |
| 12259 | 12259 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2010-11-23 | 441 | D | 0 | 1 | Y4B511 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observations, staff interviews and record review; the facility staff failed to perform hand washing to prevent cross contamination during personal cares for 3 sampled residents (Residents 45, 58, and 36). The facility census was 60 residents. The sample size was 15 residents. Findings are: A. Observation of personal cares for Resident 45 on 11/18/2010 between 9:20 AM to 9:35 AM found NA-E (Nurse Aide) performed a lathered hand wash for 10 seconds before cares and 5 seconds after cares. MA-D (Medication Aide) performed a lathered hand wash for 10 seconds after cares were completed. Observation of personal cares for Resident 45 on 11/18/2010 between 11:30 AM and 11:45 AM by the physical therapist assistant and MA-D performed a lathered hand wash for 10 seconds before and after cares. B. Observation of person cares for Resident 58 on 11/18/2010 between 1:30 PM and 1:40 PM by MA-C who ambulated Resident 58 to the bathroom lowered the clothes for the resident to sit on the toilet. MA-C did not wash the hands before Resident 58 was assisted. MA-C did wear gloves to perform personal cares. Once the cares were completed and the gloves removed MA-C washed the hands for 10 seconds. C. Observation on 11/16/2010 at 11:05 AM found LPN-A perform a 10 second lathered hand wash before checking the blood sugar for Resident 36. LPN-A wore gloves to administer the insulin. After the gloves were removed a 5 second lathered hand wash was performed. Interview with MA-D (Medication Aide) on 11/18/2010 at 2:00 PM revealed his/her hands were to be washed for 20 seconds. Interview with the Infection Control Nurse on 11/18/2010 at 2:30 PM revealed the expectation was for the staff to wash their hands for 20 seconds. The Infection Control Nurse indicated the last in-service on Infection Control for the staff was conducted on 9/16/2010. Interview with the DON (Director of Nurses) on 11/22/2010 at 2:15 PM revealed the expectations were for the staff to wash their hands for 20 seconds. Rev… | 2014-09-01 |
| 12260 | 12260 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2010-11-23 | 323 | G | 0 | 1 | Y4B511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09D7a Based on observation, record review and interview, the facility failed to ensure the safety of residents from the use of a hot air hair dryer which got hot enough to cause burns. The facility had a census of 60 and a survey sample of 15. This affected Resident 34 and potentially could affect Resident 31. Findings are: According to the 10/25/10 FACE SHEET, Resident 34 was admitted to the facility on [DATE]. An 11/8/10 REPORT OF CONSULTATION documented the following Diagnoses: [REDACTED]. Review of the 10/8/10 IPN (INTERDISCIPLINARY PROGRESS NOTES) revealed that Resident 34 was found at 6:15 PM to have a 20 cm (centimeter) by 3 cm reddened area with 2 blisters measuring 3 cm by 3 cm and 1.5 cm by 1.5 cm on the neck. A 10/8/10 UNUSUAL OCCURRENCE REPORT documented that a nursing assistant left the resident "sitting under hair dryer" from 4:30 PM till 4:45 PM. A 10/8/10 INVESTIGATION FORM documented that the hair dryer used was old and had no heat setting. A WOUND NOTIFICATION to the attending physician resulted in the resident needing Silvadene cream applied to the burn area twice daily till healed. An observation was made of Resident 34's neck on 11/23/10 at 10:00 AM. RN-B (Registered Nurse) pointed to the spot on the back/side of Resident 34's neck where the burn had been. Observation confirmed that Resident 34 continued to have redness on the neck where the burn had been. Interview on 11/22/10 at 1:20 PM with the DON (Director of Nursing) revealed that the hair dryer used on Resident 34 was donated by a former employee. The dryer was kept on the locked unit and used only for 2 residents (Resident 31 and Resident 34) who had nursing assistants set their hair on the locked unit. The DON confirmed on 11/22/10 at 3:30 PM that the hair dryer had never been checked for safety, there was no policy and procedure for the use of the hair dryer and nursing assistants received no training on how to use the hot air … | 2014-09-01 |
| 12261 | 12261 | ROSE LANE HOME | 285228 | RR 2 BOX 46, 1005 NORTH 8TH STREET | LOUP CITY | NE | 68853 | 2010-11-23 | 225 | E | 0 | 1 | Y4B511 | LICENSURE REFERENCE: 175 NAC 12-006.04A3b (2 and 3) Based on record review and staff interview, the facility failed to ensure that new employees were screened by CPS (Child Protective Services) and APS (Adult Protective Services) to ensure there was no history of abuse for 2 staff (DA - Dietary Aide M and RN - Registered Nurse G) of 5 personnel records reviewed. The survey sample size was 15 and the facility census was 60. Findings are: A. Review of the facility policy and procedure titled " ABUSE AND NEGLECT PREVENTION STANDARD " dated 04/2009 revealed the following under the section titled SCREENING: " All potential employees will be screened for history of abuse, neglect or mistreating residents ....NEBRASKA - Child Protective Services (CPS), Adult Protective Services (APS), and the sex offender registry will be checked for all potential employees " . B. Review of 2 personnel files of employees hired within the past year revealed that the facility had failed to pursue verification with CPS or APS for DA M with a hire date of 3/19/2010 and RN G with a hire dated of 9/13/2010 to ensure that they did not have a history of abuse recorded with either agency. C. Interview on 11/18/2010 at 11:38 AM with the facility Office Manager confirmed that CPS and APS had been contacted on 3/14/2010 concerning DA M; however, CPS and APS had failed to reply to the request and the facility did not contact the agencies for any further information. The facility Office Manager also stated that CPS and APS had been contacted on 9/8/2010 and again on 9/23/2010 regarding information on RN G; however, again, the facility failed to contact the agencies for any further information to ensure that the new employees were free from abuse and neglect. | 2014-09-01 |
| 2789 | 2789 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2020-01-21 | 550 | D | 0 | 1 | CCP811 | Licensure Reference Number 175 NAC - 12-006.05(6) Based on observation, record review and interview the facility failed to maintain resident's dignity as evidenced by Resident 10 and 21 having soiled clothing in public areas and Resident 41 having an uncovered catheter collection bag. The facility census was 70. Findings are: [NAME] An observation on 01/13/20 at2:29PM revealed Resident 10's body had a very strong odor present, Residents 10's jeans had a large wet area on bottom and front groin area. Resident 10 was wandering out in the hallway with soiled clothing on. An interview on 01/13/20 at 2:35PM with NA (Nursing Assistant) C revealed staff do not help Resident 10; because (gender) becomes upset. NA- C walked away, leaving Resident in doorway of room/ hall way in soiled jeans. An observation on 01/14/20 at 1:50PM revealed Resident 10 was walking in hallway and arrived at nurse's station, resident was wearing light colored jeans and there was a large wet area to the front of resident's jeans. A strong odor of urine was present when Resident 10 arrived. An interview on 01/14/20 at 1:50PM with MA (Medication Aide) D revealed Resident 10 can be very aggressive when asked to change clothing when soiled. Staff tend to leave resident alone. MA-D went to join report and left Resident 10 soiled in hallway and did not ask anyone to assist resident. An interview on 01/14/20 at 2:00PM with ADON (Assistant Director of Nursing) and DON (Director of Nursing) revealed resident is to be redirected to room to change clothing. ADON states this often takes a few tries as resident is usually focused on other matters. An interview on 01/21/20 at 3:35PM with Administrator confirmed Resident 10 having soiled clothing and being incontinent in public is a dignity issue. Record review or Resident Rights book dated (YEAR) revealed under Respect and Dignity States residents are to be treated with respect and dignity. Record review of Resident Rights policy dated 09/2019 revealed the facility will protect and promote the right of our re… | 2020-09-01 |
| 2790 | 2790 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2020-01-21 | 561 | D | 0 | 1 | CCP811 | **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 failed to ensure Resident 56's bathing preferences were honored. The facility census was 70. Findings are: An interview on 01/13/20 at 3:45 PM with Resident 56 revealed resident receives 3 baths per week usually but he would prefer to have a bath/shower daily. Resident was informed on admission that daily bathing would not be possible due to staffing. Record review of current care plan (a written document detailing how to care for an individual needs) dated 12/19/19 revealed Resident 56 requires extensive assistance by (1) staff with showering. Resident prefers showers on M-W-F. Date Initiated: 09/18/2019 Record review of Resident 56 MDS dated [DATE] revealed in section F preferences for Customary Routine and Activities Resident answered very Important in regards to how important is it to you to choose between a tub bath, shower, bed bath or sponge? Record review of Resident 56's bathing logs dated 12/1/2019-01/20/2020 revealed the following: Resident 56 received baths on the following dates: 11/8/2019 11/11/2019 11/13/2019 11/22/2019 11/25/2019 11/27/2019 11/29/2019 11/20/2019 12/2/2019 12/4/2019 12/9/2019 12/16/2019 12/18/2019 12/27/2019 12/30/2019 1/03/2020 01/15/2020 Resident 56 did not receive shower's on the following days: 11/4/2019, 11/6/2019, 11/15/2019, 11/18/2019, 12/6/2019, 12/11/2019, 12/13/2019, 12/20/ 9, 12/23/19(Christmas day 12/25/2019) 01/01/2020 (New Year's Day). An interview on 01/21/20 at 4:00PM with DON confirmed Resident 56 had not received baths on the following days: 11/4/2019, 11/6/2019, 11/15/2019, 11/18/2019, 12/6/2019, 12/11/2019, 12/13/2019, 12/20/ 9, 12/23/19(Christmas day 12/25/2019) 01/01/2020 (New Year's Day). | 2020-09-01 |
| 2791 | 2791 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2020-01-21 | 578 | D | 0 | 1 | CCP811 | .Based on record review and interview, the facility failed to ensure that the Comprehensive Care Plan (a multidisciplinary plan to meet a residents medical nursing and social needs) for 1 (Resident 36) of 39 residents reviewed included information related to advanced directives (a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). The facility census was 70. Findings are: Record review of Resident 36's Comprehensive Care Plan dated 10/24/19 revealed no information related to Advanced Directives or code status (refers to the level of medical interventions a patient wishes to have started if their heart or breathing stops). Interview conducted on 1/14/20 at 09:40 [NAME]M. with the facility social worker confirmed that the Advanced Directives and code status should be on care plan and were not. | 2020-09-01 |
| 2792 | 2792 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2020-01-21 | 584 | E | 0 | 1 | CCP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18 Based on observation and interviews the facility failed to prevent smoke odor in the dining room and a strong odor of urine in the 100 hallway. This had the potential to affect 58 residents that eat in the dining room and the 100 hallway. The facility census was 70. Findings are: [NAME] An observation on 01/13/20 at 11:15AM revealed that the dining room had a strong odor of smoke. Several resident had just come inside from smoking and the smoking door is near the dining room. Resident 1 was wearing heavy [NAME]et that had very strong smoke smell and was sitting in the middle of dining room. An interview on 01/15/20 at 5:35PM with Resident 43 revealed that in the dining room the smell of smoke was present. Resident 43 wears oxygen and has breathing problems and does not like smell of smoke. An interview on 01/15/20 at 5:37PM with DON (Director of Nursing) confirmed a strong smell of smoke was present in the dining room and this could be considered an issue for residents that do not smoke and do not like smoke in their homelike environment. B. An observation on 01/13/20 at2:29PM revealed Resident 10's body had a very strong odor present, Residents 10's jeans had a large wet area on bottom and front groin area. Resident 10 was wandering out in the 100 hallway with soiled clothing on. An observation on 01/16/20 at 8:16AM revealed Resident 21 was lying in bed and had a large wet area to jeans and pad on bed; a very strong pungent odor of urine was present. An interview on 01/15/20 at 8:55AM with Housekeeping supervisor states that Resident 21's has a strong urine odor due to resident lying in bed and soiling self and bed. An interview on 01/15/20 at 10:15AM with NA (Nursing Assistant) F revealed the 100 hallway always has a strong smell of urine. NA -F then pointed to Resident 21 name outside of room and stated the smell is from this resident urinating on bed and frequently lying in urine. An interview … | 2020-09-01 |
| 2793 | 2793 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2020-01-21 | 623 | E | 0 | 1 | CCP811 | **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 provide written reason of transfer to the hospital to the resident and resident's representative, and failed to send notice of transfer to the hospital to the Ombudsman. This affected 6 residents (Residents 54, 41, 28, 24, 36, and 64) of 6 reviewed. The facility census was 70. Findings are: A) Review of Resident 54's Progress Note dated 12/27/19 at 8:32 AM revealed the resident was sent to the emergency roiagnom on [DATE] and admitted to the hospital on [DATE] for new onset [MEDICAL CONDITION] (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident 54's EHR (electronic health record) and chart revealed an absence of documentation related to a written notice of transfer provided to Resident 54 or the resident's representative. B) Review of Resident 41's Progress Note dated 12/26/19 at 3:15 PM revealed Resident 41 was transferred to the hospital. Resident 41 had diminished lung sounds, showed signs of nasal flaring (a sign one may be having difficulty breathing), [MEDICAL CONDITION] (swelling) to lower legs and arms, and lethargy (tiredness that involves diminished energy, mental capacity, and motivation). Review of Resident 41's EHR and chart revealed an absence of documentation related to a written notice of transfer provided to the resident. C) Review of Resident 28's Progress Notes dated 10/10/19 at 7:06 PM revealed the resident was transferred to the hospital. Resident 28 was lethargic and complaining of neck and left shoulder pain. Review of Resident 28's EHR and chart revealed an absence of documentation related to a written notice of transfer provided to the resident or the resident's representative. Interview on 01/15/20 at 12:05 PM with the ADM (Administrator) revealed the facility had not been sending notice of resident transfers to the hospital to the Ombudsman. Interview on 1/21/20 at … | 2020-09-01 |
| 2794 | 2794 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2020-01-21 | 644 | D | 0 | 1 | CCP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the PASRR (Preadmission Screening and Resident Review - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) reflected current [DIAGNOSES REDACTED]. Facility census was 70. Findings are: Review of Resident 28's Admission Record dated 01/14/20 revealed [DIAGNOSES REDACTED]. Review of Resident 28's PASRR dated 4/15/13 revealed an absence of documentation related to generalized anxiety disorder, major [MEDICAL CONDITION], or [MEDICAL CONDITION] disorder under Section I: Mental Illness. Section X: Determination and Outcome revealed the outcome was negative as Resident 28 had no reported serious mental illness. Interview on 1/16/20 at 12:16 PM with the DON (Director of Nursing) confirmed Resident 28's PASRR was not updated with the resident's current diagnoses. | 2020-09-01 |
| 2795 | 2795 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2020-01-21 | 657 | D | 0 | 1 | CCP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C1c Based on observation, record review and interview the facility revise a Care Plan (a written plan of how to meet each individuals care needs) related to bladder and bowel continence issues for 2 Resident's ( Residents 21 and 10) out of 18 residents sampled. The facility census was 70. Findings are: [NAME] An interview on 01/14/20 at 8:26AM with Resident 21 revealed (gender) is always having issues with bowels and incontinent of urine. Resident 21 revealed (gender) uses incontinent depends and bed pads. An observation on 01/13/20 at 10:00AM revealed Resident 21 was standing naked by closet in room with soiled incontinent depend around ankles and threw a soiled bed pad to the floor. The hallway and room had strong pungent odor. Current care plan did not reflect new nursing assistant tasks initiated on 01/15/20 for checking residents hamper/ trash every 2 hours and cue Resident 21 for toileting every 2 hours. Record review of Resident 21 Care Plan dated 11/1/19 revealed the following information: Resident 21 has a history of Urinary Tract Infections related to poor hygiene and frequent episodes of Incontinence. Date Initiated: 08/07/2019 Goal: o Resident Will Show No Signs /Symptoms of Infection through Next review. Date Initiated: 08/07/2019 Revision on: 11/01/2019 Target Date: 02/06/2020 Interventions o PERSONAL HYGIENE/ORAL CARE: The resident is able to complete tasks related to Personal Hygiene independently. Requires cues and encouragement to complete. Date Initiated: 08/07/2019 o TOILET USE: The resident is able to: toilet independently. Requires limited Assistance by (1) staff at times during episodes of incontinence. Date Initiated: 11/06/2019 Revision on: 11/06/2019 Record review of MDS (Minimum Data Set) (is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of e… | 2020-09-01 |
| 2796 | 2796 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2020-01-21 | 690 | D | 0 | 1 | CCP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D3 Based on observations, interviews and record reviews the facility failed to ensure Residents 21 and 10 were not left in soiled or wet clothing. The facility census was 70. Findings are: According to HCFA (Health Care Financing Administration) practice guidelines specify that a resident's soiled garments should be changed and skin cleansed in a timely fashion. Cited in Hartman's Nursing Assistant Care 2014 resident are to be offered a trip to the toilet at least every 2 hours. Record review of continence management policy dated 07/18 revealed facility will provide restorative continence management programs for residents to help manage incontinence. Procedure: Within the admission assessment period the interdisciplinary Team will assess the resident's physical and cognitive status and review medications and [DIAGNOSES REDACTED]. If multiple incontinent episodes occur a bowel and bladder elimination pattern evaluation will be conducted. Second part the resident will be provided education on bowel and bladder program. A trial program will be conducted and then added to care plan. If the resident's continence cannot be improved, then appropriate in continue products and elimination care routines will be used to maintain the health and comfort of the resident. This process can also be initiated day point during a resident stay. An observation on 01/13/20 at 2:29 PM revealed Resident 10 had a strong odor present upon entering resident's room and standing next to resident. Resident's jeans had a large wet spot on bottom and front groin area. An interview on 01/13/20 at 2:35PM with NA (Nursing Assistant) C revealed staff do not help resident as (gender) becomes upset. NA-C walked away. Resident remained in soiled jeans. An observation on 01/14/20 at 1:50PM revealed Resident 10 was walking in hallway and arrived at nurse's station, resident was wearing light colored jeans and a large wet area to the front … | 2020-09-01 |
| 2797 | 2797 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2020-01-21 | 804 | E | 0 | 1 | CCP811 | Licensure Reference Number 175 NAC 12.006.11D Based on interviews, observation record review and sampling of the meal the facility failed to provide palatable meals that were visually attractive and temperatures were not served according to resident's preferences. This affected Residents 21, 49, 57, 28, 40 and 57 . The facility census was 70. Findings are: An interview on 01/14/20 at 8:28AM with Resident 21 revealed resident stated food is terrible. The meat is always tough, vegetables are soggy. An interview on 01/16/20 at 6:45PM with Resident 21 revealed resident has just received room tray. Resident's tray included vegetables soup and mandarin oranges. Resident 21 report soup was warm but not hot and some of the vegetables were partially cooked. An interview on 01/13/19 at 12:36PM with Resident 49 revealed food arrives cold and tastes nasty. An interview on 01/15/19 at 12:54PM with Resident 49 revealed hot pulled pork sandwich arrived cold. An interview on 01/15/20 at 5:45PM with Resident 28 revealed the vegetable soup was cold in temperature and some of vegetables mostly beans and potatoes were under cooked. An interview on 01/15/20 at 5:45PM with Resident 40 revealed his supper meal was Not very appetizing. An observation on 01/15/20 at 5:45PM revealed resident 40 supper meal consisted of a dish of orange stuff, green stuff, and pink, brown stuff. Resident showed on his fork a soaked piece of bread. An interview on 01/15/20 at 5:45PM with Resident 57 revealed the vegetable soup was cold and the lima beans and potatoes were undercooked and hard. Resident only ate 1 bite and did not eat anymore due to above issues. Record review of Facility Grievance Log. On 12/6/19 during resident council it was report that food not going out in proper order, still cold, ran out of milk, fish last Friday was disgusting some orders are being mixed up. A sample tray was delivered to surveyor on 01/15/20 at 6:34PM the menu was vegetable soup, cold roast beef sandwich, lettuce leaf, tomato slices and mandarin oranges. The vegetab… | 2020-09-01 |
| 2798 | 2798 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2020-01-21 | 809 | D | 0 | 1 | CCP811 | Licensure Reference Number 175 NAC 12-006.11B Based on observations, record review and interviews the facility failed to ensure room trays were delivered according to resident preferences for Residents 21 and 49. This affected 2 of 16 sampled residents. The facility census was 70. Findings are: Record review of Facility Grievance Log. On 12/6/19 during resident council it was report that food not going out in proper order, still cold, ran out of milk, fish last Friday was disgusting some orders are being mixed up. An observation on 01/15/20 at 12:54PM revealed an announcement on the overhead speaker that room trays were ready. An observation on 01/15/20 at 1:12 revealed Resident 49 room tray was just delivered. An interview on 01/15/20 at 3:40PM with Resident 49 revealed pulled pork sandwich arrived cold. An interview on 01/15/20 at 3:42PM with CNA (Certified Nursing Assistant) G revealed that in the evening's room tray orders are collected by the CNA's on each hallway. The 300 hallway is responsible for delivering evening room trays and the 100 hall takes the evening snack cart around. An observation on 01/16/20 at 12:36PM revealed an announcement that room trays were ready at this time; Resident 49 received room tray at 12:47PM. An observation on 01/16/20 at 6:00PM room trays were ready and sitting on large cart outside of kitchen. At 6:09PM an announcement over loud speaker informed CNA's (staff) trays were ready for pick up. A second announcement went out at 6:16PM. Resident 21 received room at 6:40PM. An interview on 01/16/20 at 6:45PM with Resident 21 revealed resident has just received room tray. Resident's tray included vegetables soup and mandarin oranges. Resident 21 report soup was warm but not hot and some of the vegetables were partially cooked. An interview on 01/14/20 at 11:00 AM with DM (Dietary Manager) confirms room trays have been an issue and communication with nursing staff to deliver trays in a timely manner is also a problem. B. An observation on 01/15/20 from 06:10 PM and 06:40 PM revealed… | 2020-09-01 |
| 2799 | 2799 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2020-01-21 | 812 | F | 0 | 1 | CCP811 | Licensure reference number 175 NAC 12-006.11E Based on observations, interviews and record reviews the facility failed to prevent cross contamination and food borne illness by keeping hair enclosed in hairnets, maintaining clean and sanitary kitchen and kitchen equipment, and complete hand hygiene according to facility policy. This affected 69 residents that received food prepared in the kitchen. The facility failed to ensure table surfaces were cleaned prior to seating residents at the table for Resident 272. Findings are: [NAME] Hairnets According the Nebraska Food Code 2-402.11 Hair Restraints Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair that are designed and worn to effectively keep their hair form contracting exposed food, clean equipment, utensils, and linens, and unwrapped single service and singe use articles. An observation on 01/14/20 at 10:55AM revealed DA (Dietary Aide) H was wearing baseball cap with no hairnet, multiple chunks of hair were outside hat. DM and Cook B had hair exposed outside of hairnets. An observation on 01/14/20 at 11:25AM revealed MA (Medication aide) I and J; NA (Nursing Assistant) K were behind drink prep counter without hairnets in place were food was being served and drinks were being prepared. Record review of dress code policy dated 4/13 revealed under Dietary Services Attire number 3. Hair Restraints: Employee entering the kitchen must have all hair covered by a hair bonnet. No stocking caps are to be worn. Caps may be worn with a hairnet. An interview on 01/13/19 at 11:30AM with DM confirmed all staff behind drink prep counter and kitchen must wear a hairnet and have all hair enclosed in net per facility policy and Nebraska Food Code. B. Kitchen cleaning and sanitation An observation on 01/15/20 at 1:40PM revealed stove top was covered in brown grease substance. Oven inside and out was coated in a black burned on substance. Drain under sink has strong sour odor; brown substance covers dr… | 2020-09-01 |
| 2800 | 2800 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2020-01-21 | 867 | D | 0 | 1 | CCP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.07C Based on record review and interview, the facility failed to ensure an effective Quality Assurance program related to not having a certified Infection Control Preventionist (An individual who has completed specialized training in infection prevention and control) and continued failure at F812 in consecutive surveys since (YEAR) for dietary staff, which resulted in potential harm to all residents who consume food prepared in the kitchen through the facility's failures to a) failure to perform hand hygeine and gloving b) perform/maintain a clean and sanitary kitchen c) perform/maintain clean and sanitary kitchen equipment d) wear hair nets in the dietary department. The facility census was 70. Findings are: [NAME] Review of facility Quality Assurance projects dated (MONTH) 2019, included: -Training of new Infection Control nurse. -Review of Infection Control documentation to identify areas in need of further audit and improvement. -Action items include to provide nurse training and develop audit system for Infection Control procedures to ensure the provision of a clean and safe environment for residents. -Fully train new Infection Control nurse to implement and oversee program. Review of facility Quality Assurance projects dated Sept/[DATE], included: -Continue education of Infection Control nurse and development of audit system. -Action Items include to provide nurse training and develop audit system for Infection Control procedures to ensure the provision of a clean and safe environment for residents. -Fully train new Infection Control nurse to implement and oversee program. Record review of facility Quality Assurance projects did not include information related to pneumococcal vaccinations or that the facility did not have a certified Infection Control Preventionist. Interview on 01/16/20 at 10:00 AM with Infection Control nurse revealed that Infection Control Nurse is not currently certified as … | 2020-09-01 |
| 2801 | 2801 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2020-01-21 | 880 | D | 0 | 1 | CCP811 | Licensure Reference Number 175 NAC 12-006.17 Based on observation and interview, the facility failed to ensure oxygen tubing was not in contact with the floor and was dated according to facility policy for 1 (Resident 58) of 3 residents reviewed. The facility census was 70. Findings are: Observation on 01/13/20 at 3:56 PM and 01/14/20 at 11:50 AM revealed that Resident 58 tubing to the oxygen concentrator ( a type of medical device used for delivering oxygen to individuals with breathing related disorders) was observed to be on the floor. The tubing did not have a date that identified when the tubing had last been changed. Interview on 01/14/20 at 1:53 PM with Director of Nursing (DON) confirmed that Resident 58's tubing was on the floor and should not be in contact with the floor. The DON confirmed that the tubing was not dated and tubing should be dated with the date the tubing was last changed. The DON stated tubing on the floor was an infection control issue. | 2020-09-01 |
| 2802 | 2802 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2020-01-21 | 883 | D | 0 | 1 | CCP811 | Licensure Reference Number 175 NAC 12-006.17 Based on record review and interview, the facility failed to ensure that the facility employed a certified Infection Control Preventionist (An individual who has completed specialized training in infection prevention and control). The facility census was 70. Findings are: Interview on 01/16/20 at 10:00 AM with Infection Control nurse revealed that Infection Control Nurse is not currently certified as an Infection Control Preventionist. | 2020-09-01 |
| 2803 | 2803 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2017-05-23 | 166 | F | 1 | 0 | 2FAT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.06A and B Based on record reviews and interviews, the facility failed to assure resolution of residents' complaints for 3 of 3 sampled residents (Residents 100, 200, and 222 ). This practice had the potential to affect all of the residents. The facility census was 74. Findings are: [NAME] Interview on 5-22-17 at 12:00 PM with LPN-A (Licensed Practical Nurse) revealed the facility did not have any grievances between the dates of (MONTH) 1, (YEAR) and (MONTH) 22, (YEAR). B. Interview on 5-23-17 at 8:55 AM with Resident 100 revealed the resident used to use a form called Care and Concern form for any complaints/grievances the resident wanted to report to the facility. The resident stopped using the forms because the facility did not respond back to the resident with a resolution. Now the resident stated the resident would go to the Administrator face to face to report complaints/grievances but still did not receive consistent responses back with resolution to the issues. Review of Resident 100 MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4-11-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) of 15 which indicated the resident had no cognitive impairment. C. Interview on 5-23-17 at 1:55 PM with Resident 200 revealed the resident denied having been informed of a process to follow to report complaints or concerns the resident may have about the facility, other residents, or any issues. Review of Resident 200 MDS dated [DATE] revealed a BIMS of 14 which indicated the resident had no cognitive impairment. D. Interview on 5-23-17 at 2:00 PM with Resident 222 revealed the resident denied having been informed of a process to follow to report any complaints or concerns the resident may have about the facility, other residents, or any issues. The resident revealed the resident had … | 2020-09-01 |
| 2804 | 2804 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2017-05-23 | 226 | D | 1 | 0 | 2FAT11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to report to APS (Adult Protective Services) and the State Agency a resident's fall with a potential fracture which required emergency medical attention for 1 (Resident 333) out of 2 residents reviewed. The facility census was 74. Findings are: Review of the Accidents initial and final report sent on the same day 1-5-17 for Resident 333 revealed the date of the occurrence of the incident was 12-30-16. The report revealed the Administrator and the DON (Director of Nursing) were both notified of the incident on 12-30-16. The report revealed the APS and the Regulation and Licensure department was notified on 1-5-17. Interview on 5-23-17 at 12:18 PM with LPN-A (Licensed Practical Nurse) confirmed the initial report was reported late. | 2020-09-01 |
| 2805 | 2805 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2017-05-23 | 323 | D | 1 | 0 | 2FAT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record reviews, and interviews; the facility failed to put interventions into place to prevent potential injury from falls for 2 (Residents 205 and 207) out of 3 residents sampled. The facility census was 74. Findings are: [NAME] Observation on 5-22-17 at 10:10 AM of Resident 205 revealed the resident was in bed in the resident's room. The resident was awake. The bed was a high-low bed and positioned in the high position. The mattress was a regular mattress. No fall mat was placed on the floor. Review of the undated face sheet for Resident 205 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the quarterly MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 3-14-17 revealed the resident's cognition was severely impaired. The resident required total assistance of 2 staff with bed mobility, transfers, dressing, and toileting. The resident required total assistance of 1 staff for locomotion, personal hygiene, and eating. The Assessment of Risk for Falls form was completed on 09-21-16, 02-17-17 and 3-7-17. Each time the resident scored a 13. Per this assessment tool, a score between 7-18 indicated a high risk for falls. Review of the CAA's (Care Area Assessment) from the MDS dated [DATE] revealed falls was triggered. Review of the CAT (Care Area Triggers) dated 12-21-16 revealed the resident had impaired balance. The resident also had internal risk factors of incontinence, [DIAGNOSES REDACTED], seizure disorder, traumatic brain disorder, delirium, and cognitive impairment. Resident 205 was a 2 assist with use of a Hoyer (a mechanical lift device that does not require the resident to bear weight on the legs) lift for transfers. The care plan team decided not to care plan the resident as a potential risk for falls. Review of Resident 205's care plan revealed a potential for falls was n… | 2020-09-01 |
| 2806 | 2806 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2019-09-18 | 609 | D | 1 | 0 | BEDC11 | > Licensure Reference Number 175 NAC 12-006.02(8) Based on record reviews and interviews; the facility failed to report a completed investigation to the required State Agency within 5 working days for 2 residents of (Resident 1 and 2) of 3 investigations reviewed. The facility census was 74. Findings are: Record review of fax dated 10/08/19 revealed; a fax form with Res/Room number was multiple (resident to resident faxed at one time). Please note attached resident to resident reported to APS on 9/31/18, 10/2/18 and 10/5/18. There was no confirmation number on the fax sheet the state agency received the fax. On 9/29/19 at 11:30 AM Resident 1 reported to charge nurse Resident 2 had threw an empty mouthwash bottle at their chest while attempting to use the toilet in their shared bathroom. Resident 1 was assessed for injury, no bruising or redness noted skin intact. Resident 1 denied pain. The charge nurse requested a hook lock be placed for Resident 1 to use while in the bathroom. APS was notified on 09/30/18 at 11:18AM. Record review of Progress note Resident 1 - Resident 1 came to the nurse and informed the nurse while sitting on the toilet Resident 2 came into the bathroom several times yelling at Resident 1 to get out. Resident 1 reported they were going to the bathroom and would be out in a minute. Resident 2 grabbed the empty bottle of mouth wash and hit Resident 1 in the chest. Resident 1 was assess and no bruising noted. An interview on 09/17/19 at 11:14 AM with the DON (Director of Nurses) confirmed; the incident took place on 09/29/18 and was not faxed until 10/8/18. An interview on 09/17/19 at 11:14 AM with the Administrator confirmed; the facility practice was to place a dated stamp on the fax sheet and document the confirmation number the fax was received and the process had not been done for the incident. | 2020-09-01 |
| 2807 | 2807 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2019-09-18 | 656 | D | 1 | 0 | BEDC11 | > Licensure Reference Number 175 NAC 12-006.04Ca(5) Based on record review and interview the facility failed to develop a care plan for bathing preferences for 2 residents (Resident 10 and 12) of 15 residents reviewed. The facility census was 74. Findings are: [NAME] Record review of resident Admission -Bathing/Shower dated 06/04/19 revealed; Resident 10 was to shower on Wednesdays. Record review of Resident 10 bathing preferences dated 12/12/18 with a revision date of 09/08/19 revealed; Resident 10 preferred to bath on Monday and Thursday during the day. Record review of Resident 10's care plan revealed; the care plan did not reflect the residents bathing preference. B. Record review of Resident 12 bathing preference revealed; resident 12 had a preference of bathing on Tuesday and Friday during the day. Record review of Resident 12 Care plan revealed the care plan did not reflect the residents bathing preference. An interview on 09/17/19 at 3:40 PM with the MDS Coordinator confirmed the bathing preferences for Residents are not care planned. | 2020-09-01 |
| 2808 | 2808 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2019-09-18 | 726 | F | 1 | 0 | BEDC11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on record review and interview, the facility failed to ensure staff competencies were evaluated on a routine basis. This had the potential to affect all residents who reside in the facility. The facility census was 74. Findings are: Review of LPN-C's (Licensed Practical Nurse) employee information revealed an absence of documentation related to competency evaluation completed by the facility. The facility could not provide proof of LPN-C's competency evaluation. Review of NA-E's (Nurse Aide) employee information revealed the date of hire was 1/18/18. Review of NA-E's CNA Skills Checklist dated 6/12/18 was completed. No other competency checklist was noted in NA-E's employee file. Interview on 9/18/19 at 12:43 PM with the DON (Director of Nursing) revealed LPN-C was agency staff and was not employed by the facility. The DON revealed new agency staff would review a binder containing facility policies and orientation information, but competency assessments were not completed. Interview on 9/18/19 at 1:33 PM with the DON revealed the facility did not complete competency assessments for facility staff on a regular basis. Interview on 9/18/18 at 1:35 PM with the ADM (Administrator) revealed if concerns are identified related to the care a specific staff member is providing or if a resident files a grievance, the staff member would be evaluated at that time. | 2020-09-01 |
| 2809 | 2809 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2019-09-18 | 803 | D | 1 | 0 | BEDC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.11A1 Based on observation, interview and record review; the facility staff failed to ensure 1 resident (Resident 15) received the correct portion size during meal service, and 2 random residents. The facility also failed to ensurethe meals were attractive for one resident (Resident 15). The facility census was 74. Findings are: The facility Menu for 9/17/19 at Lunch was Cheese Burger on a Bun, French Fries, Relish Plate, Mayonnaise, Ice Cream Sundae, coffee and tea. An observation on 09/17/19 at 11:19 AM of Meal Serving the Dietary staff was not using a scoop to measure the amount of food placed on plates. Observation on 09/17/19 at 11:31 AM of a tray made for Resident 15, the tray had 2 fries the cook had mashed up with their fingers and the tray had a small amount of meat without bread and ice cream that had melted to liquid. The DA (Dietary Aide) B picked up the tray to deliver it to the resident. Interview on 09/17/19 at 11:31 AM with DA B confirmed; that they were not sure how much was on the plate and sat the tray down. Interview on 09/17/19 at 11:35 AM with the DM (Dietary Manager) confirmed; that Resident 15 was to get 4 ounces of potatoes and the plate did not have the correct amount of food on it. The DM confirmed that the way the food was presented was the practice. The DM confirmed; that on the 2 plates on the counter that were ready to be served there was a difference between the amounts of fries that were on one plate than another. The DM confirmed that the fries were inconsistent related to not using a measuring utensil. An observation on 09/17/19 at 11:35AM with the DM of the trays with inconsistent amounts of food served to residents in the dining area. An interview on 19/17/19 at 11:42 AM with the DM confirmed; that the ice cream and cottage cheese was not to be placed under the heat lamp. It was noted that on most of the tables the ice cream had been melted to liquid and was serve… | 2020-09-01 |
| 2810 | 2810 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2017-09-28 | 241 | D | 0 | 1 | 7QYI11 | Based on observation and interview, the facility failed to ensure residents who required assistance with dining were provided a dignified dining experience. The facility failed to ensure staff sat while feeding residents, provided residents with timely, uninterrupted assistance, and communicated with residents in a dignified manner. Eight residents were seated at the assisted dining table. Findings include: Observation on 09/25/17 at 10:58 a.m. of the dining room revealed nine residents seated at various tables around the room. Resident #18 was seated alone at the assisted dining table. The first meal was served in the dining room at 11:07 a.m. At 11:34 a.m., six residents were seated at the assisted dining table. None of them have been served a meal. At 11:39 a.m., the first meal was served to a resident at the assisted dining table. At 11:40 a.m., a second and third meal were served at the assisted dining table. One resident fed himself. The other two sat without assistance and without feeding themselves. At 11:40 a.m., Resident #18 was served her meal, 42 minutes after being seated at the table. Resident #18 stated, Oh, good. I was hungry. At 11:41 a.m., the final resident at the assisted table was served. All but two residents (Resident #s 14 and 23) fed themselves, with different amounts of cueing and encouragement. Restorative Aide, Staff F, stood next to Resident #23 at the end of the table and fed him a bite. At 11:42 a.m. Staff F left the dining room. At 11:43 a.m. Staff F returned to the dining room, moved Resident #23's wheelchair away from the table, placed Resident #12's wheelchair at the table, tilted the wheelchair back, moved Resident #23's wheelchair back to the table and walked away. At 11:45 a.m., Staff F returned with Resident #12's meal. She stood between Resident #12 and Resident #23, feeding them. She then looked at Resident #18, who was seated across the table, and said loudly, Hey! (Resident #18)! Put your spoon down. Take a bite. Make sure you swallow! (Resident #18)! Put your spoon down… | 2020-09-01 |
| 2811 | 2811 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2017-09-28 | 314 | D | 0 | 1 | 7QYI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and staff interview, the facility failed to ensure a resident with an unavoidable Stage 3 pressure ulcer received appropriate treatment to prevent infection and promote healing. This affected one (#60) of 73 current residents. Findings include: Review of the medical record of Resident #60 on 09/26/2017 at 11:00 a.m. revealed the resident was originally admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident was admitted to hospice services on 08/16/17. Further review of the resident's medical record on 09/26/17, revealed a significant change Minimum Data Set (MDS) assessment dated [DATE] which documented the resident was severely cognitively impaired; totally dependent on one to two staff for activities of daily living; non-ambulatory; had no functional limitations in range of motion; was at risk for development of pressure ulcers; had a Stage 3 pressure ulcer and had skin and ulcer treatments in place. Review on 09/26/17 of the resident's plans of care revealed a current pressure ulcer plan of care with an intervention to provide wound care as ordered by the physician. Review on 09/26/17 at 11:13 a.m. of Mobile Wound Solutions (MWS) notes dated 08/15/17, revealed Resident #60 was documented to have a Stage 3 pressure ulcer on left lateral ankle that measured 1.7 centimeters (cm) by 1.4 cm by .40 cm with eschar and slough and serosanguineous drainage. Facility Skin Progress Notes dated 08/15/17 at 5:27 p.m. documented Resident #60 was seen by the physician with MWS at the bedside and orders were obtained for the left ankle Stage 3 pressure ulcer to clean with saline, apply nickel thick layer of Santyl to wound bed, Vaseline gauze cut to size of wound, and bordered gauze daily. On 08/22/17 MWS notes documented the area as 4.8 cm by 2.4 cm by .40 cm with slough and yellow, serosanguineous drainage. On 08/29/17 MWS notes documented the area as 1.8 cm by 1.4 cm by .30 cm wit… | 2020-09-01 |
| 2812 | 2812 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2017-09-28 | 371 | E | 0 | 1 | 7QYI11 | Based on observation and interview, the facility failed to ensure staff implemented adequate hand washing, glove changes and hand hygiene during meal preparation and service. This was observed in the dining room as staff assisted residents with their meals and in the kitchen as staff prepared and served breakfast. This affected 70 of 73 residents. Findings include: Observations during the lunch meal on 09/25/17 at 11:41 a.m. revealed Staff F, Nursing Assistant, fed Resident #23, moved his wheelchair, stepped out of the dining room, returned to the dining room. moved Resident #23's wheelchair away from the table, placed Resident #12's wheelchair at the table, went to the kitchen and returned with Resident #12's meal. She stood between the 2 residents feeding them. At 11:48 a.m., Staff F left the table and washed her hands for approximately 7 seconds. At 11:50 a.m., Staff F removed dirty dishes from the table and then washed her hands for approximately 12 seconds. Observation of the breakfast service on 09/27/17 between 7:06 a.m. and 7:51 a.m. revealed the following: Staff E, Cook, wearing a pair of disposable gloves, picked up two slices of bread, buttered them and placed them on the stovetop. She picked up two slices of cheese and placed them on the bread, using gloved hands. She turned back to the steam table, picked up a bowl, scooped hot cereal into the bowl, picked up a plate, put the bowl on the plate, lifted a lid off a container of food, used a scoop to place hash browns on the plate, grabbed a pre-packaged Danish and placed it on the plate, picked up the meal card (that had been brought in by Dietary staff who took the resident's order) and placed it on the tray, and then took the tray out to the serving station. She then used her gloved hands to remove toast from the toaster, selected an English Muffin from a package and placed it in the toaster, and turned the toaster on. She proceeded to touch plates, bowls, lids, scoops, packages of Danish, meal cards, and trays, all while wearing the same pair of glo… | 2020-09-01 |
| 2813 | 2813 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2018-10-02 | 609 | E | 1 | 1 | 667611 | > Licensure Reference Number 12-006.02(8) Based on record review and interview, the facility failed to report allegations of abuse within 24 hours and also failed to submit investigations within 5 working days to the state authorities. This had the potential to affect 3 residents of the 4 residents sampled. (Resident. 14, 10, 69 and 12) The facility census was 73. Findings: [NAME] Record review of a Resident Incident Report for Resident 12 dated 6/28/18 revealed that an allegation of abuse occurred on 6/28/18 and was called to APS (Adult Protective Services) on 7/1/18, 3 days after incident occurred. An investigation of an allegation of abuse was completed and sent to the state authority on 7/11/18, 13 days after incident occurred and 10 days after reporting to APS. On 10/01/18 02:36 PM an interview with the DON (Director of Nursing) confirmed that an allegation of abuse was not called to APS within 24 hours and confirmed the investigation of an allegation of abuse was not sent in to the state authority within 5 working days B. Record review of a Resident Incident Report for Resident 10 dated 8/11/18 revealed an allegation of abuse. This allegation of abuse was called in to APS on 8/13/18 more than 24 hours after the allegation was reported. The allegation of abuse was investigated and sent to the state authority on 8/29/18, 18 days after the allegation of abuse was reported. On 10/02/18 at 03:11 PM during an interview with the DON, the DON confirmed that APS was not called within 24 hours and the investigation was not sent to the state authority within 5 working days C. A record review of the Resident Incident Report, dated 8/11/18, for Resident 14 revealed an allegation of abuse. This allegation of abuse happened on 8/11/18. The facility called and reported the allegation of abuse to Adult Protective Services on 8/13/18, 2 days after the allegation of abuse. The allegation of abuse was investigated and the sent to the stated authority on 8/29/18, 12 working days after the incident. D. A record review of the res… | 2020-09-01 |
| 2814 | 2814 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2018-10-02 | 812 | F | 0 | 1 | 667611 | Licensure Reference Number 12-006.11E Based on observation, record review and interview; the facility failed to ensure that 1) dining room tables were sanitized between resident uses, 2) staff did not pick up residents' cups and glasses from the top, touching the rim of the glass, 3) staff delivering drinks to the tables did not set trays on the tables each time they stopped to deliver drinks, 4) staff did not distribute clothing protectors by placing them under their arms to carry them, 5) staff sanitized hands between serving and touching residents. This had the potential to affect 63 residents served in the dining room. The facility failed to ensure that a red wooden eating assisting device had a cleanable surface, this had the potential to affect one resident. The facility failed to ensure that the kitchen ceiling and the vent located above the doorway to the serving area was free from dust and debris. This had the potential to affect all residents in the facility. The facility census was 73. Findings: On 09/26/18 at 11:49 AM observations revealed Cook B and RA (Restorative Aide) F were observed cleaning the dinning room tables between residents with a cloth from a green pail. The green pail was checked with a sanitizer test strip and reveled no sanitizer in the green pail Observation on 9/27/18 from 11:00 AM to 12:15 PM revealed staff seating new residents entering the dinning room at tables as other residents departed only using the green pails with detergent and water without then sanitizing the tables. Cook A was observed serving drinks to the residents in the dining room with fingers on the rim of the cups and glasses and palm over the top of the glasses. Cook A was observed setting the drink tray on each table as drinks were handed to the residents at the table, then moving to the next table and setting the tray down on the table while serving the drinks. The Cook A was never observed to sanitize hands or the tray. Staff serving residents were observed to take a tray to the table deliver food to the res… | 2020-09-01 |
| 4621 | 4621 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2016-11-07 | 279 | E | 0 | 1 | YHLF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1b Based on record review and interview, the facility failed to develop care plans to address [MEDICAL CONDITION] medications and target behaviors for one resident (Resident 87) out of 22 sampled residents. The facility census was 71. Findings are: Record review of Resident 87's Medication Administration Record [REDACTED]. Record review of Resident 87's care plan revised on 9/27/16 with targeted goals through 10/14/16 revealed the care plan had not been developed to address target behaviors related to anxiety, nonpharmocological interventions for anxiety or possible side effects of antianxiety medication. Interview on 11/7/16 at 8:20AM with the MDS Nurse (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning) confirmed that the care plan was not complete. | 2020-04-01 |
| 4622 | 4622 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2016-11-07 | 332 | E | 0 | 1 | YHLF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.10E Based on observation, record reviews and interviews; the facility failed to ensure a medication error rate of less than 5%. Observation of 27 medications administered revealed 5 errors resulting in an error rate of 18.5%. The errors affected 3 residents (Resident 27, 61 and 88). The facility census was 71. Findings are: [NAME] Observation on 11-3-16 at 08:20 AM of MA-C (Medication Aide) revealed MA-C administered the following medications to Resident 27 in the resident's room: -[MEDICATION NAME] 20 mg (milligram) (medication used to decrease the amount of acid in the stomach). The label instructions revealed that this medication was to be given 30 minutes before meals. -[MEDICATION NAME] (medication used for Gout )100 mg. The label instructions revealed that this medication was to be given with meals. -KCL (potassium chloride), (medication used for a potassium supplement) 10 meq (milliequivilents) 3 tablets. The label instructions revealed that the medication was to be given with meals. MA-C did not ask the resident if the resident had ate breakfast or if the resident wanted any snack, crackers, or any type of food to be given with the medications administered. Interview on 11-3-16 at 8:50 AM with MA-C revealed Resident 27 refused breakfast on 11-3-16. When the resident ate breakfast, it was at 0700 in the main dining room. MA-C revealed regardless if the resident ate breakfast or not, the breakfast medications were given at the same time of the morning each day. Review of the Physician orders signed on 10-03-16 revealed the medications [MEDICATION NAME] was to be given 30 minutes before breakfast, [MEDICATION NAME] was to be given with breakfast, and KCL was to be given with breakfast. Review of the (MONTH) and (MONTH) (YEAR) MARs (Medication Administration Records) revealed the [MEDICATION NAME] and KCL were all scheduled to be given at 08:00 AM. Review of the (MONTH) and (MONTH) (YEAR) Diet Ord… | 2020-04-01 |
| 4623 | 4623 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2016-11-07 | 425 | E | 0 | 1 | YHLF11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.12. Based on observation, record reviews and interviews; the facility failed to ensure 1) the correct time scheduled for the administration of Omeprazole for Resident 27 and the correct time scheduled for the administration of the medication Levothyroxin for Resident 88. 2) Medication Aides administer medications under the direction and monitoring of a professional staff 3) staff follow administration of policies and procedures of Medication Administration. The sample size was 27 medication administration opportunities. The facility census was 71. Findings are: [NAME] Review of Resident 27's (MONTH) (YEAR) MAR (Medication Administration Record) revealed Omeprazole was scheduled to be given at 0800 AM. Review of the Physician orders signed on 10-03-16 revealed the medication Omeprazole was to be given 30 minutes before breakfast Interview on 11-3-16 at 8:50 AM with MA-C (Medication Aide) revealed Resident 27 ate breakfast at 07:00 AM. Review of Resident 88's (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the Physician orders signed on 09-21-16 revealed Levothyroxin was to be taken on an empty stomach at least 30 minutes prior to a meal. Interview on 11-3-16 at 8:50 AM with MA-C revealed Resident 88 eats breakfast at 07:00 AM. Observation on 11-2-16 at 4:20 PM revealed MA-D administered a PRN (as needed) Oxycodone 10mg (pain medication) to Resident 61 without the resident requesting the medication and without discussing the decision to administer the medication to the resident with a licensed professional staff person. Review of the facility policy titled PRN Medications versus Routine Medications revised 6/16 revealed prior to giving a PRN pain medication, the charge nurse needs to be notified and non-pharmalogical interventions were to be attempted. Review of the facility policy titled Medication Aide revised 4/15 revealed Medication Aides were to administer PRN medications under the direction and monitoring of a professional staff person. B. Observation on 11-3-16 at… | 2020-04-01 |
| 4624 | 4624 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2016-11-07 | 431 | E | 0 | 1 | YHLF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].12E4 Based on observation and interviews, the facility failed to ensure glucose test strips used for resident blood sugars lab tests were not expired. This had the potential to affect 19 of 20 (Resident 26,16, 27,41,33,44,9,50,66,39,17,45,19, 42,40,49, 23,2 and 62) residents. The facility census was 71. Findings are: Observation on [DATE] at 12:00 PM of the 100 unit medication cart revealed 3 bottles of Assure Platinum Test Strips, testing supplies used to test resident ' s glucose (blood sugar), were opened and were not dated when the bottle was opened and not dated with the 90 day expiration date. Observation of the 200 med cart had 5 bottles of Assure glucose strips and only one bottle was dated when opened. Observation of the 300 cart revealed 6 bottles and none were dated when opened. Interview on [DATE] at 12:02 PM with LPN-A (Licensed Practical Nurse) revealed LPN-A had not dated bottles when opened and was not aware of the 90 expiration from date bottles were opened. LPN-A revealed some residents have a bottle of their own who have frequent glucose check orders, the rest of the resident share from the same bottle. Record review revealed 20 residents with Physician orders [REDACTED]. Interview on [DATE] at 12:00 PM with the ADON (Assistant Director of Nursing) revealed the ADON was not aware there was a 90 day expiration date from the date the Assure Platinum glucose test strips were opened. ADON confirmed it had not been the facility practice to date the bottles when opened and the expiration date used had been the manufacturer date on the bottle. Review of The Assure Platinum Test Strips package insert revealed When you first open the bottle, write the date on the bottle label. Use the test strips within 3 months of first opening the bottle. | 2020-04-01 |
| 6686 | 6686 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2015-11-09 | 223 | E | 1 | 1 | HZ1311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.05 (9) Based on interview and record review, the facility failed to ensure that interventions were in place to prevent physical altercations between residents as follows: 1). (Resident 92 and 59) two altercations; 2). (Residents 92 and 36) three altercations and; 3) (Resident 11 and 46) one altercations. The facility census was 72. Findings are: A. Review of Resident 92's Admission History and Physical revealed the following Diagnoses: [REDACTED]. Review of Resident 92's Care Plan dated 8/7/14 revealed that the resident had deteriorating cognitive functioning secondary to dementia. The resident had hallucinations and delusions. The resident yelled out and was resistive with cares. The resident was physically aggressive with staff. The resident's goal was to cause no physical harm to self or others. An intervention was added on 11/2/14 that the resident reached out and grabbed another resident's wrist when the resident came up to the resident at the nurse's station. The resident was to be within arm's reach of staff at all times and not in walkway where other residents can walk or propel themselves through. Review of Resident 92's IDPN (Interdisciplinary Progress Notes) revealed: -On 11/19/14 at 7 am, the resident was awake yelling out and was seated in a wheelchair at the nurses' station. -On 11/19/14 at 4 pm, the resident was awake alert and yelling out. The resident was seated by the nurses cart and frequently grabbed at staff. The resident was redirected not to hit or grab. -On 11/21/14 at 5 pm, the resident was yelling out. The resident reached out and grabbed out at staff. -On 11/22/14 at 4 am, the resident was given an enema and the resident beat the wall the remainder of the shift. -On 11/22/14 at 11:45 am, Resident 92 grabbed Resident 59 as the resident walked by. Resident 59 picked up the resident's walker hit Resident 92 on the resident's hand twice. Review of Resident 92's IDPN (Interdisciplinar… | 2018-11-01 |
| 6687 | 6687 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2015-11-09 | 253 | D | 1 | 1 | HZ1311 | > Licensure Reference 12-006.18B3 Based on observations and staff interview, the facility failed to provide a safe and smooth tile floor surface in one resident room for Resident 62 who was noted to be ambulatory in room. The facility tile floor had six missing tile which were approximately one foot square each in size. Facility census 72. Findings are: Observation of Resident 62 room floor surface on all days of the survey from 11/2/15 - 11/5/15 and again on 11/9/15 revealed that six one foot square tiles were missing and the bare black gluey/sticky substance underneath the tiles was exposed. Resident 62 was observed to be ambulatory in room and only wore flip flop type sandals on all days of survey. The resident had potential risk of sticking to the exposed black surface and represented a trip hazard. Interview with Nursing staff in the afternoon on 11/4/15 during survey noted that floor tiles were on order for this room repair. The six missing tiles were located at the end (foot) of the residents bed where the resident would need to walk across to get to the restroom located on the opposite side of the room from Resident 62's bed. | 2018-11-01 |
| 6688 | 6688 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2015-11-09 | 279 | D | 1 | 1 | HZ1311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews: the facility failed to: 1) identify and develop interventions to address one sampled resident's (Resident 32) assistance with activities of daily living (ADL's); and 2) identify and develop interventions to address one samples resident's (Resident 16) non-pressure related skin condition. Facility census was 72. Finding are: A. Interview with LPN (Licensed Practical Nurse)-N on 11/4/15 at 9:35 AM revealed Resident 32 had been declining in the ability to complete ADL's for several months. Observations of Resident 32 at 10:05 AM revealed two staff members LPN-N and MA (Medication Aide)-A transferring the resident using a hoyer lift to transfer resident from recliner to bed. Record review of Resident 32's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care planning) assessments revealed a significant change in Resident 32's functional status. The MDS revealed Resident 32 required extensive assist for bed mobility, transfer, dressing, toilet use and personal hygiene. Record review of Resident 32's Care Plan printed on 11/2/15 with goal dates through 1/28/16 revealed there were no problems, goals or approaches developed or identified on the care plan to address the resident's assistance needed to complete ADL's. Interview with the Director of Nursing on 11/9/15 at 3:25 PM revealed the care plan did not address the ADL's and there should have been changes made at the time when the resident had the significant change in condition. B. Observations of Resident 16 throughout the survey revealed bruises on bilateral forearms. Record review of Resident 16's Care Plan printed on 10/22/15 with goal dates through 1/21/16 revealed there was no mention of bruising on Resident 16's care plan. Interview with the Director of Nursing on 11/9/15 at 3:20 PM revealed the care plan contained no mention of the resident's bruising. Resident 16 had received [ME… | 2018-11-01 |
| 6689 | 6689 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2015-11-09 | 323 | E | 1 | 1 | HZ1311 | > Licensure Reference 175 NAC 12-006.09D7 Based on observation, record review and staff interview, the facility failed to provide supervision or an activated alarm system to prevent elopements for 12 residents (Residents 45, 64, 27, 1, 56 65, 78, 96, 63, 29, 94 and 59). The facility also failed to provide staff education to direct care staff on knowledge of how to unlock the padlock and the bicycle lock combination wrapped toward the top of the gate located in the fence on the southeast side of the facility that surrounded the enclosed courtyard. Facility census 72. Findings are: During the survey 12 residents (Residents 45, 64, 27, 1, 56 65, 78, 96, 63, 29, 94 and 59)were observed with bracelet type of signaling device used to monitor residents and prevent the residents from exiting the building unattended by an alarm system on the exit doors. During the survey observations of the fenced courtyard located on the southeast side of the building which enclosed the 200 and 300 halls, the egress door to this courtyard from the 200 hall television solarium was not included in the system set to alarm if residents that wore the bracelet went out the door. The door did include a security code pad if the door alarm was activated, however it did not include a Code Alert monitoring device for the 12 residents that wore the bracelets. Observations of the courtyard on 11/4/15 and 11/5/15 during the survey hours of 8:00 am and 4:30 pm revealed two concrete benches were adjacent (within four inches) of the outer fence on the far east and south corners of the courtyard. A test while stand on the benches revealed a person could touch the top of the fence and see over the metal fence which was approximately six feet in height. Three metal folding chairs were also located beside the fence in the courtyard for use during the residents' scheduled smoke breaks. Interview with the Director of Nursing on 11/4/15 at 10:38 am revealed that the system for the alarm on the egress courtyard door located on the 200 hall television solarium wa… | 2018-11-01 |
| 6690 | 6690 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2015-11-09 | 332 | D | 1 | 1 | HZ1311 | **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 a medication error rate of less than 5%. Twenty-six medication opportunities were observed with two medication errors resulting in an 7.69% medication error rate. The facility census was 72. Findings are: A. Observation of Resident 32's blood sugar monitoring and insulin administration revealed: -On 11/3/15 at 7:41 am, LPN (Licensed Practical Nurse) N checked the resident's blood sugar and the glucometer (machine used to test blood sugar levels) registered 185. -At 7:44 am, LPN N drew up 1 unit of Humalog (fast acting insulin) and injected the insulin into the resident's right thigh. The bottle of Humalog was dated as open on 10/1/15. -LPN N told the resident that staff would be back in 15-20 minutes to get the resident up for breakfast. There was no food or fluids within reach of the resident. -At 8:05 am, staff was assisting the resident with morning cares. -At 8:19 am, the resident was seated in the resident's recliner. There was no food or fluids within reach. The resident had not been served breakfast. -At 9:04 am, the resident's room tray still remained in the kitchen. -At 9:06 am, the resident had not been served breakfast and no food or fluids were in the resident's reach. Interview with LPN N on 11/3/15 at 7:44 am revealed that the Humalog insulin dated as opened 10/1/15 was outdated. The LPN stated that there probably was not any other insulin in the building and the LPN administered the outdated insulin to Resident 32. Interview on 11/13/15 at 9:04 am with the Cook revealed that the staff had called for a room tray 10-15 minutes ago, but the resident's room tray remained in the kitchen. Review of Resident 32's 10/9/15 physician's orders [REDACTED]. Review of the facility's Medication Administration-Specific Information Insulin Vial Administration Dated (MONTH) 2013 did n… | 2018-11-01 |
| 6691 | 6691 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2015-11-09 | 425 | D | 1 | 1 | HZ1311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.12 Based on interview and record review, the facility failed to obtain 4 medications for one resident (Resident 46) over a two day period to treat the resident's seizures and psychiatric condition. The facility census was 72. Findings are: Review of Resident 46's History and Physical dated 2/13/15 revealed [DIAGNOSES REDACTED]. Review of Resident 46's annual MDS (Minimum Data Set: a federally mandated comprehensive care planning tool used for care planning) dated 7/14/15 revealed that the resident had a Brief Interview for Mental Status score of 11 (moderately impaired). The resident displayed thoughts of disorganized thinking daily. The resident had delusions and was independent with the resident's activities of daily living. The resident received antipsychotic medications to treat the resident's psychosis, anxiety, and traumatic brain disorder. Review of Resident 46's (MONTH) (YEAR) Medication Administration Record [REDACTED] -Zyprexa (antipsychotic medication) 20 mg (milligram) was ordered at bedtime. The Zyprexa 20 mg dose was not available on 10/18/15 and 10/19/15. -Lamactil (mood/ seizure medication) 20 mg was ordered at bedtime for mood. The Lamactil was not available on 10/18/15 and 10/19/15 for the bedtime dose. -Dilantin (treats seizures) 200 mg twice daily was not available for both doses on 10/19/15. -Simvastatin (treats high cholesterol) 20 mg at bed time was not able for administration on 10/18/15 and 10/19/15 as ordered. The medication was not available. -Gabapentin 600 mg ordered four times daily was only given three times on 10/19/15 because the medications was not available. Review of the Physician order [REDACTED]. Interview with the DON (Director of Nursing) on 11/12/15 at 10 am revealed that staff were to use the medications available in the emergency medication box when medication was not available from their contracted pharmacy. The facility had a backup pharmacy located in town for … | 2018-11-01 |
| 6692 | 6692 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2015-11-09 | 441 | E | 1 | 1 | HZ1311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.17B Based on observation, record review and interviews; the facility failed to change gloves and ensure hand washing was completed during the provision of personal hygiene cares to prevent the potential for cross contamination for two residents Resident 32 and Resident 36 and provide hoyer life (mechanical lift for non-weight bearing residents for 19 residents (Residents 65, 34, 24, 86, 50, 33, 16, 30, 11, 79, 60, 32, 36, 75, 2, 54, and 38). Facility census was 72. Finding are: A. Review of Resident 36's quarterly MDS (Minimum Data Set: a comprehensive assessment tool used for care planning) dated 9/22/15 revealed that the resident had severe impaired decision making skills. The resident had inattention and psychomotor retardation. The resident required total assistance with all activities of daily living including toileting. The resident was incontinent of urine and bowel. Observation of Resident 36's cares on 11/4/15 at 9 am revealed: -MA (Medication Aide) S removed two disposable wipes and wiped down the resident's left groin changed position of the cloth and then down the right groin and scrotum. The MA used the same disposable cloth and wiped down the shaft of the penis proximal to distal, over the urinary meatus, and then distal to proximal down the penal shaft. -The MA discarded the wipe and turned the resident to the side and used one disposable cloth to wipe the resident's rectum and buttocks without changing the position of the cloth. -MA S applied [MEDICATION NAME] ointment to the resident's perianal area wearing the same pair of gloves. B. Observation on 11/4/15 at 10:05 AM of incontinence care and toileting of Resident 32 revealed the following: -Medication Aide (MA)-A entered Resident 32's room washed hands and donned gloves. -Resident 32's incontinent garment was removed and Resident 32 was found to have been incontinent. -Resident 32 was assisted to right side and was wiped with toi… | 2018-11-01 |
| 6952 | 6952 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2015-08-13 | 157 | G | 1 | 0 | HXM711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a (6) Based on interview and record review, the facility failed to notify one resident's (Resident 2) physician of a fall with injury in order to not delay treatment. The facility census was 67. Findings are: Review of Resident 2's History of Present Illness dated 8/24/14 revealed that the resident had increased weakness, multiple falls, and was not eating or drinking well. The resident was not caring for self at home with having physical decline in multiple areas. The resident's Discharge [DIAGNOSES REDACTED]. Review of Resident 2's Quarterly MDS (Minimum Data Set: a federally mandated comprehensive tool used for care plans) revealed that the resident had a BIMS (Brief Interview for Mental Status) of 9 (8-12 is moderately cognitively impaired). The resident's Total Severity Score for mood was 2 (1-4 is minimal depression). The resident had delusions and displayed other behaviors one to three days weekly. The resident required supervision with bed mobility and transfers. The resident was independent with ambulation and locomotion with the use of a walker. The resident required limited assistance with toileting. The resident had balance issues, but was able to correct on own. The resident was frequently incontinent of urine, but was not on a toilet plan. The resident had pain rated at a 7. The resident had shortness of breath with exertion, sitting, and lying down. The resident had two falls since the last MDS with no injury. The resident took antianxiety medication, antidepressants, and anticoagulants (blood thinners). The resident did not receive therapy or restorative services. Review of Resident 2's IDPN (Interdisciplinary Progress Notes) revealed: -On Saturday, 7/25/15 at 5 PM, the IDPN stated At 1135 Res (resident was witnessed by staff losing (resident) balance while trying to sit in (resident) chair at the DR (dining room) table. (Resident) leaned up against the wall and slid down it onto t… | 2018-08-01 |
| 6953 | 6953 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2015-08-13 | 280 | D | 1 | 0 | HXM711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 12-006.09C1c Based on observation, record review and staff interviews; the facility failed to implement a system for care planning to review and revise care plans for two residents with repeated falls. The facility also failed to provide information on the change of the resident's needs/condition to direct care staff for the resident's ongoing medical needs. This practice affected Resident 2 and 3. Facility census 67. Findings are: A. Review of Resident 3's medical record revealed the resident sustained [REDACTED]. Resident 3 was admitted to the facility in (MONTH) 2012. Resident [DIAGNOSES REDACTED]. Review of the facility fall log, facility fall investigations and fall tracking log for Resident 3 on 8/13/15 for June, (MONTH) and (MONTH) (YEAR) revealed the resident had experienced 9 falls with one emergency room encounter for a head injury and one hospitalization for a fractured femur requiring surgical repair. On 7/31/15, the resident was provided with a tilt in space wheelchair for positioning needs. Interview with Nursing Assistants P and K on 8/13/15 at 2:38 pm revealed that a care sheets notebook was kept at the nursing station to refer to residents current interventions and needs. A copy of this care sheet provided on 8/13/15 revealed the date of 4/28/15 as the last time the report was reviewed/updated. Observation of a transfer for Resident 3 on 8/13/15 at 1:47 pm with the Assistant Director of Nursing and Nursing Assistant T, revealed the resident had an abductor pillow between knees and lower legs. The resident was transferred with two staff using a gait belt and residents feet were placed on a pivot disc on floor. Resident was laid in bed and the abductor/immobilizer pillow was placed on the resident. Review of the Care sheets noted Resident 3's transfer/ambulation/ mobility as one Assist, independent in wheelchair. There was no information about the resident's current fracture/use of abductor pillow or … | 2018-08-01 |
| 6954 | 6954 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2015-08-13 | 323 | G | 1 | 0 | HXM711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 12-006.09D7b Based on observations, record review and staff interview; the facility failed to conduct assessments of repeated falls and failed to identify and implement interventions to prevent resident injuries incurred after falls for two of four sampled residents (Resident 2 and 3). Facility census 67. Findings are: A. Review of Resident 3's medical record revealed the resident sustained [REDACTED]. Resident 3 was admitted to the facility in (MONTH) 2012. Resident 3's [DIAGNOSES REDACTED]. Review of the facility fall log, facility fall investigations and fall tracking log for Resident 3 on 8/13/15 for June, (MONTH) and (MONTH) (YEAR) revealed the resident had experienced 9 falls with one emergency room encounter for head injury and one hospitalization for a fractured femur: - Fall on 6/1/15 at 10:40 am - resident trying to toilet - alarm sounding. Care Plan reviewed no new interventions. Reminded staff to assist to toilet every 2 hours and prn ( as needed). - Fall on 6/5/15 at 12:30 am - resident self transferring to restroom, had bowel movement noted in toilet. All intervention appropriate. Continues to ambulate in room unattended. Bed alarm is working. On the evening of 6/5/15 resident was witnessed to stand at 7:30 pm, lost balance and fell in room by television. No apparent injuries. - Fall on 6/29/15 at 6:30 am - resident incontinent of bowel and urine. Attempted to self transfer to wheelchair which was by closet lost balance and fell hitting head. Care plan reviewed all interventions appropriate. No recent changes. - Fall on 7/3/15 at 1:45 am - resident had been in bed was found on the floor by bathroom. Assessed by nurse on duty assisted off of floor toileted and put back in bed. All interventions in place. Resident needed to use bathroom. - Fall on 7/4/15 at 2:45 am - resident was walking from bed to bathroom. All interventions in place. No current changes. Self transferring. - Fall on 7/7/15 at 9:10 pm -… | 2018-08-01 |
| 8070 | 8070 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2014-10-02 | 156 | D | 0 | 1 | 30CN11 | Based on interview and record review, the facility failed to issue the right to request a standard claim appeal be sent to the fiscal intermediary for a payment decision (Medicare A Denial Letter) for one resident (Resident 83) and two residents (Residents 3 and 42) were not given the required 48 hour notice timeframe. The facility census was 73. Findings are: A. Record review of a Centers for Medicare and Medicaid Services Survey and Certification letter 09/20 revealed that the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services when limitation of liability applies. The SNF's responsibility to provide notice can be fulfilled by use of either the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or one of 5 uniform Denial Letters. The SNFABN and the Denial Letters also inform the beneficiary of the right to have a claim (i.e. Demand bill) submitted to Medicare. Issuing the Notice to Medicare Provider Non-coverage to a beneficiary only conveys notice to the beneficiary of the right to an expedited review of a service termination and does not fulfill the provider's obligation to advise the beneficiary of potential liability of payment. The provider must still issue the SNFABN or a Denial Letter to address liability of payment. B. Review of the Centers for Medicare and Medicaid Services Survey and Certification Instruction Manual 70.3.3 Timely Delivery of SNFABN stated that the SNF must notify the beneficiary well enough in advance to all the beneficiary to make other arrangements. Last minute deliveries of the SNFABN would be considered untimely, regardless of the SNF's intentions. C. Review of the Notice of Medicare Non-Coverage stated the beneficiary must receive the Notice of Medicare Non-Coverage of services two days before the termination of services for timely delivery to occur. D. Review of Resident 3's Medicare Non-Coverage Quality Improvement Organization (QIO) notice was dated that services would end on 9/17/14. The resident re… | 2017-11-01 |
| 8071 | 8071 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2014-10-02 | 279 | D | 0 | 1 | 30CN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.04.C1a (5) Based on observation, interview, and record review; the facility failed to develop care plans related to Resident 22's medication use for [MEDICAL CONDITION]. The facility census was 73. Findings are: Review of Resident 22's 60 Day Physician Visit dated 9/21/14 revealed the following Diagnosis: [REDACTED]. Review of Resident 22's Quarterly MDS (Minimum Data Set: a mandatory comprehensive tool used for care planning) dated 9/16/14 revealed the resident's BIMS (Brief Interview for Mental Status) score was 14 (cognitively intact). The resident's mood score was 3 (minimal depression). The resident had delusions and rejected cares by staff daily. The resident required supervisions with ADL's (Activities of Daily Living). The resident was had frequent pain. The resident was on antidepressant medications. Review of Resident 22's Medication Admission Record dated September 2014 revealed that the resident received [MEDICATION NAME] (antidepressant medication) 25 mg (milligrams) at bedtimes for [MEDICAL CONDITION]. Review of Resident 22's Care Plan dated 8/28/14 stated I enjoy sleeping in in the morning. I voice that if I sleep in until 10:00 AM. I feel more refreshed. Observation on 9/30/14 at 4 pm the resident was lying down resting. Observations of Resident 22 on 10/1/14 revealed: -At 8 AM the resident was lying in bed with the room dark, eyes closed. -At 9 AM the resident was lying in bed with the room dark, eyes closed. -At 10:30 AM the resident was up in the resident's wheelchair. -At 4 PM the resident was in bed resting with the room darkened. Observations of Resident 22 on 10/2/14 revealed: -At 7:50 AM the resident was lying in bed with the room dark eyes, closed. -At 9:30 AM the resident remained lying in the resident's bed with eyes closed. -At 10:30 AM the resident remained in bed with eyes closed. -At 12:30 PM the resident was awake and at the dining room table. Interview on 10/1/14 at 2:30 PM w… | 2017-11-01 |
| 8072 | 8072 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2014-10-02 | 280 | D | 0 | 1 | 30CN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09C1c Based on observation, interview, and record review, the facility failed to ensure that two resident's (Resident 13 and 7) care plan was revised to reflect the resident's current care plan interventions. The facility census was 73. Findings are: Review of Resident 13's 30 Day Physician Visit dated 4/24/14 revealed that the resident had not been eating well and had recently been hospitalized for [REDACTED]. The resident would refuse to take the resident's [MEDICAL CONDITION] medications, or anything else by mouth. Resident 13's [DIAGNOSES REDACTED]. Review of Resident 13's History and Physical preoperative History and Physical for gastrostomy feeding tube (tube inserted into the stomach for feeding, hydration, medications) dated 8/11/14 revealed the following Diagnoses: [REDACTED].e. Hallucinations and delusions with mood [MEDICAL CONDITION] depression). Review of Resident 13's Quarterly MDS (Minimum Data Set: a federally mandated Comprehensive tool used for care planning) dated 8/12/14 revealed that the resident had long and short-term memory impairment with severe decision making skills. The resident had an alerted level of consciousness, inattention. The resident's mood score was 5 (mild depression). The resident was physically aggressive daily, other behaviors 1-3 days per week, and rejected cares daily. The resident had broken or loosely fitting dentures. The resident did not have swallowing issues. The resident was on a mechanically altered diet. The resident had no experienced a weight loss or gain. The resident was on antipsychotic, antianxiety, and antidepressant medications. Review of Resident 13's Care Plan dated 1/13/14 at nutritional and hydration risk evidenced by history of poor fluid intake prior to admission. The resident had swallowing problems, unable to get my own drink of honey think liquids. The resident had an unplanned weight loss possibly related when the resident would refuse to… | 2017-11-01 |
| 8073 | 8073 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2014-10-02 | 309 | D | 0 | 1 | 30CN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 12-006.9D2 Based on observation and record review, the facility failed to: 1) assess and treat scabbed areas for Resident 72, 2) provide fluids before or after provision of personal cares for Resident 72 who was unable to drink fluids independently, and 3) provide planned preventative creams/ointments to the perineal, groin and buttock area after cleansing skin for incontinence of urine and bowel for Resident 72. Facility census was 73. Findings are: Review of the Annual Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 09/09/2014 revealed: -BIMS (Brief interview for mental status) = 07 of 10; -Functional status for personal hygiene: was totally dependent and required the assist of one; -Had upper extremity impairment of both sides; -Requires extensive assistance for eating and drinking; -Weight was 144 with mechanically altered diet; -No non-pressure skin conditions identified; -[DIAGNOSES REDACTED]. Review of the medication and treatment administration records for September/October, 2014 revealed: -No treatment to care for the scabbed areas on each corner of Resident 72's mouth/lips. Observation of Resident 72 on 10/01/2014 at 2:30 PM in the resident's room revealed: -Thick dry scabs in each corner of the lips/mouth; -Water mug with straw on the dresser beside the resident's bed. Positioning of the mug was behind and above the resident head. Not within reach or sight to the resident. Observation of Resident 72 at 7:30 AM on 10/02/2014 in a recliner chair in resident room revealed: -Water mug with straw in lid, positioned on the dresser next to the resident's recliner chair. The mug was behind the resident's head and out of sight; -Resident's lips were dry with a thick dry scab in each corner of the mouth/lips; -Lips were dry with small cracks in the lip lines; Interview with Resident 72 on 10/02/3014 at 7:45 AM in the resident's room revealed: -No there is no … | 2017-11-01 |
| 8818 | 8818 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2014-02-25 | 205 | D | 1 | 0 | 329011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident and facility records and interview with facility staff, the facility failed to provide a Bed-Hold Policy to one (Resident 1 ) of three sampled residents at the time of an emergency transfer or within 24 hours of transfer to a hospital. Resident One was involuntarily discharged from the facility without notice. Resident One's pay source provides for a 15 day bed hold when hospitalized . Census was 74. Findings are: Review of Resident One's Face sheet revealed: -Admission 05/14/2013 and readmission 07/10/2013; -[DIAGNOSES REDACTED]. diabetes, [MEDICAL CONDITION], tobacco use disorder, [MEDICAL CONDITIONS], renal and urethral disorder and urinary tract infection; Pay sources included: medicare A/B and Medicaid. REVIEW of the Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated assessment reference date: 01/07/2014 as a return from an acute hospital revealed: -Cognitive score = 15 of 15; -Disorganized thinking is present but fluctuates; -Rejected care 4-6 days during evaluation; -Required extensive assistance of 1-2 staff for activities of daily living for: mobility, dressing,toileting and personal hygiene needs; -Balance during transfers and walking: required stabilization with staff assistance; -No limitation with range of motion; -Required a wheelchair for mobility/transport; -shortness of breath with exertion, siting and lying flat; -Life expectancy of less then 6 months = no; -History of falls of two or more without injury; -Weight 406 pounds; -Skin conditions other then ulcers with treatments and equipment; -medications include: antipsychotic, antidepressant, antibiotic and diuretic; -Hospice Services within the last 14 days; -Special treatments include: respiratory therapy. REVIEW of INTERDISCIPLINARY PROGRESS NOTES revealed: -02/09/2014 1100 .refused AM meal, noon meal in bed .ace wrap refusal non-compliant with )2 while in bed .making incoherent statements cal… | 2017-02-01 |
| 8982 | 8982 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2013-09-18 | 315 | D | 0 | 1 | 5000000000000.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09D3 (6) Based on observation, record review, and interview the facility to ensure there was a medical rationale for the use of an indwelling Foley catheter (tube inserted into the bladder to drain urine) for one resident (Resident 67). The facility census was 66. Findings are: Review of Resident 67's hospital transfer sheet dated 9/1/13 did not reveal the medical justification for the resident's Foley catheter. The Foley catheter was a 14 FR (French) (size) with a 10 cc (cubic centimeter) balloon. The catheter was inserted on 8/27/13 and was draining orange tinged urine. Interview on 9/12/13 at 10:12 am with LPN (Licensed Practical Nurse) J revealed that Resident 67 returned from the hospital with the indwelling Foley catheter. The LPN stated that the catheter was for immobility. The resident was not getting out of bed since the hospitalization . Review of Resident 67's Quarterly MDS (Minimum Data Set: a federally mandated comprehensive tool used for care plans) dated 9/1013 revealed the resident's BIMS (Brief Interview for Mental Status) score was 10 (a core of 8- 12 moderate cognitive impairment). The resident was inattentive daily. The resident's total mood score was 13 (10-14 moderate depression). The resident experienced delusions and rejected care four to six days out of seven. The resident required total to extensive staff assistance with activities of daily living which included transfer, bed mobility, toileting, personal hygiene, dressing. The resident had an indwelling Foley catheter. Review of Resident 67's Care Plan dated 9/5/13/13 revealed that the resident had a history of [REDACTED]. The resident's goal was to remain free of new areas of skin breakdown. Review of Resident 67's Assessment for Bowel and Bladder Training dated 9/1/13 revealed that the resident scored 6 (a score of 0-6 was a candidate for individual training). There was no documentation that the resident had a Foley catheter. Obs… | 2016-12-01 |
| 8983 | 8983 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2013-09-18 | 332 | D | 0 | 1 | 5000000000000.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.10D Based on observation of routine medication administration to one (Resident 74) resident, review of Physician order [REDACTED]. The resident sample size was four. Facility census was 66. Findings are: REVIEW of the Admission MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning) dated 04/24/2013 for Resident 74 revealed: Admission [DIAGNOSES REDACTED]. OBSERVATION of medication administration to Resident 74 on 09/17/2013 at 9:00 AM revealed: - Medication Aide (MA-A) handed an medication cup with pills to swallow. Included in the medications was [MEDICATION NAME] tablet 75mcg (microgram) one tablet; -MA-A then handed an inhaler of [MEDICATION NAME] aerosol inhaler to Resident 74 to self -administer one puff twice. There was a waiting period of approximately one minute between the two puffs; -MA-A then returned to the medication cart to continue the medication administration routine; -MA-A did not offer/instruct Resident 74 to rinse mouth after use of the aerosol inhaler. REVIEW of pharmacy labels for the two medications revealed: -Pharmacy label on box for [MEDICATION NAME] Aer (aerosol) 160/4.5 Inhale two puffs by mouth twice daily *rinse mouth after use*; -Pharmacy label on blister package for [MEDICATION NAME] tab (tablet) 75mcg take 1 tablet by mouth daily *give on empty stomach* INTERVIEW with MA-A at 09:07 AM at the medication cart revealed: Resident 74 had already eaten breakfast at the time the medication was administered. Resident returned to the room for medications to be given every morning (Medications were given at 9:00 AM after the breakfast meal). REVIEW of the physician's orders [REDACTED]. -[MEDICATION NAME] TAB 75MCG TAKE ONE TABLET BY MOUTH DAILY *GIVE ON EMPTY STOMACH (Equiv to: [MEDICATION NAME] tab 75mcg) scheduled: daily at 07.00; -[MEDICATION NAME] AER 160-4.5 INHALE 2 PUFFS BY MOUTH TWICE DAILY *RINSE MOUTH AFTER USE*. SCHEDULED: D… | 2016-12-01 |
| 10464 | 10464 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2012-06-21 | 253 | E | 0 | 1 | KKZN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC ,[DATE].18A Based on observation and interview, the facility failed to provide maintenance, repair and housekeeping services to Resident Rooms (Rooms 105, 108, and 111) the main dining room, the main bathing area, and teh Activities Day Room. Findings are: An environmental observation tour was conducted with the two Maintenance Supervisors on [DATE] beginning at 10.40 AM. During the tour, the following issues were identified regarding maintenance, repair and housekeeping of the facility: A. Three of eight Resident Rooms inspected revealed: - Resident Room 105 (Resident 71 and 76) and 108 (Resident 20 and 48) had baseboard next to the bathroom door ripped exposing the rough and uncleanable surface of the wooden frame. The lower edge of the bathroom door was scuffed and uncleanable . - Resident Room 111 (Resident 12 and 67) had the lower sections and edges of the bathroom door and bathroom door frame scuffed and scratched making the parts uncleanable. B. Observation of the main dining room: ? Rear exit door metal frame lower section rusted with the paint peeling off. Rust stain and holes visible on the frame ? Bottom window frames on the right side of the rear exit door revealed collection of grayish powdery substances and cobweb hanging underneath the frames ? Both main entrance door to the dining room revealed scuffs and scratches along the bottom frames door edges Both Maintenance Supervisors verified the observations during interview on [DATE] at 11.30am. C. In the Main Bath Area, metal drain cover on two showers was not fastened exposing sharp edges of the drain opening. Both drain holes were approximately four centimeters in diameter and bigger than the footings of the shower chairs. D. In the Activity Day room (Solarium) a large piece of protective covering of the main door was ripped exposing the rough and splintered surface of the door. The lower frame of two main windows near the bird cage were spli… | 2016-01-01 |
| 10465 | 10465 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2012-06-21 | 282 | D | 0 | 1 | KKZN11 | Licensure Reference Number 175 NAC 12-006.09C Based on observation, record review, and interview, the facility failed to implement care plan interventions to prevent injuries from falls for 1 resident (Resident 56). Facility census was 70. Resident record review on 6-20-2012 at 11:30am revealed Resident 56 fell three times in January, three times in February, three times in March, one time in April, one time in May and two times in June. No injuries were substained at the time. Record review of a Minimum Data Set (MDS - a federally mandated assessment used for care planning) dated 4-17-2012 revealed that: Section J documented Resident 56 had 2 or more falls with no injury. Record review of Resident 56's care plan dated 4-1-2012 revealed: - Problem: Decline in Activity of Daily Living status and at risk for falls related to confusion, unsteady at times, decline in status, dementia with behaviors, poor safety awareness. - Goals: Resident 56 will have no injury requiring hospitalization related to fall. - Approaches included: Wear hipsters at all times. Pull alarm at all times. Observation on 6-21-2012 at 7:10am revealed Resident 56 laying in bed without hipsters noted to body. Observation on 6-21-2012 at 9:50 am revealed Resident 56 in dining room drinking coffee. No hipsters were noted. Resident observation on 6-21-2012 at 10:26 am revealed Resident 56 in the solarium. Pedaling around in the wheelchair. No hipsters were noted. Staff interview with Medication Aide (MA) H on 6-21-2012 at 10:20 revealed: - Resident 56 was supposed to have hipsters on at all times. - Sometimes didn't wear them; because they get dirty. - Verified that didn't have them on currently. | 2016-01-01 |
| 10466 | 10466 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2012-06-21 | 309 | D | 0 | 1 | KKZN11 | **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 failed to provide interventions to manage pain for one resident (Resident 84). Facility census was 70. Findings are: REVIEW of the records for Resident 84 revealed: -Initial Admission was on 12/30/2011; -MDS: (MDS: a federally mandated comprehensive assessment tool used for an individualized care planning tool) dated: 03/28/2012 for a Significant Change revealed: -[DIAGNOSES REDACTED]. -BIMS (Brief Interview for Mental Status) scored 15; -Pain Management: Did not have routine pain medication provided and did have prn (as necessary) medication ordered. does not receive non-pharmacological interventions for pain management; -03/16/2012: broken hip, pelvis and pneumonia return to facility on 03/21/2012. INTERVIEW with Resident 84 on 06/19/2012 at 12:25 PM in the resident's room revealed: -Had not returned to previous abilities capable of before the fall and fracture of hip. -Did dress on own and went to the bathroom on own. -Did take PT and OT (physical and occupational therapy) for a time and now was not doing any exercise. -Did not know if medications for pain were given routinely or on a prn basis (as needed or requested). However, had frequent pain in the left hip, radiating into the lower back, going into the groin (left) and down the left leg. Resident 84 some times felt it in the right side too. -When feeling up to it, Resident 84 would get up in the room and walk up and down the hall way three-four times. -Resident 84 wanted to see a doctor about this because wasn ' t doing better and now I am not; -Family member had arranged to take the resident to see the surgeon for complaints of pain and not doing well; REVIEW of MEDICATION ADMINISTRATION RECORDS revealed: -Interventions other then medications were not provided for pain control; -Medications ordered for pain control were: **[MEDICATION NAME] HCL 50mg take 1 tablet by mouth every 6 hours a… | 2016-01-01 |
| 11948 | 11948 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2011-08-15 | 323 | G | 1 | 0 | H5PV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number:175 NAC 12-006.09D7 Based on observation, staff and resident interviews and review of facility and resident records; the facility failed to complete an investigation of causal factors for a fall from a wheelchair and identify interventions for providing transportation via wheelchair in a safe manner for 1 (Resident 1) of 3 sampled residents. Facility census was 72. Sample size was 3. Findings are: admitted for Resident 1 to current facility was on 01/22/2010 Review of the MDS (Minimum Data Set: A federally mandated comprehensive assessment tool used for care planning) dated 06/28/2011 as a Quarterly Review Assessment revealed: -[DIAGNOSES REDACTED]. -No behavioral symptoms present; -Functional Status: required extensive assistance for bed and transfer assist of one staff, did not ambulate in room or hallway, required extensive assist of one staff for locomotion in a wheelchair, required extensive assist of one staff for dressing and toileting and required limited assist of one staff for provision of personal hygiene, required physical help in part of bathing; -Balance during transition/walking: only stable with human assistance while moving on/off the toilet and transfer into a wheelchair. Not able to walk; -Functional limitation in range of motion: impairment on one side in upper and lower extremity; -Mobility devices include: wheelchair; -Falls since admission include: one fall with no injury and one fall with minor injury; -Received antipsychotic and antidepressant medications on a daily basis. Review of the MDS Assessment with reference date of 07/22/2011 done for a significant change in status revealed changes in the following: -Additional/New Diagnosis: [REDACTED]. -Functional Status: required extensive assistance for bed and transfer assist from two staff; -No transfer, ambulation or locomotion during this time; -Toileting required total assist of two staff; -No mobility out of bed during this assessment peri… | 2014-12-01 |
| 12024 | 12024 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2011-07-12 | 166 | D | 0 | 1 | 5PI011 | Licensure Reference Number: 175 NAC 12-006.06B Based on observation, interview, and record review the facility failed to make efforts to resolve grievances in accordance with the Facility Policy for 1 (Resident 30) of 35 Stage 2 sampled residents. The facility census was 75 residents. Findings are: Observation of Resident 30 at 3:40PM on 7/11/11 revealed alert and up in wheelchair. Blouse and skirt on, jewelry on, hair combed shoes and socks on. Interview with Resident 30 at 4:00PM on 7/11/11 revealed; --"I am missing some items of clothing of a slip, skirt, and blouse that I reported to staff the first week I was here and they haven't been found yet." --Resident 30 is alert and oriented to person, place, and time. Observation of Resident 30 at 9:20AM on 7/12/11 in wheelchair seated at table in dining room eating a banana. Resident 30 is alert and oriented to person, place, and time. Interview will Medication Aide (MA) D at 10:20AM on 7/13/11 revealed --for the residents that report missing clothing we first look in that residents' room and then check with laundry to see if clothing is in there; --when clothing continues to be missing we notify the contact the Social Service Department and the Laundry Manager. --Resident 30 did complain of missing clothes when first came in and they were reported it to the Social Services and Laundry. Interview with Laundry Manager (LM) at 10:26AM on 7/13/11 revealed: --When new residents are admitted all of their clothing items are to be brought to laundry except the items the resident is wearing to be marked by a laundry marker (fabric paint) or a permanent marker on the tag somewhere to identify them; --Missing items of clothing were reported to laundry and laundry has a rack of clothing that is not marked and laundry checked that rack first for any items reported; --if missing items are not found (clothing) then laundry reports it to Social Services and also looks in all rooms for clothing items to make sure it didn't get in the wrong room or closet; -- Resident 30 requested … | 2014-11-01 |
| 12025 | 12025 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2011-07-12 | 279 | D | 0 | 1 | 5PI011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number:175 NAC 12-006.09C Based resident record review and staff interview; the facility failed to develop a comprehensive interdisciplinary care plan to address's the use of routinely scheduled and PRN (as necessary) medication to manage agitation for 1 (Resident 70) of 35 Stage Two sampled residents. The facility census was 75. Findings are: Review of the quarterly MDS, (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning), for Resident 70 dated 06/07/2011 for assessment reference revealed: -Short and long term memory impairment, cognitive skills are severely impaired; -signs and symptoms of [MEDICAL CONDITION] are continuously present with inattention and disorganized thinking; -Staff observer during the assessment period: short tempered, expression of feeling bad about self, feelings or appearing down or depressed; -Behavior symptoms occurred daily included: physical and verbal behavior directed toward others as well as behaviors not directed toward others; -Rejection of care from and by staff included: refusing medications and provision of dressing, grooming; -Wandering behaviors occurred daily; -Mobility device is per wheelchair independently; -Daily incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -Scheduled medications included: pain management, antipsychotic, antidepressant and antianxiety medications daily. Review of the Medication Administration Records (MARS) for June, 2011 for Resident 70 revealed: -[MEDICATION NAME] HBR (equivalent to [MEDICATION NAME]) 20mg (milligram) take one tablet by mouth every day (diagnosis) depression in the AM; -[MEDICATION NAME] NA 125mg (same as [MEDICATION NAME]) take 2 capsules by mouth two times a day for [MEDICAL CONDITION]; -[MEDICATION NAME] 1mg take one tablet by mouth at bedtime for anxiety; -[MEDICATION NAME] 1mg/ml syringe apply cream topically every 4-6 hours PRN(as needed) for agitation/aggression. Review of the use of th… | 2014-11-01 |
| 12026 | 12026 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2011-07-12 | 280 | E | 0 | 1 | 5PI011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C1c Based on observation, interview, and record review the facility failed to review and revise the Comprehensive Care Plan (CCP), related to dentures for 1 (Resident 6) resident and urinary catheter use for 1 (Resident 13) resident. Facility census was 75 with stage 2 sampled resident number of 35. Findings are: A: Record review of Resident 13's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) assessment dated [DATE] revealed: --[DIAGNOSES REDACTED]. --will be documented in the Resident 13's CCP for [DIAGNOSES REDACTED]. Record review of Comprehensive Care Plan (CCP) for Resident 13 dated 7/12/11 revealed: --under the Problem of need assist with hygiene, risk for skin issues related to indwelling Foley catheter; --goal of will not have any hospitalization s related to indwelling Foley catheter use dated 7/12/11; --intervention of indwelling Foley per order and catheter care every shift; --no details on Foley catheter size, bulb size for fluid; --no individualized interventions about potential for infection and signs/symptoms of infection due to Foley catheter use; --no intervention for use of the leg strap for securing the Foley catheter tubing to prevent injury; Observation of Resident 13 at 3:18 PM on 7/11/11 revealed this resident up in the wheelchair seated at dining room table reading a magazine. Alert and dressed in clean shirt, sweatpants, and had socks and shoes on. Had multiple scabs with large black scab on right lower arm and multiple bruising on both arms and hands. Interview with Resident 13 at 3:20PM on 7/11/11 revealed "I take [MEDICATION NAME] (medication to thin blood), and I bruise easy." "I take it because I had a blood clot in my right ankle." Observation of medication aide (MA) B performing catheter care on Resident 13 at 12:20PM on 7/12/11 revealed: --Resident 13 in bed in room and MA B knocked and entered room explaining proced… | 2014-11-01 |
| 12027 | 12027 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2011-07-12 | 441 | F | 0 | 1 | 5PI011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.17 Based on observations, interviews, and record review; the facility failed to clean equipment in direct contact with residents skin and/or body fluids. The facility did not have a policy and/or procedure for cleaning of wrist blood pressure cuff machines. Also facility staff failed to follow the facility policy and/or procedure for handwashing with provision of foley catheter care on 2 ( Residents 50 and 13) residents and failed to control flies in dining room. The wrist blood pressure machines were used on entire population of facility which was 75 residents. Stage 2 resident sample was 35 residents. Findings are: A: Interview with LPN (Licensed Practical Nurse) A at 9:00AM on 7/6/11 revealed: --The wrist blood pressure cuff monitor (Omron) were used on all of the residents in this facility and the wrist part of machine is covered with cloth and is not cleanable. --The arm blood pressure cuffs monitor sites were cleaned with the Alcohol Prep Pads medium size and saturated with 70% [MEDICATION NAME] alcohol; --each resident that needs a blood sugar test has their own [MEDICATION NAME] which is cleaned after each use with the Alcohol Prep pads medium saturated with 70% [MEDICATION NAME] Alcohol; Observation of Medication Aide (MA) A at 3:50PM on 7/11/11 revealed: --MA A used wrist blood pressure machine (Reli On Manufacturer) on Resident 30 and recorded blood pressure; --Cleaned wrist blood pressure machine control pad and cloth surface with Alcohol Pre Pad 70% [MEDICATION NAME] alcohol; --Wrist blood pressure machine has cloth surface that was in direct contact with residents skin and is not a cleanable surface. Interview with Assistant Director of Nursing (ADON) and Infection Control Nurse, at 2:49PM on 7/12/11 revealed; -- the wrist blood pressure machines were not recommend to be used and the nursing staff brought them in; -- evidence of one wrist blood pressure cuff machine (Omron Manufacturer) … | 2014-11-01 |
| 12028 | 12028 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2011-07-12 | 425 | D | 0 | 1 | 5PI011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number:175 NAC 12-006.12B Based on staff interview and review of the medical record and medication administration record; the facility failed to ensure that medications administered were given according to directions as written by the physician for 1(Resident 7) of 35 sampled residents. The facility census was 75 residents. Findings are: Interview with the ADON (Assistant Director of Nursing) and Review of the Physician order [REDACTED]. -No [DIAGNOSES REDACTED]. -Directions for polyethylene glycol 3350 po (oral) with administration directions of "daily as needed" (when necessary). MARS identified that this was given daily. The ADON stated that it would need to be clarified if it were to be daily or prn; -Lidoderm patch apply one patch....max (maximum) of 3 patches at one time. No evidence (documentation) found of how many patches were being used or the site to which the patch was applied to for pain management. Interview with the ADON revealed: the MARS did have a place to document how many patches were used at one time and to identify the location the patch was applied to. Neither of these (location and number) were acknowledged with documentation on the MARS for the month of June or July. The ADON stated that the staff was aware that it was necessary to provide that information on the medication record. Interview with RN (Registered Nurse) A on 07/18/2011 at 11:20AM in the Nurses Station revealed: -Review of the computer program for printing the MARS did not identify staff documentation for the month of June and July, 2011 related to the location of lido-derm patch application or the number of patches applied; -The "daily as needed for polyethylene glycol" would translate as "prn" or "as needed" and the staff was giving this medication daily. | 2014-11-01 |
| 3292 | 3292 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2018-09-20 | 623 | D | 0 | 1 | K1O411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (5) Based on interview and record review, the facility staff failed to notify the Ombudsman (a person appointed by the state who advocates for residents' rights) when Resident 14 was transferred to the hospital. This affected 1 of 1 sampled residents. The facility identified a census of 19 at the time of survey. Findings are: Review of Resident 14's quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 7/18/18 revealed an admission date of [DATE]. Review of Resident 14's MDS schedule revealed Resident 14 was discharged return anticipated 9/17/2018. Review of Resident 14's Nurses Notes for (MONTH) (YEAR) revealed Resident 14 was transferred to the hospital on [DATE]. There was no documentation the Ombudsman was notified Resident 14 was transferred out of the facility to the hospital. Interview with the facility Administrator on 09/19/18 at 3:12 PM confirmed the Ombudsman was not notified when Resident 14 was transferred to the hospital. Review of the facility policy Elder Transfer and discharge date d 7/2017 revealed the following: State Ombudsman must be contacted/consulted regarding a scheduled transfer or discharge. | 2020-09-01 |
| 3293 | 3293 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2018-09-20 | 812 | F | 0 | 1 | K1O411 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.11E Based on observation and interview, the facility failed to ensure that 1) cereal bin was labeled and dated. 2) That the steam table was free from rust on the outside and inside of the lids. 3) container of powdered milk was labeled, dated and not sitting on the floor.) This had the potential to affect all 19 residents who ate from the kitchen. The facility census was 19. Findings are: Observation on 9/17/18 at 6:22 PM during the initial kitchen tour revealed the following items: -A plastic container (bin) containing different cereals was not marked or labeled with the date opened. -The lids on the steam table had rust on the outside and inside of the lids. -A gray topped plastic container of powdered milk was not marked with a label of contents or date opened. Interview on 9/18/18 at 9:01 AM with FSS (Food Service Supervisor) confirmed that the powdered milk bin with the gray lid was sitting on the floor and that it was not marked or dated. The cereal bin was not labeled or dated. The steam table pans were rusty. | 2020-09-01 |
| 3294 | 3294 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2019-12-17 | 655 | E | 0 | 1 | HRZC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1a Based on interview and record review, the facility staff failed to ensure the resident and/or responsible party received a copy of the baseline care plan and ensure that they understood it. This affected 3 of 3 sampled residents (Residents 17, 68 and 2). The facility identified a census of 18 at the time of survey. Findings are: [NAME] Review of Resident 17's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 12/4/2019 revealed an admission date of [DATE]. Review of Resident 17's Baseline Care Plan dated 9/11/2019 revealed no documentation the care plan was reviewed with and given to Resident 17 or their responsible party. Review of Resident 17's Departmental Notes dated (MONTH) 2019 revealed no documentation a copy of the baseline care plan was given to Resident 17 or their responsible party or that it was reviewed with them. B. Interview with Resident 68 on 12/11/2019 at 2:26 PM revealed they had not received a written copy of their baseline care plan. Review of Resident 68's Baseline Care Plan dated 12/6/2019 revealed an admission date of [DATE]. There was no documentation it was reviewed with Resident 68 or their responsible party or that a copy was given to them. Review of Resident 68's Departmental Notes dated (MONTH) 2019 revealed no documentation a copy of the baseline care plan was given to Resident 68 or their responsible party or that it was reviewed with them. Interview with the DON (Director of Nursing) on 12/16/19 at 1:12 PM confirmed the residents and/or responsible parties had not been given a copy of the baseline care plan. Review of the facility policy Care Plans-Preliminary dated (MONTH) 2006 revealed the following: A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within 24 hours of admission. The preliminary care plan will be used until the staff can conduct the co… | 2020-09-01 |
| 3295 | 3295 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2019-12-17 | 657 | D | 0 | 1 | HRZC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 12-006.09C1c Based on interview and record review, the facility staff failed to ensure interventions for abnormal heart beat and anticoagulant (blood thinner) use with bleeding risk were included on the comprehensive care plan for Resident 17. This affected 1 of 10 residents whose care plans were reviewed during the survey process. The facility identified a census of 18 at the time of survey. Findings are: Review of Resident 17's Quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 12/4/2019 revealed an admission date of [DATE]. Anticoagulant (blood thinner) was received 7 days of the 7 day MDS look back period. Review of Resident 17's Physician's Orders dated (MONTH) 2019 revealed an order for [REDACTED]. Review of Resident 17's MAR (Medication Administration Record) for (MONTH) 2019 revealed documentation Resident 17 was receiving the Eliquis as ordered. Review of Resident 17's Care Plan dated 9/26/2019 revealed no documentation of interventions for the abnormal heart beat and use of a blood thinner including bleeding risk. Interview with the DON (Director of Nursing) on 12/16/19 at 2:20 PM confirmed the interventions for bleeding risk were not included on Resident 17's care plan. Interview with NA-A (Nurse Aide) on 12/17/2019 at 10:23 AM revealed they got the information they needed to care for the residents from the resident's care plan. Review of the Nursing (YEAR) Drug Handbook listed the following nursing considerations for Eliquis: monitor patient for bleeding. Discontinue drug if acute pathological bleeding occurs. Alert: promptly evaluate signs and symptom of blood loss. Drug can cause serious potentially fatal bleeding. Monitor patients for neurological impairment (midline back pain, sensory or motor deficits, such as numbness or weakness in lower limbs, bowel or bladder dysfunction). Treat impairment urgently. Patient teaching: tell patient to repo… | 2020-09-01 |
| 4663 | 4663 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2016-08-30 | 253 | E | 0 | 1 | 3MR111 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A(1) Based on observation and interviews; the facility failed to fix the marred doors, hang the sagging curtains, replace the cracked wheelchair arm pad, and recaulk the sink. This affected 8 of 19 residents (Residents 1, 16, 14, 9, 23, 6, 8 and 10). The facility census was 19 at the time of the survey. Findings are: [NAME] Tour of the room occupied by Resident 1 on 8/24/2016 at 10:10 AM revealed the bathroom door frame had been chipped at the bottom edge. The curtains in the room were sagging from the curtain rod. B. Tour of the room occupied by Resident 16 on 8/24/2016 at 10:39 AM revealed the wall behind the recliner was gouged. The right arm rest on the resident's wheelchair was cracked and peeling which had become a non-cleanable surface. C. Tour of the room occupied by Resident 14 on 8/24/2016 at 10:53 AM revealed the bathroom door edges were marred and chipped. D. Tour of the room occupied by Resident 9 on 8/24/2016 at 12:33 PM revealed the bathroom door was marred and chipped on both sides of the door. E. Tour of the room occupied by Resident 23 on 8/24/2016 at 12:42 PM revealed the bathroom door was marred and chipped on both sides of the door. F. Tour of the room occupied by Resident 6 on 8/24/2016 at 12:58 PM revealed the drapes were sagging from the curtain rod from missing hooks. [NAME] Tour of the room occupied by Resident 8 on 8/24/2016 at 3:46 PM revealed in the bathroom the sink caulking was broken. The closet doors and room door were marred. H. Tour of the room occupied by Resident 10 on 8/24/2016 at 4:24 PM revealed the closet and room doors were marred. Interview with the Maintenance Supervisor on 08/30/2016 at 9:30 AM revealed the wall behind the recliner needed fixed, the wheelchair arm rest needed replaced, the doors needed fixed, the curtains needed rehung and the sink needed fixed. | 2020-04-01 |
| 4664 | 4664 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2016-08-30 | 279 | D | 0 | 1 | 3MR111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1b Based on interview and record review, the facility failed to develop a comprehensive care plan to address urinary tract infection [MEDICAL CONDITION] on Resident 31's care plan. The facility identified a census of 19 at the time of survey. Findings are: Review of Resident 31's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 7/15/2016 revealed an admission date of [DATE] and UTI in the past 30 days was marked under Active Diagnoses. Review of Resident 31's Admission History & Physical dated 7/9/2016 revealed that Resident 31 was hospitalized from [DATE] to 7/11/2016 with a UTI and had a [DIAGNOSES REDACTED]. Review of Resident 31's care plan dated 7/28/2016 revealed Resident 31 had a history of [REDACTED]. Interview with the DON on 8/30/2016 at 9:42 AM confirmed there was no documentation on Resident 31's care plan addressing the UTI including interventions the staff should have been following. Interview with MA-B on 8/30/2016 at 9:49 AM confirmed that the staff look at the resident's care plan to know what they need to do to take care of them. | 2020-04-01 |
| 4665 | 4665 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2016-08-30 | 282 | D | 0 | 1 | 3MR111 | Licensure Reference Number 175 NAC 12-006.10A3 Based on observation and interview, the facility staff failed to have the qualifications to handle the oxygen for Resident 2. This had the potential to affect Resident 2. The facility census was 19 at the time of the survey. Findings are: Observation of cares for Resident 2 on 8/29/2016 at 11:10 AM revealed NA-A (Nursing Assistant) removed the oxygen tubing and turned off the oxygen before the resident was transferred to the toilet. Continued observation revealed NA-A ambulated the resident to the resident's bed and allowed the resident to sit on the edge of the bed. NA-A applied the oxygen tubing to the resident nares and turned on the oxygen concentrator. Review of Resident 2's care plan revealed oxygen therapy was to titrate as needed to maintain the oxygen saturation greater that 90%. Also remind the resident to leave on the oxygen as when the oxygen was removed the saturation soared. Interview with NA-A 08/29/2016 at 12:19 PM revealed I am not to do anything with the oxygen like take it off and turn it off but I would rather do that than have to wait for someone to come help. Interview with the DON (Director of Nurses) on 08/29/2016 at 12:22 PM revealed the oxygen was not to be adjusted by a NA should be the MA's (Medication Aides) and/or the nurses. Reference the Basic Nursing Assistant Training Manual revealed oxygen was considered a medication and therefore must be ordered by a physician and administered by a licensed health care professional. | 2020-04-01 |
| 4666 | 4666 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2016-08-30 | 309 | D | 0 | 1 | 3MR111 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, interview and record review; the facility failed to monitor for wheelchair positioning changes and adapt the wheel chair for body alignment for Resident 6. The facility census was 19. Findings are: On 08/24/2016 at 01:29 PM, Resident 6 was observed sitting in the wheelchair with the resident's head and shoulders leaning forward and to the right side. The resident's head and shoulders were not supported by the back of the wheelchair or the adjustable head rest on the wheelchair. On 08/25/2016 at 3:48 PM, Resident 6 was sitting in the wheelchair with squirming noted. The resident was leaning to the right side with the resident's head and shoulders unsupported. On 08/29/2016 at 9:20 AM, Resident 6 was sitting in the wheelchair with the resident's head leaning to the right side. The resident's head, neck and shoulders were not supported by the head rest or the back of the wheelchair. On 08/30/2016 at 10:03 AM, Resident 6 was observed sitting in the wheelchair with the resident's head leaning to the right side and forward. The resident's head and neck were not supported by the wheelchair's head and neck rest. Record review of Resident 6's Occupational Therapy (OT) Progress & Discharge Summary dated 2/26/16 revealed the resident had abnormal posture of Kyphosis (a forward rounding of the back) and leaning to the side while seated. The skilled OT services had included wheelchair seating and repositioning assessment. The resident was discharged from OT due to the family decision to not purchase the custom wheel chair for positioning. Interview with MA (Medication Aide)-B on 08/30/2016 at 11:14 AM revealed that Resident 6 was leaning to the right side and the wheelchair head and neck rest were not providing support to the resident's head and neck. MA-B revealed that the resident daily had this positioning problem. Interview with NHA (Nursing Home Administrator) on 08/30/2016 at 12:39 PM revealed that the resident's wheelchair head rest could be adjusted f… | 2020-04-01 |
| 4667 | 4667 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2016-08-30 | 364 | E | 0 | 1 | 3MR111 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observation, interviews, and record review; the facility failed to maintain cold food temperatures. This affected Residents 2, 16, 18 and 28. The facility identified a census of 19 at the time of survey. Findings are: Observation of the lunch meal service on 8/29/2016 at 12:00 PM revealed the DS (Dietary Supervisor), using the facility kitchen thermometer, checked the temperature of the pasta salad sitting on the counter and it was 50 degrees F (Fahrenheit) prior to being served to the residents. Observation of the egg salad sandwiches on 8/29/2016 at 12:26 PM revealed they were in a pan sitting on the counter above the pan of ice but there was no ice touching the pan. The DS checked the temperature of the sandwiches and they were 52 degrees F prior to being served to the residents. Temperature check of a sample tray of food prepared immediately after the conclusion of lunch meal service on 8/29/2016 at 12:40 PM revealed the egg salad sandwich was 69.8 degrees F and the pasta salad was 54.9 degrees F. Taste test of the egg salad sandwich revealed it was not cold. Observation of the dining room on 8/29/2016 at 12:45 PM revealed that Residents 2, 16, 18, and 28 had received the egg salad sandwich and they had all consumed a portion of it. Interview with the DS on 8/29/2016 at 1:06 PM confirmed it was very warm in the kitchen and they should have left the cold sandwiches and salad in the refrigerator until they were ready to serve them. Review of the undated facility policy Temperature revealed the following: -Policy: To ensure proper temperatures are maintained to assure proper food storage, and proper serving temperatures. - Procedures: Record daily the temperature of all meal temperatures. Cold food must be served 41 degrees or colder. Review of the 3/8/2012 version of the Food Code, based on the United states Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: refrigerat… | 2020-04-01 |
| 4668 | 4668 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2016-08-30 | 371 | F | 0 | 1 | 3MR111 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview, and record review; the facility failed to ensure sanitization of the dishes and failed to maintain potentially hazardous food at a safe temperature to prevent potential food borne illness. This had the potential to affect the 19 residents who received food from the facility kitchen. The facility identified a census of 19 at the time of survey. Findings are: [NAME] Observation of the kitchen on 8/24/2016 at 8:09 AM revealed incomplete documentation on the dishwasher temperature logs. Record review of the Dishwasher Temperatures log for (MONTH) (YEAR) revealed no documentation the dishes had been sanitized on 13 out of the past 23 days. Interview with the DS (Dietary Supervisor) on 8/24/2016 at 8:34 AM confirmed the dishwasher logs were incomplete and staff were to be documenting the dishes had been sanitized daily. Review of the undated facility policy Temperature revealed the following: Policy: To ensure proper temperatures are maintained to assure proper food storage, and proper serving temperatures and that the dishwasher is working properly. Procedures: Record daily the temperature of the dishwasher. The wash temperature must be 150-165 degrees and the rinse must be 180-190 degrees. B. Observation of the lunch meal service on 8/29/2016 at 12:00 PM revealed the DS (Dietary Supervisor), using the facility kitchen thermometer, checked the temperature of the pasta salad sitting on the counter and it was 50 degrees F (Fahrenheit) prior to being served to the residents. Observation of the egg salad sandwiches on 8/29/2016 at 12:26 PM revealed they were in a pan sitting on the counter above the pan of ice but there was no ice touching the pan. The DS checked the temperature of the sandwiches and they were 52 degrees F prior to being served to the residents. Temperature check of a sample tray of food prepared immediately after the conclusion of lunch meal service on 8/29/2016 at 12:40 PM revealed the egg salad sandwich was 69.8 degrees F an… | 2020-04-01 |
| 4669 | 4669 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2016-08-30 | 441 | E | 0 | 1 | 3MR111 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observation and interview; the facility staff failed to 1) store catheter tubing off the floor for Resident 7; 2) store oxygen tubing off of the floor during cares in order to prevent contamination for Resident 2. This potentially involved 2 residents (Residents 7 and 2). The facility census was 19 at the time of the survey. Findings are: [NAME] Observation of Resident 7 on 08/29/2016 at 9:46 AM found the resident sitting in the wheelchair with the catheter tubing resting on the floor under the resident's wheelchair. Observation of Resident 7 on 08/29/2016 at 11:18 AM found the resident sitting in the wheelchair with the catheter tubing laying on the floor under the resident's wheelchair. Interview with the DON (Director of Nurses) on 08/30/2016 at 11:01 AM revealed the catheter tubing was to be stored in the cover bag and not on the floor. A policy for storage of the catheter tubing was not produced. B. Observation of cares for Resident 2 on 08/29/2016 at 11:10 AM by NA-A (Nurse Aide) revealed the nasal oxygen tubing was taken off the resident and landed on the floor in the doorway of the bathroom. Interview with NA-A on 08/29/2016 at 12:19 PM revealed the nasal cannula was not changed after it was on the floor before putting it back on the resident. Interview with the DON on 08/29/2016 at 12:22 PM revealed nasal cannula should have been changed once it was on the floor. It was addressed with the staff at the last inservice. | 2020-04-01 |
| 4670 | 4670 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2016-08-30 | 456 | D | 0 | 1 | 3MR111 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.18B3 Based on observations and staff interviews, the facility failed to ensure that wheelchair armrest was replaced when the vinyl covering was cracked and chipped for Resident 16. This had the potential to affect Resident 16. The facility census was 19 at the time of the survey. Findings are: Observation on 08/24/2016 at 10:40 AM found Resident 16's right wheelchair arm pad had cracked vinyl that had chipped. The wheelchair arm pad had become a non cleanable surface. Interview with the Maintenance Supervisor on 08/30/2016 at 9:18 AM confirmed the wheelchair arm pad was cracked and needed replaced. | 2020-04-01 |
| 6701 | 6701 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2015-09-16 | 170 | F | 0 | 1 | U1MJ11 | Based on interviews and record review, the facility failed to deliver resident mail within 24 hours of mail delivery to the Post Office. This had the potential to affect all the residents in the facility. The facility census was 23. Findings are: Interview on 09/16/2015 at 11:09 AM with the Resident Council President (RCP) revealed resident mail was not delivered on Saturdays or Sundays and residents had to wait until Monday for any weekend mail. Interview on 09/16/2015 at 11:27 AM with the Social Services Director verified resident mail was delivered to the local post office on Saturdays but resident mail was delivered to the facility Monday through Friday. Review of the website www.uspspostoffices.com revealed the city post office had office hours and delivered mail Monday through Saturday. Observation on 09/16/2015 at 11:32 AM of posted office hours at the local US Post Office revealed mail was delivered on Saturdays and the mail window was open for mail pick up Monday through Saturday. | 2018-11-01 |
| 6702 | 6702 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2015-09-16 | 242 | E | 0 | 1 | U1MJ11 | **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 ask 2 residents (Resident 12 and Resident 22) about bathing preference and failed to ask one resident (Resident 8) about wake time and bed time. Facility census was 23 at the time of survey. Findings are: A. Interview with Resident 12 on 09/14/2015 at 11:27 AM revealed that Resident 12 did not choose how many times a week Resident 12 received a bath or shower. We don't really choose. They just tell you when it is time to take a bath. Resident 12 reported that (gender) hadn't really given any thought about how baths (gender) would like or what days of the week because nobody had ever asked. Review of Resident 12's face sheet revealed an admission date of [DATE]. Review of Resident 12's Significant Change in Status MDS (Minimum Data Set-a comprehensive resident assessment tool) dated 4/8/2015 revealed Resident 12 needed limited assistance of 1 staff person for bathing. Interview with the DON (Director of Nursing) on 9/15/2015 at 3:17 PM revealed that the DON tried to schedule 2 baths for every resident. The DON reported that the facility staff tell the residents when they were admitted to the facility that they offer 2 baths a week and ask if that was okay with them. If the resident doesn't tell the facility they want their baths on certain days the facility staff just set it up. The DON reported that the resident was asked about bathing preference at admission and it was documented on the resident's care plan. Review of Resident 12's care plan dated 4/28/2015 revealed that the resident's bathing preference was not documented on the care plan. Interview with the DON on 9/15/2015 at 3:21 PM confirmed that there was no documentation regarding Resident 12's bathing preference on Resident 12's care plan. Follow up interview with Resident 12 on 9/15/2015 at 3:38 PM confirmed that the facility staff did not ask Resident 12 about bathing pref… | 2018-11-01 |
| 6703 | 6703 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2015-09-16 | 253 | E | 0 | 1 | U1MJ11 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.18A Based on observation and interview, the facility failed to clean the ceiling vent, paint the walls that had chipped paint, replace or clean the stained linoleum floors in the resident bathrooms, and store care items off the floor for 10 of 23 residents (Residents 10, 23, 20, 26, 12, 4, 15, 27, 16 and 28). The facility census was 23 at the time of the survey. Findings are: A. Tour of the room occupied by Resident 10 on 9/14/15 at 11:06 AM revealed a gallon jug marked vinegar was sitting on the floor in the bathroom. A stool riser was sitting on the floor in the Resident's bathroom. Tour of the room occupied by Resident 23 on 9/14/15 at 11:06 AM revealed a gallon jug marked vinegar sitting on the floor in the bathroom. A stool riser was sitting on the floor in the Resident's bathroom. Interview with the DON (Director of Nurses) on 09/16/2015 at 9:00 AM revealed the gallon jug of vinegar and the stool riser should not be on the floor. B. Tour of the room occupied by Resident 26 on 9/14/15 at 11:06 AM revealed the linoleum on the bathroom floor was stained. C. Tour of the room occupied by Resident 12 on 9/14/15 at 11:20 AM revealed the paint was chipped on the wall behind the bed and on the wall of the bathroom. D. Tour of the room occupied by Resident 28 on 9/14/15 at 11:24 AM revealed the ceiling vent in the bathroom was covered with a gray debris. E. Tour of the room occupied by Resident 4 on 9/15/15 at 11:36 AM revealed the linoleum on the bathroom floor was stained and the grout around the base of the toilet was rust colored. F. Tour of the room occupied by Resident 16 on 9/14/15 at 11:40 AM revealed the door to the room and the bathroom were marred. G. Tour of the room occupied by Resident 27 on 9/14/15 at 11:41 AM revealed the linoleum on the bathroom floor was stained with rust colored staining around the grout at the base of the toilet. Paint was chipped on the wall in the bathroom. H. Tour of the room occupied by Resident 20 on 9/14/15 at 1:54 PM revealed paint… | 2018-11-01 |
| 6704 | 6704 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2015-09-16 | 371 | F | 0 | 1 | U1MJ11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interviews, and record review; the facility staff failed to perform hand hygiene during food service to prevent contamination. The facility failed to label food stored in the refrigerator and freezer. This had the potential to affect 23 residents who received food from the facility kitchen and ate in the dining room. Facility census at the time of survey was 23. Findings are: A. Observation on 09/14/2015 at 12:33 PM revealed that DA-B (Dietary Aide) served Resident 24 the noon meal then took hold of the cup handle that Resident 28 had drank the coffee. DA-B filled the cup with coffee and returned the cup to Resident 28. DA-B returned to the kitchen to get another plate of food that was served to the next resident. Hand hygiene was not performed. Observation on 09/14/2015 at 12:38 PM, DA-B pushed their personal glasses up with the hand as walking back to the kitchen then picked up a plate of food and served it to a resident. Hand hygiene was not performed. Observation on 09/14/2015 at 12:46 PM, DA-B opened the door to the dirt dish room, shoved the cart through the dirty dish room to the refrigerator, took out a tray with dished peaches, and placed it on the cart. The peaches were served to the residents by DA-B. Hand hygiene was not performed. Interview with DS (Dietary Supervisor) on 09/15/2015 at 10:09 AM revealed staff were to wash hands if contact was made with resident items that they had touched before touching the next plate of food. Review of the facility policy and procedure for HANDWASHING, dated (MONTH) 2009, stated food employees wash their hands and exposed arms by appropriate and timely handwashing for at least 20 seconds. Food service employees clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single use articles used after touching bare human body parts other than clean hands and clean exposed portio… | 2018-11-01 |
| 6705 | 6705 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2015-09-16 | 431 | E | 0 | 1 | U1MJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure expired treatment/testing supplies were not available for resident use for Residents 3, 7, 22, and 30 and the facility failed to ensure medications were not available for Resident 4 without a pharmacy prescription label. The facility census was 23. Findings are: LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].12E7 A. Observation on [DATE] at 10:37 AM of the medication cart and in the medication bin for Resident 4, a box of Systane eye drops without a pharmacy label. Interview on [DATE] at 10:41 AM with the DON (Director of Nursing) confirmed the box of Systane eye drops did not have a pharmacy label. LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].E4 B. Observation on [DATE] at 11:18 AM in the medication storage room, with LPN-A (Licensed Practical Nurse), revealed 2 vials of blue colored blood draw vials in the blood draw kit that were expired ,[DATE]. LPN-A verified the expired dates on the blue colored blood draw vials. Interview on [DATE] at 12:11 PM confirmed the outdated vials. Observation on [DATE] at 11:30 AM in the medication cart revealed an opened bottle of Assure Platinum glucose test strips (used for testing blood sugar levels in diabetics) in each of the following residents medication bins: Resident 3,7, 22, and 30. None of the 4 containers of test strip bottles had the date written on the container when it was opened or the 90 day expiration date from when it was opened. Review of the Assure Platinum Test Strips instruction sheet revealed in the storage and handling section, When you first open the bottle, write the date on the bottle label. Use the test strips within 3 months of first opening the bottle. Interview on [DATE] at 12:11 PM with the DON revealed the facility did not date the test strips. The DON confirmed the test strip bottles should be dated when opened as per manufacturer instructions. | 2018-11-01 |
| 8226 | 8226 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2014-09-03 | 250 | D | 0 | 1 | WN2B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09D5a Based on interview and record review; the facility failed to assess and address one resident's (Resident 21) comments of wanting to die. The facility census was 19 at the time of the survey. Findings are: Review of Resident 21's FACE SHEET revealed admission to the facility was 4/28/2014. Admission [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set; a federally mandated comprehensive assessment tool used for care planning) dated 5/11/2014, revealed: - BIMS (brief interview for mental status) to be scored at 11 of 15, -Resident's mood was little interest or pleasure in doing things, feeling down, depressed or hopeless, feeling tired or having little energy, poor appetite or overeating, total severity score at 9 of possible 30 (mild depression), and -no behavior exhibited. Review of Resident 21's MEDICARE DAILY SKILLED CHARTING dated 5/9/14 at 6:30 PM revealed the resident stated I just don't feel good I don't care anymore. I don't have anything to live for. Review of Resident 21's MEDICARE DAILY SKILLED CHARTING dated 5/12/14 6 AM-6 PM revealed resident stated he/she was sick and wants to die. Resident 21 had been complaining of wanting to die and showed signs of depression. Review of Resident 21's MEDICARE DAILY SKILLED CHARTING dated 5/13/2014 at 6 AM to 6 PM revealed the resident shows signs of depression does not wanna eat or do therapy. Review of the SOCIAL SERVICE NOTES revealed no documentation of the resident's statement I want to die. Review of Resident 21's CARE PLAN revealed no entry addressing the resident's talk of wanting to die. Interview with the Administrator and SSW (Social Service Worker) on 9/3/2014 at 11:32 AM revealed the medical record did not contain documented evidence of monitoring or an assessment of the resident's statement of I want to die | 2017-10-01 |
| 8227 | 8227 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2014-09-03 | 279 | D | 0 | 1 | WN2B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.04C3a(5) Based on record reviews and interviews, the facility failed to develop a plan of care to include the behavior of not bathing and the interventions to be tired toward getting the resident to bathe for one sampled resident (Resident 5). The facility census was 19 at the time of the survey. Findings are: Review of Resident 5's FACE SHEET revealed admission to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. Interview with the DON (Director of Nurses) on 9/2/2014 at 3:34 PM revealed once in a while the resident will refuse to bathe and the SSW (Social Service Worker) will get the resident to bathe. The SSW revealed the incident of refusing baths did not get care planned. Review of the MAR (Medication Administration Record) dated August 2014 revealed the resident was on [MEDICATION NAME] ( a medication to treat psychotic symptoms) 25 mg (milligrams) po (by mouth) Q HS (every bedtime) for dementia with behavior. Also the resident was on [MEDICATION NAME] (a medication to treat depression symptoms) 15 mg po Q HS for dementia with behavior disturbance. Review of Resident 5's bath sheet found documentation the resident refused a bath on 6/12 and 7/18. Review of Resident 5's CARE PLAN revealed the resident was at risk for side effects from psychoactive medication use as the resident took [MEDICATION NAME] and [MEDICATION NAME]. Interventions were as follows: -administer my mediation as ordered by physician, -monitor and record my target behaviors, -Pharmacy consultant review of my medication monthly, -monitor me for signs of extrapyramidal (any of the abnormal various body movements) symptoms and document. -observe for adverse side effects, documentation and report to physician for [MEDICATION NAME] s/e [MEDICAL CONDITION], nausea, dizziness and dry mouth. Also for [MEDICATION NAME] s/e rash, dry mouth, wt gain. Continued review of the CARE PLAN revealed no additional interventions to address t… | 2017-10-01 |
| 8228 | 8228 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2014-09-03 | 329 | E | 0 | 1 | WN2B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D Based on observations, interviews and record reviews; the facility failed to monitor the effectiveness medications for two sampled residents (Residents 7 and 19). The facility census was 19 at the time of the survey Findings are: A. Resident 7's CARE PLAN addressed the following: -socially inappropriate/disruptive behavior, -yell out at others and make negative comments, -stare at people and argue with people, -take psychoactive meds as ordered, -tend to banter with staff or tells stories and will call names, -refuse meds even with education and spit them on staff, -will holler out to get attention on purpose to be loud, -will hit staff at times. Review of the MAR indicated [REDACTED]. ABHR ([MEDICATION NAME] 1 mg, [MEDICATION NAME] 25 mg , [MEDICATION NAME] 1 mg, [MEDICATION NAME] 10 mg ) gel .5 ml PRN (no route listed) for (increased hollering, restless, repetitive hollering) was administered on 8/16. Review of the PRN MONITORING sheet and NURSES NOTES revealed no documentation of the non pharmalogical intervention tried before administration of the medication. Review of the August 2014 MAR indicated [REDACTED]. Review of the PRN MONITORING sheet and NURSES NOTES revealed no documentation of the non pharmalogical intervention tried before administration of the medication. Review of the RESIDENT BEHAVIOR SIDE EFFECTS TRACKING RECORD for August 2014 revealed 9 episodes out of 30 days. Interview with DON (Director of Nursing) at 9/2/2014 at 1:51 PM revealed the nurses notes do not document the episodes and what was tried before the medication was administered. The nurses notes should explain what was tried and what was going on before an prn (as needed) medication was administered. Review of the NURSES NOTES found no documentation of the type of behavior or pain before the medication was administered. Also no documentation of interventions tried before the administration of pain med. B. Resident 1… | 2017-10-01 |
| 8229 | 8229 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2014-09-03 | 428 | D | 0 | 1 | WN2B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview; the facility failed to ensure the pharmacist identified and reported drug irregularities related to no route listed on the MAR for ABHR gel for 1 sampled resident (Resident 7). The facility census was 19 at the time of the survey. Findings are: Review of Resident 7's FACE SHEET revealed admission to the facility on [DATE] and readmitted on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of the PHYSICIAN order, dated 6/10/14, revealed an order for [REDACTED]. Review of Resident 7's August 2014 MAR (Medication Administration Record) revealed ABHR Gel (ativan 1 mg, benadryl 25 mg haldol 1 mg, reglan 10 mg) given .5 ml every 6 hours prn (increased hollering, restless, repetitive hollering) start date of 6/28/2014. The MAR indicated [REDACTED] Review of Resident 7's September 2014 MAR indicated [REDACTED]. The MAR indicated [REDACTED] Review of Resident 7's the PHARMACY REVIEW revealed completed monthly. Dated 8/26/2014 was the last review with no new recommendations. The route was not addressed for the ABHR gel. Interview with the DON (Director of Nurses) on 9/3/2014 at 1:59 PM revealed the MAR indicated [REDACTED]. Interview with LPN-D (Licensed Practical Nurse) on 9/3/2014 at 1:59 PM revealed the route was not on the MAR for the ABHR gel. | 2017-10-01 |
| 10758 | 10758 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2012-04-17 | 226 | E | 0 | 1 | R6JN11 | LICENSE REFERENCE NUMBER: 175 NAC 12-006.04A3 Based on record review and staff interview the facility failed to develop and implement a policy and procedure for pre-employment screening that included regulatory requirements. The facility failed to complete former employer reference check for 3 employees (Dietary Aide (DA)-Z, Nurse Aide (NA)-B, and NA-R) and failed to complete registry checks utilizing the Nebraska State Patrol Sex Offender Registry and the Nurse Aide Registry for 4 employees (DA-Z, Licensed Practical Nurse (LPN)-H, NA-R, and Dietary Cook/NA-A) of 5 new employees reviewed. Failure to check the backgrounds of potential employees could pose a safety risk to the residents in the facility. The facility census was 18 and the survey sample size was 22. Findings are: A. Review of the facility's policy undated BACKGROUND CHECK POLICY revealed: 3. Background checks completed include: a. State Patrol Criminal Background Check b. DHHS Adult and Child Abuse and Neglect Registry c. Sex Offender Register d. OIG Registry. The policy did not indicate references from previous employers and/or current employers should be obtained or screening checks of the Nurse Aide Registry would be completed. During an interview on 4/16/12 at 1:29 PM, the Administrator revealed the screening of potential employees included checking the Nurse Aide Registry for all employees, not just nursing staff. B. Review of 5 personnel files for new employees that had been identified by the facility as hired within the past 4 months and still employed, revealed the following: - There was no evidence that former employer reference checks had been completed for DA-Z, NA-B, and NA-R; - There was no evidence that screenings from the Nebraska State Patrol Sex Offender Registry had been completed for LPN-H and Dietary Cook/NA-A; - There was no evidence that screening from the Nurse Aide Registry had been completed for DA-Z and NA-R. During an interview on 4/16/12 at 2:05 PM, the Business Office Manager (BOM) revealed the registry screenings for the… | 2015-11-01 |
| 10759 | 10759 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2012-04-17 | 329 | D | 0 | 1 | R6JN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor the effectiveness of medication to ensure continued need for 1 resident (Resident 21). The facility census was 18 and the survey sample size was 22. This affected 1 of 18 residents. Findings are: Review of the ADMISSION and DISCHARGE SUMMARY the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the Clinic Note for Resident 21, dated 2/27/2012, revealed the [MEDICAL CONDITION] blood level would be checked every year. Review of the laboratory sheets revealed the blood levels to check the [MEDICAL CONDITION] had not been monitored since 7/13/2009. Review of the Pharmacy review, dated 3/14/2012, revealed no recent labs. Interview with the DON (Director of Nurses) on 4/17/2012 at 10:45 AM stated that labs were drawn at the Dr. office and we do not have copies at the facility. The DON stated there was no awareness of when the last lab to check the [MEDICAL CONDITION] level had been drawn. | 2015-11-01 |
| 10760 | 10760 | BERTRAND NURSING HOME | 285258 | PO BOX 97, 100 MINOR AVENUE | BERTRAND | NE | 68927 | 2012-04-17 | 371 | F | 0 | 1 | R6JN11 | LICENSURE REFERENCE 175 NAC 12-006.11E Based on observation, record review and staff interview, the facility failed to ensure staff washed hands when contaminated, failed to maintain the integrity of the walk in refrigerator, failed to ensure the cleanliness of dietary equipment, failed to serve food in a sanitary manner and failed to maintain the temperature of cold foods at serving time. This failure increased the risk that bacterial growth and food borne illness could occur which could post a food safety risk to the 18 residents residing in the facility. The facility census was 18 and the survey sample size was 22. Findings are: A. Review of the facility policy and procedure dated February 2010 titled HAND WASHING revealed the following: Food service employees clean their hands .After handling soiled equipment or utensils, During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, After engaging in other activities that contaminate the hands. B. Review of the 7/1/2007 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food services sanitation practices, revealed the following: - Statute 4-904.11: Preventing Contamination - Kitchenware and Tableware. (A) Single-service and single-use articles and cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food-and lip-contact surfaces is prevented; - Statute 2-301.14: When to Wash. Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service use articles and; - (E) After handling soiled equipment or utensils; - (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; - (I) After engaging in other activities that contaminate the h… | 2015-11-01 |
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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 );