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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 12996 | 12996 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2010-05-20 | 323 | D | 8VHJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to provide adequate supervision, assess for causal factors and implement interventions to prevent accidents from occurring for 1 (Resident 09) of 14 residents reviewed. The facility census was 55 at the time of the survey and the survey sample size was 14. Findings are: Resident 09 was admitted to the facility on [DATE] according to the FACE SHEET on the medical record. The following [DIAGNOSES REDACTED]. Review of Resident 09 ' s Nurse ' s Notes revealed that on 1/31/2010, it was noted that the resident had a skin tear on the left lower leg, with the area measuring 4 cm (centimeter) by 3 cm. Review of the investigation performed after the skin tear occurred did not contain any evidence that transfers were observed or any documentation of interviews to ensure that proper techniques were utilized by facility staff. Interview on 5/19/2010 at 3:10 PM with the DON (Director of Nursing) confirmed that there had been no observations made of the transfers of this resident or any other resident to ensure that correct techniques were utilized or that wheelchair pedals were actually removed from wheelchairs to prevent further skin tears from occurring. In addition, the DON confirmed that there were no documented interviews with the involved staff to ensure that correct techniques were utilized during transfers and that facility staff were not the cause of the skin tears. Review of Resident 09 ' s Nurse ' s Notes also revealed that on 2/9/2010 during provision of morning cares, the resident sustained [REDACTED]. Review of the investigation dated 2/9/2010 of the incident revealed that Resident 09 had very fragile skin and apparently when the staff member pulled the sleeve of the robe over forearm, the staff member pulled on the skin causing skin tears. The intervention implemented was for tubigrips to both arms for protection. Review of Resident 09 ' s comprehensive care plan da… | 2014-01-01 | ||
| 12995 | 12995 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2010-05-20 | 225 | D | 8VHJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: ,[DATE].02(8) Based on record review and staff interview, the facility failed to report 2 incidents of possible abuse and/or neglect to Adult Protective Services (APS) within 24 hours in accordance with state law involving 3 residents (Residents 101, 20, and 103). The facility failed to ensure that staff immediately notified Administration of allegations of abuse to assure complete investigations for 2 documented incidents involving 2 residents (Residents 101 and 04). The failure to report and investigate allegations of abuse has the potential to affect the residents safety. The facility census was 55 and the survey sample size was 14. Findings are: A. Review of an ,[DATE] ABUSE AND NEGLECT facility policy revealed: - PURPOSE: "To ensure that all identified incidents of alleged or suspected abuse/neglect are promptly investigated and reported"; - PROCEDURE: "1. If a staff member receives an allegation of abuse, neglect or misappropriation of resident property or witnesses suspected abuse, neglect or misappropriation of resident property, the staff member will immediately report this to a supervisor"; -- "5. Notification Procedures: a. Notify the center administrator immediately of any incidents of resident abuse, misappropriation of resident property, alleged or suspected abuse" "Immediately," in this procedure means as soon as possible after discovery of the incident, and ought not to exceed the end of the shift in the absence of a shorter state time frame requirement"; "b. Notify the designated agencies in accordance with state law, including the state survey and certification agency". B. Review of a DISCHARGE SUMMARY signed by the physician on [DATE] revealed that Resident 101 was admitted to the facility on [DATE] and expired on [DATE]. Cause of death was due to end stage Alzheimer's dementia. Review of a facility investigation dated [DATE] revealed: - "[DATE] it was reported to the Administrator that two aides… | 2014-01-01 | ||
| 12994 | 12994 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2010-05-20 | 441 | D | 8VHJ11 | LICENSURE REFERENCE: 12.006.17D Based on observation and record review, the facility failed to assure that staff washed hands as indicated, using proper technique, during resident interaction. The facility had a census of 55 and survey sample of 14. This affected the following residents: 26, 52 and 09. Findings are: A. Review of the facility policy and procedure titled INFECTION CONTROL POLICIES/PROCEDURES HAND HYGIENE AND HANDWASHING, revised and dated July 2009 revealed the following: "Wash hands with plain soap and water or with anti-microbial soap and water: If hands are visibly soiled (dirty). If hands are visibly contaminated with blood or body fluids. Before eating. After using the restroom. If hands are not visibly soiled or contaminated with blood or body fluids, use an alcohol-based hand rub for routinely cleaning your hands: Before having direct contact with residents. After having direct contact with a resident's skin. After having contact with body fluids, wounds or broken skin. After touching equipment or furniture near the resident. After removing gloves". The procedure for HAND WASHING stated the following: 1. "Wet hands with water. (Avoid hot water.) 2. Apply three to five ml (milliliter) of soap. 3. Rub hands together for at least 15 seconds. 4. Cover all surfaces of hands and fingers. 5. Rinse hands with water and dry thoroughly. 6. Use paper towel to turn off water faucet". B. Observation on 5/18/10 at 10:25 AM revealed that NA-A (Nursing Assistant) was assisting Resident 52 to use the toilet and with incontinence care. NA-A donned gloves to assist the resident with incontinence care. When NA-A removed the gloves to wash hands, the hands were rubbed together for approximately 3 seconds with failure to cover all surfaces of hands and fingers with lather before rinsing. C. Observation on 5/18/10 at 9:50 AM revealed that NA-A and MA-L (Medication Aide) were assisting Resident 26 with removing a soiled brief and providing incontinence care. Upon completion of the task, NA-A washed hands at the sin… | 2014-01-01 | ||
| 12993 | 12993 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2010-05-20 | 281 | D | 8VHJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 12-006.09 Based on record review and staff interview, the facility failed to ensure physician's orders were followed for the collection of laboratory tests for 3 residents (Residents 33, 18, and Closed Record 102). The facility census was 55 and the survey sample size was 14. Findings are: A. The "Fundamentals of Nursing, 6th Edition" by Potter and Perry, copyright 2005, stated the following: "The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or could be detrimental to clients". B. Review of an August 2008 PHYSICIAN'S ORDERS facility policy revealed: "Order Processing" "49. An order must be processed in Resident services exactly as it is written and signed; if unclear, clarification must be obtained by the Nursing Services department in the form of another physician's order". C. Review of a 1/6/10 FACE SHEET revealed Resident 33 was admitted to the facility on [DATE]. Review of a 3/31/10 COMPREHENSIVE CARE PLAN revealed Resident 33 had [DIAGNOSES REDACTED]. Review of Resident 33's medical record revealed that a PT/INR ([MEDICATION NAME] time/international normalized ratio) (a blood test that measures how long it takes blood to clot) had been drawn on 4/1/10, showing a result for the PT = 31.9 H (meaning high) (referencing range 11.9 - 14.7 seconds) and the INR = 3.03 (reference range 2.0-3.0). The physician had written that the laboratory (lab) results were to be rechecked in 2 weeks. Review of a REFERENCE LAB REQUEST revealed PT/INR blood test was to be "recheck in 2 wk" (weeks) and specified the DATE TO DRAW was 4/15/10. Review of Resident 33's medical record revealed no lab results for 4/15/10. Lab results revealed that a PT/INR had been drawn on 5/6/10 showing a result for the PT = 21.5 H and INR result was 1.84. Review of Resident 33's INTERDISCIPLINARY PROGRESS NOTES revealed: - 4/1/40 at 6:50 AM; "LAB DR… | 2014-01-01 | ||
| 12992 | 12992 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2010-05-20 | 204 | D | 8VHJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 12-006.09C2 Based on record review, staff and resident interviews; the facility failed to establish a discharge plan of care to ensure a safe and orderly discharge for 1 resident (Resident 40) that had expressed a desire on admission to return to the resident's prior living arrangements. The facility census was 55 and the survey sample size was 14. Findings are: Review of a FACE SHEET dated 3/11/10 revealed Resident 40 was admitted to the facility on [DATE]. Review of a 4/19/10 physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of Resident 40's INITIAL/TEMPORARY CARE PLAN revealed "Discharge Plan: Goal is to return home". There was no documentation of a discharge plan that specified supportive services the resident would need or a target date for discharge. Review of Resident 40's INTERDISCIPLINARY PROGRESS NOTES revealed the 3/13/10 entry "Discharge Plan: Resident goal is to regain strength & (and) return to own home (with spouse)". Review of a Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) with an assessment date of 3/14/10 revealed Resident 40 had: - No short-term or long-term memory problems; - Modified independent cognitive skills for daily decision making; - Required physical assistance with transfers between surfaces, dressing, personal hygiene, and bathing; - "DISCHARGE POTENTIAL" was that Resident 40 expressed preference to return to the community and had a support person who was positive towards discharge. Review of Resident 40's 4/22/10 OUTPATIENT/COMMUNITY UPDATED PLAN OF treatment for [REDACTED]. Review of Resident 40's COMPREHENSIVE CARE PLAN dated 3/31/10 revealed; DISCHARGE PLAN: LIVES W/ (with) (spouse), NEEDS TO REGAIN ABILITIES TO CARE FOR SELF. WILL EVAL (evaluate) DISCH (discharge) PLAN ONGOING. Review of handwritten documentation added to the COMPREHENSIVE CARE PLAN revealed: - 5/11/10: (Resident 40) has been improving (w… | 2014-01-01 | ||
| 12991 | 12991 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2013-03-25 | 323 | D | PCSY11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on observation, record review and staff interview; the facility staff failed to evaluate casual factors and implement interventions to prevent skin tears for 1 (Resident 27) of 36 sampled residents. The facility staff identified a census of 39. Findings are: Observation on 3-20-2012 at 10:22 AM revealed Resident 27 had a skin tear to the right lower leg near the calf area. Record review of an Incident/Occurrence Form dated 3-9-13 identified Resident 27 did have a skin tear to the right leg towards the calf region with 2 smaller area of redness.. According to the information on the Occurrence report, Resident 27 was " unaware of how they occurred". The Occurrence form did not identify potential casual factors that lead to the skin tear or what what intervenes were implemented to prevent further skin tears. Record review of Resident 27's medical record did not contain evidence the facility staff had attempted to identify the cause of the skin tear or what interventions had been implemented to prevent further skin tears. On 3-20-2013 at 2:26 PM an interview was conducted with Registered Nurse (RN) C. During the interview RN C reported (gender) '' was not sure how the skin tear occurred" and it "should be on a skin sheet for monitoring". on 3-21-2013 at 11:19 AM an interview with RN D was conducted. During the interview, RN D confirmed Resident 27 had a skin tear to the right lower calf area. When asked if the skin tear should be monitored, RN D stated there "should be skin monitoring". An interview with the Director of Nursing (DON) was conducted on 3-21-2013 at 12:20 PM. During the interview, the DON confirmed Resident 27 had a skin tear. The DON stated "there should be monitoring" and confirmed the casual factor for the skin tear had not been completed. | 2014-01-01 | ||
| 12990 | 12990 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2013-03-25 | 311 | D | PCSY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1b Based on closed record review and interviews; the facility failed to complete an ordered evaluation for a motorized wheelchair for 1 resident (Resident 67)of 36 sampled residents. The facility census was 39. FINDINGS ARE: Review of Resident 67's [DIAGNOSES REDACTED]. Per DC (discharge)summary dated 4-20-12, the resident was alert and oriented to person, place, and time. ADL (Activities of Daily Living) sheets reviewed for April 2012 and staff documented that resident needed assistance with transfers, ambulation, and mobility. Review of Careplan dated 2-27-12 revealed Resident 67 wished to Discharge to an Assisted Living facility. Review of Care plan attendance notes on 2-27-12 revealed that Resident 67 wanted to move to an Assisted living facility, where the resident would use a power chair. Physician orders [REDACTED]. Record review of therapy notes for Resident 67 revealed no therapy notes after March of 2012 in the closed record. Interview with the Director of Nursing (DON) on 3-25-13 at 10:37 am revealed that all inquiries are told before admission that the facility doesn't allow power chairs. There have been instances where a resident has needed it to go out of the facility then they could store it in therapy and get it right before they go out but they can not have it up around the other residents and staff for safety risks. Interview on 3-26-23 at 12:30 pm with staff member A, from therapy, stated that they were unable to locate any documentation that the evaluation had been done for the power chair. | 2014-01-01 | ||
| 12989 | 12989 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2013-03-25 | 309 | D | PCSY11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2 Based on record review and interview; the facility staff failed to evaluate and monitor a development of a skin tear for 1 (Resident 27) of 36 sampled residents. The facility staff identified a census of 39. Findings are: Observation on 3-20-2012 at 10:22 AM revealed Resident 27 had a skin tear to the right lower leg near the calf area. Record review of an Incident/Occurrence Form dated 3-9-13 identified Resident 27 did have a skin tear to the right leg towards the calf region with 2 smaller area of redness.. According to the information on the Occurrence report, Resident 27 was " unaware of how they occurred". Record review of Resident 27's medical record did not contain evidence Resident 27's skin tear to the right lower calf area was being monitored for potential complications. On 3-20-2013 at 2:26 PM an interview was conducted with Registered Nurse (RN) C. During the interview RN C reported (gender) '' was not sure how the skin tear occurred" and it "should be on a skin sheet for monitoring". on 3-21-2013 at 11:19 AM an interview with RN D was conducted. During the interview, RN D confirmed Resident 27 had a skin tear to the right lower calf area. When asked if the skin tear should be monitored, RN D stated there "should be skin monitoring". An interview with the Director of Nursing (DON) was conducted on 3-21-2013 at 12:20 PM. During the interview, the DON confirmed Resident 27 had a skin tear. The DON stated "there should be monitoring". Record review of the facility policy titled Skin Condition management dated 3-2013 revealed the following: -#5. A care plan is established within 24 hours for skin issues. -#8. Any pressure ulcers or non-pressure ulcers will be noted weekly on a log sheet (one sheet per each wound) so progress/lack of progress can be identified quickly. -#9.Re-assessment of the skin issues are done by the wound/nurse designee weekly. The assessment involves measurement of each wound, observation of the wound and re-evaluation of the treatment p… | 2014-01-01 | ||
| 12988 | 12988 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2013-03-25 | 280 | D | PCSY11 | **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 staff failed to review and revise a Comprehensive Care Plan (CCP) related skin condition for 1 (Resident 27) and failed to revise the CCP for discharge plan for 1 (Resident 70) of 36 sampled residents. The facility staff identified a census of 39. Findings are: A. Observation on 3-20-2012 at 10:22 AM revealed Resident 27 had a skin tear to the right lower leg near the calf area. Record review of an Incident/Occurrence Form dated 3-9-13 identified Resident 27 did have a skin tear to the right leg towards the calf region with 2 smaller area of redness.. According to the information on the Occurrence report, Resident 27 was " unaware of how they occurred". Record review of Resident 27's CCP dated 7-28-2012 did not contain information that Resident 27 has a skin tear identified on 3-9-2013. The care plan did not have interventions listed to prevent further skin tears. An interview with the Director of Nursing (DON) was conducted on 3-21-2013 at 12:20 PM. During the interview, the DON confirmed Resident 27 had a skin tear. The DON confirmed the care plan had not been updated. Record review of the facility policy titled Skin Condition management dated 3-2013 revealed the following: -#5. A care plan is established within 24 hours for skin issues. B. Record review of a information sheet dated 12-14-11 revealed Resident 70 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Social service Notes dated 5-06-2012 revealed that Resident 70 had the "desire to return home". Record review of Resident CCP dated 8-11-2012 did not identify Resident 70 discharge plan. An interview on 3-25-2013 was conducted with the Social Services Director (SSD). Review of Resident 70 CCP was conducted with the SSD. The SSD confirmed that Resident 70 care plan did not contain a dischage plan. | 2014-01-01 | ||
| 12987 | 12987 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2013-03-25 | 204 | D | PCSY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview; the facility staff failed to ensure information was provided to a receiving facility on the current condition of 1(Resident 72) of 36 sampled residents. The facility staff identified a census of 39. Findings are: B. Record review of a information sheet dated 8-21-12 revealed Resident 72 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Consultation report dated 8-1-2012 revealed Resident 72 had been admitted diagnosed with [REDACTED]. Record review of laboratory results dated [DATE] revealed Resident 72's White Blood Count (WBC) was 10.45. The normal range identified on the laboratory sheet was 3.60 to 10.30. The results were faxed to the physician. According to science.howstuffworks.com, How blood works buy Carl Bianco M.D. revealed WBC's are part of the immune system and help fight infection. When the number of WBC's in the blood increase, indicates a sign of infection some where in the body. Record review of laboratory results dated [DATE] revealed Resident 72's WCB was 13.67 with the results being faxed to the physician. Record review of Resident 72's Skilled Daily Nurses Notes (SDNN) dated 8-19-2012, 8-20-2012, 8-21-2012 and 8-22-2012 revealed Resident 72 was alert. Record review of Resident 72's SDNN dated 8-23-2012 at 1:15 PM revealed the SDNN identified Resident 72's " family/ girlfriend voiced concerns res (resident) seemed more sleepy than (gender) normally is". Further review of Resident 72's SDNN dated 8-23-2012 at 3:00 PM revealed the nurse had documented Resident 72 "seemed lethargic today". Resident 72's record did not contain evidence Resident 72's physician had been notified of the change in condition. Record review of Resident 72's medical record did not contain evidence the facility staff had provided information on Resident 72's current health status to the receiving facility on discharging from the facility. An interview was conducted with the Di… | 2014-01-01 | ||
| 12986 | 12986 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2013-03-25 | 203 | E | PCSY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(5) Based on record review and interviews; the facility failed to provide thirty days notice for discharge for 3 residents (Resident 67, 70, 71) of 36 sampled residents. The facility census was 39. FINDINGS ARE: A. Resident 67's [DIAGNOSES REDACTED]. Review of Careplan notes dated 2-27-12 revealed Resident 67 wished to Discharge to an Assisted Living facility. Resident 67's Discharge Summary (DC) for 4-20-12 revealed the resident was alert and oriented to person, place, and time. Social services progress notes revealed the following: - On 4-11-12; 30 day dc notice given to the resident due to noncompliance with facility policies and procedures and social services would find placement for resident. - On 4-19-12; Resident 67 was accepted to another long term care (LTC) facility. SW (Social Worker) tried to set up a meeting with family to discuss transfer and the family cancelled the meeting twice. SW tried to talk to resident about transfer and the resident refused to have a meeting in a confidential place and refused to talk about what happened when the resident was transferred. SW did let resident know the resident would be transferred to the other LTC facility on 4-20-12 and the resident's belongings would be moved. Review of Physician orders [REDACTED]. On 4-20-12 the SW called Resident 67's family to let them know of the transfer and that the resident's belongings would follow. The resident's sister stated Resident 67 would not be going there. The SW notified the ombudsman. The resident was transferred to the new LTC facility after [MEDICAL TREATMENT] on 4-20-12. Interview on 3-21-13 at 2:39pm with the facility Administrator, revealed the Administrator was unsure if a full 30 days was carried out before transfer was made. Admission paperwork reviewed and under section IV: Termination of Modification of Agreement: B. Involuntary transfer or Discharge.....Except in an emergency or other circumstanc… | 2014-01-01 | ||
| 12985 | 12985 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2013-03-25 | 164 | D | PCSY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(20) Based on record review and interview; the facility staff failed to ensure security of protected health information for 1 (Resident 70) of 36 sampled residents. The facility staff identified a census of 39. Findings are: Record review of a information sheet dated 12-14-11 revealed Resident 70 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 70's medical record revealed Resident 70 was discharged to another facility on 8-23-2012. Further review of Resident 70's medical record revealed there was not any signed permission for the facility to provided medical records to the receiving facility. An interview on 3-25-2013 at 12:57 PM was conducted with the Social Services Director (SSD). During the interview, when asked if the facility had permission to send medical information to another facility, the SSD stated" I can't find it". When asked if permission should have been obtained, the SSD state"yes". | 2014-01-01 | ||
| 12984 | 12984 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2013-03-25 | 157 | E | PCSY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12.006.04C3a(6) Based on record review, observations, and interview; the facility failed to notify the physician of changes in condition related to a potential infection for 2 Residents (Resident 11 and 72) and related to swallowing for 1 resident (Resident 32) of 36 sampled residents. The facility census was 39. FINDINGS ARE: A. Closed Record Review of Resident 11 revealed that the resident had a [DIAGNOSES REDACTED]. Review of Resident 11's Progress Notes revealed an order received from the physician dated 12-7-12 to hold [MEDICATION NAME] (a medication used to lower blood pressure) for Systolic Blood Pressure (SBP) less than 100. A Nurses Note dated 12/9/12 at 8 pm stated residents Blood Pressure (BP) was 77/62. No other documentation was made. Nurses Notes on 12/12/12, stated; resident complains of increased upper respiratory distress. Resident had increased shortness of breath and a productive cough with phlegm. Lung sounds were diminished in the right lobes with crackles in the left lower lobes. The physician was faxed with the resident's complaints and that the resident was requesting an x-ray. The resident's temperature was 98.6, respirations were 24, pulse was 106, BP was 88/60, and oxygenation was 95% on 5 liters of oxygen. Nurses notes dated 12-13-12 at 12:45 pm stated a call was received from midtown clinic to schedule an appointment for acute respiratory complaints at 2:15 pm that day. Nurses notes dated 12/13/12 at 3:55 pm revealed a call was received from the resident from the med center to let the facility nurse know Resident 11 was admitted to the hospital due to [MEDICAL CONDITION] history of [MEDICAL CONDITION], and pneumonia. Interview with the Director of Nursing (DON) on 3-21-13 at 12:15 am revealed the DON states that with BP running that low and with the resident experiencing those symptoms, the DON would've expected the nurse to call the physician that evening and not wait until the … | 2014-01-01 | ||
| 12983 | 12983 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2011-11-30 | 157 | D | OH2S11 | Licensure Reference 175-NAC-12.006-4C3a Based on observation interview, and record review the facility failed to notify the physician of an increase of depression for Resident 1. The census was 45 and the sample size was 12. Findings are: Based on the History and Physical dated 09/16/2011, Resident 1 was in the terminal stage of the disease known as Multi-System Atrophy. According to the report, Resident 1 was chronically bed bound. Resident 1 is on Hospice due to the terminal condition. Review of Resident 1's MDS's (minimum data set, a federally mandated assessment tool ) Resident 1 was assessed 3 times for depression between 06/14/2011 and 10/24/11. This was due to the Residents change of condition. On 06/24/11 the depression score was 1 On 09/27/11 the depression score was 3 On 10/24/11 the depression score was 9 In an interview with Social Worker-D (SW) on 11/29/11 at 2:30 PM, SW-D stated that the facility used the PHQ-9 to assess depression in facility residents. (The PHQ-9 is the nine item depression scale of the Patient Health Questionnaire. The PHQ-9 is a tool for assisting in diagnosing depression.) The SW used the PHQ-9 scoring card for determining severity. The card states the following: a score of 1-4 = Minimal Depression 5-9 = Mild Depression 10-14=Moderate Depression 15-19=Moderate Severe Depression 20-27=Severe Depression In the same interview, the social worker stated the facility reports any scores 5 or over to the physician. In an interview on 11/30/11 at 10:30, SW-D confirmed that the resident did have a higher score indicating mild depression and the doctor should have been notified but was not notified. | 2014-01-01 | ||
| 12982 | 12982 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2011-11-30 | 318 | D | OH2S11 | Licensure Reference Number 175 NAC 12-006.09D4 Based on observation, interview and record review, the facility failed to implement interventions to prevent further decline in range of motion for Residents 1 and 9. The facility census at the time of survey was 45 and the sample size was 12. Findings are: A. Based on the History and Physical dated 09/16/2011, Resident 1 is in the terminal stage of the disease known as Multi-System Atrophy. This has left Resident 1 chronically bed bound. Review of a doctors' order dated 11-09-11, Resident 1 is to have a rolled wash cloth in the left hand to maintain anatomical position. According to the order, this was indicated because of signs that the fingers were starting to contract. Observation on 11/29/11 at 12:00 noon revealed the resident did not have a wash cloth in the left hand. Observation made at 2 PM on 11/29/11 also revealed no washcloth in Resident 1's hand. Observation was also made on 11/30/11 at 8 AM of Resident 1 without the washcloth in the left hand. In an interview on 11-30-11 at 08:00, RN-B confirmed the washcloth was not on Resident 1's hand and it should have been there. B. Based on observation and record review of Resident 9's History and Physical dated 06/03/11 , Resident 9 suffers from the after effects of a stroke. Record review of Resident 9's chart reveals a referral letter titled "Restorative Nursing Program" dated 10/27/11 that was sent to Restorative Nursing from Occupational Therapy (OT) stated the following: Perform upper extremity(UE) exercises 3x week for 12 weeks and gives the details of how to do the exercises to the upper extremities. It also states the current splint (to the left extremity) is still appropriate and a schedule cannot be established because of resident refusals. Another similar referral note from Occupational Therapy to Restorative Nursing dated October 6, 2011 gives instructions for lower extremities (LE) and states this is to be done 3x week for 12 weeks. In an interview on 11/30/11 at 9AM with Restorative Aide-C and Resto… | 2014-01-01 | ||
| 12981 | 12981 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2011-11-30 | 314 | D | OH2S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 12-006.09D2a Based on observation, interview and record review, the facility failed to implement interventions to prevent potential pressure ulcers for Resident 4. The facility census at the time of survey was 45 and the sample size was 12. Findings are: Based on the MDS ( Minimum Data Set- a federally mandated tool used to objectively assess Resident Care ) dated 09/16/2011, Resident 4 scored a 15 out of 15 on the cognitive impairment tool indicating the resident is not cognitively impaired. The MDS also indicated Resident 4 had the [DIAGNOSES REDACTED]. The resident did also recently have an above the knee amputation related to the residents chronic diabetes. On September 22, 2011, Resident 4 ' s physician was notified that the resident had an open area on the left heel . The physicians order dated 09/22/2011 was for Resident 4 to apply [MEDICATION NAME] and wear Prevalon Boot at all times and remove only for ADL ' s. On November 28,2011 Resident 4 was at 3 PM, wearing tennis shoes rather than the Prevalon Boot. On November 29,2011 Resident 4 was seen wearing tennis shoes throughout the day shift. On November 30, 2011, Resident 4 was seen wearing the tennis shoes again. In an interview on 11/30/11 at 0730 AM, Resident 4 indicated it was preferred by Resident 4 that the boot only be worn at bedtime. When asked if the staff applied the boot the night before, Resident 4 replied they had not. Resident 4 was asked if they applied the boot the night before that, Resident 4 indicated No they had not. When asked if the staff had applied the boot every in the past couple weeks and the resident answered they had not. In an interview on 11/30/ 2011 at 08:30 Staff Development Registered Nurse ( RN) agreed the resident should have been wearing the Prevalon Boot all the time because no other order had been obtained saying otherwise. | 2014-01-01 | ||
| 12980 | 12980 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2011-11-30 | 329 | E | OH2S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview; the facility staff failed to identify target behaviors to monitor the use of [MEDICAL CONDITION] medications for 3 (Residents 6, 7 and 4) of 12 sampled residents. The facility census at the time of survey was 45. Findings are: A. Record review of Resident 6's Admission Face Sheet dated 4/21/11 revealed Resident 6 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 6's Minimum Data Set 3.0 (A federally mandated comprehensive assessment tool used for care planning) dated 11/1/11 revealed the facility staff had completed a resident mood interview with the resident and identified that Resident 6 felt down, depressed or hopeless, felt tired and had little energy and felt bad about themselves for 3 days per week over the last 2 weeks. Record review of a monthly physician's orders [REDACTED]. The [MEDICATION NAME] was started on 7/27/11. Record review of Resident 6's November 2011 Behavior Monitoring Intervention Flow Records did not identify the medications being used, the types of behaviors that should have been monitored or the interventions that staffs were to use when Resident 6 had behaviors. The facility was unable to provide documentation of behavior monitoring for Resident 6 for the months of August, September or October, 2011. Interview with the Director of Nurses on 11/30/11 at 9:45 AM confirmed there were no target behaviors identified for Resident 6 and that no behavior monitoring documentation was present for August, September or October, 2011 for Resident 6. B. Record review of Resident 7's Minimum Data Set 3.0 dated 11/9/11 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Record review of a monthly physician's orders [REDACTED]. The [MEDICATION NAME] was started on 9/07/10. Record review of Resident 7's Behavior Monitoring Intervention Flow Records from May, 2011 through November, 2011 did not identify the medications being used, the types… | 2014-01-01 | ||
| 12979 | 12979 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2011-11-30 | 441 | D | OH2S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference 175 NAC 12-006.17 Based on observation, interview and record review, the facility failed to ensure procedures were completed to prevent the potential for cross contamination related to glucometer cleaning for 1 resident (Residents 8) and wound dressing for 1 resident (Resident 1). The sample size was 12. The facility census was 45. Findings are: A. Review of Resident 8's medical record revealed a [DIAGNOSES REDACTED]. Observation on 11/29/2011 at 11:10 AM, revealed RN(Registered Nurse) A removed the facility glucometer (a machine to check blood sugar levels) from the medication cart and took it into Resident 8's room. RN A placed the glucometer on Resident 8's bedside table without placing a barrier on the table. After RN A obtained the blood sugar reading, RN A wiped the glucometer with an alcohol wipe without changing gloves and then placed the glucometer back on Resident 8's bedside table without a barrier. RN A removed gloves, washed hands and picked up glucometer from Resident 8's bedside table and left Resident 8's room laying the glucometer on the medication cart without cleaning the machine or placing a barrier on the medication cart. RN A then picked up the glucometer and placed it in the medication cart drawer without further cleaning. Interview on 11/29/2011 at 11:25 AM, with RN B staff education nurse revealed the expectation was RN A should have used a barrier in Resident 8's room when setting the glucometer on the table. RN B also confirmed that the glucometer was not cleaned as per policy and should not have been placed on the medication cart without cleaning or placing on a barrier. Review of the facility policy titled "Glucometers" with an effective date of "new", revealed the following entries: ? #6- Lay barrier and glucose meter on work space. ? #15 Remove gloves and wash hands ? #19- Cleanse meter with sani wipes and leave wet. ? #20 Put meter away B. Based on the History and Physical dated 09/16/2011, … | 2014-01-01 | ||
| 12978 | 12978 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2011-11-30 | 514 | D | OH2S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.16B Based on observation, record review and interviews; the facility failed to maintain complete documentation related to the location of a [MEDICAL TREATMENT] for 1 ( Resident 11) of 12 sampled residents. The facility census at the time of survey was 45. Findings are: Record review of Resident 11's admission orders [REDACTED]. Observation on 11/30/11 at 7:35 AM revealed Resident 11 seated on the edge of the bed in Resident 11's room with a button down shirt on. A white bandage dressing was present and visible on Resident 11's upper right chest which covered a [MEDICAL TREATMENT] access catheter . Record review of Resident 11's medical record, including an Admission Data Collection assessment dated [DATE] and again on 11/29/11, admission orders [REDACTED]'s [MEDICAL TREATMENT] access catheter. Interview on 11/29/11 at 3:45 PM with the Director of Nursing (DON) confirmed that the location of the [MEDICAL TREATMENT] was not documented in Resident 11's medical record. The DON stated that it should have been documented on the Admission Data Collection Assessment, the admission orders [REDACTED]. | 2014-01-01 | ||
| 12977 | 12977 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2010-09-23 | 280 | D | ZEZV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on record review and interview, the facility staff failed to review and revise a Comprehensive Care Plan (CCP) related to falls for 1(Resident 12)of 12 sampled and 9 non-sampled residents. The facility staff identified a census of 45. Findings are: Record review of Physician Orders/Progress Notes dated 8/10/2009 revealed Resident 12 was admitted to the facility with the [DIAGNOSES REDACTED]. Record review of an Fall Risk assessment dated [DATE] revealed Resident 12 scored a 16. A score of 10 or higher represents "high Risk". Record review of Physician order [REDACTED]. Record review of an Fall Risk assessment dated [DATE] revealed Resident 12 scored a 9. Record review of an Incident Report/ Occurrence Form dated 10/23/2010 revealed Resident 12 had slid to the floor. The form did not contain any new interventions to prevent slides. Record review of an Incident Report/ Occurrence Form dated 10/24/2009 revealed Resident 12 was found on the floor. No additional intervention to prevent re-occurrence had been identified on the form. Record review of Resident 12's CCP dated 9/29/2010 did not identify and new interventions. An interview on 9/23/2010 at 10:45 AM was conducted with the Director of Nursing (DON). During the interview, Resident 12's CCP was reviewed with the DON. The DON confirmed Resident 12's CCP had not been updated to prevent re-occurrence. The DON confirmed the resident's CCP should have been updated. | 2014-01-01 | ||
| 12976 | 12976 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2010-09-23 | 314 | D | ZEZV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 12-006.09D2a Based on observation, interview and record review, the facility failed to ensure pressure ulscer treatment was completed for Resident 5 and failed to ensure pressure ulcer interventions were functional for related to the air overlay mattress for Resident 3. The facility census at the time of survey was 45 and the sample size was 12 plus 9 non-sampled residents. Observation was made on September 23 at 10:55 AM of RN changing a dressing for Resident 5. According to a Physicians order dated 6-28-2010, Resident 5 was to have an Allevyn foam dressing to the back and spine and change every 3 days. The dressing removed from Resident 5 was dated 09/17/2010. RN agrees the dressing should have been changed 3 days prior to this date. Record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] In an interview with the Director of Nursing (DON) on September 23, 2010 at 11:00 AM, the DON stated the dressing should have been changed on 09/20/2010. B. Record review of an information sheet dated 6/25/2010 revealed Resident 3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 3's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 7/16/2010 revealed the facility staff assessed the following about the resident: -Resident 3 had short and long term memory problems. -Usually was able to make self understood and make others understand. -Required total dependence with bed mobility, transfers, dressing, toilet use and personal hygiene. -Had no pain indicators. -Did not have any pressure ulcers. -Had pressure reliving devices in bed and chair. Record review of a Braden Scale assessment ( A tool used for predicting pressure ulcer risk) dated 6/24/2010 revealed Resident 3 scored a 10. According to the information on the Braden Scale assessment sheet, a score of 10… | 2014-01-01 | ||
| 12975 | 12975 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2010-09-23 | 281 | D | ZEZV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference NAC-175-12-006.09 Based on interview, observation and record review, the facility failed to follow Physicians orders related to a dressing change for Resident 5 and failed to apply a leg positioning device as ordered by the physician for Resident 5.They also failed to follow physicians order in regards of replacing a gastrostomy tube for Resident 15. The facility census was 45 and the sample size was 12 plus 9 non-sampled residents. A. Observation was made on September 23 at 10:55 AM of RN changing a dressing for Resident 5. According to a Physicians order dated 6-28-2010, Resident 5 was to have an Allevyn foam dressing to the back and spine and change every 3 days. The dressing removed from Resident 5 was dated 09/17/2010. RN agrees the dressing should have been changed 3 days prior to this date Record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] In an interview with the Director of Nursing (DON) on September 23, 2010 at 11:00 AM, the DON stated the dressing should have been changed on 09/20/2010. B. Resident 5 is a [AGE] year old person who is on hospice and in July, broke a leg while trying to transfer independently. On September 21,2010 at 11:40 AM observation was made of Resident 5 transferring out of bed with the assistance of a Nursing Assistant K (NA) K. Resident 5 was wearing booties called bunny booties that have a ' canoe type ' bottom. They were very over stuffed and had a seam along the bottom center of the sole, making it impossible to stand flat in. NA K put a gain belt around Resident 5 and transferred with the use of the gait belt while Resident 5 put arms around NA K ' s neck. Only one assistant was there and no leg immobilizer was used. This surveyor did visualize the immobilzer in the residents closet. Record review of Resident 5 ' s careplan revealed Resident 5 should be transferred using leg immobilizer for stabilization. Review of a doctors order … | 2014-01-01 | ||
| 12974 | 12974 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2010-09-23 | 323 | D | ZEZV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, record review and interview, the facility staff failed to ensure mechanical lift slings were in good repair, failed to lock the mechanical lift brakes during a transfer for 1 Resident 3) and failed to evaluate suicidal statements for 1 (Resident 12) of 12 sampled and 9 non-sampled residents. The facility staff identified a census of 45. Findings are: A. Record review of an information sheet dated 6/25/2010 revealed Resident 3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 3's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 7/16/2010 revealed the facility staff assessed the following about the resident: -Resident 3 had short and long term memory problems. -Usually was able to make self understood and make others understand. -Required total dependence with bed mobility, transfers, dressing, toilet use and personal hygiene. -Had no pain indicators. -Did not have any pressure ulcers. -Had pressure reliving devices in bed and chair. Record review of Resident 3 Comprehensive Care Plan dated 11/16/2009 and revised on 5/06/2010 revealed Resident 3 was to use a Hoyer (mechanical lift) for all transfers. Observation on 9/22/2010 at 6:33 AM with Licensed Practical Nurse (LPN)F in attendance revealed Nursing Assistant (NA) D and NA E completed personal cares. NA E obtained a Hoyer sling (device that is placed under a resident and connected to the Hoyer) and placed it under Resident 3. NA D began to lift the resident and observations at this time revealed 1 of 2 layers of the sling cloth had a hole. LPN F instructed the NA's to place Resident 3 into the bed and LPN F obtained another sling. NA D and NA E applied the sling and transferred Resident 3 into the wheel chair. The Hoyer lift brakes were not lock before lifting the resident or placing the resident i… | 2014-01-01 | ||
| 12973 | 12973 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2010-09-23 | 309 | D | ZEZV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B2 Based on observation, record review and interview; the facility staff failed to re-evaluate interventions for pain management for 1 (Resident 3) and failed to implement the facility protocol for bowel care for 1 (Resident 11) of 12 sampled and 9 non-sampled residents. The facility staff identified a census of 45. Findings are: A. Record review of an information sheet dated 6/25/2010 revealed Resident 3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 3's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 7/16/2010 revealed the facility staff assessed the following about the resident: -Resident 3 had short and long term memory problems. -Usually was able to make self understood and make others understand. -Required total dependence with bed mobility, transfers, dressing, toilet use and personal hygiene. -Had no pain indicators. -Did not have any pressure ulcers. -Had pressure reliving devices in bed and chair. Record review of an Pain Assessment form dated 6/24/2010 revealed Resident 3 was was " currently in pain", was "at risk for pain" and had experienced "pain in the past". The assessment further identified that Resident 3 had "aggression" when painful and could hit or bite. Record review of Resident 3's Comprehensive care Plan (CCP) dated 11/16/2009 and revised on 5/06.2010 revealed that Resident 3 had the potential for pain. The goal was the Resident 3 would have "adequate levels of comfort. Interventions identified included "administer pain med (medications) as prescribe" and "assess pain every day use the cognitive impaired pain assessment tool and observer non-verbal pain expressions when doing cares and transfers. Observation on 9/22/2010 at 6:33 AM with Licensed Practical Nurse (LPN) F of personal cares and transfer for Resident 3 revealed Nursing Assistant (NA) … | 2014-01-01 | ||
| 12972 | 12972 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2010-09-23 | 225 | E | ZEZV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 12-006.02(8) Based on record review and interview; the facility staff failed to investigate and report allegations of staff to resident mistreatment for [REDACTED]. The sample size was 12 plus 9 non sampled. The facility census at the time of survey was 45. Findings are: A. Record review of the Facility Abuse Policies and Procedures dated 12/09 revealed that employees are required to report and occurrences of potential mistreatment or alleged abuse they observe, hear about, or suspect to the Administrator, Director of Nursing, or Social Services Director immediately. It will be the responsibility of the Administrator to report every instance of alleged resident abuse to the Nebraska Department of Health and Human Services immediately. Record review of Resident 8's Admission Face Sheet dated 7/28/10 revealed [DIAGNOSES REDACTED]. Record review of a Physicians Progress Note dated 9/7/09 revealed a note from Resident 8's Physician that read: "Pt also complained (gender) had broken ribs from being thrown in the bed." The progress note and the accompanying physician order [REDACTED]. Record review of the facility investigation files since 9/1/09 revealed that there was no evidence the allegation of mistreatment for [REDACTED]. Interview on 9/22/10 at 12:10 PM with the Director of Nursing (DON) confirmed that the Facility Administrative Staff were not aware of this allegation and did not investigate or send in a completed investigation to the required State Investigation Agencies. The DON stated that the facility staff should have contacted the DON with this allegation so that an investigation could be done and a report sent to the required state agencies. B. B. Resident 15 had been admitted [DATE] and discharged [DATE]. According to the [DIAGNOSES REDACTED]. Review of Resident 15 ' s nurse notes revealed an entry dated 2/23/10 at 2300 -"While CNA (certified nurse aide) was providing cares to patient, accidentally pulled… | 2014-01-01 | ||
| 12971 | 12971 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2010-09-23 | 253 | E | ZEZV11 | LICENSURE REFERENCE NUMBER 12-006.18A(1) Based on observation and interview; the facility staff failed to provide housekeeping and maintenance services to ensure the cleanliness and condition of walls, floors, ventilation systems, ceilings, call cords and doors in 8 of 30 occupied resident rooms (resident rooms 203, 204, 206, 209, 211, 218, 229 and 232) and resident use areas of the facility ( 2nd floor small dining room and 2 of 2 bathhouses on 2nd floor). The facility census at the time of survey was 45. Findings are: Observation on 9/21/10 between 8:10 AM and 9:10 AM with the facility Maintenance Director (MD), the facility Administrator (ADAM) and the Environmental Supervisor (ES) revealed the following concerns in resident rooms, resident dining areas and bathhouses in the facility: - Gouged areas in resident room walls (rooms 209 and 218). - Floors and grout soiled with wax and dirt buildup ( 2 of 2 2nd floor bathhouses and 2nd floor small dining area). - Dust coated resident ventilation exhaust systems in resident bathrooms (rooms 204 and 206). - Water damaged ceiling tiles (room 203 and the east 2nd floor bathhouse). - Stained call cords in resident bathrooms (rooms 211, 229 and 232). - Gouged areas in wooden resident bathroom door in room 206. Interview on 9/21/10 at 9:10 AM with the MD confirmed the above areas of concern and confirmed that the facility had not addressed those specific areas of concern prior to the environmental tour on 9/21/10. | 2014-01-01 | ||
| 12970 | 12970 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2010-09-23 | 167 | C | ZEZV11 | LICENSURE REFERENCE NUMBER 12.006.05(11) Based on record review and interview; the facility staff failed to include deficiency statements that resulted from past complaint investigations in the most recent survey book to ensure that these were made available for examination by residents. This had the potential to effect all residents that resided in the facility. The facility census was 45. Findings are: Record review of the book containing the results of the most recent survey of the facility conducted by the State surveyors revealed that the book did not contain statements of deficiencies which resulted from past substantiated complaint investigations which were conducted in the facility on 1/28/10 and 7/15/10. Interview on 9/20/10 at 4:40 PM with the facility Administrator confirmed that the survey result book did not contain the statements of deficiencies which resulted from past substantiated complaint investigations which were conducted in the facility on 1/28/10 and 7/15/10. | 2014-01-01 | ||
| 12969 | 12969 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2010-09-23 | 492 | B | ZEZV11 | Based on record review and interview; the facility staff failed to complete the demand billing process to ensure that the resident or the responsible party were offered the choice whether or not to request a standard claim appeal (Demand Bill) be submitted to Medicare for 3 ( Residents 11,17 and 19) of 4 resident files reviewed. The resident sample size was 12 plus 9 non-sampled residents from a facility census of 45. Findings are: Record review of 3 ( Residents 11, 17 and 19) of 4 Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) notification letters revealed that the choice boxes under Option 1 and Option 2 had been left blank. This indicated that the resident or responsible party had not made a decision as to whether or not to request an Intermediary Review for a Medicare decision. Interview on 9/22/10 at 8:30 AM with the Business Office Manager (BOM) confirmed that the boxes had been left blank. The BOM confirmed that no follow-up was completed with the residents or the responsible party to ensure that they were aware of the right to request an Intermediary decision. The BOM stated that when the letters are returned by the families or resident they come directly to the facility Business Office and are filed. The BOM confirmed that the letters for Residents 11, 17 and 19 were not reviewed to ensure that a choice had been documented in regards to the request for an Intermediary decision. Record review of a Policy and Procedure for Resident Demand Billing dated 05/06/08 revealed that after receipt of the signed SNFABN, the Buisness Services Coordinator would review with the beneficiary and/or responsible parties the option selected. Interview on 9/22/10 at 8:30 AM with the BOM confirmed that this was not done for Residents 11,17 and 19. | 2014-01-01 | ||
| 12968 | 12968 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2011-09-19 | 323 | D | CK8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D7 Based on record review and interviews, the facility failed to implement interventions when resident assessed was at risk for wandering and failed to implement interventions when the resident could not be located in the building for 1 resident (Resident 5). Sample size was 6. Facility Census was 42. Findings are: A. Review of Resident 5's medical record revealed the resident had a court appointed guardian and the following Diagnosis: [REDACTED]. ? Cognitive Deficiency ? Alcohol dependency remission ? Drug dependence ? Muscular wasting ? Lack of coordination ? Muscle weakness Review of facility report regarding Resident 5 ' s elopement revealed on 5/31/2011, Resident 5 was seen by the Social Worker standing by the elevator. Resident 5 stated (gender) was going out to get an ID (identification). The Social Worker directed the resident to call Resident 5 ' s legal guardian for permission and not to leave without telling the staff. The Social Worker was notified at 1:30 PM that Resident 5 had not eaten lunch and could not be located. Interview on 9/19/2011 with the Social Worker revealed when notified of Resident 5 missing, a search was completed of the building and grounds and Resident 5 could not be located. The guardian was called and was not aware of the resident ' s location. No further search was completed at that time. At 4:00 PM Resident 5 had not returned and a call was placed to the guardian and the decision was made to discharge the resident AMA (against medical advice) without knowing where the resident was. Review of the facility policy entitled " Elopement Policy " and dated 7/18/2011 revealed the following interventions in the case of a missing resident: ? Immediate action shall be taken by staff to locate the missing resident. ? Appropriate supervisors and other authorities shall be notified if resident is not located within 30 minutes. ? Police will be notified within 45 minutes. Int… | 2014-01-01 | ||
| 12967 | 12967 | HILLTOP ESTATES | 285163 | P O BOX 429, 2520 AVENUE M | GOTHENBURG | NE | 69138 | 2010-09-21 | 241 | E | KFGS11 | Licensure Reference: 175 NAC 12-006.05(21) Based on observation, and interview, the facility failed to ensure resident dignity was maintained by staff knocking and waiting for a response and answering call lights in a timely manner to enable a resident to remain continent, avoiding personal embarrassment. This failure to ensure resident dignity had the potential to affect 25 of 56 residents. A. Observation of three hallways from the nurses' station on 9/21/2010 from 9:50AM to 12:00Noon revealed the following: -9:50AM LPN-A entered second door on right in the 300 hall with a med cup in hand, door open, knocked as walked through into the room -10:02AM LPN-B observed entering the last room on the left in the 300 hall, door was open, no knock or announcement -10:07AM Two aides observed entering the first door on the right in the 100 hall, no knock or announcement -10:15AM NA-C entered the 3rd room on the right of the 300 hall with a sit to stand lift, no knock or announcement -10:20AM LPN-B entered the 1st room on the right of the 300 hall, door open, knocked as walking through into the room -10:42AM NA-E entered the 4th room on the left of the 300 hall, no knock or announcement -10:50AM NA-E entered the second to the last room on the left of the 100 hall, no knock or announcement -10:50AM LPN-A pushed a lift through the doorway of the second door on the right of the 100 hall, the lift was half in and half out of the doorway, and the LPN was standing by the lift chatting with another staff member -10:52AM NA-D entered the 4th door on the right of the 300 hall, no knock or announcement -10:55AM NA-F and NA-E entered the 4th room on the left of the 100 hall with a lift, no knock or announcement -11:40AM NA-E entered the first room on the right of the 300 hall with a lift, no knock, asking "You ready?" -11:44AM NA-C entered the last room on the left of the 300 hall with a lift, no knock or announcement. NA-F followed NA-C and the lift into the room and knocked as walked through the doorway. B. During an interview on 9/2… | 2014-01-01 | ||
| 12966 | 12966 | CRESTVIEW CARE CENTER | 285132 | 1100 WEST 1ST STREET | MILFORD | NE | 68405 | 2010-07-14 | 318 | D | 5S8Y11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D4 Based on record review and interview, the facility failed to ensure that 1 resident (Resident 3) was provided restorative services in accordance with the resident's individualized restorative program. The facility census at the time of survey was 41 residents. The sample size was 11 sampled residents with an additional 6 residents selected for non-sampled review. Findings are: A review of Resident 3's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 4/1/2010, revealed that the resident had a limitation in range of motion on one side of the body in the arm (including shoulder or elbow) and in the leg (including hip or knee). A review of Resident 3's NURSING REHAB/RESTORATIVE PROGRAM revealed that the resident was to receive restorative exercises three times weekly, consisting of UE (upper extremity) therapeutic exercises to maintain ROM (range of motion - the normal range of movements of the joints) to prevent discomfort; and was to ambulate 150 ft three times weekly and perform NuStep exercises to maintain LE (lower extremity strength). A review of Resident 3's NURSING REHAB/RESTORATIVE PROGRAM dated 6/2010, revealed that the resident received: - The week of 6/6/2010 - 6/12/2010 - exercises on 6/7 and 6/10. - The week of 6/13/2010 - 6/19/2010 - exercises on 6/14 and 6/18. - The week of 6/20/2010 - 6/26/2010 - exercises on 6/21 and 6/24. A review of Section III of the form (Resident's response and progress toward goals) revealed no documentation regarding why Resident 3 did not receive the restorative program three times weekly as the program was written. Interview with Restorative Aide (RA) C on 7/13/2010 at 9:50AM, confirmed that Resident 3 was supposed to receive restorative exercises three times weekly. RA C stated, "maybe it got documented somewhere else or maybe it got missed, I'm not sure". Interview with the facility ADON on 7/14/2010 at 12:10PM, revealed that the ADON was also the facility Restorative Coo… | 2014-01-01 | ||
| 12965 | 12965 | CRESTVIEW CARE CENTER | 285132 | 1100 WEST 1ST STREET | MILFORD | NE | 68405 | 2010-07-14 | 431 | D | 5S8Y11 | Licensure Reference Number: 175 NAC 12-006.12E5 Based on observation and staff interview; the facility failed to store medications requiring different routes of administration separately (from other routes) for 2 (Resident 16 and 17) residents. Facility census was 41. Sample size was 11 plus 6 non-sampled residents. Findings are: During a random audit for storage of medications and supplies in the medication carts the following was revealed: A. Resident 16 had three medications stored in one container without dividers. One medication is taken oral (by mouth) and two medications are instilled (eye drops) into the eyes. -Slow-Delay ER 64mg (milligrams) Tab (tablet) Slow Mag 3 tabs (192mg) by mouth every morning with breakfast (Do not crush or chew) Bulk; -Temolo opth (ophthalmic) 0.5% drops Timoptic Instill 1 drop in each eye daily; -Tranatan 0.004% drop Instill 1 drop in each eye at bedtime. B. Resident 17 had three medications stored in one container without dividers between medications administered by different routes (oral and inhalation). One medication given by mouth, one medication given by nebulizer four times a day and "as needed basis" and one medication given by nebulizer twice a day. -Boniva 150mg tab Take one tab by mouth every month w/8oz (with 8 ounces) of H2O (water) 60 minutes before food/med (medication) Bev (beverage). Stay upright; -Albuterol 0.5ml (milliliter) solution Mix 0.5ml (with) ipratropium via nebulizer four times daily Mix 0.5ml (with) ipratropium via nebulizer as needed; -Budesonide Inhalation Suspension 0.25mg/2ml Inhale 2ml (0.25mg) via nebulizer twice daily Rinse mouth after use. Interview with LPN Q on 07/13/10 at 10:30AM at the Medication Cart revealed: This shelf provided storage of medications that were not "bubble packed" (specific plastic wrapping of pills). Medications belonging to one resident were stored into one section/cube. Medications were not separated from each other according to routes (oral/swallow, inhaled, instilled/drops, from topical and/or sublingual/under the… | 2014-01-01 | ||
| 12964 | 12964 | CRESTVIEW CARE CENTER | 285132 | 1100 WEST 1ST STREET | MILFORD | NE | 68405 | 2010-07-14 | 280 | E | 5S8Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on observation, review of resident records and interviews; the facility failed to review and revise the comprehensive care plan to meet current needs with measurable goals for 4 (Residents 6, 10, 9 and 3) residents. The facility census was 41. The sample size was 11 plus 6 non-sampled residents. Findings are: A. Review of the Admission Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 02/19/2001 for Resident 6 revealed: -No nutritional problems, no weight change in the past 30 to 180 days; -Nutritional approaches: provide a therapeutic diet and is on a planned weight change program. Review of the RAP (Resident Assessment Protocol Summary) dated 03/03/2010 for Resident 6 revealed: -Therapeutic Diet of reduced concentrated sweets for DM (diabetes mellitus). Intakes is 88-100% and receives an HS (bedtime) snack. Review on 07/14/2010 of Physician Orders, dated 06/22/2010 revealed: -"...restrict fluids (with) 48ounces daily". Review of the MAR (Medication Administration Record) July/2010 revealed: -06/22/10 "restricted fluids to 48oz (ounces) (1440cc/cubic centimeters) daily. Review of the NURSE'S NOTES for Resident 6 revealed: -06/22/10 "...new orders noted....dietary notified of fluid restriction. (water) pitcher removed from room. Resident aware of all new orders..."; -06/24/10 "....continue on fluid restriction.."; -06/27/10 "...1:1 (with) resident about fluid restriction. Educated on intake....not having cups/water in room...Resident voiced understanding of restrictions. Aware of heart (diagnosis) and importance of being compliant (with) fluid restriction of 1440cc. Resident requesting to review ...intake log and inform nurse on where...would like to (decrease) fluids. Copy given to the dietary manager"; -06/28/10 "...agreed to prior fluid restriction sheet"; -06/29/10 "..requesting glass of (water) 1:1 (with resident)..fluid restrictio… | 2014-01-01 | ||
| 12963 | 12963 | CRESTVIEW CARE CENTER | 285132 | 1100 WEST 1ST STREET | MILFORD | NE | 68405 | 2010-07-14 | 312 | E | 5S8Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(3) Based on observation, record review and interview, the facility failed to provide complete pericare for 3 residents (Residents 3, 4 and 5). The facility census at the time of survey was 41 residents. The sample size was 11 sampled residents with an additional 6 residents selected for non-sampled review. Findings are: A. A review of Resident 3's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 4/1/2010; revealed that the resident: - Required extensive assistance of two staff with toileting; - Required total assistance of two staff with personal hygiene issues; AND - Was occasionally incontinent of bladder (two or more times a week, but not daily). A review of Resident 3's RESIDENT CARE PLAN (7/6/2010); revealed that when Resident 3 is acutely ill or lethargic, two staff members are required for transfers and toileting. Observation of pericare for Resident 3 on 7/13/2010 at 11:45AM, revealed Nursing Assistant (NA) D and NA E in the resident's room standing by the resident who was lying on the bed. A gait belt was applied around the resident's waist and the resident's shoes were put on. Both staff members assisted Resident 3 to a sitting position on the side of the bed. Resident 3 was then assisted to a standing position, the resident's pants were pulled down and the resident was assisted onto a bedside commode by both staff members. Both staff members had gloves on prior to getting the resident out of bed. NA D was on the left side of the resident and NA E was on the right side. They assisted Resident 3 to a standing position by cueing the resident using a walker and a gait belt. NA D took 1 premoistened wipe out of the package that was lying on the Resident's bed and proceeded to wipe the underside of Resident 3's panniculus and groin on each side, without turning the wipe. NA D then folded the wipe in half and made one swipe from the front… | 2014-01-01 | ||
| 12962 | 12962 | CRESTVIEW CARE CENTER | 285132 | 1100 WEST 1ST STREET | MILFORD | NE | 68405 | 2010-07-14 | 282 | D | 5S8Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on observation, record review and interview; the facility failed to implement and follow the care plan interventions for 2 residents (Residents 5 and 3). The facility census at the time of the survey was 41 residents. The sample size was 11 residents with 6 non-sampled residents. Findings are: A. A record review of Resident 5's RESIDENT CARE PLAN dated 5/17/2010 revealed; -- the resident is to have the call light within reach and -- the resident is to have the Prafo Boot on the right leg while sleeping. Approach start date for both of these approaches was 2/16/2010. -- the resident is to wear the right hand splint per Occupational therapy schedule with the approach date of 10/7/2009. A record review of Resident 5's PHYSICIAN ORDERS [REDACTED]. --the resident is to have Prafo boot to the right leg while in bed and use the kick stand to position the foot in neutral position and --the resident is to have Splint to right hand on at 9:00AM for 2 hours and on at 2:00PM for 2 hours. Observation of Resident 5 on 7/12/2010 at 10:00AM and 7/13/2010 at 10:45AM revealed; the resident had no right hand splint on at this time. Observation of Resident 5 on 7/13/2010 at 5:00PM and on 7/14/2010 at 11:50AM revealed; the resident had the right hand splint still on the right hand. Observation of Resident 5 on 7/12/2010 at 10:00AM and on 7/13/2010 at 8:47AM and 9:20AM revealed; the resident in bed with no Prafo boot on right leg. Observation of Resident 5 on 7/13/2010 at 8:47AM, 9:20AM, 12:35PM, and 1:00PM revealed; the resident did not have the call light within reach. The resident self-transferred from the wheelchair to the bed on 7/13/2010 at 8:47AM and on 7/14/2010 at 8:43AM. Interview with ASSISTANT DIRECTOR OF NURSING on 7//14/2010 at 10:50AM revealed; the resident is always suppose to have the call light within reach and this is care planned. Resident 5 has a history of falls. Resident 5 is suppose to hav… | 2014-01-01 | ||
| 12961 | 12961 | CRESTVIEW CARE CENTER | 285132 | 1100 WEST 1ST STREET | MILFORD | NE | 68405 | 2010-07-14 | 281 | E | 5S8Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview; the facility failed: to 1) provide medications according to the physician's order for 1 resident (Resident 12); 2) to provide eye medications in accordance with standards of practice for 1 resident (Resident 3); and 3) to provide 1 resident (Resident 5) with Prafo boots and splints according to physician's orders. The facility census at the time of survey was 41 residents. The sample size was 11 sampled residents, with 6 additional residents selected for non-sampled review. Findings are: LICENSURE REFERENCE NUMBER 175 NAC 12-006.10 A. Observation of Medication Administration by the facility Interim Director of Nursing (DON) on 7/12/2010 at 8:12AM; revealed that after checking the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The DON took the cup to the table, and after giving the resident oral medications on a spoon, stirred the cup with the [MEDICATION NAME] powder in it. After stirring, the DON handed the resident the cup with the [MEDICATION NAME]. The resident promptly drank the mixture. The DON then turned away from the resident and left the table to return to the medication cart. The resident was not observed drinking other fluids and the DON did not offer any additional fluids to the resident at the time. Observation of Medication Administration by Registered Nurse (RN) A on 7/13/2010 at 8:25AM; revealed that RN A measured Miramax and poured it into a plastic cup on the Medication Cart. RN A then added water so that the cup was approximately 3/4 full. RN A stirred the mixture and then proceeded to the table where Resident 12 was sitting. RN A handed the resident the cup and the resident immediately drank the [MEDICATION NAME]/water mixture. After watching the resident swallow the liquid, RN A left the table and returned to the medication cart. RN A was not observed offering the resident additional fluids or encouraging the resident to drink addit… | 2014-01-01 | ||
| 12960 | 12960 | CRESTVIEW CARE CENTER | 285132 | 1100 WEST 1ST STREET | MILFORD | NE | 68405 | 2010-07-14 | 246 | D | 5S8Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B1 Based on observation, record review, and interview; the facility failed to ensure that the call light was within reach for 1 resident (Resident 5). The facility census at the time of survey was 41 residents. The sample size was 11 sampled residents with 6 non-sampled residents. Findings are: A review of Resident 5's DAILY CARE PLAN dated 5/25/2010 revealed to keep the call light within reach. The Care Plan also revealed assistance of staff to transfer Resident 5 from the wheelchair to the bed and assistance from the bed to the wheelchair. A review of Resident 5's TRANSFER AND BED MOBILITY STATUS TOOL assessment dated [DATE] revealed; Extensive assistance for transfers; able to participate in part of the activity. Able to bear some weight for periods of time but needs weight bearing or balance assistance. Observation on 7/13/2010 at 8:47AM revealed the Resident 5 in the wheelchair in room at bedside with call light cord not within reach. Call light cord against wall behind bed. Resident 5 states "I want to go to bed" and self-transferred from the wheelchair to the bed. Resident 5 had chair alarm that was sounding while transferring. Interview on 7/13/2010 at 9:20AM with Nursing Assistant (NA) A revealed the call light was at foot of the bed where Resident 5 could not reach it. Resident 5 was lying in the bed at this time with eyes closed. NA A stated, "The call light should be where Resident 5 can reach it not down at the foot of the bed." Observation on 7/13/2010 at 12:35PM revealed the call light by wall not within reach. Resident 5 not in room at this time. Observation on 7/13/2010 at 1:00PM revealed Resident 5 in the room and the call light on the opposite side of the bed against the wall and not within reach for resident. Observation on 7/14/2010 at 8:43AM revealed Resident 5 in the room and call light not within reach on opposite side of bed against the wall. Resident 5 self-transferred from… | 2014-01-01 | ||
| 12959 | 12959 | CRESTVIEW CARE CENTER | 285132 | 1100 WEST 1ST STREET | MILFORD | NE | 68405 | 2010-07-14 | 363 | F | 5S8Y11 | LICENSURE REFERENCE 175 NAC 12-006.11A1 Based on observation, record review, and interview; the facility failed to ensure that correct serving sizes of foods were offered to residents. Facility census was 41. Sample size was 11 with 6 additional non sampled residents. Findings are: An observation on 7/12/10 at 12:45pm out revealed that the lunch menu included Salisbury steak in gravy, mashed potatoes and gravy, cooked broccoli, dinner roll and '7 Up' cake. Further observation revealed that residents with puree diet orders were served a #16 scoop (1/4 cup) of pureed Salisbury steak and a #16 scoop (1/4 cup) of pureed broccoli. Residents with regular diet orders were served one Salisbury steak cooked within a gravy sauce. No extra gravy was observed to be added to the Salisbury steaks as served. Upon request, Cook X used the facility scale and weighed a salibury steak coated with the gravy sauce it was cooked with, as served to the residents. Cook X confirmed the observed weight was slightly above 2 ounces. A review of the facility recipe for Salisbury steak puree revealed that the serving size was #10 scoop (2/5 cup). A review of the menu card revealed the serving size for broccoli residents receiving pureed foods was 1/2 cup (#8 scoop) and the serving size for Salisbury steak with gravy was 3 ounces. An observation on 7/13/10 at 12:30pm revealed that baked beef brisket was one of the lunch menu offerings. Further observation revealed that residents with puree diet orders were served a #12 (1/3 cup) scoop of pureed baked beef brisket and a #8 (1/2 cup) scoop of mashed potatoes. No gravy was available for the beef or potatoes. A review of the menu card revealed pureed baked beef brisket serving size was 4 ounces (1/2 cup) and that 2 ounces of gravy was to be served with the pureed food offerings. An interview with the Dietary Manager on 7/12/10 at 3:40pm revealed that the cooks who served meals were expected to follow the serving sizes indicated on the recipe or on the menu card. The Dietary manager stated that the… | 2014-01-01 | ||
| 12958 | 12958 | CRESTVIEW CARE CENTER | 285132 | 1100 WEST 1ST STREET | MILFORD | NE | 68405 | 2010-07-14 | 365 | E | 5S8Y11 | LICENSURE REFERENCE 175 NAC 12-006.11A2 Based on observation and interview, the facility failed to ensure that pureed foods were of an appropriate consistency for 5 residents who received pureed foods (Residents 3, 8, 9, 14, 15). Facility census was 41. Sample size was 11 with 6 non sampled residents. Findings are: An interview with Cook X on 7/12/10 at 8:00am revealed that pureed foods were prepared at each meal for 5 residents and indicated that the list of those residents was on the bulletin board in the kitchen. An observation of the list at that time revealed that Resident 3, 8, 9, 14 and 15 were to receive pureed food items. An observation of the noon meal serve out on 7/12/10 at 12:24 revealed that Cook X took a pan of pureed Salisbury steak out of the oven and sat it out on the counter by the serving window. Cook X removed the foil cover from the pan, stirred the contents with a scoop and stated "it got a little scorched on the bottom". The appearance of the pureed Salisbury steak at that time was dry with dry scorched pieces mixed in. A taste test of the pureed Salisbury steak with the Dietary Manager on 7/12/10 at 12:55pm confirmed that the finished product appeared to be scorched on the bottom, was dry in mouth and that it should not have been served. An observation of the noon meal serve out on 7/13/10 at 12:30pm revealed that pureed baked beef brisket had been prepared for residents who received pureed foods. Cook W placed a serving of the pureed beef on a plate for Resident 9. No gravy or broth was added to the serving. Further observations revealed that no gravy or broth was added to the pureed beef servings for any residents receiving pureed beef. A taste test of the pureed baked beef brisket on 7/13/10 at 12:50pm with Cook W revealed that the beef was dry and not of a moist, smooth consistency. Cook W confirmed at that time that no gravy had been made for lunch and stated "I should have put some broth on that, it is a little dry". An interview with the Dietary Manager on 7/14/10 at 2:30pm indicat… | 2014-01-01 | ||
| 12957 | 12957 | CRESTVIEW CARE CENTER | 285132 | 1100 WEST 1ST STREET | MILFORD | NE | 68405 | 2010-07-14 | 371 | F | 5S8Y11 | LICENSURE REFERENCE 175 NAC 12.006.11E Based on observation, interview, and record review; the facility failed to ensure that cooked ready to eat foods were stored in a manner to protect from potential contamination, sanitizer was used according to manufacturers direction, scoops were clean and free from dried food debris before use, foods were held for serving at required temperatures, food thermometers were accurate, gloves were used according to standards, and that ready to eat foods were not handled with bare hands. These deficient practices had the potential to affect all residents. Facility census was 41. Sample size was 11 with 6 additional non sampled residents. Findings are: A. An observation during an initial tour of the kitchen on 7/12/10 at 6:20am revealed that a reach in cooler was in use in the back hallway of the kitchen. The cooler contained a variety cooked and raw food items. Further observation revealed that the middle shelf of the cooler held 2 approximately 10 pound raw beef briskets. A cooked apple pie was on the same shelf as the raw briskets. An interview with Cook W at that time indicated that the pie had been placed by the raw meat by the previous shift kitchen. An interview with the Dietary Manager on 7/13/10 at 2:00pm indicated expectations were that raw meats would be stored below ready to eat food products. 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 service sanitation practices, revealed the following:" 3-302.11 Food shall be protected from cross contamination by 1a) separating raw animal foods during storage from cooked ready to eat food.." B. An observation on 7/12/10 at 10:55am revealed that Dietary Aide (DA)Y had prepared a bucket of sanitizing solution for use in the kitchen. An interview with DA Y confirmed that the solution would be used to wipe down counters and tables in the kitchen and dining area. DA Y was observed to test the solution with a test strip… | 2014-01-01 | ||
| 12956 | 12956 | CRESTVIEW CARE CENTER | 285132 | 1100 WEST 1ST STREET | MILFORD | NE | 68405 | 2010-07-14 | 253 | E | 5S8Y11 | LICENSURE REFERENCE 175 NAC 12-006.18A Based on observation, interview and record review; the facility failed to ensure that 2 out of 4 observed shower chairs were free from visible soiling and foreign material and that 2 of 8 observed bathroom doors (rooms 101, 209) were in smooth, cleanable condition. Facility census was 41. Sample size was 11 with 6 additional non sampled residents. Findings are: A. Observations during a tour of the environment on 7/13/10 at 8:20am revealed that 2 of 8 observed wooden bathroom doors had numerous holes, chips and/or sheared ragged areas. (Rooms 101, 209) An interview with the Maintenance Supervisor on 7/14/10 at 2:50pm indicated that (staff) was unaware of the condition of the doors, and review of the maintenance work request book with the Maintenance Supervisor at that time confirmed that no request for repair had been documented. B. Observations of the shower chairs in the North Shower House on 7/13/10 at 11:35am revealed that 2 shower chairs had visible brownish pink soil and buildup on underside areas of the frame. An interview with Bath Aide Z on 7/13/10 at 11:45am confirmed that the undersides of the chairs needed to be re-cleaned. | 2014-01-01 | ||
| 12955 | 12955 | GOLDEN LIVINGCENTER - PLATTSMOUTH | 285104 | 602 SOUTH 18TH STREET | PLATTSMOUTH | NE | 68048 | 2010-09-02 | 312 | E | VQV011 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observations, interviews and record review; the facility failed to respond to call lights in a timeframe which would meet the needs of the residents' comfort and safety. Resident sample was 19 and the facility census was 85. Findings are: Group interview was held on 8/31/10 at 2:00pm. Eleven residents were in attendance and all of them actively participated. The residents have been told that the goal of the facility is for the staff to answer the call lights within 10 minutes of being turned on. The residents stated that they have been reporting that it is taking way to long to answer the call lights for three months. The facilities' response to this is that they are working on the system it will improve. Three out of the eleven residents present said that they have many times "wet them selves" because it took so long to answer the call lights. Two of the residents present said that they just start hollering when they can't wait any longer. The Resident Council minutes for the meetings held in January 2010, March 2010, June 2010, and August 2010 all revealed that call lights were not being answered in a timely manner, or not answered at all. The Grievance Tracking Log revealed on 4/6/10 a call light took twenty minutes to answer. On 4/15/10, a call light was not answered for 45 minutes. On 5/25/10, a resident reported to family that the call light was on all night long, and the next morning the family reported that the resident smelled strongly of urine. On 5/9/10, a resident complained that the call light was on for an hour and ten minutes. On 7/24/10, a call light was not answered for 45 minutes. On 8/2/10, a resident complained that the call light was on for 30-40 minutes. On 8/2/10, a resident complained that a call light was on for 15 minutes. On 8/8/10, a resident complained that a call light was on for 20 minutes. Review of Grievance Tracking Logs since January 2010 revealed that there were at least two complaints about call lights. The facility had … | 2014-01-01 | ||
| 12954 | 12954 | GOLDEN LIVINGCENTER - PLATTSMOUTH | 285104 | 602 SOUTH 18TH STREET | PLATTSMOUTH | NE | 68048 | 2010-09-02 | 467 | E | VQV011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-007.04D Based on observations, touring of the Advanced Alzheimer's Care Unit (AACU), and staff interviews; the facility failed to provide adequate outside ventilation as evidenced by a strong persistent urine odor throughout the main corridor, the dining area and the lounge area. Twenty residents resided on the AACU. Facility census was 85. Survey sample was 19. Findings: During initial tour of the secured AACU on 8/30/10 from 10:00am - 10:22am, upon entering the AACU from the dining room door area, a strong odor of urine was present in the dining area, the next area of the activity lounge and throughout the main corridor up to the exit door leading to the center nursing station. 20 residents resided on the alarm door secured AACU, with [DIAGNOSES REDACTED]. The urine odor was still present after the housekeeping had finished the daily cleaning routine at approximately 2:26pm. The lack of air movement and lack of fresh air quality contributed to a feeling of stale and close conditions. Upon entering the unit on 8/31/10, at 8:22am a strong persistent urine odor was again noted to be present throughout the corridor, lounge area and dining area. Little air movement was again identified during the tour. This same persistent lingering odor of urine was noted at 3:44pm on 8/31/10. Discussion with Executive Director on 9/1/10 1:28pm revealed that facility maintenance staff and contractors called in the morning of 9/1/10 to evaluate the source of the odor/ventilation issue, had found that a bearing on the roof top ventilation motor unit was worn/malfunctioning and would be replaced. Interview with Maintenance Director on 9/2/10 at revealed the ventilation motor capabilities were checked monthly during environmental audits by evaluating the individual bathroom outside exhaust ventilation systems with a paper pull test. | 2014-01-01 | ||
| 12953 | 12953 | GOLDEN LIVINGCENTER - PLATTSMOUTH | 285104 | 602 SOUTH 18TH STREET | PLATTSMOUTH | NE | 68048 | 2010-09-02 | 325 | D | VQV011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER NAC 175 12-006.09D8a Based on observation, interviews and record review; the facility failed to provide a therapeutic diet and nutritional care in accordance with resident's comprehensive needs and/or physician orders [REDACTED]. The facility census was 85. Findings include: A. Review of Resident 3's Admission Record dated 8/23/10 revealed that Resident 3 had the [DIAGNOSES REDACTED]. Review of Resident 3's MDS ( Minimum Data Set -a federally mandated comprehensive assessment tool used for care planning) revealed that Resident 3 was severely impaired with decision making, mood and behaviors were negative in nature, and Resident 3 needed extensive assistance with one person for activities of daily living. The staff providing cares with the use of two person assist because Resident 3 could be combative. Review of Physicians' orders dated 8/17/10 revealed that Resident 3 had an order for [REDACTED]. Review of a dietary Communication Form from Nursing dated 8/17/10 revealed that the nurses sent the Physicians order for the therapeutic diet to the dietary staff. Observations of the meals served to Resident 3 on 8/30/10 and 8/31/10 revealed that the meals served did not have fortified foods or sauces on them. Interview with the Dietary Manager and the Consulting Dietician on 9/1/10 at 4:00pm indicated that the fortified foods with the extras sauces were not being served. Review of a General Note written on 9/1/10 at 17:59 revealed that the resident had weight loss since admission. Weights may not be accurate because, when the resident was being combative, it made Resident 3 hard to weigh. The General Note indicated that Resident 3 had the special diet order on admission, and the diet was not being served. The General Note stated that the facility would ensure that Resident 3 received the diet which was ordered. Review of the Weight record for Resident 3 reveals that Resident 3 weighed 152 pounds on 8/17/10 and on 9/1/10 w… | 2014-01-01 | ||
| 12952 | 12952 | GOLDEN LIVINGCENTER - PLATTSMOUTH | 285104 | 602 SOUTH 18TH STREET | PLATTSMOUTH | NE | 68048 | 2010-09-02 | 318 | D | VQV011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D4 Based on observations, medical record review and staff interview; the facility failed to provide 2 of 19 sampled residents (Resident 5 and 9) with a program of restorative exercise/ambulation for a functional maintenance program to prevent further decrease in residents strength/mobility/abilities. Survey sample included 19 residents from facility census of 85. Findings include: A. Based on review of medical record for Resident 9, revealed admission to facility on 1/19/10 with [DIAGNOSES REDACTED]. Resident 9 had experienced falls according to the Unit Manager during initial tour on 8/30/10 at 10:11am, and resident was now wearing a latch type seat belt in wheelchair to keep resident from falling again or getting injured. Review of medical record change in condition report - post fall/trauma, and nursing note entries revealed resident experienced falls documented on 6/16/10, 7/18/10 and 8/1/10, when resident refused to utilize standard wheeled walker for ambulation. Resident received physical therapy with a plan for strengthening and balance exercises to improve gait and functional mobility while decreasing risk for falls on 6/23/10. On 8/3/10 a nursing note and signed authorization note from residents spouse stated "called (spouse name) and asked if possible to apply a lap seatbelt for unsteadiness." On 8/10/10 a nursing note entry recorded "resident... refusing walker, resisting cares... continues to wander... increase in falls noted...new intervention to include alarmed seat belt. Resident is able to unhook seat belt but not on command. Staff are following restraint protocol... has been noted as an overall decline..." Observation of Resident 9 revealed staff assisted Resident to both breakfast meal and noon meal on 8/31/10 in standard wheelchair with lap seat belt in place and Resident sat with kyphotic posture- of shoulders slumped forward and head down throughout the meals. Review of Comprehe… | 2014-01-01 | ||
| 12951 | 12951 | GOLDEN LIVINGCENTER - PLATTSMOUTH | 285104 | 602 SOUTH 18TH STREET | PLATTSMOUTH | NE | 68048 | 2010-09-02 | 157 | D | VQV011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and staff interview the facility failed to inform one Resident's (Resident 17) family of changes in medication and condition. The facility census was 85 and the sample was 19. Findings are: Resident 17 (a closed record) had the following [DIAGNOSES REDACTED]. Review of Resident 17's 1/3/10 MDS identified Resident 17 as having short and long term memory problems; moderately impaired with decision making; understood and understands; verbally abusive and socially inappropriate/disruptive; 53 inches tall and 154 pounds; frequently incontinent of bowel and occasionally incontinent of bladder; requires extensive one person assist for dressing and personal hygiene; two person extensive assistance for bed mobility, transfers and toilet use. Interview with the DON (Director of Nurses) on 9/2/10 at 10:30 AM revealed that "It is the expectation that the staff notify the family with an incident, change of condition or medication changes." Review of Resident 17's Nurses Notes from November 2009 through January 2010 revealed the following examples of changes for the resident and no family notification: -11/19/10 A urinalysis was ordered related to burning with urination and no family notification. -11/30/10 A new order for skin irritation medication and no family notification. -12/2/09 An antibiotic ordered for an infection in a lower leg laceration. -12/4/10 Lab results called to doctor and request for change in resident skin treatment, no family notification. -1214/10 A new antibiotic ordered and no family notification. -12/20/10 Resident transferred to the hospital for nausea and vomiting. No documentation of family noted. -1/8/10 Resident transferred to the hospital. Noted an attempt made to tell family despite several phone numbers including cell phones available on the Face Sheet to use to get ahold of the family in case of an emergency. | 2014-01-01 | ||
| 12950 | 12950 | GOLDEN LIVINGCENTER - PLATTSMOUTH | 285104 | 602 SOUTH 18TH STREET | PLATTSMOUTH | NE | 68048 | 2010-09-02 | 309 | D | VQV011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D3 (5) Based on record review and staff interview the facility failed to follow their Bowel Protocol to assure that 2 residents (Resident 7 and 8) received medication to promote bowel movements and function. The facility census was 85 and the sample was 19. Findings are: Review of the facility Bowel Protocol is if no BM (bowel movements) or a small BM in 9 shifts (3 days) to start: -Step 1 stated, "If residents doesn't have a BM in 9 shifts (per Caretracker (electronic charting) &/or resident interview give MOM (Milk of Magnesia 30 cc (cubic centimeters) po (per mouth) x (by) 1. If no results after 8 hours, go to Step 2." -Step 2 stated, "If no results from MOM, administer [MEDICATION NAME] 10 mg suppository rectally x 1. If no results in 4 hours go to Step 3." -Step 3 stated, "Give Fleets enema x 1. If no results notify Physician immediately." A. Resident 7 had the following [DIAGNOSES REDACTED]. Review of Resident 7's 6/20/10 MDS (Minimum Data Set- a federally mandated comprehensive assessment tool used for care planning.) identified Resident 7 as having short term memory problems; severely impaired with decision making; rarely understood and understands; 67 inches tall and 150 pounds; incontinent of bowel and bladder; requires extensive 2 person assist for bed mobility, transfers, toilet use and one person extensive assist with dressing, eating and personal hygiene. Review of Resident 7's "Resident Continence Log" revealed: -June 2010, the resident went 5 days without a BM from 6/7/10-6/11/10; 6/13/10-6/17/10; and 6/28/10-7/2/10. The MAR (Medication Administration Record) lacks evidence that the Bowel Protocol was followed and the medication administrated as per the Protocol. -July 2010, the resident went 5 days without a BM from 7/8/10-7/12/10; and 7/23/10-7/27/10. The MAR indicated [REDACTED]. -August 2010, the resident went 5 days without a BM from 8/4/10-8/8/10; and 8/27/10-8/31/10. The MAR i… | 2014-01-01 | ||
| 12949 | 12949 | GOLDEN LIVINGCENTER - PLATTSMOUTH | 285104 | 602 SOUTH 18TH STREET | PLATTSMOUTH | NE | 68048 | 2010-09-02 | 281 | D | VQV011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER NAC175 12-006.10 Based on observation, record review and staff interviews, the facility failed to provide medications as ordered by the physician on one of 19 sampled residents (Resident 20). The facility also provided medications which had been discontinued on one of 19 sampled residents (Resident 7). Facility census was 85. Findings are: Review of Resident 20s' Physical Examination dated 4/10/10 revealed that Resident 20 had the [DIAGNOSES REDACTED]. Observation on 8/31/10 at 9:05am revealed that the MA (Medication Aide) A pulled the bubble pack card for [MEDICATION NAME] which was in the medication cart for Resident 20. MA A double checked the [MEDICATION NAME] bubble pack with the MAR (Medication Administration Record) and asked RN (Registered Nurse) A to check the last doctors' order for the [MEDICATION NAME]. The [MEDICATION NAME] in the medication cart was [MEDICATION NAME] 40 mg (milligrams) to be given once daily every other day. The MAR indicated [REDACTED]. RN A told MA A that the last physician's orders [REDACTED]. The bubble pack of [MEDICATION NAME] 40mg was placed on the medication cart on 8/27/10 which, on the August MAR, would indicate that Resident 20 received one [MEDICATION NAME] 40mg tablet instead of [MEDICATION NAME] 20mg. RN B called the Pharmacy and told them that the Pharmacy had sent the wrong dose of [MEDICATION NAME]. MA A was instructed by the pharmacy to give Resident 20 the [MEDICATION NAME] 20mg dose out of the Emergency box. B. Resident 7 had the following [DIAGNOSES REDACTED]. Review of Resident 7's 6/20/10 MDS (Minimum Data Set- a federally mandated comprehensive assessment tool used for care planning.) identified Resident 7 as having short term memory problems; severely impaired with decision making; rarely understood and understands; 67 inches tall and 150 pounds; incontinent of bowel and bladder; requires extensive 2 person assist for bed mobility, transfers, toilet use and one… | 2014-01-01 | ||
| 12948 | 12948 | THE LODGE AT HERITAGE ESTATES | 285071 | 2325 LODGE DRIVE | GERING | NE | 69341 | 2010-09-02 | 514 | D | 2CM611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.16B (1) Based on record review and interviews, the facility failed to record fluid intake for monitoring 1 sampled resident (Resident 115) on a daily fluid restriction. Facility census was 97. Findings are: Interview with Resident 115 on 9/2/10 at 10:00 AM revealed that Resident 115 had been receiving [MEDICAL TREATMENT] treatments for several years and that Resident 115 was aware of being on a fluid restriction due to these treatments. Interviews with direct care staff working with and monitoring Resident 115's fluid restriction compliance revealed the following: - 9/1/10 at 4:00 PM- MA (Medication Aide)-A verified Resident 115 was on a fluid restriction. Takes maximum of 500 cc (cubic centimeters) on the evening shift. Staff members document intakes in the computer program or Treatment Administration Record (TAR). - 9/1/10 at 4:00 PM- NA (Nurse Aide)-B verified Resident 115 was on a fluid restriction of 1000 cc per day. This is broken down to 400 cc on day shift, 400 cc on evening shift, and 200 cc on night shift. Intakes are documented in the computer. -9/1/10 at 4:30 PM- LPN (Licensed Practical Nurse)-C verified Resident 115 was on a fluid restriction of 1000 cc per day. LPN-C stated that the restriction is divided up per shift and intake is recorded on the resident's TAR. Review of Resident 115's TAR for August of 2010 revealed an order for [REDACTED]. Documentation of intakes for these shifts revealed the form was left blank and intake amounts were not recorded on the evening shift for August 3rd, August 8th, August 15th, and August 27th. The night shift intake was not recorded on August 4th. Interview with the DON (Director of Nursing) on 9/2/10 at 1:50 PM verified that Resident 115's fluid restriction intake monitoring was being done in two different places, on the computer system and on the resident's TAR. The DON verified that the TAR intake was not recorded on 8/3; 8/4; 8/8; 8/15; and 8/27… | 2014-01-01 | ||
| 12947 | 12947 | THE LODGE AT HERITAGE ESTATES | 285071 | 2325 LODGE DRIVE | GERING | NE | 69341 | 2010-09-02 | 334 | D | 2CM611 | Based on interview and record review, the facility failed to document in the residents' medical record the required education prior to each influenza vaccination for 3 residents (Resident 71, 37, and 54). Facility census was 97. A. Record review of resident 71's INFORMED CONSENT FOR INFLUENZA VACCINE form revealed that Resident 71's representative had signed the form on 11/3/2008. The form contained the reasons to get vaccinated and a list of adverse effects. The resident's medical record contained information to show that the resident received the influenza vaccination in 10/2009 but did not contain an education form for the influenza season in 2009-2010. B. Record review of resident 37's INFORMED CONSENT FOR INFLUENZA VACCINE form revealed that Resident 37's representative had signed the form on 10/19/2007. The form contained the reasons to get vaccinated and a list of adverse effects. The resident's medical record contained information to show that the resident received the influenza vaccination in 10/2009 but did not contain an education form for the influenza season in 2009-2010. C. Record review of resident 54's INFORMED CONSENT FOR INFLUENZA VACCINE form revealed that Resident 54's representative had signed the form on 10/18/2007. The form contained the reasons to get vaccinated and a list of adverse effects. The resident's medical record contained information to show that the resident received the influenza vaccination in 10/2009 but did not contain an education form for the influenza season in 2009-2010. D. Interview on 8/31/10 at 1100 with LPN-H (Licensed Practical Nurse) revealed that the INFORMED CONSENT FOR INFLUENZA VACCINE education form was signed upon admission and then no other education was provided. E. Interview on 8/31/10 at 1120 with the Director of Nursing revealed that the facility provided influenza vaccination education annually but the facility was not documenting the education. | 2014-01-01 | ||
| 12946 | 12946 | THE LODGE AT HERITAGE ESTATES | 285071 | 2325 LODGE DRIVE | GERING | NE | 69341 | 2010-09-02 | 280 | E | 2CM611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C1c Based on observations, record reviews and staff interviews, the facility failed to updated the care plans to address care interventions after a shoulder injury for 1 sampled resident (Resident 7), to reduce the risk of recurrent skin injuries for 1 sampled resident (Resident 44), to address behaviors for 1 sampled resident (Resident 144), and dietary orders for 1 sampled resident (Resident 115). The facility census was 97. Findings are: A. Review of the "Interdisciplinary Progress Notes" for Resident 7, dated 6/14/10 at 7:00 PM, revealed that the resident was found on the floor and complained of right shoulder and arm discomfort. Further review revealed that on 6/15/10, an x-ray showed a fractured right humerus. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 7/1/10, revealed that the resident required extensive assistance with 1 person physical assist with dressing. Review of the "Care Plan", dated 7/8/10, revealed a problem "Requires minimal assist with ADLs (Activities of Daily Living), occasional forgetfulness. Further review revealed no care plan approaches to include the resident's need for extensive assistance with dressing after the right shoulder injury. Interview on 9/1/10 at 2:00 PM with RN (Registered Nurse) E, MDS Coordinator, confirmed that the care plan was not updated to reflect the resident's need for extensive assistance with dressing after the shoulder injury. B. Review of the "Interdisciplinary Progress Notes" for Resident 44, dated 7/23/10 at 12:30 AM, revealed that staff reported that the resident had a skin tear at the left hand from the call light clip. The skin tear measured 2 cm. (centimeters) by 4.5 cm. Further review revealed that the family requested that the call light be clipped to the bed instead of to the resident's clothing to prevent further skin tears. Review of the "Record of Inservice", d… | 2014-01-01 | ||
| 12945 | 12945 | THE LODGE AT HERITAGE ESTATES | 285071 | 2325 LODGE DRIVE | GERING | NE | 69341 | 2010-09-02 | 353 | E | 2CM611 | Based on observations and staff interview, the facility failed to post the resident census on the daily staff posting form. The facility census was 97. Findings are: Observations on 8/30/10 at 8:20 AM, on 8/31/10 at 7:30 AM, and on 9/1/10 at 7:30 AM revealed no resident census posted on the daily staffing form at the front lobby area. Interview on 9/2/10 at 12:30 PM with the DON (Director of Nursing) confirmed that the resident census was to be included on the daily staffing posting form. | 2014-01-01 | ||
| 12944 | 12944 | SUMNER PLACE | 285002 | 1750 SOUTH 20TH STREET | LINCOLN | NE | 68502 | 2010-09-07 | 323 | G | SCJJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview, the facility failed to safely secure 2 residents (Residents 1 and 2) during transport in the facility van from a resident sample size of 5. The facility census was 100. Findings are: A. Review of Resident 1's ER (Emergency) Injury Summary dated 8/10/10 revealed that the resident had sustained a fall with a C2 (2nd cervical vertebrae) type 3 fracture; and abrasions to the posterior scalp and left hand. Review of Resident 1's Spine Trauma Consult dated 8/10/10 revealed that the resident was in a van today and when the van moved forward, the resident's wheelchair fell backwards, and the resident struck (gender) head. The resident denied loss of consciousness. The resident complained of neck pain. The resident was able to shrug the resident's shoulders and elevate the resident's legs off the bed. The resident denied paresthesia (tingling sensation) in the resident's arms or legs. The C spine (Cervical spine) x-ray revealed an acute C2 type-3 fracture through the body with minimal displacement. The physician ordered a Miami J neck collar for the resident to wear. Review of Resident 1 Nurse's Notes on 8/10/10 at 4 PM revealed that the resident's wheelchair tipped over in the van and the resident was taken to the doctor's office. The resident was transported from the doctor's office to the hospital ER. Review of Resident 1's Annual MDS (Minimum Data Set: a federally mandated comprehensive care plan used for care planning) dated 6/20/10 revealed that the resident required limited assistance for transfers and ambulation. The resident was able to eat independently with set up assistance. The resident did not have range of motion limitations. Review of Resident 1's Significant Change MDS dated [DATE] revealed that the resident required extensive to total assistance with all activities of daily living including eating. The resident was non ambulatory. The resident had ot… | 2014-01-01 | ||
| 12943 | 12943 | VALLEY COUNTY HEALTH SYSTEM LONG TERM CARE | 2.8e+287 | 220 SOUTH 26TH STREET | ORD | NE | 68862 | 2010-10-20 | 223 | E | 4BJH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.05(9) The facility failed to implement interventions to protect female residents (Resident 2, 3 and 4) from potential sexual abuse from one resident (Resident 1 ). The facility census was 43. Sample size was 4. Findings are: This report identifies three separate events involving Resident 1 (male) making inappropriate physical contact with three different female residents (Resident 2, 3 and 4) on three different days within a two week period of time.. This report includes review of the events by review of written records, reports, interviews and observations and staff interviews. Review of the DAILY CARE GUIDE, September 2010 for Resident 1 revealed: Special Instructions/Approaches: "May attempt to touch female staff inappropriately. Be stern with (Resident 1) and tell (gender) that is not ACCEPTABLE and it is INAPPROPRIATE. Alarms on after supper due to this is when most falls occur. Identified within the Plan of Care, Resident 1 has [DIAGNOSES REDACTED]. Interview with the DON (Director of Nursing) and SSD (Social Service Designee) revealed: -Resident 1 does have a different type of alarm on the bed and chair to alert staff to activity putting him at risk for falls; -There is a laser alarm, that detects motion moving by, that will sound when anyone goes past it. This is to alert staff that Resident 1 is entering or leaving the room. * The Daily Care Guide does not identify the use of a laser alarm, its purpose or placement for effective notification of Resident 1's movement. The Daily Guide does not identify that Resident 1 may touch female residents inappropriately nor expected interventions that the staff should put into place. -Review of the CARE PLAN for Resident 1 shows written entry of additions to Problem 6 Behaviors that include:Approaches: 09/16/10 "[MEDICATION NAME] increased per recommendations of (physician) to help (with) sexually inappropriate behavior, 09/07/10 do not sit (Resident 1)… | 2014-02-01 | ||
| 12942 | 12942 | LANCASTER MANOR | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2010-10-27 | 332 | E | 78PJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.10D Based on observation and record review, the facility failed to have a medication error rate of less than 5%5 percent during onsite medication administration observations. A total of 40 medications were observed with 3 errors resulting in a 7.5 % error rate. The facility census was 239. Findings are: Observations during morning medication pass on 10/27/10 at 9:45 AM revealed Medication Aide (MA) A administer the following medications to Resident 3: [MEDICATION NAME] (laxative) 3 mg (milligrams) , [MEDICATION NAME] Sodium (stool softener) 100 mg , [MEDICATION NAME] (multivitamin) one tab, [MEDICATION NAME] (a steroid spray for allergies [REDACTED]. Review of Resident 3's October Routine Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The [MEDICATION NAME] and [MEDICATION NAME] were to be given at 0800 AM. Further Review of Resident 3's October Routine Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observations during morning medication pass on 10/27/10 at 10:00 AM revealed Medication Aide (MA) A administer the following medications to Resident 4: [MEDICATION NAME] (an antidepressant)150 mg and [MEDICATION NAME] 300 mg, [MEDICATION NAME] (an antipsychotic) 100 mg, [MEDICATION NAME] (to treat high cholesterol) 600 MG, [MEDICATION NAME] (an antidepressant) 20 mg, Vitamin D 1,000 units, [MEDICATION NAME] (to treat high blood pressure) 1 mg and Tylenol (for pain) 325 mg. Review of Resident 4's October Routine Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observations during noon medication pass on 10/27/10 at 12:30 PM revealed Medication Aide (MA) A administer the following medication to Resident 5: [MEDICATION NAME] (an antipsychotic) 4 mg. Review of Resident 5's October Routine Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the sa… | 2014-02-01 | ||
| 12941 | 12941 | RIDGECREST REHABILITATION CENTER | 285239 | 3110 SCOTT CIRCLE | OMAHA | NE | 68112 | 2010-10-19 | 281 | D | P1MV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12-006.09 Based on record review and interview, the facility failed to follow physician's order [REDACTED]. The facility had a total census of 61 residents. Findings are: Resident 2 was admitted to the facility on [DATE] according to admission information. Resident 2 ' s [DIAGNOSES REDACTED]. A review of Resident 2 ' s physician orders [REDACTED]. A notation on the telephone order form stated the lab test was due on 8/24/10. A review of Resident 2 ' s medical record did not reveal the results of the PT/INR lab test that was to be completed on 8/24/10. In interviews on 10/19/10 at 10:45 AM and 3:15 PM, the DON (Director of Nursing) confirmed the lab test was not completed and a lab requisition could not be located. | 2014-02-01 | ||
| 12940 | 12940 | FLORENCE HOME | 285173 | 7915 NORTH 30TH STREET | OMAHA | NE | 68112 | 2010-10-27 | 309 | D | VVU311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2 Based on record review and interview; the facility staff failed to follow up with a physician for wound care for 1 (Resident 1) of 6 sampled residents. The facility staff identified a census of 97. Findings are: Record review of an Profile Face Sheet dated 10/24/10 revealed Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 8/11/2010 revealed the facility staff assessed the following about the resident: -Resident 1 had short term memory problems, long term was ok. -Modified independence with decision making. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. -Ambulation did not occur. -Not able to stand without assistance. -Occasionally incontinent of bladder and was on a toileting plan. -Received range of motion from restorative program. Record review of a Physicians Orders sheet and Progress Notes dated 9/07/2010 revealed Resident 1's Physician had [DIAGNOSES REDACTED]. Record review of an Discharge Summary sheet dated 10/12/2010 revealed Resident 1 had been admitted to the hospital "... with pain in the right lower extremity and gangrenous ulcer at the great toe". Gender " was admitted for blood sugar management prior to undergoing a right lower extremity angiogram with scheduled surgery later on". Record review of a Discharge Order Sheet dated 10/12/2010 revealed Resident 1 was to have a follow up appointment for vascular surgery. Record review of Resident 1's record did not contain evidence that a follow up with vascular surgery had been completed for Resident 1. On 10/26/2010 at 11:10 AM an interview was conducted with Licensed Practical Nurse (LPN) A. During the interview LPN A confirmed the appointment for Resident 1 had n… | 2014-02-01 | ||
| 12939 | 12939 | FLORENCE HOME | 285173 | 7915 NORTH 30TH STREET | OMAHA | NE | 68112 | 2010-10-27 | 323 | D | VVU311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER, 175 NAC 12-006.09D7 Based on observation, record review and interview; the facility staff failed to implement interventions to prevent bruises and falls for 2 (Resident 3 and 5) of 6 sampled residents. The facility staff identified a census of 97. Findings are: A. Record review of an Profile Face Sheet dated 8/18/2010 revealed Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of resident 3's Comprehensive Care Plan (CCP) dated 1/28/2010 revealed Resident 3 had fall identified on the care plan as 5/25/2009/ 06/09/2009, 6/18/2009/ 7/30/2009 and 1/28/2010. The goal section of the CCP identified "...will have no falls, no fall related fracture or soft tissue damage". Intervention listed on the CCP included "I have a sit/stand alarm on when in bed for my safety and one in my w/c (wheelchair)". Observation on 10/26/2010 at 8:20 AM, 9:00 AM and 9:50 AM revealed Resident 3 was in the wheelchair without a sit/stand alarm attached. An interview was conducted with Licensed Practical Nurse (LPN) B on 10/26/2010 at 9:55 AM. LPN B was asked to observe if Resident 3 had the sit/stand attached. LPN B confirmed Resident 3 did not have the alarm attached. LPN B stated "yes, she is to have that on at all times". B. Record review of Resident 3's Interdisciplinary Notes (IPN) dated 8/01/2010 revealed Resident 3 was noted to have multi bruising on the arms and legs. According to the IPN's the bruises were in " multiple stages of healing". Record review of a facility investigation revealed Resident 3 had " increased agitation and combativeness" behaviors as a possible cause of the bruising. Further review of the investigation did not include additional interventions in an attempt to prevent bruising. C. Record review of a Profile Face Sheet dated 8/18/2010 revealed Resident 5 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED… | 2014-02-01 | ||
| 12938 | 12938 | FLORENCE HOME | 285173 | 7915 NORTH 30TH STREET | OMAHA | NE | 68112 | 2010-10-27 | 281 | D | VVU311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record review, interview and observation; the facility staff failed to follow a physician order [REDACTED]. The facility staff identified a census of 97. Findings are: Record review of an Profile Face Sheet dated 10/24/10 revealed Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of a History and Physical sheet dated 9/30/2010 revealed Resident 1 had been admitted to the hospital with [REDACTED]. Record review of an admission orders [REDACTED]. Observation on 10/25/2010 at 11:07 AM, 10/25/2010 at 4:15 PM, 11/26/2010 at 8:20 AM and 9:35 AM revealed Resident right foot was positioned on the foot pedal of the wheelchair. The right foot had not been elevated during the observations. An interview with Licensed Practical Nurse (LPN) A on 10/26/2010 at 10:00 AM confirmed that Resident 1's foot should be elevated. | 2014-02-01 | ||
| 12937 | 12937 | FLORENCE HOME | 285173 | 7915 NORTH 30TH STREET | OMAHA | NE | 68112 | 2010-10-27 | 157 | D | VVU311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview; the facility staff failed to inform 1 (Resident 1) of 6 sampled residents physician and family of low blood sugars with symptoms requiring the use of PRN (as needed) injections. The facility staff identified a census of 97. Findings are: Record review of the facility policy and procedure titled Nursing Care Of The Diabetic Resident revealed the following: -[DIAGNOSES REDACTED]; #4, Document any [MEDICAL CONDITION]/[DIAGNOSES REDACTED] episodes in the resident's chart after contacting the resident's physician and family. Record review of an Profile Face Sheet dated 10/24/10 revealed Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 8/11/2010 revealed the facility staff assessed the following about the resident: -Resident 1 had short term memory problems, long term was ok. -Modified independence with decision making. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. -Ambulation did not occur. -Not able to stand without assistance. -Occasionally incontinent of bladder and was on a toileting plan. -Received range of motion from restorative program. Record review of a physician order dated 7/07/2004 revealed the residents physician had ordered [MEDICATION NAME] ( a hormone that raises the blood glucose levels) to be given when the residents blood sugars are less than 50. According to Wikipedia.org is used for severe "...[DIAGNOSES REDACTED] when the victim is unconscious or for some other reasons cannot take glucose orally". Record review of Resident 1's Interdisciplinary Note (IPN) dated 9/19/2010 revealed Resident 1 blood sugar was 49 and the [MEDICATION NAME] was administered to the residen… | 2014-02-01 | ||
| 12936 | 12936 | CRETE MANOR | 285170 | 830 EAST 1ST STREET | CRETE | NE | 68333 | 2010-10-12 | 353 | D | 43D911 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.04C Based on observations, record reviews, and interviews, the facility failed to provide sufficient staff to meet the resident's needs for 2 of 7 sampled residents (6 and 7). Facility census was 54. Findings are: Review of the "Daily Staffing" forms provided to the survey team on 10/12/10 revealed that the nursing staff scheduled staffing for September 2010 should be: -Day Shift--2 Charge Nurses (CN), 1 Medication Aides (MA), and 5 Nurse Aides (NA). -Evening Shift --2 CN's, 1 MA's, and 4 full shift NA's. -Night Shift-- 2 CN's or CN and a MA, and 3 NA's. Review of staff schedules for September 16 through September 30, 2010 revealed, -Day shift had 2 CN except on 2 days; 3 days lacked 1 NA. -Evening shift had 3 days that lacked 1NA and 1 day lacked 2 short shift NA's. -Night shift had 7 days which lacked 1 NA Review of the "Daily Staffing" forms provided to the survey team on 10/12/10 revealed that the nursing staff scheduled staffing for October 1 through October 12, 2010 should be: -Day Shift--2 Charge Nurses, 4 Nurse Aides and 2 bath aides. -Evening Shift --1 CN and 1 MA or 2 CN, 4 NA's. -Night Shift-- 1 CN and 3 NA's. Review of staff schedules for October 1 through October 12, 2010 revealed, -Day shift had 4 days which lacked 1 NA and 3 days that lacked 2 NA's. -Evening shift had 3 days which lacked 1 NA and 1 day which lacked 1 NA. -Night shift had 2 days which lacked 1 CN. It was noted that no Pool Staffing was used after 10/3/10. Resident care and treatment deficiencies were cited on the 7/13/2010 complaint survey regarding the following and may be referenced for detailed findings: -F 281- Failure to have medication available and pass medication at the scheduled time within the one hour time frame. An interview at 11:55 AM on 10/12/10 with the DON and ADM regarding the 8:00 AM medication pass not being done until 11:16 AM revealed, "That it was time for the budget review and that they were told to decrease the staffing by 2 people. They were told to have the Charge… | 2014-02-01 | ||
| 12935 | 12935 | CRETE MANOR | 285170 | 830 EAST 1ST STREET | CRETE | NE | 68333 | 2010-10-12 | 281 | D | 43D911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.10 Based on observation, record review and staff interview; Part I- The facility failed to ensure medications were available for administration to the resident as ordered for 2 residents (Resident 5 and 7). Part II- The facility failed to ensure the medications were administered as ordered by the physician for 2 residents (Resident 7 and 6). The facility census was 54 and the sample size was 7. Findings are: Part I A. Resident 5 had the following [DIAGNOSES REDACTED]. On 10/12/10 at 11:10 AM, it was noted that the [MEDICATION NAME] (A medication given to lower the blood sugar level in diabetics.) XL (extended release) 10 mg (milligrams) po (per mouth) qd (every day) was not available to administer. Review of the October 2010 MAR (Medication Administration Record) revealed that the [MEDICATION NAME] was circled as not given on 10/7/10, 10/8/10, 10/9/10, 10/11/10 and 10/12/10. Review of the October 2010 Nurses Medication Notes on the back of the MAR indicated [REDACTED] -10/7/10 0915 [MEDICATION NAME] XL 10 mg not given charge nurse notified. -10/8/10 0900 [MEDICATION NAME] XL 10 mg 1 po, med (medication) not administered. Charge nurse notified. -10/9/01 0800 [MEDICATION NAME] XL 10 mg 1 po late entry, medication not administered. Charge nurse notified. -10/11/10 0800 [MEDICATION NAME] XL 10 mg 1 po, medication no administrated. Charge nurse notified. Interview with MA (Medication Aide) J at 11:10 AM on 10/12/10 stated, "I let the charge nurse know that we didn't have the [MEDICATION NAME] here." "That is what we are suppose to do and they take care of it from there." B. Resident 6 had the following [DIAGNOSES REDACTED]. Review of the October 2010 MAR indicated [MEDICATION NAME] Powder (antifungal powder) to groin BID (twice a day)." Interview with MA J at 11:10 AM on 10/12/10 stated, "I let the charge nurse know that we didn't have the [MEDICATION NAME] here." Review of the October 2010 Nurses Medicati… | 2014-02-01 | ||
| 12934 | 12934 | GRETNA CARE CENTER | 285146 | 700 HIGHWAY 6 | GRETNA | NE | 68028 | 2010-01-28 | 465 | E | 6DM511 | LICENSURE REFERENCE NUMBER: 12.006.18 Based on observation and interview; the facility staff failed to maintain a functional, sanitary and comfortable environment as issues were identified during the environmental tour of the facility. Observation on 1/27/2010 at 8:00 AM with the Administrator, Maintenance Supervisor and Housekeeping Supervisor revealed the following: -100 Hall: -Wood hand rails worn to bare wood making the hand rails uncleanable. -Heating element next to east exit door with large areas of rust. -Areas of ripped wall paper in the hall. -200 Hall: -Wood hand rail worn portions to bare wood making them uncleanable. -Room 204 kick plate with sharp edges. -Wall paper in hall with areas that are ripped. -Room 217 with chair with wood legs chipped and scratched to bare wood. -Room 211 with fall mat that has rips revealing the foam filling and scraped and gouged wall. -8 of 12 wooden dinning room and 2 wood lobby chairs with scrapes and gouges. During an interview with the Administrator on 1/28/2010 at 12:00 confirmed the above findings. | 2014-02-01 | ||
| 12933 | 12933 | GRETNA CARE CENTER | 285146 | 700 HIGHWAY 6 | GRETNA | NE | 68028 | 2010-01-28 | 463 | F | 6DM511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER:12-007.04G Based on observation and interview; the facility staff failed to ensure that the call light system was operational at the nurse's station. This practice effected all residents in the facility. The survey sample was 14. The facility staff identified a census of 51. Findings are: Record review of a Admission Record dated 10/21/2009 revealed That Resident 6 was admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident 6's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 1/23/2010 revealed that the facility staff assessed the following about the resident: -Resident 6 had short term memory problems, long term memory was ok. -Modified independence with decision making. Required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. During an interview on 1/27/10 at 8:00 AM, Resident 6 stated " it takes a long time for them to answer my call light". Observation on 1/27/10 at 8:55 AM revealed that Resident 6's light was on above the door to Resident 6's room. Observation of the call light system panel at the nurse's station did not light up or sound indicating that Resident 6 was requesting assistance in the room. Registered Nurse B confirmed the call light was not functioning at the nurses station. A follow up interview was conducted with the facility administrator on 1/28/2010 at 7:50 AM. The Administrator confirmed that the call light system had not been functioning and that all residents were on 15 minute checks until the call light was repaired. | 2014-02-01 | ||
| 12932 | 12932 | GRETNA CARE CENTER | 285146 | 700 HIGHWAY 6 | GRETNA | NE | 68028 | 2010-01-28 | 441 | D | 6DM511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 12-006.17A4 Based on observation, record review and interview, the nursing facility staff failed to separate residents into separate rooms who had infection of different microorganisms for 1 (Resident 2), from 2 residents in contact isolation in the facility. The sampled residents totaled 14, including 1closed record, from a facility census of 51. Findings are: On 1/26/10, during the orientation entrance tour of the facility, observation revealed that 2 residents (Resident 2 and the roommate) were located in the same room with Contact Isolation to be carried out. The Registered Nurse (RN) Staff-O identified that Contact Isolation had been ordered for Resident 2 because of the presence of the microorganism of[DIAGNOSES REDACTED]. (Clostridium Difficile). The room mate had been ordered for Contact Isolation because of the presence of MRSA (Methicillin Resistant Staphylococcus Aureus) in a leg ulcer, wrapped with a dressing and changed daily. Record review of Resident 2 revealed the resident had been admitted [DATE] following an Ischemic Stroke September 2009, according to the physician ' s hospital notes. The hospital History and Physical dated 11/5/09 revealed the resident had a fall and fractured the right hip. Following the surgical repair of the hip returned to the nursing facility 11/11/09. The hospital notes identified right sided weakness and aphasia. Review of the laboratory reports dated 01/06/2010 revealed Resident 2 ' s Stool Culture was positive for Clostridium Difficile. On 01/22/2010, the physician ordered [MEDICATION NAME] 250 mgm (milligram) tablets, TID (three times daily), x (times) 2 wks (weeks). On 01/27/10 at 8:35 AM, observation revealed Nurse Aide (NA)-I and NA-J completed personal hygiene cares. Observation revealed Resident 2 had had diarrhea stool. The resident ' s skin was reddened, however, no breakdown. NA-I and NA-J remarked how the resident had come from the hospital with diarrhea and 2 … | 2014-02-01 | ||
| 12931 | 12931 | GRETNA CARE CENTER | 285146 | 700 HIGHWAY 6 | GRETNA | NE | 68028 | 2010-01-28 | 274 | D | 6DM511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 12-006.09b1(2) Based on observation, record review and interview, the nursing facility staff failed to conduct a significant change assessment for 1(Resident 5)at the required time of an annual assessment review when the resident presented with a significant change in resident status. The sampled residents totaled 14, including 1 closed record, from a facility census of 51. Findings are: On 1/26/10, at 3:30 PM observation revealed Resident 5 sitting in the bath room. Nurse Aide (NA)-C attempted to assist the resident with personal hygiene cares. Resident 5 resisted the NA ' s assistance and remarked that 'resident puts self on the toilet. ' The resident continued to talk about how the staff left the resident on the toilet for an hour at a time. Interview with NA-C on 1/26/10, during the personal hygiene cares revealed the resident does what (gender) wants to do; the resident refuses to have cares provided and or resists the NA ' s to assist with procedures for cares. Observation and interview on 1/27/10, at 8:10 AM, NA-D revealed that Resident 5 refuses to get up to go to the bathroom when the resident is in bed. The resident always requests a bedpan. On 1/27/10, at 9:10 AM, observation revealed Resident 5 eating breakfast. Resident 5 remarked; " I refuse a lot of things to eat, sometimes they all are too spicy; I ' ve lost weight in the 2 years that I ' ve been here, but not a whole lot. " Record review revealed that Resident 5's weight had remained stable since 2/08/08 (182 pounds); a current weight taken 1/27/10 at 178 pounds; and the resident remains above the Ideal Body Weight of 117-143 pounds. Review of Resident 5 ' s MDS (Minimum Data Set -a Federal required comprehensive assessment tool used for care planning) assessments revealed: *The last annual assessment MDS had been completed by the facility interdisciplinary team on 2/19/09. * The MDS quarterly assessments dated 10/02/09, 07/03/09, and 04/10/09 had b… | 2014-02-01 | ||
| 12930 | 12930 | GRETNA CARE CENTER | 285146 | 700 HIGHWAY 6 | GRETNA | NE | 68028 | 2010-01-28 | 246 | D | 6DM511 | LICENSURE REFERENCE NUMBER 12-006.18B1 Based on observations, record review and interviews; the facility failed to identify positioning needs and assess for causative factors and interventions to assist in the maintenance of upper body symmetry and alignment for 1 (Resident 8) of 14 sampled residents. The sample size was 14 including 1 closed record. The facility census at the time of the survey was 51. Findings are: Record review of Resident 8's most recent Significant Change Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 11/11/09 identified that Resident 8 exhibited severely impaired decision making, was totally dependent on staff for transfers and was not able to maintain position or upper body control while sitting without physical help from another person. Record review of Resident 8's Comprehensive Care Plan (CCP) identified no documentation of the use of assist devices in the wheelchair to maintain body symmetry and alignment of the body while seated in a wheelchair and no assessment of positioning needs or causative factors for Resident 8. Observation on 1/26/10 at 10:30 AM revealed Resident 8 seated in a regular wheelchair with no devices present to maintain upright body alignment. Resident 8's upper body leaned far to the left while seated in the wheelchair. Observation on 1/26/10 at 3:10 PM revealed Resident 8 seated in a regular wheelchair in the dining room. Resident 8's upper body leaned far to the left. Observation on 1/27/10 at 7:55 AM revealed Resident 8 seated in a wheelchair with the upper body leaning far to the right. Interview on 1/27/09 at 7:55 with MA A confirmed that Resident 8 leaned to the side in the wheelchair and that no positioning devices were used in Resident 8's wheelchair. Observation at that time revealed MA A attempted to push Resident 8's upper body back into an upright position in the wheelchair. Observation on 1/27/09 at 8:40 AM revealed Resident 8 seated in a wheelchair at the dining room table with the upper body le… | 2014-02-01 | ||
| 12929 | 12929 | GRETNA CARE CENTER | 285146 | 700 HIGHWAY 6 | GRETNA | NE | 68028 | 2010-01-28 | 280 | D | 6DM511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 12-006.09C1b Based on record review and staff interview; the facility staff failed to review and revise a Comprehensive Care Plan (CCP) related to signs and symptom of potential suicidal behavior for 1 (Resident 6 ) of 14 sampled Residents. The facility staff identified a census of 51. Findings are: Record review of a Admission Record dated 10/21/2009 revealed That Resident 6 was admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident 6's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 1/23/2010 revealed that the facility staff assessed the following about the resident: -Resident 6 had short term memory problems, long term memory was ok. -Modified independence with decision making. Required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Record review of Resident 6's Nurse's Notes dated 10/08/09 revealed the following entry: "...I'm going to drink water until I choke then hold my breath until I die". Resident 6 was monitored, family and physician was contacted and the resident was sent to the hospital for an evaluation. Record review of Resident 6's CCP dated 10/21/09 revealed that Resident 6 had a potential for suicidal ideation. The CCP did not identify specific intervention related to suicidal statements or potential self harm issue. An interview with the Director of Nursing (DON) was conducted on 1/28/2010 at 9:40 AM. Resident 6's CCP was reviewed with the DON. The DON confirmed that Resident 6's CCP did not identify specific signs and symptoms for staff to follow for the suicidal statement. Record review of the facility's Suicide and Suicidal Ideation Recognition Guideline dated 4/28/03, section 5.1.3 Titled Care Plan revealed the following instructions: " Any suicide attempt or expressed [MEDICAL CONDITION] must be integrated into the resident… | 2014-02-01 | ||
| 12928 | 12928 | GOLDEN LIVINGCENTER - NELIGH | 285124 | P O BOX 66, 1100 NORTH T STREET | NELIGH | NE | 68756 | 2010-10-06 | 428 | D | T3EI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.12B5 Based on record review and staff interview, the facility ' s Consultant Registered Pharmacist failed to identify and report to the physician and Director of Nursing a potential drug irregularity regarding Resident 2 ' s concurrent use of Aspirin and Etodolac (a non-steroidal anti-inflammatory drug used to treat arthritis). Total sample size was 5 and facility census was 66. Findings are: A. Nursing 2011 Drug Handbook, page 73 states Etodolac may interact with Aspirin if used concurrently. The use of Etodolac and Aspirin " ...May increase GI (gastrointestinal) toxicity. Avoid using together ... " Page 733 further states patient teaching should include advising the patient to avoid consuming Aspirin while taking Etodolac. B. Review of Resident 2 ' s Physician order [REDACTED]. Review of Medication Administration Records for 12/09, 1/10, 2/10, 3/10, 4/10, 5/10, 6/10 and 7/10 revealed Resident 2 continued to receive Aspirin and Etodolac. Review of Monthly Drug Regimen Reviews dated 12/31/09, 1/31/10, 2/23/10, 3/30/10, 4/30/10, 5/27/10, 6/23/10 and 7/31/10 revealed the Consultant Registered Pharmacist identified there were no irregularities regarding Resident 2 ' s medications. C. Review of a hospital Final Discharge Summary dated 8/3/10 revealed Resident 2 was admitted to the hospital on [DATE]. The Discharge [DIAGNOSES REDACTED]. Documentation further indicated the Aspirin and Etodolac were discontinued with instructions to " ...forego any further NSAIDs (non-steroidal anti-inflammatory drugs) ... " D. The Director of Nursing (DON) verified during interview on 10/6/10 from 10:30 AM until 10:35 AM that the Consultant Registered Pharmacist had not notified the resident ' s attending physician and the DON of the potential drug irregularity regarding Resident 2 ' s concurrent use of Etodolac and Aspirin. | 2014-02-01 | ||
| 12927 | 12927 | GOLDEN LIVINGCENTER - NELIGH | 285124 | P O BOX 66, 1100 NORTH T STREET | NELIGH | NE | 68756 | 2010-10-06 | 387 | D | T3EI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure Resident 2 was seen by the physician every 30 days for the first 90 days after admission and at least once every 60 days thereafter. Total sample size was 5 and facility census was 66. Findings are: Review of Resident 2 ' s Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/6/10 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Physicians Progress Notes revealed Resident 2 was seen by the physician on 12/29/09. The resident was not seen by the physician (or a physician assistant or nurse practitioner) until 5/4/10 (over 4 months later). There was no evidence in the medical record to indicate the resident and/or responsible party had declined the required physician visits. The Director of Nurses verified during interview on 10/6/10 from 10:30 AM until 10:35 AM that Resident 2 was not seen by the physician between 12/29/09 and 5/4/10. | 2014-02-01 | ||
| 12926 | 12926 | GOLDEN LIVINGCENTER - NELIGH | 285124 | P O BOX 66, 1100 NORTH T STREET | NELIGH | NE | 68756 | 2010-10-06 | 281 | E | T3EI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on review of resident records, bowel protocol policies/procedures and staff interview; the facility failed to follow physician's order [REDACTED]. Total sample size was 5 and facility census was 66. A. Review of the facility Bowel Protocol (no date indicated) revealed Milk of Magnesia (MOM) was to be administered if a resident did not have a bowel movement (BM) after 9 shifts. The Bowel Protocol further indicated [MEDICATION NAME] (a brand of rectal suppository) was to be administered if the resident had no results from the MOM. B. The Director of Nurses (DON) indicated during interview on 10/6/10 from 10:30 AM until 10:35 AM that staff members were to follow the facility Bowel Protocol for administration of PRN (as needed) laxatives to residents. The DON indicated 9 shifts was considered 3 days. Therefore, MOM was to be administered if a resident did not have a BM movement after 3 days. C. Review of Resident 2 ' s Physician order [REDACTED]. Review of Resident Continence Logs (a form used to record the frequency of BM ' s) dated 6/10 and 7/10 revealed Resident 2 had a BM on 6/28/10. No further BM ' s were documented until 7/2/10 (4 days later). Review of the 6/10 and 7/10 MAR ' s revealed neither MOM nor [MEDICATION NAME] were administered during this time. Further review of the 7/10 Resident Continence Log revealed Resident 2 had no BM ' s from 7/2/10 until 7/6/10 (4 days), 7/6/10 until 7/10/10 (4 days) and 7/10/10 until 7/14/10 (4 days). Review of the 7/10 MAR indicated [REDACTED]. D. Review of Resident 4 ' s physician's order [REDACTED]. Review of Resident Continence Logs dated 7/10 revealed Resident 4 had no BM ' s from 7/21/10 until 7/25/10 (4 days). Review of the 7/10 MAR indicated [REDACTED]. Review of Resident Continence Logs dated 7/10 and 8/10 revealed Resident 4 had no BM ' s from 7/31/10 until 8/4/10 (4 days). Review of the 8/10 MAR indicated [REDACTED]. Review of the 8/10 Reside… | 2014-02-01 | ||
| 12925 | 12925 | GOOD SAMARITAN SOCIETY - AUBURN | 285112 | 1322 U STREET | AUBURN | NE | 68305 | 2010-09-30 | 309 | D | 1H8211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 12-006.09 Based on observations, interviews and record review the facility failed to identify and communicate symptoms of pain to evaluate treatment and control on 1 Resident (Resident 11). Resident sample was 15. Facility census was 72. Findings are: Review of Resident 11's Face Sheet (not dated) revealed that Resident 11 had the [DIAGNOSES REDACTED]. Resident 11 has been on Hospice since 12/08 for end stage dementia (irrecoverable deteriorative mental status). Resident 11 is not able to verbally respond except with moaning. Resident 11 uses non verbal actions like opening eyes, pushing the staff's hands away, and body rigidity to communicate discomfort. Review of Resident 11's MDS (Minimum Data Set - a federally mandated comprehensive assessment tool used for care planning) dated 6/28/10 revealed that Resident 11 was severely impaired with daily decision making, and was totally dependent physically with two person assistance. The pain section of the MDS indicates that Resident 11 has no pain. Review of the Hospice Plan of care dated 8/3/10 reveals that Resident 11 has had weight loss, no purposeful movements/response, and poor skin turgor. The Alteration in Comfort section of Resident 11's Hospice care plan reveals that Resident 11 is on [MEDICATION NAME] 25mcg. (a narcotic pain patch) every 72 hours, and [MEDICATION NAME] .5mg (for resisting cares) three times a day, comfort medications are available. The comments section of the Hospice Care plan for Resident 11 indicates that Resident 11 has no purposeful movements or verbalization. The Hospice Care plan also indicates that Resident 11 shows no nonverbal indications of pain. Review of Resident 11's facility Comprehensive Care Plan dated 7/7/10 reveals that Resident 11 has an alteration in comfort related to the [DIAGNOSES REDACTED]. The facility goal for Resident 11 is that Resident 11 will not show signs of physical or verbal discomfort with transfers and cares… | 2014-02-01 | ||
| 12924 | 12924 | GOOD SAMARITAN SOCIETY - AUBURN | 285112 | 1322 U STREET | AUBURN | NE | 68305 | 2010-09-30 | 282 | D | 1H8211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 12-006.09C Based on observations, interviews and record review the facility failed to implement the interventions for restraint release as identified on the care plan for 1 Resident out of 15 (Resident 1) The facility census was 72. Findings are: Review of Resident 1's Face Sheet dated 4/9/09 revealed that Resident 1 had the [DIAGNOSES REDACTED]. Review of Resident 1's MDS (Minimum Data Set - a federally mandated comprehensive assessment tool used for care planning) dated 9/13/10 revealed that Resident 1 was severely impaired in daily decision making, had repetitive spastic movements, and repetitive calling out. Resident 1 was totally dependent with two person physical assist for activities of daily living. Review of the Physical Restraint Review Form dated 6/21/10 revealed that Resident 1 had a Velcro Lap Belt when in the wheelchair which was to be released at meal time, at group activities, when supervised, and released every 2 hours with skin check. The Velcro Lap Belt was initiated because Resident 1's spastic movements were continuous and the spastic movements even with the wheelchair being tilted back would cause Resident 1 to be thrown out of the wheelchair. There had not been any falls since the Velcro Lap Belt had been initiated. Review of Resident 1's Comprehensive Care Plan dated 3/30/10 revealed that Resident 1 identified that the problem was the potential for injury from falls because of decreased strength, spastic movements, and resistive behaviors. The interventions were to make sure that Resident 1's wheelchair was in the "tilt" position, make sure the blue mattress is on the floor next to Resident 1 when in the recliner, and the Velcro Lap Belt is to be used while in the wheelchair, to release it at meal times, and at group activities and release it every two hours and check the skin. Review of the Treatment Record dated 7/1/10 revealed that the Physician order [REDACTED]. Observations on 9/27/10 at… | 2014-02-01 | ||
| 12923 | 12923 | ARBOR MANOR | 285103 | 2550 NORTH NYE AVENUE | FREMONT | NE | 68025 | 2010-10-19 | 323 | J | RJGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 12-006.09d7B Based on observation, interview, and record review; the facility failed to assess residents risk for burns from hot liquids and implement interventions to prevent burns from spilling hot liquid for 1 (Resident 1) of 4 sampled residents. The facility had a total census of 110. Findings are: A. Resident 1 was readmitted to the facility from the hospital on [DATE] according to Face Sheet. Resident 1's History and Physical dated 9/1/10 included the following Diagnoses: [REDACTED]. A review of Resident 1's 9/18/10 MDS (Minimum Data Set; a comprehensive assessment used for care planning) revealed the following: -Resident 1 had short term memory problems. -Resident 1 had moderately impaired cognitive skills for daily decision making. -Resident 1 required set up help for eating. Resident 1's Care Plan included the following problem dated 9/17/10: " (Resident 1) needs assistance with (gender's) ADLs (Activities of Daily Living) due to weakness, impaired mobility & impaired cognition. " Approaches listed for Resident 1 included the following: - " (Resident 1) is usually able to feed (self). Provide set up help w/meals (with meals) & assist as needed. " - " Continue to provide supervision & setup (with) dining. " This approach was dated 10/4/10, after the coffee spill. - " Continue (with) use of lidded cup for hot liquids. " This approach was dated 9/30/10, after the coffee spill. Interview with the Assistant Director of Nursing (ADON) on 10/6/10 revealed that the interventions of supervision during dining and the lidded cup were in place prior to the coffee spill and were not changed after the spill. B. An incident report for Resident 1 dated 9/30/10 at 12:45 PM stated the following: " Res. (Resident) spilled coffee on (gender) @ lunch. Red area measured 19 x 15 cm (centimeter). After further assessment Res. has 5 fluid-filled blisters that measure 1 cm; 2 that are 2 cm. " The facility investigation dated 10/4/1… | 2014-02-01 | ||
| 12922 | 12922 | GOLDEN LIVINGCENTER - OMAHA | 285097 | 5505 GROVER STREET | OMAHA | NE | 68106 | 2010-10-22 | 498 | D | 0EBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12-006.04 Based on interviews and record reviews, the facility failed to orientation and training of 1 Nurse Aide (NA A) regarding the use of gait belts which affected 1 (Resident 1) of 8 sampled residents. The facility had a total of 109 residents. Findings are: Resident 1 was admitted to the facility on [DATE] according to admission record. Resident 1's Plan of Care included the following Diagnoses: [REDACTED]. Resident 1's 7/20/10 quarterly MDS (Minimum Data Set; a comprehensive assessment used for care planning) identified Resident 1 as requiring limited assistance of one person for transfer. Resident 1 was also identified as having short and long term memory problems and having modified independence with daily decision making. Resident 1's Care Plan included a problem dated 1/26/10 of alteration in activity of daily living status requiring limited extensive assist with transfer. Interventions list for Resident 1 included to assist of 1-2 with transfers with a gait belt. A review of Verification of Investigation dated 10/4/10 revealed Resident 1 started to sit down during a transfer from bed to wheelchair by Nurse Aide A and Resident 1 fell to the floor. A review of Verification of Investigation revealed Nurse Aide A did not use a gait belt during the transfer. A review of facility transfer activities procedure dated 2006 revealed a transfer belt was to be applied prior to initiating a transfer. A review of Nurse Aide A's orientation documentation revealed the Basic Care Skills checklist that included a gait belt transfer competency had not been completed. In an interview on 10/25/10 at 11:39 AM, RN (Registered Nurse) Consultant confirmed Nurse Aide A's competency had not been completed but Nurse Aide A was talked to about using a gait belt. RN Consultant reported competencies were to be completed with new hires. | 2014-02-01 | ||
| 12921 | 12921 | GOLDEN LIVINGCENTER - OMAHA | 285097 | 5505 GROVER STREET | OMAHA | NE | 68106 | 2010-10-22 | 281 | D | 0EBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12.006.10 Based on record review and interviews, the facility failed to ensure physician orders [REDACTED]. The facility had a total census of 109 residents. Findings are: Resident 3 was admitted to the facility on [DATE] according to admission information. Resident 3's physician orders [REDACTED]. A review of Resident 3's medication orders from the hospital dated 8/13/10 revealed an order for [REDACTED]. A review of 8/10 MAR (Medication Administration Record) revealed directions for the [MEDICATION NAME] to be administered each shift. Documentation on Resident 3's 8/10 MAR revealed Resident 3 received the [MEDICATION NAME] 2 times on 8/14/10 and 3 times on 8/15/10. A review of Resident 3's Resident Continence by Shift Report revealed no bowel movements were recorded for Resident 3 on 8/14/10 or 8/15/10. Reviews of Resident 3's 8/10 MAR and Interdisciplinary Progress Notes for 8/14/10 and 8/15/10 did not reveal any documentation of Resident 3's bowel movements. In an interview at 11:41 AM on 10/25/10, the RN(Registered Nurse) Consultant confirmed without recorded bowel movements it couldn't be determined if physician's orders [REDACTED]. | 2014-02-01 | ||
| 12920 | 12920 | GOLDEN LIVINGCENTER - OMAHA | 285097 | 5505 GROVER STREET | OMAHA | NE | 68106 | 2010-10-22 | 332 | D | 0EBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12.006.10 Based on observation, record review and interview, the facility staff failed to ensure a medication error rate was less than 5%. A total of 26 medications were observed with 3 errors resulting in an error rate of 11.5%. Resident 9 was the resident with the medication errors. The survey consisted of 8 sampled and 1 non-sampled residents. The facility had a total census of 109 residents. Findings are: A. A review of admission physician orders [REDACTED]. Observations at 8:45 AM on 10/22/10 revealed LPN (Licensed Practical Nurse) B administered [MEDICATION NAME] 500 mg, 1 tab to Resident 9. A review of Resident 9's 10/10 MAR (Medication Administration Record) revealed a physician's orders [REDACTED]. The 10/10 MAR indicated [REDACTED]. In an interview on 10/22/10 at 12:16 PM, the RN (Registered Nurse) Consultant confirmed there was a transcription error. B. A review of Resident 9's 10/10 MAR indicated [REDACTED] -[MEDICATION NAME], 400 mg, 2 times a day scheduled for 9 AM and 5 PM. -[MEDICATION NAME] 17 gm dose every day as needed. Both medications were circled indicating medication had not been given. In an interview on 10/22/10 between 10:10-10:20 AM, the RN Consultant reported the Miralex and [MEDICATION NAME] were not available at the facility. An order was received for Resident 9 10:07 AM on 10/22/10 to give 2 doses of Gauifensin staggered when it arrived and to give [MEDICATION NAME] when it arrived. A review of Resident 9's 10/10 MAR indicated [REDACTED]. | 2014-02-01 | ||
| 12919 | 12919 | LINDEN COURT | 285083 | 4000 WEST PHILIP AVENUE | NORTH PLATTE | NE | 69101 | 2010-10-21 | 323 | D | HCOX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175NAC 12-006.09D7b Based on observation, record review and interview, the facility failed to ensure interventions were implemented in an attempt to prevent further falls for Resident 2. The facility census was 111 and 6 residents were chosen for a sample. Findings are: A review of the face sheet (a cover sheet to a multipage document that contains demographic information, preferences, contact information, and limited medical information) located in Resident 2's record revealed the resident was admitted to the facility on [DATE] and resided on the special care unit. The face sheet listed admitting medical [DIAGNOSES REDACTED]. Observations of the resident on 10/20/2010 at 4:15PM, and 10/21/2010 at 9:25AM revealed the resident sitting in the recliner watching television. The call light was attached to the outside front corner of the arm protector, walker approximately 4.5 feet in front of the resident by the exterior wall. No alarm box was found on the resident's recliner, and the call light was a push button style (versus not attached to a 'silent' type alarm pad). A review of Resident 2's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 7/27/2010, and provided by the facility, revealed Resident 2 required the supervision of one person when transferring, walking in the room or corridor, toilet use, and personal hygiene. Resident 2 required limited physical assistance of one for dressing. A review of the Fall Risk Assessment form located in Resident 2's record revealed the resident was scored a 15 on 9/4/2009, 11/18/2009, 5/7/2010 and 10/5/2010; and a 17 on 2/18/2010 and 7/26/2010. According to the form, a total score of 10 or higher indicates a high risk for falls. A review of the incidents and accidents for this resident revealed the resident fell on : -9/11/10 reaching for something in the bathroom -9/20/10 according to the nurses notes in the record, the resident h… | 2014-02-01 | ||
| 12918 | 12918 | MATNEY'S COLONIAL MANOR | 285082 | 3200 G STREET | SOUTH SIOUX CITY | NE | 68776 | 2010-02-04 | 281 | D | QGTM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 12-006.09 Based on observations, record review, and staff interviews; the facility staff failed to ensure that physician orders [REDACTED]. The facility census was 44. Findings are: Record review of Resident 9's Admission Face Sheet revealed admission [DIAGNOSES REDACTED]. Record review of Resident 9's MDS dated [DATE] revealed that Resident 9 exhibited moderately impaired cognitive skills, exhibited no adverse behaviors and had limited range of motion on one side and partial loss of voluntary movement on one side. Record review of Physician order [REDACTED]." Record review of an Occupational Therapy (OT) Evaluation for Resident 9 dated 12/30/09 revealed a functional goal that included that resident would hold activities of daily living (ADL) items in right hand to assist with function. The Functional Level Progress Report indicated that the hand positioning device did help decrease tightness and pain in the right hand for Resident 9. Record review of OT weekly notes dated 12/30/09 indicated that facility staff had been instructed by the OT to keep a therapeutic carrot in Resident 9's hand at all times. Record review of the OT weekly notes dated 1/5/10 indicated that Resident 9 had been found in bed with nothing in the right hand. Record review of OT weekly notes dated 1/19/10 indicated that Resident 9 had physician orders [REDACTED]. Record review of a Occupational Therapy Restorative Referral Form dated 1/19/10 revealed program recommendations that a rolled washcloth or palm protector or a small cone be kept in Resident 9's right hand. Observations on 2/3/10 at 8:15 AM, 2:00 PM, 3:15 PM, 4:00 PM, 5:00 PM and 5:30 PM revealed Resident 9 seated in a wheelchair in the main dining and activity area with no rolled washcloth in the right hand. The fingers of the right hand were curled into the palm of the right hand. Interview on 2/3/10 at 5:30 PM with Nursing Assistant (NA) I confirmed that Resident 9 did not have anyt… | 2014-02-01 | ||
| 12917 | 12917 | MATNEY'S COLONIAL MANOR | 285082 | 3200 G STREET | SOUTH SIOUX CITY | NE | 68776 | 2010-02-04 | 246 | E | QGTM11 | LICENSURE REFERENCE NUMBER 12-006.18B2 Based on observation, interview and record review; the facility failed to provide comfortable table heights and positioning for ease of eating for 2 sampled (Residents 9 and 3) residents and 3 non-sampled (Residents 12, 13 and 14) residents of 40 residents that ate in the main dining area in the facility. The sample size was 11 residents including 1 closed record and 11 non-sampled residents. The facility census was 44 at the time of survey. Findings are: A. Observations on 2/3/10 between 8:05 AM and 8:40 AM and on 2/3/10 between 12:05 PM and 12:25 PM revealed Residents 12 and 3 seated in their respective wheelchairs in the main dining area at a dining table. Observation revealed that Resident 12 and 3 ' s wheelchair pedals were touching underneath the table preventing the Resident ' s 12 and 3 from sitting close enough to the table to easily reach the food and beverages. Resident 3 leaned forward to reach the food. Resident 12 moved the plate so that it was partially off of the table edge closer to Resident 12. Both residents ' s had to bring the food a long distance from the plate to their mouths which resulted in food being spilled on the residents' laps and on their clothing protectors. Resident 12 and 3 were able to eat independently without staff assistance. B. Observations on 2/3/10 between 8:05 AM and 8:40 AM and on 2/3/10 between 12:05 PM and 12:25 PM revealed Residents 13 and 14 seated in their respective wheelchairs in the main dining area at a dining table. Resident 13 ' s wheelchair had leg extension foot pedals attached and Resident 13's legs and feet rested on these pedals. During the observations it was noted that the leg extension foot pedals hit the feet of Resident 13 ' s table mate, Resident 14, which prevented both Resident ' s 13 and 14 from sitting close enough to the table to easily reach the food and beverages. Both Resident ' s 13 and 14 leaned forward to reach the food and food spilled on Resident 13's clothing protector. Both residents were able t… | 2014-02-01 | ||
| 12916 | 12916 | MATNEY'S COLONIAL MANOR | 285082 | 3200 G STREET | SOUTH SIOUX CITY | NE | 68776 | 2010-02-04 | 492 | F | QGTM11 | Based on record review and interview; the facility staff failed to complete the demand billing process correctly to ensure that the resident or the responsible party had accurate knowledge of the potential liability of payment and the right to request that a standard claim appeal ( i.e. demand bill) be submitted to Medicare for 4 ( Residents 3, 16, 18 and 19) of 4 residents files reviewed. The resident sample size was 11 including 1 closed record plus 11 non-sampled residents. The facility census was 44. Findings are: Record review of a Centers for Medicare and Medicaid Services Survey and Certification Letter 09-20 revealed that the Skilled Nursing Facility (SNF) must inform the beneficiary of potential liability for payment for non-covered services when limitation of Liability applies. The SNF's responsibility to provide notice can be fulfilled by use of either the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or one of 5 uniform Denial Letters. The SONANT and the Denial Letters also inform the beneficiary of the right to have a claim (i.e. demand bill) submitted to Medicare. Record review of the facilities Demand Billing process revealed that 4 ( residents 3, 16, 18 and 19) of 4 residents were informed of the right to request a demand bill and to submit a claim and that each resident or responsible party had requested that they wanted a decision made by the fiscal intermediary. A review of the portion of the SNFABN entitled Request for Medicare Intermediary Review for Residents 3, 16, 18 and 19 revealed that the "I do" box had been marked for each of the identified residents. Interview on 2/2/10 at 9:00 AM with the Business Office Manager (BOM) revealed that the documentation of requests for demand bills had been made in error and that none of the 4 residents reviewed wanted their information submitted for an independent review and decision. The BOM stated that the residents had checked "I do" on the SNFABN in error. The BOM thought that by checking the "I do" box that meant that the resident h… | 2014-02-01 | ||
| 12915 | 12915 | MATNEY'S COLONIAL MANOR | 285082 | 3200 G STREET | SOUTH SIOUX CITY | NE | 68776 | 2010-02-04 | 323 | E | QGTM11 | LICENSURE REFERENCE NUMBER 12-007.03A21. And LICENSURE REFERENCE NUMBER 12-006.18E3a1. Based on observation, interviews, policy and procedures, the nursing facility staff failed to maintain resident rooms 303, 304, 309 and 312 free from portable space heaters; and maintain the 300 hallway shower's water temperature not to exceed 110 degree Fahrenheit(F)regulation, which has the potential to affect 4 residents (Resident 1, 20, 21, and 22) that use this bathing area. The total sample size consisted of 11 residents, including 1 discharged resident, plus 11 non sampled residents. The facility census totaled 44. Findings are: PORTABLE SPACE HEATERS: A. Observation during the orientation tour 02/01/ at 3:30 PM revealed what appeared to be a small white space heater placed in the middle of the floor and plugged into an electrical outlet in room 309. Upon inquiry, the resident revealed it was an electric space heater that the family had given to the resident as a present at Christmas. B. On 02/02/2010, during the medication administration pass at 8:10 A.M to Resident 2, revealed the observation of an old space heater placed between the night stand and the wall, in front of the resident's legs. The heating element felt hot when the hand drew near to the reddened heater's element. The space heater appeared to hot to touch with the hand. Observation on 2/2/10 at 9:15AM revealed Staff-A, maintenance person, replacing the "old" heater with a black space heater. Staff-A replied, "Yes, I just got back, - "bought a newer one" and placed the heater in front of Resident 2's legs. Observation on 2/2/10 at 1:00 PM revealed a "radiator" type heater had been placed in Resident 2's room. Observation revealed the room space around the heater was hot. The front of the heater had been placed near the resident's foot stool. The rug covering over the foot stool was hot to touch with a bare hand. Observation revealed the temperature gauge had been set on 7, with a gauge that numbered 1(one) through 7 (seven), the highest setting. Staff-B, ho… | 2014-02-01 | ||
| 12914 | 12914 | MATNEY'S COLONIAL MANOR | 285082 | 3200 G STREET | SOUTH SIOUX CITY | NE | 68776 | 2010-02-04 | 371 | F | QGTM11 | LICENSURE REFERENCE NUMBER 12-006.11E NEBRASKA FOOD CODE 2-301.14(F), 2-301.12(A), 3-304.15(A) Based on observation, interview and record review; the facility kitchen staff failed to prepare and serve food under sanitary conditions related to hand washing. This had the potential to affect all residents that were served food from the facility kitchen. The facility census was 44. Findings are: Record review of a facility policy entitled Hand washing and Use of Plastic Gloves dated 2000 revealed the following policies: Dietary staff will wash hands after glove removal, when tasks are changed, after a return to the kitchen from another area, after touching meat, before touching items such as door, cupboard or oven handles and at other times hands have been soiled. Remember gloves are just like hands. They get soiled. Any time a contaminated surface is touched, the gloves must be changed: after coughing, sneezing into hands or touching hair or face, after handling garbage, after handling anything soiled. After handling boxes, crates or packages, anytime after you touch any contaminated surface. Interview on 2/2/10 at 1:45 PM with the Dietary Manager (DM) confirmed the Policy and Procedures dated 2000 and confirmed that the expectation for hand washing in the kitchen was that hands were to be washed with soap as follows: - after glove removal. - when tasks were changed. - after a return to the kitchen from another area. - after touching meat. - before touching items such as door, cupboard or oven handles. Observation of Breakfast food service with the DM on 2/2/10 between 8:10 AM and 8:30 AM revealed that Cook G wore gloves and was serving sausages, oatmeal and pancakes for breakfast. Cook G began the meal service by using tongs to pick up sausage links and pancakes. At 8:20 AM, Cook G began using gloved hands to pick up portions of sausage links and pancakes. Cook G then proceeded to touch the handles of the scoops for the oatmeal and dry cereal for each tray served with soiled gloves. Cook G continued that practice t… | 2014-02-01 | ||
| 12913 | 12913 | MATNEY'S COLONIAL MANOR | 285082 | 3200 G STREET | SOUTH SIOUX CITY | NE | 68776 | 2010-02-04 | 253 | E | QGTM11 | LICENSURE REFERENCE NUMBER: 12-006.18 B Based on observation and interview; the facility staff failed to maintain the cleanliness of floors and caulking surrounding the base of the toilets in resident bathrooms and failed to maintain furniture and window seals in good condition. This affected 19 (Rooms 101,106, 109, 110, 112, 202, 206, 209, 302, 304, 305, 306, 310, 312, 501, 505, 507 and 508 ) of 39 occupied resident rooms in the facility. The facility staff also failed to maintain a radiator baseboard heater and a cement patio in the enclosed courtyard in good condition. The census at the time of survey was 44. Findings are: Observation on 2/3/10 between 9:40 AM and 11:00 AM with the Facility Maintenance Director (MS) and the Housekeeping Supervisor (HS) and the Owner revealed concerns in the following areas: - Soiled, stained or broken caulking and floor tiles surrounding the base of the toilet in resident bathrooms Rooms 101,106, 109, 110, 112, 202, 206, 209, 302, 304, 305, 306, 310, 312, 501, 505, 507 and 508. - Loose dresser handles in rooms 109, 110, 112 and 501. - Drafty window seal in room 304. - A metal baseboard radiator heater torn away from the wall in the hall leading to the dining room. - In the enclosed outdoor courtyard cement slabs were buckled which resulted in a difference in levels of 2 inches between the slabs. This had the potential to affect 5 ( Residnets 1, 3, 15, 16 and 17) residents that utalized wheelchairs and used the courtyard for a smoking area. Interview on 2/3/10 at 2:50 PM with the MS confirmed the above observations and that the facility had not identified the above areas of concern prior to 2/3/10 and did not have any work orders for the identified concern areas. | 2014-02-01 | ||
| 12912 | 12912 | GOLD CREST RETIREMENT CENTER | 285065 | 200 LEVI LANE | ADAMS | NE | 68301 | 2010-08-09 | 278 | E | P8NF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.09B Based on observation, interview, and record review, the facility failed to ensure that Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) assessments were coded accurately on Residents 4, 8, and 9. The facility census at the time of survey was 41 residents. The sample size was 11 residents. Findings are: A. A record review of Resident 4's MDS dated [DATE] revealed that the nursing rehabilitation/restorative care (nursing interventions that promote the resident's ability to adapt and adjust to living independently and safely as possible) was provided for eating or swallowing to this resident on three out of seven days and nursing rehabilitation/restorative care was provided for communication on five out of seven days. A record review of Resident 4's NURSING RESTORATIVE PROGRAM for 7/28/2010 revealed that Resident 4 was not on a restorative program for eating or swallowing and was not on a restorative program for communication at that time. An interview with the Restorative Aide (RA) A on 8/5/2010 at 2:20PM revealed that Resident 4 was not on a restorative program for nursing to receive eating, swallowing, or communication services. RA A stated that Resident 4 was receiving physical therapy, occupational therapy, and speech/language therapy at this time and thought that this section meant it was to be counted for speech/language therapy services received at this time. B. A record review of Resident 8's MDS dated [DATE] revealed that the nursing rehabilitation/restorative care was provided for splint/brace assistance on seven out of seven days and that dressing or grooming assistance was provided on three out of seven days. A record review of Resident 8's NURSING RESTORATIVE PROGRAM for 7/2010 revealed that Resident 8 was not on a nursing restorative program for dressing assistance, grooming assistance, or splint/brace assistance. A record review of Resid… | 2014-02-01 | ||
| 12911 | 12911 | KEARNEY COUNTY HEALTH SERVICES | 2.8e+298 | 727 EAST 1ST STREET | MINDEN | NE | 68959 | 2010-11-09 | 309 | D | ROTG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09 Based on record review and staff interview, the facility failed to plan and assess for behaviors such as elopement behaviors, aggressive and threatening behaviors and inappropriate sexual comments and revise and implement interventions to protect residents and staff from those behaviors for 1 (Resident 01) of 3 residents reviewed. The facility census was 25 at the time of the complaint investigation and the sample size was 3. Findings are: Resident 01 was admitted to the facility on [DATE] according to the ADMISSION AND DISCHARGE SUMMARY on the medical record. The following [DIAGNOSES REDACTED]. Review of the facility policy and procedure for RISK OF ELOPEMENT ASSESSMENT INTERPRETATION AND IMPLEMENTATION dated 4/18/2010 revealed the following purpose: "The purpose of the Risk of Elopement Assessment is to determine on admission and routinely thereafter if a resident is at risk for elopement. The Director of Nursing or designated person will complete the RISK OF ELOPEMENT ASSESSMENT on admission, quarterly, annually and with significant change. The results of this assessment will assist with the decision for placement of a wanderguard device and other resident specific interventions to prevent elopements. A score of yes on 5 of 6 questions will warrant placement of the wanderguard. Any other score will be resident specific as to their special needs if they would need a wanderguard placement. The resident's care plan will be adjusted for the elopement risk and appropriate resident specific interventions". Interview on 11/9/2010 at 10:30 AM with the DON (Director of Nursing) and the MDS (Minimum Data Set-a federally mandated assessment tool utilized to develop the comprehensive care plan) Coordinator revealed that their definition of elopement encompassed the following: "Elopement was when someone left the facility unattended and without telling staff, but it wasn't considered an elopement when staff were pr… | 2014-03-01 | ||
| 12910 | 12910 | MILLER MEMORIAL CARE CENTER | 2.8e+296 | P O BOX 428, 589 VINCENT AVENUE | CHAPPELL | NE | 69129 | 2011-03-02 | 514 | D | Z96X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.16B (1) Based on record review and interview, the facility failed to consistently document the use of PRN (as needed) medications for 1 sampled resident (Resident 5). Sample size was 18. Facility census was 24. Findings are: Review of Resident 5's "Medication Sheet" for February 2011 revealed a physician's medication order for "[MEDICATION NAME] 0.5mg" had been initiated on 2/1/11. The order indicated the medication was to be offered at "HS (bedtime) as needed for restlessness PRN (as needed)". Further review of the February document revealed the medication was administered 22 of 28 evenings at bedtime. Review of a "Nurses Medication Notes" form utilized by the facility to document the administration of PRN medications, the dosage given, and the reason it was given, revealed the [MEDICATION NAME] had been documented on this form 18 times between 2/1/11 and 2/28/11. Further review of the "Nurse's Medication Notes" for February 2011 revealed the PRN [MEDICATION NAME] administered on 2/13/11and 2/17/11 and [MEDICATION NAME] administered on 2/15/11 had not documented the results of these medications. Interview with the DON (Director of Nursing) on 3/2/11 at 9:45 AM verified the facility procedure when administering PRN medications involves documenting the medication on the "Medication Sheet" and the "Nurses Medication Notes" each time a PRN is administered. The facility requires documenting the dosage, reason given, and results of the PRN on the Nurses Medication Notes form. The DON verified a discrepancy between the number of times [MEDICATION NAME] was administered to Resident 5 in February. The "Medication Sheet" documentation accounted for 22 doses of [MEDICATION NAME] being given while the "Nurses Medication Notes" had documented 18. The DON also verified the failure to document results of [MEDICATION NAME] and [MEDICATION NAME] administered PRN on 2/13; 2/15; and 2/17/11. | 2014-03-01 | ||
| 12909 | 12909 | MILLER MEMORIAL CARE CENTER | 2.8e+296 | P O BOX 428, 589 VINCENT AVENUE | CHAPPELL | NE | 69129 | 2011-03-02 | 428 | D | Z96X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.12B (5) Based on record reviews, and interview, the facility consultant pharmacist failed to question the continued use of a routine medication to aid in sleep for 1 sampled resident (Resident 5). Sample size was 18. Facility census was 24. Findings are: Review of Resident 5's "Record of Admission" form revealed the resident was admitted to the facility on [DATE]. Review of Resident 5's "Medication Sheet" forms for February and March of 2011 revealed Resident 5 routinely received a "Tylenol PM (acetaminophen 500mg/diphenhydramine 25mg (milligram))" tablet at bedtime for "Insomnia". Review of Resident 5's "Interdisciplinary Progress Notes" revealed the following shift entries: - 7/5/10-11:00 PM "Res (resident) ringing q (every) 15 mins (minutes) to be toileted. Attempted to explain that (resident) has been up q 15 mins x (times) 3. Res states if (resident) not taken to toilet (resident) will have panic attack, res taken to toilet, (didn ' t) void. Res denies ringing often to toilet". - 7/6/10 at 9:00 AM "Nurse talked c (with) (name of resident spouse). We discussed resident not getting adequate rest @ (at) noc (night). Continues to ring to be toileted frequently @ noc; Noc shift reported. (Spouse) asked if nurse would talk to Doctor about something for anxiety. Nurse has called into residents Doctor. Doctor's office will return call". - 7/6/10 at 5:00 PM- "New order received et (and) noted ..." Review of Resident 5's physician orders [REDACTED]. A communication fax to the physician requested a supporting [DIAGNOSES REDACTED]. Record review of "Consultant Pharmacist Drug Therapy Evaluation Form and Physician Notification" forms completed monthly by the consultant pharmacist revealed the pharmacist reviewed Resident 5's medication regiment monthly between 6/10/10 and 2/11/11. The pharmacist identified "No irregularities noted" each month based on the reviews. The pharmacist did not document or question … | 2014-03-01 | ||
| 12908 | 12908 | MILLER MEMORIAL CARE CENTER | 2.8e+296 | P O BOX 428, 589 VINCENT AVENUE | CHAPPELL | NE | 69129 | 2011-03-02 | 371 | E | Z96X11 | Licensure Reference Number 175 NAC 12-006.11E Based on observations and staff interviews, the facility failed to ensure that food items in the kitchenette refrigerator and in the dining room refrigerator were labeled with the resident's name and were dated to reduce the risk of food borne illness for the residents. The facility census was 24. Findings are: Observation on 3/1/11 at 2:15 PM revealed the refrigerator in the main dining room contained unlabeled and undated food items including a large plastic bag of shredded cheese, 1/2 glass bottle of salsa, a jar of mayonnaise, and in the freezer a glass 1/4 full with a chocolate shake, several slices of pizza in foil wrap, 3 frozen dinners, and a plastic container of tomato/meat sauce with a build up of frost in the container. Further observation revealed a sign posted on the refrigerator, dated 4/9/09, which stated that "all items in refrig (refrigerator) must have name and date on them, covered if open and date of entry". Observation on 3/1/11 at 2:25 PM of the refrigerator in the kitchenette in the main dining room revealed a bottle of Diet Pepsi opened and not labeled or dated. Interview on 3/1/11 at 2:45 PM with the CDM (Certified Dietary Manager) confirmed that the dietary staff were to label the Diet Pepsi with the resident's name. Interview at 3:00 PM with the DON (Director of Nursing) confirmed that the refrigerator in the dining room was to be used for the food items which are brought in for individual residents. Further interview confirmed that these food items were to be labeled and dated as directed. The DON stated that some of these items may belong to staff members and were not to be kept in this refrigerator. The DON removed the undated/unlabeled food items from the refrigerator and freezer. Review of the "7/1/10 version of the "Food Code", based on the Unites States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: 81-2,272.24 (1-4) "Except when packaging fo… | 2014-03-01 | ||
| 12907 | 12907 | MILLER MEMORIAL CARE CENTER | 2.8e+296 | P O BOX 428, 589 VINCENT AVENUE | CHAPPELL | NE | 69129 | 2011-03-02 | 333 | D | Z96X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.10D Based on observations, record review, and interviews, the facility failed to prevent crushing an [MEDICATION NAME] coated medication for 1 sampled resident (Resident 11). This failure could potentially lead to significant GI (gastrointestinal) side effects. Sample size was 18. Facility census was 24. Findings are: Observations of medication administration on 3/1/11 at 8:02 AM and 3/2/11 at 8:06 AM revealed MA (Medication Aide)-A setting up and preparing medications for delivery to Resident 11. During the preparation, MA-A stated Resident 11 receives medications in crushed form. MA-A was observed crushing two medications, a Calcium tablet and an Aspirin tablet. The medication label affixed to the Aspirin container read "ASA (acetasylacalic acid, generic aspirin) 81 mg (milligrams) EC ([MEDICATION NAME] coated)". MA-A mixed the crushed tablets in pudding along with an undisturbed capsule of [MEDICATION NAME]. The medications were then administered to Resident 11 orally. Interviews with MA-A during the medication delivery to Resident 11 on 3/1/11 and 3/2/11 verified the resident's routine medications are crushed and mixed with pudding except for the [MEDICATION NAME] which comes in capsule form. Interview with LPN (Licensed Practical Nurse)-B on 3/1/11 at 11:00 AM verified that Resident 11 receives all oral medications in crushed form daily. Review of Resident 11's chart revealed the following: - "Progress Note" electronically signed by the physician on 1/20/11. The note recertified a physician's medication order for for "Aspirin EC 81 mg 1 TAB daily". - Resident 11's "Medication Sheet" forms for February and March of 2011 revealed Resident 11 received "Aspirin EC 81 mg" routinely every day. In addition, the medication record forms revealed Resident 11 received "[MEDICATION NAME] 20mg" daily for "Stomach Function Dis (Disorder)". - Review of a "Resident [DIAGNOSES REDACTED]. Resident 11 had a medica… | 2014-03-01 | ||
| 12906 | 12906 | MILLER MEMORIAL CARE CENTER | 2.8e+296 | P O BOX 428, 589 VINCENT AVENUE | CHAPPELL | NE | 69129 | 2011-03-02 | 332 | E | Z96X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.10D Based on observations, record reviews, and interview, the facility failed to: 1) provide clinical rationale to crush an [MEDICATION NAME] coated aspirin administered to 1 sampled resident (Resident 11); 2) obtain orders to crush oral medications administered to 1 sampled resident (Resident 26); 3) administer medication at the specified time ordered by the physician for 2 sampled residents (Residents 1 and 24). These failures resulted in 7 observed medication errors out of 56 sampled medications administered resulting in an error rate of 12.5%. Sample size was 18. Facility census was 24. Findings are: A.Observations of medication administration on 3/1/11 at 8:02 AM and 3/2/11 at 8:06 AM revealed MA (Medication Aide)-A setting up and prepairing medications delivered for Resident 11. During the preparation, MA-A stated Resident 11 receives medications in crushed form. MA-A was observed crushing two medications, a Calcium tablet and an Aspirin tablet. The medication label affixed to the Aspirin container read "ASA (acetasylacalic acid, generic aspirin) 81 mg (milligrams) EC ([MEDICATION NAME] coated)". MA-A mixed the crushed tablets in pudding along with an undisturbed capsule of [MEDICATION NAME]. The medications were then administered to Resident 11 orally. Interviews with MA-A during the medication delivery to Resident 11 verified the resident's routine medications are crushed and mixed with pudding except for the [MEDICATION NAME] which comes in capsule form. Interview with LPN (Licensed Practical Nurse)-B on 3/1/11 at 11:00 AM verified that Resident 11 receives all oral medications in crushed form daily. Review of Resident 11's chart revealed the following: - "Progress Note" electronically signed by the physician on 1/20/11. The note identified a physician's medication order for for "Aspirin EC 81 mg 1 TAB daily". - Physician documentation from Resident 11's chart did not include any entries app… | 2014-03-01 | ||
| 12905 | 12905 | MILLER MEMORIAL CARE CENTER | 2.8e+296 | P O BOX 428, 589 VINCENT AVENUE | CHAPPELL | NE | 69129 | 2011-03-02 | 329 | D | Z96X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interview, the facility failed to identify the continued need for a routine medication to aid in sleep for 1 sampled resident (Resident 5. Sample size was 18. Facility census was 24. Findings are: Review of Resident 5's "Record of Admission" form revealed the resident was admitted to the facility on [DATE]. Observations of the resident during interviews conducted on 3/1/11 at 8:45 AM and 3/2/11 at 9:15 AM revealed Resident 5 sitting in a wheelchair, awake and alert. The resident had a urinary suprapubic catheter in place during the observations. Review of Resident 5's "Medication Sheet" forms for February and March of 2011 revealed Resident 5 routinely received a "Tylenol PM [MEDICATION NAME] 500mg/[MEDICATION NAME][MEDICATION NAME] 25mg (milligram)" tablet at bedtime for "[MEDICAL CONDITION]". Review of Resident 5's "Interdisciplinary Progress Notes" revealed the following shift entries: - 7/5/10- 11:00 PM "Res (resident) ringing q (every) 15 mins (minutes) to be toileted. Attempted to explain that (resident) has been up q 15 mins x (times) 3. Res states if (resident) not taken to toilet (resident) will have panic attack, res taken to toilet, (didn ' t) void. Res denies ringing often to toilet". - 7/6/10 at 9:00 AM "Nurse talked c (with) (name of resident spouse). We discussed resident not getting adequate rest @ (at) noc (night). Continues to ring to be toileted frequently @ noc; Noc shift reported. (Spouse) asked if nurse would talk to Doctor about something for anxiety. Nurse has called into residents Doctor. Doctor's office will return call". - 7/6/10 at 5:00 PM- "New order received et (and) noted ..." Review of Resident 5's physician orders [REDACTED]. A communication fax to the physician requested a supporting [DIAGNOSES REDACTED]. Interview with Resident 5 and Resident 5's spouse on 3/2/11 at 9:15 AM revealed the resident had recently been diagnosed and treated by a urologist. The resident ve… | 2014-03-01 | ||
| 12904 | 12904 | MILLER MEMORIAL CARE CENTER | 2.8e+296 | P O BOX 428, 589 VINCENT AVENUE | CHAPPELL | NE | 69129 | 2011-03-02 | 323 | E | Z96X11 | Licensure Reference Number 175 NAC 12-006.09D7a Based on observations and staff interviews, the facility failed to 1) ensure that chemicals were secured to reduce the risk of accidental exposure to residents and 2) ensure that a door to a staircase was kept locked to reduce the risk of accidents for 9 current residents identified as confused and wandered in the facility (Resident 30, Resident 2, Resident 6, Resident 26, Resident 16, Resident 4, Resident 19, Resident 20, and Resident 24). The facility census was 24 with a Stage 2 sample of 18 residents. Findings are: 1. Observation on 3/1/11 at 2:30 PM in the unlocked utility/storage room revealed a can of "San-Aire" spray on the the counter, a spray bottle 1/3 full of "Oasis Germicidal Non- Acid Cleaner" in the unlocked counter under the sink, and a container of "Ind/Com Deodorizer" and a can of "San-Aire" spray in an unlocked cupboard. Interview on 3/1/11 at 2:50 PM with the DON (Director of Nursing) and the Administrator confirmed that these products were to be kept locked up to minimize the risk of accidental exposure and potential injury to the residents and the chemicals were removed. Further interview with the DON revealed that residents who were confused and wandered on the unit included Resident 30, Resident 2, Resident 6, Resident 26, Resident 16, Resident 4, Resident 19, Resident 20, and Resident 24. Review of the MSDS (Material Safety Data Sheets) revealed the following health hazard data for these products: "San- Aire" - eyes, flush with water and see physician; inhalation, remove to fresh air and see physician; "Oasis Germicidal Non- Acid Cleaner" - eyes, immediately flush eyes with cool running water, remove contact lenses and continue flushing with plenty of water for at least 15 minutes, get medical attention immediately; inhalation, remove to fresh air, if exposed person is not breathing, give artificial respiration or oxygen applied by trained personnel, get medical attention immediately; "Ind/Com Deodorizer" - eye contact, flush with large amou… | 2014-03-01 | ||
| 12903 | 12903 | MILLER MEMORIAL CARE CENTER | 2.8e+296 | P O BOX 428, 589 VINCENT AVENUE | CHAPPELL | NE | 69129 | 2011-03-02 | 279 | D | Z96X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C1b Based on record reviews and interview; the facility failed to develop the care plan regarding safety interventions for 1 resident (Resident 12) with a [MEDICAL CONDITION] disorder. Sample size was 18 and the facility census was 24. Findings are: Review of Resident 12's Record of Admission revealed the resident was admitted on [DATE]. Review of Resident 12's physician progress notes [REDACTED]. Interview with the DON (Director of Nursing) on 3/2/11 at 9:00 AM was conducted. The DON agreed that Resident 12 had an active [DIAGNOSES REDACTED]. The DON agreed that the careplan did not address interventions, precautions, and safety measures for Resident 12's [MEDICAL CONDITION] Disorder. | 2014-03-01 | ||
| 12902 | 12902 | MILLER MEMORIAL CARE CENTER | 2.8e+296 | P O BOX 428, 589 VINCENT AVENUE | CHAPPELL | NE | 69129 | 2011-03-02 | 258 | D | Z96X11 | Licensure Reference Number 175 NAC 12-006.18A3 Based on observations and staff interviews, the facility failed to repair the heater in 1 sampled resident room (Resident 19) to reduce excess noise during operation. The facility census was 24 with the Stage 2 sample of 18 residents. Findings are: Observation on 3/1/11 at 10:30 AM and on 3/2/11 at 1:00 PM revealed Resident 19 seated in the room in a recliner next to the heater. Further observation revealed that the heater was on "high" and the heater had a loud rattling sound. The rattling sound was also be heard in the hallway. Observation on 3/2/11 at 8:30 AM, during the environmental tour, accompanied by the Maintenance Director and the Administrator, revealed that the heater was on and continued with the loud, rattling sound. Interview on 3/2/11 at 8:30 AM with the Maintenance Director confirmed that the heater was noisy and needed repaired. Interview on 3/2/11 at 9:00 AM with the DON (Director of Nursing) revealed that the resident liked to have the room warm and the heater was usually set on "high". | 2014-03-01 | ||
| 12901 | 12901 | MILLER MEMORIAL CARE CENTER | 2.8e+296 | P O BOX 428, 589 VINCENT AVENUE | CHAPPELL | NE | 69129 | 2011-03-02 | 253 | E | Z96X11 | Licensure Reference Number 175 NAC 12-006.18B Based on observations and staff interview, the facility failed to ensure that a ceiling vent in the bathing room was kept clean. The facility census was 24. Findings are: Observation on 3/2/11 at 8:30 AM, during the environmental tour of the facility, accompanied by the Maintenance Director and the Administrator revealed a build up of gray, fuzzy material on the ceiling vent in the bathing room. Interview on 3/2/11 at 8:30 AM with the Administrator confirmed that the ceiling vent was to be kept clean. | 2014-03-01 | ||
| 12900 | 12900 | MILLER MEMORIAL CARE CENTER | 2.8e+296 | P O BOX 428, 589 VINCENT AVENUE | CHAPPELL | NE | 69129 | 2011-03-02 | 164 | D | Z96X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05 (21) Based on observations, record reviews, and staff interview; the facility failed to provide privacy during a skin treatment for 1 current sampled resident (Resident 6). The facility census was 24 with the Stage 2 sample 18 residents. Findings are: Review of the "Record of Admissions" revealed that Resident 6 was admitted to the facility on [DATE]. Observation on 3/1/11 at 10:25 AM revealed the resident seated in a recliner in room and MA (Medication Aide)- A entered the resident's room, removed a scarf from the resident's head which covered a lesion on the resident's scalp, provided a treatment to the lesion, and then replaced the scarf on the resident's head. Further observation revealed other residents and staff members walking in the hallway and MA -A did not close the resident's door or utilize the privacy curtain to provide privacy during the treatment. Interview on 3/2/11 at 9:00 AM with the DON (Director of Nursing) confirmed that the staff were to provide privacy for the residents during cares. | 2014-03-01 | ||
| 12899 | 12899 | SIDNEY REGIONAL MEDICAL CENTER | 2.8e+294 | 645 OSAGE STREET | SIDNEY | NE | 69162 | 2010-07-12 | 225 | D | 5DNG11 | Licensure Reference Number 175 NAC 12-006.02 (8) Based on record reviews and staff interview, the facility failed to investigate and report an accident with significant injuries for 1 current sampled resident (Resident 36) to the state agency within the required timeframe. The facility census was 53 with 12 current sampled residents. Findings are: Review of the facility "Investigative Report Incident/Unusual Occurrence" revealed that on 6/20/10, Resident 36 fell and had left radial, ulnar, humerus fractures and pubic rami fractures. Further review revealed that the investigation of this accident was started on 6/29/10 and was reported tot the state agency on 7/1/10. Interview on 7/12/10 at 1:30 PM with the Administrator confirmed that the investigation was not started immediately and completed within 5 working days and the state agencies were not notified within these time frames as required. Review of the facility procedure "Suspected Resident Abuse or Neglect", dated 9/15/98, revealed the following: ". .. 5. Investigation Procedure: . . . c. The Administrator of Long Term Care and/or Director of Nursing is responsible to: A. Investigate the abuse/alleged abuse . . . C. Provide the agencies, initially contacted, with a follow up report. . . . d. The process will be completed within 5 working days of the actual incident and faxed and mailed to the appropriate agency. . . . ". | 2014-03-01 | ||
| 12898 | 12898 | SIDNEY REGIONAL MEDICAL CENTER | 2.8e+294 | 645 OSAGE STREET | SIDNEY | NE | 69162 | 2010-07-12 | 250 | D | 5DNG11 | Licensure Refernce Number: NAC 175 12-006.09D5a Based on observation, record reviews, and interviews; the facility failed to identify medically related social services needs for 1 resident (Resident 26) in regards to obtaining medication. The facility census was 53 and the sample size was 12 current residents. Findings are: Observation on 7/8/10 at 6:35 AM revealed Resident 26 had an indwelling catheter. Review of Resident 26's consultation report dated 3/19/10 from the resident's Urologist (specializes in the disorders of the urinary tract) revealed: recurrent urinary tract infections, urgency, frequency, and incomplete bladder emptying. Review of Resident 26's consultation report dated 4/16/10 from the resident's Urologist revealed: in reviewing the medications, the resident is supposed to be taking Vesicare (medication used for overactive bladder) 5 mg (miligrams) every other day, the resident is actually not taking it at all. Further review revealed: chronic urinary tract infections, frequency, urgency, and urge incontinence. Restart Vesicare 5 mg every other day as previously ordered. Review of Resident 26's consultation report dated 5/28/10 from the resident ('s Urologist revealed "the resident was supposed to be taking Vesicare, however, apparently the Medicare Part D plan will not cover Vesicare....the majority of the office visit was spent discussing a plan to get the resident on medications versus placing a catheter...." Interview with the SSD (Social Services Director) on 7/12/10 at 3:40 PM revealed the SSD was responsible for assisting residents with prescription drug plans. The SSD was not aware of any issues regarding Resident 26's medications not being covered under the resident's current medication plan. When questioned if the medication plan could be changed if a new medication was ordered that wasn't covered by the current plan, the SSD indicated that it is possible to change plans and search for a plan that might cover the new medication. Interview with the DON (Director of Nursing) on 7/12/10 … | 2014-03-01 | ||
| 12897 | 12897 | SIDNEY REGIONAL MEDICAL CENTER | 2.8e+294 | 645 OSAGE STREET | SIDNEY | NE | 69162 | 2010-07-12 | 279 | D | 5DNG11 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09C1a Based on record review and interviews, the facility failed to develop care plan problems, goals, and interventions for 1 sampled resident (Resident 1) at risk for skin impairment. Sample size was 12 current residents. Facility census was 53. Findings are: Review of Resident 1's "Annual assessment" MDS completed on 5/19/10 revealed that Resident 1 was assessed as having "Skin desensitized to pain or pressure". Review of the corresponding RAP (Resident Assessment Protocol) Summary form accompanying the assessment revealed that Resident 1 had triggered a "RAP Problem Area" for "Pressure Ulcers" and that additional RAP documentation could be found in the "Pressure Ulcer RAP" on 5/19/10. The RAP Summary form also indicated that a "Care Planning Decision" for this problem was "addressed in care plan". Review of Resident 1's "Pressure Ulcers RAP Module" dated 5/19/10 included documentation that a care planning decision to "proceed" was determined following assessment. "Additional Notes" on the form read: " ... Resident is at risk for impaired skin related to requiring extensive assistance with bed mobility. Does not independently reposition self while in chair. Has urinary incontinence and some episodes of bowel incontinence ..." Review of Resident 1's "Long Term Care Plan" modified on 5/25/10 revealed that no problem area, goals, or interventions had been developed on the resident's care plan pertaining to the risk for impaired skin identified on the RAP summary form and RAP documentation. Interviews with the MDS Coordinator, LPN-B on 7/12/10 at 3:30 PM, and the DON (Director of Nursing) on 7/12/10 at 3:40 PM verified that Resident 1's risk for skin impairment had not been developed on the resident's care plan. | 2014-03-01 |
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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 );