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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 192 | 192 | RIVER CITY NURSING AND REHABILITATION | 285058 | 7410 MERCY ROAD | OMAHA | NE | 68124 | 2019-09-12 | 812 | L | 0 | 1 | 7GF911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC ,[DATE].11E Based on observations, interviews, review of facility documents, and review of facility policies and procedures, the facility failed to ensure the staff used non-expired test strips to test the sanitizer level of the dishwashing machine, and failed to ensure the water temperature of the dishwashing machine was maintained within an acceptable range for the effective sanitization of kitchen and food-service dishware and utensils. This deficient practice created a likelihood for the occurrence of serious injury, harm, impairment, or death from foodborne illness and placed the 90 residents capable of oral intake in immediate jeopardy. The facility had a census of 93 residents on the first day of the survey. Findings include: During the initial tour of the kitchen, accompanied by the facility's Dietary Manager (DM), on [DATE] beginning at 8:38 AM, observation revealed, and the DM confirmed, that the facility used a low-temp dishwashing machine to clean and sanitize the facility's kitchen ware and food-service ware. At 8:40 AM, observation revealed Dietary Aide (DA)17 checked the water temperature of the dishwashing machine by visualizing the water temperature gauge on the front of the machine below a built-in water reservoir. DA17 reported the water temperature registered 115 degrees Fahrenheit (F). During the observation, the DM confirmed that the water temperature was below the acceptable range of 120 degrees F at the time the temperature was tested . DA17 then tested the level of sanitizer in the water by dipping a test strip into the sanitizing solution collected in the built-in water reservoir on the front of the machine. DA17 reported the sanitizer level as 100 parts per million. At that time, observation of the container of test strips just used by DA17 to test the sanitizer level, revealed the test strips had an expiration date of [DATE]. During an interview at that same time, both DA17 and the DM st… | 2020-09-01 |
| 1363 | 1363 | LIFE CARE CENTER OF ELKHORN | 285134 | 20275 HOPPER STREET | ELKHORN | NE | 68022 | 2019-02-19 | 600 | L | 1 | 0 | 2BLY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(9) Based on record review and interview; the facility staff failed to protect residents during an investigation of a sexual assault allegation. The facility failure had the potential to affect all residents residing in the facility. The facility staff identified a census of 105. Findings are: Record review of the facility Policy and Procedure for Protection of Residents: Reducing the Threat of Abuse & Neglect revised on 2-2018 revealed the following information: -Introduction: -To minimize the threat of abuse and/or neglect , nursing homes must incorporate clear cut policy and practices that demonstrate a hardline,zero tolerance approach to resident abuse. -Position Statement and Guidelines: - Residents must not be subjected to abuse by anyone. -It is the policy and practice of this facility that all residents will be protected from all types of abuse,neglect, misappropriation of resident property and exploitation. -Investigation and Protection: -It is the policy of this facility that reports of abuse (abuse, neglect, mistreatment, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. -Procedure: -1. Following identification of alleged abuse, the resident(s)receive prompt medical attention as necessary and the resident(s) are protected during the course of the investigation to prevent recurrence. Staff will respond immediately to protect the alleged victim(s)/others and integrity of the investigation. -3. When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence. Protection will be provided to the alleged victim and other residents, such as room or staffing changes as needed to protect the resident(s) from the alleged perpetrator. Record review of a Resident T… | 2020-09-01 |
| 1370 | 1370 | LIFE CARE CENTER OF ELKHORN | 285134 | 20275 HOPPER STREET | ELKHORN | NE | 68022 | 2019-02-19 | 835 | L | 1 | 0 | 2BLY11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observations, record review and interviews; the facility staff failed to utilize facility resources to ensure provision of care and services were provided to the facility residents. This had the potential to effect all residents who reside in the facility. The facility staff identified a census of 105. Findings are: Review of the facility during a survey revealed the following deficiencies: [NAME] F580. The facility staff failed to notify the practitioner of a new wound for a sampled resident. B. F600. The facility staff failed to protect the facility residents during an allegation and investigation of a sexual assault for a sampled resident. C. F684. The facility staff failed to obtain an treatment order for a new wound for a sampled resident. D. F686. The facility staff failed to evaluate a decline in pressure ulcer healing for a sampled resident. E. F690. The facility staff failed to evaluate a toileting program for a sampled resident. F. F692. The facility staff failed to obtain weights as order by the practitioner. [NAME] 726. The facility staff failed to ensure facility nursing staff had competency reviews completed. H. F730. The facility staff failed to ensure all nursing assistants had 12 hours of education per year. I. The facility failed to have and effective Quality Assurance committee. | 2020-09-01 |
| 1371 | 1371 | LIFE CARE CENTER OF ELKHORN | 285134 | 20275 HOPPER STREET | ELKHORN | NE | 68022 | 2019-02-19 | 867 | L | 1 | 0 | 2BLY11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interviews; the facility Quality Assurance (QA) program failed to identify ongoing issues relevant to F580, F600, F684, F686, F690, F692, F726 and F730 and implement plans of action to identify and correct the deficient practice. The facility staff identified a census of 105. Findings are: Record review of the facility policy and procedure for Quality Improvement revised on 6-26-2009 revealed the following information: -Policy: This facility actively participates in a formal, written quality assessment, assurance and improvement process. The comprehensive process involves all facility departments. The process included monitoring, evaluation, and follow up action. -Committee Recommendation: -Recommendation may include, but are not limited to, the following: - Communication methods to disseminate information to resident, staff, family members, community organizations, and/or regulatory agencies. On 2-12-2019 at 7:45 AM an interview was conducted with Licensed Practical Nurse (LPN) [NAME] During the interview when asked what the facility QA committee was working on, LPN G stated I'm not sure. On 2-12-2019 at 7:45 AM an interview was conducted with LPN H. During the interview when asked what the QA committee was working on, LPN H reported could not remember. On 2-12-2019 at 7:50 AM an interview was conducted with Nursing Assistant (NA) B. During the interview, NA B reported not sure what the QA committee was working on. On 2-12-2019 at 9:27 AM a interview was conducted with NA I. During the interview, NA I reported not being aware of what the QA committee was working on. On 2-12-2019 at 9:32 AM an interview was conducted with LPN [NAME] During the interview, LPN J reported not knowing what the QA committee was working on. On 2-12-2019 at 10:30 AM an interview was conducted with Registered Nurse (RN) K. During the interview RN K reported not being aware of what the QA committee was working on. | 2020-09-01 |
| 5836 | 5836 | ROSE BLUMKIN JEWISH HOME | 285059 | 323 SOUTH 132ND STREET | OMAHA | NE | 68154 | 2016-08-24 | 371 | L | 1 | 0 | Inf | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review and interview; the facility failed to maintain food temperatures in a range to prevent food borne illness. The facility staff identified 86 of 87 resident who ate out of the facility kitchen. The facility staff identified a census of 87. Findings are: Observation on 8-12-2016 at 11:30 AM revealed a weekly Deli style lunch was being offered to the facility residents and outside community. An interview was conducted on 8-12-2016 at 11:40 AM with the Director of Food Service (DFS). During the interview the DFS confirmed food for the weekly Deli was prepared in the facility kitchen. When asked if the facility residents could have their lunch from the Deli, the DFS stated yes. On 8-12-2016 at 11:55 AM an interview was conducted with the Assistant Director of Food Service (ADFS). During the interview when asked if a resident could have their meal served from the Deli, the ADFS stated yes. The ADFS reported if residents wanted to eat from the Deli, the staff would take the food order sheet to the residents' nurse to see if what was ordered was with in the diet for the resident. Observation on 8-12-2016 at 12:05 PM revealed the Deli style lunch was being served to those community members and residents who had placed lunch orders. Further observation of the meal service revealed there was a pan of raw Tuna steak. There was brownish liquid partially covering the Tuna Steak and upon request, Cook G using the facility thermometer, obtained the temperature of the Tuna steak. Cook G reported the Tuna Steak was 50 degrees. Continued observation of the Deli service revealed Egg Salad and Tuna Salad were available for community members and residents to order. The Egg salad and the Tuna salad were observed to be sitting on top of a pan of ice. When requested, Cook B using the facility thermometer, obtained the the temperature of the Egg Salad with a resulting temperature of 48 degrees. Cook B then obtained the temperature of the Tuna Salad with the… | 2019-08-01 |
| 8311 | 8311 | HENDERSON CARE CENTER | 2.8e+174 | 1621 FRONT STREET | HENDERSON | NE | 68371 | 2014-02-27 | 323 | L | 0 | 1 | WOMQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 AND 12-006.09D7a Based on observation, interview, and record review; the facility failed to ensure one resident (Resident 18) was not left unattended while bathing in a whirlpool tub with water and failed to maintain the whirlpool tub bath belt free from rips, frayed areas, and peeling plastic pieces with rough edges affecting 37 out of 38 residents. The facility census was 38. Findings are: A. During the initial tour of the facility on 2/25/14 at 8:35 am, the facility bath house door was unlocked. There was no staff member in attendance and Resident 18 was in the whirlpool tub with water, Resident 18 was leaning forward. There was a bath belt around the resident's waist and between the resident's legs. The bath belt was loosely applied and had frayed edges. Approximately one minute later a staff member entered the bath house carrying clothing. B. Interview with BA (Bath Aide) A 2/25/14 at 8:37 am revealed that the staff member never left residents alone in the whirlpool. The BA A stated that the resident lived nearby and just went down the hall to get the resident's clothing. Interview with the DON on 2/25/14 at 9:35 am and revealed that Bath Aide A was the only staff member that bathed residents. There was only one resident that preferred showers. Interview with BA A on 2/27/14 at 9:45 am revealed that with Resident 18 (gender) always used the T- strap bath belt (belt through the legs). BA A stated the staff did not bring the resident's clothing with the resident. The BA stated unsure why left the bath house to get the clothing. BA A stated that the bath belts were the original bath belts that came with the whirlpool tub two years ago. If the BA had any trouble with the tub the BA would report it to the Maintenance department. Interview with Resident 18 on 2/26/14 at 9:05 am revealed that the resident stated that (gender) was left alone in the whirlpool tub once in a while when the resident for… | 2017-09-01 |
| 12166 | 12166 | SUTTON COMMUNITY HOME, INC. | 285277 | 1106 NORTH SAUNDERS | SUTTON | NE | 68979 | 2011-06-09 | 323 | L | 1 | 1 | 3HMU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7b Based on observation, record review and interview; the facility failed to protect one (Resident 7) from injury of burn from a heat blanket. This had the potential to affect all 30 residents due to all residents have the order for heat packs as desired for generalized discomfort. The facility census was 30 with a sample size of 27 residents. Findings are: Observation of Resident 7 at 3:05 PM on 5/31/11 revealed this resident in the dining room in motorized wheelchair waiting for nails to be polished. This resident had glasses on and was dressed in a blouse and shorts. Had ankle socks on with legs supported by bilateral wheelchair leg supports. Left lower leg wrapped with with clean, dry dressing. Interview of the Resident 7 at 4:30 PM on 5/31/11 revealed that this resident stated, "No" when asked if had pain at this time. Resident was up in motorized wheelchair in dining room watching birds in aviary. Resident pointed to left lower leg dressing and stated, "It feels better now." Resident had slow, garbled speech and was asked to repeat "It feels better now" for proper understanding. Record Review on 5/31/11 of the Physician order [REDACTED]. --original order date of 9/28/10 was for the Heat Packs BID (two times a day) and PRN (when required). May use heat packs one hour after Ketoprofen (Topical medication used for pain on left knee, lower back, left shoulder, and right forearm); --[DIAGNOSES REDACTED]. --another order with original order date of 3/2/11 was for the Heat Pack to the left hand PRN for 30 minutes for comfort and keep a minimum of 30 minutes between the applications; --Heat Pack treatment for [REDACTED]. --No order for lavender spa heat blanket. Record Review on 5/31/11 of Resident 7's MDS (Minimum Data Set federally mandated comprehensive assessment tool used for care planning, version 3.0) dated 4/11/11 revealed: --type of assessment was Annual Assessment; --sometimes makes self un… | 2014-10-01 |
| 1287 | 1287 | ARBOR CARE CENTERS-NELIGH LLC | 285124 | PO BOX 66, 1100 NORTH T STREET | NELIGH | NE | 68756 | 2019-03-11 | 880 | K | 0 | 1 | UV2T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17(17B) (17D) Based on observation, interview, and record review; the facility failed to 1) prevent potential cross-contamination of blood borne pathogens related to the use of a glucometer for Residents 3 and 7, 2) wash hands and change gloves at appropriate intervals during the provision of catheter cares for Resident 14 and incontinence cares for Resident 33, and 3) store respiratory equipment in a sanitary manner for Residents 14, 25, 32, and 21. The sample size was 7 and the facility census was 36. Findings are: [NAME] Review of the undated Blood Glucose Monitoring Competency provided by the facility revealed the following procedure: - Wash hands and apply gloves, - set up a clean field for the glucometer supplies, - turn on the glucometer, - disinfect the resident's finger with an alcohol swab, - insert the test strip into the meter, - puncture the skin with a lancet, - wipe the first drop of blood with a cotton ball, - apply pressure to the finger to collect the blood sample with the glucometer, - clean the resident's finger with a cotton ball and apply pressure until the bleeding stops, - remove the test strip and dispose of it and the lancet into a biohazard container, - remove gloves and wash hands, and - disinfect the glucometer according to manufacturer's instructions. Review of the undated Assure Platinum Blood Glucose Monitoring System User Instruction Manual provided by the facility revealed the following: - Option 1 was to clean and disinfect the glucometer at one time using an EPA-registered disinfectant detergent or germicidal wipe. - To use a wipe, remove it from the container and follow the product label instructions to disinfect the glucometer. - Option 2 was to clean the glucometer first with soapy water or [MEDICATION NAME] alcohol and then disinfect it with a diluted bleach solution or a bleach wipe with a 1:10 concentration. B. Review of Resident 3's current Care Plan with a r… | 2020-09-01 |
| 1434 | 1434 | LIFE CARE CENTER OF OMAHA | 285137 | 6032 VILLE DE SANTE DRIVE | OMAHA | NE | 68104 | 2018-03-19 | 689 | K | 0 | 1 | 93SH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.18E Based on observation, interview and record review, the facility failed to evaluate the safety and provide supervision for smoking for Residents 49 and 85 and failed to ensure that a stationary fireplace did not reach a temperature that had the potential to cause [MEDICAL CONDITION] 12 residents that were identified as self-mobile with poor safety awareness (Residents 64, 25, 43, 81, 67, 13, 65, 21, 34, 32, 23 and 62). The facility Census was 92. Findings are: [NAME] Review of the facility policy dated as effective (MONTH) 2011 revealed the facility is a nonsmoking facility for residents. Residents may not smoke on the campus. The facility will provide residents with smoking cessation assistance such as Nicotine patches to assist in their smoking cessation efforts. Interview on 3/13/2018 at 10:00 AM with the administrator revealed the facility was a non-smoking facility and residents awee required to leave the property to smoke and were not monitored by staff. Review of Resident 85's medical record revealed Resident 85 was admitted to the facility on [DATE] . Review of Resident 85's medical record revealed Resident 85 had a [DIAGNOSES REDACTED]. Review of the Social Services admission assessment dated [DATE] revealed Resident 85 wanted to smoke. Resident 85 had a BIMS (Brief Interview for Mental Status-a tool used to measure cognitive function) score of 15/15 which indicates the resident is cognitively aware. Observation on 03/20/18 at 06:30 AM revealed Resident 85 sitting in a wheelchair just outside of the facility front door. Resident 85 was wearing a coat with a loose hood and cloth gloves smoking a cigarette. Resident 85 had an oxygen tank on the back of the wheelchair. Interview on 03/20/18 at 6:35 AM with Registered Nurse (RN) - J revealed Resident 85 was allowed to go outside to smoke but was not to be smoking on the facility grounds. RN-J stated Resident 85 would be educated but continued… | 2020-09-01 |
| 1442 | 1442 | LIFE CARE CENTER OF OMAHA | 285137 | 6032 VILLE DE SANTE DRIVE | OMAHA | NE | 68104 | 2018-03-19 | 835 | K | 0 | 1 | 93SH11 | Licensure Reference Number: 175 NAC 12-006.02 Based on observations, record review, and interviews; the facility administration failed to ensure effective management of facility resources to maintain the highest practical wellbeing of residents and the facility environment as evidenced by 1) failure to implement an effective plan of action to maintain correction for previously cited areas of deficient practice, 2) failure to ensure the facility identified and developed plans of action to identify multiple issues of deficient practice Facility Census was 92. Findings are: The facility was found to be deficient in multiple areas of regulatory compliance after the tasks of the standard annual survey were completed. Please refer to the Tag citations for specific detailed findings. - F550 (formerly F151) Resident Rights. Previously cited 1/2018. - F580 (formerly F157) Notification of change of condition. Previously cited 3/2017 - F609 (formerly F225) Complete and submit investigations in 5 working days. - F657 (formerly F280) Review and Revise the comprehensive care plan. Previously cited 10/2015 - F676 (formerly F312) Provide ADL assistance. - F689 (formerly F323) Accident Prevention Previously Cited 10/2015, 3/2017, 8/2017, 12/2017. - F692 (formerly F325) Nutrition-Weight loss prevention - F697 (formerly F309) Pain Management Previously Cited 1/2017 - F730 (formerly F497) Nursing Assistants 12 hours annual continuing education. - F755 (formerly F425) Medication Storage and labeling. - F758 (formerly F428) Behavior management for residents on antipsychotic medications. - F812 (formerly F317) Safe food handling and storage. Previously Cited 8/2017 - F835 (formerly F490) Administration. - F867 (formerly F520) Quality Assurance Plan - F880 (formerly F441) Infection Control - F881 (no former F tag) Antibiotic Stewardship Program Interview on 3/21/2018 at 3:40 PM with the administrator confirmed they had multiple deficient practice. | 2020-09-01 |
| 2888 | 2888 | KEYSTONE RIDGE POST ACUTE NURSING AND REHAB | 285238 | 7501 KEYSTONE DRIVE | OMAHA | NE | 68134 | 2019-04-22 | 578 | K | 0 | 1 | BJ6K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews; the facility staff failed to ensure the desired code status was documented consistently and correctly throughout the record for 7 (Resident 53, 31, 21, 51, 1, 34, and 309) residents of 30 sampled residents. The findings are: Review of the Policy and Procedure for Code Status Listing dated ,[DATE] revealed a complete list of residents with code status will be kept in a covered paper binder at each nurse's station. [NAME]Record review of Resident 53's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 53's desire to be a DNR (Do Not Resuscitate). Record review of Resident 53's electronic medical record revealed no information regarding Resident 53's code status. Interview conducted with LPN A on [DATE] at 02:15 PM confirmed the code status was not on the electronic medical record. B.Record review of Resident 31's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 31's desire to be a Full Code/CPR. Record review of Resident 31's electronic medical record revealed no information regarding Resident 31's code status. Interview conducted with LPN A on [DATE] at 02:16 PM confirmed the code status was not on the electronic medical record. C.Record review of Resident 21's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 21's desire to be a Full Code/CPR. Record review of Resident 21's electronic medical record revealed no information regarding Resident 21's code status. Interview conducted with LPN A on [DATE] at 02:17 PM confirmed the code status was not on the electronic medical record. D.Record review of Resident 51's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 51's desire to be a DNR. Record review of Resident 51's electronic medical record revealed a F… | 2020-09-01 |
| 2906 | 2906 | KEYSTONE RIDGE POST ACUTE NURSING AND REHAB | 285238 | 7501 KEYSTONE DRIVE | OMAHA | NE | 68134 | 2019-04-22 | 835 | K | 0 | 1 | BJ6K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observation, record review and interviews the facility staff failed to utilize facility resources to ensure provision of care and services were provided to the facility residents. This had the potential to effect all residents who reside in the facility. The facility staff identified a census of 60. The findings are: Review of the current survey revealed the following deficiencies: [NAME] F578. The facility staff failed to ensure the desired code status was documented consistently and correctly throughout the medical record. B. F582. The facility staff failed to inform one resident of Medicare Coverage change by not issuing the required forms. C. F584. The facility staff failed to ensure sufficient linen and adult briefs were available for use. D. F602. The facility staff failed to complete inventory sheets for residents. E. F609. The facility staff failed to report allegations of abuse within 2 hours and failed to report a significant injury within 2 hours to the state agency. F. F656. The facility staff failed to individualize the care plan for smoking. [NAME] F677. The facility staff failed to provide oral care to a dependent resident. H. F679. The facility failed to implement specific activities. I. F689. The facility staff failed to ensure a resident was supervised during smoking, failed to ensure the laundry room, maintenance room and employee restroom was secured, and failed to maintain bathing temperatures to prevent potential scalds. [NAME] F690. The facility staff failed to implement a toileting program. K. F732. The facilty failed to ensure posted nurse staffing was completely documented. L. F741. The facility failed to ensure sufficient staffing for restorative program, failed to ensure a full time wound nurse, and failed to ensure minimum staffing was completed on the facility assessment. M. F658. The facility failed to ensure insulin and [MEDICATION NAME] were administered as… | 2020-09-01 |
| 2907 | 2907 | KEYSTONE RIDGE POST ACUTE NURSING AND REHAB | 285238 | 7501 KEYSTONE DRIVE | OMAHA | NE | 68134 | 2019-04-22 | 865 | K | 0 | 1 | BJ6K11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and interview; the facility Quality Assurance Improvement Program (QAIP) failed to identify ongoing issues relevant to F578, F582, F584, F602, F609, F656, F658, F732, F741, F761, F880 and F923 and implement effective plans of action to identify and correct the deficient practice. The QAIP failed to ensure repeated deficiencies at F677, F679, F689, F690, F759, F760, F812 and F835 were corrected and the correction maintained. The facility staff identified a census of 60. Findings are: Record review of the facility QAPI Program sheet dated 1-17-2019 revealed the following information: -#3. The outcome of the QAIP is the quality of care and quality of life of the residents. -#4. QAIP includes all employees, all departments and all services provided. -#5. QAIP focuses on systems and process's. The emphasis is on identifying system gaps. -#6. Decisions are based on data, which includes the input and experience of caregivers, residents, healthcare providers and families. -Program Purpose: -The major purpose of the QAPI committee is to improve the residents' total environment and all aspects of their lives-physical, social, physiological, spiritual and intellectual; and to improve the effectiveness, efficiency and quality of healthcare services delivered to the residents. On 4-11-2019 at 7:35 AM an interview was conducted with Licensed Practical Nurse (LPN) I. When asked if LPN J was aware of what the QAPI committee was working on, LPN I reported not aware of what the issues were. On 4-11-2019 at 7:40 AM an interview was conducted with nursing Assistant (NA) C. During the interview, NA C reported now being aware of what the QAIP committee was working on. On 4-11-2019 at 7:42 AM an interview was conducted with NA [NAME] During the interview NA J reported not being aware of what the QAIP committee was working on. On 4-11-2019 at 7:50 AM an interview was conducted with NA K. During the interview NA K was not able to identify any issue the QAIP committee wa… | 2020-09-01 |
| 2992 | 2992 | OMAHA NURSING AND REHABILITATION CENTER | 285240 | 4835 SOUTH 49TH STREET | OMAHA | NE | 68117 | 2020-02-25 | 678 | K | 0 | 1 | 3ZNV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 1[AGE] NAC ,[DATE].09 Based on record review and interviews; the facility staff failed to ensure desired code status was identified consistently and correctly for 4 (Resident 3, 32, 30 and 38) of 53 sampled residents. The facility staff identified a census of 53. Findings are: A. Record review of undated Code Status Policy (CSP) sheet revealed the following information: -Full Code: -We will initiate basic life support (oxygen therapy, establishing an airway, providing manual respirations and chest compression). In the event of [MEDICAL CONDITION] or [MEDICAL CONDITION] 911 will be notified immediately for transport to the nearest hospital. -No Code: If the death of a resident is inevitable we do not call 911 for transport to the nearest hospital. We do perform all acts that will give comfort such as oxygen if needed, pain management control, suctioning etc. We keep the physician and family updated on any condition change. The resident will remain in the facility with their normal care givers. In the event either family, resident pr physician change their minds about the code status, CPR will be preformed and then be transported to the nearest hospital. B. Record review of Resident 3's Code Status Policy (CSP) sheet with a dated of [DATE] revealed Resident 3's Representative had marked the section on the CSP to indicate Resident 3 was a full Code. Record review of a second CSP dated [DATE] for Resident 3 revealed Resident 3's Representative indicated Resident 3 was a Full Code. Further review of Resident 3's second CPS revealed Resident 3's practitioner signed the CSP that identified Resident 3 as a Full Code on [DATE]. Record review of Resident 3's Admission Record sheet printed on [DATE] in the section identified as Advanced Directive revealed A DNR (Do Not Resuscitate , or commonly known as a no code). On [DATE] at 2:20 PM an interview was conducted with Licensed Practical Nurse (LPN) A. During the interview LPN A… | 2020-09-01 |
| 2997 | 2997 | OMAHA NURSING AND REHABILITATION CENTER | 285240 | 4835 SOUTH 49TH STREET | OMAHA | NE | 68117 | 2020-02-25 | 835 | K | 0 | 1 | 3ZNV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference No. 1[AGE] NAC ,[DATE].02 Based on Record Review and Interview the Administration failed to utilize resources to ensure facility staff had the correct information regarding CPR status for 4 of 53 Residents, resident 3,30,32,38. The facility staff identified a census of 53. Findings are : D. [DATE] 09:46 AM Record Review of Resident 38 Admission record sheet printed [DATE] , in the section identified as Advance Directive revealed a DNR ( Do Not Resuscitate) or commonly known as a no code. Record review of resident 38 CSP( Code Status Policy) dated [DATE] revealed Resident 38 representative indicated Resident 38 was a Full Code. Further review of Resident 38 CSP sheet revealed Resident 38 Practioner signed the CSP sheet that identified Resident 38 as a Full Code on [DATE]. [DATE] 4:30PM Interview with LPN C ,revealed that to check the code status of facility residents, she would look at electronic records, or she would look in the Code Status Book. If the resident was going to the hospital she would send a copy of the Admission record from either the electronic records or from the Code Status Book. DB [DATE] 1:00PM Record review of all Residents Advance Directives , electronic records, and Facesheets confirmed that 4 of 53 Residents, resident 3,30,32,38, had a discrepancy regarding thier CPR status. A. Record review of undated Code Status Policy (CSP) sheet revealed the following information: -Full Code: -We will initiate basic life support (oxygen therapy, establishing an airway, providing manual respirations and chest compression). In the event of [MEDICAL CONDITION] or [MEDICAL CONDITION] 911 will be notified immediately for transport to the nearest hospital. -No Code: If the death of a resident is inevitable we do not call 911 for transport to the nearest hospital. We do perform all acts that will give comfort such as oxygen if needed, pain management control, suctioning etc. We keep the physician and family updated on a… | 2020-09-01 |
| 5462 | 5462 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2017-03-22 | 323 | K | 1 | 1 | HUVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D7 Based on observation, record review, and interview; the facility failed to ensure 2 residents (Residents 30 and 42) of 2 sampled were supervised during a whirlpool bath and failed to protect 1 resident (Resident 84) from an accident while being transported in the facility van which had the potential to affect 42 residents. The facility also failed to ensure chemicals were secured to protect residents on the SCU (Special Care Unit) from potential ingestion, skin irritation or eye irritation which had the potential to affect 11 of the 18 residents on the SCU. The facility census was 59. Findings are: [NAME] Observation on 3/22/2017 at 11:58 AM revealed Resident 42 was in the bathhouse in the whirlpool tub filled with water unattended. Interview on 3/22/2017 at 11:58 AM with ED (Executive Director) revealed the resident was in the whirlpool tub alone without supervision. Interview on 3/22/2017 at 12:37 PM with NA (Nursing Assistant) K revealed Resident 42 was left alone in the whirlpool bath as NA K went out for break. NA K went on to say the other NA's had instructed NA K it was ok for Resident 42 to be left unattended while in the whirlpool tub. Interview on 3/22/2017 at 12:10 PM with Nurse BB revealed Nurse BB was not sure if the resident had been assessed to be in the whirlpool alone. Nurse BB revealed Resident 42 did not get left in the bathroom alone due to being a fall risk. Interview with Nurse CC revealed NA K did not notify Nurse CC of Resident 42 being left in the bath house alone before taking a break. Nurse CC further stated Resident 42 was not safe to be left alone in the whirlpool. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1/6/17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 8 out of 15 which indicated Resident 42 had modera… | 2020-01-01 |
| 5468 | 5468 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2017-03-22 | 431 | K | 1 | 1 | HUVK11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1 Based on observation, record review and interviews; the facility failed to ensure medications were secured at all times on both units (the SCU: Special Care Unit and general population) with the potential for imminent harm for 18 residents on the SCU. The facility census was 59. Findings are: A Observation on 3-15-17 at 7:39 PM revealed Staff A prepared medications in the med room (medication room) on the SCU (Special Care Unit: a secured unit for residents with dementia) for Resident 50. When Staff A went to administer the medication to the resident, Staff A partially closed the med room door but left it open 2 inches. Staff A went around the corner and administered the medications to the resident. Staff A's back was to the med room door and access to the med room was not within the sight of Staff [NAME] Observation revealed Resident 75 stood at the refrigerator and kitchen counter rummaging through cabinets, drawers, and the refrigerator. The refrigerator was located directly beside the medication room door. - Observation on 3-16-17 at 4:25 PM revealed Nurse [NAME] in the medication room preparing eye drops to administer to Resident 36. Nurse [NAME] exited the med room and left the med room door wide open. The nurse walked away from the med room and the nurse's back was towards the med room the entire time during the administration of the eye drops. When the nurse turned around to go back to the med room, Resident 32 was observed in the resident's wheelchair in the med room with (gender) hands on top of the counter grabbing at items on the counter. Nurse [NAME] hurried back to the med room and intervened and took the resident out of the med room. The resident did not appear to have opened any medications. There were no medications sitting on the counter. The medicaiton room had a countertop with open shelves above the counter to hold stock bottles of multi-dose medications including Tylenol, MOM (Milk of Magnesia: a laxative), and constipation medications. Undern… | 2020-01-01 |
| 5470 | 5470 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2017-03-22 | 490 | K | 1 | 1 | HUVK11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based observation, record review, and interview; the facility failed to maintain administrative programs to address areas of repeat deficiencies and to oversee the facilities compliance with regulations. This had the potential to affect all 59 residents. Findings are: The facility was found to be deficient in the following areas of regulatory compliance after the annual survey was completed on 1-26-2016. Please reference the specific tags in regard to detailed findings: -F314 Facility failed to prevent and provide ongoing monitoring for pressure ulcers. -F332 medication error rate was at 12%. -F431 Facility failed to ensure medications were secured at all times. -F441 Infection control failed to maintain an Infection Control program and failed to prevent cross contamination in the unit refrigerators. -F520 Quality Assurance failed to develop and implement plans of actions to correct issues of deficient practice. The facility was also cited with the year prior annual survey on 12-23-14 at F 314 and F 441. Additional tags cited on this survey with an exit of 3-22-17 included: F157, F159, F179, F223, F225, F226, F248, F253, F256, F309 F323, F329, F334, F425, F428, F431, F490, F497, F498, and F520. Observation, record review, and interviews during the survey revealed 4 0ther tags cites at a Scope and Severity of Immediate Jeopardys (IJ's) at -F223 Facility failed to ensure residents were not subject to physical abuse. -F323 Facility failed to provide supervision during bathing and prevent accidents during van transportation. -F431 Facility failed to ensure medications were secured at all times. - -F520 Quality Assurance failed to develop and implement plans of actions to correct issues of deficient practice. Interview on 3-22-17 at 4:00 PM with the Executive Director (ED) revealed that ED had been overseeing the facility but had no idea the facility was having these issues. Review of the undated facility Job Description for Administrator revealed, Job Summary: Responsibl… | 2020-01-01 |
| 5473 | 5473 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2017-03-22 | 520 | K | 1 | 1 | HUVK11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.07 Based on record review and interviews; the facility's Quality Assurance Committee (QA) failed to develop and implement plans of actions to correct issues of deficient practice relevant to resident care and services and the facility failed to implement effective plans of action to maintain correction for 5 areas of deficient practice identified on the 1-26-2016 survey, including: F314, F332, F431, F441, F520. This survey also had had 4 other IJ's (immediate jeopardies) cited during the survey at F223, F323, F431, and F490. This had the potential to affect all residents that reside in the facility. The facility census was 59. Findings are: Record review of the Statement of Deficiencies for the annual survey completed 1-26-2016 revealed citations at -F314 Facility failed to prevent and provide ongoing monitoring for pressure ulcers. -F332 medication error rate was at 12%. -F431 Facility failed to ensure medications were secured at all times. -F441 Infection control failed to maintain an Infection Control program and failed to prevent cross contamination in the unit refrigerators. -F520 Quality Assurance failed to develop and implement plans of actions to correct issues of deficient practice. The facility was also cited with the year prior annual survey on 12-23-14 at F 314 and F441. Additional tags cited this survey 3-22-17 included: F157, F159, F179, F223, F225, F226, F253, F309 F323, F 329, F329, F334, F425, F428, F431, F490, F497, F498, and F520. Observation, record review, and interviews during the survey revealed 4 other IJ's at -F223 Facility failed to ensure residents were not subject to physical abuse. -F323 Facility failed to provide supervision during bathing and prevent accidents during van transportation. -F431 Facility failed to ensure medications were secured at all times. -F490 Failed to have an effective Administration to oversee the facilities compliance with regulations. Interview on 3-22-17 at 3:39 PM with the interim Administrator revealed the Admini… | 2020-01-01 |
| 6414 | 6414 | LYONS LIVING CENTER | 285301 | 1035 DIAMOND STREET | LYONS | NE | 68038 | 2018-05-10 | 600 | K | 1 | 0 | 2CLY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05(9) Based on observation, record review and interview; the facility failed to protect residents from residents with adverse behaviors. This affected all residents (Residents 1, 2, and 10) who were residing on the Memory Support Unit (an enclosed wing or hallway which specializes in care of residents with dementia or [MEDICAL CONDITION]). The sample size was 14 and the facility census was 23. Findings are: A. Review of the facility policy titled Preventing Resident Abuse dated 12/13/16 revealed a facility goal to achieve and maintain an abuse free environment. The abuse prevention/intervention program included the following: -assisting or rotating staff working with difficult residents; -training staff to understand and manage a resident's verbal, physical and sexual aggression; -assessing, care planning and monitoring residents with needs and behaviors that may lead to conflict; -assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behaviors; -involving qualified psychiatrists and other mental health care professionals to help the staff manage difficult or aggressive residents; and -striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met. B. Review of the facility policy Resident to Resident Altercations dated 12/13/16 revealed all altercations, including those that may represent resident to resident abuse, shall be investigated and reported to the Director of Nursing (DON) and the Administrator. If 2 residents are involved in an altercation the staff will: -separate the residents and institute measures to calm the situation; -identify and implement interventions to prevent reoccurrence; -update the resident's care plans; and -report the incident and corrective measures to the appropriate state agencies. C. Review of the facility policy titled Protecting Residents during Abuse Investiga… | 2019-03-01 |
| 6423 | 6423 | LYONS LIVING CENTER | 285301 | 1035 DIAMOND STREET | LYONS | NE | 68038 | 2018-05-10 | 835 | K | 1 | 0 | 2CLY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observations, record review and interview, the administration failed to ensure the facility resources were utilized in a manner to ensure provision of care and services for residents. This deficient practice provided the potential to affect all residents of the facility. The sample size was 14 and the facility census was 23. Findings are: The facility was found to be deficient in multiple areas of regulatory compliance which required an extended partial survey related to substandard quality of care. The following issues related to systems failure and/or failure to follow standards of care resulted in patterns of, or widespread failure in the facility and included the following citations: -F 600. The facility failed to protect residents from residents with adverse behaviors. This affected all residents (Residents 1, 2, and 10) who were residing on the Memory Support Unit (MSU-an enclosed wing or hallway which specializes in care of residents with dementia or [MEDICAL CONDITION]). Resident 1 displayed sexually inappropriate behaviors toward Resident 2 on 3/19/18. There was no evidence interventions were developed or implemented to protect Resident 2 from sexual abuse by Resident 1. Documentation revealed Resident 1 attempted sexual contact with Resident 2 on 4/21/18. New interventions were to have 2 staff working in the MSU at all times and for staff to provide and document every 15 minute checks of the resident. Observations during the survey revealed there were not 2 staff working in the MSU at all times. In addition, Resident 1 displayed threatening behaviors towards Resident 10 on 5/2/18. There were no interventions to prevent altercations between Resident 1 and Resident 10. -F 609. The facility failed to report, investigate and submit an investigation to the State Agency, regarding potential sexual abuse involving Resident 1 and Resident 2 which occurred on 3/19/18. The facility had a… | 2019-03-01 |
| 6919 | 6919 | GOOD SHEPHERD LUTHERAN HOME | 285148 | 2242 WRIGHT STREET | BLAIR | NE | 68008 | 2015-08-27 | 323 | K | 1 | 0 | PN1L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interview, the facility failed to ensure residents were free from a potential injury of a scald from hot liquids. This finding constituted an Immediate Jeopardy situation. This had the potential to affect Residents 61, 63, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79 and 80. The facility census was 77. Observation of the secure care unit on 8/27/15 at 5:30 AM revealed an open kitchenette area located in the dining/lounge area of the unit where residents with a [DIAGNOSES REDACTED]. The area was not visible from the nurse's station. An interview of Registered Nurse 30 (RN 30) was conducted on 8/27/15 at 5:40 AM and a temperature test of the hot liquids was verified by RN 30. A test of the temperature of the liquid dispensed on 8/27/15 at 5:40 AM from the automatic hot drink dispenser revealed the cappuccino and hot chocolate liquid dispensed was 161 degrees Fahrenheit. The hot coffee was tested for a temperature of 163 degrees Fahrenheit. RN 30 was advised of the serious and immediate concerns by the survey team. RN 30 verified the drink dispenser and the coffee maker were located in an area accessible to residents on the dementia unit and the area was unsupervised. RN 30 unplugged the hot beverage dispensers and left the unit. Interview of Licensed Practical Nurse 40 (LPN 40), who was working the secure care unit on 8/27/15 at 6:00 AM, identified the following residents as confused residents who wander on the secure unit: R61, R63, R70, R71, R72 and R73 and was advised of the serious concerns for potential injury to residents by the liquids dispensed from the hot beverage machines in an unsupervised area. Observation of two facility staff Certified Nursing Assistants (CNAs) on 8/27/15 at 6:05 AM revealed they plugged the units back in to an electrical outlet and turned the hot beverage machines on and made coffee. The two CNAs then walked out of the dining area, leaving the two drink dispensers… | 2018-08-01 |
| 6921 | 6921 | GOOD SHEPHERD LUTHERAN HOME | 285148 | 2242 WRIGHT STREET | BLAIR | NE | 68008 | 2015-08-27 | 520 | K | 1 | 0 | PN1L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of the facility's policy and procedure for the Continuous Quality Improvement (QCI) Committee and staff interview, the facility failed to ensure residents were free from a potential injury of a scald from hot liquids. This finding constituted an Immediate Jeopardy situation. This affected 13 of 77 residents with a [DIAGNOSES REDACTED]. (R61, R63, R70, R71, R72, R73, R74, R75, R76, R77, R78, R79 and R80). Observation of the secure care unit on 8/27/15 at 5:30 AM revealed an open kitchenette area located in the dining/lounge area of the unit where residents with a [DIAGNOSES REDACTED]. The area was not visible from the nurse's station. An interview of Registered Nurse 30 (RN 30) was conducted on 8/27/15 at 5:40 AM and a temperature test of the hot liquids was verified by RN 30. A test of the temperature of the liquid dispensed on 8/27/15 at 5:40 AM from the automatic hot drink dispenser revealed the cappuccino and hot chocolate liquid dispensed was 161 degrees Fahrenheit. The hot coffee was tested for a temperature of 163 degrees Fahrenheit. RN 30 was advised of the serious and immediate concerns by the survey team. RN 30 verified the drink dispenser and the coffee maker were located in an area accessible to residents on the dementia unit and the area was unsupervised. RN 30 unplugged the hot beverage dispensers and left the unit. Interview of Licensed Practical Nurse 40 (LPN 40), who was working the secure care unit on 8/27/15 at 6:00 AM, identified the following residents as confused residents who wander on the secure unit: R61, R63, R70, R71, R72 and R73 and was advised of the serious concerns for potential injury to residents by the liquids dispensed from the hot beverage machines in an unsupervised area. Observation of two facility staff Certified Nursing Assistants (CNAs) on 8/27/15 at 6:05 AM revealed they plugged the units back in to an electrical outlet and turned the hot beverage m… | 2018-08-01 |
| 7411 | 7411 | PREMIER ESTATES OF CRETE, LLC | 285170 | 830 EAST 1ST STREET | CRETE | NE | 68333 | 2015-04-21 | 223 | K | 1 | 0 | GGVC11 | Licensure Reference Number: 175 NAC 12-006.05 (9) Based on record review and interview, the facility failed to provide interventions to protect four residents (Residents 3, 7, 8 and 11) that voiced feelings of fearfulness related to the administrator yelling profanity towards staff in a manner that could be witnessed by all residents. The facility had a census of 59 residents. Findings are: A. Review of a Concern Form dated 3/13/15 filed by Resident 3 revealed the following, To: DON (Director of Nursing) Tonight before supper what (the administrator) did was uncalled for yelling on the walkie (at) all the nurses in a drill sergeant tone telling you to get off your (profanity) should've at least closed the door to your office You need to call corporate and ask for a different boss because (administrator) is very unprofessional because of cussing and yelling .(the administrator) does not treat you guys right and needs to go. Further review of the same Concern Form revealed, describe the Action that has been taken: 3/16/15 faxed/scanned to (Human Resources) and 3/19/15 Ombudsman here. Interview with Resident 3 on 4/7/15 at 9:38 AM revealed a few staff were always grouchy towards residents but that Resident 3 felt it was because of the way the administrator treated them. Resident 3 went on to describe an incident that occurred on March 13th in the afternoon. The administrator came into the facility and noticed call lights were going off and had not been answered. The administrator had an outburst and started yelling and using profanity towards staff. Resident 3 continued to report that several residents overheard this exchange because they were gathered outside of the dining room waiting for the next meal to be served. Resident 3 continued to state that this was not an isolated incident and that Resident 3 had personally heard the administrator yell and use profanity while walking the hallways at the facility. Resident 3 described feeling scared and living in a hostile environment. Resident 3 stated someone from the … | 2018-04-01 |
| 10209 | 10209 | KEARNEY COUNTY HEALTH SERVICES | 2.8e+298 | 727 EAST 1ST STREET | MINDEN | NE | 68959 | 2012-08-01 | 309 | K | 0 | 1 | NRZX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D Based on record review, staff interview, and observations; the facility failed to assess residents' change in condition, failed to assess residents pain and effectiveness of medications, the facility failed to assess lab results, failed to assess the cause of skin conditions and failed to assess causes and develop nonpharmaceutical interventions for residents anxiety. (Residents 19, 22, and 32). The faciltiy census was 30 and the survey sample size was 26. Findings are: A. Review of the DISCHARGE AND DISCHARGE SUMMARY SHEET revealed the resident was admitted on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident 19's MDS (a federally mandated comprehensive assessment tool used for care planning) dated 4/12/2012 revealed the following information about the resident: -the BIMS (Brief Interview for Mental Status) score was 5 of 15 (a score of 0 to 7 indicates severe cognition impairment), -The resident experienced short and long term memory issues, -The MDS addressed no behaviors, -Limited assist of one person physical assist for bed mobility, locomotion on unit and personal hygiene, -The resident required an extensive assist of one person physical assist for transfers, walk in the room, walk in the hall and dressing,, -The resident was dependent on two staff physical assist for toilet use, -The medication review was coded as the resident received an antianxiety one day in the assessment period and an antidepressant every day for the 7 days during the assessment period. Review of the Long Term Care Communication with the Provider, dated 6/28/2012 revealed increased episodes of agitation, biting, hitting, and kicking, wants to go home. PA (Physician Assistant) wrote an order for [REDACTED].>Review of the Laboratory Report dated 6/28/2012 for Resident 19 revealed a hand written note waiting for C & S (culture and sensitivity) along with PA initials. Review of the Physician Telep… | 2016-02-01 |
| 11105 | 11105 | GOLDEN LIVINGCENTER - SORENSEN | 285107 | 4809 REDMAN AVENUE | OMAHA | NE | 68104 | 2012-01-05 | 309 | K | 1 | 1 | 9QU611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09 Based on record review and interview; the facility staff failed to assess 5 residents ( Resident 1, 7, 11, 13, and 27) of 27 sampled and 7 non-sampled residents who had fallen, on an ongoing basis to identify potential changes in condition. The facility staff identified a census of 61. Findings are: A. Record review of the facility Neurological Check Policy and Procedure dated ,[DATE] revealed the following: -It is the policy of GLC (Golden Living Center) Sorensen to perform neurological checks when the following occurs: -MD orders the neuro (neurological) checks. -Change in mental status. -Residents sustains an un-witnessed fall, is unable to state whether he/she hit their head and it is not clear that the resident did not hit their head. -1. Check every 15 minutes x 4 for 1 hour. -2. Check every 30 minutes x 2 for 1 hour. -3. Check every hour x 4 hours. -4. Then check every 8 for 72 hours. Record review of a Admission Record dated [DATE] revealed Resident 27 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Resuscitation Orders sheet dated [DATE], revealed Resident 27 had documentation for "no CPR". Record review of Resident 27's Minimum Data Set (A federally mandated comprehensive assessment tool used for care planning) dated and signed on [DATE] revealed the facility staff assessed the following about the resident: -Resident 27 had short and long term memory problems. -Decision making was severely impaired. -Required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. -Balance during transitions and walking was assessed as " not steady, only able to stabilize with human assistance". -Frequently incontinent of bowel, bladder and having falls since admission. Additional [DIAGNOSES REDACTED]. Record review of Resident 27's Progress Notes dated [DATE] revealed … | 2015-08-01 |
| 11273 | 11273 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 323 | K | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record review and staff interviews; the facility failed to assure residents were free of injury from hot liquid spills. Resident 28 was not assessed for risk of hot liquid spills and sustained a burn after spilling coffee. In addition, hot water temperatures were not monitored to ensure residents who received showers were protected from potential burn injury. This affected 23 residents (Resident 35, 10, 12, 4, 17, 6, 34, 28, 37, 33, 1, 29, 15, 9, 18, 40, 36, 23, 2, 24, 39, 43, and 38). Facility census was 33. Findings are: A. Review of facility Hot Beverage Safety Guideline policy (revision date 4/2013) revealed residents were to be assessed using the Hot Beverage Safety Evaluation upon admission, quarterly and as needed to determine ability to independently consume hot beverages safely. Staff were to ensure supervision and assistance was provided as identified by the Hot Beverage Safety Evaluation and witnessed unsafe practices associated with the consumption of hot beverages were to be reported to the Nursing Department Manager/Designee with interventions implemented as required. B. Review of Resident 28's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/18/14 revealed [DIAGNOSES REDACTED]. Review of a facsimile (fax) dated 11/21/14 at 7:52 PM revealed Resident 28's physician was notified of a "...burn from hot coffee." The resident spilled coffee and sustained reddened skin areas on the inner left thigh from groin to knee and a 3 centimeter (cm) area on the left inner foot. Documentation further indicated that 45 minutes later the redness to the resident's inner thigh had decreased to "...mid inner thigh approx. (approximately) 5 cm" and the reddened area to the foot had " ...decreased as well." Review of Resident 28's medical record revealed no evidence to indicate a Hot Beverage Safety Evaluation was completed unt… | 2015-07-01 |
| 1139 | 1139 | ARBOR CARE CENTERS-O'NEILL LLC | 285108 | PO BOX 756, 1102 NORTH HARRISON | O' NEILL | NE | 68763 | 2016-11-21 | 309 | J | 0 | 1 | QLXM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observation, interview, and record review; the facility failed to provide diet modifications to prevent potential aspiration for Resident 57 and to provide assessment and monitoring for Residents 31 and 39 who were receiving [MEDICAL TREATMENT] (A method used to treat kidney disease by clearing metabolic waste products, toxins, and excess fluid from the blood). The sample size was 43 and the facility census was 68. Findings are: [NAME] Review of the facility policy and procedure titled Thickened Liquids with a revision date of 3/9/15 revealed the following: - Thickened liquids will be served to residents as ordered by the physician. - The Food Services Director will record the ordered consistency on the resident's tray card. - Pre-thickened liquids will be used whenever possible. - For beverages which must be thickened, the beverage will be thickened by the dietary staff prior to leaving the kitchen. Review of an undated facility policy titled, Thickened Liquids revealed there were 3 types of thickened liquids: -Nectar Consistency- a consistency of nectar, or milkshakes; -Honey Consistency- a consistency of honey and thicker than nectar consistency; and -Pudding Consistency- the thickest of the three consistencies and the consistency of pudding. B. Review of a Hospital Progress Note dated 9/14/16 revealed Resident 57 was admitted to the hospital on [DATE]. Further review revealed Resident 57 aspirated after being admitted to the hospital with [REDACTED]. Review of Resident 57's Progress Note dated 9/21/16 at 4:51 PM revealed the resident returned to the facility from the hospital on [DATE] at 2:15 PM. Review of Resident 57's Order Summary Report revealed an order for [REDACTED]. Review of a Telephone Order dated 9/23/16 revealed Resident 57's diet was changed to a full-liquid diet with liquids thickened to honey consistency due to difficulty swallowing. Review of Resident 57's Progress Not… | 2020-09-01 |
| 2438 | 2438 | WAKEFIELD HEALTH CARE CENTER | 285209 | 306 ASH STREET | WAKEFIELD | NE | 68784 | 2019-01-16 | 689 | J | 1 | 0 | QW7C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER ,[DATE].09D7 Based on observations, record reviews and interviews, the facility failed to: 1) ensure interventions were in place for the prevention of elopement (when a resident leaves the premises or a safe area without authorization and/or supervision) for Residents 1, 3, 8 and 9; and 2) develop interventions for the prevention of elopement for Resident 2. The sample size was 9 and the facility census was 22. Findings are: [NAME] Review of the facility policy titled Wander Guard monitoring system dated ,[DATE] revealed the facility utilized an elopement prevention system known as Wander Guard (a bracelet/signaling device is worn by the resident and sounds an alarm if the resident comes within a certain distance of the door). The policy included the following: -Nursing staff were to determine at the time of admission, which residents were at risk for wandering. A wandering risk assessment was to be performed on the day of admission; -Residents determined to be at high risk to wander (scoring 8 or above on the wandering assessment) would have a signaling device applied to their dominant wrist. Due to certain conditions alternate placement of the signaling device might be necessary; -The 90 day signaling device would be checked daily to ensure it was functioning; and -Problems with the Wander Guard signaling devices would be immediately reported to the Director of Nursing (DON and the Administrator and the Care Plan would be updated to reflect additional safeguards. B. Interview with Licensed Practical Nurse (LPN)-A on [DATE] at 4:40 PM revealed 6 residents currently residing in the facility wore Wander Guards. LPN-A indicated the following: -Resident 1's Wander Guard was not functioning; -Resident 1's Wander Guard could not be replaced as there were no additional Wander Guard bracelets available in the facility. C. Review of Resident 1's Wandering Risk assessment dated [DATE] revealed the following regarding Resid… | 2020-09-01 |
| 2439 | 2439 | WAKEFIELD HEALTH CARE CENTER | 285209 | 306 ASH STREET | WAKEFIELD | NE | 68784 | 2019-01-16 | 835 | J | 1 | 0 | QW7C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].02 Based on observations, record review and interview, the Administration failed to ensure effective management of facility resources to: 1) ensure the safety of 6 residents who were identified at risk for elopement (when a resident leaves the premises or a safe area without authorization and/or supervision) and utilized Wander Guards (a bracelet/signaling device is worn by the resident and sounds an alarm if the resident comes within a certain distance of the door); and 2) failure to maintain an effective plan of action to prevent resident elopement with Resident 2 subsequently eloping from the facility on [DATE]. The sample size was 9 and the facility census was 22. Findings are: Review of deficient practice identified during the survey revealed the following: -F 689. [NAME] On [DATE] Wander Guard signaling devices for 2 residents (Residents 1 and 3) were expired and Resident 3's Wander Guard signaling device was not functioning when tested . There were no additional replacement Wander Guard signaling devices available in the facility. Additional interventions for the prevention of elopement were not developed. B. Facility interventions developed [DATE] for the prevention of resident elopements were ineffective as Resident 2 eloped from the facility on [DATE]. Resident 2 was identified at moderate risk for elopement, however interventions for the prevention of elopement were not developed prior to the resident eloping from the facility on [DATE]. C. Failure to ensure a safe environment for residents identified at risk for wandering was cited during the annual survey on [DATE]. The facility plan of correction indicated a Wander Guard monitoring device was installed at the entrance of the east hallway to the Assisted Living portion of the building. While this device was observed in place during the complaint survey, the alarm would not be activated if the Wander Guard signaling device worn by the r… | 2020-09-01 |
| 3020 | 3020 | OMAHA NURSING AND REHABILITATION CENTER | 285240 | 4835 SOUTH 49TH STREET | OMAHA | NE | 68117 | 2019-11-26 | 755 | J | 1 | 0 | K9BO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > State Licensure tag 175 NAC ,[DATE].10. Based on interview, observation and record review; the facility failed to administer medications for Residents 1 and 2 using the 5 Rights of medications administration. This affected 2 of 2 sampled residents. The facility identified a census of 63 at the time of the survey. Findings are: The 5 Rights of medication administration are The Right Medication The Right Dose The Right Time The Right Route The Right Patient The five rights, as stated, focus on the performance of individuals and do not reflect the fact that drug safety is a culmination of efforts of professionals from several disciplines, the responsibility for accurate drug administration lies with multiple individuals and reliable systems. Some of the factors contributing to a medical team's failure to accurately verify the five rights, despite their best efforts, include: Poor Lighting [NAME] An interview with the DON (Director of Nurses) at [DATE] at 10:48 AM revealed; that the staff had done a sweep of the property and found a bottle of Smirnoff Vodka 375ml. This was found in the front of Entrance of the building in a trash can. In the interview with the DON confirmed; that the medication administration for Resident 1 and Resident 2 was done outside the building. The DON reported that they did not know how well lit the area was at the time of medication administration. The DON confirmed that both Resident 1 and Resident 2's medication were delivered at the same time, outside. An interview on [DATE] at 10:48AM with RN (Registered Nurse) at UNMC (University of Nebraska Medical Center) revealed; Resident 1 was positive for opioid and alcohol. Resident 1's BAC (Blood Alcohol Concentration) was 239. The specific opioid and [MEDICATION NAME]. Record review of Resident 1's MAR (Medication Administration Record) revealed; No record of [MEDICATION NAME]. Record review of Resident 1's Quarterly MDS (Material Data Set- a comprehensive federally mand… | 2020-09-01 |
| 5456 | 5456 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2017-03-22 | 223 | J | 1 | 1 | HUVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05 (9) Based on record review, observation, and interview; the facility failed to ensure residents were not subjected to physical abuse. This violation effected one of five sampled residents, Resident 40. The facility census was 59. Findings are: A review of the Facility's policy and procedure titled ABUSE AND NEGLECT, last revised 11/16, revealed the purpose of the policy was to ensure residents are not subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the individual, family members or legal guardians, friends or other individuals A review of the facility's documentation of Investigation of ABUSE, NEGLECT, OR MISAPPROPRIATION dated 2/22/17, revealed that on 2/9/17, Resident 81 was observed by staff to be hitting Resident 40 on the head with a hairbrush. The residents, who resided in the same room on the facility's Special Care Unit (SCU)-for Memory Care, were immediately separated. Resident 81 was sent out to an area Hospital's Behavioral Unit for evaluation and returned to the facility on [DATE] . The outcome of the facility investigation was to continue to monitor Resident 81's interactions with roommate as well as other residents, and make a room change when one was available. A review of Nurses Notes for Resident 40 revealed a note dated 2/9/2017 at 12:41 which documented that the resident was struck with a hairbrush on the resident's head by roommate (Resident 81). Two staff members were in the resident's room when incident occurred. Residents 40 and 81 were immediately separated and no injuries are noted at the time for Resident 40. The documentation indicated that Safety precautions are being advised. Further review of Resident 40's Nurses Notes, dated 2/9-3/5/17, revealed no further documentation related to the incident on 2/9/17 nor interventions which were put into place to ensur… | 2020-01-01 |
| 5522 | 5522 | SORENSEN CARE AND REHABILITATION CENTER, LLC | 285107 | 4809 REDMAN AVENUE | OMAHA | NE | 68104 | 2016-11-14 | 309 | J | 1 | 0 | 7EEE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC ,[DATE].09 Based on record review and interview, the facility failed to assess and provide emergency treatment as needed for Resident 1. Sample size was five residents. The facility Census was 66 The facility policy titled Clinical Health Status Version# 5, dated with an effective date of [DATE] revealed: The process for identification of change of condition included gathering objective data and documenting assessment findings, resident and physician and family notification. A record review of the Admission Record, dated (MONTH) 3, (YEAR), revealed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of a Nurse's note dated [DATE] at 10:30 AM by Registered Nurse (RN) B revealed Resident 1's vital signs were a temperature of 97.2 degrees Fahrenheit. Resident 1's blood pressure had been ,[DATE] and a pulse was 108. Resident 1's respiration rate was 18 breaths per minute and had an oxygen saturation of 96% on room air. Resident 1 was alert and oriented. Resident 1 was independent with transfers and ambulated with a walker. Resident 1 was independent with activities of daily living (ADL's). Resident 1 had no shortness of breath and did not require oxygen. Resident 1 had no complaints of pain and was using the telephone and talking with family and friends. A record review of Resident 1's medical record, titled Progress Note dated [DATE] at 6:00 AM, written by Licensed Practical Nurse (LPN) A, revealed that Resident 1 was yelling and was having trouble breathing. The on-duty, Nursing Assistant (NA) requested that the nurse report to Resident 1's room. Resident 1's oxygen saturation was 84% (Lippencott's Nursing Center states that SpO2, or pulse oximetry, is normal when in the range of 97 to 99 percent). Resident 1 presented with good color and was assisted to bed. An assessment of Resident 1's lungs revealed clear sounds in the upper lungs bilaterally and diminished so… | 2019-11-01 |
| 5817 | 5817 | SIDNEY REGIONAL MEDICAL CENTER-EXTENDED CARE | 285290 | 549 KELLER DRIVE | SIDNEY | NE | 69162 | 2016-09-27 | 226 | J | 1 | 0 | CZTZ11 | > Licensure Reference Number 175 NAC 12-006.05 (9) Based on record reviews and interviews, the facility failed to ensure that staff reported allegations of staff to resident abuse immediately to administrative staff to protect the resident from further opportunities of abuse for one sampled resident (Resident 1). The facility census was 50. Findings are: Review of the facility Investigative Report Incident/Unusual Occurrence, completed by the DON (Director of Nursing), revealed that on 9/9/16 at 3:00 PM NA (Nursing Assistant) - A reported that NA - B was too rough with Resident 1 during cares on 9/2/16. Further review revealed that NA - A reported that during the cares the resident stated to NA - B don't be so rough that hurts and get out of here I don't want you in here and NA - B continued with the resident's cares. NA - A reported that NA - B bent over and got into the resident's face and prayed over the resident and stated in a mocking way God bless your angry hateful soul and sung taunting like songs over the resident. When the cares were completed NA - A tried to report the incident to a charge nurse who was on the phone and told NA - A to find (gender ) after break. Later, in the dining room, NA - A reported that NA - B was tauntingly blowing kisses and making comments to the resident during the meal. NA - A and another staff member assisted the resident later in the evening and the resident stated that (gender) didn't want NA - B in the room again. Further review of the report revealed that RN (Registered Nurse) - C, Charge Nurse, stated that NA - A reported the incident at approximately 6:00 PM on 9/2/16. RN - C instructed NA - A to write out concerns and put it under the DON's office door. RN - D, Charge Nurse, stated was aware of the incident at approximately 7:30 PM - 8:00 PM from NA - B. Review of the nursing Schedule revealed that NA - B was not suspended pending an investigation to protect the resident from potential further abuse. NA - B worked the evening shift on 9/9/16 , the day shift on 9/10/1… | 2019-09-01 |
| 5887 | 5887 | SORENSEN CARE AND REHABILITATION CENTER, LLC | 285107 | 4809 REDMAN AVENUE | OMAHA | NE | 68104 | 2016-08-16 | 223 | J | 1 | 0 | ROML11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number : 175 NAC 12-006.05 (9) Based on observations, record review and interviews; the facility failed to protect Resident 2 from residents with sexual behaviors. The facility census was 69. Findings are: A. Review of the facility investigation dated 8/1/2016 revealed Resident 2 reported to the Social Services Designee(SSD) that Resident 1 came into the sunroom where Resident 2 was reading and Resident 1 exposed genitals to Resident 2. Resident 1 then attempted to kiss Resident 2, at which time, Resident 2 told resident 1 to leave and kicked at Resident 1 who did leave. However, Resident 1 returned to the room dancing with genitalia exposed. Review of Resident 2's most recent MDS (Minimum Data Set: a federally mandated assessment tool used for care planning) dated 5/26/2016 revealed Resident 2 score was 15, indicating Resident 2 was cognitively alert and oriented and able to make decisions. Interview on 8/3/2016 at 10:00 AM with Resident 2 revealed Resident 2 confirmed the same information that was in the facility report. Resident 2 revealed that the incident with Resident 1 was really creepy and made Resident 2 very uncomfortable. Resident 2 stated (gender) did not want Resident 1 around. Resident 2 revealed a similar incident had happened about 1 1/2 years ago and Resident 1 had touched Resident 2 which that was uncomfortable also. Record review of Resident 2's medical record revealed an untitled document dated (MONTH) 27, (YEAR), indicating that Resident 2 was concerned about another resident coming into Resident 2's room. Interview on 8/3/2016 at 2:30 PM with the Administrator revealed the other resident referred to in the document was Resident 1. Interview on 8/3/2016 at 11:30 AM with the Director of Nursing (DON) revealed that Resident 1 did walk outside in the fenced in area and had been seen looking in Resident 2's window before Resident 2 was moved to the current room. Review of Resident 1 MDS dated [DATE] reve… | 2019-08-01 |
| 5896 | 5896 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2016-08-31 | 284 | J | 1 | 0 | F2SC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09C2 Based on observations, interviews, and record reviews; the facility failed to develop a post-discharge plan for one sampled resident (Resident 4) including: 1) involvement of the physician; 2) determination of safety capabilities and consultation with therapy to meet physician recommended discharge requirements; and 3) pre-assess the safety of the discharge environment and acceptance of discharge by the resident's family. The facility additionally failed by aiding the resident to transport and remain in a setting incapable of meeting the resident's safety needs. The failure resulted in Immediate Jeopardy of the resident's safety and led to a resident fall and fracture culminating in hospitalization . Facility census was 27. Findings are: Record review of Resident 4's Admission Record printed on 8/30/16 revealed the resident was initially admitted to the facility on [DATE]. Among medical [DIAGNOSES REDACTED]. Record review of Resident 4's Quarterly review assessment MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) dated 8/22/16 revealed the following: - The resident's Functional Status for Transfer- how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position was recorded as Extensive assistance- resident involved in activity, staff provide weight-bearing support at a minimum of three times during a seven day period. The Support provided for the activity was One person physical assist. - The resident's Functional Status for walking in and out of room was recorded as Activity did not occur. - The resident's Functional Status for Locomotion off unit- how resident moves to and returns from off-unit locations (e.g. areas set aside for dining, activities, or treatments) . how resident moves to and from distant areas on the floor. If in wheelchair, self sufficiency once in chair. The item recorded… | 2019-08-01 |
| 6168 | 6168 | NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER | 285271 | 2100 CIRCLE DRIVE | SCOTTSBLUFF | NE | 69361 | 2016-06-06 | 333 | J | 1 | 0 | VYV311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC ,[DATE].10D Based on record reviews and interviews, the facility failed to clarify dosage calculations prior to administering a narcotic medication to one sampled resident (Resident 5). The failure resulted in overdosing the resident resulting in the resident's death. Facility census was 47. Findings are: Record review of an undated Resident Admission Record for Resident 5 revealed the resident was admitted to the facility on [DATE]. Record review of a Palliative Care Consultation document for Resident 5 dated [DATE] revealed the resident was assessed by a Palliative Care Nurse Practitioner. The Nurse Practitioner described the resident as having steadily declined in the past 2 years since the resident fractured a hip. The resident was assessed sitting in a recliner and answered simple questions. The Nurse Practitioner recorded There are no signs of acute distress at this time. Following assessment of the resident the Nurse Practitioner ordered [MEDICATION NAME] liquid 1 mg (milligram) by mouth or sublingually (under the tongue) q (every) 12h (12 hours). Prescription sent to pharmacy. Record review of an untitled document revealed 30 cc (cubic centimeters or milliliters) of [MEDICATION NAME] was received at the facility on [DATE]. Record review of an Individual Resident's Controlled Substance Record for Resident 5 revealed 30 ml (milliliters) of [MEDICATION NAME] was received on [DATE]. Further review of the record revealed MA (Medication Aide)-J administered a 0.5 ml dose at 9:00 p.m. On [DATE], MA-F administered a 1 ml dose of [MEDICATION NAME] at 8:33 a.m. On [DATE], MA-I administered a 1 ml dose of [MEDICATION NAME] at 8:00 p.m. on [DATE]. Record review of Resident 5's Resident Progress Notes between [DATE] and [DATE] revealed no entry on ,[DATE] and an entry on [DATE] recorded at 8:41 p.m. which read: Entered room @ (at) 2030 (8:30 p.m.), resident has no noted pulse or resp (respirations) Record revi… | 2019-06-01 |
| 6171 | 6171 | NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER | 285271 | 2100 CIRCLE DRIVE | SCOTTSBLUFF | NE | 69361 | 2016-06-06 | 520 | J | 1 | 0 | VYV311 | > Licensure Reference Number 175 NAC 12-006.07C Based on record reviews and interview, the facility failed to ensure that the QA&A (Quality Assessment and Assurance) Committee 1) developed and implemented an action plan to reduce the risk for medication errors which were identified at the annual survey and 2) identified that medication administration competencies were not completed for seven medication aides to ensure safe medication administration. The facility census was 47. Findings are: A. Review of the survey findings from the annual survey, dated 2/4/16, revealed a deficiency cited for medication errors. The medication rate was eight percent. Review of the findings for the current survey revealed that a medication error occurred during the medication pass observations and a significant medication error resulting in resident death was cited. B. Review of the findings for the current survey revealed that medication administration competencies were not completed for medication aides currently administering medications for the residents. A deficiency was cited at F 499. Review of the facility Quality Assurance Policy, dated 8/30/05, revealed that the following: Policy: The Quality Assessment/Assurance Committee shall determine opportunities for improvement, develop mechanisms that scrutinize appropriateness, effectiveness, efficiency and safety of the service rendered. Interview with the Administrator on 6/6/16 at 2:00 PM confirmed that the QA&A Committee was responsible to ensure that identified deficiencies were corrected and that staff were competent to perform their jobs. | 2019-06-01 |
| 6433 | 6433 | THE AMBASSADOR LINCOLN | 285066 | 4405 NORMAL BLVD | LINCOLN | NE | 68506 | 2016-02-29 | 328 | J | 1 | 0 | 5EYL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference: 175 NAC 12-006.09D6 Based on interviews and record reviews, the facility failed to ensure an Oximeter (oxygen saturation monitoring device) was turned 'on' and functioning to alert staff of the declining oxygen saturation level for Resident 1. Facility census was 76. Findings are: A. Review of Admission report in the Medical Record for Resident 1 revealed an admission to the [MEDICAL CONDITION] Unit on 2/8/16. Resident 1's code status was changed to Do Not Resuscitate on 2/11/16 per Resident 1 Power of Attorney. Resident 1 had medical [DIAGNOSES REDACTED]. - Pneumonia, - Extreme [MEDICAL CONDITION], - Hypoventilatio[DIAGNOSES REDACTED] with severe obstructive sleep apnea, - History of Chronic [MEDICAL CONDITION] (an incision in the windpipe for artificial opening through the neck to allow passage of air or evacuate secretions), - History of Motor Vehicle Accident with chronic disability. - [MEDICAL CONDITION] requiring mechanical ventilation,(an appliance for artificial respiration/ breathing) - weaning protocol, guarded prognosis given the obesity hypoventilation history and [MEDICAL CONDITION] (without oxygen) [MEDICAL CONDITION], - previous [MEDICAL CONDITION] ( [MEDICAL CONDITION]), - Heart Failure, and - [MEDICAL CONDITION]. A Facsimile (FAX) communication report dated 2/16/16 to Resident 1's Pulmonologist (Respiratory tract/Lung disease specialist) revealed a request, (MONTH) we [MEDICAL CONDITION] (administration of air or oxygen through cannula tube in the patients neck opening) trials daytime. The Physician ordered that the facility would advance [MEDICAL CONDITION] trial for Resident 1 for daytime only but the resident required the [MEDICAL CONDITION] (machine for non-invasive form of mechanical ventilation therapy for sleep apnea) at night. Review of facility investigation report for Resident 1 from the incident on 2/20/16 revealed an unexpected death of Resident 1 when found at respiration check to be withou… | 2019-02-01 |
| 6577 | 6577 | PLATTSMOUTH CARE AND REHABILITATION CENTER, LLC | 285104 | 602 SOUTH 18TH STREET | PLATTSMOUTH | NE | 68048 | 2015-12-03 | 155 | J | 1 | 0 | YK8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC ,[DATE].05(4) Based on interview and record review, the facility failed to follow the cardiopulmonary resuscitation (CPR) directive for one resident (Resident 1). The facility census was 100. Findings are: Review of Resident 1's Resuscitation Orders dated [DATE] revealed that in the event of cardiac and/or respiratory arrest Resident 1 wanted CPR initiated. Review of Resident 1's Nurses Notes, dated [DATE], revealed that the resident was found at 7:05 PM with no vitals or respiration. CPR was initiated and 911 was called, Director of Nursing (DON) was notified. During an interview with Licensed Practical Nurse A (LPN A) on [DATE] at 2:40 PM, LPN A revealed that, on the evening shift of [DATE], LPN A came up to the nurses station on the central unit while LPN B and Registered Nurse C (RN C) were having a discussion that Resident 1 had died and that they were unsure of Resident 1's CPR status. LPN A informed them that Resident 1's directive was to initiate CPR and that 911 needed to be called. LPN A stated that LPN A got the crash cart (a mobile cart carrying medical equipment used for resuscitation) and went to Resident 1's room but didn't have the key to turn the oxygen tank on and had to go back to get it. LPN A said that this all took about 5 minutes. LPN B was interviewed by telephone on [DATE] at 2:10 PM. LPN B said that on [DATE] after supper, RN C came to the nurses station and told LPN B that Resident 1 had died . LPN B said that, We kinda thought (Resident 1) was a no code. LPN B said it was ,[DATE] minutes before CPR was started on Resident 1. On [DATE] at 5:31 PM, RN C was interviewed by telephone. RN C stated that RN C found Resident 1 in room and unresponsive at 7:05 PM. RN C went to the nurses station and called LPN B and checked the resident's chart for the code status. Asked how long from the time Resident 1 was found unresponsive until CPR was initiated, RN C said, about 10 minutes. Review … | 2018-12-01 |
| 8679 | 8679 | GRETNA CARE CENTER | 285146 | 700 HIGHWAY 6 | GRETNA | NE | 68028 | 2013-12-04 | 309 | J | 0 | 1 | T6KG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09D Based on observations, record review and interview, the facility failed to provide CPR (Cardiopulmonary Resuscitation) in accordance with the resident's signed and documented advanced directives for Resident 77. In addition, the facility failed to identify code status on room name plates with as identified in the facility policy for Resident 51 and Resident 31. Resident census was 57. Findings are: Resident 77 was admitted to the facility on [DATE] according to the Face Sheet. Resident was admitted for rehab and nursing support related to L knee non-displaced lateral tibial plateau fracture according to the Discharge summary under the category nursing summary/discharge instructions. Resident 77 died on [DATE]. Resident 77 was assisted with ADL's (Activities of Daily Living) and participated with activities and therapy during resident stay at the facility. A document entitled Preferred Intensity of Medical Care and Treatment dated [DATE] and signed by the resident's daughter and POA (Power of Attorney) for Healthcare stated: I have fully discussed my future options for medical care and treatment, with both my physician and the facility. I have been informed of the benefits and risks of such options, and the potential consequences, and I am fully aware of my right to determine the course of my future treatment. Having considered all of these factors, I hereby direct my caregivers to honor my intentions with respect to the following treatments, should the need arise, all of which have been explained to me. An X marked the area of Resuscitate (Full Code) and Hospitalize. The document was signed by the resident's Healthcare Power of Attorney and witnessed by a facility representative. The physician signed the document and dated it on [DATE]. Record review of the Nurses Notes dated [DATE] at 2110 revealed the Med pass nurse went into the resident's room to give HS (hour of sleep) medications and found … | 2017-03-01 |
| 9101 | 9101 | HUNTINGTON PARK CARE CENTER | 285251 | 1507 GOLD COAST ROAD | PAPILLION | NE | 68046 | 2014-10-16 | 309 | J | 1 | 0 | BXXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12-006.09D Based on interviews and record review, the facility failed to implement interventions to protect residents from potential harm after statements of suicidal ideation for two residents (Residents 6 and 10). The facility had a total census of 91 residents. Findings are: A. Resident 6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident 6's 9/16/14 MDS (Minimum Data Set; a comprehensive assessment used for care planning) under Staff Assessment of Resident Mood revealed Resident 6 was identified as having stated life isn't worth living, had wishes for death, or attempts to harm self for 2-6 days out of the last 2 weeks. A review of Resident 6's Care Plan revealed a focus area dated 8/1/14 regarding Resident 6's [DIAGNOSES REDACTED]. Interventions for this focus area included the following: monitor/document report as needed any risk for harm to self, suicidal plan, past attempt at suicide, risky behavior, intentional harm or tried to harm self, refusing to eat or drink, refusing medication or therapies, sense of hopelessness or helplessness, or impaired judgment or safety awareness. A review of Progress Notes for Resident 6 revealed a note dated 9/27/14 at 5 PM that stated Resident 6 had a plan to kill self. Resident 6 would not state what Resident 6's plan was. The Progress Note stated Resident 6 told staff members to get out of the room and slammed the door behind them. According to the note, RN A (Registered Nurse) went to check on Resident 6 20 minutes later and could not open door as Resident 6 had backed wheelchair up against room door. RN A entered room through the bathroom connected to another room. Resident 6 refused to respond to RN A and spit in RN A's face. A Progress Note dated 9/27/14 at 6:50 PM stated Resident 6 was transferred to the hospital for suicidal thoughts with a plan and delusions. In an interview on 9/30/14 at 2:32 PM, RN A reported after Resident … | 2016-11-01 |
| 9241 | 9241 | GOLDEN LIVINGCENTER - GRAND ISLAND PARK PLACE | 285105 | 610 NORTH DARR AVENUE | GRAND ISLAND | NE | 68803 | 2013-03-21 | 309 | J | 0 | 1 | FG2G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09 Based on record review and interview, the facility staff failed to ensure a licensed nurse assessed the change in condition of 1 resident (Resident 09) who had become unresponsive and the facility staff failed to assess the resident after a medication error. The facility census was 55 and the survey sample size was 45. Findings are: Review of an ADMISSION RECORD dated 7/12/12 revealed Resident 09 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A. During an interview on 3/12/13 at 2:57 PM, Resident 09's child revealed that on Wednesday, 3/6/13, the child came to visit the resident during supper at about 6:00 PM. Resident 09's child revealed the resident was found in the dining room and was unresponsive even after the sternum rub (a method to check for a person's response by rubbing the sternum with the knuckles of the hand). Resident 09's child stated staff were in the area, but no one noticed, so the child took Resident 09 to the bedroom and started oxygen on the resident. Resident 09's child revealed the resident was taken to the hospital and given [MEDICATION NAME] (an intravenous medication that prevents or reverses the effects of opioids/narcotics including respiratory depression, sedation and [MEDICAL CONDITION]). Resident 09's child explained the resident returned to the facility later on 3/6/13, but the next day on 3/7/13, Resident 09 became unresponsive again and returned to the hospital. During an interview on 3/12/13 at 6:23 PM, Nursing Assistant (NA) -E revealed that, at about 6:00 PM on 3/6/13, the NA first thought Resident 09 was sleeping in the dining room. Then NA-E noticed the resident did not have oxygen (O2) on and NA-E was unable to wake the resident. NA-E described that Resident 09 had the head tilted back and the skin was bluish. NA-E revealed Resident 09's unresponsiveness was brought to Registered Nurse (RN) - F's attention. The RN was on break and RN-F … | 2016-09-01 |
| 9242 | 9242 | GOLDEN LIVINGCENTER - GRAND ISLAND PARK PLACE | 285105 | 610 NORTH DARR AVENUE | GRAND ISLAND | NE | 68803 | 2013-03-21 | 333 | J | 0 | 1 | FG2G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.10D Based on record review and interview, the facility failed to ensure 3 residents (Resident 09, 64, and 57) were free of significant medication errors. These failures involved the administration of narcotic and anticoagulant medications. The facility census was 55 and the survey size was 45. Findings are: A. Review of the facility's MEDICATION ERROR AND ADVERSE DRUG REACTION REPORTING dated 10/07 revealed Medication Error/Variance shall be defined as any preventable event that may cause or lead to inappropriate medication use or resident harm; and Medication errors and adverse drug reactions are considered significant if they: a. Require discontinuing a medication or modifying the dose b. Require hospitalization c. Result in disability d. Require treatment with a prescription mediation e. Result in cognitive deterioration or impairment f. Are life threatening g. Result in death. B. Review of an ADMISSION RECORD dated 7/12/12 revealed Resident 09 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].), Cramp of limb, Chronic pai[DIAGNOSES REDACTED], and [MEDICAL CONDITIONS]. Review of Resident 09's medical record revealed the resident had been transported to the hospital emergency roiagnom on [DATE] for Decrease Level of Consciousness and on 3/7/13 for Narcotic overdose - accidental. Review of Resident 09's physician's orders [REDACTED].>- 2/20/13: [MEDICATION NAME] 50 mcg (micrograms)/hr (hour) [MEDICATION NAME] Patch at bedtime. Change every 3 days; - 3/6/13: may resume [MEDICATION NAME] 25 mcg to skin tonight; - 3/8/13: D/C (discontinue) [MEDICATION NAME] Patch. Review of the 2012 Nursing Drug Handbook revealed the [MEDICATION NAME] Patch was an opioid or narcotic medication used to treat moderate to severe chronic pain. Black box warnings revealed the [MEDICATION NAME] should be used with caution in patients with [MEDICAL CONDITION], decreased respiratory reserve, potentially compr… | 2016-09-01 |
| 9487 | 9487 | PREMIER ESTATES OF PIERCE, LLC | 285139 | P O BOX 189, 515 EAST MAIN STREET | PIERCE | NE | 68767 | 2013-08-06 | 323 | J | 0 | 1 | C9MJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7, 12-006.09D7a Based on observations, record review and staff interview; the facility failed to assure a safe environment was provided for residents identified at risk for falls and wandering. The outside exit door of the Activity Room was propped open and staff failed to respond to the door alarm for 3 minutes. Resident 38, who was at risk for wandering and falls, was seated in a wheelchair outside of the building on an unsecured patio and was unattended during this time. In addition, the facility failed to transport Resident 47 to the whirlpool room in a safe manner on 2 occasions. Facility census was 51. Findings are: A. Review of admission orders [REDACTED]. Review of facility policy entitled Resident Elopement with a revision date of 8/20/12 identified when an employee heard a door alarm, the employee should immediately go to the site of the alarm. Review of Resident 38's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 5/28/13 revealed [DIAGNOSES REDACTED]. The assessment indicated the resident had short and long term memory loss with severely impaired decision making skills, required limited assist of one with locomotion, used a wheelchair for mobility in the corridor and had behaviors of wandering, rejection of cares and physical behaviors directed at others 1-3 days during the 7 day assessment period. Review of Fall Risk Evaluation for Resident 38 dated 5/28/13 identified a total score of 20. A total score of 10 or above represents a high risk for falls. Review of an Elopement Risk Review for Resident 38 completed 5/28/13 indicated the resident was at risk for elopement. Review of Resident 38's Care Plan (revised 6/6/2013) indicated the resident was at risk for elopement due to mobility status, [DIAGNOSES REDACTED]. Interventions included: -Provide safe location for wandering behaviors as needed. -Check placement and function of wande… | 2016-07-01 |
| 9581 | 9581 | DUFF MEMORIAL NURSING HOME | 285217 | 1104 THIRD AVENUE | NEBRASKA CITY | NE | 68410 | 2015-12-09 | 323 | J | 1 | 0 | 548111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12-006.09D7 Based on observations, interviews, and record reviews; the facility failed to evaluate resident risk for elopement, provide supervision to prevent elopement, and failed to intervene when the resident did not return to the facility following a leave of absence for one resident (Resident 1). The facility had a total census of 36 residents. Findings are: A. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility investigation dated 12/3/15 stated Resident 1's truck had been parked outside the facility and on 11/30/15 Resident 1's son had brought the keys to the truck. Resident 1 had requested the keys in order to be able to start the truck and sit in it while Resident 1 smoked. Resident 1 also wanted to drive to the store or Walmart to get cigarettes and gas. According to the investigation, Resident 1 was informed that Resident 1 needed to tell facility staff if Resident 1 was leaving the facility. On 12/1/15, Resident 1 could not open the door to the truck due to the truck battery being dead. The Activity Director assisted Resident 1 in getting a locksmith to come out and unlock the truck. On 12/2/15, maintenance staff jump started the truck for Resident 1 and Resident 1 left for Walmart at 11 AM to get a new battery. The Administrator was informed at 6:30 PM on 12/2/15 that Resident 1 had not returned to the facility. The Administrator texted staff stating that the Administrator was not worried and that if the resident was not back in the morning we might start worrying. At 7:24 AM on 12/3/15, the Administrator received a text stating Resident 1's son had been informed Resident 1 had tried to enter Canada via the North Dakota border and was at Pembina County Memorial Hospital in Cavalier, North Dakota. According to the report, Resident 1 reported leaving Omaha and when turning onto I 29, Resident 1 was uncertain if Resident 1 should go left or right. A review of a note writ… | 2016-07-01 |
| 10113 | 10113 | JENNIE M MELHAM MEDICAL CENTER | 28A056 | P O BOX 250, 145 MEMORIAL DRIVE | BROKEN BOW | NE | 68822 | 2013-03-20 | 323 | J | 1 | 0 | RYUO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D7. Observation, record review and interviews revealed the facility failed to provide supervision of 1 sampled resident (Resident 37) to prevent the resident from exiting the facility through the secured door late at night. The resident was unable to return to the facility through the secured door or alert staff the resident had left the facility without the staff's knowledge. The facility census was 38 and the sample size was 5. Findings are: A. Review of Resident 37's CARE PLAN, dated 12/10/2013, revealed the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further review of Resident 37's CARE PLAN revealed Resident 37 was alert but had confusion. The resident experienced short and long term memory loss and was cognitively impaired in the ability to make decisions. The resident was forgetful and required cueing and supervision frequently and needed reminded of safety issues often due to his forgetfulness. Review of Resident 37's medical record on 3/7/2013 found no documented evidence an assessment for wandering with a risk for elopement had been completed. Review of the MDS (Minimum Data Set; a federally mandated comprehensive assessment tool used for care planning) dated 12/10/12 revealed the following: -cognition showed a short term memory problems, -the BIMs (Brief Interview for Mental Status) was scored 7 out of 15, - No behaviors, -Limited one assist for bed mobility, transfer, personal hygiene, -Supervision with walking, used a wheelchair in the corridor, and -Wandered. B. Review of the facility report entitled ADULT ABUSE REPORT FOR LICENSED/CERTIFIED FACULTIES, dated 3/5/2013, revealed Resident 37 was very forgetful but alert. Resident 37 had poor eyesight, was hard of hearing, transferd self and got around the facility without assistance. Resident 37 went outside to check the weather, the door locked behind the resident and he/she couldn't get back in. The i… | 2016-03-01 |
| 10214 | 10214 | KEARNEY COUNTY HEALTH SERVICES | 2.8e+298 | 727 EAST 1ST STREET | MINDEN | NE | 68959 | 2012-08-01 | 333 | J | 0 | 1 | NRZX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.10D Based on record review and staff interview, revealed the facility staff failed to administer medication to Resident 19 without a significant medication error. The facility census was 30 at the time of the survey and the survey sample size was 26. Findings are: Review of the DISCHARGE AND DISCHARGE SUMMARY SHEET revealed the resident was admitted on [DATE] and readmitted [DATE] with diagnoses of spinal stenosis, history of sacral fracture, hypertension, constipation, [MEDICAL CONDITION] one eye right, weakness, depression, cataract, dementia. Review of Resident 19's MDS (a federally mandated comprehensive assessment tool used for care planning) dated 4/12/2012 revealed the BIMS score was 5 of 15. The resident experienced short and long term issues. The MDS addressed no behaviors. Continued review revealed limited assist of one person physical assist for bed mobility, locomotion on unit and personal hygiene. The MDS revealed the resident required an extensive assist of one person physical assist for transfers, walk in the room, walk in the hall and dressing. The MDS revealed the resident was dependent on two staff physical assist for toilet use. Further review of the MDS revealed the medication review was coded the resident received an antianxiety on day in the assessment period and an antidepressant every day for the 7 days during the assessment period. Review of the Initial Review and Investigation dated 7/3/2012 found an entry that Resident 19 was admitted to the hospital. No definite pneumonia was noted. Resident 19 was treated with [MEDICATION NAME] (antidote may displace opiod [MEDICATION NAME] from their receptors)--for possible narcotic overdose. Review of the admitting note dated 7/3/2012 revealed the primary [DIAGNOSES REDACTED]. Was treated with [MEDICATION NAME] times 2. Review of the Physician Telephone Order dated 7/1/2012 found an order of ABH ([MEDICATION NAME]) gel 1 ml (milliliter) topica… | 2016-02-01 |
| 11563 | 11563 | REGENCY SQUARE CARE CENTER | 285076 | 3501 DAKOTA AVENUE | SOUTH SIOUX CITY | NE | 68776 | 2012-01-24 | 323 | J | 1 | 0 | 8SG711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12-006.09D7b Based on record reviews, observations, and staff interviews; the facility failed to assess residents' risk for burns from hot liquids and implement interventions to prevent burns from spilling hot liquids for 2 residents (Resident 1 and 3) of 5 sampled residents. The facility identified a total of 15 residents at risk for burns from hot liquid out of a total census of 61 residents. Findings are: A. On 1/9/12 at 12:50 PM, a cup of coffee was obtained from facility coffee machine in dining room of the facility. Coffee was poured into a thermal cup that the facility utilized to serve to coffee to residents of the facility. The following temperatures were recorded from facility thermometer in the presence of the Dietary Manager: -12:50 PM, just poured, 165 degrees Fahrenheit (F) -12:55 PM 156 degrees F -1 PM 144 degrees F -1:05 PM 138 degrees F -1:10 PM, 20 minutes after coffee was poured, 132 degrees F In an interview on 1/9/12 between 12:05-12:30 PM, the Dietary Manger reported the coffee machine temperature was set at 175 degrees F with coffee to be between 160-165 degrees F when poured into a cup. The coffee machine had been installed at the facility in 11/11 according to the Dietary Manager. In a follow-up interview on 1/10/12 at 8 AM, the Dietary Manager reported the facility started using the thermal cups at the about the same time as the facility installed the new coffee machine due to receiving complaints about the coffee being cold. A review of Equipment Service Invoice revealed coffee machine was installed on 11/17/11. Observations in the dining room at 2 PM on 1/9/12 revealed the coffee was on and accessible to residents. A visitor but no staff members or residents were observed in the dining room. In an interview on 1/10/12 at 8 AM, the Dietary Manager confirmed the coffee machine was on and coffee was available in the dining room at all times. B. Resident 1 was admitted to the facility on [D… | 2015-05-01 |
| 11652 | 11652 | OAKLAND HEIGHTS | 285281 | 207 SOUTH ENGDAHL AVENUE | OAKLAND | NE | 68045 | 2011-11-10 | 155 | J | 1 | 0 | U8LG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC ,[DATE].09D Based on record reviews, observations, and staff interviews, the facility failed to provide CPR (Cardiopulmonary Resuscitation) in accordance with the resident's signed and documented advanced directive for 1 (Resident 1) of 7 sampled residents as a result Resident 1 passed away at the facility without receiving CPR. In addition, the facility failed to provide education to staff and clarify the facility CPR policy following the incident to prevent possible reoccurrence in order to protect 6 other residents of the facility who had requested CPR. The facility had a total census of 31 residents. Findings are: A. Resident 1 was admitted to the facility on [DATE] according to the Face Sheet. History and Physical for Resident 1 dated [DATE] listed the following [DIAGNOSES REDACTED]. A review of Resident 1's CPR/No CPR form revealed Resident 1 had marked CPR as the choice that Resident 1 wanted the facility to follow and had signed the form on [DATE]. Observation of Resident 1's medical record on [DATE] revealed Resident 1's medical record had a lime green dot on the chart indicating Resident 1 wanted CPR. A review of Resident CPR Status list maintained in facility medication room identified Resident 1 as wanting CPR. Resident 1's name had been crossed off the list. B. Undated facility policy titled "Cardiopulmonary Resuscitation (CPR) stated the following: "CPR or No CPR will be performed according to the resident's wishes. Procedure: 1. The Administration, or designee, will have the resident or resident representative sign the CPR determination form upon admission. 2. The licensed nurse will inform the physician by sending the form to the doctor. 3. The chart will be marked with a green sticker, when CPR is to be done. The resident's name, outside of the resident's room, will be underlined as an indication the resident wants to have CPR. 4. When sudden [MEDICAL CONDITION] is witnessed, on a resident w… | 2015-03-01 |
| 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 | ||
| 222 | 222 | MIDWEST COVENANT HOME | 285062 | P O BOX 367, 615 EAST 9TH STREET | STROMSBURG | NE | 68666 | 2020-02-27 | 880 | I | 0 | 1 | HGI711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C Based on observation, interview, and record review; the facility staff failed to prevent potential cross contamination by failing to follow contact precautions, failing to perform hand hygiene when indicated, failing to clean equipment used by multiple residents, and failing to ensure the facility policies for infection control, immunizations, and antibiotic stewardship were reviewed annually. The facility staff also failed to ensure that staff followed isolation precautions (the use of gloves, gowns, and hand washing to help stop the spread of germs from one person with a known infection to another) and to ensure that hand hygiene (hand washing) was performed when exiting the room of a resident under isolation precautions before entering the room of another resident. This had the potential to affect all of the facility residents. The facility identified a census of 30 at the time of survey. Findings are: [NAME] Interview with the ICC (Infection Control Coordinator) on 2/27/20 at 1:36 PM revealed the facility had 8 residents who had tested positive for CP-CRE (Carbapenem-resistant [MEDICATION NAME] (CRE) are [MEDICAL CONDITION] that that can cause serious infections and require interventions in healthcare settings to prevent spread according to the CDC (Centers for Disease Control)) and required contact precautions and 2 other residents who were discharged from the facility had also tested positive. Observation of the rooms belonging to Residents 29, 6, 14, 1, 30, 22, 31 and 29 on 2/24/20 at 4:05 PM revealed they had Contact Precautions signs and PPE (Personal Protective Equipment-gowns, gloves, face masks, shoe covers worn to protect the wearer from potential infection) on their doors. Review of the undated facility document Contact Precautions received from the DON (Director of Nursing) revealed the follow… | 2020-09-01 |
| 2917 | 2917 | KEYSTONE RIDGE POST ACUTE NURSING AND REHAB | 285238 | 7501 KEYSTONE DRIVE | OMAHA | NE | 68134 | 2018-06-14 | 689 | I | 1 | 0 | BBR311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.18E3 Based on observation, interview, and record review, the facility failed to protect 1 (Resident 4) of 4 sampled residents from a hot liquid burn and the facility failed to ensure that water temperatures did not present a potential scald hazard This practice had the potential to affect 37 residents who consume hot liquids, 55 residents who take baths in the facility and 32 residents of the facility who utilized the bathroom sinks in resident rooms. The facility had a total census of 57 residents. Findings are: [NAME] Resident 4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations on 6/13/18 at 11:45 AM revealed multiple fluid filled blisters to Resident 4's lower left arm. A review of a Skin Ulcer Non-Pressure assessment dated [DATE] revealed the following: -Chin burn, two areas in close proximity, measuring 3 cm (centimeter) in length x 2 cm in width. -Chest/left breast burn, multiple areas measured as one 22 cm in length x 16.5 cm in width. -Left arm burn, multiple areas, measured as one 16.6 cm in length x 6.2 cm in width. A review of a 6/13/18 at 6:30 AM Progress Note revealed a staff member was called to the resident's room and multiple areas were found. A review of Resident 4's Hot Liquid Safety assessment dated [DATE] revealed Resident 4 required staff set up for drinking hot liquids. Recommendations were cool beverages prior to handling/drinking. Educate resident/caregivers of hot liquids as a causative factor to prevent skin injury. Resident 4 requires a 2 handle cup and lid for hot liquids. In an interview on 6/11/18 at 10:14 AM, the Director of Nursing reported an investigation had been completed the following week due to a burn on Resident 1's foot. From that investigation, it was discovered the coffee was very hot and the coffee pot was to be replaced. Staff were provided education regarding the hot coffee. A review of the In-Service Training Report dated… | 2020-09-01 |
| 2918 | 2918 | KEYSTONE RIDGE POST ACUTE NURSING AND REHAB | 285238 | 7501 KEYSTONE DRIVE | OMAHA | NE | 68134 | 2018-06-14 | 867 | I | 1 | 0 | BBR311 | > Licensure Reference Number: 175 NAC 12-006.07C Based on record review and interview, the facility failed to have an effective Quality Assurance and Performance Improvement Plan to address facility identified concerns related to coffee temperatures. The facility had a total census of 57 residents. Findings are: A review of facility policy and procedure titled Performance Improvement revised 9/2017 identified the purpose of the plan is to continually assess the facility's performance in all service areas, so that systems and processes achieve the delivery of person-centered care, and which maximizes the individual's highest practicable physical, mental, and social well-being. A review of Performance Improvement Plan initialed 6/8/18 identified potential out of range water temperatures on facility coffee machine in dietary. Interventions included checking the temperature in of the coffee in each cup before serving to each resident. If the coffee is too hot, staff are to cool down in a carafe or a coffee thermos without the lid. In an interview on 6/11/18 at 10:14 AM, the Director of Nursing reported an investigation had been completed the following week due to a burn on a Resident 1's foot. From that investigation, it was discovered the coffee was very hot and the coffee pot was to be replaced. Staff were provided education regarding the hot coffee. A review of In-Service Training Report dated 6/8/18 revealed training was provided to 7 staff members that coffee had to be cooled down and hot liquids need to be temped at 140 degrees F or lower before giving to resident. In an interview on 6/13/18 at 11:12 AM, Administrator and Director reported second degree burn had been discover on Resident 4 that morning and Director of Nursing had been notified. The Administrator reported coffee temperature was to be checked and cooled before giving to resident. The investigation was being completed at that time and the coffee machine had been locked to prevent its use. In an interview on 6/13/18 at 12:32 PM, Dietary Aide A repo… | 2020-09-01 |
| 908 | 908 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2017-08-22 | 309 | H | 1 | 1 | 2T4P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to ensure that 1) thorough skin assessments were completed at least weekly and dressings were changed as ordered to promote healing of open wounds with ongoing drainage for one current sampled resident (Resident 84), 2) pain was assessed and controlled during wound care for one current sampled resident (Resident 169), 3) ongoing severe pain was identified and managed for one current sampled resident (Resident 15), 4) pain rated severe was assessed and controlled for one closed record (Resident 173) and two current sampled residents (Resident 90 and 10), 5) a resident with an abnormal blood pressure reading was assessed and follow up completed to ensure that the resident didn't experience any adverse effects for one current sampled resident (Resident 84) and 6) a decline in behaviors was assessed and a plan to manage behaviors was developed for two current sampled residents (Residents 29 and 25). The facility census was 107 with 22 current sampled residents and three closed records. Findings are: A Review of the Admission Record, printed 8/9/17, revealed that Resident 84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations on 8/8/17 at 11:00 AM revealed the resident seated in the wheelchair with ongoing foul odors noted from dressings at lower extremities. Interview on 8/8/17 at 11:00 AM with the resident revealed they don't change my dressings like they're supposed to. Observations on 8/9/17 at 9:30 AM revealed the resident seated in room in a wheelchair and noted a strong foul smelling odor in the room and the hallway by the resident's room. Interview with the resident on 8/9/17 at 9:30 AM revealed my legs are bleeding, they're supposed to change my dressings two times a day and put some cream on my legs and lucky to get it done every 2-3 days. Further observations revealed the resident removing… | 2020-09-01 |
| 912 | 912 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2017-08-22 | 323 | H | 1 | 1 | 2T4P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review and interviews; the facility failed to ensure that 1) interventions were in place to prevent recurrent falls and a subsequent fractured finger for one current sampled resident (Resident 26) and 2) oxygen concentrators were turned off when not in use to reduce the risk of fires for five current sampled residents (Residents 25, 66, 40, 15 and 71). The facility census was 107 with 22 current sampled residents. Findings are: Licensure Reference Number: 175 NAC 12-006.09D7b (3) [NAME] Review of the Admission Record, printed 8/9/17, revealed that Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that the resident also had [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 11/3/17, revealed that the resident was at risk for falls related to poor safety awareness and self-determination related to transfers. Further review revealed that the resident fell getting out of the wheelchair on 4/24/17, slid self out of the wheelchair to the floor on 6/29/17 and had an unwitnessed fall out of the wheelchair on 7/25/17. Review of the Progress Notes, dated 7/25/17 at 1:49 PM, revealed that the resident was found to be on the floor next to the wheelchair in the dining room and no injuries were noted. Further review revealed at 2:09 PM, bruising which measured 5 cm. (centimeters) by 2 cm. was noted on the 3rd digit. At 6:14 PM, swelling was noted at the finger. On 7/27/17 at 2:45 PM, an x ray showed that the resident had a fractured right third finger and orders for a splint were received. Observations on 8/9/17 at 7:40 AM revealed the resident resting in bed and a splint in place at the right third finger. Review of the Treatment Administration Record, dated (MONTH) (YEAR), revealed an order, dated 7/26/17, for Epsom salt treatment two times a day for swelling and bruising of the right hand. Review of the Medication Administration Record, dated (MONTH) (YEAR), reveal… | 2020-09-01 |
| 1920 | 1920 | PREMIER ESTATES OF KENESAW, LLC | 285166 | P O BOX 10, 100 WEST ELM AVENUE | KENESAW | NE | 68956 | 2019-09-12 | 600 | H | 0 | 1 | WSRR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (9) Based on observation, interview, and record review; the facility failed to protect the residents from neglect by failing to ensure staff had the supplies needed to care for residents. This had the potential to affect all of the facility residents. The facility identified a census of 52 at the time of survey. Findings are: Interview with MA-O (Medication Aide) on 9/08/19 at 6:18 PM revealed the facility did not have any disposable wipes so they were using paper towels to provide perineal care to the residents as they had been directed. Observation of the facility nursing supply store room on 9/09/19 at 2:38 PM with NA-U (Nurse Aide) and NA-V revealed there were no disposable wipes. NA-U and NA-V both reported this was the storeroom they were directed to retrieve nursing supplies. NA-V revealed they had asked one of the facility staff about the wipes and they were told they had backordered. Interview with NA-U on 9/9/2019 at 2:38 PM revealed the facility never had enough disposable wipes as they frequently ran out of them. NA-U revealed they were told to use wash cloths to provide perineal care but NA-U was uncomfortable doing this as there were no wash cloths designated specifically for perineal cleansing use and NA-U felt they should not be using the same wash cloths for perineal care that the staff used to wash the residents' faces, etc. Interview with HS (Housekeeping Supervisor) on 9/11/19 at 2:27 PM revealed they were responsible for ordering nursing supplies. HS revealed there was one case of disposable wipes located in the facility. Someone had put them in the wrong storeroom. HS did not confirm or deny the facility ran out of supplies or if the storeroom was being checked regularly to ensure there were ample supplies. Review of the facility policy Central Supply issued (MONTH) 20, 2019 revealed the following: The purpose of the central supply system is to: Maintain Inventory Control. B. … | 2020-09-01 |
| 2839 | 2839 | BELLE TERRACE | 285237 | 1133 NORTH THIRD ST | TECUMSEH | NE | 68450 | 2017-06-08 | 353 | H | 1 | 0 | LUKH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure reference: 175 NAC 12-006.04C Based on observation, interview, and record revie;, the facility failed to ensure sufficient staff to meet resident needs as evidenced by not providing assistance to transfer in a safe manner for one sampled resident (Resident 3), failure to provide assistance with toileting for one sampled resident (Resident 9), failure to provide medications at scheduled times for two sampled residents (Resident 3 and 17), and failure to answer call lights within facility parameters for three sampled residents (Resident 3, 8, and 9). The sample size was 17 and facility census was 56. Findings are: [NAME] Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 3's care plan revealed a problem dated 2/22/17 of alteration in mobility with approach of Hoyer lift with 2 assist for transfer. A review of a facility investigative report dated 5/18/17 revealed on 5/14/17 at 4:50 PM Resident 3 was transferred from the wheelchair to bed by two nurse aides without using a Hoyer lift. The report stated that a popping sound was heard when the nurse aides tried to reposition the resident in to the center of the bed. Resident 3 had very limited range of motion in all joints due to severe contractures and arthritic changes according to the report. Resident 3 was diagnosed with [REDACTED]. Preventative measures put in place by the facility included staff education on safe transfers for all residents and resident education on importance of Hoyer lift due to resident condition. In an interview on 5/31/17 at 11:05 AM, Nurse Aide A reported Nurse Aide A had assisted Nurse Aide B in transferring Resident 3 without use of the Hoyer lift. When trying to reposition Resident 3 in bed a popping sound had been heard. Nurse Aide A reported that Nurse Aide A had not been trained on transferring Resident 3. Nurse Aide A confirmed Nurse Aide A was not 18 and could not operate the lift. In an interview on 5/… | 2020-09-01 |
| 2869 | 2869 | KEYSTONE RIDGE POST ACUTE NURSING AND REHAB | 285238 | 7501 KEYSTONE DRIVE | OMAHA | NE | 68134 | 2018-01-02 | 686 | H | 1 | 1 | 51KH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2a Based on observation, record review and interview; the facility staff failed to identify pressure ulcers and failed to implement assessed interventions to prevent development of pressure ulcers for 4(Resident 3, 36, 51 and 160) of 4 sampled residents. The facility staff identified a census of 66. Findings are: [NAME] Record review of Resident 51's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 12-06-2017 revealed the facility staff assessed the following about Resident 51: -Brief Interview for Mental Status (BIMS) was a 14. According to the MDS Manuel a score of 13 to 15 indicates a person is cognitively intact. -Required supervision with eating. -Required extensive assistance with 2 or more persons assisting with bed mobility, transfers, dressing, toilet use and personal hygiene. -Always incontinent of bowel and bladder. -Identified Resident 51 at risk for the development of pressure ulcers. Record review of Resident 51's Braden Scale (tool used for predicting pressure sore risk) dated 12-06-2017 revealed Resident 51 scored a High Risk rating. Record review of Resident 51's Comprehensive Care Plan (CCP) dated 11-24-2017 revealed Resident 51 had the [DIAGNOSES REDACTED]. Further review of Resident 51's CCP updated on 12-06-2017 revealed Resident 51 had returned from the hospital with an open wound to the sacrum and prevalon boots (type of pressure relieving foot wear) in place to both feet. According to Resident 51's CCP, the prevalon boots were worn at all times. Observation on 12-20-2017 at 2:49 PM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Observation on 12-21-2017 at 11:00 AM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Observation on 12-21-2017 11:22 AM revealed Resident 51 was in bed, in a back laying posi… | 2020-09-01 |
| 2883 | 2883 | KEYSTONE RIDGE POST ACUTE NURSING AND REHAB | 285238 | 7501 KEYSTONE DRIVE | OMAHA | NE | 68134 | 2018-01-02 | 835 | H | 0 | 1 | 51KH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observation, record review, and interview; the facility failed to ensure the administrative team utilized resources in a manner to ensure provision of care and services for residents. Facility census was 66. Findings are: The facility was found to be deficient in multiple areas of regulatory compliance with an extended survey required related to substandard quality of care. Please refer to the Tag citations for specific detailed findings. -F 550; The facility failed to ensure water temperature for bathing was at a comfortable level for resident 56 one of one resident, the facility census was 66. -F580; The facility failed to notify Resident 39's representative of fall for one of three residents. Facility census was 66 -F609; The facility failed to submit an investigation to the state agency as required, within 5 working days. Resident 48, 3, 15. -F 655; The facility failed to include information related to antipsychotic medication in initial plan of care for use for Resident 52, 160. -F 656; The facility failed to develop activity care plans for Residents 49, 36. -F 657; The facility failed to revise plan of care for assisting resident with nutritional intake for Resident 36. -F675; The facility failed to implement a bowel care regimen to prevent impaction for Resident 36. -F 676; The facility failed to ensure dentures were available for use and failed to ensure Resident 51 was assisted with dressing. -F677; The facility failed to provide assistance with morning cares and meals for Resident 39 and provide standard of care for transfer with use of gait belt for Residents 12, 21. -F 679; The facility failed to provide activities to meet resident interest for Resident 36 and 49. -F680; The facility failed to have a activity director that meets the required qualifications. This has the potential to affect all residents in the facility. The facility Census was 66. -F684; The facility failed to … | 2020-09-01 |
| 2884 | 2884 | KEYSTONE RIDGE POST ACUTE NURSING AND REHAB | 285238 | 7501 KEYSTONE DRIVE | OMAHA | NE | 68134 | 2018-01-02 | 867 | H | 0 | 1 | 51KH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on observations, record reviews and interviews conducted during the standard annual and extended survey process related to substandard equability of care. The facility failed to ensure an effective quality improvement plan as evidenced by new and repeat deficient practice. Facility census was 66. Findings are: Interview on 12/27/17 at 2:03 PM with the facility Director of Nursing (DON) and Nurse Consultant N revealed that the Quality Improvement Committee oversees the quality of Resident care. Nurse Consultant N confirmed the facility had not identified the current deficient practices and there were no PIP/QUAPI programs in place at this time for the following Tag citations The facility was found to be deficient in multiple areas of regulatory compliance requiring an extended survey process for substandard quality of care. Please refer to the Tag citations for specific detailed findings: -F 550; The facility failed to ensure water temperature for bathing was at a comfortable level for resident 56 one of one resident, the facility census was 66. -F580; The facility failed to notify Resident 39's representative of fall for one of three residents. Facility census was 66 -F609; The facility failed to submit an investigation to the state agency as required, within 5 working days. Resident 48, 3, 15. -F 655; The facility failed to include information related to antipsychotic medication in initial plan of care for use for Resident 52, 160. -F 656; The facility failed to develop activity care plans for Residents 49, 36. -F 657; The facility failed to revise plan of care for assisting resident with nutritional intake for Resident 36. -F675; The facility failed to implement a bowel care regimen to prevent impaction for Resident 36. -F 676; The facility failed to ensure dentures were available for use and failed to ensure Resident 51 was assisted with dressing. -F677; The facility failed to provide ass… | 2020-09-01 |
| 2944 | 2944 | RIDGECREST REHABILITATION CENTER | 285239 | 3110 SCOTT CIRCLE | OMAHA | NE | 68112 | 2018-01-23 | 692 | H | 1 | 0 | L1D311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observation, record review and interview; the facility staff failed to identify significant weight loss and failed to implement interventions to prevent weight loss for 4 of 4 sampled residents (Resident 20, 23, 24, and 25). The facility staff identified a census of 60. Findings are: [NAME] Record review of a Face Sheet dated 8-18-2017 revealed Resident 20 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 20's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) signed as completed on 12-26-17 revealed the facility staff assessed the following about the resident: -Totally depended for bed mobility, transfers, dressing, eating, dressing, toilet use and personal hygiene. Record review of a weight record sheet (WRS) provided by the facility revealed Resident 20's weight on 9-13-17 was 268 pounds. Further review of the WRS revealed Resident 20's weight on 11-8-17 was 233.4 pounds, a loss of 34.6 pound weight loss or 11.39% indicating a significant weight loss. Record review of a Progress Note (PN) dated 12-9-17 (a 31 day span from the significant weight loss identified on 11-8-17) revealed the facility Registered Dietician (RD) identified Resident 20 had lost weight, According to the RD PN dated 12-9-17, Resident 20 had not been hungry and Resident 20's weight loss was greater than 1 pound a week .which indicates a caloric deficit resulting in loss. Further review of Resident 20's RD, PN dated 12-9-17 revealed there was no evaluation of Resident 20's nutritional requirements, no evaluation of Resident 20's medical condition related to the weight loss or what interventions were to be implemented to stabilize Resident 20's weight. Record review of Resident 20's Comprehensive Care Plan (CCP) dated 5-9-16 revealed Resident 20 had impaired nutritional status. According to Resident 20's CCP da… | 2020-09-01 |
| 2950 | 2950 | RIDGECREST REHABILITATION CENTER | 285239 | 3110 SCOTT CIRCLE | OMAHA | NE | 68112 | 2018-01-23 | 835 | H | 1 | 0 | L1D311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observation, record review and interview; the facility administrative staff failed to ensure the facility resources were effectively utilized to maintain or improve the physical, psychosocial and mental well-being of the facility residents. This deficient practice had the potential to affect all residents in the building. The facility staff identified a census of 60. Findings are: Review of the following information revealed the following: -F692. The facility staff failed to identify and implement interventions to prevent weight loss. This practice affected 4 of 4 residents that were reviewed for the survey. The facility staff had identified Residents 22 and 24 had weight loss and identified interventions to prevent further weight loss. Observations during the survey revealed those interventions were not carried out for Resident 22 and 24. Resident 20's care plan indicated Resident 20 was to receive large portions and Resident 20 did not during the survey, in addition, Resident 20 had significant weight loss and the loss was not evaluated. Resident 25 had weight loss without interventions and lost a significant amount of weight. -F686. The facility staff failed to identify, evaluate casual factors and implement interventions for the development of a pressure ulcer for 1 (Resident 20) of 1 residents. Resident 20 had a history of [REDACTED]. Observations during the survey revealed Resident 20 developed a pressure ulcer. The facility staff had not identified the pressure ulcer, had not evaluated casual factors or implemented interventions. -F 744. The facility failed to have specific activities for residents with Dementia who reside in a Memory Support Unit, and failed to have specific guidelines on how activity services would be provided and what staff members would be responsible for the activities on the MSU. Observations during the survey revealed individualized activities that were res… | 2020-09-01 |
| 3940 | 3940 | VALLEY VIEW SENIOR VILLAGE | 285294 | 220 SOUTH 26TH STREET | ORD | NE | 68862 | 2018-03-21 | 686 | H | 1 | 1 | OLWQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D2b Based on observation, interview, and record review; the facility staff failed to implement interventions to promote the healing of pressure ulcers for 4 of 4 sampled residents including completing assessments, using clean technique for dressing changes, repositioning, and administering nutritional supplements as ordered. This affected Residents 3, 29, 24 and 34. The facility identified a census of 34 at the time of survey. Findings are: [NAME] Review of Resident 3's quarterly MDS (minimum data set-a comprehensive assessment tool used to develop a resident's care plan) dated 3/7/2018 revealed an admission date of [DATE]. Resident 3 had a Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer that was not present at the time of admission. Review of Resident 3's admission MDS dated [DATE] revealed Resident 3 was admitted to the facility on [DATE] and had one Stage 2 pressure ulcer that was not present upon admission/entry or reentry. The date of the oldest Stage 2 pressure ulcer was 8/4/2016. Review of Resident 3's Physician Order Report for 2/6/2018-3/6/2018 revealed a [DEVICE] was being used to treat a sacral (tailbone) wound. Observation of Resident 3 on 3/14/18 at 7:31 AM, 9:28 AM, 1:36 PM, 3:17 PM and 4:20 PM revealed Resident 3 was sitting in the wheelchair. Interview with Resident 3 on 3/14/2018 at 3:17 PM revealed Resident 3 had been up in the chair since 7:30 AM and had not laid down in bed. Review of Resident 3's Resident Progress Notes for 3/14/2018 revealed no documentation Resident 3 had been offered the opportunity to change positions or educated about the risks of refusing to change positions. Observation of Resident 3 on 3/15/18 at 7:09 AM, 10:52 AM, 1:05 PM, 1:49 PM, and 3:20 PM revealed Resident 3 was sitting in the wheelchair. Review of Resident 3's Resident Progress Notes for 3/15/2018 revealed no documentation Resident 3 had been offered the o… | 2020-09-01 |
| 4844 | 4844 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2018-03-06 | 689 | H | 0 | 1 | 9WK311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7b Based on observations, record reviews and interviews; the facility failed to ensure that 1) causal factors were identified, assessments were completed related to a dislocated shoulder and follow up interventions were in place to reduce the risk of recurrence for one current sampled resident (Resident 176), 2) a finger injury was identified, assessed and care provided for one current sampled resident (Resident 21) and 3) interventions were in place to prevent a fall with facial fractures for one current sampled resident (Resident 76). The facility census was 27 with 16 current sampled residents. Findings are: [NAME] Review of the Admission Record revealed that Resident 176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes, dated 2/24/18 at 7:29 PM, revealed that the resident required one staff member assist with toileting. Review of the Progress Notes, dated 2/25/18 at 12:00 PM revealed that the resident was seated on the toilet and upon rising stated ow and pointed to bicep area. The resident requested spouse be called. Spouse called and stated that the resident's shoulder was dislocated and requests the resident be sent to the emergency room per ambulance. Resident was assessed for pain and was transferred to the hospital per ambulance. Further review revealed that at 2:55 AM, the resident returned to the facility with no documentation of an assessment of the left shoulder until 2:59 PM. At that time, the resident denied pain at the left shoulder. Review of the hospital emergency room report, dated 2/25/18 at 12:56 AM, revealed the following including: - Final Impression: Headaches and reported shoulder dislocation; - Differential Diagnosis: [REDACTED]. - Presenting problems included history of [MEDICAL CONDITION] and brain surgery on 2/12/18, spouse received a call from the nursing home that the resident was having severe pain in the left shoulder, … | 2020-03-01 |
| 4846 | 4846 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2018-03-06 | 697 | H | 1 | 1 | 9WK311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to ensure that 1) pain assessments were completed and pain was managed for one current sampled resident related to a dislocated shoulder and chronic headaches related to a [DIAGNOSES REDACTED] (Resident 176), 2) pain assessments were completed with pain levels rated severe for one current sampled resident (Resident 11) and 3) assessments were completed and interventions were in place to relieve ongoing pain related to positioning in the wheelchair for one current sampled resident (Resident 22). The facility census was 27 with 16 current sampled residents. Findings are: [NAME] Review of the Admission Record revealed that Resident 176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes, dated 2/25/18 at 12:00 PM revealed that the resident was seated on the toilet and upon rising stated ow and pointed to bicep area. The resident requested spouse be called. Spouse called and stated that the resident's shoulder was dislocated and requested the resident be sent to the emergency room per ambulance. Resident was assessed for pain and was transferred to the hospital per ambulance. Further review revealed that at 2:55 AM, the resident returned to the facility with no documentation of an assessment of the left shoulder until 2:59 PM. Review of the hospital emergency room report, dated 2/25/18 at 12:56 AM, revealed the following including: - Presenting problems included history of [MEDICAL CONDITION] and brain surgery on 2/12/18, spouse received a call from the nursing home that the resident was having severe pain in the left shoulder, found that the left shoulder was dislocated and the left hand was blue, spouse reduced the left shoulder and restored circulation to the left arm. Interview with the resident's spouse on 2/28/18 at 7:45 AM revealed concerns related to pain management. The spous… | 2020-03-01 |
| 4851 | 4851 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2018-03-06 | 755 | H | 1 | 1 | 9WK311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.12A Based on record reviews and interviews, the facility failed to ensure that medications were available to administer as ordered 1) on admission for two current sampled residents (Residents 176 and 175), 2) for an antifungal medication to treat a skin disorder for one current sampled resident (Resident 20) and 3) for antibiotics to treat a urinary tract infection for one current sampled resident (Resident 24). The facility census was 27 with 16 current sampled residents. Findings are: [NAME] Review of the Admission Record revealed that Resident 176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record, dated (MONTH) (YEAR), revealed that the following medications were not administered as ordered on admission: - [MEDICATION NAME] daily for Major [MEDICAL CONDITION], start date 2/24/18 and not administered until 2/25/18; - [MEDICATION NAME] Ointment apply daily to wound on upper back, start date 2/24/18 and not applied until 2/25/18; - [MEDICATION NAME] tapering doses, two times a day for Malignant Neoplasm of Brain and Cerebral [MEDICAL CONDITION] (swelling), ordered 2/23/18 and not administered until 2/25/18; - [MEDICATION NAME] every four hours as needed for pain, ordered 2/23/18 and not administered until 2/26/18; - [MEDICATION NAME] every four hours as needed for pain, ordered 2/23/18 and not administered until 2/27/18. Review of the hospital emergency room report, dated 2/25/18 at 12:56 AM, revealed the following including: - Final Impression: Headaches and reported shoulder dislocation; - Differential Diagnosis: [REDACTED]. Examination showed that the patient has difficulty understanding and following commands at this time, spouse reports that since the [MEDICAL CONDITION] the patient has times periods of being alert and oriented and answers questions to period where the patient cannot follow commands, respond well, can't answer quest… | 2020-03-01 |
| 4857 | 4857 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2018-03-06 | 835 | H | 0 | 1 | 9WK311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.01 (4) Based on observations, record reviews, and interviews, the facility administration failed to identify and correct issues to maintain compliance and ensure the provision of care and treatment for [REDACTED]. Facility census was 27. Findings are: Entrance to the facility on [DATE], the facility provided a personnel form which identified the facility employed a full-time licensed Administrator responsible for managing the facility and day to day operations. Due to risk of retaliation by the company or the administration of the facility, various staff members, residents, and families were interviewed under requests for anonymity. These interviews were conducted during a complaint drop in visit conducted on 2/23/2018 between 1:25 p.m. and 3 p.m. and during the annual survey conducted beginning on 2/27/18 through 3/6/18. These interviews resulted in the following concerns being expressed: - shortages in direct care nursing staff resulting in delays of call lights, bathing not being done as scheduled, no restorative nursing program, delays in attending to resident condition changes, and lack of response by administration in dealing with concerns and issues brought to administration attention. During the survey conducted from 2/27/18 through 3/1/18, the facility was cited for the following issues related to systems failure or standards of care breaks resulting in patterns of, or widespread failure in the facility: - F561- bathing not provided for residents as requested. Interviews with staff and residents revealed this was related to nurse staffing shortages. - F684- Activity programs being canceled related to one employee in the department being pulled to do resident transport duties to and from medical and other appointments in addition to performing Social Service duties four days a week. In addition, the facility was not employing a full-time Activities Director as specified in the Facility Assess… | 2020-03-01 |
| 4860 | 4860 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2018-03-06 | 865 | H | 0 | 1 | 9WK311 | Licensure Reference Number 175 NAC 12-006.07C Based on observations, record reviews and interviews; the facility failed to ensure that the QA (Quality Assurance) and QAPI (Quality Assurance and Performance Improvement) Committees identified and corrected quality of care issues. The facility census was 27 and this failure has the potential to effect all of the residents. Findings are: Review of the findings during the annual recertification survey, dated 3/6/18, revealed the following deficient areas identified including: Emergency Preparedness: - 0001 failed to establish an emergency program as required; - 0015 failed to include subsistence needs for patients and staff; - 0029 failed to include a communication plan; - 0030 failed to include names and contact numbers; - 0035 failed to include the required components for sharing information from the emergency plan to residents, families or resident representatives; Recertification deficiencies identified at a scope higher than isolated: - F 561 failed to ensure that resident choices for bathing choices were honored; - F 665 failed to ensure that baseline care plans were developed for newly admitted residents; - F 656 failed to develop and implement comprehensive care plans as required; - F 658 failed to ensure that medications were administered per standards of practice; - F 679 failed to ensure that the activities program was in place to meet the residents' needs; - F 684 failed to provide care and treatments related to a change in condition, ongoing diarrhea and to prevent skin breakdown to ensure that the residents' needs were met; - F 686 failed to provide care and treatment to address limitations in range of motion and have a restorative nursing program in place; - F 689 failed to provide care and treatment related to a dislocated shoulder, finger injury and to prevent a fall with fractures; - F 697 failed to ensure that nutritional supplements were available and administered for residents with nutrition issues; - F 697 failed to provide effective pain managem… | 2020-03-01 |
| 4861 | 4861 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2018-03-06 | 867 | H | 0 | 1 | 9WK311 | Licensure Reference Number 175 NAC 12-006.07C Based on observations, record reviews and interviews; the facility failed to ensure that the QAPI (Quality Assurance and Performance Improvement) Committee developed and implemented a plan of correction to maintain compliance for deficiencies cited at the last annual recertification survey. The facility census was 27 and this failure had the potential to effect all of the residents. Findings are: Review of the recertification survey, dated 4/19/17, compared to the current recertification survey, dated 3/6/18, revealed that the following deficiencies were cited and not corrected: - F 157 (F 580) failed to notify the physician of a change in condition as indicated; - F 241 (F 550) failed to ensure that residents were treated with dignity; - F 279 (F 656) failed to develop a comprehensive care plan to address residents' needs; - F 323 (F 689) failed to identify potential accident hazards and prevent accidents; - F 332 (F 759) failed to ensure a medication error rate less than 5%; - F 371 (F 812) failed to ensure dietary sanitation practice; - F 431 (F 761) failed to ensure that prescription labels matched current medication orders; - F 425 (F 755 and F 658) failed to ensure medications were administered per standards of practice and that medications were available for administration; - F 441 (F 880) failed to ensure infection control procedures were in place to reduce the risk of cross contamination; - F 520 (F 865 and F 867) failed to ensure that the QAPI Committee 1) identified quality of care issues and had a plan to correct the issues and 2) ensure that the plan of correction for previous deficiencies was effective to obtain and maintain regulatory compliance. Review of the facility Quality Assurance and Performance Improvement policy, dated (MONTH) (YEAR), revealed the following including: . 11. Governance and leadership - . b. Governing oversight responsibilities include, but are not limited to the following: . vi. Ensuring that corrective actions address gaps in s… | 2020-03-01 |
| 5186 | 5186 | EL DORADO MANOR NURSING HOME | 285253 | 71434 HWY 25, BOX 97 | TRENTON | NE | 69044 | 2016-11-08 | 223 | H | 0 | 1 | 8A4D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.05 (9) Based on observation, record reviews and interviews, the facility failed to protect residents from abuse by failing to: 1) suspend employees after receiving reports of alleged verbal, psychological, and physical abuse; and 2) immediately initiate an investigation of these allegations. This affected 3 of 6 sampled residents (Residents 15, 16, and 18). The facility identified a census of 37 at the time of survey. Findings are: [NAME] Review of Resident 15's annual MDS (Minimum Data Set-a comprehensive resident assessment tool used to develop a resident's care plan) dated 12/24/2015 revealed an admission date of [DATE] and a BIMS (Brief Interview for Mental Status) score of 14 which indicated Resident 15 was cognitively intact. Interview with Resident 15 on 11/01/2016 at 11:40 AM revealed that the facility Administrator had verbally intimidated Resident 15 and Resident 16 by stating if you don't like it you can leave after they brought up concerns they felt the facility needed to address. Resident 15 also revealed that the Administrator accused Resident 15 of violating HIPAA laws because they got permission from Resident 16 to bring up an issue about Resident 16 not being able to get a haircut. Resident 15 revealed that the Administrator told Resident 16 that they should not be paying for a ride to go to their house when they did not have money to pay for other things. Resident 15 stated feeling psychologically abused and bullied by the Administrator. Interview with Resident 15 on 11/01/2016 at 11:59 AM revealed that, when Resident 15 inquired about a facility staffing change, the administrator said in an antagonistic way it's all taken care of. Resident 15 had reported to the facility staff feeling psychologically abused and bullied by the facility Administrator. Interview with the DON (Director of Nursing) on 11/02/2016 at 9:55 AM revealed the facility Administrator was brash and short with peo… | 2020-02-01 |
| 5204 | 5204 | EL DORADO MANOR NURSING HOME | 285253 | 71434 HWY 25, BOX 97 | TRENTON | NE | 69044 | 2016-11-08 | 520 | H | 0 | 1 | 8A4D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC ,[DATE].07 Based on record reviews and interviews; the facility failed to re-evaluate prior plans of correction to correct and maintain correction for previously cited deficient practice related to: dignity, housekeeping/maintenance, sanitation in the kitchen and accident hazards for residents and resolution of resident and/or family grievances. The facility failed to ensure that the Quality Assurance/Assessment Committee identified quality of life and quality of care issues, related to the abuse prohibition policies and procedures, to ensure that staff followed the procedures to protect Residents from abuse. The failures resulted in potential deficiencies affecting all 37 residents. The facility census was 37 at the time of the survey. Findings are: Record review of previous complaint and annual survey deficiencies for the facility revealed the following: -F241 The facility failed to treat residents in a dignified manner by entering resident rooms without permission, posting personal care information in a conspicuous place, exposing a resident's medical condition, and failing to cover a resident that was exposed in the dining room. -F253 The facility failed to 1)fix the doors to the room, bathrooms and closet doors that were chipped and marred, 2) clean the ceiling vents in the bathrooms, 3) replace the linoleum that has holes or a cut by equipment, 4) replace linoleum that has stains in bathrooms, holes, or scrapes, 5) paint the window frames, 6) clean the windows with a brown debris, 7) fix the ceiling light fixture hanging from the ceiling, 8) fix the cracks in the resident room between the dry wall and the cinder blocks, 9) failed to remove screw and nails that were a harm to the residents, 10) fix the dry wall with scrapes or holes and 11) fix the resident's recliner for the resident to use. -F280-The facility failed to update and revise the care plan to reflect a resident's pressure ulcer. -F371-The … | 2020-02-01 |
| 6995 | 6995 | NEBRASKA CITY CARE AND REHABILITATION CENTER, LLC | 285109 | 1420 NORTH 10TH STREET | NEBRASKA CITY | NE | 68410 | 2014-12-11 | 323 | H | 0 | 1 | 9RWM11 | **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 and re-evaluate interventions to prevent falls for 3 residents (Resident 28, 41 and 46) and failed to secure medications and chemicals on the secured unit. The facility staff identified a census of 50. Findings are: A. Record review of an Admission record sheet dated 3-10-2014 revealed Resident 41 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 41's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 9-19-2014 revealed the facility staff assessed the following about the resident; -BIMs (Brief Interview for Mental status) revealed Resident 41 scored a 5. According to the MDS Manuel, a score of 0 to 7 indicated severe impairment. -Required extensive assistance with transfers, bed mobility, dressing, personal hygiene and toilet use. -Falls occasionally. Record review of Resident 41's Quarterly Interdisciplinary Resident Review (QIRR) sheet dated 10-19-2014 revealed Resident 41 scored a 13 on the section that was identified a Devices, Restraints and Falls. According to the information on the QIRR sheet revealed a total score of 10 or above deemed the resident at risk. Record review of a Balance Assessment Screen (BAS) dated 10-19-2014 revealed Resident 41 scored a 3. According to the information on the BAS form, a score of 3 indicated a standing balance test could not be completed without physical help. Record review of Resident 41's Comprehensive Care Plan (CCP) reviewed on 9-10-2014 revealed Resident 41 was identified at risk for injury or falls related to weakness, dementia, poor balance and a history of falls. The goal was Resident 41 would not have any fall related injury requiring hospitalization . Intervention identified on the CCP included Foot wear to prevent slipping, Bed and wheelchair ala… | 2018-07-01 |
| 7001 | 7001 | NEBRASKA CITY CARE AND REHABILITATION CENTER, LLC | 285109 | 1420 NORTH 10TH STREET | NEBRASKA CITY | NE | 68410 | 2014-12-11 | 490 | H | 0 | 1 | 9RWM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on record reviews, observations and staff interviews; the facility administration failed to maintain a system to prevent non-compliance with Federal and State regulations related to assuring residents were protected from injury due to hot water temperatures in resident care areas, Maintanance of the resident environment related to the condition of the facility and failed to implement interventions to prevent accidents. The facility census was 50. A. Record review of an unused and undated Maintenance Director Orientation information check list revealed at the section titled: Water Temperature revealed the following: -Notify the Executive Director immediately of any water Temperature above 110 degrees Fahrenheit. -Water must be shut down so that residents can not utilize in the affected area, until the temperature is returned to 110 degrees Fahrenheit. Record review of a Preventative Maintenance (PM) rounds sheet dated 9-15-2014 revealed the following information: -Bathing water temperature on the skilled side of the facility was 117.8 degrees. There was no temperature of the bathing water on the secured unit of the facility. Record review of a PM rounds sheet dated 11-27-2014 revealed the following information: -Bathing water on the skilled side of the facility was 117.8 degrees. There were not any temperature of the bathing water in the secured unit of the facility. Record review of a PM rounds sheet dated 12-02-2014 revealed the following information: -Bathing water on the skilled side of the facility was 123.5 degrees. There were not any temperatures obtained of the bathing water on the secured unit of the facility. -room [ROOM NUMBER], the handwashing sink water temperature was 123.5 degrees. -room [ROOM NUMBER], the handwashing sink water temperature was 123.2 degrees. -room [ROOM NUMBER], the handwashing sink water temperature was 124.5 degrees. -room [ROOM NUMBER], the handwashing sink … | 2018-07-01 |
| 7005 | 7005 | NEBRASKA CITY CARE AND REHABILITATION CENTER, LLC | 285109 | 1420 NORTH 10TH STREET | NEBRASKA CITY | NE | 68410 | 2014-12-11 | 520 | H | 0 | 1 | 9RWM11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interview; the facility Quality Assurance Plan failed to identify ongoing issues relevant to F166, F226, F242, F248, F250, F252, F272, F309, F323, F329, F353, F411, F431, F497, F499, 517 and implement effective plans of action to identify and correct the deficient practice. The Quality Assurance Plan failed to ensure the repeated deficiencies at F 253 and F371 were corrected and the correction maintained. The facility staff identified a census of 50. Findings are; A. An interview was conducted with the facility Administrator on 12-10-2014 at 7:13 AM. During the interview the facility Quality Assurance Program was reviewed with the Administrator. During the interview when asked if the facility staffing or hot water had been identified in the facility as a problem, the Administrator stated no. B. An interview with Licensed Practical Nurse (LPN) E was conducted on 12-10-2014 at 8:12 AM. During the interview, when asked what the Quality Assurance committee was and what the committee was working on, LPN E stated I don't know what they are working on. I don't know anything about it. C. An interview was conducted on 12-10-2014 at 8:16 AM with LPN F. When asked what the Quality Assurance committee was working on. LPN F stated I don't know. D. On 12-10-2014 at 8:20 AM an interview was conducted with Nursing Assistant (NA) K. During the interview, when asked what the Quality Assurance Committee was working on, NA K stated I don't know. E. On 12-10-2014 at 8:23 AM an interview was conducted with LPN L During the interview when asked what the Quality assurance committee was working on, NA L reported not being aware of what the committee was working on. | 2018-07-01 |
| 10210 | 10210 | KEARNEY COUNTY HEALTH SERVICES | 2.8e+298 | 727 EAST 1ST STREET | MINDEN | NE | 68959 | 2012-08-01 | 318 | H | 0 | 1 | NRZX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09D1, 12-006.09D1a Based on observation, record review and interview the facility failed to provide restorative services to residents with limited range of motion in order to prevent the further decline in range of motion. The facility had a census of 30 and a survey sample of 26. This affected Residents 12, 06 and 32. Findings are: A. According to the 6/18/12 ADMISSION and DISCHARGE SUMMARY Resident 12 was admitted to the facility on [DATE]. The following [DIAGNOSES REDACTED]. Observation on 07/23/2012 at 9:44 AM revealed that Resident 12 had bone deformities of the fingers and hands bilaterally. Review of the 2/17/12 MDS (Minimum Data Set -a federally mandated comprehensive assessment tool used for care planning) revealed the following assessment of Resident 12's ability: Toilet use - extensive assistance of one person, Personal Hygiene - extensive assistance of one person. Review of the 5/19/12 MDS revealed the following assessment of Resident 12's ability: Toilet use - limited assistance of one person, Personal Hygiene - limited assistance of one person. Resident 12 had improvement in toilet use and personal hygiene from 2/17/12 to 5/19/12. Review of an ADL FLOWSHEET (Activities of Daily Living) for the period of time 7/17/12-7/25/12 confirmed that the nurse aides were providing the following assistance for Resident 12: Toilet use - full staff performance of one person, Personal Hygiene - full staff performance of one person. Interview on 7/26/12 at 10:19 AM with MA-JM (Medication Aide) confirmed that Resident 12 was dependent on staff to assist with toileting, incontinence care and brushing teeth. Resident 12 required the assistance of one person for dressing. Resident 12 had decline in toilet use and personal hygiene from the 2/17/12 and 5/19/12 MDS assessments to the 7/17/12 documentation of actual care provided by the nursing staff. Review of the 6/1/11 CARE PLAN for Resident 12 revealed that Residen… | 2016-02-01 |
| 10220 | 10220 | KEARNEY COUNTY HEALTH SERVICES | 2.8e+298 | 727 EAST 1ST STREET | MINDEN | NE | 68959 | 2012-08-01 | 490 | H | 0 | 1 | NRZX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.02 Based on observations, record reviews, and interview, the facility administration failed to utilize facility resources in a manner to achieve and maintain the highest practical physical, mental, and psychosocial well-being of each resident by 1) the failure to implement an effective plan of action to maintain correction for a previously cited area of deficient practice, and 2) the failure to ensure the facility identified and developed plans of action to identify multiple issues of deficient practice. The facility census was 30 and the survey sample size was 26. Findings are: The facility was found to be deficient in multiple areas of regulatory compliance after the tacks of the annual standard survey was completed. Please reference the specific tags in regard to detailed findings: - F156 Failed to inform residents of items and services not covered by Medicaid benefits; - F157 Failed to notify residents' families of change in condition; - F159 Failed to ensure resident personal funds accounts were available on evenings and weekends, failed to pay interest on accounts over $50, and failed to provide quarterly statements; - F161 Failed to secure a surety bond for assurance of residents' financial security; - F166 Failed to address residents' grievances; - F176 Failed to assess residents for the ability to self-medicate; - F224 Failed to protect residents belongings; - F225 Failed to report to the State agency and investigate allegations of abuse, neglect, misappropriation and injuries of unknown origin; - F226 Failed to screen new employees and failed to protect residents during abuse/neglect investigations; - F242 Failed to honor the residents' right to choose what time to get up in the morning; - F248 Failed to plan and implement activities of residents interests; - F253 Failed to provide a clean and well-maintained environment; - F258 Failed to provide comfortable sound levels; - F272 Failed to c… | 2016-02-01 |
| 10232 | 10232 | KEARNEY COUNTY HEALTH SERVICES | 2.8e+298 | 727 EAST 1ST STREET | MINDEN | NE | 68959 | 2012-08-01 | 520 | H | 0 | 1 | NRZX11 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.07C Based on observations, record review, and interviews conducted during the annual standard survey; the facility failed to ensure the Quality Assessment and Assurance Committee (QA&A) failed to identify areas of deficient practice. The QA&A committee also failed to develop and implement plans of action to correct multiple issues of deficient practice relevant to resident care and services The facility failed to implement plans of action to maintain correction for previously cited areas of deficient practice identified during survey on 9/27/11, 7/14/11, 11/9/10, 5/5/10, 5/27/09, 12/23/08, and 6/4/08. The facility census was 30. Findings are: A. Review of the facility's undated policy Long Term Care Continuous Quality Improvement Plan (CQI) revealed: - Policy Statement: This facility shall develop, implement, and maintain an ongoing program designed to monitor and evaluate he quality of resident care, pursue methods to improve quality care, and to resolve identfied problems. - Authority: 2. The administrator has been delegated responsibility for assuring the CQI Program of this facility is in compliance with federal, state, and local regulatory agency requirements. - Goals of the Committee: 1. To monitor and evaluate the appropriateness and quality of care provided within the framework of the CQI Plan; and 2. To provide a means whereby negative outcomes relative to resident care can be identified and resolved through an interdisciplinary approach, and positive outcomes can be reinforced through education and monitoring. - Committee Actions: 1. The committee will develop and implement plans of action to correct identified negative care outcomes. B. The facility was found to be deficient in multiple areas of regulatory compliance after the tasks of the annual standard survey were completed. The facility failed to maintain corrections for the regulations identified as repeat deficiencies and failed to identify and develop plans of action to prevent deficient practice in the… | 2016-02-01 |
| 11269 | 11269 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 309 | H | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2 Based on observations, record review and staff interview; the facility failed to provide care and treatment to promote healing of wounds for Residents 17, 28, and 35. Facility census was 33. Findings are: A. Review of facility policy for Actual Impaired Skin Integrity (no date indicated) revealed residents with impaired skin integrity as a result of pressure ulcers, vascular ulcers, rashes, skin tears, surgical sites and diabetic/neuropathic ulcers were to receive interventions which included the following: -Medications and treatments as ordered -Encouragement and assistance to turn and reposition every 1 - 2 hours -Measure/assess wound and skin check every week -Notify physician of signs and symptoms of impaired skin integrity -Notify physician as needed for lack of response to treatment if no improvement noted within 2-4 weeks as indicated/appropriate -Monitor status of surrounding skin every day and notify physician as needed of noted impairment -Monitor for signs/symptoms of infection or other complication and notify physician as needed B. Review of Resident 17's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/27/14 indicated the resident was admitted to the facility 2/19/14 with [DIAGNOSES REDACTED]. Review of Resident 17's Treatment Flowsheet (a record of treatments provided by nursing) for 2/2014 revealed a physician's order dated 2/19/14 for saline wet-to-dry dressings (A gauze pad soaked in saline and placed on the surface of a wound bed, followed by a dry dressing pad placed on top of the wet dressing) to left lateral ankle BID (2 times daily) at 10:00 AM and 10:00 PM. Documentation revealed the 10:00 AM dressing change to Resident 17's ankle was not documented from 2/19/14 to 2/25/14 (6 of 13 dressing changes in 7 days). Review or Resident 17's Care Plan dated 2/25/14 indicated the resident had an open wound to the left lateral… | 2015-07-01 |
| 11271 | 11271 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 314 | H | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observations, record review and staff interviews; the facility failed to identify the presence of pressure sores and/or to provide identified interventions for the prevention and treatment of [REDACTED]. Facility census was 33. Findings are: A. Review of facility policy titled "Pressure Sore Prevention and Monitoring Guidelines" (revised 6/13) revealed the goal of the facility was to maintain skin integrity. If a resident developed a pressure sore, the resident was to receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Upon identifying a pressure sore the licensed nurse was to perform the following procedures: -Notify the physician for orders to treat each pressure sore identified. -Notify resident's responsible party and physician regarding change in condition. -Ensure pressure sores are identified with goals and interventions to be addressed on the resident's Care Plan. -Schedule weekly head to toe skin assessments. -Notify the Dietary Manager and the Registered Dietician for recommendations to ensure adequate caloric and protein needs as applicable. -All pressure sores will be assessed weekly. B. Review of facility policy titled "Dressing-Non-sterile Treatment" (revised 6/13) revealed the policy of the facility was to perform treatments and dressing changes per physician orders. The licensed nurse was to follow the following procedure: -Review physician treatment orders. -Prepare clean field. -Create a barrier for dressing supplies and place on the clean field. -Wash hands. -Apply clean gloves -Remove soiled dressing and place in a biohazard container. -Remove gloves and wash hands. -Apply clean gloves. -Clean wound per physician order. Clean wound from the center to the outer borders using a circular motion (area of most contamination to the area of the least). Ensure you do not contaminate the wound bed. -Remove … | 2015-07-01 |
| 11274 | 11274 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 325 | H | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observations, record review and staff interview; the facility failed to evaluate significant weight losses for Residents 15 and 9, and gradual weight loss for Resident 10. Interventions for the prevention of weight loss were not developed and/or revised to prevent further loss of weight. Facility census was 33. Findings are: A. Review of the facility Weight Policy (Revised 08/13) included the following: 1. All residents will be weighed monthly. 2. The charge nurse will notify the Dietary Manager (DM) and Director of Nursing (DON) of weight variances. 3. Weight variance: Calculate weight loss or gain every time a resident is weighed. Significant weight variance must be brought to the attention of the Registered Dietician (RD). (Significant weight loss/gain was defined as 5% (percent) in 1 month, 7.5% in 3 months, and 10% in 6 months.) 4. RD or designee will review information, discuss with resident and document on the medical record. 5. The physician will be called by the charge nurse regarding significant weight variances. B. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/23/14 indicated the resident was admitted with [DIAGNOSES REDACTED]. The MDS further revealed the resident had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making, and required extensive assistance with eating. Review of Resident 15's Care Plan dated 2/2/13 indicated the resident had a history of [REDACTED]. Interventions included to offer ice cream if not eating the meal provided; provide 2 Cal (a high calorie nutritional supplement) 4 ounces TID (3 times daily) between meals; encourage, provide cues, and/or assist with oral intake of food and fluids although resident not always receptive to this; monitor and record weight weekly; notify physician and family of significant weight cha… | 2015-07-01 |
| 11284 | 11284 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 520 | H | 0 | 1 | ZQ0211 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on observations, record review and staff interview; the facility Quality Assurance (QA) Committee failed to maintain correction of previously cited deficiencies regarding accident prevention, infection control, Care Plan revision and implementation, timely assistance for residents who require assist with activities of daily living, treatment and care of pressure sores, QA and staffing. This failure had the potential to affect the well-being of all residents. Facility census was 33. Findings are: A. Record review of the Quality Assurance policy and procedures (undated) revealed the purpose of the program was to ensure appropriate follow-up and ongoing tracking of identified environmental and quality of care issues. The policy further indicated the QA Committee was to develop and implement plans of corrective action for identified trends and/or deficient practices. The following areas were to be addressed monthly by the QA Committee: -Infection Control -Skin Integrity -Safety/Environment -Resident Assessment -Quality of Care B. Review of facility deficiency statement from the Quality Indicator Survey (QIS) completed 11/13/13 and QIS completed 12/2/14 revealed repeated facility noncompliance with the following Federal (F) tags: -F 323-Failure to prevent accidents -F 280-Failure to revise resident Care Plans -F 282 Failure to implement assessed Care Plan interventions -F 312 Failure to provide timely assistance for residents who required toileting and feeding assistance. -F 441-Failure of staff to remove gloves and wash hands during toileting cares, dressing changes and catheter cares in a manner to prevent cross contamination. F 520-Failure to maintain correction of previously cited deficiencies through the QA program. C. Interview with the Administrator on 12/2/14 from 7:45 AM to 8:01 AM revealed the QA Committee had discussed issues regarding infection control practices and current facility pressure ulcers at the last QA meeting on 10/22/14. However, there was no… | 2015-07-01 |
| 11361 | 11361 | MONTCLAIR NURSING AND REHABILITATION CENTER | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2012-02-29 | 520 | H | 1 | 1 | IWZ611 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and interview; the facility's Risk Management/Quality Improvement Program (RM/QIP) failed to identify ongoing issues relevant to F157, F221, F225, F281, F309, F311, F315, F323, F325, F329, F332, F333, F431, F469, F490, F505 and F520 and implement effective plans of action to correct the deficient practice. The RM/QIP Committee failed to assure repeated deficiencies at F157, F253, F280, F315, F323 and F329 were corrected and the correction maintained. The sample size of the survey consisted of 26 sampled and 2 non-sampled residents. The facility staff identified a census pf 157. Findings are: Record review of the facility policy and procedure for the RM/QIP revised on 03/2011 revealed the following: -The RM/QIP is directed by the Administrator. The program is focused on minimizing risk and improving resident/patient care by implementing a process for root cause analysis ad the utilization of the Quality Improvement teams. -Procedure: -#6. Prepare a written agenda for each meeting to include the discussion of incidents, issues and concerns. -#7. Develop a action plan to improve the identified process or system. Action plan is to include goals, outcome indicators and a monitoring plan. -#8. Complete written minutes of the meeting to document items discussed and the proposed action item. -#9. Implement action plan. -#10. Collect, study and analyze the outcome data. -#11. Continue to monitor the completion and effectiveness of the action plan. Modify the action plan (if) results are not acceptable. -#12. Report results to RM/QIP committee. An interview on 2/23/2012 at 7:35 AM was conducted with Nursing Assistant (NA) C . During the interview, NA C stated (gender) was not aware of the RM/QIP committee or how the RM/QIP functioned. NA-C was not aware of what the QI (Quality Improvement) process was, did not know how to access the committee, and was not able to verbalize any specific plans of action the RM/QIP was working on. An interview on 2/23/2012 a… | 2015-06-01 |
| 11370 | 11370 | MONTCLAIR NURSING AND REHABILITATION CENTER | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2012-02-29 | 490 | H | 1 | 1 | IWZ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.02 Based on observations, record review, and interviews, the facility failed to ensure effective management of facility resources to maintain the high practical well being of residents and the facility as evidenced by failure to ensure the facility identified and developed plans of action to correct deficient practices and failure to maintain correction for previously cited areas of deficient practice and failed to provide Medical Director required docuemntation to fulfill Medical Directors duties. The survey sample was 26 residents with 4 non-sampled residents. The total facility census was 157 residents. Findings are: A. The facility was found to be deficient in multiple areas of regulatory compliance. The following is a list of F tags cited, please refer to the tag citation for specific detailed findings: -F157 Failed to notify resident's physician and/or family members of changes in condition -F221 Failed to evaluate a tilt and space wheelchair as a restraint -F225 Failed to report possible abuse or neglect immediately, investigate and submit investigation in accordance with federal requirements -F253 Failed to maintain equipment and furniture in clean condition and in good repair -F279 Failed to implement comprehensive care plan -F281 Failed to follow physician order [REDACTED]. -F309 Failed to evaluate skin breakdown and implement interventions -F311 Failed to provide restorative services -F323 Failed to evaluate causal factors, implement interventions and reevaluate interventions to prevent accidents -F325 Failed to weigh residents, evaluate weight changes and implement caloric count -F329 Failed to complete behavioral monitoring for aggressive behaviors -F332 Failed to ensure medication error rate of less than 5% with a medication error rate of 18.6% -F333 Failed to ensure residents were free from significant medication errors -F371 Failed to ensure dietary staff utilized hand washing techniq… | 2015-06-01 |
| 25 | 25 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-08-12 | 689 | G | 1 | 0 | 7ED911 | **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 staff failed to implement assessed interventions and failed to implement additional interventions to prevent falls for 3 (Resident 20, 21 and 23) of 4 residents. The facility staff identified a census of 225. Findings are: [NAME] Record review of Resident 20's Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 6-19-2019 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was a 1. According to the MDS Manuel, a score of 0 to 7 indicated severe cognitive impairment. -Extensive assistance with bed mobility and transfers requiring 2 persons physically assisting the resident. -Total dependence for locomotion on the unit, toilet use and personal hygiene requiring 2 persons to physically assist the resident. Record review of Resident 20's Comprehensive Care Plan (CCP) dated 1-29-2019 revealed Resident 20 was at high risk for falls. The goal identified for Resident 20 was no falls or no falls with injury. The interventions identified on Resident 2's CCP included 2 persons to assist with dressing, hygiene, grooming/bathing and bed mobility. Resident 20's CCP also identified Resident 20 could stand and pivot with assistance. Other interventions included a mat next to the bed and to keep Resident 20's bed in a low position. Record review of a Abuse/Neglect/Misappropriation/Crime Reporting Form (ANMCRF) dated 7-24-2019 revealed Resident 20 had .fell out of bed yesterday ,striking (gender) head on the floor sustaining an abrasion and possible head injury. Record review of a investigation report dated 7-25-2019 revealed the Nursing Assistant (NA) A had been providing care to Resident 20 when Resident 20 fell from bed. Record review of a Documentation form dated 7-24-2019 revealed NA A reported working with Resident 20. Accor… | 2020-09-01 |
| 64 | 64 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 609 | G | 1 | 0 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview the facility failed to ensure that resident abuse resulting in injury was investigated for 1 resident (Resident 87) and the facility failed to ensure that misappropriation of resident property was investigated for 1 resident (Resident 86). Based on record review and interview, the facility failed to ensure incident investigations were submitted to the state agency within 5 working days. This affected 5 residents (Residents 14, 40, 69, 86, and 87) of 10 residents reviewed. The facility census was 123. Findings are: A) Interview with Resident 87 on 9/30/19 at 10:26 AM occurred in the resident room. A splint was observed in place on the resident's right pinky finger. When asked by this surveyor what happened to the resident's right pinky finger the resident responded that the resident (Resident 87) hit another resident in the head when another resident attempted to kiss the resident (Resident87). Resident 87 confirmed that this was reported to facility staff in (MONTH) (2019). Record review of the nurse progress note for Resident 87 dated 3/5/19 at 10:45 PM revealed that the resident had complained of itching to the small right finger earlier in the evening at 9:00 PM. The finger was swollen, reddish purple in color and painful to touch, ice was applied at that time and continuing to monitor for any changes. Record review of the X-Ray report for Resident 87 dated 3/6/19 revealed that the resident had a [MEDICAL CONDITION] digit (pinky finger) of the right hand. Record review of the facility policy titled Abuse Investigations dated (MONTH) 2014 revealed the Policy Statement: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Step 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey an… | 2020-09-01 |
| 209 | 209 | ROSE BLUMKIN JEWISH HOME | 285059 | 323 SOUTH 132ND STREET | OMAHA | NE | 68154 | 2016-12-01 | 309 | G | 0 | 1 | W3MZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09 Based on observation, record review and interview; the facility staff failed to re-evaluate pain indicators and implement interventions to manage pain for 1 (Resident 112) of 1 residents reviewed. The facility staff identified a census of 86. Findings are: Record review of Resident 112's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) signed as completed on 9-26-2016 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was a 3. According to the MDS Manual, a score of 0 to 7 indicated severe cognition impairment. -Independent with bed mobility. -Supervision with personal hygiene. -Limited assistance with on and off the unit. -Extensive assistance with dressing and toilet use. -Received as needed (PRN) pain medication or was offered and the resident declined the medication. Record review of Resident 112's Comprehensive Care Plan (CCP) dated 6-13-2016 revealed Resident 112 had back pain. The goal for Resident 112 was that Resident 112 would rate pain below a 4 on the pain scale. Typed in interventions on the CCP were to balance rest and activity, use numeric scale to rate pain, Tylenol and [MEDICATION NAME] (pain medication) PRN.[MEDICATION NAME] (pain medication) PRN. Further review of Resident 112's CCP dated 6-13-2016 revealed a hand written entry update that Resident 112 received an x-ray due to increased pain and the update dated 10-26-2016 that Resident 112 was to receive Tylenol routine for back pain. Observation on 11-30-2016 at 8:02 AM of personal care for Resident 112 revealed Nursing Assistant (NA) [NAME] and NA F washed hands and donned gloves. Resident 112 was observed to be in bed. Resident 112 yelled out Oh that hurts and was heard to moan and groan as NA F started to cleans the front peri area. Resident 112 continued to yell out stop at NA F and then started to hit at NA F. NA [NAME] assiste… | 2020-09-01 |
| 258 | 258 | HIGHLAND PARK CARE CENTER | 285063 | P O BOX 950, 1633 SWEETWATER | ALLIANCE | NE | 69301 | 2018-08-23 | 689 | G | 0 | 1 | EHQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7b (3 and 4) Based on record reviews and interview, the facility failed to ensure that interventions were in place to prevent recurrent falls with injuries including a cervical fracture with ongoing pain and multiple abrasions with pain for one current sampled resident (Resident 54). The facility census was 53 with 22 current sampled residents. Findings are: Review of Resident 54's care plan, goal date 8/20/18, revealed that the resident had a history and potential for falls related to a history of self transfers and self ambulation, confusion, impaired gait and balance, incontinence, antidepressant and diuretic medications, was unaware of safety needs, weakness, difficulty in walking, refusal of cares and physical and verbal aggression and agitation at times. Further review revealed a focus area, dated 8/20/18, which stated that the resident sustained [REDACTED]. Other focus areas included that the resident had cognitive impairment related to both short term and long term memory troubles and the resident required assistance with activities of daily living including transfers and toileting. Interventions listed on 7/4/18 revealed that the resident often self transfers, attempts to self ambulate and will often transfer self to the bathroom unassisted. Review of the Progress Notes revealed the following including: - 7/24/18 at 7:20 PM The staff found the resident on the floor at the foot of the bed. The resident stated was going to the bathroom. The resident complained of neck and shoulder pain and refused to go to the hospital for evaluation. The resident was educated on the use of the call light; - 7/25/18 at 1:35 PM The resident was sent to the to physician for evaluation of severe neck and shoulder pain almost unbearable; - 8/2/18 at 11:00 AM The resident was readmitted from the hospital with a [DIAGNOSES REDACTED].; - 8/4/18 at 1:08 PM The resident transferred self back to bed after breakfast an… | 2020-09-01 |
| 364 | 364 | PARK VIEW HAVEN NURSING HOME | 285073 | 309 NORTH MADISON STREET | COLERIDGE | NE | 68727 | 2017-09-28 | 325 | G | 1 | 1 | XTJ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on record review and interview; the facility failed to revise current interventions or to develop new nutritional interventions to address ongoing significant weight loss for Resident 13. The facility census was 25 and the sample size was 27. Findings are: [NAME] Review of the facility policy Significant Weight Loss (undated) revealed a goal of identifying causes or factors contributing to significant unplanned weight loss and implementation of interventions as appropriate to stabilize weight. Review of the identified procedure revealed the following: -Review food intake records. -Interview the resident to identify possible causes and appropriate interventions. -Implement individualized nutritional interventions based on resident preferences. This may include but is not limited to; foods enhanced with extra calories or proteins. -High calorie or high protein supplements. -Possible use of an appetite stimulant if appropriate. B. Review of Resident 13's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/24/17 revealed [DIAGNOSES REDACTED]. The resident's weight was 143 lbs. (pounds) and the resident was not on a prescribed weight loss regime. Review of Resident 13's Weights and Vitals Summary Sheet (form used to document a resident's weight, blood pressure, respiration, temperature and pulse) revealed on 5/28/17 the resident's weight was 142 lbs. Review of Resident 13's current Care Plan revised on 5/30/17 revealed the resident had the potential for nutritional problems related to pain and loss of appetite. The following interventions were identified: -Offer snacks as requested by the resident. -Provide and serve diet as ordered. -Registered Dietician (RD) to evaluate and make recommendations as needed. Review of Resident 13's Weights and Vitals Summary sheet revealed the following record of weights: 6/26/17- 138 lbs. 7/24/17- 143 lbs. … | 2020-09-01 |
| 421 | 421 | ST. JOSEPH VILLA NURSING CENTER | 285078 | 2305 SOUTH 10TH STREET | OMAHA | NE | 68108 | 2018-02-12 | 689 | G | 1 | 1 | B6BN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference: 12-006.09D7 Based on observations, interview, and record review, the facility failed to implement interventions to protect 1 (Resident 59) of 9 sampled residents with falls. The facility had a total census of 170 residents. Findings are: Resident 59 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations on 2/7/18 at 9:09 AM and 1:05 PM revealed Resident 59 being fed breakfast and lunch in bed by Nurse Aide I. In an interview on 2/7/18 at 1:05 PM, Nurse Aide I reported Resident 59 was not getting up in chair due to not having a cushion for Resident 59's wheelchair. Observations on 2/8/18 at 9:06 AM revealed Resident 59 being fed breakfast in bed by Nurse Aide [NAME] In interviews on 2/8/18 at 7:28 AM and 9:06 AM, Nurse Aide J reported Resident 59 had slid out of wheelchair and Resident 59 had not been getting up. Nurse Aide J reported waiting until new wheelchair came in to get Resident 59 up. In an interview on 2/7/18 at 2:06 PM, Registered Nurse N reported physical therapy was trying to find a wheelchair for Resident 59 due to sliding out of the wheelchair. A review of Post Fall assessment dated [DATE] revealed Resident 59 was observed slid down out of wheelchair with back resting against foot pedals. Resident 59 received a 5.6 x 1.9 cm (centimeter) skin tear with redden bruising around edges to left lower arm and a 4.7 x 3.5 cm skin tear with reddened bruising around edges to left arm near elbow. A review of Interdisciplinary Therapy Screen dated 1/31/18 revealed Resident 59 was identified having a potential risk related to wheelchair positioning. The comments section stated Resident 59 was appropriate for occupation therapy due to need for wheelchair positioning assessment. In an interview on 2/8/18 at 8:36 AM, Occupational Therapist K reported that a physician's orders [REDACTED]. In an interview on 2/8/18 at 10:10 AM, Physical Therapist L confirmed a screen had been completed on 1/31/18 an… | 2020-09-01 |
| 424 | 424 | ST. JOSEPH VILLA NURSING CENTER | 285078 | 2305 SOUTH 10TH STREET | OMAHA | NE | 68108 | 2018-02-12 | 697 | G | 1 | 1 | B6BN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, record review and interview; the facility staff failed to implement and evaluate the effectiveness of the pain management program for 1 (Resident 156), and failed to evaluate the effectiveness of as needed pain medications for 1 (Resident 256) of 5 sampled residents. The facility staff identified a census of 170. Findings are: [NAME] Record review of a Face Sheet dated 1-24-18 revealed Resident 156 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 156's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 2-07-2018 revealed the facility staff assessed the following about Resident 156: -Brief Interview of Mental Status (BIM'S) was a 15. According to the MDS Manuel, a score of 13 to 15 indicate intact cognition. -Required Limited assistance with bed mobility, transfers, eating, toilet use and personal hygiene. - No pain issues were identified for Resident 156. Record review of Resident 156's Comprehensive Care Plan (CCP) dated 1-27-2018 Resident 156 had a problem area of pain. The goal identified for Resident 156 was to be able to verbalize or demonstrate minimal pain or discomfort. Interventions to manage Resident 156's pain included administering pain medication and evaluating the effectiveness, assess for non verbal signs of pain such as guarding, moaning and grimacing. Assessing pain characteristics, asking the resident to be specific regarding the duration, location and the quality of the pain. Medicate and offer to medicate for pain prior to physical activities such as Activities of Daily Living (ADL's) or Therapy. Offer non-pharmaceutical means of relief, such as, repositioning, elevation of extremities on pillows, relaxation-quite music, and 1 to 1's. Record review of Nursing Assessment and Re-Admission sheet dated 1-15-2018 revealed Resident 156 had pain … | 2020-09-01 |
| 459 | 459 | HILLCREST NURSING HOME | 285080 | P O BOX 1087, 309 WEST 7TH STREET | MCCOOK | NE | 69001 | 2018-01-24 | 760 | G | 1 | 0 | 6LD811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.10D Based on record reviews and interviews, the facility failed to transcribe a medication order for a diuretic medication (medication to reduce swelling) for one sampled resident (Resident 4). The failure resulted in a 14 day delay in the medication being provided to the resident and resulted in the resident's continued leg swelling and development of blisters. Sample size was four current residents. Facility census was 77. Findings are: Record review of Resident 4's Face Sheet printed on 1/24/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 4's electronic medical record and chart revealed the following: - from the Departmental Notes an entry dated 12/15/17 at 4:37 p.m. revealed the resident was seen and received new orders from the physician. - A Message from Organization: (name of clinic). New Medication (a web-based communication tool with communication from the clinic to the facility) dated 12/15/17 and generated on 12/16/17 revealed the physician also started (Resident 4) on 20 mg (milligrams) of [MEDICATION NAME] PO (by mouth) daily. An Electronic Prescription via Sure Scripts form from the clinic to the pharmacy revealed an order dated 12/15/17 for Resident 4 was written for [MEDICATION NAME] 20 mg oral tab with instructions to administer 1 (one) Tablet by mouth once daily. - 12/23/17 at 3:34 p.m. from the Departmental Notes the resident was assessed with [REDACTED]. 2+ indicated indention of the skin 2-4 millimeters deep which does not rebound for 10-15 seconds when pushed inward) to BLLE (bilateral lower extremities) . - A Nursing Communication form sent to the physician on a follow up visit dated 12/29/17 revealed the resident was being seen in Follow-up and requested the physician Please look @ (at) red, raised open areas to L (left) lower leg . The physician provided a communication note from the visit wh… | 2020-09-01 |
| 610 | 610 | TIFFANY SQUARE | 285087 | 3119 WEST FAIDLEY AVENUE | GRAND ISLAND | NE | 68803 | 2018-03-07 | 686 | G | 0 | 1 | K8KC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review, and interview; the facility failed to have interventions in place to promote healing of a facility acquired Stage 2 (partial thickness loss of skin) pressure ulcer on the sacrum (fused bones found at the lower end of the spinal column) for 1 of 3 sampled residents (Resident # 61) and therefore the pressure ulcer worsened from a Stage 2 to a Stage 3 (full thickness loss of skin). The facility identified a census of 82 at the time of survey. Findings are: Record review of Resident 61's MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 2/09/18 revealed an admission date of [DATE]. Resident 61 had a BIMS (Brief Interview Mental Status) score of 7 which indicated Resident 61 had severe cognitive impairment. Resident 61 required extensive assistance of 2 staff with bed mobility and was dependent with two plus persons physical assist with transfers. Review of Resident 61's Pressure Ulcer Record dated 1/23/2018 revealed Resident 61 had a Stage 2 pressure ulcer on the sacrum with an onset date of 1/21/2018. Observation of Resident 61 on 3/1/2018 at lunch time (12:00 PM) revealed Resident 61 was sitting in their wheelchair. Observation of Resident 61 on 3/1/2018 at 1:30 PM revealed Resident 61 was sitting in their wheelchair. Observation of Resident 61 on 3/1/2018 at 3:00 PM revealed Resident 61 was sitting in their wheelchair. Observation of Resident 61 on 3/1/2018 at 3:10 PM revealed staff assisted Resident 61 to lay down in bed. The resident had not been out of the wheelchair since before 12PM. Observation on 3/06/18 at 1:14 PM revealed Resident 61 was sitting in a recliner with the sling from the lift still underneath the resident. Observation on 3/06/18 at 2:40 PM revealed Resident 61 was sitting in a wheelchair at an activity with the sling from the lift underneath the resident. Interview on 3/06/18 at 10:45 AM wi… | 2020-09-01 |
| 664 | 664 | HERITAGE OF BEL AIR | 285089 | 1203 NORTH 13TH STREET | NORFOLK | NE | 68702 | 2019-06-24 | 689 | G | 0 | 1 | 2H0G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7 Based on observation, interview, and record review; the facility failed to implement interventions to prevent potential choking episodes for Resident 41. The sample size was 1 and the facility census was 84. Findings are: Review of a Progress Note dated 5/12/19 revealed at 12:50 PM Resident 41 began coughing during lunch. The resident had increased difficulty breathing and talking. The resident shook no when asked if the resident could talk. Back blows were performed with no improvement. The resident became unresponsive and cyanotic (bluish discoloration usually caused by low oxygen levels) with fixed pupils. The resident's chin was lifted, to obtain optimal airway, and the resident then coughed and was able to take breaths at that time. The resident's physician and Power of Attorney (POA) were notified per telephone. The resident's POA requested the resident's current diet remain unchanged. Review of a ST (Speech Therapy) Daily Treatment Note dated 5/14/19 revealed ST recommended a mechanical soft diet with extra sauces/gravies and no raw fruits or vegetables. Review of a Progress Note dated 5/14/19 at 10:30 PM, revealed Resident 41 was offered a ground meat sandwich. The resident coughed and had strider (high-pitched, wheezing sound caused by disrupted airflow) type respirations. The nurse attempted the [MEDICATION NAME] maneuver and performed back blows with no change. The resident began to have cyanosis to the lips, ears, and nail beds. The resident became unresponsive to tactile (sensory stimulation involving touch) and verbal stimulation. The resident was transferred out of the wheel chair, to the floor, rolled on side, and back blows were performed again. Oxygen was started and the resident started coughing. Review of a Progress Note dated 5/17/19 at 8:50 AM revealed Resident 41 had another choking/wheezing episode at the breakfast table. The wheezing lasted for a few seconds and then the … | 2020-09-01 |
| 794 | 794 | CENTENNIAL PARK RETIREMENT VILLAGE | 285094 | 510 CENTENNIAL CIRCLE | NORTH PLATTE | NE | 69101 | 2017-01-26 | 328 | G | 0 | 1 | EUUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D6 Based on observations, record reviews and interviews; the facility failed to ensure that oxygen was in place and administered as ordered and that respiratory status was monitored for one sampled resident (Resident 39) who frequently removed oxygen resulting in low oxygen blood levels. The facility census was 50 with 17 current sampled residents and 2 closed records. Findings are: Review of the Resident Face Sheet revealed that Resident 39 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, edited 1/20/17, revealed that the resident was at risk for impaired gas exchange related to chronic [MEDICAL CONDITION]. Approaches included administer oxygen per nasal cannula, assess and record signs of impaired gas exchange (confusion, restlessness, irritability), resident refuses to wear oxygen frequently, monitor oxygen saturation as ordered and monitor and document respiratory status as needed with changes in respiratory status. Interview with a family representative on 1/24/17 at 12:30 PM revealed they often found the resident without oxygen. Further interview revealed that the resident was more confused, restless and agitated when the oxygen wasn't kept on which made it even more difficult to get the resident to keep the oxygen in place. Observations on 1/24/17 at 8:45 PM revealed the resident seated in the wheelchair in room with oxygen cannula (tubing placed in the nose to administer supplemental oxygen) on the floor. Further observations revealed NA (Nursing Assistant) - M attempted to place the oxygen on the resident and the resident refused. NA - M reported to LPN (Licensed Practical Nurse)- H, Charge Nurse, that the resident refused the oxygen and was agitated. LPN - H entered the room and encouraged the resident to use the oxygen and the resident complied. LPN - H checked the resident's oxygen saturation which was 79% (normal oxygen saturation is greater t… | 2020-09-01 |
| 841 | 841 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2019-05-28 | 626 | G | 1 | 1 | 3V0011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.05 (5b) Based on record reviews and interviews, the facility failed to allow one sampled resident (Resident 89) to return to the facility following hospitalization to stabilize the resident's condition. The failure resulted in an extended hospital stay for the resident who no longer required hospital level of care. Facility census was 85. Sample size included 7 residents discharged from the facility to an acute care hospital setting. Findings are: Record review of an Admission Record for Resident 89 printed on 5/8/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of a Discharge- return anticipated MDS (Minimum Data Set, a federally mandated assessment and tracking tool) completed on 1/29/19 revealed Resident 89 had been discharged to an Acute hospital on [DATE] and the facility expected the resident to return when stabilized. Record review of Resident 89's electronic Progress Notes revealed on 1/29/19 the resident's physician was notified at 10:11 a.m. regarding the resident's aggression and anxiety and informed the the resident was either going to be put under an EPC (Emergency Protective Custody) or admitted to an available behavioral facility. At 1:39 p.m. the facility phoned the local police department, resident's physician, and resident's psychiatrist to inform them the resident was being sent EPC from the facility. At 1:53 p.m. the resident was escorted off the unit by the police department. At 1:56 p.m. an attempt was made to notify the resident's Sibling-[NAME] At 2:51 p.m. the facility received a call from the resident's psychiatrist who stated will let the psychiatrist know the resident was being EPC'd from the facility. An entry on 2/1/19 at 2:17 recorded by the facility SSD (Social Services Director) recorded an emergency contact, Sibling-B, was called and a message left that the resident was being admitted to a behavi… | 2020-09-01 |
| 847 | 847 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2019-05-28 | 684 | G | 1 | 1 | 3V0011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to ensure that 1) abnormal bleeding was assessed and follow up was completed to ensure care was provided promptly for one current sampled resident (Resident 41) on blood thinning medication, 2) low blood sugar readings were assessed and follow up care provided to ensure needs were met for one current sampled resident (Resident 42, 3) [MEDICAL CONDITION] were assessed and follow up completed to ensure healing without complications for one current sampled resident (Resident 48) and 4) a PICC (Peripherally Inserted Central Venous Catheter) line was monitored every shift and a heart monitor present on re-admission was monitored as indicated for one current sampled resident (Resident 73). The facility census was 85 with 24 current sampled residents. Findings are: [NAME] Review of the Admission Record, printed 5/21/19, revealed that Resident 41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that the resident was readmitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 6/3/19, revealed that the resident was at risk for bruising and bleeding related to the use of blood thinning medication. Interventions included that the staff were to inspect the resident's skin for bruising or unusual bleeding daily during care and report to the charge nurse and provider for further interventions. Further review revealed that the resident had both short term and long term cognitive deficits and had difficulty making self understood and understanding others. Review of the Progress Notes revealed the following including: - 2/25/19 at 4:30 AM This nurse noted a large bruise to the left side of the hip, bruise area was hardened, the resident grimaced when the area was touched, no reports of injury from the previous nurse, resident was unable to state the source o… | 2020-09-01 |
| 848 | 848 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2019-05-28 | 686 | G | 0 | 1 | 3V0011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Numbers 175 NAC 12- D2 175 NAC 12-006.09D2b Based on observations, record reviews and interviews; the facility failed to provide care to prevent pressure ulcers and to promote healing, including repositioning at least every two hours, pressure relieving seat cushions, dressing changes as ordered, aseptic technique for dressing changes and follow up with ongoing resident non compliance with interventions for two current sampled residents (Residents 42 and 48). The facility census was 85 with 24 current sampled residents. Findings are: [NAME] Review of the Admission Record, printed 5/21/19, revealed that Resident 42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 6/18/19, revealed that the resident required assistance with activities of daily living including repositioning in bed, transfers and personal hygiene and cares. Further review revealed that the resident was at risk for pressure ulcers due to assistance required with bed mobility, diabetes, history of pressure ulcers and placed a pillow in the wheelchair. On 9/12/18, the resident had a pressure area to the coccyx and right buttock, on 1/17/19 the area to the coccyx was closed, on 2/22/19 the area was opened, and 5/17/19 the area was stable with 100% granulation tissue. Interventions included treatments as ordered, weekly skin assessments, pressure reducing wheelchair cushion and air mattress, the resident frequently sits on a pillow on top of the pressure reducing wheelchair cushion and staff will continue to educate the resident on the importance of not using a pillow on top of the pressure reducing device and to comply with treatment. Review of the Wound Evaluation Flow Sheet Multiple Weeks - V 4, dated 4/28/19, revealed the following including: - 2/22/19 Stage 4 pressure ulcer ( full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, often … | 2020-09-01 |
| 850 | 850 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2019-05-28 | 689 | G | 0 | 1 | 3V0011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D7a Based on observations, record reviews and interviews; the facility failed to ensure that 1) safety measures were in place to prevent one sampled resident (Resident 44) from falling during bathing. The failure resulted in the resident sustaining a fracture; 2) care plan interventions were in place to reduce the risk for recurrent falls for one current sampled resident (Resident 41); and 3) a loose grab bar was secured to the bed frame to reduce the risk for injuries for one current sampled resident (Resident 42). The facility census was 85 with 24 current sampled residents. Findings are: [NAME] Interview with Resident 44 on 5/22/19 at 1:45 p.m. revealed the resident describing having sustained a fall and fracture requiring surgery and hospitalization about a month after being admitted . The resident described the incident by stating the fall occurred in the tub room after the bath was completed. The resident stated being in a bath chair and that Usually the staff strapped the resident in the chair and had a second person present during transfers. On this occasion, the staff did not apply the strap or have a second person present. The resident described tumbling out of the chair and fracturing a leg resulting in the need for surgery after being diagnosed with [REDACTED]. Record review of Resident 44's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessments revealed an Admission assessment was completed on 2/20/19. The assessment recorded the following items regarding the resident's condition: - The assessment recorded the resident was admitted from another nursing home on 2/14/19. - The assessment recorded a resident BIMS (Brief Interview for Mental Status) test score was 15 (cognitively intact memory). - The assessment recorded the resident's ability to transfer between surfaces (to and from bed, chair, wheelchair) required t… | 2020-09-01 |
| 861 | 861 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2019-05-28 | 867 | G | 0 | 1 | 3V0011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC ,[DATE].07 Based on observations, record reviews, and interviews, the facility Quality Assurance Program failed to identify, correct, and maintain regulatory required compliance resulting in multiple citations and repeat areas of non-compliance from prior surveys. Facility census was 89. Sample size included 24 current residents and three closed records. Findings are: Record review of the facility QAPI (Quality Assurance Program) plan developed on [DATE] revealed the purpose of the committee was to educate, support and encourage staff to increase their skills to provide quality care to all residents. To provide residents with a comfortable environment where they are involved in, and have a voice in, the daily activities of their home. The committee's plan is to review all data sources and other available data to identify, prioritize, and correct issues with performance. The QAPI committee will evaluate the effectiveness of actions taken for further recommendation. Observations, record reviews, and interviews during the survey processes from surveys conducted on [DATE] and the current survey from [DATE] through [DATE] revealed the following areas of repeated non-compliance: F578- ensuring facility staff had valid CPR (Cardiopulmonary Resuscitation) certifications. F583- providing privacy with resident personal cares. F622- documentation regarding discharges from the facility. F684- providing assessments and care for residents with skin abnormalities. F689- ensuring staff were performing safe transfer techniques preventing accidents with injury. F726- competency of staff. F732- posting staffing information daily. F757- ensuring medications were being monitored to rule out unnecessary medications. F880- infection control The current survey also identified patterns in five additional areas of non-compliance: F576- mail delivery on Saturdays. F584- environmental issues. F623- notice provision in writing for faci… | 2020-09-01 |
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CREATE TABLE [cms_NE] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );