CMS-Nursing-Home-Full-Deficiencies
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | SUMNER PLACE | 285002 | 1750 SOUTH 20TH STREET | LINCOLN | NE | 68502 | 2019-02-20 | 644 | D | 0 | 1 | J44111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a level 2 PASARR ( Pre-Admission Screening and Resident Review) Program had been completed on one resident (Resident 2) of 1 sampled resident, when newly diagnosed with [REDACTED]. The facility census was 96. Findings are: Record Review of PASSAR Level one completed in 2012 did not recommend the Level II. This PASSAR identified Bi-Polar Disorder but did not identify the Schizo-effective Disorder, Mania, [MEDICAL CONDITION] Disorder, and Depression with psychiatric features, treatment refractory [MEDICAL CONDITIONS], Atypical [MEDICAL CONDITION]. Record review of Note to Attending Physician/Prescriber revealed; Resident 2 received antipsychotic medication and the clarification for [DIAGNOSES REDACTED]. Record review of initial [DIAGNOSES REDACTED]. An interview on 02/19/19 at 04:17 PM with the DON (Director of Nurse) confirmed; Resident 2 had not been reassessed for PASSAR level 2 after the [DIAGNOSES REDACTED]. An interview on 02/21/19 at 03:29 PM with the SSD (Social Services Director) confirmed the re-evaluation PASSAR had not been submitted. An interview on 02/21/19 at 03:40 PM with the SSD confirmed; that information had been sent to the psychiatrist on 02/19/19. The information had been received by the facility on 02/21/19 and had been sent to Ascend for re-evaluation. | 2020-09-01 |
| 2 | SUMNER PLACE | 285002 | 1750 SOUTH 20TH STREET | LINCOLN | NE | 68502 | 2019-02-20 | 656 | D | 0 | 1 | J44111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** License and Reference Number 175 NAC 12 Based on observation, record review and interview, the facility failed to ensure that residents care plans were individualized to meet the the residents fluid needs. This had the potential to effect 2 residents, Residents # 21 and # 28. The facility census was 96. Resident #21 02/14/19 03:38 PM observed in room and does not respond to verbal cues. 02/19/19 10:30 AM observed in room and does not respond to verbal cues. Record review of the residents MDS (Minimum Data Set is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes and non-critical access hospitals with Medicare swing bed agreements dated 08/28/18 revealed a BIMS (Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment) of 2 indicated severely impaired cognition. Extensive assist with eating and drinking. Resident unable to voice preferences on MDS. Record review of the resident care plan dated 4/28/18 revealed no plan to address the residents inability to choose what fluids to consume, when to consume fluids or how much fluids to consume. On 02/21/19 at 12:10 PM an Interview with LPN(Licensed Practical Nurse)3 D confirmed the resident does not have the ability to choose what fluids to consume, when to consume fluids or how much fluids to consume. Resident #28 On 02/14/19 at 2:35 PM resident observed in bed with eyes open does not respond to verbal cues. On 02/20/19 at 10:16 AM resident observed in bed with eyes open does not respond to verbal cues. Record review of the residents MDS dated [DATE] revealed a BIMS of 2. Extensive assist with eating and drinking. Resident unable to voice preferences on MDS. Record review of the resident care plan dated 12/3/18 revealed no plan to address the residents inability to choose what fluids to consume, when to consume fluids or how much fluids to consume. On 02/21/19 at 12:10 PM an interview with LPN D confirmed the resident does not have the ability to choose what to consume, when to consume fluids or how much to consume. | 2020-09-01 |
| 6350 | SUMNER PLACE | 285002 | 1750 SOUTH 20TH STREET | LINCOLN | NE | 68502 | 2015-08-12 | 332 | D | 0 | 1 | UQXF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.10D Based on observation, interview, and record review the staff failed to administer one medication according to the physician's orders [REDACTED]. Twenty-five medication opportunities were observed with two errors resulting in an 8% medication error rate. The facility census was 90. Findings are: A. Observation of Resident 37's medication administration on 8/11/15 at 8:43 AM revealed: -RN (Registered Nurse) A prepared the residents medication that included [MEDICATION NAME] (proton-pump inhibitor used a backflow of acid or reflux), [MEDICATION NAME] (used to treat allergies [REDACTED]. -The label for [MEDICATION NAME] 20 mg (milligrams) said to give 30 minutes before the meal. -The resident was at the dining room table eating breakfast. -RN A gave the resident the medications. Interview with RN A on 8/11/15 at 8:47 AM revealed that the [MEDICATION NAME] should have been given sooner. Review of DAVIS DRUG GUIDE for NURSES, FOURTEENTH EDITION stated Administer doses before meals, preferably the morning. B. Interview with LPN (Licensed Practical Nurse) F on 8/12/15 at 11:50 AM revealed that the LPN did not need to check for [DEVICE] placement since it was checked for Resident 88 earlier in the day. The LPN stated that it was checked every 8 hours and would be checked at 4 PM today. Observation of Resident 88's medication administration on 8/12/15 at 11:55 AM revealed: -LPN F poured 10 ml (milliliter)/ 200 mg of [MEDICATION NAME] ([MEDICATION NAME]) into a medication cup. -LPN F did not check for placement of the resident's [DEVICE] placement. -LPN F poured approximately 30 ml of water into a 60 ml syringe into the [DEVICE]. -The LPN poured the medication into the syringe that went directly into the [DEVICE] and then finished with approximately 30 ml of water into the g tube. Review of Resident 88's Admission/ Re-admission orders [REDACTED]. Review of the facility Administering Medications through an Enteral Tube revised (MONTH) 2012 stated that for gastrostomy (G tubes) check tube placement by auscultation by placing a 60 ml syringe containing 10 ml of air and listening to the whooshing sound while the air from the tube was injected into the tubing into the stomach. Interview with the DON (Director of Nursing) on 8/12/15 at 2:20 PM revealed that placements of the [DEVICE] should be checked each time a [DEVICE] medication was given. | 2019-03-01 |
| 6351 | SUMNER PLACE | 285002 | 1750 SOUTH 20TH STREET | LINCOLN | NE | 68502 | 2015-08-12 | 441 | E | 0 | 1 | UQXF11 | LICENSURE REFERENCE 175 NAC 12-006.17 Based on observation, interview and record review the facility failed to follow infection control practice to prevent cross contamination between residents, affecting two residents (Residents 47 and 82). The facility census was 90. Findings are A. Observation of Resident 47's cares on 8/12/15 at 8:08 AM revealed: -The resident was lying in bed with a horseshoe pillow supporting the resident's head and arms. -NA (Nurses Aide) K provided the resident's cares. -During the cares NA K washed the NA's hands for 10 seconds before providing catheter cares. -The NA dropped the residents urinary catheter (tube inserted into the bladder to drain urine) drainage bag on the floor during cares. The NA picked up the bag from the floor. The urinary catheter drainage bag was not in the protective coverage bag. -The Restorative Coordinator assisted NA K with the resident's transfer. NA K attached the urinary catheter drainage bag onto the NA's uniform slacks during the transfer to the resident's wheelchair. After the transfer, NA K put the urinary catheter drainage bag into a protective cover on the wheelchair. The NA washed hands less than 1 second. Interview with the Director of Nursing (DON) on 8/13/15 at 2 PM revealed that the urinary catheter drainage bag should not be placed on the staff's uniform during transfers. B. Observation of Medication Pass on 8/10/15 between 8:15 AM and 8:45 AM revealed: -RN (Registered Nurse) A did hand washing at 8:15 AM for 12 seconds -RN A did hand washing at 8:32 AM for 10 seconds -RN A did hand washing at 8:45 AM for 13 seconds C. Observation of Resident 82's toileting cares on 8/12/15 revealed: -NA L provided the resident's cares -During the cares, NA L applied gloves with no prior hand washing prior to providing the cares -NA L assisted Resident 82 with hand washing after completing the cares. -NA L did hand washing for self when cares were completed for less than 10 seconds. Interview on 8/12/15 at 1:45 PM with Administrator revealed that handwashing was to be 20 seconds per performance check sheets. The facility's Handwashing/Hand Hygiene Infection Control Nursing Services Policy and Procedure Manual 2001 MED-PASS, Inc (Revised (MONTH) 2012) 5. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: | 2019-03-01 |
| 12065 | SUMNER PLACE | 285002 | 1750 SOUTH 20TH STREET | LINCOLN | NE | 68502 | 2011-06-30 | 279 | D | 1 | 1 | RLNR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C Based on observation, interview, and record review, the facility failed to develop and individualized the plan of care for one resident (101) receiving [MEDICAL TREATMENT] treatments. The facility census was 94 residents with a stage two sample size of 28 residents. Findings are: Observation of Resident 101 up in wheelchair in hall at 2:05PM on 6/28/11. Stated, "I was outside in the sun earlier." Alert with glasses on, dressed, shoes & socks on. Observed transfer from wheelchair to bed independently State" I go to [MEDICAL TREATMENT] on Monday, Wednesday, and Friday and the facility tabs me there and back." Observation of Resident 101 at 8:50AM on 6/30/11 revealed this person sitting up in the wheelchair in the facility entrance area. Alert and oriented and visited about the day and the weather. Glasses on and reading newspaper. Dressed with shoes and socks on. Denies pain or discomfort. Stated, "I'm going outside this morning before it gets too hot." Record review of Physician order [REDACTED]. --[DIAGNOSES REDACTED]. Record review of Minimum Data Set 3.0 (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 2/16/11 revealed: --annual assessment for Resident 101 with admission date of [DATE]; --Resident 101 received [MEDICAL TREATMENT] while a resident at facility. Record review of Plan Of Care for Resident 101 with revision date of 5/2011 revealed: --weakness secondary to [MEDICAL TREATMENT]; --requires assistance with Activities of Daily Living due to Stage 5 chronic [MEDICAL CONDITION] and received [MEDICAL TREATMENT] on M/W/F; --no information on fistula site (which arm affected) and approaches to prevent damage to site; --no problems with goal or approaches on risk factors from fistula, and [MEDICAL TREATMENT] treatment received; --no problems with goals or approaches on knowledge of emergency complications from receiving the [MEDICAL TREATMENT] upon returning to the facility; --no problem withe goals or approaches on potential infection control risks due to receiving the [MEDICAL TREATMENT]. Record review of Mediation and Treatment Records dated the month of 6/2011 revealed that there were no orders for charting assessment of fistula site or potential complications following [MEDICAL TREATMENT] three times a week. Interview with RN (Registered Nurse) A at 8:45AM on 7/5/11 revealed Resident 101 received [MEDICAL TREATMENT] out of the facility on Monday, Wednesday, and Friday. No directions are returned from the [MEDICAL TREATMENT] unit concerning risk factors or potential complications. Stated, "There are no specific plan of care approaches to follow for potential emergency complications as a result of having the [MEDICAL TREATMENT] three times a week. Interview with RN D at 9:30AM on 7/5/11 revealed; --Resident 101 received [MEDICAL TREATMENT] out of the facility on Monday/Wednesday/Friday; --Annual assessment was done on Resident 101 on 2/16/11 addressing special treatments, procedures, and programs of [MEDICAL TREATMENT]; --Plan of Care for Resident 101 doesn't specifically address fistula and [MEDICAL TREATMENT] with treatment and care approaches; Interview with the DON (Director of Nursing) at 9:45AM on 7/5/11 revealed; --Resident 101 has a fistula and received [MEDICAL TREATMENT] out of facility on Monday's, Wednesday's, and Friday's. --The medication/treatment nurse checked the fistula site when Resident 101 returned; --No specific Plan of Care addressing Resident 101 had a fistula with [MEDICAL TREATMENT] three times a week; --No approaches to address the potential for emergency situations following [MEDICAL TREATMENT]. Record review of the Policy and Procedure for the facility revised 10/2010 revealed: --To prevent infection and /or clotting at fistula site: a. Keep the access site clean at all times. b. Do not use the access site arm to take blood samples, administer intravenous fluids or give injections. c. Need assess for [MEDICAL TREATMENT] should be rotated (alert the Director of Nursing Service if it is noted that the same site is accessed repeatedly). d. Check for signs of infection (warmth, redness, tenderness or [MEDICAL CONDITION]) at the access site when performing routine care and at regular intervals. e. Do not use the access arm to take blood pressure. f. Advise the resident not to sleep on, wear tight jewelry or lift heavy objects with the a access arm. g. Check the color and temperature of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals. h. Check the patency of the site at regular intervals. Palpate the site to feel the "thrill, " or use a stethoscope to hear the "whoosh" or "bruit" of blood flow through the access. --Care Immediately following [MEDICAL TREATMENT] treatment: 1. The dressing change is done in the [MEDICAL TREATMENT] center post-treatment. 2. If the dressing become wet, dirty, or not intact, the dressing shall be changed by a licensed nurse trained in this procedure. (Note: Check with Stated Nurse Practice Act to determine licensure and competency requirements.) 3. Mild bleeding from site (post [MEDICAL TREATMENT]) can be expected. Apply pressure to insertion site and contact [MEDICAL TREATMENT] center for instructions. 4. If there is major bleeding from site (post [MEDICAL TREATMENT]), apply pressure to insertion site and contact emergency services and [MEDICAL TREATMENT] center. Verify that clamps are close on lumens. This is a medical emergency. Do not leave the resident alone until emergency services have arrived. --The general medical nurse should document in the resident's medical record every shift as followed: 1. Location of catheter. 2. Condition of dressing (interventions if needed). 3. If [MEDICAL TREATMENT] was done during shift. 4. Any part of report from [MEDICAL TREATMENT] nurse post-[MEDICAL TREATMENT] being given. 5. Observations post-[MEDICAL TREATMENT]. | 2014-10-01 |
| 12944 | SUMNER PLACE | 285002 | 1750 SOUTH 20TH STREET | LINCOLN | NE | 68502 | 2010-09-07 | 323 | G | SCJJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview, the facility failed to safely secure 2 residents (Residents 1 and 2) during transport in the facility van from a resident sample size of 5. The facility census was 100. Findings are: A. Review of Resident 1's ER (Emergency) Injury Summary dated 8/10/10 revealed that the resident had sustained a fall with a C2 (2nd cervical vertebrae) type 3 fracture; and abrasions to the posterior scalp and left hand. Review of Resident 1's Spine Trauma Consult dated 8/10/10 revealed that the resident was in a van today and when the van moved forward, the resident's wheelchair fell backwards, and the resident struck (gender) head. The resident denied loss of consciousness. The resident complained of neck pain. The resident was able to shrug the resident's shoulders and elevate the resident's legs off the bed. The resident denied paresthesia (tingling sensation) in the resident's arms or legs. The C spine (Cervical spine) x-ray revealed an acute C2 type-3 fracture through the body with minimal displacement. The physician ordered a Miami J neck collar for the resident to wear. Review of Resident 1 Nurse's Notes on 8/10/10 at 4 PM revealed that the resident's wheelchair tipped over in the van and the resident was taken to the doctor's office. The resident was transported from the doctor's office to the hospital ER. Review of Resident 1's Annual MDS (Minimum Data Set: a federally mandated comprehensive care plan used for care planning) dated 6/20/10 revealed that the resident required limited assistance for transfers and ambulation. The resident was able to eat independently with set up assistance. The resident did not have range of motion limitations. Review of Resident 1's Significant Change MDS dated [DATE] revealed that the resident required extensive to total assistance with all activities of daily living including eating. The resident was non ambulatory. The resident had other range of motion limitations. Review of Resident 1's Physician Facsimile revealed: -On 8/12/10 at 2:40 pm the facility staff notified the physician that the resident was having pain and requested a routine pain medication. The physician ordered Percocet 5/325 mg (milligrams) 1 orally every 6 hours. -On 8/17/10 Nutrition Review stated that chewing was painful for the resident and resident's food intake had declined. An order was received to change the resident's diet from a ground meat diet to a pureed diet. The resident was fed all meals. -On 8/25/10 the resident complained constantly of pain even though on Percocet 5/325 1 po (orally) (orally) (orally) qid (4 times daily) (4 times daily) (4 times daily) and Tylenol for breakthrough pain. Resident 1's physician progress notes [REDACTED]. The resident was weakly able to move all extremities. The resident could raise both legs, but could not fully raise (gender) arms. The cervical x-ray 8/17/10 showed no displacement of the C2 fracture, but function is less. A MRI (Magnetic Resonance Imaging) was ordered. Review of Resident 1's physician progress notes [REDACTED]. The resident had tight stenosis with spinal cord compression. Review of Resident 1's Progress Note dated 8/27/10 revealed that the resident's C1-5 fusions due to Cervical 2 fracture with stenosis. Review of Resident 1's Pain Assessment revealed: -On 3/20/10 and 6/18/10 the resident did not display signs of pain. -On 8/12/10 the resident displayed non-verbal signs of pain as evidenced by: crying/ moaning; aggression; increased body movements; guarding of the neck; facial grimacing; increased restlessness; and irritability. The resident only had relief from pain treatments 10% of the time. -On 8/31/10 the resident demonstrated non-verbal signs of pain with increased rest periods. The resident's pain treatments provided 100% relief. Review of Resident 1's Community Transfer Sheet dated 8/31/10 revealed that the resident had Prafo braces for hand contractures. The resident had red non blanchable sport to the resident's occipital lobe of the head (back of the head). The resident had skin breakdown from the Miami J neck collar on the front and back of the resident's chest on admission and now was wearing a soft neck collar due to the resident's poor skin integrity. Review of Resident 1's Nurse's Notes dated 9/5/10 at 1 pm revealed that the resident had an elevated temperature of 100.6 degrees F and an increase in wound drainage noted to the lower portion of the resident's dressing. The skin surround the staples were red and green drainage was around the staples. The resident was transported to the hospital. Interview with RN (Registered Nurse) A on 9/2/10 at 12:30 PM revealed that the resident was hospitalized for [REDACTED]. Review of the Van Driver A's personnel file revealed that the van driver's last competency for van driving was completed on 9/13/06. The van driver's MVR (Motor Vehicle Record) was checked yearly per the facility policy, but Van Driver A did not have the yearly competency as required per their facility policy. Review of Van Driver A's interview with facility staff, dated 8/11/10, following the accident which occurred on 8/10/10 revealed that the van driver did not secure the resident's wheelchair with the front straps. When the van driver accelerated the van on 33rd and South Streets in Lincoln, the van driver heard a boom and "Let me up!" The van driver stopped the van and went to the back where the van driver found the resident tipped over in the wheelchair with blood on the floor. The van driver assisted the resident to an upright position. A police officer assisted and the resident was transported to the resident's physician's office and the resident was later transported to the hospital for evaluation. Interview with the facility Administrator on 9/2/10 at 3 PM revealed that Van Driver A was the van program instructor which started in 2006 and therefore Van Driver A did not have a competency since 2006 in the van driver's record. Interview with the Administrator on 9/2/10 at 3:15 PM revealed that Van Driver A was instructed on the blue van in which the accident occurred when it was new by the corporate staff a year ago, but there is no documentation of the orientation to the new van found by the administrator. B. Review of records identified that Resident 2 was involved in an accident while riding in the facility van on 08/24/2010 at 10:20AM. Records identify that Resident 2 was in a wheelchair that was positioned in the back of the van for transporting to a scheduled physician appointment. The van was at a complete stop at the intersection of South Street and 20th. When Employee B (the van driver) accelerated from the stop turning onto South Street. Resident 2 tipped over backward while sitting in the wheelchair. Resident 2 was quickly transported by ambulance to BryanLGH East for emergent care. emergency room services and assessments revealed that Resident 2 had bruises on the left arm and chest and an abrasion on the back of head. Extensive x-raying and a CT scan was done to rule out any further injuries. Morphine was administered for pain and ice bags were positioned over bruised areas. Resident 2 was released on the same day and returned to Milder Manor. Facility Administration and Director of Nursing as well as family member were immediately notified of the incident. Observation of Resident 2 during the Noon Meal on 09/07/2010 and interview with Employee C, assisting Resident 2, revealed: -Resident 2 had to be fed prior to the accident as well as the same. Resident 2 has a fair appetite and drinks fluids with assist. Employee C stated that everything is the same for Resident 2 as before the accident. Interview with the facility Administrator on 09/07/2010 at 1:30PM revealed: It has been acknowledged that the van driver, a long time employee of the facility was approved to drive the van and do so as a substitute for the regular full-time driver. This employee had driven this specific van before. During the investigation Employee B acknowledged that the forward straps had not been secured to the front wheelchair wheels to secure the chair for transport. The driver explained, "I forgot". The van was taken out of service and sent to the home office for inspection. Employee B had attended the required inservice on 08/19/2010 that reviewed the facility policy and procedure on proper restraint of wheelchairs in the van. Employee B is no longer allowed to drive the facility vans. Resident 2 is recovering from the accident injuries without observed complications. Resident 2 has returned to a regular routine and employees observe previous demeanor prior to the accident. | 2014-01-01 | ||
| 3 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2017-01-03 | 241 | D | 0 | 1 | X2RI11 | Licensure Reference Number: 175 NAC 12-006.05 (4) Based on observation, record review and interview; the facility failed to ensure one resident (Resident 102) of 41 sampled was treated with respect and dignity related to communication. The facility census was 109. Findings are: Review of Resident 102's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated 9/20/16 revealed Resident 102 was cognitively intact, had no speech, understood what was being said and was usually understood. Review of Resident 102's Care Plan dated 4/20/16 revealed Resident 102 was able to mouth words but was difficult to understand and would use a spell board to communicate. Review of a Family Meeting Note for Resident 102 dated 10/12/16 revealed, The patient has identified the following goals/expectations of the program: Res (Resident) asked that staff use (Resident 102's) the communication board more. An interview with Resident 102 was conducted on 12/20/2016 at 03:16 PM with the assistance of Registered Nurse (RN) C using Resident 102's communication board (also referred to as the spell board). Resident 102 indicated staff needed to improve communication with Resident 102. Resident 102 further reported staff do not look at Resident 102's face when they are in the room and could not tell when Resident 102 was attempting to communicate with them. RN C then asked Resident 102 if the staff utilized the spell board when communicating and Resident 102 responded no. Observation of Nursing Assistant (NA) D and NA [NAME] on 12/28/2016 at 2:03 PM revealed while NA D and NA [NAME] were assisting Resident 102 with repositioning. Resident 102 mouthed a sentence in an attempt to communicate without either NA noticing. NA D and NA [NAME] were talking to each other and occasionally made eye contact with each other while continuing to provide cares for Resident 102. Resident 102 attempted an additional five times to mouth the same sentence before either NA noticed. NA D then noted Resident 102 mouthing words and asked if they could finish their cares before attempting to understand what Resident 102 was attempting to state. Resident 102 agreed. NA D and NA [NAME] finished by straightening the covers on the bed, situating the call light and supplies and removing their gloves. Resident 102 again attempted to mouth the sentence an additional 2-3 times before NA D gave up trying to read the resident ' s lips and went to get the spell board. Resident 102 was then able to spell out the sentence so NA D and NA [NAME] could understand what Resident 102 was requesting. An interview was conducted with NA D AND NA [NAME] on 12/28/16 at 2:25 PM to ask how they knew when Resident 102 was attempting to communicate. NA D and NA [NAME] revealed that staff needed to keep one eye on Resident 102 at all times. When informed that Resident 102 had attempted to communicate 6 times during the observed cares, NA D and NA [NAME] responded that Resident 102 would have wide eyes if it was important and they would noticed if that had occurred. NA D went on to report that Resident 102 did not like to use the spell board. A follow up interview with Resident 102 and a family member on 12/29/2016 at 3:32 PM revealed Resident 102's family member was aware this was a concern for Resident 102. The family member reported the staff needed to find a way to ensure Resident 102 was being heard when attempting to communicate. Resident 102 went on to state that staff just needed to make sure they were looking at Resident 102's face to know when Resident 102 was attempting to communicate. | 2020-09-01 |
| 4 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2017-01-03 | 318 | D | 0 | 1 | X2RI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFEFERENCE NUMBER 175 NAC 12-006.09D4 Based on observation, interview and record review; the facility failed to prevent the potential for a decrease in range of motion for one resident (Resident 163) of 41 sampled residents. The facility census was 109. Findings are: On 12/20/16, Resident 163 was observed seated in a wheel chair. The resident was noted to have both arms pulled up to sides, wrists bent and fingers drawn up into the palms. Restorative Aide - A (RA-A) was interviewed on 12/27/16 at 10:29 AM about the restorative program for Resident 163. RA-A said that the resident received range of motion (ROM) three times per week and that the focus had been on the contractures (a condition of fixed high resistance to the passive stretch of a muscle) of the lower extremities. When asked if Resident 163 was getting ROM to fingers and wrists, RA-A said orders had not been received for this and ROM was not being done to the upper extremities. Review of the Occupational Therapy (OT) Evaluation dated 10/3/16 revealed that Resident 163 had a [DIAGNOSES REDACTED]. The evaluation further revealed, Range of motion significantly limited by contractures throughout upper extremity joints and rigidity. The OT then referred to the functional maintenance program (FMP) in the chart for the R[NAME] Review of the personal FMP dated 10/3/16 for Resident 163 revealed the resident was to have ROM to both upper extremities including shoulders, elbows, wrists, fingers and thumbs. On 12/29/16 at 4:35 PM, Unit Manager B was interviewed about Resident 163's restorative program. The Unit Manger confirmed that ROM should have started right after the OT evaluation was completed on 10/3/16. The manager confirmed there was a communication mix up and ROM to the upper extremities had not started until 12/28/16. | 2020-09-01 |
| 5 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2017-01-03 | 329 | D | 0 | 1 | X2RI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D Based on record review and interview, the facility failed to provide non pharmacological interventions prior to the administration of an antianxiety medication and failed to evaluate the effectiveness of the medication after administration for one (Resident 265) of 41 residents sampled. The facility had a census of 109. Findings are: Review of Resident 265's MDS (The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and/or Medicaid-certified long-term care facility.) dated 12/11/16 revealed Resident 265 was cognitively intact with disorganized thinking, had indicators of depressed thoughts or feelings and no behaviors. Resident 265 required assistance to complete tasks of daily living, had occasional pain and had [DIAGNOSES REDACTED]. Review of Resident 265's Care Plan dated 12/20/16 revealed an identified problem of a potential for complications related to the use of antianxiety and antidepressant medication. Interventions included Compliment drug therapies, encourage participation in activities on the unit and therapies. Offer use of holistic cart with music and aroma therapies. Provide a quiet calm atmosphere when able. Review of Resident 265's Active Orders for (MONTH) (YEAR) revealed an order for [REDACTED]. Review of a Work List printed on 1/3/17 from the electronic medical record revealed Resident 265 was administered [MEDICATION NAME] .25 mg (milligrams) on 18 occasions during the month of (MONTH) (YEAR) at various times in the afternoon and evening. Further review of the electronic medical record revealed no documentation regarding what non pharmacological interventions were administered prior to administering the PRN antianxiety and no documentation of whether or not the [MEDICATION NAME] had been effective in treating the anxiety. Interview with Registered Nurse (RN) G on 12/27/16 at 2:30 PM revealed staff had a couple of places they could document both the effectiveness of the medication and the non-pharmacological interventions attempted prior to administration including the Adult Assessment and Interventions. RN G then confirmed that, after reviewing the medical record, RN G was unable to find where any staff had evaluated the effectiveness of the antianxiety after administration. RN G was also unable to find consistent documentation that non pharmacological interventions had been attempted prior to the administration of the [MEDICATION NAME]. Review of the Adult Assessment & Interventions in (MONTH) (YEAR) for Resident 265 revealed Resident 265 was assessed to be anxious, agitated, angry, yelling, crying, restless, and screaming at times. The Assistive Device provided for these symptoms was Antianxiety medication. A non-pharmacological intervention was implemented two times out of the 18 occasions and was documented to be frequent verbal cues/redirection to get along with others and frequent checks. Interview with the Director of Nursing (DON) on 01/03/2017 at 4:22 PM revealed staff should be offering non pharmacological interventions prior to administration and evaluating the effectiveness of thee antianxiety medication once given. | 2020-09-01 |
| 6 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2017-01-03 | 467 | D | 0 | 1 | X2RI11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B3 Based on observations and interview, the facility failed to ensure the ceiling vents were working in 2 resident rooms (Rooms 300 and 427) out of 39 resident rooms. The facility census was 109. Findings are: A) Observation on 1-03-17 at 12:40 PM revealed the ceiling vent in the bathroom of Room 427 was not working. Interview on 1-3-17 at 12:40 with the MS (Maintenance Supervisor) revealed the ceiling vent was closed and required a maintenance staff to open it. The MS confirmed the vent should not have been closed. B) Observation on 1-3-17 at 1:15 PM revealed the ceiling vent in the bathroom of [RM #]0. Interview on 1-3-17 at 1:15 PM with the MS revealed the ceiling vent was open and confirmed it was not working. Interview on 1-3-17 at 2:33 PM with the MS revealed the room ceiling vents were to be checked monthly by the Housekeeping staff and documented on an Environmental Services Inspection Sheet form. Review of the Environmental Service Inspection Sheets revealed Room 427 was last inspected on 12-16-16 and no concerns were documented about the ceiling vent. [RM #]0 was last inspected on 11-11-16 and no concerns were documented about the ceiling vent. | 2020-09-01 |
| 7 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2018-01-30 | 658 | D | 0 | 1 | BRED11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.10A2 Based on observation, record review and interview; the facility failed to provide a nourishment within the facility policy time frame for a short acting insulin. This violation had the potential to affect one resident (Resident 14) out of 5 insulin dependent residents. The census was 105. Findings are: During an observation on 1/18/18, LPN A (Licensed Practical Nurse) administered [MEDICATION NAME] ([MEDICATION NAME]) insulin (a short acting insulin) to Resident 14 at 12:12 PM. Resident 14 went to the dining room and was served lunch at 12:38 PM. An interview on 1/30/18 at 08:30 AM with LPN A revealed that short acting insulin should be given 15-20 minutes before meals. A record review of the policy entitled: medications: [REDACTED]. An interview with the Unit Director confirmed that within 15 minutes of administration of short acting insulin a nourishment should be offered or given to the resident. | 2020-09-01 |
| 8 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 561 | D | 1 | 1 | GLUX11 | > Licensure Reference Number 175 NAC 12-006.05(4) Based on interviews and record reviews, the facility failed to ensure residents bathing preferences were assessed and provided according to the resident's preferences. This failure had the potential to affect two residents, Resident #62 and 102. The facility census was 115. Findings; [NAME] 05/28/19 03:31 PM an interview with Resident #62 revealed that the resident wants 2 showers a week in the evenings, but is only receiving one a week during the day. Record review of MDS (Minimum Data Set, a health status screening and assessment tool used for all residents of long term care nursing facilities dated 4/9/19 revealed a BIMS (Brief interview of mental status) score of 14 (BIMS score ranges from 00. to 15. 13 - 15: cognitively intact. 08 - 12: moderately impaired. 00 - 07: severe impairment , Record review of the residents care plan revealed bathing not addressed on the care plan. Record review of the resident's electronic medical record revealed no documentation related to the resident's choices related to bathing. Record review of Worklist Report Visit task Shower dated from 3/4/19 to 5/31/19 revealed resident to receive 2 showers a week. Week of 3/10/19 received one shower, week of 3/17 received no showers, week of 4/7/19 received one shower, and week of 4/21/19 received one shower. Weeks 5/8/19 through 5/31/19 resident received one shower a week. Three of these showers were given in the evening. Record review of the resident's electronic medical record revealed no documentation related to the resident's choices related to bathing. 06/04/19 04:39 PM DON (Director of Nursing) confirmed resident #62 was only receiving one shower a week and preferences are not documented. B An interview on 05/28/19 at 12:34 PM with Resident 102 who had expressed the preference to have a bath every other day, the resident reported that the facility had a bath schedule for twice a week. An interview on 05/30/19 at 12:08 PM with RN C confirmed that the Resident were placed on the bathing schedule on admission. The facility has a set schedule and the new admissions were added to that, if the resident was unhappy with the schedule then they would be moved to the preferred days. RN reported that they do full showers 2 times a week and partial bed baths daily. An interview on 06/03/19 at 03:47 PM with the Administrator, the Administrator confirmed the facility ask residents at the initial care plan meeting. The Administrator confirmed the facility had offered 2 baths, no more that that per week. Record review of Active orders dated 05/29/19 revealed an Order that Resident 102 was able to shower in the trauma tub scheduled bath days were Tuesdays and Saturdays. Record review of Resident 102's care plan revealed no bathing preferences were documented An interview on 06/03/19 at 05:03 PM with the DON (Director of Nurses) confirmed that the facility did not have documentation of the personal preferences regarding bathing for Resident 102 on admission. The DON confirmed no documentation of bathing preferences in the care plan | 2020-09-01 |
| 9 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 578 | D | 0 | 1 | GLUX11 | Based on record review and interview, the facility failed to ensure that the residents advanced directives were included on resident care plans. This had the potential to affect 6 Residents (Resident #6, 53, 62, 94, 102 and 207). The facility census was 115. Findings; A Record review of St Jane de Chantel LTC (Long Term Care) Team Care Plan dated 5/22/19 for Resident # 6 revealed advanced directives were not documented on the residents care plan. Record review of St Jane de Chantel LTC Team Care Plan dated 4/9/19 for Resident # 53 revealed advanced directives were not documented on the residents care plan. Record review of St Jane de Chantel LTC Team Care Plan dated 4/17/19 for Resident # 62 revealed advanced directives were not documented on the residents care plan. Record review of St Jane de Chantel LTC Team Care Plan dated 5/7/19 for Resident # 94 revealed advanced directives were not documented on the residents care plan. Record review of St Jane de Chantel LTC Team Care Plan dated 5/23/19 for Resident # 207 revealed advanced directives were not documented on the residents care plan. Record review of the Advanced Directives for Patients including Do Not Resuscitate Status policy revealed; no documentation to include advanced directives on the residents care plans. On 05/29/19 at 02:19 PM an interview with the DON (Director of Nursing) confirmed the facility does not include advanced directives on the residents care plans. E. Record review of Resident 102's Advanced Directives revealed the preference for a Full Code Status. Record review of St Jane de Chantel LTC Team Care Plan dated 5/14/19 revealed the Advanced Directives were not documented on the resident's care plan. An interview on 05/29/19 at 02:43 PM with the DON (Director of Nurses) confirmed that the facility had not included Advanced Directives on the care plan. | 2020-09-01 |
| 10 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 623 | D | 0 | 1 | GLUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-0060.5(5) Based on interview and record review, the facility failed to notify the resident's representative of the reason for transfer to the hospital in writing. This affected 2 residents (Residents 58 and 29) of 4 residents reviewed. The facility census was 113. Findings are: [NAME] Record review of Resident 58's History and Physical dated 5/14/19 revealed [DIAGNOSES REDACTED]. Record review of Documentation of Communication/Event dated 5/2/19 revealed the Resident 58 was transferred to the hospital due to a change in vital signs and level of consciousness. The resident's representative was notified at the time of transfer. The documentation revealed an absence of mention that the reason for transfer in writing was given to the resident or resident's representative. Interview on 6/4/19 at 2:17 PM with the DON revealed the facility did not provide the reason for transfer in writing to the resident or resident's representative. B. Record review of Resident 29 face sheet revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Record review of Documentation of Communication / Event dated 12/12/18 revealed that Resident 29 was sent to the hospital for continued swelling, discoloration and pain to the right upper leg. The resident was admitted to the hospital for [MEDICAL CONDITION] (swelling) and pending tests. Interview on 5/29/19 at 3:14 PM with the family confirmed that the resident was discharged to the hospital and stated that no written information related to the reason for discharge was provided at the time of the transfer. Interview on 5/30/19 at 2:53 PM with the facility Administrator confirmed that no written notice of the reason for the transfer was provided to the resident or family at the time of the transfer. | 2020-09-01 |
| 11 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 625 | D | 0 | 1 | GLUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide information regarding bed hold to the resident at the time of transfer. This affected 1 resident (Resident 58) of 4 residents reviewed. The facility census was 113. Record review of Resident 58's History and Physical dated 5/14/19 revealed [DIAGNOSES REDACTED]. Record review of Documentation of Communication/Event dated 5/2/19 revealed the Resident 58 was transferred to the hospital due to a change in vital signs and level of consciousness. The resident's representative was notified at the time of transfer. The documentation revealed an absence of mention that the bed hold policy was given to the resident. Review of Resident's Rights policy dated 8/31/10 revealed the nursing staff, social worker, or admission personnel will ask if the resident wanted a bed hold if the resident would be out of the facility. Interview on 6/4/19 at 2:17 PM with the DON (Director of Nurses) revealed the DON was unable to find Resident 58's completed bed hold form. The DON revealed the bed form was not provided to the resident or completed for Resident 58's transfer to the hospital. | 2020-09-01 |
| 12 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 644 | D | 0 | 1 | GLUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to submit a Pre-Admission Screening and Resident Review (PASARR, an assessment used to help ensure that individuals are not inappropriately placed in nursing homes for long term care) for reevaluation after identification of a new mental health diagnosis. This affected 1 resident (Resident 53) of 1 resident reviewed. The facility census was 113. Findings are: Record review of Nebraska Level I Form PASARR dated 9/13/11 revealed the Resident 53 did not have any serious mental illness, including [MEDICAL CONDITION] Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), under Section 1 - Mental Illness. Record review of History and Physical dated 7/25/14 revealed Resident 53's past medical history included [MEDICAL CONDITION] Disorder. Record review of Resident 53's comprehensive MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1/16/19 revealed the resident did not have a Level II PASARR (evaluation of if the resident needed specialized services). The MDS did note the resident had [MEDICAL CONDITION] Disorder. Record review of Resident 53's care plan dated 4/9/19 revealed the resident was evaluated for PASARR II with a start date of 7/30/18. Interview on 6/4/19 at 1:55 PM with the DON (Director of Nursing) revealed Resident 53 was admitted to the facility with the [DIAGNOSES REDACTED]. Interview on 6/4/19 at 1:56 PM with SW-A (Social Worker) revealed the PASARR form was completed in 2011 and was unable to provide details on why the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. SW-A revealed the resident was a Level I PASARR, and was unable to provide details on why the care plan noted PASARR II. Interview on 6/4/19 at 2:13 PM with the DON revealed the facility did not submit the PASARR for re-evaluation when the [DIAGNOSES REDACTED]. | 2020-09-01 |
| 13 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 693 | D | 0 | 1 | GLUX11 | Licensure Reference Number 175 NAC 12-006.09D6 (1) Based on observation, record review and interview the facility staff failed to ensure the method to check residual (stomach fluids) for placement of a feeding tube was completed according to facility policy for 1 resident (Resident 9) of 4 sampled residents. The facility census was 115. Findings are: An observation on 06/04/19 at 12:00 PM of Nurse LPN H of medication administration for Resident 9 via PEG (Percutaneous Endoscopic Gastrostomy- a tube passed into a residents stomach through the abdominal wall to provide a means for feeding and medication administration when oral intake is inadequate) tube. LPN H checked the PEG tube for proper placement by aspiration of stomach contents with a 60 cc syringe the total amount of stomach contents aspirated was 210cc. Resident 9 had been eating lunch at the time of the aspiration. LPN H disposed of the stomach contents. Record review of the Feeding tube management policy dated 4/16/19 revealed; for Residual Procedures if the gastric residual volume 300 ml or less replace the entire residual volume obtained, Flush with 30 Ml water. Interview on 06/04/19 03:19 PM with the DON confirmed that if the residual with a tube feeding is less than 300 cc the residual is to be replaced not wasted. | 2020-09-01 |
| 14 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 758 | D | 0 | 1 | GLUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure that a [MEDICAL CONDITION] as needed medication did not exceed the required 14 day stop date for 1 (Resident 40) of 6 residents reviewed for unnecessary medication use. The facility census was 115. Findings are: Record review of a facility policy entitled Automatic Stop Orders dated 4/1/14 revealed that PRN (as needed) [MEDICAL CONDITION] (a group of medications that affect behaviors) medications have a 14 day limit. These medications may be renewed for subsequent 14 days if deemed appropriate by the licensed practitioner. Record review of Resident 40's Face sheet showed an admission date of [DATE]. Record review of Resident 40's [DIAGNOSES REDACTED]. Record review of Resident 40's admission Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 3/29/19 identified that resident 40 used a Hypnotic (a medication used to induce sleep) medication 3 times in the look back period for the assessment. Record review of Active orders dated 6/4/19 revealed an order for [REDACTED]. The order included nurse instructions that read: Time frame for administration is limited to 14 days unless a longer time frame is deemed appropriate by the prescribing practitioner. Record review of Resident 40's Medication Administration Records revealed that Resident 40 received the hypnotic medication 4 times in (MONTH) 2019, 7 times in (MONTH) 2019 and 4 times in (MONTH) 2019. Interview on 6/4/19 at 11:23 AM with the Director of Nursing confirmed that the stop date on the hypnotic was past the required 14 day time limit. It should have been stopped after 14 days and reordered as necessary. | 2020-09-01 |
| 15 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 759 | D | 0 | 1 | GLUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D The facility failed to maintain a medication error rate of less than 5 %, which affected 3 residents (Resident 9, 51 100). The medication error rate was 24.14%. The facility census was 115. FINDINGS ARE: [NAME] An Observation on 6/3/19 at 12:05PM of medication administration by LPN (Licensed Practical Nurse) J for Resident 100. LPN J performed hand hygiene, donned gloves, and prepared Guar Gum (fiber supplement) by mixing it with 60 mL (milliliters-a unit of volume) of water. LPN J measured [MEDICATION NAME] (a medication used for [MEDICATION NAME]) 10mL and mixed it with the Guar Gum. LPN J doffed gloves and donned new gloves. LPN J checked the residual (stomach contents) of the PEG tube (Percutaneous Endoscopic Gastrostomy- a tube passed into a residents stomach through the abdominal wall to provide a means for feeding and medication administration when oral intake is inadequate) tube it was zero. LPN J pushed 60cc of water for the flush prior to the medication administration. LPN J administered the commingled medications. LPN J changed gloves. LPN J administered a 15 cc flush. Gloves changed and the tubes were exchanged for enteral feeding. LPN J primed the tubing and administered 237Ml of Pedisure Peptide (a feeding) that was hung for gravity flow. Gloves were changed and LPN J added 30 mL water flush. Gloves were changed and the tubing was removed. Hand Hygiene was performed. B. An observation on 6/3/19 at 12:55PM of medication administration by RN (Registered Nurse) K for Resident 51 revealed RN K measured the medications [MEDICATION NAME] 30m. RN K donned gloves. RN K measured tap water 100mL. RN K checked residual and equaled 60MmL and this was replaced. RN K mixed approximately 30mL of water with the measured medication and drew it into the syringe. No flush was performed by RN K. RN K administered the medication/water mixture by push and the remainder of the water was administered via gravity flow. C. An observation on 6/4/19 at 12:00PM of medication administration by LPN H for Resident 9 revealed RN K did not perform hand hygiene upon entry to the room. LPN H donned gloves and prepared medications Medication [NAME]nochol 25mg (milligrams-a unit of measurement) and [MEDICATION NAME] (a medication given for high blood pressure) 20 mg was crushed, [MEDICATION NAME] was measured 10 mL and [MEDICATION NAME] was measured 30mL. Gloves were changed. No flush was given prior to the medication administration. LPN H checked residual of PEG tube and was 210mL and that was discarded. LPN H mixed the [MEDICATION NAME] 10mL with 30cc water drew it up in the syringe and pushed the medication in the PEG tube. No flush was administered. LPN H drew up [MEDICATION NAME] 30 mL and it was given push through syringe in the PEG tube. No flush was administered. The combination of the crushed medications [NAME]nochol 25mg and [MEDICATION NAME] 20mg was mixed with 20mL of water and administered by LPN H per push via PEG tube. LPN H administered 30mL water flush per push via PEG tube. Gloves were changed and eye drops were administered. LPN H doffed gloves and hand sanitizer was used. Record review of the Feeding tube management Policy dated 4/1/16 revealed that Daily use for Feeding and Medication Administration Procedure 1. Any time the tube is utilized intermittently or disconnected from a feeding pump it is vital to flush the tube with a minimum of 30 mL warm tap water. An interview on 06/04/19 at 04:43 PM with the DON (Director of Nurses) confirmed that the facility did not have a physician order [REDACTED]. The DON confirmed that prior to the use of a feeding tube the tube should be flushed. Record review of Resident 9 and Resident 100 Active Orders document dated 6/4/19 revealed that the residents did not have an order for [REDACTED].> | 2020-09-01 |
| 16 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 880 | E | 0 | 1 | GLUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.17D Based on observation interview and record review the facility failed to ensure that gloving and hand hygiene was performed when indicated to prevent the potential for cross contamination during treatments for 5 resident (Residents 42,101, 82, 84, 53) an during medication administration for 2 residents (Residents 9 and 51) of 23 sampled residents. The facility census was 115. Findings are: [NAME] An observation on 05/30/19 at 10:30 AM of wound care for Resident 82 revealed; on entry to room, RN I performed hand hygiene by using the hand sanitizer and donned gloves, RN I removed the packing from the wound and doffed gloves and without hand hygiene donned gloves. RN I used soap and water on a wash cloth to cleanse the wound. RN I rinsed the wound with wound cleanser. RN I changed doffed gloves and without hand hygiene and donned gloves. RN I applied skin prep ([MEDICATION NAME] no sting) to the skin surrounding the wound and applied gauze soaked with Vashe (a wound solution that has a skin friendly PH) into the wound. RN I doffed gloves and without hand hygiene donned gloves. RN I applied 4x4 Vaseline gauze applied and 4x4 followed by an ABD (Abdominal Pad thick dressing used for draining wounds) RN I doffed gloves and without hand hygiene donned gloves. RN I removed the dry Therabond (a wet to dry dressing used to help debride wounds) from the wound, cleansed the wound with soap and water, no glove change or hand hygiene was performed, a new piece of Therabond was cut to size, moistened and placed over wound. RN I doffed gloves and without hand hygiene donned gloves. RN I assisted with Resident 82's repositioning. RN I replaced supplies, cleansed table with wipes (Sani). RN I used hand sanitizer was used. B. An observation on 5/30/19 at 10:50 AM of wound care for Resident 101 performed by LPN (Licensed Practical Nurse) J of wound care for Resident 101. LPN J used hand sanitizer on entry to the room. LPN J donned gloves, had wet wash cloths. LPN J removed the dressing from the buttock wounds. LPN doffed gloves and without hand hygiene donned gloves. LPN J patted the wound with soap and water wet cloths. LPN doffed gloves and without hand hygiene donned gloves. The new dressings were prepared by soaking the Surgifoam (an absorbable gelatin sponge used for bleeding wounds) soaked with triple antibiotic ointment. LPN doffed gloves and without hand hygiene donned gloves. LPN J applied ointment and the soaked Surgifoam to the wounds. LPN J doffed gloves and without hand hygiene donned gloves and applied a third soaked Surgifoam sponge and moistened gauze was to the coccyx area. LPN doffed gloves and without hand hygiene donned gloves. LPN J assisted with dressing Resident 101. LPN J doffed gloves and used hand sanitizer. C. An observation on 6/3/19 at 12:55PM of medication administration by RN K for Resident 51 revealed hand hygiene was not performed prior to the medication administration. RN K measured the medications [MEDICATION NAME] 30mL (Milliliters metric system used to measure medications). RN K donned gloves. RN K measured tap water 100mL. RN K checked residual and equaled 60MmL and this was replaced. RN K mixed approximately 30mL of water with the measured medication and drew it into the syringe. No flush was performed by RN K. RN K administered the medication/water mixture by push and the remainder of the water was administered via gravity flow. D. An observation on 6/4/19 at 12:00PM of medication administration by LPN H revealed hand hygiene was not performed prior to entry to the room for medication administration. Record review of infection prevention Hand Hygiene policy dated with review date of 4/19/19 revealed; when hands were visibly soiled or contaminated with protienaceous material or visibly soiled with blood or other body fluids wash hands with soap and water. Step: 1) Vigorously lather hands with soap and rub for 15 seconds under a moderate stream of running water at a comfortable water temperature. 2) Rinse hands thoroughly, hold hands down lower than wrists, do not touch the inside of the sink 3) Dry hands thoroughly with paper towel and then turn off faucets with those towels. 4) Discard towels into the trash do not dry hands with same towel used to turn off sink. If hands are not visibly soiled alcohol based hand rub may be used for routinely decontaminating hands using the following process 1) Apply enough product to thoroughly wet both hands to the palm of one hand. 2) Rub hands together covering all surfaces of hands and fingers until hands are dry. Use alcohol based hand rub or wash hands: 1) When coming on duty. 2) Before performing invasive procedures. 3) Before preparing or handling medications, 4) Before performing dressing care, 5) Before touching preparing or serving food, 6) Before and after having contact with patient or patient environment. 7) After contact with patients on isolation, 8) After handling used dressing, urinals, bedpans catheters, contaminated tissues, linen, or patient care item. 9) After offering incontinence care, Foley care. 10) Before and after manipulation of feeding tubes. 11) Before and after manipulation of IV sites even when wearing gloves. 12) Before and after empty Foley catheter or tubing even when wearing gloves. 13) After contact with blood, urine, feces, oral secretions, mucous membranes or broken skin, 14) After handling items potentially contaminated with any patient blood excretions or secretions. 15) After personal body function use of toilet, blowing nose, wiping nose, smoking or combing hair. 16) Before and after eating. 17) Upon completion of the day. E. Record review of Resident 53's physician progress notes [REDACTED]. Record review of Resident 53's Transfer/Discharge/Active Orders dated 5/29/19 revealed [MEDICAL CONDITION] (a surgically created opening through the neck into the windpipe with a tube place to provide an airway and to remove secretions from the lungs) care was ordered to be done 2 times per day. Observation on 6/3/19 at 9:45 AM of RN-B (Registered Nurse) and RN-C providing [MEDICAL CONDITION] care for Resident 53 revealed RN-B and RN-C used hand sanitizer and applied masks and gloves. RN-B removed the dressing from the [MEDICAL CONDITION] and discarded, then changed gloves without performing hand hygiene. RN-B cleaned around the edge of the [MEDICAL CONDITION] using swab sticks, discarding after use. RN-B changed gloves without performing hand hygiene. RN-B and RN-C removed the [MEDICAL CONDITION] ties (a band that goes around the neck to hold the [MEDICAL CONDITION] in place) and RN-C held the [MEDICAL CONDITION] while RN-B washed and dried the resident's neck. RN-B got the new [MEDICAL CONDITION] tie and RN-B and RN-C secured the [MEDICAL CONDITION]. RN-B changed gloves without performing hand hygiene and applied the new [MEDICAL CONDITION] dressing, then removed gloves and performed hand hygiene. RN-B offered suctioning (removes thick mucus and secretions from the trachea), but Resident 53 refused. F. Review of Resident 42's Pressure Ulcer/Wound record dated 5/29/19 revealed the resident had a closed stage 3 pressure injury (full thickness skin loss where subcutaneous fat may be visible but bone, tendon, or muscle are not exposed) to the right ankle, a closed stage 2 pressure injury (partial thickness loss of skin presenting as a shallow open ulcer with a red/pink wound bed), and unstageable deep tissue injuries (purple area of discolored intact skin due to damage of underlying soft tissue) to the left 5th toe, back of the right ankle, and back of the left ankle. The resident also had a partial thickness (loss of skin presenting as a shallow open ulcer with a red/pink wound bed) wound to the right shin. The resident also had a surgical incision to the right buttock. Record review of Resident 42's Transfer/Discharge/Active Orders dated 5/29/19 revealed the resident received Xeroform (dressing used to maintain a moist wound environment) and [MEDICATION NAME] (absorbent foam dressing) to the wounds on the back of the right and left ankles, on the left foot, and on the right shin. The resident also received Nutrashield lotion to the intact incision line and [MEDICATION NAME] AG (dressing impregnated with silver) to the small open area near the perineum. Observation on 05/30/19 at 11:01 AM of RN-E completing wound care for Resident 42 revealed RN-E cleaned the scissors used for cutting the dressings, performed hand hygiene, and gathered supplies for the dressing change. RN-E applied gloves and pulled the resident's blankets back and removed the prafo boot (boot that alleviates pressure from the heel) from the resident's left foot. RN-E removed the dressing from the back of the resident's ankle. RN-E removed gloves, used hand sanitizer, and applied new gloves. RN-E cleansed the area with a wash rag, cut a piece of Xeroform to the size of the wound and applied to the wound bed, and covered with a [MEDICATION NAME] dressing. RN-E removed the dressing from the resident's left foot, cleansed the area with a wash rag, cut a piece of Xeroform to the size of the wound, then applied to the wound and covered with a [MEDICATION NAME] dressing. RN-E changed gloves without performing hand hygiene, inspected the resident's heels and applied Nutrashield lotion to the foot. RN-E reapplied the resident's prafo boot and changed gloves without performing hand hygiene. RN-E removed the prafo boot from the resident's right foot and removed the dressing front the resident's right shin. RN-E cleansed the wound and changed gloves without performing hand hygiene. RN-E cut Xeroform to the size of the wound and applied, then covered with a [MEDICATION NAME] dressing. RN-E changed gloves without performing hand hygiene and lifted the dressing to the right ankle, observed the wound, then secured the same dressing back into place. RN-E then secured the prafo boot back onto the resident's foot. RN-E changed gloves without performing hand hygiene, and cleaned the bandage scissors. NA-F (Nurse Aide) entered the room and assisted RN-E with repositioning the resident to the side. RN-E removed the dressing from the surgical incision on the resident's buttock and cleansed the area with a washrag. RN-E applied Nutrashield lotion to the incision, cut a piece of [MEDICATION NAME] AG to size and applied it to the open area at the end of the incision. RN-E and NA-F then continued to give the resident a bed bath. [NAME] Review of Resident 84's Pressure Ulcer/Wound report dated 5/29/19 revealed the resident had an pressure injury to the right hip, a closed stage 2 pressure injury to the sacrococcyx (bottom of the spine to the tailbone), and a stage 3 pressure injury to the right ankle. Resident 84 also had wounds due to skin graft surgery to the right thigh, right hip, and left thigh. Review of Resident 84's Transfer/Discharge/Active Orders dated 5/29/19 revealed the resident received Xeroform secured with gauze to the right thigh, Xeroform covered with [MEDICATION NAME] to skin treated with skin prep swabs to the right hip, right ankle, and left thigh, and [MEDICATION NAME] and skin prep swabs to the coccyx. Observation on 5/30/19 at 2:13 PM of LPN-G (Licensed Practical Nurse) and RN-D performing Resident 84's wound care revealed LPN-G performed hand hygiene and gathered the supplies needed for the dressing change. LPN-G applied gloves and removed the resident's right prafo boot. LPN-G removed the dressing to the resident's right ankle, changed gloves without performing hand hygiene, and cleansed the wound. LPN-G prepped the skin surrounding the wound with a skin prep swab, changed gloves without performing hand hygiene, and cut Xeroform to fit the wound and applied it, then covered the wound with a [MEDICATION NAME] dressing. LPN-G changed gloves without performing hand hygiene and removed the dressings from the resident's right hip. LPN-G changed gloves without performing hand hygiene and cleansed the wound. LPN-G swabbed the skin surrounding the wound with skin prep and changed gloves without performing hand hygiene. LPN-G cut Xeroform to fit the lower right hip wound, applied to the wound, then covered both wounds with [MEDICATION NAME] dressings. LPN-G changed gloves without performing hand hygiene. The resident repositioned in bed and LPN-G removed the dressing from the resident's coccyx. LPN-G changed gloves without performing hand hygiene, cleansed the wound then changed gloves without performing hand hygiene. LPN-G applied a [MEDICATION NAME] dressing to the wound, changed gloves without performing hand hygiene, and secured the resident's brief. LPN-G and RN-D assisted the resident with repositioning, then LPN-G removed the wrap from the resident's left thigh, and changed gloves without performing hand hygiene. LPN-G cleansed the wound and prepped the skin surrounding the wound with the skin prep swab. LPN-G then changed gloves without performing hand hygiene, cut Xeroform gauze to fit the size of the wound, applied the Xeroform to the wound and covered the wound with a [MEDICATION NAME] border dressing. LPN-G changed gloves without performing hand hygiene, wrapped the resident's thigh with gauze, and assisted the resident with repositioning. LPN-G then removed gloves and used hand sanitizer. Review of Standard Precautions Guide dated 3/2018 revealed hand hygiene was required after glove removal, and gloves changes were required moving from a dirty to a clean task. Interview on 6/3/19 at 12:29 PM with RN-D revealed the expectation was that staff would use hand sanitizer or wash hands between glove changes. | 2020-09-01 |
| 17 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 926 | E | 0 | 1 | GLUX11 | Based on observation, record review and interview, the facility failed to ensure there was a policy in place to protect smoking residents from accidents related to smoking. This failure had the potential to affect 6 smoking residents (Resident 8, 23, 27, 62, 95, and 155). The facility census was 115. Findings On 5/29/19 at 9:30 AM an observation revealed an unknown resident exit the West St Jane's entrance un accompanied and wheel self down the sidewalk next to the street smoking. On 05/30/19 06:50 AM an observation revealed Resident #155 exit the front door un accompanied and wheel self to the southwest parking lot and proceed to smoke On 06/04/19 10:05 AM an interview with the ADM (Administrator) confirmed the policy; Tobacco-Free Campus Areas, dated 9/17/2010 was a[NAME]campus smoking policy and did not specifically address St[NAME]residents. Record review of facility policy Tobacco-Free Campus Areas dated 9/17/10 revealed no documentation on how the facility will assess or protect residents that smoke from accidents related to smoking. On 05/30/19 at 3:00 PM the DON (Director of Nursing) provided a list of smoking residents that included; Residents #8, 23, 27, 62, 95 and 155. | 2020-09-01 |
| 5821 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2015-10-29 | 241 | D | 0 | 1 | 484F11 | Licensure Reference Number: 175 NAC 12-006.05 (21) Based on observation and interview, the facility failed to ensure the personal care information was not posted in an area visible to others for two residents (Residents 39 and 78). The facility's census was 121. Findings are: A. Observation of Resident 78's room on 10/21/2015 at 07:53 AM revealed a sign posted on the wall of Resident 78's room that read, Patient Care Report 9/3015 and described the amount of assistance Resident 78 required with transferring and repositions as well as Resident 78's diet order which consisted of a related diagnoses. Interview with Resident 78 on 10/21/15 at 7:54 AM revealed Resident 78 was not asked for permission to post the sign in Resident 78's room. B. Observation of Resident 39's room on 10/20/2015 at 01:41 PM revealed a posted sign on the wall above Resident 39's bed. Review of the POS [REDACTED]. revealed information regarding Resident 39's level of assistance required for transferring and repositioning, the types of devices needed for transferring and repositioning and the diet Resident 39 had been ordered. Interview with Resident 39 on 10/20/2015 at 1:42 PM revealed Resident 39 did not like that the sign was posted for visitors to see. Resident 39 went on to state, but what am I going to do about it? Resident 39 did not recall being asked for permission to post the sign. Review of Resident 39's care plan with a print date of 9/30/15 revealed, Start Date: 6-19-2015 Resident gives permission to post signage in room r/t (related to) cares. Interview with the Unit Manager on 10/29/15 on 10:30 AM revealed that when a resident was newly admitted , the care plan was developed using pre-formulated interventions that could be included if they apply to that specific resident. The Unit Manager went on to demonstrate which interventions would automatically be selected to include on the care plan when admitted . The Unit Manager then selected the intervention listing permission to post signage in the rooms as one of the automatic interventions for every resident's care plan. When asked who was responsible for actually asking the resident or the family for the permission, the Unit Manager replied that the Admissions Coordinator completed that task during the admission process. Interview with the Admission Coordinator on 10/29/15 at 1:41 PM revealed the resident and/or the responsible party are given a sheet titled, Notice of Privacy Practices. The Admissions Coordinator further confirmed that this notice did not obtain permission from the resident or the responsible party to post information. The Admission Coordinator went on to state that some one from nursing would be responsible for obtaining that consent. Review of the Notice of Privacy Practices dated 4/14/2014 revealed, This notice describes how medical information about you may be used and disclosed .We use this information (or medical record) to communicate with other health professionals who also care for you Improve the care we provide You have the right to ask us to limit how we use and disclose your health information for treatment Our Responsibilities Protect the privacy of your health information according to the law's requirements . | 2019-08-01 |
| 5822 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2015-10-29 | 242 | D | 0 | 1 | 484F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.05 (4) Based on record review and interview, the facility failed to honor choices regarding bathing for four residents (Resident 42, 3, 39 and 122). The facility census was 121. Findings are: A. Review of Resident 42's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 7/14/15 revealed Resident 42's cognition was intact and that making choices regarding daily schedule and preferences was very important to Resident 42. Review of the same form also revealed Resident 42 was dependent upon staff for assistant with bathing tasks. Interview with Resident 42 on 0/21/2015 at 08:03 AM revealed that staff provided two baths per week but with only one day in between the first bath and the second. Resident 42 went on to explain that meant Resident 42 had to wait four days between the second bath of the week and the first bath of the following week. Resident 42 did not like waiting this long and stated that the schedule had been changed awhile ago to meet the needs of the facility's schedule. Review of the undated facility bathing schedule revealed Resident 42 was scheduled to receive a bath on Wednesday and Friday. Interview with Bath Aide (BA) A on 10/29/2015 at 10:40 AM confirmed Resident 42's baths were changed to a new schedule so that every resident could be given two baths per week. B. Review of Resident 122's MDS dated [DATE] revealed Resident 122 was cognitively intact and required assistant to complete bathing tasks. Interview with Resident 122 on 10/21/2015 at 10:33 AM revealed Resident 122 took more than two baths per week when at home and would prefer more that 2 baths per week but that was all the facility offered. Review of the undated facility bathing schedule revealed Resident 122 was scheduled to receive a bath on Tuesday and Friday. C. Review of Resident 3's MDS dated [DATE] revealed Resident 3 had moderate cognitive impairment, required staff assistance to complete bathing tasks and rated the importance of making decisions regarding bathing as very important. Interview with Resident 3's family member on 10/21/2015 at 11:04 AM revealed that, when the request was made to increase Resident 3 number of baths per week, the facility replied that the they would not provide more baths but the family would be allowed to provide another bath once trained. Review of the undated facility bathing schedule revealed Resident 3 was scheduled to receive a bath on Monday and Friday. D. Review of Resident 39's MDS dated MDS 6/25/15 revealed the resident was cognitively intact and that choices were important but can't do or no choice regarding the type of bath. Assistant with bathing was marked as total dependence. Interview with Resident 39 on 10/20/2015 at 01:20 PM revealed Resident 39 received two complete baths per week and one sponge bath. Resident 39 voiced a preference of receiving three full baths per week instead of the third sponge bath. Resident 39 stated it was a little too long of a wait from the bath on Friday to the bath on the following Wednesday. Review of the undated facility bathing schedule revealed Resident 39 was scheduled to receive a bath on Wednesday and Friday. During an interview with BA B on 10/29/15 at 10:31 AM, BA B revealed that residents were given two baths per week unless they preferred only one. BA B continued to say, if a resident wanted more than two baths per week, they would have to see the Unit Manager about that request and BA B was unsure what would be done about the request. Interview with BA A on 10/29/2015 at 10:40 AM revealed only two weeks per bath are given and that there isn't a way to have three baths per week. BA A went on to further state that baths are only provided on the day shift and only on Monday through Friday. Interview with BA C on 10/29/15 at 10:56 AM revealed the bath aides were so booked with baths giving 8 to 11 baths every day that there wouldn't be any more time to provide residents with more than two baths per week. | 2019-08-01 |
| 5823 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2015-10-29 | 315 | D | 0 | 1 | 484F11 | Licensure Reference Number: 175 NAC 12-006.09D3 Based on observation, record review and interview; the facility failed to assess one resident (Resident 42) for an underlying cause of an increase in incontinent episodes and revise interventions to prevent further decline. The facility had a census of 121. Findings are: Review of Resident 42's MDS (Minimum Data Set - a federally mandated assessment tool used for care planning) dated 7/14/15 revealed Resident 42 had intact cognition, required an extensive amount of assistance with toileting tasks, was on a toileting program and was occasionally incontinent of urine. A later MDS for Resident 42 dated 10/6/15 revealed Resident 42 was still on a toileting program and was now frequently incontinent of bladder. Observation of Resident 42's room on 10/21/2015 at 08:30 AM revealed an open bag of soiled linens on Resident 42's bed with a strong urine smell noted. Review of Resident 42's care plan printed 8/4/15 revealed Resident 42 voiced concerns of needing more assistance and frequently called child anxious about incontinent products and did not like to tell staff about incontinent episodes. Staff were to provide assistance as needed for toileting, ensure the call light was with in reach and provide education and assistance with hygiene as needed. Review of four Bowel and Bladder Reports for Resident 42 from 6/28/15 to 10/25/15 revealed Resident 42 went from having 23 episodes of incontinence from late June/July to 46 times in late September/October. Interview with Resident 42 on 10/22/2015 at 11:46 AM stated Resident 42 did not like to call for assistance to the bathroom because staff leave before Resident 42 was done and then Resident 42 had to wait a long time for staff to come back. Interview with NA H (Nursing Assistant) on 10/29/15 at 9:50 AM revealed Resident 42 had become more incontinent over the last 4 months and that Resident 42 requested to use the toilet less than Resident 42 used to. NA H further stated that Resident 42 used to just have dribbling but had actual problems with incontinence. NA H continued to state that Resident 42 was very embarrassed by the incontinence. Interview with the Unit Manager and Director of Nursing (DON) on 10/29/15 at 4:30 PM revealed that a bladder assessment and voiding diary was completed upon admission. The Unit Manager also stated that, if a resident's toileting needs or continence status changed during their stay, it would be discussed in the resident's care plan meeting and the care plan would be revised. The Unit Manager confirmed that a new assessment had not been completed for Resident 42 since Resident 42's admission over a year ago. The DON then stated that a new assessment should be completed if a resident had a significant change or a decline in functioning. | 2019-08-01 |
| 5824 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2015-10-29 | 431 | D | 0 | 1 | 484F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC ,[DATE].12E7 Based on observation and interview, the facility failed to ensure two insulin vials were not expired prior to administration for two residents (Residents 155 and 137). The facility had a census of 121 residents. Finding are: A. Observation of a medication pass to Resident 155 on [DATE] at 12:08 PM revealed Licensed Practical Nurse (LPN) D to get a vial of Resident 155's Humalog (a fast acting insulin used to treat diabetes) from a zippered bag in the medication cart, prepare it and administer 4 units to Resident 155 by injection. After completion of the insulin administration the vial of Humalog insulin was observed to not be labeled with the date it was opened. B. Observation of medication pass to Resident 137 on [DATE] at 12:34 PM revealed LPN D to get a vial of Resident 137's Humalog insulin from another zippered bag in the medication cart, prepare it and administer 15 units to Resident 137 by injection. After completion of the insulin administration the vial for the Humalog insulin was observed to not be labeled with the date it was opened. C. Interview with LPN D on [DATE] at 12:50 PM revealed, when the individual resident's insulin vials were opened, they were stored in a separate zipped bag in the medication cart for administration. A follow up observation of the insulin vials on [DATE] at 4:30 PM revealed the insulin remained in the individual zippered bags and the vials remained in place for administration on the evening shift. Interview with LPN E on [DATE] at 4:33 PM confirmed that the insulin would be used for the next medication pass. LPN E further stated that LPN E had no way of knowing how many days had passed since the vials were opened because no one labeled them with the date they were opened. Interview with the Director of Nursing (DON) on [DATE] at 5:00 PM revealed all insulin should be dated when opened and discarded 28 days after being opened. | 2019-08-01 |
| 5825 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2015-10-29 | 441 | E | 0 | 1 | 484F11 | Licensure Reference Number: 175 NAC 12-006.17 Based on observation, interview and policy review; the facility failed to ensure the blood glucose machine was sanitized in a manner to prevent cross contamination for three residents (137, 155 and 2) and failed to ensure clean linens were handled in a manner to prevent contamination when being carried for use. This had the potential to effect 7 residents that utilized the blood glucose machine and all residents who utilized the facility's linen. The facility's census was 121. Findings are: A. Observation of Licensed Practical Nurse (LPN) D on 10/26/15 at 12:10 PM revealed LPN D carry the Accu Check Inform II machine into Resident 155's room and lay it on Resident 155's bed side table with no barrier. After completing the blood glucose testing LPN D carried the Accu Check machine to the medication cart and laid it down with no barrier. LPN D proceeded to clean the Accu Check machine with a Sani Cloth disposable wipe. LPN E wiped the machine three times on the front and sides but did not come in contact with underside of the machine and sat the machine back on the cart to air dry. On 10/26/15 at 12:38 PM LPN D then carried the same Accu Check machine into Resident 2's room and laid it on Resident 2's bedside table with out a barrier. After the completion of the glucose testing task, LPN D carried the Accu Check machine back out to the medication cart and laid it down with out a barrier. LPN D again used a Sani Cloth disposable wipe and wiped off the front and sides of the machine but did not cleanse the underside. LPN D again allowed the machine to air dry. Observation on 10/26/16 at 12:38 PM revealed LPN D take the same Accu Check machine into Resident 137's room and lay it on Resident 137's bed side table with out a barrier. After completion of the blood glucose testing LPN D walked the Accu Check machine down the hallway and into the supply room for storage without performing any sanitation of the machine. Interview with LPN D on 10/26/16 at 12:45 PM confirmed that the Accu Check Inform II machine was used on all of the residents requiring blood glucose testing on that hallway. Interview on 10/29/15 at 11:41 AM with the Infection Control Preventionist revealed that the bottom of the blood glucose machine would need to be sanitized to prevent cross contamination between residents. B. Observation on 10/20/2015 8:55 AM revealed Nurse Aide (NA) G carrying two soaker pads against the left sleeve of NA G's uniform. Observation on 10/20/2015 at 9:05 AM revealed Laundry Aide (LA) J pushing a cart of clean linens towards the linen closet, LA J was observed to pull a door jamb out of the clean linen cart and use it to prop open the door to the linen closet while unloading the clean linen. LA J then pulled out the door jam and laid it on top of the remaining clean linens in the linen cart. Observation of Nurse Aide (NA) F on 10/20/15 at 9:08 AM revealed NA F retrieving clean bed linens and hugging them against NA F's uniform while carrying them down the hallway and into a resident's room. Observation on 10/26/15 at 9:49 AM revealed Licensed Practical Nurse (LPN) D hugging two clean soaker pad and some bed linen down the hallway and into a resident room. Interview on 10/29/15 at 11:40 AM with the Infection Control Preventionist revealed staff are supposed to carry clean linens away from the body in order to protect them from contamination. | 2019-08-01 |
| 7521 | ST JANE DE CHANTAL LONG TERM CARE SERVICES | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2014-09-24 | 156 | F | 0 | 1 | 1E3U11 | Based on observation and interviews, the facility failed to post the contact information for the State survey and certification agency, the protection and advocacy network and the Medicaid fraud control unit. This had the potential to affect all the residents of the facility. The facility had a census of 113. Findings are: Observation on 9/14/17 at 4:40 PM revealed that facility had postings with contact information for the local and state ombudsman. A Tour of the facility during the same time revealed no other contact information was posted. Interview with Resident 37 on 9/23/14 at 1:45 PM revealed that Resident 37 did not know that residents had the right to complain formally to the State about the care they are receiving and did not know how to contact the State to make such a complaint. Interview with Social Worker K on 9/23/14 at 3:40 PM revealed Social Worker K was able to only find postings with contact information for the local and state ombudsman. | 2018-02-01 |
| 7522 | ST JANE DE CHANTAL LONG TERM CARE SERVICES | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2014-09-24 | 247 | D | 0 | 1 | 1E3U11 | Based on record review and interview, the facility failed to notify one resident, Resident 11, of a room change. The facility had a census of 113. Findings are : Interview with Resident 11 on 9/15/14 at 10:38 AM revealed that Resident 11 was in the hospital in May and upon returning had been moved to a different room. Resident 11 further explained that (Resident 11) was not notified prior to moving the new room and that it got me upset. Record review revealed that Resident 11 was on bed hold from 4/17/14 to 5/1/14. Interview with Registered Nurse (RN) L on 9/23/14 at 2:30 PM revealed that the facility does not try to move residents that are going to be in the facility for long term placement. RN L confirmed that Resident 11 was moved to a different room while out of the facility and notified of the room change when Resident 11 returned. Interview with Case Manager M on 9/24/14 at 9:26 AM revealed that the facility does not guarantee a resident will return to the same room they left but that residents are not necessarily notified of that possibility. Review of bed hold policy dated 3/26/14 revealed that LTC (Long Term Care) patients that return to acute care would be evaluated by the nurse liaison prior to returning to the facility, but did not address the rights of the residents on bed hold including the right to be notified of a room change prior to that room change. | 2018-02-01 |
| 7523 | ST JANE DE CHANTAL LONG TERM CARE SERVICES | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2014-09-24 | 253 | E | 0 | 1 | 1E3U11 | Licensure Reference Number: 175 NAC 12-006.18A (1) and 12-006.18B3 Based on observation and interview, the facility failed to maintain 14 resident rooms to provide a clean and comfortable environment. This had the potential to affect 18 residents. The facility census was 113. Findings are: A. During the Environmental tour on 9-24-14 at 10:10 AM the following observations were made: --The bathroom sink was not draining well in room 314. --Walls in room 317 were marred and the room door had multiple dings on it. --Chipped paint was noted on walls in room 328 and black marks were noted on the bathroom walls. --The bathroom walls in room 336 had areas of chipped paint as well as black marks. The ceiling vent in the the bathroom did not work. --In room 339, corners of walls had plaster chipped off in room, chipped paint, and a scratch on the floor from the bed. --Walls and door frames were scraped in room 404; a urinal was uncovered in the resident's room, and the vent in the bathroom was not working. --The bathroom vent was not working in room 407. --The over-bed light was broken (grate type cover over light) in room 420. --In room 420, the wood surrounding the heating unit had large chunk of wood missing that has left unfinished, rough wood exposed on the right side of structure. --In room 427 black stains were noted on bed spread and on privacy curtain. --The toilet seat in room 442 was stained with feces; stains around base of toilet on caulking were noted with one stain extending outward onto the flooring. --In Room 406 the wall was scratched and handicapped paint; the bathroom vent was not working; a bedpan was in the room without a cover and had dried feces in it. An interview with Maintenance Employee D on 9-24-14 at 10:50 AM confirmed findings during the Environmental tour. Employee D stated the facility was planning to replace heating and cooling units in the near future but was not aware of the time frame. B. Observation of Room 404 on 9/22/14 at 2:25 PM revealed a soiled ripped adult incontinence brief on the foot of bed A and two urinary catheter drainage bags and attached tubing draped over the grab bar in the bathroom. There was a small amount of urine noted in both bags. Interview with Licensed Practical Nurse (LPN) B on 9/24/14 at 10:30 AM revealed the drainage bags should have been disposed of. | 2018-02-01 |
| 7524 | ST JANE DE CHANTAL LONG TERM CARE SERVICES | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2014-09-24 | 312 | D | 0 | 1 | 1E3U11 | Licensure Reference Number: 175 NAC 12-006.09D1c Based on observation and interview, the facility failed to provide two residents (Residents 21 and 140) with assistance to maintain clean eye glasses and failed to provide assistance with washing the face for one resident (Resident 140) . The facility census was 113. Findings are: A. Review of Resident 21's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 7/22/14 revealed Resident 21 required extensive assistance for dressing and hygiene tasks, had adequate vision and used corrective lenses. Observation of Resident 21 on 9/17/14 at 2:00 PM revealed Resident 21 was up in the wheelchair and had eye glasses on. Closer inspection of Resident 21's eye glasses revealed they were covered in several smudges and smears. Observation of Resident 21 on 9/22/14 at 2:20 PM revealed Resident 21 again up in the wheelchair with eye glasses on. The glasses continued to be covered in the same smudges and smears. When asked if Resident 21 could see out of the glasses, Resident 21 replied, not real well. Observation of Resident 21 on 9/23/14 and on 9/24/14 at 8:00 AM revealed Resident 21's eye glasses had still not been cleaned. Interview with Medication Aide (MA) A on 9/24/14 at 8:00 AM revealed Resident 21's eye glasses were really dirty and probably made it hard to see. MA A then cleaned Resident 21's glasses and put them on Resident 21. When asked, Resident 21 reported being able to see better than before. B. Review of Resident 140's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 9/4/14 revealed Resident 140 required extensive assistance for dressing and hygiene tasks, had impaired vision (could see large print but not normal print) and used corrective lenses. Observation of Resident 140 on 09/15/2014 at 10:50 AM revealed dark colored substance on the corners of Resident 140's mouth and that Resident 140 was wearing smudged and smeared eye glasses. Observation of Resident 140 on 9/17/14 at 1:58 PM revealed Resident 140 was in bed with eyes closed and no glasses on but did have a dark substance on the corners of Resident 140's mouth. Observation of Resident 140 on 9/22/14 at 2:25 PM revealed Resident 140 in bed with dark remnants at both corners of mouth and glasses on with same smudges and smears. Observation of Resident 140 on 9/23/14 at 8 AM revealed Resident 140 in the wheelchair at the dining room table and had not yet been served breakfast. Resident 140 again had a dark substance in both corners of Resident 140's mouth. Resident 140's eye glasses continued to have smudges and smears on them, Interview with Medication Aide (MA) A on 9/24/14 at 8:15 AM revealed staff should do a better job of making sure all of the residents and their adaptive devices clean. | 2018-02-01 |
| 7525 | ST JANE DE CHANTAL LONG TERM CARE SERVICES | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2014-09-24 | 315 | D | 0 | 1 | 1E3U11 | Licensure Reference Number: 175 NAC 12-006.09 3(1) Based on observation and record review, the facility failed to perform pericare in a manner to prevent cross contamination for Resident 13. Facility census was 113. Findings are: On 9-17-14 at 1:50 PM pericare for Resident 13 was observed. Nurse Aide J had gloves on and used a wash cloth, being sure to use a clean section of cloth for each wipe and wiping front to back. When Nurse Aide J was finished, the resident asked that cream be applied to vaginal area. Nurse Aide J, with same gloves still on, reached for the cream on the bedside table, unscrewed the cap and applied the cream to the vaginal area. When done, Nurse Aide J reapplied the cap to the tube, then returned it to the bedside table before taking gloves off and washing hands. Step 28 of the Facility's Female Perineal Care Procedure states Change gloves and perform hand hygiene if applying peri cream. The Facility's Peri-Cath Care Competency, numbered 5102 states Prior to applying peri cream, gloves must be changed. | 2018-02-01 |
| 7526 | ST JANE DE CHANTAL LONG TERM CARE SERVICES | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2014-09-24 | 371 | E | 0 | 1 | 1E3U11 | Licensure Reference Number: 175 NAC 12-006.11E Based on observation and interview, the facility failed to prepare and serve food in a manner to prevent food borne illnesses. This had the potential to affect 76 residents who obtained food from the cafeteria. The facility census was 113 Findings are: On 9-17-14 during the noon meal service the following was observed: --Dietary Employee F was observed washing hands at sink for 10 seconds. --Dietary Employee G was observed applying finger cots (a plastic sheath that covers the finger often used to protect fingers or cover sores) to 2 middle fingers and then begin working in the plating area. Approximately 10 minutes after applying the finger cots Dietary Employee G was observed pushing up one of the finger cots that was slipping down the finger with an uncovered hand. This was observed three times. --Dietary Employee G was observed leaving the plating area and exiting the kitchen through the hallway door. Approximately 5 minutes later Dietary Employee G re-entered the kitchen carrying a box of salad dressings and then began opening refrigerator doors and plating food on trays for residents without performing hand hygiene. --Dietary Employee H was observed placing thumb in small condiment cups three times while putting au jus in the cups. --Dietary Employee I was observed touching the part of a plate guard that food would come in contact with bare hands. --Plastic Kennedy Cups (a non spill adaptive cup with a handle) were stacked on a shelf at the beginning of the service line then placed on trays when needed and passed on down the line for filling. The cups and/or lids were not dry and water from the cups/lids was observed on the trays. The Nebraska Food Code (effective March 8, 2012) (2-3-1.12) states .food employees shall clean their hands and exposed portions of their arms .for at least 20 seconds . Additional guidance at 2-301.14 states Food employees shall clean their hands and exposed portions of their arms .during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks .after engaging in other activities that contaminate the hands. The Nebraska Food Code (2-201.11) states if wearing an impermeable cover such as a finger cot .a single-use glove is worn over the impermeable cover. The Nebraska Food Code (81-2,272.10) states .food employees shall minimize bare hand and arm contact with exposed food. This may be accomplished with the use of suitable utensils such as .spatulas, tongs, single-use glove, or dispensing equipment. The Nebraska Food Code (4-901.11) states after cleaning and sanitizing, equipment and utensils: (A) shall be air-dried or used after adequate damning before contact with food . and 4-903.11 (B) states clean equipment and utensils .shall be stored (1) in a self-draining position that allows air drying; and (2) covered or inverted. | 2018-02-01 |
| 8644 | ST JANE DE CHANTAL LONG TERM CARE SERVICES | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2013-08-01 | 241 | D | 0 | 1 | L0VQ11 | Licensure Reference Number: 175 NAC 12-006.05 (21) Based on observation and interview, the facility failed to protect the dignity and privacy of 2 residents (Residents 19 and 241) by posting personal care instructions in areas visible to others. The facility census was 113. Findings are: A. Observation of Resident 241's room on 7/31/13 at 1:40 PM revealed a sign dated 7/29/13 posted on the wall in Resident 241's room that described the amount of assistance Resident 241 required for various activity of daily living tasks. Further observation of Resident 241's room on 8/1/13 at 10:30 AM revealed a sign dated 7/31/13 posted in Resident 241's bathroom that described the toileting schedule for Resident 241. The door the the bathroom was open and the sign was easily visible from Resident 241's bedside. Both signs also contained Resident 241's full name. Interview with Resident 241 on 7/24/13 at 5:20 PM revealed Resident 241 would not like it if personal care information was posted for everyone to see. A follow up interview with Resident 241 on 8/1/13 at 1:15 PM revealed Resident 241 was not asked permission before placing the signs and stated, those should not be there. B. Observation of Resident 19's room on 7/24/13 at 3:49 PM revealed a sign in the bathroom that described Resident 19's toileting plan. The bathroom door was ajar and the toileting plan was easily visible for Resident 19's room. Further observation revealed another sign on the wall that read Turn Me with a picture of a clock that instructed staff how to reposition Resident 19. Attached to this sign was a bright pink paper that instructed staff to place a pressure reducing cushion in Resident 19's recliner. In addition a sign explaining Resident 19's Transfer Recipe (explaining the amount of assistance the resident required for various tasks) was posted on the wall for any visitors or other residents to see. All signs identified Resident 19 by name. Interview with Licensed Practical Nurse (LPN) A on 8/1/13 at 11:50 AM revealed the signs were posted so the nursing assistance would know how to care for those residents. LPN A went on to say that the alert and oriented residents were asked permission but that family's of residents unable to consent were not consulted. In addition LPN A agreed that Resident 241 was not asked permission prior to posting the information in Resident 241's room. | 2017-03-01 |
| 8645 | ST JANE DE CHANTAL LONG TERM CARE SERVICES | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2013-08-01 | 253 | E | 0 | 1 | L0VQ11 | Based on observation and staff interview, the facility failed to provide an odor free environment as evidenced various resident room's having an odor of urine in them (Residents 241, 85, 88, 162, 83, and 148) and the 400 east hallway having a strong pervasive odor during all days of the survey. Findings include: A. On all days of the survey there was a strong urine odor outside of the utility room on the 400, east hallway, survey dates were 7/24, 7/25, 7/29, 7/30, 7/31, 8/1/13. On 7/31/13 at 10:40 AM, Interview with Director of Plant Operations, revealed that the odor was probably from the soiled linens placed in the utility room B. On 7/24/13 at 5:22 PM, Resident 241 smelled of urine and there was a wet spot on wheelchair, there was also urine odor in the bathroom. C. On 7/25/13 at 9:38 AM, there was BM (bowel movement) noted on bed pain in bathroom and in a portable commode in the bathroom in Resident 88 and 85's bathroom that they share. On 7/31/13 at 10:25 AM, during the environmental tour, an Interview with Director of Plant Operations revealed that the bed pan and portable commode could both be cleaned better to help eliminate odors. D. On 7/25/13 at 2:40 PM, during observation, the bathroom smells like urine in Resident 162's room. At this same time the toilet seat was observed to have stool on it and the bathroom smelled of urine. E. On 7/24/13 at 12:08 PM, revealed that Resident 83's room smelled of odor and so did the hallway. F. On 7/25/13 at 15:08 PM, in Resident 148's bathroom revealed a strong urine odor and stool on the side of the toilet seat. G. Observed on 7/25/13 at 1:40 PM revealed there was urine in a commode with the lid up in the resident's room and the resident was out of room for an activity. Resident returned to room at 3:15 PM, at 5:29 PM, staff attended to the commode at that time. | 2017-03-01 |
| 8646 | ST JANE DE CHANTAL LONG TERM CARE SERVICES | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2013-08-01 | 441 | E | 0 | 1 | L0VQ11 | Licensure Reference Number 175 NAC 12-006.17 Based on observation and interview, the facility failed to ensure mechanical lifts were sanitized between residents use for two Residents (Residents 70 and 83). This had the potential to effect 30 resident's who utilize the mechanical lift for transfers. The facility census was 113. Findings are: Observation of Nursing Assistant (NA) B and Nursing Assistant C on 7/30/13 at 8:02 AM revealed Resident 83 being assisted with morning cares. NA A and NA B assisted Resident 83 from the bed to the wheelchair utilizing a mechanical lift. NA B then pushed the mechanical lift down the hallway and into another resident's room for use. No sanitization was completed between use. Observation of NA D and NA E revealed Resident 70 being transferred from the bed to the wheelchair. NA E pushed the mechanical lift into a storage room after use and left it there without sanitizing the lift. Interview with Licensed Practical Nurse (LPN) D on 7/30/13 at 10:05 AM revealed mechanical lifts should be sanitized every time they are taken out of a resident's room and that sanitizing solution was available and accessible. | 2017-03-01 |
| 10233 | ST JANE DE CHANTAL LONG TERM CARE SERVICES | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2012-05-31 | 329 | D | 0 | 1 | BZYZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 12-006.05(20) Based on record reviews and staff interview, the facility failed to ensure that the drug regimen for 1 resident (Residents 205) included indications for each medication prescribed by the medical practitioner. The facility census was 118 and the survey sample size was 40. Findings are: Resident 205 had the following [DIAGNOSES REDACTED]. Review of Resident 205's May 2012 Medication Administration Record [REDACTED]. Reason for taking medication: anxiety/depression. Review of the Pharmacy Medication Review form for May 17, 2012 revealed, Patient (pt) has orders for [MEDICATION NAME] 0,5mg q (every) am and [MEDICATION NAME] 1mg q 2100, indication unknown. Patient does not have an indicated [DIAGNOSES REDACTED]. Please consider tapering pt off [MEDICATION NAME]. Review of the 3/22/12 [MEDICAL CONDITION] Physician Note: AAOx3 (awake, alert and oriented by person, place and time) not sleeping well at night [MEDICATION NAME] anxious wants to have vent (machine to assist with breathing) stopped, does not want aerosol treatments either. Has been having fevers again and UA (urine test) does show very mild start of infection could be reason .(gender) reports just doesn't feel well. Respiratory reports minimal secretions. PLAN: Blood sugars are well controlled. Will schedule [MEDICATION NAME] (antipsychotic medication) 5mg qid (4 times a day) for anxiety will readjust next week. Will leave off vent tonight [MEDICAL CONDITION](surgical opening in neck into the windpipe) uncapped with ABG (arterial blood gases) in a.m . Will start [MEDICATION NAME] and [MEDICATION NAME] bid (twice a day) with ezpap (machine to assist with positive airway pressure) and discontinue the [MEDICATION NAME]. (Gender) needs aggressive [MEDICAL CONDITION] hygiene to be successful with decannulation of [MEDICAL CONDITION] off the vent. At this time I don't feel (gender) will be successful one month post Madonna and is high risk for [MEDICAL CONDITION] with need [MEDICAL CONDITION] again. (Gender) has a brainstem infarct (tissue death) which can cause significant hypoventilatio[DIAGNOSES REDACTED] with hypercapnia (high concentration of carbon [MEDICATION NAME] in blood) .will continue to monitor. We are still suctioning through [MEDICAL CONDITION] well again which signifies we can not pull [MEDICAL CONDITION] this time. Review of the Telephone Order dated 3/23/12 revealed, Risperidal 0.5mg in a.m. and 1mg at 9:00pm. Ind (indication) anxiety. D/C (discontinue) [MEDICATION NAME]. An interview with the Director of Nursing (DON) on 5/31/12 at 11:30 AM confirmed that there was not an indicated [DIAGNOSES REDACTED]. | 2016-01-01 |
| 10234 | ST JANE DE CHANTAL LONG TERM CARE SERVICES | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2012-05-31 | 441 | D | 0 | 1 | BZYZ11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observation and staff interview, the facility failed to follow infection control guidelines to prevent the potential spread of organisms related to the lack of changing gloves prior to assisting with dressing change after touching other surfaces. The resident sample size was 40 and the facility census was 118. Findings are: Observation conducted on 5/30/12 at 11:00 AM revealed that RN A worked with the assistance of resident 219's Daughter. RN B was also in the room during the dressing change and wound vac placement. The Daughter removed kerlix from right hip wound with gloves on. Without changing gloves, the Daughter walked to the room sink and opened cabinet doors looking for a pair of scissors. The Daughter then returned to the bed side and assisted by pushing the drain sponge into the right hip wound wearing the same gloves. At no time did RN A or B remind resident 219's Daughter to wash hands and don new gloves. Interview with RN B on 5/30/12 at 10:55 revealed that Family for Resident 219 was very hands on and would be assisting with the dressing change process. Interview with RN B on 5/30/12 at 11:45 AM revealed that staff would talk with Resident 219's family about infection control practices during the dressing change and wound vac placement procedure. | 2016-01-01 |
| 12066 | ST JANE DE CHANTAL LONG TERM CARE SERVICES | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2011-06-28 | 156 | D | 1 | 1 | HQQ611 | Based on record review and interview the facility failed to inform 3 residents (Residents 4, 10 and 121) of their right to request a standard Medicare A skilled denial appeal process from a resident sample size of 33. The facility census was 109. Findings are: Review of Residents 4, 10, and 121's medical records revealed that the expedited appeal process letter was in the resident's medical record. None of the 3 resident medical records contained the required standard claim appeal form. Interview on 6/27/11 at 1:50 pm with Social Worker A revealed that when residents were denied from the skilled unit only the expedited appeal process letter was given to the resident or responsible party. Review of the facility's policy titled "SNF (Skilled Nursing Facility) Notice of Medicare Provider non-Coverage (Advance Notice) on the Subacute Rehabilitation and Lower North Units" stated "Beginning July 1, 2005, patients with Medicare have access to a fast-track expedited review process when Medicare coverage of their SNF services is about to end. SNF's are required to notify patients of their new right when they anticipate that Medicare coverage of their services will end. There are two notices required by this rule. The first notice is a Notice of Medicare Provider non-Coverage (advance notice) that the SNF will deliver whenever a patient's Medicare coverage of current services is ending. The second notice is a Detailed Explanation of Skilled Nursing Facility Non-Coverage (detailed notice) that the SNF will deliver to the patient and send to Madonna's QIO, CIMRO of Nebraska, only if the patient requests an expedited review of the decision that coverage for services should end. The intent of the advance notice is to inform the patient of an end date for Medicare coverage of the SNF services being provided, allowing time for an appeal if the patient disagrees with the coverage end date." | 2014-10-01 |
| 12067 | ST JANE DE CHANTAL LONG TERM CARE SERVICES | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2011-06-28 | 279 | D | 1 | 1 | HQQ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].04C3a Based on record review and interview the facility failed to ensure that 2 resident's (Residents 47 and 205's) care plans were kept current from a resident sample size of 31. The facility census was 109. Findings are: A. Review of Resident 47's Discharge Summary dated [DATE] revealed that the resident was admitted to the facility from an assisted living facility on [DATE] after the resident had a pelvic fracture. The resident's other admitting [DIAGNOSES REDACTED]. The resident was seen at the resident's physician's office and admitted to the hospital on [DATE]. The resident returned to the facility from the hospital on [DATE] and was on hospice services when the resident was readmitted to the facility. The resident expired on [DATE]. The resident's final [DIAGNOSES REDACTED]. Review of Resident 47's Hospital History and Physical dated [DATE]revealed that the resident was hospitalized for [REDACTED]. Review of Resident 47's physician's orders [REDACTED]. Review of Resident 47's Community Transfer Orders Form dated [DATE] revealed that the resident was being returned to the facility and was admitted to the care of Hospice for comfort care only. The resident was a no code status. Review of Resident 47's Care Plan dated [DATE] revealed that the facility had not identified that the resident was receiving hospice comfort care was a no code status. Interview with LPN (Licensed Practical Nurse) B on [DATE] at 1:55 pm revealed that the resident's hospice status was not on the resident's last care plan that was dated [DATE]. The LPN stated that it was the admitting nurse's responsibility to update the care plans on the resident's return from the hospital. B. Review of Resident 205's Discharge Summary dated [DATE] revealed that the resident expired on [DATE] at 9:15 am. The resident's admitting [DIAGNOSES REDACTED]. The resident was admitted to the facility with Hospice Care on oxygen. The resident's condition declined. [MEDICATION NAME] (antianxiety medication) was given for discomfort. The resident's final [DIAGNOSES REDACTED]. Review of Resident 205 ' s Hospital History and Physical dated [DATE] revealed that the resident was admitted with acute [MEDICAL CONDITION], critical [MEDICAL CONDITION]. Review of Resident 205's Hospital Discharge Summary dated [DATE]revealed that a meeting was held with family and it was determined due to the resident's advanced age and poor prognosis it was reasonable for nursing home setting and palliative care, comfort care, and hospice. Review of Resident 205's Hospice Notes revealed: -On [DATE] the resident was minimally responsive with mottling of the resident's feet and hands. The resident's medications were discontinued. -On [DATE]the resident was actively dying and had a difficult time with breathing. The resident's oxygen level was 87%. The resident's family was with the resident. Review of Resident 205's Initial Care Pl dated [DATE] did not address that the resident was admitted to the facility for hospice services for comfort care. Interview with LPN B on [DATE] at 1:55 pm revealed that Resident 205's care plan did not contain the fact that the resident was admitted to the facility on hospice and that it should have. The LPN stated that whoever is the admitting nurse was the nurse that should initiate the care plan. | 2014-10-01 |
| 12068 | ST JANE DE CHANTAL LONG TERM CARE SERVICES | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2011-06-28 | 425 | E | 0 | 1 | HQQ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.12C A. Based on record review, observation and staff interview the facility failed to develop a system of narcotic administration to ensure residents receive the correct medication and correct dose; and failed to administer Rocephin according to facility policy. The facility sample was 31 and the census was 109. Findings are: Review of the medication error reports on 6/27/11 at 11:30 AM revealed that there were 5 reports in which random residents were given the wrong narcotic or anti anxiety medication which required signing out in a book on the 4 North area of the facility. Review of the 5 reports revealed: -On 4/1/11 a resident received 0.5 mg (milligrams) of Ativan (anti anxiety medication) instead of 0.5 mg of Xanax (anti anxiety medication). -On 5/4/11 a resident received 1 Norco (pain medication) instead of 2 Norco. -On 5/11/11 a resident received 2 Percocet (pain medication) instead of 1 Percocet. -On 5/30/11 a resident received 2 Percocet instead of 2 Norco. -On 5/31/11 a resident received 1 Percocet instead of 1 Norco. On 6/27/11 at 1:10 PM an interview with the Director of Nurses (DON) related to how the wrong medications could be administered to the above residents if the pharmacy provides the residents with dispensing administration devices (DADS) with the residents name and medication doses and instructions on them. The DON stated that, "These medications are provided from the pharmacy to the 4 North area in bulk. That is the way the pharmacy provides the (attached) hospital with their narcotics medications too." Observation of the medications system on the 4 North area revealed 2 medication carts which were locked and contained a locked narcotic box. In the narcotic box it was found that the bulk narcotics and anti anxiety medications were in individual pencil pouches with tape stating the name of the medication inside. The pencil pouches holding the medications were in a 3 ring binder. The medications inside were in bulk and none of the medications had a label for the resident and dose they were to receive. The medications in this pouch required that the staff sign them out in the Controlled Drug Administration Record. Review of the Controlled Drug Administration Record (CDAR) for the 4 North Area revealed that the medications were listed per categories: CII (controlled substance 2), CIIl-CV (controlled substance 3 through 5) Non-Benzodiazepine, CII-CV Benzodiazepine, CII Inj. (injectable) & Top (topical). A Benzodiazepine is a class of drugs that act as tranquilizers and are commonly used in the treatment of [REDACTED]. There were Controlled Drug Administration Records on each medication cart. Cart 1's CDAR had 7 sheets that were not identified for a specific residents, 2 of the sheets listed multiple medications. Cart 2's CDAR had 12 sheets that were not identified for a specific residents, 3 of the sheets listed multiple medications. Interview with the DON on 6/28/11 at 4:45 PM verified that the medications were stored in pencil pouches. B. Review of Resident 46's MDS (Minimum Data Set; a federally mandated comprehensive assessment tool used for care planning) dated 4/17/11 revealed the following Diagnosis: [REDACTED]. Review of Resident 46's Physician order [REDACTED]. Review of Resident 46's MAR (Medication Administration Record) dated 6/27/11, revealed an order for [REDACTED]. Observation of Resident 46's medication administration on 6/27/11 at 2:47 PM revealed: - LPN (Licensed Practical Nurse) C compared computer MAR indicated [REDACTED] - LPN C stated that the nurse needed to use 4.2 ml of Lidocaine to dilute 2 grams of Rocephin. -LPN C injected 4.2 ml of Lidocaine into the Rocephin bottle. -LPN C withdrew entire contents of the Rocephin bottle containing 4.2 ml of Lidocaine and 2 grams of Rocephin. -LPN C donned gloves and injected the entire Rocephin and Lidocaine mixture IM into the resident's left deltoid muscle site. Interview with the ADON (Assistant Director of Nursing) on 6/28/11 at 4:57 pm revealed that per the facility's Policy via Potter and Perry, an injection into the deltoid muscle should not be greater than 2-3 ml. Review of the facility's Potter and Perry stated, "A normal, will-developed client can tolerate 3 ml of medication into a larger muscle without severe muscle doscomfort. A larger volume of medication is unlikely to be absorbed properly." | 2014-10-01 |
| 18 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-01-23 | 584 | E | 0 | 1 | AD1911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER NAC 175 12-006.18 [NAME] Based on observation and interview, the facility staff failed to ensure food was removed from trays and placed in front of residents in a homelike manner for 119 residents that ate food in the facility dining rooms. The facility census was 232. The findings are: Observation of breakfast meal on 1/14/19 in Miracle Garden dining room revealed that residents were served their meal on trays. All liquids were served in plastic glasses. Observation of breakfast meal on 1/15/19 in Miracle Garden dining room revealed that residents were served their meal on trays. Observation of breakfast meal on 1/22/19 in Miracle Garden dining room revealed that residents were served their meal in Styrofoam dishes on a tray. Observation of breakfast meal on 1/23/19 in [MEDICATION NAME] dining room revealed that residents were served their meal in Styrofoam dishes on a tray. Interview conducted with C.N.[NAME] C on 1/15/19 at 10:15 AM revealed no knowledge of why residents were served on trays in Miracle Garden dining room. Interview conducted with RN D on 1/23/19 at 10:15 am revealed no knowledge of why meals are served on trays on some units and not on others. Interview conducted on 1/22/19 at 08:45 AM with Kitchen Service Worker [NAME] revealed the reason residents were served on Styrofoam was because the kitchen was short staffed and there was 2 units to cover. Interview conducted with Dietary Manager on 1/23/19 at 11:00 AM revealed that how the meal is served on the units is left up to the Kitchen Service Worker assigned to the unit. B. Observation on 1/14/19 at 12:20 PM in the Willow Springs neighborhood in the facility revealed that, as residents were being served lunch, the staff left the plates and glasses on the tray and placed the tray in front of the residents. Observation revealed that the residents were served food on Styrofoam plates and drinks in flexible plastic glasses in this area. Observation on 01/15/19 at 08:58 AM and on 01/16/19 at 08:55 AM and 01/23/19 at 09:28 AM in the Willow Springs neighborhood revealed that, as residents were being served breakfast, the staff left the plates and glasses on the tray and placed the tray in front of the residents. Observation revealed that the residents were served food on Styrofoam plates and drinks in flexible plastic glasses. Interview on 01/15/19 at 09:01 AM with FSW F confirmed that plates were left on trays in front of the residents. FSW F stated that there were not enough real plates so the food was served on Styrofoam plates and plastic glasses were used. Observation on 01/23/19 at 08:25 AM in the Field of Dreams unit revealed that residents were served fluids in flexible plastic glasses. Interview on 01/23/19 at 08:25 AM with RN G, when asked why residents were served liquids in plastic cups, confirmed that was RN G did not know the reason why. Interview on 01/23/19 at 09:28 AM with RN H on the Willow Springs unit, when asked why residents were served food on trays, confirmed that was RN H did not know the reason why. Interview on 01/23/19 at 10:26 AM with the Director of Nursing (DON) confirmed that it was not homelike to keep food on the trays when served or to serve with Styrofoam plates or plastic glasses. C. Observation on 01/14/19 at 12:12 PM on Wind Song Way at the lunch meal all residents received lunch trays delivered on a tray. Dishes were not removed from the trays. Trays were placed in front of residents. Liquids were served in disposable plastic cups. Coffee was served in regular cups. Observation on 01/15/19 at 09:13 AM of breakfast meal service on Wind Song Way revealed breakfast trays were delivered to the residents on trays and plates were not removed from the trays. Plastic disposable glasses were used. Interview on 1/23/2019 at 10:30 AM with Nursing Assistant (NA)-A revealed all resident's receive cold fluids are served in disposable cups. NA-A is not aware of why that is done and has asked the question and did not get an answer why some units use them and others do not. Interview on 1/23/2019 at 10:45 AM with the RN-B revealed receiving food on trays is not homelike. | 2020-09-01 |
| 19 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-01-23 | 657 | D | 0 | 1 | AD1911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, facility failed to ensure care plans were updated with resident individualized preferences for activities for 4 residents (Residents 226, 195,136, 79). Facility census was 232. Findings are: Resident 79 On 01/21/19 a record review of annual MDS (Minimum Data Summary) (part of the federally mandated process for clinical assessment of all residents) dated 2/16/18 revealed Resident 79 likes were completed by staff and include having family or friend involved in discussions about care, listening to music, being around animals such as pets, doing things in group of people, doing favorite activity, and going outside weather permitting. On 01/22/19 a record review of Recreation Initial Assessment, Past and Present Leisure Interests, Activity List Quick Reference, dated 2/25/18 for Resident 79, revealed a current interest in small group dining out, holiday celebrations, drive/outings, and individual watching movies, listening to music, watching TV, getting outside, and pets. On 01/22/19 a record review of Care Plan for Resident 79 revealed goals of attending social/entertainment groups off neighborhood monthly, participating in activities such as music groups sensory stimulation or pet therapy monthly and attend at least one community outing of choice in next 90 days. Interventions are invite resident to activity and escort, encourage participation in activities of choice, provide socially stimulating activities, providing pet therapy, invite on outings, provide choices, hang outing slip in room as a reminder of day/time of community outing. Resident 136 On 01/21/19 a record review of annual MDS dated [DATE] for Resident 136 revealed listening to music as very important, keeping up with news as somewhat important, and to do/attend favorite activities as somewhat important. 01/22/19 12:14 PM Record review of Recreation Annual assessment dated [DATE] for Resident 136 revealed resident has a current interest in individual keeping up with current events, socializing, listening to music, watching the new, talk radio (listening), walking and pets. A current interest in small group shopping, dining out, drive/outings, listening to music, and current interest in large group shopping, dining out and listening to music. On 1/21/19 a record review of Care Plans for Resident 136 revealed goals are to participate in programs such as outdoor groups , music groups and sensory stimulation at least 3 times in next 90 days, to attend an outing 1 time in next 90 days, she will interact at least 3/12 times during 1:1's with TR staff in next 90 days. Interventions include provide opportunity for resident to visit courtyard. Invite to outdoor groups. Invite and escort resident to group activity and monitor responses, provide diversional activities for resident upon request, read calendar to resident and have resident choose group to attend, resident enjoys opera music, provide choices for community outings, announce presence when coming into room, and provide sensory stimulation. Resident #195 On 01/22/19 a record review of Recreation Annual Assessment, Past and Present Leisure Interests, Activity List Quick Reference, dated 12/27/18 for Resident 195, revealed current interest of in books/mags/newspapers,socializing, watching TV, talk radio, walking, getting outside, relaxation, and pets for individual, 1/1 and small groups. On 1/22/19 a record review of Care Plan for Resident 195 revealed interventions of offer resident the choice of community outings, offer transportation to and from activities, provide socially stimulating activities. Resident 226 On 01/17/19 a record review of annual MDS dated [DATE] for Resident 226, revealed a staff assessment of daily an activity preferences as family or significant other involved in care discussions, listening to music, doing things in a group of people, participating in favorite activities and spending time outdoors as checked for important. On 01/22/19 a record review of Recreation Annual Assessment, Past and Present Leisure Interests, Activity List Quick Reverence, dated 12/11/18, for Resident 226, revealed a current interest in individual socializing, dining out, holiday celebrations, and drive/outing, as well as individual watching movies, listening to music, and watching sports, and individual walking, bowling, and getting outside, and individual pets and a current interest in small group activities as dining out, holiday celebrations, and drive/outing. On 1/22/19 a record review of Care Plan revealed goals to increase his socialization, resident will attend activities with a social component monthly for next 90 days, resident will participate in programs such as music performances and pet therapy monthly in next 90 days. Interventions are to invite resident to activity and escort, provide pet therapy, provide sensory stimulation, invite on outings, provide choices, hang outing slip in room as a reminder of day/time of community outing and to monitor for future recreational interests and is to attend at least one community outing of choice during the next 90 days. On 01/23/19 at 02:10 PM an interview with the DON, who confirmed the care plans were not individualized. | 2020-09-01 |
| 20 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-01-23 | 661 | D | 0 | 1 | AD1911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, facility failed to develop a discharge summary for Resident 234 of 3 residents sampled. The facility census was 232. Findings are: Review of Resident 234 closed medical record revealed Resident 234 was admitted on [DATE] from the hospital for rehabilitation. Resident 234's condition improved during the stay and Resident 234 was discharged home with home health care to assist on 10/29/2018. Review of Resident 234's medical record revealed no discharge summary. Review of Resident 234's Home Health Face to Face Encounter form dated 10/26/2018 revealed Resident 234 had the following: - Diagnosis: [REDACTED]. - Services needed through home health. - No recapitulation (summary) of Resident 234's progress during the admission addressing the required information from the Interdisciplinary Team. Interview on 01/23/19 at 8:43 AM with the Director of Nursing (DON) revealed no discharge summary with a recapitulation of residents stay is completed. Short term stay rehabilitation residents have discharge summary of therapy and ongoing needs. The physician completes a summary for Home health needs titled Home Health Face to Face Encounter Form. No other discharge summary is completed. | 2020-09-01 |
| 21 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-01-23 | 802 | F | 1 | 1 | AD1911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04D Based on observation, interview and record review, the facility staff failed to ensure that meals were served on time. This had the potential to affect 228 resident served food from the kitchen. The findings are: [NAME] Review of Buffet Meal Service Long Term Care meal times dated 11/8/2018 revealed that Miracle Gardens Unit breakfast time of 7:20 AM - 8:00 AM. Safe Harbor Unit breakfast time of 8:00 AM-8:30 AM and [MEDICATION NAME] Unit breakfast time 7:50 AM - 8:30 AM. Observation on 1/15/19 on Safe Harbor breakfast was started at 08:30 AM. Observation on 1/22/2019 on Miracle Gardens Unit of breakfast was stared at 08:45 AM. Observation on 1/23/2019 on [MEDICATION NAME] Unit of breakfast being was started at 08:40 AM. Interview conducted with the Dietary Manager on 1/23/19 at 1:50 PM revealed that staffing for the kitchen included 10 food service workers, 4 Cooks, 1 pot and pan person, a youth center employee and a dish area worker. Review of dietary employee daily assignments revealed that on 1/15/19 there were 7 food service workers resulting in 3 food service workers covering 2 units. Review of dietary employee daily assignments revealed that on 1/22/19 there were 7 food service workers resulting in 3 food service workers covering 2 units. Review of dietary employee daily assignments for 1/23/19 revealed there were 5 food service workers resulting in each food service worker covering 2 units. Interview conducted with the Dietary Manager on 1/23/19 at 11:00 AM confirmed the kitchen was short staffed. B. Record review of Meal service times for Long Term Care revealed the following dining times: Willow Springs: 8:15, 12:10 and 5 PM Via [NAME]: 8 am, 12:10 and 5 PM Field of Dreams: 7:40 AM, 12:00 PM and 4:50 PM Observation on 1/14/19 at 12:20 PM in the Willow Springs neighborhood in the facility revealed that meal service did not start until 12:40 PM, 30 minutes later then the scheduled meal time. Observation on 01/15/19 at 08:45 AM in the Via [NAME] neighborhood revealed that meal service did not start until 8:45 AM, 45 minutes later then the scheduled meal time. Observation on 01/15/19 at 08:58 AM in the Willow Springs neighborhood revealed that meal service did not start until 8:50 AM, 35 minutes later then the scheduled meal time. Interview on 1/15/19 between 1:58 and 2:20 PM during the Resident Council meeting revealed a total of 7 alert and oriented residents attended the meeting. Several anonymous residents voiced the concern that meals are often served late which resulted in lukewarm food. The residents stated that this was unacceptable. Observation on 01/16/19 at 8:40 AM in the Via [NAME] neighborhood revealed that meal service did not start until 8:40 AM, 40 minutes later then the scheduled meal time. Observation on 01/16/19 at 08:55 AM in the Willow Springs neighborhood revealed that meal service did not start until 8:55 AM, 40 minutes later then the scheduled meal time. Observation on 01/23/19 at 08:20 AM in the Field of Dreams neighborhood revealed that meal service did not start until 8:20 AM, 40 minutes later then the scheduled meal time. Observation on 01/23/19 at 09:10 AM in the Willow Springs neighborhood revealed that meal service did not start until 9:10 AM, 55 minutes later then the scheduled meal time. Interview on 01/23/19 at 09:28 AM with RN H confirmed that meal service was late on that day due to kitchen staff called in due to the weather. Interview on 01/23/19 at 10:26 AM with the DON confirmed that the dining service times were later then the expected time frames for service and that this was due to staffing shortages in the dietary department. The DON confirmed that this had the potential to result in cold food and medication administration time frame issues. Interview on 01/23/19 at 11:07 AM with the DON confirmed that 21 residents on the Field of Dreams unit ate meals in the dining area, 33 residents on the Willow Springs unit ate meals in the dining area and 15 residents on the Villa [NAME] unit ate meals in the dining area. C. Observation on 01/15/19 at 8:30 AM revealed the kitchen service cart arrived in the dining area and prepared to serve the breakfast meal. At 9:13 AM the breakfast meal service on Wind Song Way was started to be delivered to the resident's seated in the dining room. The last resident tray was served at 10:00 AM. Review of the facility document dated 11/8/2018 titled Meal Service Times Long Term Care revealed meal service on Wind song Way for Breakfast is scheduled to begin at 7:55 AM. Interview on 01/23/19 at 3:09 PM with the Assistant Director of Nursing (ADON) revealed 4 residents are NPO (No oral intake) and do not eat food from the facility kitchen. | 2020-09-01 |
| 22 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2018-03-15 | 580 | D | 1 | 0 | KRL611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC12-006.04C3a(6) Based on interviews and record reviews, the facility failed to notify the resident's representative related to a transfer to the emergency room for 1 resident (Resident 3) of 5 residents sampled. The facility staff identified the census as 231. The findings are: A review of Resident 3's Care Plan dated 2-16-18 revealed that Resident 3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Resident 3's Nurses Notes dated 2-22-18 at 10:25 AM revealed that Resident 3 was unable to put weight on their left leg when working with therapy. An order was obtained to get an x-ray of the resident's left leg. A review of Resident 3's Nurses Notes dated 2-22-18 at 2:40 PM revealed that the medical practitioner was notified of the x-ray results and an order was obtained to send the resident to the emergency room . A review of Resident 3's Nurses Notes dated 2-22-18 at 2:45 PM revealed that the resident left the facility by ambulance to the emergency room with a nursing assistant escort. A review of Resident 3's Nurses Notes dated 2-22-18 at 7:00 PM revealed that the facility received a call from the emergency room notifying them that the resident was admitted to the hospital. The House Supervisor was notified and transportation was notified to go to the hospital and pick up the nursing assistant that had escorted the resident. A voicemail was left for the resident's representative to call the facility. An interview conducted on 3-15-18 at 12:01 PM with Registered Nurse (RN) B confirmed that Resident 3's representative was not notified when the resident was sent to the emergency roiagnom on [DATE] and should have been notified. An interview conducted 3-15-18 at 12:52 PM with the Assistant Director of Nursing revealed that the resident representative should be notified of transfers to the emergency room prior to the resident going to the emergency room . A review of the facility's Notification of Resident Condition Change/Room Change policy dated 2/06 revealed the following: Policy: In the event of an accident, acute medical emergency or significant change in the resident's condition or room change, the resident's family or legal guardian and the House Supervisor will be notified by the licensed nurse on duty. | 2020-09-01 |
| 23 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2018-03-15 | 689 | D | 1 | 0 | KRL611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure reference: 175 NAC 12-00.09D7b Based on observation, interview, and record review, the facility failed to evaluate falls for potential causal factors and implement interventions to prevent reoccurrence for 2 (Residents 2 and 5) of 5 sampled residents. The facility had a total census of 231 residents. Findings are: [NAME] Resident 5 was admitted to the facility on [DATE]. A review of Resident 5's care plan revealed a [DIAGNOSES REDACTED]. Observations on 3/15/18 at 8:43 AM revealed Resident 5 being assisted to transfer from recliner to wheelchair by Nurse Aide A with use of a gait belt and walker. A note attached to Resident 5's closet door reminded Resident 5 to use the call light. Resident 5's Care Plan included a problem dated of self care deficit/high risk for falls dated 1/9/18. The care plan listed the following interventions for falls: -Call light within reach. Check frequently and anticipate all needs. 15 minute safety checks or one to one supervision as needed for safety. -Resident 5 is at high risk for falls. Ensure oxygen tubing isn't a trip hazard. Assist of one for all mobility. -Fall 1/20/18 no injuries -Fall 1/25/18 no apparent injuries -Fall 2/8/18 no apparent injuries -Fall 2/21/18 no injuries noted -Fall 2/25/18 abrasion to right buttock A review of Fall Risk assessment dated [DATE] identified Resident 5 at a high risk for falling. A review of Resident 5's Nurses Notes revealed the following falls: -2/25/18 7:50 AM Resident noted to be in sitting position next chair with table partially tipped over. Resident 5 reported Resident 5 was going to get clothes. Resident had abrasion to lower buttock. Notes taped to Resident's closet to remind to ask for help. -2/21/18 9:15 PM Resident 5 observed sitting on floor in room on bottom. Resident 5 reported feet slipped out in front of Resident 5. No injuries noted. Resident encouraged to use call light. -2/8/18 7:30 AM Resident 5 slid out of recliner chair at 6:45 AM. No apparent injuries. -1/26/18 11:25 PM Resident 5 observed on the floor at 11:10 PM. Resident 5 had apparently got out of bed and slid. -1/20/18 1:45 AM Resident 5 sitting on floor next to chair. Resident 5 reported trying to get the cord that goes in my nose off the floor A review of falls questionnaire dated 1/20/18 for Resident 5 listed no recommendations for prevention of the fall. The falls questionnaires for Resident 5 dated 1/25/18, 2/8/18, and 2/25/18 all listed use call light as the recommendation for prevention of the fall. A review of Therapy Order Request Form for Resident 5 revealed order for physical and occupational therapy had been requested on 2/26/18. Order for physical and occupational therapy was signed on 3/9/18. In an interview on 3/15/19 at 12:16 PM, Physical Therapist C reported that an order for [REDACTED]. In an interview on 3/15/18 at 11:59 AM, Registered Nurse D reported the fall questionnaire is used to track falls and to monitor to ensure new interventions are put in place. Registered Nurse D reported that Registered Nurse D has not reviewed Resident 5's 2/2018 as Registered Nurse D just took over the unit. Registered Nurse D confirmed new interventions should have put in place for fall prevention. B. A review of Resident 2's Care Plan dated 3-21-17 revealed that Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's Fall Tracking Log revealed that the resident had 27 falls since 12-3-17. The falls occurred on 12-3-17, 12-9-17, 12-21-17, 12-27-17, 12-30-17, 1-2-18, 1-3-18, 1-5-18, 1-31-18, 2-1-18, 3 falls on 2-6-18, 2-13-18, 2-14-18, 2 falls on 2-16-18, 2-18-18, 2-20-18, 2-24-18, 2 falls on 2-26-18, 2-27-18, 2-28-18, 3-2-18, and 2 falls on 3-4-18. A review of Resident 2's Nurses Notes dated 12-3-17 revealed that the resident had fallen in the bathroom and sustained a laceration to their forehead. The resident was sent to the emergency room where the resident received staples to close the laceration and was admitted to the hospital for observation. A review of Resident 2's Care Plan dated 3-21-17 revealed the following fall events were documented on the care plan: 12-9-17, 12-27-17, 12-30-17, 1-2-18, 1-3-18, 1-31-18, 2-12-18, 2-13-18, 2-14-18, 2-18-18, 2-20-18, 2-24-18, 2-26-18, 2-27-18, and 3-4-18. There were no new interventions put in place with the fall events. The fall events for 1-2-18 and 2-20-18 revealed that the resident continued on 15 minute checks. An interview conducted on 3-15-18 at 11:05 with Registered Nurse (RN) B revealed that the 15 minute checks for Resident 2 were not being used to prevent falls and that the checks were mostly for night time when the resident was sleeping. RN B reported that the nursing staff filled out fall questionnaires for each fall, but that RN B disposed of the questionnaires once they had processed the data. An interview conducted on 3-15-18 at 12:56 with RN B revealed that when a resident falls, the facility tracks the falls and interventions using the Care Plan. RN B reported that the Care Plan was read after each fall and the current interventions were reviewed to see what was in place at the time of the fall. The new interventions were then written on the care plan. RN B confirmed there were no new interventions on Resident 2's Care Plan for falls. | 2020-09-01 |
| 24 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-08-01 | 689 | E | 1 | 0 | RZY811 | **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 ensure courtyard gates were secured to prevent potential elopement. The facility staff identified 29 residents who were cognitively impaired and were self mobile. The facility staff identified a census of 224. Findings are: Record review of Resident 1's Comprehensive Care Plan (CCP) printed on 6-07-2019 revealed Resident 1 had the [DIAGNOSES REDACTED]. One of the goals identified for Resident 1 was Resident 1 would not leave the facility grounds without an escort. Record review of a investigation report dated 7-30-2019 revealed Resident 1 had eloped from the courtyard. Record review of a Security Incident Report (SIR) dated 7-30-2019 with a time of 7:53 AM revealed an unknown individual was seen on video walking past the south courtyard gate, According to the (SIR) Resident 1 and the unknown individual were seen conversing and then the unknown individual opened the gate and allowed Resident 1 to leave the court yard unsupervised. Record review of a SIR dated 7-30-2019 with a time of 8:10 AM revealed a temporary pad lock was placed on the South exit gate from the courtyard and at 12:35 PM a new combination lock was placed onto the south exit gate. Observation with Registered Nurse (RN) A on 8-01-2019 revealed the courtyard had 3 exit gates with locks on them. During the observation, the Compliance Offer (CO) of the facility joined the observations of the courtyard. Further observations revealed Master Gardner's (MG) entered the courtyard through the south gate of the courtyard by dialing the code on the combination lock. On 8-01-2019 at 9:10 AM an interview was conducted with MG D and MG E. During the interview MG D and MG [NAME] reported the lock to the south courtyard gate was missing on 7-27-2019. Both, MG D and MG [NAME] reported the missing lock to the south courtyard gate to the security guards. On 8-01-2019 at 10:55 AM an interview was conducted with Chief of Security (COS). During the interview COS reported that security staff did not physically check any of the courtyard gates. The COS further reported being informed the MG's had informed security on 7-27-2019. The COS confirmed the south courtyard gate had been unsecured until the morning of 7-30-2019. The COS confirmed during the interview that the courtyards gates are to be secured al all time. On 8-01-2019 at 3:35 PM a list was provided of 29 residents who were cognitively impaired and self mobile who would have access to the courtyard. On 8-01-2019 at 3:35 PM and interview was conducted with RN F. During the interview RN F confirmed the 29 residents on the list would have access to the courtyard. | 2020-09-01 |
| 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. According to the Documentation report, NA A reported getting Resident 20 cleaned and dressed and when NA A retrieved Resident 20's wheelchair, Resident 20 fell out of bed. Record review of an undated Fall Root Cause Analysis (RCA) form revealed Resident 20 had sustained a laceration and hematoma to the right side of the face and had altered mental status. According to the RCA, the family chose not to have Resident 20 sent to the hospital. On 8-12-2019 at 1:50 PM an interview was conducted with Registered Nurse (RN) B. During the interview RN review of Resident 20's MDS and CCP were reviewed. RN B confirmed during the interview Resident 20's CCP and MDS indicated Resident 20 was to have 2 people assist with cares. When asked how many staff were assisting Resident 20 when Resident 20 fell on [DATE] resulting in a laceration and hematoma, RN B stated 1 staff was working with (gender). B. Record review of Resident 21's MDS dated as completed on 5-29-2019 revealed the facility staff assessed the following about Resident 21: -BIM's score was a 3. -Required supervision with bed mobility, transfers, walking on the unit and eating. -Required extensive assistance with toilet use and personal hygiene. Record review of Resident 21's CCP dated 3-04-2019 revealed Resident 21 had a fall on 7-30-2019 resulting in a laceration 2 lacerations to Resident 21's forehead. Further review of Resident 21's CCP revealed there were not specific interventions implemented in an attempt to prevent re-occurrence. Record review of Resident 21's progress notes dated 7-31-2019 revealed Resident 21 was seated at a table ,stood up and fell . On 8-12-2019 at 12:25 PM an interview was conducted with RN B. During the interview RN B confirmed no additional interventions had been implemented when Resident 21 fell on [DATE]. C. Record review of Resident 23's MDS signed as dated as completed on 7-03-2019 revealed the facility staff assessed the following about the resident: -BIM's score was a 3. -Required supervision with eating. -Required extensive assistance with transfers, dressing, toilet use and personal hygiene. Record review of Resident 23's CCP dated 12-03-2018 revealed Resident 23 was at risk for fall related to multiple falls and poor safety awareness. Further review of Resident 23's CCP revealed Resident 23 had a fall on 6-30-2019 at 1:45 PM and on 6-30-2019 at 10:30 PM. Review of Resident 23's record revealed there was not evidence the facility had implemented interventions in an attempt to prevent additional fall when Resident 23 fell , twice on 6-30-2019. Record review of Resident 23 progress note dated 7-16-2019 revealed Resident 23 had slipped from the wheelchair sustaining a laceration on the left side of the head. On 8-12-2019 at 4:00 PM a interview was conducted with RN B. During the interview RN B. During the interview review of Resident 23's care plan was completed. During the interview, RN B confirmed additional interventions were not implemented after he falls on 6-30-2019. RN B further confirmed Resident 23 had sustained a laceration to the left side of the head. RN B confirmed additional interventions should have been implemented. Record review of the facility Policy and Procedure for Fall Risk Assessment sheet revised on 9-2005 revealed the following information: -Purpose: -2. To facilitate implementation of preventative measures. -Procedure: -7. Revise the residents care plan to reflect care needs and interventions based on the residents potential for falling. -Key Points: -Interventions must be implemented to aid in the prevention of falls. | 2020-09-01 |
| 26 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-08-12 | 690 | D | 1 | 0 | 7ED912 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on observation, record review and interview; the facility staff failed to provide scheduled toileting for 2 (Resident 21 and 25) of 2 sampled residents. The facility staff identified a census of 130. Findings are: [NAME] Record review of Resident 25's Comprehensive Care Plan (CCP) printed on 1-11-2019 revealed Resident 25 was incontinent of bowel and bladder and that staff were to provide frequent toileting. Observation on 10-09-2019 at 6:30 AM revealed Resident 25 was ambulating in the hall of the secured unit. Observation on 10-09-2019 at 10:15 AM revealed Resident 25 was ambulating in the hall of the secured unit. Further observation revealed the back of Resident 25's red sweat pants had a large wet area to the buttock area extending down to the middle of the back of the upper legs. Observation on 10-09-2019 at 10:20 AM revealed Nursing Assistant (NA) F escorted Resident 25 to Resident 25's room and into the bathroom. NA F removed a saturated brief Resident had been wearing and placed Resident 25 onto the toilet. On 10-09-2019 at 10:30 AM an interview was conducted with NA F. During the interview NA F confirmed Resident 25 had been incontinent through Resident 25's clothing. When asked the last time Resident 25 was assisted with toileting needs, NA F reported this was the first time since 6:30 AM. On 10-09-2019 at 10:35 AM an interview was conducted with Licensed Practical Nurse (LPN) D. During the interview LPN D reported Resident 25 is a heavy wetter . and that Resident 25 should be toileted every 2 hours. On 10-09-2019 at 12:05 PM a follow up interview was conducted with LPN D. During the interview LPN D reported had spoken with the nursing assistants on the unit and none of the NA's reported taking Resident 25 to the bathroom. LPN D confirmed Resident 25 had been up since at 6:30 AM and should have been toileted prior to 10:20 AM. B. Record review of Resident 21's CCP revealed on 8-26-2019 an update to Resident 21 CCP directing the facility staff to toilet Resident 21 every 2 hours. Observation on 10-09-2019 at 7:10 AM revealed Nursing Assistant (NA) B and NA C assisted Resident 21 into a wheelchair from bed. Further observation revealed Resident 21 was taken to the dining room for breakfast. Observation on 10-09-2019 at 10:07 AM revealed Resident 21 was asleep in the wheelchair located in the dining room. Observation on 10-09-2019 at 10:15 AM revealed Resident 21 remained in the dining room asleep in the wheelchair. Observation on 10-09-2019 at 10:40 AM revealed Resident 21 remained in the dining room asleep in the wheelchair. Observation on 10-09-2019 at 11:00 AM revealed NA [NAME] and NA F assisted Resident 21 into the bathroom. A span of 3 hours and 50 minutes from 7:10 AM to 11:00 AM for toileting assistance. On 10-09-2019 at 11:07 AM an interview was conducted with Licensed Practical Nurse (LPN) D. During the interview when asked how often Resident 21 was to be assisted with toileting, LPN D stated every 2 hours. On 10-09-2019 at 2:45 PM an interview was conducted with RN [NAME] During the interview RN A reported had asked all nursing staff on the unit if Resident 21 had been assisted with toilet use and confirmed Resident 21 had not been assisted with toileting needs every 2 hours. | 2020-09-01 |
| 27 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2016-09-21 | 152 | D | 0 | 1 | 7TIB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview; the facility staff failed to obtain permission from a guardian on a behavioral modification plan to restrict privileges for 1 (Resident 7) of 1 resident sampled. The facility staff identified a census of 236. Findings are: Record review of an undated Social History sheet revealed Resident 7 had a had a Guardian to manager Resident 7's care. Record review of Resident 7's Comprehensive Care Plan (CCP) dated 6-04-2009 revealed the following: -Restrict (Resident 7) to the unit if Resident 7's blood sugars are equal or greater to 225. -If Resident 7 refuses to get up for breakfast or drinks a Glytol (supplement type of liquid), Resident 7 was to remain on the unit until the following meal for observation. -If refuses to get up for lunch or drink a [MEDICATION NAME], Resident 7 is to remain on the neighborhood until the following meal. -If verbally or physically abusive with staff or peers and unable to direct, Resident 7 was to remain on the neighborhood for 24 hours. -If resident must have a breathing treatment after smoking, there would be no smoking allowed for the remainder of the day. Review of Resident 7's medical record revealed there was no evidence that Resident 7's Guardian had given permission for the restriction of privileges. On 9-19-2016 at 9:09 AM an interview was conducted with Registered Nurse (RN) B. During the interview RN B confirmed Resident 7 had a behavioral modification plan that restricted privileges. During the interview, RN B reported that the behavioral modification plan had not been discussed with the Guardian and there was not any evidence any other staff had spoke to the guardian about the behavioral modification plan. The facility was not able to provide any evidence of the Guardian giving permission for the behavioral modification plan at the time of exit from the facility. | 2020-09-01 |
| 28 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2016-09-21 | 323 | E | 0 | 1 | 7TIB11 | Licensure Reference Number: 175 NAC 12-006.09D7a Based upon observations, interviews and record review; the facility failed to ensure Team 1's medication cart was secured when unattended on Wind Song Way unit. This had the potential to affect 14 cognitively impaired, self-mobile residents of the 44 residents that reside on the unit. The facility census was identified as 236. Findings are: [NAME] An observation on 09/21/2016 at 1:26 PM revealed that the Wing Song Way Neighborhood Team 1 medication cart was observed to be in the Wing Song Way Neighborhood commons area, with no staff members present. A check of the cart's medication drawers found them to be unsecured. There were 7 residents in the immediate area. This was confirmed by the nurse manager of the Wing Song Way Neighborhood on 09/21/2016 at 1:28 PM, who secured the cart at this time. An interview with the Nurse Manager of the Wing Song Way Neighborhood on 09/21/2016 at 1:28 PM, confirmed that the cart was unsecured and that medication carts should be secured when unattended. An interview with Registered Nurse A (RN A) at 09/21/2016 1:36 PM revealed that the cart was unlocked about five minutes and RN A had left the unit to go upstairs to fax a document. RN A confirmed that the cart should had been secured prior to RN A's leaving the cart. A record review of the facility's Medication Guidelines/Preparation/Administration Policy dated revised 5/91,7/92, 12/94, 1/95, 6/97, 3/07, 1/09, 12/10; revealed the following: The medication room/cart MUST be closed and locked at all times except when medications are being prepared by the Nurse. | 2020-09-01 |
| 29 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2016-09-21 | 412 | D | 0 | 1 | 7TIB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.14 Based upon observations, interviews and record reviews; the facility failed to follow-up a dental appointment for Resident 210. The facility census was identified as 236. Findings are: [NAME] An observation of Resident 210 on 09/14/2016 at 1:31 PM revealed Resident 210 was observed to be missing several teeth. A record review of Resident 210's care plan dated 02/26/15 revealed under the care plan that for problem #4-Self-care deficit: bathing, hygiene, dressing and grooming. In the interventions section it is noted DCHC Dental clinic without and dates or time frames. A record review of Resident 210's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 02/10/2016 revealed under section L-Oral/Dental Status it was marked: Obvious or likely cavity or broken natural teeth. Interviews with Registered Nurse L (RN L) and Unit Secretary M (US M) on 09/19/2016 at 12:35 PM revealed that Resident 210 has not been seen by a dentist since 04/07/2015. A record review of Dental Chart dated 04/7/2015, revealed the following: patient seen for annual exam and [MEDICATION NAME]. Teeth are badly worn but patient reports no pain, plaque is soft, no significant gingivitis. Recommend 3 month recall. A record review of an undated list of unit's clients needing dental services revealed that Resident 210 was listed and was to be followed up in 3 months from the 04/7/2015 visit. An interview with Director of Nursing (DON) 09/19/2016 02:57 PM revealed that the unit or neighborhood is responsible for scheduling dental appointments. An interview with Social Services Specialist K, (SSS K) on 09/20/2016 at 07:40 AM, revealed that social services does not have any documentation concerning the Resident 210's Power of Attorney (POA) not wanting to have the resident to be seen by the dentist. An interview with the DON on 09/20/2016 at 02:10 PM revealed the DON was not able to find any evidence that the Resident 210 had been back to a dentist since 04/07/2015. A follow-up interview with the DON on 09/21/2016 1:15 PM confirmed that the standard of care is that dental services should be offered at least annually to those who want the services. The DON further confirmed that there was no evidence available concerning whether or not the facility had asked, the resident or the POA, if the resident wanted to receive dental services. | 2020-09-01 |
| 30 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2017-11-14 | 371 | F | 0 | 1 | VVNM11 | Licensure Reference Number 175 NAC 2-006.11E Based on observation, record review and interview; the facility dietary staff failed to utilize hair restraints in the facility kitchen. This had the potential to affect 219 residents that ate food prepared in the facility kitchen, and failed to maintain serving temperature of cool food used for medication administration for Resident 235. The facility census was 226. Findings are: [NAME] Record review of the Nebraska Food Code dated (MONTH) (YEAR) section 2-402.11 revealed: Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens and unwrapped single service or single use articles. Observation on 11/13/2017 between 10:10 AM and 10:30 AM revealed Cook A had a mustache without a hair restraint in place over the mustache during the preparation of meat for roast. Dietary Aide (DA) B was present in the kitchen and had a beard and mustache with no hair restraint in place over the beard or mustache. DA C was present in the kitchen and had a mustache with no hair restraint in place over the mustache. Interview on 11/13/2017 4:16:31 PM with the Dietary Supervisor confirmed that Cook A and DA ' s B and C should have worn beard and mustache hair restraints while in the kitchen. Record review of a facility policy on Employee Appearance dated 1/26/17 revealed that sideburns, mustaches and beards are to be trimmed. All beards must be covered with an approved mask. Record review of a list of residents that take nothing by mouth dated 11/14/17 revealed that there were a total of 7 residents in the facility that did not eat any food prepared in the facility kitchen. B. Record review of the facility policy of Safe Food Handling dated revision 2/14/17 revealed: D. Holding and Service 1. Hot food must be held at 135 degrees Fahrenheit (F) or above, and cold food at 41 degrees F or colder. 6. When serving cold food, fill wells with ice, and cover food whenever possible to maintain temperature. Observation on 11/13/17 at 9:23 AM during medication pass, it was noted after providing medications to Resident 235, that the yogurt that was used to administer medications was 60 degrees F. Interview with Staff Member D, on 11/13/17 at 9:23 AM, revealed that Resident 235 was the only resident that yogurt was used to administer medications. Staff Member D revealed that the yogurt was taken from the unit refrigerator at 7 AM that morning, and was placed on top of the medication cart for use. Staff Member D confirmed that the yogurt was not placed in ice wells when not in use. Staff Member D confirmed that the temperature at the time of administration, at 9:23 PM was 60 degrees as tested with thermometer. Interview with Unit Manager [NAME] on 11/13/17 at 9:23 AM confirmed that the yogurt was served at a temperature higher than the facility policy of 41 degree or less. Interview with the facility Dietary Manager on 11/13/17 at 12:29 AM confirmed that yogurt was to be served at 41 degree or less and that it was to be kept on ice if out of the refrigerator waiting to be served to maintain the temperature. The dietary manager confirmed that safe food handling policy was not followed. | 2020-09-01 |
| 6194 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2015-06-24 | 248 | D | 0 | 1 | 72PT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 12-006.09D5b Based on observation, record review and staff interview; the facility failed to provide an individualized activity program for one resident (Resident 233). The facility staff identified a census of 242. Findings are: Record review of Resident 233's Admission Form dated 04/24/2015 revealed Resident 233 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 233's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used in care planning) with a reference assessment date of 05/01/2015 revealed that the facility assessed the follow about the resident: -Brief Interview for mental Status (BMI) score of a 6, with a score of 0-7 indicating severe cognitive impairment. -Resident customary routine for activity preferences were identified as: music, books, newspaper, magazines, pets or animals, keeping up with the news, going outside, groups, and religious events. -Required supervision with locomotion and transfers. -Required total dependence with dressing, toileting, personal hygiene and required a wheelchair for mobility. Record review of Resident 233's Recreation Initial assessment dated [DATE] revealed the following about Resident 233: -Able to read books or magazines. -Able to identify objects. -Able to independently make choices to express personal choices effectively. -Unable to stay on topic of conversation but did respond to social communication. -Past preference of BINGO, card games, socializing, music, TV, going outside and pets. Record review of Recreational Therapy Groups for (MONTH) 22, (YEAR) for Resident 233 to attend included: -9:30 am Fun and Fitness. -10 am Walmart outing. -10:30 am Garden Gnomes. -1:30 pm Bingo. -7:00 pm Monthly Birthday Party. Record review of Recreational Therapy Groups for (MONTH) 23, (YEAR) for Resident 233 to attend included: -9:30 am Fun and Fitness. -10:30 am Bible Study. -11:00 am McDonalds. -1:30 pm Bike Rides. Observation on 06/22/2015 at 10:02 AM through 10:35 AM revealed Resident 233 sitting in the dining area, in a wheelchair, looking around and wheeled self around the dining area with no activities with Resident 233 observed. Observation on 06/22/2015 from 11:00 AM through 11:14 AM revealed Resident 233 sitting in the TV room, off the dining room, looking out the window, glancing at the TV, and closing Resident 233's eyes at times. No activities observed during this time. Observation on 06/22/2015 from 12:45 PM through 1:35 PM revealed Resident 233 was sitting at the dining room table feeding self. No activities observed during this time. Observation on 06/23/2015 at 9:29 AM through 9:36 AM revealed Resident 233 sitting in a wheel chair, in the dining area, looking around the room with no activities with Resident 233 observed. In an interview on 06/23/2015 at 12:55 PM with Registered Nurse (RN) K confirmed that Resident 233 had not attended the scheduled activities on 06/22/2015 and 06/23/2015 and that more activities could be used for the unit that Resident 233 resided on. In an interview on 06/23/2015 at 1:59 PM with Recreational Therapist (RT) L revealed that one Recreational Therapist was scheduled to provide activities on two neighborhoods in the facility and the therapist helped with the big scheduled groups and provide activities on the neighborhoods that they were scheduled on. RT L provided documentation that Resident 233 had attended activities on the follow days for the month of (MONTH) (YEAR): -06/15/2015 root beer floats. -06/09/2015 baking brownies. -06/07/2015 garage sale. -06/05/2015 BINGO. -06/03/2015 Mass. RT L also revealed that the nursing staff, on the floor, also provided additional activities on the unit that Resident 233 resided on but was unable to provide documentation that the nursing staff provided additional activities to Resident 233. In an interview with Social Service (SS) M and Financial Director (FD) N on 06/24/2015 at 1:59 PM confirmed that Resident 233 attended 8 activities for the month of (MONTH) and (MONTH) (YEAR). SS M and FD N also confirmed that 8 activities in two months was not enough activity participation for Resident 233 and the sitting in front of the TV and looking out the window was not considered a scheduled activity for Resident 233. | 2019-05-01 |
| 6195 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2015-06-24 | 318 | D | 0 | 1 | 72PT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D4 Based on record review and interview; the facility staff failed to implement a nursing restorative program for 1 resident (Resident 13). The facility staff identified a census of 242. Findings are: Record review of a undated Patient Admission sheet Revealed Resident 13 was admitted to the facility on [DATE]. Record review of Resident 13's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 4-02-2015 revealed the facility staff assessed the following about the resident: -Resident 13 required extensive assistance with bed mobility. -Required total assistance with transfers, dressing, eating, toilet use and personal hygiene. Record review of a Restorative Nursing Program Recommendations and Goals (RNPRG) sheet dated 6-05-2015 revealed Physical Therapist (PT) F had made recommendations for Passive Range of Motion (PROM) to Resident 13's arms with the goal being to increase Range of Motion (ROM). The goal also identified for Resident 13 was to increase or maintain current ROM. The plan identified on the RNPRG was to complete PROM to both arms , 2 times daily. Further review of Resident 13's RNPRG dated 6-05-2015 revealed an additional goal of decreased pain. The plan section identified that stretching for both arms and shoulder was to be completed twice a day. The start day for the restorative plan was 6-05-2015. Record review of Resident 13's medical record that included care plans and progress notes revealed there was not any evidence that the RNPRG dated 6-05-2015 had been implemented. An interview on 6-22-2015 at 2:23 PM was conducted with Registered Nurse (RN) G. During the interview the RNPRG dated 6-05-2015 was reviewed with RN G. RN G confirmed the RNPRG recommendations had not been implemented. When asked what the time frame for acting upon a recommendation was, RN G stated a few days. An interview was conducted on 6-22-2015 at 3:01 PM with PT F. During the interview when asked why Resident 13 needed a restorative program, PT F stated to maintain or improve (gender) function. | 2019-05-01 |
| 6196 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2015-06-24 | 371 | E | 0 | 1 | 72PT11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observations and interviews; the facility failed to handle ready to eat foods in a manner to prevent potential cross-contamination for residents that consumed foods from 3 of 10 nursing units. This could potentially effect 68 residents. The facility staff identified a census of 242. Findings are: A. Observed on 06/23/2015 at 7:57 AM, the Miracle Garden dining room, Nursing Assistant (NA) D, was observed to put jelly to two pieces of toast, without wearing gloves and no hand washing observed immediately prior to or after serving the toast to the resident. An interview with NA D on 06/23/2015 at 9:26 AM revealed that NA D confirmed that NA D is to use gloves when (gender) is to prepare toast and acknowledged that (gender) was not wearing gloves. B. Observations on 6/22/15 at 12:13 PM on Miracle Gardens revealed Nurse Aide A preparing a peanut butter and jelly sandwich. Nurse Aide A was not observed to wash hands or put on gloves prior to handling bread. Nurse Aide A was observed handing tray cards, peanut butter and jelly packets before handling bread for sandwich. C. Observations on 6/23/15 at 7:39 AM on Field of Dreams revealed Dietary Aide B touching tray cards and cabinet doors with gloved hands than placing bread into toaster and buttering toast with same gloves. Dietary Aide used same gloves to place toast onto plates for service to residents. D. Observations on 6/23/15 at 8:07 AM on Eden Way revealed Dietary Aide C touching tray cards, cabinet handles, and toaster handles with gloved hands. Dietary Aide C continued to place toast on plates for service to residents without washing hands or changing gloves. E. In an interview on 6/23/15 at 2:39 PM, the Director of Dietary Department reported staff members should wash hands and put gloves on before handling any food that is not going to be cooked. Dietary Director confirmed gloves after touching other things such as cabinet handles. F. Review of the 3/8/2012 version of the Food Code , based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: -single use gloves shall be used for only one task such as working with ready to eat food and discarded when damaged or soiled, or when interruptions occur in the operation. -food employees shall minimize bare hand arm contact with exposed food | 2019-05-01 |
| 6197 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2015-06-24 | 441 | D | 0 | 1 | 72PT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation and interview; the facility staff failed to utilize handwashing and gloving techniques to prevent potential cross contamination during catheter cares for 1 Resident ( Resident 13) and failed to clean scissors before and after use during a wound treatment for 1 resident (Resident 234). Findings are: A. Record review of a undated Patient Admission sheet Revealed Resident 13 was admitted to the facility on [DATE]. Record review of Resident 13's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 4-02-2015 revealed the facility staff assessed the following about the resident: -Resident 13 required extensive assistance with bed mobility. -Required total assistance with transfers, dressing, eating, toilet use and personal hygiene. -Indwelling catheter (tube placed into the bladder to drain urine). Record review of Resident 13's Comprehensive Care Plan (CCP) printed on 1-28-2015 revealed Resident 13 used 2 types of catheters, a supra pubic catheter ( tube placed into the bladder usually through the abdominal area) and a indwelling foley catheter (tube inserted through urinary tract). Observation of catheter cares on 6-22-2015 at 10:22 AM revealed Nursing Assistants (NA) I and NA J washed hands and donned gloves. NA I cleansed the supra pubic insertion site and catheter tubing, and without changing the soiled gloves, cleansed the foley catheter, that included the penis and tubing. After completing the catheter cares, NA I and NA J removed the soiled items and washed hands. An interview was conducted with NA I on 6-22-2015 at 10:58 AM. During the interview when asked if the gloves should have been changed between cleaning catheters, NA I stated yes, I should have. B. Record review of Resident 234's Comprehensive Care Plan (CCP) printed on 5-27-2015 revealed Resident 234 was admitted on [DATE]. Record review of a Physicians Orders sheet dated 6-08-2015 revealed Resident 234 had pressure ulcers to each heel. Observation on 6-22-2015 at 11:33 AM revealed Licensed Practical Nurse (LPN) H obtained the required treatment supplies. LPN H explained to Resident 234 about the treatment. LPN H removed scissors from (gender) pocket and placed then onto Resident 234 tray table. LPN H removed socking from each foot and cut off Kling wrap from around each wound. LPN H applied the ordered medication to left heel, wrapped it with part of a new roll of Kling wrapping and using the unclean scissors, cut the excess off. LPN H completed the treatment to the right heel, wrapped it with Kling and placed the unclean scissors into (gender) pocket. An interview with LPN H was conducted 6-22-2015 at 11:58 AM. During the interview, LPN H confirmed that the scissors for the treatment were removed from (gender) pocket and had not been cleaned after cutting off the soiled dressings. | 2019-05-01 |
| 6554 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2018-07-23 | 609 | D | 1 | 0 | WMYM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference: 12-006.02 Based on record review and interview, the facility failed to report potential neglect to Adult Protective Services and submit an investigation to state survey agency within 5 working days for 1(Resident 3) of 4 sampled residents. Facility had a total census of 237 residents. Findings are: Resident 3 was admitted to the facility on ,[DATE] with a [DIAGNOSES REDACTED]. A review of incident report dated 3/8/18 revealed Resident 3 was observed standing on stairwell after going through exit door labeled CST4. A review of Nurses Notes dated 3/14/18 revealed Resident 3 was observed walking through stairwell door at the end of the hallway on Eden Way. A review of work order dated 3/15/18 revealed Maglock was removed and remounted on door frame. In an interview on 7/23/18 at 8:20 AM, Nursing Unit Manager A verified that neither elopement on 3/8/18 or 3/14/18 had been reported to the state. | 2018-12-01 |
| 7859 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2014-04-10 | 315 | D | 0 | 1 | 2J4R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on observation and interviews, the facility failed to utilize techniques for the provision of catheter care to minimize cross contamination for Resident 113. The facility census was 228. Findings are: Record Review of Resident 113, revealed a physician discharge summary dated 12-31-13 stated [DIAGNOSES REDACTED]. Coli and Staph (strong bacteria resistant to most antibiotics). Review of facility Policy for incontinent resident (care of) with revision date of 11/20 stated: 7. Giving male perineal care: Grasp the penis, clean the tip using a circular motion starting at the urethral opening and work outward. Repeat as necessary using a different part of the washcloth each time, rinse and return the foreskin to its natural position. Clean the shaft of the penis with firm downward [MEDICAL CONDITION] and rinse. Clean the scrotum, rinse well and pat dry. Observation made on 4-7-14 at 2:35pm of Resident 113 receiving catheter cares from Nurse Aide (NA) A. Resident 113 was observed lying on bed with pants pulled down and leg bag connected to Foley catheter strapped to lower leg. NA A washed hands and donned gloves and mask. NA A pulled foreskin of penis back and washed penis tip and catheter tubing all with the same area of the washcloth. NA A then changed gloves and washed penis shaft and groin without changing spots on the washcloth or getting a new one. An interview on 4-7-14 at 245pm with RN B, unit manager revealed that Resident 113 [MEDICAL CONDITION] positive (strong bacteria resistant to most antibiotics) and confirmed that NA A should have used a new place on the washcloth with each wipe or used a new washcloth. | 2017-12-01 |
| 7860 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2014-04-10 | 371 | F | 0 | 1 | 2J4R11 | Licensure Reference: 175 NAC 12-006.11E Based on observations, interview, and record review, the facility failed to clean kitchen equipment prior to preparation of foods for residents. This had the potential to affect 218 residents that ate food prepared in the facility kitchen. Findings are: A.Observations at 4/9/14 at 10:15 AM revealed Cook C putting hash browns in to the tilting fry pan to prepare for the lunch meal. The tilting fry pan was noted to have dried food residue inside of it. B. In an interview at 11:56 AM on 4/19/14, Cook C reported there had been no 9 Am Cook today so tilting fry pan had been wiped down between preparation of breakfast and lunch but not cleaned completely. Cook C reported the tilting fry pan would be cleaned completely at the end of the day. C. In an interview at 4 PM on 4/9/14, the Food Service Director reported food preparation equipment must be thoroughly cleaned between cooking different food items. D. A review of the 3/8/2012 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices revealed the following: food contact surfaces of equipment and utensils shall be clean to sight and touch. | 2017-12-01 |
| 8929 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2016-09-21 | 315 | D | 0 | 1 | 7TIB11 | Deficiency Text Not Available | 2016-12-01 |
| 8930 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2016-09-21 | 325 | D | 0 | 1 | 7TIB11 | Deficiency Text Not Available | 2016-12-01 |
| 9141 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2013-01-10 | 323 | E | 0 | 1 | UMQM11 | LINCENSURE REFERENCE NUMBER 175 NAC 12-006.18E4 Based on observation and interview the facility failed to insure the security of chemicals on 2 of 7 housekeeping carts in the facility. The sample size of the survey was 67 and the census was 237. Findings are: Observation on 01/09/2013 at 10:00 AM on the environmental tour with the Director of Support Services and the housekeeping supervisor revealed 2 of 7 housekeeping carts were not secured and chemicals were accessible to the residents. Interview with the housekeeping supervisor on 01/09/2013 at 10:30 AM revealed that the expectations of the supervisor would be that the cart be locked immediately by the housekeeper after articles are removed from the cart. 01/10/2012 Observation of two housekeeping carts that had been viewed on the environmental tour revealed 1 of 2 carts were not secured and within view of the housekeeper. Accessible to the residents were neutral disinfectant, washroom cleanser and tough job cleaner which were all Enviro Care products and Pro power stainless steel cleanser. The housekeeper was in the area with her back turned to cart. When the housekeeper viewed the surveyor near the housekeeping cart she immediately secured it. Review of the Material Safety Data Sheets were obtained on all products that were not secured on the cart. The sheets showed the products to be harmful with the Neutral Disinfectant having the most effects from exposure. Exposure from ingestion: Harmful if swallowed; Causes moderate skin irritation and may be harmful if inhaled. Corrosive to eyes and causes permanent eye damage. | 2016-10-01 |
| 9142 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2013-01-10 | 356 | C | 0 | 1 | UMQM11 | Based on observation and interview, the facility failed to post nurse staffing information in an area that was available to all residents and visitors and categorized as required by regulation. The nurse staff information was posted at the door of the Nursing office and can be viewed. The nursing office is not located in an area that is available to all residents and visitors. The information on the nurse staffing is not broken into categories for RN, LPN and CNA's as required by regulation. The categories were identified as licensed nurses and nurse aids. | 2016-10-01 |
| 9143 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2013-01-10 | 514 | D | 0 | 1 | UMQM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.16B Based on Record Review, Resident interview, and staff interview; the facility failed to ensure that staff completed documentation for [MEDICAL TREATMENT] assessment and fluid intake for 1 (Resident 141) of 67 sampled residents. The facility census was 237. FINDINGS ARE: The [MEDICAL TREATMENT] careplan last updated on 1-5-12 for Res. 141 had an intervention that specified to monitor [MEDICAL TREATMENT] site daily. The [MEDICAL TREATMENT] log treatment sheet for Jan. 2013 has no signatures for site assessment documented 4 out of the 7 days and multiple days(14) in december with no documentation of assessment. The facility policy for care of residents receiving [MEDICAL TREATMENT] states; the [MEDICAL TREATMENT] log will be completed for residents who are going outside the facility to a [MEDICAL TREATMENT] center as follows: #14. Access Site Assessment: Enter the time, and assess the site for pain, redness, drainage or Bruit. Interview with Unit Manager D on 1-9-13 at 8am stated that resident's [MEDICAL TREATMENT] site is to be assessed daily as per careplan and doucmented on the [MEDICAL TREATMENT] Log treatments sheets. Unit Manager D confirmed a lack of documentation on December 2012 and January 2013 treatment sheets. Interview with RN E on 1-9-13 at 8am states that site is assessed every day on the day shift for signs of infection such as drainage, redness or swelling, and that the dressing is intact and notifies the md if there are any concerns. Interview on 1-9-13 at 7:30am with Resident 141stated that facility staff look at the [MEDICAL TREATMENT] site at least once a day. The graphic intake and output sheet for Dec. 2012 had 32 shifts without fluid intake documented and without 8 shifts documented in Jan. of 2013. The careplan last updated on 1-5-12 shows a potential for altered health maintenacy and potential for altered fluid balance with interventions of fluid distribution: 600cc dietary, 900cc nursing, 7am-3pm: 400cc and 3p-11pm: 400cc and 11p-3am 100cc. Interview with Unit Manager D on 1-9-13 at 8am stated that resident's fluid intake should be monitored and documented every shift on the graphic intake and output sheet and confirmed missing documentation on the graphic intake sheets. Interview with Nurse Aide F on 1-9-13 at 8:30am stated that the fluids get charted on the graphic fluid sheet and the nurse on duty is to be informed of any fluid the aides give Resident 141. | 2016-10-01 |
| 10235 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2011-07-13 | 328 | D | 0 | 1 | BXXQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D6(5) Based on observation, record review and interview; the facility staff failed to ensure emergency equipment for a [MEDICAL CONDITION] (an artificial opening into the trachea through the neck with insertion of a tube to facilitate passage of air or evacuation of secretions) was immediately available for use for 2 (Residents 6 and 19) of 33 sampled and 4 non-sampled residents from a facility census of 226. Findings are: A. Record review of the facility Policy and Procedure on [MEDICAL CONDITION] Care under the section entitled Reinsertion of a Trachesotomy Tube (New facility policy written on July 7th 2011) revealed that a spare [MEDICAL CONDITION] and properly sized obturator should be kept at the bedside at all times and that in the event that [MEDICAL CONDITION] becomes dislodged (e.g. coughed out) a [MEDICAL CONDITION] will reinserted. Record review of Resident 6's Admission Physician orders dated 6/22/11 revealed an admission date of [DATE] and the following Diagnosis: [REDACTED]. Record review of Resident 6's hospital Discharge Summary dated 6/22/11 revealed that a new [MEDICAL CONDITION] had been placed on 6/3/11. Observation on 7/6/11 at 2:20 PM revealed Resident 6 laying in bed in a resident room in the facility. Observation of Resident 6 revealed a [MEDICAL CONDITION] inserted into a opening in the neck and secured with ties around the neck. Observation revealed no obturator (a curved plastic device used to aide in the emergency insertion of a [MEDICAL CONDITION]) or extra [MEDICAL CONDITION] present in Resident 6's room. Observation on 7/7/11 at 7:50 AM revealed no obturator or extra [MEDICAL CONDITION] present in Resident 6's room. Observation on 7/7/11 at 9:20 AM with the RN (Registered Nurse) Nurse Manager D resulted in a search of Resident 6's room and drawers. RN A confirmed that no obturator or extra [MEDICAL CONDITION] was present in Resident 6's room for emergency use. Interview on 7/6/11 at 9:25 AM with RN D confirmed that an obturator and extra tube should be kept in Resident 6's room in case of emergency in case [MEDICAL CONDITION] out or needs to be changed. B. Record review of Resident 19's History and Physical dated 8/12/10 revealed that Resident 19 had a history of [REDACTED]. Observation on 7/7/11 at 10:03 AM with RN Nurse Manager E revealed Resident 19 laying in bed in a resident room in the facility. Observation of Resident 19 revealed a [MEDICAL CONDITION] inserted into a opening in the neck and secured with ties around the neck. Taped above Resident 19's bed were an obturator and oxygen tubing, but no extra [MEDICAL CONDITION] was present. Observation resulted in a search of Resident 19's room and drawers by RN A. RN A confirmed that there was not an extra [MEDICAL CONDITION] present in Resident 19's room for emergency use. Interview on 7/7/11 at 10:05 with RN D confirmed that an extra [MEDICAL CONDITION] should be kept in Resident 19's room in case of emergency. Interview on 7/11/11 at 1:45 PM with the Director of Nursing confirmed that the above policies were to be followed and an obturator and extra [MEDICAL CONDITION] should be available in Resident 6 and Resident 19's rooms in case of an emergency. | 2016-01-01 |
| 10236 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2011-07-13 | 441 | D | 0 | 1 | BXXQ11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observation, record review and interview; the facility staff failed to prevent potential cross-contamination during cleansing of glucometers for 3 (Resident 34, 35 and 36) of 33 sample and 4 non-sampled residents. The facility staff identified a census of 226. Findings are: A. Observation on 7/07/2011 at 6:15 AM of an accu-check ( method of checking blood sugar levels by a finger stick) for Resident 34 revealed Licensed Practical Nurse (LPN) A placed the glucometer onto of a medication cart without a barrier. LPN A obtained the needed items to complete the accu-check, entered Resident 34's room an placed the test supplies onto a paper towel. LPN A donned gloves and explained the procedure to Resident 34. LPN A using a lancet, poked Resident 34's right index finger. LPN A squeezed the finger to obtain a drop of blood. LPN A placed the blood onto a test strip and obtained the results. LPN A placed a cotton ball onto the right index finger to stop the bleeding. LPN A removed the cotton ball and the soiled gloves. LPN A after washing (gender) hands began to clean the glucometer. LPN A without donning gloves began to cleans the glucometer with an alcohol wipe. After using the alcohol wipe, LPN A left Resident 34's room and put the glucometer into (gender) pocket. B. Observation on 7/07/2011 at 11:02 AM of an accu-check for Resident 35 revealed LPN B washed hands and donned a pair of gloves. LPN B had obtained the needed items for the accu-check test and placed them onto a clean barrier. LPN B using a lancet poked Resident 35's right index finger. LPN B squeezed Resident 35's finger to form a drop of blood. The blood was placed onto the test strip to obtain the results. After obtaining the results, LPN B discarded the used items. LPN B without changing the soiled gloves, began to cleansed the glucometer with a pre-saturated cleansing wipe (Gluco-Chlor). LPN B squeezed the wipe to reduce the moisture of the wipe. The cleansed glucometer was placed onto a clean barrier to dry. Record review of the Gluco-Chlor package directions revealed the surface of the device being cleaned was to remain wet for 5 minutes. An interview was conducted with LPN B on 7/07/2011 at 11:08 AM. During the interview, LPN B confirmed the gloves had not been changed prior to cleaning the glucometer or that, the glucometer remained wet for 5 minutes. C. Observation on 7/07/2011 at 11:27 AM of an accu-check for Resident 36 revealed LPN C washed hands and donned gloves. LPN C had a basket of accu-check supplies, including a glucometer that had been placed on the top of a metal cart. LPN C removed the glucometer from the basket and cleansed it with an alcohol wipe. LPN C placed the glucometer onto the surface of the metal cart without a barrier. LPN C poked Resident 36's left index finger and placed the blood onto the test strip for the accu-check. After obtaining the results, LPN C wiped Resident 36's finger with a cotton ball and had placed the glucometer on the surface of the metal cart with out a barrier. LPN C removed the soiled gloves, washed hands and donned a clean pair of gloves. LPN C using the Gluco-Chlor wipes, squeezed the towelette in the sink to reduce the moisture of the towelette. LPN C then cleansed the glucometer and placed it into the basket of supplies. The glucometer did not remain wet for 5 minutes. An interview with LPN C was conducted on 7/07/2011 at 11:40. During the interview, LPN C confirmed a barrier had not been used between the glucomter and the metal top and that the surface of the glucometer was not maintained in a wet condition per the instruction of the Gluco-Chlor package. | 2016-01-01 |
| 10825 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2012-10-09 | 309 | D | 1 | 0 | 48UM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09D5 Based on observations, interviews, and record review; the facility failed to ensure a medical evaluation was completed for adverse behaviors for 1 (Resident 1) of 4 sampled residents. The facility had a total census of 240 residents. Findings are: Resident 1 was admitted to the facility on [DATE] according to Resident 1's care plan. Admission history and physical dated 8/20/12 listed a [DIAGNOSES REDACTED]. A review of Nurse's Notes for Resident 1 dated 9/22/12 revealed Resident 1 was observed standing over Resident 3 touching Resident 3 on buttocks and pubic region. According to the facility investigation summary dated 9/25/12, Resident 3 was fully clothed. According to the facility investigation completed 9/26/12, the following interventions were put in place in response to the incident: -Both residents were placed on 15 minute checks; -Care plans were reviewed and Resident 1's care plan was up dated; -Geriatric Psychiatric service was notified. The facility investigative report stated both residents were followed by the Geriatric Psychiatric Service. A review of the facility investigative summary dated 9/26/12 revealed Resident 1 was observed to take a hold of Resident 2's hand while Resident 2 was walking with family member. Resident 1 stated Resident 1 would marry either one of them and pulled Resident 1's penis out of pants with other hand and shook it. According to the facility investigation completed 9/28/12, the following interventions were put in place in response to the incident: -Resident 1 was continued on 15 minute checks -On 9/26/12, Resident 1 was moved to a room closer to the nurses' station and away from Resident 2's room. -Geriatric Psychiatric Services was notified of the incident. The facility investigative report stated both residents were followed by the Geriatric Psychiatric Service. -Staff were to use 1:1 supervision intermittently to help calm resident behaviors. Observations on 10/3/12 at 8:13 AM revealed Resident 1 was being assisted out of bed in room [ROOM NUMBER]. In an interview at 8:16 AM on 10/3/12, LPN (Licensed Practical Nurse) A reported Resident 1 was moved to room [ROOM NUMBER] after Resident 1 was discovered standing over roommate making comments. Nurses' Notes for Resident 1 dated 10/2/12 at 11:45 stated Resident 1 was discovered standing over roommate stating Look at that lady, Isn't she pretty, I'm gonna get me some of that. Resident 1 was holding Resident 1's penis in Resident's 1 hand. Resident 1 was removed from the room. A review of Resident 1 medical record did not reveal any documentation which indicated Resident 1 had been seen by Geriatric Psychiatric Services although a fax was sent to Geriatric Psychiatric Services on 9/22/12 regarding the incident on 9/22/12. Nurses' Notes dated 9/25/12 stated Resident 1's primary physician was notified of incident on 9/22/12 and an order was received for a referral to Geriatric Psychiatric Services. A fax was sent to Geriatric Psychiatric Services on 9/25/12 at 10: 30 AM requesting a consult for Resident 1. A review of Resident 1's medical record revealed a fax was sent to Geriatric Psychiatric Services on 9/25/12 regarding incident involving Resident 1 on 9/25/12. A review of physicians' communication sheet for Resident 1 revealed incident on 9/25/12 was documented on this report. Entry was not signed by Resident 1's primary physician indicating that it had been reviewed. A review of Resident 1's physician progress notes [REDACTED]. In an interview on 10/3/12 at 1:43 PM, RN (Registered Nurse) B and RN C confirmed there was no evidence Resident 1's primary physician had been notified of incident on 9/25/12 or had seen Resident 1 since incident on 9/22/12. RN B and RN C also confirmed Resident 1 had not been seen by Geriatric Psychiatric Services. In an interview on 10/3/12 at 2:49 PM, RN B reported Resident 1 had been placed on one-to-one supervision. | 2015-10-01 |
| 12351 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2010-04-28 | 309 | D | 0 | 1 | V26R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER:12-006.09 Record review of a Physician's Orders sheet dated 3/29/10 revealed that Resident 5 was admitted to the facility with [DIAGNOSES REDACTED]. Record review of a Long-Term Care Pain Assessment Form dated 3/30/10 revealed that Resident 5 was not assessed with [REDACTED]. Record review of Resident 5's progress notes date 4/08/2010 revealed that Resident 5 had complained of Right arm pain. Resident 5's Physician was notified of the complaints of pain and ordered that an x-ray be obtained and that PRN Tylenol was to be scheduled every 6 hours. On 4/12/2010 the physician ordered that the PRN Tylenol be stopped and Tylenol 1 gram was to be given 4 times a day, [MEDICATION NAME] 2.5 mgs be given with severe pain and warm or cold packs to the right shoulder prn for pain. Observation on 4/26/2010 with RN H (Registered Nurse) of personal cares for Resident 5 revealed that NA K (Nursing Assistant) and NA L washed their hands and donned gloves. Observation revealed that as NA L washed and lifted Resident 5's right arm, Resident 5 complained of pain and stated " that hurts". NA K and NA L completed cleansing the front of Resident 5 and positioned Resident 5 onto the right side. Resident 5 stated " oh that hurts. Resident 5's face had become red, Resident 5 moaned, groaned and held (gender) breath. NA L and NA K completed cares on Resident 5's right side. Resident 5 was positioned onto the left side. Resident 5 stated "oh my god that hurts" and further stated " I can't do it". NA K and NA L prepared Resident 5 for a mechanical lift transfer. NA K and NA L placed the transfer sling under the resident. Resident 5 complained of pain with the repositioning needed to place the sling under the resident for the transfer into a wheelchair. Observation of Resident 5 revealed that with the repositioning Resident 5's face turned red, Resident 5 moaned, groaned, was holding (gender) breath and stated "oh my back". NA K and NA L started to lift Resident 5 off the bed when Resident 5 stated" Oh, God, Please Please". An interview was conducted with NA K on 4/26/2010 at 8:35 AM. During the interview, NA K stated that Resident 5 "is always painful, right arm hurts, it's bad". Record review of Resident 5's MAR's for April 2010 revealed that Resident 5 had received [MEDICATION NAME] 10 times from 4/12/2010 through 4/26/2010. Further review revealed that on 4/16/2010, 4/19/2010, 4/24/2010 and 4/26/2010 Resident 5 had received [MEDICATION NAME] and did not have the effectiveness evaluated. An interview was conducted with RN H on 4/28/2010 at 8:45 AM. Resident 5's information was reviewed with RN H. During the interview, RN H stated that Resident 5 "should be pre-medicated prior to cares. RN H stated Resident 5 should have had a pain assessment completed with the new indication of pain. RN H confirmed that the policy had not been followed Record review of the facility Pain Managment Policy dated 8/05 and 1/06 revealed the following: -Policy: A resident will be assess for pain/absence of pain ...and when there is a change in the resident's condition (use the Pain Assessment Form)and any time a resident is receiving pain medication (document on the PRN Medication record). Residents will be asked to rate their pain on a scale of 1-5. Both pharmacological and non-pharmacological interventions will be implemented to manage the pain and thses will be evaluated periodically for effectiveness. Staff will immediately take steps to reduce/eliminate the resident's pain. -Procedure: 1. Assess the presence/absence of pain based on the residents verbal complaints of pain or non-verbal indications of pain. If the assessment is a follow up to current complaints of pain and the administration of pain medication complete the PRN medication record. 2.When assessing pain, it is to be rated on a scale of 0 to 5. 3. Document all assessments in the medical record ( i/e. Pain assessment form, PRN Medication Record, Focus Notes) as indicated. Record the appropriate number on the pain scale with each entry regardless if assessing pain or assessing the effectiveness of interventions. -Key Points: 1. The resident is the authority of their own pain. Staff must never ignore a residents' complaint of pain. 2. It is the nurse's responsibility to ensure that the residents pain is properly managed. 3. A residents pain must be assessed on admission, at least quarterly, at the time of MDS assessment, when there is a significant change in the residents condition and anytime a resident is receiving pain medication. 4. The effectiveness of pain managment must be monitored and revisions to the plan of care made as indicated. . | 2014-07-01 |
| 12352 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2010-04-28 | 441 | D | 0 | 1 | V26R11 | LICENSURE REFERENCE NUMBER 12-006.17 Based on observations and interviews and policy review, the facility staff failed to provide hand washing hygiene and gloving procedures to prevent cross-contamination during personal hygiene cares and treatments for Resident ' s 8, 9, 6, and 22. The facility census consisted of 232. The sample size consisted of 30 residents, including 3 closed records. Findings are: A. Observation during Resident 8 ' s personal hygiene cares on 4/26/10 at 7:05 A.M., revealed Nurse Aide (NA)-A completed hand washing hygiene for 6-8 seconds prior to donning gloves. NA-A gave Resident 8 a wash cloth to wash the face. Obtaining a clean wash cloth, NA-A completed the frontal peri care for Resident 8. NA-A removed the hand gloves and continued to assist Resident 8 to dress the lower torso. After completion of dressing, NA-A assisted Resident 8 to walk to the dining room. NA-A failed to complete hand washing hygiene upon the removal of the gloves; And after assisting the Resident with toilet needs and donning daytime wearing apparel. . B. On 4/27/10 at 7:32 A.M., during Resident 9's morning personal cares revealed NA-B used Hand Sanitizer Gel prior to putting on gloves. NA-B started to use double gloves on the hands. When NA-B was asked about ' double gloving ' commented, " I use double gloves because the gloves split " . When asked about the policy for the use of hand gloves, NA-B replied, " No, there is no policy for double gloving. Observations during Resident 9's morning cares on 4/27/10, NA-B changed gloves following each task: after giving wash cloth to wash face, removed resident ' s gown, cleansed upper torso, applied lotion to skin and the deodorant. NA-B removed gloves, used Gel Sanitizer and donned clean gloves. Upon completion of personal hygiene cares, NA-B removed gloves and completed hand washing hygiene for 8 seconds. NA-B donned clean gloves, removed the used linens to the linen carts, removed gloves, used Gel Sanitizer and donned clean gloves; removed the bilateral sheepskin boots, removed gloves, used Gel Sanitizer, and left the resident ' s room without completing hand washing hygiene. On 4/27/10 at 7:53 A.M. the Licensed Practical Nurse (LPN)-C entered Resident 9 ' s room to do a dressing change on the left leg, and completed hand washing hygiene for 10 seconds. LPN-C removed the drains from the tunneled openings on the left leg with repeated pulls by the gloved fingers, holding the contaminated gauze in a gloved hand, reaching down to the open wound with the same fingers and pulling another length of the drain out. After removal of the dressing, removed the contaminated gloves and performed hand washing hygiene for 10 seconds. After putting the drain into the tunneled open wound, LPN-C removed gloves and performed hand washing for 4 seconds. After covering the open wounds with gauze and an ABD gauze, placed tape on the gauze, removed the gloves, reached into the uniform pocket for a pen to initial and dated the bandage. After bagging dirty linens, and tied plastic trash bag removed gloves and completed hand washing for 8 seconds. LPN-C took the scissors, used to cut the drain gauze, from the prep field, and the tape and placed them into a drawer of Resident 9 ' s chest of drawers. On 4/27/10 at 8:10 A.M. during an interview with LPN-C regarding the placement and cleaning of the scissors revealed, the LPN-C ask if it were necessary to clean them even though they are treatment scissors used to cut the gauze only. When the LPN was asked how the LPN would clean the scissors, the LPN responded, " I would clean them with alcohol " . C. Review of a 1996 publication from the Centers for Disease Control and Prevention entitled " Guideline for Isolation Precautions in Hospitals" at www.cdc.gov/ found it stated the following: - The recommendations are intended primarily for use in the care of patients in acute-care hospitals, although some of the recommendations may be applicable for some patients receiving care in sub acute-care or extended-care facilities. - Use Standard Precautions, or the equivalent, for the care of all patients. Within their discussion of Standard Precautions they delineate under Patient-Care Equipment - Handle used patient-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. On 4/28/10 at 11:25 A.M., during the interview with Registered Nurse-C, the Nursing Coordinator revealed that the nursing facility had no specific policy for the care of (or disinfection of) scissors. D. Review of the Nursing Facility ' s policy HAND WASHING HYGIENE, last revised 10/02 revealed the following information: 2. Hands must always be cleansed: a. Before and after resident contact. b. After contact with a source of microorganisms (body fluids and substances, mucous membranes, non-intact skin, inanimate objects including medical equipment that is likely to be contaminated). f. After handling any soiled items such as dressings and catheters. n. After removing gloves. 3. When decontaminating hands with soap, wet hands with running water. Apply hand washing agent and thoroughly distribute over hands. Vigorously rub hands together for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands thoroughly. Keep hands pointed upward and dry with paper towel. Use paper towel to turn off water and dispose of in trash container. B. Other Aspects of hand Care and Protection - 1. Glove use b. Gloves are used when working with blood, body fluids and/or open areas. Gloves are removed and hands washed when such activity ' s completed, when the integrity of the gloves is in doubt, and between residents. Gloves may need to be changed during the care of a single resident, for example when moving from one procedure to another or when doing dressing changes. E. Observation on 4/26/2010 at 12:05 PM of personal cares revealed NA M and NA N entered the resident room gowned, applied a mask and donned gloves after washing their hands. NA N cleansed the residents' catheter and tubing and without changing the soiled gloves touched Resident 6's hips. NA M cleansed Resident 6's buttocks and changed gloves. NA N continued to have the same soiled gloves on and without changing obtained a tube of barrier cream an apply it to the resident buttocks and replaced the tube onto the residents table. F. Observation on 4/27/2010 at 4:20 PM of wound care for Resident 22 revealed RN O entered Resident 22 placed the treatment supplies on the bedside table. RN O without any hand washing donned gloves. RN O removed the soiled dressing and without changing the soiled gloves touch the bottled of wound cleanser. RN O with the same soiled gloves used a wash cloth and wiped away the drainage from the wound that had been cleansed. RN O with the same soiled gloves touched the clean dressing, after applying the ointment with a Q-tip. RN O removed the soiled gloves, picked up the remaining supplies and returned them to the treatment cart. RN O did not wash hands prior to leaving Resident 22's room. An interview with RN O was conducted at 4:30 PM. During the interview, RN O confirmed that the soiled gloves had not been changed as needed. | 2014-07-01 |
| 31 | EASTMONT TOWERS | 285036 | 6315 O STREET | LINCOLN | NE | 68510 | 2017-03-30 | 371 | F | 0 | 1 | GDOK11 | LICENSURE REFERENCE 175 NAC 12-006.11E Based on observation, interview, and record review; the facility failed to ensure a Food Service Provider washed hands in a manner to prevent potential for food born illness and failed to ensure frozen foods were stored in a sanitary manor. These failures had the potential to affect all of the resident's residing in the facility. The facility census was 9. Findings are [NAME] A review of the Facility's HANDWASHING POLICY AND PR[NAME]EDURE initated 2/1/17 revealed the procedure included use a clean paper towel to dry hands and use a paper towel to turn off water. An observation on 3/28/17 at 10:45 AM of Chef-A preparing fresh vegetables revealed the Chef washed hands at appropriate times throughout the preparation. Observation of the Chef's handwashing technique revealed hands were washed the appropriate amount of time. The Cook was noted to: obtain paper towels, turn off the water faucets, and then with the same paper towels dried hands and arms possibly recontaminating hands. The Chef returned to the task of cutting/prepping the vegetables using bare hands. Observations on 03/30/2017 from 8:05 AM to 8:20 AM of Chef-A during food preparation (prep) revealed the Chef washed hands at appropriate times, paper towels were obtained and used to turn the water faucets were turned off. Chef-A then dried hands using the same paper towels. The Chef preformed handwashing in the same manner three times during the food prep observation. An interview on 03/30/2017 at 08:22 AM with Chef-A revealed the Chef was knowledgeable of need for proper handwashing at the proper times while preparing food items. The Cook confirmed using the paper towel to turn off the faucets prior to drying hands and reported that clean paper towels should be used to dry hands if the towels had been first used to turn off the water faucets. B. An observation on 03/30/2017 at 8:25 AM in the Facility's large walk in freezer revealed a gallon sized plastic container of ice cream on the floor under the food storage shelving unit. The Food Service Director (FSD) collected the container and further observation of the container revealed it had been opened and approximately 1/2 of the contents was gone. The container was not marked with the date the ice cream was opened and the remaining product was covered with ice crystals. The FSD placed the unmarked ice cream container into the trash. Further observation in the freezer revealed 5 individually wrapped ice cream sandwiches and an individual styrofoam container of ice cream, on the floor under the shelving unit. The floor of the freezer also contained several areas of visible debris. An interview on 03/30/2017 at 8:30 AM with the FSD revealed routine audits were completed in the kitchen and dietary staff were aware of the need to clean the floor of the walk in freezer. The FSD confirmed the identification of ice cream products on the floor of the freezer and the lack of marking the container with the date it was opened. | 2020-09-01 |
| 32 | EASTMONT TOWERS | 285036 | 6315 O STREET | LINCOLN | NE | 68510 | 2019-07-03 | 695 | D | 0 | 1 | RRGD11 | Licensure Reference Number 175 NAC 12-006.09D6(7) Based on observations, record reviews and interviews; the facility failed to ensure the oxygen tubing and nasal cannula were not left on the floor, and failed to ensure oxygen tubing was changed per facility policy. This had the potential to affect one resident, Resident 9. The facility census was 10. Findings are: Observation on 07/02/19 at 09:46 AM revealed Resident 9 sitting up in recliner chair, oxygen off and oxygen tubing including the nasal cannula lying on the floor. Observation on 07/02/19 at 01:00 PM revealed Resident 9 sitting up in recliner chair finishing eating lunch. Oxygen off and oxygen tubing including the nasal cannula lying on the floor. Review of Oxygen Therapy Protocol dated 9/26/12 revealed that if using PRN oxygen, change nasal cannula and tubing every other week. Record review of (MONTH) and (MONTH) Treatment Administration Record (TAR) 2019 revealed no documentation of oxygen tubing being changed. Interview with Director of Nursing (DON) on 07/02/19 at 03:35 PM confirmed that nasal cannula tubing should not be on the floor and that tubing information should be documented on the TAR. Interview with DON on 07/03/19 at 12:57 PM confirmed that no documentation was present to reflect that the oxygen tubing had been changed on Resident 9. | 2020-09-01 |
| 33 | EASTMONT TOWERS | 285036 | 6315 O STREET | LINCOLN | NE | 68510 | 2019-07-03 | 880 | D | 0 | 1 | RRGD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review and interview; the facility failed to ensure staff followed facility policy to wash hands and change gloves after handling used dressings. This had the potential to affect one resident, Resident 9. The facility census was 10. Findings are: Observation of wound care on 07/02/19 at 09:46 AM- 09:46 AM by RN (Registered Nurse) A revealed RN A washed hands and set up supplies on towel placed on chair, applied gloves, took Resident 9's shoe and sock off right foot, cleansed scissors with alcohol pad and cut off outer Kerlix dressing, then removed [MEDICATION NAME] pad and with same gloves on, went to sink and wet wash cloth, applied soap and washed wound. Then RN A removed gloves, washed hands and applied clean gloves, applied gauze drsg to wound and then wrapped area with Kerlix, applied tape, dated dressing, applied Resident 9's sock and shoe and then removed gloves and washed hands. Review of hand washing guidelines dated 12/14 revealed hand washing should be done after handling used dressings. Interview on 7/2/19 at 3:35 PM with DON (Director of Nursing) confirmed that after removing dirty dressings, gloves should be removed, hand hygiene completed and clean gloves applied before continuing with wound treatment. | 2020-09-01 |
| 5826 | EASTMONT TOWERS | 285036 | 6315 O STREET | LINCOLN | NE | 68510 | 2016-01-28 | 253 | E | 0 | 1 | XBUD11 | License Reference Number 175 NAC 12-006.18B Based on observation and interview, the facility failed to ensure the heating and cooling units in 5 resident rooms were free of rust creating an uncleanable surface. This failure affected 5 residents. (Residents 15, 16, 53, 60, and 61). The facility census was 7. Findings are: On 01/26/2016 at 3:45 PM an interview and tour with the Administrator and the Maintenance Director revealed rust on the heating and cooling units in resident rooms. On 01/27/2016 at 3:36 PM, an interview with the DON (Director of Nursing)/QA (Quality Assurance)Coordinator revealed that there were no current heating or cooling units identified as needing repair and no current plan was in place to make the needed repairs. On 1/28/16 at 12:45 PM, an environmental tour with the Maintenance Director revealed that the heating and cooling units in resident rooms (Residents 14, 15, 53, 60, and 61) were rusty creating an uncleanable surface. The Maintenance Director confirmed there was rust on these heating and air conditioning units in these resident rooms. | 2019-08-01 |
| 5827 | EASTMONT TOWERS | 285036 | 6315 O STREET | LINCOLN | NE | 68510 | 2016-01-28 | 278 | E | 0 | 1 | XBUD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to code MDS (a mandatory comprehensive assessment tool used for care planning) Assessment to reflect the resident's current status at the time of the assessment affecting three residents (Residents 18, 6, and 37). The facility census was 7. Findings are: A) A review of MDS information for Resident 18 revealed: -the 5 day assessment dated [DATE] and the Admission assessment dated [DATE] did not have question J1550C ( related to dehydration) marked. -the 30 day assessment dated [DATE] did have question J1550C marked on the assessment. A review of the RAI (Resident Assessment Instrument-instructions for coding of the MDS) Manual revealed in order to meet the coding criteria for dehydration that 2 of 3 criteria be met. None of the three criteria were met for Resident 18. An interview on 01/27/2016 at 3:48 PM with the MDS Coordinator revealed dehydration was marked on Resident 18's MDS assessment in error. Resident 18 did not meet the criteria documented in the RAI Manual. B)Record review of Resident 6's MDS dated [DATE] and 8/28/15 revealed Section J1550 was coded for dehydration. Record review of Resident 6's medical record revealed no intake or output (I and O) was documented. No meal intakes were documented IPNs(Interdisciplinary progress notes) from 8/15/15 to 8/21/15 revealed no documentation that related to dehydration. Some entries showed takes bites of food, sips of fluids and refusal of food offered. There was no entries to say the total amount of fluid the resident had on a daily basis. On 01/27/2016 at 3:16 PM an interview with the MDS Coordinator revealed that the IPNs revealed the resident had refused eating and fluids and was dying. On 01/28/2016 at 9:22 AM an interview with the MDS coordinator revealed there was no specific documentation related to intake and output. The IPN notes in the 7 day look back period from 8/15/15 to 8/21/15 documented the resident only took bites of food and sips of fluids. Review of the RAI Manual reveled in order to meet the coding criteria for dehydration was required that 2 of the 3 criteria must be met. None of the three criteria were met for Resident 6. C)Record review of Resident 37's MDS, Section J1550 revealed that dehydration was coded on 8/27/15 and 8/28/15. Record review of the resident chart revealed no documentation related to dehydration. On 1/27/16 at 4:00 PM an interview with the MDS Coordinator revealed that for this resident there was no documentation to justify coding dehydration on the MDS. The MDS Coordinator did not know why the resident got entered as dehydrated. Record review of the RAI Manual revealed in order to meet the coding criteria for dehydration it was required that 2 of the 3 criteria must be met. None of the three criteria were met for Resident 37. | 2019-08-01 |
| 5828 | EASTMONT TOWERS | 285036 | 6315 O STREET | LINCOLN | NE | 68510 | 2016-01-28 | 465 | F | 0 | 1 | XBUD11 | License Reference Number 175 NAC 12-006.18A Based on observation and interview ,the facility failed to ensure kitchen floors were free of debris. This had the potential to effect all 7 residents that reside in the facility. Facility census was 7. Findings are: On 01/25/2016 at 8:00 AM and 01/26/16 at 9:51 AM during kitchen observations it was revealed that behind and under the stoves, ovens and prep tables, there was dried debris on the floor. On 01/26/2016 at 9:56 AM it was observed the dinning room steam table had one leg sitting on an unfinished piece of wood on top of a floor drain. On 1/27/16 at 9:02 AM an interview with the Director of Dining Services confirmed there was debris on the kitchen floor under and behind some equipment. | 2019-08-01 |
| 7124 | EASTMONT TOWERS | 285036 | 6315 O STREET | LINCOLN | NE | 68510 | 2014-12-18 | 225 | D | 0 | 1 | OT8H11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on interview and record review, the facility failed to send an investigative report to the state agency within 5 days of an allegation of abuse for one resident, Resident 53. The facility census was 10. Findings are: Review of the facility's investigations of abuse allegations revealed that Resident 53 made an allegation on 11/2/14. This allegation was reported to the state agency on 11/3/14 as required. The fax cover sheet and fax activity log for sending the investigative report indicated the report was not faxed until 11/20/14. Review of the facility's Reporting Policy For Suspected Abuse or Neglect dated 3/11 under procedure 2. g. Protocols must be initiated immediately; investigations must be completed and mailed or faxed to Nebraska Health and Human Services Department within 5 working days of the initial report. The Director of Nursing stated in an interview on 12/17/2014 at 3:58 PM that the initial report was made and an investigation done but acknowledged that the investigative report was not sent within the required timeframe. | 2018-05-01 |
| 7125 | EASTMONT TOWERS | 285036 | 6315 O STREET | LINCOLN | NE | 68510 | 2014-12-18 | 323 | D | 0 | 1 | OT8H11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview, the facility failed to ensure one resident, Resident 55, was transferred in a manner to prevent an accident. The facility census was 10. Findings are: Review of Resident 55's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 10/6/14 revealed this resident required extensive assistance of two people for transfers. Review of Resident 55's care plan dated 10/7/14 also revealed the resident required two assist for transfers. Review of a form titled Weekend Transfers dated 10/4/14 revealed that Resident 55 had a CVA (stroke) with left sided paralysis and was to be transferred with the EZ lift (also referred to by staff as a Hoyer Lift which is a mechanical device which uses a sling to lift individuals for transfers and repositioning). Review of an allegation of staff to resident abuse investigation dated 10/12/14 revealed that Medication Aide B (MA-B) was asked by Medication Aide C (MA-C) to assist in repositioning Resident 55 who had slid forward in the wheel chair and needed to be sat further back in the chair. According to the investigation MA-C went to find the Hoyer lift when the resident's family member requested that they just try repositioning without the lift. The repositioning was attempted without the lift and Resident 55 moved forward to the edge of the chair and had to be lowered to the floor. On 12/17/2014 at 4:40 PM Registered Nurse D confirmed that Resident 55 was to be transferred and repositioned using a Hoyer Lift and that the staff involved were re-educated on this. | 2018-05-01 |
| 10022 | EASTMONT TOWERS | 285036 | 6315 O STREET | LINCOLN | NE | 68510 | 2012-09-19 | 279 | E | 0 | 1 | 27KL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on observation, record review and interview; the facility failed to develop comprehensive care plans related to skin breakdown, bruising and psychosocial issues for five residents (Residents 14, 17, 36, 54 and 59). The facility census was 10 and 21 residents were taken on sample. Findings are: A. Review of Resident 54's closed record revealed an MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning) dated 7/9/12 indicated that the resident was at risk for pressure ulcers but did not have them. Review of the MDS dated [DATE] revealed that a pressure area occurred on 8/24/12. Review of Resident 54's wound care flow sheets revealed the existence of a pressure area on 7/11/12 of [MEDICAL CONDITION] on left buttock which was healed on 7/19/12. Another pressure area was found on 7/31/12 measuring [MEDICAL CONDITION] at the same site and an egg crate chair pad was initiated. The area was healed on 8/6/12. The resident then developed an area on the right buttock on 8/24/12 according to the wound care flow sheet. Review of Resident 54's care plan revealed no mention of pressure areas or interventions to prevent /heal them even though the facility was providing treatments and interventions. On 9/20/12 at 5:00 PM the Director of Nursing (DON) was asked about the lack of a care plan problem for the pressure areas and acknowledged that this should have been on the care plan. B. Resident 14 was admitted to the facility on [DATE] according to the Record of Admission. The following [DIAGNOSES REDACTED]. Interview on 9/19/12 at 2:35 PM with Resident 14, revealed that Resident 14 had taken [MEDICATION NAME] (a [MEDICATION NAME] derivative) for years related to past [MEDICAL CONDITION] (bleeding in the brain) as well as for heart problems. Resident 14 stated that (gender) bruises easily, the bruises on the back of (gender) hands/arms. Resident 14 stated that (gender) did not know the actual cause of current bruises, stated probably bumped hands/arms on something but at the time did not remember the actual cause. Interview with RN C, (Registered Nurse), on 9/19/12 at 2:20 PM revealed it was standard of care to know that Residents on anticoagulation therapy may have increased risk for bruising; therefore it was not necessary to put this information on the Resident's Plan of Care. Interview with Resident 14 on 9/20/12 at 11:55 AM, revealed that there were currently bruises present on the backs of hands and on arms from taking [MEDICATION NAME]. Resident 14 stated (gender) bruises easily and has thin skin. Stated does not remember how the bruises were acquired, but did state that was not harmed in any way. Review of IPN (Interdisciplinary Progress Note) dated 9/16/12 revealed Resident 14 reported itching on (gender) arms and legs. Lotion applied. Resident 14 requested Sarna (anti-itch) cream. Interview with RN B, and RN D, on 9/19/12 at 1:55 PM, revealed that when the staff was aware that a resident was on [MEDICATION NAME] Therapy, the staff inspect the residents for bleeding gums, bruises on arms or legs, nosebleeds, tarry stools, hematuria (blood in urine) and hematemesis (blood in vomit), therefore, no information was placed on Resident 14's Plan of Care related to bruising. Review of Resident 14's Comprehensive Care plan dated 8/16/2012 revealed that potential for skin breakdown/pressure ulcer related to immobility and residual weakness [MEDICAL CONDITION]([MEDICAL CONDITION], bleeding in the brain), however, the comprehensive care plan did not address that Resident 14 had bruising. C. Resident 17 was admitted to the facility on [DATE] according to the Record of Admission. The following [DIAGNOSES REDACTED]. Interview on 9/19/12 at 11:45 AM with Resident 17, revealed that Resident 17 had been on [MEDICATION NAME], for years related to a [DIAGNOSES REDACTED]. Resident 17 also stated that the bruising on hands and arms looks good now, they weren't as bad as they normally were. Review of IPN dated 9/10/12, revealed Resident 17 had scattered bruises on BUE (bilateral upper extremities). Lab drawn times three attempts, one time to the left AC (antecubital region) with no result and one time to left hand which stopped filling after one vial was full, and third attempt to right hand which was effective. Resident stated (gender) is usually hard to obtain blood from. Interview with RN C, (Registered Nurse), on 9/19/12 at 2:20 PM stated it was standard of care to know that Residents on anticoagulation therapy may have increased risk for bruising; therefore it was not necessary to put this information on the resident's Plan of Care. Interview with RN B, and RN D, on 9/19/12 at 2:00 PM, revealed that when the staff was aware that a resident was on [MEDICATION NAME] Therapy, the staff inspect the residents for bleeding gums, bruises on arms or legs, nosebleeds, tarry stools, hematuria (blood in urine) and hematemesis (blood in vomit), therefore, no information was placed on Resident 14's Plan of Care related to bruising. Review of Resident 17's comprehensive care plan dated 8/16/2012revealed there was nothing care planned in regard to skin issues. D. A review of Resident 59's Record of Admission revealed an admission date of [DATE]. A review of the same form listed the following Diagnoses: [REDACTED]. A skin assessment done on 9-16-12 at 8:00 pm revealed a current [DIAGNOSES REDACTED]. Ecchymosis present on the face, neck, and bilateral ante-cubital/brachial region. The nasal laceration and fracture was covered with a bandage. A suture line was visible at the proximal edge. The skin on right shin was intact and there was swelling with normal color. A hard, underlying bump was palpable. The Resident stated it was an old hematoma. An interview with Resident 59 on 9-18-12 revealed resident has been on [MEDICATION NAME] prior to fall due to a risk for [MEDICAL CONDITION]. A review of the plan of care dated 9-17-12 for Resident 59 revealed there were no documented problems, goals or interventions initiated to assess, plan care and/or provide care for the nasal fracture and facial bruising resulting from the fall sustained the previous week. Resident 59 was taking the following medications from the medication order dated 9-16-12: ASA (aspirin) 81 mg( milligrams)daily, [MEDICATION NAME] 3 mg on Monday, Wednesday, Friday, and [MEDICATION NAME] 2 mg on Sunday, Tuesday, Thursday, and Saturday. An interview with an RN on 9-20-12 at 5:15 pm revealed a plan of care related to nasal fracture, bruising, and potential effects of medication regimen ([MEDICATION NAME] and Aspirin) had not been initiated. E. A Review of Resident 36's Record of Admission revealed an admission date of [DATE]. A review of the same form listed the following Diagnoses: [REDACTED]. Interdisciplinary progress notes revealed Resident 36 experienced hallucinations on 9-11-12, 9-12-12, 9-14-12 and 9-17-12. A review of the plan of care initiated 9-1-12 for Resident 36 revealed no problems goals or interventions related to assessment, care planning and/ or provision of care for a resident experiencing hallucinations. An interview with an RN on 9-20-12 at 5:15 pm revealed a plan of care related to this residents hallucinations had not been initiated. | 2016-03-01 |
| 10023 | EASTMONT TOWERS | 285036 | 6315 O STREET | LINCOLN | NE | 68510 | 2012-09-19 | 371 | F | 0 | 1 | 27KL11 | LICENSURE REFERENCE NUMBER 175 NAC 12.006.11E Based on observation, interview and record review; the facility failed to ensure handwashing technique occurred during meal preparation to prevent the potential for cross contamination. This practice had the potential to affect all residents of the facility. The facility census was 10 and 21 residents were taken on sample. Findings are: Observation of meal preparation was made on 9/18/12 at 1:45 PM with Cook A. In preparing to make sandwiches for the evening meal Cook A gloved hands and then proceeded to get paper to lay on the preparation area to put the sandwiches on while preparing them. Cook A then touched the tape dispenser to tape the paper down and went to the walk in cooler for cucumbers then the steam pans to put the sandwiches in. Cook A then weighed the precooked meat on the scales and proceeded to open the bread and lay it out for the sandwiches all without handwashing or glove change. Review of the 7/1/07 version of the Nebraska Food Code, based on the United States Food and Drug Administration food code and used as an authoritative reference for food service sanitation practices, revealed the following: 3-304.15 Gloves, Use Limitation. If used, single use gloves shall be used for only one task such as working with ready to eat food .and discardered when damaged soiled or when interruptions occur in the operation. On 9/19/12 at approximately 1:40 PM the Dietary Manager was interviewed about the facility's handwashing policy. The Dietary Manager indicated the policy was not really up to date but the expectation for hand washing would be to gather the needed ingredients and equipment for the item being prepared rather than potentially cross contaminating by touching contaminated items and then returning to prepare a food product which was ready to eat. | 2016-03-01 |
| 34 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-04 | 166 | D | 1 | 0 | 04EU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.06B Based on record reviews and interviews, the facility failed to resolve grievance / complaints for 1 resident (Resident 603) out of 3 residents sampled. The facility census was 138. Findings are: Review of the undated face sheet for Resident 603 revealed an admission date of [DATE]. Review of the undated face sheet revealed the [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4-11-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 603 was cognitively intact. Resident 603 required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and bathing. Resident 603 was frequently incontinent of urine. Review of the Grievance Log dated 3-01-16 through 3-30-17 provided by the facility revealed absence of a grievance for Resident 603. Interview via phone on 4-26-17 at 4:35 PM with the Family revealed a grievance was completed on 3-30-17 and the Family handed the grievance to Staff D. The Family never received a response back from the facility since that night for a resolution of the 3 issues the Family had concerns about. Family revealed the 3 issues were. 1) The resident had expressed concern to the staff about wheezing and requested an inhaler to help relieve the resident's lungs wheezing and it took 7 days for any of the staff to believe the resident and obtain the orders and medication from the Physician. 2) The Family had concerns the resident had to sit in incontinent urine for up to 15 minutes on multiple occasions after staff was aware of the situation. 3) The resident was not supposed to be transferring independently but the resident had reported to the Family this had occurred occasionally because staff were not available to transfer the resident. The Family revealed on 3-30-17, Staff D visited with the Family about why the resident had been left in incontinent urine for 15 minutes on 4-30-17 when the Family arrived that day. However, Staff D did not say anything about the why this had occurred on other days, or the other 2 concerns the Family had addressed on the grievance how those were being addressed. Interview on 04-26-17 at 4:45 PM with the DON (Director of Nursing) confirmed the Grievance Log was absent of a grievance for Resident 603. The DON also confirmed the DON was not aware of any grievance that had been filed by any member of Resident 603's family that had not been yet listed on the Grievance Log. The DON also denied knowledge of a grievance that had been personally handed to Staff D the end of (MONTH) by the Family. On 05-04-17 the DON provided a copy of a grievance form on Resident 603 dated 03-30-17 initiated by the Family. Documentation of Facility Follow-Up and Resolution of Grievance/Complaint sections of the form were completed by SS-E (Social Service) dated 04-10-17. Documentation on the grievance addressed the resident being left to sit in incontinent urine on 3-30-17 and an intervention if it should occur in the future. The documentation revealed the reason the resident did not get the medications for 7 days was due to the doctor not getting back to facility's request. The documentation did not reveal a resolution to ensure it would not happen again or to explain why this was acceptable. The documentation did not have when the Family was notified of the information about the medications. The ADM (Administrator) dated the form 05-01-17. Interview on 05-04-17 at 08:30 AM with the ADM revealed the ADM received the grievance form on 05-01-17 and could not explain why it took so long for the ADM to receive it even though the SS dated the form as completed on 04-10-17. The ADM revealed the ADM called the Family and reached a voicemail and left a message 05-01-17. Interview on 05-04-17 at 8:42 with SS-E revealed the facility process for grievances was to respond back to the person who filed the grievance within 1 week with a resolution. The ADM usually also responded back to the person who filed the grievance. SS-E provided the Homestead Care Handbook with the grievance process wrote in it which revealed All grievances/complaints received from Residents, Representatives and Families are addressed. All grievances will be investigated and a response given to the complainant within 5 working days. If longer than 5 days is required, the complainant will be notified. Interview on 05-04-17 at 9:48 AM with SS-F revealed the SS felt the grievance was resolved by Staff D so SS-F completed the form and notified the Family of the resolution. SS-F denied documenting the conversation with the Family of the grievance resolution on the grievance form, Progress Notes, or anywhere else. SS-F denied recalling the details of the conversation. | 2020-09-01 |
| 35 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-04 | 312 | D | 1 | 0 | 04EU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1 Based on observations, record review, and interviews; the facility failed to provide assistance with a shower and left the dependent resident unattended for 2 and 3/4 hours for 1 resident (Resident 603) out of 3 sampled residents. Resident was unable to use the call light to call for needed assistance. The facility census was 138. Findings are: Review of the face undated sheet for Resident 603 revealed an admission date of [DATE]. Review of the undated face sheet revealed [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4-11-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 603 was cognitively intact. Resident 603 required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and bathing. Interview on 04-26-17 at 10:00 AM in the resident's room revealed a few weeks ago Staff A put the resident into the shower and performed a 10 minute rinse to the left leg. When completed, Staff A left and said Staff A would be back in 5 minutes and the resident was left sitting in the shower without a call light for over 2 and 1/2 hours. At first the resident thought time was just going by slowly, then the resident realized the resident had been forgotten. At one time the resident thought the resident heard someone come into the resident's room so (gender) yelled out is anyone out there. Resident 603 revealed however the resident's voice was very soft and no one came into the bathroom. Resident 603 revealed the bathroom had a call light but it was across the room by the toilet and the cord was not long enough to have reached the resident. The resident revealed at that time, the resident was not to transfer alone and the wheelchair was not close so the resident could have reached it even if the resident would have wanted to have tried to transfer. Resident 603 revealed Staff B from the evening shift entered the bathroom while passing fresh water pitchers and emptied the old water in the sink and found the resident on the shower chair. Staff B asked the resident what the resident was doing in the shower then went and informed the charge nurse and they returned and transferred the resident into the wheelchair. Resident 603 denied any physical injury from the incident. Observation on 04-26-17 at 10:20 AM revealed the resident shower was in the bathroom of the resident's room. The shower chair was a permanently fixed chair to the wall and not a chair with wheels. The only call light in the bathroom was across the room by the toilet. Review of the facility investigation report revealed on 04-08-17 at approximately 2:00 PM a shower was given to Resident 603. The resident was dressed followed by the wound treatment to the left leg by the Staff [NAME] The resident was left sitting on the shower chair to allow the [MEDICATION NAME] to dry before the resident was transferred back into the wheelchair. The call cord was not long enough to reach the resident in the shower. Staff A left the resident to go give report to the oncoming shift. Staff A revealed (gender) believed report was told to the oncoming shift of Resident 603 being left in the shower. The oncoming nurse, Staff C, denied being told Resident 603 was in the shower. The resident was taken out of the shower at 4:45 PM when Staff B found the resident when Staff B emptied a water pitcher. Review of the Progress Notes revealed no documentation of the incident. On 04-08-17 at 9:35 PM it was documented a general overall skilled assessment of the resident which revealed resident had no visible sores noted. Interview on 04-26-17 at 4:45 PM with the DON (Director of Nursing) confirmed the incident had occurred and the staff involved were disciplined. The resident was left unattended on the shower chair in the resident's bathroom without a call light for 2 hours and 45 minutes. | 2020-09-01 |
| 36 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 578 | D | 0 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and observation; the facility failed to implement advanced directives for 1 of 2 residents sampled. This had the potential to affect Resident #330. The facility census was 131. Findings are: Review of Resident #330's Resident Face sheet dated 05/09/2018 revealed Advanced Directive: there are no Advanced Directives selected for this resident , Review of Resident #330's CONSENT FOR DO NOT RESUSCITATE (DNR) dated 05/09/2018 revealed NO I do not wish Cardiopulmonary Resuscitation efforts in the event of [MEDICAL CONDITION]. Review of Resident #330's PHYSICIAN'S DO NOT RESUSCITATE (DNR) ORDER FOR THE MEDICALLY ILL dated 05/09/2018 revealed the form was marked/selected DO NOT INTUBATE means that I do not wish a tube placed in my airway to maintain my respirations artificially and DO NOT RESUSCITATE (DNR) I understand that DNR means that if my heart stops beating or breathing is inadequate, that no artificial resuscitation will be initiated or continued. I understand that I will continue to receive support supportive medical care as deemed appropriate by health care personnel, through cardiopulmonary resuscitation will not take place. Review of Resident #330's Summary of Care Document printed 5/9/18 at 2:13 PM revealed : Current Code Status DNR On 05/16/18 at 04:08 PM Record review of Resident #330's physician's orders [REDACTED]. Interview with Staff-D on 05/21/18 at 08:36 AM revealed that Resident #330 was a DNR. Staff-D reviewed Resident #330's physician's orders [REDACTED].>Review of the facility's undated Advance Directives policy revealed: 3. Prior to admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directive. 4. Information about whether or not the resident has executed an advance directive shall be prominently displayed in the medical record. 5. If the resident indicates that he or she has not established advanced directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline this assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer and the resident's decision to accept or decline. 7. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directives. 17. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The Attending Physician will not be required to write orders for which he or she has an ethical or conscientious objection. Review of Resident #330's Admission Baseline Care Plan and current care plan revealed no code status is care planned. Review of Resident #330's Summary of Care Document printed 5/9/18 at 2:13 PM, revealed : Current Code Status DNR Review of Resident #330's Patient Demographics printed on 5/9/2018 revealed Documents on File Advanced Directives Discharge & Transfer -- Altitude Discharge Plan of Care | 2020-09-01 |
| 37 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 582 | D | 0 | 1 | HJ5H11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05.5b Based on record review and interview, the facility failed to provide the required SNFABN (forms designed to notify the residents of their right to appeal discharge from a facility based on discontinuation of Medicare Part A services). notices for residents, this had the potential to affect 3 of 4 residents sampled, (Residents 116, 103 and 98). The facility census was 131. Record review of SNFABN forms for Residents # 116 and 103, revealed the Request for Medicare Intermediary Review did not have the designations of choice of wanting bill for services submitted or not submitted. On 05/22/18 at 11:10 AM, an interview with SSD F (Social Service Designee) confirmed neither of the choices were selected. Record review for SNFABN notice for Resident 98 revealed there was no request for Medicare Intermediary Review form. On 05/22/18 at 11:10 AM an interview with SSD [NAME] confirmed there was no Request for Medicare Intermediary Review form. | 2020-09-01 |
| 38 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 584 | E | 1 | 1 | HJ5H11 | > Licensure Reference Number NAC 12-006.18A(1) Based on observation and interview, the facility failed to ensure the bath house was free from non jagged corners on the shower wall and a black substance on the shower floor and wall that had the potential to affect 60 residents on the 100 and 200 halls. The facility census was 131. Findings are: Observation of the 100 and 200 wing bath house on 5/22/18 at 8:00AM and a second observation on 5/22/18 at 11:00AM revealed a black substance in between the shower floor and wall and the edge of the shower wall had a jagged edge. Environmental tour with the Adminstrator and Maintenance Man on 5/22/18 at 11:00 AM revealed a black substance in between the shower floor and wall and the edge of the shower wall had a jagged edge. Interview with the Administrator on 5/22/18 at 2:30PM comfrmed that there was a black substance in between the shower floor and wall and the edge of the shower wall had a jagged edge | 2020-09-01 |
| 39 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 656 | E | 0 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C Based on observations, record reviews and interviews; the facility failed to develop care plans to address, A) activities and oral intake status for Resident 73, B) activities for Resident 90. Resident sample size was 31. Facility census was 131. Findings are: [NAME] Review of Resident 73's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 4-4-18 revealed total dependence for dressing and extensive assist for personal hygiene. Review of Resident 73's current Physician order [REDACTED]. Review of a Nutrition Note dated 5-6-18 revealed Resident 73 was on Tube Feeding at at 50 cc/hour and was to have no food by mouth with all nutrition via the feeding tube. Review of Resident 73's Care Plan last revised 5-14-18 noted the resident has tube feeding, but has ok for ice chips and now ok for 10 bites of pureed food with extra gravy one time daily. Review of Resident 73's Care Plan for activities last revised 5-14-18 revealed a problem start date of 1-19-2018. The first approach for the problem was dated 5-14-18. Interview with RN J (Registered Nurse) on 5-22-18 at 1423 05/22/18 the care plan interventions for Resident 73's activity needs dated 1-19-18 could not be located. B. On 05/16/18 at 01:08 PM Observation of Resident 90 revealed the resident was not engaged in activities. Review of Resident 90's Resident Face Sheet revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/21/18 at 9:46 AM Observation of Resident 90 revealed the resident was in bed in room with music playing. On 05/22/18 at 11:47 AM Observation of Resident 90 revealed the resident was in bed in room with music playing. On 05/22/18 at 01:48 PM Interview with the Activity Director revealed that the Activity Director stated read the newspaper and books to Resident 90 in room. Record review of Resident 90's care plan revealed that the facility failed to Care Plan Activities. On 05/22/18 at 02:53 PM Interview with Nurse Consultant A confirmed that activities had not been care planned for Resident 90. | 2020-09-01 |
| 40 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 660 | D | 1 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C2 Based on interviews and record review, the facility failed to develop a discharge plan based on the resident's wishes. This had the potential to affect 2 residents (Residents # 330 and 42). The facility census was 131. Findings are: [NAME] Review of Resident #330's Resident Face Sheet revealed the resident was admitted on [DATE]. Interview with Resident #330 on 05/16/18 at 03:09 PM revealed the resident wanted to return the the previous facility the resident had been. Interview on 05/21/18 at 04:25 PM with Staff [NAME] revealed that the resident was going to stay at this facility long term and that there was not a discharge plan. Review of Resident 330's Admission- Baseline Care Plan -Discharge Plan dated 5/9/18 section Discharge Plan revealed it wasn't completed. B. Review of Resident #42's Resident Face Sheet revealed the resident was admitted on [DATE]. Interview with Resident #42 on 05/16/18 at 2:10 PM revealed the resident wanted to go back to the resident's apartment. Interview with Staff [NAME] on 05/22/18 at 08:31 AM revealed that the resident wanted to return to an apartment but there were plumbing and electrical issues that have to be addressed. Review of Care Plan Snapshot on 5/17/18 revealed no care plan problem, goals or approaches related to discharging or returning to the resident's pervious apartment. | 2020-09-01 |
| 41 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 677 | D | 0 | 1 | HJ5H11 | Licensure Reference Number: 175 NAC 12-006.09D1c Based on observations and interview, the facility failed to ensure soiled clothing was changed and dirty glasses were cleaned for 1 resident (Resident 114). The sample size was 31 and census was identified as 131. Findings are: Observation of Resident 114 on 5-16-18 at 0930 revealed black and brown stains down the chest area of the resident's shirt. [NAME] and gray stains were observed on the resident's plaid pants. The lenses of the resident's glasses were smudged and dust covered. Observation of Resident 114 on 5-17-18 at 1414 revealed the resident was wearing the same shirt and pants from the prior day with brown and black colored stains down the chest. The resident's glasses remained dusty and smudged and pants were still noted to have gray and white substance. The resident was observed to be attempting to whipe the gray and white material from the pants. A Review of Resident 114's Minimum Data Set (MDS- a federally mandated comprehensive tool used for care planning) dated 4-18-18 revealed Resident 114 was severely cognitively impaired and required extensive assist for dressing, toileting and personal hygiene. Interview with Nurse Consultant A on 5-22-18 at 0719 reveals the expectation would be for staff to change a resident's clothing if stained and dirty prior to the next day. | 2020-09-01 |
| 42 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 755 | E | 0 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.10A2 Based on observation, record review and interview, the facility failed to administer medications through an Enteral Tube (is used to feed patients who cannot attain an adequate oral intake from food and/or oral nutrition supplements, or who cannot eat/drink safely) per facility policy. This was the observation for one sample resident (Resident 73). This had the potential to affect 4 residents (Residents 90, 61, 37 and 73) at the facility. Census: 153 Residents. Sample size 73 Residents. Observation on 5/22/18 from 8:33 AM until 9:10 AM RN-G (Registered Nurse) set up medications for Resident 73 to be given through an Enteral Tube. The medications were Calcium [MEDICATION NAME] (a dietary supplement used when the amount of calcium taken in the diet is not enough). [MEDICATION NAME] (a medication used to treat diabetes insipidus, betwetting, [DIAGNOSES REDACTED] A, von Willebrand diseae, and high blood urea levels). Docu Liquid (medication used to treat occasional constipation). [MEDICATION NAME] (a medication used for pain control, to help prevent or control [MEDICAL CONDITION], or as a mood stabilizer). [MEDICATION NAME] (is used to treat certain conditions where there is too much acid in the stomach. It is used to treat gastric and [DIAGNOSES REDACTED] ulcers, erosive esophagitis). [MEDICATION NAME] (is a class of drugs call steroids. [MEDICATION NAME] prevents the release of substances in the body that cause inflammation). Levetiracetam (is an anti-epileptic drug used to treat partial onset [MEDICAL CONDITION] in people with [MEDICAL CONDITION]). [MEDICATION NAME] (used to treat occasional constipation). [MEDICATION NAME] (is used to treat intestinal and stomach ulcers, [MEDICAL CONDITION] reflux disease (GERD) and conditions where your stomach makes too much acid). Vitamin D 1000Units (is a supplement that helps your body absorb calcium and phosphorous). RN-G took the listed medications to the bedside of Resident 73. RN-G was observed to check the placement of the Enteral Tube and check for residual. RN-G drew up each medication individually and administered each medication into the Enteral Tube using the syringe and plunger. Record review Administering Medications through an Enteral Tube (Revised (MONTH) 2012) 22. Reattach syringe (without plunger) to the end of the tubing 23. Administer medication by gravity flow. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. Open the clamp and deliver medication slowly. Clamp tube (or begin flush) before the tubing drains completely. 24. If administering more than one medication, flush with 5ml (or prescribed amount) warm sterile water between medications. Interview on 5/22/18 at 9:12 AM with RN-H stated was not sure if RN-G gave the medications correctly through the Enteral Tube, but would get a copy of the Policy and Procedure for the Surveyor. | 2020-09-01 |
| 43 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 758 | D | 0 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that physician orders [REDACTED].#68 and 330). The facility census was 131. Findings are: Review of Resident #330's Resident Face Sheet revealed the resident was admitted on [DATE] at 4:47 PM Review of Resident #330's Physician order [REDACTED]. [MEDICATION NAME] 0.25 mg, one tablet orally, as needed up to three times per day for anxiety disorder (a medication used to treat anxiety and panic disorders), Start Date 05/09/2018; End Date open ended [MEDICATION NAME] 25 mg, one half tab, orally, every 6 hours as needed for anxiety disorder. Start Date 05/09/2018; End Date open ended Both of these medications are psychoactive medications. Interview with Staff D on 5/21/2018 at 08:39 AM revealed Resident #330 takes Ambien, [MEDICATION NAME] and [MEDICATION NAME] as ordered, and as needed for behavior issues and anxiety. Review of Resident #330's PRN ADMINISTRATION HISTORY: 05/01/2018-05/17/2018 revealed: [MEDICATION NAME] PRN (as needed) was given on 5/10, 5/11, 5/12, 5/14, and 5/16 for other and behavior issue; [MEDICATION NAME] PRN (as needed) was given on 5/11, 5/12, 5/14 and 5/16 for other and behavior issue. Record review of Physicians orders dated 4/14/18 for Resident 68 revealed; [MEDICATION NAME] (a [MEDICAL CONDITION] medication used to treat anxiety) schedule IV concentrate; 2mg/ml; amount 1 mg; oral, start date 4/14/18 end date Open ended. Once a day on Wednesday and Saturday-PRN(as needed) 30 minutes before bath. Record review of the Physician orders [REDACTED]. Start Date: 04/25/2018, End Date: 04/25/2018. Every 6 hours PRN. Record review of the MAR (Medication Administration Record) dated 5/1/18 -5/17/18, revealed the resident was administered the above medications during this time. | 2020-09-01 |
| 44 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 791 | D | 0 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.14 Based on observation, record review, and interviews, the facility failed to assist with making dental appointments for 1 resident (Resident 19) of 31 sampled residents. The facility staff identified the census as 131. Minimum Data Set information for resident 19 dated 5-2-18 revealed a [DIAGNOSES REDACTED]. Resident 19 admitted to the facility in (MONTH) of (YEAR). Observation of Resident 19 on 5-17-18 at 0830 reveals the resident's right front tooth is cracked and shortened. Interview with the resident on 5-17-18 at 0830 reveals the front right tooth was broken about two years ago. The resident had not been seen by a dentist in about four years. The resident's tooth bothers him when eating and would like to be seen by a dentist. Interview with Nurse Consultant A on 5-17-18 at 1545 revealed Resident 19 had no information charted regarding dental consultations or that the resident or their representative had declined a dentist's evaluation. Interview with the Director of Nursing on 5-21-18 at 0839 revealed the expectation of staff would be for the mouth to be assessed and have a dentist appointment set up. The expectation would be for social worker to annually check with the resident regarding dental visit and/or cleaning. There should be something on the resident's chart regarding talking with the family regarding dental cleaning. | 2020-09-01 |
| 45 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 867 | E | 0 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.07C (2) Based on observations, interviews, and record reviews, the facility failed to Develop and implement a plan to correct and maintain compliance regarding repeat federal and State deficiencies pertaining to housekeeping and maintenance. The concerns identified had the potential to effect 66 residents. The facility census was 131. Record reviews of past re-certification survey deficiency statements dated 5-25-17 revealed the facility was cited for failures regarding the ventilation motors in resident rooms, and broken and stained caulking in resident bathroom areas. Observations and interviews conducted during the current survey from 5-16-18 to 5-22-18 revealed vents were not working in rooms [ROOM NUMBER] bathrooms. The 100 and 200 wing bath house observation revealed a black substance in between the shower floor and wall and the edge of the shower had a jagged edge. These observations were confirmed with Maintenance and the Administrator. Interview with the Administrator on 5-22-18 at 1554 revealed resident bathing area for the 100 and 200 hallways was not identified as a possible area to focus on for Quality Assurance. Record review of the facility Quality Assurance and Performance Improvement revised 5-2017 revealed the QAPI Committee oversees the quality and effectiveness of the facility operations and systems to meet the needs of the residents; to monitor and analyze facility key performance indicators to identify improvement opportunities. | 2020-09-01 |
| 46 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 923 | F | 0 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-007.04D Based on observation and interview, the facility failed to ensure the vent fans were working in bathrooms for room [ROOM NUMBER], 402, and 410. Facility Sample size was 31. Facility census was 131. Findings are: Observation of bathrooms in rooms [ROOM NUMBER] revealed that the vent fans were not working. On 05/22/18 at 10:59 AM During the Environmental tour the Administrator and Maintenance Man confirmed that the vent fans in rooms [ROOM NUMBER], were not working. On 05/22/18 at 1:59 PM an interview with the Administrator confirmed that the vent fans in rooms [ROOM NUMBER] were not working. | 2020-09-01 |
| 47 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 242 | D | 0 | 1 | 18U611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.05 (4) Based on interview and record review, the facility failed to ensure a resident was provided with a choice related to bathing for one (Resident 109) of 3 sampled residents. Facility had a total census of 131. Findings are: Resident 109 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. In an interviews on 5/22/17 at 8:45 AM and 5/25/17 at 11:19 AM, Resident 109 reported not getting a choice related to number of baths per week. Resident 109 reported receiving two baths per week and stated would like more at times. A review of undated bath schedule revealed Resident 109 was schedule for two baths per week. In an interviews on 5/23/17 at 2:57 PM and 3:19 PM, Social Worker A reported that bathing preference are being reviewed with residents on admission. Social Worker A reported that Resident 109 had not been asked about bathing preferences. | 2020-09-01 |
| 48 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 253 | E | 1 | 1 | 18U611 | > Licensure Reference Number(s) 175 NAC12-006.18B and 175 NAC 12-006.18A(1) Based on observation, interview, and record review; the facility failed to ensure two mechanical sit to stand lifts (a mechanism used to assist residents to transfer from one surface to another) were clean. This failure had the potential to affect 10 of 15 sampled residents (Residents 71, 92, 150, 109, 158, 194, 145, 169, 44, and 152) who required use of a lift for transfers. The facility also failed to ensure; 1) Eight resident rooms (306, 103, 102, 314, 216, 301, 318, and 410) had tiles with stained or broken caulking in the bath rooms; and 2) Rooms 219, 400, 306, and 410 were free from lingering odors . Findings are [NAME] An observation on 5/24/17 at 10:12 AM revealed Nursing Assistant (NA)-E using a disposable wipe to wipe the handles, upper bars, and knee rest, of a mechanical sit to stand type lift (a devices used to assist residents during transfers from one surface to another). The NA did not wipe the foot plate, lower bracing, or wheels of the lift. Further observation revealed the wheels of the lift had evidence of hair and other foreign materials wrapped around them, the foot plate and lower bracing contained visible dust and debris. An interview on 5/24/17 at 10:14 AM with NA-E revealed the NA did not clean the lower surfaces of the lift. The NA was unaware of a cleaning schedule which included all of the lifts surfaces. An interview on 5/24/17 at 10:15 AM with Registered Nurse (RN)-F revealed the mechanical lift should be cleaned after each resident use. The RN observed the lift and confirmed the lower areas of the lift were soiled and in need of cleaning. An interview on 05/25/2017 at 11:39 AM with Licensed Practical Nurse (LPN)-G revealed the area of the facility (Station 3) had two mechanical sit to stand type lifts in use, and that both of the lifts had the same concerns related to sanitation. The LPN reported that other areas of the facility had their own equipment, including mechanical lifts. Review of a facility Census roster dated 5/24/17 revealed fifteen residents who required use of a sit/stand lift for transfer assist. Ten of the fifteen residents resided on Station 3, (Residents 71, 92, 150, 109, 158, 194, 145, 169, 44, and 152). A review of the facility policy titled CLEANING AND DISINFECTION OF RESIDENT CARE ITEMS AND EQUIPMENT dated/revised (MONTH) 2014 revealed reusable resident care equipment would be cleaned and disinfected according to current CDC (Center for Disease Control) recommendations for disinfection between resident use. B. Observation of Room 514 on 5/18/17 at 9:22 AM revealed the bathroom smelled of urine . Observation of the bathroom in [RM #]6 on 5/22/17 at 10:26 AM revealed stained caulking around the toilet. Observation of the bathroom in Room 103 on 5/22/17 at 9:58 AM revealed cracked caulking around the base of the toilet. Observation of the bathroom in Room 102 on 5/18/17 at 9:18 AM revealed cracked caulking around the base of the toilet. Observation of the bathroom in Room 219 on 5/22/17 at 11:23 AM revealed a urine odor. Interview with a resident in Room 400 on 5/23/17 at 7:39 AM revealed the bathroom had an odor especially on warm days. During an environmental tour on 5/24/17 beginning at 1:00 PM, interview with the Maintenance Supervisor (MS) revealed the caulking needed replaced in the bathrooms of rooms 314, 216, 301, 318, 410. Further interview during the environmental tour on 05/24/2017 at 2:04 PM with the MS revealed odors were acknowledged in the bathrooms of 306, 219, and 410. The MS further reported the odors smelled of urine. Interview with the Housekeeping Supervisor on 05/25/2017 at 10:50 AM revealed the odors have not been alleviated with cleaning or the use of odor eliminator products. | 2020-09-01 |
| 49 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 258 | E | 1 | 1 | 18U611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.18A (3) Based on observations and interview, the facility failed to replace loud bathroom ventilation motors to promote comfortable sound levels in rooms [ROOM NUMBER]. The facility census was 131. Findings are: Observation of the bathroom in room [ROOM NUMBER] on 05/18/2017 at 9:18 AM revealed a noisy bathroom ventilation fan . Interview with a resident living in room [ROOM NUMBER] on 5/18/17 at 9:22 AM revealed the bathroom vent is so loud that the resident has to turn on the radio in the room in order to not hear it. Observation of the bathroom in room [ROOM NUMBER] on 05/22/2017 at 02:44 PM revealed a noisy bathroom ventilation fan. Observation of the bathroom in room [ROOM NUMBER] on 05/22/2017 at 09:58 AM revealed a noisy bathroom ventilation fan that could be heard in room with the bathroom door shut. Observation of bathrooms during the Environmental Tour with the Maintenance Supervisor on 5/24/2017 between 1:00 PM and 3:30 PM revealed all of Station One vents were loud. Interview with the Maintenance Supervisor on 5/24/2017 between 1:00 PM and 3:30 PM confirmed the vents were loud still loud despite having been taken out and cleaned. | 2020-09-01 |
| 50 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 281 | D | 0 | 1 | 18U611 | Licensure Reference Number: 175 NAC 12-006.10B1 Based on observations and interview, the facility failed to ensure medication was observed until administration to the resident in accordance with facility policy for one sampled resident (Resident 29) of 6 sampled residents. The facility had a total census of 131. Findings are: Observations on 5/23/17 at 9:29 AM revealed a medication cup with medications in it, two medication cups full of pro stat, eye drops, and nasal spray on over bed table in room next to Resident 29. No staff member was observed in the room. In an interview on 5/23/17 at 9:29 AM, Resident 29 reported that Resident did not like to take medications until after breakfast. In an interview on 5/23/17 at 9:35 AM, Registered Nurse B reported giving Resident 29 the medications at 8:30 Am. Registered Nurse B stated that Resident 29 doesn't like to take medication until after breakfast. Registered Nurse B reported leaving medications for Resident 29 as Resident 29 had been at facility for a long time and then returning to remind Resident 29 to take the medications. Registered Nurse B was not aware of any directives that indicated that Resident 29 could have medications at bed side. A review of Resident 29's medical record did not reveal any assessment of Resident 29's ability to self-administer medication. In an interview on 5/23/17 at 1:58 PM, Registered Nurse Consultant confirmed no assessment of Resident 29 ability to self-administer medications. Facility policy titled medication Administration Orals dated 10/07 stated the following: -Administer medication and remain with resident while medication is swallowed. Do not leave a medication in a resident's room without orders to do so along with documentation of self-administration. | 2020-09-01 |
| 51 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 312 | D | 0 | 1 | 18U611 | Licensure Reference Number: 175 NAC 12-006.09D1c Based on observation, record review and interview; the facility failed to assist one resident (Resident 187) of three sampled residents with wearing eye glasses as needed. The facility census was 131 residents. Findings are: Review of Resident 187's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 4/7/17 revealed Resident 187 had moderately impaired vision and required extensive assistance for dressing and grooming. Review of Resident 187's Care Pan revised 4/4/17 revealed Resident 187 required assistance of one with grooming and to complete all activities of daily living. There was no specific mention of Resident 187's impaired vision or need for eye glasses on Resident 187's Care Plan. Review of a Resident Assignment sheet dated 5/22/17 indicated that Resident 187 wore glasses. Interview with Family Member A on 05/18/2017 at 03:16 PM revealed Family Member A noted that Resident 187 was often not wearing Resident 187's glasses. Observation of Resident 187 on 05/23/2017 at 10:49 AM revealed Resident 187 had been assisted out of bed to the wheelchair for the lunch meal and was not assisted with donning glasses. Interview with Nursing Assistant (NA) P on 5/24/17 at 9:30 AM revealed staff found Resident 187's glasses on the floor so NA P picked them up and put them back in the case so they wouldn't get broken. Observation of Resident 187 on 5/24/17 at 12:10 PM revealed Resident 187 at the dining room table without any glasses on. After asking NA Q on 5/24/17 at 12:10 PM to obtain Resident 187's glasses and put them on Resident 187 observation revealed Resident 187 did not attempt to remove the glasses. Interview with NA Q on 5/24/17 at 12:17 PM revealed Resident 187 just liked to have something to hold onto and if Resident 187 had something to hold that Resident 187 would not attempt to remove the glasses. NA Q went on to say that staff had not tried interventions such as waiting till right before meal time or giving Resident 187 something else to hold in order to assist Resident 187 with wearing and keeping the glasses on. Interview with the unit manager/Registered Nurse (RN) F on 05/25/2017 at 12:22 PM revealed there was no problem on the care plan addressing Resident 187's impaired vision or interventions to aide in the wearing of the eye glasses but that it is noted on the Resident Assignment sheet that Resident 187 was to wear glasses. | 2020-09-01 |
| 52 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 315 | D | 1 | 1 | 18U611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC: 12-006.09D3 (1 and 2) Based on observation, interview, and record review; the facility failed to identify the need for an individualized toileting program to restore urinary continence (ability to control bladder)for one (Resident 194) of three sampled residents and the facility failed to provide pericare (washing the genitals and anal area which prevents skin breakdown of perineal area, and infections) in a manner to prevent the potential for cross contamination for two (Residents 187 and 194) of three sampled residents. The facility census was 131. Findings are: [NAME] A review of MDS (Multidisciplinary Data Set-a mandatory comprehensive assessment tool used for care planning) information for Resident 194 revealed full assessments completed on 10/28/17 for admission, and on 1/31/17 for a significant change in condition. The CAA (Care Area Assessment) page of both assessments indicated urinary incontinence triggered as an area of concern and needed to be included on the resident's care plan. A review of Resident 194's Care Plan (CP), last reviewed/revised on 5/6/17, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An entry on the CP indicated a problem identified on 11/01/2016 documented Resident 194 exhibited 'Functional' urinary incontinence, with the goal of 'will not develop skin breakdown related to incontinence. The interventions included to use pull ups or briefs when in and out of bed. Another problem identified on 11/01/2016 indicated Resident #194 had a Self-care deficit related to [DIAGNOSES REDACTED]. Resident 194 required assistance from 2 staff members for transferring and toileting. The CP indicated on 2/8/17, the resident experienced bladder incontinence related to diuretic (medication used remove excess fluid) therapy and decreased mobility. Interventions included: incontinence care with each incontinent episode, provide minimal assist with toileting, and obtain labs as ordered. The CP did not include an individualized toileting plan or interventions to prevent or improve incontinence status. A review of the electronic medical record for Resident 194 revealed a document titled DISCHARGE & TRANSFER-MEDICARE DISCHARGE PLANNING MEETING dated 10/25/16. The document revealed the resident required physical assist from 1-2 people for toileting, without a documented goal related to the concern. The section of the document titled BOWEL/BLADDER MANAGEMENT indicated Resident 194's previous level of bowel/bladder control and management was continent (able to control) of bowel and bladder. The documentation was incomplete and did not include information related to the resident's current level or goals and interventions related to toileting concerns. An interview on 05/23/2017 at 9:58 AM with Nursing Assistant (NA)-H revealed Resident 194: required assistance from 2 staff for transfers using a sit-stand lift (mechanical device used to move residents from one surface to another), was incontinent of bowel and bladder, was able to let staff know of need to use the bathroom, was toileted with staff assistance every 2 hours and as needed. An interview on 05/24/2017 at 8:41 AM with Registered Nurse (RN)-J, revealed Resident 194 was incontinent while receiving Medicare Services and residing on the Skilled Unit of the facility, 10/21/16-1/7/17, but was not on a toileting program. The RN reported that a Bowel and Bladder Voiding Diary was not completed upon admission for the resident. An interview on 05/24/2017 at 10:45 AM with RN Unit Manager-F revealed a bowel and bladder (B & B), three day diary/observation had not been completed for Resident #194 since moving to Unit 3 on 1/8/17. The RN confirmed the resident's CP did not include individualized interventions related to toileting/incontinence issues. A review of an undated facility document titled BOWEL AN BLADDER GUIDELINE revealed: all residents have a B & B observation completed on admission, quarterly, change in condition, and in the instance of a change in continence; if B&B observation shows resident is both continent and incontinent of either bladder or bowel, a 3 day tracking/voiding diary shall be initiated; Care Plan needs to include individualized toileting schedule/program or reason one is not appropriate; the facility should observe that incontinent residents have pericare completed at least every 2 hours. B. An observation on 5/23/17 at 10:02 AM of NA-H and NA-I assisting Resident 194 with toileting needs revealed a sit stand lift (a mechanical device used to move residents from one surface to another) was used to transfer the resident from a wheel chair to the bathroom and toilet with no concerns identified. NA-I was noted to apply gloves prior to assisting the resident to lower pants and remove a soiled brief. Soiled gloves were not removed prior to NA-I assisting NA-H to manipulate and reposition the mechanical lift and lower Resident 194 onto the toilet. Privacy was provided and when Resident 194 indicated completion of elimination needs, the lift was used to bring the resident to a standing position. NA-I was observed to use disposable wipes to cleanse the resident's genital area, and a different wipe was used to complete back pericare. NA-I then applied a clean brief for the resident and assisted NA-H to move the lift out into the resident's room. Resident 194 was lowered into a wheel chair in order to remove wet trousers and apply a clean pair. Neither NAs were noted to change gloves or sanitize hands throughout the provision of care for Resident 194. Interviews on 5/23/17 at 10:15 AM with NA-H and NA-I revealed the NAs did not remove soiled gloves prior to making contact with items considered clean or sanitize their hands, during the provision of toileting and incontinence care for Resident 194. A review of Lab Reports for Resident 194 revealed urine specimans tested positive for symptoms of urinary tract infection on 1/13/17 and 2/7/17. A review of the Basic Nursing Assistant Training Manual, 4th Edition dated 2009 revealed to prevent the potential for cross contamination, gloves were to be removed and hands sanitized following the completion of pericare and before touching clean clothing items. C. Review of Resident 187's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 4/7/17 revealed Resident 187 had severely impaired cognition, required extensive assist with toileting, and was always incontinent of bowel and bladder. Review of Resident 187's (MONTH) Medication Administration Record [REDACTED]. Observation of incontinent care on 05/23/2017 at 10:40 AM revealed Nursing Assistants (NAs) R, S, and T assisting Resident 187. NA S put on gloves, removed the dirty brief and providing hygiene to Resident 187's buttocks as Resident 187 was having an incontinent stool. NA S continued to wipe away the stool from Resident 187 four additional times and then assisted Resident 187 over to Resident 187's back. NA S did not remove gloves and proceeded to provide care to Resident 187's vaginal area while wearing the same gloves. Interview with NA S and Registered Nurse (RN) U on 5/23/17 at 10:55 AM revealed RN U agreed that NA S did not change gloves after providing care for incontinent stool. Review of the facility's undated Peri-Care Competency Checklist revealed staff should use a tissue/disposable peri-wipe and remove any stool that is present, then remove gloves and sanitize hands before proceeding with perineal care. | 2020-09-01 |
| 53 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 323 | E | 0 | 1 | 18U611 | Licensure Reference Number: 175 NAC 12-006.18E5 Based on observations and interviews, the facility failed to safely store chemicals in its Memory Unit (Station 4), which had the potential to affect 4 residents out of 19 residents. The facility census was 131 . Findings are: Observation on 5/17/2017 at 1:30 PM revealed an unlabeled spray bottle with a purple liquid on the counter in the dining room of Station 4. A container of disposable bleach wipes were noted in an unsecured cupboard under the sink in the same dining room. Observation on 5/23/2017 at 10:42 AM with RN AA revealed a container of Dispatch with Bleach sanitizing wipes were unsecured in a cupboard under the sink in the dining room of Station 4. Interview with RN AA during this observation confirmed the wipes were unsecured . Interview with Housekeeper Z on 5/23/17 at 10:25 AM revealed residents are allowed in the dining room unsupervised at times. Interview with the Nurse Consultant on 5/25/17 at 4:30 PM revealed there were 4 residents that wandered and rummaged on Station 4. | 2020-09-01 |
| 54 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 364 | D | 0 | 1 | 18U611 | Licensure Reference Number: 175 NAC 12-006.11D Based on observation and interview, the facility failed to ensure pureed food was prepared in a manner to maintain nutritional value. This practice had the potential to affect 9 residents receiving pureed food. The facility had a total census of 131 residents. Findings are: Observations on 5/23/17 at 1:25 PM revealed 15 slices of chicken sandwich meat, 5 slices of cheese and 10 slices of bread were blended with unmeasured amount of chicken broth and thickener to pureed consistency. Six half cup servings of pureed mixture were portioned into serving dishes. Then an additional 15 slices of chicken sandwich meat, 5 slices of cheese and 10 slices of bread were blended with unmeasured amount of chicken broth and thickener to pureed consistency for the second 5 servings of pureed food. The second batch produced 9 half cup servings of pureed sandwiches. In an interview on 5/23/17 at 1:25 PM, Cook C reported preparing 10 servings of pureed food in two batches of 5 servings. Cook C confirmed the first batch produced 6, half cup servings and the second batch produced 9, half cup servings. A review of undated document titled Pureed Food Guidelines revealed pureed sandwiches were to be made with 2 ounces meat, 1 ounce cheese and 2 slices of bread or 1 bun. Directions stated that bread, then food to be pureed is to be placed in blender or food processor. A half cup of liquid is to be added and mixture is to be pureed. Liquid is to be added in half cup amounts until product reaches the correct consistency. The document did not list a serving size for the pureed food. In an interview on 5/25/17 at 9:19 AM, Dietary Director confirmed that initially half cup liquid should be added and then more added as needed. Dietary Director reported serving size of purred sandwiches was supposed to be a full cup. | 2020-09-01 |