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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11239 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 226 | C | 0 | 1 | G3Q011 | F 226 LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on observations, record review and staff interview the facility failed to protect all residents from potential abuse/neglect. The facility failed to re-educate a staff member who was accused of neglect of Resident 16 before allowing the staff member to return to work. Facility census was 34. Findings are: On 8/6/12 at 11:00 AM the Administrator indicated an allegation of neglect involving Resident 16 and Nursing Assistant (NA) M had been reported to the State Agency that morning. The Administrator stated NA-M had been suspended until the investigation was completed. Review of the written investigation for this allegation dated 8/8/12 revealed NA-M was placed on extended probation and was to be re-educated regarding facility abuse and neglect policy. Additional staff training was to be done with all staff regarding abuse and neglect recognition and reporting. On 8/8/12 at 5:30 PM the suspended employee NA-M was observed working the 2:00 PM to 10:00 PM shift. Interview with the Director of Nursing (DON) on 8/9/12 from 10:20 AM until 10:30 AM, revealed DON thought the investigation was completed; however the interventions for re-education of the suspended employee and other staff members had not been completed. The DON stated the suspended employee was informed on 8/8/12 while working the evening shift of the need for the DON to visit with employee regarding the incident. Interview with the Administrator on 8/9/12 from 10:30 AM until 10:35 AM, revealed the suspended employee should not have returned to work until the interventions were in place to prevent further neglect of residents. | 2015-07-01 |
| 11240 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 242 | D | 0 | 1 | G3Q011 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(4) Based on record review, staff and resident interviews, the facility failed to afford Residents 20 and 22 their choice regarding the number of baths they received per week. Facility census was 34. Findings are: A. When asked about choosing how many times a week the resident received a bath, Resident 20 stated during interview on 8/7/12 from 11:23 AM until 11:40 AM, "I would like to choose. I would choose to take more. I would like it (bath) 3 times a week." The resident stated the bath aide was informed of this request; however the resident indicated 1 whirlpool bath was provided weekly. Review of the Bath/Shower Schedule revealed Resident 20 was scheduled to receive 2 baths per week on Tuesdays and Fridays. Review of documentation of baths provided for Resident 20 revealed the resident did not receive a bath for 8 or 9 days on the following dates: -4/24/12 until 5/2/12 (8 days) -5/9/12 until 5/18/12 (9 days) -5/29/12 until 6/6/12 (8 days) -6/19/12 until 6/28/12 (9 days) -7/10/12 until 7/19/12 (9 days) Interview with Nursing Assistant (NA) J on 8/9/12 from 7:25 AM until 7:30 AM revealed Resident 20 was scheduled for 2 baths per week. NA-J indicated Resident 20 did not always receive 2 baths per week. NA-J was aware the resident desired more baths per week. B. Resident 22 stated during interview on 8/6/12 from 2:00 PM until 2:20 PM that no choice was provided regarding how many times a week a bath was provided. The resident stated 1 bath a week was provided and "sometimes" 2 baths a week were provided. The resident's choice was to receive 2 baths per week. Review of the Bath/Shower Schedule revealed Resident 22 was scheduled to receive 2 baths per week on Tuesdays and Fridays. Review of documentation of baths provided for Resident 22 revealed the resident did not receive a bath for 8 to 10 days on the following dates: -4/25/12 until 5/5/12 (10 days) -5/8/12 until 5/17/12 (9 days) -5/17/12 until 5/29/12 (8 days) -5/29/12 until 6/8/12 (10 days) -6/19/12 until 6/28/12 (9 days) -7/10/12 until 7/19/12 (9 days) Interview with NA-J on 8/9/12 from 7:25 AM until 7:30 AM revealed Resident 22 was on the bath schedule for 2 baths per week and indicated this was not always completed. NA-J was aware Resident 22 desired more than 1 bath per week. | 2015-07-01 |
| 11241 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 280 | D | 0 | 1 | G3Q011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on record review, observations and staff interviews; the facility failed to revise Resident 3's Care Plan following falls. Facility census was 34. Findings are: Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/11/12 revealed [DIAGNOSES REDACTED]. The MDS indicated the resident had short term memory problems and had 1 fall in the past 3 months with no injury. Review of the MDS dated [DATE] revealed the resident continued to have short term memory problems and no falls since the last assessment. Review of an Event Report dated 1/23/12 at 2:09 PM revealed at 1:45 PM the resident lost balance while ambulating with the aid of a walker and a nursing assistant. The resident fell backwards and slid to the floor. Documentation further indicated measures taken following the fall were the "use of gait belt (a belt placed around a resident's waist to assist with transferring the resident from one position to another by providing support for the resident and a safe hand hold for the caregiver) during transfers". Review of the current Care Plan dated 5/10/12 revealed the resident had a potential for injury as a result of poor safety awareness. The Care Plan specified a goal for the resident to remain free from injury. There was no documentation to indicate the intervention of using a gait belt during transfers was added to the Care Plan. On 8/6/12 from 4:05 PM until 4:10 PM, Nursing Assistant (NA) C was observed to transfer Resident 3 out of a wheelchair and into bed. The resident required extensive assistance and no gait belt was used during the transfer. Review of an Event Report dated 7/21/12 at 12:27 AM revealed the resident was heard screaming and crying at 11:40 PM (on 7/20/12). Documentation further indicated the resident was confused. The resident was assisted to the bathroom, placed on the toilet and instructed to use the call light when finished on the toilet. At 12:00 midnight the resident was found sitting on the floor in front of the toilet and sink. Review of the current Care Plan (last updated 5/10/12) revealed it had not been revised to address the resident's increased risk of falls when left unattended in the bathroom. On 8/8/12 Resident 3 was observed left unattended while on the toilet in the bathroom from 9:26 AM until 9:45 AM (19 minutes). At 9:45 AM, NA-B entered the bathroom to assist the resident off of the toilet. NA-B had to awaken the resident and stated Resident 3 was "very sleepy" and "usually isn't that sleepy." Interview with NA-B on 8/8/12 from 9:56 AM until 9:58 AM revealed NA-B was not the staff member who had assisted the resident onto the toilet. NA-B stated "I don't usually leave the resident alone in there." Interview with the Director of Nurses on 8/8/12 from 10:20 Am until 10:25 AM revealed Resident 3 should not be left alone while in the bathroom. | 2015-07-01 |
| 11242 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 309 | D | 0 | 1 | G3Q011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on record review, observations and staff interviews, the facility failed to reposition Residents 10 and 15 every 2 hours in accordance with the facility's standard of practice. These residents were unable to reposition themselves. Facility census was 34. Findings are: A. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/25/12 revealed [DIAGNOSES REDACTED]. The MDS dated [DATE], 4/18/12 and 7/19/12 indicated the resident had short and long term memory problems, was totally dependent with bed mobility, and was on a turning/repositioning program. Review of Resident 15's current Care Plan dated 7/12/12 revealed the resident was limited in bed mobility. Interventions were to turn and reposition the resident frequently. Resident 15 was observed seated in a wheelchair without benefit of repositioning on 8/8/12 at 6:50 AM, 8:00 AM, 9:22 AM, 10:34 AM, 11:00 AM, 12:00 PM, 12:50 PM and 1:50 PM (7 hours). On 8/8/12 at 1:50 PM, Nursing Assistants (NA) G and H were observed to transfer the resident from the wheelchair into bed. Interviews with NA-H and NA-A at this time revealed NA-H had gotten the resident out of bed that morning. NA-H and NA-G were unaware if the resident had been repositioned since that time. NA-G stated the resident was usually laid down for a while between the breakfast and noon meal, but did not know if this had been done on this day. NA-H and NA-G proceeded to check the resident's disposable incontinent brief. The resident ' s slacks and disposable incontinent brief were saturated with urine (which indicated the resident had not been checked for incontinence and repositioned in a timely manner). B. Review of Resident 10's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS dated [DATE], 3/21/12 and 6/21/12 indicated the resident had short and long term memory problems, was totally dependent with bed mobility and was on a turning/repositioning program. Review of Resident 10's current Care Plan dated 6/22/12 revealed the resident was limited in bed mobility and wheelchair mobility as a result of weakness and impaired mobility. The Care Plan identified a goal for the resident to participate in bed mobility with assistance of 2 and to accept total assistance with wheelchair mobility. Interventions included provision of 2 assistants for repositioning, use of pillows and/or bolsters for repositioning and to provide adequate rest periods between activities. Resident 10 was observed lying in bed on right side without benefit of repositioning on 8/7/12 at 1:40 PM, 2:58 PM, 3:20 PM, 3:50PM and 4:10 PM (2 hours and 30 minutes). Resident 10 was observed sitting in the wheelchair without benefit of repositioning on 8/8/12 at 8:00 AM and 10:34 AM (2 hours and 34 minutes). Resident 10 was observed lying in bed on right side without benefit of repositioning on 8/8/12 at 2:05 PM, 3:00 PM, 4:00 PM, 4:20 PM, 4:35 PM, 4:45 PM and 5:10 PM (3 hours and 5 minutes). C. The Director of Nurses indicated during interview on 8/8/12 from 11:15 AM until 11:20 AM that the facility standard of practice was for staff members to reposition residents every 2 hours when residents were unable to reposition themselves. | 2015-07-01 |
| 11243 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 323 | D | 0 | 1 | G3Q011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review, observations and staff interview; the facility failed to implement interventions for the prevention of falls for Resident 3. Facility census was 34. Findings are: Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/11/12 revealed [DIAGNOSES REDACTED]. The MDS indicated the resident had short term memory problems and had 1 fall in the past 3 months with no injury. Review of the MDS dated [DATE] revealed the resident continued to have short term memory problems and no falls since the last assessment. Review of an Event Report dated 1/23/12 at 2:09 PM revealed at 1:45 PM the resident lost balance while ambulating with the aid of a walker and a nursing assistant. The resident fell backwards and slid to the floor. Documentation further indicated measures taken following the fall were the "use of gait belt (a belt placed around a resident's waist to assist with transferring the resident from one position to another by providing support for the resident and a safe hand hold for the caregiver) during transfers". Review of the current Care Plan dated 5/10/12 revealed the resident had a potential for injury as a result of poor safety awareness. The Care Plan specified a goal for the resident to remain free from injury. Interventions included the following: give resident verbal reminders not to ambulate/transfer without assistance, keep bed in lowest position with brakes locked, fall prevention program, provide an environment free of clutter, provide with safety device/appliance wheeled walker and wheelchair and use of a tabs alarm (A pull-string is attached to the resident's garment and sounds an alarm if the resident attempts to rise out of a chair or bed) at all times. There was no documentation to indicate the intervention of using a gait belt during transfers was added to the Care Plan. On 8/6/12 from 4:05 PM until 4:10 PM, Nursing Assistant (NA) C was observed to transfer Resident 3 out of a wheelchair and into bed. The resident required extensive assistance and no gait belt was used during the transfer. Review of an Event Report dated 7/21/12 at 12:27 AM revealed the resident was heard screaming and crying at 11:40 PM (on 7/20/12). Documentation further indicated the resident was confused. The resident was assisted to the bathroom, placed on the toilet and instructed to use the call light when finished on the toilet. At 12:00 midnight the resident was found sitting on the floor in front of the toilet and sink. On 8/7/12 Resident 3 was observed seated in a wheelchair with no tabs alarm in place at 3:00 PM, 4:00 PM, 4:35 PM and 5:30 PM. On 8/8/12 Resident 3 was observed left unattended while on the toilet in the bathroom from 9:26 AM until 9:45 AM (19 minutes). At 9:45 AM, NA-B entered the bathroom to assist the resident off of the toilet. NA-B had to awaken the resident and stated Resident 3 was "very sleepy" and "usually isn't that sleepy." No tabs alarm was in place. Interview with NA-B on 8/8/12 from 9:56 AM until 9:58 AM revealed NA-B was not the staff member who had assisted the resident onto the toilet. NA-B stated "I don't usually leave the resident alone in there." Interview with the Director of Nurses on 8/8/12 from 10:20 Am until 10:25 AM revealed Resident 3 should not be left alone while in the bathroom. Resident 3 was observed seated in a wheelchair in the dining room with no tabs alarm in place on 8/8/12 at 5:40 PM. | 2015-07-01 |
| 11244 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 371 | F | 0 | 1 | G3Q011 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.11e Based on observations, staff interview and record review; the facility failed to ensure dishes and utensils were cleaned under sanitary conditions and food was served in a sanitary manner and at safe temperatures. Facility staff did not maintain and operate the dishwashing machine according to manufacturer ' s instructions. In addition, facility staff did not wash hands and change gloves during meal service according to facility policy. A poached egg and a glass of milk were served to Resident 35 at an unsafe temperature. Facility census was 34. Findings are: A. Review of facility policy titled; "Food Preparation and Service" (revised November 2010) Cooking and Holding Temperatures and Times and Food Service/Distribution" revealed the following: -The "danger zone" for food temperatures is between 41 degrees and 135 degrees Fahrenheit (F). This temperature range promotes the rapid growth of pathogenic microorganisms that cause food borne illness. Food temperatures must be maintained at 40 degrees F or below or at 136 degrees F and above. -Potentially hazardous foods include meats, poultry, cut melon, eggs, milk, yogurt and cottage cheese. -Gloves must be worn when handling food directly. However, gloves can become contaminated and/or soiled and must be changed between tasks. B. During observation of the noon meal in the Assisted Dining Room on 8/6/12 from 11:50 AM until 12:34 PM, the Dietary Manager (DM) put on gloves and dished up plates of food from the steam table. The DM placed a plate of food in front of Resident 8 and offered to cut the chicken off of the bone. With gloved hands, the DM picked up the resident's fork and cut the chicken off of the bone. The DM did not remove gloves, returned to the steam table and proceeded to dish up plates of food for other residents. C. Observation of the breakfast meal in the Assisted Dining Room on 8/8/12 revealed the following: -At 8:00 A.M., the Dietary Cook (DC)-K placed a bowl of hot cereal and a plate with a poached egg and a cinnamon roll at the table setting for Resident 35. DC-K used empty plates to cover the cereal bowl and the plate with the egg and cinnamon roll. Resident 35 was not in the dining room and when asked DC-K stated the resident was, " still in bed. " In addition an uncovered 8 ounce glass of chocolate milk and a 4 ounce glass of orange juice was left at the table. -At 8:30 A.M., Nursing Assistant (NA)-B brought Resident 35 into the Dining Room and placed the resident at the table. NA-B handed the resident the glass of chocolate milk and removed the plate covering the cinnamon roll and poached egg. NA-B then cued the resident to begin eating. At that time, NA-B was asked to take the temperature of the poached egg and chocolate milk. NA-B left the dining room and returned with the DM who checked the food temperatures. The egg was 98 degrees Fahrenheit (F) and the glass of milk was 53 degrees F. C. Review of maintenance logs during the kitchen sanitation tour on 8/8/12 from 11:15 AM to 12:15 PM revealed no documentation for the routine testing of the concentration of the sanitizing solution for the facility dishwasher. Interview with the DM during the sanitation tour on 8/8/12 from 11:15 AM to 12:15 PM, verified no routine testing had been completed. D. During observation of the noon meal on 8/8/12 from 12:15 to 12:30 PM, DC-K washed hands and put on gloves then removed serving cart from the kitchen and took the cart to the Assisted Dining Room. With the same gloves on DC-K served 10 residents in the Assisted Dining Room, placed a piece of buttered bread on 9 out of 10 resident ' s plates, handled the serving cart, obtained supplies from a cupboard and handled residents ' diet cards. DC-K failed to wash hands or change gloves throughout the meal observation. At 12:30 PM, DC-K returned to the kitchen with the food cart and removed soiled gloves and washed hands. DC-K donned clean gloves and proceeded to plug in the serving cart, completed temperature checks of the food in the steam table and then began meal service for the Main Dining Room. Without the benefit of washing hands and changing gloves, DC-K picked up buttered pieces of bread for 22 out of 23 residents served. In addition throughout the meal service, DC-K handled each resident's diet card, stopped service to remove a piece of Salisbury steak from the refrigerator, heated the steak in the microwave and then checked the temperature of the steak. DC-K did not remove gloves or wash hands throughout the entire meal service. E. Dietary Manager when interviewed 8/9/12 from 9:45 AM to 10:00 AM confirmed DC-K did not use appropriate hand washing and gloving during meal service; and that DC-K should not have served Resident 35's meal when the resident was not available to eat. F. Review of the 7/1/2007 version of the " Food Code " , based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food sanitation practices, revealed: -4-501.115: " Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device " . -3-202.11 (A): " Potentially hazardous food shall be at a temperature of 41 degrees F. or below when received " . -3-202.11 (D) " Potentially hazardous food that is cooked to a temperature and for a specified amount of time and received hot shall be at a temperature of 135 degrees F. or above " . -2-301.14: " Food employees shall clean their hands and exposed portions of their arms ... (F); as often as necessary to prevent cross contamination when changing tasks and (I); after engaging in other activities that contaminate the hands " . | 2015-07-01 |
| 11245 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 441 | D | 0 | 1 | G3Q011 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observations, staff interview and record review; the facility failed to ensure respiratory equipment was stored and maintained in a sanitary manner to prevent cross contamination. Oxygen tubing with nasal cannula and a nebulizer machine with mask and tubing for Residents 34 and 35 were observed lying on the floor, in a trash receptacle and in Resident 34 ' s recliner. Facility census was 34. Findings are: Review of the Infection Control Policy titled; " Department (Respiratory Therapy) -Prevention of Infection " (revised October 2010) revealed the following: -Keep the oxygen cannula and tubing in a plastic bag when not in use. -Store Nebulizer equipment in a plastic bag, marked with date and the resident ' s name, between uses. Observations on 8/6/12 at 12:04 PM, 8/7/12 at 4:30 PM and 8/8/12 at 9:00 AM, revealed Resident 34 ' s nebulizer machine, tubing and mask were lying uncovered in the seat of Resident 34 ' s recliner. In addition the oxygen tubing and cannula to Resident 34 ' s oxygen concentrator were uncovered and were observed lying directly on the floor. Observation on 8/6/12 at 11:55 AM revealed the tubing and cannula to Resident 35 ' s oxygen concentrator were uncovered and tubing was draped across a trash receptacle at the resident ' s bedside. 2 cleansing cloths covered with feces were in the trash receptacle. The cannula was lying across the resident ' s water pitcher on the bedside table. On 8/7/12 at 9:00 AM, Resident 35 ' s oxygen tubing and cannula were again uncovered with the tubing lying directly on the floor and the cannula resting inside the bedside trash receptacle. Interview with the Administrator on 8/9/12 from 9:00 to 9:45 AM, revealed the nebulizer and oxygen equipment should be cleaned and stored according to facility policy. | 2015-07-01 |
| 11246 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-11-20 | 323 | G | 1 | 0 | R4Z111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE: 175 NAC 12-006.09D7 Based on observation, record review and staff interview; the facility failed to assess Resident 1who was identified with a history of falls. Assessments were not completed to identify causal factors and additional interventions were not developed to protect residents from further falls with injury. The facility had a census of 35. Findings are: A. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/16/12 revealed resident had short and long term memory loss with severely impaired decision making skills. Identified [DIAGNOSES REDACTED]. The MDS reflected Resident 1 required extensive assist of 2 staff with bed mobility and total assist of 1 staff with transfers and dressing. Assessment further revealed Resident 1 had a history of [REDACTED]. Review of Resident 1's Care Plan dated 6/15/12 reflected the resident had potential for injury related to restlessness, poor balance and due to unawareness of safety hazards. Care Plan interventions included: -3/17/11 Fall assessment every quarter and prn (as needed). -3/17/11 TABS alarm (a personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) at all times. -3/3/11 Give verbal reminders not to ambulate or transfer without assistance. -3/17/11 Provide proper, well maintained footwear. -3/17/11 Keep call light within reach at all times. -3/17/11 Provide with a clutter free environment. -3/17/11 Keep personal items and frequently used items within reach. -3/17/11 Keep bed in lowest position (mattress on floor with mat at bedside) -3/17/11 Encourage resident to participate in restorative program. -3/17/11 Assure the floor is free of glare, liquids, and foreign objects. -3/17/11 Assure resident is wearing eyeglasses. Assure eyeglasses are clean and in good repair. -10/3/12 Ask resident if resident would like a snack or is lonely. Assist resident to dining area to be with people. -10/8/12 Give Rx (prescription) as ordered for restlessness. Review of facility Event Report revealed: Resident fell on [DATE] at 6:34 PM. Family had just left from visiting the resident and staff heard the resident hollering for help. Staff found resident in the bathroom on knees in front of the stool with urine all over the floor and clothes half off. Staff documented an intervention for a bed alarm on the Event Report. Review of Fall Risk Assessment completed for Resident 1 on 9/20/12 revealed a total documented score of 25. Assessment further identified a score greater than 10 indicated a high risk for falls. Review of facility Event Reports from 9/29/12 through 10/27/12 revealed: -Resident fell on [DATE] at 3:56 AM. Resident was restless and confused and refused to remain in bed. Staff placed the resident in a wheelchair and brought to the Nurse's Station. The resident pulled TABS alarm off repeatedly in attempts to self- transfer. Staff took resident back to room as was loudly yelling out "nurse". When checked in room, staff found resident on the floor by the doorway. Resident complained of pain to back. Staff documented an intervention for bed alarm and chair/wheelchair alarm on Event Report. -Resident fell [DATE] at 6:30 PM. Resident was making repeated attempts to stand up in wheelchair. Staff told the resident to sit down. Resident put feet on outside of wheelchair peddles, stood up and leaned forward. The resident went to take a step and fell back into the doorway and then to the floor. Staff documented "other" for a new intervention on the Event Report. -Resident fell [DATE] at 1:02 AM. Resident 1 was found sitting on the floor in the assisted eating area of the dining room. Staff documented an intervention for a bed alarm on the Event Report. -Resident fell [DATE] at 6:10 PM. Resident fell when attempted to stand up from wheelchair unassisted. Staff documented an intervention for personal alarm and for "other" on the Event Report. -Resident fell [DATE] at 9:30 PM. Resident was found on the floor at the foot of the bed with head leaning against the wall. No interventions were documented on the Event Report. Review of Resident 1's Progress Notes revealed: -On 11/3/12 at 7:45 AM Resident 1's TABS alarm was sounding and when staff entered the resident's room the resident was observed to be lying on back near the bathroom door. Resident complained of left hip pain and was unable to straighten left leg. Order received to transfer the resident to emergency room for evaluation. At 11:45 AM call was received from the hospital and resident was diagnosed with [REDACTED]. -On 11/9/12 at 12:30 PM Resident 1 returned from the hospital after surgical repair of left hip fracture. Review of Resident 1's Care Plan dated 6/15/12 indicated there were no interventions initiated for the prevention of falls until 10/3/12, a nursing intervention to ask the resident if the resident would like a snack, or to ask the resident if the resident is lonely, and 10/8/12 to give Rx as ordered for restlessness. No additional interventions were developed to protect the resident from falls or injury. During observation of on 11/20/12 from 11:48 AM to 11:54 AM, Nursing Assistant (NA)-C and NA-A assisted Resident 1 from the bed to the wheelchair. There was a pressure pad alarm and a TABS alarm on the resident's bed and staff transferred the alarms to the resident's wheelchair. The resident's bed was in the low position and fall mat was on the floor next to the bed. There were no further interventions for the prevention of falls observed than those indicated on the Care Plan 10/3/12 and 10/8/12. Interview on 11/20/12 from 10:55 AM to 11:33 AM with the Director of Nursing (DON) confirmed Resident 1 had falls that occurred on 8/12/12, 9/29/12, 10/9/12, 10/22/12, 10/27/12 and 11/3/12 with no new interventions identified on the Care Plan to prevent further falls from occurring or to protect the resident from injury. The DON also verified no new Fall Risk Assessments were completed since 9/20/12 on Resident 1 to help identify causal factors for falls. B. Review of Resident 2's admission MDS revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] indicated the resident required limited assistance with bed mobility and transfers, and extensive assistance with locomotion/ambulation and toileting. The same MDS further indicated Resident 2 had severely impaired cognitive skills for daily decision making. Review of a Fall Risk assessment dated [DATE] revealed Resident 2 was at risk for falls and care plan interventions were initiated to use personal alarms at all times. Review of Resident 2's Care Plan dated 10/15/12 indicated the resident had a potential for falls related to decreased mobility, strength and endurance, decreased safety awareness, and an alteration in balance. The following nursing interventions were in place: "Start Date" 7/23/12 - sensor mat (a pad placed beneath a resident that sounds an alarm when the resident gets up) and TABS alarm on at all times, remind to call for help before mobilizing, place call light within reach, involve in meaningful activities, check every 1 to 2 hours for safety and positioning. "Start Date" 8/23/12 - keep bed at low position, fall mat on floor next to bed at all times Review of Resident 2's Nursing Progress Notes from 9/1/12 until 10/02/12 revealed the following: - 9/3/12 at 2:30 AM - After supper, a resident alerted staff that Resident 2 "set on the floor" inside room. The TABS alarm was not on but the resident "has been known to remove it" on own. - 9/6/12 at 3:33 PM - Resident found on floor in room with TABS alarm in hand. The physician was notified of low blood pressure (BP) and order obtained to hold BP medication until BP above 150/80. - 9/8/12 at 2:15 PM - Resident found on floor in room; TABS alarm and chair sensor alarm on and active. - 9/13/12 at 2:03 PM - Non-compliant with asking for help and using call light. Caught resident trying to get out of chair and almost on floor. Both alarms were on resident. - 9/22/12 at 10:00 AM - Staff responded to TABS alarm and found resident kneeling on floor beside bed. Resident was agitated and indicated need to use the bathroom. - 9/26/12 at 11:15 AM - Found resident in bathroom and on the floor. TABS alarm and pressure pad in place and actively working. - 9/27/12 at 1:53 PM - Resident removes TABS alarm but bed alarm does work. TABS alarm was tied to resident ' s night gown and resident became very upset because could not get it off. - 10/2/12 at 2:44 PM- Seated on floor at foot of bed, pants to ankles, clean incontinent brief in hand, shoes off and attempting to don the incontinent brief. " Mobility alarm " remains on bed but not attached. " Speculate " resident got up per self for toileting, had soiled incontinent brief and went to closet to get a clean one. Review of Resident 2's Care Plan dated 10/15/12 indicated there were no new interventions initiated for the prevention of falls until 9/26/12, a nursing intervention to provide positive reinforcement to have resident utilize the call light system, and 10/3/12 to attend to the resident quickly once alarms are heard as resident doesn ' t wait for assistance. Review of Resident 2's Nursing Progress Notes dated 10/5/12 at 1:36 PM indicated the resident was found on the floor in the bathroom doorway wedged between the wheelchair and the door jam. Review of a Falls Risk assessment dated [DATE] indicated Resident 2 was at high risk for falls and the current plan of care would be continued. Documentation further indicated the resident was currently receiving restorative nursing and on a falls prevention program. Review of Resident 2's Nursing Progress Notes from 10/19/12 until 11/5/12 revealed the following: - 10/19/12 at 1:19 AM - At 8:30 PM heard a banging sound and found Resident 2 trying to sit on garbage can to use as a toilet as the bathroom was occupied. Resident was holding the TABS alarm cord. Assisted to standing position. - 10/22/12 at 1:24 AM - At 7:15 PM staff answered call light and found Resident 2 sitting on floor in front of recliner. Roommate witnessed the resident slide self to the floor. - 10/25/12 at 3:44 PM - Found resident on floor in room, lying on right side. - 10/27/12 at 1:38 PM - At 7:20 PM resident was found lying on right side on floor in front of dresser. Alarm and call light were sounding when staff found resident on floor. At 8:15 PM resident was having difficulty ambulating, complained of pain, and did not want to bear weigh on right leg. The physician was notified and an order received to transport the resident to hospital for evaluation. - 11/5/12 at 4:25 PM - Resident 2 returned to the facility from the hospital, status [REDACTED]. Review of Resident 2's Care Plan dated 10/15/12 indicated the plan of care had not been reviewed and/or revised related to nursing interventions for the prevention of falls since 10/3/12. During observation on 11/20/12 from 10:26 AM until 10:30 AM, Nursing Assistant (NA)-C and the hospital Physical Therapy Assistant (PTA) assisted Resident 2 from the wheelchair to the bed so the PTA could perform range of motion (ROM) exercises. The PTA indicated the resident was receiving therapy 5 days weekly. There was a sensor alarm in the seat of wheelchair and on the resident's bed. There was a floor mat on the floor in the corner of the room. NA-C reminded the PTA to position the floor mat next to the bed when finished with the ROM exercises. There were no further interventions for the prevention of falls observed other than those initially indicated on the care plan 7/23/12 and 8/23/12. | 2015-07-01 |
| 11247 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-05-02 | 312 | E | 1 | 0 | L4W811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observations, record review and staff interview; the facility failed to provide toileting assistance and personal hygiene for 4 residents (Residents 5, 9, 7 and 1) who required assistance with activities of daily living. Facility census was 24. Findings are: A. Review of Resident 5's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/4/13 indicated the resident was totally dependent with toileting and personal hygiene. Nursing Assistant (NA)-A and NA-B were observed to assist Resident 5 to the toilet on 5/1/13 from 2:18 PM until 2:41 PM. The resident's disposable incontinent brief and slacks were saturated with urine. Following toileting, NA-B assisted Resident 5 to stand. NA-B cleansed the resident's buttock and rectal area. NA-B did not cleanse the resident's frontal perineal area and inner groin/thighs. The resident's hands were not washed upon completion of care. Interview with NA-B on 5/1/13 from 2:18 PM until 2:41 PM revealed NA's were "about an hour late" in assisting Resident 5 to the toilet and the resident was last toileted approximately 11:30 AM or 11:45 AM (which indicated the resident had not been toileted for approximately 2 hours 33 minutes to 2 hours 48 minutes. B. Review of Resident 9's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. NA-A and NA-B were observed to assist Resident 9 to the toilet on 5/1/13 from 3:20 PM until 3:30 PM. The resident's disposable incontinent brief was wet with urine. Upon completion of toileting, NA-B did not cleanse the resident's frontal perineal area and inner groins/thighs. The resident's hands were not washed upon completion of care. C. Review of Resident 7's MDS dated [DATE] and 5/2/13 indicated the resident was totally dependent with toileting and personal hygiene. NA-A and NA-B were observed to assist Resident 7 to the toilet on 5/1/13 from 3:40 PM until 4:05 PM. The resident's disposable incontinent brief and slacks were saturated with urine. The seat cushion in the resident's wheelchair was also wet with urine. At 3:55 PM, NA-D was summoned to the room to monitor the resident who was still seated on the toilet. NA-A and B exited the room after giving NA-D instructions to call for assistance when Resident 7 was finished on the toilet. At 4:00 PM, NA-D and Registered Nurse (RN)-C assisted Resident 7 off of the toilet. NA-D cleansed the resident's rectal and buttock area but did not cleanse the resident's inner groin/thigh and frontal perineal areas. The resident's hands were not washed upon completion of care. D. Review of Resident 1's MDS dated [DATE] indicated the resident was totally dependent with toileting and personal hygiene. NA-A and NA-B were observed to assist Resident 1 to the toilet on 5/1/13 from 4:50 PM until 5:05 PM. NA-B pulled down the resident's slacks. The resident was wearing 2 disposable incontinent briefs. The outer disposable incontinent brief was dry but the inner brief was wet with urine. Upon completion of toileting, NA-B did not cleanse the resident's frontal perineal area and inner groins/thighs. The resident's hands were not washed upon completion of care. NA-B indicated during interview on 5/1/13 from 4:50 PM until 5:05 PM that the resident refused to use the toilet at approximately 1:30 PM or 1:45 PM (which indicated the resident had not been offered another opportunity to use the toilet for 3 hours 5 minutes to 3 hours 20 minutes). | 2015-07-01 |
| 11248 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-05-02 | 353 | E | 1 | 0 | L4W811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observations, record review and staff interviews; the facility failed to provide sufficient nursing staff to meet resident's needs related to: 1) failure to provide personal hygiene and toileting assistance for Residents 5, 9, 7 and 1 who required assistance with activities of daily living; 2) concerns regarding shortage of nursing staff on duty voiced during 2 of 3 confidential family interviews; 3) concerns regarding insufficient staffing voiced during 2 confidential resident interviews and; 4) failure to ensure the number of staff on duty was in accordance with the planned staffing pattern on 4/27/13. Findings are: A. Review of Resident 5's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/4/13 indicated the resident was totally dependent with toileting and personal hygiene. Nursing Assistant (NA)-A and NA-B were observed to assist Resident 5 to the toilet on 5/1/13 from 2:18 PM until 2:41 PM. The resident's disposable incontinent brief and slacks were saturated with urine. Following toileting, NA-B assisted Resident 5 to stand. NA-B cleansed the resident's buttock and rectal area. NA-B did not cleanse the resident's frontal perineal area and inner groin/thighs. The resident's hands were not washed upon completion of care. Interview with NA-B on 5/1/13 from 2:18 PM until 2:41 PM revealed NA's were "about an hour late" in assisting Resident 5 to the toilet and the resident was last toileted approximately 11:30 AM or 11:45 AM (which indicated the resident had not been toileted for approximately 2 hours 33 minutes to 2 hours 48 minutes. B. Review of Resident 9's MDS dated [DATE] indicated the resident was totally dependent with toileting and personal hygiene. NA-A and NA-B were observed to assist Resident 9 to the toilet on 5/1/13 from 3:20 PM until 3:30 PM. The resident's disposable incontinent brief was wet with urine. Upon completion of toileting, NA-B did not cleanse the resident's frontal perineal area and inner groins/thighs. The resident's hands were not washed upon completion of care. C. Review of Resident 7's MDS dated [DATE] and 5/2/13 indicated the resident was totally dependent with toileting and personal hygiene. NA-A and NA-B were observed to assist Resident 7 to the toilet on 5/1/13 from 3:40 PM until 4:05 PM. The resident's disposable incontinent brief and slacks were saturated with urine. The seat cushion in the resident's wheelchair was also wet with urine. At 3:55 PM, NA-D was summoned to the room to monitor the resident who was still seated on the toilet. NA-A and B exited the room after giving NA-D instructions to call for assistance when Resident 7 was finished on the toilet. At 4:00 PM, NA-D and Registered Nurse (RN)-C assisted Resident 7 off of the toilet. NA-D cleansed the resident's rectal and buttock area but did not cleanse the resident's inner groin/thigh and frontal perineal areas. The resident's hands were not washed upon completion of care. D. Review of Resident 1's MDS dated [DATE] indicated the resident was totally dependent with toileting and personal hygiene. NA-A and NA-B were observed to assist Resident 1 to the toilet on 5/1/13 from 4:50 PM until 5:05 PM. NA-B pulled down the resident's slacks. The resident was wearing two disposable incontinent briefs. The outer disposable incontinent brief was dry but the inner brief was wet with urine. Upon completion of toileting, NA-B did not cleanse the resident's frontal perineal area and inner groins/thighs. The resident's hands were not washed upon completion of care. NA-B indicated during interview on 5/1/13 from 4:50 PM until 5:05 PM that the resident refused to use the toilet at approximately 1:30 PM or 1:45 PM (which indicated the resident had not been offered another opportunity to use the toilet for 3 hours 5 minutes to 3 hours 20 minutes). E. Two of three confidential family interviews voiced concerns regarding a shortage of nursing staff. One family member stated "No, they don't have enough help." Another family member indicated there was not enough staff on duty especially in the early evening hours. Both family members indicated there were occasions when they had observed their family member (resident) or other residents of the facility to be incontinent of urine. F. Two out of five confidential resident interviews voiced concerns regarding a shortage of nursing staff. One resident stated, "When I pull my call light to go to the bathroom sometimes it takes a really long time before someone comes to help me." Another resident stated, "This last Saturday I pulled my light on the night shift because I had to go to the bathroom and no one came and helped me until the morning." Both residents indicated they waited for longer time frames for response to call lights during the evening and the night shifts. G. Review of the facility Nursing Schedule revealed that from 4/27/13 at 6:00 PM until 4/28/13 at 6:00 AM (12 hour night shift) Licensed Practical Nurse (LPN)-E and NA-H were scheduled to work. H. Review of Resident 3's MDS dated [DATE] indicated the resident required extensive assistance with transfers and toileting and had a history of [REDACTED]. Review of Progress Notes dated 4/27/13 for Resident 3 revealed the following: --At 9:02 PM, resident became weak while walking to the dining room and had difficulty with moving right leg. -At 11:05 AM, resident complained of a headache and was unable to stand on left leg and complained of not being able to see out of left eye. Blood pressure reading was 150/100. Resident was taken to the clinic to be evaluated by a physician. -At 2:26 PM, Resident 3 returned from the clinic with a [DIAGNOSES REDACTED]. Director of Nursing (DON) was notified and instructed staff to complete "round the clock vitals for 24 hours or longer until resident stabilizes". -At 3:00 PM, resident's alarm sounded and staff found the resident with legs and feet still on the bed and the resident's face on the floor. -At 4:00 PM, DON was notified of the resident's fall and stated, "If resident continues to be so restless, to place in room near the Nurse's station". -At 8:30 PM, resident assisted with 2 staff into bed as continued to have difficulty standing on own. Resident remained confused. Review of Progress Notes dated 4/28/13 for Resident 3 revealed the following: -5:39 AM, "Resident has rested most of the shift, has been awakened for vitals and with this is mostly confused on date and time. Continues to be unsteady with ambulation and we have been using 2 staff to assist on this shift. One time when we checked on the resident and did our vital signs, the resident had the alarm off and was trying to get out of bed. An additional alarm was added to the bed as an extra precaution." I. A review of Resident 10's MDS dated [DATE] indicated the resident had signs and symptoms of delusions and [MEDICAL CONDITION] with frequent verbal and physical behaviors directed at others. A review of Progress Notes dated 4/27/12 for Resident 10 revealed the following: -At 6:00 PM, resident was seated at the dining room table yelling, "Nurse". -At 7:22 PM, resident continued to yell at the staff and attempted to swing at the staff. -At 7:35 PM, resident's family was called and came to the facility to sit with the resident due to behaviors. Resident was swinging at family members as they visited. J. Interview with DON on 5/2/13 from 10:00 AM to 10:15 AM revealed the facility normally scheduled one nurse and one NA from 6:00 PM until 6:00 AM, and another NA from 2:00 PM until 8:00 PM. DON verified on 4/27/13 the nursing assistant who was to work from 2:00 PM until 8:00 PM did not show up for work and no other staff was available to work during this time frame. In addition, the DON confirmed facility staff called in family for Resident 10 due to the resident's behaviors and Resident 3 requiring hourly checks throughout the shift due to medical condition. | 2015-07-01 |
| 11249 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 226 | D | 1 | 1 | 320W11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on record review and staff interview, the facility failed to report, investigate and protect Resident 5 following an injury of unknown origin. Facility census was 27. Findings Are: Review of Abuse-Allegation and Reporting Policy/Procedure revised 06/13 revealed the following: - "The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress" . - "Report any knowledge of all alleged violations involving mistreatment, neglect or abuse immediately to a Supervisor or Administrator or in his/her absence, to his/her designee. Bruises, cuts, skin tears or other injury of unknown origin will be investigated and reported as potential resident abuse" . - "During the investigation process, the facility must prevent further physical abuse, mistreatment or verbal aggression ....ensure increased monitoring of at risk residents" . Review of Resident 5's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 9/22/13 revealed Resident 5 had severely impaired cognitive functioning and required total assist for toilet use, personal hygiene, dressing, bed mobility and transferring. Review of Resident 5's medical record revealed a progress note written on 11/5/13 at 2:54 PM stating, "Noted bruise to upper sternum. Resident cannot verbalize how (resident) received the bruise. 3.5 centimeter (cm) by 3 cm. Two small dots just to the bottom left and bottom right also noted. Resident denies any pain related to bruises. Will continue to monitor" . During an interview with the Director of Nursing (DON) on 11/12/13 at 11:28 AM the DON was unaware of Resident 5's bruising. DON stated staff would look to see if an investigation had been done on the bruising. Interview with DON on 11/12/13 at 12:19 PM revealed an investigation was begun on 11/12/13 and the nurse was working on the investigation currently. Interview with DON on 11/12/13 at 4:33 PM confirmed the investigation had not been done prior to 11/12/13. The DON confirmed all bruises, injuries, and falls should be reported through an event report. Review of the Event Report dated 11/12/13 for Resident 5 revealed no new interventions in place to prevent further bruising. | 2015-07-01 |
| 11250 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 253 | E | 0 | 1 | 320W11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A1 Based on observations and staff interview; the facility failed to maintain clean ventilation systems in the bathrooms of 11 resident rooms (Resident Rooms 105, 106, 107, 108, 109, 112, 113, 114, 119, 121 and 124). Facility census was 27. Findings are: During the environmental tour of the facility on 11/7/13 from 9:15 AM until 10:21 AM and accompanied by the Maintenance Supervisor, bathroom vents and/or ventilation ducts were heavily coated with dust and lint in Resident Rooms 105, 106, 107, 108, 109, 112, 113, 114, 119, 121 and 124. During interview on 11/7/13 from 9:15 AM until 10:21 AM, the Maintenance Supervisor verified there was a build-up of dust and lint in the bathroom ventilation system, and that the system was in need of cleaning. | 2015-07-01 |
| 11251 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 280 | E | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews; the facility failed to review and revise Care Plans related to fall interventions for Residents 27, 15 and 23. In addition, Resident 15's Care Plan was not revised for prevention and treatment of [REDACTED]. A. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for Care Planning) dated 10/16/13 indicated [DIAGNOSES REDACTED]. The assessment indicated Resident 15 was at risk for pressure sore development and had a history of [REDACTED]. The MDS further indicated Resident 15 was at risk for falls and the resident had sustained 1 fall without injury and 2 falls with injury since the previous assessment. Review of Care Plan dated 11/1/13 revealed Resident 15 had a history of [REDACTED]. Interventions included the following: -9/25/12 Tab alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) on at all times -10/17/12 pressure pad alarm (an electronic pressure sensitive sensor pad designed for use in chairs or beds which will alarm if a resident tries to get up without assistance) on at all times -12/13/12 may put mattress on floor for resident to sleep on per resident's request -7/25/13 may use tilt-n-space wheelchair -10/30/13 ensure Tabs alarm cord length is adjusted to proper length -may use sit-to-stand mechanical lift for transfers -bolsters to resident's bed and fall mat on floor next to bed -keep bed in lowest position with brakes locked -observe resident frequently and place in supervised areas when out of bed In addition Resident 15's Care Plan indicated the resident was at risk for pressure sores. Interventions included the following: -keep heels elevated. -keep feet and heels moisturized -keep heels protected as resident allows and remind resident that rubbing heels on the chair aggravates the wound on heel. -6/15/13 to keep heels on "heels up" device to prevent pressure Review of Resident 15's Event Reports revealed the following: -8/22/13 at 4:30 PM, the resident was found on the floor by the bathroom door. Wheelchair was behind the resident, resident noted to have 3 skin tears to right hand/forearm. There was no documentation of any causal factors identified or of any new interventions to protect resident from further falls. -9/18/13 at 11:40 AM, the resident was found lying on the floor in front of the wheelchair with no injuries evident. There was no documentation of any causal factors identified or of any new interventions to protect resident from further falls. Review of Resident 15's Fall Risk assessment dated [DATE] revealed the resident was identified at high risk for falls. Review of Resident 15's Braden Scale For Predicting Pressure Sore Risk dated 10/15/13 indicated a total score of 14 (score of 13-14 indicated moderate risk). Review of Resident 15's Event Report dated 10/29/13 revealed at 4:05 PM, the resident slid out of wheelchair onto the Dining Room floor. Tabs alarm was in place but was not activated. Staff shortened the cord of the alarm to ensure prompt activation of the alarm; however no casual factors for the fall were documented. Review of "Event Report" dated 11/1/13 revealed a Hospice Nurse had informed facility staff of an intact blister to Resident 15's left lateral heel. This report indicated the area surrounding the blister was intact, slightly red and had a "mushy" feeling. The report further identified Resident 15 refused to leave heel protectors on feet and had requested to wear shoes. The resident's Care Plan did not reflect the resident's non-compliance with use of heel protectors. During an interview on 11/7/13 from 11:00 to 11:15 AM, the Director of Nursing (DON) confirmed staff was expected to review interventions after all falls and that staff were to revise and implement new interventions to prevent potential injury from further falls. During an interview on 11/6/13 from 2:47 PM to 2:55 PM, Nursing Assistant (NA)-A verified Resident 15 was to wear heel/ankle protectors at all times but indicated the resident was not always compliant with leaving them in place. NA-A stated, "The resident used to have heel protectors in the room but I don ' t know where they are or what happened to them." Review of the Registered Dietician's progress notes dated 11/6/13 indicated the resident was receiving adequate nutrition to promote healing but the resident chose to consume less than adequate nutrition. Furthermore, healing was not expected unless friction could be removed. No new interventions were identified on the Resident's Care Plan Review of fax from the physician dated 11/7/13 (6 days after the areas to the resident's left heel were identified) revealed an order for [REDACTED]. Review of "Event Report" dated 11/7/13 revealed facility staff had identified a new reddened area to Resident 15's medial left heel. The area measured 1 cm x 2.5 cm and was not opened at the time. There was no documentation on the resident's Care Plan related to this area. During an interview with the Director of Nursing (DON) on 11/7/13 from 11:00 AM to 11:15 AM, the DON verified facility staff should have updated and revised Resident 15's Care Plan to reflect new areas of breakdown to the left heel and recommendations from the Registered Dietician and the physician. B. Review of Resident 23's MDS dated [DATE] revealed the following: - Resident 23 scored 7 on the Brief Interview for the Mental Status (an assessment used to determine mental ability). A score of 0-7 indicated the resident's cognition was severely impaired. - Resident 23 required extensive assistance with bed mobility, transferring, dressing, toilet use and personal hygiene. Review of Resident 23's Care Plan dated 1/13/13 revealed a problem of "Risk for falls related to (R/T) unsteadiness" , a goal of "Resident will remain free of falls " and the following Approaches: - "Encourage/Remind resident to ask for assistance before transferring (gender) to the bathroom" . - "Encourage and praise resident for asking for assistance" . - "Tabs at all times" . - "Wheelchair (W/C) for ambulation at all times with exception of full weight walker (FWW) walker w/stand by staff assist per physical therapy (PT) orders" . - "Staff is to make resident's bed daily" . - "Assure resident is wearing eyeglasses. Assure eyeglasses are clean and in good repair" . - "Assure the floor is free of glare, liquids, foreign objects" . - "Encourage resident to assume a standing position slowly" . - "Encourage resident to use environmental devices: (e.g., handrails, grab bars, etc.) Walker can be used with stand by assist only" . - "Keep bed in lowest position with brakes locked" . - "Keep call light in reach" . - "Keep environment free of clutter" . - "Keep personal items and frequently used items within reach" . - "Leave night light on in room" . - "Provide proper, well-maintained footwear. Do not allow resident to walk in stocking feet" . - "Resident (res.) Will ask staff for help when she wants to hang clothes in closet" . Review of Resident 23's Care Plan dated 8/21/13 revealed a problem of " Resident non-compliant w/transfers and ambulation. Walking without the recommended assistance. Benefits versus Risk have been explained to resident and power of attorney (POA) and form signed" , a goal of "Resident will ask for assistance for transfers and ambulation" and the following Approaches: - "Frequent resident contact" . - "Remind resident of the benefits vs. risk" . - "Remind resident to use (gender) call light at all times" . Review of Resident 23's Care Plan dated 3/9/11 revealed a problem of "Resident is limited in mobility and requires the use of a wheel chair. Can ambulate w/front wheel walker with stand by assist only" , a goal of " ...will safely ambulate thru out the facility with the use of wheeled walker (w/w)" and the following Approaches: - "Teach resident safety measures. Instructed res to use call light to kill bugs" . - "Adapt environment to maximize (Resident 23) safety and independence: grab bars and clear pathways" . - "Instruct (Resident 23) in proper technique" . - "Provide oversight for ambulation" . - "Teach (Resident 23) safety measures" . Observations of Resident 23 on 11/6/13 from 12:51 PM until 2:57 PM and on 11/7/13 from 6:38 AM until 8:08 AM revealed Resident 23 to have a tabs and sensor alarm attached to the back of her wheelchair. Observations of Resident 23 on 11/7/13 at 9:11 AM revealed RN-E exit Resident 23's bathroom, shutting the door but not latching it. Resident 23's wheelchair was not observed to be in the room. At 9:20 AM Resident 23 was heard yelling for help 3 times before NA-H entered the room to assist Resident 23. During an interview with NA-H on 11/7/13 at 10:21 AM it was confirmed Resident 23 was left unsupervised in the bathroom. NA-H confirmed Resident 23's wheelchair was in the bathroom with the resident and the resident ' s tabs alarm had been removed from the wheelchair, attached to the resident and left attached to a handrail in the bathroom. During an interview with DON and Administrator on 11/7/13 at 11:28 AM it was revealed residents who have tabs alarms not be left in the bathroom unattended. Observations of Resident 23 on 11/12/2013 from 9:30 AM until 2:48 PM and 11/13/2013 at 7:14 AM revealed Resident 23 to have a tabs and sensor alarm attached to the back of resident's wheelchair. Review of Resident 23's Care Plan revealed the approaches of a sensor alarm and not leaving the resident unattended in the restroom were not identified. C. Review of Resident 27's Care Plan dated 11/29/12 indicated the resident was at risk for falls related to unsteady gait, poor vision and cognitive deficits. Interventions included assistance with ambulation as needed and keeping the resident's bed in the lowest position. Review of Resident 27's Care Plan dated 1/18/13 indicated the resident was at risk for falls due to decreased safety awareness and unsteady gait. Additional interventions included to assure the floor was free of glare, liquids and foreign objects, involve the resident in meaningful activities, and leave a night light or room light on during the night. An additional intervention dated 4/29/13 was to monitor seating at activities. Review of an Event Report dated 6/26/13 at 4:20 PM indicated Resident 27 fell in the dining room. The report indicated the resident was standing independently; the resident's legs "twisted" as the resident turned, and the resident "tripped over right leg". The resident was transferred to the hospital for x-rays of the right hip. Review of a Progress Note dated 6/26/13 at 8:32 PM revealed Resident 27 had a [MEDICAL CONDITION] and was admitted to the hospital for a hip repair. Following Resident 27's fall with fracture, there was no documentation to indicate the resident's Care Plan was reviewed and revised to prevent the occurrence of further falls. | 2015-07-01 |
| 11252 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 282 | E | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on observations, record review and staff interview; the facility failed to implement Care Plan interventions for Resident 36 regarding prevention of agitated behaviors, Resident 15 regarding prevention of falls and pressure sores, and Resident 24 regarding toileting assistance. Facility census was 27. Findings are: A. Review of Resident 36's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/18/13 identified [DIAGNOSES REDACTED]. The same MDS indicated the resident had severely impaired cognitive functioning and displayed adverse behavioral symptoms on a daily basis. Review of current Care Plan dated 9/11/13 revealed the resident displayed behaviors of crying, being tearful and having "outbursts" with a goal for the resident to exhibit fewer behaviors in the next 90 days. Interventions included the following: -"Outbursts; intervene if necessary and remove to quite (quiet) area ..." -"When I become socially inappropriate/disruptive, move resident to a quiet, calm environment ..." Resident 36 was observed seated at a table in the dining room on 11/6/13 at 3:15 PM while a group activity was in progress. The television at the end of the dining room was also on which caused additional noise in the area. The resident had an anxious expression and talked in a loud voice about getting some popcorn for a sibling. No attempts were made to move the resident to a quieter area. At 3:40 PM, the resident remained seated at a table in the dining room and was speaking in a loud shrill voice. Other residents were seated in the dining room and continued to participate in the group activity. At 3:41 PM, Licensed Practical Nurse (LPN) D stated the resident was going to receive a dose of prn (as needed) [MEDICATION NAME] (medication used for anxiety). LPN-D commented the [MEDICATION NAME] "really does work" in decreasing the resident's anxiety and agitation. LPN-D proceeded to administer an oral dose of [MEDICATION NAME] to Resident 36. No attempt was made to move the resident to a quiet area of the facility. At 3:53 PM Resident 36 remained seated at the table in the dining room with an anxious expression. At 3:56 PM, Resident 36 wheeled self away from the dining room table and sat in the center of the dining room while the group activity remained in progress. The resident continued to speak loudly and talked about wanting to lie down. An unidentified resident called out and asked Nursing Assistant (NA)-A to help Resident 36 lie down. NA-A then offered to help Resident 36 lie down and the resident stated in a loud voice "no way". At 4:00 PM, Resident 36 remained seated in the center of the dining room with an anxious expression. No attempts were made to move the resident to a quiet, calm area. B. Review of Resident 15' s MDS dated [DATE] indicated [DIAGNOSES REDACTED]. The assessment indicated Resident 15 was at risk for pressure sore development and had a history of [REDACTED]. The MDS further indicated Resident 15 was at risk for falls and the resident had sustained 1 fall without injury and 2 falls with injury since the previous assessment. Review of Care Plan dated 11/1/13 revealed Resident 15 had a history of [REDACTED]. Interventions included the following: -9/25/12 Tab alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) on at all times -10/17/12 pressure pad alarm (an electronic pressure sensitive sensor pad designed for use in chairs or beds which will alarm if a resident tries to get up without assistance) on at all times -12/13/12 may put mattress on floor for resident to sleep on per resident's request -7/25/13 may use tilt-n-space wheelchair -10/30/13 ensure Tabs alarm cord length is adjusted to proper length -may use sit-to-stand mechanical lift for transfers -bolsters to resident's bed and fall mat on floor next to bed -keep bed in lowest position with brakes locked -observe resident frequently and place in supervised areas when out of bed In addition Resident 15's Care Plan indicated the resident was at risk for pressure sores. Interventions included the following: -keep heels elevated. -keep feet and heels moisturized -keep heels protected as resident allows and remind resident that rubbing heels on the chair aggravates the wound on heel. -6/15/13 to keep heels on "heels up" device to prevent pressure During observations of Resident 15 on 11/5/13 from 3:13 PM to 4:50 PM, the resident was observed seated in a Broda (a wheelchair alternative that allows for repositioning of the resident) chair with no heel/ankle protectors and no pressure relieving device noted to the foot rest of the chair to keep the resident's heels elevated. Observations on of Resident 15 on 11/6/13 revealed the following: -at 6:48 AM, the resident was lying in bed. The resident's bed was in the low position with bolsters in bed, fall mat on the floor and Tabs alarm in place. The pressure pad alarm was not on the resident's bed but was lying in the recliner next to the resident's bed. -8:14 AM to12:50 PM, the resident was positioned in wheelchair with Tabs alarm in place. No heel/ankle protectors were in place and no pressure relieving device was in place to keep the resident's legs elevated. In addition, the pressure pad alarm was not attached to the resident's chair. During an observation on 11/6/13 at 3:24 PM, Resident 15 was seated in the Broda chair with the chair reclined and the foot rest elevated. The resident was barefoot with no heel/ankle protectors in place and no pressure relieving device in place to foot of chair to keep the resident's heels elevated. Observations of Resident 15 on 11/7/13 revealed the following: -at 6:40 AM, resident was awake, lying in bed. No pressure pad alarm was in place to the resident's bed. All other identified fall interventions were in place. The resident was not wearing heel/ankle protectors, the resident's legs were not elevated and the resident's heels were lying directly on the surface of the mattress. The "heels up" positioning device was lying in the resident's recliner next to the resident's bed. -8:04 AM to 10:24 AM, the resident was positioned in wheelchair without pressure pad alarm and no heel/ankle protectors. The resident's legs were not elevated with any pressure relieving device. During an interview on 11/7/13 from 11:00 AM to 11:15 AM, the Director of Nursing (DON) confirmed Resident 15 was to have the pressure pad alarm on at all times as indicated on the resident's Care Plan. The DON also indicated the staff should have ensured the resident had identified pressure reduction interventions in place at all times as identified on the resident's Care Plan but added, "the resident is not always compliant." During observations of Resident 15 on 11/12/13 from 9:15 AM to 1232 PM, the resident was seated in a wheelchair and the resident had a heel/ankle protector to left heel but only a non-skid sock to right foot. No pressure relieving device was in place to keep the resident's legs elevated. During an observation on 11/13/13 at 7:30 AM, Resident 15 was lying uncovered in bed. The resident's feet were bare and were resting directly on the surface of the mattress. The resident's heel protectors and the "heels up" positioning device were lying in the recliner next to the resident's bed. During an interview on 11/13/13 at 7:40 AM, the Administrator confirmed the resident's pressure relieving devices should have been in place as identified on the resident's Care Plan. C. Review of Resident 24's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The same assessment indicated the resident required total staff assistance with bed mobility and transfers and extensive staff assistance with toileting and that the resident was frequently incontinent of bladder and occasionally incontinent of bowel. Review of Resident 24's Care Plan dated 9/10/13 indicated the resident did not always wait for staff to provide assistance with toileting and was at risk for falls. Interventions included the following: -Staff to assist with toileting, may use the sit- to-stand mechanical lift as needed -Answer the resident ' s call light promptly -Report signs and symptoms of urinary tract infection -Ask and assist resident with toileting upon arising, whenever in room, before and after meals, before going to bed and as needed. Observations of Resident 24 on 11/7/13 revealed the following: -at 6:25 AM, NA-G assisted resident out of room and into Dining Room for breakfast. -at 9:14 AM, NA-G propelled resident in wheelchair out of the Dining Room and back to the resident's room. NA-G immediately left the room and did not offer the resident the opportunity to use the bathroom. -at 9:31 AM, NA-H asked the resident to go to the group exercise activity and propelled the resident in a wheelchair to the Activity Room. The resident was not offered an opportunity to use the bathroom before leaving the room. -at 10:05 AM, Resident 24 remained in wheelchair in the Activity Room for Bible Study. -at 10:25 AM, a volunteer assisted the resident from the Activity Room back to the resident's room. -at 12:00 PM, the resident was assisted back to the dining room for the noon meal by NA-H. Resident 24 was still not offered an opportunity to use the bathroom. During an interview on 11/12/13 from 1:50 PM to 2:00 PM, NA-G indicated Resident 24 was toileted on 11/7/13 after lunch stating "it was probably about 1:30 PM and the resident was incontinent". NA- G further indicated the resident was usually incontinent of urine; however Resident 24 was on a bladder management program and should have been taken to the bathroom at least every 2 hours as identified on the residents Care Plan. | 2015-07-01 |
| 11253 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 312 | E | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observations, record review, staff and resident interview; the facility failed to provide toileting and bathing assistance for Residents 9, 13 and 24 who required assistance with activities of daily living. Facility census was 27. Findings are: A. Resident 9 stated during interview on 11/6/13 at 8:58 AM that "...bath supposedly set up for once a week. Haven't had a bath for nearly 2 weeks now. Maybe they forgot about me." Review of Resident 9's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/24/13 revealed the resident required physical help with personal hygiene and part of bathing activity. Review of Resident 9's Shower/Bath record (a form used to record provision of each resident ' s shower/bath) revealed the resident received a bath on 10/11/13 and 10/18/13. Documentation indicated the resident did not receive another bath until 11/1/13 (14 days later). A confidential staff interview stated, "When we are short on the floor they pull the bath aide to the floor and the baths don't get done." The DON verified during interview on 11/13/13 at 7:30 AM that there was no evidence to indicate Resident 9 received a bath between 10/18/13 and 11/1/13. B. Review of Resident 24's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The same assessment indicated the resident required total staff assistance with bed mobility and transfers and extensive staff assistance with toileting and that the resident was frequently incontinent of bladder and occasionally incontinent of bowel. Review of Resident 24's Care Plan dated 9/10/13 indicated the resident did not always wait for staff to provide assistance with toileting and was at risk for falls. Interventions included the following: -Staff to assist with toileting, may use the sit- to-stand mechanical lift as needed -Answer the resident's call light promptly -Report signs and symptoms of urinary tract infection -Ask and assist resident with toileting upon arising, whenever in room, before and after meals, before going to bed and as needed. Observations of Resident 24 on 11/7/13 revealed the following: -at 6:25 AM, NA-G assisted resident out of room and into Dining Room for breakfast. -at 9:14 AM, NA-G propelled resident in wheelchair out of the Dining Room and back to the resident's room. NA-G immediately left the room and did not offer the resident the opportunity to use the bathroom. -at 9:31 AM, NA-H asked the resident to go to the group exercise program and propelled the resident in a wheelchair to the Activity Room. The resident was not offered an opportunity to use the bathroom before leaving the room. -at 10:05 AM, Resident 24 remained in wheelchair in the Activity Room for Bible Study. -at 10:25 AM, a volunteer assisted the resident from the Activity Room back to the resident's room. -at 12:00 PM, the resident was assisted back to the dining room for the noon meal by NA-H. Resident 24 was still not offered an opportunity to use the bathroom. During an interview on 11/12/13 from 1:50 PM to 2:00 PM, NA-G indicated Resident 24 was toileted on 11/7/13 after lunch stating "it was probably about 1:30 PM and the resident was incontinent". NA- G further indicated the resident was usually incontinent of urine; however Resident 24 was on a bladder management program and should have been taken to the bathroom at least every 2 hours. B. Review of Resident 13's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The same MDS indicated the resident required extensive staff assistance with bed mobility, transfers and toileting. Review of Resident 13 ' s Care Plan dated 7/18/13 indicated the resident did not always wait for assistance from staff with toileting. The resident had impaired mobility and was at risk for bladder incontinence due to inability to transfer self to the bathroom. Interventions included the following: -Report signs and symptoms of urinary tract infection -Provide with extensive assist with toileting -Use of incontinent pads as needed for clothing protection and dignity -Provide incontinence care after each incontinent episode Observations of Resident 13 on 11/7/13 revealed the following: -at 6:53 AM, resident was seated in a wheelchair in the Dining Room -at 8:30 AM, Resident 13 self- propelled wheelchair to the resident ' s room -from 9:05 AM to 9:30 AM, Resident 13 remained seated in wheelchair in room. During this time, none of the facility staff offered to assist the resident with using the bathroom. -at 9:31 AM, NA-H asked the resident to attend the group exercise program in the Activity Room and then assisted the resident to the Activity Room. -at 9:56 AM, Resident 13 requested to return to room to use the bathroom and NA-H told the resident that Bible Study was next and the resident could not leave until after Bible Study was finished. -at 10:24 AM, a volunteer assisted the resident back to the resident's room -at 10:25 AM, resident 13 had turned on the bathroom call light and had wheelchair positioned in the doorway of the bathroom calling out for assistance -at 10:26 AM, the volunteer was in the hallway looking for staff to assist Resident 13 with using the bathroom. -at 10:27 am the Director of Nursing entered Resident 13's and assisted the resident with using the bathroom. During an interview with Resident 13 on 11/7/13 at 10:45 AM the resident stated, "I really needed to go to the bathroom and they didn't want me to go, no one would take me when I asked and I know I am supposed to wait for help." | 2015-07-01 |
| 11254 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 314 | D | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observations, record review and staff interview; the facility failed to consistently implement assessed interventions for the prevention of pressure sores and to revise interventions as needed to promote healing of pressure sores for 1 resident (Resident 15). Facility census was 27. Findings are: Review of facility policy titled "Pressure Sore Prevention and Monitoring Guidelines" (revised 10/12) revealed the following: Upon identifying a pressure sore the licensed nurse will perform the following procedures -Ensure pressure sore identification, goals and interventions are addressed on the resident's Care Plan. -Notify the Dietary Manager upon identifying a pressure sore and Dietary Manager will notify the Registered Dietician for recommendations. -The Interdisciplinary Team will meet at least weekly and as needed to make recommendations and will conduct weekly wound rounds on all pressure sores not responding to current treatment orders. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for Care Planning) dated 10/16/13 indicated [DIAGNOSES REDACTED]. The MDS further indicated Resident 15 was at risk for pressure sore development and had a history of [REDACTED]. Review of Resident 15's physician orders [REDACTED]. The physician orders [REDACTED]. Review of Resident 15's Braden Scale For Predicting Pressure Sore Risk dated 10/15/13 indicated a total score of 14 (score of 13-14 indicated moderate risk). Review of Progress Notes dated 10/20/13 revealed Resident 15 had a red area noted to left heel. The note indicated staff was to keep the resident's legs propped up on pillows while in bed to reduce pressure to left heel. Review of "Event Report" dated 11/1/13 revealed a Hospice Nurse had informed facility staff of an intact blister to Resident 15's left lateral heel. This report indicated the area surrounding the blister was intact, slightly red and had a "mushy" feeling. The report further identified Resident 15 refused to leave heel protectors on feet and had requested to wear shoes. Review of "Weekly Pressure Ulcer Record" dated 11/1/13 revealed Resident 15 had a stage 2 (partial thickness skin loss that presents as an abrasion, blister or shallow crater) pressure ulcer to left inner aspect of left lateral heel which measured 1.5 centimeters (cm) x 1.8 cm. Documentation also identified an eschar (dead black, brown or tan tissue that adheres firmly to the wound bed of a pressure sore) patch to left heel measuring 3 cm x 2 cm. Review of facsimile (fax) dated 11/1/13 to the physician revealed the physician was notified of the blister and the eschar patch to Resident 15's left heel. Review of Resident 15's medical record revealed no documentation to indicate the physician had responded to this fax. Review of Resident 15's Care Plan dated 11/1/13 revealed the following interventions dated 11/1/13; keep heels elevated, keep feet and heels moisturized, keep heels protected as resident allows and to remind resident that rubbing heels on the chair aggravates the wound on heel. Care Plan also identified an intervention dated 6/15/13 to keep heels on "heels up" device to prevent pressure. During observations of Resident 15 on 11/5/13 from 3:13 PM to 4:50 PM, the resident was observed seated in a Broda (a wheelchair alternative that allows for repositioning of the resident) chair with no heel/ankle protectors and no pressure relieving device noted to the foot rest of the chair to keep the resident's heels elevated. During observations of Resident 15 on 11/6/13 from 8:14 AM to 12:50 PM, the resident was seated in a wheelchair with no heel/ankle protectors in place and no pressure relieving device in place to keep the resident's legs elevated. During an interview on 11/6/13 from 9:10 AM to 9:17 AM, Licensed Practical Nurse (LPN)-D indicated staff were currently not performing any treatment to the pressure sores on Resident 15's left heel. During an interview on 11/6/13 from 2:47 PM to 2:55 PM, Nursing Assistant (NA)-A verified Resident 15 was to wear heel/ankle protectors at all times but indicated the resident was not always compliant with leaving them in place. NA-A stated, "The resident used to have heel protectors in the room but I don't know where they are or what happened to them." During an observation on 11/6/13 at 3:24 PM, Resident 15 was seated in the Broda chair with the chair reclined and the foot rest elevated. The resident was barefoot with no heel/ankle protectors in place and no pressure relieving device in place to foot of chair to keep the resident's heels elevated. Review of fax to the physician dated 11/6/13 revealed the facility provided a second notification to the physician of the blister to the resident's right heel. Review of the Registered Dietician's progress notes dated 11/6/13 (5 days after the areas to the resident's left heel were identified) indicated the resident was receiving adequate nutrition to promote healing but the resident chose to consume less than adequate nutrition. Furthermore, healing was not expected unless friction could be removed. Observations of Resident 15 on 11/7/13 at 6:40 AM revealed the resident was lying in bed, the resident was not wearing heel/ankle protectors, the resident's legs were not elevated and the resident's heels were lying directly on the surface of the mattress. The "heels up" positioning device was lying in the resident's recliner next to the resident's bed. Review of fax from the physician dated 11/7/13 (6 days after the areas to the resident's left heel were identified) revealed an order for [REDACTED]. Review of "Event Report" dated 11/7/13 revealed facility staff had identified a new reddened area to Resident 15's medial left heel. The area measured 1 cm x 2.5 cm and was not opened at the time. Review of fax to the physician dated 11/7/13 revealed the physician was notified of the new reddened area to the medial left heel. During observations of Resident 15 on 11/7/13 from 8:04 AM to 10:24 AM, the resident was observed seated in wheelchair with no heel/ankle protectors and legs were not elevated with any pressure relieving device. During an interview with the Director of Nursing (DON) on 11/7/13 from 11:00 AM to 11:15 AM, the DON verified Resident 15's physician and the Registered Dietician should have addressed the resident's skin breakdown to the left heel in a timelier manner. The DON also indicated the staff should have ensured the resident had identified pressure reduction interventions in place at all times but added, "the resident is not always compliant." Review of fax from the physician dated 11/8/13 revealed no new orders related to the new reddened area to Resident 15's left heel. During observations of Resident 15 on 11/12/13 from 9:15 AM to 1232 PM, the resident was seated in a wheelchair and the resident had a heel/ankle protector to left heel but only a non-skid sock to right foot. No pressure relieving device was in place to keep the resident's legs elevated. During an observation on 11/13/13 at 7:30 AM, Resident 15 was lying uncovered in bed. The resident's feet were bare and were resting directly on the surface of the mattress. The resident's heel protectors and the "heels up" positioning device were lying in the recliner next to the resident's bed. During an interview on 11/13/13 at 7:40 AM, the Administrator confirmed the resident's pressure relieving devices should have been in place to promote the management of current pressure sores and to prevent further skin breakdown. | 2015-07-01 |
| 11255 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 323 | E | 1 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Numbers 175 NAC 12-006.09D7 and 175 NAC 12-006.184 Based on observations, record review and staff interviews; the facility failed to assure Residents 15 and 23 were protected from falls as fall intervention measures were not consistently provided and the facility failed to identify causal factors and revise interventions to prevent ongoing falls for Resident 15. In addition, the facility failed to secure hazardous chemicals in resident rooms and the beauty shop which allowed access to 7 residents who were identified at risk for wandering. Facility census was 27. Findings are: A. Review of Resident 15' s Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for Care Planning) dated 10/16/13 indicated [DIAGNOSES REDACTED]. The MDS further indicated Resident 15 was at risk for falls and the resident had sustained 1 fall without injury and 2 falls with injury since the previous assessment. Review of Care Plan dated 11/1/13 revealed Resident 15 had a history of [REDACTED]. Interventions included the following: -9/25/12 Tab alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) on at all times -10/17/12 pressure pad alarm (an electronic pressure sensitive sensor pad designed for use in chairs or beds which will alarm if a resident tries to get up without assistance) on at all times -12/13/12 may put mattress on floor for resident to sleep on per resident's request -7/25/13 may use tilt-n-space wheelchair -10/30/13 ensure Tabs alarm cord length is adjusted to proper length -may use sit-to-stand mechanical lift for transfers -bolsters to resident's bed and fall mat on floor next to bed -keep bed in lowest position with brakes locked -observe resident frequently and place in supervised areas when out of bed Review of Resident 15's Event Reports revealed the following: -8/22/13 at 4:30 PM, the resident was found on the floor by the bathroom door. Wheelchair was behind the resident, resident noted to have 3 skin tears to right hand/forearm. There was no documentation of any causal factors identified or of any new interventions to protect resident from further falls. -9/18/13 at 11:40 AM, the resident was found lying on the floor in front of the wheelchair with no injuries evident. There was no documentation of any causal factors identified or of any new interventions to protect resident from further falls. Review of Resident 15's Fall Risk assessment dated [DATE] revealed the resident was identified at high risk for falls. Review of Resident 15's Event Report dated 10/29/13 revealed at 4:05 PM, the resident slid out of wheelchair onto the Dining Room floor. Tabs alarm was in place but was not activated. Staff shortened the cord of the alarm to ensure prompt activation of the alarm; however no casual factors for the fall were documented. Observations on of Resident 15 on 11/6/13 revealed the following: -at 6:48 AM, the resident was lying in bed. The resident' s bed was in the low position with bolsters in bed, fall mat on the floor and Tabs alarm in place. The pressure pad alarm was not on the resident's bed but was lying in the recliner next to the resident's bed. -8:14 AM to 12:50 PM, the resident was positioned in wheelchair with Tabs alarm in place. The pressure pad alarm was not attached to the resident's chair. Observations of Resident 15 on 11/7/13 revealed the following: -at 6:40 AM, resident was awake, lying in bed. No pressure pad alarm was in place to the resident's bed. All other identified interventions were in place. -8:04 AM to 10:24 AM, the resident was positioned in wheelchair without pressure pad alarm. During an interview on 11/7/13 from 11:00 AM to 11:15 AM, the Director of Nursing (DON) confirmed Resident 15 was to have the pressure pad alarm on at all times as indicated on the resident's Care Plan. The DON further indicated facility staff was expected to review interventions after all falls and that staff were to revise and implement new interventions to prevent potential injury from further falls. B. Review of Resident 23's MDS dated [DATE] revealed the following: - Resident 23 scored 7 on the Brief Interview for the Mental Status (an assessment used to determine mental ability). A score of 0-7 indicated the resident's cognition was severely impaired. - Resident 23 required extensive assistance with bed mobility, transferring, dressing, toilet use and personal hygiene. Review of Resident 23's Care Plan dated 1/13/13 revealed a problem of "Risk for falls related to (R/T) unsteadiness" , a goal of "Resident will remain free of falls" and the following Interventions: - "Encourage/Remind resident to ask for assistance before transferring (gender) to the bathroom" . - "Encourage and praise resident for asking for assistance" . - "Tabs at all times" . - "Wheelchair (W/C) for ambulation at all times with exception of full weight walker (FWW) walker w/stand by staff assist per physical therapy (PT) orders" . - "Staff is to make resident ' s bed daily" . - "Assure resident is wearing eyeglasses. Assure eyeglasses are clean and in good repair " . - "Assure the floor is free of glare, liquids, foreign objects" . - Encourage resident to assume a standing position slowly" . - " Encourage resident to use environmental devices: (e.g., handrails, grab bars, etc.) Walker can be used with stand by assist only" . - "Keep bed in lowest position with brakes locked" . - Keep call light in reach" . - "Keep environment free of clutter" . - "Keep personal items and frequently used items within reach" . - "Leave night light on in room" . - "Provide proper, well-maintained footwear. Do not allow resident to walk in stocking feet" . - Resident (res.) Will ask staff for help when she wants to hang clothes in closet" . Review of Resident 23's Care Plan dated 8/21/13 revealed a problem of "Resident non-compliant w/transfers and ambulation. Walking without the recommended assistance. Benefits versus Risk have been explained to resident and power of attorney (POA) and form signed" , a goal of "Resident will ask for assistance for transfers and ambulation" and the following Interventions: - "Frequent resident contact" . - "Remind resident of the benefits vs. ris " . - "Remind resident to use (gender) call light at all times" . Review of Resident 23's Care Plan dated 3/9/11 revealed a problem of "Resident is limited in mobility and requires the use of a wheel chair. Can ambulate w/front wheel walker with stand by assist only" , a goal of "...will safely ambulate thru out the facility with the use of wheeled walker (w/w)" and the following Interventions: - "Teach resident safety measures. Instructed res to use call light to kill bugs " . - "Adapt environment to maximize (Resident 23) safety and independence: grab bars and clear pathways" . - "Instruct (Resident 23) in proper technique" . - "Provide oversight for ambulation" . - "Teach (Resident 23) safety measures" . Observations of Resident 23 on 11/7/13 at 9:11 AM revealed Registered Nurse (RN)-E exit Resident 23's bathroom, shutting the door but not latching it. Resident 23's wheelchair was not observed to be in the room. At 9:20 AM Resident 23 was heard yelling for help 3 times before NA-H entered the room to assist Resident 23. During an interview with NA-H on 11/7/13 at 10:21 AM it was confirmed Resident 23 was left unsupervised in the bathroom. NA-H confirmed Resident 23's wheelchair was in the bathroom with the resident and the resident ' s tabs alarm had been removed from the wheelchair, attached to the resident and left attached to a handrail in the bathroom. During an interview with DON and Administrator on 11/7/13 at 11:28 AM it was revealed residents who have tabs alarms are not be left in the bathroom unattended. Review of Resident 23's Care Plan revealed the intervention of not leaving the resident unattended in the restroom was not identified. C. Review of Material Safety Data Sheets (MSDS - informational material intended to provide workers and emergency personnel with procedures for handling or working with substances in a safe manner; including information such as physical data, toxicity, health effects, first aid, reactivity, storage, disposal, protective equipment, and spill-handling procedures.) included the following: - Lysol Foaming Disinfectant Cleaner (Issue date 7/20/10) - "Hazards to humans and domestic animals." "Avoid contact with eyes or skin." "May cause eye irritation." "May cause skin irritation." "Symptoms may include redness, edema, drying, defatting and cracking of the skin. Symptoms of overexposure may be headache, dizziness, tiredness, nausea and vomiting." - Caviwipes Disinfecting Towelettes (Dated February 2007) - "Contact with eyes can cause reversible damage." "May cause low or mild irritation" if inhaled. "Keep out of reach of children. Do not ingest. Avoid eye contact and contamination of food." - Champion Sprayon Spray Disinfectant (Issue date 1/17/11) - "Can cause irritation after contact with the eyes." "May cause skin irritation after prolonged contact with skin." "Deliberate inhalation of concentrated vapor or mist may cause headaches, dizziness and nausea." "May aggravate pre-existing skin and respiratory disorders." D. The following were observed during the environmental tour of the facility on 11/7/13 from 9:15 AM until 10:21 AM and accompanied by the Maintenance Supervisor: - Resident Room 101 bathroom - There was a can of Lysol Foaming Disinfectant Cleaner, a dispenser of Caviwipes Disinfecting Towelettes, and a can of Champion Sprayon Spray Disinfectant stored in an unlocked cabinet to the left of the toilet. - Resident Room 102 - There was a dispenser of Caviwipes Disinfecting Towelettes stored on top of the resident's dresser. - Resident Room 114 bathroom - There was a can of Champion Sprayon Spray Disinfectant stored on a shelf above the toilet. - Resident Room 119 bathroom - There was a spray bottle of Shout stain remover on a shelf above the toilet and a dispenser of Clorox disinfecting wipes on a table to the left of the hand washing sink. A resident residing in the room indicated the items were provided by family members. E. On 11/13/13 at 9:50 AM, the Director of Nursing provided a list of residents who were identified at risk for wandering. The list included Residents 24, 8, 36, 6, 31, 23 and 35. (Surveyor ) F. The Beauty Shop door was unlocked and there was a dispenser of Caviwipes Disinfecting Towelettes stored on a ledge immediately inside the entrance to the room on 11/5/13 at 4:00 PM, 11/6/13 at 7:00 AM, 11:30 AM and 3:30 PM, and 11/7/13 at 6:51 AM. | 2015-07-01 |
| 11256 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 353 | E | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observations, record review, staff and resident interviews; the facility failed to provide sufficient nursing staff to meet resident's needs related to: 1) 5 of 10 resident interviews voiced concerns regarding lack of staff; 2) provision of baths in accordance with bath schedules for Residents 24, 9 and 1 who required assistance with bathing/personal hygiene; and 3) provision of toileting assistance for Residents 13 and 24 who required assistance with toileting. Facility census was 27. Findings are: A. 4 confidential resident interviews revealed the following comments when asked, "Do you feel there is enough staff available to make sure you get the care and assistance you need without having to wait a long time?" -Confidential interview on 11/5/13 at 3:26 PM-"Not really. If you call them and they are someplace else it takes a while." The resident further stated 2 baths were to be provided per week but "...about once a month only gets1bath during the week." -Confidential interview on 11/5/13 at 4:12 PM-"There is a little bit of shortage on that. Weekend is the worst." -Confidential interview on 11/6/13 at 8:57 AM-"No, we turn on the call light and then we have to wait and wait until someone comes to help you. Mostly in the morning when I want to get up out of bed. Sunday I had to wait quite a while to get into the bathroom." -Confidential interview on 11/6/13 at 9:02 AM-Resident voiced not enough staff as "have to wait for call lights." B. Interview with Resident 9 on 11/6/13 at 8:58 AM revealed the resident had concerns about staffing. The resident stated, "...bath supposedly set up for once a week. Haven't had a bath for nearly 2 weeks now. Maybe they forgot about me." Review of Resident 9's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/24/13 revealed the resident required physical help with personal hygiene and part of bathing activity. Review of Resident 9's Shower/Bath record (a form used to record provision of each resident ' s shower/bath) revealed the resident received a bath on 10/11/13 and 10/18/13. Documentation indicated the resident did not receive another bath until 11/1/13 (14 days later). A confidential staff interview stated, "When we are short on the floor they pull the bath aide to the floor and the baths don ' t get done." The DON verified during interview on 11/13/13 at 7:30 AM that there was no evidence to indicate Resident 9 received a bath between 10/18/13 and 11/1/13. C. Review of Resident 1's MDS dated [DATE] revealed the resident was totally dependent with personal hygiene and bathing. Review of Resident 1's Shower/Bath record revealed the resident received a bath on 10/11/13. Documentation indicated the resident did not receive another bath until 10/26/13 (15 days later). No further baths were documented on the Shower/Bath record after 10/26/13. Review of Bath/Shower Schedule (weekly schedule of baths provided each day and used to record temperature of water used during each residents bath/shower) dated 10/28/13 through 11/1/13 indicated Resident 1 did not receive a bath during that week. Review of Bath/Shower Schedule dated 11/4/13 through 11/8/13 revealed Resident 1 received a bath on 11/8/13 (13 days since the last bath). The DON verified during interview on 11/13/13 at 7:30 AM that there was no evidence to indicate Resident 1 received a bath between 10/11/13 and 10/26/13 or from 10/26/13 until 11/18/13. D. Review of Resident 24's MDS dated [DATE] revealed the resident required physical help with personal hygiene and part of bathing activity. Review of Resident 24's Shower/Bath record revealed the resident received a bath on 10/15/13. Documentation indicated the resident did not receive another bath until 10/26/13 (11 days later) The DON verified during interview on 11/13/13 at 7:30 AM that there was no evidence to indicate Resident 24 received a bath from 10/15/13 until 10/26/13. E. Review of Resident 24's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The same assessment indicated the resident required total staff assistance with bed mobility and transfers and extensive staff assistance with toileting and that the resident was frequently incontinent of bladder and occasionally incontinent of bowel. Review of Resident 24's Care Plan dated 9/10/13 indicated the resident did not always wait for staff to provide assistance with toileting and was at risk for falls. Interventions included the following: -Staff to assist with toileting, may use the sit- to-stand mechanical lift as needed -Answer the resident's call light promptly -Report signs and symptoms of urinary tract infection -Ask and assist resident with toileting upon arising, whenever in room, before and after meals, before going to bed and as needed. Observations of Resident 24 on 11/7/13 revealed the following: -at 6:25 AM, NA-G assisted resident out of room and into Dining Room for breakfast. -at 9:14 AM, NA-G propelled resident in wheelchair out of the Dining Room and back to the resident's room. NA-G immediately left the room and did not offer the resident the opportunity to use the bathroom. -at 9:31 AM, NA-H asked the resident to go to the group exercise activity and propelled the resident in a wheelchair to the Activity Room. The resident was not offered an opportunity to use the bathroom before leaving the room. -at 10:05 AM, Resident 24 remained in wheelchair in the Activity Room for Bible Study. -at 10:25 AM, a volunteer assisted the resident from the Activity Room back to the resident's room. -at 12:00 PM, the resident was assisted back to the dining room for the noon meal by NA-H. Resident 24 was still not offered an opportunity to use the bathroom. During an interview on 11/12/13 from 1:50 PM to 2:00 PM, NA-G indicated Resident 24 was toileted on 11/7/13 after lunch stating "it was probably about 1:30 PM and the resident was incontinent". NA- G further indicated the resident was usually incontinent of urine; however Resident 24 was on a bladder management program and should have been taken to the bathroom at least every 2 hours. F. Review of Resident 13's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The same MDS indicated the resident required extensive staff assistance with bed mobility, transfers and toileting. Review of Resident 13's Care Plan dated 7/18/13 indicated the resident did not always wait for assistance from staff with toileting. The resident had impaired mobility and was at risk for bladder incontinence due to inability to transfer self to the bathroom. Interventions included the following: -Report signs and symptoms of urinary tract infection -Provide with extensive assist with toileting -Use of incontinent pads as needed for clothing protection and dignity -Provide incontinence care after each incontinent episode Observations of Resident 13 on 11/7/13 revealed the following: -at 6:53 AM, resident was seated in a wheelchair in the Dining Room -at 8:30AM, Resident 13 self- propelled wheelchair to the resident ' s room -from 9:05 AM to 9:30 AM, Resident 13 remained seated in wheelchair in room. During this time, none of the facility staff offered to assist the resident with using the bathroom. -at 9:31 AM, NA-H asked the resident to attend the group exercise program in the Activity Room and then assisted the resident to the Activity Room. -at 9:56 AM, Resident 13 requested to return to room to use the bathroom and NA-H told the resident that Bible Study was next and the resident could not leave until after Bible Study was finished. -at 10:24 AM, a volunteer assisted the resident back to the resident's room -at 10:25 AM, resident 13 had turned on the bathroom call light and had wheelchair positioned in the doorway of the bathroom calling out for assistance. -at 10:26 AM, the volunteer was in the hallway looking for staff to assist Resident 13 with using the bathroom. -at 10:27 am the Director of Nursing entered Resident 13's and assisted the resident with using the bathroom. During an interview with Resident 13 on 11/7/13 at 10:45 AM the resident stated, "I really needed to go to the bathroom and they didn't want me to go, no one would take me when I asked and I know I am supposed to wait for help." | 2015-07-01 |
| 11257 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 441 | E | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B and 175 NAC 12- D Based on observations, record review and staff interview; the facility failed to assure staff members washed hands at appropriate intervals, and that the mechanical sit/stand lift was cleaned between each resident use, during the provision of nursing cares for Residents 15 and 5. This provided the potential for cross contamination between 7 residents ( Residents 19, 24, 38, 15, 26, 1 and 5) who were identified as requiring use of the mechanical sit/stand lift for transfers. Facility census was 27. Findings are: A. Review of facility policy titled Handwashing/Hand Hygiene with a revision date of June 2010 revealed the following: - "Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: ... c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); ... h. Before and after assisting a resident with personal care (e.g., oral care, bathing); ... l. Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident); ... n. Before and after assisting a resident with toileting (hand washing with soap and water); ... r. After handling soiled or used linens, dressings, bedpans, catheters and urinals; ... s. After handling soiled equipment or utensils; ...u. After removing gloves or aprons; and v. After completing duty." - "If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for all the following situations: a. Before and after direct contact with residents; b. Before donning sterile gloves; ... g. After contact with a resident's intact skin; h. After handling used dressings, contaminated equipment, etc.; i. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and j. After removing gloves." B. During observation of incontinent cares on 11/7/13 from 6:46 AM until 7:14 AM, Nursing Assistant (NA)-G and NA-F assisted Resident 5 to the toilet using the mechanical sit/stand lift (a device used to support the resident in a standing position during transfers, with the resident grasping handles on the lift to assist in supporting their weight). Following toileting, NA-G provided perineal hygiene for Resident 5. Without removing soiled gloves, NA-G pulled up the resident's incontinent brief and skirt, straigtened out the resident's shirt and sweater, transferred the resident to the wheelchair using the mechanical sit/stand lift, touched the handles on the resident's wheelchair, and adjusted the pillow at the back of the resident. NA-G then removed the soiled gloves, and without washing hands, handled the resident's hair, removed the mechanical lift sling from behind the resident, and draped the sling on the frame of the mechanical lift. NA-G then washed hands at the sink. The mechanical lift was removed from the room and parked in the hallway. The mechanical sit/stand lift was not sanitized before or after use. C. During interview on 11/13/13 at 6:56 AM, the Director of Nursing (DON) verified the facility had no policies related to cleaning of resident care equipment. However, the DON expressed an expectation that the mechanical sit/stand lift be sanitized between residents' use, particularly those surfaces that were handled by the residents. D. NA-F and G were observed to provide Resident 15's incontinent care on 11/7/13 from 7:42 AM until 8:04 AM. NA-F put on gloves and removed Resident 15's disposable incontinent brief which was soiled with urine. NA-F provided the resident's perineal hygiene and without removing soiled gloves, adjusted the resident's clothing and assisted to transfer the resident out of the bathroom in the mechanical sit/stand lift. NA-F removed soiled gloves and without washing hands, straightened the resident's clothing, adjusted the resident's position in the wheelchair and attached the resident's fall alarm to the back of the resident's clothing. NA-F then removed the mechanical sit/stand lift from the resident's room before returning to the resident's room and washing hands in the bathroom sink. The mechanical sit/stand lift was not sanitized before or after use. E. During an interview on 11/7/13 from 8:05 AM to 8:12 AM, NA-G indicated staff were expected to sanitize the mechanical lift before and after resident use but normally NA-G only cleaned prior to using on a resident. NA-F further indicated that in the morning when staff was getting the residents up and out of bed, the staff was usually too busy to clean the lift between resident use. | 2015-07-01 |
| 11258 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 520 | F | 1 | 1 | 320W11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interview; the facility failed to assure an effective Quality Assurance program was in place to correct previously cited deficiencies regarding sufficient staffing, accidents and activities of daily living (ADL) care. Facility census was 27. Findings are: Review of facility deficiency statement from the Quality Indicator Survey (QIS) completed on 5/24/11 revealed the facility was cited for failure to implement interventions for the preventions of falls. Review of facility deficiency statement from QIS completed on 8/9/12 revealed the facility was cited for failure to implement interventions for the prevention of falls. Review of facility deficiency statement from a complaint survey completed on 11/20/12 revealed the facility was cited for failure to assess 1 resident with a history of falls. Review of facility deficiency statement from a complaint survey completed 5/2/13 revealed the facility was cited for failure to provide toileting assistance and personal hygiene for residents and failure to provide sufficient nursing staff to meet residents needs. Review of the preliminary citations for the current survey revealed these deficiencies were not corrected. Review of the facility's policy "Monthly Quality Assurance Meeting Policy and Procedure" (revised 6/13) revealed the following: - "Purpose: To ensure appropriate follow-up and ongoing tracking of identified environmental and quality of care issues by the facility Quality Assurance team. To develop and implement plans of corrective action for identified trends and/or deficient practices. To ensure the provision of the highest possible quality of care to facility residents" . - "Policy: If a trend is identified, the Quality Assurance Committee will develop a Plan of Action, appoint a team leader and project a target date of completion" . - "Possibly Quality Assurance areas and trends may be identified through Focused Rounds, Resident Counsel Meeting, Consultant Reports, Grand Rounds by management personnel and Resident Satisfaction Surveys" . During an interview with the Administrator on 11/13/13 from 7:48 AM until 8:09 AM it was confirmed focused rounds had not yet been implemented. It was further confirmed the Quality Assurance committee has not put a plan into place to ensure staffing meets residents needs, that a fall prevention plan has not yet been put into place and that audits in the area of ADL care has not yet been put into place. | 2015-07-01 |
| 11259 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-05-15 | 164 | E | 1 | 0 | C4V911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(20) Based on observation and staff interview; the facility failed to ensure medical record confidentiality for 14 residents (Residents 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15). Medication and treatment administration records were left open and information was exposed when the medication/treatment carts were not attended. In addition, resident care information was lying on top of the Nurses Station desk and was accessible to anyone passing by. Facility census was 29. Findings are: A. During observations on 5/15/14, Registered Nurse (RN)-B left the medication cart unattended in the hallway with the Medication Administration Record [REDACTED]. B. During observations on 5/15/14, RN-B left the treatment cart unattended in the hallway with the Treatment Administration Record (TAR-a record maintained for each individual resident that lists their treatments, allergies and other personal information) on top of the cart and open, exposing information on Resident 8 from 6:59 AM until 7:05 AM, 7:13 AM until 7:21 AM and 7:27 AM until 7:33 AM. C. The desk of the Nurses Station located adjacent to the dining room was unattended on 5/15/14 from 7:37 AM until 7:45 AM. The following items and documents were lying on top of the desk and within view of anyone passing by: -an empty box of [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]) prefilled syringes labeled with Resident 9's name and instructions for use -an empty bubble pack (a packaging system for medication administration) of [MEDICATION NAME] (an antibiotic) labeled with Resident 10's name and instructions for use -a form titled "REPORT FOR HALLS ONE AND THREE" which identified 10 residents (Residents 1, 11, 12, 13, 8, 14, 2, 15, 3 and 9) by name and included details of their personal care such as urine output, bowel movements, and/or behaviors of wandering/exit seeking, touching, crying and hitting. D. During observations on 5/15/14, RN-B left the medication cart unattended in the hallway with the MAR indicated [REDACTED]. E. During observation on 5/15/14 from 7:38 AM until 7:47 AM (9 minutes), RN-B left the treatment cart unattended in the hallway with the TAR on top and open, exposing information on Resident 6. F. During interview on 5/15/14 at 2:00 PM, the Director of Nursing (DON) verified nursing staff were to shield MAR/TAR information, and/or close the notebook when the carts were left unattended. | 2015-07-01 |
| 11260 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-05-15 | 226 | D | 1 | 0 | C4V911 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and staff interview; the facility failed to immediately report an allegation of potential abuse to the Stage Agency. This involved 2 residents (Resident 1 and 2). Facility census was 29. Findings are: Review of facility Abuse Allegation and Reporting Policy and Procedure (revision date 6/13) revealed: "The facility must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator." The procedure further identified "The Administrator will assure immediate notification of proper authorities in compliance with regulatory/licensing requirements that an allegation has been made and a facility investigation is underway. State specific reporting requirements and timeframes pertaining to the reporting and submission of preliminary reports will be observed ..." Interview with the Director of Nurses (DON) on 5/14/14 at 11:30 AM revealed the DON received a report on 4/27/14 regarding verbal abuse of Resident 1 and Resident 2 by Licensed Practical Nurse(LPN)-J and Nursing Assistant(NA)- K which occurred on 4/26/14. The DON indicated LPN-J and NA-K were placed on administrative leave until an investigation was completed. Review of facility investigation records dated 5/1/14 regarding potential verbal abuse of Residents 1 and 2 revealed the allegations were not reported to the State Agency until 4/30/14 (3 days after the facility was made aware of the incident). During interview on 5/15/14 at 2:00 PM the DON verified the facility did not immediately report the allegation of potential verbal abuse involving Residents 1 and 2 to the State Agency. | 2015-07-01 |
| 11261 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-05-15 | 318 | D | 1 | 0 | C4V911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D4 Based on record review and staff interview; the facility failed to provide range of motion (ROM) exercises in accordance with physician's orders [REDACTED]. Facility census was 29. Findings are: A. Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/17/14 indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The same MDS indicated the resident required extensive to total assistance with activities of daily living (ADL), and had functional limitation of ROM in upper and lower extremities on both sides. Review of physician's orders [REDACTED]. Review of Resident 3's Care Plan dated 3/13/14 revealed a problem in ADL function and rehabilitation potential, with a goal to provide a "satisfying" restorative program that met the resident's needs. Nursing interventions included assessing health issues that could result in a lack of or reduced participation in the restorative program, adapting the restorative program to meet the resident ' s current abilities, praising involvement and offering encouragement. Review of Restorative Flowsheets (a form used to document when Restorative Therapy (RT) exercises were provided) indicated Resident 3 was to receive AAROM to upper and lower extremities every day, and documentation revealed the following: - During 3/2014, the resident received AAROM 3 times weekly for a total of 12 times. - During 4/2014, the resident received AAROM 3-4 times weekly for a total of 13 times. - From 5/1/14 until 5/14/14, the resident received AAROM 1 time weekly for a total of 2 times. B. Review of Resident 2's MDS dated [DATE] indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The same MDS indicated the resident required extensive to total assistance with ADL's, and had functional limitation of ROM in lower extremities on both sides. Review of Resident 2's Care Plan dated 4/15/14 revealed a problem in ADL function and rehabilitation potential with a restorative nursing program recommended by the Physical Therapist, and with a goal that the resident participate in RT at least 3 days weekly. Nursing interventions were to provide AAROM to all extremities and PROM (Passive ROM-exercises used when the resident is unable to move independently, and the resident's joints are moved through full ROM by staff) to all extremities 1 time daily. Review of the Restorative Flowsheet dated 5/1/14 through 5/14/14 revealed Resident 2 was to receive AAROM/PROM to all extremities 1 time daily. Documentation indicated Resident 2 received RT 2 times weekly for a total of 4 times. C. During interview on 5/15/14 at 11:30 AM, the Director of Nursing (DON) stated the RA was scheduled 3 days weekly, and if not available, another Nursing Assistant would complete RT tasks. The DON acknowledged the PO for RT on Resident 3 specified it was to be provided daily, however, the DON indicated it was the expectation that RT be provided 3 to 5 days a week. | 2015-07-01 |
| 11262 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-05-15 | 373 | E | 1 | 0 | C4V911 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C7b Based on record review and staff interview; the facility failed to ensure staff members who assisted residents to eat had completed a State-approved training course in feeding techniques. Facility census was 29. Findings are: Review of Resident 4's Progress Notes dated 1/7/14 at 12:35 PM revealed the Administrator fed Resident 4 a couple of bites of the breakfast meal until a nursing assistant returned to feed the resident the rest of the meal. Interview with the Administrator on 5/14/14 at 11:30 AM revealed the Administrator had on occasion provided feeding assistance to residents. The Administrator verified the facility did not provide a State-approved training course in feeding techniques (also known as a paid feeding assistant program) and the Administrator had not been trained to assist and feed residents. Interview with the Social Services Director (SSD) on 5/15/14 at 1:07 PM revealed the SSD provided residents with feeding assistance at times. The SSD verified a State-approved training course in feeding techniques had not been completed. | 2015-07-01 |
| 11263 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 157 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review, staff interview and observation; the facility failed to ensure physicians were notified regarding significant weight loss for Residents 9 and 15, and development of pressure ulcers for Resident 38, 10 and 19. Facility census was 33. Findings are: A. Review of facility policy for weight loss titled "Weight" (revision date 8/2013) revealed weight loss or gain was to be calculated every time a resident was weighed. Significant weight losses were identified as 5 percent (%) in 1 month, 7.5% in 3 months and 10% in 6 months. The policy further specified the physician was to be notified regarding significant weight variances. B. Review of Resident 9's Weight Variance Reports from 10/3/14 through 11/17/14 and Weight and Vital Signs Monitoring Record from 10/3/14 through 11/19/14 revealed the following weights: -10/3/14-117.8 pounds -10/10/14-117 pounds -10/24/14-116.8 pounds -11/3/14-116.8 pounds -11/5/14-110 pounds -11/10/14-106.6 pounds (an 8 percent significant weight loss in 1 month) Review of Resident 9's medical record revealed no evidence to indicate the physician was notified of the significant weight loss. C. Review of Resident 10's Admission and Weekly Skin Integrity Action Tool for 9/2014, 10/2014 and 11/2014 revealed the following: -9/14/14-"red/purple area above coccyx, no open areas noted" -9/21/14-"red/purple area remains. No open sore" -9/28/14-"no new skin issues" -10/5/14-"no new skin issues" -10/12/14-"No new skin issues" -There was no documentation on 10/19/14 and 10/26/14 -11/2/14-"no new skin issues" -There was no documentation on 11/9/14 -11/16/14-"No new skin issues" On 11/19/14 at 4:32 PM, NA-C commented Resident 10 had a "little schiff" (a small open area) on the "backside" (coccyx area) which had been reported to the Director of Nurses earlier that day. A small Stage 2 pressure sore (partial thickness skin loss that presents as an abrasion, blister or shallow crater) was observed on Resident 10's coccyx area. NA-E voiced awareness of Resident 10's pressure sore of the coccyx during observation of care at 10:40 AM on 11/20/14. At 12:13 PM on 11/24/14, Licensed Nurse (LN)-F examined the pressure sore on Resident 10's coccyx area and stated "It is superficial. It's from moisture." Review of the medical record revealed no evidence to indicate the physician was notified of the pressure sore on Resident 10's coccyx. D. Review of Resident 38's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/14/14 indicated [DIAGNOSES REDACTED]. The MDS further indicated Resident 38 had the following pressure sores identified: -Two Stage 2 pressure sores (The staging system is a method of summarizing certain characteristics of pressure sores, including the extent of tissue damage. Stage 2 refers to partial thickness skin loss that presents as an abrasion, blister or shallow crater). -Two Stage 3 pressure sores (full thickness skin loss with damage to subcutaneous (under the skin) tissue). -One unstageable pressure sore (unstageable refers to a full thickness tissue loss in which the base of the pressure sore is covered by slough and/or eschar (dead tissue) in the wound bed). -One unstageable pressure sore with suspected deep tissue injury (pressure related injury to subcutaneous tissue). The MDS identified use of pressure reducing devices to chair and bed, a turning and repositioning program, nutritional and hydration interventions, pressure sore care and application of non-surgical dressings. Review of Resident 38's "Wound Assessment Tool" dated 10/8/14 revealed the resident had a 9.5 centimeter (cm) by 5.7 cm pressure sore with 10 cm depth to gluteal sacral area (lower back above the buttock crease) and a 4 cm by 3.7 cm pressure sore with 3 cm depth to left [MEDICATION NAME] area. Review of facility "Weekly Pressure Sore Record" dated 10/8/14 revealed the resident had a stage 3 pressure sore (no measurements) to the left heel which was debrided (removal of eschar to promote healing). Review of facility "Wound Assessment Tool" dated 10/10/14 and completed by Physical Therapy (PT) revealed Resident 38's gluteal sacral pressure sore measured 11.0 cm by 5.6 cm with 5 cm depth (1.5 cm increase of wound length from measurements on 10/8/14). review of the resident's medical record revealed [REDACTED]. sacral pressure sore. Review of facility "Wound Assessment Tool" completed by PT revealed the following measurements and assessments for the pressure sore to Resident 38's gluteal sacral wound: -10/13/14- 9.0 cm by 5.6 cm with 6 cm depth. -10/15/14- 10.4 cm by 4.5 cm with 5 cm depth (1.4 cm increase of wound length from measurement on 10/13/14) -10/17/14- 8.7 cm by 5.4 cm with 3 cm depth. -10/20/14- 9.9 cm by 5.2 cm with 3.7 cm depth ( 1.2 cm increase in length and .2 cm increase in depth since measurement on 10/17/14) -10/22/14- 5 cm by 8.5 cm with 2.7 cm depth (3.3 cm increase in width since measurement 10/20/14) -10/24/14- 5.2 cm by 10 cm with 2.7 cm depth (1.5 cm increase in width since measurement on 10/22/14) -10/26/14- Increased odorous drainage noted to dressing when removed. Review of Resident 38's medical record from 10/13/14 to 10/26/14 revealed no documentation to indicate the resident's physician was notified of the increased measurements and of the increased odorous drainage to the resident's gluteal sacral pressure sore. Review of facility "Wound Assessment Tool" completed by PT revealed the following measurements and assessments for the pressure sore to Resident 38's left heel: -11/7/14- 1.2 cm length by 1.3 cm width with 0.3 cm depth. The pressure sore had minimal drainage and minimal odor. -11/10/14- assessment revealed the pressure sore continued to have drainage with minimal odor and skin surrounding wound bed was red and swollen. Therapist used [MEDICATION NAME] (ointment used to treat a bacterial infection) on wound and covered the pressure sore with [MEDICATION NAME] (dressing which is used to help control the growth of bacteria) dressing and gauze wrap. -11/12/14- 1.5 cm length by 1.3 cm width and 0.3 cm depth. (.3 cm increase in length since measurements on 11/7/14) -11/17/14- assessment revealed maceration (break down of skin resulting from prolonged exposure to moisture) to skin surrounding wound bed with an increased odor. Review of Resident 38's medical record from 11/7/1 4 to 11/17/14 revealed no documentation that the resident's physician was notified of the change in the resident's left heel pressure sore. During an interview on 11/25/14 from 11:00 AM to 11:12 AM, the Director of Nursing (DON) verified Resident 38's physician was not notified of the increase in measurements of the gluteal sacral pressure sore on 10/10/14, 10/15/14, 10/20/14, 10/22/14, 10/24/14 and 10/26/14. The DON further verified Resident 38's physician was not notified of the increase in size, odor, maceration and drainage to the resident's left heel pressure sore until 11/24/14. E. Review of Resident 19's MDS dated [DATE] indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The same MDS indicated the resident was at risk for the development of pressure sores and received Hospice services. Review of the Weekly Skin Integrity Action Tool (used by nursing to document the assessment of skin problems) dated 9/4/14 revealed "slight redness to gluteal (buttocks) folds" and "healed wound to (L) (left) gluteal" and "no open skin". Review of Hospice Visit Note Report dated 9/25/14 revealed Resident 19 had a Stage 1 (a pressure-related alteration of intact skin that presents as a defined area of persistent redness or discoloration) pressure sore on the right buttock measuring 5 cm x 2 cm, and a Stage 2 pressure sore on the left buttock measuring 3.5 cm x 1 cm. Documentation indicated the Hospice nurse notified the physician and obtained orders for treatment. Review of Hospice Visit Note Report dated 10/2/14 revealed a "white pin point (sic) area to top of left second toe" and "a dark brown soft spot on top of left great toe". There was no documentation to indicate Resident 19's physician was notified of these areas. Review of the Weekly Skin Integrity Action Tool for 10/2014 revealed the following: - 10/3/14 - reddened and abraded areas to the left buttock measuring 3 cm x 2 cm, and to the right buttock measuring 5 cm x 3 cm (This indicated the areas increased in size from the previous measurements on 9/25/14.) - 10/10/14 - 3 cm x 1.5 cm scabbed area to the left buttock and 3.5 cm x 1.5 cm reddened scabbed area to right buttock with red/purple skin surrounding both areas (This indicated worsening of the resident's skin integrity on bilateral buttocks.) - 10/17/14 - excoriated areas noted 7 cm x 3 cm to left buttock and 3 cm x 3 cm to right buttock (This indicated the area on the left buttock had increased in size.) There was no documentation to indicate the resident's physician was notified of the worsening condition of Resident 19's pressure sores to the bilateral buttocks. Review of Hospice Visit Note Report dated 10/23/14 revealed an area of black eschar (dead tissue on top of a wound) measuring 1 cm in diameter on the left great toe. Review of Resident 19's Weekly Skin Integrity Action Tool for 10/2014 revealed a "new unstageable" pressure sore on the left second toe measuring 0.6 cm x 0.8 cm. There was no documentation to indicate Resident 19's physician was notified of the pressure sores on the resident's left great toe and left second toe. Review of Hospice Visit Note Report dated 11/3/14 revealed black eschar remained on the resident's left great toe and the surrounding area was "bright red". Documentation also indicated the presence of a pressure are on the second toe of the left foot with a raised, tender area surrounding. Review of a Physician Verbal Order dated 11/3/14 indicated Hospice notified Resident 19's physician of the scabbed area on left second toe (32 days after the area was first observed on 10/2/14) and an order was obtained for treatment. There was no documentation to indicate the physician was notified of the eschar area on Resident 19's left great toe. During observation of nursing care on 11/24/14 from 11:20 AM until 11:44 AM, a dressing was observed on Resident 19's left second toe, and the left great toe was open to air. There was a dark black spot on the end of the left great toe and the surrounding skin was dry, flaky and discolored red/purple. The resident's buttock area was open to air and was purple in color with no open areas noted. F. Review of Resident 15's MDS dated [DATE] indicated the resident was admitted with [DIAGNOSES REDACTED]. Review of the Weight Variance Report (a record of weekly weights) indicated Resident 15 weighed 87# on 8/4/14 and 82# on 9/2/14. This represented a 5.7% significant weight loss in 1 month. There was no documentation in the medical record to indicate the resident's physician was notified of the significant weight loss at this time. Review of the Weight Variance Report indicated Resident 15 weighed 81.7# on 9/8/14, 79.5# on 9/17/14 and 82.1# on 9/24/14. Review of a Nursing Progress Note dated 9/24/14 at 1:45 PM indicated Resident 15's physician was notified of the resident's weight loss (22 days following the significant weight loss on 9/2/14). Review of the Weight Variance Report indicated Resident 15 weighed 79.2# on 10/20/14 and 78.2# on 10/29/14. Review of a Weight/Skin Condition Review completed by the Director of Nursing and Dietary Manager on 10/31/14 revealed Resident 15 had a 10% significant weight loss in 3 months. There was no documentation in the medical record to indicate the resident's physician was notified of the significant weight loss. | 2015-07-01 |
| 11264 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 241 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(21) Based on observations, staff interview and record review; the facility failed to ensure residents were treated with respect and dignity related to: 1) transporting Resident 9 to the bathing room and prolonged wait time to receive meal service; 2) positioning Resident 29's urinary catheter drainage bag to prevent visual exposure; and 3) prolonged wait time to receive meal service and soiled clothing/equipment for Resident 15. Facility census was 33. Findings are: A. Review of Resident 9's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/3/14 revealed [DIAGNOSES REDACTED]. The same MDS indicated the resident had moderate cognitive impairment, was dependent upon staff for transfers and personal hygiene and required extensive assistance with eating. Review of Resident 9's Care Plan dated 10/9/14 revealed the resident wore a wig and removed it when napping/sleeping during the day and at night. The Care Plan indicated a goal to provide the resident with dignity and respect. The intervention indicated the privacy curtain was to be closed when the resident was napping/sleeping to provide privacy and dignity. In addition, the Care Plan indicated Resident 9's family requested the resident not be taken to the dining room "too early" in the morning. The Care Plan indicated the resident was to remain in room until "shortly before breakfast is served." On 11/19/14 at 7:18 AM, Resident 9 was observed seated in a shower chair (a chair on wheels which allows the resident to be rolled into the shower while seated). Nursing Assistant (NA)-B pulled Resident 9 backwards with 1 hand and with the other hand pushed the resident's wheelchair through the Wing 1 corridor while en-route to the bathing room. Resident 9 was not wearing the wig, was dressed in a hospital gown and covered with a torn frayed blanket. The resident's bare legs and feet dangled below the blanket. The resident's wig was lying in the seat of the wheelchair. At 7:41 on 11/19/14, NA-B was observed to wheel Resident 9 out of the bathing room and into the dining room. Resident 9 was not served the breakfast meal until 8:35 AM (53 minutes later). On 11/20/14 Resident 9 was observed seated at the table in the dining room waiting to be served the breakfast meal from 7:11 AM until 10:03 AM (2 hours and 52 minutes later). B. Review of Resident 29's MDS dated [DATE] identified a [DIAGNOSES REDACTED]. Review of Resident 29's Care Plan with revision date of 9/14/14 revealed the resident had a supra-pubic urinary catheter (tube inserted into the bladder through a hole in the stomach to drain urine from the bladder) with an intervention to store the urinary catheter drainage bag inside a protective dignity pouch. Observations of Resident 29 revealed the following: -11/19/14 from 8:23 AM to 9:06 AM- the resident was observed seated in a wheelchair in the Dining Room. A urinary catheter drainage bag was observed attached to the wheelchair frame. The urinary catheter drainage bag was stored in a dignity pouch, but the pouch had bunched around the tubing and the top of the drainage bag. The drainage bag contained dark yellow urine which was visible to any other residents and/or visitors seated in the Dining Room. -11/24/14 at 5:38 PM- the resident was observed seated in a wheelchair in the dining room. A urinary catheter drainage bag was observed attached to the frame of the wheelchair. The lower 5 inches of the urinary catheter drainage bag was uncovered and dark yellow urine was visible to any residents and/or visitors seated or passing through the Dining Room. -11/25/14 from 7:01 AM to 8:02 AM- the resident was observed seated in a recliner. The foot rest of the recliner was elevated and the resident's urinary catheter drainage bag was observed uncovered and attached to the framework under the foot rest. The catheter bag and 300 cubic centimeters (CC) of dark yellow urine were visible from the doorway of the resident's room. -12/1/14 from 6:40 AM to 7:50 AM- the resident's urinary catheter drainage bag was uncovered and lying directly on the floor in the entrance of the resident's room. The catheter bag contained 350 cc of dark yellow urine and was visible from the hallway and the entrance of the resident's room. During an interview on 12/2/14 from 8:30 AM to 8:45 AM, the Director of Nursing verified Resident 29's supra-pubic urinary catheter drainage bag should have been kept covered at all times to maintain the resident's dignity. C. The following was observed during Resident 15's breakfast meal on 11/20/14: - The resident sat in the wheelchair at the dining room table with no food or fluids from 6:55 AM until 7:48 AM. - At 7:48 AM (53 minutes after first observed in the dining room) the resident was served water, juice and nutritional supplement. The resident retrieved and drank the fluids independently. - At 9:21 AM the resident sat with head down and eyes closed, still awaiting service of the breakfast meal. The resident had consumed 100% of the nutritional supplement and juice, and 50% of the water. - At 9:54 AM (2 hours and 59 minutes after the resident was first observed in the dining room awaiting service of the meal) the resident was served a piece of toast with jelly and ate independently. During observation of incontinent care for Resident 15 on 11/24/14 from 1:12 PM until 1:25 PM, NA-D and NA-E transferred the resident from wheelchair to toilet. The resident's sweatshirt and pants were soiled with food splatter. There was a sheet of clear plastic beneath the cushion in the seat of the wheelchair that extended out the side of the chair and was heavily soiled with food spillage. The tire of the wheelchair on the same side was splattered as well. Without cleaning the sheet of clear plastic, NA-E replaced it beneath the wheelchair cushion so it no longer extended out the side of the chair and was no longer visible. Following incontinent care, Resident 15 was transferred to bed. The resident's soiled clothing was not changed, and the resident was left to rest in bed. During interview on 12/1/14 at 10:18 AM, the Director of Nurses verified the clear plastic sheet beneath Resident 15's wheelchair cushion was used to keep the cushion from sliding. The DON further verified staff should have changed the resident's soiled clothing prior to laying the resident in bed to rest. | 2015-07-01 |
| 11265 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 258 | C | 0 | 1 | ZQ0211 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A(3) Based on observations, confidential resident interviews and staff interview; the facility failed to ensure comfortable noise levels related to an audible chime alarm in the corridor of Wing 1 which sounded repeatedly. This had the potential to affect the comfort of all residents as the noise could be heard throughout the Wing 1 corridor and extended into the dining room area. Facility census was 33. Findings are: A. On 11/19/14 at 6:56 AM, a motion alarm (an alarm activated by movement) was observed positioned on the ceiling in the corridor outside of Resident 40's room. The motion alarm sounded an audible chime alarm each time Resident 40 entered or exited the room and whenever anyone passed by in the corridor. The audible chime alarm sounded repeatedly between 6:56 AM and 8:37 AM as residents and staff passed by in the corridor. The sound from the audible chime alarm was heard throughout the Wing 1 corridor and extended into the dining room area. At 9:45 AM, Resident 40 repeatedly walked in and out of the room triggering the audible chime alarm. B. 2 confidential resident interviews conducted on 11/19/14 between 10:48 AM and 11:31 AM indicated they were able to hear the audible chime alarm. 1 resident stated "I hear it and try not to pay attention to it. I don't complain". Another resident stated the audible chime alarm had started recently and "It's a nuisance". C. The audible chime alarm in the corridor of Wing 1 sounded repeatedly on 11/20/14 between 8:35 AM and 9:30 AM as staff and residents walked by Resident 40's room. The sound was heard throughout the Wing 1 corridor and extended into the dining room area. D. Interview with the Director of Nurses (DON) on 11/25/14 at 8:40 AM revealed the audible chime alarm was placed outside Resident 40's room in an effort to monitor the resident's whereabouts. The DON verified the audible chime alarm needed to be re-set as it sounded when anyone passed by in the corridor. | 2015-07-01 |
| 11266 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 279 | D | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04c3a(5) Based on observations, record review and staff interview; the facility failed to develop a plan of care to address the need for turning and repositioning for Resident 15 who was assessed to be at risk for the development of pressure ulcers. Facility census was 33. Findings are: Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/23/14 revealed the resident was admitted with [DIAGNOSES REDACTED]. The MDS further indicated Resident 15 required extensive to total assistance with bed mobility and transfers. Review of the Braden Scale For Prediction of Pressure Ulcer Risk dated 10/23/14 revealed Resident 15 was at high risk for the development of pressure ulcers and nursing interventions included pressure reducing devices in the chair and bed, and a turning and repositioning program. During observations of Resident 15 were noted on 11/20/14: - The resident was seated in wheelchair at the dining room table for the breakfast meal at 6:55 AM, 7:44 AM, 7:48 AM, 8:09 AM, 8:39 AM, 9:21 AM, 9:42 AM, 10:07 AM, and 10:12 AM when the resident was wheeled to the activity room. - The resident remained in wheelchair for an activity from 10:12 AM until 10:34 AM when the resident was returned to room. - The resident remained seated in wheelchair from 10:34 AM until 11:30 AM when Nursing Assistant (NA)-G was observed to wheel the resident from room to the dining room. During interview on 11/20/14 at 11:30 AM, NA-G verified Resident 15 was not toileted or repositioned prior to being wheeled to the dining room for the noon meal. (The resident was observed seated in wheelchair without repositioning for 4 hours and 35 minutes.) The following observations of Resident 15 were noted on 11/24/14: - The resident was seated in wheelchair at the dining room table for the breakfast meal from 9:15 AM until 10:00 AM when the resident was wheeled to the activity room for an exercise activity. - The resident remained seated in wheelchair for an activity from 10:00 AM until 10:30 AM when the resident was wheeled to the dining room to attend Bingo. - The resident remained in wheelchair in the dining room for Bingo from 10:30 AM until 11:45 AM when the resident's wheelchair was positioned at the dining room table in preparation for the noon meal. - The resident remained in wheelchair in the dining room for the noon meal from 11:45 AM until 1:12 PM when the resident was wheeled to room for toileting (3 hours and 57 minutes since first observed in wheelchair in the dining room for breakfast). During interview on 11/24/14 at 1:25 PM, NA-E indicated Resident 15 was to be repositioned every 2 hours. During interview on 11/25/14 at 9:29 AM, the DON verified Resident 15 was to be repositioned every 2 hours. Review of Resident 15's current Care Plan dated 7/31/13 revealed nursing interventions were not developed to address the resident's need for turning and repositioning. | 2015-07-01 |
| 11267 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 280 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on observations, record review and staff interviews; the facility failed to review and revise Care Plans related to the treatment of [REDACTED]. Facility census was 33. Findings are: A. Review of facility policy titled "Pressure Sore Prevention and Monitoring Guidelines" (revised 6/13) revealed the goal of the facility was to maintain skin integrity. If a resident developed a pressure sore, the resident was to receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Upon identifying a pressure sore the licensed nurse was to ensure pressure sores were identified with goals and interventions to be addressed on the resident's Care Plan. B. Review of Resident 38's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/14/14 revealed resident 38 was admitted on [DATE] with [DIAGNOSES REDACTED]. -Two Stage 2 pressure sores (The staging system is a method of summarizing certain characteristics of pressure sores, including the extent of tissue damage. Stage 2 refers to partial thickness skin loss that presents as an abrasion, blister or shallow crater). -Two Stage 3 pressure sores (full thickness skin loss with damage to subcutaneous (under the skin) tissue). -One unstageable pressure sore (unstageable refers to a full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (dead tissue) in the wound bed). -One unstageable pressure sore with suspected deep tissue injury (pressure related injury to subcutaneous tissue). Review of Resident 38's "Wound Assessment Tool" dated 10/8/14 revealed Resident 38 had a 9.5 centimeter (cm) by 5.7 cm pressure sore with 10 cm depth to gluteal sacral area (lower back above buttock crease) and a 4 cm by 3.7 cm pressure sore with 3 cm depth to left [MEDICATION NAME] area (upper back). Review of Resident 38's "Weekly Pressure Sore Record" dated 10/8/14 revealed Resident 38 had a stage 3 pressure sore (no measurements) to the left heel which was debrided (removal of eschar to promote healing). Review of Resident 38's Care Plan with revision date 10/8/14 reflected a stage 3 pressure sore to sacral gluteal area and a stage 3 pressure sore to posterior [MEDICATION NAME] area. The following interventions were identified: -[DEVICE] to [MEDICATION NAME] and gluteal pressure sores with dressing change to be completed by PT 3 times per week. -Case Manager to update physician on wound progress. -Avoid shearing skin when repositioning resident. -Conduct a skin inspection weekly. -Observe and report signs [MEDICAL CONDITION] or osteo[DIAGNOSES REDACTED]. -To wear heel pressure booties at all times to bilateral feet. -High protein diet. Further review of the resident 38's Care Plan revealed no documentation related to the presence of a stage 3 pressure sore to the resident's left heel. During an interview on 11/25/14 from 11:00 AM to 11:12 AM, the Director of Nursing (DON) confirmed Resident 38's Care Plan had not been revised to address the pressure sore to the resident's left heel. C. Review of Resident 10's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The 9/30/14 MDS further indicated the resident was dependent with bed mobility and transfers, was at risk for pressure sores, had moisture associated skin damage, and was on a turning/repositioning program. On 11/19/14 at 4:32 PM, Resident 10 was observed to have a small Stage 2 pressure sore on the coccyx area. NA-E voiced awareness of Resident 10's pressure sore of the coccyx during observation of care at 10:40 AM on 11/20/14. At 12:13 PM on 11/24/14, Licensed Nurse (LN)-F examined the pressure sore on Resident 10's coccyx area and stated "It is superficial. It's from moisture." Review of Resident 10' s current Care Plan dated 11/5/14 revealed interventions were not revised to address the presence of the Stage 2 pressure sore of the coccyx. D. Review of Resident 35's MDS dated [DATE] revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The same MDS indicated the resident had moisture associated skin damage. Nursing Assistants A and E were observed to provide Resident 35's perineal hygiene on 11/25/14 at 7:35 AM. The skin on the resident's buttocks, coccyx and rectal areas was red and excoriated. Nursing Assistant (NA)-E stated the reddened excoriated areas had "gotten better then gets worse again" and "it comes and goes". NA-A and NA-E indicated [MEDICATION NAME] (topical cream containing menthol and zinc oxide) was applied each time incontinent care was provided. Review of Resident 35's Care Plan dated 9/19/14 revealed interventions were not revised to address the resident's excoriated skin on the buttocks/coccyx/rectal areas. E. Review of Resident 9's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The same MDS indicated the resident had moderate cognitive impairment, required extensive assistance with eating and weight was 117 pounds. Review of Weight Variance Reports and Weight and Vital Signs Monitoring Records for 10/2014 and 11/2014 revealed Resident 9's weight dropped from 117 pounds on 10/10/14 to 106.6 pounds on 11/10/14 which was an 8 percent significant weight loss in 1 month. Review of Resident 9's current Care Plan dated 10/9/14 revealed interventions were not revised in an attempt to prevent further weight loss. F. Review of Resident 15's MDS dated [DATE] indicated the resident was admitted with [DIAGNOSES REDACTED]. The MDS further revealed the resident required extensive assistance with eating. Review of Resident 15's current Care Plan dated 2/2/13 indicated the resident had a history of [REDACTED]. Interventions included to offer ice cream if not eating the meal provided; provide 2 Cal (a high calorie nutritional supplement) 4 ounces TID (3 times daily) between meals; encourage, provide cues, and/or assist with oral intake of food and fluids although resident not always receptive to this; monitor and record weight weekly; notify physician and family of significant weight changes; and monitor/record intake of food. Review of a Referral Form dated 4/22/14 indicated a request by nursing to discontinue use of 2 Cal nutritional supplement as resident refused it all but once in the last 22 days. A physician's orders [REDACTED]. There was no documentation to indicate the resident's current Care Plan was revised related to the discontinued use of 2 Cal supplement. Review of a Weight/Skin Condition Review completed 9/4/14 revealed the following: - the resident was getting a 4 ounce shake as a nutritional supplement TID, and - a new intervention was added to provide Magic Cup (another type of nutritional supplement) TID with meals. There was no documentation to indicate the resident's current Care Plan was revised to include the 4 ounce shake TID and the addition of Magic Cup TID with meals. Review of a Weight/Skin Condition Review completed 10/17/14 revealed the resident was receiving Instant Breakfast as a nutritional supplement. There was no documentation to indicate the resident's current Care Plan was revised to include Instant Breakfast as a nutritional supplement. During interview on 11/25/14 at 9:29 AM, the Director of Nursing verified Resident 15 was receiving Instant Breakfast with meals. During interview on 12/2/14 at 12:48 PM, the Dietary Manager indicated the Resident 15 was to be offered Magic Cup instead of ice cream if meal intake was poor. There was no documentation on the resident's current Care Plan to indicate Magic Cup was to be offered if the resident was not eating the meal provided. G. Review of Resident 19's MDS dated [DATE] indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The same MDS indicated the resident was at risk for the development of pressure sores and received Hospice services. Review of Resident 15's current Care Plan dated 10/16/14 indicated the resident had a pressure sore related to end stage disease poor nutrition and healing properties. Nursing interventions included to prevent or treat pain by applying dressings provided by Hospice to the resident's coccyx; keep resident off coccyx; is to be first down and last up for and after all meals; turn and reposition every 2 hours and as needed; and use moisture barrier product to the perineal area. Review of Hospice Visit Note Report and Physician Verbal Order dated 11/6/14 indicated the following regarding Resident 15: - The left great toe had a pressure sore measuring 1.0 cm in diameter and extending into the nail bed, covered by black eschar, and surrounded by "bright red" skin. - The left second toe had a pressure sore measuring 1.0 cm in diameter with redness extending to 2.0 cm. There was a large amount of tan/yellow drainage, necrotic (dead) tissue present, and the surrounding tissue was dark red and swollen. - The resident's physician was notified and treatment orders were obtained. During observation of nursing care on 11/24/14 from 11:20 AM until 11:44 AM, there was a dressing observed on the left second toe and the left great toe was open to air. There was a dark black spot on the end of the left great toe and the surrounding skin was dry, flaky and discolored red/purple. Review of Resident 15's current Care Plan dated 10/16/14 revealed the pressure sores on the resident's left foot were not addressed. | 2015-07-01 |
| 11268 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 282 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on observations, record review and staff interview; the facility failed to implement Care Plan interventions related to activities of daily living, repositioning, nutrition, pressure sores and management of urinary catheters for Residents 9, 15, 10, 17 and 29. Facility census was 33. Findings are: A. Review of Resident 29's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/3/14 identified [DIAGNOSES REDACTED]. Review of Resident 29's Care Plan with revision date of 9/14/14 identified the resident had a supra-pubic catheter (tube inserted into the resident's bladder through a small hole in the stomach to drain urine from the bladder). Resident 29's Care Plan further identified the resident was at risk for urinary tract infections and skin breakdown and listed the following interventions: -Do not allow drainage bag to touch the floor or the surface of the bed. -Use principles of infection control and standard precautions (procedures designed by the Centers for Disease Control and Prevention (CDC) to prevent the spread of known and unknown sources of infections. It applies to blood; body fluids, excretions, and secretions of the skin; and oral mucosa) when doing any treatments or catheter care. -Store catheter drainage bag inside a protective dignity pouch. -Perform catheter care per facility policy. During an observation on 11/19/14 at 4:30 PM, Resident 29 was seated in a recliner in the resident's room. The resident's supra-pubic urinary catheter drainage bag was hung on the outside of a trash receptacle next to the resident's recliner. The trash receptacle contained soiled Kleenex and crumpled papers. The bottom of the drainage bag rested directly on the floor next to the trash receptacle. During an observation on 11/20/14 at 7:45 AM, Resident 29 was seated in a recliner in the resident's room with foot rest elevated. The resident's supra-pubic urinary catheter drainage bag was positioned directly on the floor underneath of the recliner foot rest. Observation of the treatment to Resident 29's supra-pubic catheter site on 11/24/14 from 10:49 AM to 10:53 AM, revealed Registered Nurse (RN)-L entered the resident's room carrying 3 washcloths, a pair of gloves and a 4 x 4 dressing. Without washing or cleansing hands, RN-L donned clean gloves and removed the current 4 x 4 dressing which was soiled with a moderate amount of brown drainage from the resident's supra-pubic catheter insertion site. RN-L placed the soiled dressing in bedside trash receptacle and without removing soiled gloves, entered the resident's bathroom. RN-L placed the 3 washcloths directly into the basin of the resident's sink to dampen the washcloths with water. RN-L returned to the resident's room and used the washcloths to cleanse the resident' s supra-pubic urinary catheter insertion site. Without removing soiled gloves, RN-L opened the package containing the 4 x 4 dressing and placed the dressing directly on the insertion site, adjusted the resident's clothing and exited the resident's room. RN-L removed soiled gloves in the hallway outside of the resident's room, but did not wash or sanitize hands before returning to the Nurse's station to complete documentation of the dressing change. Observations of Resident 29 seated in a recliner in the resident's room revealed the following: -11/25/14 from 7:01 AM to 8:26 AM- The supra-pubic urinary catheter drainage bag was uncovered and lying directly on the floor underneath of recliner foot rest. -12/1/14 at 1:45 PM- The bottom of the supra-pubic urinary catheter drainage bag was uncovered and rested directly on the floor underneath of recliner foot rest. -12/2/14 from 6:40 AM to 7:50 AM- The supra-pubic urinary catheter drainage bag and attached tubing was uncovered and lying directly on the floor to the right of the resident's recliner, in the doorway of the resident's room. During an interview on 12/2/14 from 8:30 AM to 8:45 AM, the Director of Nursing (DON) verified facility staff should have followed the resident's Care Plan related to urinary catheter cares and handling of Resident 29's urinary catheter drainage bag. B. Review of Resident 9's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The same MDS indicated the resident had moderate cognitive impairment, was dependent upon staff for transfers and personal hygiene and required extensive assistance with eating. Review of Care Plan dated 10/9/14 revealed Resident 9's family requested the resident not be taken to the dining room "too early" in the morning. The Care Plan indicated the resident was to remain in room until "shortly before breakfast is served." At 7:41 on 11/19/14, NA-B was observed to wheel Resident 9 into the dining room. Resident 9 was not served the breakfast meal until 8:35 AM (53 minutes later). On 11/20/14 Resident 9 was observed seated at the table in the dining room waiting to be served the breakfast meal from 7:11 AM until 10:03 AM (2 hours and 52 minutes later). C. Review of Resident 10's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The 9/30/14 MDS further indicated the resident was dependent with bed mobility and transfers, was at risk for pressure sores, had moisture associated skin damage, and was on a turning/repositioning program. Review of Resident 10's Care Plan dated 11/5/14 revealed a potential for skin breakdown with an intervention to turn and reposition the resident every 2 hours and as needed. On 11/20/14, Resident 10 was observed seated in a wheelchair without benefit of repositioning from 7:10 AM until 10:40 AM (3 hours and 30 minutes). On 11/24/14, Resident 10 was observed seated in a wheelchair without benefit of repositioning from 9:16 AM until 12: 13 PM (2 hours 57 minutes). On 11/25/14, Resident 10 was observed seated in a wheelchair without benefit of repositioning from 6:45 AM until 9:56 AM (3 hours 11 minutes). D. Review of Resident 15's MDS dated [DATE] indicated the resident was admitted with [DIAGNOSES REDACTED]. The MDS further revealed the resident had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making, and required extensive assistance with eating. Review of Resident 15's Care Plan dated 2/2/13 indicated the resident had a history of [REDACTED]. Interventions included to offer ice cream if not eating the meal provided. During observation of Resident 15's breakfast meal on 11/24/14 from 9:15 AM until 10:00 AM, the resident was served a pancake with peanut butter and syrup, a glass of water, a glass of orange juice, and a glass of pink nutritional supplement in sippy cups with straws. The resident sat with head down and eyes closed, making no attempts to eat. NA-B cued the resident to drink fluids but made no attempt to assist the resident with eating. At 10:00 AM the resident was wheeled from the dining room, having consumed less than 25% of food and fluids. The resident was not offered ice cream or other alternate as indicated by the Care Plan. During observation of Resident 15's noon meal on 11/24/14 from 12:29 PM until 12:52 PM, the resident was served fried chicken, cabbage, potato, and a fruit cup. The resident sat with eyes closed and made no attempt to eat and only bites of the meal were consumed. NA-A attempted to give the resident bites of food and the resident refused. The resident was not offered ice cream or other alternate considering the poor intake of the meal, and as indicated by the Care Plan. E. Review of Resident 17's MDS dated [DATE] indicated the resident was admitted to the facility 2/19/14 with [DIAGNOSES REDACTED]. Review or Resident 17's current Care Plan dated 2/25/14 indicated the resident had an open wound to the left lateral ankle and included the following interventions: - dressing changes 3 times weekly by Physical Therapy (PT) assisted by the Case Manager (a nurse employed by the facility), - area monitored by PT and Case Manager, - area measured by PT with every dressing change, and - measure the area weekly with skin assessments and document. Review of Treatment Flowsheets for 3/2014 and 4/2014 revealed the following the wound was measured weekly on 3/5/14, 3/12/14, 3/19/14, 3/26/14 and 4/2/14. There was no documentation of measurement of the wound after 4/2/14. Review of PT Evaluation and Daily/Weekly Progress Notes dated 2/20/14 through 5/22/14 revealed no evidence to indicate PT assessed and/or measured the wound, or completed dressing changes 3 times weekly. Review of the Treatment Flowsheet dated 5/2014 revealed measurements of Resident 17's wound were not documented. Review of a Wound Assessment Tool completed by the PT and dated 6/4/14 indicated Resident 17's wound on the left lower leg measured 4.7 cm x 1.6 cm x 0.1 cm. This was the first recorded measurement of the wound since 4/2/14. Review of Weekly Skin Integrity Action Tool (a tool used by nursing to document assessment and measurements of wounds) for Resident 17 revealed the following: - In 8/2014 the wound was not measured weekly as there were no measurements documented on 8/20/14. - In 9/2014 there were no measurements documented of the wound. During interview on 12/1/14 at 5:00 PM, the Director of Nursing (DON) verified assessments and measurements of the resident's wound were not completed by nursing staff in accordance with the Care Plan. | 2015-07-01 |
| 11269 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 309 | H | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2 Based on observations, record review and staff interview; the facility failed to provide care and treatment to promote healing of wounds for Residents 17, 28, and 35. Facility census was 33. Findings are: A. Review of facility policy for Actual Impaired Skin Integrity (no date indicated) revealed residents with impaired skin integrity as a result of pressure ulcers, vascular ulcers, rashes, skin tears, surgical sites and diabetic/neuropathic ulcers were to receive interventions which included the following: -Medications and treatments as ordered -Encouragement and assistance to turn and reposition every 1 - 2 hours -Measure/assess wound and skin check every week -Notify physician of signs and symptoms of impaired skin integrity -Notify physician as needed for lack of response to treatment if no improvement noted within 2-4 weeks as indicated/appropriate -Monitor status of surrounding skin every day and notify physician as needed of noted impairment -Monitor for signs/symptoms of infection or other complication and notify physician as needed B. Review of Resident 17's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/27/14 indicated the resident was admitted to the facility 2/19/14 with [DIAGNOSES REDACTED]. Review of Resident 17's Treatment Flowsheet (a record of treatments provided by nursing) for 2/2014 revealed a physician's order dated 2/19/14 for saline wet-to-dry dressings (A gauze pad soaked in saline and placed on the surface of a wound bed, followed by a dry dressing pad placed on top of the wet dressing) to left lateral ankle BID (2 times daily) at 10:00 AM and 10:00 PM. Documentation revealed the 10:00 AM dressing change to Resident 17's ankle was not documented from 2/19/14 to 2/25/14 (6 of 13 dressing changes in 7 days). Review or Resident 17's Care Plan dated 2/25/14 indicated the resident had an open wound to the left lateral ankle and included the following interventions: - dressing changes 3 times weekly by Physical Therapy (PT) assisted by the Case Manager (a nurse employed by the facility), - area monitored by PT and Case Manager, - area measured by PT with every dressing change, and - measure the area weekly with skin assessments and document. Review of Treatment Flowsheets dated 2/2014 and 3/2014 revealed the 10:00 AM dressing change to Resident 17's ankle was not documented on 2/26/14, 2/27/14 and 2/28/14, and the 10:00 PM dressing change was not documented on 2/27/14, 2/28/14 and 3/5/14 (6 of 16 dressing changes in 8 days). Review of a Visit Summary by Resident 17's physician dated 3/5/14 indicated an order to continue dressing changes BID, and "should be as close to q (every) 12 hours as possible". The physician further ordered the wound to be measured weekly. Review of Treatment Flowsheets for 3/2014 and 4/2014 revealed the following: - On 3/5/14 the wound measured 5.4 cm (centimeters) x (by) 2.2 cm (This was the first documentation of the size of the wound since the resident was admitted on [DATE].) - The wound was measured weekly on 3/12/14, 3/19/14, 3/26/14 and 4/2/14 with a decrease in size noted. - There was no documentation of measurement of the wound after 4/2/14. - The 10:00 AM dressing change was not documented on 17 of 56 days, and the 10:00 PM dressing change was not documented on 3 of 56 days (20 of 112 dressing changes in 56 days). Review of PT Evaluation and Daily/Weekly Progress Notes dated 2/20/14 through 5/22/14 revealed no evidence to indicate PT measured the wound or completed dressing changes 3 times weekly. Review of the Treatment Flowsheet dated 5/2014 revealed the following: - Measurements of Resident 17's wound were not recorded. - The 10:00 AM dressing change was not documented on 3 of 5 days from 5/1/14 through 5/5/14. - Documentation indicated "new times start 5/6/14", and the morning dressing change was to be done between the hours of 6:00 AM and 2:00 PM and the evening dressing change between the hours of 6:00 PM and 11:00 PM. - From 5/6/14 through 5/31/14, Resident 17's morning dressing change was not documented on 6 of 26 days, and the evening dressing change was not documented on 1 of 26 days (7 of 52 dressing changes in 26 days). - There was no documentation to indicate the actual time of the dressing change within the ranges specified in order to assure a 12 hour interval between dressing changes as recommended by the physician. Review of Resident 17's medical record revealed no physician's order to change the timing of dressing changes. Review of a Referral Form dated 6/2/14 indicated Resident 17's wound to the left lower leg was treated since admission and had improved, however, "in the last week it has declined and the overall size has increased". A physician's order was obtained for PT to evaluate and treat the resident's wound. Review of a Wound Assessment Tool completed by the PT and dated 6/4/14 indicated Resident 17 ' s wound on the left lower leg measured 4.7 cm x 1.6 cm x 0.1 cm (depth). This was the first recorded measurement of the wound since 4/2/14 and represented an increase in size of the wound. The PT recommended daily wound dressing changes to be performed by nursing staff using [MEDICATION NAME] gauze or xeroform gauze (non-adhering mesh dressings used to treat wounds) to the wound bed followed by a non-adhesive pad, cotton bandage and tape. Documentation indicated PT would inspect the wound weekly and make further recommendations as needed. Review of an Addendum to Wound Assessment Tool completed by PT and dated 6/5/14 revealed PT would work with Resident 17 on left lower leg wound care 3 times weekly for 4 weeks. Documentation further indicated PT would provide guidance and instruction to nursing staff regarding wound care and dressing changes for the days PT did not perform the wound care. Review of the Treatment Flowsheet dated 6/2014 indicated the following: - Beginning 6/8/14 the dressing change would be done 3 times weekly on Monday, Wednesday and Friday by PT, and nursing was to complete dressing changes on the other 4 days of the week to assure daily dressing changes were completed. - There was no evidence to indicate nursing staff changed the dressing on Thursday 6/12/14, Saturday 6/14/14, Sunday 6/15/14, Thursday 6/19/14, Saturday 6/21/14, Sunday 6/22/14, and Thursday 6/26/14. Review of Daily/Weekly Progress Notes by PT dated 7/1/14 through 7/30/14 revealed PT performed wound dressing changes and measurements 3 times weekly. Review of Nursing Progress Notes dated 7/1/14 through 7/31/14 revealed nursing staff performed the wound dressing 1 time on 7/19/14 (which indicated the dressings were not changed daily as ordered). Review of a PT Discharge Summary dated 7/30/14 indicated Resident 17's left lower leg wound measured 3.0 cm x 1.1 cm x 0.1 cm which was a decrease in size. Review of the Treatment Flowsheet for 8/2014 revealed a physician's order dated 8/1/14 to dress Resident 17's leg wound as recommended by PT. The physician's order included the following: -Change the dressing every other day (qod) -Measure and document the wound length, width and depth qod -Cover the wound bed with [MEDICATION NAME] (a type of dressing used to treat wounds) cut slightly smaller than wound margins to allow granulation tissue (new tissue that forms on the surface of a wound during the healing process) to close inward -Cover the [MEDICATION NAME] with [MEDICATION NAME] (a non-adhesive dressing) and secure with kerlix (a gauze dressing) and Ace wrap (an elastic bandage) Review of a Medication Error report dated 8/5/14 revealed Resident 17's treatment to left lower leg was incorrectly performed by nursing staff on 8/3/14. Documentation indicated the wound measured 5.0 cm x 3.0 cm x 0.1 cm (an increase in size from measurements 7/30/14) because the [MEDICATION NAME] was not cut smaller than the wound margins as instructed, and therefore, "ruined healthy healed skin surrounding" . Documentation on the Treatment Flowsheet revealed the dressing change was performed qod except Friday 8/29/14. Review of Weekly Skin Integrity Action Tool (skin sheet used by nursing to document assessment and measurements of wounds) for 8/2014 revealed the following: -Resident 17's wound was not measured and assessed qod with dressing changes as ordered as no measurements were recorded on 8/1/14, 8/3/14, 8/7/14, 8/9/14, 8/11/14, 8/17/14, 8/21/14, 8/23/14, 8/25/14, 8/29/14 and 8/31/14. -The wound measured 3.2 cm x 1.7 cm on 8/13/14 and 4 cm x 2.4 cm on 8/27/14 (the depth of the wound was not documented) -The size of the wound had increased Review of the Treatment Flowsheet for 9/2014 indicated a physician's order dated 9/3/14 to change the treatment to saline wet-to-dry dressings to left lower leg wound BID at 7:00 AM and 8:30 PM. Documentation indicated the dressing change was performed BID from 9/3/14 through 9/15/14. Review of Weekly Skin Integrity Action Tool for 9/2014 revealed Resident 17's wound was not assessed or measured by nursing staff. Review of a PT Evaluation form dated 9/15/14 revealed Resident 17's leg wound measured 3.4 cm x 1.8 cm x 0.1 cm. Documentation further indicated the wound was being treated by nursing staff per PT recommendations, however, the treatment "was not followed exactly" . During interview on 12/1/14 at 5:00 PM, the Director of Nursing (DON) verified wound dressing changes on Resident 17's left lower leg were not performed in accordance with physician's orders and PT recommendations. The DON further verified assessments and measurements of the resident's wound were not completed by nursing staff in accordance with the plan of treatment. C. Review of Resident 28's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. Review of a facsimile (fax) dated 11/21/14 at 7:52 PM revealed Resident 28's physician was notified of a "...burn from hot coffee." The resident spilled coffee and sustained reddened skin areas on the inner left thigh from groin to knee and a 3 cm area on the left inner foot. Cool water was applied to the site followed by [MEDICATION NAME] (topical cream used to treat burns). Documentation further indicated 45 minutes later the redness to the resident's inner thigh had decreased to "...mid inner thigh approx.(approximately) 5 cm" and the reddened area to the foot had "...decreased as well." No further treatment was ordered by the physician other than to "Observe". Review of Resident 28's Progress Notes revealed no evidence to indicate the burn injury was monitored and treated until 11/23/14 at 2:37 AM (over 24 hours later). Documentation stated "...Blistering showing in leg burn yesterday that occurred during supper time. [MEDICATION NAME] applied". The location of the blistered skin areas of the leg were not identified and measured. There was no evidence to indicate assessment and monitoring of the burn until 11/24/14. Review of Resident 28's Progress Notes dated 11/24/14 at 2:52 AM documented "...burn to left inner thigh, blister the size of quarter has popped and skin is very red, superficial, open wound noted. Area around wound is red, area to left inner knee red, and left foot is red. When asked what happened to resident, aide tells this nurse that resident spilled coffee on (self) on 11/21/14". Documentation indicated a plan to notify the physician for orders for ointment or some type of dressing. On 11/24/14 at 1:30 PM, Nursing Assistant (NA)-B was observed assisting Resident 28 out of bed. The resident had an open skin area on the left inner thigh from a blister that had popped. The area was not measured at that time but the approximate size was larger than a 50 cent piece. During interview on 11/25/14 at 10:40 AM, the Director of Nursing (DON) verified Resident 28's left inner thigh wound had not been measured. The DON indicated the physician was notified for treatment orders on 11/24/14 and the physician ordered application of [MEDICATION NAME] to the wound 2 times daily. Review of a Weekly Wound Record initiated 11/25/14 revealed Resident 28 had a wound on the left inner thigh that measured 3.8 cm x 4.7 cm on 11/25/14. On 11/30/14 the wound measured 3 cm x 3.8 cm. D. Review of Resident 35's MDS dated [DATE] revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The same MDS indicated the resident had moisture associated skin damage. Review of Transfer and Referral Record from the hospital dated 9/17/14 revealed Resident 35's coccyx was slightly reddened. Review of Resident 35's Progress Notes dated 9/17/14 at 4:02 PM revealed the resident's skin was described as "....warm dry and intact". There was no evidence to indicate the resident's coccyx or buttock area was reddened. Review of Admission and Weekly Skin Integrity Action Tool dated 9/24/14 revealed no evidence to indicate Resident 35 had a skin integrity problem. Review of Admission and Weekly Skin Integrity Action Tool dated 10/6/14 and 10/13/14 revealed Resident 35's buttocks were reddened and [MEDICATION NAME] (topical medication containing menthol and zinc oxide which protects skin from moisture and minor irritation) cream was applied after incontinent brief changes. There was no further assessment regarding the resident's reddened buttocks area. Review of Physician Orders dated 10/16/14 revealed orders for [MEDICATION NAME] (topical medication used to treat minor skin irritation by forming a barrier on the skin to protect it from irritants/moisture) cream as needed and [MEDICATION NAME] cream as needed. Review of Resident 35's Medication Flowsheet dated 10/2014 revealed an order for [REDACTED]. Review of the Admission and Weekly Skin Integrity Action Tool dated 10/20/14 revealed Resident 35's buttocks were red and [MEDICATION NAME] was used with incontinent brief changes. There was no documentation on the Admission and Weekly Skin Integrity Action Tool dated 10/27/14 regarding Resident 35's skin condition. Review of the Admission and Weekly Skin Integrity Action Tool dated 11/3/14, 11/10/14 and 11/17/14 revealed no assessment or documentation regarding Resident 35's reddened buttocks area. Review of progress notes dated 11/19/14 at 7:15 PM indicated the resident was seen by the physician due to possible yeast infection beneath the resident's breasts and lower abdominal folds and "...Do show MD residents bottom". There was no assessment or documentation regarding the skin condition on the resident's buttocks/coccyx area. Review of Resident 35's Medication Flowsheet dated 11/1/14 through 11/24/14 revealed no evidence to indicate [MEDICATION NAME] or [MEDICATION NAME] creams had been used. Review of the Admission and Weekly Skin Integrity Action Tool dated 11/24/14 revealed no assessment or documentation regarding Resident 35's buttocks area. Nursing Assistants A and E were observed to provide Resident 35's perineal hygiene on 11/25/14 at 7:35 AM. The skin on the resident's buttocks, coccyx and rectal areas was red and excoriated. Nursing Assistant (NA)-E stated the reddened excoriated areas had "gotten better then gets worse again" and "it comes and goes". NA-A and NA-E indicated [MEDICATION NAME] (topical cream containing menthol and zinc oxide) was applied each time incontinent care was provided. | 2015-07-01 |
| 11270 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 312 | D | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observations, record review and staff interview; the facility failed to provide toileting assistance for Resident 38 and feeding assistance for Resident 9 who both required assistance with activities of daily living. Facility census was 33. Findings are: A. Review of Resident 38's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/14/14 indicated [DIAGNOSES REDACTED]. Observations of Resident 38 on 11/17/14 revealed the following: -At 7:01 AM, the resident's call light was on and the resident was lying in bed. The resident indicated the call light had been turned on as the resident needed to use the bathroom. -At 7:15 AM, (14 minutes later) The Registered Nurse (RN) Consultant entered Resident 38's room, turned off the call light and told the resident help was coming, before exiting the resident's room. -At 7:22 AM, (21 minutes after call light was first turned on) Resident 38 turned the call light back on stating, "They still haven't taken me to the bathroom". -At 7:39 AM, (38 minutes after the call light was first turned on) Nursing Assistant (NA)-M entered the resident's room and turned off the resident's call light, NA-M indicated an additional staff member was needed to help the resident and NA-M exited the resident's room. -At 7:52 AM, (51 minutes after Resident 38 initially turned on the call light to seek assist with toileting) NA-A entered the resident's room, closed the door and turned off the resident's call light. During an interview on 11/17/14 from 8:05 AM to 8:12 AM, NA-A confirmed Resident 38 was not taken to the bathroom until the call light was turned off at 7:52 AM. In addition, NA-A verified Resident 38 was incontinent of urine by the time the resident was assisted to the bathroom. B. Review of Resident 9's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. At 7:41 AM on 11/19/14, NA-B was observed to wheel Resident 9 into the dining room. Resident 9 was not served the breakfast meal until 8:35 AM (53 minutes). Resident 9 made no attempt to feed self and received no eating assistance until 8:53 AM (18 minutes). On 11/24/14, Resident 9 was observed lying in bed at 11:39 AM, 12:00 noon, 1:00 PM and 2:00 PM. The resident did not receive a noon meal. NA-A indicated during interview on 11/25/14 at 10:17 AM that Resident 9 had slept through the noon meal on 11/24/14. NA-A indicated the resident was usually offered something to eat after waking, however the resident had not been offered anything to eat when NA-A went off duty at 2:00 PM as the resident was still in bed. Review of Resident 9 ' s medical record revealed no evidence to indicate the resident was assisted to eat something after missing the noon meal on 11/24/14. | 2015-07-01 |
| 11271 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 314 | H | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observations, record review and staff interviews; the facility failed to identify the presence of pressure sores and/or to provide identified interventions for the prevention and treatment of [REDACTED]. Facility census was 33. Findings are: A. Review of facility policy titled "Pressure Sore Prevention and Monitoring Guidelines" (revised 6/13) revealed the goal of the facility was to maintain skin integrity. If a resident developed a pressure sore, the resident was to receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Upon identifying a pressure sore the licensed nurse was to perform the following procedures: -Notify the physician for orders to treat each pressure sore identified. -Notify resident's responsible party and physician regarding change in condition. -Ensure pressure sores are identified with goals and interventions to be addressed on the resident's Care Plan. -Schedule weekly head to toe skin assessments. -Notify the Dietary Manager and the Registered Dietician for recommendations to ensure adequate caloric and protein needs as applicable. -All pressure sores will be assessed weekly. B. Review of facility policy titled "Dressing-Non-sterile Treatment" (revised 6/13) revealed the policy of the facility was to perform treatments and dressing changes per physician orders. The licensed nurse was to follow the following procedure: -Review physician treatment orders. -Prepare clean field. -Create a barrier for dressing supplies and place on the clean field. -Wash hands. -Apply clean gloves -Remove soiled dressing and place in a biohazard container. -Remove gloves and wash hands. -Apply clean gloves. -Clean wound per physician order. Clean wound from the center to the outer borders using a circular motion (area of most contamination to the area of the least). Ensure you do not contaminate the wound bed. -Remove gloves and wash hands. -Apply clean gloves. -Apply dressing as ordered. -Remove gloves and wash hands. C. Review of Resident 38's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/14/14 indicated [DIAGNOSES REDACTED]. The MDS further indicated Resident 38 had the following pressure sores identified: -Two Stage 2 pressure sores (The staging system is a method of summarizing certain characteristics of pressure sores, including the extent of tissue damage. Stage 2 refers to partial thickness skin loss that presents as an abrasion, blister or shallow crater). -Two Stage 3 pressure sores (full thickness skin loss with damage to subcutaneous (under the skin) tissue). -One unstageable pressure sore (unstageable refers to a full thickness tissue loss in which the base of the sore is covered by slough and/or eschar (dead tissue) in the wound bed). -One unstageable pressure sore with suspected deep tissue injury (pressure related injury to subcutaneous tissue). The MDS identified use of pressure reducing devices to chair and bed, a turning and repositioning program, nutritional and hydration interventions, pressure sore care and application of non-surgical dressings. Review of Resident 38's admission physician orders [REDACTED]. Review of Resident 38's "Wound Assessment Tool" dated 10/8/14 revealed the resident had a 9.5 centimeter (cm) by 5.7 cm pressure sore with 10 cm depth to gluteal sacral area (lower back above the buttock crease) and a 4 cm by 3.7 cm pressure sore with 3 cm depth to left [MEDICATION NAME] area (upper back). Review of Resident 38's "Weekly Pressure Sore Record" dated 10/8/14 revealed the resident had a stage 3 pressure sore (no measurements) to the left heel which was debrided (removal of eschar to promote healing). Review of Resident 38's Care Plan with revision date 10/8/14 reflected the resident had a stage 3 pressure sore to sacral gluteal area and a stage 3 pressure sore to [MEDICATION NAME] area. The following interventions were identified: -[DEVICE] to [MEDICATION NAME] and gluteal pressure sores with dressing change to be completed by PT 3 times per week. -Case Manager to update physician on wound progress. -Avoid shearing skin when repositioning resident. -Conduct a skin inspection weekly. -Observe and report signs [MEDICAL CONDITION] or osteo[DIAGNOSES REDACTED]. -To wear heel pressure booties at all times to bilateral feet. -High protein diet. Further review of the resident 38"s Care Plan revealed no documentation related to the presence of a stage 3 pressure sore to the resident's left heel. Review of Resident 38's "Wound Assessment Tool" dated 10/10/14 and completed by PT revealed Resident 38's gluteal sacral pressure sore measured 11.0 cm by 5.6 cm with 5 cm depth (1.5 cm increase of wound length from measurements on 10/8/14). review of the resident's medical record revealed [REDACTED]. sacral pressure sore. Review of Resident 38's Progress Notes dated 10/10/14 at 4:30 PM revealed PT dressed the areas to the resident's left foot with Vaseline gauze (non-adherent absorbent dressing impregnated with white [MEDICATION NAME]). Review of Resident 38's medical record revealed no further documentation or assessment of the pressure sore to the resident's left heel. Review of Resident 38's "Wound Assessment Tool" completed by PT revealed the following measurements and assessments for the pressure sore to Resident 38's gluteal sacral wound: -10/13/14- 9.0 cm by 5.6 cm with 6 cm depth. -10/15/14- 10.4 cm by 4.5 cm with 5 cm depth (1.4 cm increase of wound length from measurement on 10/13/14) -10/17/14- 8.7 cm by 5.4 cm with 3 cm depth. -10/20/14- 9.9 cm by 5.2 cm with 3.7 cm depth ( 1.2 cm increase in length and .2 cm increase in depth since measurement on 10/17/14) -10/22/14- 5 cm by 8.5 cm with 2.7 cm depth (3.3 cm increase in width since measurement 10/20/14) -10/24/14- 5.2 cm by 10 cm with 2.7 cm depth (1.5 cm increase in width since measurement on 10/22/14) -10/26/14- Increased odorous drainage noted to dressing when removed. Review of Resident 38's medical record from 10/13/14 to 10/26/14 revealed no documentation to indicate the resident's physician was notified of the increased measurements and of the increased odorous drainage to the resident's gluteal sacral pressure sore. Review of Resident 38's "Wound Assessment Tool" completed by PT on 10/24/14 revealed due to increased odor and drainage the therapist debrided necrotic area to left heel pressure sore. The wound was covered with Vaseline gauze and secured with [MEDICATION NAME] and gauze. Review of Resident 38's medical record revealed no further documentation or assessment of the pressure sore to the resident's left heel. Review of Resident 38's Medication Administration Record [REDACTED]. Further review revealed the resident only received a snack on 10/26/14 and 10/27/14 (2 out of 24 days). Review of the Registered Dietician's Progress Note dated 11/5/14 at 12:52 PM (8 days after Resident 38 was admitted to the facility) revealed the resident was receiving an extra glass of milk and large portions of meat with all meals for added protein. Further review of the Registered Dietician's documentation revealed no documentation of Resident 38's caloric or protein intakes and no further assessment or recommendations for the resident's needs. Review of the Resident 38's medical record from 10/25/14 to 11/7/14 revealed no further assessment or documentation to the pressure sore on the resident's left heel. Review of Resident 38's "Wound Assessment Tool" completed by PT revealed the following measurements and assessments for the pressure sore to Resident 38's left heel: -11/7/14- 1.2 cm length by 1.3 cm width with 0.3 cm depth. The pressure sore had minimal drainage and minimal odor. -11/10/14- assessment revealed the pressure sore continued to have drainage with minimal odor and skin surrounding wound bed was red and swollen. Therapist used [MEDICATION NAME] (ointment used to treat a bacterial infection) on wound and covered the pressure sore with [MEDICATION NAME] (dressing which is used to help control the growth of bacteria) dressing and gauze wrap. -11/12/14- 1.5 cm length by 1.3 cm width and 0.3 cm depth. (.3 cm increase in length since measurements on 11/7/14) -11/17/14- assessment revealed maceration (break down of skin resulting from prolonged exposure to moisture) to skin surrounding wound bed with an increased odor. Review of Resident 38's medical record from 11/10/1 4 to 11/17/14 revealed no documentation that the resident's physician was notified of the change in the left heel pressure sore. During observations on 11/17/14 from 7:01 AM to 8:21 AM, Resident 38 was observed in the resident's room with no pressure relieving devices to bilateral feet. During observations on 11/20/14 from 11:56 PM to 12:55 PM, Resident 38 was observed seated in a wheelchair with no pressure relieving device to the right foot and the right heel resting directly on the surface of an unpadded foot pedal. Observation of the dressing change to Resident 38's pressure sores to gluteal sacral area, [MEDICATION NAME] area and left heel on 11/24/14 from 9:10 AM to 10:15 AM, revealed PT-J removed the [DEVICE] dressing to the resident's gluteal sacral wound. Without removing soiled gloves, PT-J measured the pressure sore, cleansed the skin approximately 6 inches on all sides around the perimeter of the wound with alcohol, applied a skin protectant to the skin around the wound bed and applied several strips of the transparent drape approximately 6 inches away from the wound, right up to the wound edges. PT-J removed soiled gloves but without washing or cleansing hands, donned clean gloves and proceeded to pack the wound bed with strips of foam which had been cut and shaped to fit the wound bed. PT-J applied [MEDICATION NAME] ointment to the foam used to pack the center of the wound bed followed by application of additional transparent drape over the foam packing. While still wearing soiled gloves, PT-J used a pair of tweezers to tuck the sides of the drape into the borders of the wound bed, cut a 2 cm hole in the center of the transparent drape directly over the top of the pressure ulcer, attached a pad with tubing over the hole and attached the tubing to the canister of the [DEVICE]. PT-J removed soiled gloves but did not wash or cleanse hands before donning clean gloves. PT-J removed the soiled dressing to the resident's [MEDICATION NAME] pressure sore, palpated the edges of the wound with gloved fingers, measured and cleansed the wound and applied a border foam (absorbent foam) dressing before removing soiled gloves and washing hands. PT-J donned clean gloves and removed the soiled dressing to the resident's left heel with odor noted immediately after removal of dressing. PT-J indicated the pressure sore had increased maceration to the edges of the wound and stated the heel was "mushy". PT-J measured, cleansed and applied calcium alginate to the wound bed and covered with a border foam dressing before removing gloves and washing hands. Before leaving the resident's room, PT-J again identified the left heel was looking worse and indicated the dressing should be changed at least on a daily basis. Review of "Wound Assessment Tool" dated 11/24/14 revealed a recommendation by the PT to change the dressing to Resident 38's left heel daily. Review of Resident 38's "Wound Assessment Tool" completed by PT on 11/24/14 revealed the pressure sore to Resident 38's left heel measured 1.5 cm in length by 1.0 in width and 0.5 cm depth. The resident had identified increased pain with treatment, and the therapist documented increase of maceration to skin surrounding the wound bed with continued odor. Therapist changed the treatment to calcium alginate (absorbent dressing which aids in debridement and is used for wounds with increased drainage or infection) to the wound bed followed by a border foam dressing. During observations on 11/24/14, Resident 38 was observed seated in a wheelchair with no pressure relieving device to the right foot and the right heel resting directly on the surface of an unpadded foot pedal from 11:16 AM to 12:32 PM, from 2:14 PM to 2: 48 PM and from 4:30 PM to 5:30 PM. During an observation on 11/24/14 at 5:15 PM, Resident 38 was served a meal which consisted of a bowl of vegetable soup, one half of a corn beef sand-which and one glass of milk. Resident 38 was not provided with an extra glass of milk or with an additional portion of meat. Review of Resident 38's MAR from 11/1/14 to 11/24/14 revealed Resident 38 received a high protein snack before bed from 11/7/14 to 11/13/13 and from 11/15/14 to 11/19/14 (12 out of 24 days). During an interview on 11/25/14 from 11:00 AM to 11:12 AM, the Director of Nursing (DON) and the Infection Control Coordinator confirmed PT-J should have followed the facility policy related to non-sterile dressing changes. In addition, the DON verified Resident 38's physician was not notified of the increase in measurements of the gluteal sacral wound on 10/10/14, 10/15/14, 10/20/14, 10/22/14, 10/24/14 and 10/26/14 and no assessments were completed for Resident 38's left heel from 10/10/14 to 10/23/14 and from 10/25/14 to 11/17/14. The DON further verified Resident 38's physician was not notified of the increase in size, odor, maceration and drainage to the resident's left heel pressure sore until 11/24/14. The DON identified Resident 38 was to have heel protectors to both feet at all times as assessed on the resident's Care Plan and confirmed Resident 38's Care Plan did not address the pressure sore to the resident's left heel. Review of "Wound Assessment Tool" dated 11/25/14 to 12/1/14 revealed the dressing to Resident 38's left heel was changed on 11/26/14 and 11/28/14 and 12/1/14 (3 out of 7 days) instead of on a daily basis as recommended by the PT. During an interview on 12/1/14 from 10:20 AM to 10:40 AM, the DON confirmed the dressing change on Resident 38's left heel was not completed on 11/25/14, 11/27/14, 11/29/14 and 11/30/14. During observations on 12/1/14 at 9:00 AM and on 12/2/14 at 7:42 AM, Resident 38 was seated in a wheelchair in the dining room with no pressure relieving device to the right foot. In addition, the resident was served a breakfast meal on both days which consisted of only one glass of milk. During an interview on 12/2/14 from 8:50 AM to 9:05 AM the Dietary Manager (DM) confirmed Resident 38 was to receive an extra glass of milk and an additional portion of meat at all meals for increased protein. In addition, the DM confirmed the snack cart was not always passed in the evening due to fluctuations in staffing. D. Review of Resident 19's MDS dated [DATE] indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The same MDS indicated the resident required total assistance with activities of daily living, was at risk for the development of pressure sores, and received Hospice services. Review of resident 19's Care Plan dated 9/9/14 indicated the resident was at risk for skin breakdown related to immobility and pain. Nursing interventions included a systematic skin inspection weekly and as needed with bath, and report any signs of skin breakdown including sore, tender, red or broken areas. Review of the Weekly Skin Integrity Action Tool (a tool used by nursing to document the assessment of skin problems) dated 9/4/14 revealed "slight redness to gluteal (buttocks) folds" and "healed wound to (L) (left) gluteal" and "no open skin". Review of the Treatment Flowsheet (a record of treatments provided by nursing) for 9/2014 revealed orders dated 9/4/14 for head to toe skin assessments every week on Friday, and for [MEDICATION NAME] silicone foam dressing (a type of dressing used to treat skin breakdown) to bilateral buttock pink areas, change every (q) 3 days as needed (prn) for shearing (friction causing trauma to the skin) and skin breakdown. There was no documentation to indicate the [MEDICATION NAME] dressing was applied. Review of Hospice Plan of Care Update Report dated 9/10/14 revealed Resident 19 had a [DIAGNOSES REDACTED]. Review of Hospice Visit Note Report dated 9/11/14 indicated redness was observed to Resident 19's bilateral buttocks and [MEDICATION NAME] (a protective paste) was applied. There was no documentation to indicate the [MEDICATION NAME] dressing was applied. Review of the Weekly Skin Integrity Action Tool dated 9/12/14 indicated "no new skin issues". Review of a Nursing Progress Note dated 9/20/14 at 8:30 PM indicated excoriation was noted on bilateral buttocks and "some shallow open areas present with surrounding redness". Documentation indicated the area was cleaned and a protective barrier cream applied, and the physician was notified by facsimile (fax). There was no documentation to indicate the [MEDICATION NAME] dressing was applied as previously ordered by the physician, and there was no documentation to indicate the size or staging of the pressure sores. Review of Hospice Visit Note Report dated 9/25/14 revealed Resident 19 had a Stage 1 (a pressure-related alteration of intact skin that presents as a defined area of persistent redness or discoloration) pressure sore on the right buttock measuring 5 cm x 2 cm, and a Stage 2 pressure sore on the left buttock measuring 3.5 cm x 1 cm. Documentation indicated the Hospice nurse applied a silicone foam dressing to the areas. Review of a Physician Verbal Order dated 9/25/14 indicated Hospice notified Resident 19's physician and obtained an order for [REDACTED]. Review of Treatment Flowsheets for 9/2014 and 10/2014 revealed a physician's orders [REDACTED]. There was documentation to indicate the treatment was completed on 9/26/14 and 9/29/14, however, there was no documentation to indicate the treatment was provided 10/1/14 through 10/31/14. Review of Hospice Visit Note Report dated 10/2/14 revealed a "white pin point (sic) area to top of left second toe" and "a dark brown soft spot on top of left great toe". Review of the Weekly Skin Integrity Action Tool for 10/2014 revealed the following: -10/3/14 - reddened and abraded areas to the left buttock measuring 3 cm x 2 cm, and to the right buttock measuring 5 cm x 3 cm (This indicated the areas increased in size from the previous measurements taken 9/25/14.) -10/10/14 - 3 cm x 1.5 cm scabbed area to the left buttock and 3.5 cm x 1.5 cm reddened scabbed area to right buttock with red/purple skin surrounding both areas (This indicated worsening of the resident's skin integrity on bilateral buttocks.) -10/17/14 - excoriated areas noted 7 cm x 3 cm to left buttock and 3 cm x 3 cm to right buttock (This indicated the area on the left buttock had increased in size.) -There was no documentation to indicate staging of the areas. -There was no documentation related to areas observed 10/2/14 by hospice on the resident's left toes. Review of Hospice Visit Note Report dated 10/23/14 revealed an area of black eschar (dead tissue on top of a wound) measuring 1 cm in diameter on the left great toe. (This was the first documentation related to the left great toe since 10/2/14, 21 days prior.) Review of Resident 19's Weekly Skin Integrity Action Tool for 10/2014 revealed the following: -10/24/14 - a "new unstageable" pressure sore on the left second toe measuring 0.6 cm x 0.8 cm. (This was the first documentation of this wound since hospice noted it on 10/2/14, 22 days prior.) - 10/24/14 - buttocks "still red" and applying cream and dressings (There were no measurements or description of the area documented.) -There was no documentation related to the area of eschar on the left great toe. -There was no weekly skin assessment documented on 10/31/14. Review of Hospice Visit Note Report dated 11/3/14 revealed black eschar remained on the resident's left great toe (no measurements documented) and the surrounding area was "bright red". (This was the first documentation related to this area since first noted by hospice on 10/23/14, 11 days prior.) Documentation also indicated the presence of a pressure sore on the second toe of the left foot (no measurements or staging documented) with a raised, tender area surrounding. Review of a Physician Verbal Order dated 11/3/14 indicated Hospice notified Resident 19's physician of "scabbed area on left second toe for a couple of weeks" and "area is raised, has a white border around it, is soft, tender to touch, does have red streaks coming from area". Documentation indicated the physician ordered Bactrim (an antibiotic medication) liquid 200/40 milligrams (mg) per 5 milliliters (ml), give 20 ml 2 times daily (BID) for 7 days. There was no documentation to indicate the physician was notified of the eschar area on Resident 19's left great toe. Review of a Nursing Progress Notes for Resident 19 revealed the following: -11/3/14 at 11:40 PM - the "left great toe" had a "dime sized white area with a brown scabbed area in center oozing whitish brown thick substance." -11/4/14 at 1:48 PM ("Recorded as Late Entry on 11/05/14 02:18 PM") - resident's "left second toe" had a "dime sized white area with a brown scabbed area in center and was oozing bloody drainage", and the antibiotic ordered by the physician had not yet arrived. -11/5/14 at 2:10 AM - initial dose of Bactrim administered for infection of second great toe. Review of Hospice Plan of Care Update Report dated 11/5/14 revealed Resident 19's buttocks were "still red" and continued to be treated. Review of the Treatment Flowsheet for 11/2014 revealed there was no documentation to indicate the q 3 day [MEDICATION NAME] dressing to the resident's buttocks was completed on 11/4/14 and 11/19/14. Review of Hospice Visit Note Report dated 11/6/14 indicated Resident 19 had the following pressure sores: -left great toe - 1.0 cm in diameter and extending into the nail bed, black eschar, and surrounding skin "bright red" (This was the first documentation of size and description of this pressure ulcer since 10/23/14, 14 days prior.), and -left second toe - 1.0 cm diameter with redness extending to 2.0 cm, large amount of tan/yellow drainage, necrotic (dead) tissue present, area surrounding dark red and swollen (This was the first documentation of size and description of this pressure ulcer since 10/24/14, 13 days prior.) Review of a Physician Verbal Order dated 11/6/14 indicated Hospice notified Resident 19's physician that the area on resident's left second toe had opened and was draining dark brown, thick drainage. A physician's treatment order was received to cover the area with [MEDICATION NAME] (a non-adhesive wound dressing) and gauze after cleansing the wound daily. There was no documentation to indicate the physician had been notified of the area on Resident 19's left great toe. Review of Hospice Visit Note Report dated 11/13/14 indicated the resident had the following pressure sores: - left second toe - 1.0 cm in diameter, small amount pale red/pink drainage, no necrotic issue, area surrounding bright red and "entire toe is swollen", - left great toe - 1.0 cm diameter, black eschar extending into nail bed, surrounding tissue a white/gray pallor, and - buttocks were "white/red" with no open areas noted. Review of a Physician Verbal Order dated 11/13/14 indicated Hospice notified Resident 19's physician that the left second toe was swollen and red, but the red streaks up the foot and into the calf were resolved with administration of the antibiotic. The physician ordered a thin film of [MEDICATION NAME] (an antibiotic ointment) be applied to the area with each dressing change. There was no documentation to indicate the physician had been notified of the area on Resident 19's left great toe. During observation on 11/20/14 from 8:49 AM until 9:15 AM, Licensed Practical Nurse (LPN)-F provided treatment to Resident 19's left second toe pressure ulcer. The soiled [MEDICATION NAME] dressing was adhered to the wound bed with dried drainage and was released using a spray cleanser. The area was located on the joint of the toe and measured 1 cm in diameter. The skin surrounding the area was a purple color. LPN-F dressed the area using antibiotic ointment, [MEDICATION NAME] dressing and gauze as prescribed. There was no treatment provided to the left great toe and no measurements made. During the same observation, Nursing Assistant (NA)-E and NA-D provided incontinent care. There was no dressing on Resident 19's coccyx/buttock area, and the skin was a dark purple color. During observation of nursing care on 11/24/14 from 11:20 AM until 11:44 AM, NA-A, NA-B and NA-E provided incontinent care for Resident 19. There was a dressing on the left second toe and the left great toe was open to air. There was a dark black spot on the end of the left great toe and the surrounding skin was dry, flaky and discolored red/purple. The resident's coccyx area was open to air and was purple in color with no open areas noted. E. Review of Resident 15's MDS dated [DATE] revealed the resident was admitted with [DIAGNOSES REDACTED]. The MDS further indicated Resident 15 had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making, and required extensive to total assistance with bed mobility and transfers. Review of Resident 15's Care Plan dated 7/31/13 revealed the resident was at risk for pressure ulcers and nursing interventions included to elevate the resident's heels while in bed, and to avoid shearing (friction that could result in trauma to the skin) during positioning, transferring and turning. The Care Plan did not indicate the frequency of repositioning for Resident 15. Review of the Braden Scale For Prediction of Pressure Ulcer Risk dated 10/23/14 revealed Resident 15 was at high risk for the development of pressure ulcers and nursing interventions included pressure reducing devices in the chair and bed, and a turning and repositioning program. During observations of Resident 15 on 11/20/14 the following were noted: - At 6:55 AM, 7:44 AM, 7:48 AM, 8:09 AM, 8:39 AM, 9:21 AM, 9:42 AM and 10:07 AM, the resident was observed seated in the dining room for the breakfast meal. - At 10:12 AM the Activities volunteer wheeled the resident from the dining room to the activity room for a music event. - At 10:34 AM the Activities volunteer wheeled the resident to room. - There were no nursing staff observed to enter the resident's room until 11:30 AM when Nursing Assistant (NA)-G was observed to wheel the resident from room to the dining room. During interview on 11/20/14 at 11:30 AM, NA-G verified Resident 15 was not toileted or repositioned prior to being wheeled to the dining room for the noon meal. (The resident was observed seated in wheelchair without repositioning for 4 hours and 35 minutes.) During observation on 11/24/14 from 9:15 AM until 9:44 AM, Resident 15 was seated in wheelchair at the dining room table for the breakfast meal. During interview on 11/24/14 at 9:44 AM, NA-B revealed Resident 15 was up since 6:30 AM to 7:00 AM. The following observations of Resident 15 were noted on 11/24/14: - At 10:00 AM the resident was wheeled directly from the dining room to the activity room for an exercise activity and remained there until 10:30 AM when the resident was wheeled directly to the dining room to attend a Bingo activity. - The resident remained in wheelchair at the dining room table for Bingo until 11:45 AM when a staff member moved the resident's wheelchair to the other side of the table for placement for the noon meal. The resident was not taken to room for toileting and/or preparation for the noon meal. - At 1:12 PM the resident was wheeled to room for toileting (3 hours and 57 minutes since first observed in wheelchair in the dining room for breakfast). During interview on 11/24/14 at 1:25 PM, NA-E indicated Resident 15 was to be repositioned every 2 hours. During interview on 11/25/14 at 9:29 AM, the DON verified Resident 15 was to be repositioned every 2 hours. F. Review of Resident 10's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The 9/30/14 MDS further indicated the resident was dependent with bed mobility and transfers, was at risk for pressure sores, had moisture associated skin damage, and was on a turning/repositioning program. Review of Resident 10's Admission and Weekly Skin Integrity Action Tool for 9/2014, 10/2014 and 11/2014 revealed the following: -9/14/14-"red/purple area above coccyx, no open areas noted" -9/21/14-"red/purple area remains. No open sore" -9/28/14-"no new skin issues" -10/5/14-"no new skin issues" -10/12/14-"No new skin issues" -There was no documentation on 10/19/14 and 10/26/14 -11/2/14-"no new skin issues" -There was no documentation on 11/9/14 -11/16/14-"No new skin issues" Review of Resident 10's Care Plan dated 11/5/14 revealed a potential for skin breakdown with an intervention to turn and reposition the resident every 2 hours and as needed. NA-C and NA-D were observed to provide Resident 10's perineal hygiene on 11/19/14 at 4:32 PM. NA-C commented Resident 10 had a "little schiff" (a small open area) on the "backside" (coccyx area) which had been reported to the Director of Nurses earlier that day. A Stage 2 pressure sore was observed on Resident 10's coccyx area. On 11/20/14, Resident 10 was observed seated in a wheelchair without benefit of repositioning from 7:10 AM until 10:40 AM (3 hours and 30 minutes). NA-E voiced awareness of Resident 10's pressure sore of the coccyx during observation of care at 10:40 AM on 11/20/14. NA-E applied a barrier cream (over the counter topical medication to protect skin from moisture and minor irritation) to the resident's coccyx area upon completion of care. Review of Resident 10's Progress notes for 11/2014 revealed no evidence to indicate the pressure sore of the coccyx was assessed. Review of Resident 10's Admission and Weekly Skin Integrity Action Tool dated 11/23/14 revealed no documentation regarding the pressure sore of the coccyx. On 11/24/14, Resident 10 was observed seated in a wheelchair without benefit of repositioning from 9:16 AM until 12:13 PM (2 hours 57 minutes). NA-A and NA-B were observed to transfer Resident 10 onto the toilet at 12:13 PM on 11/24/14. Following toileting, Licensed Nurse (LN)-F examined the pressure sore on Resident 10's coccyx area and stated "It is superficial. It's from moisture." There was no evidence further assessments or measurements were completed. On 11/25/14, Resident 10 was observed seated in a wheelchair without benefit of repositioning from 6:45 AM until 9:56 AM (3 hours 11 minutes). | 2015-07-01 |
| 11272 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 315 | G | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D3 (1) Based on observations, record review and staff interview: the facility failed to provide catheter care and to provide treatment and handling of a urinary catheter drainage bag in a manner to prevent recurrent urinary tract infections for 1 resident (Resident 29). Facility census was 33. Findings are: A. Review of facility policy titled "Urinary/ Catheter Care" (revised 2/2012) indicated the purpose of catheter care was to minimize the risk of catheter-associated urinary tract infection and its related problems. The policy identified the following procedures: -Wash hands and apply gloves. -Cleanse the catheter insertion site daily with soap and water. Cleanse the proximal third of the catheter with soap and water, washing away from the insertion site and manipulating the catheter as little as possible. -Apply a sterile 4 x 4 to catheter insertion site as ordered or as indicated. -Remove gloves and wash hands. B. Review of Resident 29's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/3/14 identified [DIAGNOSES REDACTED]. Review of Resident 29's Care Plan with revision date of 9/14/14 revealed the resident had drainage from the insertion site of a supra pubic catheter (tube inserted into the bladder through a small hole in the stomach to drain urine from the bladder) with a goal for the area to be without drainage and to heal. An intervention was identified to wash the insertion site BID (twice a day) with soap and water and to apply [MEDICATION NAME] (topical antibiotic use to treat/prevent infections and to promote healing) as needed followed by a dressing. Resident 29's Care Plan further identified the resident was at risk for urinary tract infections and skin breakdown related to indwelling supra-pubic urinary catheter and listed the following interventions: -Monitor site for signs and symptoms of infection every shift. -Change dressing daily. -Keep catheter insertion site clean. -Do not allow drainage bag to touch the floor or the surface of the bed. -Use principles of infection control and standard precautions (procedures designed by the Centers for Disease Control and Prevention (CDC) to prevent the spread of known and unknown sources of infections. It applies to blood; body fluids, excretions, and secretions of the skin; and oral mucosa) when doing any treatments or catheter care. -Store catheter drainage bag inside a protective dignity pouch. -Monitor vital signs and report presence of a fever. -Perform catheter care per facility policy. Review of Resident 29's Progress Notes revealed the following: -7/11/14 at 2:44 PM- The resident had increased confusion and agitation with yellow drainage to the resident's supra-pubic urinary catheter insertion site. The resident's physician was notified and a new order was received for a U/A (urinalysis). -7/12/14 at 10:29 AM- The resident's physician was notified regarding results of U/A and a new order was received for a culture and a sensitivity (a culture is done to find out what kind of organism (usually bacteria) is causing an infection and a sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the infection) and to start the resident [MEDICATION NAME](antibiotic) 500 mg (milligrams). -7/15/14 at 9:32 PM- The area to the resident's supra-pubic urinary catheter insertion site was excoriated and "fire engine red". Drainage to site was "green and foul smelling". -7/16/14 at 3:54 PM- The area to the supra-pubic urinary catheter insertion site remained red with foul smell. -7/16/14 at 10:32 PM- Supra-pubic urinary catheter insertion site remained "very odorous and fire engine red". -7/19/14 at 1:30 PM- The resident received the last dose [MEDICATION NAME] physician orders. -8/5/14 at 10:43 PM- The dressing was changed to the supra-pubic urinary catheter insertion site and area was red with a slight odor. -9/10/14 at 6:54 PM- The resident's supra-pubic catheter insertion site was red with yellow foul smelling drainage. -9/12/14 at 10:30 AM- New order to wash supra-pubic urinary catheter insertion site with soap and water BID and apply [MEDICATION NAME] as needed was received from resident's physician regarding drainage to catheter insertion site. -9/17/14 at 11:05 AM- The resident's physician was notified of increased agitation and mood swings. New order was received to complete a urinalysis and to [MEDICATION NAME] mg BID for 10 days. -11/6/14 at 6:00 PM- Resident complained of back pain and of not feeling well. Urine in supra-pubic urinary catheter drainage bag was amber colored with increased sediment. Order received for a urinalysis with a culture and sensitivity and [MEDICATION NAME] mg BID for 10 days. -11/8/14 at 2:15 AM- The initial dose [MEDICATION NAME] administered. Resident continued to have cloudy urine to supra-pubic urinary catheter drainage bag. -11/15/14 at 11:44 AM- The resident continued on antibiotic for urinary tract infection and continued to complain of lower back pain with tea colored urine with a foul odor to supra-pubic catheter drainage bag. During an observation on 11/19/14 at 4:30 PM, Resident 29 was seated in a recliner in the resident's room. The resident's supra-pubic urinary catheter drainage bag was hung on the outside of a trash receptacle next to the resident's recliner. The trash receptacle contained soiled Kleenex and crumpled papers. The bottom of the drainage bag rested directly on the floor next to the trash receptacle. During an observation on 11/20/14 at 7:45 AM, Resident 12 was seated in a recliner in the resident"s room with foot rest elevated. The resident's supra-pubic urinary catheter drainage bag was positioned directly on the floor underneath of the recliner footrest. During an interview on 11/20/14 from 9:45 AM to 10:00 AM, Nursing Assistant (NA)-A identified facility staff had been trained to keep urinary catheter drainage bags and tubing below the level of the resident's bladder and were never to be stored directly on the floor. Review of Resident 29's Treatment Administration Record (TAR) dated November 2014 revealed the following treatment orders: -12/2/13 Daily dressing change to supra-pubic catheter insertion site once a day. -9/12/14 Wash around supra-pubic catheter insertion site with soap and water BID and apply [MEDICATION NAME] as needed. Observation of the treatment to Resident 29's supra-pubic catheter site on 11/24/14 from 10:49 AM to 10:53 AM, revealed Registered Nurse (RN)-L entered the resident's room carrying 3 washcloths, a pair of gloves and a 4 x 4 dressing. Without washing or cleansing hands, RN-L donned clean gloves and removed the current 4 x 4 dressing which was soiled with a moderate amount of brown drainage from the resident's supra-pubic catheter insertion site. RN-L placed the soiled dressing in bedside trash receptacle and without removing soiled gloves, entered the resident's bathroom. RN-L placed the 3 washcloths directly into the basin of the resident's sink to dampen the washcloths with water. RN-L returned to the resident's room and used washcloths to cleanse the resident's supra-pubic urinary catheter insertion site. Without removing soiled gloves, RN-L opened the package containing the sterile 4 x 4 dressing and placed the dressing directly on the insertion site, adjusted the resident's clothing and exited the resident's room. RN-L removed soiled gloves in the hallway outside of the resident's room, but did not wash or sanitize hands before returning to the Nurse's station to complete documentation of the dressing change. Observations of Resident 29 seated in a recliner in the resident's room revealed the following: -11/25/14 from 7:01 AM to 8:26 AM- The supra-pubic urinary catheter drainage bag was uncovered and lying directly on the floor underneath of recliner foot rest. -12/1/14 at 1:45 PM- The bottom of the supra-pubic urinary catheter drainage bag was uncovered and rested directly on the floor underneath of recliner foot rest. -12/2/14 from 6:40 AM to 7:50 AM- The supra-pubic urinary catheter drainage bag and attached tubing was uncovered and lying directly on the floor to the right of the resident's recliner, in the doorway of the resident's room. During an interview on 12/2/14 from 8:30 AM to 8:45 AM, the Director of Nursing verified Resident 29's supra-pubic urinary catheter drainage bag and tubing should have never been stored on the floor. In addition, RN-L should have followed the resident's Care Plan and the facility policy for supra-pubic urinary catheter care to prevent the resident's recurrent urinary tract infections. | 2015-07-01 |
| 11273 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 323 | K | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record review and staff interviews; the facility failed to assure residents were free of injury from hot liquid spills. Resident 28 was not assessed for risk of hot liquid spills and sustained a burn after spilling coffee. In addition, hot water temperatures were not monitored to ensure residents who received showers were protected from potential burn injury. This affected 23 residents (Resident 35, 10, 12, 4, 17, 6, 34, 28, 37, 33, 1, 29, 15, 9, 18, 40, 36, 23, 2, 24, 39, 43, and 38). Facility census was 33. Findings are: A. Review of facility Hot Beverage Safety Guideline policy (revision date 4/2013) revealed residents were to be assessed using the Hot Beverage Safety Evaluation upon admission, quarterly and as needed to determine ability to independently consume hot beverages safely. Staff were to ensure supervision and assistance was provided as identified by the Hot Beverage Safety Evaluation and witnessed unsafe practices associated with the consumption of hot beverages were to be reported to the Nursing Department Manager/Designee with interventions implemented as required. B. Review of Resident 28's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/18/14 revealed [DIAGNOSES REDACTED]. Review of a facsimile (fax) dated 11/21/14 at 7:52 PM revealed Resident 28's physician was notified of a "...burn from hot coffee." The resident spilled coffee and sustained reddened skin areas on the inner left thigh from groin to knee and a 3 centimeter (cm) area on the left inner foot. Documentation further indicated that 45 minutes later the redness to the resident's inner thigh had decreased to "...mid inner thigh approx. (approximately) 5 cm" and the reddened area to the foot had " ...decreased as well." Review of Resident 28's medical record revealed no evidence to indicate a Hot Beverage Safety Evaluation was completed until 11/24/14 (3 days after the resident was burned). Review of Resident 28's Care Plan dated 11/24/14 (3 days after the resident was burned by spilled coffee) revealed an intervention started on 11/21/14 to allow Resident 28's coffee to cool down before serving. The Care Plan did not specify what temperature the coffee was to be cooled down to before serving. There was no evidence in Resident 28's medical record to indicate Resident 28's coffee was cooled before serving or to indicate coffee and hot liquid temperatures had been monitored from 11/21/14 to 11/24/14. On 11/24/14 at 1:30 PM, Nursing Assistant (NA)-B was observed assisting Resident 28 out of bed. The resident had an open skin area on the left inner thigh from a blister that had popped. The area was not measured at that time but the approximate size was larger than a 50 cent piece. (Review of a Weekly Wound Record dated 11/25/14 revealed Resident 28 had a wound on the left inner thigh that measured 3.8 cm by 4.7 cm.) Observation on 11/24/14 at 1:40 PM revealed the coffee when served from the coffee carafe in the kitchen was 158 degrees Fahrenheit (F). Interview with the Director of Nurses (DON) on 11/25/14 at 8:50 AM revealed Hot Beverage Safety Evaluations were completed on all residents on 11/24/14. The DON further indicated 3 residents (Residents 28, 2 and 9) were identified at risk for hot liquid spills with an intervention to place lids on cups of hot liquids. Observation of the breakfast meal on 11/25/14 at 8:55 AM revealed Residents 2 and 9 were served coffee in regular coffee cups without lids. Interview with the Dietary Manager (DM) on 11/25/14 at 9:30 AM revealed hot liquid temperatures were not checked following Resident 28's coffee burn on 11/21/14 and were not checked until 11/24/14. The DM verified Resident 2's hot liquids were not served in accordance with the plan of care. The DM was not aware Resident 9 was to have hot liquids served in a cup with a lid. ABATEMENT STATEMENT Based on the following, the facility removed the immediacy of the situation: 1.) Assessments regarding risk for hot liquid spills were completed on all residents and written plans were in place to address each resident ' s needs. 2.) All staff educated regarding policy for hot liquid assessments and prevention of hot liquid spills. All staff educated on following individual plans of care to assure residents received correct interventions to prevent hot liquid spills. 3.) Assigned a staff member to monitor and document each meal to assure hot liquids were served safely and in accordance with plans of care. 4.) Continue to monitor and record temperatures of hot liquids served at every meal. Although the immediacy was removed due to facility intervention, Resident 28 sustained a burn injury. Therefore, the scope and severity was lowered to H. C. Record review of the Long Term Care Regulation Appendix PP, F323 Guidance to surveyors revealed water temperatures at 120 degrees F could result in third degree burn (penetration of the entire thickness of skin with permanently destroyed tissue) within 5 minutes of exposure. Water temperatures at 127 degrees F could result in a third degree burn within 1 minute of exposure. Water temperatures at 133 degrees F could result in a third degree burn in 15 seconds of exposure. D. Observations on 11/19/14 of hot water temperatures in residents' bathrooms revealed the following: -8:20 AM in room 22 on Hallway 3 the temperature was 139.1 degrees F. -8:24 AM in room 11 on Hallway 3 the temperature was 130.3 degrees F. During an interview on 11/19/14 from 8:42 AM to 8:45 AM, NA-B confirmed residents had been receiving showers since 6:00 AM that morning. NA-B identified no water temperatures were checked prior to giving any residents a shower stating, "We have never been expected to check water temperatures before giving showers. I regulate the water temperature by feel and will adjust the temperature if the resident's complain". NA-B further identified a concern about the water getting hotter this morning but had not notified anyone about the excessive hot water. During an observation on 11/19/14 at 2:08 PM the water temperature of the hand-washing sink of the Activity Room was measured at 133.2 degrees F. Hot water temperatures were reported to the Registered Nurse (RN) Consultant on 11/19/14 at 2:13 PM. The RN Consultant indicated facility staff completed and documented hourly hot water temperatures, and on the last checks, water temperatures were above 130 degrees on all 3 hallways. The RN Consultant further indicated a plumber was working at the facility at this time. The RN Consultant identified a plan was in place to continue to monitor and document hot water temperatures, all staff had been educated regarding excessive hot water temperatures, signs had been placed in all the residents' bathrooms regarding excessive hot water temperatures, and a log was placed in the shower room for staff to use to monitor and document water temperatures before all showers. Review of the facility shower/bath schedules dated 11/20/14 through 12/1/14 revealed 23 residents (Residents 35, 10, 12, 4, 17, 6, 34, 28, 37, 33, 1, 29, 15, 9, 18, 40, 36, 23, 2, 24, 39, 43 and 38) received a total of 38 showers. Further review revealed no documentation of hot water temperatures prior to completion of the 38 resident showers. During an interview on 12/1/14 from 12:20 PM to 12:25 PM, the DON verified NA-B was the only staff scheduled for baths/showers 11/20/14 through 12/1/14. During an interview with NA-B on 12/2/14 from 9:10 AM to 9:20 AM, NA-B confirmed no other staff had been scheduled to complete baths/showers between 11/20/14 to 12/1/14. NA-B further confirmed no hot water temperatures had been checked or documented before completion of the 38 resident showers from 11/20/14 to 12/1/14. E. On 12/1/14, the facility Hourly Hot Water Temperature Checks record was reviewed for the days the majority of showers were provided to residents in the facility, and during the hours that baths would have been provided. The following elevated hot water temperatures were recorded: - 11/19/14 at 4:30 PM, Hall 3, Room 23/24 - 135.9 degrees F - 11/25/14 at 7:30 AM, Hall 3, Room 25 - 129.1 degrees F - 11/29/14 at 8:00 AM, Hall 1, Room 3/4 - 130.9 degrees F; Hall 2, Room 8/9 - 130.0 degrees F; and Hall 3, Room 17/18 - 133.2 degrees F. | 2015-07-01 |
| 11274 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 325 | H | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observations, record review and staff interview; the facility failed to evaluate significant weight losses for Residents 15 and 9, and gradual weight loss for Resident 10. Interventions for the prevention of weight loss were not developed and/or revised to prevent further loss of weight. Facility census was 33. Findings are: A. Review of the facility Weight Policy (Revised 08/13) included the following: 1. All residents will be weighed monthly. 2. The charge nurse will notify the Dietary Manager (DM) and Director of Nursing (DON) of weight variances. 3. Weight variance: Calculate weight loss or gain every time a resident is weighed. Significant weight variance must be brought to the attention of the Registered Dietician (RD). (Significant weight loss/gain was defined as 5% (percent) in 1 month, 7.5% in 3 months, and 10% in 6 months.) 4. RD or designee will review information, discuss with resident and document on the medical record. 5. The physician will be called by the charge nurse regarding significant weight variances. B. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/23/14 indicated the resident was admitted with [DIAGNOSES REDACTED]. The MDS further revealed the resident had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making, and required extensive assistance with eating. Review of Resident 15's Care Plan dated 2/2/13 indicated the resident had a history of [REDACTED]. Interventions included to offer ice cream if not eating the meal provided; provide 2 Cal (a high calorie nutritional supplement) 4 ounces TID (3 times daily) between meals; encourage, provide cues, and/or assist with oral intake of food and fluids although resident not always receptive to this; monitor and record weight weekly; notify physician and family of significant weight changes; and monitor/record intake of food. Review of a Referral Form dated 4/22/14 indicated a request by nursing to discontinue use of 2 Cal nutritional supplement as resident refused it all but once in the last 22 days. A physician's orders [REDACTED]. There was no documentation to indicate an alternate supplement was attempted. Review of a Nutritional Assessment by the RD dated 8/4/14 revealed Resident 15 weighed 87 pounds (#). Documentation indicated the resident's ideal body weight was 85-95#, the goal body weight was 85-88#, meal intakes provided 76-100% of estimated needs, the resident was nutritionally stable and determined to be at no/low risk for nutritional problems, and no new dietary interventions were recommended. Review of the Weight Variance Report (a record of weekly weights) indicated Resident 15 weighed 87# on 8/4/14 and 82# on 9/2/14. This represented a 5.7% significant weight loss in 1 month. Review of a Weight/Skin Condition Review completed by the DON and DM on 9/4/14 revealed the following: - the resident had a significant weight change, - average meal intakes were 0-25% except for the breakfast meal, - the resident was getting a 4 ounce shake as a nutritional supplement TID, and - a new intervention was added to provide Magic Cup (a nutritional supplement) TID with meals. Review of Resident 15's Medication/Treatment Flowsheet (a record of medications and treatments provided by nursing) for 9/2014 indicated there was no documentation of administration of nutritional supplements of 4 ounce shake TID and Magic Cup TID. There was documentation of a bedtime (HS) snack offered at 8:00 PM, however, it was not indicated what the HS snack consisted of, and the resident refused it 100% of the time. Review of the Weight Variance Report indicated Resident 15 weighed 81.7# on 9/8/14, 79.5# on 9/17/14 and 82.1# on 9/24/14. Review of a Nursing Progress Note dated 9/24/14 at 1:45 PM indicated Resident 15's physician was notified of the resident's weight loss (22 days following the significant weight loss on 9/2/14). No recommendations were made by the physician. There was no documentation to indicate the RD had been notified of the significant weight loss to evaluate the need for additional dietary interventions. Review of the Weight Variance Report indicated Resident 15 weighed 80.0# on 9/29/14, and 79.3# on 10/8/14 and 10/16/14. This indicated a continued gradual weight loss. Review of a Weight/Skin Condition Review completed by the DM on 10/17/14 revealed the following: - average meal intakes continued to be 0-25%, - Instant Breakfast as a nutritional supplement (the amount and frequency were not specified), and - no additional interventions recommended. Review of the Weight Variance Report indicated Resident 15 weighed 79.2# on 10/20/14 and 78.2# on 10/29/14, a continued gradual weight loss. Review of a Weight/Skin Condition Review completed by the DON and DM on 10/31/14 revealed the following: - 10% significant weight loss in 3 months, - continued average meal intakes of 0-25%, - Instant Breakfast as a nutritional supplement (the amount and frequency were not specified), and - no additional interventions recommended. There was no documentation to indicate the RD was notified of the resident's continued significant weight loss to evaluate the need for additional dietary interventions. Review of Resident 15's Medication/Treatment Flowsheets for 10/2014 and 11/2014 indicated there was no documentation of administration of nutritional supplements of 4 ounces shake TID, Magic Cup TID and/or Instant Breakfast. There was documentation of an HS snack offered at 8:00 PM, however, it was not indicated what the HS snack consisted of, and the resident refused it 100% of the time. During observation on 11/19/14 from 9:40 AM until 9:52 AM, Resident 15 was seated in wheelchair in room with breakfast meal on bedside table that consisted of an English muffin with butter and jelly and 3 glasses of fluids in sippy cups with straws. 1 of the glasses was labeled "Ensure" (a type of nutritional supplement). The resident sat with head down and eyes closed, but responded when spoken to and stated "I need some help". Nursing Assistant (NA)-M was observed in the hallway and, upon request, entered Resident 15's room to assist with the breakfast meal. At 9:53 AM, NA-M remained in the room feeding the resident. 100% of the English muffin and 1 glass of fluid were consumed, and NA-M was attempting to give the resident Ensure. Review of an entry in the Bath Book dated 11/19/14 indicated Resident 15 weighed 80.6#. The following was observed during Resident 15's breakfast meal on 11/20/14: - The resident sat in the wheelchair at the dining room table with no food or fluids from 6:55 AM until 7:48 AM. - At 7:48 AM (53 minutes after first observed in the dining room) the resident was served water, orange juice and a pink supplement in sippy cups. The resident retrieved and drank the fluids independently. - At 9:21 AM the resident sat with head down and eyes closed, still awaiting service of the breakfast meal. The resident had consumed 100% of the pink supplement and orange juice, and 50% of the water. - At 9:54 AM (2 hours and 59 minutes after the resident was first observed in the dining room awaiting service of the meal) the resident was served a piece of toast with jelly and ate independently. - The resident was not offered anything more to eat or drink. - At 10:12 AM the resident was removed from the dining room. The following was observed during Resident 15's breakfast meal on 11/24/14: - At 9:15 AM the resident was observed seated in wheelchair at the dining room table with full plate of food consisting of a pancake with peanut butter and syrup on it, a glass of water, a glass of orange juice, and a glass of pink supplement in sippy cups with straws. - NA-B cued the resident to drink fluids but made no attempt to assist the resident with eating, and no alternates were offered. - At 10:00 AM the resident was wheeled from the dining room, having consumed less than 25% of food and fluids. The resident was not offered ice cream or other alternate as indicated by the Care Plan. The following was observed during Resident 15's non meal on 11/24/14: - At 12:29 PM the resident was served fried chicken, cabbage, potato, and a fruit cup. The resident sat with eyes closed and made no attempt to eat. - At 12:32 PM, NA-B offered the resident a bite of food which was received, then moved away from the resident's table to assist another resident. - At 12:33 PM, NA-B returned to the resident who was drinking supplement, and while the resident had the glass of supplement at mouth, NA-B offered a bite from the fruit cup. The resident shook head in refusal and NA-B left the table to assist another resident. Resident 15 put down the glass of supplement and continued to sit without eating. - At 12:47 PM the resident continued to sit without eating. NA-A returned to the resident's side and offered bites of food which were accepted by the resident. NA-A then left Resident 15's table to assist another resident. Resident 15 occasionally took sips from the glass of supplement and/or attempted to take bites of food using fingers. - At 12:52 PM the resident sat without further attempts to eat food. The pink supplement was 100% consumed, but only bites of food were eaten. - NA-A attempted to give the resident bites of food at 1:01 PM and 1:10 PM and the resident refused. The resident was not offered ice cream or other alternate considering the poor intake of the meal, and as indicated in the Care Plan. During interview on 11/25/14 at 9:29 AM, the DON verified the pink supplement served to Resident 15 at meals was Instant Breakfast. During interview on 12/2/14 at 12:48 PM, the DM verified there was no documentation to indicate administration and consumption of nutritional supplements. The DM further indicated the resident was to be offered Magic Cup instead of ice cream if meal intake was poor. C. Review of Resident 9's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The same MDS indicated the resident had moderate cognitive impairment, required extensive assistance with eating and weight was 117 pounds. Review of Resident 9's Care Plan dated 10/9/14 revealed a problem (start date 7/31/12) regarding weight loss with current body weight of 131 pounds and acceptable body weight of 128 pounds. The long term goal (target date 10/10/14) indicated the resident "will maintain current body weight of 133 pounds). An intervention (started 7/31/12) was to increase portion size at breakfast meal. Further review of Resident 9's Care Plan dated 10/9/14 revealed a goal for the resident to maintain body weight plus/minus 10 percent of baseline body weight. The baseline body weight was identified as 119 pounds (which was different from the other Care Plan goal which addressed 128 pounds as the acceptable body weight). Interventions included provision of assistance at meals, encourage oral intake of food and fluids and offer available substitutes if problems with food served. Review of Weight Variance Reports from 10/3/14 through 11/17/14 and Weight and Vital Signs Monitoring Record from 10/3/14 through 11/19/14 revealed the following weights: -10/3/14-117.8 pounds -10/10/14-117 pounds -10/24/14-116.8 pounds -11/3/14-116.8 pounds -11/5/14-110 pounds -11/10/14-106.6 pounds (an 8 percent significant weight loss in 1 month) -11/16/14-111.8 pounds -11/17/14-111.8 pounds -11/19/14-112.7 pounds Review of Resident Meal Consumption Records for 10/2014 revealed Resident 9 refused breakfast on 5 occasions and there was no documentation regarding meal consumption for 2 breakfast meals. Documentation further indicated Resident 9 refused the noon meal on 3 occasions and ate less than 25 percent (%) on 1 occasion. Resident 9 refused the supper meal on 1 occasion and ate less than 25% on 6 occasions. Review of Resident Meal Consumption Records from 11/1/14 through 11/24/14 revealed Resident 9 refused the breakfast meal on 3 occasions, ate less than 25% on 4 occasions and there was no documentation regarding consumption on 3 occasions. Resident 9 refused the noon meal on 1 occasion, ate less than 25% on 8 occasions and there was no documentation regarding consumption on 3 occasions. Resident 9 refused the supper meal on 1 occasion, ate less than 25% on 3 occasions and there was no documentation on 1 occasion. Review of Resident 9's medical record revealed no evidence to indicate the significant weight loss had been evaluated and additional interventions to prevent further weight loss were not developed. At 7:41 AM on 11/19/14, NA-B was observed to wheel Resident 9 into the dining room. Resident 9 was not served the breakfast meal until 8:35 AM (53 minutes). Resident 9 made no attempt to feed self and received no eating assistance until 8:53 AM (18 minutes). On 11/24/14, Resident 9 was observed lying in bed at 11:39 AM, 12:00 noon, 1:00 PM and 2:00 PM. The resident did not receive a noon meal. NA-A indicated during interview on 11/25/14 at 10:17 AM that Resident 9 had slept through the noon meal on 11/24/14. NA-A indicated the resident was usually offered something to eat after waking, however the resident had not been offered anything to eat when NA-A went off duty at 2:00 PM as the resident was still in bed. Review of Resident 9's medical record revealed no evidence to indicate the resident was provided with something to eat after missing the noon meal on 11/24/14. Review of the Resident Meal Consumption Record dated 11/24/14 revealed there was no documentation regarding the noon meal. Interview with the DM on 11/25/14 at 10:10 AM revealed Resident 9 was receiving extra food at the breakfast meal, however no other nutritional interventions or supplements were provided. The DM was not sure if the RD had evaluated the resident's nutritional status in the past year. D. Review of Resident 10's MDS dated [DATE] and 9/30/14 revealed [DIAGNOSES REDACTED]. The 7/7/14 MDS indicated the resident's weight was 158 pounds and the 9/30/14 MDS indicated the resident's weight was 156 pounds. Review of Weight Variance Reports from 4/2/14 through 11/17/14 revealed Resident 10 had a gradual weight loss as evidenced by the following weights: -4/2/14-164.6 pounds -5/3/14-163.5 pounds -6/4/14-161 pounds -7/3/14-158.9 pounds -8/6/14-160.0 pounds -9/3/14-158.6 pounds -10/3/14-154.6 pounds -10/6/14-153 pounds Review of a Mini Nutritional Assessment completed 10/10/14 at 11:20 AM revealed Resident 10's weight was 153 pounds, a moderate decrease in food intake was noted and the assessment score indicated the resident was malnourished. Review of Resident 10's Progress Notes revealed the RD did not assess the resident's weight loss until 11/5/14. The RD made no additional interventions for the prevention of further weight loss. | 2015-07-01 |
| 11275 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 353 | F | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observations, record reviews and confidential resident and family interviews; the facility failed to provide nursing staff to meet resident's needs related to: 1) 9 of 12 resident interviews and 2 of 5 family interviews voiced concerns regarding lack of staff; 2) provision of toileting assistance and prompt response to call light for Resident 38; 3) provision of repositioning for Resident 15 and Resident 10 and; 4) provision of repositioning and feeding assistance/meal service for Resident 9. Facility census was 33. Finding are: A. Nine residents voiced concerns regarding insufficient nursing staff during confidential interviews conducted on 11/18/14 from 2:29 PM until 11/19/14 at 11:38 AM. Comments included the following: -"Call light response-as a rule 20 minutes to maybe an hour." -"Very understaffed. Sometimes have to wait quite a while. 20 minutes or more to have help after we push our call lights." -"They don't have enough staff, sometimes (waits) 15 to 20 minutes". -"Not enough staff...Have had to wait ? hour to an hour." -"Always short of help here." -"When you ring the bell, it takes forever for them to come to you. Typically I have to wait ? hour to 45 minutes to have my call light answered." -"Sometimes I feel like it takes up to 45 minutes to an hour to get help." -"One time I waited so long I forgot what I wanted." -"They just don't have enough help. If you have to go to the bathroom usually takes 15 minutes or more to get someone to help you." B. Two family members voiced concerns regarding insufficient nursing staff during confidential interviews conducted on 11/24/14 from 1:43 PM until 4:27 PM. Comments included the following: -"...it takes so long for staff to come and get (resident) to the bathroom" and they "complain daily when (resident's) care is delayed." -"There is not enough staff here to take care of the residents." C. Observations of Resident 38 on 11/17/14 revealed the resident used the call light to call for assistance to the bathroom at 7:01 AM, 7:15 AM, 7:22 AM, 7:30 AM and 7:52 AM. At 7:52 AM, (51 minutes after Resident 38 initially turned on the call light to seek assist with toileting) NA-A entered the resident's room, closed the door and turned off the resident's call light. During an interview on 11/17/14 from 8:05 AM to 8:12 AM, NA-A confirmed Resident 38 was not taken to the bathroom until 7:52 AM. In addition, NA-A verified Resident 38 was incontinent of urine by the time the resident was assisted to the bathroom. D. Review of Resident 15's MDS dated [DATE] revealed the resident required extensive to total assistance with bed mobility and transfers and was on a turning/repositioning program. Resident 15 was observed seated in a wheelchair without benefit of repositioning on the following dates and times: -11/20/14 from 6:55 AM until 11:30 AM (4 hours and 35 minutes). -11/24/14 from 9:15 AM until 1:12 PM (3 hours and 57 minutes). E. Review of Resident 10's MDS dated [DATE] revealed the resident was dependent with bed mobility and transfers and was on a turning/repositioning program. Review of Resident 10's Care Plan dated 11/5/14 revealed the resident was to be turned and repositioned every 2 hours and as needed. Resident 10 was observed seated in a wheelchair without benefit of repositioning on the following dates and times: -11/20/14 from 7:10 AM until 10:40 AM (3 hours and 30 minutes). -11/24/14 from 9:16 AM until 12: 13 PM (2 hours 57 minutes). -11/25/14 from 6:45 AM until 9:56 AM (3 hours 11 minutes). F. Review of Resident 9's MDS dated [DATE] revealed the resident was dependent upon staff for bed mobility, and transfers, was on a turning/repositioning program, and required extensive assistance with eating. At 7:41 AM on 11/19/14, NA-B was observed to wheel Resident 9 into the dining room. Resident 9 was not served the breakfast meal until 8:35 AM (53 minutes). Resident 9 made no attempt to feed self and received no eating assistance until 8:53 AM (18 minutes). Resident 9 was observed seated in a wheelchair without benefit of repositioning on 11/19/14 from 7:41 AM until 10:05 AM (2 hours 24 minutes) and 11/20/14 from 7:00 AM until 11:22 AM (4 hours 22 minutes). On 11/24/14, Resident 9 was observed lying in bed at 11:39 AM, 12:00 noon, 1:00 PM and 2:00 PM. The resident did not receive a noon meal. NA-A indicated during interview on 11/25/14 at 10:17 AM that Resident 9 had slept through the noon meal on 11/24/14. NA-A indicated the resident was usually offered something to eat after waking, however the resident had not been offered anything to eat when NA-A went off duty at 2:00 PM as the resident was still in bed. Review of Resident 9's medical record revealed no evidence to indicate the resident was assisted to eat something after missing the noon meal on 11/24/14. | 2015-07-01 |
| 11276 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 356 | C | 0 | 1 | ZQ0211 | Based on observations and staff interview; the facility failed to post and retain the required daily nurse staffing information. This had the potential to affect all residents, family members and visitors. Facility census was 33. Findings are: Observations during entrance tour of the facility on 11/18/14 at 12:00 noon revealed the nurse staffing information was not posted. During interview on 11/18/14 at 12:15 PM, the Director of Nursing (DON) verified the nurse staffing information was not posted. Interview with the DON at 7:35 AM on 12/2/14 revealed nurse staffing information had not been posted since the end of 7/2014. The DON further indicated nurse staffing information had not been retained since that time. Therefore, nurse staffing records were not maintained for 18 months as required. | 2015-07-01 |
| 11277 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 364 | F | 0 | 1 | ZQ0211 | Licensure Reference: 175 NAC 12-006.11D Based on observations, record review and resident/staff interviews; the facility failed to provide food at temperatures palatable to residents. This practice had the potential to affect all facility residents. Facility census was 33. Findings are: A. Confidential resident interviews conducted on 11/18/14 through 11/19/14 revealed 5 residents responded "No" when asked if food was served at the proper temperature. B. Observations on 11/24/14 revealed the following: -12:13 PM- The Dietary Manager (DM) served Resident 33 an uncovered plate consisting of cooked cabbage, mashed potatoes with butter and a chicken breast. Resident 33 took a bite of the mashed potatoes and indicated the food was not hot enough. -1215 PM- The DM completed temperature checks on the lunch plate served to Resident 33. The following temperatures were measured; cooked cabbage 138 degrees F (Fahrenheit), mashed potatoes with butter 139 degrees and chicken breast 128 degrees F. C. During an interview on 11/24/14 from 12:30 PM to 12:38 PM, the DM identified all food should be at least 140 degrees F when served to the residents. The DM indicated the cook was to complete food temperatures before meal service and temperatures were to be documented on a "Food Temperature Record ". The DM further identified meal temperatures were routinely checked after the meal service but were never documented. D. Review of the facility "Food Temperature Records" from 11/1/14 to 11/30/14 revealed missing documentation of meal temperatures on 11/6/14, 11/10/14, 11/17/14, 11/18/14, 11/24/14, 11/26/14, 11/27/14 and 11/29/14 (meal temperatures were not documented for all food items served on 8 out of 30 days in November). E. During an interview on 12/1/14 from 9:00 AM to 9:12 AM, the DM indicated no further "Food Temperature Records" were available for review. The DM indicated food temperatures were routinely checked but had not been documented. | 2015-07-01 |
| 11278 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 371 | F | 0 | 1 | ZQ0211 | Licensure Reference: 175 NAC 12-006.11E Based on observations, record review and staff interview; the facility failed to 1) ensure food items were labeled and dated, 2) maintain kitchen equipment, food contact/non-contact surfaces, floors, walls, light fixtures, and ceiling vents in a clean and sanitary manner, 3) ensure food and bottled water were not stored directly on the floor and 4) ensure hand-washing and glove changes were completed during meal preparation and service to prevent potential cross contamination of food. These practices had the potential to affect all of the facility residents. Facility census was 33. Findings are: During the initial kitchen tour with the Dietary Manager (DM) on 11/18/14 from 11:00 AM to 11:30 AM the following were observed: -The edges of all of the kitchen counters had surfaces completely worn away with bare wood visible making the surfaces not easily cleanable. -The kitchen floor was soiled throughout with dust, dirt and food crumbs; including under the steam table and a 2 compartment food preparation sink, between the refrigerator/freezer and the stove and in front and underneath of the dishwashing area. In addition, the kitchen floor had 2 approximately 6 inch slits in the flooring between the stove and the refrigerator and the floor had several black and gray colored stains underneath of the 2 compartment sink and the dishwashing area. -The kitchen counter immediately to the left of the steam table; contained a sealed plastic bag with biscuits, a metal cake pan with a Rice Krispy dessert covered with a plastic wrap and a metal cake pan with a chocolate dessert covered with a plastic wrap. Further observations revealed neither the plastic bag nor the metal cake pans were labeled or contained a date as to when the foods were originally prepared. -The kitchen counter immediately to the right of the 2 compartment food preparation sink had no available open space and was packed with several baking products including opened containers of salt, baking soda, baking powder and cornstarch. The DM indicated when cooking, it was easier to just leave everything out and available. - The kitchen's dry storage area contained dead insects and debris in the light fixtures immediately above the shelves containing cans and packages of food and condiments and the facility ice machine. A sealed case containing "Black Beans"and an open case of bottled water were stored directly on the floor of the food storage area and an onion was lying directly on the floor underneath of a shelving unit which contained cases of canned food items. Observations on 11/20/14 from 8:15 AM to 10:15 AM revealed DM placed several cracked eggs onto the grill with gloved hands, handled toast and then placed bacon on plates with same gloves. DM did not wash hands or change gloves when switching between handling raw eggs, cooked bacon and toast a total of four times during the meal observation. During the follow-up kitchen sanitation tour with the DM on 11/20/14 from 10:15 AM to 11:00 AM the kitchen counter top edges and the kitchen flooring remained unchanged from earlier observation. In addition, the following were observed: -The top of the coffee maker, tops and sides of the flour and sugar containers, the shelves of the steam table, a stack of 10 divided plates stored on the top shelf of the steam table, a wooded shelf above the steam table, the top and sides of 3 sealed plastic containers with dried cereal stored directly on the wooden shelf, the front and the sides of the microwave, stove and convection oven were all soiled with a build-up of dust, grease, and dried food spills. -The wall directly above the steam table had a 6 x 6 inch area of paint which had peeled away from the wall but continued to remain intact at the top border. -The counter top to the right of the steam table contained an uncovered food scale which the DM indicated was used at times for meal preparation. A staff member's cell phone was propped against the scale and the cell phone was connected to a battery charger cord which was draped across the top of the scale and was plugged into the wall above the scale. In addition, 2 cords attached to speakers were also draped down the front of the scale and were attached to the cell phone propped in front of the scale. -2 compartment meal preparation sink contained a heavy layer of lime build-up to the sink basins and around the facet handles. Above the 2 compartment sink was a window surrounded by a white painted wood frame with an air conditioning unit installed in the window. The white wooden frame was paint chipped and the frame, window glass and air conditioning unit contained a layer of grease and dust/debris with dried food splatter. -Vents located in the ceiling directly above the stove, food preparation area and above the dishwashing area contained a layer of dust/debris. During an interview on 11/20/14 from 11:00 AM to 11:15 AM, the DM confirmed the areas identified on the initial kitchen tour and on the follow-up kitchen sanitation tour needed to be cleaned and/or repaired. The DM confirmed the kitchen had a cleaning schedule but identified cleaning had not been completed due to concerns with staffing in October and November of 2014. In addition, the DM confirmed failure to wash hands and/or change gloves when switching between handling raw eggs, cooked bacon and toast during the breakfast meal service. 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: -4-601.11 (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust and food residue -6-501.12 Physical facilities shall be cleaned as often as necessary to keep them clean -3-305.11 Food storage. Food shall be protected from contamination by storing the food in a clean, dry location, where it is not exposed to splash, dust or other contaminations and at least 15 centimeters (6 inches) above the floor. -3-304.15 (A) Single use gloves shall be used for only one task and should be discarded when soiled or when interruptions occur in the operation -4-101.11 Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors or tastes to food and under normal use conditions shall be finished to have a smooth, easily cleanable surface resistant to pitting, chipping, crazing, scratching, scoring, distortion and decomposition - 81-2,272.24 (1) "...refrigerated, ready-to-eat, potentially hazardous food...prepared and held in a food establishment for more than twenty-four hours shall be clearly marked to indicate the date of preparation. The food shall be sold, consumed on the premises, or discarded within: (a) Seven calendar days or less if the food is held refrigerated at forty-one degrees Fahrenheit...or below; or (b) Four calendar days or less if the food is held refrigerated between forty-five degrees Fahrenheit...and forty-one degrees Fahrenheit..." - (2) "...refrigerated, ready-to-eat, potentially hazardous food...prepared and packaged by a food processing plant and held refrigerated at such food establishment, shall be clearly marked, at the time the original container is opened in a food establishment, to indicate the date the food container was opened. The food shall be sold, consumed on the premises, or discarded within: (a) Seven calendar days or less if the food is held refrigerated at forty-one degrees Fahrenheit...or below; or (b) Four calendar days or less if the food is held refrigerated between forty-five degrees Fahrenheit...and forty-one degrees Fahrenheit..." | 2015-07-01 |
| 11279 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 387 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview; the facility failed to ensure physician visits were conducted as required for 3 (Residents 36, 34 and 40) of 4 residents reviewed. Facility census was 33. Findings are: A. Review of facility policy for Physician Services (revision date 6/2013) revealed the physician was to see each facility resident at least every 30 days for the first 90 days after admission and at least every 60 days thereafter. B. Review of Resident 34's Admitting Physician order [REDACTED]. Review of Resident 34's medical record revealed no evidence to indicate the resident was seen by the physician since 9/3/14. During interview on 12/2/14 at 10:15 AM, the Director of Nurses (DON) verified Resident 34 had not been seen by the physician for the 30 day and 60 day visits and was last seen by the attending physician on 9/3/14. C. Review of Resident 36's Referral Form dated 9/29/14 revealed the resident was admitted on [DATE] and was seen by the physician on 9/29/14. Review of Resident 36's medical record revealed no evidence to indicate the resident was seen by the physician between 9/29/14 and 11/19/14. Review of Resident 36's Referral Form dated 11/19/14 revealed the resident was seen by the physician on that day. During interview on 12/2/14 at 9:25 AM, the DON verified Resident 36 had not been seen by the physician between 9/29/14 and 11/19/14. The DON indicated the resident should have been seen by the physician on 10/22/14 when the physician was in the facility. D. Review of Resident 40's Care Plan revealed the resident was admitted to the facility on [DATE]. Review of Resident 40's medical record revealed no evidence to indicate the resident had been seen by the physician since admission to the facility on [DATE]. During interview on 12/2/14 at 12:00 noon, the DON verified Resident 40 had not been seen by the physician since 10/22/14. | 2015-07-01 |
| 11280 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 388 | D | 0 | 1 | ZQ0211 | Based on record review and staff interview; the facility failed to assure Resident 12's physician and nurse practitioner conducted alternate visits. Resident 12 was seen by the nurse practitioner on 3 consecutive 60 day visits. Facility census was 33. Findings are: Review of facility policy for Physician Services (revision date 6/2013) revealed the physician was to see each facility resident at least every 30 days for the first 90 days after admission and at least every 60 days thereafter. After the initial visit following admission, a qualified nurse practitioner or physician assistant may make every other required visit. Review of Referral Forms dated 4/1/14, 6/2/14 and 8/4/14 revealed Resident 12 was seen by the nurse practitioner on those days. There was no evidence in Resident 12's medical record to indicate the resident was seen by the physician until 9/11/14. Review of a Referral Form dated 9/11/14 revealed the resident was seen by the physician on that day. The Director of Nurses (DON) indicated during interview on 12/2/14 at 11:40 AM that Resident 12's physician was reminded recently of the need to alternate visits with the nurse practitioner. The DON verified during interview on 12/2/14 at 12:00 noon that Resident 12's physician and nurse practitioner had not conducted alternate visits. | 2015-07-01 |
| 11281 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 441 | E | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B, 12-006.17D Based on observations, record review and staff interviews; facility staff failed to utilize hand-washing and gloving techniques to prevent cross contamination during the provision of toileting cares for Residents 2 and 19, during a treatment for [REDACTED]. In addition, facility staff failed to handle Resident 29's urinary catheter drainage bag in a manner to prevent cross contamination. Facility census was 33. Findings are: A. Review of facility policy titled "Dressing-Non-sterile Treatment" (revised 6/13) revealed the facility staff was to perform treatments and dressing changes per physician orders. The licensed nurse was to follow the following procedure: -Review physician treatment orders. -Prepare clean field. -Create a barrier for dressing supplies and place on the clean field. -Wash hands. -Apply clean gloves -Remove soiled dressing and place in a biohazard container. -Remove gloves and wash hands. -Apply clean gloves. -Clean wound per physician order. Clean wound from the center to the outer borders using a circular motion (area of most contamination to the area of the least). Ensure you do not contaminate the wound bed. -Remove gloves and wash hands. -Apply clean gloves. -Apply dressing as ordered. -Remove gloves and wash hands. B. Review of facility policy titled "Urinary/ Catheter Care" (revised 2/12) indicated the purpose of catheter care was to minimize the risk of catheter-associated urinary tract infection and its related problems. The policy identified the following procedures: -Wash hands and apply gloves. -Cleanse the catheter insertion site daily with soap and water. Cleanse the proximal third of the catheter with soap and water, washing away from the insertion site and manipulating the catheter as little as possible. -Apply a sterile 4 x 4 to catheter insertion site as ordered or as indicated. -Remove gloves and wash hands. C. Review of facility policy titled "Personal Protective Equipment - Using Gloves" (revised 8/11) indicated gloves were to be worn when touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin. In addition, gloves were to be worn for cleaning up spills or splashes of blood or body fluids and when cleaning potentially contaminated items. Further review identified staff were to wash hands before putting on clean gloves and when taking off soiled gloves. D. Review of facility policy titled "Hand-washing-All Staff" (revised 6/13) revealed the following recommendations of when hand-washing was indicated: -Before and after every resident contact. -Before and after handling dressings or touching open wounds. -After touching resident care equipment that is likely to be contaminated. -Before and after feeding a resident. -Before and after changing an incontinent resident. E. During an observation on 11/19/14 at 4:30 PM, Resident 29 was seated in a recliner in the resident's room. The resident's supra-pubic urinary catheter drainage bag was hung on the outside of a trash receptacle next to the resident's recliner. The trash receptacle contained soiled Kleenex and crumpled papers. The bottom of the drainage bag rested directly on the floor next to the trash receptacle. During an observation on 11/20/14 at 7:45 AM, Resident 29 was seated in a recliner in the resident's room with foot rest elevated. The resident's supra-pubic urinary catheter drainage bag was positioned directly on the floor underneath of the recliner footrest. During an interview on 11/20/14 from 9:45 AM to 10:00 AM, Nursing Assistant (NA)-A identified facility staff had been trained to keep urinary catheter drainage bags and tubing below the level of the resident's bladder and were never to be stored directly on the floor. Observation of the treatment to Resident 29's supra-pubic catheter site on 11/24/14 from 10:49 AM to 10:53 AM, revealed Registered Nurse (RN)-L entered the resident's room carrying 3 washcloths, a pair of gloves and a 4 x 4 dressing. Without washing or cleansing hands, RN-L donned clean gloves and removed the current 4 x 4 dressing which was soiled with a moderate amount of brown drainage from the resident's supra-pubic catheter insertion site. RN-L placed the soiled dressing in bedside trash receptacle and without removing soiled gloves, entered the resident's bathroom. RN-L placed the 3 washcloths directly into the basin of the resident's sink to dampen the washcloths with water. RN-L returned to the resident's room and used washcloths to cleanse the resident's supra-pubic urinary catheter insertion site. Without removing soiled gloves, RN-L opened a package containing a sterile 4 x 4 dressing and placed the dressing directly on the insertion site, adjusted the resident's clothing and exited the resident's room. RN-L removed soiled gloves in the hallway outside of the resident's room, but did not wash or sanitize hands before returning to the Nurse's station to complete documentation of the dressing change. Observations of Resident 29 seated in a recliner in the resident's room revealed the following: -11/25/14 from 7:01 AM to 8:26 AM- The supra-pubic urinary catheter drainage bag was lying directly on the floor underneath of recliner foot rest. -12/1/14 at 1:45 PM- The bottom of the supra-pubic urinary catheter drainage bag rested directly on the floor underneath of recliner foot rest. -12/2/14 from 6:40 AM to 7:50 AM- The supra-pubic urinary catheter drainage bag and attached tubing was lying directly on the floor to the right of the resident's recliner, in the doorway of the resident's room. During an interview on 12/2/14 from 8:30 AM to 8:45 AM, the Director of Nursing (DON) verified Resident 29's supra-pubic urinary catheter drainage bag and tubing should have never been stored on the floor. In addition, RN-L should have followed the facility policy for supra-pubic urinary catheter care to prevent the resident's recurrent urinary tract infections. F. Observation of the dressing change to Resident 38's pressure sores to gluteal sacral area, [MEDICATION NAME] area and left heel on 11/24/14 from 9:10 AM to 10:15 AM, revealed Physical Therapy ( PT)-J removed the [DEVICE] dressing to the resident's gluteal sacral wound. Without removing soiled gloves, PT-J measured the pressure sore, cleansed the skin approximately 6 inches on all sides around the perimeter of the wound with alcohol, applied a skin protectant to the skin around the wound bed and applied several strips of the transparent drape approximately 6 inches away from the wound, right up to the wound edges. PT-J removed soiled gloves but without washing or cleansing hands, donned clean gloves and proceeded to pack the wound bed with strips of foam which had been cut and shaped to fit the wound bed. PT-J applied [MEDICATION NAME] ointment to the foam used to pack the center of the wound bed followed by application of additional transparent drape over the foam packing. While still wearing soiled gloves, PT-J used a pair of tweezers to tuck the sides of the drape into the borders of the wound bed, cut a 2 cm hole in the center of the transparent drape directly over the top of the pressure ulcer, attached a pad with tubing over the hole and attached the tubing to the canister of the [DEVICE]. PT-J removed soiled gloves but did not wash or cleanse hands before donning clean gloves. PT-J removed the soiled dressing to the resident's [MEDICATION NAME] pressure sore, palpated the edges of the wound with gloved fingers, measured and cleansed the wound and applied a border foam dressing before removing soiled gloves and washing hands. PT-J donned clean gloves and removed the soiled dressing to the resident's left heel with odor noted immediately after removal of dressing. PT-J measured, cleansed and applied calcium alginate to the wound bed and covered with a border foam dressing before removing gloves and washing hands. During an interview on 11/25/14 from 11:00 AM to 11:12 AM, the Director of Nursing (DON) and the Infection Control Coordinator confirmed PT-J should have followed the facility policy related to non-sterile dressing changes. G. During observation of incontinent cares on 11/24/14 from 11:03 AM until 11:18 AM, NA-A and NA-E assisted Resident 2 to the toilet using the mechanical sit/stand lift (a device used to support the resident in a standing position during transfers, with the resident grasping handles on the lift to assist in supporting their weight). Following toileting, NA-E provided perineal hygiene for Resident 2. Without removing soiled gloves, NA-E pulled up the resident's disposable incontinent brief and adjusted the resident ' s clothing. NA-E removed soiled gloves, and without washing or sanitizing hands, transferred the resident to the wheelchair, removed the lift sling from beneath the resident and adjusted the pillow at the back of the resident. NA-E positioned the pedals on the resident's wheelchair and pinned the call light to the resident's clothing before washing hands in the resident's bathroom. During an interview on 11/25/14 from 11:00 AM to 11:12 AM, the DON verified facility staff had been trained to wash and/or sanitize their hands immediately after removal of soiled gloves. H. During observation of cares on 11/20/14 from 8:49 AM until 9:15 AM, NA-E and NA-D provided morning cares for Resident 19. With the resident lying in bed, NA-E provided perineal hygiene with gloved hands. NA-E removed the soiled gloves, and without washing hands, donned a new pair of gloves. NA-E then assisted to put a new incontinent brief and pants on the resident, positioned the mechanical lift sling beneath the resident, and assisted to transfer the resident to the wheelchair using the mechanical lift. NA-E then removed gloves and washed hands. During observation of incontinent care on 11/24/14 from 11:20 AM until 11:44 AM, Resident 19 was transferred from wheelchair to bed using the full mechanical lift. The resident was incontinent of a large amount of bowel movement (BM) that extended to cover the anterior perineum. NA-B provided perineal hygiene with gloved hands and using multiple perineal cloths because of the extent of the incontinence and difficulty removing the BM. NA-B removed the soiled gloves, and without washing hands, donned a new pair of gloves and assisted to transfer the resident to the commode using the full mechanical lift. NA-B then removed gloves, and without washing hands, opened the door to the resident's room, left the room and returned shortly with cloth incontinent pads that NA-B placed atop the resident's bed and onto the recliner. NA-B was still not observed to wash hands. The resident had a small BM on the commode, and using the full mechanical lift, NA-B assisted to transfer the resident back to bed, and went to the resident's closet to retrieve a clean pair of slacks. NA-E provided perineal hygiene with gloved hands. NA-E removed soiled gloves, and without washing hands, assisted NA-B to replace the resident's incontinent brief and slacks, and transfer the resident to the wheelchair using the full mechanical lift. NA-E collected soiled linens while NA-B searched through 2 dresser drawers, then retrieved a comb and combed Resident 19's hair. NA-B and NA-E then went to the bathroom sink to wash hands. | 2015-07-01 |
| 11282 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 490 | F | 0 | 1 | ZQ0211 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on record reviews and staff interviews; Facility Administration failed to maintain a system to prevent non-compliance with Federal and State regulations related to assuring residents were protected from injury due to hot liquid spills and hot water temperatures in resident care areas. In addition, Facility Administration failed to assure correction of previously cited deficiencies was maintained. This had the potential to affect all residents within the facility. The facility census was 33. Findings are: A. Interview with the Director of Nurses on 11/25/14 at 8:50 AM revealed Hot Beverage Safety Evaluations were completed on all residents on 11/24/14 (which was 3 days after Resident 28 sustained a burn from a hot liquid spill). The DON further indicated 3 residents were identified at risk for hot liquid spills and the intervention was to place lids on cups of hot liquids. Interview with the Dietary Manager (DM) on 11/25/14 at 9:30 AM revealed interventions for prevention of hot liquid spills were not implemented at the breakfast meal on 11/25/14 for 2 of 3 residents who were identified at risk for hot liquid spills. B. Interview with the Registered Nurse Consultant (RNC) on 11/19/14 at 2:13 PM revealed hourly monitoring of hot water temperatures was in progress due to hot water temperatures throughout the facility in excess of 130 degrees Fahrenheit. The RNC indicated all staff were educated regarding excess hot water temperatures and a log was placed in the shower room for staff to monitor and document water temperatures before all showers/baths. Review of facility shower/bath schedules from 11/20/14 through 12/1/14 revealed no documentation to indicate hot water temperatures were checked/monitored prior to provision of showers for 38 residents. This was verified during interview with the staff member who provided showers/baths during that time frame. C. The following deficient practices were cited during the previous Quality Indicator Survey (QIS) completed 11/13/13 and the most recent QIS completed 12/2/14: -F 323-Failure to prevent accidents -F 280-Failure to revise resident Care Plans -F 282-Failure to implement Care Plan interventions -F 312-Failure to provide timely assistance for resident who required toileting and feeding assistance. -F 441-Failure of staff to use infection control techniques to prevent cross contamination -F 520-Failure to maintain correction of previously cited deficiencies through the QA program | 2015-07-01 |
| 11283 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 497 | F | 0 | 1 | ZQ0211 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.04B2a Based on record review and staff interview; the facility failed to ensure annual employee performance evaluations were completed for 6 of 6 personnel records reviewed. The facility census was 33. Findings are: Review of personnel files for Nursing Assistants (NA) A, B, C, H, E and N revealed the following: -NA-A was hired on 7/15/10 with no evidence that a performance evaluation had ever been completed. -NA-B was hired on 2/7/14 with no evidence of a completed performance evaluation. -NA-C was hired on 10/22/13 with no evidence that a performance evaluation had ever been completed. -NA-H was hired on 8/1/13 with no evidence that a performance evaluation had ever been completed. -NA-E was hired on 9/16/13 with no evidence that a performance evaluation had ever been completed. -NA-N was hired on 3/24/14 with no evidence of a completed performance evaluation. During an interview on 12/2/14 from 11:45 AM to 12:00 PM, the Director of Nursing verified performance evaluations were to be completed annually but was unaware when evaluations were last completed. | 2015-07-01 |
| 11284 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 520 | H | 0 | 1 | ZQ0211 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on observations, record review and staff interview; the facility Quality Assurance (QA) Committee failed to maintain correction of previously cited deficiencies regarding accident prevention, infection control, Care Plan revision and implementation, timely assistance for residents who require assist with activities of daily living, treatment and care of pressure sores, QA and staffing. This failure had the potential to affect the well-being of all residents. Facility census was 33. Findings are: A. Record review of the Quality Assurance policy and procedures (undated) revealed the purpose of the program was to ensure appropriate follow-up and ongoing tracking of identified environmental and quality of care issues. The policy further indicated the QA Committee was to develop and implement plans of corrective action for identified trends and/or deficient practices. The following areas were to be addressed monthly by the QA Committee: -Infection Control -Skin Integrity -Safety/Environment -Resident Assessment -Quality of Care B. Review of facility deficiency statement from the Quality Indicator Survey (QIS) completed 11/13/13 and QIS completed 12/2/14 revealed repeated facility noncompliance with the following Federal (F) tags: -F 323-Failure to prevent accidents -F 280-Failure to revise resident Care Plans -F 282 Failure to implement assessed Care Plan interventions -F 312 Failure to provide timely assistance for residents who required toileting and feeding assistance. -F 441-Failure of staff to remove gloves and wash hands during toileting cares, dressing changes and catheter cares in a manner to prevent cross contamination. F 520-Failure to maintain correction of previously cited deficiencies through the QA program. C. Interview with the Administrator on 12/2/14 from 7:45 AM to 8:01 AM revealed the QA Committee had discussed issues regarding infection control practices and current facility pressure ulcers at the last QA meeting on 10/22/14. However, there was no documentation to indicate previous interventions had been reviewed or additional interventions were implemented. In addition, the Administrator denied any knowledge of the deficiencies cited at the facilities previous QIS. | 2015-07-01 |
| 11775 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 241 | E | 1 | 1 | 6TPT11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(21) Based on observations and staff interview, the facility failed to assure all residents were treated in a dignified manner as Residents 7, 22 and 23 were fed meals while seated next to the bird aviary which was soiled with bird droppings and feathers. Facility census was 38. Findings are: A. The interior glass surface of the bird aviary, located in the main dining room, was observed to be soiled with dried bird droppings on 5/17/11 at 11:50 AM and 5/18/11 at 6:45 AM and 9:00 AM. From 9:00 AM until 9:07 AM on 5/18/11, Residents 7, 22 and 23 were observed seated at the dining room table adjacent to the bird aviary. The residents had just finished eating the breakfast meal. Resident ' s 22 and 23 sat facing the soiled glass of the bird aviary. Resident 7 was seated in a wheelchair which was placed sideways next to the bird aviary. The wheels of Resident 7 ' s wheelchair were touching the glass of the bird aviary. B. At 10:20 AM on 5/19/11 the interior glass surface of the bird aviary was observed to remain soiled with dried bird droppings and there was an accumulation of bird feathers on the floor. The Administrator verified during interview at this time that the bird aviary was in need of cleaning and a pleasant dignified dining experience was not provided for residents. The Administrator indicated there were plans to remove the bird aviary from the dining room at some point. | 2015-01-01 |
| 11776 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 253 | E | 1 | 1 | 6TPT11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A Based on observations and staff interview, the facility failed to assure the facility was free from odors and failed to maintain walls, doors/door jams, closet doors, dresser drawers, floors and the bird aviary in clean condition and/or good repair. This affected 15 (Rooms 1, 2, 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 21, 22 and 25) out of 21 occupied resident rooms and 3 residents (Residents 7, 22 and 23) who ate their meals while seated next to the bird aviary located in the main dining room. Facility census was 38. Findings are: A. The interior glass surface of the bird aviary, located in the main dining room, was observed to be soiled with dried bird droppings on 5/17/11 at 11:50 AM and 5/18/11 at 6:45 AM and 9:00 AM. At 9:00 AM on 5/18/11, Residents 7, 22 and 23 were observed seated at the dining room table adjacent to the bird aviary. Resident ' s 22 and 23 sat facing the soiled glass of the bird aviary. Resident 7 was seated in a wheelchair which was placed sideways next to the bird aviary. The wheels of Resident 7 ' s wheelchair were touching the glass of the bird aviary. B. At 10:20 AM on 5/19/11 the interior glass surface of the bird aviary was observed to remain soiled with dried bird droppings and there was an accumulation of bird feathers on the floor. Interview with the Maintenance Supervisor at this time revealed the bird aviary was not on a routine cleaning schedule and the last time it had been cleaned might have been in December 2010. C. The following was observed during environmental tour of the facility with the Administrator and Maintenance Supervisor on 5/19/11 from 10:20 AM until 11:10 AM: -Room 1-Bathroom walls were paint chipped and gouged below the sink and beneath the call light system. -Room 2-There was duct tape holding the vinyl covering in place on the bottom edge of the door to the room. -Room 3-There was a strip of red tape on the floor between the resident ' s beds. The tape was torn and frayed and did not present a smooth easily cleanable surface. -Room 4-6 floor tiles at the entrance to the room were cracked and broken. -Room 5-The walls, dresser drawers and the closet door to the left of the bathroom were paint chipped. -Room 6-The vinyl door cover on the door to the room was torn and rough. The wall on the right side of the entrance to the bathroom was gouged and paint chipped. The bathroom walls were gouged and paint chipped beneath the soap dispenser and the drywall next to the soap dispenser was torn. The baseboard on the right side of the toilet was loose. -Room 9-Bathroom walls were paint chipped and marred below the sink and behind the toilet. -Room 10-Closet doors and the lower drawers of the dresser were paint chipped and marred. The wooden surface of the bathroom door jam was gouged and paint chipped. The baseboard on the corner of the wall next to the bathroom was broken and the particle board was exposed. The bathroom walls were paint chipped and marred. Room 12-The wall next to the bathroom door was broken out in an area approximately the size of a golf ball. The baseboard on the right side of the toilet was loose. Walls were paint chipped and gouged behind the toilet, below the sink and beneath a wooden cupboard. The paint was chipped and peeling off of a towel bar attached to a wooden cupboard in the bathroom. Room 13-The wall behind 2 recliners had been patched but the area had not been painted which left an unfinished surface. Room 14-The baseboard on the right side of the toilet was loose. The paint was chipped and peeling along the baseboard behind the toilet. The drywall next to the soap dispenser was torn. Room 25-The wall molding to the left of the toilet base was crumbling in an approximately 6 inch area. -There were 3 cracked floor tiles in the corridor at the entrance to the Unit dining room, 7 cracked floor tiles in the corridor outside the Social Services office, and 3 cracked floor tiles by the utility room adjacent to the Social Services office. -A fecal odor was noted in Wing 1 corridor (during the entire length of the environmental tour which was 50 minutes). (Surveyor ) D. A urine odor was noted in the bathroom which is shared by 4 residents in Rooms 21 and 22 on 5/17/11 at 11:20 AM, 11:50 AM and 2:20 PM. (Surveyor ) A urine odor was noted in the same bathroom during the environmental tour on 5/19/11 from 10:20 AM until 11:10 AM. E. On 5/19/11 from 10:20 AM until 11:10 AM, and 5/23/11 at 9:45 AM and 3:25 PM, the floor mat by the exit door of the sunroom was observed to be soiled with an accumulation of dust and dirt residue. The floor tiles beneath the floor mat were soiled with a gray sticky residue. The Administrator verified during interview on 5/23/11 from 3:30 PM until 4:15 PM that the floor mat and floor by the sunroom exit door were soiled and in need of more frequent cleaning. The Administrator further indicated the bird aviary was last cleaned by the aviary company during their routine quarterly visit in 2/11; however no one in the facility had been assigned to clean the aviary in between times. (Surveyor ) F. Food particles were observed to be stuck to the floor in front of the bedside cabinet by the first bed in Room 11 on 5/23/11 at 10:15 AM. On the same day at 1:00 PM, the food particles had been removed, however the floor was soiled with a gray residue of food soil, dirt, smudges and scraps of paper. The floor was sticky to touch. On 5/24/11 at 8:05 AM the floor remained soiled with a gray residue of food soil, dirt, smudges and scraps of paper. The Administrator verified during interview at this time that the floor was soiled and in need of cleaning. | 2015-01-01 |
| 11777 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 323 | D | 1 | 1 | 6TPT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E4 Based on observations, record review and staff interviews the facility failed to assure Resident 38 was protected from falls, as fall prevention measures were not consistently provided. The sensor alarm was not in place on one occasion and the floor mat to be used in the resident's room was not used throughout the days of the survey. Facility census was 38. Findings are: Review of Resident 38's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for Care Planning) dated 5/12/11 identified an admission date of [DATE] with current [DIAGNOSES REDACTED]. The MDS identified Resident 38 required extensive assist of 2 staff for all transfers, bed mobility, dressing, toileting and bathing. This assessment reflected the resident had a history of [REDACTED]. Review of Care Plan dated 5/6/11 reflected the resident was a fall risk due to weakness and surgical repair of right hip fracture. Care Plan interventions included; -High/low bed -Mat on the floor -Sensor alarms -Call light in place and resident educated to use it Review of Resident Progress Notes dated 5/12/11 at 3:49 AM indicated Resident 38's bed alarm went off and resident was found sitting beside the bed on the floor. The bed had been in the lowest position. Resident 38 stated that resident was going to the bathroom and forgot to call. 2 staff assisted resident back into bed. The bed alarm was changed to immediate ring instead of a 2 second delayed ring. Staff reminded Resident 38 to use the call light to call for help. During observation of Resident 38 on 5/18/11 at 1:18 PM resident was seated in a wheelchair next to the bed in the resident ' s room. No fall mat was noted on the floor. Resident was observed 5/18/11 at 2:30 PM asleep on resident ' s bed. No fall mat was noted on floor. At 3:21 PM on 5/18/11 Resident 38 was seated in a wheelchair in the Activity Room and no sensor alarm was noted to wheelchair. During observation of Resident 38 in resident's room on 5/19/11 at 6:20 AM and 10:35 AM, resident was seated in a wheelchair parked next to bed and no fall mat was noted on the floor. On 5/23/11 at 1:30 PM Resident 38 was seated in a recliner in resident's room next to the bed and no fall mat was noted to the floor. Resident was again observed on 5/24/11 at 6:40 AM sitting in the recliner in the resident's room next to the bed and no fall mat was noted on the floor. During interview on 5/23/11 from 3:13 PM to 2:27 PM, the DON (Director of Nursing) confirmed that Resident 38 was to have a fall mat on the floor in the resident's room and resident was to have a sensor alarm on at all times. After a search of Resident 38's room DON verified that there was no fall mat available in the resident's room. DON was unaware of why fall mat was not available for Resident 38 and why sensor alarm was not placed on resident's wheelchair on 5/18/11 at 3:21 PM. During interview with NA (nursing assistant) 3 and NA-4 on 5/24/11 from 7:30 AM to 7:42 AM, both staff confirmed that Resident 38 was to have a sensor alarm on at all times and was to have a fall mat on the floor in the resident's room. | 2015-01-01 |
| 11778 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 329 | D | 1 | 1 | 6TPT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview; the facility failed to assure drug regimens were free from unnecessary drugs for Residents 6 and 30. The facility failed to monitor behaviors on Resident 6 whose drug regimen included [MEDICATION NAME] (a medication used to treat anxiety). Furthermore, the facility failed to routinely monitor Resident 30 ' s blood pressure to evaluate use of [MEDICATION NAME] (a medication used to treat hypertension). Facility census was 38. Findings are: A. Review of Resident 6 ' s Face Sheet with an admission date of [DATE] indicated [DIAGNOSES REDACTED]. Review of Resident 6 ' s Current physician's order [REDACTED].? tablet (0.25 mg) 3 times daily (TID). There was no documentation in the electronic medical record to indicate what resident behaviors were targeted for use of [MEDICATION NAME], nor was there documentation of behavior monitoring. Observations on 5/18/11 at 2:10 PM and 3:30 PM and 5/19/11 at 7:50 AM and 9:00 AM revealed Resident 6 seated in the recliner in room with eyes closed. During interview on 5/23/11 from 10:00 AM to 10:05 AM, Licensed Practical Nurse (LPN) - A verified there was no behavior monitoring documentation in the medical record. LPN - A revealed Resident 6 was administered [MEDICATION NAME] for " restlessness " . Observations on 5/23/11 at 10:15 AM, 1:30 PM and 3:15 PM revealed Resident 6 seated in the recliner in room with eyes closed. During interview on 5/23/11 from 3:30 PM to 4:15 PM, the Director of Nursing and the Administrator verified Resident 6 did not exhibit signs of restlessness or anxiety. B. Review of Resident 30 ' s Face Sheet with an admission date of [DATE] indicated [DIAGNOSES REDACTED]. Review of Resident 30 ' s Medications Flowsheet dated 5/11 indicated Resident 30 had a physician's order [REDACTED]. Review of the Vitals Report dated 11/1/10 through 5/24/11 revealed Resident 30 ' s blood pressure (BP) was not measured during the month of 11/10. It further revealed Resident 30 ' s BP measured 120/80 on 12/11/10, 140/62 on 12/12/10, 144/88 on 12/22/10, and 94/72 on 1/4/11. Further review of the Vitals Report indicated Resident 30 ' s BP wasn ' t measured again until 4/25/11 (3 months and 21 days following the last reading) at which time it measured 129/90. There was no further documentation to indicate the resident ' s BP had been measured since 4/25/11. | 2015-01-01 |
| 11779 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 356 | C | 0 | 1 | 6TPT11 | Based on observations and staff interview, the facility failed to post Nurse Staffing information on a daily basis. In addition, the facility failed to maintain the Nurse Staffing information for a minimum of 18 months as required. This potentially affected all 38 residents who currently resided in the facility. Findings are: A. Observations on 5/17/11 at 9:45 AM, 5/18/11 at 7:00AM and 1:20 PM, and 5/19/11 at 6:20 AM and 10:00 AM revealed the Nurse Staffing information was not posted. B. Interview with the Director of Nursing on 5/19/11 from 10:00 AM until 10:12 AM revealed the facility had not been posting the Nurse Staffing information and there were no past records to indicate the information had been completed and maintained. | 2015-01-01 |
| 11780 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 516 | F | 0 | 1 | 6TPT11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.16C Based on observations and staff interview, the facility failed to assure confidentiality of resident records as resident medical record information could be easily obtained from the shredding machine storage container which was located in the sunroom (an area readily accessible to residents, visitors and staff members). This had the potential to affect all 38 residents currently residing in the facility. Findings are: A. On 5/19/11 at 11:00 AM, the shredding machine storage container was observed in the sunroom of the facility. The sunroom was located in a public area and available for use by residents, visitors and staff members. The shredding machine storage container was full of papers, including discarded confidential medical records, which could easily be removed from an open slot on the container. B. The Administrator verified during interview on 5/19/11 from 11:15 AM until 11:20 AM that the shredding machine storage container needed to be emptied. The Administrator stated the facility had a contract with a paper shredding service. The Administrator was not sure when the contract service had last emptied the container. C. Observations on 5/23/11 at 2:44 PM and 3:30 PM and 5/24/11 at 6:45 AM revealed the shredding machine storage container remained full of papers, including discarded confidential medical record information which could easily be removed. | 2015-01-01 |
| 12669 | ALEGENT HEALTH IMMANUEL FONTENELLE HOME | 285085 | 6809 N 68TH PLAZA | OMAHA | NE | 68152 | 2010-03-03 | 332 | D | 9OFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 12-006.10D Based on observation, record review and interview: the facility staff failed to ensure a medication error rate of 5 percent or less. A total of 45 opportunities were observed with 3 medication errors which gave an error rate of 6.66 percent. The survey consisted of 24 sampled and 6 non-sampled residents. The facility staff identified a census of 152. Findings are: Record review of a Resident Face Sheet dated 10/15/2009 revealed that Resident 4 was admitted to the facility on [DATE]. Record review of Resident 4's Physician order [REDACTED]. that the resident's physician had ordered medication including [MEDICATION NAME] ( antiemetic) 10 mg (milligrams) before meals and at bed time by a tube. Resident 4 had a gastrostomy tube in place. (a tube placed into the stomach usually through the abdomen). Record review of an physician's orders [REDACTED]. Observation on 2/25/2010 at 12:30 PM of a medication administration revealed that Certified Medication Assistant (CMA) G administered the [MEDICATION NAME] and [MEDICATION NAME] to Resident 4. When asked if Resident 4 had eaten lunch, CMA G stated "yes". When asked if the medication identified above was to be given before meals, CMA G stated ''yes". CMA G confirmed that the medications had been given after the meal and not before as ordered. Record review of a Face Sheet dated 3/01/2010 revealed that Resident 25 was admitted to the facility on [DATE]. Record review of a transfer sheet dated 6/16/09 revealed that Resident 25's Physician had ordered Asprin 81 mg a day. Observation on 3/01/2010 at 7:10 AM revealed Licensed Practical Nurse (LPN) H prepared Resident 25 medications. Observation at this time revealed the Asprin was [MEDICATION NAME] coated. LPN G placed the Asprin in a small package with several other medications and crushed those medication. LPN H placed the crushed medications into apple sauce and administered them to Resident 25. An interview on 3/02/2010 was conducted with the facility Pharmacist. During the interview the Pharmacist confirmed that [MEDICATION NAME] coated Asprin should not be crushed. Record review of Nursing 2009 Drug Handbook by Lippincott Williams and Wilkins page 715, revealed under the title Patient Teaching identified the following information: "Tell the patient not to crush or chew sustained-release or [MEDICATION NAME] coated forms but to swallow them whole". | 2014-04-01 | ||
| 12670 | ALEGENT HEALTH IMMANUEL FONTENELLE HOME | 285085 | 6809 N 68TH PLAZA | OMAHA | NE | 68152 | 2010-03-03 | 280 | D | 9OFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 12-006.09C1c Based on record review and interview; the facility staff failed to revise Comprehensive Care Plans to include specific interventions to address [MEDICAL CONDITION] for 1 (Resident 18) of 24 sampled residents. The facility census was 152. Findings are: Record review of Resident 7's Admission Face Sheet showed an admission date of 2/5/10. Record review of an Admission History and Physical dated 1/29/10 revealed [DIAGNOSES REDACTED]. Record review of Resident 7's Skilled Admission Note by the Nursing Home Network dated 2/8/10 revealed that a Short Geriatric Depression Scale assessment for Resident 7 had been completed on that date. The score for Resident 7 was 3 out of 5 possible points with "yes" answers given to the questions " Do you often feel helpless" and "Do you feel pretty worthless the way you are now". Documentation was present on the form that Resident 7 indicated that those feelings were related to the recent illness. Record review of an E.A.C. H. ( A facility process initiated each time a resident makes a suicidal statement or gesture) document dated 2/10/10 revealed that Resident 7 had made the comment " I don't know if life is worth living". Record review of the E.A.C.H Process for the incident dated 2/10/10 revealed that, after this comment was made by Resident 7, the facility followed their process as required. Record review of an E.A.C.H. document dated 2/11/10 revealed that Resident 7 made another suicidal statement to facility staff. Record review of the E.A.C.H Process for the incident dated 2/11/10 revealed that, after this comment was made by Resident 7, the facility followed their process as required. Record review of Resident 7's Comprehensive Care Plan (CCP) dated 2/18/10 revealed that the E.A.C.H. process was done on 2/10/10 and 2/11/10 and that Resident 7 was sent to the emergency room after the 2/11/10 incident. The CCP did not contain any specific interventions related to the suicidal ideation statements made by Resident 7 on 2/10/10 or 2/11/10. Interview on 3/3/10 at 9:20 AM with the Care Plan Coordinator confirmed that Residents 7's CCP did not contain any specific interventions to address Resident 7's history of suicidal statements. Interview on 3/3/10 at 9:45 AM with the Director of Nursing (DON) revealed the expectation that CCP's should contain specific interventions to address [MEDICAL CONDITION] and confirmed that Resident 7's CCP did not contain any specific interventions to address Resident 7's history of suicidal statements. | 2014-04-01 | ||
| 12671 | ALEGENT HEALTH IMMANUEL FONTENELLE HOME | 285085 | 6809 N 68TH PLAZA | OMAHA | NE | 68152 | 2010-03-03 | 441 | E | 9OFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F441 LICENSURE REFERENCE NUMBER-12-006.17B-Prevention of Cross-Contamination LICENSURE REFERENCE NUMBER-12-006.17D -Hand washing Based on observation, record review and interview the nursing staff failed to follow infection control practices during the provision of treatment and services related to hand washing and gloving during personal hygiene cares for incontinent residents, administering fluids per Gastrostomy tube, handling and transporting soiled linens and disinfecting the glucose meter. The total samples of 24 residents within the nursing facility census of 152 were reviewed. Findings are: A. Review of the Alegent Health Skills Demonstration, revised 01/06/10, requires Hand Washing, Item 3. Lathers all surfaces of fingers, hands and wrists, producing friction for at least 20 seconds; And Item 4. Can state that the minimum length of time to wash hands is 20 seconds. B. Review of GLOVE INFORMATION HEALTH CARE WORKERS, Occupational safety and Health Administration updated Blood borne pathogens Standard, effective April 2001: in part states: *it is crucial for Health Care Worker ' s (HCW ' s) to wash hands following glove removal when hands are visibly soiled. Hands should also be washed when the integrity of the gloves has been compromised (torn, etc.) during use. In the absence of visible (or any perceived) contamination of hands, hand hygiene with alcohol hand rubs is appropriate, following glove removal. Gloves should also be changed any time the healthcare worker switches from contaminated to clean tasks. C. On 3/2/2010, from 8:15 to 9:10 A.M., observation of both NA (Nurse Aide) F and E during the provision of personal hygiene cares for Resident 1 revealed both NA (Nurse Aide) F and E contaminated their hand gloves with stool while attempting to remove the resident ' s brief. NA-F commented, " I ' m contaminated " and held both hands up off the resident. While NA-E continued to hold the resident over by the buttock covered with stool and stool contaminated hand gloves, NA-F attempted to wipe the stool off the right buttock with a wash cloth contaminated with stool. NA-F attempted to reposition the resident with the contaminated gloved hands. A suggestion was made for the NA ' s to start over. Both NA ' s removed the contaminated gloves, completed hand washing for 4-6 seconds and donned clean gloves. NA-E completed catheter care. Using the same gloves, NA-E started to put the barrier creme on the buttocks. NA-E was gently reminded the gloves were the same gloves used for catheter cares. NA-E completed hand hygiene and donned clean gloves. NA-E put underarm deodorant on, under Resident 1 ' s arms, with out cleansing the under arm axilla first. D. *1.On 3/1/10 at 4:05 P.M. observation revealed the LPN (License Practical Nurse) Nurse-A failed to complete hand washing hygiene after the removal of gloves upon the completion of Gastrostomy cares and administration of oral medications for Resident 7. *2.On 3/2/10 from 9:20 to 9:45 A.M. observation of Resident 7 ' s personal hygiene cares revealed NA-D failed to perform hand hygiene prior to donning clean gloves to provide the personal cares. After placement of the bed pan, NA-D removed the gloves and performed hand washing for 6 seconds. NA-E arrived to assist NA-D. NA-E completed hand washing in 9 seconds. At 9:25 A.M. NA-E removed the bed pan, emptied and rinsed it, and changed gloves with no hand hygiene and or alcohol rub. NA-E left the resident ' s room and returned to get the wheel chair ready for transfer and washed hands for 4 seconds. After NA-E applied Barrier Creme to the abdominal fold, removed the contaminated gloves and performed hand washing for 6 seconds. *3.Interview with NA-E and NA-D confirmed the hand washing should be 20 seconds. *4.NA-D washed hands for 6 seconds and donned gloves. The NA placed all soiled linens in a plastic bag and the trash into a separate plastic bag. Both bags were tied with the contaminated gloves. NA-D proceeded to pick up 3 plastic bags filled with soiled items and preceded to carry them out of Resident 7 ' s room. On the way to the soiled utility room, NA-D stopped, walked into another resident ' s room and pick up 2 additional plastic bags with soiled items in them. NA-D continued to the soiled utility room to deposit the 5 plastic bags. After placing the bags in the utility room, NA-D picked up a can of bleach wipes from the carrier bag hanging on a Hoyer lift in the hallway, returned to Resident 7 ' s room and wiped down the mattress cover that had been contaminated with urine, wiped down the mechanical lift in the resident ' s room, removed the contaminated gloves, performed no hand washing, left the room to place the bleach wipes on the lift in the hallway, went to the linen closet, gathered clean linens, returned to the resident ' s room and placed the linens on the mattress at 9:55 A.M. NA-D performed hand washing for 10 seconds. E. *1. On 03/02/2010 at 7:00 A.M. observations revealed the Medication Aide (MA) -C performed an Accu-Check on Resident 30. MA-C failed to perform hand washing prior to donning gloves to handle the glucose meter. The glucose meter was carried into Resident 30 ' s room, placed on the surface of the chest of drawers. After using the Lancet and obtaining the drop of blood for the glucose strip, MA-C cleansed the blood from the finger, removed the strip from the meter, deposited the needle into the sharps container in the bathroom at the same time carrying the equipment in the gloved hand. MA-C ran the menu to punch in the message for the end result of the procedure, " informed nurse " . MA-C removed the gloves in the resident ' s bathroom and returned the glucose meter to the top of the medication cart. No cleansing of the meter had been performed. *2. On 03/02/2010 at 7:18 A.M. observations revealed LPN-Nurse-B donned gloves taken from the top of the medication cart. Resident 30 ' s 2 different types of insulin had been prepared in 2 separate syringes. Nurse-B took the prepared insulin shots and 2 antiseptic wipes into Resident 30 ' s room to be given. The resident had raised the clothes on the abdomen to receive the shots. Nurse-B cleansed the first area of skin to receive the first insulin shot and placed the antiseptic wipe on its packaged container on the resident ' s bedside stand. After administering the first shot, Nurse-B took the same antiseptic wipe used for the first skin cleansing and cleansed the second skin site to receive the second shot. The syringes were placed into the sharps container in the bathroom and Nurse-B left Resident 30 ' s room wearing the same gloves. After walking a distance down the hallway, Nurse-B removed the contaminated hand gloves and carried them back to the medication cart, placing the gloves into the trash container on the medication cart, and then used hand gel to cleanse hands. Upon completion of the procedure, interview with Nurse-B related to no hand washing and no removal of contaminated gloves replied " yes, I did " , and confirmed that hand hygiene had not completed. F. Record review of a Face Sheet revealed that Resident 9 was admitted to the facility on [DATE]. Record review of Resident 9's MDS dated and signed as completed on 10/01/2009 revealed that Resident 9 had an indwelling catheter ( a tube placed into the bladder). Further review of the MDS revealed that Resident 9 had the [DIAGNOSES REDACTED]. Observation on 3/3/2010 at 8:10 AM revealed NA I and CMA G entered Resident 9's room washed their hands and donned gloves. NA I began to cleanse Resident 9's peri-area cleaning in-between the abdominal folds and groin. CMA G began to cleans the indwelling catheter, cleaning from the insertion site outward. CMA G completed the cleansing and without changing the soiled gloves touched Resident 9's blanket, hair, clean adult brief and Resident 9's legs. CMA G then removed the soiled gloves and used hand sanitizer. An interview with CMA G was conducted on 3/03/2010 at 8:45 AM. During the interview, CMA G confirmed that the gloves had not been changed. G. Observation on 3/01/2010 between 6:45 AM and 7:25 AM of glucose monitoring via a Accu-Chek ( a procedure of checking a residents blood sugar level by sticking the resident finger with a lancet and placing a drop of the residents blood onto a strip that has been inserted into the Accu-Chek machine) revealed LPN H calibrated the Accu-Chek machine at the medication cart. LPN H took the Accu-Chek machine into Resident 26's room. LPN H placed the machine onto Resident 26's bed and donned gloves. LPN H stuck Resident 26's 3 finger on the right hand and placed a drop of blood onto the strip that had been placed in the Accu-chek machine. LPN H removed the strip after obtaining the results and held it in (gender) gloved hands. LPN H picked up the Accu-Chek machine and without removing the soiled gloves or handwashing returned to the medication cart and placed the meter on top of the cart. LPN H removed the soiled gloves and picked up the soiled Accu-Chek machine and obtained the reading for documentation into the residents record. The Accu-Chek machine had not been cleansed before or after being used for Resident 28. LPN H calibrated the same uncleansed Accu-Chek machine and went into Resident 28 room. LPN H placed the Accu-Chek machine onto the residents bed with out a barrier in betweenthe meter and bed, donned gloves and stuck Resident 28's finger with a lancet and placed the drop of the resident's blood onto the strip that had been placed into the meter. After obtaining the results, LPN H removed the strip, gave the resident a cotton ball for the finger that had been stuck to wipe the blood off the finger. LPN H holding the used strip, the Accu-Chek machine, removed the soiled cotton ball and returned to the medication cart. LPN H placed the uncleaned meter on top of the medication cart and removed the soiled gloves with the used strip and cotton ball inside of them. LPN H picked up the soiled meter with bare hands, obtained the reading for documentation and placed the soiled meter back on top of the medication cart. The meter had not been cleansed before or after use for Resident 25. LPN H without handwashing obtained a vial of insulin to administer insulin to Resident 28. LPN H administered the insulin to Resident 28 in (gender) room. LPN H removed gloves that had been worn and completed handwashing for 24 seconds. LPN H returned to the medication cart, picked up the uncleansed Accu-Chek machine, calibrated it for use and went into Resident 27's room. LPN H placed the meter onto Resident 27's bed side table. No barrier had been placed between the table and meter. LPN H donned gloves, stuck Resident 27's second finger on the left hand with a lancet, placed the drop of blood onto a strip that had been placed into the meter. After obtaining the results, LPN H removed the gloves and picked up the soiled meter with bare hands and returned to the medication cart, records the results into the residents record and prepares insulin to be administered to Resident 27. LPN H hands had not been washed or the Accu-Chek machine cleansed before or after use. An interview with LPN H was conducted on 3/01/2010 at 7:25 AM. During the interview, LPN H was asked when should the Accu-Chek machine be cleansed? LPN H stated " before and after each resident". LPN H confirmed that the Accu-Chek machines had not been cleansed before and after use with Residents 26, 27 and 28. LPN H further confirmed that handwashing had not been completed as identified above. On 3/01/2010 an interview with the DON was conducted related to the Accu-Chek meters. During the interview, the DON stated that the expectation is that the Accu-Chek machines are to be cleansed in between each resident use. Record review of the facility policy and procedure titled Blood Glucose- Accu-Check Inform System effective date 7/08 and reviewed on 8/09 revealed the following: -#6 A. Normal infection control guidelines are exercised when handling laboratory reagents. -7B,#1. Cleaning should be preformed dailywhen running the daily quality control, when there is visible blood on the Accu-Chek... H. On March 1, 2010 at 10:45 AM, observation was made of Resident 12 receiving help with toileting cares. Resident 12 is a two person pivot to transfer. When needing assistance with transferring off the commode to the wheelchair, Nursing Assistant J opened door to hallway and asked LPN K for help transferring Resident 12. LPN K entered room and donned gloves without washing hands. LPN K assisted Resident 12 on one side lifting under Resident 12 ' s arm. As Resident 12 was finishing being lowered to the wheelchair, the unit telephone (which was located in LPN K' s pocket) began to ring. LPN K reached into the uniform pocket, with gloved hand, and pushed the talk button on the phone, putting the phone in the crook of LPN K's neck and began talking. While still talking, LPN K removed gloves and threw them in the trash and turned water on to wash hands. LPN K put hands under water and then removed in less then 2 seconds, using no soap. LPN K used paper towels to dry hands and threw them in trash while still talking on phone as walking out the door. | 2014-04-01 | ||
| 12672 | ALEGENT HEALTH IMMANUEL FONTENELLE HOME | 285085 | 6809 N 68TH PLAZA | OMAHA | NE | 68152 | 2010-03-03 | 281 | D | 9OFY11 | LICENSURE REFERENCE NAC 175 12-006.10B1 Based on interview and observation and record review, the Facility staff failed to document medications after administration for 2 residents (Resident 7 and Resident 29).These observations were made during the survey that occurred from February 25, 2010 to March 3, 2010. The facility census was 152 and the sample size was 24 plus 6 non-sampled residents. Findings are: A. Observation was on March 2, 2010 at 08:!0 AM of LPN K preparing insulin for Resident 29. When finished drawing insulin into the syringe, LPN K was observed initialing the MAR. (Medication Administration Record). Review of the facility ' s Skills Demonstration Document of Medication Administration, item #13 states, " Meds charted immediately after given " . In an interview with LPN K done at the time of the initialing, LPN K admitted to initialing the medication prior to giving, stating that it was known that was not a correct procedure and this is not the way LPN K normally charts medications. B. On 03/01/2010 at 4:05 P.M. observation of the LPN (License Practical Nurse) Nurse-A revealed the nurse charted the medications for Resident 7 at the time the medications were prepared instead of documenting the medications as given following the administration of the medications. During the discussion of the administration and documentation of medications with LPN Nurse-A, the nurse confirmed that medications are to be charted after the administration of the medications. C. Review of the ALEGENT HEALTH I Skills Demonstration, MEDICATION ADMINISTRATION, last revised 04/08, has documented under item 13. Meds charted immediately after given. | 2014-04-01 | ||
| 12673 | ALEGENT HEALTH IMMANUEL FONTENELLE HOME | 285085 | 6809 N 68TH PLAZA | OMAHA | NE | 68152 | 2010-03-03 | 322 | D | 9OFY11 | LICENSURE REFERENCE NUMBER 12-006.09D6(1) Based on observation, interview and the policy for Skills Demonstration the faculty failed to ensure cleansing of the equipment for administration of fluids through a Gastrostomy tube for 1 (Resident 7) resident. The total samples of 24 residents within the nursing facility census of 152 were reviewed. Findings are: On 03/01/2010, 4:05 P.M., observation during the administration of Resident 7 ' s water flush per Gastrostomy tube, revealed the LPN (License Practical Nurse) Nurse-A prepared the graduate with 200cc (Centimeters) water; placed the graduate and the syringe on the resident ' s bed linens. Upon completion of the water flush through the Gastrostomy tube, LPN-A separated the syringe, placed the barrel and plunger into the graduate and returned the equipment, without rinsing, to Resident 7 ' s bedside table. On 03/01/2010, following the Gastrostomy tube water flush for Resident 7, an interview with LPN-A revealed " it didn ' t occur to me to rinse it " . Review of the ALEGENT HEALTH Senior Health Services Skills Demonstration, MEDICATION ADMINISTRATION VIA GASTROINTESTINAL TUBE, last revised 12/08, has documented under item 21. Rinses graduate and syringe (separate barrel and plunger) and sets in clean area to dry. | 2014-04-01 | ||
| 2237 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2019-02-26 | 609 | D | 0 | 1 | 1UP111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report to the State agency an allegation of potential abuse and/or neglect related to a hot liquid spill that resulted in injury for Resident 19. 3 residents were reviewed for abuse, and the total facility census was 32. Findings are: [NAME] Review of the facility policy titled Abuse, Neglect, and Misappropriation of Resident Property (not dated) included the following related to reporting of potential abuse and/or neglect: -allegations are reported in accordance with Federal and State law; and -all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later that 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials in accordance with State law. B. Review of Resident 19's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/25/18 included the following: -[DIAGNOSES REDACTED]. -severely impaired cognition; and -required extensive assistance with eating. Review of Progress Notes dated 8/3/18 at 2:40 PM revealed Resident 19 spilled coffee at the lunch meal. Staff were present at the time. The area was assessed and the skin observed to be pink. Ice was applied. The area was reassessed at 2:00 PM and the skin remained red and cold from ice, and tender to touch. The ice was removed in order to assess whether the redness was related to the ice or a potential burn. Review of a Skin Occurrence assessment dated [DATE] at 6:15 PM revealed the following related to Resident 19: -had a burn on the right inner thigh measuring 0.7cm (centimeters) x (by) 1.7cm; -spilled coffee on lap at lunch time and the area was assessed throughout the day; -at 4:45 PM observed a small dime size or less intact blister; -the area was tender and the surrounding skin red; and -a physician's order was obtained for [MEDICATION NAME] (a cream used to prevent and treat wound infections in residents with burns) daily. Review of a Skin Occurrence assessment dated [DATE] at 10:35 AM revealed the following related to Resident 19: -had a fluid filled blister on the left upper/inner thigh measuring 1.1cm x 1.0cm; -an open area that most likely started as a fluid filled blister that is now drained measuring 1.0cm x 0.5cm; and -spilled coffee on lap 8/3/18 and area presented to right inner thigh initially with this area presenting last evening. There was no evidence this incident of alleged abuse and/or neglect was reported to the State agency in accordance with the facility policy and State law. During interview on 2/26/19 at 8:40 AM, the Director of Nursing (DON) confirmed Resident 19's hot liquid spill incident was not reported to the State agency, and verified a report should have been made. | 2020-09-01 |
| 2238 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2019-02-26 | 689 | E | 0 | 1 | 1UP111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, record review and interview; the facility failed to evaluate and implement interventions for the prevention of hot liquid spills for 3 of 3 residents (Residents 4, 19 and 29) who were reviewed related to a history of hot liquid spills. The total facility census was 32. Findings are: [NAME] Review of the facility policy titled Hot Liquids Assessment, Revised 2/25/19, included that following: -to identify and protect residents who are at risk for burning themselves while drinking hot liquids; -residents will be identified by utilizing a Hot Liquids Risk Assessment tool; -assess all residents on admission, annually and with a significant change; -residents considered At Risk (score of 6-9 on the assessment) will wear a long vinyl insulated clothing protector and/or have a lidded cup; -residents considered High Risk (score of 10 or greater) will wear a long vinyl insulated clothing protector, use a cup with a lid and have added either 1/4 cup cold water/broth to hot liquids or have their hot liquid food (soup/hot cereal) dished up and set aside in the kitchen until it reaches 145 degrees or less before it is served to the resident; -staff will notify the DON (Director of Nursing)/Administrator immediately of any hot liquid spills so a State report can be filed; -monitor skin for 4 days following hot liquid spills, whether injury occurs or not; and -if injury occurs a weekly skin occurrence will be created and initiated, and monitoring will continue until the area is resolved. B. Review of Resident 19's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/25/18 included the following: -[DIAGNOSES REDACTED]. -severely impaired cognition; and -required extensive assistance with eating. Review of Resident 19's Care Plan dated 6/18/18 revealed the resident was at risk for hot liquid spills/burns, and lids for coffee cups and vinyl insulated clothing protectors are utilized. Review of a Hot Liquids Risk assessment dated [DATE] indicated a score of 6 which indicated Resident 19 was At Risk for hot liquid spills. Review of Progress Notes dated 8/3/18 at 2:40 PM revealed Resident 19 spilled coffee at the lunch meal. Staff were present at the time. The area was assessed and the skin observed to be pink. Ice was applied. The area was reassessed at 2:00 PM and the skin remained red and cold from ice, and tender to touch. The ice was removed in order to assess whether the redness was related to the ice or a potential burn. Review of a Skin Occurrence assessment dated [DATE] at 6:15 PM revealed the following related to Resident 19: -had a burn on the right inner thigh measuring 0.7cm (centimeters) x (by) 1.7cm; -spilled coffee on lap at lunch time and the area was assessed throughout the day; -at 4:45 PM observed a small dime size or less intact blister; -the area was tender and the surrounding skin red; and -a physician's order was obtained for [MEDICATION NAME] (a cream used to prevent and treat wound infections in residents with burns) daily. Review of a Skin Occurrence assessment dated [DATE] at 10:35 AM revealed the following related to Resident 19: -had a fluid filled blister on the left upper/inner thigh measuring 1.1cm x 1.0cm; -an open area that most likely started as a fluid filled blister that is now drained measuring 1.0cm x 0.5cm; and -spilled coffee on lap 8/3/18 and an area presented to the right inner thigh initially with this area presenting last evening. Review of the Care Plan entry dated 8/3/18 revealed the resident spilled hot coffee at lunch, the hot liquid risk assessment was updated, and lids to be placed on cups utilized by Resident 19 (an intervention identified on the Care Plan dated 6/18/18). There was no evidence a Hot Liquids Risk Assessment was completed for Resident 19 following the hot liquid spill, or since 7/30/18. Furthermore, there was no evidence the facility assessed the circumstances surrounding the incident and/or the probable causal factors, or that interventions were reviewed and revised to prevent further incidents. During interview on 2/26/19 at 8:40 AM, the Director of Nursing (DON) verified Resident 19 should have been reassessed for risk of hot liquid spills following the incident on 8/3/18. C. Review of Resident 4's MDS dated [DATE] included the following: -[DIAGNOSES REDACTED]. -severely impaired cognition; and -required extensive assistance with eating. Review of Resident 4's current Care Plan revealed the following: -8/30/18 - spilled lukewarm chocolate drink with no injuries. Coffee cups are lidded and vinyl clothing protector is worn; -11/29/18 - Hot Liquids Risk Assessment completed, score 06, indicating at risk for hot liquid spills/burns. Spouse/POA signed a Waiver of Interventions to refuse the lid on the coffee. Vinyl clothing protector is offered; and -12/29/18- spilled lukewarm chocolate drink with no injuries. Coffee cups are lidded and vinyl clothing protector is worn. Review of Hot Liquid Spill Forms (completed when an episode occurs and submitted to the DON and Dietary Manager for follow-up) revealed the following related to Resident 4: -8/30/18 at 10:15 AM - drinking hot chocolate on couch by nurses' station. Cup did have lid on. Noted hot chocolate spilled on floor and 2 nickel size spill spots on the right inner pant leg. The hot chocolate was lukewarm to touch and no injuries were noted; and -12/29/18 at 10:00 AM - in recliner near nurse's desk holding cocoa and spilled in lap. Staff immediately assisted to room and changed pants. Skin in the mid to upper bilateral inner thighs pink. No redness, swelling, blisters or indication of discomfort. Cool packs applied for 20 minutes. No pinkness or indication of discomfort when skin assessed when cool packs removed. Dietary staff notified and they stated cocoa is cooled before leaving the kitchen. There was no evidence a Hot Liquids Risk Assessment was completed for Resident 4 following the hot liquid spill episode, or since 11/29/18. Furthermore, there was no evidence the facility assessed the circumstances surrounding the incidents and/or the probable causal factors, or that interventions were reviewed and revised to prevent further incidents. During meal observations on 2/21/19 at 8:29 AM and 12:00 PM, on 8/25/19 at 8:03 AM and 12:01 PM, and on 2/26/19 at 8:15 AM, Resident 4 was observed seated at the dining room table drinking hot chocolate from a coffee cup with no lid. During interview on 2/26/19 from 8:40 AM until 10:36 AM, the DON indicated Resident 4's spouse signed a Waiver of Intentions to refuse the lid on Resident 4's coffee cup as they noted the resident would not drink from a lidded cup and would take the lid off. The DON further verified the Waiver of Intentions related to the spouse's refusal to allow lidded coffee cups had not been reviewed with the spouse since 10/25/17. D. Review of Resident 29's Care Plan revealed on 11/27/18 a Hot Liquid Risk Assessment was completed and the resident was at risk for hot liquid spills and used a lidded cup and a vinyl clothing protector. Review of Resident 29's Hot Liquids Risk assessment dated [DATE] indicated a score of 8 which indicated the resident was At Risk for hot liquids spills. Review of Resident 29's Progress Notes revealed: - On 12/31/18 at 7:08 PM, it was reported the resident had a minor coffee spill. Upon inspection a fifty-cent piece sized red area was noted to the resident's right upper thigh. - On 1/6/19 at 9:25 AM, the reddened area to the resident's thigh from the coffee spill was resolved. Review of Resident 29's Medical Record revealed no evidence to indicate an investigation was completed using the Hot Liquid Spill Form to determine causal factors and to implement interventions to prevent further incidents. Interviews with the DON on 2/25/19 at 1:26 PM and 2:54 PM confirmed an investigation should be completed after a hot liquid spill using the Hot Liquid Spill Form. Further interview confirmed the Hot Liquid Spill Form was not completed after Resident 29's hot coffee spill. During an interview with Dietary Aide-G on 2/26/19 at 11:35 AM, Dietary Aide-G revealed the facility used 2 different sets of water/coffee carafes. The set used for the resident's that needed assistance (which included Resident 29) was temped down by adding cold water and should be below 150 degrees. Further interview confirmed the temperatures were not recorded to ensure the hot liquids were cooled consistently below 150 degrees. | 2020-09-01 |
| 2239 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2019-02-26 | 880 | E | 0 | 1 | 1UP111 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observations, record review and interview; the facility failed to ensure hand hygiene and/or gloving was provided when indicated during the completion of blood glucose testing for Resident 10 and with administration of an eye drop for Resident 25. This had the potential to put 8 residents (Residents 25, 15, 19, 23, 1, 8, 29 and 12) who received routine eye drops and 5 residents (Residents 10, 32, 29, 12 and 18) who received routine blood glucose testing at increased risk for potential cross contamination. The total sample size was 21 and the facility census was 32. Findings are: [NAME] Review of the facility policy titled Standard Precautions (undated) revealed standard precautions included the following practices: -hand hygiene refers to hand-washing with soap or using an alcohol based hand rub; -hands were to be washed with soap and water whenever visibly soiled with dirt, blood or body fluids, or after direct or indirect contact with such; -wear gloves when anticipated direct contact with blood, body fluids, mucous membranes, non-intact skin and potentially infected material; -change gloves as necessary during the care of a resident to prevent cross contamination from one body site to another; and -remove gloves promptly after use, before touching non-contaminated items and environmental surfaces and before going to another resident and wash hands immediately to avoid transfer of microorganisms. B. During an observation of blood glucose testing on 2/21/19 at 11:30 AM, the following was observed: -Registered Nurse (RN)-D gathered supplies at the medication cart in the corridor, then entered Resident 10's room and set up supplies on a table. Without washing hands, RN-D donned gloves and proceeded to perform blood glucose testing; -RN-D removed disposable gloves and without performing hand hygiene, gathered supplies and returned to the medication cart; -still without completing hand hygiene, RN-D donned a clean pair of gloves and proceeded to cleanse the glucometer (a machine used to determine a resident's blood glucose level); and -RN-D removed gloves and without washing hands or using hand sanitizer proceeded to push the medication cart to the dining room. C. During an observation on 2/25/19 at 9:11 AM, RN-I positioned the medication cart outside of Resident 25's room. Without performing hand hygiene or donning a pair of gloves, RN-I administered an eye drop into both of Resident 25's eyes. D. During an interview with the Director of Nursing on 2/26/19 at 11:45 AM the DON confirmed the following: -staff were to follow the facility policy regarding hand hygiene and the use of disposable gloves; -8 residents (Residents 25, 15, 19, 23, 1, 8, 29 and 12) received routine eye drops; and -5 residents (Residents 10, 32, 29, 12 and 18) had routine blood glucose testing. | 2020-09-01 |
| 2240 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2016-09-08 | 280 | D | 0 | 1 | QVJK11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on observations, record review and interview; the facility failed to revise Care Plans following a resident to resident altercation involving Residents 1 and 13. The sample size was 20 and the facility census was 44. Findings include: [NAME] Review of Progress Notes dated 4/7/16 at 11:00 AM revealed a verbal confrontation was noted between Resident 1 and Resident 13 who were roommates. Documentation indicated Resident 13 reported being hit by Resident 1. Resident 13 was observed to have .a red mark to neck and shoulder area. Review of a facility investigation of potential abuse/neglect dated 4/11/16 revealed that on 4/7/16 at 11:00 AM, Resident 1 was seated in a wheelchair in the doorway of the room. Resident 1 was positioned directly behind Resident 13 who was also seated in a wheelchair. Staff responded after hearing yelling and Resident 13 reported being hit by Resident 1. Resident 1 voiced a need to use the bathroom and indicated Resident 13 was in the way. Resident 13 was noted to have a reddened area on the right side of the shoulder/neck. Documentation further indicated preventative measures put in place to prevent reoccurrence were to remind Resident 1 to use the call light for assistance and Resident 13 was removed from the room for lunch. B. Review of Resident 1's previous Care Plan (revision date 2/11/16) revealed the altercation with the roommate (Resident 13) on 4/7/16 was identified and the interventions were: -Staff to monitor and; -Roommate encouraged to spend time in the commons area (public sitting area of facility). Review of Resident 1's current Care Plan (revision dates 5/12/16 and 8/5/16) revealed the altercation with the roommate on 4/7/16 was not identified and there were no interventions to prevent a reoccurrence. C. Review of Resident 13's previous Care Plan (revision date 2/26/16) revealed the altercation with the roommate (Resident 1) on 4/7/16 was identified. The intervention to prevent a reoccurrence was to encourage Resident 13 to spend time in the commons areas. Review of Resident 13's current Care Plan (revision date 9/1/16) revealed no interventions were identified to prevent altercations with Resident 1. Observations on 8/31/16 revealed the following: -Resident 1 and Resident 13 were roommates; -1:35 PM-Resident 1 and Resident 13 were seated in wheelchairs on opposite sides of the room in their room; -2:19 PM-Resident 1 was lying in bed and Resident 13 was seated in a wheelchair on the opposite side of the room. Resident 1 and Resident 13 were observed seated in wheelchairs in their room on 9/6/16 from 10:00 AM until 12:01 PM. Interview with Nursing Assistant (NA)-C on 9/6/16 at 2:05 PM revealed Resident 1 was no longer self mobile in the wheelchair; however Resident 13 remained self mobile in the wheelchair. | 2020-09-01 |
| 2241 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2016-09-08 | 309 | D | 0 | 1 | QVJK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observations, record review and interview; the facility failed to develop interventions to: 1) address Resident 1's adverse behaviors toward Resident 13 and; 2) address Resident 27's positioning. The sample size was 20 and the facility census was 44. Findings include: [NAME] Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/4/16 revealed [DIAGNOSES REDACTED]. Review of Progress Notes dated 4/7/16 at 11:00 AM revealed a verbal confrontation was noted between Resident 1 and Resident 13 who were roommates. Documentation indicated Resident 13 reported being hit by Resident 1. Resident 13 was observed to have .a red mark to neck and shoulder area. Review of a facility investigation of potential abuse/neglect dated 4/11/16 revealed on 4/7/16 at 11:00 AM, Resident 1 was seated in a wheelchair in the doorway of the room. Resident 1 was positioned directly behind Resident 13 who was also seated in a wheelchair. Staff responded after hearing yelling and Resident 13 reported being hit by Resident 1. Resident 1 voiced a need to use the bathroom and indicated Resident 13 was in the way. Resident 13 was noted to have a reddened area on the right side of the shoulder/neck. Documentation further indicated preventative measures put in place to prevent reoccurrence were to remind Resident 1 to use the call light for assistance and Resident 13 was removed from the room for lunch. Review of Resident 1's previous Care Plan (revision date 2/11/16) revealed the altercation with the roommate on 4/7/16 was identified and the interventions were: -Staff to monitor and; -Roommate encouraged to spend time in the commons area (public sitting area of facility). Observations on 8/31/16 revealed the following: -Resident 1 and Resident 13 were roommates; -1:35 PM-Resident 1 and Resident 13 were seated in wheelchairs on opposite sides of the room in their room; -2:19 PM-Resident 1 was lying in bed and Resident 13 was seated in a wheelchair on the opposite side of the room. Resident 1 and Resident 13 were observed seated in wheelchairs in their room on 9/6/16 from 10:00 AM until 12:01 PM. Interview with Nursing Assistant (NA)-C on 9/6/16 at 2:05 PM revealed Resident 1 was no longer self mobile in the wheelchair; however Resident 13 remained self mobile in the wheelchair. B. Review of Resident 27's current undated Care Plan revealed the resident had a [DIAGNOSES REDACTED]. Further review revealed no evidence the resident's positioning had been assessed. Observations of Resident 27 revealed: -On 9/1/16 at 7:38 AM, the resident was seated in an upright recliner bent over at the waist with the resident's chest and abdomen lying on the resident's lap. -On 9/6/16 at 9:26 AM, the resident was seated in an upright recliner with resident's lower back vertical and shoulders approximately 6 inches from the back of the recliner. -On 9/6/16 at 11:24 AM, the resident remained seated in the upright recliner but was now bent over at the waist with the resident's chest and abdomen lying on the resident's lap. -On 9/8/16 at 7:34 AM, the resident was seated in an upright recliner bent over at the waist with the resident's chest and abdomen lying on the resident's lap. Interviews on 9/8/16 with NA-C at 10:03 AM and Registered Nurse-F at 10:25 AM, revealed the facility had not tried any interventions to improve Resident 27's positioning when the resident was in the recliner. Interview with the Director of Nursing on 9/8/16 at 11:25 AM, confirmed Resident 27 had better positioning when initially placed in the recliner, but would tire over time and then become bent over in the recliner. Further interview confirmed Resident 27 had not been assessed for proper positioning in the resident's recliner. . | 2020-09-01 |
| 2242 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2016-09-08 | 315 | D | 0 | 1 | QVJK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on interview and record review, the facility failed to implement interventions to prevent further decline in bladder function and/or improve current bladder function for Resident 48. The sample size was 20 and the facility census was 44. Findings are: Review of the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/18/16 revealed Resident 48 was admitted on [DATE], and was always continent of urine. Review of the MDS dated [DATE] revealed Resident 48 was occasionally incontinent of urine (meaning less than 7 episodes of incontinence during the 7 day assessment period). Review of Resident 48's Bowel and Bladder Program Screener (a tool used to review a residents bowel and bladder status and identify their ability for retraining) dated 7/13/16 revealed Resident 48 was incontinent of urine at least daily, and was a good candidate for retraining. Review or Resident 48's undated Care Plan revealed no interventions to prevent further decline in bladder function and/or improve current bladder function. Interview with Nursing Assistant-C on 9/8/16 at 10:01 AM revealed Resident 48 had an increase in bladder incontinence. Further interview revealed Resident 48 was toileted on a routine schedule that was consistent for all residents that required assistance with toileting. Interview with Licensed Practical Nurse-A on 9/8/16 at 10:08 AM, confirmed Resident 48 did not have a bladder retraining program. Interview with Registered Nurse -F on 9/8/16 at 10:28 AM confirmed Resident 48 had an increase in bladder incontinence. | 2020-09-01 |
| 2243 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2016-09-08 | 323 | D | 0 | 1 | QVJK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on record review and interview, the facility failed to assess causal factors and to develop and/or revise interventions for the prevention of falls for 1 resident (Resident 35). The sample size was 20 and the facility census was 44. Findings are: Review of Resident 35's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/13/16 indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident 35's current Care Plan with revision date 6/23/16 indicated the resident was at risk for falls related to impaired safety awareness and a history of frequent falls. Nursing interventions included: -Be sure the resident's call light was within reach at all times and to provide prompt response to all requests for assistance. -Ensure the resident has appropriate footwear when out of bed (black rubber soled lace up shoes). -Pin alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) to the resident's recliner, bed and wheelchair. -Low bed with a defined edge mattress. -Toilet the resident after meals. -Lift chair recliner. Review of Incident/Accident Report dated 6/26/16 at 3:45 PM revealed the resident was found lying on the floor of the resident's room. The resident's personal alarm was in place and was alarming at the time of the fall. Review of the Post Fall Assessment completed 6/26/16 at 3:45 PM revealed the resident had been seated in a lift recliner in the resident's room prior to the fall. The fall was unwitnessed and the resident was unable to identify the reason for the fall. A new intervention was identified to assess use of the recliner to determine if a different recliner should be implemented to prevent ongoing falls. Review of Resident 35's medical record revealed no evidence the facility assessed the use of the resident's lift recliner or that a different recliner was ever implemented for the resident. Review of Fall Risk assessment dated [DATE] revealed a score of 18 indicating the resident was at high risk for falls. Review of Incident/Accident Report dated 8/1/16 at 5:40 PM revealed staff responded to the resident's personal alarm and found the resident on the floor of the resident's room. The report indicated the resident had a laceration with dark bruising above the left eyebrow which measured 1.5 centimeters (cm) by 0.1 cm. Review of the Post Fall assessment dated [DATE] at 5:40 PM revealed the resident had attempted to self-transfer out of the wheelchair and fell into a night stand. Further review of the assessment revealed no causal factors were identified and no new interventions were developed to prevent ongoing falls. Interview with the Director of Nursing (DON) on 9/6/16 from 2:30 PM to 2:45 PM revealed there was no evidence the resident's lift recliner had been assessed after the resident's fall on 6/26/16 and confirmed a different recliner had never been provided for the resident. The DON further identified no causal factors were identified and no new interventions were developed after the resident fell on [DATE] to prevent ongoing falls. | 2020-09-01 |
| 2244 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2017-12-14 | 684 | D | 0 | 1 | MZNW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observation, interview, and record review; the facility failed to assess causal factors and develop interventions to 1) prevent ongoing bruising/skin tears for Resident 37, and 2) prevent ongoing skin tears for Resident 17. The sample size was 15 and the facility census was 42. [NAME] Review of Resident 17's current Care Plan with a review date of 10/23/17 revealed the resident was at risk for impaired skin integrity related to impaired mobility. Observation of Resident 17 on 12/12/17 at 9:49 AM revealed a skin tear to the right hand with steri-strips (surgical tape strips used to close small wounds) in place and a skin tear to the left forearm with steri-strips in place. Review of Resident 17's Skin Occurrence Assessments from 8/31/17 through 12/9/17 revealed the following: - On 8/31/17, the resident had a skin tear to the middle finger of the left hand caused by the resident's dresser. No new interventions were identified. - On 10/27/17, the resident had a deep slit between the 4th and 5th toes on the left foot. No causal factors or new interventions were identified. - On 11/9/17, the resident had a skin tear to the left lateral forearm. No causal factors or new interventions were identified. - On 12/4/17, the resident had a skin tear to the back of the right hand from the grab bar in the bathroom. No new interventions were identified. - On 12/9/17, the resident had a skin tear to the left forearm from bumping into a railing. No new interventions were identified. During an interview on 12/14/17 at 11:40 AM the Director of Nursing (DON) confirmed causal factors were not assessed for skin tears and/or bruising, and interventions were not put in place to prevent potential recurrence. B. Review of Resident 37's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/22/17 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had severe cognitive impairment and displayed adverse physical and verbal behaviors. Review of Resident 37's Skin Occurrence assessment dated [DATE] at 2:02 PM revealed a Skin tear noted to the medial back of right hand measuring 2 cm (centimeters) by 0.3 cm after resident was seen hitting wall with back of hand. Resident was hitting wall with a knocking motion using back of hand. Review of a Skin/Wound QI (Quality Improvement) Log dated 8/17/17 (no time indicated) revealed Resident 37 sustained a 1.4 cm x 0.9 cm skin tear on the top of the left hand after hitting hand on the lift (mechanical lift used to transfer the resident in and out of bed/chair). Review of a Skin Occurrence assessment dated [DATE] at 5:26 PM revealed a skin tear was observed on Resident 37's right hand at 4:00 PM which measured 1 cm x 0.1 cm. There was no documentation as to the potential cause of the injury. Review of the Skin/Wound QI Log dated 9/29/17 revealed the intervention for prevention of further skin tears was mindful hand placement. Review of a Progress Note dated 10/9/17 at 7:20 PM revealed Resident 37 was hitting at staff while being transferred into bed with a mechanical standup lift. The resident sustained [REDACTED]. Review of a Skin Occurrence assessment dated [DATE] at 10:01 AM revealed Resident 37 struck out during transfer with the mechanical standup lift. The resident bumped the top of the left hand on the mechanical standup lift and sustained 2 skin tears which measured 0.6 cm x 0.5 cm x 0.1 cm and 2.3 cm x 0.1 cm. Review of Resident 37's Care Plan (revision date 12/5/17) revealed the resident was at risk for skin breakdown related to impaired mobility, diabetes, obesity and incontinence. There were no interventions for the prevention of bruises and skin tears caused by the resident striking out at the mechanical standup lift or from hitting the wall. On 12/13/17 at 8:00 AM, Resident 37 was observed to have a large bruised area on the left forearm and the top of the left hand. Interview with Nursing Assistant (NA)-B on 12/14/17 at 9:40 AM revealed Resident 37 received skin tears and bruises due to the resident striking out during transfers with the mechanical standup lift. NA-B further indicated Resident 37 frequently hit the bathroom wall with a fist while seated on the toilet which caused bruises on the resident's hands and knuckles. Interview with the DON on 12/14/17 at 11:50 AM confirmed there was no evidence to indicate interventions were developed in an attempt to prevent further skin tears and bruises as a result of Resident 37's combative behaviors. | 2020-09-01 |
| 2245 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2017-12-14 | 689 | D | 0 | 1 | MZNW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record review and interview; the facility failed to ensure Resident 16 was safe to be outside without staff supervision. The facility census was 42 and the sample size was 15. Findings are: Review of Resident 16's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/11/17 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had modified independence with cognitive skills for daily decision making and displayed episodes of disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Review of Resident 16's Care Plan dated 4/20/17 revealed the use of a Wanderguard (a bracelet worn by the resident and sounds an alarm if the resident comes within a certain distance of the exit door). Review of a Wandering Risk assessment dated [DATE] revealed Resident 16 was at moderate risk for wandering. Review of Resident 16's Progress Notes dated 11/16/17 at 11:53 AM revealed the resident was at moderate risk for wandering per the assessment completed 11/16/17 following a recent room change. Documentation indicated the following: -no increased confusion or attempts to exit the facility had been noticed; -the Wanderguard was discontinued; and -staff would continue to monitor for exit seeking behaviors. Review of Progress Notes dated 12/6/17 at 10:21 AM revealed Resident 16 was .attempting to enter the Assisted portion (assisted living) of the facility today-to this time has attempted 3 times and each time was either redirected or pushed to (resident's) room by staff. There was no evidence to indicate Resident 16's attempt to exit the facility was assessed. On 12/11/17 at 10:30 AM, Resident 16 was observed seated in a wheelchair and was attempting to re-enter the facility from outside through the front door. The resident was unable to completely open the front door and the wheelchair became wedged against the door which prevented the resident from independently re-entering the building. The Business Office Manager (BOM) was present in the office next to the front door and immediately assisted the resident back into the building. Interview with the BOM on 12/14/17 at 7:55 AM revealed Resident 16 was allowed to sit outside without supervision. The BOM confirmed Resident 16 required assistance to re-enter the building on 12/11/17 as the resident did not consistently remember how to use the handicapped automatic door opener. Interview with the Director of Nurses (DON) on 12/14/17 at 8:03 AM confirmed an assessment had not been completed to ensure Resident 16 was safe to sit outside without staff supervision. | 2020-09-01 |
| 6309 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2015-07-08 | 205 | D | 0 | 1 | KV0V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview; the facility failed to provide written notification of bed hold options for Residents 28 and 22 who were discharged from the facility for hospitalization . Facility census was 41. Findings are: A. Review of the facility's undated Bed Hold Policy revealed that in the event of temporary absence from the facility, Medicare does not allow for Bed Hold payment, and therefore, Medicare residents must pay privately for Bed Hold. B. Review of Resident 28's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/30/15 indicated the resident was admitted with [DIAGNOSES REDACTED]. Review of Social Services (SS) Progress Notes dated 12/5/14 at 4:04 PM revealed Resident 28 was admitted to the facility for skilled nursing services and therapies with Medicare as the payment source. Review of SS Progress Notes dated 2/26/15 at 4:54 PM indicated staff from another facility visited to evaluate Resident 28 for possible transfer to their facility. Documentation revealed Resident 28 changed (resident's) mind about wanting to leave at this time, but that the visiting facility would accept the resident if there were changes in the future. Review of Resident 28's Nursing Progress Notes dated 2/27/15 revealed the following: - At 9:35 AM, the physician called, was updated on lab results and current condition, and ordered transfer to the hospital. - At 9:58 AM, the resident was transferred to the hospital by rescue unit. There was no documentation in the medical record to indicate written notification of the Bed Hold Policy was presented to the resident and/or responsible party, or that a decision was made related to holding the bed until the resident returned from the hospital. C. Review of Resident 22's Nursing Progress Notes on 5/14/15 revealed the following: - 6:40 AM - receiving Medicare payments for skilled services of therapy, wound care and management of pain; - 11:02 AM - orthopedic surgeon ordered transfer to the emergency room at the hospital for assessment of wound to the right hip; and - 3:33 PM - the resident was admitted to the hospital for wound care. There was no documentation in the medical record to indicate written notification of the Bed Hold Policy was presented to the resident and/or responsible party. Review of Nursing Progress Notes dated 5/19/15 at 10:43 PM indicated Resident 22 was readmitted to the facility following hospitalization , and receiving Medicare payment for skilled services related to wound care. D. During interviews on 7/7/15 from 2:40 PM until 2:50 PM the following was revealed: - The Social Services Director (SSD) verified residents/family were provided the facility Bed Hold Policy upon admission to the facility, but was unaware of any notification provided at the time of discharge for temporary absence. - The SSD verified it was understood by facility staff that Resident 22 would return post-hospitalization , and the resident's bed was held as a courtesy. - The Administrator confirmed residents and/or responsible party were to be notified of the Bed Hold Policy upon admission, and within 24 hours of discharge to the hospital. | 2019-04-01 |
| 6310 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2015-07-08 | 221 | D | 0 | 1 | KV0V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(8) Based on observations, record review and interviews; the facility failed to protect Resident 53 from the use of physical restraints as a fully reclined tilt-in-space wheelchair (wheelchair which allows for manual recline of resident at various degrees to assist with positioning) was implemented following falls and was used without [DIAGNOSES REDACTED]. Furthermore, the physical restraint was used without evidence of monitoring and without plans for reduction or elimination of the physical restraint. Facility census was 41. Findings are: Review of the Restraint Management Policy (revised 2/20/11) revealed the following: -Physical restraints were defined as any device, method or drug that hinders or restricts a resident from any action, mental or physical. -Restraints were used only when authorized in writing by a physician for a specified and limited time period. -When restraints were ordered, the order would be incorporated in the Care Plan, along with the mechanism for monitoring and controlling their use. -It was expected that, for those residents whose Care Plans indicate the need for restraints, the facility would engage in a systematic and gradual process towards reducing restraints. -During the time a restraint was in place, the restraint was periodically removed and the resident assisted with change of position, range of motion and/or stretching. Review of Resident 53's Minimum Data Set (MDS-a comprehensive assessment tool used for care planning) dated 5/13/15 revealed diagnoses of dementia and [MEDICAL CONDITION]. The same MDS indicated the resident's cognitive status was severely impaired and the resident required extensive staff assistance with activities of daily living. Review of Resident 53's Care Plan with revision date 5/21/15 revealed the resident was at risk for falls due to resistance with cares and impaired safety awareness. Further review of Resident 53's Care Plan revealed an intervention dated 5/28/15 to position the resident in the wheelchair when increased restlessness was noted. Observations of Resident 53 on 7/7/15 revealed the following: -7:12 AM, resident was seated in a tilt-in-space wheelchair in the resident's room. Resident 53 was fully reclined and the foot pedals had been removed from the chair. The resident's lower legs hung dependent and dangled as the resident's feet were unable to reach the floor. -11:00 AM to 12:02 PM, resident in room and positioned in tilt-in-space wheelchair. The resident was fully reclined and foot pedals were removed from the chair. Resident 53 repeatedly attempted to sit upright in the chair. The resident became agitated when unable to remain upright and repeatedly stated, I am alone, I am alone. -1:12 PM to 3:00 PM, resident remained seated in tilt-in-space wheelchair, fully reclined and without foot pedals. The resident was positioned in front of the window. The resident made repeated attempts to sit up in the chair to look out the window and cried out and call for assistance when unable to remain upright. During an observation on 7/8/15 from 8:50 AM to 9:35 AM, Resident 53 was positioned in the tilt-in-space wheelchair in the resident's room. Resident 53 was fully reclined and wheelchair pedals had been removed. Resident 53 made repeated attempts to sit upright in chair and swung lower legs back and forth. Resident 53 began to run fingers through hair, clap hands and call out for help. The following was observed on 7/8/15 from 9:38 AM until 9:55 AM during the provision of toileting: -Resident 53 was seated in tilt-in-space wheelchair, fully reclined and without foot pedals. -Nursing Assistant (NA)-I placed the wheelchair upright, Resident 53 placed feet on the floor and immediately stood up from chair. Resident 53 was cued to sit back down. -Na-I and NA-C assisted Resident 53 to a standing position and transferred the resident to the toilet. -Following toileting, NA-I and NA-C transferred Resident 53 to the tilt-in-space wheelchair and fully reclined the chair. The NA's did not attempt to place foot rests on the wheelchair and the resident's feet dangled above the floor while sitting in the wheelchair. During interview on 7/8/15 from 10:24 AM to 10:35 AM, the Director of Nursing (DON) verified when Resident 53 was fully reclined in the tilt-in-space wheelchair, without the foot pedals, the chair prevented the resident from rising and therefore should be considered a restraint. The DON indicated the Occupational Therapist had evaluated the resident on admission and made the recommendation for the tilt-in-space wheelchair. Furthermore, it was the therapist's recommendation to fully recline the resident and to remove the foot pedals to keep the resident from attempting to self-transfer from the wheelchair. The DON further verified there was no [DIAGNOSES REDACTED]. | 2019-04-01 |
| 6311 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2015-07-08 | 279 | D | 0 | 1 | KV0V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on observations, record review and staff interview; the facility failed to develop a Care Plan that addressed use of a tilt-in-space wheelchair (wheelchair which allows for manual recline of resident at various degrees to assist with positioning) as a restraint for Resident 53. Facility census was 41. Findings are: Review of Resident 53's Minimum Data Set (MDS-a comprehensive assessment tool used for care planning) dated 5/13/15 revealed [DIAGNOSES REDACTED]. The same MDS indicated the resident's cognitive status was severely impaired and the resident required extensive staff assistance with activities of daily living. Review of Resident 53's Care Plan with revision date 5/21/15 revealed the resident was at risk for falls due to resistance with cares and impaired safety awareness with an intervention dated 5/28/15 to position the resident in the wheelchair when increased restlessness noted. Observations of the Resident 53 on the following dates and times revealed the resident sitting in the tilt-in-space wheelchair fully reclined, without foot rests, and attempting to get out of the chair: - 7/7/15 at 7:12 AM, 11:00 AM to 12:02 PM, and 1:12 PM to 3:00 PM; - 7/8/15 at 8:50 AM to 9:35 AM; and - 7/8/15 at 10 :00 AM to 10:25 AM. During interview on 7/8/15 from 10:24 AM to 10:35 AM, the Director of Nursing (DON) verified when Resident 53 was fully reclined in the tilt-in-space wheelchair, without the foot pedals, the chair prevented the resident from rising and therefore should be considered a restraint. The DON further verified the resident's Care Plan did not address use of the tilt-in-space wheelchair as a restraint. Furthermore, no interventions were developed for the monitoring or reassessment of the tilt-in-space wheelchair for reduction or elimination. | 2019-04-01 |
| 6312 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2015-07-08 | 371 | F | 0 | 1 | KV0V11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review and interviews; the facility failed to prevent the potential for food borne illness as staff failed to follow the manufacturer's recommendations for safe usage of the dishwashing machine and temperatures were not monitored in accordance with facility policy. These practice had the potential to affect all facility residents. Facility census was 41. Findings are: Review of Policy/Procedure for Dish Machine Temperature Log (undated) revealed facility staff were to monitor and record dish machine temperatures during wash and rinse cycle at each meal to assure proper sanitizing of dishes. Observation of the dish room during the initial tour of the kitchen on 6/30/15 from 2:10 PM to 2:35 PM, revealed the facility's dish machine was a low temperature dishwasher and utilized chemical sanitation to clean dishware. Review of the manufacturer's recommendations, which were posted on the front of the dish machine revealed the water temperature during the wash cycle was to be a minimum of 120 degrees Fahrenheit (F). Review of the facility Dishwasher Temperature Log dated 6/1/15 through 6/30/15 revealed the following: -Breakfast wash temperature of 110 degrees F on 6/16/15 and 115 degrees F on 6/18/15. No wash temperatures were recorded 6/1/15 through 6/15/15, 6/17/15, 6/19/15 through 6/27/15 and on 6/30/15. (12 out of 30 days) -No lunch wash temperatures were recorded 6/1/15 through 6/17/15, 6/19/15 through 6/27/15 and 6/30/15. (27 out of 30 days) -Dinner wash temperature was 115 degrees F on 6/29/15. There was no documentation of wash temperatures 6/1/15 through 6/28/15. (28 out of 29 days). -Further review of temperature log from 6/1/15 through 6/30/15 revealed no documentation at any meal of rinse temperatures. Interview with the Dietary Manager (DM) on 6/30/15 at 2:30 PM, verified staff were to monitor and record wash and rinse cycle temperatures of the dish machine before every meal. The DM verified the wash and rinse cycle temperatures were to be a minimum of 120 degrees F to assure dishware were clean and sanitized. The DM further indicated a problem with maintaining hot water temperatures due to issues with the facility water heater. | 2019-04-01 |
| 6607 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2015-12-28 | 225 | D | 1 | 0 | FEDO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to report and/or investigate a potential allegation of abuse and/or neglect for 1 resident (Resident 2). The facility census was 41. Findings are: A. Review of the facility Abuse Reporting and Investigation policy (revision date 2/11/12) included the following: -In all cases of alleged abuse/neglect the facility was to intervene in the situation, report the situation to the proper authorities, investigate the allegation and prevent abuse/neglect while the investigation was in process. -The abuse reporting procedure was to be initiated when an accident with significant injury occurred and resulted in the resident needing immediate medical attention. B. Review of Nursing Progress Noted dated 10/7/15 at 10:55 AM revealed Resident 2 had been seated on a couch next to the Nurse's Station. Documentation indicated Resident 2 stood up unassisted and was heard by staff shuffling feet and then falling. The resident sustained [REDACTED]. Review of Nursing Progress Note dated 10/7/15 at 11:40 AM revealed Resident 2 was seen at the physician clinic and received 6 sutures to the laceration above the resident's left eye. Review of the facility investigations of potential abuse/neglect from 7/8/15 through 12/28/15 revealed no report had been filed with the State Agency regarding Resident 2's fall on 10/7/15 which resulted in the need for immediate medical attention. There was no evidence to indicate an investigation had been completed or submitted to the State Agency. Interview with the Administrator on 12/28/15 at 12:00 PM confirmed Resident 2's fall with injury on 10/7/15 was not reported to the State Agency and an investigation had not been completed. | 2018-12-01 |
| 7758 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2014-05-12 | 156 | C | 0 | 1 | 7XFG11 | LICENSURE REFERENCE NUMBER NAC 12-006.06C Based on resident and staff interviews, record review and observations, the facility failed to make the ombudsman's information readily available to residents and/or responsible parties. The census was 37. Findings Are: A. During an interview on 5/7/14 at 2:00 PM the Resident Council president voiced that it was not known where the ombudsman's information was posted and/or who the ombudsmen was. During confidential interviews on 5/7/14 at 2:19 PM and 5/8/14 at 9:54 AM, 2 residents stated they were unaware of who the ombudsmen was or where the ombudsman's information was posted. During an interview with the Activity Director, Social Services Director and the Administrator, on 5/8/14 from 10:48 AM until 11:27 AM, it was revealed the ombudsmen visits the facility every 3 months, but staff were unaware if the ombudsmen spoke with residents during these visits. Review of the Resident Council Meeting Minutes from November 2012 through April 2014, revealed staff did not inform residents of who the ombudsman was or where the information for the ombudsman could be found. Observations on 5/8/14 at 11:38 AM revealed a sign measuring 8 inches x 10 inches posted in the hallway next to the activity room in an enclosed case, approximately 5 foot above the floor, inaccessible to residents in wheelchairs, with information on how to contact the ombudsman. | 2018-01-01 |
| 7759 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2014-05-12 | 250 | D | 0 | 1 | 7XFG11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.04E3 Based on record review and staff interview; the facility failed to determine Resident 12's and/or the resident's Power of Attorney's (POA-someone who is either appointed or chosen to provide assistance in executing another individual's health decisions) wishes for dental services. Facility census was 37. Findings are: Record review of Resident 12's Admission Records dated 7/28/06 revealed the POA at that time wanted Resident 12 to have routine dental appointments. Further review of the Medical Record revealed POA paperwork signed 8/31/07 appointing a different individual as Resident 12's POA. During an interview with the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) Coordinator and Social Services Director (SSD) on 5/8/14 from 9:40 AM until 9:55 AM it was revealed the POA had been contacted in 12/12 via telephone call with no answer and in 2/13 by letter with no response. The MDS coordinator went on to state that the facility was unsure of how to handle Resident 12's dental status as the POA had not responded to the facility's attempts to contact the POA. The SSD stated that in addition to trying to contact the POA with dental concerns message had been left in regards to clothing and personal belonging issues. The SSD revealed the possible need of a change in POA to meet the residents ' needs had not been discussed. There was no documentation in Resident 12 ' s Medical Record to indicate when Resident 12 had last had a dental appointment. Review of Resident 12's Progress Notes dated from 3/21/14 through 5/5/14 revealed the facility had attempted to contact Resident 12's POA due to varying issues on 6 occasions with no response from the POA. | 2018-01-01 |
| 7760 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2014-05-12 | 329 | D | 0 | 1 | 7XFG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview; the facility failed to assure Resident 15's medication regimen was free from unnecessary medications as the resident was receiving [MEDICATION NAME] (an antipsychotic medication that acts on the central nervous system to alter brain function) in a dosage above the recommended daily dose threshold. In addition, Resident 15's [MEDICATION NAME] dosage was increased on 2 occasions with no indication why the increased dosage was needed. Facility census was 37. Findings are: A. Review of facility policy for Antipsychotic Medication Use dated 3/14/14 indicated .All antipsychotic medications will be used within the dosage guidelines listed in F 329 (Federal Guidelines), or clinical justification will be documented for dosages that exceed the listed guidelines for more than 48 hours. B. Review of Resident 15's Care Plan revised 2/25/14 included [DIAGNOSES REDACTED]. The Care Plan further indicated the resident's target behaviors were screaming/yelling, hitting, hallucinations/delusions/paranoia. Review of Resident 15's physician's orders [REDACTED]. Review of Progress Notes revealed the following 4 entries regarding Resident 15's behaviors: -9/17/13 at 1:02 AM- .returns from supper per w/c (wheelchair). Calling out in loud humming sound. Very agitated, face red. Fluids offered and relaxes somewhat . -9/17/13 at 9:16 AM-Resident yelling loudly in dining room. Staff assist resident with breakfast and (resident) does quite (quiet) down. -9/21/13 at 2:33 PM-resident has been very loud today-at meals low pitched droning noise is constant only decreasing when (resident) has food or fluid in (resident) mouth . and when resident in room the sound .continues and at times takes on the nature of a loud roar . -9/22/13 at 6:25 PM-resident has been making loud droning noise for much of this day-at times noise becomes very loud and resident may say words or call out . Review of Resident 15's physician's orders [REDACTED]. There was no documentation to indicate why the dose increase was indicated or why a dosage above the daily recommended threshold was required. Review of Progress Notes from 10/5/13 to 11/7/13 revealed the following entries: -10/5/13 at 10:05 AM-Resident making nearly continuous droning sound today with occasional episodes of becoming quite loud -10/6/13 at 3:14 PM-resident noisy at breakfast but during forenoon is quiet and remains so during lunch-does have some noisy outburst during cares -10/13/13 at 10:15 AM-resident was .hollering 'hurry up' and incomprehensible low pitched wail during breakfast . -10/23/13 at 6:08 PM-Does a low droaning (droning) while at supper table tonight, but once staff assisted with feeding (resident) quieted. -11/2/13 at 1:23 PM-during this day resident has been droning frequently with the sound becoming louder and louder until it becomes a roar Review of Resident 15's Physician order [REDACTED]. There was no documentation to indicate why the dose increase was indicated or why a dosage above the daily recommended threshold was required. During interview on 5/12/14 at 9:55 AM, the Director of Nurses verified there was no documentation to indicate rationale for increasing the dosage of Resident 15's [MEDICATION NAME] or why the [MEDICATION NAME] was ordered above the daily recommended dose. | 2018-01-01 |
| 7761 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2014-05-12 | 334 | D | 0 | 1 | 7XFG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview; the facility failed to provide pneumococcal vaccination in accordance with documented consent by Resident 37's authorized representative, and to provide education related to the benefits and side effects of the pneumococcal vaccine to Resident 33 who refused the vaccination. Facility census was 37. Findings are: A. Review of the facility policy titled Pneumococcal Vaccine (not dated) included the following: - Prior to or upon admission, residents would be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, would be offered the vaccination within 30 days of admission unless medically contraindicated or the resident had already been vaccinated. - Before receiving the vaccination, the resident or legal representative would receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine, and provision of such education would be documented in the resident's medical record. - Residents/representatives had the right to refuse the vaccination, and if refused, appropriate entries would be documented in the resident's medical record indicating the date of the refusal. - For residents who received the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination would be documented in the resident's medical record. B. Review of Resident 33's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/19/14 indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The MDS indicated the resident was cognitively intact related to short-term and long-term memory and memory recall, and had modified independence for daily decision making (some difficulty in new situations only). Review of a Pneumococcal Immunization Informed Consent form dated 9/12/11 revealed Resident 33 gave the facility permission to administer the vaccination. Review of electronic documentation of Immunizations dated 12/22/11 indicated Resident 33 refused administration of the pneumococcal vaccination. However, there was no signed consent by the resident indicating the vaccination had been refused, and there was no documentation to indicated the resident had been educated on the benefits of the vaccination to assure an informed decision. C. Review of Resident 37's MDS dated [DATE] indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The MDS indicated the resident's Brief Interview for Mental Status (BIMS-a brief screen that aids in detecting cognitive impairment) score was 6 (a score of 0-7 indicates the resident has severe cognitive impairment). Review of a Pneumococcal Immunization Informed Consent form dated 8/16/12 indicated the resident's authorized representative gave permission for the facility to administer the vaccination to Resident 37. There was no documentation to indicate Resident 37 received the pneumococcal vaccine injection. During interview on 5/12/14 at 9:15 AM, the Director of Nursing (DON) verified there was no written documentation to indicate Resident 37 received the pneumococcal vaccination as authorized by the legal representative. The DON further verified there was no signed consent by Resident 33 for refusal of the pneumococcal vaccination, and no documentation that education had been provided related to the benefits of the vaccination. | 2018-01-01 |
| 7762 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2014-05-12 | 371 | F | 0 | 1 | 7XFG11 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.11E Based on observations, staff interview and record review; the facility failed to ensure staff washed hands and changed gloves at appropriate intervals during the meal service to prevent the potential contamination of food. Facility census was 37. Findings are: A. Review of facility Policy entitled Glove Use in Dietary Department (revision date of 5/12) revealed employees should wash hands thoroughly before and after wearing or changing gloves, change disposable gloves between tasks and not wear them continuously, and not use food contact gloves for nonfood tasks. B. During observations of the noon meal on 5/7/14 from 11:40 AM to 11:58 AM Dietary Cook (DC)-M picked up buttered bread, sandwich slices and unpackaged crackers with gloved hands. During the meal service, DC-M touched various kitchen surfaces including the residents' dietary cards, dishes, utensils and the refrigerator door handle, and without changing gloves or washing hands returned to handling the bread, sandwiches and crackers. From 11:59 AM to 12:09 PM, without changing gloves or washing hands, DC-M used a hand mixer to liquefy food items in coffee cups, took the temperature of the food items, and documented the temperatures on a food temperature log. DC-M returned to serving bread slices, sandwiches and crackers without first changing gloves or washing hands. C. 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 discarded when interruption occurs in the operation. -hand washing shall be completed before donning gloves for working with food. D. During an interview on 5/8/14 from 9:30 AM to 9:45 AM, the Dietary Manager confirmed DC-M should have washed hands and changed gloves before directly handling food items and when changing tasks during the meal service. | 2018-01-01 |
| 7763 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2014-05-12 | 412 | D | 0 | 1 | 7XFG11 | LICENSURE REFERNCE NUMBER NAC 12-006.14 Based on observations, record review and staff interview; the facility failed to provide dental services as needed for Resident 12. Facility census was 37. Findings are: A. Review of Resident 12's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/30/13 revealed the resident had obvious broken teeth. Review of Resident 12's Admission Record, dated 7/28/06, revealed that the resident's Power of Attorney (POA-someone who is either appointed or chosen to provide assistance in executing another individual's health decisions) wished for the resident to receive routine dental check-ups. Review of Resident 12's current Care Plan, initiated 12/11/12 and reviewed 4/22/14, revealed the resident had chipped and broken teeth and staff were to coordinate arrangements for dental care as needed and/or ordered. Observations of Resident 12 on 5/6/14 at 9:21 AM revealed the resident had missing teeth on both the upper and lower front jaw. During an interview with the MDS coordinator on 5/8/14 at 9:40 AM, it was revealed the MDS coordinator had tried several times to contact the POA regarding Resident 12's broken/missing teeth and need to see a dentist with no response. It was also revealed a letter had been sent to the POA asking for a decision on how to handle Resident 12's dental status with no response. Furthermore, the MDS coordinator was not able to verify when Resident 12 had last received dental care. | 2018-01-01 |
| 9295 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2013-03-28 | 323 | E | 0 | 1 | UVQR11 | Licensure Reference Number: 175 NAC 12-006.184 Based on observations, record reviews, and staff interviews; the facility failed to secure potentially hazardous chemicals which had the potential of access for 13 (Residents 51, 5, 22, 13, 20, 28, 52, 26, 23, 12, 1, 67, and 68) out of 46 sampled residents identified as mobile, cognitively impaired and at risk for wandering. The facility had a total census of 46. Findings are: A. Observations during the initial facility tour conducted on 3/19/13 at 10:10 AM to 10:40 AM revealed an unlocked storage room labeled Oxygen Storage. Observation of the unlocked storage area revealed 2 unsecured cupboards containing 3 bottles of HBV Quat Disinfectant Cleaner, 1 bottle of Stain Blaster A Cleaner and a gallon container of Clorox Bleach. Observations of the Oxygen Storage room revealed the following: -On 3/20/13 at 9:35 AM, 12:55 PM and 2:45 PM the storage room was unlocked. Unsecured cupboards in the room contained 3 bottles of HBV Quat Disinfectant Cleaner, 1 bottle of Stain Blaster A Cleaner and a gallon container of Clorox Bleach. -On 3/21/13 at 7:44 AM the storage room was unsecured with 3 bottles of HBV Quat Disinfectant Cleaner, 1 bottle of Stain Blaster A Cleaner and a gallon bottle of Clorox Bleach stored in unlocked cupboards. During an interview on 3/21/13 from 8:05 AM to 5:20 AM, the Administrator confirmed the Oxygen Storage room was to be locked at all times and potentially hazardous chemicals should not have been left unsecured. B. Observations of the facility house-keeping cart revealed the following: -On 3/20/13 from 8:00 AM to 8:12 AM the housekeeping cart was observed unsupervised in the 300 wing corridor. The bottom shelf of the cart contained an aerosol container of Ocean Breeze Scent Air Freshener, one bottle of Stain Blaster A, one bottle of Humidifier Bacteriostatic Treatment and one bottle containing HBV Quat Disinfectant Cleaner. -On 3/21/13 from 7:39 AM to 7:54 AM and from 10:50 AM to 11:00 AM, the housekeeping cart was observed unsupervised in the 100 wing corridor. The bottom shelf of the cart contained an aerosol container of Ocean Breeze Scent Air Freshener, a bottle of Stain Blaster A, one bottle of Humidifier Bacteriostatic Treatment and a bottle of HBV Quat Disinfectant Cleaner. An interview with the Head Housekeeper on 3/21/13 from 11:05 AM to 11:10 AM revealed housekeeping staff were trained to keep the cart with them at all times and the carts were never to be left unattended in the hallways. During an interview on 3/21/13 from 11:10 AM to 11:20 AM, the Administrator verified housekeepers should not have left chemicals unsecured on their carts. Observations on 3/27/13 from 7:45 AM to 8:00 AM revealed the housekeeping cart unsupervised in the 300 wing corridor. The bottom shelf of the cart contained a bottle of Stain Blaster A, a bottle of Humidifier Bacteriostatic Treatment and a bottle of HBV Quat Disinfectant. During an interview on 3/27/13 at 9:00 AM, the Director of Nursing (DON) verified housekeepers should not have left chemicals unsecured on their carts. In addition, the DON identified Residents 51, 5, 22, 13, 20, 28, 67, 68, 52, 26, 23, 1 and 12 as mobile, cognitively impaired and at risk for wandering. C. Review of Medical Safety Data Sheets (MSDS) dated 6/4/1999 revealed the following; -HBV Quat Disinfection Cleaner; this product may cause upper respiratory tract, eye and skin irritation. If this product is swallowed it can lead to pain, vomiting, abdominal tenderness, and nausea, blood in vomitus and blood in feces. -Stain Blaster A; this product may cause respiratory tract, eye and skin irritation. In addition this product may cause an allergic skin reaction and asthmatic like reactions in sensitive individuals. -Clorox Bleach; this product is corrosive and harmful if swallowed. This product can cause severe irritation or damage to eyes, skin and mucous membranes. | 2016-09-01 |
| 9296 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2013-03-28 | 329 | E | 0 | 1 | UVQR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on record review and staff interview; the facility failed to assure 3 residents (Residents 2, 3 and 24) were free from the use of unnecessary drugs. Psychoactive medications (medications that act primarily on the central nervous system to alter brain function, resulting in temporary changes in perception, mood and behavior) were used without adequate indication for use and /or documentation to support dosages used above daily recommendations. In addition, gradual dose reductions (GDR) were not attempted and there was no documentation to indicate why GDR were clinically contraindicated. Sample size was 33 and facility census was 46. Findings are: A. A review of Resident 2's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/9/13 revealed [DIAGNOSES REDACTED]. The MDS further indicated Resident 2 exhibited no behaviors. Review of Physician Admission/Monthly Orders dated 7/30/12 indicated an order for [REDACTED]. Review of Behavior Summary reports from 12/1/12 through 3/26/13 revealed the resident displayed no adverse behaviors. Review of the Chronological Record of Medication Regimen Review for Resident 2 revealed on 1/9/13 the Consultant Pharmacist recommended a GDR of the [MEDICATION NAME]. There was no documentation in the medical record to indicate a GDR of [MEDICATION NAME] had been attempted. There was no documentation to indicate why a GDR was clinically contraindicated. During an interview on 3/27/13 from 9:20 AM to 9:35 AM, Nursing Assistant (NA)-M verified adverse behaviors were not exhibited by Resident 2. During an interview on 3/27/13 from 10:00 AM to 10:11 AM the Director of Nursing (DON) confirmed the Consultant Pharmacist had recommended a GDR of the [MEDICATION NAME] for Resident 2 and no GDR had been attempted. Furthermore the DON verified adverse behaviors were not exhibited by Resident 2. B. Review of Resident 3's MDS dated [DATE] revealed the resident was admitted to the facility on [DATE] with diagnoses of hypertension, diabetes mellitus, [MEDICAL CONDITIONS], dementia, [MEDICAL CONDITION] and depression. The same MDS indicated the resident rejected cares on 1 to 3 days during the 7 day assessment period, and that no other behaviors were exhibited by the resident. physician's orders [REDACTED]. Review of a Medication Review form dated 5/7/09 revealed a request for a GDR of Resident 3's [MEDICATION NAME] 0.25mg daily. Documentation indicated No reduction attempted since admission. and nursing staff comments revealed No behavioral problems noted by nursing at this time. The physician declined the GDR. There was no documentation to indicate why a GDR was clinically contraindicated. Review of a Medication Review form dated 9/16/09 revealed a request for a GDR of Resident 3's [MEDICATION NAME] 0.25mg daily. Nursing staff comments revealed Yearly documentation or reduction attempt is needed .No problems noted at this time by staff. The physician declined the GDR and indicated a previous dose reduction had failed, the current doseage was required to maintain baseline functions, and a further dose reduction was clinically contraindicated. However, there was no evidence to indicate a GDR had been attempted. Review of a Medication Review form dated 8/9/10 revealed the physician agreed to discontinue a prn (as needed) order for [MEDICATION NAME] 0.25mg as requested by the Consultant Pharmacist as the prn [MEDICATION NAME] had not been used in greater than 3 months. However, the physician declined a GDR of the resident's routine dose of [MEDICATION NAME] 0.25mg daily, indicating a previous dose reduction had failed, the current doseage was required to maintain baseline functions, and a further dose reduction was clinically contraindicated. However, there was no evidence to indicate a GDR had been attempted. Review of a Medication Review form dated 7/8/11 revealed a request for a GDR of Resident 3's [MEDICATION NAME] 0.25mg daily. The physician declined the GDR and indicated a previous dose reduction had failed, the current doseage was required to maintain baseline functions, and a further dose reduction was clinically contraindicated. However, there was no evidence to indicate a GDR had been attempted. Review of a Medication Review form dated 6/8/12 addressed Resident 3's orders for [MEDICATION NAME] (an anxiety relieving medication) 0.5mg daily and BID (twice daily) prn, [MEDICATION NAME] 0.25mg daily, and [MEDICATION NAME] (an antidepressant medication) 25mg daily. The Consultant Pharmacist requested the physician consider a trial discontinuation of 1 of these medications as no behavior problems noted in quite sometime. Although the physician discontinued the routine dose of [MEDICATION NAME], no other changes were made, and Resident 3 continued to receive [MEDICATION NAME] 0.25mg daily. Review of Progress Notes dated 11/1/12 through 3/27/13 revealed 2 instances of documentation related to Resident 3's behaviors: 11/5/12 - staff attempting to feed Resident 3 and the resident indicated didn't want any of that (expletive). 3/4/13 at 1:11 PM - resident more difficult to feed at breakfast and dinner as constantly talking about dog and sister. Review of the Behavior Summary Reports dated 2/1/13 through 3/26/13 revealed Resident 3 rejected cares 3 times on the day shift and 2 times on the evening shift, and had yelling/screaming behaviors 2 times on the day shift. There was no documentation to indicate any other behaviors were demonstrated. During interview on 3/27/13 at 2:30 PM the Director of Nursing (DON) verified a GDR of [MEDICATION NAME] was never attempted for Resident 3. C. Review of Resident 24's MDS dated [DATE] revealed diagnoses of dementia, anxiety disorder and depression. The MDS indicated the resident had hallucinations and delusions. Review of Resident 24's MDS dated [DATE] also revealed the resident had hallucinations and delusions. The same MDS further indicated the resident displayed adverse physical and verbal behaviors and rejected care 1 to 3 days per week. Review of a facsimile (fax) dated 6/15/12 revealed Resident 24's physician was notified regarding the resident's increased behaviors of yelling, fear of fire and restlessness. The fax indicated the resident's [MEDICATION NAME] had been discontinued on 6/1/12. The physician gave orders to restart .5 mg of [MEDICATION NAME] 2 times daily. Review of a fax dated 7/9/12 indicated Resident 24's behaviors of yelling and being disruptive were increasing. The physician gave orders to start [MEDICATION NAME] (another type of medication used to treat psychotic symptoms) 50 mg twice daily (and in addition to the previously ordered dose of [MEDICATION NAME]). Review of a Nursing Home Progress Note by the physician on 8/7/12 at 1:00 PM revealed the resident was having severe dementia issues with hallucinations. The physician increased Resident 24's [MEDICATION NAME] to 2 mg twice daily which was 4 times the previous daily dose. The physician also increased the [MEDICATION NAME] to 100 mg 3 times daily which was 3 times the previous dose. (According to Transmittal 274 Appendix PP-Guidance to Surveyors, the recommended daily dose threshold for [MEDICATION NAME] should not exceed 150 mg daily. Resident 24's [MEDICATION NAME] dose was 2 times above the recommended dosage.) Review of Resident 24's MAR indicated [REDACTED]. There was no documentation in the medical record to indicate a GDR of [MEDICATION NAME] or [MEDICATION NAME] had been attempted. There was no documentation to indicate why a GDR was clinically contraindicated or why Resident 24 continued to receive [MEDICATION NAME] above the recommended dosage. The DON confirmed during interview on 3/27/13 from 1:05 PM until 1:10 PM that Resident 24's physician had not ordered a GDR of [MEDICATION NAME] and [MEDICATION NAME] since the dosages were increased on 8/7/12. | 2016-09-01 |
| 9297 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2013-03-28 | 428 | D | 0 | 1 | UVQR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.12B5 Based on record review and staff interview; the Consultant Registered Pharmacist (RP) failed to identify and/or report a potential drug irregularity related to duplicate drug therapy for Resident 24 who was receiving Risperdal (a medication used to treat psychotic symptoms by changing the actions of chemicals in the brain) and Seroquel (another type of medication used to treat psychotic symptoms). In addition, the RP failed to identify Resident 24's Seroquel was above the daily recommended dose. Total sample size was 33 and facility census was 46. Findings are: Review of Resident 24's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/3/12 revealed [DIAGNOSES REDACTED]. The MDS indicated the resident had hallucinations and delusions. Review of Resident 24's MDS dated [DATE] also revealed the resident had hallucinations and delusions. The same MDS further indicated the resident displayed adverse physical and verbal behaviors and rejected care 1 to 3 days per week. Review of a Nursing Home Progress Note dated 8/7/12 revealed Resident 24's physician ordered Risperdal 2 milligrams (mg) twice daily and Seroquel 100 mg 3 times daily. (According to Transmittal 274 Appendix PP-Guidance to Surveyors, the recommended daily dose threshold for Seroquel should not exceed 150 mg daily. Resident 24's Seroquel dose was 2 times above the recommended dosage). Review of the Chronological Record of Medication Regimen Review dated 8/10/12 through 3/9/13 revealed the RP failed to identify the concurrent use of Risperdal and Seroquel. The RP did not identify the Seroquel dose was above daily recommendations. Review of Resident 24's Medication Administration Record [REDACTED]. During interview on 3/27/13 from 1:05 PM until 1:10 PM, the Director of Nursing indicted the RP was aware Resident 24 was receiving Risperdal but the RP was not aware the resident was also receiving Seroquel. | 2016-09-01 |
| 9298 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2013-03-28 | 431 | E | 0 | 1 | UVQR11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.121 Based on observations, staff interviews and record review; the facility failed to assure medications were stored and secured at all times in accordance with facility policy and to prevent access from unauthorized persons. Observations revealed unlocked medication carts were not under direct observation of the persons administering the medications and medications were left unsecured during the medication pass. This had the potential to affect 13 residents (Resident 15, 1, 12, 23, 26, 52, 68, 67, 28, 20, 13, 22 and 5) identified as mobile, cognitively impaired and at risk for wandering. Facility census was 46. Findings are: A. Review of the facility policy for Storage of Medications (revised 4/07) included the following; Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biological shall be locked when not in use and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. B. During observations on 3/25/13 from 11:35 AM to 11:48 AM, Registered Nurse (RN) - F and Licensed Practical Nurse (LPN) - E parked 2 medication carts in the dining room by the entrance of the chapel area as residents and staff were entering and exiting the room for the breakfast meal. RN-F and LPN-E left the medication carts unlocked, unattended and not under direct supervision as they crossed the dining room to administer medications to residents. C. On 3/26/13 from 7:56 AM to 8:15 AM, RN-N parked a medication cart in the dining room by the entrance of the chapel area as staff and residents were entering and exiting the area for the breakfast meal. The medication cart was unlocked and a drawer containing numerous medication cassettes was stored on the top of the medication cart. RN-N left the medication cart and medication cassettes unlocked, unattended and not in direct supervision while administering medications to the residents in the dining room. D. Interview with RN-N on 3/26/13 at 9:00 AM revealed usual practice was to leave the medication cart unlocked when staff were passing medications in the dining room. E. On 3/26/13 from 11:57 AM until 12:07 PM, Medication Assistant (MA) I parked a medication cart in the dining room by the entrance of the chapel as staff and residents were entering and exiting the area for the noon meal. MA-I placed a box containing Resident 5's medication cassettes on top of the medication cart. The medication cart was unlocked. MA-I proceeded to walk across the dining room to the kitchen door which left the medication cart and Resident 5's medication box unattended and not under direct supervision. (Surveyor ) F. During an interview on 3/27/13 from 9:00 AM to 9:15 AM, the Director of Nursing confirmed staff should have followed facility policy regarding medication storage. In addition, the following residents were identified as cognitively impaired, mobile and at risk for wandering; Residents 51, 5, 22, 13, 20, 28, 67, 68, 52, 26, 23, 12 and 1. | 2016-09-01 |
| 9299 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | 706 JAMES STREET | VERDIGRE | NE | 68783 | 2013-03-28 | 441 | E | 0 | 1 | UVQR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.17 Based on observations, record review and staff interviews; the facility failed to practice infection control techniques to prevent cross contamination and the spread of infection during the provision of cares for Residents 3, 66, 10, and 48; indwelling urinary catheter cares for Residents 66 and 33; and wound care for Residents 5 and 47. Blood glucose monitoring meters (machines used to determine a resident's blood sugar level from a small sample of the resident's blood) were not cleaned in accordance with facility policy, providing a source of cross contamination which had the potential to affect 13 residents (Residents 63, 53, 8, 21, 40, 47, 6, 68, 33, 34, 31, 18 and 55) identified as routinely using the meters. In addition the mechanical sit-to-stand lift was not routinely sanitized between resident uses, which had the potential to affect 15 residents (Residents 2, 10, 23, 27, 7, 29, 25, 48, 40, 1, 18, 20, 3, 32, and 39) who were identified as using the mechanical sit-to-stand lift on a routine basis. Facility census was 46 and sample size was 33. Findings are: A. Review of the facility policy titled Hand-washing/Hand Hygiene dated 11/13/12 indicated employees must wash their hands before and after direct contact with residents; before and after performing any invasive procedure such as finger-stick blood sampling; before and after assisting a resident with personal care; after coming in contact with a resident's intact skin; before and after assisting a resident with toileting; after contact with a resident's mucous membranes and body fluids or excretions; after handling soiled or used linens, dressings, bedpans, catheters and urinals; after handling soiled equipment or utensils; and after removing gloves. The policy further indicated hand hygiene is always the final step after removing and disposing of personal protective equipment and the use of gloves does not replace hand-washing/hand hygiene. B. Review of facility Infection Control Policies and Procedures with a revision date of 3/2000 indicated cleaning, disinfecting or sterilizing resident care equipment was required between resident uses C. During an observation on 3/25/13 from 10:29 AM to 10:41 AM of the pressure ulcer treatment to Resident 5's left foot, Registered Nurse (RN)-N entered the room, washed hands and donned gloves. RN-N removed the soiled dressings from Resident 5's left foot and then removed soiled gloves. Without washing or sanitizing hands, RN-N donned clean gloves and opened a 2 x 2 centimeter (cm) [MEDICATION NAME] square and then applied the square of [MEDICATION NAME] directly to the surface of wounds on the top of each toe on the left foot and to blackened areas between each toe. Without removing gloves RN-N then opened a second [MEDICATION NAME] 2 x 2 cm square and used the square to apply [MEDICATION NAME] to wound bed on the top of the left foot and then to the wound bed on the left side of the foot extending from the little toe to the mid foot. Without removing gloves, RN-N opened a third 2 x 2 cm [MEDICATION NAME] square and used the square to directly apply [MEDICATION NAME] to Resident 5's left heel. RN-N proceeded to remove soiled gloves but without washing or sanitizing hands donned clean gloves. RN-N applied 4 x 4 cm dressings to the wounds on Resident 5's left foot then wrapped the foot in a gauze wrap before removing gloves and washing hands in the resident's bathroom. During an interview from 3/25/13 from 10:42 AM to 10:46 AM, RN-N confirmed hands were not washed or sanitized with removal of gloves and that facility policy was not followed. D. During observations of indwelling urinary catheter care for Resident 66 on 3/25/13 from 1:18 PM to 1:32 PM, Nursing Assistant (NA)-C provided the resident's catheter cares then removed a disposable incontinence brief which was soiled with feces. Without removing soiled gloves, NA-C applied a clean disposable incontinent brief to the resident, adjusted the resident's clothing, repositioned the resident in bed and picked up the water glass on Resident 66's bedside table to offer the resident a drink of water. NA-C then removed soiled gloves but without washing or sanitizing hands, donned a clean pair of gloves and drained the urine from the indwelling urinary catheter drainage bag into a urinal. Without removing soiled gloves, NA-C exited the resident's door and walked to the soiled utility room across the hall and emptied and cleansed the urinal. Without removing gloves, NA-C re-entered the resident's room and placed the urinal in the resident's bathroom before removing soiled gloves and washing hands. E. During an observation of pressure ulcer treatment for [REDACTED]. Without washing or sanitizing hands, LPN-O donned clean gloves and cleansed wound bed with wound cleanser and normal saline then removed soiled gloves. Without washing or sanitizing hands, LPN-O donned clean gloves and used an applicator to apply [MEDICATION NAME] (topical medication used to help prevent and treat wound infections) to the wound bed on the resident ' s right great toe and then removed soiled gloves. Without washing or sanitizing hands, LPN-O donned clean gloves and applied a dressing to the wound before removing gloves and washing hands in the resident's bathroom. During interview on 3/27/13 from 11:15 AM to 11:20 AM, LPN-O verified hand hygiene had not been performed between glove changes during wound care for Resident 47. LPN-O further indicated hands were not washed routinely between glove changes unless hands were visibly soiled. F. During observation of incontinent care for Resident 10 on 3/25/13 from 11:00 AM until 11:12 AM, NA-B and NA-A assisted the resident to stand using the mechanical sit-to-stand lift. The resident's incontinent brief was wet with urine. With gloved hands, NA-B assisted Resident 10 to use the urinal. NA-B then provided the resident's perineal hygiene, and without removing the soiled gloves, pulled up Resident 10's clean incontinent brief and pants, and lowered the resident into the wheelchair. NA-B offered the resident a drink of water. Without removing the soiled gloves or washing hands, NA-B picked up the resident's mug of water, then set it down and removed soiled gloves. Without washing hands, NA-B picked up the mug of water again and handed it to the resident to drink, then went into the bathroom to wash hands at the sink. G. During observation of incontinent care on 3/25/13 from 11:12 AM until 11:23 AM, NA-C and NA-D assisted Resident 48 to ambulate to the toilet. The resident's incontinent brief was dry and the resident voided on the toilet. With gloved hands, NA-C provided Resident 48's perineal hygiene, then removed the soiled gloves. Without washing hands, NA-C pulled up Resident 48's incontinent brief and pants, adjusted the resident's shirt, flushed the toilet, assisted the resident to turn to the sink to wash (resident's) hands, removed a towel from the towel bar and handed it to the resident to dry hands, assisted the resident out of the bathroom and into the hallway to ambulate toward the dining room. In the sitting area outside the dining room, NA-C assisted Resident 48 to sit in a chair to await the noon meal. NA-C then approached a visitor in the hallway and placed hand on the visitor's upper arm while speaking to the visitor, took a walkie-talkie out of uniform pocket and spoke into it, ambulated back down the hallway toward Resident 48's room, and then used hand sanitizer to clean hands. H. During observation of incontinent care on 3/26/13 from 9:15 AM until 9:30 AM, NA-K and NA-J assisted Resident 3 to the toilet using the mechanical sit-to-stand lift. Resident 3's incontinent brief was wet with urine. NA-K changed the resident's soiled incontinent brief, provided perineal hygiene, pulled up the clean incontinent brief and pants, then removed the soiled gloves. Without washing hands, NA-K maneuvered the mechanical sit-to-stand lift and lift controls during transfer of the resident to wheelchair, removed the lift sling from the resident and hung it on the bathroom door, colected the garbage, then washed hands at the sink in the bathrom. NA-K pushed the sit-to-stand lift out of the resident's room and parked it in the hallway outside the utility room. Without disinfecting the sit-to-stand lift, NA-J wheeled the lift into Resident room [ROOM NUMBER] for use on another resident. During interview on 3/26/13 at 9:30 AM, NA-K verified hands were to be washed immediately after removal of soiled gloves. I. During observation of catheter cares on 3/26/13 from 11:02 AM until 11:15 AM, RN-N disconnected Resident 33's suprapubic catheter (an indwelling urinary catheter that is placed directly into the bladder through an opening in the lower abdomen), performed a flush of the catheter using antibiotic solution, reconnected the suprapubic catheter, and secured the catheter tubing to the resident's leg strap. Without removing gloves, RN-N opened the top drawer of the treatment cart and retrieved supplies, then exposed Resident 33's suprapubic catheter site and cleaned the skin surrounding the site with an alcohol wipe. This provided potential for cross contamination. RN-N then removed gloves and washed hands at the bahroom sink. J. During observation of blood glucose monitoring (a blood test conducted to determine a resident's blood sugar level using blood obtained through a finger stick) for Resident 33 on 3/26/13 from 11:15 AM until 11:25 AM, RN-N donned gloves and removed supplies from the top drawer of the treatment cart. RN-N placed the blood glucose monitoring meter directly on top of Resident 33's bed sheets during the procedure. RN-N viewed the screen on the blood glucose monitoring meter and commented that something was wrong with the meter and the test would have to be performed using a different blood glucose monitoring meter. RN-N placed the used blood glucose monitoring meter directly on top of the treatment cart and, without removing gloves and/or washing hands, retrieved a second meter from the top drawer of the treatment cart and repeated the test on Resident 33. RN-N returned to the treatment cart, picked up the first blood glucose monitoring meter from the top surface of the treatment cart and placed it on the keyboard of the computer that was stored on top of the treatment cart, stating that one will have to be fixed. RN-N returned the second blood glucose monitoring meter to the top drawer of the treatment cart. Neither of the 2 blood glucose monitoring meters or the top of the treatment cart were cleaned, and the treatment cart was pushed out of the resident's room and into the hallway. During interview on 3/26/13 at 11:25 AM, RN-N indicated blood glucose monitoring meters were cleaned according to the cleaning schedule on the night shift. RN-N verified there were 2 meters stored in the treatment cart and they were used to perform blood glucose testing on all residents in the facility with physician orders for blood glucose testing. K. Review of facility policy titled Cleaning Blood Glucose Monitoring Meters (accucheck machines) with a revision date of 8/27/2010 indicated the outside of the meter was to be cleaned with a disinfectant cloth after each use. The policy further indicated 2 accucheck machines would be available to allow 5 minutes disinfection time between each use. | 2016-09-01 |
| 11027 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | PO BOX 130, 706 JAMES STREET | VERDIGRE | NE | 68783 | 2011-12-19 | 280 | D | 0 | 1 | ULX411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on record reviews and staff interview; the facility failed to revise Comprehensive Care Plans (CCP) following Resident 26 and 49 ' s falls. Facility census was 42. Findings are: Review of Resident 49 ' s MDS dated [DATE] indicated [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated the resident ' s cognition was intact and extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene was required. Review of Resident 49 ' s current Care Plan revealed the resident was at risk for falls. Interventions included the following: Be sure the oxygen tubing is out of way prior to ambulating, needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night, personal items within reach, use of chair/bed electronic silent alarms (A silent alarm is a device which consists of a pad placed beneath the resident which triggers an alarm if the resident should attempt to rise. The alarm is not audible in the resident ' s room but does sound on a pager which is carried by staff members and alerts the staff member that the resident is attempting to get up without assistance), anticipate and meet the resident ' s needs, be sure the call light is within reach, encourage the resident to use the call light and prompt response to all requests for assistance. Review of Nurse ' s Notes dated 11/20/11 at 1:10 PM revealed the following documentation: staff enter rm (room) to answer light & (and) resident is seated in easy chair & tells staff (resident) fell in bathroom . Documentation further indicated the resident got a little dizzy , sat down faster than expected and the resident ' s back bumped into the toilet tank. The resident stated I couldn ' t ' t wait for staff to get there. Review of a Report of Incident/Accident form dated 11/20/11 revealed Resident 49 reported falling against the toilet tank in the bathroom and .staff did not note that silent alarm pager sounded. Documentation indicated no call was recorded on the pagers. Review of a Resident Falls Follow Up Investigation form dated 11/20/11 indicated the silent alarm was in use at the time of the fall and the alarm Had been working all day-however (no) staff heard if did sound and Resident said used call light but did not come up on pagers-did show up on screen @ (at) about stated time . There was no documentation in the medical record to indicate further investigation was completed regarding failure of the silent alarm and call light to sound on the pagers. There was no further assessment to determine causal factors and additional interventions were not developed in an attempt to prevent further falls. The Director of Nurses indicated during interview on 12/15/11 from 2:00 PM until 2:20 PM that Resident 49 ' s CCP was not revised following the fall on 11/20/11. B. Review of the [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/11/11 indicated Resident 26 had severely impaired cognition, required extensive 2 person physical assistance with transfers, and had 1 fall with injury since the previous assessment. Review of the Comprehensive Care Plan (CCP) with a review date of 5/23/11 indicated Resident 26 was at risk for falls due to decreased cognition, unsteady gait, incontinence, a history of falls, and extensive medication use that included antipsychotic and antidepressant medications. Nursing interventions included to assure the resident ' s call light and frequently used objects were within reach; use of non-skid foot wear; reminders to the resident to call when needing assistance; extensive assistance with toileting; assistance of 1 to 2 with transfers; if transferring poorly, use stand-up lift (a mechanical lift used to transfer residents in a standing position); chair and wheelchair alarms (alarm devices attached to the resident ' s chair/wheelchair that sound an alarm to alert staff when the resident attempts to leave the chair/wheelchair unattended) in place and functional; and bathroom door alarm (an alarm attached to the bathroom door that sounds an alarm to alert staff when the bathroom door is opened). Review of Nurse ' s Notes dated 6/5/11 at 6:40 PM indicated Resident 26 ' s bathroom door alarm sounded. When staff answered the alarm, the resident was found on the floor in the bathroom and the resident ' s wheelchair was just outside the bathroom door. There was no documentation to indicate the CCP was revised to include additional nursing interventions to prevent further falls. Review of Nurse ' s Notes dated 6/30/11 at 7:45 AM indicated a Nursing Assistant (NA) reported Resident 26 was turning around in the bathroom and attempting to sit in the wheelchair when the resident ' s knees gave out and the resident went down on (resident ' s) knees in front of the wheelchair. There was no documentation to indicate the CCP was revised to include additional nursing interventions to prevent further falls. Review of Nurse ' s Notes dated 9/24/11 at 5:00 PM indicated staff responded when Resident 26 ' s chair alarm sounded. Staff found the resident seated on the floor in front of the wheelchair in resident ' s room. The same note indicated the wheelchair brakes were not locked, the resident was encouraged to call for assistance, the resident was Alert with usual confusion , the alarms were in place, and the call light was within reach. There was no documentation to indicate the CCP was revised to include additional nursing interventions to prevent further falls. Review of the MDS dated [DATE] indicated the resident had short-term and long-term memory problems and moderately impaired cognitive skills for daily decision making (decisions poor; cues/supervision required). The same MDS indicated the resident required extensive 2 person physical assistance with transfers, and that the resident had 1 fall without injury since the previous assessment. Review of Nurse ' s Notes dated 12/11/11 at 7:20 PM indicated a NA reported that while transferring Resident 26 from the wheelchair to the easy chair with the stand-up lift, the resident let knees go slack and raised right arm above head, causing the resident to slide out of sling . The NA attempted to complete the transfer to the chair but Resident 26 slid to the floor. Review of the Resident Fall Tracking Form dated 12/11 indicated Resident 26 had a fall on 12/11/11 in the resident ' s room and with use of the stand-up lift. The form further indicated staff were to encourage Resident 26 to help support self while standing during transfers with the mechanical lift, and that staff were to use the hoyer stand-up sling (a cloth sling-type device used to support the resident ' s back and buttocks as the resident stands in the stand-up lift) when the resident was weak. Review of the current CCP with a review date of 1/19/12 indicated the CCP was not revised and updated to include these additional interventions to prevent further falls during transfers with the stand-up lift. During interview on 12/15/11 from 2:00 PM through 2:20 PM, the Director of Nursing verified the CCP was not revised to include additional nursing interventions to prevent further falls. | 2015-09-01 |
| 11028 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | PO BOX 130, 706 JAMES STREET | VERDIGRE | NE | 68783 | 2011-12-19 | 323 | D | 0 | 1 | ULX411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b(3)(4) Based on record review and staff interview; the facility failed to initiate new interventions for the prevention of falls for Residents 26 and 49 who had a history of [REDACTED]. Findings are: A. Review of the [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/11/11 indicated Resident 26 had severely impaired cognition, required extensive 2 person physical assistance with transfers, and had 1 fall with injury since the previous assessment. Review of the Care Plan with a review date of 5/23/11 indicated Resident 26 was at risk for falls due to decreased cognition, unsteady gait, incontinence, a history of falls, and extensive medication use that included antipsychotic and antidepressant medications. Nursing interventions included to assure the resident ' s call light and frequently used objects were within reach; use of non-skid foot wear; reminders to the resident to call when needing assistance; extensive assistance with toileting; assistance of 1 to 2 with transfers; if transferring poorly, use stand-up lift (a mechanical lift used to transfer residents in a standing position); chair and wheelchair alarms (alarm devices attached to the resident ' s chair/wheelchair that sound an alarm to alert staff when the resident attempts to leave the chair/wheelchair unattended) in place and functional; and bathroom door alarm (an alarm attached to the bathroom door that sounds an alarm to alert staff when the bathroom door is opened). Review of Nurse ' s Notes dated 6/5/11 at 6:40 PM indicated Resident 26 ' s bathroom door alarm sounded. When staff answered the alarm, the resident was found on the floor in the bathroom and the resident ' s wheelchair was just outside the bathroom door. There was no documentation in the medical record to indicate causal factors leading to the fall were investigated, or that additional nursing interventions were initiated to prevent further falls. Review of Nurse ' s Notes dated 6/30/11 at 7:45 AM indicated a Nursing Assistant (NA) reported Resident 26 was turning around in the bathroom and attempting to sit in the wheelchair when the resident ' s knees gave out and the resident went down on (resident ' s) knees in front of the wheelchair. There was no documentation in the medical record to indicate causal factors leading to the fall were investigated, or that additional nursing interventions were initiated to prevent further falls. Review of Nurse ' s Notes dated 9/24/11 at 5:00 PM indicated staff responded when Resident 26 ' s chair alarm sounded. Staff found the resident seated on the floor in front of the wheelchair in resident ' s room. The same note indicated the wheelchair brakes were not locked, the resident was encouraged to call for assistance, the resident was Alert with usual confusion , the alarms were in place, and the call light was within reach. There was no documentation in the medical record to indicate causal factors leading to the fall were investigated, or that additional nursing interventions were initiated to prevent further falls. During interview on 12/15/11 from 2:00 PM through 2:20 PM, the Director of Nursing verified there were no additional nursing interventions initiated following these falls and to prevent further falls B. Review of Resident 49 ' s MDS dated [DATE] indicated [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated the resident ' s cognition was intact and extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene was required. Review of a Resident Fall Tracking form (no date or time indicated) revealed silent bed and chair alarms were implemented on 10/23/11 following Resident 49 ' s fall on 10/22/11 (A silent alarm is a device which consists of a pad placed beneath the resident which triggers an alarm if the resident should attempt to rise. The alarm is not audible in the resident ' s room but does sound on a pager which is carried by staff members and alerts the staff member that the resident is attempting to get up without assistance). The Resident Fall Tracking form further indicated Resident 49 was encouraged to call for assistance and reminded to use a walker when ambulating. Review of Resident 49 ' s current Care Plan revealed the resident was at risk for falls. Interventions included the following: Be sure the oxygen tubing is out of way prior to ambulating, needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night, personal items within reach, use of chair/bed electronic silent alarms, anticipate and meet the resident ' s needs, be sure the call light is within reach, encourage the resident to use the call light and prompt response to all requests for assistance. Review of Nurse ' s Notes dated 11/20/11 at 1:10 PM revealed the following documentation: staff enter rm (room) to answer light & (and) resident is seated in easy chair & tells staff (resident) fell in bathroom . Documentation further indicated the resident got a little dizzy , sat down faster than expected and the resident ' s back bumped into the toilet tank. The resident stated I couldn ' t ' t wait for staff to get there. Review of a Report of Incident/Accident form dated 11/20/11 revealed Resident 49 reported falling against the toilet tank in the bathroom and .staff did not note that silent alarm pager sounded. Documentation indicated no call was recorded on the pagers. Review of a Resident Falls Follow Up Investigation form dated 11/20/11 indicated the silent alarm was in use at the time of the fall and the alarm Had been working all day-however (no) staff heard if did sound and Resident said used call light but did not come up on pagers-did show up on screen @ (at) about stated time . There was no documentation in the medical record to indicate further investigation was completed regarding failure of the silent alarm and call light to sound on the pagers. There was no further assessment to determine causal factors and additional interventions were not developed in an attempt to prevent further falls. The Director of Nurses indicated during interview on 12/15/11 from 2:00 PM until 2:20 PM that the facility computer system did register activation of Resident 49 ' s call light on 11/20/11; however, the individual pagers did not register this. The DON further indicated the silent alarm system is not registered on the computer and was uncertain why staff members did not receive notification on their pagers that the silent alarms were activated. The DON indicated the alarms and call light have been functioning since that time. | 2015-09-01 |
| 11029 | ALPINE VILLAGE RETIREMENT CENTER | 285190 | PO BOX 130, 706 JAMES STREET | VERDIGRE | NE | 68783 | 2011-12-19 | 441 | E | 0 | 1 | ULX411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 D Based on observations, staff interviews and record review; the facility failed to utilize infection control techniques during the cleaning of Resident 49 ' s indwelling urinary catheter bag and for the cleaning of a mechanical lift following use on Resident 26. In addition, staff failed to remove gloves and/or wash hands when providing personal hygiene for Resident 42. Facility census was 42. Findings are: A. Review of the facility's policy for Hand washing (undated) and for Perineal Care dated 10/2011 revealed the staff should wash their hands for 20 seconds before applying gloves and after removing gloves. -Review of Resident 42's Minimum Data Sets (MDS, a federally mandated comprehensive assessment tool used for care planning) dated 10/26/11 identified [DIAGNOSES REDACTED]. The MDS reflected Resident 42 required limited assist with personal hygiene, bathing and toileting and extensive assist with dressing. The MDS also identified Resident 42 was occasionally incontinent of bladder. -Review of Resident 42's Care Plan dated 8/10/11 identified interventions for one staff to assist with toileting, transfers, and personal hygiene. -Nursing Assistant (NA)-B was observed providing cares for Resident 42 on 12/14/11 from 8:20 AM to 8:30 AM. NA-B assisted Resident 42 onto the toilet and donned gloves but did not wash hands prior to direct resident contact. After Resident 42 finished on the toilet, NA-B cleansed the resident ' s perineal area and buttocks with a pre-moistened cleansing cloth and applied a barrier cream to the resident ' s buttocks. NA-B did not remove soiled gloves and assisted the resident with adjusting incontinence brief and clothing. NA-B then removed soiled gloves but failed to wash hands. NA-B proceeded to position the resident in bed, removed the resident ' s glasses and positioned the resident ' s call light. NA-B removed the trash can liner from the bathroom trash and left the resident ' s room without washing hands. NA-B disposed of the trash in a soiled utility room in the hallway across from Resident 42 ' s room before using alcohol gel to cleanse hands. -During interview 12/19/11 from 1:30 PM to 1:38 PM, the Director of Nursing verified NA-B should have followed facility policy for Hand washing and Perineal cares. B. Review of the Cleaning and Disinfection of Resident-Care Items and Equipment Policy dated 8/10 indicated durable medical equipment must be cleaned and disinfected before reuse by another resident . During observation of nursing care on 12/14/11 from 2:10 PM until 2:30 PM, Licensed Practical Nurse (LPN)-A and NA-B transferred Resident 26 from the wheelchair to the toilet using the stand-up lift (a mechanical lift used to transfer residents in a standing position), then returned the resident to the wheelchair. LPN-A and NA-B failed to disinfect the handles of the stand-up lift, used by Resident 26 to support self during transfer, prior to and/or following use of the stand-up lift. . During observation of nursing care on 12/15/11 from 10:10 AM until 10:30 AM, LPN-I transferred Resident 26 from the wheelchair to the toilet using the stand-up lift, then returned the resident to the wheelchair. LPN-I failed to disinfect the handles of the stand-up lift, used by Resident 26 to support self during transfer, prior to and/or following use of the stand-up lift. During interview on 12/15/11 from 10:30 AM until 10:34 AM, LPN-I verified there were 5 other residents on the South wing of the facility that used the same stand-up lift as Resident 26. During interview on 12/19/11 from 1:15 PM until 1:35 PM, the Director of Nursing verified staff were expected to disinfect the handles of the stand-up lift in accordance with facility policy. C. Review of the Cleaning Catheter Drainage Bags policy/procedure updated/revised on 8/6/11 indicated staff members were to wash hands, apply gloves, place items to be cleaned in a blue basin, wash the catheter drainage bag with vinegar or soapy water solution, rinse with clear water, pat dry in clean towel, place in another clean towel, place in basin in stand (bedside stand) or drawer until it ' s to be used again. Review of the Handwashing Procedure (undated) revealed staff members should wash hands, dry hands with a paper towel and turn off the water using a paper towel to protect hands from contaminated faucets. During observation of care on 12/14/11 from 7:56 AM until 8:35 AM, NA-B put on a pair of gloves, disconnected Resident 44 ' s urinary catheter drainage bag and placed it in a plastic bag. NA-B removed the right hand glove and with the left gloved hand carried the plastic bag out of the room, down the hall and into the soiled utility room. NA-B removed the urinary catheter drainage bag from the plastic bag and hung the urinary catheter drainage bag on the spigot of the hopper (a fixture used to flush waste). The urinary catheter drainage bag was touching a toilet bowl mop (used for cleaning soiled commodes) which was also hanging on the spigot. NA-B removed the remaining glove from the left hand but did not wash hands and proceeded to take a bottle of vinegar out of the cupboard. NA-B filled a small squirt bottle with half vinegar and half water then proceeded to rinse the urinary catheter drainage bag with this solution. After emptying the solution from the urinary catheter drainage bag, NA-B washed hands but used bare hands to turn off the water faucet. NA-B then placed the urinary catheter drainage bag in a clean plastic bag, washed hands and turned off the water faucet with bare hands. NA-B then carried the plastic bag back to the resident ' s room and tied it onto the grab bar on the bathroom wall. NA-B did not wash hands, picked up bags of soiled linens and exited the room. | 2015-09-01 |
| 934 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-07-03 | 657 | E | 1 | 0 | 5XJ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on interview and record review, the facility staff failed to review and revise 3 residents' care plans after falls to prevent further falls and potential injury. This affected 3 of 4 residents whose care plans were reviewed during the survey process (Residents 1, 3, and 4). The facility identified a census of 22 at the time of survey. Findings are: [NAME] Review of Resident 1's quarterly MDS (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 6/11/2019 revealed an admission date of [DATE]. Resident 1 had no falls since prior assessment. Review of Resident 1's Fall reports revealed Resident 1 had falls documented on 3/2/2019 and 6/19/2019. Review of Resident 1's Care Plan dated 3/15/2018 revealed no documentation of interventions implemented to prevent further falls and injuries after Resident 1 fell on [DATE] and 6/19/2019. Interventions were added to the care plan on 6/25/2019, 6 days after Resident 1 fell on [DATE]. B. Review of Resident 3's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 3 required extensive assistance with transfers. Resident 3 had 1 fall with injury since the prior assessment. Review of Resident 3's Fall report revealed documentation Resident 3 had a fall on 3/1/2019. Review of Resident 3's Care Plan dated 12/7/2018 revealed no documentation of interventions implemented to prevent further falls and injuries after Resident 3 fell on [DATE]. C. Review of Resident 4's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 4 was rarely/never understood. Staff assessment for mental status revealed Resident 4 had short tern and long term memory problems and Resident 4 had moderately impaired cognitive skills for daily decision making. Resident 4 required limited assistance of 1 staff person for transfers. Resident had 2 falls with no injury since prior assessment. Review of Resident 4's Fall reports revealed documentation that Resident 4 had falls on 1/22/19, 2/13/19, 3/31/19, and 6/10/19. Review of Resident 4's Care Plan dated 2/16/2018 revealed no documentation of interventions implemented to prevent further falls and injuries after Resident 4 fell on [DATE], 2/13/19, 3/31/19, and 6/10/19. Interview with the MDS Coordinator on 7/3/2019 at 10:09 AM confirmed the fall interventions were not on the care plans and the care plans were not reviewed and revised. The MDS Coordinator revealed the care plans were supposed to be updated after falls and they were not. Interview with NA-B (Nurse Aide) on 7/3/2019 at 10:30 AM revealed they got the information they needed to care for the residents from the care plan. | 2020-09-01 |
| 935 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2017-08-22 | 371 | F | 0 | 1 | GG8P11 | Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview and record review; the facility failed to utilize a facial hair restraint to prevent the potential for hair contact with food and failed to change gloves during food preparation in a manner to prevent the potential for food borne illness. This had the potential to affect 32 residents that ate food prepared in the facility kitchen. The facility census was 32. Findings are: [NAME] Observation on 08/16/2017 between 11:00:40 AM and 11:10 AM during the initial tour of the kitchen revealed Dietary Aide (DA) A had a goatee beard and mustache with no facial hair restraint in place during food preparation of the lunch meal. B. Observation on 08/16/2017 at 12:01:37 PM revealed DA A served lunch with no facial hair restraint in place. C. Observation on 08/21/2017 at 10:31:12 revealed DA A was in the food preparation area of the facility kitchen with no facial hair restraint in place. D. Record review of the 7/1/07 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: - 2.402.1(A) Food employees shall wear hair restraints such as beard restraints that are designed and worn effectively to keep hair from contacting exposed food, clean equipment, utensils and linens. E. Observation on 8/21/17 between 11:00 AM and 11:15 AM during food preparation revealed Cook B removed a box of ground beef patties from the freezer. Cook B washed hands and donned gloves. [NAME] removed 2 frozen ground beef patties from a bag and placed them on a pan. Cook B placed the meat soiled bag on top of the plastic wrap container. It remained in that position for the entire observation. Cook B repeated the process of removing the individual ground beef patties and placed them on the pan until the pan was full. With meat soiled gloves, Cook B touched the oven door handle and opened the oven door, placed the pan in the oven and closed the oven door. Cook B removed the gloves and performed hand washing, donned new gloves and repeated the process. While wearing meat soiled gloves, Cook B opened the oven door, placed the pan of beef patties in the oven and closed the oven door. While wearing the same meat soiled gloves, Cook B closed the box of leftover meat patties, labeled it with a pen taken from her pocket, placed the pen back into the pocket, picked up the box and touched and opened the storage and freezer doors. Still wearing the meat soiled gloves, Cook B returned to the food preparation area and carried 2 single onions to the food preparation table. Cook B removed the soiled gloves and performed hand washing. F. Record review of the 7/1/07 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: - 3-304.15: Gloves shall only be used for one task such as working with raw animal food and discarded when soiled. [NAME] Interview on 08/22/2017 at 8:21:59 AM with the Dietary Manager (DM) confirmed that DA A should have worn a beard and mustache hair restraint. The DM confirmed that Cook B should have removed the gloves and performed hand washing after the meat product was touched and before other items were touched. The DM confirmed all residents that resided in the facility ate food that had been prepared in the facility kitchen. H. Record review of the facility Policy and Procedure for Nutritional Services dated 5/19/14 for kitchen sanitation practices included the following employee requirements: - Beard restraints must be worn to keep hair from contacting the food and food contact surfaces. - Hands should be washed after handling raw foods (before and after). - Gloves should be changed after touching a source of contamination and when soiled. | 2020-09-01 |
| 936 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2018-09-05 | 637 | D | 0 | 1 | Y9XX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B1(2) Based on observation, interview, and record review; the facility staff failed to complete a SCSA (Significant Change in Status Assessment) MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) when Resident 8 was admitted to Hospice (care designed to give supportive care to people in the final phase of a terminal illness). This affected 1 of 16 residents whose MDS assessments were reviewed during the survey process. The facility identified a census of 22 at the time of survey. Findings are: Review of Resident 8's Annual MDS dated [DATE] revealed Resident 8 was admitted to the facility on [DATE]. Resident 8 had a terminal prognosis and received Hospice care during the assessment period. Observation of Resident 8's room on 8/30/18 at 3:59 PM revealed a Hospice aide was sitting in the Resident 8's room. Interview with the unidentified Hospice aide at this time revealed they provided Resident 8 Hospice care twice a week. Interview with NA-A (Nurse Aide) on 9/04/18 at 1:34 PM revealed Resident 8 received Hospice services. Review of Resident 8's Hospice Certification and Plan of Care dated 9/18/2017 revealed a start of Care Date of 9/14/2017. Review of Resident 8's MDS assessments revealed the following assessments were completed: 6/15/2018 Annual 3/15/2018 Quarterly 12/18/2017 Quarterly 9/18/2017 Quarterly 6/15/2017 Annual There was no documentation a SCSA MDS was completed after Resident 8 was admitted to Hospice on 9/14/2017. Review of the Centers for Medicare and Medicaid RAI (Resident Assessment Instrument) 3.0 manual revealed the following: A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD (Assessment Reference Date) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving his/her highest practicable well-being at whatever stage of the disease process the resident is experiencing. Interview with the DON (Director of Nursing) who was also the MDS Coordinator on 9/04/18 at 1:14 PM confirmed the SCSA MDS was not completed after Resident 8 was admitted to Hospice. | 2020-09-01 |
| 937 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2018-09-05 | 641 | E | 0 | 1 | Y9XX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09b Based on interview and record review, the facility staff failed to code the MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) to reflect the PASRR (Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) requirement. This affected 3 of 3 sampled residents (Residents 10, 21, and 1). The facility identified a census of 22 at the time of survey. Findings are: [NAME] Review of Resident 10's annual MDS dated [DATE] revealed a response to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?in section A1500 PASRR was marked No. Resident 10 had an active [DIAGNOSES REDACTED]. Resident 10's admitted was 1/31/2011. Review of the Ascend Nebraska Level 1 PASRR Screening Instructions revised 11/25/2015 revealed the following: The federal definition for mental illness is designed to include individuals with a potential for and history of episodic changes in treatment and service needs. Federal guidelines include a three component definition that includes: [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Anxiety disorder may require further evaluation through PASRR depending upon their extent and severity. Review of Resident 10's [DIAGNOSES REDACTED]. Resident #21 B. Review of Resident 21's annual MDS dated [DATE] revealed a response to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?in section A1500 PASRR was marked No. Resident 21 had an active [DIAGNOSES REDACTED]. Resident 21's admitted was 9/14/2015. Review of the Ascend Nebraska Level 1 PASRR Screening Instructions revised 11/25/2015 revealed the following: The federal definition for mental illness is designed to include individuals with a potential for and history of episodic changes in treatment and service needs. Federal guidelines include a three component definition that includes: [DIAGNOSES REDACTED].These [DIAGNOSES REDACTED]. Review of Resident 10's [DIAGNOSES REDACTED]. Interview with the DON (Director of Nursing) on 9/04/18 at 1:15 PM confirmed the MDS assessments for Resident 10 and Resident 21 were not coded to reflect they had [DIAGNOSES REDACTED]. Findings are: C. Record review of Resident 1's comprehensive MDS dated [DATE] revealed Resident 1 had active [DIAGNOSES REDACTED].? in section A1500 PASRR was marked No. Interview on 09/05/18 at 09:33 AM with the DON (Director of Nursing) confirmed that Resident 1's MDS was not marked to reflect the [DIAGNOSES REDACTED]. | 2020-09-01 |
| 938 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2018-09-05 | 727 | F | 0 | 1 | Y9XX11 | Licensure Reference Number 175 NAC 12-006.04C1 Based on record review and interview, the facility failed to provide 8 hours of RN (Registered Nurse) coverage for every 24 hour period. This had the potential to affect all the residents at the facility. The facility census was 22. Findings are: Record review of the facility nursing staff schedule revealed that the nursing staff schedule did not reflect 8 hour RN coverage on the following dates: (MONTH) 5, (MONTH) 18, (MONTH) 25, (MONTH) 1 and (MONTH) 2. Interview (MONTH) 4th, (YEAR) at 11:30 AM with the DON (Director of Nursing) confirmed there was no RN coverage on those dates. | 2020-09-01 |
| 939 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2018-09-05 | 812 | F | 1 | 1 | Y9XX11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview, and record review; the facility staff failed to serve food in a manner to prevent potential cross contamination; failed to maintain cookware and dishes to prevent potential cross contamination; and failed to keep kitchen surfaces clean. This had the potential to affect all of the facility residents. The facility identified a census of 22 at the time of survey. Findings are: [NAME] Initial tour of the kitchen on 8/29/18 at 9:44 AM revealed the following: Mixing bowls, plate warmers and lids for room trays were stored on bottom shelves upright and uncovered. Plates were uncovered in the rack by the steam table. Refrigerator and freezer doors were visibly soiled with smears of white and brown material. A window air conditioner was blowing back behind the stove over the sink; the front cover had gray debris on it. B. Observation of evening meal service on 8/30/2018 at 5:30 PM revealed Cook-B wearing gloves. Cook-B grabbed the handles of 2 carts and wheeled them over to where the steam table was. At 5:37 PM Cook-B touched the buns for the riblet sandwiches with the same gloved hands that they had touched the cart handles with and the handles of the utensils. Cook-B did not change gloves. Cook-B then picked up trays off the bottom shelf of the food prep table and continued to serve. Cook-B also handled the diet cards. Cook-B then touched the ham sandwiches with the same gloved hands. At 5:42 PM Cook-B opened the cupboard door and got plastic cups out and put them on the condiment cart. Cook-B then grabbed more trays off the shelf. At 5:43 PM Cook-B put their fingers in the ramekins then put corn in them using the same gloved hands. Cook-B then served the corn to the residents. At 5:46 PM Cook-B got more trays off the shelf then continued to serve touching the buns with the same gloved hands and putting fingers in the ramekins. At 5:50 PM Cook-B got more trays and proceeded to touch the buns and put fingers inside the ramekins with the same gloved hands. At 5:56 PM Cook-B got more trays and proceeded to touch the buns and put fingers inside the ramekins. Cook-B did not change their gloves during the entire meal service. 16 residents received a riblet on a bun that Cook-B had touched with the soiled gloves. 5 residents received a ham sandwich that Cook-B had touched with the gloves. All of the residents received corn or creamed corn that was served in the ramekins. Interview with the FSS (Food Service Supervisor) on 8/30/2018 at 6:04 PM confirmed Cook-B should have used tongs to served the buns/sandwiches and should not have been touching the food with the gloves. The FSS revealed Cook-B should have changed their gloves and performed hand hygiene after touching the potentially contaminated surfaces (carts, cupboard doors, trays, diet cards). Review of the facility policy Hand Washing/Hand Hygiene revised (MONTH) 2014 revealed the following: The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of the facility policy Nutritional Services Hand Washing dated 5/19/2014 revealed the following: Hands should be washed after the following occurrences: touching un-sanitized equipment, work surfaces, or wash cloths. C. Tour of the kitchen with the FSS on 9/05/18 at 10:44 AM revealed the following: There was a tub of plastic pitcher lids on the bottom shelf of one of the prep tables. The inside of the tub was soiled with a brown substance as well as one of the lids on top. There was another tub on the bottom shelf also that was uncovered and full of plastic pitcher lids. The rack with plates, bowls, ramekins, and pans with all stored upright was uncovered. Large plates were stored upright in a plate holder by the steam table and not covered. The room tray plate holder bottoms and lids were stored upright on the bottom shelf of one of the prep tables and the mixing bowls were stored upright on the bottom shelf of the prep table. There was visible debris on the shelf. The refrigerator doors were soiled with smears of brown and white substances on both of the large 3 door refrigerators and on the 3 door freezer. The cover on the air conditioner was soiled with gray debris. The lids for the steam table trays were sitting on the prep sink under the air conditioner. Interview with the FSS at this time revealed that the dishes should be stored to keep them clean and kitchen surfaces should be clean. Review of the Cleaning list received from the FSS for (MONTH) (YEAR) revealed the following: Cleaning list is due to be checked off by the FSS when you are ready for your item to be looked at with the FSS before (MONTH) 31st. | 2020-09-01 |
| 940 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 582 | E | 0 | 1 | DGFB11 | Based on record review and interview, the facility failed to ensure that residents were provided a Notice of Medicare Non coverage for 3 (Resident 8, Resident 124, and Resident 125) of 3 sampled residents. The facility census at the time of the survey was 21. Finds are: [NAME] Record review of Resident 8's Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) dated 9/1/19 resident was notified of discharge from skilled services but did not receive the required Notice of Medicare Non Coverage (NOMNC). B. Record review of Resident 124's Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) dated 6/22/19 resident was notified of discharge from skilled services but did not receive the required Notice of Medicare Non Coverage (NOMNC). C. Record review of Resident 125's Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) dated 5/28/19 resident was notified of discharge from skilled services but did not receive the required Notice of Medicare Non Coverage (NOMNC). An interview on 10/16/19 at 4:29 PM with the DON (Director of Nursing) revealed the DON issues the denial letters for SNFABN and NOMNC. The DON stated that Resident 8, Resident 124, and Resident 125 did not initiate their discharges and that each one had days remaining for Medicare A Services. The DON confirmed that the NOMNC letters were not given to Resident 8, Resident 124 or Resident 125. | 2020-09-01 |
| 941 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 584 | D | 1 | 1 | DGFB11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-007.04D Based on observation and interview the facility failed to ensure the vents in the bathroom were free from dirt and dust for 2 (Resident 10 and Resident 15) of 16 sampled residents. The census at the time of the survey was 21. Findings Are: [NAME] Observation on 10/10/19 at 8:40 AM of the bathroom for Resident 10 revealed that the ceiling vent was covered with a fuzzy gray debris that rained down when touched with a piece of toilet tissue. B. Observation on 10/10/19 at 8:43 AM of the bathroom for Resident 15 revealed that the ceiling vent was covered with a fuzzy gray debris that rained down when touched with a piece of toilet tissue. An interview on 10/16/19 at 5:28 PM with the HS (Housekeeping Supervisor) confirmed that the bathroom vents for Resident 10 and Resident 15 were covered with a fuzzy gray debris. | 2020-09-01 |
| 942 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 602 | D | 1 | 1 | DGFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 12-006.05(9) Based on interview and record review, the facility failed to protect residents from potential misappropriation by failing to conduct reference checks, a criminal background check, and licensure certification verification checks for RN-B (Registered Nurse) who subsequently diverted medications from the facility residents. This affected 2 of 21 residents in the facility (Resident 1 and 17) who received medication. The facility identified a census of 21 at the time of survey. Findings are: Review of the facility report Misappropriation dated 9/15/2019 revealed the current facility DON (Director of Nursing) and other nursing staff suspected there were medications missing from the medication cart that had belonged to Resident 1 and Resident 17. The report contained documentation of discrepancies in the amount of medications that were sent to the facility from the pharmacy for Residents 1 and 17, the amount of the medication that was administered to the residents, and the amount remaining in the supply. The facility discovered that 86 tablets of [MEDICATION NAME] (a narcotic like pain reliever) for Resident 17, 32 tablets of [MEDICATION NAME] (antianxiety medication) for Residents 1 and 17, and 51 tablets of [MEDICATION NAME] (an opioid or narcotic pain reliever) that were slated for destruction had potentially been diverted from the facility and residents' medication supply. Review of the facility report of the investigation into drug diversion dated 9/17/2019 revealed documentation RN-B (the DON at the time of the incident) was confronted about the missing medications. RN-B admitted to diverting the mediations from the facility medication cart for their own use including [MEDICATION NAME] and [MEDICATION NAME]. RN-B was suspended then terminated from the facility. Interview with the facility administrator on 10/16/19 at 4:46 PM confirmed the medications belonging to Resident 1 and Resident 17 were diverted from the medication cart by RN-B. RN-A was also present during the interview and confirmed this. No other active residents had medications missing and the facility replaced the medications immediately per the administrator. RN-A revealed Resident 1 and Resident 17 were not without the medications when they were needed so there was no harm done to these 2 residents. The [MEDICATION NAME] was supposed to be destroyed and was not being actively used by any residents. Review of RN-B's General Orientation Checklist revealed a hire date of 2/4/2019. Review of RN-B's Separation Acton Form dated 9/17/2019 revealed their last day worked was 9/13/2019. Review of the personnel file for RN-B revealed their date of hire was 2/4/2019 and their day of separation (termination date) was 9/17/2019. RN-B's last day worked was listed as 9/13/2019. There was no documentation a criminal background check, reference checks, or nursing licensure verification check was completed. RN-B's employment application was also missing from the file. Review of the document Employment Profile Form dated and signed by RN-B on 1/24/2019 revealed documentation RN-B had a conviction 2010/2011 of misdemeanor attempt to possess narcotics. There was documentation the form had been faxed to the criminal background check company but there was no documentation of the results of the criminal background check. Interview with the facility Administrator on 10/15/19 at 10:08 AM revealed they could not find the criminal background check for RN-B. The administrator revealed the criminal background check had been completed but they did not have access to the results because the company would not release it because they did not receive payment. The administrator confirmed they didn't have any way of knowing what the results were of the criminal background check. The administrator confirmed it should have been completed/results available so they could act on it. Interview with the facility Administrator on 10/15/19 at 11:23 AM revealed the BOM (Business Office Manager) had a misunderstanding about the job application and the reference checks. The Administrator confirmed they did not have a job application or reference checks for RN-B. The Administrator confirmed the employment application and reference checks should have been done. Interview with the facility Administrator on 10/16/19 at 9:57 AM revealed RN-B's personnel file did not contain documentation their licensure certification had been checked. The Administrator confirmed it should have been completed. Review of RN-B's RN Licensure Certification form from the Licensure Certification website revealed RN-B's RN license was suspended from 2/21/2011 to 2/21/2012 and RN-B was on probation from 3/13/2014 to 3/13/2017. Review of RN-B's Disciplinary Information attached to their RN License Certification revealed RN-B had been suspended and placed on probation for theft of controlled substances from their place of employment. Review of the Nursing Staff schedules for (MONTH) through (MONTH) 2019 revealed RN-B was working in the facility during the time frame from when they were hired until they were terminated. Review of the facility policy Abuse, Neglect, and Exploitation dated 11/17 revealed the following: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The facility must not employ or otherwise engage individuals who: have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Background, reference and credentials' checks should be conducted on employees prior to or at the time or employment, by facility administration in accordance with applicable state and federal regulations. Any person having knowledge that an employees license or certification is in question should report such information to the administrator. | 2020-09-01 |
| 943 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 606 | D | 1 | 1 | DGFB11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3d Based on interview and record review, the facility failed to maintain 3 of 6 personnel files with evidence the NA (Nurse Aide) registry was checked for adverse findings prior to employment for the HS (Housekeeping Supervisor) and DA-C (Dietary Aide), failed to ensure staff working did not have a criminal conviction involving misappropriation on their record prior to employment, failed to ensure personnel files contained evidence that prospective employees had not been found guilty of abuse, neglect, exploitation or misappropriation, failed to ensure reference checks were completed for RN-B, and failed to check licensure certification verification status for RN-B prior to employment. The facility identified a census of 21 at the time of survey. Findings are: [NAME] Review of RN-B's General Orientation Checklist revealed a hire date of 2/4/2019. Review of RN-B's Separation Acton Form dated 9/17/2019 revealed their last day worked was 9/13/2019. Review of the personnel file for RN-B revealed their date of hire was 2/4/2019 and their day of separation (termination date) was 9/17/2019. RN-B's last day worked was listed as 9/13/2019. There was no documentation a criminal background check, reference checks, or nursing licensure check was completed upon hire. RN-B's employment application was also missing from the file. Review of the document Employment Profile Form dated and signed by RN-B on 1/24/2019 revealed documentation RN-B had a conviction 2010/2011 of misdemeanor attempt to possess narcotics. There was documentation the form had been faxed to the criminal background check company, but there was no documentation of the results of the criminal background check. Interview with the facility Administrator on 10/15/19 at 10:08 AM revealed they could not find the criminal background check for RN-B. The administrator revealed the criminal background check had been completed but they did not have access to the results because the company would not release it. The administrator confirmed they didn't have any way of knowing what the results were of the criminal background check. The administrator confirmed it should have been completed/results available so they could act on it. Interview with the facility Administrator on 10/15/19 at 11:23 AM revealed the BOM (Business Office Manager) had a misunderstanding about completing the reference checks and licensure certification. The Administrator confirmed they did not have a job application or reference checks for RN-B. The Administrator confirmed the employment application and reference checks should have been done. Interview with the facility Administrator on 10/16/19 at 9:57 AM revealed RN-B's personnel file did not contain documentation their licensure certification had been checked. The Administrator confirmed it should have been completed. Review of RN-B's RN Licensure Certification form from the Licensure Certification website revealed RN-B's RN license was suspended from 2/21/2011 to 2/21/2012 and RN-B was on probation from 3/13/2014 to 3/13/2017. Review of RN-B's Disciplinary Information attached to their RN License Certification revealed RN-B had been suspended and placed on probation for theft of controlled substances from their place of employment. Review of the Nursing Staff schedules for (MONTH) through (MONTH) 2019 revealed RN-B was working in the facility during the time frame from when they were hired until they were terminated for diverting medications from the facility residents. B. Review of the personal file for HS with a DOH (Date of Hire) of 4/10/2019 and DA-C with a DOH of 7/12/2019 revealed no documentation the NA Registry checks were completed. Interview with the facility Administrator on 10/10/2019 at 10:25 AM confirmed that the HS and DA-C had been working in the facility since they were hired and they confirmed the NA registry checks were not completed. Review of the untitled documents received from and identified by the facility Administrator as the Housekeeping staff schedule and the Dietary staff schedule revealed documentation the HS and DA-C had been working in the facility since they were hired. Review of the facility policy Abuse, Neglect, and Exploitation dated 11/17 revealed the following: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The facility must not employ or otherwise engage individuals who: have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Background, reference and credentials' checks should be conducted on employees prior to or at the time or employment, by facility administration in accordance with applicable state and federal regulations. Any person having knowledge that an employees license or certification is in question should report such information to the administrator. | 2020-09-01 |
| 944 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 607 | E | 1 | 1 | DGFB11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3b Based on interview and record review, the facility staff failed to follow the facility policy for screening 3 of 6 employees RN-B (Registered Nurse), HS (Housekeeping Supervisor), and DA-C (Dietary Aide) for abuse, neglect, and misappropriation prior to employment. This had the potential to affect all of the facility residents. The facility identified a census of 21 at the time of survey. Findings are: [NAME] Review of RN-B's General Orientation Checklist revealed a hire date of 2/4/2019. Review of RN-B's Separation Acton Form dated 9/17/2019 revealed their last day worked was 9/13/2019. Review of the personnel file for RN-B revealed their date of hire was 2/4/2019 and their day of separation (termination date) was 9/17/2019. RN-B's last day worked was listed as 9/13/2019. There was no documentation a criminal background check, reference checks, or nursing licensure check was completed upon hire. RN-B's employment application was also missing from the file. Review of the document Employment Profile Form dated and signed by RN-B on 1/24/2019 revealed documentation RN-B had a conviction 2010/2011 of misdemeanor attempt to possess narcotics. There was documentation the form had been faxed to the criminal background check company, but there was no documentation of the results of the criminal background check. Interview with the facility Administrator on 10/15/19 at 10:08 AM revealed they could not find the criminal background check for RN-B. The administrator revealed the criminal background check had been completed but they did not have access to the results because the company would not release it. The administrator confirmed they didn't have any way of knowing what the results were of the criminal background check. The administrator confirmed it should have been completed/results available so they could act on it. Interview with the facility Administrator on 10/15/19 at 11:23 AM revealed the BOM (Business Office Manager) had a misunderstanding about completing the reference checks and licensure certification. The Administrator confirmed they did not have a job application or reference checks for RN-B. The Administrator confirmed the employment application and reference checks should have been done. Interview with the facility Administrator on 10/16/19 at 9:57 AM revealed RN-B's personnel file did not contain documentation their licensure certification had been checked. The Administrator confirmed it should have been completed. Review of RN-B's RN Licensure Certification form from the Licensure Certification website revealed RN-B's RN license was suspended from 2/21/2011 to 2/21/2012 and RN-B was on probation from 3/13/2014 to 3/13/2017. Review of RN-B's Disciplinary Information attached to their RN License Certification revealed RN-B had been suspended and placed on probation for theft of controlled substances from their place of employment. Review of the Nursing Staff schedules for (MONTH) through (MONTH) 2019 revealed RN-B was working in the facility during the time frame from when they were hired until they were terminated for diverting medications from the facility residents. B. Review of the personal file for HS with a DOH (Date of Hire) of 4/10/2019 and DA-C with a DOH of 7/12/2019 revealed no documentation the NA Registry checks were completed. Interview with the facility Administrator on 10/10/2019 at 10:25 AM confirmed that the HS and DA-C had been working in the facility since they were hired and they confirmed the NA registry checks were not completed. Review of the untitled documents received from and identified by the facility Administrator as the Housekeeping staff schedule and the Dietary staff schedule revealed documentation the HS and DA-C had been working in the facility since they were hired. Review of the facility policy Abuse, Neglect, and Exploitation dated 11/17 revealed the following: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The facility must not employ or otherwise engage individuals who: have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Background, reference and credentials' checks should be conducted on employees prior to or at the time or employment, by facility administration in accordance with applicable state and federal regulations. Any person having knowledge that an employees license or certification is in question should report such information to the administrator. | 2020-09-01 |
| 945 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 657 | D | 0 | 1 | DGFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on interview and record review, the facility failed to include 2 residents and their responsible party in planning their care (Residents 3 and 13). This affected 2 of 14 residents whose care plans were reviewed during the survey process. The facility identified a census of 21 at the time of survey. Findings are: Interview with Resident 3 on 10/09/19 at 2:43 PM revealed they had not been invited to a care plan meeting nor had been involved in the planning of their care. Review of Resident 3's quarterly MDS (MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) revealed an admission date of [DATE]. Resident 3 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated moderate cognitive impairment. Review of Resident 3's Care Plan dated 1/27/2019 revealed no documentation Resident 3 had participated in their care plan meeting. Review of Resident 3's Progress Notes revealed no documentation Resident 3 or their responsible party was invited to the care plan meeting. B. Interview with Resident 13 on 10/10/19 at 11:33 AM revealed they had not had a care plan meeting for 6-7 months. Review of Resident 13's annual MDS dated [DATE] revealed an admission date of [DATE]. Resident 13 had a BIMS score of 12. Interview with Resident 13's responsible party on 10/16/19 at 2:00 PM confirmed they have not had a care plan meeting for quite some time. They had one set up after the first of the year and the facility canceled it for some reason; they were unable to have it. Resident 13's responsible party said the facility staff had tried to schedule it on a Friday and the responsible party said they were here every Wednesday and Saturday and they had told the facility staff they would like to have the meeting when they were here. I am here. We could have the meeting. Review of Resident 13's Progress Notes revealed no documentation Resident 13 or their responsible party had been invited to or had attended a care plan meeting in the past 6-7 months. Interview with the DON (Director of Nursing) on 10/16/19 at 2:16 PM confirmed was no recent documentation Resident 13 or their responsible party had been to a care plan meeting in the past 6-7 months. Review of Resident 13's Care Plan dated 12/28/2016 revealed no documentation Resident 13 or their responsible party had been invited to or had attended a care plan meeting in the past 6-7 months. Interview with the DON on 10/16/19 on 3:14 PM revealed RN-D (Registered Nurse) had sent out invitations for care plans but they did not keep a copy of the invitation or document they sent them out. Review of the facility policy Care Plan Process dated 9/2019 revealed the following: The plan of care must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and social well-being. Interim care plans are developed within 24 hours of admission for high-risk problems, including major medications or diagnoses. The resident' family or legal representative is involved if the resident is unable to participate and/or the resident approves. Team member may include but is not limit to resident, family/legal representative. At the resident's option, every effort will be made to involve the resident and family or responsible party including private duty or nursing assistant, in the development, implementation, maintenance, and evaluation of the resident plan of care. The resident has the right to refuse to participate in establishing care plan goals and objectives. When such refusals are made, appropriate documentation will be entered into the resident's medical record. Residents, families, or legal representatives will be notified of the care planning conference in writing at least 7 days prior to the conference. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. Participation in the resident care planning process will be documented by obtaining the signature of the resident, family, or legal representative. | 2020-09-01 |
| 946 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 688 | D | 0 | 1 | DGFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D4 Based on observation, interview, and record review; the facility failed to offer a restorative nursing program to Resident 13 to restore or prevent further contractures. This affected 1 of 2 residents reviewed for restorative care. The facility identified a census of 21 at the time of survey. Findings are: Review of Resident 13's annual MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 8/16/2019 revealed an admission date of [DATE]. Resident 13 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated moderate cognitive impairment. Resident 13 required extensive assistance from 2 staff for bed mobility and Resident 13 was dependent upon staff for transfer and locomotion. No therapy or nursing restorative minutes were documented. Resident 13 had a functional limitation in range of motion on one side both upper and lower extremity. Interview with Resident 13 on 10/10/19 at 11:36 AM revealed they only had use of their right arm and leg. Resident 13 revealed the facility had not offered a restorative nursing program. Observation of Resident 13 on 10/15/19 at 10:00 AM, 10/16/2019 at 7:59 AM, and 10/16/2019 at 2:00 PM revealed both of Resident 13's hands had contractures (permanent shortening of tissue, such as muscle, tendon or skin, as a result of disuse, injury or disease. Contracture leads to the inability to straighten joints fully and to permanent deformity and disability). Resident 13's left hand was misshapen: it was curled over and their thumb was sticking out of the opposite side of their hand through their fingers. Resident 13's right hand was misshapen and fixed in a bent manner without the ability to perform spontaneous movement. Interview with the DON (Director of Nursing) on 10/16/19 at 10:03 AM revealed at one time Resident 13 was receiving a restorative nursing program for range of motion but they were refusing it. The DON revealed there was no documentation of Resident 13 refusing restorative care. Interview with Resident 13's responsible party on 10/16/19 at 2:00 PM revealed that Resident 13 had splints for their hands but they did not have any insurance so they could not pay for any more therapy. Resident 13's responsible party revealed they did not know if therapy staff had showed the nurses how to use the braces. Resident 13's responsible party said the facility staff had not offered any nursing restorative program after their therapy had ended and Resident 13 said they would like to have a nursing restorative program. Review of Resident 13's OT (Occupational Therapy) Plan of Care dated 9/4/2018 revealed Resident 13 was referred for a decline in ROM (Range of Motion) and functional abilities following hospitalization . Resident 13 would benefit from skilled OT interventions to improve function ROM and assess for proper wheelchair positioning to maximize patient's independence and engagement in daily activities. Goal: facility staff will follow positioning protocol and properly don splints with independence in order to prevent deformity and/or skin breakdown. Review of Resident 13's OT Plan of Care dated 10/22/2018 revealed Resident 13 was referred for a new wheelchair. Resident 13 had a limitation in range of motion documented on the OT plan of care. Review of Resident 13's [DIAGNOSES REDACTED]. Review of Resident 13's Care Plan dated 11/21/2016 revealed Resident 13 had a physical functioning deficit related to an [MEDICAL CONDITIONS]. Resident 13 had self care, mobility and ROM limitations and required staff assist with all ADL's (Activities of Daily Living). An intervention was to monitor and report changes in ROM ability. Review of Resident 13's Progress Notes revealed no documentation of a nursing restorative program implemented after Resident 13's skilled Medicare A therapy services ended in (YEAR). Interview with the DON 10/16/19 on 2:43 PM revealed they thought Resident 13 did use the splints a few times and refused but they cannot find any documentation as such. Interview with DON on 10/16/19 at 3:11 PM revealed the facility staff did exercises with Resident 13's right hand and they used the ball for that. The DON confirmed there was no documentation the therapists recommendations for the splints were communicated to the nursing staff. Review of Resident 13's Medical Record revealed no documentation of any restorative nursing being completed for Resident 13. Review of the facility policy Restorative Nursing Services dated 5/1/2017 revealed the following: Residents will be evaluated for Restorative Nursing Services to maintain/attain their highest practicable level of function. Assessment for restorative needs is initially accomplished through the nursing evaluation which is completed upon admission, quarterly, and with a significant change. Therapy or Nursing develops care plans designed to reflect resident strengths, risk factors, and preferences. | 2020-09-01 |
| 947 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 689 | D | 0 | 1 | DGFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E43-8-17 Based on observation, record review, and interview; the facility failed to ensure hazardous/poisonous chemicals in the housekeeping close were stored to prevent accidental ingestion, inhalation or consumption by one wandering resident (Resident 11) out of one wandering resident on the unit. The facility census at the time of the survey was 21. Findings Are: Observation on 10/09/19 at 11:42 AM the housekeeping storage room was left unlocked. No staff were observed in the hallway. Chemicals inside the unlocked storage room were: -Multi-Surface Peroxide, an agent according to the MSDS (Material Safety Data Sheet) was harmful if swallowed or came into contact with the skin. Causes [MEDICAL CONDITION] eye damage. Avoid breathing dust/fume/gas/mist/vapors/spray. -Kling Toilet Bowl and Urinal Cleaner, an agent according to the MSDS was dangerous causing [MEDICAL CONDITION] eye damage. If swallowed immediately call a Poison Center or a Physician. Review of Resident 11's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used in care planning) dated 8/8/19 revealed that wandering behavior occurred daily. Behavior of pacing and rummaging were observed. Review of Resident 11's Progress Notes revealed documentation of Resident 11 wandering the hallways and not being easily redirected. An interview on 10/9/19 at 11:42 AM with the HS (House Supervisor) revealed that the door was unlocked and residents could have wandered into the room. The HS confirmed that harmful and dangerous chemicals were being stored in the storage room. | 2020-09-01 |
| 948 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 700 | D | 1 | 1 | DGFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B Based on observations, interviews, and record reviews; the facility failed to assess Resident 11 and Resident 21 for the use of bed rails. This affected 2 of 2 sampled residents. The facility census at the time of the survey was 21. Findings are: [NAME] Observation of Resident 11's bed on 10/9/19 at 10:51 AM revealed a bed rail in the raised position with a 13.5 gap between the head of the bed and the rail. There was greater than a 4 gap between the mattress and the bed rail. A closed fist could be placed between the mattress and the rail. An interview on 10/9/19 at 11:20 AM with the ADM (Administrator) revealed that the bed in the room to the right should have been appropriate for Resident 11 just in case Resident 11 wanted to lay in the bed. 10/09/19 11:51 AM Interview with RN-A (Registered Nurse) revealed that the bed in room [ROOM NUMBER] on the right side of the room had a space between the mattress and the bed rail of greater than 4. Review of the Side Rail Assessment for Resident 11 revealed the only assessment completed was dated 10/9/19. B. Observation of Resident 21's bed on 10/9/19 at 10:59 AM revealed a side rail on the exit side of the bed with no cover over the rail and a 7 gap in the rail. A head could easily fit into this space. 10/09/19 11:51 AM Interview with RN-A (Registered Nurse) revealed that the side rail in room [ROOM NUMBER] on the exit side of the bed had a space that Resident 21 could have put Resident 21's head through the opening. An interview on 10/09/19 at 11:55 AM with the MS (Maintenance Supervisor) revealed that the side rail did not belong to the facility. The maintenance man was informed by RN- A (Registered Nurse) that the rail needed to be remove immediately. The MS then slid the rail off of the bed which had been attached to a wooden board and place under the mattress. Review of the Side Rail Assessment for Resident 21 revealed the only assessment completed was dated 10/9/19. Review of the policy Proper Use of Side Rails revealed: This facility prohibits the use of side rails as a restraint. The Policy Explanation and Compliance Guidelines: 1. Side rails are considered a restraint when they limit the resident's freedom of movement depending upon the individual's condition and circumstances. 2. An assessment of the resident' symptoms and the reason for using side rails will be conducted prior to use, including their mental status and reason for use of the side rails, and will be documented in the residents' record. 3. The physician will also review and order side rails usage as he deems necessary. 4. Side rails may only be used in order to assist in mobility and transfer of residents. 5. If the resident is using the side rail for positioning, turning and getting out of bed assistance it is not considered a restraint. 6. The use of side rails as an assistive device will be will be addressed in the residents' care plan. | 2020-09-01 |
| 949 | ARBOR CARE CENTERS-FRANKLIN LLC | 285096 | 1006 M STREET | FRANKLIN | NE | 68939 | 2019-10-16 | 909 | E | 1 | 1 | DGFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B3 Based on observation, interview, and record review; the facility staff failed to have a program in place to ensure residents' beds were maintained to prevent a potential entrapment hazard for Residents 3, 5, 20, 22, 11, and 21. This affected 6 of 16 residents' beds evaluated during the survey process. The facility identified a census of 21 at the time of survey. Findings are: [NAME] Observation of Resident 3's bed on 10/09/19 at 11:49 AM revealed the bed was up against the wall and the mattress was not secured to the bed. The mattress could be slid off the bed frame creating a gap between the wall and the bed that created a potential entrapment hazard. B. Observation of Resident 5's bed on 10/09/19 at 11:48 AM revealed the bed was up against the wall. The mattress was not secured to the bed and could be slid off the bed frame creating a gap between the wall and the bed and a potential entrapment hazard for Resident 5. C. Observation of Resident 20's bed on 10/09/19 at 11:50 AM revealed the mattress was not secured to the bed and could be slid off the creating a gap between the wall and the bed creating a potential entrapment hazard. Resident 20's bed was up against the wall. There are mattress stops on the bed but the mattress did not fit into the stops as the mattress was too big for the bed. D. Observation of Resident 22's bed on 10/09/19 at 11:45 AM revealed Resident 22's bed was against the wall. The mattress was not secured to the bed and could be slid off the bed frame creating a gap between the wall and the bed and a potential entrapment hazard. Interview with RN-A (Registered Nurse) 10/09/19 at 3:03 PM confirmed the facility should have a program in place to ensure the beds did not create a potential entrapment hazard for the residents. Interview with the facility Administrator on 10/09/19 at 5:10 PM confirmed the beds could potentially create an entrapment hazard for the residents and needed to be corrected. The Administrator did not have documentation the facility staff had a program in place to monitor the resident beds for potential entrapment hazards. Review of the facility document Environmental Education 10/9/19 revealed the following: it is the expectation that all beds will be routinely checked to ensure that mattresses are secure, there are no gaps between headboards, footboards or rails that could cause entrapment, and that rails are securely fastened to the bed frame. Beds, mattresses and rails will be checked on preventative maintenance rounds weekly, and bed data sheets will be completed at a minimum of quarterly to ensure that beds are in proper working order. E. Observation of Resident 11's bed on 10/9/19 at 10:51 AM revealed a bed rail in the raised position with a 13.5 gap between the head of the bed and the rail. There was greater than a 4 gap between the mattress and the bed rail. A closed fist could be placed between the mattress and the rail. An interview on 10/9/19 at 11:20 AM with the ADM (Administrator) revealed that the bed in the room to the right should have been appropriate for Resident 11 just in case Resident 11 wanted to lay in the bed. 10/09/19 11:51 AM Interview with RN-A (Registered Nurse) revealed that the bed in room [ROOM NUMBER] on the right side of the room had a space between the mattress and the bed rail of greater than 4. Review of the Side Rail Assessment for Resident 11 revealed the only assessment completed was dated 10/9/19. F. Observation of Resident 21's bed on 10/9/19 at 10:59 AM revealed a side rail on the exit side of the bed with no cover over the rail and a 7 gap in the rail. A head could easily fit into this space. 10/09/19 11:51 AM Interview with RN-A (Registered Nurse) revealed that the side rail in room [ROOM NUMBER] on the exit side of the bed had a space that Resident 21 could have put Resident 21's head through the opening. An interview on 10/09/19 at 11:55 AM with the MS (Maintenance Supervisor) revealed that the side rail did not belong to the facility. The maintenance man was informed by RN- A (Registered Nurse) that the rail needed to be remove immediately. The MS then slid the rail off of the bed which had been attached to a wooden board and place under the mattress. Review of the Side Rail Assessment for Resident 21 revealed the only assessment completed was dated 10/9/19. Review of the policy Proper Use of Side Rails revealed: This facility prohibits the use of side rails as a restraint. The Policy Explanation and Compliance Guidelines: 1. Side rails are considered a restraint when they limit the resident's freedom of movement depending upon the individual's condition and circumstances. 2. An assessment of the resident' symptoms and the reason for using side rails will be conducted prior to use, including their mental status and reason for use of the side rails, and will be documented in the residents' record. 3. The physician will also review and order side rails usage as he deems necessary. 4. Side rails may only be used in order to assist in mobility and transfer of residents. 5. If the resident is using the side rail for positioning, turning and getting out of bed assistance it is not considered a restraint. 6. The use of side rails as an assistive device will be will be addressed in the residents' care plan. | 2020-09-01 |