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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6989 | NEBRASKA CITY CARE AND REHABILITATION CENTER, LLC | 285109 | 1420 NORTH 10TH STREET | NEBRASKA CITY | NE | 68410 | 2014-12-11 | 248 | D | 0 | 1 | 9RWM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -LICENSURE REFERENCE NUMBER: NAC 12-006.09D5b Based on observation, record review and staff interview; the facility failed to provide individualized activities for two residents (Resident 55 and 53). The facility identified a census of 50 residents. Findings are: A. A records review of the care plan dated 6/17/2013 for Resident 55 revealed Resident 55 was admitted on [DATE] for the following diagnoses- Unspecified after Cataract, Urinary Frequency, Acute pain due to trauma, [MEDICAL CONDITION], Dementia condition classified elsewhere without behavioral disturbance, swelling of limb, unspecified [MEDICAL CONDITIONS], Obstructive chronic [MEDICAL CONDITION] with exacerbation, other vitamin B 12 deficiency [MEDICAL CONDITION], unspecified essential hypertension, unspecified vitamin D deficiency. A records review of the Resident 55's MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning) dated 09/15/2014, revealed the facility assessed the following about the resident: Resident 55 has a BIMS (Brief Interview for Mental Status) score of 00, (BIMS is used to determine a resident's cognitive understanding. A BIMS score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment.) Resident 55 is assessed as having Inattention and Disorganized Thinking. Preferences for Customary Routine and Activities has the following marked: Reading books, newspapers or magazines, listening to music, Being around animals such as pets, Keeping up with the news, Doing things with groups of people, Participating in favorite activities, Spending time outdoors, Participating in religious activities or practices. Total dependence in bed mobility and transfers. Mobility is by wheelchair A records review of Recreation Services assessment dated [DATE] Resident 55, revealed Resident 55's activity preferences are- Independent, 1:1, with friends and family, small groups, out of room, outside, outings, with no time preferences noted. A records review of the care plan dated 6/17/2013 for Resident 55 revealed: I have a short attention span exhibited by: Wandering in and out of activities. Because of cognitive loss I need cuing with simple directions to stay on task. The goal identified for Resident 55 was to participate in short activities when offered. Interventions identified on the care plan were reading the newspaper, music programs, socials and games, going outside when the weather is nice, invite me to Catholic Services or ask Father to stop by and see me. A record review of the Activity Logs for the months of October, (MONTH) and (MONTH) revealed that there was no church activity, 1:1, reading, current events or outings documented. On the following dates and times, Resident 55 was observed to be in Resident ' s 55 wheel chair doing no activities in various locations of the ACU (Alzheimer Care Unit): 12/03/2014 2:03 PM, 12/04/2014 10:27 AM, 12/08/2014 11:21 AM and 12/08/2014 3:13 PM An interview on 12/08/2014 at 12:32 PM with AA (Activity Assistant) B revealed the following: AA B states that AA B didn't do the activity assessment, but does do the calendar. So the residents will do the parachute, fishing game, crafts-every other week. But AA B does not run the activity, the NAs (Nursing Assistants) or nurses run it. AA B states that AA B is not very involved with things back there unless it's a craft, then AA B will set it up and/or provide the example. An interview on 12/08/2014 at 2:02 PM with SW (Social Worker) C, revealed the following: Since there has been no ACU director for a time and no one has been dealing with residents' activities. SW C agrees that TV is not an appropriate activity for Resident 55 due to short attention span. SW C confirmed that the care plan is not individualized to Resident 55. B. Record review of an Admission Record dated 12/02/2014 revealed Resident 53 was admitted to the facility on [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Physician Fax sheet dated 10/31/2014 with facility request for Resident 53 be placed in the Alzheimer's unit due to wandering behaviors with physician response of OK. Record review of Recreation Services assessment dated [DATE] revealed that Resident 53 provided information that Resident 53 is blind, hearing intact, and had clear speech. Resident 53 was alert, cooperative and activity interest were: games/cards, puzzles/trivia, computer/video games, exercise/sports, television/movies, music, reading, writing, pets, and outdoor activities and outings. The Recreation Services Assessment also revealed Resident 53 sometimes liked discussion groups. Record review of (MONTH) 2014 Activity Calendar with highlighted activities that Resident 53 attended to include: - Snack and Chat with Staff on (MONTH) 3rd at 14th at 3 PM. - Snack and Chat with Staff on (MONTH) 18th, 19th, and 24th at 10 AM. - Snack and Chat with Staff refused by Resident 53 on (MONTH) 8th, 12th, and 17th. Record review of (MONTH) 2014 Activity calendar on 12/4/2014 with no documentation of activities attended for Resident 53. Review of (MONTH) 2014 Activity Calendar for Alzheimer's Unit included Snack and Chat with Staff schedule for 10 AM and 3 PM Monday through Friday every week through (MONTH) and Hot Chocolate and Coffee with Staff scheduled at 10 AM and Movie/Games or Picture Bingo at 3 PM for Saturdays and Sundays for the month. Observation on 12/04/201 at 9:50 AM, 11:49 AM, and 1:55 PM revealed resident lying in bed with eyes closed with no activities being provided. Observation on 12/04/2014 at 2:31 PM revealed Resident 53 sitting at the side of the bed, stands, and walk toward the door, walks into the hallway telling a nurse walking by that Resident 53 has to go to the bathroom. Licensed Practical Nurse (LPN) assisted Resident 53 to the bathroom and stay in the bathroom with Resident 53 until Resident 53 is finished. At 2:48 PM Resident 53 was encouraged by LPN to walk to the dining room to eat something and Resident 53 agreed he/she would eat something. LPN served chocolate milk and juice to Resident 53 and LPN leaves dining room with no activity being provided to Resident 53. Observation on 12/08/2014 at 10:36 AM revealed Resident 53 sitting on edge of the bed with no activities being provided. Observation on 12/08/2014 1st 3:07 PM revealed Resident 53 in room [ROOM NUMBER] bathroom stating, I got turned around. Resident 53 was redirected back to his/her room by the Alzheimer's Care Unit (ACU) Director. Observation on 12/09/2014 at 10:38 AM revealed Resident 53 sitting on the edge of the bed with no activities being provided. Observation on 12/09/2014 at 2:43 PM to 3:05 PM revealed Resident 53 in the bathroom with the Hospice Aide sitting on Resident 53's bed. At 3:05 PM Resident 53 came out of the bathroom and laid down in bed and closed Resident 53's eyes. Interview with Social Service Director on 12/08/2014 at 2:18 PM confirms that the Activity Log for Resident 53 for (MONTH) 2014 is blank and would indicated that Resident 53 had not attended activities in the month of (MONTH) as of today's date. Interview with Director of Nursing and ACU Director on 12/09/2014 at 1:40 PM confirmed that the activity calendar does not meet the individualized needs for Resident 53. | 2018-07-01 |
| 1426 | LIFE CARE CENTER OF OMAHA | 285137 | 6032 VILLE DE SANTE DRIVE | OMAHA | NE | 68104 | 2017-01-11 | 431 | E | 0 | 1 | N57P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC ,[DATE] 12E Based on observation, interview and record review; the facility failed to ensure that medications were kept secure in the medication storage room on the South nurses unit, and failed to ensure that outdated medications and unlabeled medications were not available for resident use. The facility identified a census 85. Findings are: [NAME] An observation on [DATE] 07:55 AM the medication storage room door was propped open with a full garbage bag, with no nursing staff present in the area. A housekeeper appeared shortly after the observation of the door was made and entered the open area. This observation revealed that medications were present on the counter. The medications included: Carvedilol 12.5 mg - a drug used to treat heart failure and hypertension Atrovastatin Calcium 10 a drug used as a lipid-lowering agent and for prevention of events associated with cardiovascular disease Eliqus 2.5 mg a drug used to inhibit blood clotting and reduce the risk of heart attack and blood clots. Levothyroxine 25 mcg. a drug used to increase thyroid levels Protonix 40 mg a drug used to treat various gastric disorders such as ulcers Diltiazem 24 hour 300 mg a drug used to treat hypertension and chest pain, and treat irregular heart rhythm Alprazolam 0.25 mg a drug that is a Controlled substance used to treat anxiety Januvia 100 mg a drug used to treat diabetes and control blood sugar levels Carvedilol 12.5 mg a drug used to treat high blood pressure and heart failure Namenda 14 mg a drug used to treat memory loss Lasix 20 mg a drug used treat heart failure and decrease swelling Escitalopram 20 mg a drug used to treat depression and anxiety Alprazolam 0.5 mg a drug that is a Controlled substance used to treat anxiety Metromidazole 500 mg a drug used to treat infections Levocetirizine 5 mg a drug uses to treat allergies [REDACTED]. ADON K confirmed that nursing staff are to be present when the door is open. ADON K confirmed the housekeeping staff did have access to the medication storage room unsupervised and did have access to the drugs listed above. Record review of the facility Medication Storage and Security in the Facility Policy revised ,[DATE] revealed : 2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized are allowed access to medications. Medications rooms, carts, and medication supplies are locked or attended by persons with authorized access. 175 NAC ,[DATE] 12E B) Findings are: Observation on [DATE] 7:25 AM revealed that a stock medication, present on the medication cart for the 400 hall on the North wing, had Geri-Lanta Antacid ( used to treat stomach discomforts such as heartburn) that had the expiration date of [DATE]. Interview with Licensed Practical Nurse B on [DATE] 7:25 AM confirmed that the medication had expired on ,[DATE] and should have been disposed of. Record review of the facility policy titled Expiration Dates, dated [DATE] revealed that : Drugs, including those in the medication carts, are to be checked monthly for expiration date by nursing personnel. If the drug is outdated, it must be disposed of as per state and federal laws. 175 NAC ,[DATE] 12E C. Findings are: Observation on [DATE] at 7:25 AM revealed that there were 3 resident specific [NAME]fen DM/AF ,[DATE]mg/5cc bottles of liquid (cough medication) that had been prescribed by the physician in (MONTH) of (YEAR). The pharmacy provided a label that required the open date to be placed on the label. There was no open date present on the label or on the bottles. Interview with LPN B on [DATE] at 7:25 AM confirmed that the medication pharmacy label did have area for date opened to be placed on the 3 bottles, and no where on the bottles was there a date opened. Interview with ADON K on [DATE] at 07:55 AM Confirmed that a date open should be placed on any medication when the pharmacy label requests the date open. | 2020-09-01 |
| 1407 | LIFE CARE CENTER OF ELKHORN | 285134 | 20275 HOPPER STREET | ELKHORN | NE | 68022 | 2016-11-07 | 431 | F | 0 | 1 | 6P3W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC ,[DATE].12E1 Based on observation, record review and interview; the facility failed to ensure that medications were maintained at the required temperatures, failed to ensure outdated medications were not available for resident use, and failed to ensure medications were dated when they were opened. This had the potential to affect all the residents that reside in the facility. The facility census was 95. Findings are: Record review of the facility policy for Medication Administration revised ,[DATE] revealed that medications that require refrigeration should be stored at temperature of 36 to 46 degree Fahrenheit (F). Medications that are out dated, contaminated or deteriorated are immediately removed from stock. Medications that are multi-dose are to be labeled with a date open date, this date provides expiration date of medication, based on manufacturer recommendations outlined in the table in this policy. [NAME] Observation on [DATE] at 8:10 AM revealed that the temperature control record on the south medication storage refrigerator had temperatures below the recommended storage temperature for medication. Record review of the Temperature Log revealed that the log has Required Temperature ,[DATE] degree F posted on the top of the log, it also states Notify Maintenance Immediately if Variation of Temperature. The temperatures readings were 30 degrees on ,[DATE] ,[DATE], Temperatures read 32 degrees on ,[DATE]/,,[DATE],,[DATE],,[DATE], ,[DATE] of (YEAR). The temperature log revealed no temperatures were logged on the temperature log for the following dates ,[DATE],,[DATE], ,[DATE],,[DATE],,[DATE],,[DATE], ,[DATE], ,[DATE] ,[DATE], ,[DATE],,[DATE], ,[DATE],,[DATE],,[DATE] of (YEAR). Medications present in this refrigerator included insulin and albuterol (for respiratory treatments). Observation on [DATE] at 8:30 AM of the North medication refrigerator revealed that the facility had not documented the temperature of the medication refrigerator for the month of (MONTH) or (MONTH) of (YEAR). Medications present in this refrigerator included Aplisol 10 test vial (tuberculin), Pneumoccal (pneumonia) vaccine,Prevnar 13 (pneumonia vaccine) for stock, Insulins, Vancomycin (antibiotic) and Promethazine Hydrochloride suppositories (Antiemetic therapy). Interview with Licensed Practical Nurse (LPN) B on [DATE] at 8:30 AM confirmed that the temperatures of the medication storage refrigerators failed to ensure that medications were maintained at the required temperatures. B Observation on [DATE] at 8:10 AM revealed that Preperation H ointment( ointment for rectal use) had expired on [DATE] and was opened for resident use on [DATE]. Observation on [DATE] at 8:30 AM revealed the 4 vials of Pneumococcal vaccine for facility wide use had expired in (MONTH) of (YEAR). Interview with LPN B on [DATE] confirmed that the Preperation H was outdated on [DATE] and had been dated as opened for use [DATE]. LPN B confirmed that the Pneumococcal vaccine had expired in (MONTH) of (YEAR) and that the facility failed to ensure outdated medications were not available for resident use. C. Observation on [DATE] at 8:00 AM revealed that medication of nasal spray was open, there was a sticker on the side for a date to be written on for date open, there was no date written on the tag. Medication of Albuterol Sulfate had a tag on the side for date open, there was no date written on the tag. Interview with LPN B on [DATE] at 8:00 AM confirmed that the nasal spray and the albuterol container should have a date written as to when the medication was opened. LPN B confirmed that upon opening the date is placed on the container so that the expiration begins on the date that it was opened, and that most expire 30 days after opening. | 2020-09-01 |
| 4487 | AZRIA HEALTH AT MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2016-05-17 | 279 | D | 0 | 1 | Z8DT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.04C3a(5) Based on record review and interview, the facility staff failed to develop a comprehensive care plan related to the care and use of an Intravenous (IV) device for Resident 6 and to address bathing refusals for Resident 42. Facility census was 134. Findings Are: Physician order [REDACTED]. The order also said to place a Peripherally Inserted Central Catheter ( PICC) line (a catheter placed into a vein and extends to the heart). Record Review revealed that the PICC line was placed in Resident 6's left arm by a contracted agency on 5-2-16. Record review revealed that the comprehensive care plan was updated on 5/2/16 to include the infection and the intervention of the antibiotic IV medication. The comprehensive care plan did not contain care needed for the PICC line. Interview with Registered Nurse (RN) B on 5/16/16 at 3:30 PM confirmed that no comprehensive plan of care was developed for Resident 6's PICC line. B. Interview on 5/16/16 at 4:58 PM with Nursing Assistant (NA) C revealed that Resident 42 often refused a bed bath. NA C revealed that when Resident 42 would refuse a bath, most staff would mark it as refused. NA C stated if encouraged Resident 42 would then permit bathing. Interview with NA D on 5/17/16 at 8:16 AM revealed that Resident 42 would need encouragement to have any hygiene care performed, that you would have to talk the resident into it. NA D revealed that a pillow case was to be placed under the abdominal folds and breasts, after drying, but the resident didn't like it very much and would refuse it. Record review of Resident 42's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 4/9/16 revealed a Brief Interview for Mental Status (BIMS) score of 10 ( 8 to 12 is moderately impaired). Resident 42 required extensive extensive assist of one person for personal hygiene and bathing. Record Review of the form titled Resident Bathing Type by Day Chart for the month of (MONTH) revealed that Resident 42 received 3 bed baths for the month of (MONTH) (4/3/16, 4/10/16 and 4/17/16). Record Review of the Plan of Care for Resident 42 revealed that the facility identified that Resident 42 was non-compliant with bathing. A goal was developed that Resident 42 would comply with medical/nursing treatments of bathing. The plan care did not have interventions or approaches for staff to follow to achieve this goal. | 2020-04-01 |
| 11641 | MAPLE CREST CARE CENTER | 285149 | 2824 NORTH 66TH AVENUE | OMAHA | NE | 68104 | 2011-11-08 | 157 | D | 1 | 0 | MU3W12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to notify resident's physician of critical lab value for 1 (Resident 2) of 14 sampled residents. The facility had a total census of 124 residents. Findings are: A. Resident 2 was admitted to the facility on [DATE] according to Admission Record. Hospital Discharge Summary dated 9/30/11 listed [DIAGNOSES REDACTED]. A review of Resident 2's Care Plan revealed a focus area dated 10/23/11 related Resident 2's pressure ulcer-left ischeal buttock, right hip and history of [MEDICAL CONDITION] in left elbow. Resident 2's Care Plan listed the following intervention "Obtain and monitor lab/diagnostic work with regards to IV medications as ordered. Report results to MD (Medical Doctor)-infectious disease, and to the Pharm D (Doctor of pharmacy) who preps (Resident 2's) IV (intravenous) meds; ensure that new orders are followed per Pharm D orders. A review of Resident 2's 10/11 MAR (Medication Administration Record) revealed a physician's orders [REDACTED]. A review of laboratory results dated [DATE] for Resident 2 revealed a [MEDICATION NAME] Trough of 17.2 which was identified as a critical result. The reference range for the [MEDICATION NAME] Trough was listed as 5-10 micrograms/milliliter. Documentation on the laboratory results report stated results were called to VNA (Visiting Nurses Association) and directions received to continue same dose of [MEDICATION NAME]. Case Communication Report from facility pharmacy dated 10/17/11 stated the following: "Spoke with (RN F) RN/Maplecrest. Dose given at 0900 this am, trough drawn around 0800. Trough result=17.2. Will plan to continue same dose unless we hear otherwise from MD (Medical Doctor). They do not have any more doses. Will send enough to get through next Mondays labs." In interviews on 11/8/11 at 10:40 AM and 12:10 PM, RN (Registered Nurse) Unit Manager E reported [MEDICATION NAME] trough lab reports are faxed to the VNA's pharmacist and pharmacist confers with resident's physician. RN Unit Manager E reported it is facility policy that critical lab values be called to the resident's physician. RN Unit Manager E confirmed there was no evidence to show Resident 2's physician was notified of Resident 2's critical [MEDICATION NAME] Trough level. Facility policy titled "Lab and Diagnostic Test Results-Clinical Protocol" revised October 2010 stated the following: "High or toxic drug levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician." | 2015-03-01 |
| 10739 | MT CARMEL HOME- KEENS MEMORIAL | 285216 | 412 WEST 18TH STREET | KEARNEY | NE | 68847 | 2012-11-20 | 157 | D | 1 | 0 | PO3011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.04C3a6 Based on interview and record review the facility failed to notify the physician of a resident having an open area. The facility had a census of 74 and a complaint investigation sample of 6. This failure affected Resident 01.Findings are:According to the undated ADMISSION & DISCHARGE SUMMARY Resident 01 was admitted to the facility on [DATE]. The following [DIAGNOSES REDACTED]. Review of a 10/25/12 ACCIDENT/INCIDENT REPORT revealed that a nursing assistant reported to the charge nurse that Resident 01 had an open area on the left side of the middle abdomen at 7:00 PM. The nurse assessed the area to be a 1 centimeter round open area that was draining. Review of the 10/26/12 NURSES NOTES confirmed that the open area was red and warm to touch. The nurse documented cleansing the area and applying a dressing at 7:15 PM on 10/26/12. Review of the NURSE'S NOTES dated 10/27/12 at 9:30 AM revealed that the nurse noted the abdominal open area to be reddened and the dressing was changed. Review of the NURSE ' S NOTES confirmed that the physician was notified of the open area on 10/27/12 at 2:00 PM (43 hours after the staff first documented the open area). The physician prescribed Keflex 500 miligrams twice daily to treat the open area. Interview on 11/20/12 at 2:20 PM with the DON (Directror Of Nursing) revealed that the expectation was for the nurse to report the open area to the doctor as soon as the nurse became aware of it or the very next morning at the latest. The physican should have been consulted for a treatment plan as soon as possible. The DON reported that the physician notification in the situation with the open area on Resident 01 was tardy. | 2015-11-01 |
| 4416 | SCHUYLER CARE AND REHABILITATION CENTER, LLC | 285110 | 2023 COLFAX STREET | SCHUYLER | NE | 68661 | 2018-07-18 | 604 | D | 0 | 1 | NXEG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.05 (8) Based on observation, record review and interview; the facility failed to use a restraint for the least time possible; failed to provide monitoring and evaluation for continued use of a physical restraint; and failed to develop and implement interventions for the restraint for 1 resident (Resident 3) Census was 28 and sample size was 13. Interview on 7/12/18 at 08:07 AM with Resident 3 revealed that the resident was reluctant to get up related to the alarm going off. Resident 3 stated, If I get up the alarm goes off. Observation on 7/12/18 at 08:07 AM of revealed a safety alarm on the bed of Resident 3. Interview on 7/16/18 at 10:09 AM with the Director of Nurses (DON) confirmed that the resident had 2 falls on 12/30/17. The DON confirmed that the alarm was a restraint if the resident felt that they were unable to get up related to the alarm going off. Interview with a staff member on 07/16/18 at 10:10 AM revelaed that the resident was thinking the resident could walk and tried to maneuver out of bed. The resident was bed ridden. Record review of Resident 3's MDS (Minimum Data Set) revealed the resident was at risk for falls related to new environment balance problems. The resident had 2 falls on 12/30/17. Intervention initiated on12/30/17 was a Bed alarm. The MDS dated ,[DATE] and 7/2018 revealed no falls since last assessment. The nurses note dated 7/5/2018 by the Intradisciplinary Care Plan Team revealed; no recent falls, refuses floot mat, and refuses the bed in the low position. | 2020-07-01 |
| 11784 | MAPLE CREST CARE CENTER | 285149 | 2824 NORTH 66TH AVENUE | OMAHA | NE | 68104 | 2011-09-12 | 309 | D | 1 | 0 | MU3W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09 Based on record review and interviews, the facility failed to assess effectiveness of pain management for 1 (Resident 9) of 10 sampled residents. The facility had a total census of 124 residents. Findings are: Resident 9 was admitted to the facility on [DATE] according to admission record. Resident 9's 8/29/11 history and physical included a [DIAGNOSES REDACTED]. Occurrence Report for Resident 9 dated 8/28/11 at 11:15 PM stated "Dr. White' called; noted res outside of room in hallway laying flat on (gender) back." The Occurrence Report stated Resident 9 complained of right hip pain. A review of physician orders [REDACTED]. Radiology Report dated 8/29/11 for Resident 9 stated Resident had an acute right [MEDICAL CONDITION]. A review of physician's orders [REDACTED]. A review of Resident 9's MAR (Medication Administration Record) revealed physician orders [REDACTED]. According to back side of 8/11 MAR, Resident 9 was administered Tylenol 650 mg orally for complaint of right hip pain at 3 AM on 8/29/11. The section of Resident 9's MAR for results or response was not completed. Nurse's Notes dated 8/28/11 at 5 AM stated the following: "Still sore and hurts." In an interview on 9/8/11 at 7:45 AM, RN D reported not wanting to sedate the resident. A review of Nurse's Notes and Resident 9's MAR indicated [REDACTED]. Nurse's Note dated 8/28/11 at 12:39 PM stated Resident 9 received pain medication from ambulance crew prior to departing the facility for transport to hospital. In an interview on 9/12/11 between 11:45-11:55 AM, the DON reported expecting residents pain be reevaluated to see if another pain medication is needed and to contact the resident's physician if needed. | 2015-01-01 |
| 12349 | LANCASTER REHABILITATION CENTER, LLC | 285275 | 1001 SOUTH STREET | LINCOLN | NE | 68502 | 2011-01-19 | 279 | D | 1 | 1 | VFG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09C Based on observation of residents, interview with staff and record review; the facility failed to develop comprehensive care plan goals and interventions regarding 1) the provision of oxygen therapy for 1 resident (Resident 110); 2) [MEDICAL TREATMENT] care and services for 1 resident (Resident 143); 3) hospice services for 1 resident (Resident 258); and 4) regarding pain management for 1 residents (Residents 98). Findings are: A. Review of the Comprehensive Care Plan for Resident 258 on 01/19/2011 revealed; -Identified Hospice service initiated: 11/13/2010 for "end stage heart" with plan to invite Resident, family and hospice to all care plan reviews; spiritual support will be provided by personal pastor and St. Elizabeth chaplain. Interview and observation of Resident 258 on 01/18/2011 in resident room revealed: -A medication was provided on a regular basis and that there was medication to take at other times. The pain did increase at times it depended on what activity the resident was or had been doing; -The resident was currently taking an antibiotic for a "cough" and had a respiratory illness. Interview with the Nursing Station 2 Manager on 01/19/2011 revealed: -Hospice service was initiated on 11/15/2010; -No Hospice contract or individualized Plan of Care for Hospice Service could be located in the medical records or provided by the staff. - A Hospice Nurse visited on 01/08/2011 to discuss medication therapy for pain control for routine administrations and which medications should be given on a as needed basis, use of other medications for congestive heart and kidney failure. Other alternative treatments (non-pharmacological) were were ordered that included: topical creams for muscle pain, heat and massage. Plan included assessment for hydration. This information is found in the Progress notes for physician/nurse communications with orders; -Review of the current care plan for Resident 258 with the Nurse Manager did not reveal an Initial Plan of Care coordinated with Hospice for the care and treatment for [REDACTED]. B. Review of the Resident Admission Record and MARS (medication administration records) for Resident 98 on 01/18/2011 revealed: -[DIAGNOSES REDACTED]. Review of the Annual MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for car planning), 09/20/2010 evaluates pain for Resident 98: -"pain is less then daily and mild intensity, non-specific sites". Had scheduled pain medication at bedtime and pain medication ordered for "as needed" every 4-6 hours. Interview with the Station 1 Nurse Manger on 01/19/2011 at Station 1 revealed: -Non-pharmacological interventions are not used with routine administration of pain medications. The use of routine medications given for pain are not identified in the care plan. Non-pharmacological interventions used for pain management are not cited in the care plan either but would be documented in the notes when provided with "as needed" medications. Review of the current individualized Care Plan for Resident 98 on 01/18/2011 revealed: There is no INITIAL entry to identify pain/pain management, the use of medications, individualized alternative interventions or measurable goals. C. Review of the CARE PLAN for Resident 110 01/19/2011 with Nurse Manager, Station One revealed: Care Plan had entry for: 12/06/2010 [DIAGNOSES REDACTED]. -Approaches for use include "O2 (oxygen) at 2L (liter)/minute at night. Review of the MDS 2.0 review coded "2" for an annual review with a reference date of 08/12/2010 for Resident : -Required oxygen therapy. Review of PHYSICIAN ORDERS/MEDICATION REVIEW for 60 day recertification dated 04/17/10 revealed: "Professional Med Admin Record: O2 to keep SAO2 88% prn (as necessary)". Review of the MARS (Medication Administration Records) for December, 2010 revealed: -1/29/2010 O2 to keep SAO2 88%PRN (as necessary); --04/23/2010 O2 at NOC (night) via N/C (nasal cannula) to keep SAO2 90%; -08/17/2010 SAO2 at NOC. Review of the Medication Administration Record [REDACTED] -December, 2010 did not reveal recordings of oxygen levels or assessments for day hours/activities; -January, 2011 did not reveal recordings of oxygen levels recorded for day hours/activities. Review of the Physician Orders and 60 day Medication Review/Recert and faxed communication for Physician Orders, 12/14/2010, do not meet the facility policy/procedure for orders and instructions for the use of oxygen therapy; -Review of the facility policy and procedure expectations for OXYGEN THERAPY revealed: -"Oxygen order will include: *Length of time oxygen is to be used; *Titrate oxygen to keep SAO2 above 88%; *Mode (mask, cannula); *Liter Flow; *Portable oxygen tank for mobility; *[DIAGNOSES REDACTED]. *Oxygen must be at a minimum of five (5) liters per minute when using a mask. Directions for provision of oxygen therapy were incomplete and without measurable interventions and goals within the Plan of Care for Resident 110. Based on observation, interview and record review; the facility failed to develop comprehensive care plan goals and interventions regarding 1) the provision of oxygen therapy for 1 resident (Resident 110); 2) [MEDICAL TREATMENT] care and services for 1 resident (Resident 143); 3) hospice services for 1 resident (Resident 258); and 4 regarding pain management for 2 residents (Residents 98 and 81). C) Record review of Resident's 143's Minimum Data Set ( A federally mandated comprehensive assessment tool used for care planning) dated 11/6/10; revealed a [DIAGNOSES REDACTED]. Record review of the History and Physical dated 2/17/10; revealed Resident 143 has [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Interview with Registered Nurse (RN) M at 4:04PM on 1/18/10; revealed that the nursing staff monitor with full body assessment for 24 hours when returned to center from the [MEDICAL TREATMENT] treatments. Received [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. The facility takes this resident to and from for [MEDICAL TREATMENT] treatments. Interview with Resident 143 at 2:30 on 1/18/11; revealed that this resident goes to [MEDICAL TREATMENT] treatments at another facility three times a week and this facility provides the transportation. Record review of Plan of Care with target date of 2/24/11; revealed no documentation of [MEDICAL TREATMENT] problem with no specific goal and/or approaches. This resident received [MEDICAL TREATMENT] on Monday, Wednesday, and Friday of each week. No documentation in plan of care of nursing performing a 24 hour assessment or other assessment interventions. Interview with RN M on Unit 4 at 3:00PM on 1/18/11; revealed that Residents 143's plan of care was worded that this resident received [MEDICAL TREATMENT] on Monday, Wednesday, and Friday with no individual problems, goals, or approaches done. | 2014-08-01 |
| 1958 | WILBER CARE CENTER | 285172 | 611 NORTH MAIN | WILBER | NE | 68465 | 2018-08-30 | 655 | D | 0 | 1 | FIS811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09C1a Based on record review and interview, the facility failed to ensure that the base line care plan was accurate for Resident 36. Facility sample size was 24. The facility census was 48. Record review revealed that the resident was admitted on with 5/17/18 complicated urinary tract infection. The Baseline Care Plan did not address the UTI (Urinary Tract Infection) or risk of UTI. Record review of Medication Administration Record [REDACTED]. Record review of Care plan Baseline had not addressed the UTI or the risk of UTI. On 08/28/18 at 02:04 PM, interview with DON (Director of Nurses) confirmed that the admitting [DIAGNOSES REDACTED]. | 2020-09-01 |
| 4346 | BCP MILFORD, LLC | 285132 | 1100 WEST 1ST STREET | MILFORD | NE | 68405 | 2017-04-24 | 318 | D | 0 | 1 | 3QPH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09D4 Based on observations, record review and interview, the facility failed to provide range of motion and application of splint device to prevent further decline in range of motion for 1 (Resident 23) of 3 sampled residents. The facility had a total census of 45 residents. Findings are: Resident 23 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations on 4/18/17 at 10:38 AM revealed Resident 23's hand was contracted into a fist with no splint device in place. Observations on 4/20/17 at 10:04 AM revealed Resident 23's left hand was contracted in to a fist with no splint device in place. A review of MDS (Minimum Data Set; a comprehensive assessment used for care planning) dated 4/15/17 revealed Resident 23 had functional limitation of range of motion on both sides of upper and lower extremities. A review of Resident 23's Care Plan revealed a problem dated 2/17/12 related to activities of daily living. Resident 23 was noted to have contractures to all extremities, trunk and neck. Approaches for this problem included receiving range of motion during dressing and other daily cares by nursing staff; encourage resident to consider splints for hands to prevent further contractures, nursing staff unable to provide range of motion to lower extremities due to contractures of extension, and praise resident when participates in exercise or range of motion. A review of Occupational Therapy Discharge Summary dated 8/29/16 indicated that Resident 23 met goal of increasing right shoulder flexion and extension all joints/all planes. Discharge summary identified Resident 23 had reached maximum potential was being referred to restorative nursing program/functional maintenance program. Occupational Therapy Note dated 8/29/16 stated Resident 23 requesting something to open hand up. Resident 23 was given choices and selected palm contracture guard device. A review of Restorative Nursing Care Record for 10/2016 revealed Resident 23 received range of motion to upper extremities 27 times in 10/2016. Monthly restorative review and note dated 10/31/17 stated goals were met and restorative would be discontinued. A review of Restorative Screening and Assessment revealed notation dated 1/31/17 that Resident 23 had no change in activities of daily living. In interviews on 4/23/17 at 10:57 AM and 12:15 PM Nurse Aide A reported staff assist resident with dressing but do not provide range of motion. Nurse Aide A did not recall seeing a splint device for Resident 23. In an interview on 4/24/17 at 12:07 PM Occupational Therapist B reported that that a palm guard was order for Resident 23. Occupational Therapist B reported showing nursing staff how to use but did not follow up after that. Occupational Therapist B confirmed a resident with contractures would benefit from ongoing range of motion. In an interview on 4/24/17 at 9:56 AM, the Director of Nursing reported residents are placed on restorative based on needs including an increase in need for assistance with activities of daily living or falls. When a resident is taken off depends on how they are doing. The Director of Nursing reported range of motion for Resident 23 would be provided with dressing. | 2020-08-01 |
| 10825 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2012-10-09 | 309 | D | 1 | 0 | 48UM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09D5 Based on observations, interviews, and record review; the facility failed to ensure a medical evaluation was completed for adverse behaviors for 1 (Resident 1) of 4 sampled residents. The facility had a total census of 240 residents. Findings are: Resident 1 was admitted to the facility on [DATE] according to Resident 1's care plan. Admission history and physical dated 8/20/12 listed a [DIAGNOSES REDACTED]. A review of Nurse's Notes for Resident 1 dated 9/22/12 revealed Resident 1 was observed standing over Resident 3 touching Resident 3 on buttocks and pubic region. According to the facility investigation summary dated 9/25/12, Resident 3 was fully clothed. According to the facility investigation completed 9/26/12, the following interventions were put in place in response to the incident: -Both residents were placed on 15 minute checks; -Care plans were reviewed and Resident 1's care plan was up dated; -Geriatric Psychiatric service was notified. The facility investigative report stated both residents were followed by the Geriatric Psychiatric Service. A review of the facility investigative summary dated 9/26/12 revealed Resident 1 was observed to take a hold of Resident 2's hand while Resident 2 was walking with family member. Resident 1 stated Resident 1 would marry either one of them and pulled Resident 1's penis out of pants with other hand and shook it. According to the facility investigation completed 9/28/12, the following interventions were put in place in response to the incident: -Resident 1 was continued on 15 minute checks -On 9/26/12, Resident 1 was moved to a room closer to the nurses' station and away from Resident 2's room. -Geriatric Psychiatric Services was notified of the incident. The facility investigative report stated both residents were followed by the Geriatric Psychiatric Service. -Staff were to use 1:1 supervision intermittently to help calm resident behaviors. Observations on 10/3/12 at 8:13 AM revealed Resident 1 was being assisted out of bed in room [ROOM NUMBER]. In an interview at 8:16 AM on 10/3/12, LPN (Licensed Practical Nurse) A reported Resident 1 was moved to room [ROOM NUMBER] after Resident 1 was discovered standing over roommate making comments. Nurses' Notes for Resident 1 dated 10/2/12 at 11:45 stated Resident 1 was discovered standing over roommate stating Look at that lady, Isn't she pretty, I'm gonna get me some of that. Resident 1 was holding Resident 1's penis in Resident's 1 hand. Resident 1 was removed from the room. A review of Resident 1 medical record did not reveal any documentation which indicated Resident 1 had been seen by Geriatric Psychiatric Services although a fax was sent to Geriatric Psychiatric Services on 9/22/12 regarding the incident on 9/22/12. Nurses' Notes dated 9/25/12 stated Resident 1's primary physician was notified of incident on 9/22/12 and an order was received for a referral to Geriatric Psychiatric Services. A fax was sent to Geriatric Psychiatric Services on 9/25/12 at 10: 30 AM requesting a consult for Resident 1. A review of Resident 1's medical record revealed a fax was sent to Geriatric Psychiatric Services on 9/25/12 regarding incident involving Resident 1 on 9/25/12. A review of physicians' communication sheet for Resident 1 revealed incident on 9/25/12 was documented on this report. Entry was not signed by Resident 1's primary physician indicating that it had been reviewed. A review of Resident 1's physician progress notes [REDACTED]. In an interview on 10/3/12 at 1:43 PM, RN (Registered Nurse) B and RN C confirmed there was no evidence Resident 1's primary physician had been notified of incident on 9/25/12 or had seen Resident 1 since incident on 9/22/12. RN B and RN C also confirmed Resident 1 had not been seen by Geriatric Psychiatric Services. In an interview on 10/3/12 at 2:49 PM, RN B reported Resident 1 had been placed on one-to-one supervision. | 2015-10-01 |
| 12386 | GOLDEN LIVINGCENTER - GRAND ISLAND PARK PLACE | 285105 | 610 NORTH DARR AVENUE | GRAND ISLAND | NE | 68803 | 2010-09-23 | 248 | D | 1 | 1 | E49Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09D5b The facility failed to ensure that an ongoing program of meaningful activities was developed and provided for 2 residents (Residents 57 and 62). The facility census was 56 residents. The sample size was 26 residents. Findings are: A. A review of Resident 57's Initial Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 4/3/2008 revealed that Resident 57 was born on 5/9/1959; had previously resided at a MR/DD (Mental [MEDICAL CONDITION]/Developmentally Disabled) facility prior to admission to the nursing home; and had a customary routine that included being involved in group activities. Activity preferences at that time included: crafts/art; exercise/sports; music; reading; spiritual activities; and television. A review of Resident 57's most recent Annual MDS Assessment was completed on 5/6/2010. At that time, Resident 57's activity interests were documented as crafts/art; exercise/sports; music; reading; spiritual activities; and television. A review of Resident 57's CARE PLAN (5/30/2010) revealed that Resident 57 had been identified as responding well to "being outdoors and playing catch with a ball...able to kick a ball with instructions,,,responds well to in room activities...can give high five and able to hold hands". Interventions included: being seated near the activity leader or volunteer for assistance and using sensory materials during 1:1 visits. A review of Resident 57's RECREATION PARTICIPATION RECORDS revealed the following: - June 2010 - Resident 57 participated in "music" activities on 6 out of 30 days during the month; and participated in "Fit & Fun" on 1 day during the month. - July 2010 - Resident 57 participated in "movies" one day during the month; "music" activities 3 days during the month; "sensory/relaxing" activities 5 days during the month; "entertainment" once during the month; went outdoors twice during the month; had 2 documented 1:1 visits during the month; and watched/listened to television/radio 26 days during the month. - August 2010 - Resident 57 participated in one 1:1 visit during the month; and - September 1 - 22, 2010 - Resident 57 participated in "entertainment" activities once; "Fit & Fun" three times; 1:1 visits five times; and watched/listened to television/radio on 22 days during the month. A review of Resident 57's ACTIVITY DOCUMENTATION TOOL FOR IN ROOM USE revealed that the resident's "Activities of Choice" were documented on top of the form as: Music; outdoors - rides in wheelchair; hand massages; sound; spas; soft conversation; reading bible passages; also noted was to open the window curtains in room during the day. There were multiple documented entries regarding Resident 57 being "in the wheelchair watching television" or "listening to music". There were no documented entries regarding hand massages; wheelchair rides outdoors; using the sound machine; or reading the bible passages to the resident. NOTE: Observation of residents' room revealed no direct outside window in Resident 57's cubicle section within the room. A review of Resident 57's LIFE ACTIVITY PREFERENCES completed upon admission to the facility 4/2008; revealed that Resident 57's interests included: switches/vibrations; aquatics; tambourines; dancing; tactile exploration; auditory stimuli; and visual stimulation. A review of Resident 57's ANNUAL RECREATION assessment dated [DATE]; revealed that the resident had low vision/[MEDICAL CONDITION] issues; was able to sit in events for audio stimulus and enjoyed Fit & Fun; sound stimulus; reading out loud; pet visits; wheeling outdoors; holiday celebrations; music stimulus; and was able to hold and pass objects back and forth with 1:1 assistance Observations of Resident 57 included: - 9/20/2010 10:20AM - Resident observed sitting in wheelchair in room. Aquatic box sitting on dresser to the left of the resident. Television not on/music not playing. - 9/20/2010 2:10PM - Resident sitting in wheelchair in room. Aquatic box on dresser turned on. Television set playing Hawaiian music/videos. - 9/20/2010 4:30PM - Resident sitting in wheelchair. Residents' wheelchair is close to the wall between the television and the bed. The resident has one sock on one foot and the other foot is bare with a sock observed lying on the floor beside the wheelchair. The resident was observed making "bucking" movements in the wheelchair and yawning. The television was on playing Hawaiian music/videos. - 9/21/2010 9:38AM - Resident observed sitting in wheelchair facing television. Television channel on the Animal Planet station. The resident was moving about in the wheelchair in a "thrashing" motion. No noises being made, just moving back and forth. The Aquatic box on the dresser was turned on, but the resident was unable to see it from where the residents' wheelchair was placed. B. A review of Resident 62's Initial Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 4/3/2008 revealed that Resident 62 was born on 11/29/1959; had previously resided at a MR/DD (Mental [MEDICAL CONDITION]/Developmentally Disabled) facility prior to admission to the nursing home; and had a customary routine that included being involved in group activities. Activity preferences at that time included: cards/games; exercise/sports; music; reading; trips, wheeling outdoors; and television. At that time, Resident 62 was involved in activities 'some' of the time (1/3 to 2/3's of the time). A review of Resident 62's most recent full MDS Assessment was completed on 2/28/2010. At that time, Resident 62's activity interests were documented as being music; reading ; television and talking. A review of Resident 62's CARE PLAN (3/4/2010) revealed that Resident 62 was identified as having a "poor response" to others due to [DIAGNOSES REDACTED]. Interventions included: being provided with 1:1 activities; a trial of sensory stimulating activities such as massaging hands and 1:1's. A review of Resident 62's RECREATION PARTICIPATION RECORDS revealed the following: - July 2010 - Resident 62 participated in music once; participated in special events once; participated in sensory/relaxation activities once; participated in entertainment once; participated in "window view" on 26 days out of the month; participated in watching television/radio on 26 days out of the month; went outdoors on 3 occasions; and participated in 1:1's on 3 occasions. - August 2010 - Resident 62 participated in one Fit & Fun group during the month and one 1:1 visit during the month; and - September 1 - 22, 2010 - Resident 62 participated in five 1:1's during the month and watched television/radio on 22 days during the month. Observations of Resident 62 included: - 9/20/2010 3:00PM - Resident observed sitting in tilt in space wheelchair in residents room after being brought back into room by Activity director. Per interview, the Activity Director had just taken Resident 57 outside in the wheelchair for a ride around the building. - 9/20/2010 4:30PM Resident sitting in wheelchair in room. No television or music playing. Window curtains open. - 9/21/2010 9:42AM Resident observed sitting in wheelchair in room, facing out the window. Curtains open and light on in room. No music or television on. 9/22/2010 - 2:20PM Resident observed lying in bed on back. No TV, lights or music on. Resident eyes closed. No movements noted. Bed in low position. The residents' call light was in reach. 9/22/2010 - 2:20PM Resident observed lying in bed on back. No TV, lights or music on. Resident eyes closed. No movements noted. Bed in low position. The residents' call light was in reach. A review of Resident 62's ACTIVITY DOCUMENTATION TOOL FOR IN ROOM USE revealed that the resident's "Activities of Choice" were documented on top of the form as: Music; outdoors; rides in wheelchair; hand massages; sound machine; spas; soft conversation; reading Bible passages; and open the window curtains in room during the day. There were multiple entries with the resident documented as being up in the chair; music on; curtains open; being down in bed; looking outside; listening to music. There were no documented activities of being outdoors; reading Bible passages; hand massages or sound machine/spas. 9/22/2010 - 3:30pm Interview with the facility Activity Director revealed that nursing staff is responsible to complete ACTIVITY DOCUMENTATION TOOL FOR IN ROOM USE. Those are the activities that nursing staff provide for the residents. The Activity director confirmed that the residents weren't being taken out of their rooms very often and so now is slowly trying to do that for them. The activity director didn't know why they weren't taken out of the room for a facility birthday party stating that "staff aren't used to taking Resident 57 and Resident 62 out of the room". Interview with the Corporate Clinical Director on 9/22/2010 at 4:10PM revealed that the facility had not developed a quality assurance plan addressing the individualized activity issues for Resident 57 and Resident 62. | 2014-07-01 |
| 11666 | GOOD SAMARITAN SOCIETY - MILLARD | 285098 | 12856 DEAUVILLE DRIVE | OMAHA | NE | 68137 | 2011-10-20 | 323 | D | 1 | 0 | HIJ811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09D7 Based on observations, interviews, and record review, the facility failed to place Secure Guard bracelet (elopement prevention device) on resident in accordance with manufacturer's instructions for 1 (Resident 5) of 13 sampled and 2 non-sampled residents, failed to monitor function of Secure Guard bracelet on a daily basis in accordance with manufacturer's instructions and facility policy for 1 (Resident 4) of 13 sampled and 2 non sampled residents, and facility to implement assessed interventions to prevent falls for 1 (Resident 2) of 13 sampled and d2 non-sampled residents. The facility had a total census of 102 residents. Findings are: A. Resident 5 was admitted to the facility on [DATE] according to face sheet. Resident 5's Cumulative [DIAGNOSES REDACTED]. Resident 5's Care Plan included a problem dated 7/7/11 related to being at risk for elopement. The following Plans and Approaches were listed for Resident 5: -Take a picture of resident and keep in Medication Administration Record -Label all clothing with name -Secure guard transmitter to left wrist check placement each shift and functioning every day expiration May 2014 -Provide appropriate activities 1:1 if wandering -Notify family, medical doctor and Director of Nursing, Administrator of any elopement -Discuss possible move to a dementia unit with family. A Secure Guard transmitter/bracelet emits a radio frequency which triggers an alarm and/or locks the door when a resident wearing the bracelet approaches a monitored exit door. Incident Report dated 7/9/11 stated Resident 5 was found standing in front of the front door. The facility investigative report stated Resident 5 ". . . exited out of front door of the building and was standing in front of the door." The investigative report stated ". . .if resident had arm that had secure guard attached was raised more than 6 inches from the door handle the secure guard system did not function. Staff placed an additional secure guard bracelet on (Resident 5's) ankle, contacted family. Maintenance has had secure guard out to re-evaluate the secure guard system and maintenance on the system was completed." A review of undated investigative report regarding Resident 5 revealed the following: "On 7/17/2011 the above mentioned resident had exited the activity room door. Staff were alarmed by the alarm from (Resident 5's) secure guard bracelets and responded when staff arrived (Resident 5) was back in the activity room (Resident 5) stated "it was too hot out there." When visualized on the camera the time on the camera showed that (Resident 5) was outside the threshold of the door for 35 seconds and then came back in. Recently we had secure guard out to the building to upgrade our status of their devices at our front entrance. At this time we also have the secure guard devices working on the activity door." physician's orders [REDACTED]. In an interview on 10/19/11 at 10:09 AM, Staff Development Nurse F clarified doors equipped with Secure Guard lock when a resident wearing a Secure Guard bracelet approach the door in addition to an alarm sounding at the nurse's station. Observations at 10:46 AM on 10/19/11 revealed Resident 5 had Secure Guard bracelet on left wrist. Observations between 3:31-3:45 PM on 10/19/11 revealed Resident 5 had Secure Guard bracelet on left wrist. A check of functioning by Nurse G revealed Secure Guard bracelet on Resident 5's left wrist was functioning correctly. In an interview at 4:07 PM on 10/19/11, the DON (Director of Nursing) reported the range around the front door that would activate the Secure Guard system to lock the front door had been increased after Resident 5 eloped. The DON reported the second bracelet on Resident 5's ankle had been removed at that time. The exit doors equipped with the Secure Guard system were tested with a functioning Secure Guard bracelet beginning at 4:25 PM on 10/19/11. Observations revealed the locking system was not activated on the 200 unit courtyard door when the Secure Guard bracelet was held approximately 5 feet off the floor. The Secure Guard on the 200 unit courtyard door and the activity door was located near the floor. A review of Secure Care Products, Inc. Strap Instructions revised 8/24/04 stated "To ensure proper operation of the Transmitter, it must be in an upright or vertical position on the ankle." B. Resident 4 was admitted to the facility on [DATE] according to Face Sheet and discharged from the facility on 9/30/11 according to Discharge Summary. Resident 4 had a [DIAGNOSES REDACTED]. A review of facility investigative report dated 9/9/11 revealed the following: "on 9/3/11 about 4:30 pm, (Resident 4) was outside by the driveway about 15 ft from the front door in (Resident 4's) w/c (wheelchair). A staff member that was leaving brought (Resident 4) inside. (Resident 4) stated (Resident 4) wanted to leave, wanted to go home, didn't want to stay here. (Resident 4) calmed (Resident 4) and placed a secure band on (Resident 4's) w/c." The facility investigative report dated 9/9/11 stated the following later in the report: "On 9/6/11 about 4:00 pm, (Resident 4) again went out the front door. The secure guard did not alarm or lock the door. A visitor informed a staff that (Resident 4) was outside by the front door, and staff bought (Resident 4) in. (Resident 4) secure guard was not working and was replaced by a new one. Both secure guards were checked prior to them being placed on (Resident 4's) w/c. Upon further investigation, it is felt the first one may not have been at full strength. It worked with the tester, but apparently was not strong enough to lock the door." Interdisciplinary Progress Notes for Resident 4 dated 9/4/11 stated "Wanderguard in place on chair." Interdisciplinary Progress Notes dated 9/5/11 for Resident 4 did not address checking Resident 4's Secure Guard bracelet for either functioning or placement. A review of Resident 4's Treatment Administration Record revealed checking Secure Guard for placement was first initialed as completed on the 3 PM-11 PM shift on 9/6/11 and checking Secure Guard for functioning was first initialed as completed on the 7 AM-3 PM shift on 9/10/11. In an interview on 10/20/11 at 2:10 PM, the DON confirmed there was no documentation that the functioning of Resident 4's Secure Guard bracelet had been checked on 9/5/11. Secure Care Products, Inc. manual revised 8/24/04 stated the following: "A documented test of each ankle transmitter at the facility must be made each day." A review of facility Policy & Procedure regarding bed, chair and door alarms revised 10/08 revealed wandering bracelets are to be checked daily to see if alarm sounds. Record review of a Face Sheet dated 8/29/2011 revealed Resident 2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Falls Data Collection Tool sheet dated 10/07/2011 revealed Resident 2 scored a 23. According to the information on the Falls Data Collection Tool sheet, a score of 12 or higher equals high risk. record review of Resident 2's Comprehensive Care Plan (CCP) dated 8/29/2011 revealed Resident 2 had "decreased mobility" and had a history of [REDACTED]. The interventions identified in the CCP included using a pressure relief alarm to the bed and wheelchair. Observations on 10/19/2011 at 9:47 AM and 10:28 AM revealed Resident 2 was seated in a wheelchair without a pressure relieving alarm. Observation on 10/20/2011 at 8:00 AM revealed Resident 2 was in the dining room for breakfast. Resident 2 did not have a pressure Relieving alarm in place. A interview with Licensed Practical Nurse (LPN) E was conducted on 10/20/2011 at 8:02 AM, During the interview, LPN E confirmed Resident 2 did not have a pressure relieving alarm in place. A follow up interview with LPN E was conducted on 10/20/2011 at 8:07 AM. during the interview, LPN E confirmed Resident 2 was to have the alarm on at all times. | 2015-02-01 |
| 11631 | MAPLE CREST CARE CENTER | 285149 | 2824 NORTH 66TH AVENUE | OMAHA | NE | 68104 | 2011-09-12 | 323 | G | 1 | 0 | MU3W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09D7 Based on record review, observations, and interviews, the facility failed to implement care planned fall alarm interventions to prevent falls for 1 (Resident 9) of 10 sampled residents. The facility had a total census of 124 residents. Findings are: Resident 9 was admitted to the facility on [DATE] according to admission record. Resident 9's 8/29/11 history and physical included a [DIAGNOSES REDACTED]. Resident 9's care plan included a problem dated 7/12/11 of potential risk for falls. Interventions listed included use of a bed alarm when in bed. Occurrence Report for Resident 9 dated 8/28/11 at 11:15 PM stated "Dr. White' called; noted res outside of room in hallway laying flat on (gender) back." On occurrence checklist alarm and alarm activated were both checked no. In an interview on 9/8/11 at 7:45 AM, RN D reported Resident 9's bed alarm was on Resident 9's bed and not attached to Resident 9 when Resident 9 was found on floor in hallway. Radiology Report dated 8/29/11 for Resident 9 stated Resident had an acute right hip fracture. A review of acute care plan dated 8/29/11 for Resident 9 revealed Resident 9 was to have bed and chair alarms and floor mats down when in bed. Observations of Resident 9 in wheelchair in room at 7:45 AM on 9/8/11, in wheelchair in dining room at 8:05 AM and in wheelchair in resident lounge at 9 AM revealed Resident 9's chair alarm was not hooked up. In an interview on 9/12/11 at 11:45 AM, the DON (Director of Nursing) confirmed Resident 9 was to have sit stand alarm in place. | 2015-03-01 |
| 6152 | BEAVER CITY MANOR | 285269 | P O BOX 70, 905 FLOYD STREET | BEAVER CITY | NE | 68926 | 2016-02-11 | 431 | D | 0 | 1 | Q2NL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.12E4 Based on observation, record review and interviews; the facility failed to ensure a discontinued medication was not available for resident use for Resident 10. The facility census was 21. Findings are: Observation of the medication administration by LPN (Licensed Practical Nurse)-G for Resident 10 on 02/09/2016 at 7:01 AM revealed LPN-G took a tube of Triamcinolone Cream 0.1% (a steroid cream used to treat skin inflammation) from the medication cart drawer. Interview with LPN-G on 02/09/2016 at 7:01 AM revealed Resident 10 had been receiving the Triamcinolone Cream 0.1% routinely and was currently receiving it quite regularly on a PRN (as needed) basis. Observation on 02/09/2016 at 7:02 AM revealed LPN-G reviewed the electronic MAR (medication administration record) and then said that the Triamcinolone Cream 0.1% had been discontinued and there was not a PRN order. LPN-G placed the medication back into the medication cart drawer. Record review revealed the medication had been ordered on [DATE] and was to be given for 2 weeks. Observation of the medication cart storage on 2/11/2016 at 5:05 PM revealed Resident 10's discontinued Triamcinolone Cream 0.1% was in the medication cart drawer. Interview with LPN-H on 2/11/2016 at 5:06 PM confirmed that the Triamcinolone Cream 0.1% order was discontinued and there was no PRN order. LPN-H confirmed the discontinued medication was still in the medication cart and available for Resident 10's use. Interview with DON (Director of Nursing) and NHA (Nursing Home Administrator) on 2/11/2016 at 5:30 PM revealed that their expectations were that all discontinued medications would be removed by the nurse from the medication/treatment cart at the time the order was received. | 2019-06-01 |
| 11681 | LIFE CARE CENTER OF OMAHA | 285137 | 6032 VILLE DE SANTE DRIVE | OMAHA | NE | 68104 | 2011-10-17 | 411 | D | 1 | 0 | 6KY011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.14 Based record review and interview, the facility failed to arrange routine dental services for 2 (Residents 3 and 5) of 9 sampled and 3 non-sampled residents. The facility had a total census of 104 residents. Findings are: A. Resident 5 was admitted to the facility on [DATE] according to the Face Sheet. According to Diagnosis/History, Resident 5 has a [DIAGNOSES REDACTED]. A review of Resident 5's medical record did not reveal any evidence of Resident 5 being provided or refusing routine dental services. In an interview at 10/17/11 on 11:25 AM, Social Worker A reported there was no documentation of Resident 5 being seen by a dentist since admission to the facility. In an interview on 10/17/11 at 11:34 AM, Resident 5 confirmed Resident 5 had not seen a dentist since admission to the facility. Undated facility policy stated the following: "Residents are provided with routine and emergency dental care when needed." Interviews with Social Worker A and Social Worker E at 10/17/11 at 10:07 AM revealed dental services are offered to residents and family members at a meeting held within 72 hours of admission. They reported the facility did not have a mechanism for tracking resident dental visits. B. Record review of a Face sheet dated 9/23/2011 revealed Resident 3 re-admitted to the facility on [DATE]. Record review of a Oral Assessment Form dated 6/24/2011 revealed the assessment did not identify Resident 3 with missing teeth. The sections of the assessment form identified as upper and lower had an area to be marked if the resident had missing teeth. These sections of the assessment were left blank. Record review of Oral Assessment Form dated 9/13/2011 revealed Resident 3 was assessed to have missing teeth to both, the upper and lower sections. An interview on 10/17/2011 at 10:15 AM was conducted with the Social Service Director (SSD). During the interview, the SSD was asked if Resident 3 had been seen by the Dentist, the SSD stated "no". Record review of a undated policy for dental services revealed he following: -Residents are assessed for oral health status and needs ninety (90) days after admission or fourteen (14) days after by a qualified dental professional. | 2015-02-01 |
| 1425 | LIFE CARE CENTER OF OMAHA | 285137 | 6032 VILLE DE SANTE DRIVE | OMAHA | NE | 68104 | 2017-01-11 | 325 | D | 0 | 1 | N57P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12.006.09D Based on interview, record review, and observation; the facility failed to evaluate the diet needs and provide the correct diet for one of one resident reviewed (Resident 141) related to [MEDICAL CONDITION] requiring [MEDICAL TREATMENT] and Diabetes. The facility census was 85. Findings are: Record review of Resident 141 medical record, revealed that Resident 141 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 141's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated 11/16/2016 revealed that, Resident 141's cognitive status score was 15 out of 15. Interview with Resident 141 revealed that with the [DIAGNOSES REDACTED]. Resident 141 revealed that prior education, to the diet that should be followed, was received, and that the diet being provided makes it difficult to follow the restrictions that Resident 141 had followed at the hospital and at home. Resident 141 revealed that it included limiting foods high in potassium, sugar, carbohydrates and phosphorus. Resident 141 revealed that family had provided food items, to maintain the diet restrictions. Record review of Resident 141's Physician order [REDACTED]. Record review of Resident 141 ' 2 Physician order [REDACTED]. Potassium is a nutrient that is critical to the function of nerve and muscle cells, including those in your heart. Your blood potassium level is normally 3.6 to 5.2 millimoles per liter (mmol/L).(* mayoclinic) and required 15 grams of [MEDICATION NAME] in 60 ml of [MEDICATION NAME] by mouth on Sunday (12/4/16) evening and to recheck potassium level on 12/5/16. ([MEDICATION NAME]/[MEDICATION NAME] drug to remove the potassium from the system by way of the gastric system). Record review of lab values, for Resident 141, from the [MEDICAL TREATMENT] center, performed on 11/28/16 revealed that Resident 141's Potassium was 6.4 mmol/L. Record review of Resident 141's Lab performed on 12/5/16 revealed a Potassium of 4.9 mmol/L. Record review of Resident 141's Nutrition Data Collection assessment dated [DATE] , Section 1, included a list of Resident 141's current [DIAGNOSES REDACTED]. Record revealed resident was on a Regular diet with regular condiments, with a supplement of a snack at bedtime. Section 2 revealed Resident 141's labs. Section 3 listed that Resident 141's energy needs of calories to be 1575 to 1875 calories per day, Protein needs of 69-88 grams per day, and fluid needs of 1575-1875 milliliters (ml) per day. A summary found in section 3 revealed that Resident 141's height was 60 inches, and had a current body weight of 250 pounds. Resident 141 was eating an average of 65% of meals on a regular diet with diet condiments. Resident 141's medications and labs were reviewed and that Resident 141 went to [MEDICAL TREATMENT] three times a week. Resident 141 had some weight loss, that may have been expected with [MEDICAL TREATMENT]. Resident 141 had a higher protein need related to [MEDICAL TREATMENT], and recommended to add 30 ml of prosource (a drink with protein) daily. Record review of a Progress note from Dietary on 11/14/16 revealed that Resident 141 ' s weight was stable, and oral intake was adequate. Recommendation was to continue with the same diet. Record review of Resident 141's comprehensive plan of care, dated 9/21/16, revealed that, Resident 141 had been at risk for complications, associated with [MEDICAL CONDITION] (high blood sugars) or [DIAGNOSES REDACTED] (low blood sugars), related to the [DIAGNOSES REDACTED]. Resident 141's goal was that hyperglycemic/hypoglycemic episodes would be minimized with medications and nutritional interventions, as ordered, through next review date of 12/21/16. Approaches to achieve this goal were listed as follows: Administer insulin as ordered. Observe for signs and symptoms of unstable blood sugar levels. Observe intake of meals and offer substitutes, supplements or alternative choices as needed. Perform blood sugars as order with sliding scale and long acting insulin as ordered. Report to physician signs or symptoms of unstable blood sugars. Record review of Resident 141's comprehensive plan of care, dated 9/21/16, revealed that Resident 141 had a nutritional risk related to the [DIAGNOSES REDACTED]. The goal set, for Resident 141, had been that there would not be a significant weight loss through next review, with the target dates of 12/21/16 and 3/2017. Approaches to achieve this goal were listed as follows: Diet per Physician order. Weights per Physician order. Offer meal substitutes as desired. Continue to monitor and encourage food intake at meals and as needed. Supplements per Physician order. Interview with Registered Nurse (RN) L, from the [MEDICAL TREATMENT] center that Resident 141 attended three times a week, on 01/10/2017 at 10:38 AM revealed that, the [MEDICAL TREATMENT] center's plan of care recommended a Renal diet. (*a diet prescribed in [MEDICAL CONDITION] and designed to control intake of protein, potassium, sodium, phosphorus, and fluids, depending on individual conditions) Interview with the Registered Dietitian (RD) M, from the [MEDICAL TREATMENT] center that Resident 141 attended three times a week, on 01/10/2017 at 1:09 PM revealed that, Resident 141 had been working with this RD, since (MONTH) of (YEAR). RD M revealed that Resident 141 was to be on a Renal diet and had increased protein needs. RD M revealed that Resident 141 demonstrated knowledge of a renal diet and that education was provided to Resident 141 regarding increasing protein was needed, and what items to choose. RD M stated that the [MEDICAL TREATMENT] center was not aware that Resident 141 was on a regular diet with regular condiments. Record review of a fax of Resident 141's [MEDICAL TREATMENT] Kardex, date of print, 1/10/17, was received from the [MEDICAL TREATMENT] center. The Kardex confirmed that Resident 141's Nephrologist ordered . dated 7//15/16, had specific of Protein 126gm/day, Sodium 2500mg/day, Phosphorus 1260 mg/day Potassium 2500 mg/day. Resident 141's fluids would be limited to 1200cc in a 24 hour period. The Nephrologist order was for a Renal Diet. Resident 141's was to also have had Carbohydrate controlled diet related to the Diabetes, and that these were established daily needs based on Average body weight of 105 kg, it had also included a plan to promote gradual weight loss. Record review of RD M's Physician Patient Notes for Resident 141, received 1/10/17 revealed Nutritional Status concerns as follows: Resident 141 had low [MEDICATION NAME], that began on the date of 11/3/16, [MEDICATION NAME] target goal was greater than or equal to 4.0 and the goal was not met. RD M's note listed the contributing factors and interventions to include Resident 141's diet, appetite, and pain, with education provided to resident. Resident 141 had a High Potassium, that began on the date of 11.30/16, the goal of the Potassium level for Resident 141 was 3.5-5.5 and the goal was not met. RD M's note revealed that Resident 141 had stated that there had been increase in consuming excess amount of fruits and vegetables, revealed that the diet at the facility, had included cling peaches and cottage cheese at some meals. RD M and Resident 141 discussed portion size and educated patient on diet. Resident 141 previously had potassium in target range. Resident 141 had Low [MEDICATION NAME], that began on the date of 12/07/16. The goal a target >=4.0 for Resident 141 was not met. RD M's note listed contributing factors as appetite with no change, education was provided to resident. Comments section revealed that Resident 141 was working on getting increased protein foods at the facility. Resident 141 requiring 5 hours of [MEDICAL TREATMENT]. Weight loss is desired. Resident 141 had a Elevated Phosphorus on 12/06/16. Resident 141's goal Phosphorus was 3.0-5.5,and goal was not met. Contributing factors and interventions were, RD M, evaluated Resident 141 ' s appetite, Resident 141 has had presence of gastrointestinal symptoms and nutrition related changes. [MEDICATION NAME] binders ([MEDICATION NAME] binders are medications used to reduce the absorption of [MEDICATION NAME] and taken with meals and snacks), reviewed by RD M with Resident 141. Resident having limited mobility and is on pain medication and managing bowels with medications, RD M would continue to follow. Interview with facility RD on 01/10/16 at 2:30 PM revealed that she had not reviewed Resident 141's record due to being new to the facility during survey. Facility RD did provide a copy of the facility Liberal Renal Diet, a diet moderately restricting sodium, potassium, and phosphorus and is extended on the facility menu. Food is prepared without additional salt. This diet does include Protein choices for the Resident, as well as lists of foods that are low, medium and high in Potassium and Phosphorous. Interview on 01/10/2017 at 9:55AM with Assistant Director Of Nursing (ADON) K confirmed that Resident 141 was on a regular diet, and confirmed that Resident 141 has had problems with elevated potassium. ADON K confirmed that Resident 141's plan of care does reveal that a consult with a Dietitian was to be as needed, for nutritional support, related to [MEDICAL CONDITION]. ADON K confirmed that when Resident 141's potassium was elevated, the facility Dietitian had not reviewed Resident 141's diet. Interview on 01/10/2017 at 11:55 AM Interview with facility Director of Nursing (DON) confirmed that a resident that required [MEDICAL TREATMENT] does have special dietary needs. The DON confirmed that Resident 141's diet was not communicated with the [MEDICAL TREATMENT] center and that the facility had not consulted with the [MEDICAL TREATMENT] Center's Dietitian to meet Resident 141's deitary needs. | 2020-09-01 |
| 9545 | GOOD SAMARITAN SOCIETY - SUPERIOR | 285187 | 1710 IDAHO STREET | SUPERIOR | NE | 68978 | 2013-01-31 | 278 | D | 0 | 1 | OXQ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC Licensure Reference Number: 12-006.09B Based on record review and interviews, the facility failed to accurately code MDS (Minimum Data Set, a federally mandated comprehensive tool utilized to develop resident care plans) for one sampled resident (Resident 40). Facility census was 63. Findings are: Record review of an MDS revealed the most recent assessment of ADL (Activities of Daily Living) Assistance as Limited assistance, staff provide guided maneuvering of limbs or other non-weight bearing assistance. The previous assessment as Independent and no assistance. Record review of Care Plan dated 12/26/12 revealed that resident had a problem identified as Self Care Deficit r/t (related to) Diabetes, [MEDICATION NAME] Degeneration, Diabetic [MEDICAL CONDITION], Arthritis, and was either independent or supervised with ADL's, needs limited assist with bathing. Further record review revealed that interventions were identified as the resident was independent with AM cares and dressing, may need occasional supervision and/or set-up assistance and was independent with PM cares and undressing, may need occasional supervision and/or set-up assistance. Interview on 1/31/13 with MA (Medication Aide) - I at 9:15 AM revealed that resident had not had any decline in ADL's, and was independent in dressing. Interview with MDS Coordinator at 9:30 AM on 1/31/13 confirmed that the resident had not had any significant changes or declines. Further interview revealed that the MDS Coordinator did see the MDS was incorrectly coded. | 2016-07-01 |
| 147 | TABITHA NURSING HOME | 285057 | 4720 RANDOLPH STREET | LINCOLN | NE | 68510 | 2019-10-22 | 661 | D | 0 | 1 | J64C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 661 Based on record review and interview the facility failed to ensure a recapitulation of stay was completed for 1 resident (Resident 125) of 1 resident reviewed for discharge to Long-term Care. The facility census was 162. Findings are: The facility failed to ensure a recapitulation of stay was completed for one resident (Resident 125). Record review of the Recapitulation of stay IDT summary revealed; that the document was not completed. Information on the IDT summary included; 1. Resident 125 had a fall with right hip repair, 2. The admission dx was fracture of unspecified part of neck of right femur. 3. The discharge date was 9 to a SNF (Skilled Nursing Facility). 4. Resident 125 had no complications during stay, 5. The equipment that would be needed was a manual wheelchair and Resident 125 had no teeth. 6. Resident 125'sCognition had not been completed 7. Resident 125's Communication was documented that (gender) was able to make needs known. 8. Resident 125's Dietary needs had not been completed 9. Resident 125's Activity needs had not been completed. 10. Resident 125's vitals had been recorded. 11. Resident 125's ambulation, Transfer, ADL(Activities of Daily Living) status had not been completed. 12. Resident 125's Skin integrity had not been completed. 13. Resident 125 was continent of bowel and bladder. 14. Resident 125's Medications were on the order summary report. 15. Resident 125's Post Discharge Plan of Care revealed; follow up physician appointments. Record review of Lab Corp revealed an order dated 9 for IV [MEDICATION NAME] for 7 days and had been diagnosed with [REDACTED]. Record review of 14 day MDS dated 9 revealed; 1. Section C Cognition revealed Resident 125 had a BIMS (Brief Interview for Mental Status an interview to determine memory loss) score was 12 indicated moderately impaired cognition. 2. Section G revealed; Resident 125 required extensive assist of 2 person with the following ADL's bed mobility, transfers, toileting, and dressing. Resident 125 was total dependent on staff for Locomotion on and off unit. 3. Section Q revealed; Resident 125 had participated in the Assessment. An interview with the ADON (Assistant Director of Nursing) on 10/17/19 at 11:30 AM confirmed; the recapitulation had not been completed for Resident 125 | 2020-09-01 |
| 1970 | WILBER CARE CENTER | 285172 | 611 NORTH MAIN | WILBER | NE | 68465 | 2019-12-17 | 759 | D | 0 | 1 | Q3K311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 759 LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review and interview the facility failed to ensure a medication rate of less than 5%. The medication error rate was 7.69% resulting from 2 errors of 26 opportunities. The facility census was 48. Findings are: [NAME] An observation on 12/16/19 at 12:05PM of medication administration by LPN (Licensed Practical Nurse B for Resident 41. The [MEDICATION NAME] 25mcg(micrograms), Aspirin 325mg(milligrams), Vitamin D3 1000 units, and [MEDICATION NAME] 5mg were crushed and added to pudding. [MEDICATION NAME] 125mg Sprinkles 2 capsules were opened with gloved hands and added to the pudding. The medication was administered while Resident 41 was eating the noon meal. Record review of Resident 41's physician orders [REDACTED].>[MEDICATION NAME] tablet; 25 mcg; amount: 25 mcg; oral Once a Day at 09:30. [MEDICATION NAME] tablet, delayed release (DR/EC); 125 mg; amount: 2 caps; oral Three Times A Day 10:00AM, 4:00PM, and 8:00PM. [MEDICATION NAME] chloride tablet; 5 mg; amount: 5 mg; oral Twice A Day 10:00 - 1PM 7:00 - 9:00PM. Aspirin (OTC) tablet; 325 mg; amount: 325 mg; oral Once A Day 10:00 - 1:00PM [MEDICATION NAME] (vitamin D3) (OTC) capsule; 1,000 unit; amount: 1,000 unit; oral Once A Day 10:00 - 1:00PM. An interview on 12/17/19 12:49 PM with DON (Director of Nurses) confirmed; the [MEDICATION NAME] should be given on an empty stomach. B. An observation on 12/16/19 at 12:27PM of medication administration by MA (Medication Aide) C for Resident 21. [MEDICATION NAME] 1 tsp (teaspoon) was added to 5.5 ounces of Cranberry Juice and mixed. Record review of Resident 21's physician order [REDACTED].>An interview on 12/17/19 12:49 PM with the DON confirmed; that the [MEDICATION NAME] for Resident 21 had not been given per the physician order. | 2020-09-01 |
| 11599 | MID-NEBRASKA LUTHERAN HOME | 285213 | 109 NORTH 2ND STREET | NEWMAN GROVE | NE | 68758 | 2011-07-13 | 309 | D | 0 | 1 | J4GR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ;LICENSURE REFERENCE NUMBER 175 NAC 12-006-09 Based on observations, record review and staff interviews, the facility failed to provide interventions to meet the individualized needs of Resident 24 with wheelchair positioning. Resident 24 was observed sitting in the wheelchair with head, neck and shoulders slumped forward. Facility census was 30. Findings are: Review of Resident 24 ' s Minimum Date Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/13/11 identified [DIAGNOSES REDACTED]. This MDS reflected Resident 24 required extensive assist with bed mobility, transfers, ambulation, dressing, toileting, personal hygiene and eating. The resident was also identified as having functional limitations to bilateral upper and lower extremities. Review of the Comprehensive Care Plan dated 6/13/11 indicated Resident 24 required assistance with all cares. The care plan indicated Resident 24 " cries to return to bed soon after the resident is gotten up in the chair. " Nursing approaches included placing resident in the wheelchair for meals and to get resident up only a short time before meals, then to return the resident to bed as quickly as possible after the meal. Resident 24 was observed sitting in a wheelchair in the dining room on 7/7/11 at 7:33 AM, 7/11/11 at 8:10 AM and 12:00 PM, 7/12/11 at 7:20 AM and 1:06 PM, and 7/13/11 at 8:15 AM with head, neck and shoulders slumped forward. No interventions were used to assist the resident to maintain an upright posture or to prevent the resident from slumping forward. During an interview 7/7/11 from 8:15 AM to 8:20 AM in the dining room NA-D (Nursing Assistant D) was observed feeding Resident 24 and stated " different positioning would probably help, we haven ' t tried anything that I know of. " During interview on 7/11/11 from 3:20 PM to 3:30 PM with RN-C (Registered Nurse C) and Director of Nursing (DON), the DON verified Resident 24 had poor positioning when sitting in current wheelchair and no interventions were in place to improve positioning. RN-C stated " I think Occupational Therapy (OT) put Resident 24 in current wheelchair, but I looked through the resident ' s medical record and could not find any documentation. " DON verified no documentation was available regarding previous evaluation of Resident 24 ' s sitting posture in current wheelchair. Review of Resident 24 ' s physician's order [REDACTED]. Review of Therapy Treatment Progress Notes dated 7/13/11 revealed OT assessment of wheelchair positioning. " Chair is too large for resident in all directions. Kyphosis (a curving of the spine that causes a bowing or rounding of the back, which leads to a hunchback or slouching posture) and slumped posture with chin almost touching abdomen. Currently sits in chair approximately 6 hours a day. Nursing reports starting to have difficulty with swallowing due to rounded posture. OT has made contact with a wheelchair vendor for assessment of seating system and to make appropriate changes to improve posture and bring resident into a more upright position. " Interview with the OT on 7/13/11 from 10:00 AM to 10:40 AM, verified a previous evaluation had not been performed. | 2015-04-01 |
| 3924 | HILLCREST COUNTRY ESTATES-COTTAGES | 285293 | 6082 GRAND LODGE AVENUE | PAPILLION | NE | 68133 | 2018-07-18 | 770 | D | 1 | 1 | NCIW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 175 NAC 12-006.09 Based on interview and record review, the facility failed to obtain physician order to discontinue previously ordered lab for 1 (Resident 78) of 1 sampled residents. The facility had a total census of 46 residents. Findings are: Resident 78 was admitted to the facility on [DATE] and discharged on [DATE] according to Face Sheet. A review of Care Plan Report for Resident 78 revealed a [DIAGNOSES REDACTED]. A review of Resident 78's physician orders revealed an order for [REDACTED].>A review of Clinical Notes dated 6/7/18 revealed Resident 78's physician had discontinued order for urinalysis. A review of Resident 78's physician orders revealed an order dated 6/13/18 to change Foley catheter and bag. A urinalysis and culture and sensitivity was to be obtained from the new bag. A review of Resident 78's Clinical Notes dated 6/13/18 at 7 PM revealed no clean Foley bag could be found after calling several cottages. A message was left with Director of Nursing that a new bag needed to be obtained and a specimen sent in the morning. A review of Resident 78's physician orders did not reveal any orders to discontinue the order for the urinalysis on 6/6/18 or 6/13/18. In an interview on 7/17/18 at 9:46 AM, Physician B verified that orders for urinalysis on 6/6/18 had been discontinued due to Resident 78 not showing signs or symptoms of a urinary tract infection and the urinalysis on 6/13/18 had been discontinued due to moving up Resident 78's appointment with the urologist. In an interview 7/17/18 at 11:33 AM, Regional Director of Clinical Services confirmed there was no physician order to discontinue orders for urinalysis on 6/6/18 or 6/13/18. | 2020-09-01 |
| 4424 | SCHUYLER CARE AND REHABILITATION CENTER, LLC | 285110 | 2023 COLFAX STREET | SCHUYLER | NE | 68661 | 2018-07-18 | 880 | E | 1 | 1 | NXEG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 175 NAC 12.006.17 175 NAC 12.006.17B 175 NAC 12.006.17D Infection Prevention and Control Based on observations, record review, and interview; the facility failed to ensure interventions were in place to prevent cross contamination related to resident care supplies being stored together affecting 4 residents; and related to not doing hand hygiene to prevent cross contamination for 2 residents. This had the potential to affect Resident 22, 24, 1, 23, 11 and 18. Sample size was 13. Facility census was 28. Observation on 07/16/18 at 03:09 PM revealed Perineal Care was provided to Resident 22 by NA A and B (Nurse Aides). It was noted that no hand washing was done upon entry to the room. Both nurse aides donned gloves and gathered the supplies. Nurse Aide B had done perineal-care to the front with a wet wipe then retrieved the trash bin and set it next to the bed and continued the perineal care without change of gloves nor hand sanitization. Perineal-care was done to the buttocks and anal area. Nurse aide B changed gloves without hand sanitization and applied cream to the buttocks bilateral. Nurse aide A applied cream to the front perineal area. Gloves removed by Nurse Aide B and put in the trash can, the liner was removed and Nurse Aide B left the room. Nurse Aide A removed gloves and put them in the trash, entered hall way where Nurse Aide A then touched other residents without evidence of hand sanitization. Interview on 07/17/18 at 02:41PM with the Assistant Director of Nursing revealed that there were no competencies for Nurse Aide [NAME] Record review on 07/17/18 at 02:41 PM revealed Perineal Care Policy and Perineal-care Audit that the staff was to gather the supplies prior to the start of the care, after washing the resident, gloves were to be removed and hand hygiene performed. The audit read that the staff were to clean up the work area, dispose of soiled linen in the trash bag, remove gloves and perform hand hygiene before leaving the room. B. Observation on 07/12/18 at 03:10 PM with Registered Nurse C (RN) revealed that RN C completed hand washing prior to hooking up the [MEDICATION NAME] for 7 seconds Record review of the facility's hand washing policy revealed that hand washing should be 20 seconds. C. Room observation on 7/12/18 at 2:09 PM revealed no individual names on towel bars in bathrooms of Residents 1, 23, 11, and 18. Room observation on 7/18/18 at 8:20 AM revealed no individual names on towel bars in bathrooms of Residents 1, 23, 11, and 18. Interview with the Administrator on 07/18/18 at 09:04 AM confirmed that that the towel bars weren't marked in the bathroom of resident rooms and this could possibly put residents at risk for infection. | 2020-07-01 |
| 4069 | HILLCREST MILLARD | 285302 | 13225 WESTWOOD LANE | OMAHA | NE | 68144 | 2019-09-25 | 725 | E | 1 | 0 | EL7411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 725 Licensure reference 12-006.04C Based on observations, interviews, and record reviews, the facility failed to ensure sufficient numbers of nursing staff to provide bathing assistance to 3 (Residents 8, 9, 10 and 14) of 6 current sampled residents, failed to answer call lights in a timely manner for 3 (Resident 8, 11, and 14) of 6 current sampled residents and in 3 of 5 confidential interviews residents reported concerns about staffing and ability to get call light answered. The facility had a total census of 65 residents. Findings are: [NAME] In confidential interviews conducted on 9/23/19 between 11 AM-2 PM and on 9/25/19 between 10:55-11:29 AM, 3 of 5 sampled residents reported concerns related to staffing and ability to get call lights answered. Comments included the following: -weekend staffing is a nightmare -resident reported waiting for an hour for assistance then getting self ready for bed -not uncommon to wait 20 minutes to get call lights answered -resident reported taking self to bathroom when was non-weight bearing -delay in answering call lights B. A review of Device Monitoring Records revealed the following: -Resident 14 had 25 call lights on for greater than 15 minutes out of 128 between 9/14/19-9/25/19 with one call light on for 62 minutes and 15 seconds -Resident 8 had 26 call lights on for greater than 15 minutes out of 96 between 9/13/19-9/23/19 with one call light on for 65 minutes and 58 seconds -Resident 11 had 17 call lights on for greater than 15 minutes out of 171 between 9/13/19-9/25/19 with one call light on for 47 minutes and 23 seconds In an interview on 9/24/19 at 2:38 PM, the Director of Nursing reported the goal is to have call lights answered within 15 minutes. In an interview on 9/23/19 at 3:15 PM, the Administrator reported that the facility has working on improving call light times by changing the escalation of call lights to nurse and management pagers, encouraging nurses to answer pages and implementing angel rounds in which administrative staff are given 6-8 rooms to round on each day to check with residents about needs. C. Resident 14 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations on 9/25/19 at 10:57 AM revealed Resident 14 had long whiskers on face. In an interview on 9/25/19 at 10:57 AM, Resident 14 reported having a shower the day before for the first time since admission but would have liked one sooner. Resident 14 reported Resident 14 would like to shave but did not have a razor. A review of Resident 14's Nurse Tech Care Plan revealed Resident 14 required 1 assist for transfer and walking. Resident 14's Nurse Tech Care Plan listed Resident 14 has preferring evening showers. In an interview on 9/25/19 at 11:29 AM, Nurse Manager A reported that staff should have asked Resident 14 if Resident 14 wanted to shave when getting a shower. In an interviews on 9/25/19 at 2:47 PM and 3:16 PM, the Director of Nursing reported no documentation could be found of Resident 14 getting a bath or shower. D. Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 8's Nurse Tech Care Plan revealed Resident 8 required 1 assist for transfers. Resident 8 bath preferences were listed as Monday and Friday morning. A review of Resident 8's bathing report revealed no documented baths between 9/11/19 and 9/23/19, a total of 12 days. In an interview on 9/25/19 at 3:17 PM, the Director of Nursing reported no other documentation of Resident 8 having a bath/shower since 9/11/19 had been located. E. Resident 9 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. In an interview on 9/23/19 at 12:30 PM, Resident 9 reported that sometimes it would take a couple of days to get a bath after asking. A review of Resident 9's Nurse Tech Care Plan revealed bath preference of evening on Sunday and Wednesday. A review of Resident 9's bathing reported revealed no documented baths between 8/31/19 and 9/13/19, a total of 13 days. In an interview on 9/25/19 at 3:17 PM, the Director of Nursing did not have evidence of additional baths being provided to Resident 9. F. In an interview on 9/24/19 10:16 AM, Nurse Aide B verified that resident baths are not getting done. In an interview on 9/24/19 on 2:38 PM, the Director of Nursing reported that there was a problem with the bath scheduling in the computer and the facility is working on getting it corrected. [NAME] In an interview on 9/24/19 at 2:38 PM, the Director of Nursing reported staffing has been a challenge with staff calling in and not coming in. | 2020-09-01 |
| 5310 | RIVER CITY NURSING AND REHABILITATION | 285058 | 7410 MERCY ROAD | OMAHA | NE | 68124 | 2017-01-23 | 225 | D | 1 | 0 | 5YZX12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Record review and interview the facility failed to complete a thorough investigation for 1 of 3 residents reviewed (Resident 4) related to an allegation of neglect. The facility census was 96 Findings are: Review of Resident 4 Admission Record dated 8/25/2016 revealed Resident 4 had the following Diagnosis: [REDACTED]. The facility investigation states the resident had an apneic(absence of breathing) episode on 11/1/2016 and staff were able to suction Resident 4's [MEDICAL CONDITION] and remove the obstruction and send Resident 4 to the hospital for further treatment. Review of the facility investigation revealed on 11/3/2016 the complainant voiced concerns regarding the need for Resident 4 to have been suctioned more often prior to Resident 4's hospitalization . Review of the facility investigation revealed a summary of the event that resulted in Resident 4 being transfered to the hospital on [DATE], however, did not address the care of Resident 4's [MEDICAL CONDITION] prior to the event. Review of Resident 4's progress note dated 11/1/2016 revealed no documentation of Resident 4's condition prior to or during the event requiring transfer to the hospital. Review of Resident 4s Treatment Administration Record (TAR) dated for (MONTH) (YEAR) revealed no suctioning or [MEDICAL CONDITION] site care was completed on the following dates: - 10/8/16 - 10/9/16 - 10/13/16 - 10/15/16 - 10/19/16 - 10/20/16 - 10/23/16 - 10/24/16 - 10/29/16 Interview with the Administrator revealed the Treatment Administration Record (TAR) had not been looked at during the investigation to determine if suctioning was completed as ordered and that should have been reviewed to determine the outcome of the concern voiced by the complainant. | 2020-01-01 |
| 1386 | LIFE CARE CENTER OF ELKHORN | 285134 | 20275 HOPPER STREET | ELKHORN | NE | 68022 | 2018-05-17 | 609 | D | 1 | 0 | 69JP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Record review and interview, the facility failed to report a fall resulting in a significant injury for 1 of 3 residents reviewed (Resident 1) to the state agency within 2 hours. The facility census was 95. Findings Are: [NAME] Review of Resident 1's progress notes revealed Resident 1 fell on [DATE] at 10:00 PM. Resident 1 did not initially complain of pain however, on 4/29/2018 Resident 1 did report increased pain. Review of Resident 1 progress notes revealed Resident 1 complained of leg pain and an x-ray was completed. The results of the x-ray was called to the facility at 9:00 PM indicating a fractured femur. Review of the facility VOI (Verification of Investigation) dated 5/3/3018 revealed the state agency was notified of the fall resulting in a significant injury on 4/30/2018 at 6:45 AM. Review of the facility policy dated 2/2018 titled Protection of Residents: Reducing the Threat of Abuse and Neglect revealed all events resulting in serious bodily injury are to be reported to the state agency within 2 hours. Interview with the VP Vice President) of clinical services revealed a report was called within 2 hours of the time the facility is aware of a significant injury. | 2020-09-01 |
| 1086 | EMERALD NURSING & REHAB LAKEVIEW | 285106 | 1405 WEST HWY 34 | GRAND ISLAND | NE | 68801 | 2018-05-07 | 625 | D | 1 | 1 | QN7C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility staff failed to issue notice of bed hold for 3 of 3 sampled residents's legal representative when Resident 22, Resident 33, and Resident 49 were transferred to the hospital. The facility identified a census of 55 at the time of survey. Findings are: [NAME] Review of Resident 22's Discharge Tracking and Entry records revealed Resident 22 was hospitalized [DATE] to 9/17/2017; 9/29/2017 to 10/2/2017; 10/6/2017 to 10/24/2017; 11/18/2017 to 11/21/2017; and 1/12/2018 to 1/13/2018. Record review of Resident 22's admission and discharge records revealed no documentation Resident 22's legal representative was given written notice of the facility's bed hold policy at the time Resident 22 was transferred from the facility to the hospital. Interview with the AC (Admission Coordinator) on 5/07/18 at 3:51 PM confirmed there was no documentation Resident 22's legal representative had been issued notice of the facility bed hold policy when Resident 22 was transferred to the hospital. The AC confirmed the bed hold notices had not been issued. Review of the undated facility policy Bed Hold Policy and Notification revealed the following: it is our policy to inform residents/legal representatives upon admission and after leaving the facility for hospitalization , observation or therapeutic leave of our bed hold policy and notification. Each resident/legal representative will be informed by of the facility's bed hold policy and notification upon admission to to the facility and/or when a resident leaves for hospitalization , observation or therapeutic leave. Before the resident may be transferred to a hospital or for a therapeutic leave, the facility is required to provide the facility's bed hold policy to the resident or legal representative. B. Review of the Progress Notes for Resident 33 dated 1/10/17 revealed the resident was a direct admission from a Physician Office visit to the hospital. The documentation was absent about notifying the family of the bed hold by the nursing staff. The family being notified of the admission to the hospital was absent. Review of Residents Census Tab (list changes in the residents admission status) revealed that on 1/10/18 Resident 33 was sent to hospital. C. Review of Resident 49's MDS's dated 10/16/17 and 2/16/18 revealed a discharge MDS with return anticipated for both dates. There were two (2) hospitalization s. Review of Progress Note dated 10/16/17 revealed Resident 49 was a direct admission to the hospital from a Physician Office visit. Attempts were made to contact the family. Documentation was absent about the bed hold policy education. Review of Progress Note dated 10/18/17 revealed the family was notified but the documentation was absent about the bed hold policy education. Review of Progress Noted dated 2/16/18 revealed Resident 49 was a direct admission to the hospital from a Physician Office visit. The family was notified but the documentation was absent about the bed hold policy education. Review of Residents Census Tab (list changes in the residents admission status) revealed that on 10/16/17 and 2/16/18 Resident 49 was sent to hospital. Interview on 05/07/18 at 01:49 PM with BOM (Business Office Manager) revealed that the Bed Hold Policy and letters are not being given with every discharge or transfer to hospital. | 2020-09-01 |
| 1986 | FLORENCE HOME | 285173 | 7915 NORTH 30TH STREET | OMAHA | NE | 68112 | 2017-12-06 | 578 | E | 1 | 1 | CVPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure the wishes for CPR (Cardiopulmonary Resuscitation) for 4 residents (Resident 13, 60, 32, 72) of 25 residents sampled were communicated to the nursing staff. The facility staff identified the facility census at 68. The findings are: [NAME] An interview conducted on [DATE] at 12:18 with Licensed Practical Nurse (LPN) A revealed that if a resident was unexpectedly found to not be breathing or without a heartbeat, the nursing staff would check their report sheets if they had one or for a blue dot on the spine of the resident's chart to see if the resident was to receive CPR. The residents that were supposed to receive CPR would have a blue dot on the spine of their chart. LPN A reported they would also look for a blue dot on the door, but that the dots on the door were not always up to date. Resident 72 was the only resident that had received CPR in the past 3 months and the resident expired after arriving to the hospital. A review of Resident 72's Face Sheet dated [DATE] revealed that the resident was admitted to the facility on [DATE] and that the resident was listed as no for resuscitate. A review of Resident 72's Resuscitate Policy form dated [DATE] revealed that Resident 72 had elected to not receive CPR if found to be without a heartbeat. A review of Resident 72's nurse's note dated [DATE] revealed that the resident was found without a pulse and not breathing and that CPR was started and maintained until the ambulance squad arrived and took the resident to the hospital. At the hospital, the resident was declared deceased . An interview conducted on [DATE] at 2:12 PM with the Social Services Director (SSD) revealed that the process for communicating CPR wishes was the responsibility of Admissions on admission or Social Services if the resident chose to change their CPR status after admission. The SSD reported that in (MONTH) (YEAR), the Social Services and Admissions department staff went through 100% of the residents charts to ensure each resident's CPR elections were accurately reflected on the chart, name plate, and Face Sheet. The SSD reported that there was not much of a chance that the blue dot sticker would fall off the charts as the stickers are on the resident's name label that is inside a plastic holder. An interview conducted on [DATE] at 2:27 PM with LPN B revealed that when Resident 72 was found without a heartbeat, their Face Sheet said they were a full code and that the old Resuscitate policy indicating resident was to receive CPR was in the chart. LPN B reported that new staff were trained in new hire orientation that blue dots signified the resident was to receive CPR. LPN B reported that Social Services had gone through the entire building in (MONTH) making sure each resident's CPR elections were correct on the chart, name plate, and Face Sheet. A review of the facility's CPR Guideline dated ,[DATE] revealed the following: CPR, when indicated, will be performed on those residents who have yes checked on the Resuscitate Policy in their chart. A blue dot will be placed on the name plate outside of the resident's room, a blue dot will be placed on the outside of their chart B. A review of Resident 13's Face Sheet dated [DATE] revealed that the resident was admitted to the facility on [DATE] and that the resident was listed as yes for resuscitate. A review of Resident 13's Resuscitate Policy form dated [DATE] revealed that Resident 13 had elected to receive CPR if found without a heartbeat. An observation conducted on [DATE] at 10:18 AM revealed that Resident 13's chart did not have a blue dot on the spine which would make nursing staff think the resident was not to receive CPR. An interview conducted on [DATE] at 3:03 PM with Registered Nurse G confirmed that Resident 13's chart did not have a blue dot on the spine. C. A review of Resident 32's Face Sheet dated [DATE] revealed that the resident was admitted to the facility on [DATE] and that the resident was listed as yes for resuscitate. A review of Resident 32's Resuscitate Policy form dated [DATE] revealed that Resident 32 had elected to receive CPR if found without a heartbeat. An observation conducted on [DATE] at 10:20 AM revealed that Resident 32's chart did not have a blue dot on the spine. An interview conducted on [DATE] at 2:53 PM with LPN C revealed that Resident 32's chart did not have a blue dot on the spine which would make nursing staff think the resident was not to receive CPR. D. A review of Resident 60's Face Sheet dated [DATE] revealed that the resident was admitted to the facility on [DATE] and that the resident was listed as no for resuscitate. A review of Resident 60's Resuscitate Policy form dated [DATE] revealed that Resident 60 had elected to not receive CPR if found without a heartbeat. An observation conducted on [DATE] at 10:59 PM revealed a blue dot on the resident's name plate. An interview conducted on [DATE] at 2:53 PM with LPN C revealed that Resident 60's name plate was marked with a blue dot which would make nursing think the resident was to receive CPR. | 2020-09-01 |
| 2373 | GOOD SAMARITAN SOCIETY - BEATRICE | 285203 | 401 S 22ND STREET | BEATRICE | NE | 68310 | 2017-09-13 | 323 | D | 1 | 1 | 9PTJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to investigate ongoing falls for 1 of 3 residents reviewed for Accidents (Resident #94) in order to determine if identified interventions were implemented and/or effective and to develop new interventions to prevent recurrence. Findings are: Resident #94 was deceased and not available for interview or observation. According to the [DATE] Summary of Skilled Services admission note, Resident #94 was admitted to the facility due to a history of falls, required two staff assistance with transfers and required a lot of assistance pulling himself into an upright position. The Care Conference note, dated [DATE], revealed the resident's spouse indicated that (resident) had a lot of falls at home as the resident did not use the walker. The Falls Tool, dated [DATE], identified the resident was at low risk for falls. The Physical Device and Restraint Assessment, dated [DATE], indicated an assist grab bar on the bed would be appropriate as it would make the resident able to repo(sition) and sit up by self. Review of Nursing Progress Notes between the resident's admission on [DATE] and death on [DATE] revealed he experienced 19 falls. Review of the Fall Scene Huddle Worksheets and Investigation forms, completed after each fall, revealed staff documented sometimes conflicting information, or lacked the details necessary to assess the cause of each fall and to develop new interventions to prevent recurrence. In addition, the facility failed to identify potential trends related to the grab bar as a risk factor for injury with falls. For example: According to a nurse progress note, dated [DATE] 0133, residents call light was on, staff went to answer his light, staff turned on the light and saw him lying on the floor with his head between the hand rail and bed. staff removed the hand rail and bed . Review of the Fall Scene Huddle Worksheet, dated [DATE], indicated the resident fell at 12:35 a.m. This form also identified the resident last had contact with a staff member at 11:30 p.m. about an hour prior to the fall. The form also indicated the resident was last toileted at 12:30 a.m. There was no clarification to this contradictory information. The Investigation indicated the resident, was rolling over and was too close to edge of bed and he couldn't stop and kept rolling. There was no indication the call light was on, as identified in the progress note. Neither the Fall Scene Huddle Worksheet or Investigation were signed by the staff member who completed them, making follow-up difficult. Neither of these forms identified the resident was caught between the grab bar and the bed. There was no follow up by the facility regarding this discrepancy, and the resident continued to have the grab bar on his bed. The [DATE] 0137 progress note indicated the resident was, found upper body still in bed, lower body on fall mat next to bed. The Fall Scene Huddle Worksheet included a hand drawn picture that made it appear as though the grab bar was potentially involved. There was no follow up by staff to determine if that was the case, or whether the grab bar could be a risk factor given the resident's upper body remaining in the bed after a fall. The [DATE] 2359 progress note identified the, Resident rolled out of bed. Lower half of body on fall mat. Neck area caught on grab bar. Resident face red in color. Lowered grab bar to free neck area . No injuries noted. After this incident, the facility re-assessed the grab bar and removed it from the resident's bed. Additional falls, without the grab bar as a potential factor, also lacked specific, consistent details in order to prevent recurrence. The [DATE] Fall Scene Huddle Worksheet indicated the resident fell in the bathroom attempting to self-transfer. When asked to identify the time the resident was last toileted (information that could be used to determine if the resident received the care he required, was having urgency or frequent voiding, or required any new interventions), staff documented, at time of incident. In addition, the form was not signed or dated by the staff member who completed it making follow-up difficult. The [DATE] Fall Scene Huddle Worksheet was not signed or dated by the staff member who completed it. It did not provide responses to the questions of what staff member last had contact with the resident prior to the fall, or when that had occurred. It did not identify when the resident was last toileted. The Investigation identified the resident was in bed, reaching for the call light and slid out of bed. The intervention to prevent recurrence was, make sure call light is within reach. The investigation did not identify where the call light was when the resident fell . This information would be useful to determine if staff had met the resident's needs prior to the fall or whether an alternative call light might be useful. The [DATE] Fall Scene Huddle Worksheet indicated the resident fell at 9:00 a.m. It also identified the resident was last provided care, 2 hours prior to the fall when he was toileted. The same worksheet also noted the resident was last toileted at 5:30 a.m. (3 1/2 hours prior to the fall). This conflicting information was not clarified on the worksheet, preventing the facility from determining if he had been provided care as care planned or needed more frequent toileting. The [DATE] Fall Scene Huddle Worksheet indicated the resident was last seen by staff 8 minutes prior to his fall at 6:43 p.m. The intervention to prevent recurrence was, Staff to monitor every 2 hours. There was no indication how this would prevent recurrence when the resident was frequently found to have fallen less than 30 minutes after being seen by staff, and in the case of this fall, less than 10 minutes after staff observed him. In an interview on [DATE] at 4:29 p.m., Staff A, Administrator, stated she did not recall anything about the [DATE] incident involving the grab bar. She stated the Fall Scene Huddle Worksheet should always be signed by the staff member who completed it. She stated she expected the progress note and the Fall investigations to match, and if there was contradictory information it would be addressed when the Administrator, Director of Nursing, and Social Worker reviewed (and signed) the Investigation forms. She was unable to explain why this, and other discrepancies had not been identified by the facility. In an interview on [DATE] at 9:24 a.m., Unit Manager, Staff D, reviewed the above-mentioned fall investigations. She stated for the [DATE] fall, the investigatory forms should be complete and detailed. She stated the time the resident was last toileted should be identified and that the staff member who completed the form should sign it. She stated staff review the fall investigations, however, don't always see those things. For the [DATE] fall, she stated the location of the call light should have been included, otherwise we can't tell what was happening. She also stated the last time he was cared for or seen should be included. She stated the information in the [DATE] fall was inconsistent, for the [DATE] she could not tell if the grab bar was included in the fall, and that the intervention to check every two hours after the [DATE] fall was not appropriate given the circumstances of the falls. | 2020-09-01 |
| 1347 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2017-08-02 | 156 | D | 1 | 1 | YKIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide a cost listing of what Medicaid would and would not cover upon admission. This effected 2 residents (Resident 161 and 285 ). The facility census was 110. Findings are: [NAME] Record review of Resident 161's Face Sheet, dated 7/27/17, revealed that, Resident 161 was admitted to the facility on [DATE]. Record review of Resident 161's Census History, dated 7/27/17, revealed that Resident 161 became Medicaid eligible on 5/1/2016 . Interview on 7/26/17 at 3: 40 PM with Resident 161's family revealed that staff did not provide a list of services and items that would and would not be charged for when Resident 161 became eligible for Medicaid. Interview with the facility business office, Staff Member I, on 7/27/17 at 3:10 PM confirmed that there was not a form provided to Resident 161's family upon eligibility for Medicare. Interview with the facility Administrator on 7/27/17 at 3:11 PM confirmed that the facility did not provide information to Resident 161's family regarding Medicaid coverage and charges. B. Record review of Resident 285's Face Sheet, dated 7/27/17, revealed that, Resident 161 was admitted to the facility on [DATE]. Record review of Resident 161's Census History, dated 7/27/17, revealed that Resident 161 became Medicaid eligible on 7/22/16. Interview on 7/26/17 at 2:45 PM with Resident 285's family revealed that staff did not provide a list of services and items that would and would not be charged for when became eligible for Medicaid. Interview with the facility business office, Staff Member I, on 7/27/17 at 3:10 PM confirmed that there was not a form provided to Resident 285's family upon eligibility for Medicare. Interview with the facility Administrator on 7/27/17 at 3:11 PM confirmed that the facility did not provide information to Resident 285's family regarding Medicaid coverage and charges. | 2020-09-01 |
| 3416 | WESTFIELD QUALITY CARE OF AURORA | 285263 | PO BOX 166, 1313 1ST STREET | AURORA | NE | 68818 | 2019-11-13 | 712 | D | 1 | 0 | P0CC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility staff failed to ensure Resident 2 was seen by their physician/medical provider or physician delegate (physician delegate: physician assistant, nurse practitioner, or clinical nurse specialist) every 60 days. This affected 1 of 3 sampled residents. The facility identified a census of 64 at the time of survey. Findings are: Review of Resident 2's Admission Record revealed an admission date of [DATE]. Review of Resident 2's Clinical Health Records revealed Resident 2 was seen by a physician/medical provider on 6/5/19, 6/18/19, 6/24/19, and 8/26/2019. Resident 2 was seen by an optometrist/ophthalmologist (eye doctor) on 10/9/2019. There was no documentation Resident 2 had been seen by their physician/medical provider since (MONTH) 26, 2019. Review of Resident 2's Progress Notes revealed no documentation Resident 2 had been seen by their physician/medical provider since (MONTH) 26, 2019. Interview with the BOM (Business Office Manager) on 11/13/2019 at 2:45 PM revealed that some residents only wanted to be seen by their physician annually. The residents and/or responsible parties were to sign a Physician Visit Form which indicated they only wanted to see their physician/medical provider annually. The BOM confirmed Resident 2's appointment in (MONTH) was an eye Dr. appointment, not with their physician/medical provider. Requested documentation that Resident 2 refused to be seen by their physician/medical provider every 60 days. Review of Resident 2's medical record revealed no documentation Resident 2 or their responsible party had declined to see their physician/medical provider every 60 days. Interview with the BOM on 11/14/2019 at 3:35 PM confirmed they could not find Resident 2's Physician Visit Form which would have indicated Resident 2's preference of when they wanted to see their medical provider. Review of the facility policy Physician Visits and Physician Delegation dated (YEAR) revealed the following: It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. The Physician should see resident within 30 days of initial admission to the facility. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by State Law. | 2020-09-01 |
| 736 | EMERALD NURSING & REHAB COZAD | 285093 | 318 WEST 18TH STREET | COZAD | NE | 69130 | 2018-02-07 | 625 | D | 1 | 0 | Y9LY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility staff failed to notify the legal representative for Resident 1 and Resident 3 of the facility Bed Hold policy at the time of discharge. This affected 2 of 3 sampled residents. The facility identified a census of 58 at the time of discharge. Findings are: [NAME] Review of Resident 1's Discharge Tracking Form dated 1/11/2018 revealed Resident 1 was admitted to the facility on [DATE] and discharged from the facility to the hospital on [DATE]. Interview with Resident 1's legal representative on 2/7/2018 at 12:12 PM revealed the facility had not given Resident 1's legal representative notice of Bed Hold when Resident 1 was transferred to the hospital. Review of Resident 1's medical record revealed no documentation Resident 1's legal representative had been given notice of Bed Hold upon discharge to the hospital. B. Review of Resident 3's Discharge Tracking Form dated 12/26/2017 revealed Resident 3 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Review of Resident 3's medical record revealed no documentation Resident 3's legal representative had been given notice of Bed Hold when Resident 3 was transferred to the hospital. Interview with the DON (Director of Nursing) on 2/7/2018 at 3:59 PM confirmed there was no written documentation the legal representatives for Resident 1 or Resident 3 were given notice of Bed Hold. Interview with the interim SSD (Social Services Director) on 2/7/2018 at 4:05 PM confirmed the facility residents and/or legal representatives were to be issued the facility Bed Hold policy at the time of transfer and/or discharge. Review of the undated facility policy Bed Hold Policy and Notification revealed the following: It is our policy to inform residents/legal representatives upon admission and after leaving the facility for hospitalization , observation or therapeutic leave of our bed hold policy and notification. Each resident/legal representative will be informed by of the Facility's Bed Hold Policy and Notification upon admission to the facility and/or when a resident leaves for hospitalization , observation or therapeutic leave. | 2020-09-01 |
| 3421 | WESTFIELD QUALITY CARE OF AURORA | 285263 | PO BOX 166, 1313 1ST STREET | AURORA | NE | 68818 | 2019-11-13 | 842 | D | 1 | 0 | P0CC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review; the facility failed to ensure meal intakes were documented. This affected 2 of 3 sampled residents (Residents 3 and 4). The facility identified a census of 64 at the time of survey. Findings are: Resident 3 [NAME] Review of Amount Eaten by Resident 3 revealed that Resident 3 had 2 meals on 10//17/19; 2 meals on 10/24/19 and 2 meals on 10/29/19 there was no documentation of refusals for a meal. Review of PN (Progress Notes) for Resident 3 revealed: PN dated: 10/18/19 at 8:46 PM Resident very upset about supper. States resident was tired of sitting in the dining room for long periods of time waiting for residents food. States staff don't feed resident in a timely manner. States that resident can't transfer by self anymore to bed or bathroom and that upsets resident. Tried to comfort and talk with resident regarding the meals. Informed resident that meals are rotated with who staff serve first and that do to staffing. 400 hall and those that need assistance need to come first. Resident 4 B. Review of Amount eaten by Resident 4 revealed that Resident 4 had 2 meals recorded on 11/7/19; 1 meal on 11/8/19; 2 meals on 11/9/19; and 2 meals on 11/10/19 there was only one documentation of a meal not received for Resident 4. Review of PN ( Progress Notes) for Resident 4 revealed there was no documentation stating resident refused meals. There was a documentation of the following. PN dated: 11/7/19 at 9:13 PM Resident did not receive room tray at supper do to staff error. Spouse went outside of facility and bought resident supper. Dietary and staff educated on this and the responsibilities of room trays. Dietary states resident was on a long term list for room trays and staff are aware of that. An interview on 11/13/19 at 11:10 AM with LPN-A (Licensed Practical Nurse) revealed the Charge Nurse documents in the progress notes if the resident refused a meal. Also the staff can document that the Resident refused the meal. The only time Resident 4 goes out of the facility was for a physician's appointment. Review of a Concern/Compliment Form filed by Resident 4 revealed after an investigation was completed that staff were aware Resident 4 did not go into the dining room. There was no documentation on the grievance to indicate Resident 4 was taken a room tray or if Resident 4 refused. Review of the notes from the staff meeting held on 11/7/19 at 1:00 PM & 2:15 PM, prior to the Concern/Compliment Form being filed for Resident 4, revealed *Room tray changes/pick up trays in timely manner. We can work as a team on this. Open for suggestions to make this go [MEDICATION NAME] with an undated hand written note -staff decided to chart own room trays on their assigned halls. An interview on 11/13/19 at 5:32 PM with the DON (Director of Nursing) the dietary staff charts the meal if the resident is in the dining room. Nursing documents the room tray when the trays are picked up by staff. The dietary staff also keep track of what the intake was on the Room Tray slips. The staff are aware that documentation is done. The previous dietary staff were to document the room trays. The staff were informed that when a resident refuses anything the charge nurse needs to be informed and the charge nurses are told to document any refusal. Review of the documentation of the Room Trays revealed documentation for the reason for the room tray such as Never out, Just being mean, was out but got taken back to room, never comes out, doesn't want to, hand leftovers for noon, sick, and out with family. There was no documentation on the meals consumed on (MONTH) 9, 2019 and (MONTH) 10, 2019. | 2020-09-01 |
| 4052 | HILLCREST FIRETHORN | 285300 | 8601 FIRETHORN LANE | LINCOLN | NE | 68520 | 2018-06-14 | 698 | D | 1 | 0 | U8OO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation and record review the facility: 1) failed to assess residents before and after [MEDICAL TREATMENT] treatments, 2) failed to ensure orders were in place for [MEDICAL TREATMENT] care related to the infusion site, 3) failed to give medications as ordered to ensure absorption of the medications occurred prior to [MEDICAL TREATMENT], and 4) failed to coordinate care with the [MEDICAL TREATMENT] Provider for the continuation of care related to the residents [MEDICAL TREATMENT] needs. This had the potential to affect 2 residents (Resident 46 and 41) out of 2 sampled residents. The facility census was 30. Findings are: An observation on 6/13/18 at 8:33 AM of Resident 41 revealed the resident eating breakfast in the resident's room. The Resident reported had not received any of scheduled morning medications. Blood Glucose level had not been checked this am, and that the assessment was usually completed late. Yesterday's lunch time check was completed at 2:00 PM. The Resident had already been to therapy, and went on to report that the scheduled dressing change had not been completed, and planned on leaving the facility for [MEDICAL TREATMENT] about 10:00 AM. A review of the Medication Administration Record [REDACTED]. The medications were scheduled to be given 6:00-9:30 AM and the documentation did not indicate they had been administered as of 9:30 AM on 6/13/18. Further review of MAR for Resident 41, revealed [MEDICATION NAME] is ordered 800mg Tablet 3 times daily with meals, was held on 5/23/18 at noon and 5/24/18 morning and noon dose. The signed physician orders [REDACTED]. The order for [MEDICATION NAME] was on the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The dose on (MONTH) 12, at 9:14 AM and 2:16 PM was documented not available. Per Nursing Drug Handbook (YEAR), [MEDICATION NAME] is a polymeric [MEDICATION NAME] binder and is to be given with meals. The drug may bind with other medication and decrease bioavailability. Recommendation is to give other drugs 1 hour before or 3 hours after this medication. Patient teaching; 1) Instruct patient to take with meals and to adhere to diet 2) inform patient to take whole do not chew or crush the medication, 3) tell patient to take other drugs 2 hours before or 4 hours after the medication. Per article Phosphorus Binders ([MEDICATION NAME] Binders) and the [MEDICAL TREATMENT] Diet www.davita. Com, Phosphorus binder [MEDICATION NAME] soaks up [MEDICATION NAME] like a sponge and it is then excreted in the stool. This medication is taken 5-10 minutes prior to meals or immediately after meals. An interview on 6/13/18 at 9:43 AM, with Resident 41, revealed the resident's scheduled medications were offered at 8:45 AM, after the Resident had eaten breakfast. The Resident reported declining to take the medications as they were offered to close to the scheduled [MEDICAL TREATMENT] and they would be flushed out. An interview on 6/13/18 at 9:48 AM, with Licensed Practical Nurse (LPN)-E revealed the LPN had visited with the APRN (Advanced Practice Registered Nurse) who was in the building, and had any of Resident 41's medication ordered for once daily could be safely rescheduled for 4:00 PM, or whenever the Resident returned from [MEDICAL TREATMENT]. The LPN reported/confirmed Resident 41 did not receive the medication [MEDICATION NAME] or [MEDICATION NAME], and did not have Blood sugar/glucose checked before the morning meal, as ordered. The LPN continued to anticipate being able to complete the ordered wound care prior to the Guest leaving for [MEDICAL TREATMENT] this morning. An observation on 6/13/18 at 10:15 AM was conducted of wound care/dressing change to Resident 41's foot by LPN-E revealed the LPN , wrapped the Resident's foot and lower leg, reapplied a pressure relieving boot. The Resident's foot was positioned on foot pedal of wheel chair (w/c), then immediately transported per w/c out of the room to transportation staff who had been waiting to take Resident 41 out for [MEDICAL TREATMENT]. No further assessments were completed prior to Resident 41 leaving the facility. Review of the MAR/TAR (medication/treatment administration record) and Care Plan, printed 6/12/18, revealed no documentation related to resident assessments recommended to be completed prior to and after receiving [MEDICAL TREATMENT]. The documentation indicated Resident 41 did not receive medications as ordered on a routine basis. Interview with the Medical Director (MD) and Acting Director of Clinical Services (DCS) on 6/14/18 at 2:34 PM, confirmed Resident 41's disease processes had not all been fully addressed. The Medical Director reported that Resident 41 was knowledgeable and wanted to be in control of the disease process, wanted to change the timing of a medication, and take the medication once a day on [MEDICAL TREATMENT] days, rather than the three times daily as ordered by the Resident's Liver Specialist. The MD revealed the MD made the requested changes to take the medication 1 time daily on [MEDICAL TREATMENT] days, and take two times daily on other days of the week. Staff are working with Resident 41 on the timing of the resident's medications. When asked if Resident 41's Kidney and Liver Specialists had been consulted with related to the changes, the MD reported (gender) had not personally consulted with the Specialty MDs. B. On (MONTH) 14, (YEAR) an observation at 1:00 PM revealed Resident 46 was not in room, and the corporate nurse revealed that Resident 46 was at [MEDICAL TREATMENT]. On (MONTH) 14, (YEAR), a record review of physician's orders [REDACTED]. On (MONTH) 14, (YEAR), a record review of Care Plan date range 4/1/2018-6/14/2018 revealed Resident 46 received [MEDICAL TREATMENT] 3 times a week on Tues, Thurs, and Sat. Observe fistula (a surgically made passage between a vein and an artery, which allows connecting to the [MEDICAL TREATMENT] machine) site in the evening after [MEDICAL TREATMENT]. Monitor for Bruit/Thrill (A bruit is a sound associated with blood flow in the fistula. Although usually heard with the stethoscope, such sounds may occasionally also be felt as a thrill) daily. On (MONTH) 14, (YEAR) a record review of Clinical Notes Report and Resident Vital Sign Report with date range of 5/14/18-6/14/18 revealed on Tuesday 5/22/18 at 2:49 am that Resident 46 woke up with nausea and vomiting, given 7-up. No vital signs or assessment were done. On Saturday 5/26/18 no assessment was done. Saturday 6/2/18 no vital signs were done, on Sat 6/9 no assessment on [MEDICAL TREATMENT] and on Tues 6/12 no vital signs were done. On (MONTH) 14, (YEAR) an observation at 3:30 PM revealed Resident 46 was back in room from [MEDICAL TREATMENT]. No fistula was seen, Resident 46 did have a dressing on right upper chest. On (MONTH) 14, (YEAR) at 3:30 PM and interview with corporate nurse revealed Resident 46 does not have a fistula, Resident 46 had a PICC ( A peripherally inserted central catheter or PICC is a thin, soft, flexible tube - an intravenous (IV) line). | 2020-09-01 |
| 3656 | RIDGEWOOD REHABILITATION & CARE CENTER | 285279 | 624 PINEWOOD AVENUE | SEWARD | NE | 68434 | 2018-06-05 | 744 | D | 1 | 1 | RVGM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation, and record review; the facility failed to ensure that psychosocial needs were met for residents with dementia. This failure had the potential to affect one resident, Resident 32. The facility census was 73. Findings are An interview on 5/30/18 at 11:00 AM with Resident 32's Family Member revealed Resident 32 had recently been moved out of a room in the Facility's SCU (Special Care Unit) for Memory Care, into a room within the general population of the facility. The Family Member reported the dependent resident had resided in the SCU since being admitted to the facility, and had been included in all of the scheduled social and recreational activities offered while residing in the SCU. The Family Member went on to report since being moved, Resident 32 spent an increased amount of time alone in the resident's room; and it seemed as if the staff assigned to the current living area did not know the resident, so therefore the staff were unable to anticipate Resident 32's care needs. A review of an undated Care Plan (CP) for Resident 32 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the CP revealed a CP Focus initiated on 4/20/17 and revised on 1/6/18 that indicated the resident experienced cognitive impairment due to [DIAGNOSES REDACTED]. Resident 32 had a history of [REDACTED]. Resident 32 triggered for a high elopement risk however IDT (interdisciplinary team) reviewed and did not feel the resident was at risk at this time. Interventions included Resident to reside in secure memory support unit, which was initiated on 4/20/17 and had not been revised. On 06/04/18 at 10:35 AM, an interview with the DON (Director of Nursing) revealed the facility was unable to locate documentation related to the decision to relocate Resident 32 from the Memory Care Unit into the General Population. The DON reported knowledge that the team felt the resident no longer fit into the Social Model for the Memory Care Unit related to a continued decline in condition. They talked to Resident 32's family to receive the ok and the resident was moved the next day. A review of a facility document titled FAMILY MEMORY SUPPORT HIGHLIGHTS, dated 2/2017, revealed the memory support philosophy was to provide a secure, structured, and calm environment where residents with dementia can be engaged in meaningful social activities. The Memory Care Household door was shut/secured to promote safety, smaller environment with less noise and less people walking in and out, to minimize the feeling of confusion and fear. The household was designed to be a supportive living environment for residents with dementia and was not a behavioral health unit. Meaningful activities, approach, and communication were the best ways to manage these issues. Discussions regarding admission/discharge/transfer would involve the resident and/or designee, the interdisciplinary team; and would at minimum occur within care plan meetings and/or special meetings requested by the resident and/or designee. The interdisciplinary team would identify if there were care needs that surpass the goals of the memory support household and would be better served outside of the specialized environment. Goals of the facility included: to be a resource and support for families with loved ones with dementia, and to provide consistency in memory support caregivers who have received additional training to effectively provide care for residents with dementia. A review of Progress Notes for Resident 32 revealed a note dated 9/6/17 indicating notification of room change was given to the resident's Responsible Party. The notes did not indicate a reason for the move or a change of condition/decline for Resident 32. | 2020-09-01 |
| 1644 | MAPLE CREST HEALTH CENTER | 285149 | 2824 NORTH 66TH AVENUE | OMAHA | NE | 68104 | 2018-12-18 | 609 | D | 1 | 1 | 864P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to ensure investigation of possible abuse were submitted to state survey agency within 5 working days for 2 (Residents 70 and 441) of 8 sampled residents. The facility had a total census of 138. Findings are: [NAME] Resident 441 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Adult of Protective Service reported dated 11/16/18 revealed a facility self-report regarding Resident 441's hair being cut. The report stated that Resident 441's family had not wanted Resident 441's haircut. A review of facility State Reportable Log investigations did not include report regarding Resident 441's hair being cut. In an interview on 12/13/18 at 1:30 PM, Social Worker A confirmed an investigation of Resident 441's hair being cut being cut was not submitted to the state agency. A review of facility policy titled Abuse Investigations revised (MONTH) 2006 revealed results of all investigations and reports shall be faxed or emailed to the state survey and certification agency within 5 days of notification of allegations. B. Record Review of Progress Notes dated 11/21/2018 for Resident 70 revealed: a call was placed to the state agency to report a fracture to the right 4th finger that showed on the x-ray after Resident 70 presented with a cyst to the knuckle. The nurse practitioner asked for a re-read of the x-ray and it was determined that it was not a fracture, but results of Uric Acid eating at the resident's joint. DON placed another call to the state agency to update with the current findings. Interview conducted on 12/17/2018 at 04:00 PM with the DON confirmed the call was placed to the state agency, but an investigation had not been completed or reported to the state agency within the 5 working days. | 2020-09-01 |
| 4747 | SORENSEN CARE AND REHABILITATION CENTER, LLC | 285107 | 4809 REDMAN AVENUE | OMAHA | NE | 68104 | 2017-06-15 | 280 | D | 1 | 1 | F9RW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to ensure the responsible party was involved in the care planning process for 1 resident (Resident 87) of 3 residents sampled. The facility staff identified the census at 68. The findings are: An review of Resident 87's Admission Record dated 6/15/17 revealed the resident was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. A review of Resident 87's most recent Minimum Date Set (MDS: A federally mandated comprehensive assessment tool used for care planning) their Brief Interview for Mental Status (BIMS) score was 5 out of 15 indicating severe cognitive impairment. An interview conducted on 6/12/17 at 4:32 PM with Resident 87's responsible party revealed that the responsible party had not been notified of care plan meetings and had not been included in the care planning process for Resident 87. A review of Resident 87's progress notes since admission revealed no documentation regarding a care plan meeting or that the responsible party was notified of a care plan meeting. An interview conducted on 6/14/17 at 3:29 PM with the Social Services Director revealed that they documented care plan meetings in the progress notes on the computer, but would look for other documentation. A review of an untitled form used to document care plan meetings, supplied by the Social Services Director, dated 4-20-17 revealed the care plan meeting was attended by social services and activities representatives only. The area to document if a letter was sent to the responsible party was left blank. The area to document if a letter was given to the resident was left blank. | 2020-03-01 |
| 1159 | PRESTIGE CARE CENTER OF NEBRASKA CITY | 285109 | 1420 NORTH 10TH STREET | NEBRASKA CITY | NE | 68410 | 2017-05-02 | 323 | E | 1 | 1 | 4KPH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to monitor interventions when a resident was identified at risk of elopement and failed to implement interventions to prevent future elopements for 3 of 3 Residents (Residents 44, 51, and 68). The facility census was 43. Findings are: [NAME] Review of resident census revealed Resident 68 was admitted on [DATE] and discharged on [DATE]. Review of the resident's care plan revealed a care plan for elopement related to anger at placement in living center. Intervention included that the resident wore a wanderguard bracelet (A device used to alert staff if a residents wearing one is too close to the doors). Staff were to check for placement and functioning every shift and as needed and change every 90 days and as needed. Review of the facility investigation revealed Resident 68 left the faciity on [DATE] without the staff knowledge and Resident 68 did have a wanderguard in place. Although Resident 68 did not score as an elopement risk on the assessment. Resident 68 did have poor safety awareness. Review of a Social Service Note dated 11/25/2016 at 4:57 PM revealed a Nursing Assistant (NA) noticed that the resident was outside of the facility. The NA came in to ask the staff if the resident was to be outside. The Charge nurse stated that Resident 68 was not. When asked what resident was doing, the resident stated that the alarms did not sound. Review of progress note dated 10/24/2016 at 5:08 PM revealed Resident 68 did have a wanderguard on at that time. Interview on 4/20/2017 at 3:30 PM with the administrator revealed the wanderguard checks were documented on the TAR (Treatment Administration Record). Resident 68 did have a wanderguard on at the time of leaving the facility and it did not sound the alarm. Review of the TAR dated for (MONTH) (YEAR) revealed no documentation of wanderguard checks for Resident 68. 04/25/2017 12:04:52 PM, interview with Health DON (Director of Nursing) revealed no documentation on the TAR dated for (MONTH) (YEAR) prior to or after the elopement to indicate if the wanderguard was checked for functioning. B . Review of Resident 51's MDS dated 11//25/2017 revealed a cognitive score of 7/15, indicating poor cognitive function. Review of a Nursing Note dated 12/4/2016 at 10:06 AM revealed Resident 51 was observed in the courtyard of the memory support unit ambulating across the grounds in a direction away from the back of the building. Resident 51 exited the building unsupervised. Review of Nursing Note dated 12/6/2016 revealed that, at 9:15 PM, Resident 51 went out the snack room door. Resident 51 stated the resident was going to the gas station. Review of care plan dated 11/8/2016 revealed Resident 51 was to have a wanderguard in place. Review of Resident 51's TAR for (MONTH) (YEAR) revealed no documentation of monitoring the functioning of the wanderguard. Review of Resident 51's TAR dated 12/2016 revealed Resident 51's wanderguard was not being monitored prior to Resident 51's elopement. C. Record review of an Elopement Risk assessment dated [DATE] revealed Resident 44 had scored a 21. According to the information, a score of 10 or higher identified a resident was at risk for elopement. Record review of Resident 44's Comprehensive Care Plan dated 1-03-2017 revealed a wanderguard ( device placed on Resident 44 that would sound an alarm if the resident were too close to an exit door) that was to be checked for placement and function every shift. Record review of Resident 44's Medication Administration Record (MAR) and TAR for (MONTH) (YEAR) revealed the wandergaurd was not identified on either document that staff were monitoring the device. On 5-01-2017 at 1:35 PM, an interview was conducted with the DON. During the interview, Resident 44's MAR and TAR for (MONTH) (YEAR) were review. The DON confirmed that Resident 44's wanderguard had not been monitored and should have been. | 2020-09-01 |
| 75 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 761 | E | 1 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review the facility failed to ensure insulin (a medication used to treat diabetes mellitus) was dated when opened This had the potential to affect 2 residents (Resident 34, and 277). The facility failed to provide safe storage of drugs and biologicals as medications were left unlocked and unattended, and medications were left on top of the medication carts. This had the potential to affect all the residents on the 100, 200, 300, 400, and 500 halls. The facility failed to ensure a vial of insulin was labeled updated with the current administration information for 1 resident (Resident 62 and 79). The facility census was 123. Findings are: [NAME] An observation 9 at 07:10 AM Medication administration RN V prepared medications for administration for Resident 79. 1. Acidophilus 500 Million per 2 caps per day (from a stock medication bottle)-take 2 capsules per gastric tube 2. Vitamin B -1 tablet 100mg daily gastric tube 3. Vitamin C 1000mg daily 4. Folic Acid 1 mg daily every afternoon (on the card) - in the EMAR (Electronic Medical Record) the order reflected that the medication was to be given at 0700AM. 5. Modafnil 100mg 1 tab in am. 6. Ocean Nasal Spray 0.65% amount 2 sprays per nasal - The nasal spray was given 2 sprays per nostril. Record review of an order dated 06/13/18 revealed; a standing order that read, (MONTH) change the time of daily medications for compliance with taking medications, to avoid interaction with other medications unless contraindicated by manufacturer or specific time ordered by physician. Order dated 6/13/18 revealed that the medication Folic Acid 1mg was to be given in the afternoon. An interview with the DON on 09/25/19 confirmed that the labels were not the same, there was a standing order to change the times of the medication administration times. B. An observation on 09/2/519 at 12:50 PM of medication administration for Resident 227 revealed; the Humalog Pen was opened and used and not dated with an opened date. An interview on 09/2/519 at 12:52 PM with RN W confirmed; that the Humalog insulin pen was not dated and was opened. C. An observation on 09/30/19 at 09:30AM of 3 cups of liquid with spoons in it on the top of the cart, also on the top of the cart were Medication of Azelastine HCL nasal spray and Breo Ellipta inhaler that were Resident 120's. No staff was present medications were unsecured. An interview with MA (Medication Aide X) on 09/30/19 at 09:40 AM confirmed; that the medications in the cup were [MEDICATION NAME] that were premixed prior to administration and the medications belonged to Resident 69, 120, and 324. The MA revealed that medication on the cart were not secured. C) Observation on 9/25/19 at 2:26 PM of 200 hall treatment cart revealed there were 2 boxes containing multi-dose vials of [MEDICATION NAME] 70/30 bound together with a rubber band. One box contained an unopened vial and one box was opened and contained a partially used vial. The open and partially used vial was labeled by the facility pharmacy with instructions to administer 11 units before breakfast. The unopened vial was labeled with instructions to administer 13 units before breakfast. Interview on 9/25/19 at 2:36 PM with the DON (Director of Nursing) confirmed the label on the partially used vial did not match the current order. Review of Resident 62's Physician order [REDACTED]. Review of Storage of Medications policy revise (MONTH) 2007 revealed drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. D) Observation on 9/25/19 at 4:50 PM of the 100 hall medication cart revealed Resident 34's [MEDICATION NAME] inhaler (a medication to keep the airway relaxed and open) did not have an open date documented on the inhaler or on the box. Interview on 9/25/19 at 4:50 PM with the DON confirmed the inhaler did not have an open date documented. E) Observation on 9/25/19 at 4:20 PM of 600 hall medication cart revealed Resident 373's Toujeo insulin (a long acting insulin (a medication to lower the blood sugar level)) did not have an open date documented on the pen. Interview on 9/25/19 at 4:20 PM with the DON confirmed the insulin pen did not have an open date documented. Review of Storage of Medications policy revised (MONTH) 2007 revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. F) Observation on 9/26/19 at 7:13 AM of the 200 hall medication cart revealed the cart was unattended and unlocked. Interview on 9/26/19 at 7:15 AM with LPN-B confirmed the medication cart was left unlocked while unattended. LPN-B revealed the expectation was for the medication cart to be locked when unattended. Interview on 9/26/19 at 11:17 AM with CSC (Clinical Services Coordinator) revealed the expectation for securing the medication cart was for the medication cart to be locked when unattended. Review of Storage of Medications policy revised (MONTH) 2007 revealed compartments containing drugs and biologicals shall be locked when not in use, and carts used to transport such items shall not be left unattended if open or other potentially available to others. | 2020-09-01 |
| 4070 | HILLCREST MILLARD | 285302 | 13225 WESTWOOD LANE | OMAHA | NE | 68144 | 2019-09-25 | 761 | D | 1 | 0 | EL7411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review the facility failed to ensure the medication cart was locked and supervised, the facility failed to ensure medications were not left at bedside for Resident 7, the facility failed to ensure that nebulizer treatment was given for Resident 11. The facility census was 63 Findings: 09/24/19 record review of Medication Policy-Medications are documented as administered after the medication Aide/nurse has assured the guest consumed the medication- During administration of medications, the medication cart/medications cabinet will be kept closed and locked when out of sight of the medication team member. No medications can be left on top of Medication cart or medications cabinet in rooms without team member that is administering medications within sight of the medications. [NAME] Observation during Medication Pass on 09/24/19 at 7:50AM with RN E, revealed medication for Resident 7 was in medication cup on bedside table. Interview with Resident 7 revealed that she had not taken her medications left at bedside last night, she had forgotten. Interview with RN11 passing medications agreed that medication should not have been left at bedside. Record Review of MAR (Medication Administration Record) for Resident 7 for 09/23/19 revealed medications were charted as taken. B. 09/24/19 7:55AM Observation during Medication Pass with RN E, revealed breathing treatment (nebulizer) contained liquid in the container for Resident 11 Interview with Resident 11 revealed that he had not taken his breathing treatment last night and was wondering if he could take it now. Interview with RN [NAME] agreed that the treatment should have been observed as having been completed Record Review of Resident 11 MAR (medication administration Record) IPRAT-ALBUT 0.5-3mg/3ml inhale 1 vial via nebulizer 4 times /day. C .09/24/19 10:15AM Observation , Medication cart was sitting in doorway of room [ROOM NUMBER], medication pack with medication was laying on top of cart and medication drawer of cart was not locked and was unattended by authorized staff. 09/24/19 10:20 AM Interview with Nurse E, who returned to the unlocked medication cart, agreed that nurse [NAME] should not have walked away from unlocked cart and that medications should not have been left unattended on top of cart. 09/24/19 8:15AM Interview DON (director of Nursing) confirmed that the medication policy does state that medications should not have been left in resident 7,and resident 11 room for them to take unattended. And that medications should not be charted that were not observed being taken by resident. | 2020-09-01 |
| 2175 | LEGACY GARDEN REHABILITATION & LIVING CENTER | 285186 | 200 VALLEY VIEW DRIVE | PENDER | NE | 68047 | 2018-10-04 | 880 | F | 1 | 1 | JIFC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review; the facility staff failed to perform hand hygiene for care/treatment of [REDACTED]. The facility census was 34. Findings are: Observation on 10/04/18 at 1:10 PM during wound care observation for Resident 5 revealed two NA's (Nurse Aides F and G) came in to assist with the procedure. NA G did not use hand sanitizer nor did hand washing prior to application of gloves before care for Resident 5. Record review of Infection Control policy dated 01/2018 revealed staff members were to use either antimicrobial soap and water or alcohol based hand rub before performing resident care procedures. Record review of the facility's Hand Hygiene Policy dated 01/2018 revealed staff members were to use either antimicrobial soap and water or alcohol based hand rub between resident contact. | 2020-09-01 |
| 97 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2018-09-17 | 580 | D | 1 | 1 | XOYL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview: the facility failed to notify the physician of the presence of a pressure ulcer (a localized injury to the skin/underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and /or friction) to obtain treatment orders at the time of admission to promote healing of a pressure ulcer for 1 (Resident 105) of 5 residents reviewed with pressure ulcers. The facility census was 126. Findings are: Record review of a facility Policy and Procedure for Skin and Wound Management standard dated revised (MONTH) (YEAR) revealed the following policies: - A resident having pressure sores receives necessary treatment and services to promote healing and prevent infection: Pressure Ulcer Skin Condition: - Initial identification of a new pressure ulcer will include an assessment and measurement of the wound. Documentation of findings, assessment results and notification of the physician and family will be made in the residents clinical record. Treatment: - The treatment plan will be specific for each individual resident as directed by the physician. Appropriate treatment will address length, width, depth, odor, drainage, pain, wound bed and surrounding skin. Evidence of slough, necrotic tissue or infection should be communicated to the physician and treated accordingly. Record review of Resident 105's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/18 revealed that Resident 105 was admitted to the facility on [DATE] with 1 unhealed pressure sore that was unstageable due to coverage of the wound bed by slough (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and /or eschar) and/or eschar (thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissues that has lost its usual physical properties and biological activity. Eschar may be lose or firmly adhered to the wound.) The MDS identified that the pressure ulcer was covered by Eschar. Record review of a Braden Scale ( a risk assessment for pressure ulcers) dated 8/4/18 identified that Resident 105 was at high risk for the development of pressure sores with a score of 15. A score of 20 and below was considered to be high risk. Record review of a nursing Admission Summary Progress Note dated 8/2/18 identified that Resident 105 had a pressure ulcer to the heft heel that measured 4 centimeters (cm) by 1.4 cm. Record review of Resident 105's Skin Assessments revealed the following measurements and description of Resident 105's pressure ulcer to the left heel: - 8/3/18: left heel pressure 4 cm x 1.4 cm unstageable, black dry/eschar to left heel - 8/10/18 left heel pressure 4 cm x 1 cm, black dry eschar/scab to left heel - 8/18/18 left heel not identified on the skin assessment, identified no alteration in skin integrity - 8/23/18: left heel pressure 1.4 x 1.3 0.3 cm, stage 3, Wound has about 50 percent eschar to the wound bed, recommend alginate AG with 4 by 4 bordered gauze, change q (every) 3 days and prn (as needed) soiled or dislodged dressing. - 9/1/18: left heel pressure 1.1 x. 75 x .2 - 9/8/18: left heel pressure, no measurements documented. Observation on 09/12/18 at 08:00 AM with the Wound Care Registered Nurse (RN) confirmed the presence of a pressure ulcer to the left heel. The Wound Care RN confirmed that the wound was open and not covered by eschar. Record review of Resident 105's discharge orders from the hospital and admission orders [REDACTED]. The treatment wound care orders only covered treatments to bilateral lower leg stasis ulcers and did not address treatment of [REDACTED]. Record review of Resident 105's Physician orders [REDACTED]. Cover wound bed with Alginate Silver (a medication used to treat pressure ulcers) and apply bordered gauze. Change every 3 days and as needed for soiled or dislodged dressing. Record review of Resident 105's (MONTH) (YEAR) Treatment Sheets revealed that treatments to the left heel pressure ulcer were not started until 8/27/18, a total of 24 days after admission when the left heel ulcer was first identified on 8/2/18. Interview on 09/13/18 at 09:41 AM with the RN Wound Nurse confirmed that there were no treatment orders for the treatment of [REDACTED]. The RN Wound Nurse confirmed that Resident 105's admission Nursing Assessment Progress Note documentation dated 8/3/18 identified the presence of a left heel ulcer and that treatment orders should have been obtained at the time of admission. Interview on 09/13/18 at 01:05 PM with the Director of Nursing (DON) confirmed that there were no treatments provided or ordered for Resident 105's left heel pressure ulcer until 8/27/18. The DON confirmed that the hospital did not send treatment orders for the left heel wound and there was no follow up with the physician regarding the treatment of [REDACTED]. The facility DON was unable to provide evidence that the physician had been notified of the presence of a heel at the time of admission. The DON confirmed that he expectation would be to notify the physician and obtain treatment orders and that this was not done. | 2020-09-01 |
| 5520 | SORENSEN CARE AND REHABILITATION CENTER, LLC | 285107 | 4809 REDMAN AVENUE | OMAHA | NE | 68104 | 2016-11-14 | 155 | D | 1 | 0 | 7EEE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview; the facility failed to ensure that an Advanced Directive (information about the residents wishes for end of life care) had been formulated for Resident 4 and Resident 3. Sample size was two. The census was 66. Findings are: [NAME] Record review of the facility Policy and Procedure for Advance Directives dated [DATE] revealed that the resident had a right to execute or refuse to execute an advance directive which stipulates how the decisions regarding his/her medical care will be made. The procedure revealed that prior to or upon admission, family members, and or legal representatives were informed and provided written materials governing their legal rights pertaining to medical decisions upon admission to the facility. These rights included the right to formulate an advanced medical directives such as a living will, Power of attorney for Health Care, Do not resuscitate or health care surrogate. The procedure identifies that prior to or upon admission to the facility, the admissions Coordinator or Social Services Designee ascertains the presence of any existing advance directives and a copy is placed under the advance directive tab in the medical record. Prior to or on admission, the Social services designee will provide written information to the resident/legal representative concerning right to make decisions regarding medical care including the right to accept /refuse medical /surgical treatment and the right to formulate advance directives. Record review of Resident 4's Face Sheet dated [DATE] revealed that Resident 4 had been admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 4's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) dated [DATE] and quarterly MDS dated [DATE] revealed that Resident 4 had a cognitive score of ,[DATE] which indicated that Resident 4 was independent with cognitive decision making. Interview on [DATE] at 10:10 AM with Resident 4 revealed that the facility staff had not talked to Resident 4 regarding Advance Directive wishes or what was to be done if (gender) heart stopped. Resident 4 indicated that Resident 4 did not wish to have anything done and no pushing on the chest or anything. Record review of Resident 4's medical record showed no Advance Directive information or Cardiopulmonary Resuscitation status (CPR, a basic emergency method of lifesaving) present in chart. Resident 4's physician orders contained no information about Advance Directives or CPR orders. Record review of Resident 4's Care Plan dated [DATE] and updated [DATE] contained no indications of Advance Directives or CPR status. Interview on [DATE] at 11:14 AM with the Administrator confirmed there was no designation of code status in Resident 4's medical record. Interview on [DATE] at 11:20 PM with SW confirmed that there was no CPR status or Advanced Directive information present in Resident 4's chart. B. Review of the face sheet for Resident 3 revealed that the resident admitted to the facility on [DATE]. Review of Resident 3's entire medical record revealed no cardiopulmonary resuscitation (CPR) wishes were designated in the medical record. Review of Resident 3's care plan dated [DATE] revealed no designation of Residents 3's CPR status. Review of the Quarterly Nursing Assessment for Resident 3 dated [DATE], revealed that Resident 3 was alert and oriented with no memory problems and was independent in decision making. An interview with Resident 3 on [DATE] at 10 AM revealed that the facility had never asked Resident 3 about CPR wishes. Resident 3 revealed that Resident 3 would like to have CPR done and kept alive until (gender) children could arrive then they should pull the plug. An interview with the social worker on [DATE] at 10:55 am confirmed that their was no evidence that the facility had evaluated Resident 3's CPR wishes and they should have and confirmed there was no CPR status present in Resident 4's chart. | 2019-11-01 |
| 5857 | ST. JOSEPH VILLA NURSING CENTER | 285078 | 2305 SOUTH 10TH STREET | OMAHA | NE | 68108 | 2016-08-10 | 441 | D | 1 | 0 | 142711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview; the facility staff failed to wash hands and changes gloves to prevent potential cross contamination during the provision of personal cares for 2 residents (Resident 1 and 3). The facility staff identified a census of 164. Findings are: A. Record review of an undated Resident Face Sheet revealed Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 8-05-2016 revealed the facility staff assessed the following about the resident: -Short and long term memory problem with severely impaired cognition. -Required total assistance with bed mobility, transfers, locomotion, dressing, eating, personal hygiene. -Required extensive assistance with toilet use. -Always incontinent of bowel and bladder. -Had indicators of pain or possible pain with possible pain observed 3 to 4 times out of 5 days. -Other [DIAGNOSES REDACTED]. Observation on 8-09-2016 at 7:56 AM of personal care revealed Nursing Assistant (NA) E and NA G washed hands and donned gloves. Resident 1 was observed to have a splinting device to the right leg. NA E and NA G unfastened the adult briefs Resident 1 was wearing. NA G, using a white washcloth wiped the resident's groin folds revealing brown stains on the wash cloth. NA G without changing gloves and hand washing, obtained another wash cloth and wiped down the vaginal area. Resident 1 was then positioned onto the left laying position. NA G without changing the soiled gloves cleansed in between each buttock. NA G without changing the soiled gloves obtained a clean adult brief and placed it onto Resident 1. An interview with NA G was conducted on 8-09-2016 at 10:13 AM. During the interview, NA G confirmed the soiled gloves had not been changed and should have been. B. Record review of Resident 3's MDS signed as completed on 6-04-2016 revealed the facility staff assessed the following about Resident 3: -Short and long term memory impairments. -Required extensive assistance with transfers,eating, toilet use and personal hygiene. -Required limited assistance with bed mobility and walking in the corridor and had fall in the facility. Record review of Resident 3's Comprehensive Care Plan (CCP) dated 7-08-2015 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review of Resident 3's CCP revealed an updated problem area that identified Resident 3 at risk for falls and injury due to impaired cognition, and use of an antidepressant medication. The goal was Resident 3 would be free from falls and injuries. A new intervention to prevent falls dated 5-21-2016 was that Resident 3 was to have a fall mat in place. Observation on 8-10-2016 at 7:02 AM revealed Nursing Assistant (NA) J assisted Resident 3 into the bathroom, assisted with pulling down Resident 3's pants and sat Resident 3 onto the toilet. Once Resident 3 completed using the toilet, NA J cued Resident 3 into an upright position. NA J obtained toilet paper and wiped Resident 3's buttocks. NA J then obtained a wet wash cloth cleansed Resident 3 buttocks. Without changing the soiled gloves, NA J obtained a clean washcloth and cleansed Resident 3's penis and groin area. NA J without changing the soiled gloves, obtained a clean, dry towel and dried off Resident 3. An interview on 8-10-2016 at 7:26 AM was conducted with NA J. During the interview, NA J confirmed the soiled gloves had not been changed and should have been. Record review of the facility Handwashing Policy and procedure dated 12-2009 revealed the following: -Purpose: - To provide guidelines to employees for proper and appropriate hand washing techniques that will aid in the prevention of the transmission of infections. -When to wash hands: -After handling any contaminated items, linens, soiled diapers, garbage, etc. | 2019-08-01 |
| 3403 | WESTFIELD QUALITY CARE OF AURORA | 285263 | PO BOX 166, 1313 1ST STREET | AURORA | NE | 68818 | 2019-05-14 | 695 | D | 1 | 0 | V7OX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interviews, the facility failed to obtain an order for [REDACTED]. Findings are: Record review of Resident 36's Admission Record dated 5-7-19 revealed date of admission 7-9-18 with [DIAGNOSES REDACTED]. Review of Resident 36's admission MDS dated [DATE] revealed the resident used oxygen while 'not' a resident and 'while' a resident. The MDS also revealed the resident had a [DIAGNOSES REDACTED]. Observation on 5/06/19 at 10:00 AM of Resident 36's room revealed the oxygen concentrator turned on but the tubing was no where near the resident who was on the opposite side of the bed. Inteview with NA-F (Nurse Aide) revealed the resident only wore oxygen when in bed at night time. Record review on 5/06/19 at 10:26 AM of undated Physician orders [REDACTED]. Review of (MONTH) and (MONTH) TARS/MARS (treatment / medication administration records) revealed absence of an order for [REDACTED]. Review of current order summary report dated (MONTH) 7, 2019 revealed absence of an oxygen order for Resident 36. Interview on 5/07/19 at 4:30 PM with LPN-G (Licensed Practical Nurse) revealed the Oxygen orders were not documented on the TAR or MAR. LPN-G confirmed when a resident had an order for [REDACTED]. LPN-G reviewed Resident 36's medical record and confirmed the absence of an oxygen order but confirmed the resident had used oxygen per nasal cannula via concentrator at night time only since admission last July. Interview on 5-7-109 at 4:33 PM with RN-H (Registered Nurse) reviewed the medical record of Resident 36 and confirmed the resident had been on oxygen and the facility the resident transferred from and the transfer papers revealed the resident was to be on oxygen 1-5 liters per nasal cannula at bedtime. RN-H confirmed after reviewing the facility's admission orders [REDACTED]. Review of Resident 36's admission orders [REDACTED] | 2020-09-01 |
| 5409 | SORENSEN CARE AND REHABILITATION CENTER, LLC | 285107 | 4809 REDMAN AVENUE | OMAHA | NE | 68104 | 2017-01-25 | 323 | D | 1 | 0 | TUGY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interviews; the facility failed to ensure residents were transferred in a safe manner for 1 of 3 residents reviewed (Resident 2). The facility census was 86. Review of Resident 2 ' s medical [DIAGNOSES REDACTED]. Review of Resident 2 ' s progress notes dated 10/31/2016 revealed Resident 2 fell on [DATE] while being transferred to the toilet. Review of Resident 2 ' s care plan dated 10/31/2016 revealed a new intervention stated that staff were to transfer Resident 2 with the sit to stand lift (a mechanical device to assist resident to stand) at all times. Interview on 1/25/2017 at 2:10 PM with NA-B revealed that Resident 2 only needed a little assistance to transfer. Observation on 1/25/2017 at 2:15 PM revealed Nursing Assistant (NA)-A and NA-B entered Resident 2 ' s room to transfer Resident 2 to the toilet. NA-A pushed Resident 2 into the bathroom in the wheelchair. While standing behind Resident 2 without a gait belt (a device used to assist in stabilizing resident) or using a sit to stand lift. NA-A leaned over the back of the wheelchair, instructed Resident 2 to hold on to safety bars and to pivot onto the toilet. Interview on 1/25/2017 at 2:25 PM with the Director of Nursing (DON) revealed Resident 2 is only to be transferred with the sit to stand lift with all straps secured. DON confirmed transferring Resident 2 without the use of the sit to stand lift was not a safe transfer. | 2020-01-01 |
| 161 | RIVER CITY NURSING AND REHABILITATION | 285058 | 7410 MERCY ROAD | OMAHA | NE | 68124 | 2017-07-12 | 225 | D | 1 | 1 | 0ROU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interviews; the facility failed to report and investigate allegations of potential abuse for 5 of 5 residents reviewed Residents 48, 53, 148, 117, and 50. The facility census was 72. [NAME] Review of Resident 117's progress notes revealed on 7/8/2017 friends of Resident 117 voiced concern Resident 117 was being abused. The Assistant Director of Nursing (ADON) was notified. Interview on 7/10/2017 at 11:09 AM with the ADON revealed the staff had reported the allegation of abuse to the ADON on 7/8/2017, however, no report was called to the state agency and an investigation was not started for 2 days. Review of the facility policy titled Abuse Prevention, Intervention, Investigation and crime reporting policy dated (MONTH) (YEAR), revealed all allegations of abuse are to be reported to the state agency immediately but not later than 2 hours after the allegation is made. Interview on 7/11/2017 at 8:53 AM with the Director of Nursing (DON) revealed the facility should have reported the allegation of abuse in the regulatory timeframe. B. A review of Resident 50's Admission Record dated 7/11/17 revealed Resident 50 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Resident 50's medical record revealed a progress note dated 6/9/17 that revealed Resident 50 had yelled at a resident from another unit that they did not belong on Resident 50's unit and to leave. The author of the note documented that Resident 50 became agitated and continued yelling and that the other resident felt threatened and chose to leave. When the other resident got up to leave, Resident 50 walked towards the other resident calling them profane names. An interview conducted on 7/11/17 at 10:35 AM with the Director of Nursing revealed that the incident should have been investigated as suspected abuse and reported to the state agency. C) Interview with Resident 48 on 7/5/17 at 9:30 AM revealed that there was a nurse currently working at the facility that was verbally abusive and called Resident 48 Crazy, he was unsure of the name. Resident revealed that the event took place over a month ago and that the nurse keeps coming into his room. Resident 48 was told that this nurse was not to come into his room except to care for the roommate. Interview with DON on 7/5/17 at 9:45 AM revealed that there was no staff member of the name that Resident 48 had stated, works or had worked there, and that there was not abuse investigation performed during that time for Resident 48. Interview with DON on 7/11/17 at 0800 confirmed that Licensed Practical Nurse (LPN) M was the nurse that Resident 48 had requested not provide care. The facility did provide a Grievance Form dated Resident 48. The DON confirmed that this was not investigated as an abuse allegation and that other residents had not been interviewed. The facility did not follow their abuse policy for this alleged abuse complaint. D) Record review of Grievance Record for Resident 53 revealed that Resident 53 on 5/1/17 reported to Social Service Designee that a NA was going to help with getting dressed, but when Resident 53 had had wanted to put on socks first, the NA then took the pants and shirt, wadded them up, threw them in the chair and told Resident 53 to do it himself. Record review revealed that on 5/1/17 the DON spoke with resident who spoke kindly of the resident and completed the Grievance as resolved on 5/11/17. Interview with DON and ADON on 7/11/17 at 11:34 AM confirmed that the facility did not report or investigate Resident 53's concerns as abuse. The DON and ADON confirmed that this should have been investigated as Abuse under the Facility Abuse Policy and that the proper agencies should have been notified of this investigation. E) Record review of Grievance Record for Resident 148, dated 2/13/17, revealed that Resident 148 and significant other expressed concern regarding late shift aide had yelled and was angry with Resident 148 and told Resident to go to bed. The facility resolution was to educate the NA to use a lower voice when instructing patient to move or not move. Interview with DON and ADON on 7/11/17 at 11:34 AM confirmed that the facility did not report or investigate Resident 148's concerns as abuse. The DON and ADON confirmed that this should have been investigated as Abuse under the Facility Abuse Policy and that the proper agencies should have been notified of this investigation. | 2020-09-01 |
| 3321 | BLUE VALLEY LUTHERAN NURSING HOME | 285259 | P O BOX 166, 220 PARK AVENUE | HEBRON | NE | 68370 | 2017-08-08 | 314 | D | 1 | 0 | 2H1K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record reviews, and interviews; the facility failed to initiate preventative pressure ulcer interventions on 2 (Resident 100 and 112) out of 4 residents sampled. Resident census was 46. Findings are: A Review of Resident 112's undated face sheet revealed an admitted 11 18 12. Review of the undated [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) for Resident 112 dated 5 18 17 revealed the resident had moderately impaired cognition. The resident required extensive assist of 2 staff with transfers, dressing, and toileting. The resident required extensive assist of 1 staff for locomotion and eating. Interview on 08 07 17 at 11:00 AM with the Administrator revealed Resident 112 had facility acquired pressure ulcers on the resident's toes caused by the resident's shoes. Review of the PN (Progress Notes) dated 07 10 17 revealed the resident went to the Physician's clinic to be seen for the open/reddened sores on the 2nd and 3rd toes. The resident returned with new orders to treat the pressure ulcers. Review of Resident 112's Careplan revealed absence of any pressure ulcer interventions . Review of the last annual MDS dated 09 10 16 CAA's (Care Area Assessment) revealed the risk for pressure ulcers was triggered. Review of the CAA worksheet revealed the decision was to care plan the risk for pressure ulcers and therefore put interventions into place to help prevent pressure ulcers. Review of Resident 112's Kardex revealed absence of any documentation that the resident had pressure ulcers or any pressure ulcer interventions . Interview on 08 07 17 at 3:50 with the DS (Dietary Supervisor) revealed the DS was not aware Resident 112 had any pressure ulcers or was at risk for pressure ulcers. The DS revealed when a resident initially had a pressure ulcer, the DS would be informed then the DS would notify the RD (Registered Dietician) who was contracted for the facility. B Review of Resident 100's undated face sheet revealed an admitted 02 15 17. Review of the undated [DIAGNOSES REDACTED]. congested heart failure, [MEDICAL CONDITION], abnormal weight loss, [DIAGNOSES REDACTED] of the skin of the nose. Review of the admission MDS for Resident 100 revealed a BIMS Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 13 which indicated Resident 100 had no cognition impairment. The resident required limited assist of 1 staff with bed mobility and extensive assist of 1 staff with transfers, personal hygiene, bathing, dressing, walking, locomotion, and toileting. The resident did not admit with a pressure ulcer. Review of the CAA's revealed the risk for pressure ulcers was triggered. Review of the CAA worksheet revealed the decision was to care plan the risk for pressure ulcers . Review of Resident 100's Care plan revealed the absence of the resident being at risk for pressure ulcers and the absence of pressure ulcer interventions. Interview on 08 08 17 at 3:05 PM with the MDS Nurse confirmed there were no pressure ulcer interventions documented. Interview on 08 08 17 at 11:10 AM with the family revealed on 07 11 17 the resident was transferred from the facility to the hospital. The admitting hospital informed the family the resident had a stage 2 pressure ulcer on the resident's coccyx area. Interview on 08 08 17 at 3:00 PM with the DON (Director of Nursing) confirmed the facility did not do a skin assessment on the resident before the resident was transferred to the hospital. The DON revealed besides the pressure reducing mattress which every resident in the facility had, no other pressure ulcer interventions were initiated. | 2020-09-01 |
| 5754 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2016-09-20 | 441 | E | 1 | 0 | TD4511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations and interviews, the facility failed to ensure that 1) the whirlpool chair in the 300 wing bathing room (which was used for routine bathing for 13 residents) and the whirlpool chair in the Special Care Unit bathing room (which was used for routine bathing for 36 residents) were cleaned and free of a buildup of whitish gray material on the metal surfaces which created a rough surface that had the potential to harbor bacteria, 2) towel bars used in semiprivate bathrooms were labeled so that the residents or staff could identify which hand towels and washcloths belonged to which resident for 10 sampled residents (Residents 107 and 91 in room [ROOM NUMBER], 104 and 162 in room [ROOM NUMBER], 77 and 13 in room [ROOM NUMBER], 76 and 28 in room [ROOM NUMBER] and 121 and 132 in room [ROOM NUMBER]), 3) bathroom call light strings with a buildup of brownish, black and gray colored material were replaced for four sampled residents (Residents 30 and 7 in room [ROOM NUMBER] and 104 and 162 in room [ROOM NUMBER]), 4) bathroom light pull strings with a buildup of brownish, black and gray colored material were replaced for four sampled residents (Residents 2 and 45 room [ROOM NUMBER] and 125 and 66 in room [ROOM NUMBER]), 5) torn vinyl covered calf pads were replaced for one sampled resident (Resident 54), 5) four plastic gallon containers of distilled water were not stored on the floor in the 300 wing medication room and 6) hand washing was performed after removing disposable gloves during cares and before continuing with other tasks for two sampled residents (Residents 88 and 52) to reduce the risk of cross contamination. The facility census was 114. Findings are: Licensure Reference Number 175 NAC 12-006.17B A. Observations of the 300 wing bathing room and the SCU (Special Care Unit) bathing room on 9/12/16 at 11:30 AM, during the environment tour with the Administrator, Maintenance Director and Housekeeping Supervisor, revealed that the whirlpool bathing chairs had a buildup of debris and whitish, gray colored material resembling hard water stains on the metal surfaces. Interview on 9/14/16 at 7:45 AM with RN (Registered Nurse) - A, Infection Control Nurse, confirmed that the whirlpool bathing chairs needed to be cleaned to reduce the risk of cross contamination. RN - A confirmed that 13 residents utilized the whirlpool on the 300 wing and 36 residents used the whirlpool on the SCU. B. Observations of resident rooms on the 400 wing and the 500 wing 9/7/16 from 9:30 AM through 10:30 AM revealed shared bathroom towel bars were not labeled with the resident ' s name or bed number to ensure that the residents or staff members could identify which washcloths and hand towels belonged to which resident. The bathroom towel bars were not labeled for Residents 107 and 91 in room [ROOM NUMBER], Residents 104 and 162 in room [ROOM NUMBER], Residents 77 and 13 in room [ROOM NUMBER], Residents 76 and 28 in room [ROOM NUMBER] and Residents 121 and 132 in room [ROOM NUMBER]. Interview on 9/14/16 at 7:45 AM with RN - A, Infection Control Nurse, confirmed that the bathroom towel bars should be labeled with the resident's name or bed number to reduce the risk of cross contamination by using another resident's linens. C. Observations of resident rooms on the 200 wing, 400 wing and the 500 wing on 9/7/16 from 9:30 AM through 10:30 AM revealed bathroom call light strings soiled with brownish black and gray colored material utilized by four sampled residents (Residents 30 and 7 in room [ROOM NUMBER] and Residents 104 and 162 in room [ROOM NUMBER]). Further observations revealed bathroom light strings soiled with brownish black, and gray colored material for four sampled residents (Residents 2 and 45 in room [ROOM NUMBER] and Residents 125 and 66 in room [ROOM NUMBER]). Interview on 9/14/16 at 7:45 AM with RN - A, Infection Control Nurse, confirmed that the bathroom call light and light strings needed to be replaced when soiled to reduce the risk for cross contamination. D. Observations on 9/8/16 at 7:10 AM and 11:00 AM and on 9/12/16 at 11:40 AM revealed Resident 54 seated in the wheelchair in the hallway. Further observations revealed that the vinyl covered wheelchair calf pads had multiple tears and worn edges which exposed the material underneath. Interview on 9/14/16 at 8:00 AM with RN - A confirmed that the calf pads needed to be replaced as they were no longer cleanable. E. Observations of the 300 wing medication room on 9/8/16 at 2:30 PM revealed four plastic gallon containers of distilled water, one opened and about half full, on the floor. Interview on 9/8/16 at 2:30 PM with LPN (Licensed Practical Nurse) - B, Charge Nurse, confirmed that the containers should not be stored on the floor to reduce the risk of cross contamination. Licensure Reference Number 175 NAC 12-006.17D F. Observations on 9/8/16 at 7:00 AM revealed LPN - C, Charge Nurse, donned disposable gloves and checked Resident 88's blood sugar. Further observations revealed LPN - C removed the gloves, placed the glucometer (machine used to measure blood sugar) on the medication cart, documented the blood sugar on the computer and continued with further tasks without hand washing. Observations on 9/8/16 at 8:10 AM revealed RN - D, Charge Nurse, prepared medications for Resident 52, donned disposable gloves, administered the medications, removed the gloves, returned to the medication cart, signed off the medications on the computer and continued to prepare medications for the next resident without hand washing. Interview on 9/14/16 at 2:00 PM with RN - A, Infection Control Nurse, confirmed that the nurses were to wash their hands when disposable gloves were removed and before continuing with other tasks to reduce the risk of cross contamination. | 2019-09-01 |
| 6387 | NORTH PLATTE CARE CENTER, LLC | 285165 | 2900 WEST E STREET | NORTH PLATTE | NE | 69101 | 2016-03-02 | 367 | E | 1 | 0 | BM4911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews and record reviews; the facility failed to ensure that evening snacks were offered to four sampled insulin dependent diabetic residents (Resident 1, 6, 8 and 9). The facility census was 47. Findings are: A. Observations on 3/1/16 at 7:30 PM and 8:10 PM revealed MA (Medication Aide) - B passed snacks to several residents. Interview on 3/1/16 at 8:15 PM with MA - B revealed that snacks were offered to residents but there was no list of residents who needed a snack because they were diabetic. Further interview revealed there was no documentation of which residents were offered or accepted the snacks. B. Review of Resident 1's Routine Medications, dated (MONTH) (YEAR), revealed that the resident had a [DIAGNOSES REDACTED]. Further review revealed no documentation that the resident received an evening snack. Interview with the resident's family member on 3/1/16 at 7:45 PM revealed that the resident did not always receive a bedtime snack. C. Review of Resident 6's Routine Medications, dated (MONTH) (YEAR), revealed that the resident had a [DIAGNOSES REDACTED]. Further review revealed no documentation that the resident received an evening snack. Interview with the resident on 3/2/16 at 9:15 AM revealed that evening snacks were not always offered. D. Review of Resident 8's Routine Medications, dated (MONTH) (YEAR), revealed that the resident had a [DIAGNOSES REDACTED]. Further review revealed no documentation that the resident received an evening snack. Interview with the resident on 3/2/16 at 9:30 AM revealed that was not always offered an evening snack. E. Review of Resident 9's Routine Medications, dated (MONTH) (YEAR), revealed that the resident had a [DIAGNOSES REDACTED]. Further review revealed no documentation that the resident received an evening snack. Interview on 3/2/16 at 3:30 PM with the DON (Director of Nursing) confirmed that there was no documentation that evening snacks were offered to diabetic residents every night. Further interview confirmed that the evening snacks should be offered every evening and should be documented on the Routine Medications forms to reduce the risk for low blood sugar levels during the night or in the morning. | 2019-03-01 |
| 2165 | LEGACY GARDEN REHABILITATION & LIVING CENTER | 285186 | 200 VALLEY VIEW DRIVE | PENDER | NE | 68047 | 2017-07-20 | 329 | D | 1 | 1 | E93U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, and record reviews; the facility failed to implement non pharmacological interventions prior to administering a [MEDICAL CONDITION] medication for 2 residents (Residents 28 and 7) of the 5 residents sampled. The facility staff identified the resident census at 31. [NAME] Review of Resident 7's undated Face Sheet revealed that Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 7's Medication Administration Record [REDACTED]. A review of Resident 7's Progress Note dated [DATE] at 2:11 AM revealed Resident 7 was confused with rambling speech and was yelling out for their deceased spouse; resident was given [MEDICATION NAME] 1mg and [MEDICATION NAME] 1mg as needed. No non-pharmacological interventions were documented in the progress note. Resident 7 was documented as having rested quietly after the [MEDICATION NAME] and [MEDICATION NAME] was given. A review of Resident 7's [MEDICAL CONDITION] Drug Use Care Plan dated [DATE] revealed a goal for the resident to be prescribed the lowest effective dose of medications. The approaches included to have staff attempt to redirect the resident with non-medication interventions and to monitor and document mood and behaviors. An interview conducted on [DATE] at 3:09 PM with the Director Of Nursing (DON) confirmed that Resident 7 received on [DATE] [MEDICATION NAME] 1mg as scheduled at 8:00 PM, [MEDICATION NAME] 1mg as needed at 8:29 PM, and [MEDICATION NAME] 1mg as needed at 8:29 PM. The DON confirmed there was no non-pharmacological interventions documented as completed prior to the administration of the as needed [MEDICATION NAME] and [MEDICATION NAME]. The DON reported that the resident had been having behaviors of acting out aggressively towards staff and that numerous staff had refused to take care of the resident. The DON reported that Resident 7's family wanted the resident to remain in the facility and that the only way to do so was to medicate the resident to the point the resident did not have any behaviors. The DON reported that the facility staff had not evaluated the resident for pain prior to starting the scheduled [MEDICATION NAME]. B. A review of Resident 28's undated Face Sheet revealed that Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 28's (MONTH) (YEAR) MAR indicated [REDACTED]. A review of Resident 28's Behavior Administration History dated [DATE] to [DATE] revealed no behaviors were documented on [DATE]. A review of Resident 28's Progress Noted revealed no documentation regarding behaviors on [DATE]. A review of Resident 28's Behavior Analysis dated [DATE] to [DATE] revealed there were no behaviors documented on [DATE]. A review of Resident 28's [MEDICAL CONDITION] Drug Use Care Plan dated [DATE] revealed approaches to attempt non-pharmacological interventions and objectively document the resident's mood and behavior. An interview conducted on [DATE] at 3:03 PM with the DON revealed that there are no behaviors documented on [DATE] indicating the need for the [MEDICATION NAME] and there are no non-pharmacological interventions documented prior to the [MEDICATION NAME] being given. The DON reported that the behaviors and non-pharmacological interventions should have documented. A review of the facility's Psychoactive Drug Monitoring policy dates [DATE] revealed the following Legacy Garden Policy: Every effort is made to ensure that residents receiving these medications obtain the maximum benefit with the minimum of untoward effects. Policy Guidelines: 7. Behavioral monitoring charts or a similar mechanism are used to document the resident's need for and response to drug therapy. | 2020-09-01 |
| 912 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2017-08-22 | 323 | H | 1 | 1 | 2T4P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review and interviews; the facility failed to ensure that 1) interventions were in place to prevent recurrent falls and a subsequent fractured finger for one current sampled resident (Resident 26) and 2) oxygen concentrators were turned off when not in use to reduce the risk of fires for five current sampled residents (Residents 25, 66, 40, 15 and 71). The facility census was 107 with 22 current sampled residents. Findings are: Licensure Reference Number: 175 NAC 12-006.09D7b (3) [NAME] Review of the Admission Record, printed 8/9/17, revealed that Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that the resident also had [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 11/3/17, revealed that the resident was at risk for falls related to poor safety awareness and self-determination related to transfers. Further review revealed that the resident fell getting out of the wheelchair on 4/24/17, slid self out of the wheelchair to the floor on 6/29/17 and had an unwitnessed fall out of the wheelchair on 7/25/17. Review of the Progress Notes, dated 7/25/17 at 1:49 PM, revealed that the resident was found to be on the floor next to the wheelchair in the dining room and no injuries were noted. Further review revealed at 2:09 PM, bruising which measured 5 cm. (centimeters) by 2 cm. was noted on the 3rd digit. At 6:14 PM, swelling was noted at the finger. On 7/27/17 at 2:45 PM, an x ray showed that the resident had a fractured right third finger and orders for a splint were received. Observations on 8/9/17 at 7:40 AM revealed the resident resting in bed and a splint in place at the right third finger. Review of the Treatment Administration Record, dated (MONTH) (YEAR), revealed an order, dated 7/26/17, for Epsom salt treatment two times a day for swelling and bruising of the right hand. Review of the Medication Administration Record, dated (MONTH) (YEAR), revealed an order, dated 8/1/17, to take the splint off and check skin daily and reapply the splint daily until 9/7/17. Review of the Medication Administration Record, dated (MONTH) (YEAR), revealed that the resident received Hydrocodone - Acetaminophen (narcotic analgesic) for pain on 7/24/17 and 7/26/17. Interview on 8/14/17 at 1:45 PM with LPN (Licensed Practical Nurse) - D, Unit Coordinator, confirmed that the care plan interventions were not effective to prevent further falls from the wheelchair and the subsequent fractured finger. Licensure Reference Number: 175 NAC 12-006.09D7 B. Observations on 8/8/17 at 8:30 AM revealed Resident 15 (Room 104 B) and Resident 17 (Room 215 B) oxygen concentrators on while the residents were out of the room. Observations on 8/14/17 at 7:45 AM revealed Resident 25 (Room 220 B), Resident 66 (219 B) oxygen concentrators on while the residents were out of the room. Observations on 8/14/17 at 8:00 AM revealed Resident 40 sleeping in bed with the oxygen concentrator on and the mask on the bed. Interview on 8/14/17 at 8:15 AM with the Interim Director of Nursing confirmed that the oxygen concentrators were to be turned off when not in use to reduce the risk of accidental fires and to promote safety. | 2020-09-01 |
| 2490 | PIONEER MANOR NURSING HOME | 285212 | P O BOX 310, 318 N 3RD STREET | HAY SPRINGS | NE | 69347 | 2019-02-13 | 689 | G | 1 | 0 | U39J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interview; the facility failed to ensure that 1) interventions were in place to prevent an elopement and resulting injuries from the facility for one current sampled resident (Resident 4) with multiple attempts to leave the facility unattended, 2) identify causal factors to reduce the risk for further injuries related to skin injuries for one current sampled resident (Resident 2) and falls for two current sampled residents (Residents 7 and 8) and one closed record (Resident 6). The facility census was 51 with nine current sampled residents and one closed record reviewed. Findings are: Licensure Reference Number 175 NAC 12-006.097 [NAME] Review of the Resident Face Sheet, printed 2/11/19, revealed that Resident 4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, printed 2/12/19, revealed that the resident was a higher risk for elopement related to confusion and frequent wandering. Approaches, dated 1/31/19, included wanderguard device in place on the wheelchair, charge nurse will check functioning of the device two times a day and replace as needed. Further review revealed that the resident had moderate impaired cognition and was not able to make good decisions, had impaired vision and communication, significant memory loss and poor judgement regarding safety with transfers and required assistance for transfers. Review of the Resident Progress Notes revealed the following including: - 12/16/18 at 7:50 PM Resident opened the door at the end of the west hall and set the alarm off, did not exit; 9:32 PM Resident continued exit seeking between 7:40 PM and 8:30 PM, activity caused alarms to sound repeatedly and redirection was not successful; - 12/19/18 at at 2:48 PM Resident opened the west door in the main dining room and attempted to go outside, redirected to the assistance dining room; 6:28 PM Resident exit seeking throughout the day, wanderguard alarm alerted at this time, found resident attempting to exit from the west wing door and the resident was stopped before exiting the building; 6:38 PM assisted the resident from the west door, tried to exit, resident was disoriented and confused; - 12/22/18 at 2:19 AM Resident self ambulated into the hallway at 1:30 AM; 10:47 PM Resident ambulated in the hallway without the wheelchair with a very unsteady gait; - 12/24/18 at 5:40 PM Resident attempted to elope out of the west wing door, opened the door and was stopped before going out; - 12/31/18 at 1:13 AM Resident's behaviors are more resistive and aggressive as well as increased exit seeking; - 1/6/19 at 12:15 AM at 11:50 PM The resident was up walking with roommate's walker in the hallways; - 1/24/19 at 8:15 PM Resident exited out of the front door, wanderguard in place under the wheelchair; - 1/26/19 at 6:06 PM Resident wandering throughout the facility into restricted areas, sets off alarms often today; - 1/27/19 at 11:40 AM Resident pushed east hall door open, staff intervened before resident could elope; - 2/1/19 at 1:45 PM Resident followed family member out the front door, alarm sounded and staff assisted the resident back into the facility; - 2/7/19 at 4:15 AM Resident ambulated independently in room and the halls; - 2/8/19 at 1:04 AM During shift change, just before dinner, staff heard banging on the window outside the assistance dining room, the nurse ran outside to discover the resident on knees in the snow, a wheelchair was immediately rushed outside where two staff assisted the resident into the chair and brought the resident inside. The resident's pants were covered with snow and bare hands were red and cold. The resident walked outside and the wheelchair was left inside, the wanderguard was attached to the wheelchair. The resident's temperature was initially 92.5, oxygen saturation were difficult to obtain reading 75 - 80% to hands and 89 - 90% on great toe. At 7:10 PM, the resident's temperature was 96.3, then 97.9 and oxygen saturations were 84- 85% on room air, lung sounds coarse. Oxygen was applied at 4-5 liters per minute and oxygen saturation came up to 90%. 2:59 AM Resident very restless and agitated, refused oral pain medication, very confused and difficult to redirect, right hand swollen, all fingers and thumb. The resident was coughing up thick green phlegm. - 2/8/19 at 5:26 AM Large yellow blisters on right fingers; 1:57 PM Resident had a harsh wet cough; 9:00 PM Resident restless, rubbed the blisters and opened two of the blisters, noted tears from the resident's eyes; - 2/9/19 at 6:23 PM Resident complained of back and rib pain, pain medication administered, agitated and unable to redirect, wandered into other resident's rooms and yelled; - 2/10/19 at 3:05 AM Skin assessment included large bruise to the left shoulder and right posterior shoulder to the elbow, large bruise to the left hip area, multiple intact and ruptured blisters to both hands and multiple fingers. Observations on 2/12/19 at 4:10 PM revealed the resident seated in the wheelchair banging on the east hallway exit door. LPN (Licensed Practical Nurse) - C responded and redirected the resident away from the exit door. Interview with the Administrator on 2/13/19 at 10:00 AM confirmed that interventions were not in place to manage the resident's ongoing attempts for elopement and to prevent elopements from the facility. Reference: Taber's Cyclopedic Medical Dictionary, Edition 20, Copyright 2005 Body temperature varies with the time of day and the site of measurement. Oral temperature is usually 97.5 degrees to 99.5 degrees F (Fahrenheit). Hypothermia is a body temperature below 95 degrees F, can be life threatening and is due to exposure to wet and cold conditions. Fundamentals of Nursing, Potter-Perry, 6th Edition Oxygen Saturation normal range is 95% - 99%. Licensure Reference Number 175 NAC 12-006.09D7b (1) (3) B. Review of the Resident Progress Notes for Resident 2 revealed that on 12/24/18 at 4:28 PM staff noted a faded yellow bruise under the resident's right great toe. The resident was unable to state how the bruise was obtained. Further review revealed no documentation that potential causal factors were identified. Review of the Abuse, Neglect or Misappropriation report, dated 12/24/18, revealed that the resident had a bruise to the right great toe and after interviewing the resident and staff, the origin of the injury was still unknown. Review of the Care Plan, printed 2/12/19, revealed that the resident required assistance of two staff to transfer with a pivot disc, had impaired vision and was alert with fair recall. Further review revealed no care plan to address the injury or changes in care to prevent further injuries. C. Review of the Abuse, Neglect or Misappropriation report, dated 11/27/18, revealed that on 11/26/18, Resident 7 was found on the floor in another resident room. Further review revealed no documentation of potential causal factors related to the fall. Review of the Resident Progress Notes, dated 11/26/18, revealed that at 10:30 AM, staff alerted the nurse that the resident was sitting on the floor in another resident's room. The resident sustained [REDACTED]. (centimeters), a skin tear to back of the right hand which measured 1 cm. and both areas had large amount of bruising around them. The resident also had a large bruise and raised area at the right cheek. The resident complained of increased right hip and leg pain and was sent to the hospital for evaluation. The resident returned to the facility with no new orders. Review of the Care Plan, goal date 5/2/19, revealed that the resident had cognitive loss, dementia, impaired vision, conversations were disorganized, unrelated or delusional and required limited assistance with activities of daily living. D. Review of the Resident Progress Notes for Resident 8 revealed the following including: - 2/2/19 at 8:00 AM Resident was on the floor in the room by the recliner; 10:30 AM Resident was on the floor in front of the recliner; - 2/4/19 at 9:25 PM Resident was found sitting on the floor in room; - 2/9/19 at 8:35 PM Resident fell by the nurses station, attempted to self transfer from the chair to the wheelchair with the breaks off. Further review revealed no documentation of potential causal factors related to the falls. Review of the Care Plan, printed 2/12/19, revealed that the resident had a fall on 2/9/29 due to self transferring, a fall on 2/4/19, was no longer to ambulate independently, had cognitive loss and dementia, memory was impaired and unable to make proper decisions or make self understood, often resisted cares, had impaired vision and hearing and required assistance with activities of daily living and transfers. E. Review of the Resident Progress Notes for Resident 6 revealed the following including: - 11/25/18 at 12:20 AM Resident was found laying on the floor in room with head leaning on the wall; - 12/9/18 at 4:45 PM Resident was found on the floor by the bed; - 12/12/18 at 5:45 AM Resident was found on the floor in the assist dining room. Further review revealed no documentation of causal factors related to the falls. Review of the Care Plan, printed 2/11/19, revealed that the resident required supervision with ambulation and activities of daily living and cognition was severely impaired and was not able to make good decisions. Interview with the Administrator on 2/13/19 at 10:15 AM confirmed that causal factors, related to injuries and falls, needed to be determined so that care plan interventions could be reevaluated and changed to reduce the risk for further injuries or falls. | 2020-09-01 |
| 6688 | SUNRISE COUNTRY MANOR | 285232 | PO BOX A, 610 224TH STREET | MILFORD | NE | 68405 | 2015-11-09 | 279 | D | 1 | 1 | HZ1311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews: the facility failed to: 1) identify and develop interventions to address one sampled resident's (Resident 32) assistance with activities of daily living (ADL's); and 2) identify and develop interventions to address one samples resident's (Resident 16) non-pressure related skin condition. Facility census was 72. Finding are: A. Interview with LPN (Licensed Practical Nurse)-N on 11/4/15 at 9:35 AM revealed Resident 32 had been declining in the ability to complete ADL's for several months. Observations of Resident 32 at 10:05 AM revealed two staff members LPN-N and MA (Medication Aide)-A transferring the resident using a hoyer lift to transfer resident from recliner to bed. Record review of Resident 32's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care planning) assessments revealed a significant change in Resident 32's functional status. The MDS revealed Resident 32 required extensive assist for bed mobility, transfer, dressing, toilet use and personal hygiene. Record review of Resident 32's Care Plan printed on 11/2/15 with goal dates through 1/28/16 revealed there were no problems, goals or approaches developed or identified on the care plan to address the resident's assistance needed to complete ADL's. Interview with the Director of Nursing on 11/9/15 at 3:25 PM revealed the care plan did not address the ADL's and there should have been changes made at the time when the resident had the significant change in condition. B. Observations of Resident 16 throughout the survey revealed bruises on bilateral forearms. Record review of Resident 16's Care Plan printed on 10/22/15 with goal dates through 1/21/16 revealed there was no mention of bruising on Resident 16's care plan. Interview with the Director of Nursing on 11/9/15 at 3:20 PM revealed the care plan contained no mention of the resident's bruising. Resident 16 had received [MEDICAL CONDITION] Therapy and would have been strapped to the table to prevent movement, which could have caused the brusing it could have happened at that time. | 2018-11-01 |
| 4816 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2017-04-19 | 323 | D | 1 | 1 | HWP011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to 1) change fall interventions after a fall to reduce the risk of recurrent falls for one closed sampled resident (Resident 5) and 2) ensure that a portable oxygen cylinder was secured to reduce the risk of accidents for one sampled resident (Resident 13). The facility census was 24 with eight current sampled residents and five closed records reviewed. Findings are: Licensure Reference Number 175 NAC 12-006.09D7b [NAME] Review of the Admission Record, printed 4/18/17, revealed that Resident 5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility Investigation Report, dated 2/22/17, revealed that on 2/22/17 the resident was found on the floor in room after attempting to reach a brief package off the dresser. The immediate measures put into place to protect the resident was request staff assistance as needed .Further review revealed that the resident sustained [REDACTED]. Review of the care plan, target date 6/1/17, revealed that the resident was at risk for falls related to dizziness, history of multiple falls and impaired balance and mobility. Interventions included assistance of two staff members for transfers, bed alarm and chair alarm, and place call light and personal belongings within reach. Further review revealed no changes in interventions after the fall on 2/22/17 to reduce the risk for further falls. Interview with the Administrator on 4/19/17 at 10:15 AM confirmed that fall interventions were not changed after the fall on 2/22/17 to reduce the risk for further falls. Licensure Reference Number 175 NAC 12-006.09D1a B. Observations of Resident 5's room on 4/17/17 at 11:30 AM and at 2:15 PM revealed an unsecured portable oxygen tank leaning against the wall. Interview with the Director of Nursing on 4/17/17 at 2:15 PM confirmed that the portable oxygen tank was not secured and needed to be secured to reduce the risk of accidents. | 2020-03-01 |
| 487 | HILLCREST NURSING HOME | 285080 | P O BOX 1087, 309 WEST 7TH STREET | MCCOOK | NE | 69001 | 2017-10-11 | 323 | E | 1 | 1 | T01F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to ensure that 1) fall interventions were in place to reduce the risk for falls for two current sampled residents (Residents 48 and 31), 2) oxygen concentrators were turned off while not in use to reduce the risk of accidental fires for four current sampled residents (Residents 83, 65, 5 and 48), 3) potentially hazardous chemicals were secured to reduce the risk of accidental exposure and injuries for eight current residents identified as confused and wandering (Residents 44, 49, 53, 62, 26, 100, 90 and 107) and 4) grab bars were tightly secured on beds for five sampled residents (Residents 64, 14, 86, 38 and 52). The facility census was 81 with 35 sampled residents. Findings are: Licensure Reference Number 175 NAC 12-006.09D7 [NAME] Review of the Face Sheet, printed 10/4/17, revealed that Resident 48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, printed 10/4/17, revealed that the resident had impaired physical mobility related to weakness and interventions included ambulation with a walker and staff assistance. Further review revealed that the resident was at risk for injuries due to history of falls and interventions included remind resident to ask for help when getting up. On 6/13/17, staff education do not leave alone in the bathroom was added to the care plan. Further review revealed that the resident was legally blind, had difficulty hearing and had dementia with episodes of disorientation. Review of the Departmental Notes revealed the following including: - 6/13/17 Resident noted sitting on the floor in the bathroom in front of the toilet at 7:40 AM. Resident complained of bottom hurting and no injuries noted; - 6/15/17 at 9:41 AM Care team met to discuss the resident's fall. The resident was left unattended in the room and staff education was provided not to leave the resident unattended in the bathroom. Interview with the DON (Director of Nursing) on 10/11/17 at 8:45 AM confirmed that the resident was at risk for falls and needed assistance with ambulation. Further interview confirmed that the resident should not have been left unattended in the bathroom to reduce the risk for falls. B. Review of the Face Sheet, printed 10/4/17, revealed that Resident 31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, dated 9/7/17, revealed that the resident was at risk for falls related to new admission, mental status, recent fall and history of falls. Interventions included encourage the resident to ask for assistance, bed alarm, chair alarm and place call light within reach. Further review revealed a problem of self care deficit due to confusion and weakness and interventions included assist of one with walker and gait belt (applied around the resident's waist for staff to assist the resident to transfer and ambulate) for ambulation and assist of one to the bathroom. Review of the Departmental Notes revealed the following including: - 9/8/17 at 4:39 AM Resident was up and to the bathroom at 4:30 AM, did not use the call light for assistance. The resident was reeducated on the importance of using the call light and the need for assistance to prevent falls; - 9/11/17 at 9:43 AM Care team met to discuss 9/9/17 at 9:00 AM resident stated (gender) was getting out of bed to go to the bathroom and when (gender) legs gave out and (gender) sat on the floor. No injury noted at this time, alert and confused . Alarm sounded.; - 9/15/17 at 2:23 AM Resident was noted on the floor at 6:45 PM. Resident received a skin tear on left posterior hand. No other injuries or pain noted; 10:02 AM Care team met to discuss fall that occurred on 9/14/17 at 6:45 PM. The resident was noted on the floor in the bathroom. Staff and family educated to ensure that alarms are in place. Observations on 10/4/17 at 9:30 AM revealed the resident seated in the recliner in room. Further observation revealed the call light positioned on the bed out of reach for the resident. Observations on 10/5/17 at 6:45 AM revealed the resident standing in the bathroom with no staff present for assistance. Interview with the DON (Director of Nursing) on 10/11/17 at 8:45 AM confirmed that the resident was at risk for falls and fall interventions were not consistently in place to reduce the risk of falls and injuries. Licensure Reference Number 175 NAC 12-006.09D7a C. Observations on 10/3/17 at 12:30 PM, during the initial tour of the facility, revealed the oxygen concentrators on in Room 200 (Resident 83), Room 418 (Resident 65) and Room 401 (Resident 5). Further observations revealed that the residents were not in their rooms. Observations on 10/11/17 at 7:00 AM revealed the oxygen concentrator on in Room 410 (Resident 48) and the resident was not in the room. Interview with the Administrator on 10/11/17 at 7:45 AM confirmed that the oxygen concentrators were to be turned off while not in use to reduce the risk of accidental fires. Licensure Reference Number 175 NAC 12-006.18E4 D. Observations on 10/3/17 at 12:30 PM, during the initial tour of the facility, revealed the following including: - 200 wing utility room door unlocked with a container of Hydrogen Peroxide Cleaner Disinfectant Wipes on the counter; - 300 wing utility room door unlocked with a container of Clorox Bleach wipes on the counter; - 300 wing treatment cart by the nurses station with a container of Sani-Cloth Plus Germicidal wipes on the top of the cart; - Special Care Unit bathing room door unlocked with Virex 11 256 Disinfectant spray container and MARC 120 Cherry Blossom Air Freshener spray container in an unlocked cupboard. Interview on 10/3/17 at 12:30 PM with RN (Registered Nurse) - G confirmed that the chemicals were to be kept locked up to reduce the risk of accidental exposure and injuries for the residents. RN - G identified Resident 53 (100 wing), Resident 62 (200 wing), Residents 44 and 49 (400 wing) and Residents 26, 100, 90 and 107 (Special Care Unit) as being confused and wandered in the facility and at risk for accidental exposure and injuries. References Safety Data Sheets/Toxicological Information: Hydrogen Peroxide Cleaner Disinfectant Wipes - Inhalation - may cause irritation of the respiratory tract; - Eye contact - may cause slight irritation; - Skin contact - may cause slight skin irritation; - Ingestion - may cause irritation to mucous membranes, gastrointestinal irritation, nausea, vomiting and diarrhea. Sani-Cloth Plus Germicidal Disposable Cloth - Eye contact - mildly irritating to eyes on test data; - Exposed individuals may experience eye tearing, redness and discomfort. Virex 11 256 One-Step Disinfectant Cleaner and Deodorant - Skin contact - corrosive, causes severe burns, blisters redness and pain which may be delayed; - Eye contact - corrosive, serious eye damage, pain, burning sensation, redness watering, blurred vision or loss of vision; - Ingestion - causes burns, serious damage to mouth, throat and stomach, harmful if swallowed - vomiting, nausea; - Inhalation - may cause irritation and corrosive effects to nose, throat and respiratory tract, coughing and difficulty breathing. MARC 120 Cherry Blossom Air Freshener - Eyes - direct contact may irritate eyes; - Skin - prolonged or repeated contact can irritate or dry skin. E. Licensure Reference Number: 175 NAC 12-006.18B3 Observations conducted on 10/3/2017 and 10/4/2017 of resident rooms revealed the following: -[RM #]2A Repositioning rail on both sides of the bed were loose. -[RM #]4B Repositioning rail on both sides of the bed were loose. -[RM #]5A Repositioning rail on both sides of the bed were loose. -Room 311A Repositioning rail on both sides of the bed were loose. -Room 422A Repositioning rail on both sides of the bed were loose. Interview and inspection of resident rooms with the Maintenance Man on 10/10/2017 2:53 PM confirmed that the repositioning rails to the beds were loose and needed tightening to the bed frame. | 2020-09-01 |
| 2614 | WAUNETA CARE AND THERAPY CENTER | 285220 | PO BOX 520, 427 LEGION STREET | WAUNETA | NE | 69045 | 2017-07-20 | 323 | E | 1 | 1 | 3Q2711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to ensure that 1) interventions were in place to reduce the risk for falls for one sampled resident (Resident 34) and 2) chemicals were secured to reduce the risk for accidental exposure and injury for nine residents identified as confused and wandered in the facility (Residents 14, 17, 20, 26, 22 13, 21, 34 and 28). The facility census was 31 with 11 current sampled residents. Findings are: Licensure Reference Number 175 NAC 12-006.09D7b [NAME] Review of Resident 34's Departmental Notes, dated 2/5/17, revealed that at 4:20 PM, the resident was heard hollering and was found sitting on the floor. The resident stated was in my closet and my shoe slipped and I lost my balance abd (sic) fell to my right and hit my right arm. Review of the Care Plan, goal date 3/2/17, revealed a problem that the resident had a history of [REDACTED]. Approaches included Ensure that (resident) has and wears properly - fitting non-skid soled shoes for ambulation, Removed unsafe slippers and replace with closed heel slippers. and Give (resident) verbal reminders not to ambulate or transfer without assistance. Interview with the Director of Nursing on 7/19/17 at 2:20 PM confirmed that the resident was at risk for falls. Further interview confirmed that the care plan interventions were not in place to reduce the risk for falls as the resident was not wearing safe shoes at the time of the fall and did not call for assistance to transfer or ambulate. Licensure Reference Number 175 NAC 12-006.09D7a [NAME] Observations on 7/17/17 at 6:50 PM, during the initial tour of the facility, revealed an unlocked oxygen storage room across from the nurses station and resident lounge area. Further observations revealed a can of Lynx disinfectant spray on the counter. Several residents were in the hallways and in the lounge area. Interview with LPN (Licensed Practical Nurse ) - A on 7/17/17 at 6:50 PM confirmed that the chemicals were to be kept in locked cupboards to reduce the risk of accidental exposure and injuries for confused and wandering residents. LPN - A identified nine residents who were confused and wandered in the facility (Residents 14, 17, 20, 26, 22 13, 21, 34 and 28). Reference: Material Safety Data Sheet for Lynx Surface Disinfectant Spray Emergency Overview . Primary Route of Entry: Skin contact, inhalation . EYES: Causes severe irritation, experienced as discomfort or pain, excess blinking and tear production, which redness and swelling of the conjunctiva. SKIN: Brief contact may cause slight irritation. Prolonged contact may cause more severe irritation with pain, local redness and swelling. INHALATION: High vapor/aerosol concentrations (>1000ppm (parts per million)) are irritating to the respiratory tract. INGESTION: (MONTH) cause headache, dizziness, un-coordination, nausea, vomiting, diarrhea and general weakness. | 2020-09-01 |
| 5745 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2016-09-20 | 323 | E | 1 | 0 | TD4511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to ensure that 1) interventions were in place to reduce the risk of recurrent falls for one sampled resident (Resident 132), 2) ensure potentially hazardous chemicals were secured to reduce the risk of accidental exposure and injury for two residents identified as confused and wandering in the unit (Residents 67 and 159), 3) footrests were utilized when transporting residents in wheelchairs to support the resident's feet and to reduce the risk for injuries for three sampled residents (Residents 132, 4, and 97), 4) one staff member did not transport two residents seated in wheelchairs in the hallway at the same time (Residents 7 and 124), 5) a safety assessment was completed for grab bars on the bed which contained gaps large enough for potential entrapment of limbs for one sampled resident (Resident 132) and 6) oxygen concentrators were turned off when not in use or when residents were out of the room to reduce the risk for fires for four sampled residents (Residents 2, 12, 68 and 86). The facility census was 114. Findings are: Licensure Reference Number 175 NAC 12-006.09D7 A. Review of the Admission Record, printed 9/8/16, revealed that Resident 132 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, with a goal date of 11/20/16, revealed that the resident was confused with impaired cognition, had poor vision, was incontinent of bowel and bladder and was at risk for falls related to history of falls and wandering behaviors. Further review revealed that the resident fell on [DATE], 8/16/16, 8/22/16, and 8/23/16. Interventions included encourage resident to use call light for help, frequent checks, non slip footwear, encourage and remind to toilet frequently, toileting after supper, keep resident close while in the wheelchair and keep environment fee of clutter and well lit. Review of the Progress Notes revealed the following including: - 8/16/16 at 12:33 PM, Resident slipped on the floor, hit head and sustained an open area to the right forehead, hematoma to the right forehead, skin tear to the right elbow, open area to the right hand; - 8/17/16 at 9:25 PM, Resident was found sitting on the floor between the bed and the wall. Skin tear to right elbow; - 8/18/16 at 1:05 PM, Resident tried to walk in the hallway independently. Staff reminded of the need to have staff walk with the resident; - 8/22/16 at 5:53 AM, Resident found lying on the floor at the foot of the bed and in front of the wheelchair, skin tear to right elbow. 9:23 PM, Resident observed on the floor on knees, transferred self to chair and lowered self to the floor. No new injuries observed. Resident was transferred to the emergency room for evaluation due to multiple falls in the last week; - 8/23/16 at 7:30 PM, Resident found sitting on the floor next to bed and in front of the wheelchair. The floor was noted to be wet; - 8/25/16 at 9:50 AM, Resident tried to walk the hallway without assistance. Staff reminded resident to have staff walk with the resident; - 8/28/16 at 3:33 AM, Resident self transferred to the bathroom. Educated resident to utilize call light for transfers; - 9/3/16 at 10:37 AM, Resident was confused and forgetful. Got up and walked in hallway. Discouraged to walk alone and to call for help but does it anyway; - 9/11/16 at 2:53 PM, Resident observed trying to help another resident out of a recliner; - 9/12/16 at 3:25 AM, Resident was found on the floor in room, sitting in the doorway of the bathroom. Small elevated area at the posterior left ear with an abrasion; - 9/12/16 at 9:35 AM, Resident tried to walk independently several times. Staff redirected multiple times and resident continued to get out of the wheelchair without assistance; - 9/13/16 at 4:00 PM, Resident got up and ambulated without assistance; - 9/14/16 at 3:15 AM, Resident continued to self transfer and ambulate without assistance. Educated to have staff assist with transfers and to use wheelchair. Observations on 9/12/16 at 7:20 AM revealed the resident ambulated independently in the dining room and the hallways and, at 2:00 PM, ambulated independently in room. Further observations revealed healing bruising on right forehead and multiple skin tears at various stages of healing on arms and legs. Observations on 9/15/16 at 1:55 PM revealed the resident ambulated independently in room and bathroom. Observations on 9/19/16 at 4:20 PM revealed the resident ambulated independently in the hallways and the front lobby area. Interview with the DON (Director of Nursing) on 9/19/16 at 3:30 PM confirmed that the resident was a high risk for falls with injuries and current interventions were not effective to ensure that the the resident does not ambulate without staff assist. Interview with LPN (Licensed Practical Nurse) - E, Charge Nurse, confirmed that the care plan interventions were not effective as the resident continued to get up and walk independently and will not use the call light to ask for assistance. Licensure Reference Number 175 NAC 12-006.09D7a B. Observations on 9/6/16 at 1:30 PM, during the initial tour of the facility, revealed an unlocked and unattended shower room by Room 225 with an opened container of Classic Whirlpool Disinfectant Cleaner on the floor by the shower chair. Interview on 9/6/16 at 1:30 PM with LPN - O, Charge Nurse, confirmed that the shower door was to be locked. Further interview revealed that Resident 67 and Resident 159, residents on the unit, were confused and wandered in the hallways and were at risk for accidental exposure to the disinfectant. Interview on 9/6/16 at 3:45 PM with the Administrator confirmed that the whirlpool disinfectant was to be kept locked up to reduce the risk of accidental exposure to residents. Observations on 9/8/16 at 11:00 AM revealed the shower room on the 200 wing next to Room 225 unlocked and unattended with the whirlpool disinfectant unsecured on the floor by the shower chair. Interview on 9/8/16 at 11:10 AM with RN (Registered Nurse) - A, Charge Nurse, confirmed that the shower room was to be kept locked to reduce the risk of accidental exposure for confused and wandering residents. Review of the Material Safety Data Sheet for Classic Whirlpool Disinfectant Cleaner revealed that potential health hazards included eye irritation, can be harmful if swallowed or if spray mist is inhaled, redness, irritation or burning sensation to skin. C. Observations on 9/7/16 at 3:20 PM revealed Resident 132 seated in the wheelchair without footrests propelled in the hallways by spouse. Observations on 9/8/16 at 7:30 AM revealed NA (Nursing Assistant) - P transported Resident 4 in the wheelchair in the hallway with no footrests. D. Observations on 9/8/16 at 11:30 AM revealed NA - Q pushed Resident 7 in the wheelchair and pulled Resident 124 in the wheelchair in the hallway at the same time. E. Observations of Resident 132's room on 9/7/16 at 12:20 PM revealed a grab bar on each side of the bed with gaps within the grab bars large enough for potential entrapment of limbs. Observations of the grab bars on 9/19/16 at 11:30 AM revealed gaps including the following: -13 inches from the headboard to the grab bar; - horizontal gap of 13 inches by 3 inches; - vertical gaps 24 inches by 3.5 inches and 18.5 inches by 4.5 inches. Interview on 9/19/16 at 11:30 AM with NA (Nursing Assistant) F, Unit Coordinator, confirmed that the resident used the grab bars for bed mobility. Further interview confirmed that the gaps within the grab bars posed a risk for entrapment of the resident's limbs and no safety assessment was completed to ensure the safe use of the grab bars. F. Observations of Resident 2's room on 9/7/16 at 3:20 PM revealed the oxygen concentrator on while the resident was out of the room with the oxygen cannula placed on top of the concentrator next to the privacy curtain. G. Observation on 9/19/16 at 10:00 AM of Resident 97 pushed through the hallway on a bath chair with no foot rests in place. Interview on 9/20/16 at 4:00 PM with the Administrator and the (Director of Nursing) DON verified that Resident 97 should not have been pushed through the hallway in a shower chair without footrests for safety issues. H. Observation on 9/7/16 at 9:30 AM of Resident 12's oxygen concentrator left running and tubing hanging draped over the chair while the resident was at breakfast. Observation on 9/19/16 at 9:30 AM of Resident 12's oxygen concentrator left running and laying on the bed in the residents room while the resident was at breakfast. I. Observation on 9/7/16 at 9:30 AM of the oxygen concentrator running in the room of Resident 68 and laying over the concentrator. Further observation revealed that Resident 68 was out of the room at breakfast with a portable oxygen tank. Observation on 9/12/16 at 9:45 AM of Resident 68's oxygen concentrator running in the room and the tubing draped over the concentrator while the resident was at breakfast. Interview with (Nursing Assistant) NA - CC on 9/19/16 at 9:50 AM revealed that some of the residents remove their own oxygen and turn off their concentrators prior to leaving their rooms. Occasionally the residents forget and leave the concentrators running. Further interview verified that Resident 12 and 68 had left the concentrator running while they were at breakfast. Continued interview confirmed that it was not safe to leave the concentrators running in the rooms and the oxygen concentrators were shut off by NA - CC. Interview on 9/20/16 at 4:10 PM with the Administrator and the DON confirmed that it was not safe to have oxygen concentrators running in the rooms of Residents' 12 and 68 while the residents were at breakfast. | 2019-09-01 |
| 918 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2017-08-22 | 425 | E | 1 | 1 | 2T4P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to ensure that 1) medications were available to administer for a newly admitted resident (Resident 173) closed record, 2) Medication Aides reported a discrepancy with a prescription label and the doctor's order to a nurse before administering the medication for two current sampled residents (Residents 143 and 75) and 3) medication aides checked the prescription labels with the current medication order at least three times before administration of medications to reduce the risk for errors for five sampled residents observed for medication administration (Residents 53, 19, 143, 75 and 8). The facility census was 107 with five residents sampled for observation of medication administration and three closed records reviewed. Findings are: Licensure Reference Number: 175 NAC 12-006.12A [NAME] Review of the Admission Record, printed 8/9/17, revealed that Resident 173 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MAR (Medication Administration Record), dated (MONTH) (YEAR), revealed that the evening doses of Bumetanide and Carvedilol (ordered for heart failure) and Florajen and Sennosides (ordered for bowel maintenance) were not administered. Review of the Treatment Administration Record, dated (MONTH) (YEAR), revealed that the evening treatment of [REDACTED]. Interview on 8/15/17 at 3:00 PM with LPN (Licensed Practical Nurse) - C, Unit Coordinator, confirmed that the evening doses of medications were not administered because the medications were not delivered to the facility from the pharmacy until late that evening. Licensure Reference Number: 175 NAC 12-006.10A3 B. Observations on 8/10/17 at 7:45 AM revealed MA (Medication Aide) - T prepared to administer morning medications for Resident 143. MA - T removed the medication card for Metoprolol. Further observations revealed that the prescription label had instructions to administer 25 mg. (milligrams) one tablet two times a day. Review of the electronic MAR indicated [REDACTED]. daily. MA - T did not identify the discrepancy with the prescription label and the medication order. MA - T did not clarify the order with a nurse when the discrepancy was questioned, administered 25 mg. and documented that 75 mg. were administered. Observations on 8/10/17 at 8:50 AM revealed MA - M prepared to administer Flonase nasal spray for Resident 75. Further observations revealed MA - M compared the prescription label with the order on the electronic MAR indicated [REDACTED]. MA - M did not clarify the order with a nurse when the discrepancy was questioned and administered the medication. Interview on 8/10/17 at 9:30 AM with the Interim Director of Nursing confirmed that the Medication Aides were to identify discrepancies with prescription labels and current orders. Further interview confirmed that the Medication Aides were to notify a nurse to clarify the orders before administration of the medications to reduce the risk for errors. C. Observations on 8/9/17 at 3:00 PM revealed MA - FF prepared to administer Oxycodone for Resident 19. Further observations revealed MA - FF removed the medication card from the medication cart, compared the prescription label with the order on the electronic MAR indicated [REDACTED]. D. Observations on 8/10/17 at 7:40 AM revealed MA - GG prepared to administer morning medications for Resident 53. Further observations revealed MA - GG removed the medication cards from the medication cart, compared the prescription label with the orders on the electronic MAR indicated [REDACTED]. MA - GG removed stock medications from the medication cart, checked the labels one time, poured the medications and returned them to the medication cart. MA - GG administered the medications and returned to the medication cart to sign off the medications administered. E. Observations on 8/10/17 at 7:45 AM revealed MA - T prepared to administer morning medications for Resident 143. Further observations revealed MA - T removed the medication cards from the medication cart, compared the prescription label one time with the orders on the electronic MAR, poured the medications, placed the medication cards back into the medication cart and administered the medications. Further observations revealed that MA - T returned to the medication cart and signed off the medications administered. F. Observations on 8/10/17 at 8:50 AM revealed MA - M prepared to administer Flonase nasal spray for Resident 75. Further observations revealed MA - M compared the prescription label with the order on the electronic MAR indicated [REDACTED]. Observations on 8/10/17 at 9:00 AM revealed MA - M administered medications for Resident 8 in the same manner described above. Review of the facility policy Medication Administration, revised 5/1/11, revealed the following including Procedure: . 8. Read the Medication Administration Record [REDACTED]. 10. Verify the pharmacy prescription label on the drug and the manufacturer's identification system matches the MAR. If there is a discrepancy, check the original physician's order and notify the pharmacy. Do not give the medication until clarified. 11. Verify that any further medication identifiers match the label and the medication . 12. Verify the correct medication, expiration date, dose, dosage form, route, and time again by comparing to MAR before administering. Interview on 8/14/17 at 3:45 PM with the Interim Director of Nursing confirmed that the Medication Aides were to compare the prescription label at least three times with the medication order before administration of medications to reduce the risk of errors. | 2020-09-01 |
| 5742 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2016-09-20 | 309 | D | 1 | 0 | TD4511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to ensure that 1) ongoing aggressive behaviors were managed to reduce the risk of physical altercations with other residents for two sampled residents (Resident 131 and 104) and 2) interventions were in place prevent skin injuries for one sampled resident (Resident 13) identified at high risk for skin injuries and ensure weekly skin assessments were completed which included measurements of skin tears to ensure healing without complications. The facility census was 114. Findings are: Licensure Reference Number 175 NAC 12-006.09D A. Review of Resident 131's Care Plan, goal date 6/30/16, revealed that the resident had [DIAGNOSES REDACTED]. Further review revealed that the resident had behaviors including crying, cursing, trying to help other residents, wandering in and out of other resident's rooms and waking them up and agitated and combative with attempts to redirect the behaviors. Interventions included medications as ordered, avoid upsetting situations or people and attempt interventions before behaviors begin such as one on one time with staff. Review of theBehavior Detail Report revealed the following including: - 6/1/16 at 9:36 AM, resident wandered in other resident's rooms and refused medications, interventions ineffective; - 9:37 AM, resident screamed at staff, interventions ineffective; - 9:45 AM, resident hit staff, cursed, screamed at staff, scratched staff, shoved staff, undressed in public, rejected cares, rejected medications, wandered in the halls; - 10:18 AM, resident hit, shoved, scratched staff, undressed in public; - 12:32 PM, resident had physical behaviors directed towards others; - 1:07 PM, resident wandered in hall, screamed at staff and others; - 3:35 PM and 8:55 PM, resident wandered in hall, redirection not effective. Review of the Progress Notes, revealed the following including: - 6/1/16 at 12:50 PM, resident was noted by staff to be holding another resident up against the wall, squeezing and pushing the resident's left arm with hands; - 6/2/16 at 5:35 AM, resident wandering in hallway and other resident's room, crying and laughing at times, medication given for anxiety with no effect, exit seeking, removing clothing in the hallway; 7:39 AM, standing on bed trying to get out out the window, redirection interventions unsuccessful; 1:41 PM, resident slapped another resident in the back of the head while the resident was seated in a wheelchair assisted by staff in the hallway; - 6/3/16 at 10:41 AM, resident was yelling at another resident in Spanish, reached out and pulled the resident back as the resident was walking away; 6:59 PM, resident observed hitting another resident on the arm. B. Review of Resident 104's Care Plan, goal date 9/13/16, revealed that the resident had [DIAGNOSES REDACTED]. Interventions included watch for nonverbal cues, pacing, increased fighting and signs of pain, encourage activities, offer snacks and beverages and help with toileting. Review of Resident 104's Progress Notes revealed the following including: - 1/17/16 at 10:03 AM, Resident was very agitated, chasing after staff with lower half of body undressed, hollering and shoving staff, tight grip on staff's hands, threw drink offered, screaming and grunting; 3:28 PM, Resident agitated, yelling and grabbing at other residents, as needed anti anxiety medication and snack administered and resident became calm; - 2/2/16 at 9:08 AM, Resident was observed pushing another resident (Resident 123) from behind to the floor; - 2/10/16 at 7:13 AM, Resident was agitated and restless this morning with morning cares, pacing the halls, circled another resident's chair in the living room and sat down and kicked the resident in the leg. Interview on 9/20/16 at 7:15 AM with LPN (Licensed Practical Nurse) - E, Charge Nurse, confirmed that behavior management interventions were not always effective to manage ongoing aggressive behaviors towards other residents or staff. Licensure Reference Number 175 NAC 12-006.09D2c C. Review of Resident 13's Care Plan, goal date 12/13/16, revealed that the resident required extensive assistance with activities of daily living, used a mechanical lift for transfers, used a wheelchair for locomotion and was on a blood thinner medication. Interventions included gerigloves (soft gloves utilized to protect the resident's fragile skin) to be put on resident by staff. Review of the Progress Notes, dated 9/1/16 at 2:02 PM, revealed that, at 7:50 AM, the resident had skin tears on the right arm which measured 5 x 1 cm. (centimeter). The skin tear was cleansed and dressings were applied for protection. There was no documentation that the gerigloves were in place when the skin tear was identified. Review of the Weekly Skin Review, dated 9/1/16, revealed that the resident had a skin tear which measured 5 x 1cm. Review of the Weekly Skin Review, dated 9/8/16, revealed that the resident had a skin tear at the right forearm, right elbow and the left forearm with no signs and symptoms of infection. There were no measurements recorded for these skin tears. Review of the Weekly Skin Review, dated 9/15/16, revealed that the resident had a skin tear at the right forearm which was cleaned and a dressing applied. There were no measurements of the skin tear. Observations on 9/8/16 at 2:30 PM revealed the resident seated in the wheelchair in room. Further observation revealed a geriglove on the left arm but not on the right arm. Observations on 9/19/16 at 1:45 PM revealed the resident resting in bed. LPN (Licensed Practical Nurse) - E and LPN - N, removed the dressing at the resident's right arm and measured the skin tear as 4.5 cm . X 3 cm. There was no geriglove observed on the resident's right arm. Interview on 9/19/16 at 1:45 PM with LPN - E confirmed that the weekly skin assessments did not include measurements of the skin tears to ensure healing without complications. Interview with the DON (Director of Nursing) on 9/19/16 at 3:30 PM confirmed that the resident was at risk for skin tears and gerigloves were to be worn to protect the resident's skin. | 2019-09-01 |
| 5717 | NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER | 285271 | 2100 CIRCLE DRIVE | SCOTTSBLUFF | NE | 69361 | 2016-10-03 | 425 | E | 1 | 0 | SRLF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews the facility failed to: 1) ensure that ordered medications were available for three sampled residents (Residents 8, 10, 14); 2) prevent medication omission errors involving three sampled residents (Residents 12, 13, and 14); 3) question an ordered medication provided for one sampled resident (Resident 8) which was listed among resident allergies [REDACTED]. residents (Residents 2, 8, 9, 10, 12, 13, and 14). Sample size was 12 current residents. Facility census was 51. Findings are: Licensure Reference Number: 175 NAC 12-006.12 A. Record review of Resident 8's Medications Administration History form for (MONTH) of (YEAR) revealed the following medication omissions: -an order for [REDACTED]. -a scheduled dose of Losartan, ordered to be administered at bedtime was not administered on 9/28/16 due to the medication being unavailable from the pharmacy. -Scheduled doses for the resident's Omeprazole ordered for administration twice daily were not administered on 9/22/16 at 8 p.m. and 9/23/16 at 6 a.m. due to the medication being unavailable from the pharmacy. Record review of Resident 10's Medications Administration History form for (MONTH) of (YEAR) revealed the following omission on 8/11/16 for Tramadol (pain medication) which was ordered on [DATE]. The comment for why the medication was not administered read: Drug Item unavailable. Record review of Resident 14's Medications Administration History form for (MONTH) of (YEAR) revealed an order for [REDACTED]. Licensure Reference Number: 175 NAC 12-006.12A B. Record reviews of Resident facility medication error reports revealed the following errors were investigated: - Error occurring on 8/23/16 revealed Resident 12's ordered medications for: Omeprazole, Simethicone, Levothyroxine, Hydrochlorothiazide, Losartin, and Nifadipine scheduled for 8 a.m. doses were omitted and not given. - Error occurring on 8/23/16 revealed Resident 13's ordered medications for Metoprolol and Namenda were omitted and not given to the resident as scheduled for 8 a.m. doses. - Error occurring on 8/20/16 revealed Resident 14's ordered medication for Coreg, ordered twice daily was omitted and not given the resident during the scheduled 5 p.m. dose. C. Record review of Resident 8's Physician Order Report for 9/3/16 through 10/3/16 revealed a list of resident allergies [REDACTED]. Record review of Resident 8's Medications Administration History form for (MONTH) of (YEAR) revealed Resident 8 was administered the Morphine Concentrate solution on 9/27; 9/28; 9/29; and 9/30/16. D. Observation on 9/29/16 at 6:30 a.m. revealed LPN (Licensed Practical Nurse)-H administering medications for Resident 2. During the observation, LPN-H prepared and administered a dose of Pepcid to the resident. LPN-H stated that the time was incorrectly inputted into the computerized medical record for administration at 8 a.m. and that the time needed to be changed so the resident would receive the medication prior to meals as the manufacturer directs. Record review of Resident 2's Medications Administration History for 9/1/16 through 9/28/16 revealed an order for [REDACTED].>Second interview with LPN-H on 9/29/16 at 1:20 p.m. confirmed the order was taken on 9/24/16 and incorrectly entered to administer at 8 a.m. which was after the resident's usual breakfast time. LPN-H confirmed the order was not changed until today 9/29/16, five days after the order was received. E. Record reviews of facility Medications Administration History forms revealed the following documentation regarding ordered medication doses not being administered to residents: Resident 2's (MONTH) (YEAR) administration forms revealed: - Resident 2's aspirin dose scheduled daily at bedtime was not given due to the resident sleeping. -Resident 2's Restasis scheduled twice daily was not administered in the evening on 8/1/16 due to the resident sleeping. and on 8/23/16 the morning dose was not administered due to the resident being at activities. Resident 9's (MONTH) (YEAR) administration record forms revealed: - an ordered dose for Combigan eye drops with instructions for twice a day dosing was not administered on 9/19/16 for the scheduled 9 p.m. dose due to the eye drops not in the box couldn't find. Resident 12's (MONTH) (YEAR) administration record forms revealed: - an ordered dose for Aspirin with orders to administer the medication daily at 7 a.m. was not administered to the resident until 12:03 p.m. on 8/23/16. - an ordered dose of Miralax scheduled daily at 8 a.m. was not administered to the resident until 12:07 p.m. on 8/23/16 - an ordered dose of Refresh eye drops scheduled daily at 8 a.m. was not administered until 12:07 p.m. on 8/23/16. Resident 14's (MONTH) (YEAR) administration record forms revealed: - an ordered dose for a daily vitamin scheduled to be administered at bedtime was omitted and not administered to the resident on 8/23/16 due to the resident being asleep. F. Record reviews of facility Medications Administration History forms revealed the following: Review of Resident 2's administration records for (MONTH) and (MONTH) of (YEAR) revealed 20 instances where medications were documented late (after the scheduled time with one hour leeway before and after scheduled times) in (MONTH) and 19 instances where medications were documented late in September. Review of Resident 9's administration records for (MONTH) and (MONTH) of (YEAR) revealed 11 instances where medications were documented late in (MONTH) and 9 instances where medications were documented late in September. Review of Resident 10's administration records for (MONTH) (YEAR) 11 instances where medications were documented late in August. Review of Resident 12's administration records for (MONTH) (YEAR) 41 instances where medications were documented late in August. Review of Resident 13's administration records for (MONTH) (YEAR) 29 instances where medications were documented late in August. Review of Resident 23's administration records for (MONTH) (YEAR) 11 instances where medications were documented late in August. Record review of the facility policy for Administering Medications revised (MONTH) of 2012 revealed policy directions for staff to: The individual administering the medication must initial the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones. Interview was conducted with the facility Administrator, Director of Nursing, Nurse Consultants, and Corporate Chief Executive Officer on 10/3/16 beginning at 11:45 a.m. During the interview the findings from this review along with document reviews of sampled resident Medication Administration Histories. The Administrator, Director of Nursing, and Nurse Consultants verified documentation that medications were unavailable for residents 8, 10, and 14; medication errors omitting resident scheduled medications were investigated and confirmed for Residents 12, 13, 14; Time of administration was incorrectly entered into Resident 2's computerized medical record; documentation of omissions of medications occurred for Residents 2, 9, 12, and 14; and the staff were failing to document medications as soon as they were administered according to facility policy and current standards of practice for medication administration for Residents 2, 8, 9, 10, 12, 13, and 14. | 2019-10-01 |
| 5302 | BLUE VALLEY LUTHERAN CARE HOME | 2.8e+280 | P O BOX 166, 755 SOUTH 3RD STREET | HEBRON | NE | 68370 | 2019-01-02 | 604 | E | 1 | 0 | JR9H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews, the facility failed to ensure 3 (Resident 12, 100, and 23) out of 3 residents were free from physical restraints and the restraints that were being used, were used to treat medical symptoms. The facility census was 30. Findings are: [NAME] Observation of Resident 12 on 1-2-18 at 10:10 [NAME]M. revealed the resident was sitting in the wheelchair with a locked laptray, seatbelt, and wrist restraints on both wrists that prevented the resident from lifting either arm up off of the lap tray. Observations of the residents hands revealed both fingers/hands were contracted into a fist like shape. The lap tray was absent of any activity or food/drink items for the resident. Record review of Resident 12's Face Sheet dated 1-2-19 revealed the date of admission as 6-2-14 and [DIAGNOSES REDACTED]. Review of the Annual MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-12-18 revealed no restraints. Interview on 1-2-19 at 2:55 PM with NA-B (Nurse Aide) revealed Resident 12 was admitted with the seatbelt, laptray, and wrist restraints. NA-B revealed the resident had the laptray, the seatbelt, and the wrist restraints applied whenever up in the wheelchair. NA-B confirmed the resident was unable to remove the seatbelt, the laptray or the wrist restraints. NA-B confirmed the staff do not remove the restraints once applied unless they are transferring the resident back to bed. The resident was fed via a feeding tube into the stomach so did not need the hands to eat. Interview on 1-2-19 at 3:00 PM with LPN-A (Licensed Practical Nurse) revealed the resident was not able to remove the lap tray or the seatbelt. LPN-A revealed sometimes the resident by shear force may break free of the wrist restraints but was not able to remove them in the same manner they were applied. LPN-A confirmed the laptray, seatbelt, and wrist restraints were applied every time the resident was placed in the wheelchair and removed when transferred back to bed. LPN-A revealed the purpose of the wrist restraints were to prevent the resident from flailing the arms and cause injury to self and other residents from the spastic muscle movements the resident had. Review of the Annual Restorative Therapy Summary dated 12-13-18 revealed the wheelchair was equipped with a tray which included wrists/forearm straps to assist in positioning the bilateral upper extremities to prevent injuries from the residents unpredictable extremity movements. On 9-19-18 a representative from an Occupation Therapy Company and fitted the resident for a better-fitted seating and positioning system and modifications to the lap tray. Review of the notes revealed absence of what the medications were or why. Record review of the resident's Physician orders revealed absence of an order to apply and identify the medical symptoms for the the seatbelt, laptray, and wrist restraints. Record review revealed absence of documentation related to: -The seatbelt, laptray, and wrist restraints being used were the least restraints to be used on Resident 12, used for the least amount of time, and other interventions attempted to treat the medical symptom were ineffective. -The legal representative was informed of the potential risks and benefits of all options under consideration including using the restraint, not using a restraint, and alternatives to restraint use. -The resident could demonstrate to staff the ability to 'intentionally' remove the device in the same manner that the staff applied it. -The type of specific direct monitoring and supervision provided during the use of the seatbelt, laptray, and wrist restraints including documentation of the monitoring by the staff. -The on going re-evaluation to show the need for the laptray, seatbelt, and wrist restraints and how it was effective in treating the medical symptom it was being used for. B. Observation on 1-2-19 at 10:15 AM of Resident 100 sitting in the wheelchair with a locked lap tray on in the hallway near the nurses' desk. The lap tray was absent of any activity or food/drink items on the tray for the resident. Resident also had a locked seatbelt on around the waist. Record review of Resident 100's Face sheet dated 1/2/19 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident 100's MDS dated [DATE] revealed the resident did not use restraints. The BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) revealed the resident was severely cognitively impaired. Interview on 1-2-19 at 2:55 PM with NA-B revealed Resident 100 was deaf and blind and a high fall risk. Whenever the resident was up in the wheelchair, the staff applied the seatbelt and the laptray on the resident or the resident would slide right out of the chair. NA-B revealed a few times new staff were not aware to apply the seatbelt and laptray and the resident right away started scooting self down in the chair. NA-B revealed the resident was not able to remove the seatbelt of the laptray independently. Interview on 1-2-19 at 3:05 PM with LPN-A revealed Resident 100 was not able to remove the lap tray or the seatbelt independently. LPN-A revealed both the seatbelt and the laptray were on anytime the resident was up in the wheelchair for positioning to prevent the resident from sliding out of the wheelchair. Record review of the resident's Physician orders revealed absence of an order to apply and identify the medical symptoms for the the seatbelt and laptray restraints. Record review revealed absence of documentation related to: -The seatbelt and laptray being used were the least restraints to be used on Resident 100, used for the least amount of time, and other interventions attempted to treat the medical symptom were ineffective. -The legal representative was informed of the potential risks and benefits of all options under consideration including using the restraint, not using a restraint, and alternatives to restraint use. -The resident could demonstrate to staff the ability to 'intentionally' remove the device in the same manner that the staff applied it. -The type of specific direct monitoring and supervision provided during the use of the seatbelt and laptray restraints including documentation of the monitoring by the staff. -The on going re-evaluation to show the need for the laptray and seatbelt restraints and how it was effective in treating the medical symptom it was being used for. C. Observation on 1-2-19 at 10:30 AM revealed Resident 23 sitting in a merrywalker (framed walker/chair combination assistive device) in the hallway with the strap intact between the resident legs and the bar secured in front of the resident to prevent the resident from exiting the merrywalker device. Review of Resident 23's Face Sheet dated 12-24-18 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of annual MDS dated [DATE] revealed restraints used daily. Review of the CAA worksheet with this MDS revealed restraints were triggered with the following documentation: This triggered due to the need for a merry walker. (Resident 23) used the merry walker for mobility within the facility. This allowed the resident freedom of movement while decreasing the risk of falls. However, the resident was not able to open the front bar and transfer at will. Due to this the merry walker must be considered both an enabler and a restraint. Record review of the resident's Physician orders revealed absence of an order to use the merrywalker and identify the medical symptoms for the restraint. Record review revealed absence of documentation related to: -The merrywalker restraint used was the least restraint to be used on Resident 23, used for the least amount of time, and other interventions attempted to treat the medical symptom were ineffective. -The resident could demonstrate to staff the ability to 'intentionally' remove the device in the same manner that the staff applied it. -The type of specific direct monitoring and supervision provided during the use of the merrywalker restraint including documentation of the monitoring by the staff. Review of the facility policy titled Use of Restraints revised (MONTH) 2011 revealed if the resident cannot remove a device in the same manner in which the staff applied it given the resident's physical condition, and the device restricts the residents' typical ability to change position or place, that device is considered a restraint. Examples of devices listed were arm restrains, trays that the resident could not remove. The policy also revealed prior to placing a resident in restraints, there shall be a pre-restraint assessment and review to determine the need for restraints. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. Safety guidelines shall be implemented and documented while a resident is in restraints and shall not cause physical injury to the resident. To ensure the least possible discomfort to the resident a resident will be observed at leased every 30 minutes by nursing personnel and an account of the resident condition shall be recorded in the medical record. The opportunity for motion and exercise would be provided for a period of not less than 10 minutes during each 2 hours in which restraints were employed. Resident must be repositioned every 2 hours on all shifts. Residents/family shall be informed about the potential risks and benefits of all options under consideration, including the use of restrains, not using restraints, and the alternative to restraint use. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reeducation, less restrictive methods of restraints, or total restraint elimination. Documentation regarding the use of restraints shall include observation, range of motion, and repositioning flow sheets. Interview on 1-2-19 at 1:15 PM with the (ADM) Administrator confirmed none of the documentation had been completed on the residents with restraints. The ADM also confirmed the facility had reviewed their current restraint policy and were going to start 3 new assessment forms, a physical restraint assessment, a physical evaluation worksheet and a physical restraint consent form. The Administrator confirmed none of the 3 forms had been started on any resident yet after they were cited for F604 'Right to be Free from Physical Restraints' on 12-4-18 at their annual survey. | 2020-02-01 |
| 4298 | OGLALA SIOUX LAKOTA NURSING HOME | 2.8e+301 | 7835 ELDERS DRIVE, STATE HIGHWAY 87 | RUSHVILLE | NE | 69360 | 2017-11-16 | 309 | D | 1 | 1 | XK2J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews, the facility failed to ensure staff monitored one sampled resident's (Resident 30) [MEDICAL TREATMENT] port on a daily basis. Resident 30 was the only current resident receiving [MEDICAL TREATMENT] services. 14 Residents were sampled. Facility census was 29. Findings are: Record review of Resident 30's Admission Record printed on 11/14/17 revealed the resident was admitted to the facility on [DATE]. Among the resident's medical [DIAGNOSES REDACTED]. Observation of Resident 30 on 11/14/17 at 1:39 p.m. revealed the resident had a shunt to the left forearm. Interview with Resident 30 on 11/14/17 at 1:39 p.m. revealed the facility assisted transporting the resident to a [MEDICAL TREATMENT] center for treatment three times a week. Record review of Resident 30's Care Plan revealed a Focus problem revised on 11/13/17 which identified a problem of at risk for complications related to [MEDICAL TREATMENT] for the [DIAGNOSES REDACTED]. Among interventions to address the problem included directions to check the resident's shunt site daily and as needed for symptoms of infection, pain, or bleeding. Record review of Resident 30's medical record including treatment sheets, medication sheets, and progress notes revealed there was no documentation that the staff were monitoring the shunt daily for signs of bleeding or infection. Interview with the DON (Director of Nursing) on 11/16/17 at 10:27 a.m. confirmed the staff were not recording daily assessments of Resident 30's shunt site condition. | 2020-09-01 |
| 470 | HILLCREST NURSING HOME | 285080 | P O BOX 1087, 309 WEST 7TH STREET | MCCOOK | NE | 69001 | 2018-04-03 | 690 | D | 1 | 0 | 0YN711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews, the facility failed to: 1) Ensure facility staff followed up with assessments and urinary condition changes for one sampled resident (Resident 3) with a urinary catheter; and 2) ensured facility staff prevented catheter bags from potential cross-contamination during transfers for two sampled residents (Residents 3 and 1). Sample size was three current residents with urinary catheters. Facility census was 87. Findings are: [NAME] Licensure Reference Number: 175 NAC 12-006.09D3 Record review of Resident 3's Face Sheet printed on 4/3/18 revealed the resident was admitted to the facility on [DATE]. Further review of the document revealed the resident had medical [DIAGNOSES REDACTED]. Record review of a facility Investigation Report dated 3/29/18 describing an incident involving Resident 3 falling on 3/20/18. In the section entitled Describe the incident the investigation recorded the resident was noted on the floor by the wheelchair on 3/20/18 at 9:23 p.m. Further review of the description recorded: . Resident having dark, foul urine in catheter bag and had several days reported to nurse for confusion and hallucinations, so on 3/21/2018 nurse obtained an order for [REDACTED]. Record review of Resident 3's Departmental Notes between 3/6/18 through 4/3/18 printed on 4/3/18 revealed the following entries: - 3/9/18 through 3/11/18 entries revealed the resident was treated for [REDACTED]. - Between 3/11/18 through 3/20/18 there were no entries describing the resident's urinary status. - 3/20/18 at 9:23 p.m. the resident was discovered on the floor. Nothing charged about the resident's urinary status or condition. - 3/21/18 at 9:44 a.m. the entry read: Urine collected at this time via foley cath (catheter) port. Urine dark yellow, cloudy and malodorous (foul smelling). Coolected per orders for: Recent falls, increased confusion and cloudy urine. Sample sent to (clinic). - Between 3/21/18 and 3/27/18 there were no assessments of the resident's urinary condition or any vital sign readings to determine if the resident had an elevated temperature associated with the abnormal urinary symptoms recorded on 3/21/18. - 3/27/18 at 3:42 p.m. a note recorded that at 10:15 p.m. on 3/26/18 the resident had been found on the floor. The note continued stating: . will observe. and see how (the resident) is doing in the morning . if needed can make clinic appointment, also told of waiting UA (urinalysis) status . Nothing was recorded in this entry about the condition of the resident's urine. - Between 3/27/18 and 4/3/18 there were no other entries recording anything regarding the UA results or the resident's urinary status or vital signs. On 4/3/18 during interview with the facility DON (Director of Nursing) at 10:45 a.m., a request was made as to the UA results for REsident 3 from a sample sent to the clinic on 3/21/18. Following the request, the ADON (Assistant Director of Nursing) returned with a UA results form obtained through the facility's portal (electronic system for communication between the facility and physician) dated 4/3/18 at 11:11 a.m. The form revealed abnormal UA results for positive [MEDICATION NAME], trace blood, UA [NAME] blood cells present, UA red blood sells present, and Moderate UA Bacteria. An additional portal note dated 4/3/18 at 12:52 p.m. identified the physician chose not to treat the finding with antibiotic therapy. Interview with the DON and ADON on 4/3/18 at 2:55 p.m. confirmed that the facility noted abnormal urinary symptoms and confusion on 3/21/18 precipitating receiving an order for [REDACTED]. B. Licensure Reference Number: 175 NAC 12-006.09D3 (1) Observation of Resident 3's morning transfer from the bed to the motorized wheelchair was conducted on 4/3/18 beginning at 7:30 a.m. and concluding at 8:00 a.m. During the observation, NA (Nurse Aide)-C and NA-D were assisting Resident 3 with a mechanical lift transfer. The resident was placed in a sling and lifted with the mechanical lift. NA-D removed the resident's catheter bag from a cover bag and it was placed directly on the floor in front of the resident's wheelchair and remained in direct contact with the floor while the resident was lifted in the sling and positioned in the motorized wheelchair. Once the resident acknowledged comfort with the positioning, NA-C picked the urinary catheter drainage bag off the floor and placed it in a covered bag attached to the resident's wheelchair. C. Review of the Face Sheet revealed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Plan of Care, dated 3/3/18, revealed that the resident had increased confusion, had an indwelling urinary catheter and often had bladder infections. Observations on 4/4/18 at 7:45 AM, 8:10 AM and at 1:45 PM revealed the resident resting on the bed with the uncovered urinary catheter drainage bag placed directly on the floor on the floor mat next to the bed. Observations on 4/4/18 at 8:10 AM revealed MA (Medication Aide) - A and NA (Nursing Assistant) - B assisted the resident with morning cares. Further observations revealed NA - B emptied the urinary drainage bag without cleaning the drainage spout with an alcohol wipe before and after the urine was drained into the collection container. Interview with the Director of Nursing on 4/4/18 at 3:00 PM confirmed that urinary catheter drainage bags were not to be placed on the floor and that the drainage bags were to be cleaned with an alcohol wipe before and after the urine was drained into the collection container to reduce the risk of cross contamination and infection. | 2020-09-01 |
| 4299 | OGLALA SIOUX LAKOTA NURSING HOME | 2.8e+301 | 7835 ELDERS DRIVE, STATE HIGHWAY 87 | RUSHVILLE | NE | 69360 | 2017-11-16 | 323 | D | 1 | 1 | XK2J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews, the facility failed to: 1) ensure oxygen concentrators were turned off when not in use and unattended for one sampled resident (Resident (Resident 2). This failure could potentially oxygenate the room resulting in increased fire hazard; and 2) identify causal factors and develop strategies to prevent re-occurrence of falling for one sampled resident (Resident 12) after a fall occurred. Sample size was 14 residents. Facility census was 29. Findings are: Licensure Reference Number: 175 NAC 12-006.09D7 [NAME] Record review of Resident 2's Admission Record printed on 11/14/17 revealed the resident was admitted to the facility on [DATE] and had medical [DIAGNOSES REDACTED]. Record review of Resident 2's Admission MDS (Minimum Data Set, a federally mandated comprehensive tool utilized to develop resident care plans) completed on 9/26/17 revealed the resident received Oxygen therapy. Observation on 11/15/17 at 9 a.m.; 10 a.m.; 11:00 a.m.; and 12 noon revealed Resident 12's oxygen concentrator was running set on two liters while the resident was out of the room and the room was unattended to. Another observation with the DON (Director of Nursing) on 11/15/17 at 12:15 p.m. revealed Resident 12's concentrator was left on and unattended. Interview with the DON during the observation on 11/15/17 at 12:15 p.m. confirmed Resident 12's oxygen concentrator was left on while unattended in the room. Licensure Reference Number: 175 NAC 12-006.09D7b B. Record review of Resident 12's Admission Record printed on 11/14/17 revealed the resident was admitted to the facility on [DATE] and had a medical [DIAGNOSES REDACTED]. Record review of Resident 12's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) revealed revealed a Significant Change in Status MDS was completed for the resident on 8/18/17. The MDS recorded the resident's cognition had declined from a score of 6 to 3 on a scale where score of 0-7 suggests severe memory impairments. The MDS also recorded the resident did not walk and was assisted by two staff for extensive assistance with transfers. The MDS identified the resident had not fallen in the previous 90 days. Record review of Resident 12's Progress Notes revealed an entry on 10/12/17 at 8:10 a.m. recording a Nurse Aide reported finding the resident on the floor in front of the bathroom and the resident was bleeding. The charge nurse, LPN (Licensed Practical Nurse)-C assessed the resident and provided a cool washcloth to the forehead while the staff assisted the resident into a wheelchair. The resident was assessed with [REDACTED]. The charge nurse cleansed the areas and applied a Telfa pad. The resident was sent to the ER (emergency room ). A note recorded at 11:06 a.m. on 10/12/17 recorded the resident returned from the ER with 10 staples to the forehead. There was nothing in the progress notes between 10/12/17 and 10/25/17 identifying causal factors related to the resident's fall or any changes in staff interventions to prevent re-occurrence of the fall. Progress Notes entry on 10/25/17 at 11:33 a.m. revealed the resident was found on floor in room with the wheelchair behind the resident. Resident was lying on side, pressure applied to the forehead and the resident was transferred to the ER for evaluation. The resident returned at 4:42 p.m. with no new medical treatment while at the ER. Record review of a facility investigation of the incident involving Resident 12, dated 10/16/17 revealed the resident fell on [DATE] after trying to take self to the bathroom. With regard to measures put in place to prevent reoccurrence of the fall, the facility recorded they would provide re-education to Resident to use (the resident's) call button. There was nothing recorded in the investigation identifying precipitating factors or cause of the resident attempting to get up unassisted, nor intervention changes to prevent the resident from falling again. Interview with the DON (Director of Nursing) on 11/16/17 at 10:34 a.m. revealed prior to Resident 12 falling on 10/12/17, the resident used a urinal and didn't like the urinal. At the time of the fall, the DON stated the resident experienced a UTI (Urinary Tract Infection) with increased confusion causing the resident to attempt transferring self to the bathroom instead of using the call light. The DON confirmed there was no evidence the facility identified factors leading to the resident's fall, the possible causes of the resident attempting to get up unassisted, or identifying interventions to prevent re-occurrence. The DON confirmed a resident with confusion would not recall reminders to use a call button. | 2020-09-01 |
| 4820 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2017-04-19 | 425 | E | 1 | 1 | HWP011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews, the facility failed to: 1) obtain medications for administration as ordered for one sampled resident (Resident 26); and 2) ensure medication labels were compared to instructions on resident Medication Administration Records a minimum of three times per nursing standards of practice for medications administered to eight current residents (Residents 43, 15, 41, 10, 8, 21, 28, and 3). Sample included fifteen current residents and five closed records. Facility census was 24. Findings are: [NAME] Licensure Reference Number: 175 NAC 12-006.12A Record review of Resident 26's Admission Record printed on 4/18/17 revealed the resident was admitted to the facility initially on 12/2/2014. Among the medical diagnoes listed on the document were: Hypertension, Chronic Kidney Disease, and Chronic Obstructive Pulmonary Disease. Record review of Resident 26's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) records revealed the following: - The resident was discharged from the facility to a hospital setting on 3/1/17 and returned on 3/7/17. - The resident was discharged from the facility to a hospital setting on 3/13/17 and returned on 3/14/17. - The resident was discharged to another nursing facility on 3/31/17. Closed medical record review of Resident 26's medical physician orders [REDACTED]. The instructions read for the resident to take two tablets at 7 a.m.; and one tablet at 11 a.m.; 2 p.m.; and 6 p.m. Record review of Resident 26's Medication Administration Record [REDACTED]. Record review of Resident 26's Progress Notes (including Nurses Notes) revealed on 3/14/17 at 12:15 p.m. the resident was readmitted to the facility. Further review of the notes revealed an entry on 3/14/17 at 5:42 p.m. recording the resident's Lasix was not administered to the resident in the evening due to Product unavailable, pharmacy notified. Record review of Resident 26's Order Summary Report signed by the physician for orders ranging between 3/1/17 and 3/31/17 revealed a physician's orders [REDACTED]. Record review of Resident 26's Medication Administration Record [REDACTED]. Record review of Resident 26's Progress Notes revealed an entry on 3/15/17 at 6:47 a.m. recording the Singulair was not given due to being ordered on its way from pharmacy. An entry on 3/16/17 at 7:56 a.m. recorded the Singulair was not administered due to: medication on its way ordered coming by pharmacy. Interview with the Administrator on 4/19/17 at 11:00 a.m. confirmed that Resident 26 was in and out of the hospital in (MONTH) of (YEAR) and was experiencing issues with fluid retention. The Administrator confirmed the resident was re-admitted to the facility on [DATE] at 12:15 a.m. with orders for Lasix administration with the next doses due at 2:00 p.m. and 6 p.m. The Administrator verified the Medication Administration Record [REDACTED]. Reference Licensure Number 175 NAC 12-006.10A2 B. Observations on 4/18/17 at 7:10 AM to 11:30 AM of (Licensed Practical Nurse) LPN - B administer medications to 6 sampled residents (Resident 43, 15, 41, 10, 8, and 28). During the observation, the med packets for each resident were placed on the top of the medication cart and the LPN looked at the (Electronic Medical Record) Order summary for (MONTH) (YEAR) and then grabbed the packets quickly and popped the pills into medication cups and placed the medication packets back into the medication cart and then administered the medications to the 5 sampled residents. Interview on 4/18/17 at 3:00 PM with the Interim (Director of Nursing) DON confirmed that 3 complete medication checks should be done prior to administering medications to residents per standards of nursing medication administration practice. Further observation verified that the 3 checks had not been done by the LPN - B as there were medication labeling discrepancies noted later. Continued interview verified if the checks would have been completed there would not have been discrepancies from the original orders, to the Order Summary, to the administration of residents medications. Interview on 4/18/19 at 3:30 PM with the Interim Administrator verified that prior to administering medications to residents the medications should be checked 3 times to ensure that the correct medications are administered to residents. Potter/Perry Reference: Fundamentals of Nursing Potter/Perry, 6th Edition, Copyright @ 2005, Mosby, Inc. Standards are those actions that ensure safe nursing practice .When medications are first ordered, the nurse compares the medication recording form or computer orders with the prescribe's written orders. when administering medications, the nurse compares the label of the medication container with the medication form. The nurse does this 3 times: (1) before removing the container from the drawer or shelf, (2) as the amount of medication ordered is removed from the container, and (3) before returning the container to storage . | 2020-03-01 |
| 5714 | NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER | 285271 | 2100 CIRCLE DRIVE | SCOTTSBLUFF | NE | 69361 | 2016-10-03 | 323 | D | 1 | 0 | SRLF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews; the facility failed to: 1) Transfer a cognitively impaired resident with balance impairments with the use of a gait belt as identified in the resident's care plan; 2) Assess the need for and safety for the use of a grab bar device attached to the resident's bed; and 3) Investigate all potential causes for a bruise of unknown origin. All of these failures affected one sampled resident (Resident 2). Sample size included four current residents. Facility census was 51. Findings are: Licensure Reference Number: 175 NAC 12-006.09D7a A. Record review of Resident 2's Resident Face Sheet printed on 9/28/16 revealed the resident was admitted to the facility on [DATE] with the latest return recorded 5/23/16. Among the resident's medical [DIAGNOSES REDACTED]. Record review of Resident 2's Quarterly review MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) completed on 7/18/16 revealed the following: - The resident's BIMS (Brief Interview of Mental Status, a test to assess resident memory capabilities) scored a 6 (0-7=severe cognitive impairment) - The resident's ability to transfer between surfaces and walk were recorded as: Extensive Assist (Resident involved in activity, staff provide weight-bearing support). - The resident's ability to move on and off the unit was recorded as: Limited Assist (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance). - The resident's ability to balance while moving from seat to standing, walking, and turning around while walking was assessed as: Not steady, only able to stabilize with staff assistance. Record review of Resident 2's Care Plan with Goal Target Dates through 10/17/2016 revealed the resident had a problem identified as falls due to a history of falling, poor judgment and reasoning, and decline in cognition. An additional problem regarding ADL (Activities of Daily Living) functionality revealed the resident leaned to the right when sitting and needed extensive assistance with toileting, ambulation in the room and hall with use of a walker. Approaches to the problem directed staff to: Walk to dine with a gait belt and assistance of one and walker and Use gait belt 1 assist and 4 wheeled walker for all toileting, use gait belt and hand held assistance for all other transfers. Interview with Resident 2's family members on 9/28/16 at 11:20 a.m. revealed the family had concerns regarding facility staff utilizing the gait belt during resident transfers. The family reported having installed a video camera in the room so family could monitor the resident throughout the day and reported on several occasions having observed staff performing transfers of the resident without using a gait belt. The family had documented times specifically observing improper transfers and described on 9/10/16 they observed a nurse aide transferring the resident from the chair by pulling on both hands from the armpit area of the resident's right arm. Observation on 9/29/16 at 1:15 p.m. revealed NA (Nurse Aide)-C assisting Resident 2 from the bathroom. The resident was in a wheelchair and when asked by NA-C, the resident stated preference to lie down in bed. NA-C positioned the wheelchair next to the bed and transferred the resident from the wheelchair to the bed by guiding the resident, holding on to the resident's right arm. A gait belt was not used during the transfer. Second interview with Resident 2's family members on 10/2/16 at 5:00 p.m. revealed the family had been monitoring the video camera earlier this morning and observed staff transferring the resident to the resident's chair at 5:26 a.m. The family stated staff had not utilized a gait belt during the transfer. Interview with the Administrator, Director of Nursing, and facility Nurse Consultants on 10/3/16 beginning at 11:45 a.m. confirmed Resident 2's family had expressed concerns about observing transfers of the resident without the gait belt use. The Administrator, Director of Nursing, and facility Nurse Consultants confirmed the facility required staff to utilize gait belts during transfers with residents experiencing balance problems or requiring assistance/dependence with transfers between surfaces. B. Observations of Resident 2 during initial tour of the facility on 9/28/16 at 11:20 a.m. revealed Resident 2's bed had a metal grab bar device attached to the right side of the bed which was positioned against the resident's room wall. Interview with NA-C and NA-D on 9/29/16 at 7:20 a.m. revealed the two staff members provided daily cares for the resident on the day shift. Both NA-C and NA-D stated the resident required assistance from the staff with positioning in bed and with transfers. When questioned about the grab bar attached to the bed, both NA-C and NA-D stated the resident does not use the device for positioning and to their knowledge did not ever see the resident hang on to or use the bed cane. Record review of Resident 2's chart revealed their were no assessments pertaining to the resident's need for the grab bar and whether or not the device had been deemed safe for the resident's use. Record review of Resident 2's Care Plan with Goal Target Dates through 10/17/2016 revealed the grab bar device was not included in the resident's care plan. Interview with Resident 2's family members on 10/2/16 at 5:00 p.m. discussed the grab bar device on the resident's bed. The family members confirmed from their observations that the resident had never used the device while in bed and they were unaware of the reason for the device being attached to the bed. Interview with NA-E on 10/2/16 at 6:50 p.m. revealed NA-E worked with Resident 2 and assisted with direct cares on the evening shift. NA-E was not certain why the resident's bed had a grab bar and stated not having observed the resident utilizing the device during time in bed. Interview with the Director of Nursing and facility Nurse Consultants on 10/3/16 beginning at 11:45 a.m. confirmed there were no assessments in Resident 2's medical record to determine the need for a metal grab bar device attached to the bed or whether or not the device would be safe for the resident. Licensure Reference Number: 175 NAC 12-006.09D7b (1) C. Record review of a facility Verification of Investigation form for an event occurring on 9/7/16 at 5:30 a.m. revealed Resident 2 was taken for a bath and noted to have a purple bruise measuring 17 x 4 cm (centimeters). The resident was assessed and noted to be taking Plavix and aspirin daily (medications that may cause bleeding/bruising). The investigation included an interview with the resident who was unsure how the bruise was obtained. The summary and outcome of the investigation concluded the resident was observed by staff member to be pushing arm against table while pushing drinks into place. The measures put in place to prevent re-occurrence were to educate staff to position resident's drinks where resident prefers them. Further review of the facility's investigation revealed a photo of the injury which extended from the resident's elbow to above the wrist on the anterior portion of the resident's right arm. Interview with Resident 2's family members on 9/28/16 at 11:20 a. m. revealed the family had concerns related to the facility findings of how the bruise occurred. The family stated having observed the bruise which was located on the resident's top side of the right arm extending from the elbow to the resident's wrist. The family questioned if this came from pushing items on the dining room table concluding the resident would have had to have done so with the right arm inverted and the resident's top of the hand in touch with the table. The family stated that they were not satisfied the facility had ruled out other possible causes for the injury. They believed that for the resident to have obtained a bruise on the anterior portion of the arm by pushing objects on the table, the injury would have been on the posterior side of the arm rather than the anterior. The family provided a photo of the injury (the same one from the facility investigation) confirming the location of the bruise was on the anterior right arm extending from the elbow to the wrist. The family also stated they wondered if the injury may have occurred during transfers as they had observed several occasions where staff members were not utilizing gait belts as directed on the resident's care plan. Observation of Resident 2's right arm on 9/28/16 at 11:45 a.m. revealed the resident's bruising had healed. Observations of Resident 2's care during the survey revealed the following: - 9/28/16 at 12:14 p.m. NA-F assisted the resident into the bathroom and to the dining room. The resident was observed using a wheeled walker. The doorways into the bathroom and out of the resident's room were observed in which the spacing was tight. - 9/29/16 at 10:30 a.m. the resident was observed sitting in a wheelchair in a lounge area attending a Bible group study. Observation revealed the resident sitting with the anterior portion of the resident's right arm in the resident's lap and in contact with the resident's wheelchair arm. - 9/29/16 at 1:15 p.m. the resident was observed being assisted by NA-A. The observation revealed the resident in the wheelchair coming out of the bathroom being pushed by NA-A. The doorway to the bathroom accommodated the wheelchair width but left about two inches leeway on either side. Further observation of the resident's transfer at this time revealed NA-A failed to use a gait belt during the transfer and held onto the resident's right forearm during the transfer from the wheelchair to the bed. - Meal observations of the resident during the breakfast and noon meals on 9/29/16 and supper meal on 10/2/16 revealed the resident was fidgeting at times by folding, refolding the napkin and would push glasses and silverware away from the edges of the table. The observations did not reveal the resident pushing with the anterior side of the arm on the table, but the posterior side was in contact. In addition, the resident's dining chair was observed with wooden arm rests in which the resident's anterior portion of the arms rested on while staff fed the resident. - Observations of the resident's bed throughout the survey beginning with an initial tour observation on 9/28/16 at 11:40 a.m. through 10/3/16 revealed a metal grab bar attached to the right side of the resident's bed. Interview with the facility Administrator, Director of Nursing, and facility Nurse Consultants on 10/3/16 beginning at 11:45 a.m. confirmed Resident 2 obtained a bruise injury discovered by staff on 9/7/16 during bathing. Interviews with staff members revealed no one had discovered the bruise or concluded how the resident may have obtained the bruise until the resident's bath. Interviews with staff had not concluded how the resident obtained the injury except one staff member reported observing the resident pushing glasses away from the table during dining. The Administrator and Director of Nursing stated that based on the observation of pushing glasses on the table, the facility concluded this was the likely cause. During the interview the Director of Nursing and Administrator verified having received concerns of the resident's family that the resident was not consistently transferred with the use of a gait belt. They also confirmed the resident had a metal grab bar on the right side of the bed which had not been assessed for safety use. The Administrator and Director of Nursing stated they had not considered improper transfers, doorway clearances, wheelchair and dining room arm rests, or the grab bar as potential causes for the injury during their investigation. | 2019-10-01 |
| 6670 | GRAND ISLAND PARK PLACE CARE AND REHABILITATION CE | 285105 | 610 NORTH DARR AVENUE | GRAND ISLAND | NE | 68803 | 2015-11-19 | 431 | D | 1 | 0 | 67D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure that one residents (Resident 8) Wound Vac (wound healing through negative pressure wound therapy) was at the prescribed level as ordered by the physician. The facility census was 54. Findings are: Review of Resident 8's Wound Clinic Visit on 10/23/15 revealed: -The resident was finished with the antibiotic. -The resident had more edema in left foot. The resident kept feet up except when eating. -The resident's Wound Vac pressure was increased to 150 mmHg (millimeters of mercury) continuously with a black sponge. The sponge was to be changed three times weekly. -The wounds were to be washed with soap and water at each dressing change. Review of Resident 8's Wound Clinic Visit dated 10/29/15 revealed: -The left foot was more swollen around the ankle. -There was an increase in serosanguinous drainage (blood and serum part of the blood leaving the body from a new wound) from a wound under the dressings. -The resident was having more pain and had medication adjustment for pain. -The resident's Wound Vac pressure remained at 150 mmHg continuously with a black sponge. -The sponge was to be changed three times weekly. -The wounds were to be washed with soap and water at each dressing change. -The resident was to remain at non-weight bearing on both feet.-The resident was to elevate both legs as much as possible. Review of Resident 8's (MONTH) (YEAR) TAR (Treatment Administration Record) revealed: -The resident's Wound Vac order on 10/23/15 for an increase in pressure from 125 to 150 mmHg was not updated. The order still read Wound Vac at 125 mm on both feet to be changed on Monday, Wednesday, and Friday to continuous suction. -The residents Wound Vac dressing change was not completed on 11/4/15. Review of Resident 8's (MONTH) (YEAR) TAR revealed: -The resident had an order for [REDACTED]. -The resident's Wound Vac order on 10/23/15 for an increase in pressure from 125 to 150 mmHg was not updated. -The residents Wound Vac dressing changes were not completed on 10/19/15, 10/21/15, 10/23/15, and 10/28/15. Interview with the DON (Director of Nursing) on 11/30/15 at 2:30 pm the facility had discovered the change in the resident's Wound Vac pressure and clarified the order with the physician. | 2018-11-01 |
| 3944 | VALLEY VIEW SENIOR VILLAGE | 285294 | 220 SOUTH 26TH STREET | ORD | NE | 68862 | 2018-03-21 | 712 | D | 1 | 1 | OLWQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure 2 (Resident 14 and 15) out of 4 residents Physician visits were completed at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. The census was 34. Findings are. [NAME] Review of Resident 14's undated Face Sheet revealed the resident was admitted on [DATE]. Review of Resident 14's Physician's PN (Progress Notes) revealed the resident had an initial Physician visit on 12-02-16. The Physician PN revealed the next 30 day Physician visit was not until 02-28-17 which was 60 days later and not the 30 days later as required. Review of Resident 15's undated Face Sheet revealed the resident was admitted on [DATE]. Review of Resident 15's Physician's PN revealed the resident had an initial Physician visit on 12-14-16. The Physician PN revealed the next 30 day Physician visit was 01-12-17. The 3rd 30 day Physician visit was absent from the medical record. Interview on 03/20/18 at 04:13 PM with MA-D (Medication Aide), who was the[NAME] Clerk, confirmed the Progress Notes were absent for the 2nd 30 day Physician visit for Resident 14 and for the 3rd 30 day Physician visit for Resident 15. B. Review of Resident 15's 60 day Physician visits revealed the resident received a 60 day visit from the Primary Care Physician in April, (MONTH) and (MONTH) (YEAR) then another visit was not documented until (MONTH) (YEAR). Interview on 03/20/18 at 04:13 PM with MA-D revealed the MA-D could not find any documentation of a 60 day Physician visit which occurred between (MONTH) (YEAR) and (MONTH) (YEAR). | 2020-09-01 |
| 4933 | PREMIER ESTATES OF WEST POINT, LLC | 285158 | 960 PROSPECT ROAD | WEST POINT | NE | 68788 | 2018-06-12 | 757 | D | 1 | 1 | ELDP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure 2 residents (Resident 31 and 1) were free from the use of unnecessary medications as medications were given without indication for use and not in accordance with physician's orders [REDACTED]. Findings are: [NAME] Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/7/18 revealed [DIAGNOSES REDACTED]. Review of Resident 1's Medication Administration Record [REDACTED]. Further review revealed orders dated 9/28/17 for Tylenol 650 mg every 6 hours as needed for mild pain with pain rated as 1-4 on a pain scale. Review of the 5/2018 MAR indicated [REDACTED] -5/12/18 at 8:35 for pain level of 3; -5/14/18 at 7:00 PM for pain level of 4; -5/15/18 at 8:30 AM for pain level of 4; -5/18/18 at 1:44 AM for pain level of 4; -5/21/18 at 9:22 PM for pain level of 4; -5/22/18 at 11:59 PM for pain level of 4; -5/26/18 at 9:39 PM for pain level of 3; and -5/27/18 at 5:41 AM for pain level of 3. Review of the 6/2018 MAR indicated [REDACTED]. Documentation indicated the following: -6/6/18 at 8:01 AM for pain level of 3; -6/7/18 at 9:17 AM for pain level of 2; -6/8/18 at 7:24 PM for pain level of 4; -6/10/18 at 7:05 PM for pain level of 4; -6/11/18 at 8:06 AM for pain level of 4; and -6/12/18 at 7:01 AM for pain level of 3. B. Review of Resident 1's MAR indicated [REDACTED] -[MEDICATION NAME] (medication used to treat anxiety) 1 mg every 8 hours PRN for anxiety (order date 1/2/18); and -[MEDICATION NAME] 1 mg every 6 hours PRN for restlessness related to anxiety disorder (order date 5/15/18). Further review of Resident 1's MAR indicated [REDACTED] -Resident 1 received [MEDICATION NAME] 1 mg on 5/12/18 at 5:03 PM and again at 8:36 PM (3 hours and 30 minutes between doses); -No [MEDICATION NAME] was given on 5/27/18 and an order was obtained for [MEDICATION NAME] 10 mg IM (intramuscular) every 4 hours PRN for agitation/aggression/confrontation/anxiety; and -[MEDICATION NAME] 10 MG IM was given on 5/27/18 at 6:13 PM. C. Interview with the Director of Nurses (DON) on 6/12/18 at 9:00 AM confirmed Resident 1's [MEDICATION NAME] was not given as indicated and ordered for pain and [MEDICATION NAME] was given without an indication for use. D. Review of Resident 31's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. Review of Resident 31's MARs dated 4/2018, 5/2018 and 6/2018 revealed an order dated 7/12/16 for [MEDICATION NAME] 0.5 mg via [DEVICE] (gastrostomy tube, a tube inserted through the abdomen that delivers nutrients directly to the stomach) every 1 hour as needed for [MEDICAL CONDITION] activity. Review of the 4/2018 MAR indicated [REDACTED] -4/1/18 at 2:12 AM; -4/7/18 at 10:31 PM; -4/15/18 at 3:05 AM; -4/17/18 at 11:31 PM; -4/18/18 at 2:02 AM and at 9:26 PM; -4/19/18 at 12:14 AM; -4/21/18 at 2:30 AM; -4/29/18 at 1:06 AM and at 3:02 AM; and -4/30/18 at 1:31 AM and at 3:33 AM. Review of Resident 31's MAR indicated [REDACTED] -5/3/18 at 6:47 PM; -5/17/18 at 11:58 PM; -5/18/18 at 2:46 PM; -5/27/18 at 10:00 PM; and -5/28/18 at 3:10 AM. Review of Resident 31's MAR indicated [REDACTED] -6/9/18 at 5:57 PM; and -6/10/18 at 8:54 PM. During an interview on 6/12/18 at 9:31 AM the DON confirmed Resident 31 was given the [MEDICATION NAME] when the staff felt the resident was restless or was moaning and not for [MEDICAL CONDITION] activity as the practitioner's order for the medication indicated. | 2020-03-01 |
| 5465 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2017-03-22 | 334 | E | 1 | 1 | HUVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure 5 of 59 residents (Residents 82, 78, 61, 85 and 71) were offered the pneumococcal vaccinations as required. The facility census was 58. Findings are: [NAME] Review of Resident 82's electronic medical record revealed Resident 82 was admitted on [DATE] and had no documented evidence of being offered the pneumococcal vaccination. Review of Resident 82's MDS (The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a medicare and/or Medicaid-certified long-term care facility.) dated 2/8/17 revealed Resident 82's pneumococcal vaccination was not up to date and was not offered. B. Review of Resident 78's electronic medical record revealed Resident 78 was admitted on [DATE] and had no documented evidence of being offered the pnuemococcal vaccination. Review of Resident 78's MDS dated [DATE] revealed Resident 78's pneumococcal vaccination was not up to date. C. Review of Resident 61's electronic medical record revealed Resident 61 was admitted on [DATE] and had no documented evidence of being offered the pnuemococcal vaccination. Review of Resident 61's MDS dated [DATE] revealed Resident 61's pneumococcal vaccination was not up to date. D. Review of Resident 85's electronic medical record revealed Resident 85 was admitted on [DATE] and had no documented evidence of being offered the pnuemococcal vaccination. Review of Resident 85's MDS dated [DATE] revealed Resident 85's pneumococcal vaccination was not up to date and had not been offered. E. Review of Resident 71's electronic medical record revealed Resident 71 was admitted on [DATE] and had no documented evidence of being offered the pnuemococcal vaccination. Review of Resident 71's MDS dated [DATE] revealed Resident 71's pneumococcal vaccination was not up to date and had not been offered. Interview with the Assistant Director of Nursing (ADON) on 03/20/2017 at 4:39 PM revealed documentation could be found to indicate any of the above residents had been offered the pneumococcal vaccination as required. Review of the facility's policy for Immunizations for Residents revised 11/16 revealed, Upon admission, each resident and/or resident representative will receive the Vaccination Information Statements for influenza and pneumococcal vaccines. The policy continues to direct staff to assess the resident's current immunization status for pneumococcal vaccination and receive a physician's orders [REDACTED]. | 2020-01-01 |
| 6383 | FULLERTON CARE AND REHABILITATION CENTER, LLC | 285115 | PO BOX 648, 202 NORTH ESTHER | FULLERTON | NE | 68638 | 2016-03-10 | 247 | E | 1 | 0 | UFFQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure Resident's Responsible Parties were notified prior to transferring residents into different rooms within the facility. This violation had the potential to affect four residents (Residents 2, 6, 8, and 11). The facility census was 70. Findings are: A review of a facility Policy/Document # SS-705 titled Transfers and Discharges with a review date of 2/26/2015 revealed the Social Services Director (SSD) would ensure systems were implemented to provide written notification to the resident and family prior to transfer. A review of the Notice of Transfer or Discharge forms for sampled residents revealed the following: -Resident 2 was moved from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on 6/26/15 and from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on 7/6/15; -Resident 6 was moved from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on 11/25/15; -Resident 8 was moved from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on 7/6/15, and from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-1 on 3/3/16; -Resident 11 was moved from room [ROOM NUMBER]-1 to room [ROOM NUMBER]-2 on 9/22/15, from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-1 on 10/22/15, and from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on 2/12/16. Further review of the forms revealed the Resident's Legal Representatives were notified by mail on the actual date of the moves and not before the moves. An interview on 3/9/16 at 2:45 PM with Social Services Assistant (SSA)-J confirmed the sampled Resident's Legal Representatives were not notified prior to the day of the resident moves. The SSA reported written notification of the resident moves were mailed out on the day of the actual transfers. | 2019-03-01 |
| 5331 | PREMIER ESTATES OF FREMONT, LLC | 285103 | 2550 NORTH NYE AVENUE | FREMONT | NE | 68025 | 2017-01-31 | 285 | D | 1 | 0 | BKZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that a new Pre-Admission Screening and Resident Review (PASRR) was performed, according to the requirements for 1 resident (Resident 81) out of 1 sampled resident . The facility census was 69. Findings are: Record review of the facility policy titled, Pre-Admission Screening for MR/MI, dated 02/15, revealed that the facility would verify that all residents were screened prior to admission to determine whether they have a mental illness (MI) or mental [MEDICAL CONDITION]/developmental disability (MR/DD) [DIAGNOSES REDACTED]. A Level II screen was done to assist the facility in determining the types of services required to care for the resident. Record review of Resident 81's Admission Record, dated 1/30/17 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Record review of Resident 81's PASRR revealed a review date of 8/7/14 for admission to a receiving nursing facility on 4/12/14 that was not this facility. Interview with Social Service Director (SSD) on 1/30/17 at 2:57 PM revealed that Resident 81 did not have a PASRR performed upon admission to this facility. The SSD confirmed that the only PASRR present for Resident 81's record was the one provided by the transferring facility dated 8/7/14. Interview with the facility Administrator on 01/30/2017 at 3:02 PM confirmed that the facility failed to request a PASRR upon admission to the facility. | 2020-01-01 |
| 4415 | SCHUYLER CARE AND REHABILITATION CENTER, LLC | 285110 | 2023 COLFAX STREET | SCHUYLER | NE | 68661 | 2017-06-20 | 205 | B | 1 | 0 | KY7C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure the bed hold policy was provided to residents or resident representative prior to the resident leaving the building for therapeutic leave or hospitalization . This failure had the potential to effect three sampled residents (Residents 3, 5, and 6). The facility census was 31 at the time of survey. Findings are [NAME] A review of the Census Tab in Resident 3's medical record, printed on 6/20/17, revealed the resident had one Therapeutic Leave and three Hospital Leaves from the facility from 10/29/16 thru 5/26/17. Further review of Resident 3's record revealed no documented evidence indicating the resident received information related to the facility's Bed Hold Policy, at the time of admission or with any of the resident's temporary leaves from the facility. An interview on 6/20/17 at 9:20 AM with the Social Services Director (SSD) revealed the facility's bed hold policy is gone over and signed upon admission, notification is not given at the time of hospitalization or other forms of tempore leaves from the facility. The SSD reported inability to locate a Bed Hold Policy and Notification form for Resident 3. B. An interview on 6/15/17 at 5:30 AM with Registered Nurse (RN)-A, revealed Resident 5 was out of the building on Bed Hold status related to being hosptalized on [DATE]. Review of an Investigation Report dated 6/18/17, revealed Resident 5 fell in the resident's room on 6/13/17. The fall caused the resident to be hospitalized and placed on Bed Hold status at the facility. A review of Resident 5's records revealed an undated BED HOLD POLICY AND NOTIFICATION form containing the resident's signature. Review of the Facility's form, revised 3/25/16, revealed each resident/legal representative will be informed of the facility's Bed Hold Policy and Notification upon admission to the facility and/or when a resident leaves for hospitalization , observation or therapeutic leave. Resident 5's record did not contain evidence indicating the Bed Hold Policy was reviewed with the resident prior to being sent to the hospital on [DATE]. An interview on 6/20/17 at 9:20 AM with the SSD, confirmed the facility's bed hold policy was not reviewed with Resident 5 prior to the resident's hospitalization . C. An interview on 6/15/17 at 5:30 AM with RN-A revealed Resident 6 was out of the building on bed hold status following hospitalization on [DATE]. A review of physician's orders [REDACTED]. A review of MDS (a mandatory comprehensive assessment tool used for care planning) information for Resident 6 revealed assessments were in place for Entry into the facility, dated 2/10/17; and an assessment for Discharge with return anticipated, dated 6/10/17. A review of Resident 6's records revealed a BED HOLD POLICY AND NOTIFICATION form dated 2/10/17, which contained the signature of the Resident Representative. Further review of the Facility's form, revised 3/25/16, revealed each resident/legal representative will be informed of the facility's Bed Hold Policy and Notification upon admission to the facility and/or when a resident leaves for hospitalization , observation or therapeutic leave. Resident 6's record did not contain evidence indicating the Bed Hold Policy was reviewed with the Resident's Representative prior to or with notification of the resident's hospitalization on [DATE]. An interview on 6/20/17 at 9:20 AM with the SSD, confirmed the facility's bed hold policy was not reviewed with Resident 6's Representative prior to or with notification of the resident's hospitalization . | 2020-07-01 |
| 1764 | PLUM CREEK CARE CENTER | 285159 | 1505 NORTH ADAMS STREET | LEXINGTON | NE | 68850 | 2018-05-02 | 578 | D | 1 | 0 | GG8Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure the wishes for CPR (Cardiopulmonary Resuscitation) for 2 (Residents 1 and 6) out of 5 sampled residents were communicated to the nursing staff. The facility census was 36. Findings are: [NAME] Review of the nursing progress notes identified that Resident 1 was admitted to the facility for skilled care services on [DATE]. Interview on [DATE] at 1:10 PM with the MDS (Minimal Data Set) Coordinator revealed that they were unable to locate the advanced directive in the resident's medical record. Interview on [DATE] at 3:00 PM with LPN (Licensed Practical Nurse)-A revealed that Resident 1 had fallen in their room on [DATE] and became combative. LPN-A stated that the physician wanted the resident to be transferred to the hospital. LPN-A stated that there was no advanced directive in their medical record, so LPN-A had to call the resident's spouse to find out what the resident's wishes were in case something would happen to the resident. After the call, LPN-A stated that they went to the resident's room and resident became unresponsive, so LPN-A started CPR per the spouse's wishes. When the paramedics arrived, they continued the CPR on the resident during the transfer to the hospital. Resident passed away later that night. Interview on [DATE] at 3:00 PM revealed that the ADM (Administrator) had found the advanced directive for Resident 1. The form revealed that the resident had marked DNR (Do Not Resuscitate) on the form on [DATE]. The form was sent to the primary care physician who had signed the form on [DATE] and returned it to the facility. The ADM confirmed that there was no copy of the advanced directive in the resident's chart at the time of the incident on [DATE]. B. Review of the facility's list of new admissions for the past 3 months identified that Resident 6 was admitted to the facility on [DATE] and discharged on [DATE]. Interview on [DATE] at 1:10 PM with the MDS Coordinator revealed that the facility did not have a copy of the resident's advance directive in the resident's medical record. MDS Coordinator stated that usually if the primary care physician is in town, then the facility hand delivered the advance directive for their signature. If the physician was out of town, then the form is faxed to the physician for the signature. However, the MDS Coordinator stated that they had no copy of Resident 6's advance directive wishes. Interview on [DATE] at 3:00 PM with the ADM confirmed that the facility did not have a copy of the advance directive for Resident 6. | 2020-09-01 |
| 5581 | BROKEN BOW CARE AND REHABILITATION CENTER, LLC | 285120 | 224 EAST SOUTH E STREET | BROKEN BOW | NE | 68822 | 2018-05-17 | 645 | D | 1 | 1 | 1IGA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to have 1 resident (Resident 23) referred for a level 2 PASARR (Preadmission Screening and Resident Review) evaluation and determination prior to admission or within 30 days after admission based off of the resident's current medical [DIAGNOSES REDACTED]. The sample of residents used was 2. The facility census was 30. Findings are: [NAME] Review of Resident 23's undated Face Sheet revealed date of admission 3-22-18. The Face Sheet revealed [DIAGNOSES REDACTED]. Review of Resident 23's PASARR dated 4-7-14 revealed the resident had no serious MI (mental illness) or ID (intellectual disability). The resident did have anxiety and was on the medication [MEDICATION NAME] (an antianxiety medication). The PASARR revealed the resident did not need a level 2. Interview on 5-16-18 at 8:54 AM with the SSD (Social Service Director) revealed the resident transferred to their facility on 3-22-18 from another facility Alzheimer's unit. The SSD reviewed the resident's current medical diagnoses, medications, and behaviors and confirmed the resident should have had a review for a potential level 2 services. B. Review of Resident 21's undated Face Sheet revealed date of admission 1-17-18. The Face Sheet revealed [DIAGNOSES REDACTED]. Review on 5-15-18 at 9:04 AM of Resident 21's PASARR dated 1-17-18 revealed the resident was to be evaluated for a level 2 PASARR, however the level 2 PASARR was not in the medical record. Interview on 5-15-18 at 10:51 AM with SSD revealed the PASARR for Resident 21 was done but probably did not get filed in the chart. Interview on 5-15-18 at 2:57 PM with the SSD confirmed the facility did not have the level 2 results for Resident 21 and the SSD had to contact the State Designated Authority to obtain it. The SSD revealed the SSD called the State Designated Authority to confirm the results documented on the form which read the level 2 was halted and meant Resident 21 did not qualify for level 2 services so the evaluation was stopped back in (MONTH) (YEAR). The SSD confirmed the facility had not been aware of the PASARR results until today, 5-15-18. Review of the level 2 determination and evaluation on the PASARR for Resident 21 revealed halted and had a fax stamp dated 5-15-18 at 11:35 AM on the form. | 2019-11-01 |
| 3954 | VALLEY VIEW SENIOR VILLAGE | 285294 | 220 SOUTH 26TH STREET | ORD | NE | 68862 | 2018-03-21 | 838 | E | 1 | 1 | OLWQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to have an accurate facility assessment to care for the residents with pressure ulcers as competencies were not completed for licensed nursing staff showing the licensed nursing staff were competent to provide care and treatment for [REDACTED]. Findings are: Review of the Facility Assessment Tool completed by the ADM (Administrator) identified that the facility could provide care and treatment for [REDACTED]. Review of the facility's education and in service books identified that there were no competencies completed for the licensed nursing staff that were providing the care and treatment for [REDACTED]. The only competency that was found for pressure ulcer care was for a registered nurse in 2006. Interview on 3/20/18 at 8:24 AM with the DON (Director of Nursing) confirmed that any competencies for the licensed nursing staff would be in the education binder. The DON further stated that the DON was not aware that any of the licensed nursing staff had been competency trained on the care and treatment for [REDACTED]. Interview on 3/20/18 at 5:01 PM with the ADM (Administrator) confirmed that the Facility Assessment Tool identified that the facility would be able to care and treat residents with pressure ulcers. The ADM also confirmed that the facility did not have completed competencies documented for the licensed nursing staff to care and treat residents with pressure ulcers. | 2020-09-01 |
| 3719 | GOOD SAMARITAN SOCIETY - GRAND ISLAND VILLAGE | 285285 | 4061 TIMBERLINE STREET & 4055 TIMBERLINE STREET | GRAND ISLAND | NE | 68803 | 2019-02-19 | 646 | D | 1 | 0 | XNDC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to notify the Physician of one resident (Resident 100) out of one resident sampled, change of condition. The facility census was 61. Findings are: Record review of Resident 100's Admission Record dated 2-14-19 revealed [DIAGNOSES REDACTED]. Review of Resident 100's MDS dated [DATE] revealed a BIMS of 14 which indicated the resident had no cognitive impairment. The resident required limited assistance of one staff with bed mobility, transfers, walking, locomotion, and toileting. Record review of Resident 100's PN dated 1-23-19 at 1:53 AM revealed the resident ambulated with the walker and the walker started to collapse. The resident used the resident's right hand to attempt to prevent a fall. The nurse assessed the resident and discovered the right ring finger had a slight amount of bleeding and the right middle finger had some swelling. The fingers were cleansed and wrapped with gauze and coban. The resident was assisted back into bed. The resident was adamant with refusal to go do the ER (emergency room ) to have the fingers examined during the night. PN on 1-23-19 at 7:43 AM revealed the resident's right hand was assessed and the middle finger appeared rotated at a 30-45 degree angle and bent away from body. The nurse called the on-call Physician and orders were received to send the resident to the ER to be evaluated. Record review of the Incident Report for Resident 100 dated 1-23-19 revealed the third finger assessed to be limp and possibly broken. Report was given to the oncoming shift to follow-up on the injury. Review of the Incident Report revealed absence of documentation of the Physician notified of the resident change of condition based on the nurse assessment on 1-23-19 at 1:53 AM. Review of the Hospital Physician order [REDACTED]. Interview on 2-19-19 at 3:30 PM with the DON (Director of Nursing) confirmed the Physician should have been notified 1-23-19 immediately after the night nurse assessed Resident 100's right hand fingers at 1:53 AM and the assessment revealed suspected fracture, even though the resident had refused to seek treatment during the middle of the night. | 2020-09-01 |
| 416 | ST. JOSEPH VILLA NURSING CENTER | 285078 | 2305 SOUTH 10TH STREET | OMAHA | NE | 68108 | 2018-02-12 | 625 | D | 1 | 1 | B6BN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide a copy of the bed hold policy at time of discharge to the hospital for 1(Resident 29) of five sampled residents. The facility had a total census of 170 residents. Findings are: A review of resident census record revealed Resident 29 was admitted to the facility on [DATE] with a Medicaid payer source. Resident 29 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE], discharged to the hospital on [DATE] and readmitted to the facility on [DATE], and discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. A review of Resident 29's medical record did not reveal documentation of Resident 29 being provided with a copy of the facility bed hold policy for any of the discharges to the hospital. In an interviews on 2/12/18 at 1:46 PM and 2:08 PM, Admission Coordinator reported residents are given a copy of the bed hold policy on admission but residents with a Medicaid payment source are not given a copy of the bed hold policy each time the resident is discharged to the hospital. A review of undated facility policy titled Bed Hold Policy revealed residents are to receive a copy of the bed hold policy upon admission to the facility and when the resident is transferred to an acute care hospital. | 2020-09-01 |
| 3839 | OLD MILL REHABILITATION (OMAHA TCU) | 285289 | 1131 PAPILLION PARKWAY | OMAHA | NE | 68154 | 2018-05-07 | 625 | D | 1 | 0 | PUW011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide bed hold policy to 1 (Resident 1) of 1 sampled residents on transfer to the hospital. The facility had a total census of 41 residents. Findings are: Resident 1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Progress note dated 2/12/18 at 10:03 PM reported that Resident 1 was voiding small amount with complaint of burning and pain in kidney and bladder and Resident 1 was being transported to the hospital for evaluation. Progress note dated 2/13/18 at 7:58 AM noted that Resident 1 was admitted to the hospital and was not discharging for a while. In an interview on 5/7/18 at 8:19 AM, Social Worker G reported families are contacted when a residents is sent to the hospital. If a resident is not expected back to the facility in a couple of days, the family is asked if they can pick up the resident's personal items or if they want the facility to pack them up. Families are requested to pick up the resident's personal items in a couple of days. In an interview on 5/10/18 at 8:45 AM, the Administrator reported that residents are given information on the bed hold policy on admission. No information is given at the time that a resident is sent to the hospital regarding bed hold. A review of Admission Packet revised 1/2018 revealed the following bed hold policy: If a patient requires a hospital stay overnight, we do not hold any beds at Old Mill Rehabilitation. A new referral will need to be sent to our facility for review to see if we can meet the patient's needs. If we hold or reserve a vacant bed for you at your request and the charges for the bed are not paid by insurance or any third-party payor, you are responsible for paying our daily charges for the bed for each day we hold or reserve the bed for you. This will need to be approved and arranged with our facility administrator. | 2020-09-01 |
| 3945 | VALLEY VIEW SENIOR VILLAGE | 285294 | 220 SOUTH 26TH STREET | ORD | NE | 68862 | 2018-03-21 | 726 | F | 1 | 1 | OLWQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide competencies for the nursing staff to care for the residents with pressure ulcers. This affected 4 sampled residents with pressure ulcers and the facility census was 34. Review of the Facility Assessment Tool completed by the ADM (Administrator) identified that the facility could provide care and treatment for [REDACTED]. Review of the facility's education and in service books identified that there were no competencies completed for the licensed nursing staff that were providing the care and treatment for [REDACTED]. The only competency that was found for pressure ulcer care was for a registered nurse in 2006. Interview on 3/20/18 at 8:24 AM with the DON (Director of Nursing) confirmed that any competencies for the licensed nursing staff would be in the education binder. The DON further stated that she was not aware that any of the licensed nursing staff had been competency trained on the care and treatment for [REDACTED]. | 2020-09-01 |
| 5580 | BROKEN BOW CARE AND REHABILITATION CENTER, LLC | 285120 | 224 EAST SOUTH E STREET | BROKEN BOW | NE | 68822 | 2018-05-17 | 644 | D | 1 | 1 | 1IGA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to reflect 1 resident's (Resident 26) level 2 PASARR (Preadmission Screening and Resident Review) status on the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) out of 1 resident sampled. The facility census was 30. Findings are: Review of Resident 26's Face Sheet dated 2-13-18 revealed the resident's date of admission 10-13-17. The Face Sheet revealed the resident's [DIAGNOSES REDACTED]. Review of Resident 26's admission MDS dated [DATE] revealed the resident did not have a level 2 PASARR. Review of the Resident 26's admission PASARR dated 10-13-17 revealed a level 2 with the final determination results of the resident met the minimum criteria for nursing home admission and required the following services: ongoing medication review by a psychiatrist, ongoing med review by a medical doctor, and therapy by an OT/PT (Occupational Therapist/Physical Therapist). Interview on 5-16-18 at 8:08 AM with the SSD (Social Service Director) confirmed the resident had a level 2 PASARR and the admission MDS did not reflect the resident's current PASARR status and another MDS had not been done to update it. | 2019-11-01 |
| 1348 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2017-08-02 | 225 | D | 1 | 0 | YKIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report a significant injury for Resident 3 to the state agency within the regulatory timeframe and failed to submit a completed investigation for Resident 2 to the state agency within 5 days. The facility census was 110 . Findings are: [NAME] Review of the facility report dated 5/5/2017 for Resident 3 revealed Resident 3 sustained a fall and was sent to the hospital emergency room . Resident 3 returned to the facility at 11:55 PM on 4/29/2017 with a [DIAGNOSES REDACTED]. Review of the facility report revealed a call was placed to the state agency at 2:00 PM on 4/30/2017. Review of the facility undated policy titled Reporting Allegations of Abuse/Neglect/Exploitation revealed the facility was to notify the appropriate agencies immediately: In the case of serious bodily injury, no later than 2 hours after discovery. Interview on 5/17/2017 at 11:30 AM with the Director of Nursing (DON ) revealed the incident with injury was not reported to the state agency within 2 hours. B. Review of the facility report dated 4/30/2017 for Resident 2 revealed Resident 2 sustained a head injury and was admitted to the hospital on [DATE]. Review of the facility report revealed a facsimile (fax) report dated 4/30/2017 at 3:13 PM with a result of NO ANS (Answer). Interview on 5/17/2017 at 11:20 AM with the DON revealed the report should have been resubmitted to the state agency due to the initial report not arriving. The DON stated no other confirmation reports could be found. Review of the undated facility policy titled Reporting Allegations of Abuse/Neglect/Exploitation revealed the facility should follow up with government agency to confirm the report was received and to report the results of the investigation when a final report as required by the state agency. | 2020-09-01 |
| 2286 | GOOD SAMARITAN SOCIETY - OSCEOLA | 285193 | 600 CENTER DRIVE | OSCEOLA | NE | 68651 | 2017-08-03 | 225 | D | 1 | 1 | X4SG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report allegations of abuse. This had the potential to effect 2 of 3 residents sampled, Residents 27 and 25. Investigation: [NAME] Record review of a grievance dated 7/11/17 revealed that Resident 27 alleged that NA (Nursing Assistant) A was rough tossing things all over the place and left resident on the toilet for over 30 minutes. Record review of the MDS (Minimum Data Set, a tool for implementing standardized assessment and for facilitating care management in nursing homes) dated 6/21/17 revealed a BMS (Brief Interview for Mental Status, the level of cognitive ability among nursing home residents) of 10 (08-12 indicates moderately impaired). On 08/03/2017 at 1:06 PM, an interview with the DON (Director of Nursing) revealed, this was not reported to the state authority because, on re-interview, the resident denied the staff did anything wrong. Record review of reportable incidents provided by the facility revealed no documentation of this allegation of abuse being reported to the state authority. B. Record review of a grievance dated 9/21/16 revealed that on 9/19/16 Resident 25 alleged that gender got slapped, while rubbing left cheek. Record review of a grievance dated 9/22/16 revealed that on 9/17/16 Resident 25 alleged that a girl slapped me, while putting gender's hand to left cheek. Record review of the MDS dated [DATE] revealed a BIMs of 4 (00-07 indicates severe impairment). On 08/03/2017 at 1:10 PM, an interview with the DON reveled that, on re-interview, the resident's story kept changing and no determination could be made so this allegation of abuse was not reported to the state authority. Record review of investigation of the allegation of abuse revealed that upon receiving the allegation, all female Hispanic aides had been suspended pending investigation. An investigation was completed with no findings of abuse. Further review revealed there was no documentation that this allegation of abuse was reported to the state authority. C. Record review of the facility Abuse and neglect policy dated 2/2013 revealed, alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse will be reported immediately to the administrator and to other officials in accordance with state law. | 2020-09-01 |
| 92 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2018-06-26 | 609 | D | 1 | 0 | 49DM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report an elopement (leaving a secure area without staff knowledge or supervision) to the state agency for Resident 4. The facility census was 131. Findings are: Interview on 6/26/2018 at 8:30 AM with the Director of Nursing (DON) revealed on 5/6/2018 Resident 4 left the building when a visitor left. Resident 4's Wanderguard braclet (a device used to alert staff a vulnerable resident is leaving a secured area) did activate the alarm however the visitor turned off the alarm and Resident 4 left the building. Review of the facility incident tracking assessment dated [DATE] revealed Resident 4 had gone outside to go home to check on the horses. The resident was confused and only oriented to person at the time staff were called to assist Resident 4. Review of the facility reports and investigations for the past 4 months revealed no report of the elopement (leaving a secure area without staff knowledge or supervision) was present for Resident 4. Review of the undated facility policy titled Abuse Investigations defines essential services as those necessary to safeguard the person including proper supervision of the vulnerable adult. Review of the undated facility policy titled Abuse Investigation revealed if there is a reason to suspect or believe conditions are present that could result in neglect the incident should be reported to the state agency immediately and an investigation completed. Interview with the DON on 6/26/2018 revealed no report was filed for Resident 4's elopement on 5/6/2018. | 2020-09-01 |
| 2684 | HERITAGE OF EMERSON | 285222 | 607 NEBRASKA STREET | EMERSON | NE | 68733 | 2018-12-03 | 610 | D | 1 | 0 | BWYO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to submit an investigation to the State Agency within 5 working days after 1 resident (Resident 50) had a fall with injury requiring medical treatment. The sample size was 4 and the facility census was 31. Findings are: [NAME] Review of the facility policy titled Abuse and Neglect Prevention Standard (revision date 3/2017) included the following: -Any accident that resulted in serious resident injury should be reviewed for potential abuse/neglect and also must be reported to the proper agency; and -After conducting an internal investigation, a report of all investigation results must be reported to the state within five working days. B. Review of Progress Notes dated 11/11/18 at 7:20 AM revealed Resident 50 was observed sitting on the floor in front of the room door and bathroom. The resident sustained [REDACTED]. Documentation further indicated the laceration was 6 centimeters in length and required staples. The resident was to remain overnight at the hospital for observation. Review of facility investigations of potential abuse/neglect for 11/2018 revealed an investigation was not submitted to the State Agency regarding Resident 50's fall with injury on 11/11/18. Interview with the Administrator on 12/3/18 at 11:35 AM confirmed an investigation regarding Resident 50's fall with injury was not submitted to the State Agency as required. | 2020-09-01 |
| 4934 | PREMIER ESTATES OF WEST POINT, LLC | 285158 | 960 PROSPECT ROAD | WEST POINT | NE | 68788 | 2018-06-12 | 758 | D | 1 | 1 | ELDP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to: 1) ensure there was an indication for the use of PRN (as needed) [MEDICATION NAME] (an antipsychotic drug used to alter certain chemicals in the brain to effect changes in behavior, mood and emotions); and 2) ensure PRN [MEDICATION NAME] was not prescribed for more than 14 days without an evaluation by the Healthcare Practitioner (HCP) and without a new written order for the PRN [MEDICATION NAME]. This involved 1 resident (Resident 1). The sample size was 22 and the facility census was 39. Findings are: Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/7/18 revealed [DIAGNOSES REDACTED]. The MDS further indicated the following regarding Resident 1: -short term and long term memory problems; -displayed no adverse behavioral symptoms; -received antipsychotic medication daily in the past 7 days; and -received 1 antianxiety medication and 1 opioid (a drug derived from [MEDICATION NAME] and used to alleviate pain) medication in the past 7 days. Review of Resident 1's Medication Administration Record [REDACTED]. Review of Progress Notes dated 5/27/18 at 2:31 PM revealed Resident 1 had slept very little through the night and during the day hours. The resident .appears anxious at times pacing and wandering. Staff have attempted one on one, change in location/environment, snacks and coloring. Documentation further indicated the resident was currently socializing with staff and cueing was provided to assist the resident to participate in an activity. The resident was redirected early that morning from entering other resident rooms. Review of Progress Notes dated 5/27/18 at 5:10 PM revealed Resident 1 .is wandering and restless and has been confrontational with staff and other residents today was reported by the dayshift staff. Documentation indicated the resident had several instances in the last 30 days of being aggressive and agitated with staff and .Staff has offered many interventions daily and PRN medications for anxiety and pain with little or no improvement. Documentation further indicated the .on call provider would be contacted for .direction with resident concerning increased agitation, behaviors and lack of sleep. Review of Progress Notes dated 5/27/18 at 5:23 PM revealed the on call provider (not the resident's psychiatric Health Care Practitioner) was contacted and an order was received for Resident 1 to receive 10 mg of [MEDICATION NAME] (an antipsychotic medication) by intramuscular injection (IM) every 4 hours PRN for aggression, agitation, restlessness, and other behaviors. Documentation further indicated the resident was wandering from the living area, dining room area and stopped occasionally at the door while sometimes carrying a duffle bag. Review of Resident 1's MAR indicated [REDACTED]. Review of Resident 1's Progress Notes dated 6/5/18 at 9:32 PM revealed the resident was evaluated by the psychiatric Health Care Practitioner (HCP) that day and there were no new orders. Review of the Geriatric Psych (psychiatric) Form (a progress report by the psychiatric HCP) dated 6/5/18 revealed no evidence the psychiatric HCP was aware Resident 1 had received PRN [MEDICATION NAME] on 5/27/18. No orders were given for a new prescription for PRN [MEDICATION NAME]. Review of Resident 1's MAR indicated [REDACTED]. Review of Resident 1's Progress Notes dated 6/8/18 at 10:36 PM documented the .Resident was wandering into rooms behind staff and was reluctant to take direction. The resident was seen in the nurses' station unattended and was then taken to the resident's room to prepare for bed. The resident was given an injection for restlessness and agitation. Review of Resident 1's MAR indicated [REDACTED]. There was no evidence the HCP evaluated the resident or the need for the PRN [MEDICATION NAME]. A new prescription for PRN [MEDICATION NAME] was not obtained. Interview with the Director of Nurses on 6/12/18 at 9:00 AM confirmed Resident 1 received PRN [MEDICATION NAME] on 2 occasions and the order for the PRN [MEDICATION NAME] had not been re-evaluated by the HCP. | 2020-03-01 |
| 6616 | OMAHA NURSING AND REHABILITATION CENTER | 285240 | 4835 SOUTH 49TH STREET | OMAHA | NE | 68117 | 2015-12-07 | 309 | D | 1 | 0 | JX0E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview; the facility staff failed to evaluate respiratory status for 1 resident (Resident 1). The facility staff identified a census of 60. Findings are: Record review of an Admission Record sheet printed on 12-07-2015 revealed Resident 1 was admitted to the facility with the [DIAGNOSES REDACTED]. Record review of an Order Summary Report sheet printed on 12-07-2015 revealed Resident 1 was to have nothing by mouth (NPO). Record review of a Fax sheet noted on 9-02-2015 revealed the facility staff had notified Resident 1's physician that Resident 1 was observed drinking water and reported did not know (gender) was NPO. According to the information on the fax sheet, Resident 1 reported eating and drinking when goes out with a family member. Resident 1's physician gave an order to . try thicken liquids PO (by mouth). Record review of Resident 1's medical record revealed there was not an ongoing evaluation of Resident 1's respiratory status for the trail of the thicken liquids. An interview was conducted with the facility Director of Nursing (DON). During the interview review of the Fax sheet notes on 9-02-2015 was reviewed. When asked how often Resident 1's respiratory status should be evaluated, the DON reported every shift. The DON confirmed during the interview Resident 1's respiratory status had not been monitored every shift and should have been. | 2018-12-01 |
| 5938 | ST. JOSEPH VILLA NURSING CENTER | 285078 | 2305 SOUTH 10TH STREET | OMAHA | NE | 68108 | 2016-07-26 | 225 | D | 1 | 0 | 10VG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to complete an investigation to determine the causal factors of an injury of unknown origin for Residents 1 and Resident 3. The facility census was 163. Findings are: A. Review of Resident 1's Care plan dated 7/8/2016 revealed Resident 1 has a [DIAGNOSES REDACTED]. Review of the Nurses Notes dated 7/4/2016 for Resident 1 revealed Resident 1 complained of pain in the left leg with no traumatic event identified. Review of the Nurses Notes dated 7/6/2016 revealed Resident 1 was admitted to the hospital with [REDACTED]. Review of the facility investigation revealed Resident 1 had not experienced a recent fall and Resident 1 could not explain how the injury occurred. The facility did not interview the staff working with Resident 1 from other shifts except the shift the pain was found on. Interview on 7/25/2016 at 3:55 PM with the Director of Nursing (DON) revealed that the only staff that were interviewed were the staff that was working at the time the injury was found. No interviews were done with the staff assigned to Resident 1 on prior shifts to determine how the injury occurred. Interview on 7/25/2016 at 4:00 PM with the DON revealed the investigation should have included the staff from the previous shift and the health care practitioner to attempt to determine the causal factors of the injury. B. Record review of a Incident/Accident Report sheet dated 4-11-2016 revealed Resident 3 was evaluated as having a bruise to the right inner leg. Record review of a Resident's Statement sheet dated 4-11-2016 revealed the resident did not know how the bruise happened. Record review of a Injuries of Unknown Source Investigation sheet dated 4-11-2016 revealed the bruise to the right inner thigh measured 14 centimeters (cm) by 5 cm and purple in color. Record review of Resident 3's medical record revealed there was not evidence that the facility staff had conducted interviews with facility staff on prior shifts in an attempt to determine when and how the bruise occurred. An interview was conducted with the DON on 7-25-2016 at 3:42 PM. During the interview, the DON confirmed that staff on other shifts had not been interviewed. The DON confirmed during the interview the investigation into the injury of unknown source was not completed. | 2019-07-01 |
| 1381 | LIFE CARE CENTER OF ELKHORN | 285134 | 20275 HOPPER STREET | ELKHORN | NE | 68022 | 2018-02-27 | 758 | D | 1 | 1 | YXZR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to complete behavior monitoring for continued use of [MEDICAL CONDITION] medications for 2 residents (Residents 4 and 82) of 5 residents sampled. The facility staff identified the census at 101. The findings are: [NAME] A review of Resident 4's undated Face Sheet revealed that the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Resident 4's Medication Administration Record [REDACTED]. The resident received the medication on 2-18-18. A review of Resident 4's MAR for (MONTH) (YEAR) revealed the resident received [MEDICATION NAME] (an anti-anxiety medication) on an as needed basis for anxiety. The resident received the medication on 1-1-18, 1-11-18, 1-12-18, 1-15-18, 1-19-18, 1-24-18, 1-26-18, and 1-27-18. A review of Resident 4's Behavior/Intervention Monthly Flow Record for (MONTH) (YEAR) revealed the resident was documented as having no behavior episodes the entire month. A review of Resident 4's Behavior/Intervention Monthly Flow Record for (MONTH) (YEAR) revealed the resident's behaviors were no longer documented after 2-8-18. An interview conducted on 2-22-18 at 1:25 PM with Medication Assistant (MA) [NAME] revealed that the process for giving an as needed anti-anxiety medication was that the MA would notify the charge nurse that the resident had requested a medication or that the resident was having behaviors and the non-pharmacological interventions were not effective. The medication would be given by the MA at the direction of the charge nurse. The MA would document on the MAR indicated [REDACTED]. The charge nurse would document on the Behavior/Intervention Monthly Flow Record for that shift what the behaviors were and what was done for the resident to alleviate the behaviors. B. Record review of a Policy and Procedure for Psychopharmacological (medications used to manage behaviors) Medications dated 8/23/17 revealed the following: - That each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: without adequate monitoring. - The facility would establish an ongoing process of assessing the resident's behavior indicators, monitoring for adverse consequences, response and efficacy of psychopharmacological medications. - Accurate and thorough assessment of the resident's behavior indicators are fundamental in determining the appropriate utilization of psychopharmacological medications. - Documentation will be noted in the resident's medical record and will include but not be limited to: type of behaviors, new or worsening behaviors, times observed and frequency, interventions provided and resident's response to intervention. Record review of Resident 82's Comprehensive Care Plan (CCP) dated 1/27/18 identified that Resident 82 used [MEDICAL CONDITION] medication (medications used to manage behaviors), an antidepressant and an anti-anxiety medication related to [DIAGNOSES REDACTED]. Resident 82's behavior care plan identified the following behavior problems: physically abusive, socially inappropriate, and sexually inappropriate and resists cares. Target behaviors were identified as: restless, combative, socially inappropriate and sexually inappropriate. Interventions included: Observe behavior episodes, attempt to determine underlying cause and monitor for effectiveness of [MEDICAL CONDITION] drugs. Record review of Resident 82's Physician orders [REDACTED]. Record review of Resident 82's Behavior Intervention Monthly Flow Records dated (MONTH) and (MONTH) (YEAR) revealed target behaviors of combative and fidgety. The Behavior Flow Records did not identify any other target behaviors as were identified in Resident 82's CCP. Review of the (MONTH) and (MONTH) Behavior Flow Records for Resident 82 revealed that behavior monitoring was documented sporadically throughout the month. There were many blank spots on the flow record. Interview on 2/27/18 at 9:48 AM with the Director of Nursing (DON) confirmed that Resident 82's Behavior /Intervention Monthly Flow Sheets were not filled out correctly and there was only sporadic documentation of the monitoring of Resident 82's behaviors. The DON confirmed that not all of Resident 82's target behaviors had been identified on the monthly flow records. | 2020-09-01 |
| 3844 | OLD MILL REHABILITATION (OMAHA TCU) | 285289 | 1131 PAPILLION PARKWAY | OMAHA | NE | 68154 | 2017-07-20 | 225 | E | 1 | 1 | ZXDC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to ensure all significant injuries and allegations of abuse were reported to the State Agency and investigated for 4 residents. (Residents 93, 240, 250). The facility census was 43. [NAME] Review of the facility abuse reporting policy includes material dated 8/20/2012 indicating an injury that is significant for the resident requires reporting to the state agency. Review of Resident 93's progress notes revealed Resident 93 fell on [DATE] and received a laceration requiring 7 staples in the emergency room . Review of Resident 93's progress notes on 7/16/2017 revealed Resident 93 required Extensive assist of 1 staff to ambulate to the bathroom. Review of Resident 93's progress notes dated 2/17/2017 at 2:00 AM revealed resident 93 had a change of ADL status and required Extensive assist of 2 staff to ambulate to the bathroom. Interview on 07/19/2017 at 10:27 AM with the Administrator and Director of Nursing (DON) revealed the significant injury on[NAME]O'Hara was not called to the state agency. B. Review of the facility policy titled Reporting Abuse to the Facility Management dated (MONTH) 2009 revealed verbal abuse is defined as any use of oral language that willfully includes disparaging and derogatory terms to residents or their families. Record review revealed on 6/21/2017 Resident 250 filed a concern form with the Social Worker stating a staff member was rude, derogatory and mocking Resident 250. Interview on 7/19/2017 at 10:30 AM with the DON revealed Resident 250's concern was not identified as abuse or called into the state agency as an allegation of abuse. Interview on 7/19/2017 at 10:35 AM with the Administrator revealed the staff member was not suspended and a thorough investigation was not completed. C. Review of the facility policy titled Reporting Abuse to Facility Management dated (MONTH) 2009 revealed mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Record review revealed on 6/23/2017 the facility received a letter from Resident 240's family in which they alleged a staff member was confrontational regarding why the family and resident would not allow a male caregiver and that since Resident 240 had made that decision Resident 240 would have to wait for assistance with toileting or let the male caregiver assist. The family stated this was inappropriate. Interview on 7/19/2017 at 10:31 AM with the DON and the Administrator revealed this was not identified as abuse and was not called to the state agency. | 2020-09-01 |
| 1100 | EMERALD NURSING & REHAB LAKEVIEW | 285106 | 1405 WEST HWY 34 | GRAND ISLAND | NE | 68801 | 2019-05-29 | 625 | D | 1 | 0 | X6N711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to notify the residents' legal representative of the bed hold policy for transfer to the hospital for 1 of 4 sampled residents (Resident 4). The facility census was 69. Findings Are: Review of Resident 4's Admission status revealed an admission date of [DATE] Review of Resident 4's medical [DIAGNOSES REDACTED]. Review of MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 3/6/19 revealed for Section C: Cognitive Patterns C0100 Should Brief Interview for Mental Status be conducted the answer was coded as No (Resident is rarely/never understood) C1000. Cognitive Skills for Daily Decision Making was coded as 3. Severely impaired. Review of MDS dated [DATE] a Significant Change in status MDS revealed for Section C: Cognitive Patterns C0100 Should Brief Interview for Mental Status be conducted the answer was coded as No (Resident is rarely/never understood) C1000. Cognitive Skills for Daily Decision Making was coded as 3. Severely impaired. Review of Resident 4's bed hold letter revealed that resident's name was signed on form dated 2/4/19 and then again on 5/9/19. Both letters are written with Residents name present and the Facility representative Signature. There is no documentation that the POA (Power of Attorney) was informed of the bed hold notification or who the copy of the notification letter was sent to. Review of Resident 4's Progress Notes revealed no documentation that a copy of the Bed Hold Policy had been sent to Resident 4's legal representative. Interview on 5/29/19 at 11:44 AM with DON (Director of Nursing) revealed, there is a bed hold letter sent with the resident to the hospital and copies are kept, along with the Ombudsman monthly notifications in a calendar book. Interview on 5/29/19 at 11:55 AM with ADM (Administrator) revealed that the POA (Power of Attorney) or legal representative has never been notified in writing that someone has gone to the hospital and what the rate of private pay will be. We complete the bed hold letter and send it to the hospital with the resident. We make a copy and place it in the bed hold book. Review of the Bed Hold Policy dated 05-17 revealed: The Policy: PR[NAME]EDURE FOR BED HOLD NOTIFICATION PURPOSE: The facility shall inform and provide in writing to the resident and/or the resident's representative the facility's bed hold and return to the facility policy at the time of transfer or leave of absence specifying the duration of the bed hold policy. PR[NAME]EDURE 1. The nurse will obtain the Bed Hold Policy and Return to Facility notice and provide the notice to the resident and their representative at the time of transfer or leave of absence. 2. The nurse will ensure that a copy of the notice accompanies the resident as the resident leaves the facility. 3. The nurse will inform the resident representative, on the telephone if necessary about the bed hold and return to facility policy and ask how best to provide a copy of the notice to the representative. a. The nurse will inform the representative that the notice accompanied the resident at the time the resident left the facility. b. The nurse will document the provision of the Bed Hold Policy and Return to Facility notice to the resident and information given to the representative in the resident's record. | 2020-09-01 |
| 3919 | HILLCREST COUNTRY ESTATES-COTTAGES | 285293 | 6082 GRAND LODGE AVENUE | PAPILLION | NE | 68133 | 2017-05-04 | 428 | E | 1 | 1 | POAF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, and interview the pharmacy failed to identify irregularities of medication and notify the facility staff and physician of irregularities for 3 residents (55, 27, and 29) of 5 sampled. The facility census was 46. Findings are: [NAME] Record review of Resident 55's electronic medical record revealed that Resident 55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of Activities of Daily Living (ADL's), on 5/3/17 at 11:44 AM revealed that Resident 55 had multiple prescription creams present in the room for use. Record review of Resident 55's physician orders [REDACTED]. 1) Desoximetasone 0.25% apply topically two times daily as needed for rash . 2) Hydrocortisone 2.5% apply topically to back, as needed for itching.3) Mometasone Furoate 0.1% apply topically to affected areas daily as needed. 4) Triamcinolone 0/1% ointment apply to affected area's 2 to 3 times daily as needed. 5) Risamine ointment apply to buttocks twice daily. Record review of Resident 55's Monthly Pharmacy review, dated 12/2/16, revealed a request for a clinical rationale for Desoximetasone 0.25% cream, Clobetasol Propionate cream, and Mometasone Furoate cream. Record review of Resident 55's Monthly Pharmacy reviews dated 1/6/17, 2/6/17, 3/3/17 and 4/3/17 reveal no follow up on the request for clinical rationale for the above listed creams. ` Interview with Resident 55's pharmacy revealed that all the creams were the same medication but in different strengths. The Pharmacist confirmed that Resident 55 did have unnecessary medications, evidenced by the multiple creams that provide the same treatment at different strengths. B. Record review of Resident 27's physician orders [REDACTED]. Record review of Resident 27's Medication Administration Records for January, February, March, (MONTH) and (MONTH) revealed that Resident 27 had not been administered the Fluconazole in the past 5 months. Record review of Resident 27's Weekly Skin Assessments for the past (MONTH) and (MONTH) revealed no areas of concern under breast, and the Nystatin powder continued to be applied every shift and was not discontinued. Record review Resident 27's Monthly Pharmacy Reviews revealed no irregularities noted. Interview with facility administrator on 5/4/17 17 at 2:09 PM confirmed that pharmacy had not alerted the facility to the medication irregularities for Resident 27. C. Record review of Resident 99's physician orders [REDACTED]. Miconazole Nitrate 2% cream (Miconazole is used to treat skin infections such as athlete's foot, jock itch, ringworm, and other fungal skin infections) , orders for Monostat cream (used to treat yeast infections) , and Clotrimazole (used to treat skin infections such as athlete's foot, jock itch, ringworm, and other fungal skin infections) . Record review of Resident 99's Medication Administration Records for January, February, March, (MONTH) and (MONTH) revealed that these medications have not been used in the past 5 months. Record review of Resident 99's weekly skin assessments for the months of March, (MONTH) and May, have no documentation of skin issues that would require this medication. Record review of Resident 99's Pharmacy reviews revealed no irregularities noted. Interview with facility administrator on 5/4/17 17 at 2:09 PM confirmed that pharmacy had not alerted the facility to the medication irregularities for Resident 27. | 2020-09-01 |
| 5790 | WAYNE COUNTRYVIEW CARE AND REHABILITATION | 285135 | 811 EAST 14TH STREET | WAYNE | NE | 68787 | 2016-09-14 | 309 | D | 1 | 0 | IB0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation and interview; the facility failed to develop interventions to prevent the reoccurrence of skin breakdown and to complete cares per practitioner's orders related to the application of ted hose (compression devices worn to assist with swelling) for Resident 4. In addition, the facility failed to provide assessment and cares to promote healing of a wound for Resident 1. The sample size was 5 and the facility census was 37. Licensure Reference Number: 175 NAC 12-006.09D2c Findings are: A. Review of facility Policy and Procedure entitled Skin and Wound Monitoring and Management Care Guidelines (revised 1/2016) revealed the following: -At the time of admission or readmission to the facility, a licensed nurse was to complete a comprehensive assessment to identify risk factors related to the potential development of skin breakdown. -A comprehensive plan of care should be developed using the assessment with individualized interventions developed to meet the resident's needs. -Wounds identified after admission should be assessed and evaluated on a weekly basis by a licensed nurse. -The assessment should include but not be limited to; measurement and a description of the wound location, the nature of the wound, characteristics of the wound and any signs and/or symptoms of infection or complications of the wound. Review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 6/28/16 revealed the resident required extensive staff assistance with transfers, personal hygiene, bed mobility and toileting. The assessment further revealed the resident had [DIAGNOSES REDACTED]. The resident was identified as having Moisture Associated Skin Damage (MASD- the general term to describe inflammation, or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat or wound drainage) with interventions for a pressure reduction device to the resident's chair and bed. Review of Resident 1's current Care Plan dated 1/7/16 revealed the resident was at risk for impaired skin integrity related to history of fragile skin, [MEDICAL CONDITION] (infection of the skin) and [MEDICAL CONDITION] (swelling). The following interventions were identified: -Monitor and document the location, size and treatment of [REDACTED]. -Educate resident and family of causative factors and interventions to prevent skin injury. -Report abnormalities, failure to heal, signs of infection or maceration to the physician. Review of Resident 1's Treatment Administration Record (TAR) revealed an order dated 4/19/16 for [MEDICATION NAME] dressing (absorbent, semi-permeable and waterproof dressing used for treatment of [REDACTED]. Review of Weekly Skin Assessment and Evaluation of the MASD to Resident 1's coccyx revealed the following: -4/19/16 Slough (stringy mass that may or may not be attached to surrounding tissue. Slough can range in color and thickness) noted to the wound bed and area measured 0.7 centimeters (cm) by 0.5 cm. -4/26/16 Area was covered with a [MEDICATION NAME] dressing. Measurements were unchanged. -5/3/16 Area measured 0.8 cm by 0.4 cm by 0.1 cm. Review of Resident 1's medical record revealed no evidence the resident's physician was notified the resident's wound had increased in size or that any new interventions were developed to prevent further decline of the wound. Review of Weekly Skin Assessment and Evaluation of the MASD to Resident 1's coccyx revealed the following: -5/17/16 Dressing in place to the wound and staff continued to monitor. (No measurement of the wound was documented with the assessment). -5/24/16 Wound now measured 0.9 cm by 0.4 cm by 0.1 cm. -5/31/16 Assessment and measurement of the wound was unchanged. -6/14/16 Assessment revealed no change in the size, shape or measurement of the wound. Review of Resident 1's medical record revealed no evidence the resident's physician was notified when the resident's wound had increased in size on 5/24/16 or that any new interventions were developed to promote healing of the resident's wound. Review of Weekly Skin Assessment and Evaluation of the MASD to Resident 1's coccyx revealed the following: -6/28/16 Area measured 0.6 cm by 0.4 cm by 0.2 cm. No further assessment was documented. -7/13/16 Assessment revealed the area remained unchanged in size and depth. -7/26/16 Area measured 0.3 cm by 0.1 cm. No further assessment was documented. Weekly Skin Assessments were completed of the MASD to the resident's coccyx on 8/2/16 and on 8/9/16. The assessments indicated the area remained unchanged. No measurements were documented with the assessments and the assessments did not identify any characteristics of the resident's wound or if the wound had any signs of infection. Review of Resident 1's medical record revealed no further assessments of the MASD to the resident's coccyx. During an observation on 9/13/16 from 10:33 AM to 10:55 AM, Nursing Assistant (NA-H) provided Resident 1 with perineal hygiene. A [MEDICATION NAME] dressing was observed to cover the resident's coccyx area. During an interview on 9/13/16 from 12:55 PM to 1:15 PM, NA-H indicated the resident had a sore to the coccyx area and the area was to be covered with a dressing at all times to protect it. NA-H was unaware of what the wound looked like as staff had never seen the area without a dressing. During an interview on 9/14/16 from 2:00 PM to 2:15 PM, the Administrator verified the resident's physician should have been notified for a potential change in treatment when the resident's wound increased in size. The Administrator further identified a licensed nurse should have assessed the area to Resident 1's coccyx and documented the assessment weekly until the area was healed. The Administrator indicated assessments had not been completed due to concerns with staffing levels. B. Observation of Resident 4's wound treatment with LPN (Licensed Practical Nurse)-F on 9/14/16 at 10:21 AM revealed the resident had a scabbed abrasion to the left Achilles (area to the back of the heel approximately 2 to 3 inches above the base of the foot). Resident 4's feet were bare inside of black slip on dress shoes. Review of Resident 4's Medical Record revealed the following: -Weekly Skin Assessment and Evaluation dated 5/16/16 indicated a scabbed area to the back of the resident's heel. The charting did not identify which heel. -Weekly Skin Assessment and Evaluation dated 6/6/16 indicated an abrasion to both left and right Achilles. -Weekly Skin Ulcer Non-Pressure assessment dated [DATE] indicated the area to the right Achilles was a previous abrasion that re-opened. -Weekly Skin Assessment and Evaluation dated 7/4/16 indicated abrasions had resolved. -Weekly Skin Ulcer Non-Pressure assessment dated [DATE] indicated the resident had an open area measuring 1.5 cm by 1 cm to the back of the left heel. -Weekly Skin Assessment and Evaluation dated 9/12/16 indicated a superficial abrasion/scab remained to the resident's left heel. Review of Resident 4's undated Care Plan revealed no evidence to indicate causal factors were assessed or addressed to prevent skin breakdown. Interview with Resident 4 on 9/14/16 at 10:25 AM revealed the scabbed abrasion was likely from the shoes rubbing. Further interview revealed the resident had been wearing the same shoes for a year and previously had trouble with skin breakdown caused from the same shoes that were currently being worn. Interview with LPN-F on 9/14/16 at 10:40 AM confirmed Resident 4 had open areas on the Achilles areas in the past that had healed, and now had developed a new area. LPN-F felt the open areas were caused by the resident's shoes rubbing or by the way the resident removed the shoes. Further interview confirmed interventions had not been put in place to prevent re-occurrence of skin breakdown. Licensure Reference Number: 175 NAC 12-006.09 C. Review of Resident 4's Order Summary Report (signed physician's orders [REDACTED]. Observation of Resident 4 on 9/14/16 at 10:20 AM revealed the resident was not wearing ted hose and had [MEDICAL CONDITION] to both feet. Interview with LPN-F on 9/14/16 at 1:35 PM confirmed Resident 4 had an order to wear ted hose daily, but did not have them on as ordered. LPN-F described Resident 4's [MEDICAL CONDITION] to both feet as 3 plus (+) [MEDICAL CONDITION] (Pitting [MEDICAL CONDITION] leaves an indentation in the [MEDICAL CONDITION] area when pressure is applied. Pitting [MEDICAL CONDITION] is scored from 1+ to 4+ with 4+ being the most [MEDICAL CONDITION]). | 2019-09-01 |
| 5486 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2018-05-22 | 849 | D | 1 | 0 | NLW911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation and interview; the facility failed to ensure Hospice representatives were involved as part of the interdisciplinary group to update, follow and provide hospice comprehensive care plan recommendations to reflect current information and care needs for terminally ill residents. This failure had the potential to effect 2 of 4 sampled residents (Resident 10 and 23.) Facility census was 39. [NAME] Record review on 5/24/18 at 9:00 AM revealed that Resident 10 was admitted to hospice on 12/8/17. The care plan meeting was on 1/3/18 and the Hospice representative had not attended the meeting. No documentation on a follow up meeting with hospice team to create the comprehensive hospice care plan. Record review of Resident 10's Hospice care plan with the initiation date of 5/21/15. The correct Hospice admitted was 12/8/17. The care plan was not updated or revised until 2/22/18. The care plan meeting date was 1/3/18. Record review on 5/24/18 at 11:00 AM revealed the focused person centered comprehensive care plan for hospice addressed the following for Resident 10: Resident seen 4 times per month for extra companionship. Social Worker will visit 1 time a month for support of resident and family. Facility to work with nursing staff to provide maximum comfort for the resident by review date. Hospice RN (Registered Nurse) will visit 1 time a week and Hospice nurse aide will visit 2 times a week. Pastoral services will visit 2 times a month. Resident will be comfortable physically, spiritually, and emotionally and receive spiritual support and prayer from visits. There were no documented notes in the facility documentation of follow through with visits. Record review on 5/21/18 at 2:01 Care plan revealed Focus: The resident had a terminal [DIAGNOSES REDACTED]. Goal: resident's comfort will be maintained through the review date initiated on 4/17/18 target date 5/30/18. Intervention 1. Work with Aseracare to provide maximum comfort for the resident. RN 3 times per week, nurse aide 3 times per week 1 time per month, pastor to evaluate on 4/17/18 of need for visits. 2. Environmental: Aseracare to provide pressure reducing mattress for resident to be used for maximum comfort. B. Record review on 5/24/18 at 1:52 PM for Resident 23 revealed hospice start of care date as 4/13/18. Aseracare was not in attendance of the scheduled care plan meeting on 4/27/18 and there was no follow up documentation on a care plan meeting with Hospice to maintain a collaborative development of the comprehensive care plan. An Interview on 5/22/18 at 4:00PM, with the Corporate Nurse Consultant confirmed that the Corporate Nurse Consultant was unable to locate documentation on hospice and that the Consultant had to call the hospice company to requestthe records. The records were not located at the facility and the records had to be retrieved from the Hospice Company. C. Review of facility policy with a revised date of 3/17, revealed that a coordinated plan of care shall be jointly developed by the rehab skilled care location and hospice. Hospice participation in the care plan conference and input from the hospice representative is required. The plan of care must include directives for managing pain and other symptoms associated with hospice care and must be revised and updated to reflect the current clinical psychosocial and spiritual condition. | 2020-01-01 |
| 3804 | MITCHELL CARE CENTER | 285287 | 1723 23RD STREET | MITCHELL | NE | 69357 | 2018-06-19 | 758 | D | 1 | 0 | 57D211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interview, the facility failed to ensure PRN (as needed) anti-psychotic (tranquilizing medications used to control hallucinations, delusions, and behavioral aggression) medications were not extended beyond the required 14-day limitation without evaluation by a medical practitioner and documented rationale for extending the PRN for two sampled residents (Residents 2 and 6). Sample size was 3 current residents receiving anti-psychotic medications. Facility census was 49. Findings are: [NAME] Record review of Resident 2's Admission Record printed on 6/19/18 revealed the resident was admitted to the facility on [DATE] and had a medical [DIAGNOSES REDACTED]. Record review of Resident 2's Medication Review Report dated 6/4/18 signed by the resident's physician revealed the resident had orders for [MEDICATION NAME] Solution (an anti-psychotic medication) with instructions to administer 2 milligrams of the medication either by intramuscular injection or by mouth every 12 hours as needed for severe agitation. The report recorded the medication start date was 4/05/2018. Record review of Resident 2's Medication Administration Records for May, and (MONTH) of (YEAR) revealed the resident continued to have active orders for [MEDICATION NAME] 2 milligrams every 12 hours as needed. The resident was administered the medication 10 times by mouth and twice by injection in (MONTH) and was not administered the medication anytime in June. Record review of Resident 2's medical record charting and electronic chart revealed there was no re-evaluation of the use of PRN [MEDICATION NAME] beyond 14 days by the practitioner nor was there any documentation by the practitioner of a rationale to continue the PRN [MEDICATION NAME] beyond the required 14 day limit. B. Record review of Resident 6's Admission Record printed on 6/19/18 revealed the resident was admitted to the facility on [DATE]. Among the resident's [DIAGNOSES REDACTED]. Record review of Resident 6's Progress Notes revealed an entry on 5/14/18 at 3:20 p.m. which read: Received orders to d/c (discontinue) [MEDICATION NAME] and start [MEDICATION NAME] (an anti-psychotic medication) 2.5 mg (milligrams) po (by mouth) bid (twice daily) prn for [MEDICAL CONDITION]. Record review of Resident 6's medical practitioner documentation revealed the following: - A Palliative Medicine progress note was documented by a Nurse Practitioner on 5/15/18. The Practitioner documented the plan included: [MEDICATION NAME] 2.5 mg po bid. Continue prn. There was no documentation including recommendations for the duration of the PRN use. - A physician's orders [REDACTED]. There was no change written in the resident's use of [MEDICAL CONDITION] medication and nothing documented regarding recommendations for the duration of the PRN use. Record review of Resident 6's Medication Administration Record [REDACTED]. Record review of Resident 6's medical record charting and electronic chart revealed Resident 6 was ordered PRN [MEDICATION NAME] on 5/15/18 with no recommended duration of use. There was no documentation of a re-evaluation of the PRN order beyond the 14 day requirement, nor any documentation of a rationale to extend the PRN medication beyond 14 days by the resident's medical practitioners. Interview with LPN (Licensed Practical Nurse)-A, the facility's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) Coordinator, on 6/19/18 at 2:35 p.m. verified Residents 2 and 6 had been ordered PRN anti-psychotic medications in which the orders extended beyond the required 14 day limit without re-evaluation by a practitioner or documented rationale to extend the medication orders. | 2020-09-01 |
| 5463 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2017-03-22 | 329 | D | 1 | 1 | HUVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews the facility failed to trial GDR's (gradual dose reductions) and/or document the rationale or need to continue the use of psychoactive (medications used to treat depression and or other psychiatric symptoms) for 2 residents (Resident 6 and 47) out of the 5 sampled residents. The facility census was 59. Findings are: A Review of the undated census sheet for Resident 6 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1-17-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 3 which indicated Resident 6 had severe cognition impairment. Review of Resident 6's current Physician orders [REDACTED]. [MEDICATION NAME] 100mg (milligram) daily for depression [MEDICATION NAME] 5mg bid (twice a day) for dementia with behaviors ABH ([MEDICATION NAME]: an antianxiety medication, [MEDICATION NAME]: an [MEDICATION NAME]: an antipsychotic) gel TID (three times a day) and PRN (as needed) for agitation Review of Resident 6 medical record revealed no documentation of 6 month reviews of the resident's [MEDICAL CONDITION] medications and attempts to reduce the medications. No documentation was also found from the Physician documenting the clinical rationale why not to attempt a GDR. B) Review of the undated census sheet for Resident 47 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-28-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 3 which indicated Resident 47 had severe cognition impairment. Review of Resident 47's current Physician orders [REDACTED]. [MEDICATION NAME] 50mg TID for anxiety/agitation [MEDICATION NAME] 0.5 mg every 2 hours PRN for agitation Review of Resident 6 medical record revealed no documentation of 6 month reviews of the resident's [MEDICAL CONDITION] medications and attempts to reduce the medications. No documentation was also found from the Physician documenting the clinical rationale why not to attempt a GDR. Interview on 3-15-17 at 3:26 PM with the RP (Registered Pharmacist) revealed the pharmacy contract did not include for their company to review and recommend GDR's on the residents at this facility. The RP revealed the DON (Director of Nursing) and the MD (Medical Director) would complete monitor the psychoactive medications of all the residents and conduct the GDR's. Interview on 3-20-17 at 11:44 AM with the DON revealed the DON was aware the RP did not do the GDR's. The DON revealed the former Administrator set up the process for the DON to meet monthly with the MD and review residents on psychoactive medications. The MD would make recommendations and those recommendation would be sent to the resident's primary Physicians requesting orders. The DON revealed a reduction in psychoactive medications was not requested routinely every 6 months. The DON also confirmed there was not documentation from the Physician documenting the clinical rationale why not to attempt a GDR. The DON revealed the DON and MD reviewing [MEDICAL CONDITION] medications was only being done on residents who were not under the medical care of the APRN from [NAME] Lanning Memorial Hospital Behavioral Unit. The DON revealed those residents medications did not require to be reviewed. | 2020-01-01 |
| 5511 | GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE | 285072 | 926 EAST E STREET | HASTINGS | NE | 68901 | 2016-12-22 | 309 | D | 1 | 0 | B6C911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to assess and treat a laceration in a manner to promote healing for one resident out of the 4 sampled residents. The facility census was 105. Findings are: Review of the undated [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 11-30-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 100 had no cognitive impairment. Resident 100 required limited assistance of one staff with bed mobility, transfers, dressing, and toileting. Review of the Incident Report dated 11-30-16 revealed Resident 100 was found on the floor at 1:40 PM with an injury of an 8 x 5 cm (centimeter) skin tear on the left lower leg on the front side. The nurse cleansed the wound and applied skin prep (a liquid film-forming dressing applied to the skin which prepared the skin for adhesives) to the skin that surrounded the wound. Next the nurse applied steri-strips (thin adhesive strips used to close open wounds) to the wound and wrapped the leg in a dry dressing. The Physician was notified of the resident's fall and of the skin tear to the leg. Review of the Physician orders [REDACTED]. Review of the (MONTH) and (MONTH) (YEAR) TAR (Treatment Administration Record) revealed no nursing orders to monitor or treat the skin tear on the left lower leg. Review of the Nursing Notes revealed no assessment of the skin tear wound to the left lower leg. Interview on 12-22-16 at 3:42 PM with the Facility Nursing (UM) Unit Manager on the unit Resident 100 resided on revealed the UM had not observed the skin tear to the resident's leg. The UM spoke to the nurse who initially assessed the wound and was informed the wound was a large skin tear. The UM revealed the UM had been informed that, for the top portion of the skin tear, the nurse was able to roll the skin back over the wound and steri-strip the area. For the lower portion of the skin tear wound, the skin was missing and therefore the nurse was not able to steri-strip that portion of the wound together. Interview on 12-22-16 at 2:35 PM with Nurse-A revealed Resident 100 was seen on 12-14-16 by the resident's PCP (Primary Care Physician) at the Physician's clinic. The nurse revealed the physician had assessed the wound to the left lower leg as a large gapping full thick untreated laceration. The Physician informed the resident and resident's spouse that the wound should have had sutures initially after injury and that it was not a skin tear. Review of the PCP clinic notes dated 12-14-16 revealed the Physician was notified on 11-30-16 by the facility that Resident 100 had received a skin tear to the left lower leg. As the area was not suturable, the facility would dress the wound. On 12-14-16, the wound was assessed as a large full thickness laceration which remained opened and was draining serum constantly. Interview on 12-22-16 at 4:11 PM with the Resident 100's spouse revealed the spouse had observed the wound on the left lower leg after the incident had occurred and had felt the wound was large and required sutures. The spouse denied the resident having had reinjured or bumped the left lower leg since the resident had left the faciity on [DATE] up through the time the resident saw the physician on 12-14-16. | 2019-11-01 |
| 2499 | PIONEER MANOR NURSING HOME | 285212 | P O BOX 310, 318 N 3RD STREET | HAY SPRINGS | NE | 69347 | 2018-08-07 | 726 | G | 1 | 0 | 9WZ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to ensure a newly hired nursing employee (Nurse Aide-A) received orientation competency demonstrations in safely transferring residents while providing direct care/transfers. The failure resulted in an improper transfer of one sampled resident (Resident 1) which resulted in a major injury requiring medical attention. Sample size was 3 current residents. Facility census was 51. Findings are: Record review of a facility investigative report entitled Fall with major injury dated 7/23/18 revealed the facility investigated an incident which occurred on 7/18/18 involving Resident 1. The report indicated non-residents involved in the incident included NA (Nurse Aide)-[NAME] The report revealed that during a transfer between surfaces Resident 1's leg seemed to break during mid transfer and the resident transported to the hospital for potential broken leg. Record review of a Hospital History and Physical dated 7/18/18 revealed the resident was seen in the emergency room after arriving via rescue unit. The resident had fallen with bruising and swelling of the left lower leg. The x-ray findings recorded on the document indicated the resident sustained [REDACTED]. Record review of Resident 1's Care Plan History report revealed a problem dated 6/6/18 indicated the resident had been lowered to the floor in the bathroom and the approach to prevent serious injury was updated on 6/6/18 directing staff to transfer the resident with 2 staff members assisting. Record review of the facility's Nursing Schedule documents between 5/27/18 and 6/23/18 revealed NA-A was working evening shifts as an orientee during scheduled days during this time frame. Record review of NA-A's employee records revealed no documentation of the resident's competency testing from orientation or indicating the employee had demonstrated competency in safely transferring residents. Interview with the Administrator on 8/7/18 at 11:45 a.m. confirmed that on 7/18/18 NA-A transferred Resident 1 without the assistance of another staff member and the resident lost balance during the transfer and fell . The Administrator verified NA-A had transferred from dietary to nursing and was employed as an orientee in nursing between 5/27/18 and 6/23/18 but that there was no record the employee had demonstrated competency as a direct care staff member or competency in safely transferring residents. | 2020-09-01 |
| 6643 | MITCHELL CARE CENTER | 285287 | 1723 23RD STREET | MITCHELL | NE | 69357 | 2015-12-21 | 514 | D | 1 | 0 | BM5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to: 1) record late entry information in the medical record; record events related to wound care and an emergency room visit; and record accurate wound assessments for one sampled resident (Resident 2); and 2) record the administration of a narcotic topical medication in the resident's medical record for one sampled resident (Resident 1). Facility census was 47. Findings are: Licensure Reference Number: 175 NAC 12-006.16A A. Record review of Resident 2's Admission Record printed on 12/21/15 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 2's Progress Notes revealed the following entries: - 10/23/15 at 8:14 p.m.- the entry was recorded as a Late Entry documented the Resident taken to ER (emergency room ) via private vehicle . The entry failed to record the actual date and time the resident was taken to the ER. - 10/23/15 at 11:20 p.m.- the entry was recorded as a Late Entry documented Resident back from ER . The entry failed to record the actual date and time the resident returned from the ER. - 10/24/15 at 10:18 a.m.- the entry was recorded as a Late Entry documented the resident's condition. The entry failed to record the actual date and time of the assessed condition. - 10/27/15 at 1:23 p.m.- the entry was recorded as a Late Entry documented the resident's condition. The entry failed to record the actual date and time of the assessed condition. - 10/28/15 at 8:13 p.m.- the entry recorded an assessment of the resident's forehead and a notation the physician office had not responded to the facility about removal of staples from the wound. The entry failed to record the actual date and time of the assessment. Source: The American Health Information Management Association LTC (Long-Term Care) Health Information Practice & Documentation Guidelines Version 1.0 (MONTH) 2001. - 5.3.2.1 Making a Late Entry. When a pertinent entry was missed or not written in a timely manner, a late entry should be used to record the information in the medical record . Identify or refer to the date and incident for which late entry is written . Licensure Reference Number: 175 NAC 12-006.16B (1) Record review of Resident 2's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessments revealed Resident 2 was discharged to an other location on 12/3/15 and re-entered the facility from an other location on 12/4/15. Record review of Resident 2's Progress Notes revealed the following documentation: - 12/3/15 at 9:55 p.m. the staff recorded the resident had fallen and developed a laceration. An on-call physician provided orders for the facility to transport the resident to the emergency room for evaluation and treatment. There were no further entries or late entry notes regarding when the resident was transported to the emergency room or returned. Record review of Resident 2's medical record revealed the following: - Physician Telephone Orders form dated 10/29/15 revealed an order was received on 10/29/15 for the staff to remove (wound) staples today. - Review of Progress Notes revealed an entry dated 10/29/15 at 12:46 a.m. revealed Staples intact. An entry on 10/30/15 at 1:44 p.m. recorded Resident's laceration to forehead now has steri stripes (sic for strips) that are intact . -There were no entries on 10/29/15 or 10/30/15 recording when the forehead staples were removed or the condition of the wound and resident's response to the procedure at the time of their removal. Record review of the resident's Treatment Administration Record for (MONTH) of (YEAR) revealed no documentation of the date or time the resident's forehead staples were removed. Licensure Reference Number 175 NAC 12-006.16B (2) Record review of Resident 2's Progress Notes revealed the following discrepancies in describing the resident's wound and treatment following a laceration from a fall on 10/22/15: -10/23/15 at 3:44 p.m. the entry recorded the resident Sutures remain clean, dry, and intact. - 10/23/15 at 3:51 p.m. the entry recorded the resident was seen in theER on [DATE], orders received . to take out staples . in 7-14 days. -10/23/15 at 11:20 p.m. a Late Entry recorded the resident returned from the emergency room with 6 staples to laceration on forehead . - 10/24/15 at 10:18 a.m. a Late Entry recorded the resident had 7 stapes are intact on 5 cm (centimeter) laceration . - 10/25/15 at 3:12 p.m. the entry recorded all seven staples are intact with edges approximated measures 7 cm in length . - 10/28/15 at 3:25 a.m. the entry recorded . Staples x6 remain intact to forehead . Interview with the Director of Nursing (DON) and the Administrator on 12/21/15 at 3:30 p.m. verified that Resident 2's Progress Notes contained Late Entry documentation on 10/23; 10/24; 10/27; and 10/28/15. The DON and Administrator confirmed these late entries had not recorded the actual date and time of the events documented as late entries. The DON and Administrator verified Resident 2 sustained a fall and was transported to the emergency roiagnom on [DATE] and there was no documentation pertaining to when the resident was transported and no assessment and record of the resident's return and condition following the emergency room visit. The DON and Administrator verified an order was received and staples removed from Resident 2's forehead and confirmed there was no documentation describing the procedure or identifying when the procedure was done. The DON and Administrator verified discrepancies in the description of Resident 2's forehead wound and treatment confirming that entries differed as to the number of staples, whether sutures or staples were in place, and the measurements of the resident's wound. Licensure Reference Number 175 NAC 12-006.16B(1) B. Review of the facility reports to State Agency dated 12/2/15 revealed a completed investigation in regards to misappropriation of a [MEDICATION NAME] on Resident 1. Further review revealed that a new patch was placed on the resident on 11/25/15. Review of the Medication Administration Record [REDACTED]. Review of the facility Narcotic Patch Change Sheet dated as starting 10/24/15 revealed an entry of 11/25/15 with the placement of a new patch on the left upper shoulder for Resident 1. Interview with LPN - C on 11/25/15 at 10:00 AM verified that the Narcotic Patch Change Sheet did reveal that Resident 1 had a [MEDICATION NAME] placement to the left upper shoulder on 11/25/15. Further interview verified that the resident's MAR indicated [REDACTED]. Interview with the Administrator on 12/21/15 at 3:30 PM verified that Resident 1 did have a [MEDICATION NAME] missing that had been replaced on 11/25/15. Further interview verified that the [MEDICATION NAME] had been checked out on the Narcotic Patch Change Sheet on 11/25/15. Continued interview confirmed that the MAR for Resident 1 had not been completed to include the [MEDICATION NAME] administered on 11/25/15. | 2018-12-01 |