CMS-Nursing-Home-Full-Deficiencies
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | SUMNER PLACE | 285002 | 1750 SOUTH 20TH STREET | LINCOLN | NE | 68502 | 2019-02-20 | 644 | D | 0 | 1 | J44111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a level 2 PASARR ( Pre-Admission Screening and Resident Review) Program had been completed on one resident (Resident 2) of 1 sampled resident, when newly diagnosed with [REDACTED]. The facility census was 96. Findings are: Record Review of PASSAR Level one completed in 2012 did not recommend the Level II. This PASSAR identified Bi-Polar Disorder but did not identify the Schizo-effective Disorder, Mania, [MEDICAL CONDITION] Disorder, and Depression with psychiatric features, treatment refractory [MEDICAL CONDITIONS], Atypical [MEDICAL CONDITION]. Record review of Note to Attending Physician/Prescriber revealed; Resident 2 received antipsychotic medication and the clarification for [DIAGNOSES REDACTED]. Record review of initial [DIAGNOSES REDACTED]. An interview on 02/19/19 at 04:17 PM with the DON (Director of Nurse) confirmed; Resident 2 had not been reassessed for PASSAR level 2 after the [DIAGNOSES REDACTED]. An interview on 02/21/19 at 03:29 PM with the SSD (Social Services Director) confirmed the re-evaluation PASSAR had not been submitted. An interview on 02/21/19 at 03:40 PM with the SSD confirmed; that information had been sent to the psychiatrist on 02/19/19. The information had been received by the facility on 02/21/19 and had been sent to Ascend for re-evaluation. | 2020-09-01 |
| 2 | SUMNER PLACE | 285002 | 1750 SOUTH 20TH STREET | LINCOLN | NE | 68502 | 2019-02-20 | 656 | D | 0 | 1 | J44111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** License and Reference Number 175 NAC 12 Based on observation, record review and interview, the facility failed to ensure that residents care plans were individualized to meet the the residents fluid needs. This had the potential to effect 2 residents, Residents # 21 and # 28. The facility census was 96. Resident #21 02/14/19 03:38 PM observed in room and does not respond to verbal cues. 02/19/19 10:30 AM observed in room and does not respond to verbal cues. Record review of the residents MDS (Minimum Data Set is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes and non-critical access hospitals with Medicare swing bed agreements dated 08/28/18 revealed a BIMS (Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment) of 2 indicated severely impaired cognition. Extensive assist with eating and drinking. Resident unable to voice preferences on MDS. Record review of the resident care plan dated 4/28/18 revealed no plan to address the residents inability to choose what fluids to consume, when to consume fluids or how much fluids to consume. On 02/21/19 at 12:10 PM an Interview with LPN(Licensed Practical Nurse)3 D confirmed the resident does not have the ability to choose what fluids to consume, when to consume fluids or how much fluids to consume. Resident #28 On 02/14/19 at 2:35 PM resident observed in bed with eyes open does not respond to verbal cues. On 02/20/19 at 10:16 AM resident observed in bed with eyes open does not respond to verbal cues. Record review of the residents MDS dated [DATE] revealed a BIMS of 2. Extensive assist with eating and drinking. Resident unable to voice preferences on MDS. Record review of the resident care plan dated 12/3/18 revealed no plan to address the residents inability to choose what fluids to consume, when to consume fluids or how much fluids to consume. On 02/21/19 at 12:10 PM an interview with LPN D confirmed the resident does not have the ability to choose what to consume, when to consume fluids or how much to consume. | 2020-09-01 |
| 3 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2017-01-03 | 241 | D | 0 | 1 | X2RI11 | Licensure Reference Number: 175 NAC 12-006.05 (4) Based on observation, record review and interview; the facility failed to ensure one resident (Resident 102) of 41 sampled was treated with respect and dignity related to communication. The facility census was 109. Findings are: Review of Resident 102's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated 9/20/16 revealed Resident 102 was cognitively intact, had no speech, understood what was being said and was usually understood. Review of Resident 102's Care Plan dated 4/20/16 revealed Resident 102 was able to mouth words but was difficult to understand and would use a spell board to communicate. Review of a Family Meeting Note for Resident 102 dated 10/12/16 revealed, The patient has identified the following goals/expectations of the program: Res (Resident) asked that staff use (Resident 102's) the communication board more. An interview with Resident 102 was conducted on 12/20/2016 at 03:16 PM with the assistance of Registered Nurse (RN) C using Resident 102's communication board (also referred to as the spell board). Resident 102 indicated staff needed to improve communication with Resident 102. Resident 102 further reported staff do not look at Resident 102's face when they are in the room and could not tell when Resident 102 was attempting to communicate with them. RN C then asked Resident 102 if the staff utilized the spell board when communicating and Resident 102 responded no. Observation of Nursing Assistant (NA) D and NA [NAME] on 12/28/2016 at 2:03 PM revealed while NA D and NA [NAME] were assisting Resident 102 with repositioning. Resident 102 mouthed a sentence in an attempt to communicate without either NA noticing. NA D and NA [NAME] were talking to each other and occasionally made eye contact with each other while continuing to provide cares for Resident 102. Resident 102 attempted an additional five times to mouth the same sentence before either NA noticed. NA D then noted Resident 102 mouthing words and asked if they could finish their cares before attempting to understand what Resident 102 was attempting to state. Resident 102 agreed. NA D and NA [NAME] finished by straightening the covers on the bed, situating the call light and supplies and removing their gloves. Resident 102 again attempted to mouth the sentence an additional 2-3 times before NA D gave up trying to read the resident ' s lips and went to get the spell board. Resident 102 was then able to spell out the sentence so NA D and NA [NAME] could understand what Resident 102 was requesting. An interview was conducted with NA D AND NA [NAME] on 12/28/16 at 2:25 PM to ask how they knew when Resident 102 was attempting to communicate. NA D and NA [NAME] revealed that staff needed to keep one eye on Resident 102 at all times. When informed that Resident 102 had attempted to communicate 6 times during the observed cares, NA D and NA [NAME] responded that Resident 102 would have wide eyes if it was important and they would noticed if that had occurred. NA D went on to report that Resident 102 did not like to use the spell board. A follow up interview with Resident 102 and a family member on 12/29/2016 at 3:32 PM revealed Resident 102's family member was aware this was a concern for Resident 102. The family member reported the staff needed to find a way to ensure Resident 102 was being heard when attempting to communicate. Resident 102 went on to state that staff just needed to make sure they were looking at Resident 102's face to know when Resident 102 was attempting to communicate. | 2020-09-01 |
| 4 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2017-01-03 | 318 | D | 0 | 1 | X2RI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFEFERENCE NUMBER 175 NAC 12-006.09D4 Based on observation, interview and record review; the facility failed to prevent the potential for a decrease in range of motion for one resident (Resident 163) of 41 sampled residents. The facility census was 109. Findings are: On 12/20/16, Resident 163 was observed seated in a wheel chair. The resident was noted to have both arms pulled up to sides, wrists bent and fingers drawn up into the palms. Restorative Aide - A (RA-A) was interviewed on 12/27/16 at 10:29 AM about the restorative program for Resident 163. RA-A said that the resident received range of motion (ROM) three times per week and that the focus had been on the contractures (a condition of fixed high resistance to the passive stretch of a muscle) of the lower extremities. When asked if Resident 163 was getting ROM to fingers and wrists, RA-A said orders had not been received for this and ROM was not being done to the upper extremities. Review of the Occupational Therapy (OT) Evaluation dated 10/3/16 revealed that Resident 163 had a [DIAGNOSES REDACTED]. The evaluation further revealed, Range of motion significantly limited by contractures throughout upper extremity joints and rigidity. The OT then referred to the functional maintenance program (FMP) in the chart for the R[NAME] Review of the personal FMP dated 10/3/16 for Resident 163 revealed the resident was to have ROM to both upper extremities including shoulders, elbows, wrists, fingers and thumbs. On 12/29/16 at 4:35 PM, Unit Manager B was interviewed about Resident 163's restorative program. The Unit Manger confirmed that ROM should have started right after the OT evaluation was completed on 10/3/16. The manager confirmed there was a communication mix up and ROM to the upper extremities had not started until 12/28/16. | 2020-09-01 |
| 5 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2017-01-03 | 329 | D | 0 | 1 | X2RI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D Based on record review and interview, the facility failed to provide non pharmacological interventions prior to the administration of an antianxiety medication and failed to evaluate the effectiveness of the medication after administration for one (Resident 265) of 41 residents sampled. The facility had a census of 109. Findings are: Review of Resident 265's MDS (The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and/or Medicaid-certified long-term care facility.) dated 12/11/16 revealed Resident 265 was cognitively intact with disorganized thinking, had indicators of depressed thoughts or feelings and no behaviors. Resident 265 required assistance to complete tasks of daily living, had occasional pain and had [DIAGNOSES REDACTED]. Review of Resident 265's Care Plan dated 12/20/16 revealed an identified problem of a potential for complications related to the use of antianxiety and antidepressant medication. Interventions included Compliment drug therapies, encourage participation in activities on the unit and therapies. Offer use of holistic cart with music and aroma therapies. Provide a quiet calm atmosphere when able. Review of Resident 265's Active Orders for (MONTH) (YEAR) revealed an order for [REDACTED]. Review of a Work List printed on 1/3/17 from the electronic medical record revealed Resident 265 was administered [MEDICATION NAME] .25 mg (milligrams) on 18 occasions during the month of (MONTH) (YEAR) at various times in the afternoon and evening. Further review of the electronic medical record revealed no documentation regarding what non pharmacological interventions were administered prior to administering the PRN antianxiety and no documentation of whether or not the [MEDICATION NAME] had been effective in treating the anxiety. Interview with Registered Nurse (RN) G on 12/27/16 at 2:30 PM revealed staff had a couple of places they could document both the effectiveness of the medication and the non-pharmacological interventions attempted prior to administration including the Adult Assessment and Interventions. RN G then confirmed that, after reviewing the medical record, RN G was unable to find where any staff had evaluated the effectiveness of the antianxiety after administration. RN G was also unable to find consistent documentation that non pharmacological interventions had been attempted prior to the administration of the [MEDICATION NAME]. Review of the Adult Assessment & Interventions in (MONTH) (YEAR) for Resident 265 revealed Resident 265 was assessed to be anxious, agitated, angry, yelling, crying, restless, and screaming at times. The Assistive Device provided for these symptoms was Antianxiety medication. A non-pharmacological intervention was implemented two times out of the 18 occasions and was documented to be frequent verbal cues/redirection to get along with others and frequent checks. Interview with the Director of Nursing (DON) on 01/03/2017 at 4:22 PM revealed staff should be offering non pharmacological interventions prior to administration and evaluating the effectiveness of thee antianxiety medication once given. | 2020-09-01 |
| 6 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2017-01-03 | 467 | D | 0 | 1 | X2RI11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B3 Based on observations and interview, the facility failed to ensure the ceiling vents were working in 2 resident rooms (Rooms 300 and 427) out of 39 resident rooms. The facility census was 109. Findings are: A) Observation on 1-03-17 at 12:40 PM revealed the ceiling vent in the bathroom of Room 427 was not working. Interview on 1-3-17 at 12:40 with the MS (Maintenance Supervisor) revealed the ceiling vent was closed and required a maintenance staff to open it. The MS confirmed the vent should not have been closed. B) Observation on 1-3-17 at 1:15 PM revealed the ceiling vent in the bathroom of [RM #]0. Interview on 1-3-17 at 1:15 PM with the MS revealed the ceiling vent was open and confirmed it was not working. Interview on 1-3-17 at 2:33 PM with the MS revealed the room ceiling vents were to be checked monthly by the Housekeeping staff and documented on an Environmental Services Inspection Sheet form. Review of the Environmental Service Inspection Sheets revealed Room 427 was last inspected on 12-16-16 and no concerns were documented about the ceiling vent. [RM #]0 was last inspected on 11-11-16 and no concerns were documented about the ceiling vent. | 2020-09-01 |
| 7 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2018-01-30 | 658 | D | 0 | 1 | BRED11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.10A2 Based on observation, record review and interview; the facility failed to provide a nourishment within the facility policy time frame for a short acting insulin. This violation had the potential to affect one resident (Resident 14) out of 5 insulin dependent residents. The census was 105. Findings are: During an observation on 1/18/18, LPN A (Licensed Practical Nurse) administered [MEDICATION NAME] ([MEDICATION NAME]) insulin (a short acting insulin) to Resident 14 at 12:12 PM. Resident 14 went to the dining room and was served lunch at 12:38 PM. An interview on 1/30/18 at 08:30 AM with LPN A revealed that short acting insulin should be given 15-20 minutes before meals. A record review of the policy entitled: medications: [REDACTED]. An interview with the Unit Director confirmed that within 15 minutes of administration of short acting insulin a nourishment should be offered or given to the resident. | 2020-09-01 |
| 8 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 561 | D | 1 | 1 | GLUX11 | > Licensure Reference Number 175 NAC 12-006.05(4) Based on interviews and record reviews, the facility failed to ensure residents bathing preferences were assessed and provided according to the resident's preferences. This failure had the potential to affect two residents, Resident #62 and 102. The facility census was 115. Findings; [NAME] 05/28/19 03:31 PM an interview with Resident #62 revealed that the resident wants 2 showers a week in the evenings, but is only receiving one a week during the day. Record review of MDS (Minimum Data Set, a health status screening and assessment tool used for all residents of long term care nursing facilities dated 4/9/19 revealed a BIMS (Brief interview of mental status) score of 14 (BIMS score ranges from 00. to 15. 13 - 15: cognitively intact. 08 - 12: moderately impaired. 00 - 07: severe impairment , Record review of the residents care plan revealed bathing not addressed on the care plan. Record review of the resident's electronic medical record revealed no documentation related to the resident's choices related to bathing. Record review of Worklist Report Visit task Shower dated from 3/4/19 to 5/31/19 revealed resident to receive 2 showers a week. Week of 3/10/19 received one shower, week of 3/17 received no showers, week of 4/7/19 received one shower, and week of 4/21/19 received one shower. Weeks 5/8/19 through 5/31/19 resident received one shower a week. Three of these showers were given in the evening. Record review of the resident's electronic medical record revealed no documentation related to the resident's choices related to bathing. 06/04/19 04:39 PM DON (Director of Nursing) confirmed resident #62 was only receiving one shower a week and preferences are not documented. B An interview on 05/28/19 at 12:34 PM with Resident 102 who had expressed the preference to have a bath every other day, the resident reported that the facility had a bath schedule for twice a week. An interview on 05/30/19 at 12:08 PM with RN C confirmed that the Resident were placed on the bathing schedule on admission. The facility has a set schedule and the new admissions were added to that, if the resident was unhappy with the schedule then they would be moved to the preferred days. RN reported that they do full showers 2 times a week and partial bed baths daily. An interview on 06/03/19 at 03:47 PM with the Administrator, the Administrator confirmed the facility ask residents at the initial care plan meeting. The Administrator confirmed the facility had offered 2 baths, no more that that per week. Record review of Active orders dated 05/29/19 revealed an Order that Resident 102 was able to shower in the trauma tub scheduled bath days were Tuesdays and Saturdays. Record review of Resident 102's care plan revealed no bathing preferences were documented An interview on 06/03/19 at 05:03 PM with the DON (Director of Nurses) confirmed that the facility did not have documentation of the personal preferences regarding bathing for Resident 102 on admission. The DON confirmed no documentation of bathing preferences in the care plan | 2020-09-01 |
| 9 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 578 | D | 0 | 1 | GLUX11 | Based on record review and interview, the facility failed to ensure that the residents advanced directives were included on resident care plans. This had the potential to affect 6 Residents (Resident #6, 53, 62, 94, 102 and 207). The facility census was 115. Findings; A Record review of St Jane de Chantel LTC (Long Term Care) Team Care Plan dated 5/22/19 for Resident # 6 revealed advanced directives were not documented on the residents care plan. Record review of St Jane de Chantel LTC Team Care Plan dated 4/9/19 for Resident # 53 revealed advanced directives were not documented on the residents care plan. Record review of St Jane de Chantel LTC Team Care Plan dated 4/17/19 for Resident # 62 revealed advanced directives were not documented on the residents care plan. Record review of St Jane de Chantel LTC Team Care Plan dated 5/7/19 for Resident # 94 revealed advanced directives were not documented on the residents care plan. Record review of St Jane de Chantel LTC Team Care Plan dated 5/23/19 for Resident # 207 revealed advanced directives were not documented on the residents care plan. Record review of the Advanced Directives for Patients including Do Not Resuscitate Status policy revealed; no documentation to include advanced directives on the residents care plans. On 05/29/19 at 02:19 PM an interview with the DON (Director of Nursing) confirmed the facility does not include advanced directives on the residents care plans. E. Record review of Resident 102's Advanced Directives revealed the preference for a Full Code Status. Record review of St Jane de Chantel LTC Team Care Plan dated 5/14/19 revealed the Advanced Directives were not documented on the resident's care plan. An interview on 05/29/19 at 02:43 PM with the DON (Director of Nurses) confirmed that the facility had not included Advanced Directives on the care plan. | 2020-09-01 |
| 10 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 623 | D | 0 | 1 | GLUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-0060.5(5) Based on interview and record review, the facility failed to notify the resident's representative of the reason for transfer to the hospital in writing. This affected 2 residents (Residents 58 and 29) of 4 residents reviewed. The facility census was 113. Findings are: [NAME] Record review of Resident 58's History and Physical dated 5/14/19 revealed [DIAGNOSES REDACTED]. Record review of Documentation of Communication/Event dated 5/2/19 revealed the Resident 58 was transferred to the hospital due to a change in vital signs and level of consciousness. The resident's representative was notified at the time of transfer. The documentation revealed an absence of mention that the reason for transfer in writing was given to the resident or resident's representative. Interview on 6/4/19 at 2:17 PM with the DON revealed the facility did not provide the reason for transfer in writing to the resident or resident's representative. B. Record review of Resident 29 face sheet revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Record review of Documentation of Communication / Event dated 12/12/18 revealed that Resident 29 was sent to the hospital for continued swelling, discoloration and pain to the right upper leg. The resident was admitted to the hospital for [MEDICAL CONDITION] (swelling) and pending tests. Interview on 5/29/19 at 3:14 PM with the family confirmed that the resident was discharged to the hospital and stated that no written information related to the reason for discharge was provided at the time of the transfer. Interview on 5/30/19 at 2:53 PM with the facility Administrator confirmed that no written notice of the reason for the transfer was provided to the resident or family at the time of the transfer. | 2020-09-01 |
| 11 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 625 | D | 0 | 1 | GLUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide information regarding bed hold to the resident at the time of transfer. This affected 1 resident (Resident 58) of 4 residents reviewed. The facility census was 113. Record review of Resident 58's History and Physical dated 5/14/19 revealed [DIAGNOSES REDACTED]. Record review of Documentation of Communication/Event dated 5/2/19 revealed the Resident 58 was transferred to the hospital due to a change in vital signs and level of consciousness. The resident's representative was notified at the time of transfer. The documentation revealed an absence of mention that the bed hold policy was given to the resident. Review of Resident's Rights policy dated 8/31/10 revealed the nursing staff, social worker, or admission personnel will ask if the resident wanted a bed hold if the resident would be out of the facility. Interview on 6/4/19 at 2:17 PM with the DON (Director of Nurses) revealed the DON was unable to find Resident 58's completed bed hold form. The DON revealed the bed form was not provided to the resident or completed for Resident 58's transfer to the hospital. | 2020-09-01 |
| 12 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 644 | D | 0 | 1 | GLUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to submit a Pre-Admission Screening and Resident Review (PASARR, an assessment used to help ensure that individuals are not inappropriately placed in nursing homes for long term care) for reevaluation after identification of a new mental health diagnosis. This affected 1 resident (Resident 53) of 1 resident reviewed. The facility census was 113. Findings are: Record review of Nebraska Level I Form PASARR dated 9/13/11 revealed the Resident 53 did not have any serious mental illness, including [MEDICAL CONDITION] Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), under Section 1 - Mental Illness. Record review of History and Physical dated 7/25/14 revealed Resident 53's past medical history included [MEDICAL CONDITION] Disorder. Record review of Resident 53's comprehensive MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1/16/19 revealed the resident did not have a Level II PASARR (evaluation of if the resident needed specialized services). The MDS did note the resident had [MEDICAL CONDITION] Disorder. Record review of Resident 53's care plan dated 4/9/19 revealed the resident was evaluated for PASARR II with a start date of 7/30/18. Interview on 6/4/19 at 1:55 PM with the DON (Director of Nursing) revealed Resident 53 was admitted to the facility with the [DIAGNOSES REDACTED]. Interview on 6/4/19 at 1:56 PM with SW-A (Social Worker) revealed the PASARR form was completed in 2011 and was unable to provide details on why the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. SW-A revealed the resident was a Level I PASARR, and was unable to provide details on why the care plan noted PASARR II. Interview on 6/4/19 at 2:13 PM with the DON revealed the facility did not submit the PASARR for re-evaluation when the [DIAGNOSES REDACTED]. | 2020-09-01 |
| 13 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 693 | D | 0 | 1 | GLUX11 | Licensure Reference Number 175 NAC 12-006.09D6 (1) Based on observation, record review and interview the facility staff failed to ensure the method to check residual (stomach fluids) for placement of a feeding tube was completed according to facility policy for 1 resident (Resident 9) of 4 sampled residents. The facility census was 115. Findings are: An observation on 06/04/19 at 12:00 PM of Nurse LPN H of medication administration for Resident 9 via PEG (Percutaneous Endoscopic Gastrostomy- a tube passed into a residents stomach through the abdominal wall to provide a means for feeding and medication administration when oral intake is inadequate) tube. LPN H checked the PEG tube for proper placement by aspiration of stomach contents with a 60 cc syringe the total amount of stomach contents aspirated was 210cc. Resident 9 had been eating lunch at the time of the aspiration. LPN H disposed of the stomach contents. Record review of the Feeding tube management policy dated 4/16/19 revealed; for Residual Procedures if the gastric residual volume 300 ml or less replace the entire residual volume obtained, Flush with 30 Ml water. Interview on 06/04/19 03:19 PM with the DON confirmed that if the residual with a tube feeding is less than 300 cc the residual is to be replaced not wasted. | 2020-09-01 |
| 14 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 758 | D | 0 | 1 | GLUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure that a [MEDICAL CONDITION] as needed medication did not exceed the required 14 day stop date for 1 (Resident 40) of 6 residents reviewed for unnecessary medication use. The facility census was 115. Findings are: Record review of a facility policy entitled Automatic Stop Orders dated 4/1/14 revealed that PRN (as needed) [MEDICAL CONDITION] (a group of medications that affect behaviors) medications have a 14 day limit. These medications may be renewed for subsequent 14 days if deemed appropriate by the licensed practitioner. Record review of Resident 40's Face sheet showed an admission date of [DATE]. Record review of Resident 40's [DIAGNOSES REDACTED]. Record review of Resident 40's admission Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 3/29/19 identified that resident 40 used a Hypnotic (a medication used to induce sleep) medication 3 times in the look back period for the assessment. Record review of Active orders dated 6/4/19 revealed an order for [REDACTED]. The order included nurse instructions that read: Time frame for administration is limited to 14 days unless a longer time frame is deemed appropriate by the prescribing practitioner. Record review of Resident 40's Medication Administration Records revealed that Resident 40 received the hypnotic medication 4 times in (MONTH) 2019, 7 times in (MONTH) 2019 and 4 times in (MONTH) 2019. Interview on 6/4/19 at 11:23 AM with the Director of Nursing confirmed that the stop date on the hypnotic was past the required 14 day time limit. It should have been stopped after 14 days and reordered as necessary. | 2020-09-01 |
| 15 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 759 | D | 0 | 1 | GLUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D The facility failed to maintain a medication error rate of less than 5 %, which affected 3 residents (Resident 9, 51 100). The medication error rate was 24.14%. The facility census was 115. FINDINGS ARE: [NAME] An Observation on 6/3/19 at 12:05PM of medication administration by LPN (Licensed Practical Nurse) J for Resident 100. LPN J performed hand hygiene, donned gloves, and prepared Guar Gum (fiber supplement) by mixing it with 60 mL (milliliters-a unit of volume) of water. LPN J measured [MEDICATION NAME] (a medication used for [MEDICATION NAME]) 10mL and mixed it with the Guar Gum. LPN J doffed gloves and donned new gloves. LPN J checked the residual (stomach contents) of the PEG tube (Percutaneous Endoscopic Gastrostomy- a tube passed into a residents stomach through the abdominal wall to provide a means for feeding and medication administration when oral intake is inadequate) tube it was zero. LPN J pushed 60cc of water for the flush prior to the medication administration. LPN J administered the commingled medications. LPN J changed gloves. LPN J administered a 15 cc flush. Gloves changed and the tubes were exchanged for enteral feeding. LPN J primed the tubing and administered 237Ml of Pedisure Peptide (a feeding) that was hung for gravity flow. Gloves were changed and LPN J added 30 mL water flush. Gloves were changed and the tubing was removed. Hand Hygiene was performed. B. An observation on 6/3/19 at 12:55PM of medication administration by RN (Registered Nurse) K for Resident 51 revealed RN K measured the medications [MEDICATION NAME] 30m. RN K donned gloves. RN K measured tap water 100mL. RN K checked residual and equaled 60MmL and this was replaced. RN K mixed approximately 30mL of water with the measured medication and drew it into the syringe. No flush was performed by RN K. RN K administered the medication/water mixture by push and the remainder of the water was administered via gravity flow. C. An observation on 6/4/19 at 12:00PM of medication administration by LPN H for Resident 9 revealed RN K did not perform hand hygiene upon entry to the room. LPN H donned gloves and prepared medications Medication [NAME]nochol 25mg (milligrams-a unit of measurement) and [MEDICATION NAME] (a medication given for high blood pressure) 20 mg was crushed, [MEDICATION NAME] was measured 10 mL and [MEDICATION NAME] was measured 30mL. Gloves were changed. No flush was given prior to the medication administration. LPN H checked residual of PEG tube and was 210mL and that was discarded. LPN H mixed the [MEDICATION NAME] 10mL with 30cc water drew it up in the syringe and pushed the medication in the PEG tube. No flush was administered. LPN H drew up [MEDICATION NAME] 30 mL and it was given push through syringe in the PEG tube. No flush was administered. The combination of the crushed medications [NAME]nochol 25mg and [MEDICATION NAME] 20mg was mixed with 20mL of water and administered by LPN H per push via PEG tube. LPN H administered 30mL water flush per push via PEG tube. Gloves were changed and eye drops were administered. LPN H doffed gloves and hand sanitizer was used. Record review of the Feeding tube management Policy dated 4/1/16 revealed that Daily use for Feeding and Medication Administration Procedure 1. Any time the tube is utilized intermittently or disconnected from a feeding pump it is vital to flush the tube with a minimum of 30 mL warm tap water. An interview on 06/04/19 at 04:43 PM with the DON (Director of Nurses) confirmed that the facility did not have a physician order [REDACTED]. The DON confirmed that prior to the use of a feeding tube the tube should be flushed. Record review of Resident 9 and Resident 100 Active Orders document dated 6/4/19 revealed that the residents did not have an order for [REDACTED].> | 2020-09-01 |
| 16 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 880 | E | 0 | 1 | GLUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.17D Based on observation interview and record review the facility failed to ensure that gloving and hand hygiene was performed when indicated to prevent the potential for cross contamination during treatments for 5 resident (Residents 42,101, 82, 84, 53) an during medication administration for 2 residents (Residents 9 and 51) of 23 sampled residents. The facility census was 115. Findings are: [NAME] An observation on 05/30/19 at 10:30 AM of wound care for Resident 82 revealed; on entry to room, RN I performed hand hygiene by using the hand sanitizer and donned gloves, RN I removed the packing from the wound and doffed gloves and without hand hygiene donned gloves. RN I used soap and water on a wash cloth to cleanse the wound. RN I rinsed the wound with wound cleanser. RN I changed doffed gloves and without hand hygiene and donned gloves. RN I applied skin prep ([MEDICATION NAME] no sting) to the skin surrounding the wound and applied gauze soaked with Vashe (a wound solution that has a skin friendly PH) into the wound. RN I doffed gloves and without hand hygiene donned gloves. RN I applied 4x4 Vaseline gauze applied and 4x4 followed by an ABD (Abdominal Pad thick dressing used for draining wounds) RN I doffed gloves and without hand hygiene donned gloves. RN I removed the dry Therabond (a wet to dry dressing used to help debride wounds) from the wound, cleansed the wound with soap and water, no glove change or hand hygiene was performed, a new piece of Therabond was cut to size, moistened and placed over wound. RN I doffed gloves and without hand hygiene donned gloves. RN I assisted with Resident 82's repositioning. RN I replaced supplies, cleansed table with wipes (Sani). RN I used hand sanitizer was used. B. An observation on 5/30/19 at 10:50 AM of wound care for Resident 101 performed by LPN (Licensed Practical Nurse) J of wound care for Resident 101. LPN J used hand sanitizer on entry to the room. LPN J donned gloves, had wet wash cloths. LPN J removed the dressing from the buttock wounds. LPN doffed gloves and without hand hygiene donned gloves. LPN J patted the wound with soap and water wet cloths. LPN doffed gloves and without hand hygiene donned gloves. The new dressings were prepared by soaking the Surgifoam (an absorbable gelatin sponge used for bleeding wounds) soaked with triple antibiotic ointment. LPN doffed gloves and without hand hygiene donned gloves. LPN J applied ointment and the soaked Surgifoam to the wounds. LPN J doffed gloves and without hand hygiene donned gloves and applied a third soaked Surgifoam sponge and moistened gauze was to the coccyx area. LPN doffed gloves and without hand hygiene donned gloves. LPN J assisted with dressing Resident 101. LPN J doffed gloves and used hand sanitizer. C. An observation on 6/3/19 at 12:55PM of medication administration by RN K for Resident 51 revealed hand hygiene was not performed prior to the medication administration. RN K measured the medications [MEDICATION NAME] 30mL (Milliliters metric system used to measure medications). RN K donned gloves. RN K measured tap water 100mL. RN K checked residual and equaled 60MmL and this was replaced. RN K mixed approximately 30mL of water with the measured medication and drew it into the syringe. No flush was performed by RN K. RN K administered the medication/water mixture by push and the remainder of the water was administered via gravity flow. D. An observation on 6/4/19 at 12:00PM of medication administration by LPN H revealed hand hygiene was not performed prior to entry to the room for medication administration. Record review of infection prevention Hand Hygiene policy dated with review date of 4/19/19 revealed; when hands were visibly soiled or contaminated with protienaceous material or visibly soiled with blood or other body fluids wash hands with soap and water. Step: 1) Vigorously lather hands with soap and rub for 15 seconds under a moderate stream of running water at a comfortable water temperature. 2) Rinse hands thoroughly, hold hands down lower than wrists, do not touch the inside of the sink 3) Dry hands thoroughly with paper towel and then turn off faucets with those towels. 4) Discard towels into the trash do not dry hands with same towel used to turn off sink. If hands are not visibly soiled alcohol based hand rub may be used for routinely decontaminating hands using the following process 1) Apply enough product to thoroughly wet both hands to the palm of one hand. 2) Rub hands together covering all surfaces of hands and fingers until hands are dry. Use alcohol based hand rub or wash hands: 1) When coming on duty. 2) Before performing invasive procedures. 3) Before preparing or handling medications, 4) Before performing dressing care, 5) Before touching preparing or serving food, 6) Before and after having contact with patient or patient environment. 7) After contact with patients on isolation, 8) After handling used dressing, urinals, bedpans catheters, contaminated tissues, linen, or patient care item. 9) After offering incontinence care, Foley care. 10) Before and after manipulation of feeding tubes. 11) Before and after manipulation of IV sites even when wearing gloves. 12) Before and after empty Foley catheter or tubing even when wearing gloves. 13) After contact with blood, urine, feces, oral secretions, mucous membranes or broken skin, 14) After handling items potentially contaminated with any patient blood excretions or secretions. 15) After personal body function use of toilet, blowing nose, wiping nose, smoking or combing hair. 16) Before and after eating. 17) Upon completion of the day. E. Record review of Resident 53's physician progress notes [REDACTED]. Record review of Resident 53's Transfer/Discharge/Active Orders dated 5/29/19 revealed [MEDICAL CONDITION] (a surgically created opening through the neck into the windpipe with a tube place to provide an airway and to remove secretions from the lungs) care was ordered to be done 2 times per day. Observation on 6/3/19 at 9:45 AM of RN-B (Registered Nurse) and RN-C providing [MEDICAL CONDITION] care for Resident 53 revealed RN-B and RN-C used hand sanitizer and applied masks and gloves. RN-B removed the dressing from the [MEDICAL CONDITION] and discarded, then changed gloves without performing hand hygiene. RN-B cleaned around the edge of the [MEDICAL CONDITION] using swab sticks, discarding after use. RN-B changed gloves without performing hand hygiene. RN-B and RN-C removed the [MEDICAL CONDITION] ties (a band that goes around the neck to hold the [MEDICAL CONDITION] in place) and RN-C held the [MEDICAL CONDITION] while RN-B washed and dried the resident's neck. RN-B got the new [MEDICAL CONDITION] tie and RN-B and RN-C secured the [MEDICAL CONDITION]. RN-B changed gloves without performing hand hygiene and applied the new [MEDICAL CONDITION] dressing, then removed gloves and performed hand hygiene. RN-B offered suctioning (removes thick mucus and secretions from the trachea), but Resident 53 refused. F. Review of Resident 42's Pressure Ulcer/Wound record dated 5/29/19 revealed the resident had a closed stage 3 pressure injury (full thickness skin loss where subcutaneous fat may be visible but bone, tendon, or muscle are not exposed) to the right ankle, a closed stage 2 pressure injury (partial thickness loss of skin presenting as a shallow open ulcer with a red/pink wound bed), and unstageable deep tissue injuries (purple area of discolored intact skin due to damage of underlying soft tissue) to the left 5th toe, back of the right ankle, and back of the left ankle. The resident also had a partial thickness (loss of skin presenting as a shallow open ulcer with a red/pink wound bed) wound to the right shin. The resident also had a surgical incision to the right buttock. Record review of Resident 42's Transfer/Discharge/Active Orders dated 5/29/19 revealed the resident received Xeroform (dressing used to maintain a moist wound environment) and [MEDICATION NAME] (absorbent foam dressing) to the wounds on the back of the right and left ankles, on the left foot, and on the right shin. The resident also received Nutrashield lotion to the intact incision line and [MEDICATION NAME] AG (dressing impregnated with silver) to the small open area near the perineum. Observation on 05/30/19 at 11:01 AM of RN-E completing wound care for Resident 42 revealed RN-E cleaned the scissors used for cutting the dressings, performed hand hygiene, and gathered supplies for the dressing change. RN-E applied gloves and pulled the resident's blankets back and removed the prafo boot (boot that alleviates pressure from the heel) from the resident's left foot. RN-E removed the dressing from the back of the resident's ankle. RN-E removed gloves, used hand sanitizer, and applied new gloves. RN-E cleansed the area with a wash rag, cut a piece of Xeroform to the size of the wound and applied to the wound bed, and covered with a [MEDICATION NAME] dressing. RN-E removed the dressing from the resident's left foot, cleansed the area with a wash rag, cut a piece of Xeroform to the size of the wound, then applied to the wound and covered with a [MEDICATION NAME] dressing. RN-E changed gloves without performing hand hygiene, inspected the resident's heels and applied Nutrashield lotion to the foot. RN-E reapplied the resident's prafo boot and changed gloves without performing hand hygiene. RN-E removed the prafo boot from the resident's right foot and removed the dressing front the resident's right shin. RN-E cleansed the wound and changed gloves without performing hand hygiene. RN-E cut Xeroform to the size of the wound and applied, then covered with a [MEDICATION NAME] dressing. RN-E changed gloves without performing hand hygiene and lifted the dressing to the right ankle, observed the wound, then secured the same dressing back into place. RN-E then secured the prafo boot back onto the resident's foot. RN-E changed gloves without performing hand hygiene, and cleaned the bandage scissors. NA-F (Nurse Aide) entered the room and assisted RN-E with repositioning the resident to the side. RN-E removed the dressing from the surgical incision on the resident's buttock and cleansed the area with a washrag. RN-E applied Nutrashield lotion to the incision, cut a piece of [MEDICATION NAME] AG to size and applied it to the open area at the end of the incision. RN-E and NA-F then continued to give the resident a bed bath. [NAME] Review of Resident 84's Pressure Ulcer/Wound report dated 5/29/19 revealed the resident had an pressure injury to the right hip, a closed stage 2 pressure injury to the sacrococcyx (bottom of the spine to the tailbone), and a stage 3 pressure injury to the right ankle. Resident 84 also had wounds due to skin graft surgery to the right thigh, right hip, and left thigh. Review of Resident 84's Transfer/Discharge/Active Orders dated 5/29/19 revealed the resident received Xeroform secured with gauze to the right thigh, Xeroform covered with [MEDICATION NAME] to skin treated with skin prep swabs to the right hip, right ankle, and left thigh, and [MEDICATION NAME] and skin prep swabs to the coccyx. Observation on 5/30/19 at 2:13 PM of LPN-G (Licensed Practical Nurse) and RN-D performing Resident 84's wound care revealed LPN-G performed hand hygiene and gathered the supplies needed for the dressing change. LPN-G applied gloves and removed the resident's right prafo boot. LPN-G removed the dressing to the resident's right ankle, changed gloves without performing hand hygiene, and cleansed the wound. LPN-G prepped the skin surrounding the wound with a skin prep swab, changed gloves without performing hand hygiene, and cut Xeroform to fit the wound and applied it, then covered the wound with a [MEDICATION NAME] dressing. LPN-G changed gloves without performing hand hygiene and removed the dressings from the resident's right hip. LPN-G changed gloves without performing hand hygiene and cleansed the wound. LPN-G swabbed the skin surrounding the wound with skin prep and changed gloves without performing hand hygiene. LPN-G cut Xeroform to fit the lower right hip wound, applied to the wound, then covered both wounds with [MEDICATION NAME] dressings. LPN-G changed gloves without performing hand hygiene. The resident repositioned in bed and LPN-G removed the dressing from the resident's coccyx. LPN-G changed gloves without performing hand hygiene, cleansed the wound then changed gloves without performing hand hygiene. LPN-G applied a [MEDICATION NAME] dressing to the wound, changed gloves without performing hand hygiene, and secured the resident's brief. LPN-G and RN-D assisted the resident with repositioning, then LPN-G removed the wrap from the resident's left thigh, and changed gloves without performing hand hygiene. LPN-G cleansed the wound and prepped the skin surrounding the wound with the skin prep swab. LPN-G then changed gloves without performing hand hygiene, cut Xeroform gauze to fit the size of the wound, applied the Xeroform to the wound and covered the wound with a [MEDICATION NAME] border dressing. LPN-G changed gloves without performing hand hygiene, wrapped the resident's thigh with gauze, and assisted the resident with repositioning. LPN-G then removed gloves and used hand sanitizer. Review of Standard Precautions Guide dated 3/2018 revealed hand hygiene was required after glove removal, and gloves changes were required moving from a dirty to a clean task. Interview on 6/3/19 at 12:29 PM with RN-D revealed the expectation was that staff would use hand sanitizer or wash hands between glove changes. | 2020-09-01 |
| 17 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 926 | E | 0 | 1 | GLUX11 | Based on observation, record review and interview, the facility failed to ensure there was a policy in place to protect smoking residents from accidents related to smoking. This failure had the potential to affect 6 smoking residents (Resident 8, 23, 27, 62, 95, and 155). The facility census was 115. Findings On 5/29/19 at 9:30 AM an observation revealed an unknown resident exit the West St Jane's entrance un accompanied and wheel self down the sidewalk next to the street smoking. On 05/30/19 06:50 AM an observation revealed Resident #155 exit the front door un accompanied and wheel self to the southwest parking lot and proceed to smoke On 06/04/19 10:05 AM an interview with the ADM (Administrator) confirmed the policy; Tobacco-Free Campus Areas, dated 9/17/2010 was a[NAME]campus smoking policy and did not specifically address St[NAME]residents. Record review of facility policy Tobacco-Free Campus Areas dated 9/17/10 revealed no documentation on how the facility will assess or protect residents that smoke from accidents related to smoking. On 05/30/19 at 3:00 PM the DON (Director of Nursing) provided a list of smoking residents that included; Residents #8, 23, 27, 62, 95 and 155. | 2020-09-01 |
| 18 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-01-23 | 584 | E | 0 | 1 | AD1911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER NAC 175 12-006.18 [NAME] Based on observation and interview, the facility staff failed to ensure food was removed from trays and placed in front of residents in a homelike manner for 119 residents that ate food in the facility dining rooms. The facility census was 232. The findings are: Observation of breakfast meal on 1/14/19 in Miracle Garden dining room revealed that residents were served their meal on trays. All liquids were served in plastic glasses. Observation of breakfast meal on 1/15/19 in Miracle Garden dining room revealed that residents were served their meal on trays. Observation of breakfast meal on 1/22/19 in Miracle Garden dining room revealed that residents were served their meal in Styrofoam dishes on a tray. Observation of breakfast meal on 1/23/19 in [MEDICATION NAME] dining room revealed that residents were served their meal in Styrofoam dishes on a tray. Interview conducted with C.N.[NAME] C on 1/15/19 at 10:15 AM revealed no knowledge of why residents were served on trays in Miracle Garden dining room. Interview conducted with RN D on 1/23/19 at 10:15 am revealed no knowledge of why meals are served on trays on some units and not on others. Interview conducted on 1/22/19 at 08:45 AM with Kitchen Service Worker [NAME] revealed the reason residents were served on Styrofoam was because the kitchen was short staffed and there was 2 units to cover. Interview conducted with Dietary Manager on 1/23/19 at 11:00 AM revealed that how the meal is served on the units is left up to the Kitchen Service Worker assigned to the unit. B. Observation on 1/14/19 at 12:20 PM in the Willow Springs neighborhood in the facility revealed that, as residents were being served lunch, the staff left the plates and glasses on the tray and placed the tray in front of the residents. Observation revealed that the residents were served food on Styrofoam plates and drinks in flexible plastic glasses in this area. Observation on 01/15/19 at 08:58 AM and on 01/16/19 at 08:55 AM and 01/23/19 at 09:28 AM in the Willow Springs neighborhood revealed that, as residents were being served breakfast, the staff left the plates and glasses on the tray and placed the tray in front of the residents. Observation revealed that the residents were served food on Styrofoam plates and drinks in flexible plastic glasses. Interview on 01/15/19 at 09:01 AM with FSW F confirmed that plates were left on trays in front of the residents. FSW F stated that there were not enough real plates so the food was served on Styrofoam plates and plastic glasses were used. Observation on 01/23/19 at 08:25 AM in the Field of Dreams unit revealed that residents were served fluids in flexible plastic glasses. Interview on 01/23/19 at 08:25 AM with RN G, when asked why residents were served liquids in plastic cups, confirmed that was RN G did not know the reason why. Interview on 01/23/19 at 09:28 AM with RN H on the Willow Springs unit, when asked why residents were served food on trays, confirmed that was RN H did not know the reason why. Interview on 01/23/19 at 10:26 AM with the Director of Nursing (DON) confirmed that it was not homelike to keep food on the trays when served or to serve with Styrofoam plates or plastic glasses. C. Observation on 01/14/19 at 12:12 PM on Wind Song Way at the lunch meal all residents received lunch trays delivered on a tray. Dishes were not removed from the trays. Trays were placed in front of residents. Liquids were served in disposable plastic cups. Coffee was served in regular cups. Observation on 01/15/19 at 09:13 AM of breakfast meal service on Wind Song Way revealed breakfast trays were delivered to the residents on trays and plates were not removed from the trays. Plastic disposable glasses were used. Interview on 1/23/2019 at 10:30 AM with Nursing Assistant (NA)-A revealed all resident's receive cold fluids are served in disposable cups. NA-A is not aware of why that is done and has asked the question and did not get an answer why some units use them and others do not. Interview on 1/23/2019 at 10:45 AM with the RN-B revealed receiving food on trays is not homelike. | 2020-09-01 |
| 19 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-01-23 | 657 | D | 0 | 1 | AD1911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, facility failed to ensure care plans were updated with resident individualized preferences for activities for 4 residents (Residents 226, 195,136, 79). Facility census was 232. Findings are: Resident 79 On 01/21/19 a record review of annual MDS (Minimum Data Summary) (part of the federally mandated process for clinical assessment of all residents) dated 2/16/18 revealed Resident 79 likes were completed by staff and include having family or friend involved in discussions about care, listening to music, being around animals such as pets, doing things in group of people, doing favorite activity, and going outside weather permitting. On 01/22/19 a record review of Recreation Initial Assessment, Past and Present Leisure Interests, Activity List Quick Reference, dated 2/25/18 for Resident 79, revealed a current interest in small group dining out, holiday celebrations, drive/outings, and individual watching movies, listening to music, watching TV, getting outside, and pets. On 01/22/19 a record review of Care Plan for Resident 79 revealed goals of attending social/entertainment groups off neighborhood monthly, participating in activities such as music groups sensory stimulation or pet therapy monthly and attend at least one community outing of choice in next 90 days. Interventions are invite resident to activity and escort, encourage participation in activities of choice, provide socially stimulating activities, providing pet therapy, invite on outings, provide choices, hang outing slip in room as a reminder of day/time of community outing. Resident 136 On 01/21/19 a record review of annual MDS dated [DATE] for Resident 136 revealed listening to music as very important, keeping up with news as somewhat important, and to do/attend favorite activities as somewhat important. 01/22/19 12:14 PM Record review of Recreation Annual assessment dated [DATE] for Resident 136 revealed resident has a current interest in individual keeping up with current events, socializing, listening to music, watching the new, talk radio (listening), walking and pets. A current interest in small group shopping, dining out, drive/outings, listening to music, and current interest in large group shopping, dining out and listening to music. On 1/21/19 a record review of Care Plans for Resident 136 revealed goals are to participate in programs such as outdoor groups , music groups and sensory stimulation at least 3 times in next 90 days, to attend an outing 1 time in next 90 days, she will interact at least 3/12 times during 1:1's with TR staff in next 90 days. Interventions include provide opportunity for resident to visit courtyard. Invite to outdoor groups. Invite and escort resident to group activity and monitor responses, provide diversional activities for resident upon request, read calendar to resident and have resident choose group to attend, resident enjoys opera music, provide choices for community outings, announce presence when coming into room, and provide sensory stimulation. Resident #195 On 01/22/19 a record review of Recreation Annual Assessment, Past and Present Leisure Interests, Activity List Quick Reference, dated 12/27/18 for Resident 195, revealed current interest of in books/mags/newspapers,socializing, watching TV, talk radio, walking, getting outside, relaxation, and pets for individual, 1/1 and small groups. On 1/22/19 a record review of Care Plan for Resident 195 revealed interventions of offer resident the choice of community outings, offer transportation to and from activities, provide socially stimulating activities. Resident 226 On 01/17/19 a record review of annual MDS dated [DATE] for Resident 226, revealed a staff assessment of daily an activity preferences as family or significant other involved in care discussions, listening to music, doing things in a group of people, participating in favorite activities and spending time outdoors as checked for important. On 01/22/19 a record review of Recreation Annual Assessment, Past and Present Leisure Interests, Activity List Quick Reverence, dated 12/11/18, for Resident 226, revealed a current interest in individual socializing, dining out, holiday celebrations, and drive/outing, as well as individual watching movies, listening to music, and watching sports, and individual walking, bowling, and getting outside, and individual pets and a current interest in small group activities as dining out, holiday celebrations, and drive/outing. On 1/22/19 a record review of Care Plan revealed goals to increase his socialization, resident will attend activities with a social component monthly for next 90 days, resident will participate in programs such as music performances and pet therapy monthly in next 90 days. Interventions are to invite resident to activity and escort, provide pet therapy, provide sensory stimulation, invite on outings, provide choices, hang outing slip in room as a reminder of day/time of community outing and to monitor for future recreational interests and is to attend at least one community outing of choice during the next 90 days. On 01/23/19 at 02:10 PM an interview with the DON, who confirmed the care plans were not individualized. | 2020-09-01 |
| 20 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-01-23 | 661 | D | 0 | 1 | AD1911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, facility failed to develop a discharge summary for Resident 234 of 3 residents sampled. The facility census was 232. Findings are: Review of Resident 234 closed medical record revealed Resident 234 was admitted on [DATE] from the hospital for rehabilitation. Resident 234's condition improved during the stay and Resident 234 was discharged home with home health care to assist on 10/29/2018. Review of Resident 234's medical record revealed no discharge summary. Review of Resident 234's Home Health Face to Face Encounter form dated 10/26/2018 revealed Resident 234 had the following: - Diagnosis: [REDACTED]. - Services needed through home health. - No recapitulation (summary) of Resident 234's progress during the admission addressing the required information from the Interdisciplinary Team. Interview on 01/23/19 at 8:43 AM with the Director of Nursing (DON) revealed no discharge summary with a recapitulation of residents stay is completed. Short term stay rehabilitation residents have discharge summary of therapy and ongoing needs. The physician completes a summary for Home health needs titled Home Health Face to Face Encounter Form. No other discharge summary is completed. | 2020-09-01 |
| 21 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-01-23 | 802 | F | 1 | 1 | AD1911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04D Based on observation, interview and record review, the facility staff failed to ensure that meals were served on time. This had the potential to affect 228 resident served food from the kitchen. The findings are: [NAME] Review of Buffet Meal Service Long Term Care meal times dated 11/8/2018 revealed that Miracle Gardens Unit breakfast time of 7:20 AM - 8:00 AM. Safe Harbor Unit breakfast time of 8:00 AM-8:30 AM and [MEDICATION NAME] Unit breakfast time 7:50 AM - 8:30 AM. Observation on 1/15/19 on Safe Harbor breakfast was started at 08:30 AM. Observation on 1/22/2019 on Miracle Gardens Unit of breakfast was stared at 08:45 AM. Observation on 1/23/2019 on [MEDICATION NAME] Unit of breakfast being was started at 08:40 AM. Interview conducted with the Dietary Manager on 1/23/19 at 1:50 PM revealed that staffing for the kitchen included 10 food service workers, 4 Cooks, 1 pot and pan person, a youth center employee and a dish area worker. Review of dietary employee daily assignments revealed that on 1/15/19 there were 7 food service workers resulting in 3 food service workers covering 2 units. Review of dietary employee daily assignments revealed that on 1/22/19 there were 7 food service workers resulting in 3 food service workers covering 2 units. Review of dietary employee daily assignments for 1/23/19 revealed there were 5 food service workers resulting in each food service worker covering 2 units. Interview conducted with the Dietary Manager on 1/23/19 at 11:00 AM confirmed the kitchen was short staffed. B. Record review of Meal service times for Long Term Care revealed the following dining times: Willow Springs: 8:15, 12:10 and 5 PM Via [NAME]: 8 am, 12:10 and 5 PM Field of Dreams: 7:40 AM, 12:00 PM and 4:50 PM Observation on 1/14/19 at 12:20 PM in the Willow Springs neighborhood in the facility revealed that meal service did not start until 12:40 PM, 30 minutes later then the scheduled meal time. Observation on 01/15/19 at 08:45 AM in the Via [NAME] neighborhood revealed that meal service did not start until 8:45 AM, 45 minutes later then the scheduled meal time. Observation on 01/15/19 at 08:58 AM in the Willow Springs neighborhood revealed that meal service did not start until 8:50 AM, 35 minutes later then the scheduled meal time. Interview on 1/15/19 between 1:58 and 2:20 PM during the Resident Council meeting revealed a total of 7 alert and oriented residents attended the meeting. Several anonymous residents voiced the concern that meals are often served late which resulted in lukewarm food. The residents stated that this was unacceptable. Observation on 01/16/19 at 8:40 AM in the Via [NAME] neighborhood revealed that meal service did not start until 8:40 AM, 40 minutes later then the scheduled meal time. Observation on 01/16/19 at 08:55 AM in the Willow Springs neighborhood revealed that meal service did not start until 8:55 AM, 40 minutes later then the scheduled meal time. Observation on 01/23/19 at 08:20 AM in the Field of Dreams neighborhood revealed that meal service did not start until 8:20 AM, 40 minutes later then the scheduled meal time. Observation on 01/23/19 at 09:10 AM in the Willow Springs neighborhood revealed that meal service did not start until 9:10 AM, 55 minutes later then the scheduled meal time. Interview on 01/23/19 at 09:28 AM with RN H confirmed that meal service was late on that day due to kitchen staff called in due to the weather. Interview on 01/23/19 at 10:26 AM with the DON confirmed that the dining service times were later then the expected time frames for service and that this was due to staffing shortages in the dietary department. The DON confirmed that this had the potential to result in cold food and medication administration time frame issues. Interview on 01/23/19 at 11:07 AM with the DON confirmed that 21 residents on the Field of Dreams unit ate meals in the dining area, 33 residents on the Willow Springs unit ate meals in the dining area and 15 residents on the Villa [NAME] unit ate meals in the dining area. C. Observation on 01/15/19 at 8:30 AM revealed the kitchen service cart arrived in the dining area and prepared to serve the breakfast meal. At 9:13 AM the breakfast meal service on Wind Song Way was started to be delivered to the resident's seated in the dining room. The last resident tray was served at 10:00 AM. Review of the facility document dated 11/8/2018 titled Meal Service Times Long Term Care revealed meal service on Wind song Way for Breakfast is scheduled to begin at 7:55 AM. Interview on 01/23/19 at 3:09 PM with the Assistant Director of Nursing (ADON) revealed 4 residents are NPO (No oral intake) and do not eat food from the facility kitchen. | 2020-09-01 |
| 22 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2018-03-15 | 580 | D | 1 | 0 | KRL611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC12-006.04C3a(6) Based on interviews and record reviews, the facility failed to notify the resident's representative related to a transfer to the emergency room for 1 resident (Resident 3) of 5 residents sampled. The facility staff identified the census as 231. The findings are: A review of Resident 3's Care Plan dated 2-16-18 revealed that Resident 3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Resident 3's Nurses Notes dated 2-22-18 at 10:25 AM revealed that Resident 3 was unable to put weight on their left leg when working with therapy. An order was obtained to get an x-ray of the resident's left leg. A review of Resident 3's Nurses Notes dated 2-22-18 at 2:40 PM revealed that the medical practitioner was notified of the x-ray results and an order was obtained to send the resident to the emergency room . A review of Resident 3's Nurses Notes dated 2-22-18 at 2:45 PM revealed that the resident left the facility by ambulance to the emergency room with a nursing assistant escort. A review of Resident 3's Nurses Notes dated 2-22-18 at 7:00 PM revealed that the facility received a call from the emergency room notifying them that the resident was admitted to the hospital. The House Supervisor was notified and transportation was notified to go to the hospital and pick up the nursing assistant that had escorted the resident. A voicemail was left for the resident's representative to call the facility. An interview conducted on 3-15-18 at 12:01 PM with Registered Nurse (RN) B confirmed that Resident 3's representative was not notified when the resident was sent to the emergency roiagnom on [DATE] and should have been notified. An interview conducted 3-15-18 at 12:52 PM with the Assistant Director of Nursing revealed that the resident representative should be notified of transfers to the emergency room prior to the resident going to the emergency room . A review of the facility's Notification of Resident Condition Change/Room Change policy dated 2/06 revealed the following: Policy: In the event of an accident, acute medical emergency or significant change in the resident's condition or room change, the resident's family or legal guardian and the House Supervisor will be notified by the licensed nurse on duty. | 2020-09-01 |
| 23 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2018-03-15 | 689 | D | 1 | 0 | KRL611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure reference: 175 NAC 12-00.09D7b Based on observation, interview, and record review, the facility failed to evaluate falls for potential causal factors and implement interventions to prevent reoccurrence for 2 (Residents 2 and 5) of 5 sampled residents. The facility had a total census of 231 residents. Findings are: [NAME] Resident 5 was admitted to the facility on [DATE]. A review of Resident 5's care plan revealed a [DIAGNOSES REDACTED]. Observations on 3/15/18 at 8:43 AM revealed Resident 5 being assisted to transfer from recliner to wheelchair by Nurse Aide A with use of a gait belt and walker. A note attached to Resident 5's closet door reminded Resident 5 to use the call light. Resident 5's Care Plan included a problem dated of self care deficit/high risk for falls dated 1/9/18. The care plan listed the following interventions for falls: -Call light within reach. Check frequently and anticipate all needs. 15 minute safety checks or one to one supervision as needed for safety. -Resident 5 is at high risk for falls. Ensure oxygen tubing isn't a trip hazard. Assist of one for all mobility. -Fall 1/20/18 no injuries -Fall 1/25/18 no apparent injuries -Fall 2/8/18 no apparent injuries -Fall 2/21/18 no injuries noted -Fall 2/25/18 abrasion to right buttock A review of Fall Risk assessment dated [DATE] identified Resident 5 at a high risk for falling. A review of Resident 5's Nurses Notes revealed the following falls: -2/25/18 7:50 AM Resident noted to be in sitting position next chair with table partially tipped over. Resident 5 reported Resident 5 was going to get clothes. Resident had abrasion to lower buttock. Notes taped to Resident's closet to remind to ask for help. -2/21/18 9:15 PM Resident 5 observed sitting on floor in room on bottom. Resident 5 reported feet slipped out in front of Resident 5. No injuries noted. Resident encouraged to use call light. -2/8/18 7:30 AM Resident 5 slid out of recliner chair at 6:45 AM. No apparent injuries. -1/26/18 11:25 PM Resident 5 observed on the floor at 11:10 PM. Resident 5 had apparently got out of bed and slid. -1/20/18 1:45 AM Resident 5 sitting on floor next to chair. Resident 5 reported trying to get the cord that goes in my nose off the floor A review of falls questionnaire dated 1/20/18 for Resident 5 listed no recommendations for prevention of the fall. The falls questionnaires for Resident 5 dated 1/25/18, 2/8/18, and 2/25/18 all listed use call light as the recommendation for prevention of the fall. A review of Therapy Order Request Form for Resident 5 revealed order for physical and occupational therapy had been requested on 2/26/18. Order for physical and occupational therapy was signed on 3/9/18. In an interview on 3/15/19 at 12:16 PM, Physical Therapist C reported that an order for [REDACTED]. In an interview on 3/15/18 at 11:59 AM, Registered Nurse D reported the fall questionnaire is used to track falls and to monitor to ensure new interventions are put in place. Registered Nurse D reported that Registered Nurse D has not reviewed Resident 5's 2/2018 as Registered Nurse D just took over the unit. Registered Nurse D confirmed new interventions should have put in place for fall prevention. B. A review of Resident 2's Care Plan dated 3-21-17 revealed that Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's Fall Tracking Log revealed that the resident had 27 falls since 12-3-17. The falls occurred on 12-3-17, 12-9-17, 12-21-17, 12-27-17, 12-30-17, 1-2-18, 1-3-18, 1-5-18, 1-31-18, 2-1-18, 3 falls on 2-6-18, 2-13-18, 2-14-18, 2 falls on 2-16-18, 2-18-18, 2-20-18, 2-24-18, 2 falls on 2-26-18, 2-27-18, 2-28-18, 3-2-18, and 2 falls on 3-4-18. A review of Resident 2's Nurses Notes dated 12-3-17 revealed that the resident had fallen in the bathroom and sustained a laceration to their forehead. The resident was sent to the emergency room where the resident received staples to close the laceration and was admitted to the hospital for observation. A review of Resident 2's Care Plan dated 3-21-17 revealed the following fall events were documented on the care plan: 12-9-17, 12-27-17, 12-30-17, 1-2-18, 1-3-18, 1-31-18, 2-12-18, 2-13-18, 2-14-18, 2-18-18, 2-20-18, 2-24-18, 2-26-18, 2-27-18, and 3-4-18. There were no new interventions put in place with the fall events. The fall events for 1-2-18 and 2-20-18 revealed that the resident continued on 15 minute checks. An interview conducted on 3-15-18 at 11:05 with Registered Nurse (RN) B revealed that the 15 minute checks for Resident 2 were not being used to prevent falls and that the checks were mostly for night time when the resident was sleeping. RN B reported that the nursing staff filled out fall questionnaires for each fall, but that RN B disposed of the questionnaires once they had processed the data. An interview conducted on 3-15-18 at 12:56 with RN B revealed that when a resident falls, the facility tracks the falls and interventions using the Care Plan. RN B reported that the Care Plan was read after each fall and the current interventions were reviewed to see what was in place at the time of the fall. The new interventions were then written on the care plan. RN B confirmed there were no new interventions on Resident 2's Care Plan for falls. | 2020-09-01 |
| 24 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-08-01 | 689 | E | 1 | 0 | RZY811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview; the facility staff failed to ensure courtyard gates were secured to prevent potential elopement. The facility staff identified 29 residents who were cognitively impaired and were self mobile. The facility staff identified a census of 224. Findings are: Record review of Resident 1's Comprehensive Care Plan (CCP) printed on 6-07-2019 revealed Resident 1 had the [DIAGNOSES REDACTED]. One of the goals identified for Resident 1 was Resident 1 would not leave the facility grounds without an escort. Record review of a investigation report dated 7-30-2019 revealed Resident 1 had eloped from the courtyard. Record review of a Security Incident Report (SIR) dated 7-30-2019 with a time of 7:53 AM revealed an unknown individual was seen on video walking past the south courtyard gate, According to the (SIR) Resident 1 and the unknown individual were seen conversing and then the unknown individual opened the gate and allowed Resident 1 to leave the court yard unsupervised. Record review of a SIR dated 7-30-2019 with a time of 8:10 AM revealed a temporary pad lock was placed on the South exit gate from the courtyard and at 12:35 PM a new combination lock was placed onto the south exit gate. Observation with Registered Nurse (RN) A on 8-01-2019 revealed the courtyard had 3 exit gates with locks on them. During the observation, the Compliance Offer (CO) of the facility joined the observations of the courtyard. Further observations revealed Master Gardner's (MG) entered the courtyard through the south gate of the courtyard by dialing the code on the combination lock. On 8-01-2019 at 9:10 AM an interview was conducted with MG D and MG E. During the interview MG D and MG [NAME] reported the lock to the south courtyard gate was missing on 7-27-2019. Both, MG D and MG [NAME] reported the missing lock to the south courtyard gate to the security guards. On 8-01-2019 at 10:55 AM an interview was conducted with Chief of Security (COS). During the interview COS reported that security staff did not physically check any of the courtyard gates. The COS further reported being informed the MG's had informed security on 7-27-2019. The COS confirmed the south courtyard gate had been unsecured until the morning of 7-30-2019. The COS confirmed during the interview that the courtyards gates are to be secured al all time. On 8-01-2019 at 3:35 PM a list was provided of 29 residents who were cognitively impaired and self mobile who would have access to the courtyard. On 8-01-2019 at 3:35 PM and interview was conducted with RN F. During the interview RN F confirmed the 29 residents on the list would have access to the courtyard. | 2020-09-01 |
| 25 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-08-12 | 689 | G | 1 | 0 | 7ED911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview; the facility staff failed to implement assessed interventions and failed to implement additional interventions to prevent falls for 3 (Resident 20, 21 and 23) of 4 residents. The facility staff identified a census of 225. Findings are: [NAME] Record review of Resident 20's Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 6-19-2019 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was a 1. According to the MDS Manuel, a score of 0 to 7 indicated severe cognitive impairment. -Extensive assistance with bed mobility and transfers requiring 2 persons physically assisting the resident. -Total dependence for locomotion on the unit, toilet use and personal hygiene requiring 2 persons to physically assist the resident. Record review of Resident 20's Comprehensive Care Plan (CCP) dated 1-29-2019 revealed Resident 20 was at high risk for falls. The goal identified for Resident 20 was no falls or no falls with injury. The interventions identified on Resident 2's CCP included 2 persons to assist with dressing, hygiene, grooming/bathing and bed mobility. Resident 20's CCP also identified Resident 20 could stand and pivot with assistance. Other interventions included a mat next to the bed and to keep Resident 20's bed in a low position. Record review of a Abuse/Neglect/Misappropriation/Crime Reporting Form (ANMCRF) dated 7-24-2019 revealed Resident 20 had .fell out of bed yesterday ,striking (gender) head on the floor sustaining an abrasion and possible head injury. Record review of a investigation report dated 7-25-2019 revealed the Nursing Assistant (NA) A had been providing care to Resident 20 when Resident 20 fell from bed. Record review of a Documentation form dated 7-24-2019 revealed NA A reported working with Resident 20. According to the Documentation report, NA A reported getting Resident 20 cleaned and dressed and when NA A retrieved Resident 20's wheelchair, Resident 20 fell out of bed. Record review of an undated Fall Root Cause Analysis (RCA) form revealed Resident 20 had sustained a laceration and hematoma to the right side of the face and had altered mental status. According to the RCA, the family chose not to have Resident 20 sent to the hospital. On 8-12-2019 at 1:50 PM an interview was conducted with Registered Nurse (RN) B. During the interview RN review of Resident 20's MDS and CCP were reviewed. RN B confirmed during the interview Resident 20's CCP and MDS indicated Resident 20 was to have 2 people assist with cares. When asked how many staff were assisting Resident 20 when Resident 20 fell on [DATE] resulting in a laceration and hematoma, RN B stated 1 staff was working with (gender). B. Record review of Resident 21's MDS dated as completed on 5-29-2019 revealed the facility staff assessed the following about Resident 21: -BIM's score was a 3. -Required supervision with bed mobility, transfers, walking on the unit and eating. -Required extensive assistance with toilet use and personal hygiene. Record review of Resident 21's CCP dated 3-04-2019 revealed Resident 21 had a fall on 7-30-2019 resulting in a laceration 2 lacerations to Resident 21's forehead. Further review of Resident 21's CCP revealed there were not specific interventions implemented in an attempt to prevent re-occurrence. Record review of Resident 21's progress notes dated 7-31-2019 revealed Resident 21 was seated at a table ,stood up and fell . On 8-12-2019 at 12:25 PM an interview was conducted with RN B. During the interview RN B confirmed no additional interventions had been implemented when Resident 21 fell on [DATE]. C. Record review of Resident 23's MDS signed as dated as completed on 7-03-2019 revealed the facility staff assessed the following about the resident: -BIM's score was a 3. -Required supervision with eating. -Required extensive assistance with transfers, dressing, toilet use and personal hygiene. Record review of Resident 23's CCP dated 12-03-2018 revealed Resident 23 was at risk for fall related to multiple falls and poor safety awareness. Further review of Resident 23's CCP revealed Resident 23 had a fall on 6-30-2019 at 1:45 PM and on 6-30-2019 at 10:30 PM. Review of Resident 23's record revealed there was not evidence the facility had implemented interventions in an attempt to prevent additional fall when Resident 23 fell , twice on 6-30-2019. Record review of Resident 23 progress note dated 7-16-2019 revealed Resident 23 had slipped from the wheelchair sustaining a laceration on the left side of the head. On 8-12-2019 at 4:00 PM a interview was conducted with RN B. During the interview RN B. During the interview review of Resident 23's care plan was completed. During the interview, RN B confirmed additional interventions were not implemented after he falls on 6-30-2019. RN B further confirmed Resident 23 had sustained a laceration to the left side of the head. RN B confirmed additional interventions should have been implemented. Record review of the facility Policy and Procedure for Fall Risk Assessment sheet revised on 9-2005 revealed the following information: -Purpose: -2. To facilitate implementation of preventative measures. -Procedure: -7. Revise the residents care plan to reflect care needs and interventions based on the residents potential for falling. -Key Points: -Interventions must be implemented to aid in the prevention of falls. | 2020-09-01 |
| 26 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-08-12 | 690 | D | 1 | 0 | 7ED912 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on observation, record review and interview; the facility staff failed to provide scheduled toileting for 2 (Resident 21 and 25) of 2 sampled residents. The facility staff identified a census of 130. Findings are: [NAME] Record review of Resident 25's Comprehensive Care Plan (CCP) printed on 1-11-2019 revealed Resident 25 was incontinent of bowel and bladder and that staff were to provide frequent toileting. Observation on 10-09-2019 at 6:30 AM revealed Resident 25 was ambulating in the hall of the secured unit. Observation on 10-09-2019 at 10:15 AM revealed Resident 25 was ambulating in the hall of the secured unit. Further observation revealed the back of Resident 25's red sweat pants had a large wet area to the buttock area extending down to the middle of the back of the upper legs. Observation on 10-09-2019 at 10:20 AM revealed Nursing Assistant (NA) F escorted Resident 25 to Resident 25's room and into the bathroom. NA F removed a saturated brief Resident had been wearing and placed Resident 25 onto the toilet. On 10-09-2019 at 10:30 AM an interview was conducted with NA F. During the interview NA F confirmed Resident 25 had been incontinent through Resident 25's clothing. When asked the last time Resident 25 was assisted with toileting needs, NA F reported this was the first time since 6:30 AM. On 10-09-2019 at 10:35 AM an interview was conducted with Licensed Practical Nurse (LPN) D. During the interview LPN D reported Resident 25 is a heavy wetter . and that Resident 25 should be toileted every 2 hours. On 10-09-2019 at 12:05 PM a follow up interview was conducted with LPN D. During the interview LPN D reported had spoken with the nursing assistants on the unit and none of the NA's reported taking Resident 25 to the bathroom. LPN D confirmed Resident 25 had been up since at 6:30 AM and should have been toileted prior to 10:20 AM. B. Record review of Resident 21's CCP revealed on 8-26-2019 an update to Resident 21 CCP directing the facility staff to toilet Resident 21 every 2 hours. Observation on 10-09-2019 at 7:10 AM revealed Nursing Assistant (NA) B and NA C assisted Resident 21 into a wheelchair from bed. Further observation revealed Resident 21 was taken to the dining room for breakfast. Observation on 10-09-2019 at 10:07 AM revealed Resident 21 was asleep in the wheelchair located in the dining room. Observation on 10-09-2019 at 10:15 AM revealed Resident 21 remained in the dining room asleep in the wheelchair. Observation on 10-09-2019 at 10:40 AM revealed Resident 21 remained in the dining room asleep in the wheelchair. Observation on 10-09-2019 at 11:00 AM revealed NA [NAME] and NA F assisted Resident 21 into the bathroom. A span of 3 hours and 50 minutes from 7:10 AM to 11:00 AM for toileting assistance. On 10-09-2019 at 11:07 AM an interview was conducted with Licensed Practical Nurse (LPN) D. During the interview when asked how often Resident 21 was to be assisted with toileting, LPN D stated every 2 hours. On 10-09-2019 at 2:45 PM an interview was conducted with RN [NAME] During the interview RN A reported had asked all nursing staff on the unit if Resident 21 had been assisted with toilet use and confirmed Resident 21 had not been assisted with toileting needs every 2 hours. | 2020-09-01 |
| 27 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2016-09-21 | 152 | D | 0 | 1 | 7TIB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview; the facility staff failed to obtain permission from a guardian on a behavioral modification plan to restrict privileges for 1 (Resident 7) of 1 resident sampled. The facility staff identified a census of 236. Findings are: Record review of an undated Social History sheet revealed Resident 7 had a had a Guardian to manager Resident 7's care. Record review of Resident 7's Comprehensive Care Plan (CCP) dated 6-04-2009 revealed the following: -Restrict (Resident 7) to the unit if Resident 7's blood sugars are equal or greater to 225. -If Resident 7 refuses to get up for breakfast or drinks a Glytol (supplement type of liquid), Resident 7 was to remain on the unit until the following meal for observation. -If refuses to get up for lunch or drink a [MEDICATION NAME], Resident 7 is to remain on the neighborhood until the following meal. -If verbally or physically abusive with staff or peers and unable to direct, Resident 7 was to remain on the neighborhood for 24 hours. -If resident must have a breathing treatment after smoking, there would be no smoking allowed for the remainder of the day. Review of Resident 7's medical record revealed there was no evidence that Resident 7's Guardian had given permission for the restriction of privileges. On 9-19-2016 at 9:09 AM an interview was conducted with Registered Nurse (RN) B. During the interview RN B confirmed Resident 7 had a behavioral modification plan that restricted privileges. During the interview, RN B reported that the behavioral modification plan had not been discussed with the Guardian and there was not any evidence any other staff had spoke to the guardian about the behavioral modification plan. The facility was not able to provide any evidence of the Guardian giving permission for the behavioral modification plan at the time of exit from the facility. | 2020-09-01 |
| 28 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2016-09-21 | 323 | E | 0 | 1 | 7TIB11 | Licensure Reference Number: 175 NAC 12-006.09D7a Based upon observations, interviews and record review; the facility failed to ensure Team 1's medication cart was secured when unattended on Wind Song Way unit. This had the potential to affect 14 cognitively impaired, self-mobile residents of the 44 residents that reside on the unit. The facility census was identified as 236. Findings are: [NAME] An observation on 09/21/2016 at 1:26 PM revealed that the Wing Song Way Neighborhood Team 1 medication cart was observed to be in the Wing Song Way Neighborhood commons area, with no staff members present. A check of the cart's medication drawers found them to be unsecured. There were 7 residents in the immediate area. This was confirmed by the nurse manager of the Wing Song Way Neighborhood on 09/21/2016 at 1:28 PM, who secured the cart at this time. An interview with the Nurse Manager of the Wing Song Way Neighborhood on 09/21/2016 at 1:28 PM, confirmed that the cart was unsecured and that medication carts should be secured when unattended. An interview with Registered Nurse A (RN A) at 09/21/2016 1:36 PM revealed that the cart was unlocked about five minutes and RN A had left the unit to go upstairs to fax a document. RN A confirmed that the cart should had been secured prior to RN A's leaving the cart. A record review of the facility's Medication Guidelines/Preparation/Administration Policy dated revised 5/91,7/92, 12/94, 1/95, 6/97, 3/07, 1/09, 12/10; revealed the following: The medication room/cart MUST be closed and locked at all times except when medications are being prepared by the Nurse. | 2020-09-01 |
| 29 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2016-09-21 | 412 | D | 0 | 1 | 7TIB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.14 Based upon observations, interviews and record reviews; the facility failed to follow-up a dental appointment for Resident 210. The facility census was identified as 236. Findings are: [NAME] An observation of Resident 210 on 09/14/2016 at 1:31 PM revealed Resident 210 was observed to be missing several teeth. A record review of Resident 210's care plan dated 02/26/15 revealed under the care plan that for problem #4-Self-care deficit: bathing, hygiene, dressing and grooming. In the interventions section it is noted DCHC Dental clinic without and dates or time frames. A record review of Resident 210's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 02/10/2016 revealed under section L-Oral/Dental Status it was marked: Obvious or likely cavity or broken natural teeth. Interviews with Registered Nurse L (RN L) and Unit Secretary M (US M) on 09/19/2016 at 12:35 PM revealed that Resident 210 has not been seen by a dentist since 04/07/2015. A record review of Dental Chart dated 04/7/2015, revealed the following: patient seen for annual exam and [MEDICATION NAME]. Teeth are badly worn but patient reports no pain, plaque is soft, no significant gingivitis. Recommend 3 month recall. A record review of an undated list of unit's clients needing dental services revealed that Resident 210 was listed and was to be followed up in 3 months from the 04/7/2015 visit. An interview with Director of Nursing (DON) 09/19/2016 02:57 PM revealed that the unit or neighborhood is responsible for scheduling dental appointments. An interview with Social Services Specialist K, (SSS K) on 09/20/2016 at 07:40 AM, revealed that social services does not have any documentation concerning the Resident 210's Power of Attorney (POA) not wanting to have the resident to be seen by the dentist. An interview with the DON on 09/20/2016 at 02:10 PM revealed the DON was not able to find any evidence that the Resident 210 had been back to a dentist since 04/07/2015. A follow-up interview with the DON on 09/21/2016 1:15 PM confirmed that the standard of care is that dental services should be offered at least annually to those who want the services. The DON further confirmed that there was no evidence available concerning whether or not the facility had asked, the resident or the POA, if the resident wanted to receive dental services. | 2020-09-01 |
| 30 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2017-11-14 | 371 | F | 0 | 1 | VVNM11 | Licensure Reference Number 175 NAC 2-006.11E Based on observation, record review and interview; the facility dietary staff failed to utilize hair restraints in the facility kitchen. This had the potential to affect 219 residents that ate food prepared in the facility kitchen, and failed to maintain serving temperature of cool food used for medication administration for Resident 235. The facility census was 226. Findings are: [NAME] Record review of the Nebraska Food Code dated (MONTH) (YEAR) section 2-402.11 revealed: Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens and unwrapped single service or single use articles. Observation on 11/13/2017 between 10:10 AM and 10:30 AM revealed Cook A had a mustache without a hair restraint in place over the mustache during the preparation of meat for roast. Dietary Aide (DA) B was present in the kitchen and had a beard and mustache with no hair restraint in place over the beard or mustache. DA C was present in the kitchen and had a mustache with no hair restraint in place over the mustache. Interview on 11/13/2017 4:16:31 PM with the Dietary Supervisor confirmed that Cook A and DA ' s B and C should have worn beard and mustache hair restraints while in the kitchen. Record review of a facility policy on Employee Appearance dated 1/26/17 revealed that sideburns, mustaches and beards are to be trimmed. All beards must be covered with an approved mask. Record review of a list of residents that take nothing by mouth dated 11/14/17 revealed that there were a total of 7 residents in the facility that did not eat any food prepared in the facility kitchen. B. Record review of the facility policy of Safe Food Handling dated revision 2/14/17 revealed: D. Holding and Service 1. Hot food must be held at 135 degrees Fahrenheit (F) or above, and cold food at 41 degrees F or colder. 6. When serving cold food, fill wells with ice, and cover food whenever possible to maintain temperature. Observation on 11/13/17 at 9:23 AM during medication pass, it was noted after providing medications to Resident 235, that the yogurt that was used to administer medications was 60 degrees F. Interview with Staff Member D, on 11/13/17 at 9:23 AM, revealed that Resident 235 was the only resident that yogurt was used to administer medications. Staff Member D revealed that the yogurt was taken from the unit refrigerator at 7 AM that morning, and was placed on top of the medication cart for use. Staff Member D confirmed that the yogurt was not placed in ice wells when not in use. Staff Member D confirmed that the temperature at the time of administration, at 9:23 PM was 60 degrees as tested with thermometer. Interview with Unit Manager [NAME] on 11/13/17 at 9:23 AM confirmed that the yogurt was served at a temperature higher than the facility policy of 41 degree or less. Interview with the facility Dietary Manager on 11/13/17 at 12:29 AM confirmed that yogurt was to be served at 41 degree or less and that it was to be kept on ice if out of the refrigerator waiting to be served to maintain the temperature. The dietary manager confirmed that safe food handling policy was not followed. | 2020-09-01 |
| 31 | EASTMONT TOWERS | 285036 | 6315 O STREET | LINCOLN | NE | 68510 | 2017-03-30 | 371 | F | 0 | 1 | GDOK11 | LICENSURE REFERENCE 175 NAC 12-006.11E Based on observation, interview, and record review; the facility failed to ensure a Food Service Provider washed hands in a manner to prevent potential for food born illness and failed to ensure frozen foods were stored in a sanitary manor. These failures had the potential to affect all of the resident's residing in the facility. The facility census was 9. Findings are [NAME] A review of the Facility's HANDWASHING POLICY AND PR[NAME]EDURE initated 2/1/17 revealed the procedure included use a clean paper towel to dry hands and use a paper towel to turn off water. An observation on 3/28/17 at 10:45 AM of Chef-A preparing fresh vegetables revealed the Chef washed hands at appropriate times throughout the preparation. Observation of the Chef's handwashing technique revealed hands were washed the appropriate amount of time. The Cook was noted to: obtain paper towels, turn off the water faucets, and then with the same paper towels dried hands and arms possibly recontaminating hands. The Chef returned to the task of cutting/prepping the vegetables using bare hands. Observations on 03/30/2017 from 8:05 AM to 8:20 AM of Chef-A during food preparation (prep) revealed the Chef washed hands at appropriate times, paper towels were obtained and used to turn the water faucets were turned off. Chef-A then dried hands using the same paper towels. The Chef preformed handwashing in the same manner three times during the food prep observation. An interview on 03/30/2017 at 08:22 AM with Chef-A revealed the Chef was knowledgeable of need for proper handwashing at the proper times while preparing food items. The Cook confirmed using the paper towel to turn off the faucets prior to drying hands and reported that clean paper towels should be used to dry hands if the towels had been first used to turn off the water faucets. B. An observation on 03/30/2017 at 8:25 AM in the Facility's large walk in freezer revealed a gallon sized plastic container of ice cream on the floor under the food storage shelving unit. The Food Service Director (FSD) collected the container and further observation of the container revealed it had been opened and approximately 1/2 of the contents was gone. The container was not marked with the date the ice cream was opened and the remaining product was covered with ice crystals. The FSD placed the unmarked ice cream container into the trash. Further observation in the freezer revealed 5 individually wrapped ice cream sandwiches and an individual styrofoam container of ice cream, on the floor under the shelving unit. The floor of the freezer also contained several areas of visible debris. An interview on 03/30/2017 at 8:30 AM with the FSD revealed routine audits were completed in the kitchen and dietary staff were aware of the need to clean the floor of the walk in freezer. The FSD confirmed the identification of ice cream products on the floor of the freezer and the lack of marking the container with the date it was opened. | 2020-09-01 |
| 32 | EASTMONT TOWERS | 285036 | 6315 O STREET | LINCOLN | NE | 68510 | 2019-07-03 | 695 | D | 0 | 1 | RRGD11 | Licensure Reference Number 175 NAC 12-006.09D6(7) Based on observations, record reviews and interviews; the facility failed to ensure the oxygen tubing and nasal cannula were not left on the floor, and failed to ensure oxygen tubing was changed per facility policy. This had the potential to affect one resident, Resident 9. The facility census was 10. Findings are: Observation on 07/02/19 at 09:46 AM revealed Resident 9 sitting up in recliner chair, oxygen off and oxygen tubing including the nasal cannula lying on the floor. Observation on 07/02/19 at 01:00 PM revealed Resident 9 sitting up in recliner chair finishing eating lunch. Oxygen off and oxygen tubing including the nasal cannula lying on the floor. Review of Oxygen Therapy Protocol dated 9/26/12 revealed that if using PRN oxygen, change nasal cannula and tubing every other week. Record review of (MONTH) and (MONTH) Treatment Administration Record (TAR) 2019 revealed no documentation of oxygen tubing being changed. Interview with Director of Nursing (DON) on 07/02/19 at 03:35 PM confirmed that nasal cannula tubing should not be on the floor and that tubing information should be documented on the TAR. Interview with DON on 07/03/19 at 12:57 PM confirmed that no documentation was present to reflect that the oxygen tubing had been changed on Resident 9. | 2020-09-01 |
| 33 | EASTMONT TOWERS | 285036 | 6315 O STREET | LINCOLN | NE | 68510 | 2019-07-03 | 880 | D | 0 | 1 | RRGD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review and interview; the facility failed to ensure staff followed facility policy to wash hands and change gloves after handling used dressings. This had the potential to affect one resident, Resident 9. The facility census was 10. Findings are: Observation of wound care on 07/02/19 at 09:46 AM- 09:46 AM by RN (Registered Nurse) A revealed RN A washed hands and set up supplies on towel placed on chair, applied gloves, took Resident 9's shoe and sock off right foot, cleansed scissors with alcohol pad and cut off outer Kerlix dressing, then removed [MEDICATION NAME] pad and with same gloves on, went to sink and wet wash cloth, applied soap and washed wound. Then RN A removed gloves, washed hands and applied clean gloves, applied gauze drsg to wound and then wrapped area with Kerlix, applied tape, dated dressing, applied Resident 9's sock and shoe and then removed gloves and washed hands. Review of hand washing guidelines dated 12/14 revealed hand washing should be done after handling used dressings. Interview on 7/2/19 at 3:35 PM with DON (Director of Nursing) confirmed that after removing dirty dressings, gloves should be removed, hand hygiene completed and clean gloves applied before continuing with wound treatment. | 2020-09-01 |
| 34 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-04 | 166 | D | 1 | 0 | 04EU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.06B Based on record reviews and interviews, the facility failed to resolve grievance / complaints for 1 resident (Resident 603) out of 3 residents sampled. The facility census was 138. Findings are: Review of the undated face sheet for Resident 603 revealed an admission date of [DATE]. Review of the undated face sheet revealed the [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4-11-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 603 was cognitively intact. Resident 603 required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and bathing. Resident 603 was frequently incontinent of urine. Review of the Grievance Log dated 3-01-16 through 3-30-17 provided by the facility revealed absence of a grievance for Resident 603. Interview via phone on 4-26-17 at 4:35 PM with the Family revealed a grievance was completed on 3-30-17 and the Family handed the grievance to Staff D. The Family never received a response back from the facility since that night for a resolution of the 3 issues the Family had concerns about. Family revealed the 3 issues were. 1) The resident had expressed concern to the staff about wheezing and requested an inhaler to help relieve the resident's lungs wheezing and it took 7 days for any of the staff to believe the resident and obtain the orders and medication from the Physician. 2) The Family had concerns the resident had to sit in incontinent urine for up to 15 minutes on multiple occasions after staff was aware of the situation. 3) The resident was not supposed to be transferring independently but the resident had reported to the Family this had occurred occasionally because staff were not available to transfer the resident. The Family revealed on 3-30-17, Staff D visited with the Family about why the resident had been left in incontinent urine for 15 minutes on 4-30-17 when the Family arrived that day. However, Staff D did not say anything about the why this had occurred on other days, or the other 2 concerns the Family had addressed on the grievance how those were being addressed. Interview on 04-26-17 at 4:45 PM with the DON (Director of Nursing) confirmed the Grievance Log was absent of a grievance for Resident 603. The DON also confirmed the DON was not aware of any grievance that had been filed by any member of Resident 603's family that had not been yet listed on the Grievance Log. The DON also denied knowledge of a grievance that had been personally handed to Staff D the end of (MONTH) by the Family. On 05-04-17 the DON provided a copy of a grievance form on Resident 603 dated 03-30-17 initiated by the Family. Documentation of Facility Follow-Up and Resolution of Grievance/Complaint sections of the form were completed by SS-E (Social Service) dated 04-10-17. Documentation on the grievance addressed the resident being left to sit in incontinent urine on 3-30-17 and an intervention if it should occur in the future. The documentation revealed the reason the resident did not get the medications for 7 days was due to the doctor not getting back to facility's request. The documentation did not reveal a resolution to ensure it would not happen again or to explain why this was acceptable. The documentation did not have when the Family was notified of the information about the medications. The ADM (Administrator) dated the form 05-01-17. Interview on 05-04-17 at 08:30 AM with the ADM revealed the ADM received the grievance form on 05-01-17 and could not explain why it took so long for the ADM to receive it even though the SS dated the form as completed on 04-10-17. The ADM revealed the ADM called the Family and reached a voicemail and left a message 05-01-17. Interview on 05-04-17 at 8:42 with SS-E revealed the facility process for grievances was to respond back to the person who filed the grievance within 1 week with a resolution. The ADM usually also responded back to the person who filed the grievance. SS-E provided the Homestead Care Handbook with the grievance process wrote in it which revealed All grievances/complaints received from Residents, Representatives and Families are addressed. All grievances will be investigated and a response given to the complainant within 5 working days. If longer than 5 days is required, the complainant will be notified. Interview on 05-04-17 at 9:48 AM with SS-F revealed the SS felt the grievance was resolved by Staff D so SS-F completed the form and notified the Family of the resolution. SS-F denied documenting the conversation with the Family of the grievance resolution on the grievance form, Progress Notes, or anywhere else. SS-F denied recalling the details of the conversation. | 2020-09-01 |
| 35 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-04 | 312 | D | 1 | 0 | 04EU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1 Based on observations, record review, and interviews; the facility failed to provide assistance with a shower and left the dependent resident unattended for 2 and 3/4 hours for 1 resident (Resident 603) out of 3 sampled residents. Resident was unable to use the call light to call for needed assistance. The facility census was 138. Findings are: Review of the face undated sheet for Resident 603 revealed an admission date of [DATE]. Review of the undated face sheet revealed [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4-11-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 603 was cognitively intact. Resident 603 required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and bathing. Interview on 04-26-17 at 10:00 AM in the resident's room revealed a few weeks ago Staff A put the resident into the shower and performed a 10 minute rinse to the left leg. When completed, Staff A left and said Staff A would be back in 5 minutes and the resident was left sitting in the shower without a call light for over 2 and 1/2 hours. At first the resident thought time was just going by slowly, then the resident realized the resident had been forgotten. At one time the resident thought the resident heard someone come into the resident's room so (gender) yelled out is anyone out there. Resident 603 revealed however the resident's voice was very soft and no one came into the bathroom. Resident 603 revealed the bathroom had a call light but it was across the room by the toilet and the cord was not long enough to have reached the resident. The resident revealed at that time, the resident was not to transfer alone and the wheelchair was not close so the resident could have reached it even if the resident would have wanted to have tried to transfer. Resident 603 revealed Staff B from the evening shift entered the bathroom while passing fresh water pitchers and emptied the old water in the sink and found the resident on the shower chair. Staff B asked the resident what the resident was doing in the shower then went and informed the charge nurse and they returned and transferred the resident into the wheelchair. Resident 603 denied any physical injury from the incident. Observation on 04-26-17 at 10:20 AM revealed the resident shower was in the bathroom of the resident's room. The shower chair was a permanently fixed chair to the wall and not a chair with wheels. The only call light in the bathroom was across the room by the toilet. Review of the facility investigation report revealed on 04-08-17 at approximately 2:00 PM a shower was given to Resident 603. The resident was dressed followed by the wound treatment to the left leg by the Staff [NAME] The resident was left sitting on the shower chair to allow the [MEDICATION NAME] to dry before the resident was transferred back into the wheelchair. The call cord was not long enough to reach the resident in the shower. Staff A left the resident to go give report to the oncoming shift. Staff A revealed (gender) believed report was told to the oncoming shift of Resident 603 being left in the shower. The oncoming nurse, Staff C, denied being told Resident 603 was in the shower. The resident was taken out of the shower at 4:45 PM when Staff B found the resident when Staff B emptied a water pitcher. Review of the Progress Notes revealed no documentation of the incident. On 04-08-17 at 9:35 PM it was documented a general overall skilled assessment of the resident which revealed resident had no visible sores noted. Interview on 04-26-17 at 4:45 PM with the DON (Director of Nursing) confirmed the incident had occurred and the staff involved were disciplined. The resident was left unattended on the shower chair in the resident's bathroom without a call light for 2 hours and 45 minutes. | 2020-09-01 |
| 36 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 578 | D | 0 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and observation; the facility failed to implement advanced directives for 1 of 2 residents sampled. This had the potential to affect Resident #330. The facility census was 131. Findings are: Review of Resident #330's Resident Face sheet dated 05/09/2018 revealed Advanced Directive: there are no Advanced Directives selected for this resident , Review of Resident #330's CONSENT FOR DO NOT RESUSCITATE (DNR) dated 05/09/2018 revealed NO I do not wish Cardiopulmonary Resuscitation efforts in the event of [MEDICAL CONDITION]. Review of Resident #330's PHYSICIAN'S DO NOT RESUSCITATE (DNR) ORDER FOR THE MEDICALLY ILL dated 05/09/2018 revealed the form was marked/selected DO NOT INTUBATE means that I do not wish a tube placed in my airway to maintain my respirations artificially and DO NOT RESUSCITATE (DNR) I understand that DNR means that if my heart stops beating or breathing is inadequate, that no artificial resuscitation will be initiated or continued. I understand that I will continue to receive support supportive medical care as deemed appropriate by health care personnel, through cardiopulmonary resuscitation will not take place. Review of Resident #330's Summary of Care Document printed 5/9/18 at 2:13 PM revealed : Current Code Status DNR On 05/16/18 at 04:08 PM Record review of Resident #330's physician's orders [REDACTED]. Interview with Staff-D on 05/21/18 at 08:36 AM revealed that Resident #330 was a DNR. Staff-D reviewed Resident #330's physician's orders [REDACTED].>Review of the facility's undated Advance Directives policy revealed: 3. Prior to admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directive. 4. Information about whether or not the resident has executed an advance directive shall be prominently displayed in the medical record. 5. If the resident indicates that he or she has not established advanced directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline this assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer and the resident's decision to accept or decline. 7. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directives. 17. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The Attending Physician will not be required to write orders for which he or she has an ethical or conscientious objection. Review of Resident #330's Admission Baseline Care Plan and current care plan revealed no code status is care planned. Review of Resident #330's Summary of Care Document printed 5/9/18 at 2:13 PM, revealed : Current Code Status DNR Review of Resident #330's Patient Demographics printed on 5/9/2018 revealed Documents on File Advanced Directives Discharge & Transfer -- Altitude Discharge Plan of Care | 2020-09-01 |
| 37 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 582 | D | 0 | 1 | HJ5H11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05.5b Based on record review and interview, the facility failed to provide the required SNFABN (forms designed to notify the residents of their right to appeal discharge from a facility based on discontinuation of Medicare Part A services). notices for residents, this had the potential to affect 3 of 4 residents sampled, (Residents 116, 103 and 98). The facility census was 131. Record review of SNFABN forms for Residents # 116 and 103, revealed the Request for Medicare Intermediary Review did not have the designations of choice of wanting bill for services submitted or not submitted. On 05/22/18 at 11:10 AM, an interview with SSD F (Social Service Designee) confirmed neither of the choices were selected. Record review for SNFABN notice for Resident 98 revealed there was no request for Medicare Intermediary Review form. On 05/22/18 at 11:10 AM an interview with SSD [NAME] confirmed there was no Request for Medicare Intermediary Review form. | 2020-09-01 |
| 38 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 584 | E | 1 | 1 | HJ5H11 | > Licensure Reference Number NAC 12-006.18A(1) Based on observation and interview, the facility failed to ensure the bath house was free from non jagged corners on the shower wall and a black substance on the shower floor and wall that had the potential to affect 60 residents on the 100 and 200 halls. The facility census was 131. Findings are: Observation of the 100 and 200 wing bath house on 5/22/18 at 8:00AM and a second observation on 5/22/18 at 11:00AM revealed a black substance in between the shower floor and wall and the edge of the shower wall had a jagged edge. Environmental tour with the Adminstrator and Maintenance Man on 5/22/18 at 11:00 AM revealed a black substance in between the shower floor and wall and the edge of the shower wall had a jagged edge. Interview with the Administrator on 5/22/18 at 2:30PM comfrmed that there was a black substance in between the shower floor and wall and the edge of the shower wall had a jagged edge | 2020-09-01 |
| 39 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 656 | E | 0 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C Based on observations, record reviews and interviews; the facility failed to develop care plans to address, A) activities and oral intake status for Resident 73, B) activities for Resident 90. Resident sample size was 31. Facility census was 131. Findings are: [NAME] Review of Resident 73's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 4-4-18 revealed total dependence for dressing and extensive assist for personal hygiene. Review of Resident 73's current Physician order [REDACTED]. Review of a Nutrition Note dated 5-6-18 revealed Resident 73 was on Tube Feeding at at 50 cc/hour and was to have no food by mouth with all nutrition via the feeding tube. Review of Resident 73's Care Plan last revised 5-14-18 noted the resident has tube feeding, but has ok for ice chips and now ok for 10 bites of pureed food with extra gravy one time daily. Review of Resident 73's Care Plan for activities last revised 5-14-18 revealed a problem start date of 1-19-2018. The first approach for the problem was dated 5-14-18. Interview with RN J (Registered Nurse) on 5-22-18 at 1423 05/22/18 the care plan interventions for Resident 73's activity needs dated 1-19-18 could not be located. B. On 05/16/18 at 01:08 PM Observation of Resident 90 revealed the resident was not engaged in activities. Review of Resident 90's Resident Face Sheet revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/21/18 at 9:46 AM Observation of Resident 90 revealed the resident was in bed in room with music playing. On 05/22/18 at 11:47 AM Observation of Resident 90 revealed the resident was in bed in room with music playing. On 05/22/18 at 01:48 PM Interview with the Activity Director revealed that the Activity Director stated read the newspaper and books to Resident 90 in room. Record review of Resident 90's care plan revealed that the facility failed to Care Plan Activities. On 05/22/18 at 02:53 PM Interview with Nurse Consultant A confirmed that activities had not been care planned for Resident 90. | 2020-09-01 |
| 40 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 660 | D | 1 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C2 Based on interviews and record review, the facility failed to develop a discharge plan based on the resident's wishes. This had the potential to affect 2 residents (Residents # 330 and 42). The facility census was 131. Findings are: [NAME] Review of Resident #330's Resident Face Sheet revealed the resident was admitted on [DATE]. Interview with Resident #330 on 05/16/18 at 03:09 PM revealed the resident wanted to return the the previous facility the resident had been. Interview on 05/21/18 at 04:25 PM with Staff [NAME] revealed that the resident was going to stay at this facility long term and that there was not a discharge plan. Review of Resident 330's Admission- Baseline Care Plan -Discharge Plan dated 5/9/18 section Discharge Plan revealed it wasn't completed. B. Review of Resident #42's Resident Face Sheet revealed the resident was admitted on [DATE]. Interview with Resident #42 on 05/16/18 at 2:10 PM revealed the resident wanted to go back to the resident's apartment. Interview with Staff [NAME] on 05/22/18 at 08:31 AM revealed that the resident wanted to return to an apartment but there were plumbing and electrical issues that have to be addressed. Review of Care Plan Snapshot on 5/17/18 revealed no care plan problem, goals or approaches related to discharging or returning to the resident's pervious apartment. | 2020-09-01 |
| 41 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 677 | D | 0 | 1 | HJ5H11 | Licensure Reference Number: 175 NAC 12-006.09D1c Based on observations and interview, the facility failed to ensure soiled clothing was changed and dirty glasses were cleaned for 1 resident (Resident 114). The sample size was 31 and census was identified as 131. Findings are: Observation of Resident 114 on 5-16-18 at 0930 revealed black and brown stains down the chest area of the resident's shirt. [NAME] and gray stains were observed on the resident's plaid pants. The lenses of the resident's glasses were smudged and dust covered. Observation of Resident 114 on 5-17-18 at 1414 revealed the resident was wearing the same shirt and pants from the prior day with brown and black colored stains down the chest. The resident's glasses remained dusty and smudged and pants were still noted to have gray and white substance. The resident was observed to be attempting to whipe the gray and white material from the pants. A Review of Resident 114's Minimum Data Set (MDS- a federally mandated comprehensive tool used for care planning) dated 4-18-18 revealed Resident 114 was severely cognitively impaired and required extensive assist for dressing, toileting and personal hygiene. Interview with Nurse Consultant A on 5-22-18 at 0719 reveals the expectation would be for staff to change a resident's clothing if stained and dirty prior to the next day. | 2020-09-01 |
| 42 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 755 | E | 0 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.10A2 Based on observation, record review and interview, the facility failed to administer medications through an Enteral Tube (is used to feed patients who cannot attain an adequate oral intake from food and/or oral nutrition supplements, or who cannot eat/drink safely) per facility policy. This was the observation for one sample resident (Resident 73). This had the potential to affect 4 residents (Residents 90, 61, 37 and 73) at the facility. Census: 153 Residents. Sample size 73 Residents. Observation on 5/22/18 from 8:33 AM until 9:10 AM RN-G (Registered Nurse) set up medications for Resident 73 to be given through an Enteral Tube. The medications were Calcium [MEDICATION NAME] (a dietary supplement used when the amount of calcium taken in the diet is not enough). [MEDICATION NAME] (a medication used to treat diabetes insipidus, betwetting, [DIAGNOSES REDACTED] A, von Willebrand diseae, and high blood urea levels). Docu Liquid (medication used to treat occasional constipation). [MEDICATION NAME] (a medication used for pain control, to help prevent or control [MEDICAL CONDITION], or as a mood stabilizer). [MEDICATION NAME] (is used to treat certain conditions where there is too much acid in the stomach. It is used to treat gastric and [DIAGNOSES REDACTED] ulcers, erosive esophagitis). [MEDICATION NAME] (is a class of drugs call steroids. [MEDICATION NAME] prevents the release of substances in the body that cause inflammation). Levetiracetam (is an anti-epileptic drug used to treat partial onset [MEDICAL CONDITION] in people with [MEDICAL CONDITION]). [MEDICATION NAME] (used to treat occasional constipation). [MEDICATION NAME] (is used to treat intestinal and stomach ulcers, [MEDICAL CONDITION] reflux disease (GERD) and conditions where your stomach makes too much acid). Vitamin D 1000Units (is a supplement that helps your body absorb calcium and phosphorous). RN-G took the listed medications to the bedside of Resident 73. RN-G was observed to check the placement of the Enteral Tube and check for residual. RN-G drew up each medication individually and administered each medication into the Enteral Tube using the syringe and plunger. Record review Administering Medications through an Enteral Tube (Revised (MONTH) 2012) 22. Reattach syringe (without plunger) to the end of the tubing 23. Administer medication by gravity flow. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. Open the clamp and deliver medication slowly. Clamp tube (or begin flush) before the tubing drains completely. 24. If administering more than one medication, flush with 5ml (or prescribed amount) warm sterile water between medications. Interview on 5/22/18 at 9:12 AM with RN-H stated was not sure if RN-G gave the medications correctly through the Enteral Tube, but would get a copy of the Policy and Procedure for the Surveyor. | 2020-09-01 |
| 43 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 758 | D | 0 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that physician orders [REDACTED].#68 and 330). The facility census was 131. Findings are: Review of Resident #330's Resident Face Sheet revealed the resident was admitted on [DATE] at 4:47 PM Review of Resident #330's Physician order [REDACTED]. [MEDICATION NAME] 0.25 mg, one tablet orally, as needed up to three times per day for anxiety disorder (a medication used to treat anxiety and panic disorders), Start Date 05/09/2018; End Date open ended [MEDICATION NAME] 25 mg, one half tab, orally, every 6 hours as needed for anxiety disorder. Start Date 05/09/2018; End Date open ended Both of these medications are psychoactive medications. Interview with Staff D on 5/21/2018 at 08:39 AM revealed Resident #330 takes Ambien, [MEDICATION NAME] and [MEDICATION NAME] as ordered, and as needed for behavior issues and anxiety. Review of Resident #330's PRN ADMINISTRATION HISTORY: 05/01/2018-05/17/2018 revealed: [MEDICATION NAME] PRN (as needed) was given on 5/10, 5/11, 5/12, 5/14, and 5/16 for other and behavior issue; [MEDICATION NAME] PRN (as needed) was given on 5/11, 5/12, 5/14 and 5/16 for other and behavior issue. Record review of Physicians orders dated 4/14/18 for Resident 68 revealed; [MEDICATION NAME] (a [MEDICAL CONDITION] medication used to treat anxiety) schedule IV concentrate; 2mg/ml; amount 1 mg; oral, start date 4/14/18 end date Open ended. Once a day on Wednesday and Saturday-PRN(as needed) 30 minutes before bath. Record review of the Physician orders [REDACTED]. Start Date: 04/25/2018, End Date: 04/25/2018. Every 6 hours PRN. Record review of the MAR (Medication Administration Record) dated 5/1/18 -5/17/18, revealed the resident was administered the above medications during this time. | 2020-09-01 |
| 44 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 791 | D | 0 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.14 Based on observation, record review, and interviews, the facility failed to assist with making dental appointments for 1 resident (Resident 19) of 31 sampled residents. The facility staff identified the census as 131. Minimum Data Set information for resident 19 dated 5-2-18 revealed a [DIAGNOSES REDACTED]. Resident 19 admitted to the facility in (MONTH) of (YEAR). Observation of Resident 19 on 5-17-18 at 0830 reveals the resident's right front tooth is cracked and shortened. Interview with the resident on 5-17-18 at 0830 reveals the front right tooth was broken about two years ago. The resident had not been seen by a dentist in about four years. The resident's tooth bothers him when eating and would like to be seen by a dentist. Interview with Nurse Consultant A on 5-17-18 at 1545 revealed Resident 19 had no information charted regarding dental consultations or that the resident or their representative had declined a dentist's evaluation. Interview with the Director of Nursing on 5-21-18 at 0839 revealed the expectation of staff would be for the mouth to be assessed and have a dentist appointment set up. The expectation would be for social worker to annually check with the resident regarding dental visit and/or cleaning. There should be something on the resident's chart regarding talking with the family regarding dental cleaning. | 2020-09-01 |
| 45 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 867 | E | 0 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.07C (2) Based on observations, interviews, and record reviews, the facility failed to Develop and implement a plan to correct and maintain compliance regarding repeat federal and State deficiencies pertaining to housekeeping and maintenance. The concerns identified had the potential to effect 66 residents. The facility census was 131. Record reviews of past re-certification survey deficiency statements dated 5-25-17 revealed the facility was cited for failures regarding the ventilation motors in resident rooms, and broken and stained caulking in resident bathroom areas. Observations and interviews conducted during the current survey from 5-16-18 to 5-22-18 revealed vents were not working in rooms [ROOM NUMBER] bathrooms. The 100 and 200 wing bath house observation revealed a black substance in between the shower floor and wall and the edge of the shower had a jagged edge. These observations were confirmed with Maintenance and the Administrator. Interview with the Administrator on 5-22-18 at 1554 revealed resident bathing area for the 100 and 200 hallways was not identified as a possible area to focus on for Quality Assurance. Record review of the facility Quality Assurance and Performance Improvement revised 5-2017 revealed the QAPI Committee oversees the quality and effectiveness of the facility operations and systems to meet the needs of the residents; to monitor and analyze facility key performance indicators to identify improvement opportunities. | 2020-09-01 |
| 46 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 923 | F | 0 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-007.04D Based on observation and interview, the facility failed to ensure the vent fans were working in bathrooms for room [ROOM NUMBER], 402, and 410. Facility Sample size was 31. Facility census was 131. Findings are: Observation of bathrooms in rooms [ROOM NUMBER] revealed that the vent fans were not working. On 05/22/18 at 10:59 AM During the Environmental tour the Administrator and Maintenance Man confirmed that the vent fans in rooms [ROOM NUMBER], were not working. On 05/22/18 at 1:59 PM an interview with the Administrator confirmed that the vent fans in rooms [ROOM NUMBER] were not working. | 2020-09-01 |
| 47 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 242 | D | 0 | 1 | 18U611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.05 (4) Based on interview and record review, the facility failed to ensure a resident was provided with a choice related to bathing for one (Resident 109) of 3 sampled residents. Facility had a total census of 131. Findings are: Resident 109 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. In an interviews on 5/22/17 at 8:45 AM and 5/25/17 at 11:19 AM, Resident 109 reported not getting a choice related to number of baths per week. Resident 109 reported receiving two baths per week and stated would like more at times. A review of undated bath schedule revealed Resident 109 was schedule for two baths per week. In an interviews on 5/23/17 at 2:57 PM and 3:19 PM, Social Worker A reported that bathing preference are being reviewed with residents on admission. Social Worker A reported that Resident 109 had not been asked about bathing preferences. | 2020-09-01 |
| 48 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 253 | E | 1 | 1 | 18U611 | > Licensure Reference Number(s) 175 NAC12-006.18B and 175 NAC 12-006.18A(1) Based on observation, interview, and record review; the facility failed to ensure two mechanical sit to stand lifts (a mechanism used to assist residents to transfer from one surface to another) were clean. This failure had the potential to affect 10 of 15 sampled residents (Residents 71, 92, 150, 109, 158, 194, 145, 169, 44, and 152) who required use of a lift for transfers. The facility also failed to ensure; 1) Eight resident rooms (306, 103, 102, 314, 216, 301, 318, and 410) had tiles with stained or broken caulking in the bath rooms; and 2) Rooms 219, 400, 306, and 410 were free from lingering odors . Findings are [NAME] An observation on 5/24/17 at 10:12 AM revealed Nursing Assistant (NA)-E using a disposable wipe to wipe the handles, upper bars, and knee rest, of a mechanical sit to stand type lift (a devices used to assist residents during transfers from one surface to another). The NA did not wipe the foot plate, lower bracing, or wheels of the lift. Further observation revealed the wheels of the lift had evidence of hair and other foreign materials wrapped around them, the foot plate and lower bracing contained visible dust and debris. An interview on 5/24/17 at 10:14 AM with NA-E revealed the NA did not clean the lower surfaces of the lift. The NA was unaware of a cleaning schedule which included all of the lifts surfaces. An interview on 5/24/17 at 10:15 AM with Registered Nurse (RN)-F revealed the mechanical lift should be cleaned after each resident use. The RN observed the lift and confirmed the lower areas of the lift were soiled and in need of cleaning. An interview on 05/25/2017 at 11:39 AM with Licensed Practical Nurse (LPN)-G revealed the area of the facility (Station 3) had two mechanical sit to stand type lifts in use, and that both of the lifts had the same concerns related to sanitation. The LPN reported that other areas of the facility had their own equipment, including mechanical lifts. Review of a facility Census roster dated 5/24/17 revealed fifteen residents who required use of a sit/stand lift for transfer assist. Ten of the fifteen residents resided on Station 3, (Residents 71, 92, 150, 109, 158, 194, 145, 169, 44, and 152). A review of the facility policy titled CLEANING AND DISINFECTION OF RESIDENT CARE ITEMS AND EQUIPMENT dated/revised (MONTH) 2014 revealed reusable resident care equipment would be cleaned and disinfected according to current CDC (Center for Disease Control) recommendations for disinfection between resident use. B. Observation of Room 514 on 5/18/17 at 9:22 AM revealed the bathroom smelled of urine . Observation of the bathroom in [RM #]6 on 5/22/17 at 10:26 AM revealed stained caulking around the toilet. Observation of the bathroom in Room 103 on 5/22/17 at 9:58 AM revealed cracked caulking around the base of the toilet. Observation of the bathroom in Room 102 on 5/18/17 at 9:18 AM revealed cracked caulking around the base of the toilet. Observation of the bathroom in Room 219 on 5/22/17 at 11:23 AM revealed a urine odor. Interview with a resident in Room 400 on 5/23/17 at 7:39 AM revealed the bathroom had an odor especially on warm days. During an environmental tour on 5/24/17 beginning at 1:00 PM, interview with the Maintenance Supervisor (MS) revealed the caulking needed replaced in the bathrooms of rooms 314, 216, 301, 318, 410. Further interview during the environmental tour on 05/24/2017 at 2:04 PM with the MS revealed odors were acknowledged in the bathrooms of 306, 219, and 410. The MS further reported the odors smelled of urine. Interview with the Housekeeping Supervisor on 05/25/2017 at 10:50 AM revealed the odors have not been alleviated with cleaning or the use of odor eliminator products. | 2020-09-01 |
| 49 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 258 | E | 1 | 1 | 18U611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.18A (3) Based on observations and interview, the facility failed to replace loud bathroom ventilation motors to promote comfortable sound levels in rooms [ROOM NUMBER]. The facility census was 131. Findings are: Observation of the bathroom in room [ROOM NUMBER] on 05/18/2017 at 9:18 AM revealed a noisy bathroom ventilation fan . Interview with a resident living in room [ROOM NUMBER] on 5/18/17 at 9:22 AM revealed the bathroom vent is so loud that the resident has to turn on the radio in the room in order to not hear it. Observation of the bathroom in room [ROOM NUMBER] on 05/22/2017 at 02:44 PM revealed a noisy bathroom ventilation fan. Observation of the bathroom in room [ROOM NUMBER] on 05/22/2017 at 09:58 AM revealed a noisy bathroom ventilation fan that could be heard in room with the bathroom door shut. Observation of bathrooms during the Environmental Tour with the Maintenance Supervisor on 5/24/2017 between 1:00 PM and 3:30 PM revealed all of Station One vents were loud. Interview with the Maintenance Supervisor on 5/24/2017 between 1:00 PM and 3:30 PM confirmed the vents were loud still loud despite having been taken out and cleaned. | 2020-09-01 |
| 50 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 281 | D | 0 | 1 | 18U611 | Licensure Reference Number: 175 NAC 12-006.10B1 Based on observations and interview, the facility failed to ensure medication was observed until administration to the resident in accordance with facility policy for one sampled resident (Resident 29) of 6 sampled residents. The facility had a total census of 131. Findings are: Observations on 5/23/17 at 9:29 AM revealed a medication cup with medications in it, two medication cups full of pro stat, eye drops, and nasal spray on over bed table in room next to Resident 29. No staff member was observed in the room. In an interview on 5/23/17 at 9:29 AM, Resident 29 reported that Resident did not like to take medications until after breakfast. In an interview on 5/23/17 at 9:35 AM, Registered Nurse B reported giving Resident 29 the medications at 8:30 Am. Registered Nurse B stated that Resident 29 doesn't like to take medication until after breakfast. Registered Nurse B reported leaving medications for Resident 29 as Resident 29 had been at facility for a long time and then returning to remind Resident 29 to take the medications. Registered Nurse B was not aware of any directives that indicated that Resident 29 could have medications at bed side. A review of Resident 29's medical record did not reveal any assessment of Resident 29's ability to self-administer medication. In an interview on 5/23/17 at 1:58 PM, Registered Nurse Consultant confirmed no assessment of Resident 29 ability to self-administer medications. Facility policy titled medication Administration Orals dated 10/07 stated the following: -Administer medication and remain with resident while medication is swallowed. Do not leave a medication in a resident's room without orders to do so along with documentation of self-administration. | 2020-09-01 |
| 51 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 312 | D | 0 | 1 | 18U611 | Licensure Reference Number: 175 NAC 12-006.09D1c Based on observation, record review and interview; the facility failed to assist one resident (Resident 187) of three sampled residents with wearing eye glasses as needed. The facility census was 131 residents. Findings are: Review of Resident 187's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 4/7/17 revealed Resident 187 had moderately impaired vision and required extensive assistance for dressing and grooming. Review of Resident 187's Care Pan revised 4/4/17 revealed Resident 187 required assistance of one with grooming and to complete all activities of daily living. There was no specific mention of Resident 187's impaired vision or need for eye glasses on Resident 187's Care Plan. Review of a Resident Assignment sheet dated 5/22/17 indicated that Resident 187 wore glasses. Interview with Family Member A on 05/18/2017 at 03:16 PM revealed Family Member A noted that Resident 187 was often not wearing Resident 187's glasses. Observation of Resident 187 on 05/23/2017 at 10:49 AM revealed Resident 187 had been assisted out of bed to the wheelchair for the lunch meal and was not assisted with donning glasses. Interview with Nursing Assistant (NA) P on 5/24/17 at 9:30 AM revealed staff found Resident 187's glasses on the floor so NA P picked them up and put them back in the case so they wouldn't get broken. Observation of Resident 187 on 5/24/17 at 12:10 PM revealed Resident 187 at the dining room table without any glasses on. After asking NA Q on 5/24/17 at 12:10 PM to obtain Resident 187's glasses and put them on Resident 187 observation revealed Resident 187 did not attempt to remove the glasses. Interview with NA Q on 5/24/17 at 12:17 PM revealed Resident 187 just liked to have something to hold onto and if Resident 187 had something to hold that Resident 187 would not attempt to remove the glasses. NA Q went on to say that staff had not tried interventions such as waiting till right before meal time or giving Resident 187 something else to hold in order to assist Resident 187 with wearing and keeping the glasses on. Interview with the unit manager/Registered Nurse (RN) F on 05/25/2017 at 12:22 PM revealed there was no problem on the care plan addressing Resident 187's impaired vision or interventions to aide in the wearing of the eye glasses but that it is noted on the Resident Assignment sheet that Resident 187 was to wear glasses. | 2020-09-01 |
| 52 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 315 | D | 1 | 1 | 18U611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC: 12-006.09D3 (1 and 2) Based on observation, interview, and record review; the facility failed to identify the need for an individualized toileting program to restore urinary continence (ability to control bladder)for one (Resident 194) of three sampled residents and the facility failed to provide pericare (washing the genitals and anal area which prevents skin breakdown of perineal area, and infections) in a manner to prevent the potential for cross contamination for two (Residents 187 and 194) of three sampled residents. The facility census was 131. Findings are: [NAME] A review of MDS (Multidisciplinary Data Set-a mandatory comprehensive assessment tool used for care planning) information for Resident 194 revealed full assessments completed on 10/28/17 for admission, and on 1/31/17 for a significant change in condition. The CAA (Care Area Assessment) page of both assessments indicated urinary incontinence triggered as an area of concern and needed to be included on the resident's care plan. A review of Resident 194's Care Plan (CP), last reviewed/revised on 5/6/17, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An entry on the CP indicated a problem identified on 11/01/2016 documented Resident 194 exhibited 'Functional' urinary incontinence, with the goal of 'will not develop skin breakdown related to incontinence. The interventions included to use pull ups or briefs when in and out of bed. Another problem identified on 11/01/2016 indicated Resident #194 had a Self-care deficit related to [DIAGNOSES REDACTED]. Resident 194 required assistance from 2 staff members for transferring and toileting. The CP indicated on 2/8/17, the resident experienced bladder incontinence related to diuretic (medication used remove excess fluid) therapy and decreased mobility. Interventions included: incontinence care with each incontinent episode, provide minimal assist with toileting, and obtain labs as ordered. The CP did not include an individualized toileting plan or interventions to prevent or improve incontinence status. A review of the electronic medical record for Resident 194 revealed a document titled DISCHARGE & TRANSFER-MEDICARE DISCHARGE PLANNING MEETING dated 10/25/16. The document revealed the resident required physical assist from 1-2 people for toileting, without a documented goal related to the concern. The section of the document titled BOWEL/BLADDER MANAGEMENT indicated Resident 194's previous level of bowel/bladder control and management was continent (able to control) of bowel and bladder. The documentation was incomplete and did not include information related to the resident's current level or goals and interventions related to toileting concerns. An interview on 05/23/2017 at 9:58 AM with Nursing Assistant (NA)-H revealed Resident 194: required assistance from 2 staff for transfers using a sit-stand lift (mechanical device used to move residents from one surface to another), was incontinent of bowel and bladder, was able to let staff know of need to use the bathroom, was toileted with staff assistance every 2 hours and as needed. An interview on 05/24/2017 at 8:41 AM with Registered Nurse (RN)-J, revealed Resident 194 was incontinent while receiving Medicare Services and residing on the Skilled Unit of the facility, 10/21/16-1/7/17, but was not on a toileting program. The RN reported that a Bowel and Bladder Voiding Diary was not completed upon admission for the resident. An interview on 05/24/2017 at 10:45 AM with RN Unit Manager-F revealed a bowel and bladder (B & B), three day diary/observation had not been completed for Resident #194 since moving to Unit 3 on 1/8/17. The RN confirmed the resident's CP did not include individualized interventions related to toileting/incontinence issues. A review of an undated facility document titled BOWEL AN BLADDER GUIDELINE revealed: all residents have a B & B observation completed on admission, quarterly, change in condition, and in the instance of a change in continence; if B&B observation shows resident is both continent and incontinent of either bladder or bowel, a 3 day tracking/voiding diary shall be initiated; Care Plan needs to include individualized toileting schedule/program or reason one is not appropriate; the facility should observe that incontinent residents have pericare completed at least every 2 hours. B. An observation on 5/23/17 at 10:02 AM of NA-H and NA-I assisting Resident 194 with toileting needs revealed a sit stand lift (a mechanical device used to move residents from one surface to another) was used to transfer the resident from a wheel chair to the bathroom and toilet with no concerns identified. NA-I was noted to apply gloves prior to assisting the resident to lower pants and remove a soiled brief. Soiled gloves were not removed prior to NA-I assisting NA-H to manipulate and reposition the mechanical lift and lower Resident 194 onto the toilet. Privacy was provided and when Resident 194 indicated completion of elimination needs, the lift was used to bring the resident to a standing position. NA-I was observed to use disposable wipes to cleanse the resident's genital area, and a different wipe was used to complete back pericare. NA-I then applied a clean brief for the resident and assisted NA-H to move the lift out into the resident's room. Resident 194 was lowered into a wheel chair in order to remove wet trousers and apply a clean pair. Neither NAs were noted to change gloves or sanitize hands throughout the provision of care for Resident 194. Interviews on 5/23/17 at 10:15 AM with NA-H and NA-I revealed the NAs did not remove soiled gloves prior to making contact with items considered clean or sanitize their hands, during the provision of toileting and incontinence care for Resident 194. A review of Lab Reports for Resident 194 revealed urine specimans tested positive for symptoms of urinary tract infection on 1/13/17 and 2/7/17. A review of the Basic Nursing Assistant Training Manual, 4th Edition dated 2009 revealed to prevent the potential for cross contamination, gloves were to be removed and hands sanitized following the completion of pericare and before touching clean clothing items. C. Review of Resident 187's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 4/7/17 revealed Resident 187 had severely impaired cognition, required extensive assist with toileting, and was always incontinent of bowel and bladder. Review of Resident 187's (MONTH) Medication Administration Record [REDACTED]. Observation of incontinent care on 05/23/2017 at 10:40 AM revealed Nursing Assistants (NAs) R, S, and T assisting Resident 187. NA S put on gloves, removed the dirty brief and providing hygiene to Resident 187's buttocks as Resident 187 was having an incontinent stool. NA S continued to wipe away the stool from Resident 187 four additional times and then assisted Resident 187 over to Resident 187's back. NA S did not remove gloves and proceeded to provide care to Resident 187's vaginal area while wearing the same gloves. Interview with NA S and Registered Nurse (RN) U on 5/23/17 at 10:55 AM revealed RN U agreed that NA S did not change gloves after providing care for incontinent stool. Review of the facility's undated Peri-Care Competency Checklist revealed staff should use a tissue/disposable peri-wipe and remove any stool that is present, then remove gloves and sanitize hands before proceeding with perineal care. | 2020-09-01 |
| 53 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 323 | E | 0 | 1 | 18U611 | Licensure Reference Number: 175 NAC 12-006.18E5 Based on observations and interviews, the facility failed to safely store chemicals in its Memory Unit (Station 4), which had the potential to affect 4 residents out of 19 residents. The facility census was 131 . Findings are: Observation on 5/17/2017 at 1:30 PM revealed an unlabeled spray bottle with a purple liquid on the counter in the dining room of Station 4. A container of disposable bleach wipes were noted in an unsecured cupboard under the sink in the same dining room. Observation on 5/23/2017 at 10:42 AM with RN AA revealed a container of Dispatch with Bleach sanitizing wipes were unsecured in a cupboard under the sink in the dining room of Station 4. Interview with RN AA during this observation confirmed the wipes were unsecured . Interview with Housekeeper Z on 5/23/17 at 10:25 AM revealed residents are allowed in the dining room unsupervised at times. Interview with the Nurse Consultant on 5/25/17 at 4:30 PM revealed there were 4 residents that wandered and rummaged on Station 4. | 2020-09-01 |
| 54 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 364 | D | 0 | 1 | 18U611 | Licensure Reference Number: 175 NAC 12-006.11D Based on observation and interview, the facility failed to ensure pureed food was prepared in a manner to maintain nutritional value. This practice had the potential to affect 9 residents receiving pureed food. The facility had a total census of 131 residents. Findings are: Observations on 5/23/17 at 1:25 PM revealed 15 slices of chicken sandwich meat, 5 slices of cheese and 10 slices of bread were blended with unmeasured amount of chicken broth and thickener to pureed consistency. Six half cup servings of pureed mixture were portioned into serving dishes. Then an additional 15 slices of chicken sandwich meat, 5 slices of cheese and 10 slices of bread were blended with unmeasured amount of chicken broth and thickener to pureed consistency for the second 5 servings of pureed food. The second batch produced 9 half cup servings of pureed sandwiches. In an interview on 5/23/17 at 1:25 PM, Cook C reported preparing 10 servings of pureed food in two batches of 5 servings. Cook C confirmed the first batch produced 6, half cup servings and the second batch produced 9, half cup servings. A review of undated document titled Pureed Food Guidelines revealed pureed sandwiches were to be made with 2 ounces meat, 1 ounce cheese and 2 slices of bread or 1 bun. Directions stated that bread, then food to be pureed is to be placed in blender or food processor. A half cup of liquid is to be added and mixture is to be pureed. Liquid is to be added in half cup amounts until product reaches the correct consistency. The document did not list a serving size for the pureed food. In an interview on 5/25/17 at 9:19 AM, Dietary Director confirmed that initially half cup liquid should be added and then more added as needed. Dietary Director reported serving size of purred sandwiches was supposed to be a full cup. | 2020-09-01 |
| 55 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 428 | D | 0 | 1 | 18U611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to identify potential medication irregularities related to use of psychotropic medications for 2 (Resident 106 and 163) of 5 sampled residents. The facility had a total census of 131 residents. Findings are: Resident 106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 106's 5/2017 Medication Administration Record [REDACTED]. A review of Resident 106's care plan revealed a problem dated 3/28/17 related to Resident 106 being at risk for adverse consequences related to use of antipsychotic medications for treatment of [REDACTED]. A review of order history for Resident 106 revealed Resident 106 was started on Seroquel 25 mg daily on 12/23/2015. Resident 106's Seroquel was increased to 50 mg on 5/6/2015 according to order history. A review of progress note from nurse practitioner dated 9/2/16 revealed Resident 106's Seroquel was increased to 75 mg for [DIAGNOSES REDACTED]. A review of pharmacist monthly reviews for Resident 106 revealed no irregularities were noted during the following reviews: 9/22/16, 10/24/16, 11/16/16, 12/19/16, 1/23/17, 2/27/17, 3/21/17, and 4/25/17. In an interview on 5/25/17 at 10:50 AM, Pharmacist D reported progress notes are reviewed during monthly medication reviews. Pharmacist D reported that gradual dose reductions are not recommended for residents being seen by a mental health practitioner as Pharmacist D trusts the mental health practitioner's judgement. B. A review of the MAR (Medication Administration Record) dated (MONTH) 1-24, (YEAR) for Resident 163, revealed the resident was admitted to the Memory Care Area of the facility on 8/2/14. The resident's [DIAGNOSES REDACTED]. Current medication administration orders indicated the resident was taking medications including: Citalopram (an antidepressant) 40 mg (milligrams) daily, Neurontin (used to treat neuralgia (nerve pain) and seizures) 400 mg threes times a day given for dx of unspecified dementia without behavior disturbance-started on 11/16/16, Seroquel an antipsychotic medicine (changes the actions of chemicals in the brain-used to treat schizophrenia and bipolar disorder) 25 mg four times a day started on 3/24/17, and Trazodone (an antidepressant) 100 mg daily started on 8/26/16. A review of pharmacist monthly reviews for Resident 163 revealed documentation that no irregularities were noted during the following reviews: 9/22/16, 10/24/16, 11/16/16, 12/19/16, 1/23/17, 2/27/17, 3/21/17, and 4/25/17. Review of Resident #163's medical record revealed no documented evidence of AIMS Testing (Abnormal Involuntary Movement Scale which aids in the early detection of movement disorders related to the use of antipsychotic medications as well as providing a method for on-going surveillance). An interview on 05/25/2017 at 3:49 PM with RN (Registered Nurse)-L revealed no AIMS testing had been completed for Resident 163. A review of a Drug Interaction Report obtained from Drugs.com revealed taking Trazodone, Seroquel, and Citalopram had the potential for a major negative drug interaction. Use of the medications together have the potential to cause severe side effects. An interview on 05/25/2017 at 2:11 PM interview with Pharmacist-D revealed the medications prescribed for Resident 163 had not been reviewed for possible negative drug interactions. The Pharmacist reported the lack of AIMS testing for Resident 163 had not been identified as an irregularity. A review of a facility policy titled MEDICATION THERAPY, revised (MONTH) 2007, revealed all medication orders will be supported by appropriate care processes and practices. Resident medications will be reviewed, assisted by the Consultant Pharmacist, upon admission and periodically to identify whether postential or suspected side effects are present. | 2020-09-01 |
| 56 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 441 | D | 1 | 1 | 18U611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.17 Based on observation, interview and policy review; the facility failed to ensure the glucometer was sanitized in a manner to prevent cross contamination for five residents( Resident 197, 110, 104 31, and 209) of seven residents who used the glucometer, failed to ensure hand washing and glove changes occurred in order to prevent the potential for spread of infection for two residents (Resident 98 and 194); and failed to ensure the mechanical lift was sanitized between resident use for two residents (Residents 194 and 158) which had to potential to cause cross contamination. The facility census was 131. Findings are: [NAME] Observation on 5/24/2017 at 11:35 AM of Licensed Practical Nurse (LPN) V revealed LPN V remove a glucometer (a portable machine used to test the amount of glucose in one's blood) labeled PRN 2 from the medication cart and laid it down on top of the cart. LPN V then took the glucometer into Resident 209's room and laid it down directly on Resident 209's bedside table. LPN V then picked up the glucometer to test Resident 209's blood and laid it back down onto Resident 209's bedside table. LPN V gathered the rest of the supplies, picked the glucometer back up and went back to the medication cart, laying the glucometer back down on top of the medication cart. LPN V proceeded to remove a Sani-Cloth Bleach Germicidal disposable wipe from an individual size packet and wrap the sani cloth around the glucometer machine from front to back. The cloth was not big enough to stay wrapped around the back of the machine. LPN V then laid the glucometer back on top of the medication cart with the sani cloth wrapped around the top of the machine only. LPN V did not make any attempt to wipe the surfaces of the glucometer before wrapping it with the disposable sani cloth. At 11:45 AM (on 5/24/17) LPN V then took out another glucometer machine labeled PRN 3. LPN V took this machine into Resident 104's room, laid the machine directly onto Resident 104's bedside table, picked up the glucometer and tested Resident 104's blood, again laying the glucometer down directly onto Resident 104's bedside table. LPN V then gathered all supplies, left the room and laid the glucometer on top of the medication cart. LPN V then removed another disposable sani cloth and wrapped it in the same fashion as before, laying the machine back on top of the cart with only the top of the machine in contact with the disinfecting wipe. LPN V again failed to make any effort to wipe down the machine with the cloth before wrapping it. LPN V then removed the sani wipe off of the 1st glucometer used labeled PRN 2 and reported the machine needed to air dry now. LPN V disposed of the wipe never wiping down the machine and never touching the underside of the machine. This was observed at 11:46 AM on the same date. At 11:48 AM (on 5/24/17) LPN V proceeded to remove another glucometer machine from the cart labeled PRN 1 and laid it on top of the medication cart. LPN V gathered the supplies and took the machine labeled PRN 1 into Resident 31's room and laid the glucometer directly on top of Resident 31's bedside table. LPN V then picked up the machine and used it to test Resident 31's blood, gathered the supplies and went back to the medication cart, laying the glucometer back on top of the medication cart. LPN V then removed another sani cloth and wrapped this glucometer in the same fashion and laid it back down directly on top of the medication cart. At 11:51 am (on 5/24/17) LPN V picked up the first glucometer (labeled PRN 2) that was now dry and took it to Resident 197's room, laid it on the bedside table before picking it up again to and used it to test Resident 197's blood. LPN V then laid the glucometer back onto Resident 197's bedside table before taking it back out to set it on top of the medication cart. Interview with LPN V on 5/24/17 at 11:58 AM revealed LPN V would proceed to take off the disposable wipes from the machines and replace the glucometers back into the medication cart in the same manner as before, without wiping down any of the surfaces with the sani cloth. Interview with the Director of Nursing (DON) on 5/24/17 at 1:48 PM revealed the policy was not followed for cleaning the machine. Review of the facility's undated policy for Maintenance of Assure Platinum Blood Glucose Monitoring System revealed, Cleaning and Disinfecting guidelines: Remove wipe from container, wipe all sides and end of machine. Allow machine to sit for 10 minutes after using wipe to totally disinfect the machine before using the machine again. It is critical that the meter be completely dry before testing a resident's glucose level. B. An observation on 5/23/17 at 10:02 AM of staff assisting Resident 194 with toileting needs revealed Nursing Assistant (NA)-H and NA-I applied gloves prior to assisting the resident to remove a soiled brief. Further observation revealed NA-I did not remove soiled gloves prior to having contact with/touching clean items. Interviews on 5/23/17 at 10:15 AM with NA-I revealed the staff member did not remove soiled gloves prior to making contact with items considered clean, during the provision of toileting and incontinence care for Resident 194. A review of a facility policy titled PERSONAL PROTECTIVE EQUIPMENT-GLOVES, revised (MONTH) 2009, revealed gloves were to be worn when touching body fluids and excretions. Gloves should be used for one resident contact and then discarded. C. An observation on 5/24/2017 at 10:29 AM of staff providing cares for Resident 98, revealed: Nursing Assistant (NA)-M washed hands prior to and following the provision of care for 7 seconds each time; NA-N was noted to wash hands for 10 seconds prior to providing needed assist Interviews on 5/24/17 at10:35 AM with NA-M and NA-N revealed the Nursing Assistants were knowledgeable of need for recommended 20 seconds for effective handwashing. Both NA-M and NA-N confirmed they did not wash hands for the recommended 20 seconds. A review of the facility policy titled HANDWASHING/HAND HYGIENE, revised (MONTH) 2008, revealed Appropriate ten (10) to fifteen (15) second handwashing or sanitation via an alcohol based hand rub was to be completed before and after direct contact with residents. The policy did not include the most current CDC (Center for Disease Control) recommendation of 20 seconds for handwashing. D. An observation on 5/23/17 at 10:02 AM of staff providing transfer/toileting assistance for Resident 194 revealed: a sit to stand type lift (a reusable mechanical device used to transfer residents from one surface to another) was obtained from a soiled utility area on Station 3, by Nursing Assistant (NA)-H; the lift was visibly soiled with a dried black colored substance noted to the base/foot rest of the lift, a dry crusty substance and debris were noted to the wheels and locking mechanism of the lifts wheels; and the lift was not cleaned/sanitized prior to entering Resident 194's room. Following the use of the lift to transfer Res 194, NA-H removed the lift from the resident's room and proceeded down the hallway, the lift was intercepted by NA-O who positioned the lift next to the wall. NA-O left the lift momentarily and returned taking the lift into resident room [ROOM NUMBER], without sign of sanitation. An interview on 5/23/17 at 10:20 AM with NA-H confirmed the NA did not sanitize the sit to stand lift prior to, or after use with Resident 194. An interview on 5/23/17 at 10:28 AM with NA-O revealed the NA did not sanitized the lift prior to using the equipment to transfer Resident 158, in room [ROOM NUMBER]. A review of the facility policy titled CLEANING AND DISINFECTION OF RESIDENT CARE ITEMS AND EQUIPMENT dated/revised (MONTH) 2014 revealed reusable Resident care equipment would be cleaned and disinfected according to current CDC recommendations for disinfection between resident use. | 2020-09-01 |
| 57 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-06-13 | 607 | D | 1 | 0 | YEOP11 | > Licensure Reference Number 175 NAC 12-006.02(8) Based on interviews and record review, the facility failed to ensure staff followed the facility policy regarding reporting allegations of abuse to the state authority. This had the potential to affect one resident (Resident 7). Sample size was 3. Facility census was 131. Findings are: Interview with the Activity Director on 6/13/2018 at 9:00 AM revealed that on Monday at 9:30 that Resident 8 was in Resident 7's room exposing self and was undressing Resident 7. This incident was not consensual and the Activity Director reported this incident to the Charge Nurse and sent an E-mail to the Administrator. The Administrator sent an E-mail to the Activity Director that the incident was being handled by the Director of Nursing and Nurse Consultants. Interview with Resident 7 on 6/13/2018 at 10:00 AM revealed that on 6/11/18 Resident 8 came into Resident 7's room uninvited, exposed self and began disrobing Resident 7 before staff came in and intervened. Resident 7 said that this act was not consensual. Resident 7 did not want Resident 8 in the room at all. Record review of the facility Abuse Policy revealed the administrator or designee shall report allegations of abuse to their state agency and should be reported within 2 hours of the incident. Interview with the Administrator, Director of Nursing and Nurse Consultant on 6/13/18 at 2:30 PM confirmed that the incident did happen and the facility failed to report the incident because the facility felt that the incident was consensual. Interview with the Activity Director on 6/13/2018 revealed the incident that was witnessed was not consensual between Resident 7 and Resident 8. | 2020-09-01 |
| 58 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 550 | E | 1 | 1 | UZYC11 | > Licensure Reference Number 175 NAC 12-006.05(6) Based on Observation, record review and interview the facility failed to ensure residents dignity and respect were maintained at all times. This affected 6 residents, residents (274, 54, 70, 96, and 82). The facility census was 123. Findings are: [NAME] Record review of Quality of Life- Dignity Policy dated 10/2009 revealed staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or cares. An Observation on 09/23/19 at 12:05 PM revealed restorative aide- H asking resident 274 if (gender) needed help removing bib. NA (nursing assistant) G and Restorative aide H talking over a table of residents (274, 54, 70, and 82) called the residents Feeders. Referring to residents that needed help with eating. An interview on 09/30/19 at 3:46PM with DON and CSC (Clinical Service Coordinator) revealed staff should not be referring to residents that sit at an assist table as feeders and the discussion of calling clothing protectors bibs/ crumb catchers had not been reviewed but will be looked at. | 2020-09-01 |
| 59 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 561 | D | 1 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05 (4) Based on Interview and record review the facility failed to ensure resident bathing preferences were honored for 2 residents (Residents 114, 329) and the facility failed to accommodate resident's care giver preferences for 1 resident (Resident 10). The facility census was 123. Findings are: [NAME] An interview on 09/23/19 at 2:45 PM revealed resident has not had choice when bath is performed. Resident states (gender) documents when baths were given and not given. The following are from Residents 10 calendar notes: 9/5/19 no bath, 9/9/19 no bath, 9/10/19 received bath, 9/12/19 no bath, 9/13/19 no bath, 9/16/19 received bath, 9/19/19 received bath, 9/23/19 received bath. Resident states that bath aide is often taken off baths and used on the floor due to short staffing, sometimes bath aide comes in on off days to catch up on baths but doesn't always get them done as there are 13-15 baths a day. Record review of bath log dated 8/26/19-9/25/19 revealed resident bath schedule and preference of 2 baths a week has not been honored and the agreed upon Mondays and Thursdays are often not the days resident receives baths. The bathing record notes no bath was preformed for 7 days from 09/03/19- 09/09/19. An interview on 09/26/19 with DON confirmed that facility has been short a bath aide and residents have missed scheduled bath days and may only received 1 bath a week during those short staffing times. B. Record Review of care plan dated 5/19/19 Resident would like to get a shower 3x/week to keep from getting skin issues. Staff will try to give (gender) a bath 3x/week. Staff to offer an extra shower if they are available. Record review of dermatology office noted dated 02/22/19 revealed resident has seborrheic [MEDICAL CONDITION] (a skin condition that can cause the scalp to be itchy and causing dry skin and dandruff) located on face and scalp. Resident is to be bathed and have hair shampooed every other day. Record review of bathing log notes that resident only received baths on 02/23/19 and 02/25/19. Next bath was 7 days later on 03/5/19. Next bath was 3 days later on 03/09/19. Following bath was 3 days later on 03/13/19. Resident was admitted to hospital on [DATE] for bowel obstruction. 9 days later a bath was completed on 03/23/19. An interview on 09/26/19 with DON and CSC ( Clinical Service Coordinator) confirmed that facility has been short a bath aide and residents have missed scheduled bath days and may only receive 1 bath a week during those short staffing times. C. An interview on 09/23/19 at 10:40 AM with Resident 10 revealed that (gender) prefers to have female care givers perform perineal cares (the cleaning of genital areas) and not male care givers. Record Review of Care Plan dated 07/31/19 revealed no documentation of Resident 10's choice of no male care givers. Record Review of Progress note dated 9/13/19 revealed resident does not want a male care giver. An interview on 09/24/19 @ 4:25PM with DON stated Resident 10 has gone back and forth with allowing male staff to assist with cares. But the unit it's typically staffed with at least 1 female staff member. An interview on 09/25/19 at 2:30PM with NA (Nursing assistant) I revealed Resident 10 requests to not have male staff help with perineal care. Record review of green binder called (Resident 10's book) revealed a list of Resident 10's care preferences; specifically states resident requested no male care givers. Facility has informed Resident 10 that they cannot accommodate this request. Facility stated they would provide 1 female and 1 male caregiver, if 2 female care takers are not available. Resident 10 has the right to refuse care, the reason that cares are not completed will be documented in green binder. An interview on 09/26/19 at 3:00PM with DON and Clinical Services Coordinator revealed the facility did not understand that they need to provide residents with gender specific caregivers per resident preferences and that facility assessment would need to reflect gender specific caregivers ( no males) as admission denial criteria. Record Review of Facility Assessment not dated revealed under section Guidelines for Conducting the Assessment; For example, if the facility decides to admit resident with care needs who were previously not admitted , such as resident on ventilators the facility assessment would be be reviewed and updated to address how the facility staff, resources, physical environment, etc,. Meet the needs of those resident and any areas requiring attention, such as any training or supplies required to provide care. On page 5 of The Facility Assessment under Ethnic, Cultural or religious factors 1.6 revealed a resident/patients ethnic, cultural, or religious factors, or personal resident preferences, that might potentially affect the care provided to residents. | 2020-09-01 |
| 60 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 565 | E | 1 | 1 | UZYC11 | > Licensure Reference Number 175NAC 12-006.06B Based on record review and interview the facility failed to ensure that residents and other persons filling out a grievance (complaint) were informed of the findings of the investigation and the corrective actions taken by the facility within 3 working days. This had the potential to affect all residents of the facility. The facility census was 123. Findings are: Record review of the facility policy titled Resident/Family Grievances dated 1/22/19 step 7 revealed: The resident or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions taken to correct any identified problems. Such report will be made orally by the Grievance Official, administrator, or his or her designee, within 3 working days of filing of the grievance or complaint with the facility. A written summary of the report will also be provided to the resident upon their request, and a copy will be filed in the Social Services department. Interview on 9/24/19 at 1:40 PM in the facility activity room with Resident 121 and Resident 77 confirmed that they did not know who the facility Grievance Officer was and confirmed that residents do not receive a follow up report for filed grievances. Record review of the facility grievances revealed no documentation that the report of findings was provided to the person filing the grievance. Interview with the facility Administrator on 9/24/19 at 2:55 PM confirmed that the facility is missing documentation for grievances. B. Record review of an email dated 09/16/19 at 10:17 AM revealed an email was sent to SSD (Social Services Director) J from Staff member K regarding Resident 58's missing under garment. It had been missing for several weeks, the front desk personnel was unsure if the resident had reported the loss to the right person. Inquired if the SSD knew of the missing item. A hand written note on the form revealed that SSD was looking in laundry for the missing item. Record review of the Policy for Grievances dated 01/22/19 revealed; any resident, his or her representative, family or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of, or missing property. The administrator had appointed a Grievance Official to be the contact person for the residents, their representatives, other interested family members or advocates. Upon receipt of a grievance and or complaint a designated individual will investigate and submit a written report of the findings to the Grievance official. The Grievance Official will submit the report to the appropriate leadership team member and appropriate actions will be taken to ensure appropriate resolution. The resident or representative will be informed on the findings of the investigation and the actions taken to correct the identified problems with in 3 working days of the filing of the grievance. The facility will follow state law in accordance with any reports of abuse and neglect and take appropriate steps to ensure the degree of residents safety. An interview on 09/24/19 01:04 PM with the Administrator confirmed; that the staff was not currently using the grievance form. If a grievance was presented it would be emailed to Staff Member K and then the email would be forwarded to the appropriate department and would be addressed. A reply to the correction would go to the Grievance Officer. The department would follow up with the person who filed the grievance. The facility had 3 days to complete the process and have a resolution for the resident or family. An interview on 09/24/19 02:31 PM with Resident 58 reported that no one had come to discuss the missing item with them and there had been no follow up on the residents missing item. Resident 58 reported the missing item to several people with no resolution. Resident 58 reported there was not a Resident Belonging Tracking document filled out on admission. Interview with the Administrator on 09/24/19 03:05 PM confirmed; that the resolution for the missing item for Resident 58's garment was beyond the 3 day resolution per the facility policy. The Administrator reported that the facility does not call in missing items they just replace them. Record review of Resident Belonging Tracking Procedure dated 1/5/15 revealed; that an inventory sheet would be provided the resident and family to fill out to identify all of the belongings upon admission. The instructions were to complete the inventory sheet in its entirety and sign and date. Include all items, clothing, dentures, glasses, watches, jewelry, picture, etc. All clothing items were to be labeled even if the family intended to launder. It was recommended the Resident bring 5 days worth of items. All clothing needed to be marked or labeled regardless of who did the laundry. The original goes to the UM mail box, a copy will be placed in a 3 ring binder in the labeling room. This facility shall not be liable for the loss of or the damage to personal property, unless it ha been placed on the facilities aforementioned secured area for safe keeping of money and valuables. Plea be aware of this policy and take precautions necessary to protect valuables per homestead personal property and missing property handbook. ' Record review of Resident 58 Resident Belonging Inventory revealed that the inventory document was not filled out. An interview on 09/24/19 02:40 PM with the DON(Director of Nurses) confirmed; that the inventory sheet had not been done and that it was nurses responsibility to complete the document. The DON confirmed that there had been a PIP in place for this and that the Administrator had started this prior to the DON starting. Additional information provided from the facility revealed : a Missing Item Policy not dated, the policy revealed; it was the responsibilty of the nursing home to establish and maintain a written inventoy of residents property, add to teh inventory list upon request, and provide a copy to the resident/resident representative. | 2020-09-01 |
| 61 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 583 | F | 1 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(21) Based on record review, interview and observations the facility failed to protect resident privacy by posting photos/videos of residents on a social media site for 2 residents (Resident 45 and 86), the facility failed to ensure that a resident was draped during personal cares for 1 resident (Resident 58), and the facility failed to protect residents privacy by having the EMR (Electronic Medical Records) open to public view, this had the potential to affect all residents past and present. The facility census was 123. Findings are: [NAME] Record review of a report dated 05/24/19 revealed Resident 45 was admitted on [DATE]. Resident 45 [DIAGNOSES REDACTED]. Assist level is total dependence for all activities of daily living. Record review of Quarterly MDS dated [DATE] revealed; Section G 0110 Functional status Resident 45 required extensive 2 person assist for bed mobility, transfers, dressing, toilet use, and personal hygiene. BIMS ( Brief Interview for Mental Status) was 0 of 15 indicating severe impaiment. Section I 8000 revealed; TODD's paralysis (post epileptic), Diabetes, Parkinson, encephalopath, dysphasia and [MEDICAL CONDITION] following cerebral infarct. Record review of a report dated 05/24/19 revealed; an anonymous reporter had notified the Administrator that a staff member had posted videos and photos of residents making fun of them on snap chat. It was found that NA (Nursing Assistant) L had posted the photos. The Administrator had confirmed the 2 resident in the photos were Resident 45 and 86. The Administrator and CSC (Clinical Services Coordinator) had called NA L, who had become agitated with the questions. On 05/31/19 NA L's employment was terminated. The conclusion was that NA L violated the facility policy of Abuse, Neglect and Exploitation. The facility action was to terminate NA [MI] The facility notified APS (Adult Protective Services), DHHS (Department of Health and Human Services), and the NA registry. Record review of the Policy for Homestead personal cellular phones revealed; while on duty to use a cell phone was prohibited. Since this policy was overly abused the facility was no longer allowing cell phones in the building. Employees were not to carry cellular phones on them in person while at work. Managers were to use cell phones for business purposes only. Record review of the Policy for Social Networking Media Policy signed and dated by NA L on 04/24/19 revealed; Photos of the facility/company or residents were not to be used or posted on any site. Photographs of other employees could only be posted with permission of the employee and may not identify the employer. Please refer to resident privacy and HIPPA (Health Insurance Portability and Accountability Act- is United States legislation that provides data privacy and security provisions for safeguarding medical information) policy for further guidance. Record review of a document signed by NA L dated 9 revealed; NA L had been given a copy of the reporting requirements for elder abuse and neglect. Record review of a document signed by NA L dated 9 confirmed; that NA L had read the HIPAA/Privacy Policy. Record review of Nebraska Central Registry Check Request revealed; NA L had no records found for APS (Adult Protective Services) or CPS (Child Protective Services). Record review of Public health Licensure Unit Certification of Licensure revealed; no disciplinary action taken against this license. Record An observation with the CSC on 09/25/19 at 3:50PM of a video that had been posted to a social media site of Resident 45, the facility was able to identify that the resident in the video was Resident 45. The film showed the employee prior to the resident filmed. An interview on 9 at 3:50 PM with the CSC confirmed; that the facility identified the employee who had posted the video because they had filmed themselves prior to the filming the resident. The CSC reported that the employee would not answer questions and employee had been terminated post investigation. B Record review of investigation document initiated on 05/24/19 and completed on 05/30/19 revealed; that Resident 86 was admitted on [DATE]. Primary [DIAGNOSES REDACTED]. BIMS score was 7/of 15 indicating severe cognitive impairment. Record review of a photo posted to the social media site provided by the facility revealed; Resident 86 was seated in a wheelchair with a cover and had laughing emoji's with my life help, help, help. The post was dated 9. NA L's name was posted and the photo was posted 14 hours ago. Record review of Resident 86's MDS Quarterly dated 05/29/19 revealed; Section G 0110 Resident 86 was extensive assist with 2 person for Bed mobility, transfers, dressing, and toileting, was one assist for eating and locomotion, the MDS revealed; resident 86 did not ambulate was able to surface to surface transfers with assistance. Section I 4800 revealed; dx of dementia, I 5700 anxiety, C. An observation on 09/25/19 at 10:23 AM of Perineal care for Resident 58. Resident 58's pants were pulled down to the residents ankles and the resident was exposed (no blanket covered the resident) the brief was removed and the resident had been incontinent. Perineal care was completed. Resident 58 requested to be covered. The NM (Nurse Manager) had to exit room to ask staff to get a cover. The bed spread was on the floor between the wall and bed. There was not sheet located on the bed. An interview on 09/30/19 03:30 PM with the DON confirmed; that staff should have linen in the room prior to the start of cares. Record review of Perineal Care Policy dated 9 revealed; Fold the bed spread toward the foot of the bed, Fold the sheet down to the lower part of the body and cover the torso with a sheet, raise the gown or lower the pajamas, and avoid unnecessary exposure of the resident's body. D) Observation on 9/24/19 at 7:47 AM revealed the 200 hall medication cart computer was left unattended with the screen unlocked and displaying resident information. Observation on 9/24/19 at 7:48 AM revealed LPN-A (Licensed Practical Nurse) returned to the 200 hall medication cart and was preparing to administer a resident's medications. Observation on 9/24/19 at 7:50 AM revealed the 200 hall medication cart was left unattended with the screen unlocked and displaying resident information. Interview on 9/24/19 at 7:51 AM with LPN-A revealed the computer with access to resident medical records should have been secured when left unattended. E) Observation on 9/26/19 at 7:13 AM revealed the 200 hall medication cart computer was left unattended with the screen unlocked and displaying resident information. Interview on 9/26/19 at 7:15 AM with LPN-B revealed the computer screen should not have been unlocked and displaying resident information when unattended. Interview on 9/26/19 at 11:17 AM with CSC (Clinical Services Coordinator) revealed the expectation for securing resident medical information was to secure the computer and ensure resident information is not displayed when the computer would be left unattended. | 2020-09-01 |
| 62 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 584 | D | 1 | 1 | UZYC11 | > Licensure Reference Number 175 NAC 12-006.18A Based on observations and interview, the facility failed to keep resident living areas clean for 2 residents (Resident 77 and Resident 324). Facility Census was 123. Finding are: An observation in the bathroom of Resident #77 and #324 on 9/24/19 at 2:28 PM revealed that the toilet riser was stained and the toilet had numerous areas of dried on feces. An observation and interview with the facility Administrator on 9/30/19 at 2:10 PM confirmed there was dried feces on the toilet riser, and the toilet itself has BM in it. This was in the bathroom that is shared by Resident #77 and Resident #324. | 2020-09-01 |
| 63 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 600 | D | 1 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175NAC 12-006.05 (9) Based on record review, observation, and interview the facility failed to ensure that residents were kept free from abuse resulting in an injury for 1 resident (Resident 87) of 1 resident reviewed, and the facility to report misappropriation of medications for 2 residents (Resident 326 and 333). The facility census was 123. Findings are: [NAME] Record review of the facility policy titled Abuse Prevention Program dated (MONTH) 2006 revealed: Preventing Abuse Step 1: Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Preventing Abuse Step 3i: The implementation of changes to prevent future occurrences of abuse. Interview with Resident 87 on 9/30/19 at 10:26 AM occurred in the resident room. A splint was observed in place on the resident's right pinky finger. When asked by this surveyor what happened to the resident's right pinky finger the resident responded that the resident (Resident 87) hit another resident in the head when another resident attempted to kiss the resident (Resident87). Resident 87 confirmed that this was reported to facility staff in (MONTH) (2019). Record review of the nurse progress note for Resident 87 dated 3/5/19 at 10:45 PM revealed that the resident had complained of itching to the small right finger earlier in the evening at 9:00 PM. The finger was swollen, reddish purple in color and painful to touch, ice was applied at that time and continuing to monitor for any changes. Record review of the X-Ray report for Resident 87 dated 3/6/19 revealed that the resident had a [MEDICAL CONDITION] digit (pinky finger) of the right hand. Record review of the Progress Notes and the Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 87 revealed no documentation of facility measures to protect the resident from resident to resident abuse. B. Record review of an APS (Adult Protective Services) report dated 07/01/19 revealed; an anonymous reporter reported that Resident 326 was discharged to home on a Friday. Resident 326 had been picked up by a friend, and asked the MA (Medication Aide) if they could speak with the nurse for instructions for the medications and discharge instructions. Resident/Resident friend was told that the nurse was not available, the mediations were bagged and ready to go. Resident 326 and friend went to HyVee pharmacy to get instructions. The pharmacist reported that the bagged medications were not the Resident 326's medications. The Reporter told APS that the medications belonged to Resident 333. The caller reported that the facility was called, spoke to SSD asked that the medication be brought back to the facility. The caller reported that the facility staff was to go the pharmacy and pick up the medications. Record review revealed; no facility self-report of misappropriation of medication for Resident 333 that were sent home with Resident 326. Record review of Resident 326's medications revealed; [MEDICATION NAME] 10 mg (milligrams) tablet one daily 0800 Fish oil 1000 mg 120mg-180mg daily 0800 [MEDICATION NAME] 0.4 mg daily 8PM [MEDICATION NAME] 88 mcg daily 0500 [MEDICATION NAME] 3.4/5.4 gram 1 packet daily 0800 [MEDICATION NAME] 40 mg BID (Twice a day) 0730/3:30PM [MEDICATION NAME] (Vitamin B6) 25 mg 1 tab 0800 [MEDICATION NAME] XL 25mg 1 tab daily 0800 Vitamin D 3 1 tablet daily 0800 [MEDICATION NAME] 1 gr QID (four times a day) 0800/1200/4:00P/8:00P Record review of Resident 333 medications revealed; [MEDICATION NAME] 200mg 1 tablet once a day at 0800 ASA 81 mg daily 0800 [MEDICATION NAME] 150 mg once a day at the 1st of the month 0800 [MEDICATION NAME] Fiber Singles BID Multivitamin with minerals 1 tab daily Pantoprazole 1 tab once a day 0800 Potassium chloride 10 MEQ (Millaequivalent) 1 cap daily 0800 Requip 4 mg BID 0800/8:00PM [MEDICATION NAME] 100mg 1 tablet daily 0800 [MEDICATION NAME] HFA 160-4.5 Mcg 2 puffs Rinse after use- 0800/8:00PM Mag oxide 400 mg 1 tab TID 0800/1:00PM /6:00PM [MEDICATION NAME]-[MEDICATION NAME] 5/325mg 1 tab QID 0800/1200/4:00PM/8:00PM An interview on 09/25/19 at 03:05PM with the CSC confirmed; that Resident 326 was sent home with another residents medications. Both Resident 326 and 333 had medications bagged for home and the nurse grabbed the wrong bag of medications. The CSC reported that the nurse on duty was to have disciplinary action by the Unit Manager and there was no documentation that the discipline had been completed. The nurse manager was sent to Hy Vee and retrieved the medications and the residents correct medications were delivered to the resident at the place of discharge. The Unit Manager was no longer employed. The nurse who gave the medications to Resident 326 was no longer employed. The CSC confirmed; that the facility had not reported the incident. | 2020-09-01 |
| 64 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 609 | G | 1 | 0 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview the facility failed to ensure that resident abuse resulting in injury was investigated for 1 resident (Resident 87) and the facility failed to ensure that misappropriation of resident property was investigated for 1 resident (Resident 86). Based on record review and interview, the facility failed to ensure incident investigations were submitted to the state agency within 5 working days. This affected 5 residents (Residents 14, 40, 69, 86, and 87) of 10 residents reviewed. The facility census was 123. Findings are: A) Interview with Resident 87 on 9/30/19 at 10:26 AM occurred in the resident room. A splint was observed in place on the resident's right pinky finger. When asked by this surveyor what happened to the resident's right pinky finger the resident responded that the resident (Resident 87) hit another resident in the head when another resident attempted to kiss the resident (Resident87). Resident 87 confirmed that this was reported to facility staff in (MONTH) (2019). Record review of the nurse progress note for Resident 87 dated 3/5/19 at 10:45 PM revealed that the resident had complained of itching to the small right finger earlier in the evening at 9:00 PM. The finger was swollen, reddish purple in color and painful to touch, ice was applied at that time and continuing to monitor for any changes. Record review of the X-Ray report for Resident 87 dated 3/6/19 revealed that the resident had a [MEDICAL CONDITION] digit (pinky finger) of the right hand. Record review of the facility policy titled Abuse Investigations dated (MONTH) 2014 revealed the Policy Statement: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Step 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and other as may be required by state or local laws, with five (5) working days of the reported incident. Interview with the Clinical Services Consultant (CSC) on 9/30/19 at 11:07 AM confirmed that a state report was not completed or submitted for the resident to resident altercation that resulted in a [MEDICAL CONDITION] pinky finger for resident 87. B) Record review of the Progress note for Resident 86 dated 5/26/19 10:19 PM revealed that the family reported that the resident's watch was missing and that it was gold in color. Record review of the Progress note for Resident 86 dated 5/31/19 9:59 AM revealed that the resident's family member was here and reported that they bought the resident a new watch, gave the receipt to Social Services for reimbursement of the lost item and stated that it may have been stolen by a former employee. Record review of the facility grievances revealed an email dated 5/31/19 from the facility Social Services Director (SSD J) to the facility Grievance Officer. The email revealed that Resident 86 was missing a watch since 5/26/19. A resident family member bought a new watch for the resident on 5/31/19 and the receipt was submitted to the business office for reimbursement. Record Review of the facility policy titled Reporting Abuse to Facility Management dated (MONTH) 2014 revealed Step 2 definitions: To help with recognition of incidents of abuse, the following definitions of abuse are provided: Step 2 h. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Interview with the facility Administrator on 9/24/19 at 2:55 PM confirmed that if an item is reported as stolen, it is reported right away. If an item is missing, the facility looks for it to try and find it first. The Administrator confirmed that the facility was unable to provide documentation showing that an investigation was completed and submitted to the state agency within 5 working days. C) Review of Abuse/Neglect Investigation Report Form dated 5/30/19 revealed that on 5/25/19 Resident 14 was walking by Resident 40 when Resident 40 reached out and hit Resident 14 on the arm. No documentation related to submission of the investigation report to the state agency within 5 working days was present. Interview on 9/30/19 at 8:23 AM with the DON (Director of Nursing) revealed the facility was unable to provide documentation showing the investigation was submitted to the state agency within 5 working days. D) Review of Abuse/Neglect Investigation Report Form dated 6/12/19 revealed that on 6/7/19 Resident 69 reported NA-C (Nurse Aide) pushed Resident 69 into a wheelchair while being assisted to the bathroom. No documentation related to submission of the investigation report to the state agency within 5 working days was present. Interview on 9/24/19 at 3:24 PM with CSC (Clinical Services Coordinator) revealed the facility was unable to provide documentation showing the investigation was submitted to the state agency within 5 working days. | 2020-09-01 |
| 65 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 610 | D | 1 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview the facility failed to ensure that investigations of abuse were completed and that documentation of investigations of abuse were maintained for misappropriation of resident property for 1 resident (Resident 86), and for resident abuse resulting in injury for 1 resident (Resident 87). The facility census was 123. Findings are: A) Record review of the Progress note for Resident 86 dated 5/26/19 10:19 revealed that the family reported that the resident's watch was missing and that it was gold in color. Record review of the Progress note for Resident 86 dated 5/31/19 9:59 AM revealed that the resident's family member was here and reported that they bought the resident a new watch, gave the receipt to Social Services for reimbursement of the lost item and stated that it may have been stolen by a former employee. Record review of the facility grievances revealed an email dated 5/31/19 from the facility Social Services Director (SSD J) to the facility Grievance Officer. The email revealed that Resident 86 was missing a watch since 5/26/19. A resident family member bought a new watch for the resident on 5/31/19 and the receipt was submitted to the business office for reimbursement. Record Review of the facility policy titled Reporting Abuse to Facility Management dated (MONTH) 2014 revealed Step 2 definitions: To help with recognition of incidents of abuse, the following definitions of abuse are provided: Step 2 h. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Record review of the facility policy titled Abuse Prevention Program dated (MONTH) 2006 revealed the following steps: 3 f. Timely and thorough investigations of all reports and allegations of abuse; 3 g. The reporting and filing of accurate documents relative to incidents of abuse. Interview with the facility Administrator on 9/24/19 at 2:55 PM confirmed that if an item is reported as stolen, it is reported right away. If an item is missing, the facility looks for it to try and find it first. The Administrator confirmed that the facility was unable to provide documentation showing that an investigation was completed and submitted to the state agency within 5 working days. B) Interview with Resident 87 on 9/30/19 at 10:26 AM occurred in the resident room. A splint was observed in place on the resident's right pinky finger. When asked by this surveyor what happened to the resident's right pinky finger the resident responded that the resident (Resident 87) hit another resident in the head when another resident attempted to kiss the resident (Resident 87). Resident 87 confirmed that this was reported to facility staff in (MONTH) (2019). Record review of the nurse progress note for Resident 87 dated 3/5/19 at 10:45 PM revealed that the resident had complained of itching to the small right finger earlier in the evening at 9:00 PM. The finger was swollen, reddish purple in color and painful to touch, ice was applied at that time and continuing to monitor for any changes. Record review of the X-Ray report for Resident 87 dated 3/6/19 revealed that the resident had a [MEDICAL CONDITION] digit (pinky finger) of the right hand. Record review of the facility policy titled Abuse Prevention Program dated (MONTH) 2006 revealed the following steps: 3 f. Timely and thorough investigations of all reports and allegations of abuse; 3 g. The reporting and filing of accurate documents relative to incidents of abuse. Interview with the Clinical Services Consultant (CSC) on 9/30/19 at 11:07 AM confirmed that a state report was not completed or submitted for the resident to resident altercation that resulted in a [MEDICAL CONDITION] pinky finger for resident 87. The CSC confirmed that no notes or emails were located regarding the incident or an investigation. | 2020-09-01 |
| 66 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 622 | D | 1 | 1 | UZYC11 | > Licensure Reference Number 175 NAC 12-006.12E8b Based on record review and interview, the facility failed to ensure discharge instructions to included medication instructions and medication reconciliation with the resident or resident representative. This had the ability to affect one resident (Resident 326) of 1 reviewed. The facility census was 123. Findings are: Record review of an APS (Adult Protective Services) report dated 07/01/19 revealed; an anonymous reporter reported that Resident 326 was discharged to home on a Friday. Resident 326 had been picked up by a friend, and asked the MA (Medication Aide) if they could speak with the nurse for instructions for the medications and discharge instructions. Resident/Resident friend was told that the nurse was not available, the mediations were bagged and ready to go. A Pharmacist at the pharmacy reported that the bagged medications were not Resident 326's medications. Record review of Resident 326 Nurses note dated 06/28/2019 at 10:46 Resident 326's vital signs were stable. Discharge paperwork was signed by the M.D. and resident and the paper work was reviewed with resident and medications were sent home with (gender). A friend picked Resident 326 up at approximately 10 am and (gender) will call the Primary Care physician with any questions or concerns. Also Resident 326 had Interim health care at home phone number and has met with HHC (Home Health Care) Representative for info regarding services they offer. An interview on 09/25/19 at 03:05PM with the CSC confirmed; that Resident 326 was sent home Resident 333's medications. Both Resident 326 and 333 had medications bagged for home and the nurse grabbed the wrong bag of medications. The nurse manager was sent to the Pharmacy and retrieved Resident 333's medication. | 2020-09-01 |
| 67 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 644 | D | 0 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure a PASARR (Pre-admission/Resident Review an assessment to determine placement recommentations and services for residents with serious mental illness or mental disability) level 2 referral was completed for two sampled residents (Residents 77 and 116). The faciilty census was 123. Findings are: [NAME] Record review of Resident 77's, Face Sheet printed on 9/24/19 revealed the resident was admitted to the facility on [DATE]. Among the psychiatric [DIAGNOSES REDACTED]. Record review of Resident 77's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessments revealed the resident had a Quarterly assessment completed on 8/14/19. The MDS recorded the resident had not been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental [MEDICAL CONDITION] or a related condition. The MDS identified Psychiatric/Mood Disorder [DIAGNOSES REDACTED]. In the medication section of the MDS, the facility identified the resident received an Antipsychotic medication and an Antidepressant medication on 7 of the previous 7 days. Record review of Resident 77's PASRR documents from the resident's medical record revealed the resident received a PASRR Level I assessment on 1/18/05 and no PASRR Level II assessments during the resident's stay. Review of the PASRR Level I revealed the resident has substantial limitations for major life activities due to inability to make decisions, and capacity to independent living. The assessment did not record a [DIAGNOSES REDACTED]. The PASRR level I did not record that the resident received [MEDICATION NAME] (an antipsychotic medication) daily for dementia. Interview with CSC (Clinical Services Consultant) on 9/24/19 at 3:30 PM revealed there is not another PASRR for Resident 77 since the one that was completed on 1/18/05. The CSC confirmed Resident 77 was diagnosed with [REDACTED]. The CSC verified that Resident 77 was diagnosed with [REDACTED]. B. Record review of PASARR for Resident 116 dated 11/16/15 revealed; no SMI (Serious Mental Illness), no history of mental disorders, No behaviors, No concentration/task related problems, no adaptation to change, no mental health problems, and no significant disruption in life. Resident 116 had a primary [DIAGNOSES REDACTED]. Record review of Psychiatric Services dated 4/12/19 revealed; dx of [MEDICAL CONDITION] Major neurocognitive disorder, HX of [MEDICAL CONDITION]/anxiety with development of cognitive deficits. The Provider was asked to see due to agitation period of yelling out Resident 116 was noted to be confused but was calm during exam. Medications were increased [MEDICATION NAME] to 200mg TID (3 times daily) better overall. The medications prescribed for Resident 116 were [MEDICATION NAME] for [MEDICAL CONDITION] and [MEDICATION NAME] for [MEDICAL CONDITION] per chart. Record review of Care plan dated with a start date of 10/02/2018 Category: [MEDICAL CONDITION] Drug Use Resident 116 was at risk for adverse consequences R/T receiving antidepressant medication [MEDICATION NAME] and antipsychotic medication [MEDICATION NAME] for treatment of [REDACTED]. Care Plan dated with a start date of 07/03/2018 revealed that Resident 116 had behaviors of calling out help me frequently. [DIAGNOSES REDACTED]. On [MEDICATION NAME] for [MEDICAL CONDITION]. An interview on 09/24/19 03:36 PM CSC Q confirmed; the PASARR received from the facility that discharged Resident 116 did not reflect the residents current [DIAGNOSES REDACTED]. Record review of Resident 116 Annual MDS dated 9 revealed; Section A 1500 Prescreening and Resident Review was answered no, Level II 1510, 1550 had not been marked. Section I 4800 Non-Alzheimer's Dementia Section I 5300 [MEDICAL CONDITION] Section I 5900 [MEDICAL CONDITION] Section O No special therapies. | 2020-09-01 |
| 68 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 657 | D | 0 | 1 | UZYC11 | LICENSURE REFERENCE NUMBER 175 NAC 12-009.C1c Based on observation, record review, and interview the facility failed to ensure that the resident care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) was updated to include care for a facility acquired pressure ulcer (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin) for 1 resident (Resident 21) of 1 resident observed. The facility census was 123. Findings are: Record review of the physician Referral Form dated 8/29/19 confirmed that Resident 21 had a decubitus (pressure) ulcer on the 4th digit of the left foot. Record review of the nurse progress note for Resident 21 dated 8/29/19 at 5:35 PM noted a pressure ulcer to the resident's left foot 4th toe. Observation of wound care on 9/25/19 at 1:13 PM revealed Licensed Practical Nurse D (LPN D) entered Resident 21's room and removed the band aid from the resident's left 4th toe and the left great toe. A wound was observed on top of the resident's left 4th toe that was approximately 1 centimeter x 0.3 centimeter in size per visual measurement that was yellow and dry in the center with light red tissue around the wound edges. Record review of the resident care plan for Resident 21 revealed no interventions for the care of the resident's pressure ulcer. Interview with the Director of Nursing (DON) on 9/26/19 at 10:44 AM confirmed that the care plan for Resident 21 did not identify the resident pressure ulcer and required care. | 2020-09-01 |
| 69 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 661 | D | 1 | 1 | UZYC11 | > Based on record review and interview the facility failed to ensure a recapitulation of stay was completed for 1 resident of 1 reviewed (Resident 326). The facility census was 123. Findings are: Record review of Resident 326's medical record revealed; there was not a recapitulation of stay in the records. An interview on 09/26/19 at 10:33 AM with the CSC revealed; for Resident 326 there was not a recapitulation of stay that was documented. The facility had a PIP (Process Improvement Plan) in place on discharge planning and documentation. A part of the action plan was the facility was to do audits. The CSC reported that the employee that was in charge of the audits was no longer an employee. An interview on 09/26/19 at 10:46 AM with the CSC confirmed; that the employee had not kept the information from the audits for discharge planning PIP. | 2020-09-01 |
| 70 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 676 | D | 1 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D1c Based on record review and interview the facility failed to ensure that 1 Resident (Resident 332) received 2 baths per week. The facility census was 123. Findings are: Record review of MDS dated [DATE] revealed resident needed 1 assist during bathing. Record Review of care plan dated 02/26/19 revealed no documentation about residents bathing preferences. Record review of Preferences for Customary Routines sheet dated 12/30/17 revealed resident likes to shower in the evenings on Mondays and Thursdays. Record review of bathing log dated 01/01/2019-04/30/19 revealed no bath from 01/23/19- 03/18/19. Record review of bathing refusal dated 01/01/19- 04/25/19 revealed resident was in the hospital from 02/21/19-02/26/19, refused baths on 3/30/19,04/01/19,04/04/19, 04/06/19, 04/07/19, 04/21/19. An interview on 09/30/19 with DON confirmed Resident 332 did not receive baths from 01/23/19 - 03/18/19 with the exception of when the resident was in hospital or refused. | 2020-09-01 |
| 71 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 686 | D | 0 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review, and interview the facility failed to ensure that staff followed the standard of practice for wound care for pressure ulcers (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin), and the facility failed to document weekly assessment details for required wound assessment of a facility acquired pressure ulcer for 1 resident (Resident 21) of 1 resident observed. The facility census was 123. Findings are: [NAME] Record review of the physician Referral Form dated 8/29/19 confirmed that Resident 21 had a decubitus (pressure) ulcer on the 4th digit (toe) of the left foot. Record review of the facility procedure titled Wound Care dated (MONTH) (YEAR) revealed the following steps: 1. Use disposable cloth (paper towel is adequate) or disposable plastic cover to establish clean field on resident's over bed table or other appropriate area. Place all items to be used during procedure on the clean field. 6. Put on clean gloves. 7. Use tongue blades or applicators to remove ointments and creams from their containers. Observation of wound care on 9/25/19 at 1:13 PM revealed Licensed Practical Nurse D (LPN D) entered Resident 21's room and removed the band aid from the resident's left 4th toe. A wound was observed on top of the resident's left 4th toe that was approximately 1 centimeter x 0.3 centimeter in size per visual measurement that was yellow and dry in the center with light red tissue around the wound edges. LPN D placed the container of Silver [MEDICATION NAME] 1% cream (a topical antibiotic used on skin wounds to prevent infection) directly on the seat of the chair near the resident's bed along with two bandages with no cloth or barrier on the chair. LPN D performed soap hand washing and obtained a wash cloth with soap and water and cleaned the wound area on the top of the left 4th toe. LPN D dried the area lightly with a new wash cloth. LPN D put a glove on the right hand and squeezed the Silver [MEDICATION NAME] 1% cream from the tube directly onto the glove and then applied the cream to the 4th left toe wound. LPN D removed the glove from the right hand and discarded it. No hand washing was performed. LPN D applied a band aid to the resident's left 4th toe to cover the wound. LPN D gathered the cream and the soiled wash cloths and exited the resident room and walked to the soiled room on the 100 hall. LPN D entered the soiled room and then exited holding the cream container. LPN D walked to the 200 nurse station and started to chart on the computer at the nurse's station. Interview on 9/25/19 at 4:14 PM with the Clinical Services Consultant (CSC) confirmed that staff should use a q tip or something else to get the cream or ointment from the container to apply to the wound and not apply the cream or ointment to a glove for application. B. Record review of the physician Referral Form dated 8/29/19 revealed that Resident 21 had a 0.2 centimeter decubitus ulcer on the 4th digit of the left foot. Record review of the facility policy titled Skin Assessments and Pressure Ulcers/Skin Breakdown-Clinical Protocol dated (MONTH) (YEAR) revealed step 3a: Weekly skin assessments will be completed by the nurse and documented in the EHR (electronic health record). Record review of the facility Weekly Skin Assessment (a tool used to thoroughly document the assessment of a wound) revealed a section to document any skin issues present, a section directing the nurse to document the wound size (length x width X depth) for any skin issue present, and a section to document the character of the wound bed. The Weekly Skin Assessment also contained a section to describe the following: odor, pain, color, drainage, and surrounding tissue. Record review of the facility Weekly Skin assessment dated [DATE] for Resident 21 identified the pressure ulcer on the 4th digit (toe) of the left foot. The Weekly Skin Assessment contained no documentation of the wound size, character, or descriptions of the wound. Record review of the facility Weekly Skin assessment dated [DATE] for Resident 21 identified the pressure ulcer on the 4th digit (toe) of the left foot. The Weekly Skin Assessment contained no documentation of the wound size, character, or descriptions of the wound. Record review of the facility Weekly Skin assessment dated [DATE] for Resident 21 identified the pressure ulcer on the 4th digit (toe) of the left foot. The Weekly Skin Assessment contained no documentation of the wound size, character, or descriptions of the wound. Interview on 9/25/19 at 4:14 PM with the Clinical Services Consultant (CSC) confirmed that weekly skin assessments are completed for follow up of resident wounds and that the weekly skin assessment should contain a description and measurements of the wound. Interview with the Director of Nursing (DON) on 9/26/19 at 10:44 AM confirmed that Resident 21 had a pressure ulcer identified on the facility Nurses Weekly Skin assessment dated [DATE] and that the assessment did not include documentation of the wound size as directed by the assessment. The DON confirmed that the facility Nurses Weekly Skin Assessments dated 9/9/19 and 9/16/19 identified the resident pressure ulcer and did not include documentation of the wound size as directed on the assessment. | 2020-09-01 |
| 72 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 689 | D | 0 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, record review, and interview the facility failed to ensure that a fall event was documented and root cause analysis was completed for 1 resident (Resident 45) of 2 residents reviewed, and the facility failed to ensure residents were assessed for smoking safety on admission for 1 resident (Resident 6) of 2 residents reviewed. The facility census was 123. Findings are: An 09/25/19 at 12:30 PM of staff in the hallway addressing the w/c (wheelchair) for Resident 45 the NA reported that the they felt the back of the chair did not go back and the resident was at risk for a fall. RN V told the staff member to wait and get Resident 45 up later and set them at the table. A Record review of Fall Event - Altitude fall form dated 5/24/19 revealed; the document had not been completed. An interview on 09/26/19 at 01:14 PM with the CSC confirmed; that the fall event Altitude fall form had not been completed. Progress note IDT (Interdisciplinary Team) Risk Note dated 05/24/19 revealed; Resident 45 had a fall from the w/c (wheelchair), Resident 45 had pulled out call light from the wall and had self-transferred from the w/c to the bed. The alarm was not place back on the resident post therapy. The intervention: Resident 45 would have a safety alarm before and after therapy. Record review of Care Plan dated 05/01/2019 revealed; Resident 45 was at risk for falls due to: TODD paralysis (a paralysis is a neurological condition experienced by individuals with [MEDICAL CONDITIONS]([MEDICAL CONDITION] (Stroke)) and confusion. An intervention dated 05/24/19 for Resident 45 was to have alarm placed on wheelchair during all therapies. Occupational Therapy, Physical Therapy, Speech Therapy Approach Start Date: 05/24/2019 An observation on 09/26/19 at 1:00PM of Resident 45 seated at the table in a tilt in space w/c. Record review of Resident 45's MDS (Minimal Data Set an assessment used to assist in development of a comprehensive plan of care) Quarterly dated 9: Section C- revealed; Resident 45 was moderately impaired both short and long term memory. Section [NAME] revealed; No behaviors Section G revealed; Resident 45 required extensive assist with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Section H revealed; Resident 45 was always incontinent bowel and bladder. Section J Falls revealed; Resident 45 had falls since admission. Section O revealed; Resident 45 had not been in therapy. Section P revealed; resident 45 did not have alarms. B. Record review of the care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 6 revealed that the resident is a current tobacco user with the potential for smoking related injury. Interventions on the care plan included that a Smoking Observation (an assessment to identify resident safety and interventions for smoking safety) be performed upon admit, quarterly, and as needed. Record review of the Electronic Health Record for Resident 6 revealed the completion of the Facility Smoking Safety Observation on 8/6/19. No other Smoking Safety Observations assessments were documented in the resident record. The Smoking Safety Observation dated 8/6/19 confirmed that Resident 6 is allowed for supervised group smoking only, including smoking apron and staff to light cigarette. Record review of the Resident Face Sheet (a document that gives a resident's information at a quick glance that can include contact details, a brief medical history and the patient's level of functioning) for Resident 6 confirmed that the resident was admitted to the facility on [DATE]. Observation on 9/24/19 at 3:32 PM revealed that Resident 6 walked out into the facility courtyard. Certified Nursing Assistant (CNA) M handed a smoking apron (a protective cover to shield against hot ashes and dropped cigarettes) to Resident 6 and the resident put it on without assistance. CNA M handed a cigarette to Resident 6 and lit the cigarette for the resident. Interview with Resident 6 on 9/26/19 at 8:55 AM in the Lancaster dining room of the facility revealed that the resident came to the facility to live in (MONTH) of this year. Resident 6 confirmed that the resident was allowed to smoke from the time of admission to the facility. Observation on 9/26/19 at 9:47 AM in the facility courtyard revealed that Resident 6 was handed a smoking apron and a cigarette. CNA N then handed a cigarette lighter to Resident 6. Resident 6 lit the cigarette and then handed the lighter to CNA N. Interview on 9/26/19 at 9:47 AM with CNA N in the facility courtyard confirmed that Resident 6 lit his own cigarette and that the resident gave the lighter back right away. Interview on 9/26/19 at 10:44 AM with the Director of Nursing (DON) confirmed that Resident 6 was admitted to the facility on [DATE] and that the first and only Smoking Safety Observation completed for the resident was on 8/6/19. The DON confirmed that the facility Smoking Policy dated 8/17/19 directed that smoking risk observations are to be performed upon admission. The DON confirmed that the Smoking Safety Observation identified that Resident 6 required group supervised smoking only including a smoking apron and for staff to light the cigarette. | 2020-09-01 |
| 73 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 758 | D | 0 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.12B Based on record review and interview the facility failed to ensure that antipsychotic (a medication used to treat serious mental health conditions) gradual dose reduction (the periodic physician review of the amount of an antipsychotic medication to consider a decrease in the amount of the medication) (GDR) was addressed by the resident physician for 1 resident (Resident 17) of 3 residents reviewed. The facility census was 123. Findings are: Record review of the current Physician Orders for Resident 17 confirmed that the resident had an order to receive [MEDICATION NAME] (an antipsychotic medication used to treat [MEDICAL CONDITION]) 400 milligrams by mouth daily at bedtime that started on 11/14/16. Record review of the face sheet (a document that gives a resident's information at a quick glance that can include contact details, a brief medical history and the patient's level of functioning) confirmed that Resident 17 had a [DIAGNOSES REDACTED]. Record review of the facility policy titled Medication Management dated 9/10 revealed Guidelines for Psychotherapeutic Medication Monitoring of Antipsychotics step 1 g: Tapering of a medication dose/gradual dose reduction (GDR): Within the first year in which a resident is admitted on an antipsychotic medication or after the nursing care center has initiated an antipsychotic medication, the nursing care center must attempt a GDR in two separate quarters (a 3 month calendar period) (with at least one month between the attempts), unless clinically contraindicated. After the first year, a GDR must be attempted annually (yearly), unless clinically contraindicated. Record review of the health record for Resident 17 revealed a Note to Attending Physician/Prescriber dated 6/30/19 requesting that the physician evaluate the current dose and consider a dose reduction (GDR) for the [MEDICATION NAME] 400 milligrams. No documentation of the physician response to the GDR request was in the resident record. Interview on 9/30/19 at 1:53 PM with the Clinical Services Consultant (CSC) confirmed that Resident 17 had a current order for the antipsychotic [MEDICATION NAME] that was started on 11/14/16. The CSC confirmed that the gradual dose reduction request on 6/30/19 was not addressed and documented by the physician and that there was no documentation of a GDR attempt in the past year addressed by the physician. The CSC confirmed that a GDR must be attempted annually after the first year after starting an antipsychotic medication. | 2020-09-01 |
| 74 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 759 | D | 1 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation interview and record review the facility failed to maintain a medication error rate of less than 5 % which affected 2 residents (Residents 27 and 62) of 8 residents observed. The facility census was 123. Findings are: [NAME] An observation on 09/25/19 at 12:50 PM of RN (Registered Nurse) W prepared Humalog 100units/ML Kwik Pen, 10 units ( sub Q) subcutaneous ( a shot given in the skin between fat and musle layer) 3 times a day with meals. The Pen was dialed to 10 units. Hand Hygiene was performed with hand sanitizer. The insulin was taken to Resident 227 gloves donned and administered to the right abdominal area, gloves doffed, hand hygiene with hand sanitizer was completed. An interview on 9 at 12:55PM with RN W confirmed; the insulin pen had not been primed. The RN reported that they had not had training for priming the insulin pens. Record review of the Insulin Administration Policy dated [DATE] revealed; in the procedure step 11. When using an insulin pen, prime the pen, i.e. turn the vial dose to the select 2 units, press holding the dose button and make sure a drop appears. Record review of Insulin Administration Competency Check for Connie Blankenship RN revealed that the competency had not included insulin Pen. An interview on 09/25/19 at 245PM with CSC confirmed; the Insulin Administration Competency had not include the insulin pen. B) Observation on 9/25/19 at 7:20 AM of LPN-D (Licensed Practical Nurse) administering Resident 62's insulin revealed LPN-D drew 11 units of [MEDICATION NAME] 70/30 insulin (medication that lowers blood sugar - contains 70% intermediate-acting insulin and 30% short-acting insulin) into an insulin syringe and administered subcutaneous (under the skin, between the skin and muscle) into Resident 62's abdomen. Review of Resident 62's Physician order [REDACTED]. Interview on 9/25/19 at 2:33 PM with LPN-D confirmed LPN-D administered 11 units of 70/30 insulin to Resident 62. LPN-D confirmed the physician's orders [REDACTED]. | 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 |
| 76 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 802 | F | 1 | 1 | UZYC11 | > Licensure Reference Number 175 NAC 12-006.04D Based on Observation, interview and record review the facility fails to ensure sufficient dietary staffing to provide meals to residents. This had the potential to affect 121 residents that receive food from the facility kitchens. The facility census was 123. Findings are: Observation on 09/24/19 at 12:00 - 1:00PM revealed first food to leave kitchen was unit 1 - 2 room trays at 12:05 PM; Scheduled meal time 11:25PM. Station 4 cart left kitchen at 12:14 PM, meal time 11:45AM. Lincoln dining room cart left at 12:23PM; First tray served at 12:25 PM- last tray served at 12:34PM. Lancaster cart left kitchen at 12:44 PM, meal time 12:00PM. Station 3 meal trays left kitchen at 12:48 PM, Meal time 12:15 PM An interview on 09/24/19 at 10:40AM with DM ( Dietary Manager) revealed current dietary staff consists of 3 aides on day and 1 cook, evenings 4 aides and 1 cook. DM states she is the only cook so she is currently filling the positions of Dietary Manager and cook. An interview on 09/24/19 at 12:35PM with Residents 14 and 42 revealed the lunch meal is scheduled to be served at 11:45AM; frequently meal are not served until 12:30PM or later. | 2020-09-01 |
| 77 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 812 | E | 1 | 0 | UZYC11 | > Licensure Reference Number 175 NAC 12-006.11E Based on observation and interview the facility failed to ensure all hair was enclosed in hairnets, complete proper hand hygiene to prevent the spread of food borne illness, to maintain a clean kitchen and to follow facility policy after employee injury. This had the potential to affect all residents that consume food prepared in the facility kitchen. The facility census as 123. Findings are: [NAME] Record review of The Nebraska Food Code dated (MONTH) 2012 Section 2-402.11 revealed the following related to Hair Restraints effectiveness: Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair that are designed and worn to effectively keep their hair from contracting exposed food, clean equipment, utensils and linens and unwrapped single service and singe use articles. Observation on 09/24/19 at 10:10 AM revealed DA (Dietary Aide) S and T and DM (Dietary Manager) had hair exposed outside of hairnets. Observation on 09/24/19 at 10:48AM revealed DA - S had hair outside of hairnet while working in kitchen. Observation on 09/24/19 at 11:05 AM revealed SP (speech pathologist) U was in kitchen without a hairnet covering hair. An interview on 09/24/19 at 4:40 PM with DM (Dietary Manager) revealed (gender) was not aware that all hair needed to be enclosed in hairnet. B. Record review of Policy titled Handwashing/Hand Hygiene dated 04/2012 revealed the following steps: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow he handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Employees must wash their hands for at least Fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: 5 c. Before and after direct resident care (for which hand hygiene is indicated by acceptable professional practice); 5 f. Before and after eating or handling food (hand washing with soap and water); 5 g. Before and after assisting a resident with personal care; 5 k. Before and after assisting a resident with toileting (hand washing with soap and water); 5 o. After handling soiled or used linens, dressing, bedpans, catheters, and urinals; 5 p. After handling soiled equipment or utensils; 5 r. After removing gloves RA (Restorative Aide) H assisted Resident 274 to unlock wheelchair breaks and move out of the dining room. RA- H then preformed hand washing for 9 seconds then continued to help residents eat. Observation on 09/24/19 at 10:28AM revealed DM washed hands for 11 seconds. Observation on 09/24/19 at 10:45-10:48AM revealed DM started food processor and walked away leaving food processor running, DM washed hands for 11 seconds. Observation on 09/24/19 at 11:55 AM revealed TA (Tray Aide) R washed hands for 8 second after preparing desserts. Observation on 09/24/19 at 11:58AM revealed TA-R preformed hand hygiene for 8 seconds after preparing food in the kitchen. C. Observation on 09/23/19 from 7:40-8:00AM revealed a white substance on the wall behind ice machine. Mixer was dirty with white yellow dried on substance. Observation on 09/23/19 at 9:18[NAME]M revealed dishwasher component box was covered in a fuzzy gray substance. Observation on 09/24/19 at 9:25 AM kitchen floors covered in grease, very slippery. Observation on 09/24/19 at 11:01 AM revealed cob webs on lights above stove, crumbs around toaster and steam table had dried yellow substances to lids and table. An interview on 09/24/19 at 4:40 PM with DM (Dietary Manager) confirmed the kitchen should be clean and free from dried on food particles. D. Record review of Policy titled Accidents Causing Breaks in Skin in Nutritional Service Area not dated revealed the following: Nutritional Service personnel should wear gloves after performing hand washing to provide a barrier between hands and food during food preparation or service as appropriate. In the event a food service worker is cut, sliced or nicked on hand or finger the following should be completed. 1. Immediately stop preparing, cooking food and go to hand washing sink. 2. Cover open are with paper towel and apply light pressure to stop the bleeding. 3. Determine if stich or other type of closure is necessary for the wound. 4. Wash hands using antibacterial soap. 5. If closure of wound is not needed, apply bandage, finger cot or finger stall to the open area. 6. Apply gloves prior to restarting your work flow. The bandage finger cots or finger stalls represent a potential physical hazard when worn by a food employee during food preparation. 7. Any food product that was in contact with blood or body fluid must be discarded. 8. The work service area must be cleaned with bleach wipe if blood or body fluid were present following instruction on the bleach wipe container. Observation on 09/24/19 at 10:58AM revealed DM was cutting open frozen packages of broccoli with large a kitchen knife. I Surveyor noticed red color through glove to left hand middle finger. DM did not notice, informed DM of cut. DM stated she did not think knife had went through the glove. DM instructed to removed gloves and wash hands; assess cut.DM removed gloves and washed hands and applied band aide to middle finger on left hand. DM returned to broccoli in pan with knife, DM stated I don't think anything was contaminated. Instructed DM to discard pan with broccoli and knife and start over with new equipment and broccoli. An interview on 09/24/19 at 11:59 AM with DM revealed any time an incident happens in the kitchen a report is completed and they are to seek assistance from nursing if injury is severe. DM stated (gender) would write up incident report after lunch services. | 2020-09-01 |
| 78 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 880 | E | 1 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175NAC 12-006.117D Based on observation, record review, and interview the facility failed to ensure that handwashing was performed after glove removal during resident cares and wound cares for 4 residents (Residents 21, 10, 77 and 86). This had the potential to cause cross contamination between dirty and clean areas. The facility failed to ensure that handwashing to prevent the potential for cross contamination occurred during activities of daily living (ADLs). This had the potential to affect 2 residents (Residents 10 and 38). The facility census was 123. Findings are: Record review of the facility policy titled Handwashing/Hand Hygiene dated (MONTH) 2012 revealed the following steps: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow he handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Employees must wash their hands for at least Fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: 5 c. Before and after direct resident care (for which hand hygiene is indicated by acceptable professional practice); 5 g. Before and after assisting a resident with personal care; 5 o. After handling soiled or used linens, dressing, bedpans, catheters, and urinals; 5 p. After handling soiled equipment or utensils; 5 r. After removing gloves [NAME] Observation on 9/25/19 at 7:34 AM revealed that nursing assistant I (NA I), certified nursing assistant O (CNA O), and Registered Nurse P (RN P) entered the room of Resident 86. NA I entered the resident bathroom and turned the water on in the sink. NA I placed soap on NA I hands and immediately placed the hands under the running water while scrubbing the hands under the running water for 15 seconds. NA I dried the hands and turned the water off with a new paper towel and put on gloves. NA I talked to Resident 86 and explained the cares that would be provided to the resident. NA I removed the gloves and obtained a trash bag and placed it at the foot of the resident bed. NA I entered the resident bathroom and put soap on the hands and scrubbed the hands under running water for 5 seconds and dried the hands. NA I put on new gloves. NA I obtained a disposable wipe and wiped the perineal area (the genitals and anal area) turning the disposable wipe after each wipe. NA I removed and discarded the gloves and put new gloves on with no handwashing performed. NA I obtained a new disposable wipe and completed washing of the resident front perineal area. NA I removed the gloves and put on new gloves with no handwashing performed. NA I repositioned Resident 86 onto the resident's right side and removed the resident brief from the resident buttocks. NA I wiped the resident anal area from front to back and then disposed of the wipe and removed the gloves. NA I put on new gloves with no handwashing performed. NA I applied skin protectant lotion to the resident anal area and buttocks. NA I removed the gloves and put on new gloves with no handwashing performed. NA I placed a new brief underneath the resident's buttocks and secured the brief on the resident. NA I removed the gloves and put on new gloves with no handwashing performed. CNA O removed gloves from CNA O's hands and put on new gloves with no handwashing performed. NA I dressed the resident putting elastic hose on both resident legs and then placed the soiled soaker pad from under the resident into the trash bag at the foot of bed. NA I removed NA I's gloves and put on new gloves with no handwashing performed and put pants on the resident. NA I untied and removed the gown from Resident 86 and put a shirt on the resident. NA I placed the resident gown in the trash bag at the foot of the resident's bed and removed the gloves. NA I put on new gloves with no handwashing performed. NA I placed a lift sling underneath the resident. CNA O removed the gloves from CNA O's hands and no handwashing was performed. NA I placed shoes on the resident's feet. NA I positioned the total body lift (a mechanical device used to lift and transfer residents from one surface to another) and connected the lift straps to the lift. NA I informed Resident 86 of the transfer to the resident's wheelchair from the bed. The resident was transferred from the bed into the wheelchair by NA I and CNA O. NA I moved the mechanical lift away from the resident wheelchair and removed the gloves. NA I performed handwashing for 3 seconds scrubbing with soap under running water. RN P placed a sweater on Resident 86 and placed a lap blanket over the resident's legs and lap. NA I put on gloves and applied denture adhesive to the resident's upper and lower dentures. NA I placed the lower denture in the resident's mouth and then placed the upper denture in the resident's mouth. NA I removed the gloves and performed soap handwashing under running water for 3 seconds and dried the hands and put on new gloves. NA I wet a wash cloth and cleaned Resident 27's face. NA I patted the resident face dry with a dry cloth and then removed the gloves and put on new gloves with no handwashing performed. B. Observation of wound care on 9/25/19 at 1:13 PM in Resident 21's room. LPN D entered the resident room and removed the band aid from the resident's left 4th toe. LPN D performed handwashing with soap in the bathroom sink and obtained a wash cloth soaked with soap and water and cleaned the wound area on the top of the left 4th toe. LPN D dried the area lightly with a new wash cloth. LPN D put a glove on the right hand of LPN D and squeezed the Silver [MEDICATION NAME] 1% cream (a topical antibiotic used on skin wounds to prevent infection) from the tube directly onto the glove and then applied the cream to the 4th left toe wound of the resident. LPN D removed the glove from the right hand and discarded it. No handwashing was performed. LPN D applied a band aid to the resident's left 4th toe to cover the wound. LPN D gathered the Silver [MEDICATION NAME] 1% cream and the soiled wash cloths and exited the resident room and walked to the soiled room on the 100 hall. LPN D entered the soiled room and then exited holding the Silver [MEDICATION NAME] 1% cream container. LPN D walked to the 200 nurse station and started to chart on the computer at the nurse's station. No handwashing was performed. Interview with the Director of Nursing (DON) on 9/26/19 at 10:44 AM confirmed that hand washing is to be performed by staff each time after glove removal. Interview with on 9/26/19 at 10:57 AM the facility Infection Control Coordinator U (ICC U) confirmed that the facility hand washing procedure directed staff to scrub the hands with soap for a minimum of 15 seconds over the sink and not scrub under running water before rinsing the soap off. ICC U confirmed that staff are to complete hand washing each time gloves are removed. C. Observations of Resident 77's wound care on 9/24/19 from 7:17 AM until 7:45 AM with LPN-T (Licensed Practical Nurse) and NA-I (Nurse Assistant) revealed the following: -LPN-T donned gloves to provide cares to resident's legs and feet, -LPN-T removed gloves and washed hands less than 10 seconds -LPN-T donned gloves and provided ordered cream to resident legs -NA-I removed gloves but failed to wash or sanitize hands and left resident room -LPN-T removed gloves but failed to wash or sanitize hands -NA-I applied gloves after reentering the room but failed to wash or sanitize hands -LPN-T applied gloves and provided ordered lotion to residents legs -LPN-T removed gloves but failed to wash or sanitize hands -LPN-T applied gloves and washed area on back of left leg, and applied a [MEDICATION NAME] boarder (a versatile all-in-one bordered foam dressing, that minimizes patient pain and trauma to the wound and surrounding skin at removal while reducing the risk of maceration (occurs when skin is in contact with moisture for too long, skin looks lighter in color and wrinkly, it may feel soft, wet or soggy to touch) -NA-I removed gloves and washed hands less than 10 seconds and exited the resident room -LPN-T removed gloves and washed hands less than 10 seconds -LPN-T applied gloves and sterilized (cleansed with alcohol pad) scissors and proceeded to cut Interdry roll (fabric is a moisture-wicking antimicrobial silver that effectively manages complications associated with skin folds) -LPN-T removed gloves but failed to wash or sanitize hands -LPN-T applied gloves and placed the cut Interdry in abdomen folds -LPN-T removed gloves but failed to wash or sanitize hands -LPN-T applied gloves and cleansed the basin -LPN-T removed gloves but failed to wash or sanitize hands, removed trash and the linen bag -LPN-T left the resident room and obtained a container of chlorox wipes (a disinfecting wipe used to remove germs, and bacteria) -LPN-T applied gloves and wiped off the scissors and basin with chlorox wipes -LPN-T removed gloves but failed to wash or sanitize hands -LPN-T applied gloves and put the basin in a plastic bag -LPN-T removed gloves but failed to wash or sanitize hands -LPN-T put gloves in trash bag, box of gloves in the bathroom, and washed hands less than 10 seconds -LPN-T left resident room During an interview on 9/25/19 at 7:48 AM, LPN-U (Licensed Practical Nurse) verified that NA-I and LPN-T should have washed or sanitized hands before starting resident cares, before putting on clean gloves and after removing soiled gloves. D. The CDC (Center for Disease Control and Prevention) Campaign 4 Moments of Hand Hygiene (MONTH) 15, (YEAR). Hand hygiene should be performed before gloves are removed from the glove box (non-sterile) or package (sterile) to prevent contamination of the box or package and to ensure hands are clean under the gloves. If possible, leave the gloves in their original box or package until they are donned (applied). Gloves that touch anything unclean (e.g. surfaces, objects, face, pockets) are contaminated and become a means for spreading micro-organisms. Record review of the facility policy titled Handwashing/Hand Hygiene dated (MONTH) 2012 revealed the following steps: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow he handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Employees must wash their hands for at least Fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: 5 c. Before and after direct resident care (for which hand hygiene is indicated by acceptable professional practice); 5 f. Before and after eating or handling food (hand washing with soap and water); 5 g. Before and after assisting a resident with personal care; 5 k. Before and after assisting a resident with toileting (hand washing with soap and water); 5 o. After handling soiled or used linens, dressing, bedpans, catheters, and urinals; 5 p. After handling soiled equipment or utensils; 5 r. After removing gloves Record review of Resident 10's MDS (Minimum Data Set) (dated 9/16/19 revealed resident is always incontinent of bowel and bladder; no current bowel program. Observation on 09/23/19 at 10:50AM revealed LPN ( Licensed Practical Nurse) A arrived to resident room knocked on door, entered room, did not perform hand hygiene, applied gloves, asked resident to spread her legs to view private area, nurse stated area on labia is red and raw, resident then asked bottom to be looked at, resident turned on side, bowel movement present nurse preformed perineal care and removed gloves, no hand hygiene preformed, new gloves applied; bottom area assessed no red area noted. Bed pad was removed and placed on floor not in a bag. New pad was placed under resident. Nurse then went into restroom to get trash bag for soiled bed pad, removed gloves and took bed pad trash bag out of room, leaving bowel movement and wipes in trash with soiled gloves. Nurse did not perform hand hygiene before leaving residents room. Record Review of TAR (Treatment Administration Record) dated 07/16/2019 revealed an order to treat wounds to Resident 10's bilateral lower legs: lotion to all areas (other than open areas) daily. Record review of TAR dated 08/13/2019 revealed the following order wound care order: wash bilateral legs daily and apply [MEDICATION NAME] (topical antibiotic used to prevent infections or treat burns) ointment to open areas, apply ABD's (Abdominal pads) (used to cover large wound areas), gauze wrap and tub grip (a comfortable skin friendly tubular support bandage that easily contours to body) on Mondays, Wednesdays, and Fridays. Observation on 09/25/19 from 10:25 AM - 11:03 AM revealed LPN (Licensed Practical Nurse) T washed hands for 20 seconds, applied new gloves, removed towel covering resident's legs, removed gloves, and applied new gloves. Opened cream tube, placed cap from tube on bed face down. Removed ointment from tube with Q-tip applied to areas on left leg and right leg, removed gloves. Preformed hand hygiene for 20 seconds. Applied new Gloves, lotion applied to remaining areas. LPN -T washed hands for 12 seconds. Gloves applied, ABD's were applied to legs. Bilateral legs wrapped with gauze starting at top of leg working down. Tearing tape during procedure contaminating entire roll of tape. Hand washing completed for 20 seconds. Nylons applied to resident's feet/ legs. NA (Nursing Assistant) I entered room washed hands for 3 seconds, removed gloves from pant leg pocket and applied them, assisted in applying tub grip. NA-I removed gloves. Applied new gloves again from pant pocket. NA Reese washed hands for 8 seconds. ICC (Infection Control Coordinator) U assisted with holding residents legs, then washed hands for 8 seconds. An interview on 09/26/19 at 2:30 PM with DON confirmed hand hygiene should be performed for 15-20 seconds following facility policy and gloves should not be carried in staff pockets and used. E. An observation on 09/25/19 at 10:23 AM of Perineal care for Resident 58 - NA [NAME] performed Hand Hygiene from 10:33:12 to10:33: 27 (15 seconds). The wheel chair pedals were removed from the wheelchair. Resident 58 was transferred with one person assist and a gait belt to the bed via pivot transfer. NA [NAME] gloves were donned gloves while Resident 58 was able to get into the bed from the bed side without assistance. Resident 58's pants were pulled down to the residents ankles and the resident was exposed (no blanket covered the resident) the brief was removed and the resident had been incontinent. Perineal care was completed. Gloves doffed and hand hygiene was performed with hand sanitizer, gloves donned bed pan was placed per resident request. NA [NAME] removed the gloves. Resident 58 requested to be covered. The NM (Nurse Manager) had to exit room to ask staff to get a cover. The resident asked for privacy and was given privacy. NA [NAME] performed hand hygiene from 10:45:07-10:45:17 (8 seconds). NA [NAME] donned gloves and perineal care was completed. NA [NAME] performed hand hygiene from10:51:59-10:52:05 (6 seconds). An interview on 09/25/19 11:01 AM with NA [NAME] confirmed; that hand hygiene, lathering of the hands should be for 20 seconds. Hand washing policy dated (MONTH) 2012 revealed; that Employees must wash hands for 20 seconds using antimicrobial or non antimicrobial soap and water. | 2020-09-01 |
| 79 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-12-23 | 710 | D | 1 | 0 | BF8Z11 | > LICENSURE REFERENCE NUMBER 12-006.08 AND 12.006.08A The facility failed to ensure that the facility followed practictioners orders regarding the residents order for resident care. This affected 1 resident. Findings are: Record review revealed that the staff did not follow the practictioners orders in regards to the residents and specific orders for resident care. The record review confirmed that the facility staff allowed alternate practioners to write orders and follow thru with care areas by a different practioner. 12/23/2019 at 1:45 PM Interview with the Director of Nurses revealed that the facility staff did allow alternate practioners to write orders on resident 3. | 2020-09-01 |
| 80 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2019-03-13 | 561 | D | 1 | 0 | 4O5N11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(4) The findings are: Based on interview and record review the facility staff failed to ensure that 1 resident (Resident 2) of 1 sampled resident was bathed according to their bathing preference. Interview conducted on 3/12/19 at 1:00 PM with Resident 2 revealed that Resident 2 prefers a bath twice a week and had not had a bath since admission on 3/4/19. Record Review of bath preferences dated 3/5/19 revealed that Resident 2 preferred a shower twice a week. Record Review of progress notes since admission revealed no documentation of Resident 2 receiving or refusing a bath. Interview conducted on 3/13/19 at 1:43 PM with the Director of Nursing confirmed that Resident 2 had a preference of 2 showers a week and there was no documentation that resident 2 had received a bath. | 2020-09-01 |
| 81 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2019-03-13 | 657 | D | 1 | 0 | 4O5N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1b Based on record review and interview the facility failed to revise a care plan with current diet for 1 (Resident 4) of 1 sampled resident. The facility staff reported a census of 129. The findings are: Review of current physician orders [REDACTED]. Review of the meal intake documentation revealed that Resident 4 consumed 25-75% of meals. Review of Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 2/18/2019 revealed a functional status of supervision for eating. Record review of the current CCP (Comprehensive Care Plan) dated 1/6/19 and updated 2/20/19 revealed that Resident 4 was tube feeding dependent and NPO (Nothing by Mouth). Interventions included: 1. Calorie/Protein/Fluid needs will be met with tube feeding regime. 2. NPO per doctors' orders. 3. Provide tube feeding per doctors' orders. The CCP did not include the current dietary status for Resident 4 of Pureed Diet with Honey Thickened Liquids. Review of the Policy and Procedure dated (MONTH) (YEAR) revealed Assessments of residents are ongoing and care plans are revised as information about the residents' condition changes. Interview on 3/13/19 at 1:11 PM conducted with the Director of Nursing confirmed that the CCP should have been revised to include current dietary status for Resident 4. | 2020-09-01 |
| 82 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2017-06-06 | 157 | D | 0 | 1 | LLQX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview; the facility staff failed to notify the physician of low blood pressures for 1 (Resident 219) of 1 residents. The facility staff identified a census of 128. Findings are: [NAME] Record review of a Physician Order's Sheet for 6-2017 revealed an order for [REDACTED]. Record review of Resident 219's Medication Administration Record [REDACTED]. Review of Resident 219's medical record that included progress notes, physician progress notes [REDACTED]. blood pressures as directed. On 6-6-2017 at 10:41 am an interview was conducted with the facility Director of Nursing (DON). During the interview the DON reported not being able to locate any information that Resident 219's physician had been called when Resident 219's blood pressures were low as directed. | 2020-09-01 |
| 83 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2017-06-06 | 242 | D | 0 | 1 | LLQX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05 (4) Based on record review and interviews, the facility failed to ensure resident choices for bathing were followed for Resident 182 and Resident 222. The facility Census was 128. Findings are: [NAME] Interview with Resident 182 on 05/31/2017 at 03:04 PM revealed Resident 222 had not been offered a bath since being admitted to the facility 6 days prior on 5/25/2017. Interview on 06/05/2017 at 11:05 PM with the Assistant Director of Nursing (ADON)-D revealed the nursing staff ask the residents on admission about their bathing preferences and forward the preference sheets to ADON-D. ADON-D places the resident on the bath schedule with the use of the sheet. Interview on 06/05/2017 at 12:58 PM with the Director of Nursing (DON) revealed Resident 222 should be placed on the bath schedule based on personal preference. Review of facility form titled Bath Preferences dated 5/25/2017 revealed Resident 222 prefers 2 baths per week on Tuesday and Friday in the morning and prefers a shower. Review of the bath schedule dated as updated on 6/2 revealed Resident 222 is scheduled for Tuesday and Thursday and does not specify that Resident 222 prefers it in the morning. Review of the facility documentation of baths located under tasks in the electronic medical record revealed Resident 222 had received one bath since admission on Thursday, 6/1/2017 at 2:29 PM. Interview with the DON on 6/6/2017 at 1:30 PM revealed Resident 222 is not scheduled for baths on her preferred schedule. Findings are: B. Record review of Resident 182's Admission Record dated 6/6/17 revealed that Resident 182 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident 182 on 6/1/17 at 8:50 AM revealed that his choice of bathing was a shower, 2 x a week and to be performed by the male musing assistant, in the evening. Resident 182 revealed that he had not been receiving his shower 2 x week. Resident 182 revealed that the male who performs his showered had changed shifts, and after that he did not receive a shower. Record review of Resident 182's comprehensive care plan revealed that the facility identified a Self Care Performance Deficit. The plan of care for Resident 182 included interventions that follow: Resident 182 requires extensive staff participation with personal hygiene, dated 1/17/17 Resident 182 is dependent on staff to provide a bath as necessary, dated 1/17/17 Record review of the facility bathing schedule revealed that Resident 182 was to receive shower two times per week in the evening on Sunday and Wednesday. Record review of the facility documentation of bathing received by resident revealed that Resident 182 had bathing performed on the following dates, for the month of May; 5/10,5/17,5/21,5/28,5/31. There was no record of bathing for the month of June. Interview with Nursing Assistant (NA) G on 6/6/17 at 8:44 AM confirmed that the schedule performed had changed from evening shift to day shift. NA G confirmed that the duties of the shower for Resident 182 had been changed to other staff. Interview with Assistant Director of Nursing (ADON) D confirmed that Resident 182's choices of bathing had not been met, that Resident 182 had not been provided shower 2 x week for (MONTH) or June. ADON D confirmed that the facility had made staffing changes and had not provided care as per Resident 182's plan of care. | 2020-09-01 |
| 84 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2017-06-06 | 253 | D | 0 | 1 | LLQX11 | Licensure Reference Number 175 NAC 12-006.18A Based on observations and interviews, the facility failed to ensure the cleanliness of rooms and ventilation systems in 4 resident rooms (103,104,201, 203) of 88 resident rooms. The facility identified the resident census at 128. The findings are: An observation conducted on 5/31/17 at 10:37 AM of the bathroom in room 104 revealed a puddle of liquid on the floor with rust colored stains on the flooring and a urine odor. An observation conducted on 5/31/17 at 10:35 AM of the bathroom in room 103 revealed a buildup of tan fluffy material resembling dust on the vent to the ventilation system. An observation conducted on 5/31/17 at 10:43 AM of the bathroom in room 201 revealed cobwebs were hanging from the ceiling above the sink and from the ventilation system vent. An observation conducted on 6/1/17 at 9:12 AM of room 203 revealed an unpainted drywall patch with a buildup of wall sanding dust on the wall and chair rail. An environmental tour conducted on 6/6/17 from 8:10 AM to 8:27 AM with the facility Administrator revealed the following: -Room 103 bathroom had cobwebs and dust buildup on the ventilation system vent. - Room 104 bathroom had a puddle of liquid on the floor around the toilet with rust stains and a small red tablet resembling a pill was dissolving in the liquid which had developed a red stain on the floor. -Room 104 bathroom had a urine odor. -Room 201 bathroom had cobwebs on the ceiling and ventilation system vent. -Room 203 had a buildup of white dust from sanding drywall patch on the wall and chair rail. The Administrator confirmed the above findings during the tour. | 2020-09-01 |
| 85 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2017-06-06 | 315 | D | 0 | 1 | LLQX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D3 Based on observations, interviews, and record reviews; the facility failed to evaluate incontinence and implement a toileting program for 1 resident (Resident 119) of 3 residents sampled. The facility identified the census at 128. The findings are: A review of Resident 119's Admission Record dated 6-5-2017 revealed Resident 119 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An observation conducted on 5/31/17 at 10:37 AM of Resident 119's bathroom revealed a urine odor in the bathroom with puddles of liquid that resembled urine on the floor surrounding the toilet. An observation conducted on 5/31/17 at 2:17 PM revealed Resident 119 had a urine odor about them. An observation conducted on 6/5/17 at 7:31 AM revealed Resident 119 sitting on the side of the bed with a urine odor about them. Resident 119's bathroom was observed to have a urine odor, puddles of liquid that resembled urine surrounding the toilet, and a sticky floor. An interview conducted on 6/5/17 at 12:32 PM with Nursing Assistant (NA) C revealed that Resident 119 was independent with dressing, toileting, and hygiene. NA C reported that Resident 119 was occasionally incontinent of urine and would turn on their call light when they needed a new incontinence brief. NA C also reported that the resident would often miss the toilet when urinating. An observation conducted on 6/5/17 at 3:38 PM of Resident 119's bathroom revealed a urine odor and a sticky floor. An observation conducted on 6/6/17 at 9:44 AM revealed Resident 119 sitting in their recliner with a urine odor about them. Resident 119's bathroom was observed to have a puddle that resembled urine on the floor next to the toilet. A review of Resident 119's Comprehensive Care Plans dated 11/23/15 and 2/7/17 revealed that Resident 119 was occasionally incontinent of urine and nursing staff were to complete an Incontinence Data Collection Tool quarterly and as needed. A review of Resident 119's medical record revealed a Quarterly Data Collection Tool dated 6/3/16 that indicated Resident was continent and was not on a bladder retraining program. A review of Resident 119's medical record revealed a Quarterly Data Collection Tool dated 11/3/16 that indicated Resident was usually incontinent and was not on a bladder retraining program. A review of Resident 119's Annual Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 11/17/16 revealed that Resident 119 was occasionally incontinent of urine and was not on a toileting plan. A review of the facility's Urinary Incontinence-Clinical Protocol dated (MONTH) 2013 Monitoring: 1. The staff and physician will review the progress of individuals with impaired continence until continence is restored or improved as much as possible, or it is identified that further improvement is unlikely. a. This should include documentation of a resident's responses to attempted interventions such as scheduled toileting, prompted voiding, or medications to treat incontinence. An interview conducted on 6/5/17 at 3:49 PM with the Director of Nursing (DON) revealed the expectation was that incontinence was to be evaluated at onset for medical or physical cause of incontinence. An interview conducted on 6/6/17 at 8:55 AM with The DON revealed that the Quarterly Data Collection Tool was the only tool that the facility used to evaluate incontinence on a quarterly basis. The DON reported they were not sure if there were any completed on Resident 119 since (MONTH) (YEAR). An interview conducted on 6/6/17 at 10:27 AM with the DON revealed that their was not a quarterly evaluation completed on Resident 119 since (MONTH) (YEAR) and they were not sure when or why the tool was not being completed. The DON reported the facility's system for the evaluation and treatment of [REDACTED]. | 2020-09-01 |
| 86 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2017-06-06 | 323 | E | 0 | 1 | LLQX11 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.18E3a Based on observation and interview the facility failed to maintain water temperatures in a manner to prevent potential burns in 17 resident rooms (315, 317, 401, 403, 404, 405, 104,101,204,100,105,203, 112,201,209,103, and 208). Findings are: The facility policy for Water Temperatures, Safety of dated revised (MONTH) 2010 revealed that: Tap water in the facility shall be kept within a temperature range to prevent scaling of residents. Policy Interpretation and Implementation 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more that 108 degrees Fahrenheit, or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. Observations on 5/31/17 at 10:20 AM thru 10:55 AM the following rooms were found to have the following temperatures: Room 315 - 127.7 degrees Fahrenheit Room 317 - 129.7 degrees Fahrenheit Room 401 - 131.5 degrees Fahrenheit Room 403 - 136.7 degrees Fahrenheit Room 404 - 139.2 degrees Fahrenheit Room 405 - 133.2 degrees Fahrenheit Room 104 - 134.2 degrees Fahrenheit Room 101 - 134.8 degrees Fahrenheit Room 204 - 132.2 degrees Fahrenheit Room 100 - 125.0 degrees Fahrenheit Room 105 - 133.6 degrees Fahrenheit Room 203 - 138.5 degrees Fahrenheit Room 112 - 136.9 degrees Fahrenheit Room 201 - 137.1 degrees Fahrenheit Room 209 - 129.6 degrees Fahrenheit Room 103 - 133.0 degrees Fahrenheit Room 208 - 127.2 degrees Fahrenheit Interview with Resident 166 on 5/31/17 at 10:40 AM revealed that the water temperature from the handwashing fixtures was too hot, Resident 166 stated that, is careful not put a hand under the hot water, until cold was added. Interview with Resident 111 confirmed that the water temperature from the handwashing fixtures was hot but that has not been burned, knows to add cold water to wash hands. Interview with Resident 172 confirmed that the water temperature from the handwashing fixtures was in need of being regulated with the cold before using. Record review of Maintenance Logs for the facility revealed that daily temperature checks were being performed in random rooms at random times and that the facility record revealed temperatures of a range of 102-108 on 5/31/17 at 9 AM. Observation on 5/31/17 at 10:50 AM in room 404 with the facility Administrator and Maintained Supervisor revealed that the water temperature from the handwashing fixtures was 133.8 degrees Fahrenheit, with facility and surveyor thermometers. Observation on 5/31/17 at 10:49 AM in room 405 B with the facility Administrator and Maintenance Supervisor revealed that the water temperature from the handwashing fixtures was 133.2 Interview with the facility Administrator confirmed that the water temperatures in resident rooms 315, 317, 401, 403, 404, 405, 104,101,204,100,105,203, 112,201,209,103,and 208, was not in a temperature range to prevent scalding of residents. The facility administrator confirmed that water temperatures feel excessive to the touch. | 2020-09-01 |
| 87 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2017-06-06 | 329 | D | 0 | 1 | LLQX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on interviews and record reviews, the facility failed to identify current behaviors and implement non-pharmacological interventions prior to administering an as needed psychoactive medication for 1 resident (Resident 152) of 5 residents sampled. The facility identified the census at 128. The findings are: A review of Resident 152's Admission Record dated 6/6/17 revealed Resident 152 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 152's Medication Administration Record [REDACTED]. According to documentation on the MAR indicated [REDACTED]. A review of Resident 152's Behavior/Intervention Monthly Flow Record for (MONTH) (YEAR) revealed there were no behaviors or non-pharmacological interventions documented for the days and times that the as needed [MEDICATION NAME] was administered. A review of Resident 152's Medical Record revealed no behaviors or non-pharmacological interventions were documented in the progress notes for the days and times that the as needed [MEDICATION NAME] was administered except for the dose given on 5/19/17 at 10:05 PM. A review of Resident 152's Comprehensive Care Plan for [MEDICAL CONDITION] medication use dated 1/27/17 revealed an intervention for staff to administer the medications as ordered by the physician, document the occurrence of target behaviors symptoms, and document the effectiveness of the medications administered. An interview conducted on 6/5/17 at 1:57 PM with Licensed Practical Nurse (LPN) [NAME] revealed that their procedure for administering an as needed psychoactive medication was to attempt 3 non-pharmacological interventions prior to giving the medication and to document in the progress notes the behaviors, interventions attempted, medication given, and effectiveness of the medication. An interview conducted on 6/5/17 at 2:15 PM with Registered Nurse (RN) F revealed that their procedure for administering an as needed was to find out what was wrong, attempt activities, and document in notes after the medication is given what activities were done, what medication was given, and the effectiveness of the medication. An interview conducted on 6/5/17 at 3:49 PM with the Director of Nursing (DON) revealed that the expectation for administration of an as needed psychoactive medication was that the staff were to try non-pharmacological interventions prior to administration and the behaviors, interventions, medication effectiveness were to be documented on the Behavior/Intervention Monthly Flow Record. The DON reported that prior to their start at the facility the documentation was supposed to be done in the progress noted, but that the nursing staff had received education in (MONTH) to document on the Flow Record. | 2020-09-01 |
| 88 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2017-06-06 | 332 | D | 0 | 1 | LLQX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation record review and interview; the facility staff failed to ensure a medication error rate of less than 5%. Observation of 26 medications administered revealed 3 errors resulting in an error rate of 11.53 %. The errors affected 2 (Resident 219 and 224) of 4 sampled residents. The facility staff identified a census of 128. Findings are: [NAME] Record review of Resident 219's Medication Administration Record [REDACTED]. The directions to give the Potassium was that it was to be given with food and a full glass of water. The directions for the [MEDICATION NAME] (anti hypertension medication) 75 milligrams (mg) daily was that the medication was to be held if Resident 219's systolic (top number of a blood pressure) was less than 110 and to call the physician. Observation on 6-05-2017 at 7:08 AM of the medication administration for Resident 219 revealed Medication Assistant (MA) A prepared Resident 219's medication and administered them to Resident 219 with a half a cup of water and no food. Resident 219 stated after taking the medications it's not good to give me medications on an empty stomach. No blood pressure was observed to have been obtained prior to giving the [MEDICATION NAME] medication. On 6-5-2017 at 7:23 AM an interview was conducted with MA [NAME] During the interview, review of Resident 219's MAR for (MONTH) (YEAR) was reviewed. When asked if Resident 219's blood pressure was obtained prior to giving the [MEDICATION NAME] or was the Potassium given with food, MA A stated no. B. Record review of Resident 224's MAR for (MONTH) (YEAR) revealed Resident 224 had orders for medications that included Potassium Chloride (supplement) 20 meq to be given daily. The directions to give the Potassium was that it was to be given with food and a full glass of water. Observation on 6-05-2017 at 7:25 AM revealed MA B prepared and administered Resident 224's medications with water and no food. On 6-05-2017 at 7:33 AM an interview was conducted with MA B. MA B confirmed during the interview Resident 224's potassium was not administered with food as directed. | 2020-09-01 |
| 89 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2017-06-06 | 333 | D | 0 | 1 | LLQX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation record review and interview; the facility staff failed to ensure 1 (Resident 219) of 9 residents reviewed was free of significant medication errors. The facility staff identified a census of 128. Findings are: [NAME] Record review of a Physician Order's Sheet for 6-2017 revealed an order for [REDACTED]. Observation on 6-5-2017 at 7:08 AM of the medication administration for Resident 219 revealed Certified Medication Assistant (CMA) A prepared Resident 219's medication and administered them to Resident 219 with a half a cup of water and no food. Resident 219 stated after taking the medications it's not good to give me medications on an empty stomach. No blood pressure was observed to have been obtained prior to giving the [MEDICATION NAME] medication. On 6-5-2017 at 7:23 AM an interview was conducted with CMA [NAME] During the interview, review of Resident 219's MAR for (MONTH) (YEAR) was reviewed. When asked if Resident 219's blood pressure was obtained prior to giving the [MEDICATION NAME], CMA A stated no. Record review of Resident 219's MAR for (MONTH) (YEAR) revealed on 5-19-2017 Resident 219's [MEDICATION NAME] medication was signed of as being given with a recorded blood pressure of 106/62. On 6-6-2017 at 7:58 AM an interview was conducted with the facility Pharmacist. During the interview review of Resident 219's order for the [MEDICATION NAME] was reviewed. When asked if the medication was given outside of the physicians orders would that be a significant error, the Pharmacist stated yes. | 2020-09-01 |
| 90 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2018-06-06 | 580 | D | 1 | 0 | GX5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12- C3a(6) Based on record review and interview; the facility staff failed to notify the practitioner of refusal of medications for 1 (Resident 45) of 5 sampled residents. The facility staff identified a census of 127. Findings are: Record review of Resident 45's Medication Administration Record [REDACTED] -[MEDICATION NAME], 5 units at bed time, refused 16 times in May. -[MEDICATION NAME] (antihypertensive medication) 20 milligrams (mg), 1 time a day, refused 21 times in May. -[MEDICATION NAME] (antidepressant medication) 15 mg at bed time, refused 10 times in May. -[MEDICATION NAME] (antibiotic medication) 875 mg , 2 times a day for 10 days, refused 5 times in may. -Carvedilol (antihypertensive medication) 3.125 mg, 2 times a day, refused 19 times in May. -Eliquis (anticoagulant medication) 5 mg, 2 times a day, refused 4 times, medication was started on 5-21-2018. -[MEDICATION NAME] (medication used for pain control) 100 mg, 2 times a day, refused 21 times. -Pantoprazole (medication used to decrease stomach acid) 40 mg, 2 times a day, refused 20 times. -Senna Plus (medication used for bowels), 1 tablet every day, refused 20 times. Review of Resident 45's medical record revealed there was no evidence the facility had followed up with the practitioner regarding Resident 45 refusing the medications at the time of the refusals. On 6-06-2018 at 2:47 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported not being able to provide evidence Resident 45's practitioner had been notified of the refusals of taking the medications at the time of occurrence. | 2020-09-01 |
| 91 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2018-06-06 | 686 | D | 1 | 0 | GX5K11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on observation, record review and interview; the facility staff failed to implement interventions to prevent pressure ulcers for 1 (Resident 43) of 5 sampled residents. The facility staff identified a census of 127. Findings are: [NAME] Record review of Resident 43's Comprehensive Care Plan (CCP) dated 3-01-2018 revealed Resident 43 was high risk or the development of a pressure ulcer and currently had a pressure ulcer. The goal identified on Resident 43's CCP was not have have any complications related to the pressure ulcer. Interventions identified on Resident 43's CCP included applying a pressure relieving cushion to the wheelchair, a special mattress to the bed and to off load ( remove pressure) both heels when in bed every shift and as needed. Observation on 6-05-2018 at 10:43 AM revealed Resident 43 was in bed and Resident 43's heels were pressing into the mattress. Observation on 6-06-2018 at 6:40 AM resident 43 was in bed with the heels on the mattress. Observation on 6-06-2018 at 8:40 AM revealed Resident 43 heels were on the mattress. Observation on 6-06-2018 at 9:12 AM with Licensed Practical Nurse (LPN) A revealed Resident 43's heels were resting on the mattress. On 6-06-2018 at 10:25 AM a interview was conducted with LPN [NAME] During the interview, review of Resident 43's CCP was completed with LPN [NAME] LPN A confirmed Resident 43's heels should have been off loaded and were not. B. Record review of a Physician/Prescriber orders sheet dated 5-23-2018 revealed Resident 43's practitioner had order the facility provide a Trapeze ( Devices that is placed over the bed so that a person is able to pull self up) for the bed so Resident 43 could better reposition self. Observation on 6-5-18 at 2:12 PM revealed Resident 43 was in bed and did not have a trapeze bar in place. Observation on 6-06-2018 at 8:40 AM revealed Resident 43 was in bed and there was not a trapeze bar in place. Observation on 6-06-2018 at 10:16 AM with LPN A revealed Resident 43 was in bed and did not have the trapeze bar in place. A interview was conducted on 6-06-2018 at 10:16 AM with LPN [NAME] During the interview LPN A confirmed Resident 43 did not have the trapeze bar in place for Resident 43 to use. | 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 |
| 93 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2018-06-26 | 610 | D | 1 | 0 | 49DM11 | > Based on record review and interview the facility failed to submit a completed investigation to the state agency within 5 working days for 2 residents (Residents 1 and 5) and failed to complete an investigation of an elopement (leaving a secure area without staff knowledge or supervision) for Resident 4. The facility census was 131. Findings are: [NAME] Review of the facility policy revealed the facility will conduct an investigation of all incidents involving the potential or allegation of abuse or neglect and submit a written report of the results of all abuse investigations to the state agency in 5 working days of the reported incident. Review of facility investigation related to an unwitnessed fall for Resident 1 revealed a fall occurred in the morning of 6/5/2018 and Resident 1 received a laceration to the head and was sent to the hospital for treatment. The facility completed an investigation and submitted it to the state agency 6 day later on 6/13/2018. Review of the facility investigation revealed Resident 1 fell a second time in the evening of 6/5/2018 and went to the hospital for treatment as remained at the hospital until 6/6/2018 Review of the facility investigation revealed it was submitted to the state agency 6 days later on 6/13/2018. Interview on 6/26/3028 at 8:45 with the Social Services Director revealed both investigations were submitted late. B. Review of a facility report for Resident 5 revealed a facsimile (fax) confirmation sheet attached to the investigation indicated the status of the fax to be S-OK. Review of the fax cover sheet revealed that S-OK means stop communication Interview on 6/26/2018 at 8:45 AM with the Director of Nursing revealed that the confirmation sheet would indicate that the fax did not go to the state agency. C. Review of the facility investigations for the past 4 months revealed that no investigation was completed or submitted to the state agency regarding an elopement for Resident 4. Interview on 6/26/2018 at 10:30 AM with the Director of Nursing revealed that an investigation was not completed or submitted to the state agency. | 2020-09-01 |
| 94 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2018-06-26 | 812 | E | 1 | 0 | 49DM11 | > Licensure Reference Number: 175 NAC 12-006.11C Based on observation, record review and interview, the facility failed to ensure the ice scoop was not stored in the ice chest to prevent the potential for foodborne illness. This had the potential to effect 14 residents that were provided ice from the ice chest. The facility census was 131. Findings are: Observation on 6/25/2018 revealed Nursing Assistant (NA)-A obtained a Styrofoam cup from the ice cart and opened the lid of the cooler. NA-A reached into the cooler and picked up the scoop from on top of the ice. NA-A obtained a scoop of ice from the cooler and placed the scoop back into the ice. NA-A gave the ice to Resident 7. Review of the facility policy dated 10/30/2017 titled IC208 Ice Chests revealed scoops are to be kept in the scoop holder that is attached to each ice chest. Interview on 6/26/2018 at 9:35 AM with the Dietary Manager revealed the scoop should not be left in the ice chest. Interview on 6/26/2018 at 11:00 with the Social Services Director revealed 14 resident reside on the designated unit and receive ice from the ice chest. | 2020-09-01 |
| 95 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2019-07-30 | 554 | D | 1 | 0 | N7DY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10A1 Based on observation, record review and interview the facility staff failed to assess a resident for self-administration of medication for 1 (Resident 3) of 1 sampled resident. The facility staff identified a census of 133. The findings are: During an observation of wound care on 7/29/19 at 02:36 PM for Resident 3 revealed Resident 3's husband removed an inhaler from his pocket and handed it to Resident 3. Resident 3 administered 2 puffs of the inhaler. Record review of current physician orders for (MONTH) 2019 revealed an order for [REDACTED]. Record review of Resident 3's medical record revealed no evidence that Resident 3 was assessed for self-administration of medication. Review of the facility policy for self-administration of medications revealed that if a resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the residents' cognitive, physical, and visual ability to carry out this responsibility during the care planning process and there is a prescriber's order to self-administer. Interview conducted on 7/29/19 at 03:06 PM confirmed that Resident 3 did not have an order to self-administer medications and did not have an assessment for self-administration of medications. | 2020-09-01 |
| 96 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2019-08-27 | 689 | D | 1 | 0 | GSSL11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E1 Based on observation, record review and interview; the facility staff failed to implement assessed intervention for fall prevention for 1 (Resident 3) of 5 sampled residents. The facility staff identified a census of 140. Findings are: Record review of Resident 3's Comprehensive Care Plan (CCP) updated on 4-24-2018 revealed the facility staff identified Resident 3 was at risk for falls. Interventions identified on Resident 3's CCP to prevent potential falls included ensuring belongings were within reach, call light reminder sign and to ensure Resident 3's call light was within reach. Observation on 8-26-2019 at 2:20 PM revealed Resident 3 was placed next to the bed after using the bathroom. Resident 3's call light was not in reach of the resident. Observation on 8-26-2019 at 3:00 PM with Social Services (SS) [NAME] During the observation SS A confirmed Resident 3's call light was not within reach of Resident 3 and should have been. | 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 |
| 98 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2018-09-17 | 623 | E | 0 | 1 | XOYL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify residents representatives and the ombudsman in writing of resident transfers for 5 (Residents 15, 94, 90, 80, 104) of 6 residents reviewed for hospitalization . The facility census was 126. Findings are: [NAME] Review of Resident 15's progress note revealed on 9/1/2018 Resident 15 Change of Condition Note revealed the resident has a change of condition and was transferred to the hospital for evaluation and treatment. Review of Resident 15's scanned documents revealed no documentation regarding notification in writing to the Resident 15's representative or the State Ombudsman regarding the reason for Resident 15's transfer. 09/13/18 10:40 AM Interview with the director of nursing(DON) revealed they do not send a letter to the family or resident regarding reason for the transfer and they do not notify the State Ombudsman. Review of the facility policy dated (MONTH) (YEAR) titled Bed-holds and Returns revealed; prior to transfer written information will be given to the residents and the resident representatives that explains in detail including the details of the transfer using the Notice of Transfer. B. Review of Resident 80's progress notes revealed Resident 80 was admitted to the hospital on [DATE]. Review of Resident 80's scanned documents revealed no evidence of notification to Resident 80, the family representative or the State Ombudsman in writing of the reason for Resident 80's transfer to the hospital. Interview on 09/13/18 at 11:01 AM with the (DON) revealed the facility has not been using the Notice of Transfer referenced in the facility policy. C. Review of Resident 90's progress notes revealed Resident 90 was admitted to the hospital on [DATE]. Interview on 09/13/18 at 10:40 AM with the DON revealed families are verbally notified of transfer and the reason for the transfer. The State Ombudsman is not notified. D. Review of Resident 94's progress notes revealed Resident 94 was transferred to the hospital on [DATE]. Review of Resident 90's scanned documents revealed no evidence of notification to Resident 80 or the family representative or the State Ombudsman in writing of the reason for Resident 80's transfer to the hospital Interview 9/13/2018 at 10:49 AM with the Social Services Director revealed transfers are not reviewed with the State Ombudsman. E. Review of Resident 104's progress notes revealed Resident 104 was transferred to the hospital on [DATE]. Review of Resident 90's scanned documents revealed no evidence of notification to Resident 80 or the family representative or the State Ombudsman in writing of the reason for Resident 80's transfer to the hospital Interview on 09/13/18 at 11:00 PM with the DON revealed no letter was provided to the family or resident regarding the reason for transfer. The ombudsman was not notified of transfers. | 2020-09-01 |
| 99 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2018-09-17 | 625 | E | 0 | 1 | XOYL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify residents of the right to hold a bed during hospitalization at the time of transfer for 5 of 6 residents (Resident's 15, 94, 90, 80, and 104). The facility census was 126. Findings are: [NAME] Review of Resident 15's progress note revealed on 9/1/2018 at 18:22 a Change of Condition Note revealed the resident has a change of condition and was transferred to the hospital for evaluation and treatment. Review of Resident 15's Bed hold revealed Resident 15 was issued a Bed hold notice on return to the facility. Review of the policy dated (MONTH) (YEAR) titled Bed-holds and Returns Prior to a transfer revealed written information will be given to the residents and the resident representatives that explains in detail: - The rights and limitations of the resident regarding bed-holds. - The reserve bed payment policy as indicated by the state plan - The facility per diem rate required to hold a bed or to hold a bed beyond the state bed-hold period. Interview on 9/13/2018 at 10:45 AM with the Business office manager revealed the only time bed hold are completed are on admission or readmission from the hospital. B. Review of Resident 80's progress notes revealed Resident 80 was admitted to the hospital on [DATE]. Review of resident scanned documents revealed the only bed hold was signed on admission. No bed hold located in the medical record for admission o 8/10/2018. Interview 9/13/2018 at 10:49 AM with the Social Services Director revealed bed holds are completed by the Business Office Manager. C. Review of resident 90's progress notes revealed resident 90 was admitted to the hospital on [DATE]. Review of Resident 90's scanned documents a Bed Hold was issued on 7/13/2018 on Resident 90's return to the facility. Interview on 9/13/2018 at 10:45 AM with the Business office manager revealed the Business office manager was not aware of the requirement to provide the bed hold on transfer to the hospital. D. Review of Resident 94's progress notes revealed Resident 94 was transferred to the hospital on [DATE]. Review of Resident 94's scanned document titled bed hold revealed it was issued on 7/24/2018 when resident 94 was readmitted to the facility. 09/13/18 11:00 PM DON Confirmed no bed hold was obtained when resident transferred to the hospital or followed up on and no letter was provided to the family or resident regarding the reason for transfer. The ombudsman was not notified of transfers. E. Review of Resident 104's progress notes revealed Resident 104 was transferred to the hospital on [DATE]. Review of Resident 104's scanned document titled Bed hold revealed no bed hold was issued to the resident on transfer to the hospital or during the hospitalization . 09/13/18 11:00 AM DON revealed no bed hold was provided when resident was transferred to the hospital. | 2020-09-01 |
| 100 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2018-09-17 | 656 | D | 1 | 1 | XOYL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on record review and interview, the facility staff failed to implement a CCP (Comprehensive Care Plan) to reflectthe current status of smoking for 1 (Resident 75) of 2 sampled residents. The facility staff identified the census of 126. Findings are: Record review of Smoking assessment dated [DATE] for Resident 75 revealed that Resident 75 required physical assist to smoking area destination due to uneven terrain and low vision. Record review of the CCP dated 02/21/2018 for Resident 75 revealed that the current status of smoking was not identified on the CCP until 09/12/2018. Interview conducted on 09/12/2018 at 10:30 AM with the Director of Nursing confirmed that the CCP was not updated with Resident 75's smoking status until 09/12/2018. | 2020-09-01 |
| 101 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2018-09-17 | 657 | D | 1 | 1 | XOYL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on record review and interview the facility staff failed to revise the CCP (Comprehensive Care Plan) to reflect current status of smoking for 1 (Resident 27) of 2 sampled residents. Facility staff identified a census of 126. The findings are: Record review of Smoking assessment dated [DATE] for Resident 27 revealed that Resident 27 was unsafe to smoke independently and propel self to designated area safely. Patient required supervision to complete smoking task. Record review of behavior note dated 7/19/2018 revealed that Resident 27 was let out of the building by another resident and staff found Resident 27 outside smoking with 2 other residents. Record review of behavior note dated 9/11/2018 revealed that Resident 27 was in the courtyard smoking by self. Record Review of the CCP dated 8/31/2017 revealed that Resident 27 desired to smoke while at a smoke free campus. The goal was that Resident 27 would demonstrate compliance with non-smoking campus policies. There were no updates to the CCP reflecting Resident 27's non-compliance with the smoking policy. Interview with the Director of Nursing on 09/13/2018 at 02:45 PM confirmed that the CCP had not been updated to reflect Resident 27's non-compliance with the smoking policy. | 2020-09-01 |