Keystone Ridge Post Acute Nursing and Rehabilitati
For profit - Corporation
100 Beds
THE ENSIGN GROUP
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#157 of 177 in NE
Photo by Keystone Ridge Post Acute Nursing and Rehabilitation
Photo by Keystone Ridge Post Acute Nursing and Rehabilitation
Photo by Keystone Ridge Post Acute Nursing and Rehabilitation
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Keystone Ridge Post Acute Nursing and Rehabilitation has received a Trust Grade of F, indicating significant concerns about the facility's quality of care. It ranks #157 out of 177 nursing homes in Nebraska, placing it in the bottom half of all facilities in the state. Although the facility is showing signs of improvement, with issues decreasing from 17 in 2024 to 5 in 2025, it still faces considerable challenges. Staffing is a concern, with a rating of 2 out of 5 stars and a high turnover rate of 71%, much higher than the Nebraska average of 49%. The facility has also incurred $70,103 in fines, which is alarming as it is higher than 94% of other Nebraska facilities, suggesting ongoing compliance issues. There are some strengths, including better RN coverage than 75% of Nebraska facilities, which can help catch potential problems. However, there have been critical incidents, such as failing to properly monitor a resident’s medication levels and administering medications incorrectly for two residents, which raises serious safety concerns. Additionally, the kitchen was found to be unsanitary, with food debris and buildup that could pose a risk of foodborne illness for residents. Overall, families should weigh these factors carefully when considering this facility for their loved ones.
- Trust Score
- F
- In Nebraska
- #157/177
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 71% turnover. Very high, 23 points above average. Constant new faces learning your loved one's needs.
- Penalties ○ Average
- $70,103 in fines. Higher than 63% of Nebraska facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 43 minutes of Registered Nurse (RN) attention daily — more than average for Nebraska. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 24 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 12%
Review needed
17 → 5 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 17 issues
2025: 5 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Nebraska average (2.9)
Significant quality concerns identified by CMS
Staff Turnover: 71%
25pts above Nebraska avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $70,103
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: THE ENSIGN GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is very high (71%)
23 points above Nebraska average of 48%
The Ugly 24 deficiencies on record
2 life-threatening
May 2025
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175NAC 12-006.15 (A) &(B)
Based on record reviews and interviews, the facility failed to assist residents in making a dental appointment. This had the potential to affect 2 ...
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Licensure Reference Number 175NAC 12-006.15 (A) &(B)
Based on record reviews and interviews, the facility failed to assist residents in making a dental appointment. This had the potential to affect 2 (Resident 11 and Resident 5) out of 2 residents sampled. The facility staff identified a census of 69.
Findings are:
A. Record review of Resident 11's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 04/29/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. The MDS manual identified a score of 15 as resident was cognitively intact.
An interview was conducted with Resident 11 on 05/18/2025 at 9:55 AM. During the interview Resident 11 reported having a dental appointment that never occurred.
A record review of a progress note dated 06/18/2024 revealed Resident 11 had returned from a dental appointment at oral and maxillofacial surgery with a follow up appointment for 06/06/2024.
Record review of a the transportation calendar revealed Resident 11 had an appointment scheduled for 08/06/2024 to see oral surgery at the Nebraska Medical Center at 1:30 PM.
An interview with the Director of Nursing (DON) on 05/19/2025 at 1:39 PM revealed that Resident 11's appointment was not completed. The DON further confirmed that there was not a rescheduled appointment.
B. Record review of Resident 5's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 04/22/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. The MDS manual identified a score of 15 as resident was cognitively intact.
An interview was conducted on 05/18/2025 at 12:33 PM with Resident 5. During the interview it was revealed that the facility had lost the Resident's partial during a room move and the facility had not replaced it. Resident 5 reported the missing partial was reported to the Administrator in Training (AIT).
An interview was conducted on 05/21/2025 at 09:55 AM with the AIT. During the interview, the AIT reported that resident did report the partial was missing. A Missing Item form dated 03/12/2025 was written regarding the lost partial.
A record review of an email dated 03/13/2025 from 360 Care Dental Care revealed Resident 5 would be seen by the dentist on 04/03/2025.
An email dated 04/02/2025 from 360 Care Dental Care revealed the appointment was canceled as the doctor could not make it to the facility.
Record review of the facility's policy of Dental Services dated 01/01/2018:
Policy: It is the policy of this facility to ensure that its residents who require dental services on a routine or emergency basis have access to such services without barrier. It is likewise the policy of the facility to repair or replace the dentures of a resident except in those situations where the loss or damage directly results from the action of an alert and oriented resident who is responsible for his/her own medical decisions.
2. In the event that a facility resident requires emergency dental services for the repair or replacement of dentures or otherwise, the Facility will:
-Promptly and, in any event, no later than 3 business days from the date of loss/damage, refer the resident for dental services.
-Assist the resident in making the necessary dental appointments, when necessary or requested
-Arrange for transportation to and from the dental services appointment/location, using the lowest cost or no cost option to minimize the financial burden on the resident.
3. If a referral for dental services does not occur within 3 business days from the date of the loss/damage, the Facility will:
-document what actions were taken to ensure the resident could eat, drink, and communicate (if applicable) adequately while awaiting dental services
-Document the nature of the extenuating circumstances which led to the delay
Guidelines for facility compliance:
In order to comply with the facility's obligations as set forth in 42 CFR Section 483.55, the facility will:
-provide or obtain from an outside resource, routine and emergency dental services for each resident
-assist the resident as necessary or requested to make appointments for dental services or arrange for transportation to and from dental services locations.
-Promptly, and within 3 days refer a resident with lost or damage partial or full dentures and/or documented extenuating circumstances that led to a delay]
-Document what the Facility did to ensure that a resident with missing or damaged partial or full dentures could still eat and drink adequately while awaiting dental services
-Not charge a resident for the loss or damage of partial or full dentures determined to by Facility policy to be the Facility's responsibility
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
LICENSURE REFERENCE NUMBER 12-006.18(B)
Based on observation, interview, and record review; the facility failed to store a urinary catheter drainage bag in a manner to prevent cross-contamination for ...
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LICENSURE REFERENCE NUMBER 12-006.18(B)
Based on observation, interview, and record review; the facility failed to store a urinary catheter drainage bag in a manner to prevent cross-contamination for 1 (Resident 66) of 2 sampled residents; and failed to disinfect the glucometer during blood glucose checks. This had the potential to affect 1 (Resident 16) of 2 sampled residents. The facility staff identified a census of 69.
Findings are:
A. Record review of Resident 66's admission Record revealed the facility admitted Resident 66 on 02/28/2025 and identified the following diagnoses: hyperosmolality (a condition where the blood is too concentrated) and hypernatremia (too much sodium in blood); severe protein-calorie malnutrition; pressure ulcer of sacral region; anoxic brain damage (a result of the brain not receiving enough oxygen, causing brain cells to die); sepsis (the body's extreme response to an infection); depression; epilepsy; and secondary pulmonary arterial hypertension (high blood pressure in the arteries of the lungs that is caused by another underlying health condition).
Record review of Resident 66's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 03/14/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 3. According to the MDS manual, a score of 3 indicated that the resident had severe cognitive impairment. Further review of the MDS identified Resident 66 utilized a urinary catheter for bladder elimination.
An observation on 05/20/2025 at 9:45 AM revealed Resident 66 sitting in a wheelchair with the urinary catheter drainage bag hung inside a red trash can.
An observation on 05/20/2025 at 11:07 AM revealed Resident 66 in a wheelchair in the resident's room watching television with the urinary catheter drainage bag directly on the floor.
An observation on 05/20/2025 at 12:11 PM revealed Resident 66 in a wheelchair in the resident's room watching television with the urinary catheter drainage bag directly on the floor.
An observation on 05/20/2025 at 12:43 PM revealed Resident 66 with a noon meal watching television with the urinary catheter drainage bag directly on the floor.
An interview on 05/20/2025 at 12:46 PM with Nurse Aide (NA)-C confirmed that Resident 66's catheter bag was on the floor and should not be. NA-C further confirmed that the urinary catheter drainage bag should not be stored inside a trashcan.
B. An observation on 05/19/25 at 7:43 AM of Licensed Practical Nurse (LPN)-A completing a blood glucose check of Resident 16. LPN-A performed hand hygiene and applied gloves, completed the blood glucose check and returned to the treatment cart. LPN-A wiped the glucometer with an alcohol wipe and placed the glucometer on a clean surface.
An Interview was conducted on 05/19/25 8:30 AM with the Director of Nursing (DON) and DON confirmed the glucometers should be disinfected with the Sani-Cloth Germicidal Wipes.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.19(A)
Based on observation and interview, the failed to maintain the cleanliness and c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.19(A)
Based on observation and interview, the failed to maintain the cleanliness and condition of fixtures, doors, walls, ceilings, baseboards, door jams, curtains, grip strips, lights, beds and odor control in 17 (rooms 511, 514, 516, 518, 520, 525, 528, 5099, 5101, 5102, 5104, 5105, 5106, 5109, 5115, 5119, 5126) of 41 occupied resident rooms. The facility had a total of 50 rooms and the facility census was 69.
Findings are:
Observation on 05/21/25 between 8:04 AM and 9:10 AM with the Maintenance Director [MD] and the facility Housekeeping Supervisor revealed the following concerns with the facility environment:
- The caulking surrounding the base of the toilet was cracked and stained brown in resident bathrooms in rooms 511, 514, 516, 518, 520, 525, 528, 5102, 5104, 5106, and 5109.
- There were scrapes present in the drywall on walls in resident rooms and bathrooms in rooms 514, 516, 518, 520, 525, 528, 5099, 5101, 5102, 5104, 5105, 5106, and 5126.
- The ceiling tile was cracked and bubbled in resident room [ROOM NUMBER] along the seam of the wall.
- The baseboard was pulled away from the wall in the bathroom in resident room [ROOM NUMBER] and 5106 (in the room near the closet).
-There were food stains on the ceiling in resident room [ROOM NUMBER] and red and brown water damage stains present in resident room [ROOM NUMBER] and 5104 in the bathroom.
- There were scraped areas / holes in the wood of bathroom and room doors in resident rooms 516, 518, 520, 528, 5099, 5101, 5104, 5105, 5106, and 5115.
- The nightlight cover in the bathroom was broken / loose in resident room [ROOM NUMBER], 5105, and 5106.
- The kick plate was loose from the bathroom door in resident rooms [ROOM NUMBER],
- The toilet paper holder is missing / broken in bathrooms in resident rooms 511, 518, 525, 5101, and 5126,
- The towel bars were missing or broken in resident bathrooms in rooms 521,5118, 5123, and 5124.
- The window curtains / blinds were broken and loose in rooms [ROOM NUMBER]
- There was a very strong urine odor in rooms 518, 525 and 5109.
- The floors were soiled, wet and sticky in resident rooms 518, 525 and 5109.
- There was a missing towel bar in the resident bathroom in room [ROOM NUMBER].
- Fall stop strips were loose and torn which created a surface not able to be cleaned in rooms 520, 5104, 5105, 5115, and 5119.
- A overhead light cover was missing from the ceiling in room [ROOM NUMBER].
- Lights were out in resident bathrooms in rooms 518, 5101, 5102, and 5115.
- A light was out above the bed in room [ROOM NUMBER].
- The bed was broken and the head of the bed could not be raised in room [ROOM NUMBER] bed 1.
- A fall mat had spots of dried tube feeding solution spattered and dried on in room [ROOM NUMBER].
- The finish was peeled in spots on the floor and was coming loose in resident rooms [ROOM NUMBERS].
- The call light cord was missing in the resident bathroom in room [ROOM NUMBER].
Interview on 05/21/25 at 9:00 AM with the MD confirmed that those areas identified needed to be cleaned / repaired. The MD confirmed there were no work orders for the areas identified and that the concerns had not been identified prior to the environmental tour of the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
LICENSURE REFERENCE NUMBER 175 NAC 12-006.11(E)
Nebraska Food Code 2017 4-602.13; 6-201.11
Based on observation, interview and record review; the facility failed to maintain the dual ovens, kitchen st...
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LICENSURE REFERENCE NUMBER 175 NAC 12-006.11(E)
Nebraska Food Code 2017 4-602.13; 6-201.11
Based on observation, interview and record review; the facility failed to maintain the dual ovens, kitchen stand mixer, and floor in a manner to prevent food borne illness. This had the potential to affect all 69 residents that ate food prepared in the facility kitchen. The facility staff identified a census of 69.
Findings are:
Observation on 05/17/2025 from 7:17 AM through 7:32 AM during the initial kitchen tour revealed the following:
-the presence of black buildup to the bottom of both ovens.
-the presence of food debris buildup on the arm and stand of the kitchen mixer.
-an absence of grout between two rows of tiles that was eight tiles wide located between the stove top and the dual ovens with a buildup of food debris in the unfilled space.
Observation on 05/20/2025 at 10:22 AM with the Certified Dietary Manager (CDM) and the Registered Dietitian (RD) revealed the presence of black buildup to the bottom of both ovens, the presence of food debris buildup on the arm and stand of the kitchen mixer, and the absence of grout with food debris between the tiles between the stove top and dual ovens.
An interview on 05/20/2025 at 10:22 AM with the CDM confirmed the presence of black buildup to both ovens, the presence of food debris buildup on the arm and stand of the kitchen mixer, and the absence of grout between the tiles. The CDM revealed that there is a cleaning checklist for the kitchen and confirmed that the ovens should be cleaned weekly, and the kitchen mixer should be cleaned after use.
An interview on 05/20/2025 at 10:25 AM with the RD confirmed grout was missing between the tiles and allowed food particles to build up.
A record review of facility policy entitled Kitchen Cleaning Policy dated 08/2023 revealed:
-the purpose was to maintain a clean, safe, and sanitary kitchen environment that supports the health and well-being of residents, staff, and visitors, and complies with local, state, and federal health regulations.
-The CDM oversaw implementation and compliance with the policy.
-Kitchen staff were responsible for daily, weekly, and monthly cleaning tasks.
A record review of the Nebraska Food Code 2017 revealed the following:
-4-602.13: Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
-6-201.11: Floors, floor coverings, walls, wall coverings, and ceilings shall be designed constructed and installed so they are smooth and easily cleanable.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
Licensure Reference Number 175 NAC 12-006.07C
Based on record review and interviews; the facility failed to ensure the Quality Assurance Performance Improvement Program [QAPI, a facility process that ...
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Licensure Reference Number 175 NAC 12-006.07C
Based on record review and interviews; the facility failed to ensure the Quality Assurance Performance Improvement Program [QAPI, a facility process that identifies problems in the facility and works to correct the concerns] identified and addressed concerns related to deficient practice identified on the annual survey 2025 ( F 584, F 791, F 812, F 865 and F880) and to ensure correction for repeat deficient practice from previous surveys (March 2023 and May 2024 for F 584 and May 2024 survey for F 812) was maintained. This had the potential to affect 69 residents that resided in the facility. The facility census was 69.
Findings are:
Record review of an undated facility policy entitled QAPI Program revealed the following QAPI goals and benefits:
QAPI goals:
-Develop regulations that help facilities meet new standards
-identify areas of need and advancement
-expand the level of activities required by existing quality standards
-involve all caregivers in problem solving
QAPI Benefits
-Improve quality of care and life for patients
-Prevents or decreases the likelihood of problems in care delivery
-addresses gap in health care systems
Meeting Times and Scope:
The Quality Assurance and performance improvement (QAPI) Committee will meet quarterly at minimum and at each meeting the QAPI Committee will review areas such as:
1. Plan of Correction and Survey results. Including any internal reviews and audits. From this we will review that audits have been completed and are effective to ensure compliance.
2. Infection control data - could include PPE [Personal protective equipemnt] data, clinical data, guidance issued from CDC [Centers for Disease Control] or DIA [unknown] and any other information to ensure infection control program is utilized and data driven with benchmarks tracking and best practices
3. Grievance - including tracking and trending
4. Accidents/incidents - reviewed, tracked, and trended to determine if a PIP [Performance Improvement Project] is necessary
5. Clinical Outcomes tracked, and trended to determine if a PIP is necessary
6. Dietary Performance - tracked, and trended to determine if a PIP is necessary
7. Performance Improvement Plans (PIPs) - discussion based on trends to implement PIP and review monthly current PIPs to determine effectiveness of interventions and how to graduate from the PIP.
The QAPI committee will strive to formally meet monthly. The meeting will be extensive and include discussions of data/trends and the appropriateness of PIPS and interventions. During the meeting PIPS will be reviewed and new interventions put in place as needed. Ad Hoc meetings will occur when needed, including when high-risk incidents occur or if current PIPS are not met or interventions are ineffective. (We will not wait for the next meeting if we recognize the need for new interventions) each member of the QAPI committee will be required to prepare their data, create plans to improve outcomes, and report during QAPI meeting.
Post-Acute QAPI Goals:
The goals of Keystone Ridge Post Acute QAPI Committee for 2025:
1. Implement a QAPI program that involves all staff and focuses on benchmarks to ensure quality for care and quality of life
2. Continued improvement with infection control.
3. Continued improvement of QAPI Program to include data and improvement plans to see overall improvement in all areas of the facility that are identified in QAPI.
During the recent survey, with an end date of 05/21/2025, the following citations and repeated citations were identified:
- F 584: The facility failed to ensure Resident 5's property was protected from loss and failed to maintain the cleanliness and condition of fixtures, doors, walls, ceilings, baseboards, door jams, curtains, grip strips, lights, beds and odor control in 17 of 41 occupied resident rooms in the facility.
- F 791: The facility failed to ensure follow up on dental appointments were provided for Resident 11.
- F 812: The facility failed to maintain kitchen appliances and the floor in the facility kitchen in a manner to prevent food borne illness. This had the potential to affect all 69 residents that ate foods prepared in the facility kitchen.
- F 865: The facility failed to ensure the Quality Assurance Performance Improvement program [QAPI, a facility process that identifies problems in the facility and works to correct the concerns] identified and addressed concerns related to deficient practice identified on the annual survey 2025 ( F 584, F 791, F 812, F880) and to ensure correction for repeat deficient practice from previous surveys (March 2023 and May 2024 for F 584 and May 2024 survey for F 812) was maintained. This had the potential to affect 69 residents that resided in the facility.
-F 880: The facility failed to use a disinfectant wipe to clean a glucometer between resident use for Residents 16 and Resident 44 and failed to ensure Resident 66's catheter bag was not in contact with the trash can or floor.
Repeat citations:
- F 584 from previous surveys 03/09/2023 and 05/02/2024: environmental concerns
-F 812: from previous survey 05/02/2025: kitchen sanitation concerns
Interview on 05/21/25 at 11:31 AM with the facility Administrator confirmed that an environmental tag had been written for the past 2 years and was written again this year and no PIP had been brought through the QAPI program related to the environment. The Administrator confirmed that the kitchen tag had been written last year, and a PIP had been started in March but had not been effective in maintaining correction related to kitchen cleanliness. The Administrator confirmed that the QAPI process had identified the kitchen issues but was not effective to avoid a tag this year.
Oct 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure reference: 175 NAC 12-006.04(F)(i)(5).
Based on record review and interview, the facility failed to ensure medical pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure reference: 175 NAC 12-006.04(F)(i)(5).
Based on record review and interview, the facility failed to ensure medical provider was notified of blood pressures outside of established parameters for 1 [Resident 6] of 10 sampled residents. The facility had a total census of 67 residents.
Findings are:
A review of Resident 6's admission Record revealed Resident 6 was admitted to the facility on [DATE]. Resident 6's admission Record included the following diagnoses: type 2 diabetes mellitus [a disease that occurs when the body doesn't use insulin properly], chronic obstructive pulmonary disease [lung disease causing restricted air flow and breathing problems], essential hypertension [high blood pressure], and dependence on renal dialysis.
A review of Resident 6's 6/2024 MAR [Medication Administration Record] revealed the following orders:
-Carvedilol [a medication to treat high blood pressure and heart failure] 25 mg give 1 tablet orally in the evening every Tuesday, Thursday, and Saturday. Hold for SBP [systolic blood pressure] less than 120 and HR [heart rate] less than 50.
-Carvedilol 25 mg give 1 tablet orally 2 times a day every Monday, Wednesday, Friday, and Sunday hold for systolic blood pressure less than 120 and heart rate less than 50
-Hydralazine [a medication to treat high blood pressure] 25 mg give 3 tablets orally 3 times per day Monday, Wednesday, Friday, and Sunday
-Hydralazine 25 mg give 3 tablets orally 2 times per day every Tuesday, Thursday, and Saturday
-Weekly vital signs notify MD of systolic blood pressure greater than 180 or less than 80, Heart rate greater than 120 or less than 50, temperature greater than 100 F, or oxygen saturation less than 88%
A review of Resident 6's Progress Notes dated 6/1/24 revealed Resident 6 was admitted to the hospital for hypotensive episode [low blood sugar].
A review of Resident 6's Blood Pressure Summary revealed the following blood pressures:
-6/19/24 at 10:47 AM 74/57
-6/21/24 9:48 AM 77/58
A review of Resident 6's Progress Notes did not reveal any documentation of Resident 6's provider being notified of blood pressure of 74/57 on 6/19/24 and 77/58 on 6/21/24.
In an interview on 10/24/24 at 12:40 PM, the Director of Nursing confirmed that Resident 6's physician should have been notified for a blood pressure outside of the parameters.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report and submit an investigation of potential neglect for 1 [Resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report and submit an investigation of potential neglect for 1 [Resident 1] of 10 sampled residents. The facility had a total census of 67 residents.
Findings are:
A review of Resident 1's admission Record revealed Resident 1 admitted to the facility on [DATE] with diagnoses of epilepsy [seizure disorder] and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side [left side paralysis after stroke].
A review of Resident 1's Progress Notes revealed a Progress Note dated 10/13/24 at 10:22 AM revealed Resident 1 reported that Resident 1 had spilled coffee on self in the upstairs dining room yesterday evening. Resident 1 reported pain in groin. Resident 1 was found to have a 10 cm by approximately 2 cm wide area of redness with raised areas through including a fluid filled blister measuring 3 cm x 0.5 cm and a second distal fluid filled blister measuring approximately 0.3 cm x 0.4 cm. A scant amount of blood was noted to redness on inner groin area. The Progress Note stated that Assistant Director of Nursing and Administrator were notified.
A review of undated list of facility investigations from 9/23/24 through 10/15/24 did not include an investigation of Resident 1's burn.
A review of Performance Improvement Plan initiated 10/13/24 revealed the facility took the following action due to burn from coffee:
-10/13/24 Resident 1 was re-evaluated by Occupational Therapy for lidded cup,
-10/13/24 A hot liquid evaluation was completed for Resident 1,
-10//13/24 Certified Dietary Manager reviewed hot liquid temperature log for 10/12/24 and 10/13/24,
-10/14/24 hot liquid policy revised and education provided to staff,
-Dietary staff interviewed to verify competency in process from machine to resident,
-10/132/4 Staff education provided regarding temperature, coffee handling, and dining.
In interviews on 10/21/24 at 1:02 PM and 4:58 PM and 10/24/24 at 2:20 PM, the Administrator reported conducting interviews regarding the burn. The Administrator confirmed that the burn was not reported to Adult Protective Services or a report submitted to the survey agency as the burn was not considered a significant injury.
A review of facility policy titled Abuse: Prevention of and Prohibition Against revised 12.2023 revealed the following:
-All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee.
-The investigation will include the following:
-An interview with the person(s) reporting the incident;
-An interview with the resident(s);
-Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate;
-A review of resident's medical record;
-An interview with staff members who may have information regarding the alleged incident;
-Interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident;
-An interview with staff members having contact with the accused employee; and
-A review of all circumstances surrounding the incident.
-Allegations of abuse, neglect, misappropriation or resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable time frames, as per this policy and applicable regulations.
Oct 2024
3 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0757
(Tag F0757)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H)
Based on record review and interview, the facility failed to complete INR monito...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H)
Based on record review and interview, the facility failed to complete INR monitoring tests to ensure therapeutic dosing of Coumadin for 1 [Resident 1] of 1 sampled resident requiring INR monitoring.
The facility Administrator and Director of Nursing was notified on 10/9/24 at 5:00 PM of an Immediate Jeopardy (IJ) which began on 7/10/24. The IJ was removed on 10/9/24, as confirmed by surveyor onsite verification.
The Findings are:
Record Review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 09-30-2024 revealed the facility staff assessed the following about the resident:
-Brief Interview of Mental Status (BIMS) was scored as a 10. According to the MDS [NAME] a score of 8-12 indicates moderate cognitive impairment.
-Had Diagnosis of Atrial Fibrillation (a heart condition that causes the heart to beat irregularly and sometimes very fast), Coronary Artery Disease (a condition that occurs when the coronary arteries narrow or become blocked, preventing the heart muscle from receiving enough blood and oxygen) Cerebrovascular accident (a medical condition that occurs when blood flow to the brain is suddenly interrupted), and seizure disorder.
-had a heart valve replacement.
-Resident was taking an anticoagulant (medications that prevent blood clots from forming in the bloodstream.). They are given to people who are at high risk of developing blood clots, which can lead to serious conditions like heart attacks and strokes).
Record Review of Resident 1's Electronic Health Record (EHR, a digital version of a patient's paper chart) revealed the following for PT/INR (A PT/INR test is most often used to: See how well Coumadin, an anti-coagulant or blood-thinning medicine, is working to prevent blood clots.) testing:
-Check PT/INR on 07-10-2024- Resident 1's Treatment Administration Record (TAR) revealed a PT/INR was completed at 6:46 PM and no Coumadin dosing was present on the Medication Administration Record (MAR) for 07-10-2024.
-Progress notes dated 07-11-2024 revealed facility followed up with prescriber for Coumadin orders.
-Progress notes dated 07-12-2024 revealed the prescriber ordered a PT/INR on 07-15-2024
-Record review of Resident 1's progress notes, MAR, TAR, and Coumadin Flow Sheet (CFS) revealed no PT/INR completed and no Coumadin dosing obtained. Furthermore, no Coumadin dosing was present on the MAR from 07-15-2024 through 07-22-2024.
-Record review of Resident 1's progress notes dated 07-18-2024 revealed a PT/INR was obtained per order.
-Record review of Resident 1's order listing, MAR, and TAR revealed no order to check PT/INR on 07-18-2024.
-Record review of Resident 1's progress notes dated 07-19-2024 revealed Resident 1's responsible partly was updated on a new Coumadin order.
-Record review of Resident 1's MAR, TAR and order listing revealed no order for Coumadin on 07-19-2024.
-Record review of Resident 1's TAR for August 2024 revealed an order to check a PT/INR and call results to Coumadin clinic. The TAR revealed the PT/INR was completed at 8:37 PM.
-Record review of Resident 1's progress notes dated 08-05-2024 revealed the staff were to follow up with the prescriber for Coumadin orders.
-Record review of Resident 1's MAR for August revealed an order for Coumadin starting 08-06-2024 and no orders or dosing noted in the MAR for 08-05-2024.
-Record review of Resident 1's TAR for August 2024 revealed an order to check a PT/INR on 08-09-2024 and call results to Coumadin clinic by noon. The TAR revealed the PT/INR was checked at 4:33 PM.
-Record review of Resident 1's orders revealed an order to check a PT/INR on 08-26-2024 and call and communicate the results for new instructions.
-Record review of Resident 1's TAR revealed a PT/INR was completed on 08-26-2024 at 5:20 AM. Results of INR were not called to prescriber until 08-27-2024 and the facility did not receive orders for dosing until 08-28-2024.
-Record review of Resident 1's TAR revealed an order to check a PT/INR on 10-07-2024 and call results to the Coumadin clinic by noon. The TAR also revealed the PT/INR was completed on 10-07-2024 at 3:35 PM.
-Record review of Resident 1's progress notes dated 10-08-2024 revealed the facility received for Coumadin dosing and an order to recheck PT/INR.
An interview on 10-09-2024 at 3:50 PM with the Director of Nursing (DON) confirmed the missed doses of Coumadin were a significant medication error.
Record Review of the Facility Policy Medication Errors and Adverse Reactions dated 01-2022 identified a medication error as an administration of medications that was not in accordance with the prescriber's order. Furthermore, Nursing must immediately implement and follow the physician's orders.
An interview with the DON on 10-10-2024 at 1:23 PM confirmed the expectation is nursing staff should have called the prescriber with the PT/INR results on the day the PT/INR was taken to avoid a lapse in Coumadin therapy.
The Immediate Jeopardy situation was determined to have begun on 07/10/24. The facility was informed to the Immediate Jeopardy status on 10/9/24. The facility abatement plan was implemented on 10/9/24. The specific requirements that were violated was F760 and 175 NAC 12-006.10 (D) for failure to ensure medications were administered to residents in accordance with physician orders.
The facility implemented the following actions on 10/9/24 to remove the immediacy of the situation and to protect the residents:
-The DNS [Director of Nursing Services] or designee will identify all other residents on routine narcotics to complete full audit of eMAR [electronic Medication Administration Records] documented administration and verification of medication availability. This audit and verification will be completed by 8:00 PM 10/9/24.
-The DNS or designee will educate nurses and CMAs [Certified Medication Aides] currently working and all other licensed staff prior to working their next shift. Electronic education will be completed with all nurses and CMAs by end of day 10/9/24. Education will include expected use and instructions on use of facility emergency medication kit, correct ordering of medication and clear expectation on time and expectation to complete physician ordered PT/INR [prothrombin time/international normalized ration] blood draw, as well as expectation of time deadlines to notify PCP [Primary Care Physician] or coumadin clinic, manually entering telephone orders for next INR and coumadin dose.
-The DNS or designated clinical manager will complete all INR draws and notification x 2 weeks, while completing follow up education and verification of understanding with nurses.
-The ED [Executive Director] or designee will audit staff education completion of the above areas every shift x 2 days. The DNS or designee will audit e MAR for omissions of missed narcotic prior to end of shift x 7 days or until substantial compliance is determined. The DNS or designee will audit eMAR and progress notes for omissions of INR completion and PCP notification x 4 weeks or until substantial compliance is determined. The above audits will submitted to QAPI [Quality Assurance Performance Improvement] monthly x 3 until substantial compliance is determined.
-Resident 1 coumadin is on the building and the INR will be completed by ADON on 10/10/24 in the AM. Results will be called to coumadin clinic on 10/10/24.
-Resident 4 is in the hospital but fentanyl patches are available in the EKit and oxycodone is currently available.
At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the D level.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0760
(Tag F0760)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.10(D)
Based on record review and interview, the facility failed to ensure medications ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.10(D)
Based on record review and interview, the facility failed to ensure medications were administered in accordance with physician orders for 2 [Residents 1 and 4] of 4 sampled residents which resulted in significant medication errors.
The facility Administrator and Director of Nursing was notified on 10/9/24 at 5:00 PM of an Immediate Jeopardy (IJ) which began on 7/10/24. The IJ was removed on 10/9/24, as confirmed by surveyor onsite verification.
The Findings are:
A.
Record Review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 09-30-2024 revealed the facility staff assessed the following about the resident:
-Brief Interview of Mental Status (BIMS) was scored as a 10. According to the MDS [NAME] a score of 8-12 indicates moderate cognitive impairment.
-Had Diagnosis of Atrial Fibrillation (a heart condition that causes the heart to beat irregularly and sometimes very fast), Coronary Artery Disease (a condition that occurs when the coronary arteries narrow or become blocked, preventing the heart muscle from receiving enough blood and oxygen) Cerebrovascular accident (a medical condition that occurs when blood flow to the brain is suddenly interrupted), and seizure disorder
-had a heart valve replacement.
-Resident was taking an anticoagulant (medications that prevent blood clots from forming in the bloodstream. They are given to people who are at high risk of developing blood clots, which can lead to serious conditions like heart attacks and strokes).
Record Review of Resident 1's Record Review of Resident 1's Medication Administration Record (MAR, a report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional) and Treatment Administration Record (TAR) for July 2024 revealed the following:
-07-10-2024 no orders or coumadin (Coumadin (warfarin) is a blood-thinning medication that requires regular blood tests to monitor how well it's working and prevent blood clots. These tests measure your prothrombin time (PT) and calculate your international normalized ratio (INR) administered.)
-07-10-2024 Check PT/INR (a test to evaluate blood clotting) -documented as completed.
-07-12-2024 lovenox (an injectable blood thinner) 100 Milligrams (MG or mg) /Milliliter (ML or ml) inject 1 ml twice a day- documented administered.
-07-13-2024 lovenox 100 MG/ML twice a day- documented as administered.
-07-14-2024 lovenox 100 MG/ML twice a day- documented as administered.
-07-15-2024 lovenox 100 MG/ML twice a day- documented as administered.
-07-15-2024 no coumadin orders.
-07-16-2024 lovenox 100 MG/ML twice a day- documented as administered.
-07-16-2024 no coumadin orders.
-07-17-2024 lovenox 100 MG/ML twice a day- documented as administered.
-07-17-2024 no coumadin orders.
-07-18-2024 lovenox 100 MG/ML twice a day- documented as administered.
-07-18-2024 no coumadin orders.
-07-19-2024 lovenox 100 MG/ML twice a day- documented as administered.
-07-19-2024 no coumadin orders.
-07-20-2024 lovenox 100 MG/ML twice a day- documented as administered.
-07-20-2024 no coumadin orders.
-07-21-2024 lovenox 100 MG/ML twice a day- documented as administered.
-07-21-2024 no coumadin orders.
-07-22-2024 lovenox 100 MG/ML twice a day- documented as administered
-07-23-2024 lovenox 100 MG/ML twice a day- documented as administered.
-07-24-2024 lovenox 100 MG/ML twice a day- documented as administered.
-07-25-2024 lovenox 100 MG/ML twice a day- documented as administered.
Record review of Resident 1's orders revealed no orders to hold or skip a day of coumadin on 07-10-2024, or 07-15-2024 through 07-22-2024.
Record review of Resident 1's progress note dated 07-11-2024 revealed new orders for coumadin 8 mg now and start lovenox 100 mg injection twice a day and follow up with the coumadin clinic tomorrow per on call prescriber instruction.
Record review of Resident 1's progress note dated 07-12-2024 revealed staff followed up with coumadin clinic and received orders for coumadin 8 mg today, 6 mg 07-13-2024 and 07-14-2024. Continue lovenox injection 100 mg twice a day. Obtain a PT/INR on 07-15-2024 and call the coumadin clinic with the results.
Record review of Resident 1's progress notes, order listing and MAR revealed no PT/INR testing was completed for 07-15-2024.
Record review of Resident 1's progress notes revealed on 07-18-2024 a PT/INR was collected and sent to the lab.
Record review of Resident 1's progress notes dated 07-19-2024 Resident 1's responsible party was notified of new coumadin order.
Record review of Resident 1's progress notes dated 07-22-2024 revealed staff received an order for Coumadin 8 mg on 07-22-2024, 07-23-2024, and 07-24-2024. Recheck PT/INR on 07-25-2024 and continue lovenox injections daily with subsequent coumadin dosing.
Record Review of Resident 1's Record Review of Resident 1's MAR and TAR for August 2024 revealed the following:
08-05-2024- Recheck PT/INR -documented as completed on 10-05-2024.
08-05-2024- no coumadin orders present on MAR for this date.
08-12-2024 no coumadin orders present on MAR for this date.
08-15-2024 coumadin 4 mg documented as not given.
08-22-2024 coumadin 4 mg no documentation that medication was given.
08-26-2024 Recheck PT/INR prior to 12 pm. -documented as completed.
08-27-2024 no coumadin orders present on MAR for this date.
Record review of Resident 1's orders dated 08-05-2024 revealed no orders for coumadin or follow up PT/INR testing.
Record review of Resident 1's orders dated 08-09-2024 revealed orders for coumadin 6 mg on 08-09-2024 and 08-12-2024. Recheck PT/INR on 08-13-2024.
Record review of Resident 1's orders for 08-13-2024 revealed an order for coumadin 6 mg on 08-13-2024 and coumadin 4 mg on 08-14-2024 and 08-15-2024. Recheck PT/INR on 08-16-2024.
Record review of Resident 1's orders for 08-19-2024 revealed an order for coumadin 4 mg on 08-19-2024 and 08-20-2024 and 08-22-2024.
Record review of Resident 1's orders on 08-23-2024 revealed an order to recheck PT/INR on 08-26-2024 prior to 12 pm.
Record review of Resident 1's orders on 08-27-2024 revealed no orders for coumadin or follow up PT/INR testing.
An interview on 10-09-2024 at 3:50 PM with the Director of Nursing (DON) confirmed the missed doses of coumadin were a significant medication error.
A follow up interview with the DON on 10-09-2024 at 5:00 PM confirmed no records were found for the identified omissions in July, August, September and October except on 08-26-2024 which the facility identified that missing dose as a medication error.
Record review of Resident 1's MAR and TAR for September 2024 revealed the following:
-09-10-2024 coumadin 6 mg no documentation that medication was given.
Record review of Resident 1's orders dated 09-09-2024 revealed an order for coumadin 6 mg give on 09-09-2024, 09-10-2024, 09-12-2024, 09-13-2024, and 09-15-2024 and to give 4 mg on 09-11-2024 and 09-14-2024.
Record Review of Resident 1's MAR and TAR for October 2024 revealed the following:
-10-07-2024 Check PT/INR and call results into the Coumadin Clinic before noon. -Documented as completed at 3:35 PM.
-10-07-2024 No coumadin ordered or given.
An interview was conducted on 10-09-2024 with Licensed Practical Nurse (LPN) A at 2:00 PM revealed LPN A had worked on 10-07-2024 but did not know who checked the PT/INR on that day. LPN A confirmed they received orders for coumadin on 10-08-2024.
An interview with the DON on 10-10-2024 at 1:23 PM confirmed the expectation is nursing staff should have called the prescriber with the PT/INR results on the day the PT/INR was taken to avoid a lapse in coumadin therapy.
Record Review of the Facility Policy Medication Errors and Adverse Reactions dated 01-2022 identified a medication error as an administration of medications that was not in accordance with the prescriber's order. Furthermore, Nursing must immediately implement and follow the physician's orders.
B.
A review of Resident 4's admission Record revealed Resident 4 was admitted to the facility on [DATE] with diagnoses of Pick's disease [a type of frontotemporal dementia], Opioid Dependence [physical and psychological reliance on opioids], and Chronic Pain Syndrome.
A review of Resident 4's quarterly Minimum Data Set [a comprehensive assessment used for care planning] dated 7/16/24 revealed the following:
-Resident 4 had pain frequently over the last 5 days
-Resident 4 occasionally had pain that effected sleep in the last 5 days
-Resident 4 occasionally had pain that limited day-to-day activities
-Resident 4 rated pain intensity at 5 on a scale of 1-10 over the last 5 days
A review of Resident 4's Care Plan revealed a focus area dated 3/31/222 for having chronic pain related to Pick's disease and chronic knee pain with a goal of voicing a level of comfort and the following interventions:
-Medications and treatments as ordered initiated 7/25/24.
-Monitor and document for side effects of pain medications including constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness, and falls. Report occurrences to the physician initiated 3/31/22.
-Monitor and report to nurse loss of appetite, or refusal to eat and weight loss initiated 3/31/22.
-Monitor and report to nurse resident complaints of pain or requests for pain treatment initiated 3/31/22.
-Occupational, Physical, speech-Language therapy evaluation and treatment per physician orders initiated 3/31/22.
-Pain assessment every shift initiated 3/31/22.
-Prefers to have pain controlled by medication initiated 3/31/22.
A review of Resident 4's 10/2024 MAR [Medication Administration Record] revealed the following orders:
-Fentanyl [synthetic opioid] 25 mcg [microgram]/hour apply to middle of chest topically one time a day every 3 days dated 3/14/2024
-Oxycodone HCl [opioid analgesics] 5 mg [milligrams] tablet, 1 tablet by mouth 3 times per day for pain management dated 8/27/24
A review of Resident 4's Progress Notes revealed the following:
-Progress Note dated 10/6/24 7:41 AM stated Fentanyl Patch was not available for administration. Patch was reordered pending delivery.
-Progress Note dated 10/3/24 11:59 AM stated Fentanyl Patch was not available for administration
-Progress Note dated 9/28/24 at 1:29 PM stated Oxycodone 5 mg tablet was not available for administration waiting on pharmacy
-Progress Note dated 9/28/24 at 9:49 AM stated Oxycodone 5 mg tablet waiting on pharmacy for delivery
-Progress Note dated 9/27/24 at 5:07 PM stated Oxycodone 5 mg not given waiting for pharmacy
-Progress Note dated 9/27/24 at 2:02 PM Oxycodone 5 mg not given waiting on pharmacy
A review of Resident 4's 10/2024 MAR revealed Fentanyl Patch 25 mcg/hour apply to middle of chest topically 1 time per day every 3 days was scheduled to be administered on 10/3/24 and 10/6/24 and was not administered on either date.
A review of Resident 4's 9/2024 MAR revealed Oxycodone 5 mg 1 tablet 3 times per day was not administered on 9/27/24 or 9/28/24.
A review of Resident 4's 9/2024 MAR revealed the following pain levels on a scale of 1-10 with 10 being the most pain for 9/27/24-9/28/24:
-9/27/24 6 AM-5; 12 PM 3; 6 PM 6
-9/28/24 6 AM 0; 12 PM 3; 6 PM 3;
A review of Resident 4's 10/2024 MAR revealed the following pain levels on a scale of 1-10 with 10 being the most pain for 10/3/24-10/8/24:
-10/3/24 6 AM 0; 12 PM 7; 6 PM 5;
-10/4/24 6 AM 0; 12 PM 3; 6 PM 3;
-10/5/24 6 AM 0; 12 PM 6; 6 PM 0;
-10/6/24 6 AM 0; 12 PM 5; 6 PM 4;
-10/7/24 6 AM 0; 12 PM 0; 6 PM 5;
-10/8/24 6 AM 0; 12 PM 0; 6 PM 5;
A review of Resident 4's Progress Notes revealed the following:
-10/8/24 at 5:09 PM resident with increased agitation and confusion during the day, scooting self on floor while throwing objects in rooms, knocked trash can over and ripped brief into shreds while on floor. Resident temp [temperature], 02 [oxygen saturation] and pulse within normal limits, resident refuses blood pressure check. Call placed to [Doctor] office with request for UA [urine analysis]. Awaiting return phone call
-10/8/24 11:55 PM Res continues series of jacking [jerking] movements uncontrollable series of motion. Sometimes hitting head, lower extremities. Attempts to get VS [vital signs] and make assessment and Resident continue to show signs of stress. New bruises observed coming from the uncontrollable movements. Call made to ON-CALL DON [Director of Nursing] for order. Call placed for [doctor name] with order received to send resident to Hospital to eval [evaluate] and treat. ER [Emergency Room] at [hospital] informed and Transfer documents forwarded with arrival of Squad. 11:45 PM Squad arrived for transportation of res to [hospital]
-10/9/24 1:18 AM 1:15 AM Revisiting ER for information on admission. Resident would be admitted for dehydration and AKI [acute kidney injury] possibility of a kidney injury would be determined after the result of CT scan.
In an interview on 10/9/24 at 2:22 PM, MA [Medication Aide] B confirmed that Resident 4 did not have a Fentanyl patch for administration on Sunday [10/6/24]. MA B stated that MA B had notified the nurse.
In an interview on 10/9/24 at 1:43 PM, RN [Registered Nurse] C reported Resident 4 was having fits on the floor. RN C reported calling Resident 4's provider but did not receive a return call by the end of the shift. RN C reported that Resident 4's agitation increased throughout the day and Resident 4 was ripping off brief. RN C indicated that RN C was not aware that Resident 4 was missing medications.
In an interview on 10/9/24 at 3:38 PM, LPN D reported Resident 4 was not responding in an understandable manner and was shaking so bad that vital signs could not be taken. LPN D reported Resident 4 had leg bruising from hitting body on the trash can. LPN D reported being unaware that Resident 4 did not have a Fentanyl patch and would have gotten one from the emergency kit. LPN D reported calling Resident 4's doctor and sending Resident 4 to the hospital.
A review of email from facility pharmacy dated 10/9/24 at 3:54 PM revealed that Resident 4's Fentanyl patch was reordered thru Point Click Care [medical record and medication administration system] on 10/6/24. The email stated that narcotics cannot be reordered through that interface resulting in the refill request not going through. The email stated that controlled substances reorder requests must be faxed.
In an interview on 10/9/24 at 5:01 PM, the DON confirmed that narcotics reorders must be faxed and can not be reordered thru Point Click Care. The DON confirmed that Resident 4's Fentanyl patch and Oxycodone were not refilled for the same reason. The DON confirmed that missing Oxycodone and Fentanyl would both be considered a significant medication error. The DON reported that both Fentanyl patches and Oxycodone were available in the facilities emergency kit.
A review of facility policy titled Medication Errors and Adverse Reactions revised 1/2022 revealed the following:
-Medication Error' means the observed or identified preparation or administration of medications or biologicals which is not in accordance with:
-The prescriber's order;
-Manufacturer's specifications (not recommendations) regarding the preparation or administration of the medication or biological; or
-Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils.
A review of facility policy and procedure titled Care and Treatment under section Medications, Provision of Routine, Emergency and OTC [over the counter] revised 2/2022 revealed the following procedure:
-1. Medications prescribed on a routine, emergency, or PRN should be administered in a timely manner.
-2. When an emergency or stat order is received, the charge nurse:
-Determines that the order is a true emergency, i.e., cannot be delayed until the scheduled pharmacy delivery.
-Ascertains whether the ordered medication is contained in the emergency kit by referring to the list of contents posted at the nursing station or on the box.
-If the medication is not available, calls the pharmacy, using the after-hours emergency number(s), if necessary.
-3. The provider pharmacy supplies emergency or stat medications according to the provider pharmacy agreement.
-4. Medications are not borrowed from other residents. The required medication is obtained either from the emergency box or from the provider pharmacy.
-5. The provider pharmacy is called if an emergency arises requiring immediate pharmacist consultation, using the after-hours emergency number(s), if necessary. In the event that the provider pharmacy is unable to supply essential information regarding the appropriateness of a new drug order, the consultant Pharmacist is contacted.
-6. OTC medication could be ordered from a supplier that the facility choses to, an inventory must be kept for the medication ordered and replaced the used ones.
The Immediate Jeopardy situation was determined to have begun on 07/10/24. The facility was informed to the Immediate Jeopardy status on 10/9/24. The facility abatement plan was implemented on 10/9/24. The specific requirements that were violated was F760 and 175 NAC 12-006.10 (D) for failure to ensure medications were administered to residents in accordance with physician orders.
The facility implemented the following actions on 10/9/24 to remove the immediacy of the situation and to protect the residents:
-The DNS [Director of Nursing Services] or designee will identify all other residents n routine narcotics to complete full audit of eMAR [electronic Medication Administration Records] documented administration and verification of medication availability. This audit and verification will be completed by 8:00 PM 10/9/24.
-The DNS or designee will educate nurses and CMAs [Certified Medication Aides] currently working and all other licensed staff prior to working their next shift. Electronic education will be completed with all nurses and CMAs by end of day 10/9/24. Education will include expected use and instructions on use of facility emergency medication kit, correct ordering of medication and clear expectation on time and expectation to complete physician ordered PT/INR [prothrombin time/international normalized ration] blood draw, as well as expectation of time deadlines to notify PCP [Primary Care Physician] or coumadin clinic, manually entering telephone orders for next INR and coumadin dose.
-The DNS or designated clinical manager will complete all INR draws and notification x 2 weeks, while completing follow up education and verification of understanding with nurses.
-The ED [Executive Director] or designee will audit staff education completion of the above areas every shift x 2 days. The DNS or designee will audit e MAR for omissions of missed narcotic prior to end of shift x 7 days or until substantial compliance is determined. The DNS or designee will audit eMAR and progress notes for omissions of INR completion and PCP notification x 4 weeks or until substantial compliance is determined. The above audits will submitted to QAPI [Quality Assurance Performance Improvement] monthly x 3 until substantial compliance is determined.
-Resident 1 coumadin is on the building and the INR will be completed by ADON on 10/10/24 in the AM. Results will be called to coumadin clinic on 10/10/24.
-Resident 4 is in the hospital but fentanyl patches are available in the EKit and oxycodone is currently available.
At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the D level.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 006.09(H)
Based on record review and interview, the facility failed to evaluate 1 (Resident 4...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 006.09(H)
Based on record review and interview, the facility failed to evaluate 1 (Resident 4) of 3 sampled residents following identification of an injury from unknown sources. The facility had a total census of 67 residents.
Findings are:
A.
A record review of Resident 4's admission Record revealed Resident 4 was admitted to the facility on [DATE] with diagnoses of Pick's disease (a type of frontotemporal dementia), Opioid Dependence (physical and psychological reliance on opioids), and Chronic Pain Syndrome.
A record review of Resident 4's Care Plan revealed a focus area of being at risk for falls dated 3/31/24 with an identified preference of Resident 4's to sit on the floor. The Care Plan identified that the Team will not count my preference of sitting on the floor as a fall unless Resident 4 has visible injury.
The following interventions were identified in the Care Plan:
-Offer resident extra pillow to help define perimeter of bed and decrease change of rolling off, initiated on 1/7/23.
-Fall mat placed next to bed to prevent injury, initiated 5/22/24.
-Avoid rearranging furniture, dated 3/31/22.
-Be sure the call light is within reach and encourage to use it to call for assistance as needed, initiated 3/31/22.
-Ensure resident is wearing appropriate footwear when ambulating or wheeling in wheelchair, initiated 3/31/22.
-Maintain a clear pathway, free of obstacles, initiated 3/31/22.
-Occupational, Physical, Speech-Language Therapy evaluation and treatment per physician orders, initiated 3/31/24.
-Place sign in room for a reminder to use call light for assistance, initiated 3/9/23.
-Resident self-transfers from floor to recliner per therapy. Resident is aware to call for assistance but refuses to at times because resident wants to get in dresser and get out clothes and look through items, initiated 10/17/22.
-Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter or remove any potential causes if possible. Educate resident/family/caregivers/interdisciplinary team as to causes, initiated 3/31/22.
-Staff will ensure resident's bed is in the lowest position while the resident is in bed, initiated 3/4/23.
A record review of a Weekly Skin Evaluation dated 10/8/24 at 12:19 AM revealed Resident 4 had some swelling on their left eye but Resident 4 said it was an itching spot.
A record review of Resident 4's Progress Notes revealed the following:
-10/8/24 at 5:09 PM resident with increased agitation and confusion during the day, scooting self on floor while throwing objects in rooms, knocked trash can over and ripped brief into shreds while on floor. Resident's temperature, 02 (oxygen saturation) and pulse within normal limits, resident refuses blood pressure check. Call placed to (Doctor) office with request for UA (urine analysis). Awaiting return phone call.
-10/8/24 at 11:55 PM Resident continues series of jacking [jerking] movements, uncontrollable series of motion. Sometimes hitting head, lower extremities. Attempts to get vital signs and make assessment and Resident continues to show signs of stress. New bruises observed coming from the uncontrollable movements. Call made to On-Call DON (Director of Nursing) for order. Call placed to [doctor name] with order received to send resident to hospital to eval [evaluate] and treat. ER (Emergency Room) at (hospital) informed and Transfer documents forwarded with arrival of Squad. At 11:45 PM, Squad arrived for transportation of resident to (hospital).
-10/9/24 at 1:18 AM At 1:15 AM, re-visiting ER for information on admission. Resident would be admitted for dehydration and AKI [acute kidney injury], possibility of a kidney injury would be determined after the result of CT scan.
Further record review of Resident 4's Progress Notes did not reveal any documentation of an evaluation of Resident 4's left eye.
In an interview on 10/9/24 at 12:06 PM, Medication Aide (MA)-E revealed that the left side of Resident 4's face was swollen and Resident 4 had dried blood on their mouth. MA-E also revealed that they had noted purple and red bruising on Resident 4's legs. MA-E also revealed that injuries were reported to the nurse.
In an interview on 10/9/24 at 1:27 PM, MA-F reported Resident 4 had a black eye and their mouth had dried blood in it. MA-F stated that the Resident 4 had reported hitting their head on the floor. MA-F reported Resident 4 had bruises on their legs from rolling on the floor. MA-F reported the injuries to the Assistant Director of Nursing (ADON)
In an interview on 10/9/24 at 1:43 PM, Registered Nurse (RN)-C reported that Resident 4 had a black eye when RN-C came on shift. RN-C stated they had reported their concerns to Assistant Director of Nursing (ADON).
In an interview on 10/9/24 at 3:38 PM, Licensed Practical Nurse (LPN)-D confirmed that Resident 4 had a black eye which was not unusual for Resident 4. LPN-D confirmed that the black eye had started small and had gotten much bigger.
In interviews on 10/9/24 at 3:26 PM and 10/10/24 at 1:21 PM, the Director of Nursing (DON) reveaeled Resident 4's black eye had not been reported to them. The DON confirmed that neuro (neurological) checks should have been started and an incident report should have been completed. The DON reported that an order should have been placed in the Treatment Administration Record for a change of condition and shiftly follow up completed for 72 hours, then weekly until resolution.
A record review of facility policy titled Quality of Care, in the subject section Incidents and Accidents revised 11/2023 revealed the following procedure:
1. Assisting Incident/Accident Victim: Any staff witnessing an accident/incident, or find it necessary to aid an accident victim (resident, staff), should:
A. Render immediate assistance. Do not move the victim until he/she has been examined for possible injuries;
B. If possible, move the injured to the treatment room, or if it is a resident in his/her room, move the resident to his or her bed; and
C. If assistance is needed, summon help. If you cannot leave the victim ask someone to report to the nurses' station that help is needed, or if possible, use the call system located in the resident's room to summon help.
2. Licensed nurse will assess the resident (or visitor or staff), including vital signs, neuro checks if needed, complaints of pain and location, and determine if treatment or additional care is needed, including accessing the EMS [Emergency Medical System] system.
3. Licensed nurse will notify medical provider for residents, and obtain orders for further treatment or diagnosis as deemed necessary by the provider.
Jul 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D(l)
Based on record review, interviews, and observations, the facility failed to im...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D(l)
Based on record review, interviews, and observations, the facility failed to implement assessed interventions to prevent potential injuries for 3 of 3 residents (Residents 1, 4, and 5). The facility identified a census of 65.
Findings are:
A. Record review of Resident 1 Census Sheet revealed the resident was admitted to the facility on [DATE].
Record review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 6/11/24 revealed the resident had a Brief Interview for Mental Status (BIMS, is a brief screener that aids in detecting cognitive impairment) with a score of 10. According to the MDS [NAME] a BIMS score of 10 identified the resident is moderately cognitively impaired. Resident 1 required set up or clean up assist with eating. The resident required substantial/maximum assist with toileting, bed mobility and transfers. Resident 1 is frequently incontinent of urine and occasionally incontinent of bowel.
Record review of Resident 1's Fall assessment dated [DATE] revealed the resident had a score of 13. A score of 13 on the fall assessment dated [DATE] revealed the resident to be at high risk for falls.
Record review of Resident 1's Care Plan dated 2/17/22 revealed the resident is at risk for falls related to deconditioning, gait/balance problems, unaware of safety needs, preference to be independent and forgetfulness. The following intervention with dates had been put into place for fall preventions:
-03/17/24 Frequent checks by staff.
Date Initiated: 03/18/2024
-03/17/24 Offer activities outside of room.
Date Initiated: 03/18/2024
-6/3/24 Offer assistance to bed and/or toileting after evening smoke time.
Date Initiated: 06/03/2024
-Be sure the call light is within reach and encourage to use it to call for assistance as
needed.
Date Initiated: 02/17/2022
-Ensure resident is wearing appropriate footwear when transferring, ambulating or
wheeling in wheelchair.
Date Initiated: 11/20/2022
-Low bed
Date Initiated: 02/17/2022
-Occupational, Physical, Speech-Language Therapy evaluation and treatment per
physician orders
Date Initiated: 03/10/2022
-Resident prefers to get up and ready for the day before breakfast. Staff will offer assistance with rising and activities of daily living and ensure resident gets to dining room for
breakfast by 8 am as is her preference. (3/26/24)
Date Initiated: 03/26/2024
-Staff to offer toileting assistance after meals (3/4/2022)
Date Initiated: 03/04/2022
-Wheelchair next to bed.
Date Initiated: 02/17/2022
Record review of the facility Adult Protective Services (APS) report dated 6/4/24 revealed on 6/3/24 at 7:30 PM Resident 1 was observed lying on their back on the floor of Resident 1's room next to the bed. When inquired about what happened, Resident 1 reported I was trying to get from my chair to my bed and just fell down. Resident 1 reported hit their head but had no loss of consciousness. Resident 1 was alert and oriented to person, place, time, and situation. Resident 1 complained of head pain, sharp neck and sharp, radiating back pain and was rated a 10/10. A call was made to the on-call physician and an order was received to send the resident to the emergency room (ER) for evaluation. Director of Nursing (DON) and Executive Director (ED) were notified of fall and transport of Resident 1 to the ER.
Observation on 7/2/24 at 6:45 AM revealed Resident 1 was laying in bed with their eyes closed. The right side of Resident 1's bed was pushed up against the wall and the call light was hanging down the side with the call light button on the floor and out of reach of Resident 1.
A interview on 7/2/24 at 6:57 AM was conducted with the Assistant Director of Nursing (ADON). During the interview the ADON confirmed Resident 1's call light was out of the resident's reach.
B. Record review of Resident 4's Census Sheet revealed the resident was admitted to the facility on [DATE].
Record review of Resident 4's MDS dated [DATE] revealed the resident had a BIMS score of 15. According to the MDS [NAME] a score of 13 to 15 indicates a person is cognitively intact. According to Resident 4's MDS dated [DATE] Resident 4 was dependent for assistance with toileting, bed mobility, and transfer and was frequently incontinent of bowel and bladder.
Record review of Resident 4's Fall assessment dated [DATE] revealed a score of 12. A score of 12 on the Fall Assessment revealed the resident to be at high risk for falls.
Record review of Resident 4's Care Plan dated 5/26/15 revealed Resident 4 was at risk for fall related to activities of daily living and mobility deficits, seizure disorder, psychoactive drug use, use of narcotic medication, incontinence of bowel and bladder, and weakness. Resident 4 had a history of behaviors as evidenced by sliding out of wheelchair for attention and pretending (gender) was having a seizure. The goal of the care plan was to prevent serious injury. To meet the goal interventions with dates were identified as follows on Resident 4's Care Plan:
-08/22/23 Add non-skid mat to seat of wheelchair to prevent sliding down.
Date Initiated: 08/23/2023
-5/8/24- placed on 1:1 until transferred to hospital related to psychosis and intentionally
sliding out of wheelchair.
Date Initiated: 05/08/2024
-5/8/24- When up in wheelchair provide 1:1 with staff during moments of psychosis, yelling,
paranoia, accusatory remarks until resident can be transferred into low bed.
Date Initiated: 05/08/2024
-Anticipate and meet needs as able.
Date Initiated: 05/26/2015
-Be sure the call light is within reach and encourage to use it to call for assistance as
needed.
Date Initiated: 05/26/2015
-Bed will placed in lowest position while in it. (12/17/2023); lock bed control to
prevent resident from raising height. (5/3/24)
Date Initiated: 12/17/2023
-Ensure proper positioning in wheelchair as needed.
Date Initiated: 05/26/2015
-Fall risk assessment quarterly, and as needed.
Date Initiated: 05/26/2015
-Foam placed on foot rests to prevent injury when sliding out of chair. (2/5/24)
Date Initiated: 02/05/2024
-Grab bars to both sides of bed to assist with repositioning.
Date Initiated: 05/26/2015
-Keep needed items, water, etc, in reach.
Date Initiated: 05/26/2015
- Observe for seizure activity and notify MD as needed if noted.
Date Initiated: 05/26/2015
-Patient to be placed on 1:1 activities ongoing 1-2 times weekly per patient preference.
(5/2/24)
Date Initiated: 05/03/2024
-Resident will have side pillow to assist with positioning while in wheelchair. Date Initiated 11/21/2023
-Wheelchair lap belt to wheelchair. Resident 4 is able to release it.
Date Initiated: 02/05/2024
Record review of the facility APS report dated 5/14/24 revealed the following information:
-Resident 4 was found on the floor in the dining room sitting on the footrest of wheelchair with legs extended out straight and arms crossed over chest.
-Resident was last seen shortly before when (gender) had asked to go sit in the dining room with a safety belt was in place at that time.
-When questioned about what happened and how (gender) slid out of wheelchair, Resident 4 replied (gender) did it intentionally because (gender) likes to cause trouble.
-When staff approached Resident 4 to reposition the resident off the foot pedals to prevent injury, Resident 4 became physically combative, cursing at staff, and stated (gender) wanted to kill (gender).
-Resident 4 was placed in a low bed to prevent injury should (gender) continue behaviors or throw (gender) out of bed.
-Nurse Practitioner for Resident 4 was called and Resident 4 was placed on 15-minute checks for safety.
-Resident 4 continued to have aggressive behavior with Resident 4 being sent to the ER for evaluation of mental/behavioral status.
-Resident 4 returned to the facility at 5:45 P.M. via a ambulance with no new orders.
-Resident 4 continued to be combative with staff, refusing assessment, vital signs, and neuro checks the remainder of the evening.
-Immediate steps taken to protect the resident were staff to remain with Resident 4 on a 1:1 until Resident 4 could be relocated in bed with the bed placed in low position and locked to prevent injury as a consequence of ongoing behaviors,
- Resident 4 was placed on 15-minute checks and all potentially harmful objects removed from the Resident's room following harm statement.
A observation on 7/2/24 at 6:53 AM revealed Resident 4 in bed with the bed in the high position.
A interview with the ADON on 7/2/24 at 6:57 AM confirmed Resident 4's bed was in the high position and should be in low position. ADON demonstrated during the interview that Resident 4's bed control cannot be locked as indicated on Resident 4's Care Plan.
Interview with Nursing Assistant-A (NA-A) on 7/2/24 at 9:37 AM, NA-A confirmed (gender) was not aware of how to find the Care Plan interventions for the resident under (gender) care.
C. Record review of Resident 5's Census Sheet revealed Resident 5 was admitted to the facility on [DATE].
Record review of Resident 5's MDS dated [DATE] revealed Resident 5 had a BIMS score of 14. The MDS also revealed Resident 5 required set-up/clean-up assist with eating, substantial/maximum assist with transfers and toileting. Resident 5 required partial/moderate assist with bed mobility and was frequently incontinent of urine and always continent of bowel.
Record review of Resident 5's Fall assessment dated [DATE] revealed a score of 10. A score of 10 was considered medium risk for falls.
Record review of report dated 6/03/24 to APS revealed the following:
-Resident was found sitting on the side of low bed when staff entered the room and noticed swelling a developing bruise of (gender) nose and left orbital (eye) area.
-Resident 5 reported Resident 5 had been lying in bed and reached for something and rolled out onto the floor and hit (gender) nose.
-Area examined by the nurse, no blood present, vision unaffected, but resident complains of pain. Resident 5's Nurse Practitioner was contacted and gave telephone order for nasal X-ray, OK for mobile X-ray per resident preference.
-The X-ray was completed at approximately with the results diagnosed as a nasal fracture received at 1:59 PM.
Record review of Resident 5's Care Plan dated 3/31/22 revealed Resident 5 was at risk for falls related to disease process, antidepressant use, decreased vision, and cognitive deficits. The goal for Resident 5's was not to sustain serious injury. To meet this goal the following interventions with dates were on Resident 5's Care Plan:
-1/07/2023: Offer resident extra pillow to help define perimeter of bed and decrease
chance of rolling off.
Date Initiated: 01/07/2023
-5/22/24: Fall mat placed next to bed to prevent injury.
Date Initiated: 05/22/2024
-Avoid rearranging furniture.
Date Initiated: 03/31/2022
-Be sure the call light is within reach and encourage to use it to call for assistance as
needed.
Date Initiated: 03/31/2022
-Ensure resident is wearing appropriate footwear when ambulating or wheeling in
wheelchair.
Date Initiated: 03/31/2022
-Maintain a clear pathway, free of obstacles.
Date Initiated: 03/31/2022
-Occupational, Physical, Speech-Language Therapy evaluation and treatment per
physician orders
Date Initiated: 03/31/2022
-Place sign in room for a remind to use call light for assistance. (3/9/23)
Date Initiated: 03/09/2023
-Reminder to use call light for assistance
Date Initiated: 03/09/2023
-Resident self-transfers from floor to recliner per therapy. Resident is aware to call for assistance but refuses to at times because resident wants to get in dresser and get out clothes and look through her items.
Date Initiated: 10/17/2022
-Review information on past falls and attempt to determine cause of falls. Record
possible root causes. Alter/remove any potential causes if possible. Educate
resident/family/caregivers/Interdisciplinary Team as to causes.
Date Initiated: 03/31/2022
-Staff will ensure residents bed is in lowest position while in bed (3/4/23)
Date Initiated: 03/04/2023
Observation on 7/2/24 at 6:38 AM of Resident 5 revealed no floor mat on the floor beside the bed.
Interview with Resident 5 on 7/2/24 at 6:39 AM revealed Resident 5 reported a staff member took the floor mat about a week ago for another resident.
Interview with the ADON on 7/2/24 at 6:47 AM, ADON confirmed a floor mat should be on the floor next to Resident 5's bed.
Record review of the Policy/Procedure for Fall Management System dated 6/2022 revealed the following:
-Standards
This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices, and functional programs as appropriate to prevent accidents.
-Policy:
It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.
Procedures:
1 On admission, the Fall Risk evaluation will be completed to determine his/her risk for sustaining a fall.
2 Residents with high risk factors identified on the Fall Risk evaluation will have an individualized care plan developed that includes measurable objectives and time frames. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk.
3 When a resident sustains a fall, an assessment will be completed by a licensed nurse, with results documented in the medical record. Unwitnessed falls and witnessed falls with impact to head will also include the initiation of neurological assessment. The Attending physician and Resident rep shall be notified of the fall and the resident status. Follow-up documentation will be completed for a minimum of 72 hours following the incident. A Fall Risk Evaluation will be completed post fall incident.
4 Review of the fall incident will include investigation to determine probable causal factors.
5 The investigation will be reviewed by the Interdisciplinary Team. A Summary of the investigation and recommendations will be documented in the Risk Management system.
6 Resident's care plan will be updated.
7 The Quality Assurance committee will analyze trends related to falls and will determine if further intervention is needed.
May 2024
11 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175 NAC 12-006.05(21)
Based on observation and interviews, the facility failed to treat 2 of 2 sampled residents (Residents #36 and #8) with dignity, respect, and care that ...
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Licensure Reference Number 175 NAC 12-006.05(21)
Based on observation and interviews, the facility failed to treat 2 of 2 sampled residents (Residents #36 and #8) with dignity, respect, and care that promotes maintenance and enhancement of the resident's quality of life while recognizing the individuality of each resident. The facility identified a census of 73.
Finding are:
On 5/01/2024 during observation of meal service in the main dining room between 12:10 PM and 12:46 PM revealed Cook-F dishing food and serving in the dining room in random order and not according to where residents sat resulting in residents eating food in front of their tablemates for up to 30 minutes before other table mates being served. At 12:19 PM, Resident # 36 was sitting at a table by themselves but became visibly upset when surrounding tables of residents were served their meal between 12:10 PM and 12:20 PM. At 12:27 PM Resident #36 stood and reached for their walker to leave the dining room when their meal was served and sat back down at the table to eat lunch meal. Three residents seated together at a table in the main dining room were served at different times (12:10 PM, 12:16 PM, and 12:30 PM).
An interview on 5/1/2024 at 12:19 PM with Resident # 36 revealed that the resident was upset that tables all around were being served lunch and then stated, This is bullshit and points to the other residents were being served.
Observation at 5/01/2024 at 12:32 PM noted the Certified Dietary Manager (CDM) asking in a loud raised voice to Cook-F What is this for? The CDM was holding a plate resembling a Peanut Butter and Jelly sandwich. [NAME] -F replied back in a loud, raised voice It is for 'resident's first name'.
An observation on 5/2/2024 at 8:04 AM revealed Dietary Assistant (DA)-G was preparing to serve breakfast to residents in the Garden Café. DA-G did not refer to the individual meal tickets but instead spoke in a loud, raised voice to the residents when they entered the dining room What do you want for breakfast? The residents were over approximately 40 feet away.
An observation in the Garden Café dining room on 5/02/2024 at 8:10 AM revealed Resident #52 saying out loud, This is how they always talk to us, always yelling at us.
An observation on 5/02/2024 at 8:20 AM in the Garden Café Dining Room, revealed Resident #8 pouring coffee from their coffee cup into a Pepsi Bottle and the resident accidentally spilled the coffee on the table and the floor. The CDM was overheard speaking to Resident #8, in a loud voice, asking the resident if they were pouring their coffee and spilling it. The CDM went on to say, You can't do that! You will get burned! Other residents in the dining room stopped talking and eating to look at the resident who was being talked to. Resident #8 appeared embarrassed and tried to explain that (gender) wanted to save the coffee for later.
An observation on 5/02/2024 at 8:21 AM in the Garden Café' Dining Room revealed Resident #52 stating loudly, See, this happens all the time, you should be here every day.
On 05/02/2024 at 11:50 AM an interview with Resident #8 revealed when asked if it bothered them how the CDM talked to them that morning. The resident replied, I don't let things like that bother me.
Review of CMS document Your Rights and Protections as a Nursing Home Resident referenced at https://downloads.cms.gov/medicare/Your_Resident_Rights_and_Protections_section.pdf revealed You have the right to be treated with dignity and respect.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175 NAC 12-006.05(15)
Based on observation and interview; the facility failed to ensure full visual privacy in 3 (resident rooms 511, 513 and 529) of 49 dual occupancy rooms...
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Licensure Reference Number 175 NAC 12-006.05(15)
Based on observation and interview; the facility failed to ensure full visual privacy in 3 (resident rooms 511, 513 and 529) of 49 dual occupancy rooms as evidenced by no privacy curtains present that would surround the bed to ensure visual privacy from the doorway or the resident's roommate. This had the ability to affect 3 residents, Residents 8, 38 and 63, that resided in those rooms. The facility census was 73.
Findings are:
Observation on 04/29/24 at between 3:00 PM and 3:15 PM in the Garden level of the facility revealed no privacy curtains were present that could surround the beds to provide visual privacy in resident rooms 511, 513 and 529.
Interview on 05/02/24 between 8:00 and 9:15 AM with Maintenance Director confirmed that there were no privacy curtains present that could surround the beds that would provide visual privacy from the doorway or the residents roommate if they had to exit the room in double occupancy resident rooms 511, 513 and 529. The Maintenance Director confirmed that, without privacy curtains, the residents could be visibly seen from the hallway or the residents' roommate.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Record review of Resident 61 Electronic Medical Record (EMR) revealed the resident had the following diagnosis: encephalopath...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Record review of Resident 61 Electronic Medical Record (EMR) revealed the resident had the following diagnosis: encephalopathy (an acute neurological disorder), altered mental status, epilepsy, dysarthria following a cerebral vascular accident (CVA, a stroke), CVA, Hemiplegia (paralysis on one side of the body), retention of urine, repeated falls, need for assistance with personal cares, muscle weakness, abnormal gait, atrial fibrillation, hypertension, weakness, lack of coordination, dependence on wheelchair, and difficulty in walking.
Record review of Resident 61's Quarterly MDS dated [DATE] revealed a BIMS of 12, which indicated a moderate cognitive impairment. Section GG revealed Resident 61 can walk 10 feet and required partial to moderate assist, which indicated a helper lifted or held resident's truck or limbs and provided less than half the effort. Section GG revealed Resident 61's transfers required supervision or touching assist, which indicated a helper provided verbal cues and/or touching and/or contact guard assistance as the resident completed the activity.
Record review of Facility Incident Report dated 11/5/23 reveald the following statement: This nurse was notified that resident fell at 7:50 AM. When walking into the room a Certified Nurses' Aide (CNA) and Registered Nurse (RN) were with the patient on the floor. Resident's head was bleeding above his right eyebrow and the RN was holding pressure. Vital signs were taken, and the results were: blood pressure-153/109, heart rate-89, temperature-97.7, and respiratory rate-20. Resident's pupils were equal and reactive. Right eye appears to have a broken blood vessel. Right cheekbone looked swollen, and the right eyebrow bleeding stopped. Patient is alert and oriented. When asked where we were resident stated, the hospital. When asked the date resident answered the 5th (correct date). When asked the year resident stated, 1950 . wait no 20 . Primary physician was called and ordered resident to be sent out via 911. 911 was called and arrived at the facility at 8:15 AM. Resident was taken to Immanuel Hospital; report was called to the RN in the emergency room (ER) of Immanuel Hospital. Residents' family was notified. Director of Nursing (DON) was notified. According to the Facility Incident report dated 11/5/23 Resident 61 reported (gender) was getting up then fell and hit (gender) head on the floor.
Record review of After Visit Summary from Immanuel Hospital admission which occurred from 11/5/23-11/7/23 revealed a primary diagnosis of Subdural Hematoma (a collection of blood that forms on the surface of the brain), open wound of the face, high sodium levels, ground level fall, taking blood thinners, and blurred vision.
Record review of Policy entitled Reporting alleged Violations of Abuse, Neglect, exploitation or Mistreatment revealed:
Procedure:
In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will:
1. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but:
-Not later than 2 hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury.
-Not later than 24 hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury.
2. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to:
A. The administrator of the facility
B. The state survey agency
C. Adult Protective services (as appropriate).
3. Ensure that, after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident(s).
4. Ensure that he results of all investigations are reported within 5 working days of the incident to:
A. The administrator
B. The state survey Agency.
Interview on 05/01/24 at 09:39 AM with the Facility Administrator confirmed no record of the fall incident could be found that the incident was reported to APS.
Based on record review and interview the facility failed to submit an abuse investigation to the state agency in 5 working days for 2 (Resident 61 and 80) of 7 residents. The facility staff identified a census of 73.
Findings are:
A. Record review of Resident 80's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 10-25-2023 revealed a diagnosis of fractured hip, dementia, and high blood pressure. The MDS also revealed Resident 80 needed moderate assistance with transfers and upper body dressing and needed maximal assistance with lower body dressing.
Record review of Resident 80's progress notes dated 12-22-2024 revealed Resident 80 had fallen and was sent to the hospital for an x-ray for possible injury to (gender) recently fractured hip.
Record review of the facility's investigation of the fall on 12-22-2024 revealed the state agency was not listed as notified.
An interview with the Administrator (ADM) on 05-01-2024 at 1:58 PM revealed the facility did not follow up and send the investigation to the state agency.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 12-006.05(5)
Based on record review and interview the facility failed to notify 1( Resident 43's and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 12-006.05(5)
Based on record review and interview the facility failed to notify 1( Resident 43's and Resident 43's family representative) of 1 sampled in writing of the resident's transfer to the hospital. The facility had a census of 73.
Findings are:
A record review of Resident 43's Minimum Data Sheet (MDS a federally mandated assessment tool used for care planning) dated 3/24/2024 revealed Resident 43 had a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident is cognitively intact. Resident 43 had the following diagnoses: Neuroleptic induced Parkinsonism, Unspecified Convulsions, Schizoaffective Disorder, Depressive type, Schizoaffective Disorder, Bipolar Type, Anxiety Disorder, unspecified, Cognitive Communication Deficit and generalized Muscle Weakness. Resident 43 did not want to be interviewed.
A record review of Resident 43's Clinical Census Sheet revealed Resident 43 was transferred to the hospital on [DATE].
A record review of Resident 43's electronic health record did not reveal a written notice of transfer/discharge for resident's hospitalization on 11/27/2023.
An interview on 05/01/2024 at 2:58 PM with the facility Administrator confirmed the facility could not produce transfer/discharge documentation for Resident 43's hospitalization on 11/27/2023.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175 NAC 12-006.09D1C
Based on record review, interview, and observation, the facility failed to provide bathing per resident preference for 1(Resident 4) of 3 sampled reside...
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Licensure Reference Number 175 NAC 12-006.09D1C
Based on record review, interview, and observation, the facility failed to provide bathing per resident preference for 1(Resident 4) of 3 sampled residents. The facility identified a census of 73.
Findings are:
Record review of the facility policy labeled Policy/Procedure-Nursing Services dated 5/2022. Section: Showers/bathing. Subject: Shower, Bed bath, and Sponge Bathing revealed the following: It is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care.
Procedure:
1. Showers, bed baths, and sponge baths will be provided to residents in accordance with the resident's shower schedule or preferences.
2. If a resident is unable to showered on their scheduled day related to room changes or appointments, will attempt to reschedule.
3. Showers, bed baths, and sponge baths will be documented in the medical record/POC. Refusals will also be documented.
Record review of Resident 4's Significant Change Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 4/25/24 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) a score of 15. According to the MDS manual, a score of 15 indicated the resident's cognition was intact. Review of section GG of the MDS revealed Resident 4 was dependent on staff for bathing/showering and personal hygiene.
Record review of Resident 4's Care Plan dated 4/25/2020 revealed a focus of Activity of Daily Living (ADL) Self Care Performance Deficit related to disease process, obesity, cognitive impairment, and knee pain. The goal of this care plan focus is ADL needs will be met daily with staff assistance. The intervention for bathing was as follows: Bathing: (Resident 4 stated) I prefer to take a shower and need assist of one.
Observation of Resident 4 on 4/29/24 at 3:24 PM revealed Resident 4's hair was uncombed and greasy.
On 4/29/2024 at 3:24 PM an interview was conducted with Resident 4. During the interview Resident 4 stated I haven't had a shower in 2 weeks.
Record review of Resident 4's showering/bathing electronic record revealed Resident 4 received showers on 4/5, 4/9, 4/13, 4/21, and 4/22. Resident 4 did not receive a shower between 4/22 and 5/1, a total of nine days lapsed between showers.
A interview was conducted on 05/01/24 at 8:50 AM with the Director of Nursing (DON). During the interview the DON confirms Resident 4 had not received a shower two times a week per resident preference.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18
Based on observation and interview, the facility failed to maintain the cleanliness...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18
Based on observation and interview, the facility failed to maintain the cleanliness and condition of walls, floors, curtains, fixtures, ceiling tiles, ventilation covers, baseboards, doors and nightlight's in 23 (Rooms 511, 512, 513, 514, 516, 520, 521, 525, 526, 528, 5101, 5104, 5106, 5109, 5110, 5116, 5118, 5119, 5121, 5123, 5124, 5126 and 5128 ) of 43 total occupied resident rooms, the bath house on both levels of the facility, the activity room on the garden level of the facility, the walls across from the elevator and across the nurses station on the garden level and hand rails on both levels of the facility. The facility failed to ensure that rooms were homelike as evidenced by no closet doors present in 19 (Rooms: 510, 511, 512, 513, 514, 515, 516, 517, 518, 519, 520, 521, 522, 524, 525, 526, 527, 528, 529) of 19 occupied resident rooms on the garden level of the facility. The facility census was 73.
Findings are:
Observation on 05/02/24 between 8:00 AM and 9:15 AM with Maintenance Director [MD] revealed the following concerns with the facility environment:
- The caulking surrounding the base of the toilet was cracked and broken in resident bathrooms in rooms [ROOM NUMBERS] and the garden level bathhouse.
- There were scrapes present in the drywall on walls in resident rooms 511, 513, 516, 521, 526, 5101, 5104, 5106, 5109, 5116, 5118, 5119, 5123, and 5126 and along the length of the wall by the nurses' station and the elevator on the garden level of the facility.
- There were stained, brown areas present around the base of the toilet in resident bathrooms in rooms 514, 5118 and 5106 and the garden level bathhouse.
- The ceiling tile was cracked/missing and bubbled in resident room [ROOM NUMBER] above the window, in room [ROOM NUMBER]'s bathroom, in the garden level bathhouse and in the activity area on the garden level of the facility.
- The baseboard was pulled away from the wall in the bathroom in resident rooms 512, 516, 525, and 521 (in the room near the closet),
-There were patched areas of the ceiling that were not painted in resident bathrooms in rooms [ROOM NUMBER].
- There were scraped areas in the wood of bathroom and room doors in resident rooms 512, 514, 516, 520, 5285101, 5104, 5106, 5110, and 5121.
- The ventilation system covers in resident bathrooms were coated with a gray fuzzy substance that resembled dust in resident rooms 511, 525, 526, 5101, 5109, 5116, 5118, 5119, 5121, 5123, 5124, 5126 and 5128.
- There were round holes in the wall behind the door from where the doorknob came into contact with the wall in resident rooms [ROOM NUMBERS].
- The nightlight in the bathroom was broken in resident room [ROOM NUMBER].
- A wall plate was not securely attached to the wall in resident bathroom in room [ROOM NUMBER].
- The toilet paper holder is missing / broken in bathrooms in resident rooms 521, 5101, 51165118, 5119, and 5126.
- The towel bars were missing or broken in resident bathrooms in rooms 521,5118, 5123, and 5124.
- The window curtains were broken and loose in rooms 5101, 5104 and 5106.
- A plastic glove holder was broken and jagged plastic present along the broken edge in resident bathroom in room [ROOM NUMBER].
- There was a very strong urine odor in room [ROOM NUMBER].
- The floors were soiled, wet and sticky in resident rooms [ROOM NUMBERS].
- The bathroom door in room [ROOM NUMBER] would not close unless lifted up and pushed in.
- A toilet support bar in resident bathroom in room [ROOM NUMBER] was loose and missing one side of the support. It was laying on the floor and the other support bar was very loose and pushed outward away from the toilet. A toilet support bar (left side) was missing on the toilet in the bathhouse on the med center level of the facility.
- There were several areas that had scrapes on the wooden handrails on both levels of the facility.
- There were no closet doors present in resident rooms 510, 511, 512, 513, 514, 515, 516, 517, 518, 519, 520, 521, 522, 524, 525, 526, 527, 528, and 529.
Interview on 05/02/24 at 9:15 AM with the MD confirmed that those areas identified needed to be cleaned / repaired. The DM confirmed that there were no work orders for the areas identified and that the concerns had not been identified prior to the environmental tour of the facility. The DM confirmed that having no closet doors on closets was not homelike.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0923
(Tag F0923)
Could have caused harm · This affected multiple residents
Licensure Reference Number 175 12-007.04D
Based on observation and interview, the facility failed to ensure that ventilation systems were operational in resident bathrooms in 6 (rooms 5116, 5119, 5121...
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Licensure Reference Number 175 12-007.04D
Based on observation and interview, the facility failed to ensure that ventilation systems were operational in resident bathrooms in 6 (rooms 5116, 5119, 5121, 5124, 5126, and 5128) of 43 occupied rooms in the facility. The facility census was 73.
Findings are:
Observation on 5/2/24 between 08:00 AM to 9:15 AM with the facility Maintenance Director revealed that the ventilation system was not functional and would not draw a 1 ply square of toilet paper to the surface of the ventilation cover in resident bathrooms in resident rooms 5116, 5119, 5121, 5124, 5126, and 5128.
Interview on 05/2/24 at 09:15 AM with the Maintenance Director confirmed that the ventilation system did not draw a 1 square ply of toilet paper in resident bathrooms 5116, 5119, 5121, 5124, 5126, and 5128. The Maintenance Director confirmed that the ventilation system had not been for draw and that there was no documentation of when the last time the system had been checked to ensure it was operational.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
License Reference Number 175 NAC 12.006.04C2
Based on record review and interview the facility failed to ensure a Registered Nurse (RN) was present in the facility for at least 8 consecutive hours on ...
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License Reference Number 175 NAC 12.006.04C2
Based on record review and interview the facility failed to ensure a Registered Nurse (RN) was present in the facility for at least 8 consecutive hours on 03-31-2024 and 4-28-2024, which had the potential to affect all residents that reside in the facility. The facility census was 73.
Findings are:
Record review of the facility's Daily Nursing Daily Deployment sheets revealed there was not a RN present in the facility for 8 consecutive hours on 03-31-2024 and 04-28-2024.
Record review of the facility's Nurse Staffing Hours posting revealed there was not a RN present in the facility for 8 consecutive hours on 03-31-2024 and 04-28-2024.
An interview conducted with the Administrator (ADM) on 05-02-2024 at 1:06 PM who confirmed there was not a RN working for 8 consecutive hours on 03-31-2024 and 04-28-2024.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Licensure Reference Number 175 NAC 12-006.11D
Based on observation, interviews, and facility documentation review, the facility failed to prepare and serve food that is palatable, attractive and at a...
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Licensure Reference Number 175 NAC 12-006.11D
Based on observation, interviews, and facility documentation review, the facility failed to prepare and serve food that is palatable, attractive and at a safe and appetizing temperature. This failure could place all residents who received food prepared in the facility kitchen at increased risk of exposure to food-borne illnesses. Total census was 73 and potentially affected all 73 residents.
Observation on 5/01/2024 at 9:10 AM revealed [NAME] -E was preparing lunch meal for the facility residents. [NAME] -E had previously placed ham in 4 different pans and was observed adding brown sugar and pineapple on top of each ham. [NAME] -E placed foil over the top of the pans with ham and placed the ham into the oven. [NAME] -E performed hand hygiene for 12 seconds and applied gloves. Cook-E opened four (4) boxes of diced potatoes and took the bags of diced potatoes out of the box and placed them on the prep table. Cook-E opened a bag of diced potatoes and dumped them in a large bowl and then sprinkled them with garlic seasoning, pepper, parsley flakes, onion powder, liquid butter and salt. No measurements of any spices or butter was completed. Cook-E placed the paper liner on a baking sheet and pushed the paper liner down on the baking sheet with a soiled glove. [NAME] -E sprayed [NAME] (a cooking spray) on the baking sheet and poured the potatoes onto the pan and covered them with foil with Cook-E repeated this same process for the remaining 3 bags of potatoes. Cook-E removed their gloves, put spices away after wiping the spice containers and the counter with a sanitizer wipe. Cook-E obtained five (5) cans of corn and opened them with a attached can opened, obtained other spices and applied gloves without the benefit of hand hygiene. Cook-E obtained four (4) cooking pans and placed one can of corn into each pan. Cook-E added the 5th can of corn and added 8 cups of corn into two (2) of the pans. Cook-E put approximately ½ tablespoon of salt in each pan and squeezed an unmeasured amount of liquid butter into each pan. Cook-E filled the liquid butter bottle, removed gloves, and placed foil on top of the pans, put masking tape on top of pan to label. [NAME] -E placed the potatoes that were on baking sheets on a wheeled rack cart and placed in the refrigerator. [NAME] -E placed the corn into the over and performed hand hygiene for 10 seconds. At 10:00 AM Cook-E took the ham out of the oven, washed hands for 5 seconds and then put gloves on. Cook-E obtained the temperature of the ham which was at 162 degrees for 15 seconds, re-covered the ham with foil and placed back into the oven. [NAME] -E lowered the oven temperature to 180 degrees to keep the ham warm.
An interview on 5/01/2024 at 9:40 AM with Cook-E revealed that the corn recipe was for 133 residents. Cook-E confirmed there were 73 residents in the facility and that they were all receiving the lunch meal out of this kitchen. There were no other options different serving sizes. Cook-E reported that is hard to determine how much ingredients and spices to put in when you have to make the corn in four different pans.
B. On 5/01/2024 Cook-F left the kitchen at 11:47 AM and returned at kitchen at 12:04 PM. Cook-F spoke to residents who were present in the dining room to get their meal choices and then lined up meal tickets. [NAME] -F performed hand hygiene for 12 seconds, applied gloves, prepared a plate, wiped off a dirty cart with a rag and changed gloves without performing hand hygiene. [NAME] -F dished 5 more plates and at 12:08 PM with the same soiled gloves on took the cart to the dining room and served those residents who were at different tables. In the main dining room, the Certified Dietary Manager (CDM) loudly cued [NAME] -F to serve all residents at one table then move on and asked why the cook had gloves on. The CDM reminded [NAME] -F to wash hands with glove changes. [NAME] -F returned to the kitchen, applied gloves without completing hand hygiene and plated 6 more plates of food and took them to the dining room at 12:21 PM. Cook-F returned to kitchen and removed gloves and performed hand hygiene for 18 seconds and put on new gloves. [NAME] -F continued to touch clean and dirty surfaces with gloves on including touching a serving counter (dirty surface) and then touch serving ladles and then touching the inside of serving bowls with soiled gloves.
C. An observation of the meal being served on 5/01/2024 from 11:40 AM to 12:42 PM revealed [NAME] -F was preparing room trays out of the main kitchen. Room trays were dished first and placed into a wheeled multi-rack kitchen tray serving cart. A Test tray that had been requested was plated and put into serving cart at 11:45 AM. Test tray delivered to the conference room on 5/01/2024 at 11:47 AM with the CDM using the facility thermometer revealed the food temperatures were as followed:
-Ham 102 degrees.
-Ground Ham 104.1 degrees.
-Diced potatoes 98.4 degrees.
-Corn 106 degrees.
On 5/01/2024 at 11:47 AM an interview was completed with the CDM. During the interview the CDM confirmed the food did not reach 135 degrees and confirmed the ham and potato's were cold.
An interview on 5/02/2024 at 7:55 AM with the CDM confirmed the facility uses RD Dining Menu and it is for 133 servings. CDM also confirmed that the cook should have mixed the potatoes in a large tote and followed the recipe.
Review of the Nebraska Food Code, Section 3-501.19 revealed:
(1) The FOOD shall have an initial temperature of 5ºC (41ºF) or less when removed from cold holding temperature control, or 57°C (135°F) or greater when removed from hot holding temperature control; P
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.11E
Based on observation, interviews, and facility documentation review, the facility...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.11E
Based on observation, interviews, and facility documentation review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in accordance with professional standards for food service safety, in that foods were kept past their expiration date, and foods were not labels or dated when they were opened. The facility failed to ensure the food equipment and food preparation areas are clean and sanitized. This failure could place residents who received food prepared in the facility kitchen at increased risk of exposure to food-borne illnesses. Total census was 73 and potentially affected all 73 residents.
Findings are:
A. During the initial tour of the kitchen 4/29/2024 from 1:05 PM to 1:55 PM revealed the following;
-There was a buildup of grease on the floor in the dish room with dirt and food crumbs, a cup on the floor under a storage rack and cups lying in a tin all stacked together.
-The floor behind and beside the oven area had grease build up with food debris and visible dirt stuck to it.
-There were small bowls and small plates stacked face up on a tray on the shelf by the wash sink. While staff washing their hands in the wash sink, it was observed that water splash from the wash sink, splattered water onto these small bowls and small plates.
-There were three (3) trays with dark, dry substances on this shelf with other plates and bowls. Two (2) plates and one (1) bowl with dried food debris on them.
-Dishes and cooking equipment stored on a wired rack cart that had dust and rust on it. A wired rack, near the food prep counter, had three (3) loaves of bread, one (1) canister of opened oatmeal, a personal lunch box, a personal cell phone, and menus with clean pots and pans.
-The meat slicer stored on the lower shelf was visibly dirty with large amount of dried old food particles.
-Another wired rack, next to the other rack, had a large box of bananas and 14 bottles of syrup on a blue tray.
-Several small steam tray pans turned upside down directly on the food rack which had visible food debris. These small steam tray pans were later used to serve food in.
-On a blue tray there were observed a three (3) hole puncher, along with a bottle of Vanilla and an outdated bottle of green food coloring dated 2/22/2020.
-Two (2) woks were dirty with old food crumbs. On the top shelf of this rack were one (1) lamp with 2 extension cords. The Certified Dietary Manager (CDM) reported that the lamp and extension cords are used when they have to look into the walk- in freezer as the light did not work.
-The floor by the oven revealed a drain that had grease, dirt and other unidentified substances all around it.
-The flour bin had an open paper bag of undated flour in it along with 2 Styrofoam cups and dish towels lined the bottom of the bin. Dust and a spilled dark, dry, substances were observed on the large prep table along with a square storage container of what looked like grape jelly but had no label, and a roll of toilet paper.
-The shelf below the large prep table observed with cutting board stacked on it had a dried purple substance along with food crumbs and dust on it.
-The floor the large prep table below with corrosion and a metal box covered with rust. A utensil rack hanging above a prep table revealed an Emerald lanyard with a key hanging on in direct contact with a food strainer. A large floor mixer had four (4) walkie-talkies laying on the shelf it was sitting on.
-A prep cart with wheels revealed dried, sticky substance on the bottom shelf with a butter knife lying on it. Two (2) large cooking pots had dust on them.
-The prep table with the microwave on it with food debris, food crumbs and dust on the bottom shelf. A large shop vac was sitting on the floor beside the stove and directly across from a food prep area.
- The three (3) compartment sink was dirty with splattered food and water stains. The counter attached to the three-compartment sink had dried food debris on it along with four (4) bags of what appeared to be frozen chili.
An observation at 1:35 PM on 4/29/2024 revealed a dietary staff member taking the trash out on a cart and returned to the kitchen without cleaning the cart, the dietary staff member took the cart into the dry storage room and loaded boxes of food for meal prep. The back up chest freezer located near the dry storage room had 9 boxes of bread on it.
The Dry Storage Room revealed several bottles of bleach on the shelves below other food items. A different shelf had a large bottle of Lime Away, a cleaning caddy with an open bottle of Windex, a can of rust blaster, and 2 bottles of [NAME] protein hair conditioner. One (1) bottle of spray hand sanitizer, 1 can of Comet, 1 can of wasp spray, 1 large jug of multi quat solution on the cart beside food. Wrappers and dirt observed on the floor under the shelves. A personal black jacket hanging on a cart that smelled of smoke. A thick red substance noted on the wall above the food in the dry storage room. Inside the upright refrigerator there were 2 cups of poke cake not covered and not dated. The cart beside the refrigerator showed a coffee maker that had buildup on the floor below of dirt and grime. The walk-in freezer revealed a large amount of ice buildup inside and outside of the freezer door. The freezer door did not close completely; a large vacant space noted below the freezer door which allowed room air to come in, which resulted in a thick layer of ice on the inside of the freezer door and ice on the bottom of the outside of the freezer door. The freezer door jam had a black wire on it, which the CDM reported the light switch and wire caught on fire a while back and it doesn't work. There were pancakes in the freezer with ice on them.
Record Review of the Daily Cleaning Duties in the kitchen for April 2024 revealed the following were cleaned 2 days out of the month of April:
-Oven Face, Sides, and Top Scrubbed Clean
-Flour/Sugar Bins Cleaned
-Can Opener Cleaned
-Hand Sink Cleaned/Soap and Paper Towels Full
-Grill trap emptied/Fryer Cleaned, and Grease Fresh (It is to note that facility does not have a fryer).
An observation in the kitchen on 4/29/2024 at 3:05 PM revealed a chest freezer located near the dry storage room with excessive frost on all sides and on the rim of the freezer. One thermometer inside the chest freezer read negative 10 degrees and another thermometer inside the chest freezer read negative 20 degrees. The following items were in the freezer:
-1 bag of what looked like chicken patties with freezer burn and had no label or date.
-¼ bag of chicken wings that had a buildup of ice on them with no date and label.
-1 bag of Canadian bacon dated 07/02 with no year had a large amount of freezer ice all over it.
- 2 Sysco sliced corned beef with pack dated 10/05/2022, freeze by date of 12/19/2022 had large amount of freezer ice all over the package.
- 1 bag of frozen hot dogs dated 02/22/2023 that were discolored and with ice buildup on them.
An observation on 4/29/2024 at 1:20 PM with the CDM revealed all the above listed items were not clean, sealed, labeled, and/or dated.
An interview on 5/01/2024 at 12:15 PM with [NAME] -E about cleaning schedule in the kitchen revealed that there is a cleaning log for the kitchen and copies were obtained. Cook-E reported that it is difficult to deep clean the kitchen floor without functioning drains on the floor.
An interview with Maintenance Director (MD) on 5/02/2024 at 10:24 AM confirmed that the floor drains in the kitchen had not been working and approximately 2 weeks ago a plumber was called in and snaked all the kitchen floor drains and added an additional cover over the floor drain next to the oven. Maintenance Director confirmed that all drains have been working now for 2 weeks. Maintenance Director (MD) verified that the metal box located under the food prep table that was covered with rust, grease and food debris was a junction box.
An interview with the CDM on 4/29/2024 at 1:20 PM confirmed that the facility had ordered a new freezer door before COVID and it didn't get installed due to COVID because the company who had ordered the door gave it to another facility.The CDM confirmed that It's been years since requesting a new freezer door. The CDM confirmed the CDM observed and confirmed the above listed items were not clean, sealed, labeled, and/or dated and should have been.
B. An observation of meal service on 5/2/24 at 8:04 AM in the Garden Café dining room revealed CDM arrived with food cart for the Garden Café. The CDM placed 3 medium size pans in the steamer,2 small pans on top of steam tray and 1 large pan on top of the cart.The CDM proceeded to make coffee and Dietary Aide (DA)-G without a hair net on, entered the dining room and performed hand hygiene for 6 seconds. DA-G was observed touching resident plates with bare hands. After [NAME] goves, DA-G put a steam tray lid on top of the bread and cups. While scooping food, DA-G leaned over the cart with their sweatshirt and fanny pack touching the clean plates. DA-G did not refer to any meal tickets while serving the residents in the dining room and instead hollered across the dining room to ask the residents what they wanted to eat, touched the coffee cake with soiled gloves. Four meal plates were dished, and DA-G delivered them to the residents at their table. DA-G stopped to wrap silverware in napkins then continued to serve meals with same soiled gloves on. DA-G without removing the soiled gloves and completing hand hygiene touch the coffee cake that was being served to the residents. Sugar packets for a resident was obtained by DA-G obtained sugar packets and with the same soiled gloves poured the sugar onto a resident's cereal. DA-G continued to touch plates in center of plate and then served food on those plates with the same soiled gloves. DA-G placed soiled gloved fingers in bowls, used the soiled gloved fingers to put eggs, sausage and coffee cake into a bowl from a plate and used the same soiled gloved fingers to tear up the sausage.The DA -G continued to serve plates to residents with the same soiled gloves. DA-G removed gloves and opened sugar packets to put in cereal bowl for a resident without completing hand hygiene. DA-G applied new gloves without performing hand hygiene, sorted through the meal tickets with gloves on to see if everyone in the dining room had been served.The DA-G placed the meal tickets on the trays on the room tray cart and removed gloves and their sweatshirt. DA-G hand hygiene was performed for 7 seconds and new gloves applied. DA -G started to plate room trays at 8:35 AM and while filling plates DA-G obtained toast with soiled gloves on that was being served to residents. DA-G prepared drinks for the cart for the residents in their rooms, removed the soiled gloves gloves,wiped sweat from forehead with a paper towel and performed hand hygiene for 7 seconds. DA-G finished pouring drinks and then stopped to wrap silverware for resident use.
A interview was conducted with Resident #20 on 5/02/2024 at 9:33 AM. During the interview Resident #20 reported the ground sausage was ice cold and they would not eat the eggs because they are never good.
An interview with CDM on 5/02/2024 at 11:45 AM confirmed the concerns with hand hygiene and gloving and cross contamination in the Garden Café Dining Room.
C. Record review of the facility undated policy titled Infection Control Prevention and Control Program- Hand Hygiene under the Policy revealed, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy also stated that Use an alcohol-based hand rub containing at least 62% alcohol: or alternatively, soap (antimicrobial or non-antimicrobial) and water . which included Before and after eating or handling food.
According to the Centers for Disease Control (CDC) Hand Hygiene in Health-Care Settings (2022) at https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf revealed the following:
-When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel.
Review of the Nebraska Food Code, Section 3-501.19 revealed:
(1) The FOOD shall have an initial temperature of 5ºC (41ºF) or less when removed from cold holding temperature control, or 57°C (135°F) or greater when removed from hot holding temperature control; P.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected most or all residents
Based on record review and interview the facility failed to maintain staff documentation of offering the COVID 19 vaccine, education on COVID 19 vaccine, and the current Covid 19 vaccination status of...
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Based on record review and interview the facility failed to maintain staff documentation of offering the COVID 19 vaccine, education on COVID 19 vaccine, and the current Covid 19 vaccination status of 1 of 1 staff record audited. This has the potential to affect all the current residents in the facility. The facility reported a census of 73.
Findings are:
Record review of CNA-A personnel record revealed no record of the facility offering the COVID 19 vaccine, education on the COVID 19 vaccine, or record of current COVID vaccination status.
Record review of policy entitled: Immunization Staff.
Policy-The facility has established a process for staff immunizations based on:
The CDC
ACIP
State or local health department
The intent is to help reduce the risk of staff contracting and spreading influenza or SAR-COVID to reduce the chance of staff contracting Hepatitis B from exposure to blood or other contaminated sources, and as part of wound management.
The facility will educate staff on the risks and benefits for the specific vaccines, offer to administer vaccine(s) and report vaccination data to the CDC National Healthcare Safety Network and/or state/local agencies as required.
Interview on 4/30/24 at 3:40 PM with the Director of Nursing (DON) revealed staff are offered the Hepatitis B vaccine series, influenza vaccine, and the COVID 19 vaccine.
Interview on 05/02/24 at 10:39 AM with the DON confirmed no education, screening, or records of COVID vaccine for the staff could be found.
Mar 2023
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 (1)
Based on observation, interview and record review; the facility failed to provide catheter care in a manner that would prevent Resident # 50 from a p...
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LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 (1)
Based on observation, interview and record review; the facility failed to provide catheter care in a manner that would prevent Resident # 50 from a potential urinary tract infection (UTI). The facility census was 74.
The findings are:
Observation on 03/09/23 at 6:31 AM revealed catheter care was completed on Resident #50 by Licensed Practical Nurse (LPN) A and Nursing Assistant (NA) B. NA B placed a peri wipe at the Y port of the catheter and proceeded to clean the catheter towards the urinary meatus.
On 3/9/23 at 6:41AM LPN A confirmed the catheter care was completed incorrectly and potentially could place Resident # 50 at risk for a urinary tract infection.
Record review of the facility's policy and procedure for Indwelling Urinary Catheter Care revealed; using moistened disposable wipes, clean the catheter in a downward motion (front to back) beginning at the urinary meatus (insertion point) and at least 4 inches down (from resident toward the collection bag).
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006-18
Based on observation and interview, the facility failed to maintain the cleanliness...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006-18
Based on observation and interview, the facility failed to maintain the cleanliness and condition of electrical outlets, phone cord, walls, doors, baseboard trim, ceilings, toilet paper holders and lights in 16 (Resident rooms 511, 512, 513, 514, 515, 516, 517, 518, 519, 520, 522, 524, 527, 528, 5110 and 5128) of 46 occupied resident rooms. The facility census was 74.
Findings are:
Observations during the environment tour on 3/9/2023 from 7:45AM to 8:30 AM with the Facility Administer [ADM] identified the following concerns:
- Electric outlet by the bed was loose from wall, a phone cord was frayed and cut with exposed wires in room [ROOM NUMBER].
- Paint was peeling off of walls in rooms 5128, 511, 512, 513, 514, 515, 516, 517, 518, 519, 520, 522, 524, 527 and 528.
- Gouges / holes in walls in rooms 511, 512, 513, 514, 515, 516, 517, 518, 519, 520, 522, 524, 527 and 528.
- Missing / loose baseboard trim in resident rooms and bathrooms in rooms 512, 516, 517 and 527.
- Holes in doors in rooms 514, 524 and 528.
- Missing / loose toilet paper holder in resident bathrooms [ROOM NUMBERS].
- Water damage to ceiling in resident bathrooms in rooms 511, 514, 515 and 519.
- Broken or missing light fixtures in rooms [ROOM NUMBERS].
Interview on 3/9/23 at 8:25 AM with the ADM confirmed the condition of electrical outlets, phone cord, walls, doors, baseboard trim, ceilings, toilet paper holders and lights in resident rooms 511, 512, 513, 514, 515, 516, 517, 518, 519, 520, 522, 524, 527, 528, 5110 and 5128. The ADM confirmed that those issues needed to be repaired and that there were no work orders in place for the identified areas.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), $70,103 in fines. Review inspection reports carefully.
- • 24 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $70,103 in fines. Extremely high, among the most fined facilities in Nebraska. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Keystone Ridge Post Acute Nursing And Rehabilitati's CMS Rating?
CMS assigns Keystone Ridge Post Acute Nursing and Rehabilitati an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Nebraska, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Keystone Ridge Post Acute Nursing And Rehabilitati Staffed?
CMS rates Keystone Ridge Post Acute Nursing and Rehabilitati's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 71%, which is 25 percentage points above the Nebraska average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Keystone Ridge Post Acute Nursing And Rehabilitati?
State health inspectors documented 24 deficiencies at Keystone Ridge Post Acute Nursing and Rehabilitati during 2023 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 22 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Keystone Ridge Post Acute Nursing And Rehabilitati?
Keystone Ridge Post Acute Nursing and Rehabilitati is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by THE ENSIGN GROUP, a chain that manages multiple nursing homes. With 100 certified beds and approximately 70 residents (about 70% occupancy), it is a mid-sized facility located in Omaha, Nebraska.
How Does Keystone Ridge Post Acute Nursing And Rehabilitati Compare to Other Nebraska Nursing Homes?
Compared to the 100 nursing homes in Nebraska, Keystone Ridge Post Acute Nursing and Rehabilitati's overall rating (1 stars) is below the state average of 2.9, staff turnover (71%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Keystone Ridge Post Acute Nursing And Rehabilitati?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Keystone Ridge Post Acute Nursing And Rehabilitati Safe?
Based on CMS inspection data, Keystone Ridge Post Acute Nursing and Rehabilitati has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Nebraska. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Keystone Ridge Post Acute Nursing And Rehabilitati Stick Around?
Staff turnover at Keystone Ridge Post Acute Nursing and Rehabilitati is high. At 71%, the facility is 25 percentage points above the Nebraska average of 46%. Registered Nurse turnover is particularly concerning at 67%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Keystone Ridge Post Acute Nursing And Rehabilitati Ever Fined?
Keystone Ridge Post Acute Nursing and Rehabilitati has been fined $70,103 across 1 penalty action. This is above the Nebraska average of $33,780. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Keystone Ridge Post Acute Nursing And Rehabilitati on Any Federal Watch List?
Keystone Ridge Post Acute Nursing and Rehabilitati is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.