Arbor Care Centers - Ord, LLC
For profit - Limited Liability company
60 Beds
ARBOR CARE CENTERS
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
28/100
#104 of 177 in NE
Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Arbor Care Centers - Ord, LLC has received a trust grade of F, which indicates significant concerns about the quality of care provided. The facility ranks #104 out of 177 nursing homes in Nebraska, placing it in the bottom half, and is the only option in Valley County. Unfortunately, the facility is worsening, with the number of identified issues increasing from 7 in 2023 to 10 in 2024. Staffing is a major concern, with a 71% turnover rate, significantly higher than the Nebraska average, which can disrupt continuity of care. Although there have been no fines issued, which is positive, the facility lacks sufficient RN coverage, being below 80% of other facilities in the state. Notably, recent inspector findings revealed critical issues such as rodent droppings in food storage areas and inadequate air conditioning during hot weather, raising serious health and safety concerns. Overall, while the absence of fines is a strength, the facility's numerous deficiencies and low staffing stability indicate significant weaknesses that families should carefully consider.
- Trust Score
- F
- In Nebraska
- #104/177
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 71% turnover. Very high, 23 points above average. Constant new faces learning your loved one's needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Nebraska facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for Nebraska. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
28/100
Bottom 42%
Review needed
7 → 10 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 7 issues
2024: 10 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Nebraska average (2.9)
Below average - review inspection findings carefully
Staff Turnover: 71%
24pts above Nebraska avg (46%)
Frequent staff changes - ask about care continuity
Chain: ARBOR CARE CENTERS
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 29 deficiencies on record
1 life-threatening
Aug 2024
10 deficiencies
CONCERN
(D)
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** B.
Record review of Resident 24's admission Record dated 08/19/2024 revealed the resident admitted on [DATE]. The admission reco...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B.
Record review of Resident 24's admission Record dated 08/19/2024 revealed the resident admitted on [DATE]. The admission record also reveals an admission and primary diagnosis of Parkinson's Disease (a progressive brain disorder that affects the nervous system and causes unintended or uncontrollable movements).
Record review of Resident 24's Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 08/18/2024 revealed the resident takes and anti-Parkinson medication. The care plan goals and interventions revealed:
-The resident will be free of any discomfort or adverse side effects of anti-Parkinson therapy,
-will remain free of signs and symptoms (s/s),
-administer medications per physician orders,
-monitor/document/report as needed (PRN) adverse reactions of anti-Parkinson therapy: increased risk of low BP on rising and falls; significant confusion, restlessness, delirium, difficulty walking/moving, nausea, dizziness, hallucinations, and agitation.
Record review of Resident 24's physician orders revealed the following orders:
-Carbidopa-Levodopa oral tablet 25-250 milligram (MG) give 1 tablet by mouth 3 times a day related to Parkinson's Disease: order date 02/15/2024.
-Notify doctor if systolic blood pressure is greater than (>)150 or less than (<)100, heart rate >110 or <50, respiratory rate >24 or <12, oxygen saturation <90%. temperature > 100.5 Fahrenheit (F) or <95.8 F: order date 03/07/2024.
Record review of Resident 24's Blood Pressure Summary report revealed the systolic blood pressure >150 or less than <100 were found on dates:
-08/14/2024: 99/54
-08/05/2024: 99/54
-07/22/2024: 99/60
-04/22/2024: 89/45
Record review of Progress Notes and medical records of physician notification of blood pressure summaries or notification of systolic blood pressure >150 or less than <100 revealed no documentation that the physician was notified.
C.
Record review of Resident 4's admission Record dated 08/20/2024 revealed the resident admitted on [DATE]. The admission record also reveals an admission and primary diagnosis of an injury of the cervical spinal cord, quadriplegia (a symptom of paralysis that affects a person's limbs and body from the neck down) and hypertensive heart disease (heart problems that occurred due to high blood pressure).
Record review of Resident 4's Care Plan revealed the high-risk medications the resident takes are a hypertension (a condition where the pressure in your blood vessels is consistently too high) medication, and an anticoagulant (a blood thinner medication used to prevent the formation of blood clots) medication. An intervention listed for taking the medications are to notify the physician if systolic blood pressure is greater than (>)150 or less than (<)100.
Record review of Resident 4's physician orders revealed the following orders:
-Notify the physician if: systolic blood pressure is >150 or less than <100: order date 03/13/2024.
Record review of Resident 4's Blood Pressure Summary report revealed the systolic blood pressure >150 or less than <100 found on dates:
-08/20/2024: 98/54
-07/25/2024: 99/54
-07/11/2024: 94/55
-07/04/2024: 94/58
-05/30/2024: 97/70
-04/11/2024: 90/58
-03/28/2024: 96/69
-03/27/2024: 93/53
-03/26/2024: 98/68
-03/16/2024: 96/58
-03/15/2024: 88/54
-03/13/2024: 98/54
Record review of Progress Notes and medical records of physician notification of blood pressure summaries or notification of systolic blood pressure >150 or less than <100, revealed no documentation that the physician was notified.
During an interview with Registered Nurse-E (RN-E) on 08/21/2024 at 4:21 PM revealed when an out-of-range vital sign is noted, and an order to notify is present, the physician's office is either called, or a fax to the physician's office is sent. Once that is completed a progress note is completed.
The DNS was interviewed on 08/21/2024 at 4:40 PM confirmed there was no documentation that a physican was notified of Resident 24 and Resident 4's blood pressures out side of paramters on the listed dates. The DNS also revealed the expectation of the nurse or the charge nurse on duty is to contact the physician's office on the out-of-range vital signs. The information is then documented in the progress notes.
Licensure Reference Number 175NAC 12-006.09
Based on observation, record review, and interviews; the facility failed to ensure the provider was notified of abnormal laboratory results affecting 1 Resident (Resident 21) of 5 sampled residents, and failed to notify a physican of blood pressures that were out of range per the physcian order for 2 Residents (Resident 24 and Resident 4) of 3 sampled residents. The facility census was 33.
Findings are:
A.
Review of an admission Record revealed the facility admitted Resident 21 on 12/01/2022 with diagnoses that included type two diabetes (which is when the body has trouble controlling blood sugar and using it for energy).
Review of Resident 21 Physician Orders revealed an order for the facility to obtain a Hemoglobin A1C (HbA1C, a blood test that measures the average amount of glucose(sugar) in the blood over the past three months) every 3 months to be performed on the 5th of the month with a start date of 03/05/2024.
Review of Resident 21's medical health record revealed a laboratory value for a HbA1C of 9.10 with a collection date of 06/07/2024. The normal reference range for this laboratory value was documented as 4.80-6.00. The result of 9.10 was indicated on the document as an abnormal value listed as High. The document provided no indication of provider review or acknowledgment of the abnormal laboratory value.
Review or Resident 21's progress notes for the month of June 2024 revealed no documentation of the provider being notified of the abnormal HbA1C level or the provider reviewing the abnormal HbA1C level.
In an interview completed on 08/21/2024 at 3:45 PM with the facility Medical Records (MEDR), the MEDR confirmed there was no documentation indicating the provider had been notified of the abnormal HbA1C lab value.
In an interview completed on 08/21/2024 at 4:43 PM with the facility Director of Nursing (DNS), the DNS confirmed that Resident 21's HbA1C was an abnormal laboratory value, and the provider should have been notified of the abnormal value and reviewed the abnormal laboratory value indicating further directions for treatment or not to the facility. The DNS confirmed that this was not present in the resident's medical health record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175NAC 12-006.(I)
Licensure Reference Number 175NAC 12-006.(I)(i)(3)
Based on observation, record review, and interviews; the facility failed to implement fall prevention in...
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Licensure Reference Number 175NAC 12-006.(I)
Licensure Reference Number 175NAC 12-006.(I)(i)(3)
Based on observation, record review, and interviews; the facility failed to implement fall prevention interventions to prevent falls for 1 resident (Resident 25) and failed to ensure the mattress was secured to the bedframe to prevent the potential for entrapment or falls for 1 resident (Resident 25). The facility census was 33.
Findings are:
A.
Record review of the facility policy Fall Prevention and Fall Leaf Program dated 2/2020 revealed that the purpose is to ensure fall risks are identified and interventions are implemented in an effort to prevent falls, as possible, and to maintain a safe environment for each resident of the facility. The section titled Falls revealed that if a resident incurred a fall, a Fall Incident and Investigation report is completed. The Fall Incident and Investigation report will be reviewed at the next Department Clinical Meeting for interdisciplinary review of the fall, interventions, and determination of need for additional interventions or revision of current interventions.
Record review of the admission Record dated 8/19/24 for Resident 25 revealed that Resident 25 admitted into the facility on 6/22/23 wiht diagnoses of: anxiety, unsteadiness on feet, muscle weakness, and history of falling.
Observation on 8/19/24 at 4:13 PM in the hall between the atrium and the sunshine room revealed that Resident 28 pushed Resident 25 in a wheelchair. Resident 25 held onto a walker to the right side of the wheelchair. Resident 25 steered the walker alongside the wheelchair with their right hand. Resident 28 continued to push Resident 25 in the wheelchair through the sunshine room. Nurse Aide-A (NA-A) approached Residents 28 and 25. NA-A took the walker from Resident 25 and took the walker to the resident's room. Resident 28 continued to push Resident 25 in the wheelchair towards the resident room.
Record review of the Progress Note dated 3/20/24 at 3:38 AM for Resident 25 revealed that at 3:00 AM Resident 25 called out to their spouse/roommate (Resident 28) for help. The unidentified nurse arrived at the resident room and found Resident 25 and Resident 28 on the floor. Resident 25 was bleeding from the left front of their head. Emergency Medical Technicians arrived at 3:30 AM and left Resident 25 at 4:00 AM.
Record review of the Progress Note dated 8/19/24 at 8:35 PM for Resident 25 revealed that Resident 25 was found lying on the floor with their spouse/roommate (Resident 28) in the resident's room. Resident 25 could not recall why they fell. Resident 28 stated that Resident 28 tried to get Resident 25 to the toilet. During transfer, Resident 28 lost their balance, and both fell to the floor. Resident 25 complaint of a headache and soreness to the back of the head. Resident 25 got more confused and started telling staff that they were running into a wall. 911 was called. Emergency Medical Services transported Resident 25 to the emergency room at 9:15 PM.
Record review of the Care Plan for Resident 25 dated 8/21/24 revealed a care focus for falls. The care plan revealed that on 3/20/24 Resident 25 called for their spouse/roommate (Resident 28) to help in the bathroom. Resident 25 fell with Resident 28 to the floor. 8/19/24 Resident 28 attempted to transfer Resident 25 to the bathroom. Resident 28 lost their balance and both Resident 28 and Resident 25 fell to the floor. Intervention for the fall on 3/20/24 revealed only that Resident 25 was sent to the emergency room and returned the same day with no acute fractures. No fall intervention to prevent future falls was developed for the 3/20/24 fall. Intervention added to the care plan on 8/19/24 for the fall on 8/19/24 revealed that staff are to place Resident 25 in a chair at meals, and staff to assist Resident 25 back to the room from meals and do cares right then so the spouse/roommate (Resident 28) is not tempted to transfer Resident 25. The intervention was dated 8/19/24.
Observation on 8/21/24 at 7:33 AM in the facility dining room revealed that Resident 25 sat in a wheelchair at the dining room table.
Observation on 8/21/24 at 8:07 AM in the facility dining room revealed that Resident 25 remained in the wheelchair at the dining room table feeding themselves breakfast.
Observation on 8/21/24 at 8:30 AM in the facility dining room revealed that Resident 25 sat in the wheelchair at the dining room table.
Observation on 8/21/24 at 8:33 AM at the nurse's station revealed that Resident 28 pushed Resident 25 in the wheelchair from the dining room through the sunshine room to the resident's room. Resident 28 pushed the wheelchair into the bathroom in the resident's room. Resident 25 stood from the wheelchair and Resident 28 backed the wheelchair out of the bathroom. An alarm was beeping at a low volume. The facility Infection Coordinator (IC) came to the room at a fast pace. IC entered the room and closed the door at 8:35 AM.
Observation on 8/21/24 at 11:33 AM at the room of Resident 25 revealed that Medication Aide-H (MA-H) transferred Resident 25 from the resident's room in a wheelchair. MA-H transferred Resident 25 into the dining room and positioned Resident 25 in the wheelchair up to the dining room table. Resident 25 thanked MA-H and then asked where their spouse (Resident 28) was. MA-H told Resident 25 that they were coming. MA-H exited the dining room. Resident 28 entered the dining room at 11:34 AM and sat down in a chair at the table. Resident 28 sat to the right of Resident 25.
Interview on 8/21/24 at 1:56 PM with Medication Aide-G (MA-G) confirmed that Resident 25 is at increased risk of falls. MA-G revealed that interventions to prevent falls are used to keep residents safe from falls. MA-G revealed that the charge nurse or the stand up meeting team develops new or revised fall prevention interventions after a resident has a fall. MA-G revealed that new or revised interventions are communicated to staff through the computer. MA-G revealed that when the staff log onto the computer the dashboard page displays with new messages including new fall interventions. MA-G revealed that staff usually just glance at it and move on to chart cares. MA-G revealed that staff don't have time to read it. MA-G offered to show this surveyor what the page looks like on the computer. MA-G logged onto a computer. The dashboard page was displayed. The dashboard contained no information regarding the fall of Resident 25 and contained no updated fall prevention measures.
Observation on 8/21/24 at 4:50 PM in the facility dining room revealed that Resident 25 sat in a wheelchair at the table.
Interview on 8/22/24 at 7:28 PM with the facility Director of Nursing Services (DNS) confirmed that new or revised interventions are expected to be developed for fall prevention after a resident has a fall. The DNS confirmed that staff are expected to follow fall interventions to try to prevent resident falls and injuries.
Observation on 8/22/24 at 7:38 AM in the facility dining room revealed that Resident 25 sat at the dining room table in a wheelchair. Resident 28 was seated in a chair to the right of Resident 25.
Interview on 8/22/24 at 7:55 AM with Director of Nursing Services (DNS) confirmed observation at the facility dining room that Resident 25 was seated in a wheelchair at the dining room table eating breakfast. The DNS confirmed that Resident 25 is to be placed in a regular chair at the table for the new fall prevention intervention after the resident fall on 8/19/24. The DNS confirmed that the new intervention had not been implemented.
B.
Record review of the facility admission Agreement dated 10/2019 revealed that the facility must not charge a resident for room/bed maintenance services. The section titled Safe Environment revealed that the resident has a right to a safe, homelike environment. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes independence and does not pose a safety risk.
Record review of the admission Record dated 8/19/24 for Resident 25 revealed that Resident 25 admitted into the facility on 6/22/23 with diagnoses of: anxiety, unsteadiness on feet, altered mental status, and history of falling.
Record review of the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) dated 8/8/24 for Resident 25 revealed that Resident 25 is independent with rolling from their back to their right and their left when lying in bed. The MDS revealed that Resident 25 had a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score of 7 (a score of 0-7 indicates severe cognitive impairment).
Observation on 8/18/24 at 7:40 PM in the room of Resident 25 revealed that Resident 25 was in bed. Resident 25 was lying on their back.
Observation on 8/19/24 at 8:29 AM in the room of Resident 25 revealed that the mattress on the bed of Resident 25 was not secured to the bedframe. The mattress slid over approximately 14 inches from the bedframe from side to side. This created a gap for potential entrapment on the side of the bed against the wall. This created a fall hazard on the side of the bed away from the wall.
Interview on 8/21/24 at 1:34 PM with facility Maintenance Manager (MM) revealed that the facility does not check to see if resident mattresses are secured to the bedframe. MM confirmed that the mattress on the bed of Resident 25 was not secured to the bedframe. MM was unaware of devices to secure mattresses to the frame. MM confirmed that MM was not aware that the mattress had to be secured to the bedframe.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175NAC 12-006.09(H)
Based on observation, record review, and interviews; the facility failed to manage pain for 2 Residents (Resident 18 and Resident 21) of 2 sampled reside...
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Licensure Reference Number 175NAC 12-006.09(H)
Based on observation, record review, and interviews; the facility failed to manage pain for 2 Residents (Resident 18 and Resident 21) of 2 sampled residents. The facility census was 33.
Findings are:
Review of a facility policy titled Pain Management dated 02/2020 revealed in order to help a resident attain or maintain their highest practicable level of well-being and to prevent or manage pain the facility manages or prevents pain consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. If the resident's pain is not controlled by the current treatment regimen, the practitioner should be notified.
Review of a document titled Determining mild, moderate, and serve pain equivalency across pain intensity tools in nursing home residents by the Journal of Rehabilitation Research and Development dated 11/02/2007 revealed responses to pain rating of 1 through 4 on a 0 though 10 scale indicated mild pain, responses of 5 though 6 for moderate pain, and 7 though 10 for severe pain.
A.
A review of an admission Record dated 08/18/2024 revealed the facility admitted Resident 18 on 04/10/2024 with diagnoses that of preprhial vascular disease (which is a chronic disorder that causes blood vessels to narrow reducing blood flow to the organs they supply), restless leg syndrome (which is a disorder that causes uncontrollable urge to move the legs and is often accompanied by an unpleasant sensation), polyneuropathy (which the simultaneous malfunction of many peripheral nerves throughout the body), fibromyalgia (which a chronic disorder that causes widespread pain and tenderness in the body), rheumatoid arthritis (which is a chronic disease that causes inflammation and pin in the joints), and pressure related wound (which is a wound caused by pressure) of the buttock.
The Quarterly Minimum Data Set (MDS, a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning) with the Assessment Reference Date (ARD), of 07/11/2024 revealed Resident 18 had a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score of 13 indicating the resident was cognitively intact. The resident received both routine and as needed pain medication during the last 5 days prior to the ARD. The resident stated they frequently had pain that interfered with sleep, therapy activities, and day to day activities. The resident rated the pain on a descriptor scale as Moderate.
Review of Resident 18's Comprehensive Care plan (a written interdisciplinary comprehensive plan to meet the resident's needs that are identified in the resident's comprehensive assessment), dated 08/19/2024, revealed a focus of Pain with a tolerable pain level stated as Mild. The goal was listed as the resident will have pain at a tolerable level for them of Mild. An intervention was listed if the resident was receiving frequent as needed pain medication for breakthrough pain, to visit with the provider about getting a different medication or stronger medication to get the residents pain to a tolerable level.
In an interview with Resident 18 on 08/19/2024 at 9:35 AM, Resident 18 stated they are often uncomfortable and in pain. Resident 18 stated [gender] is to get up for one hour and get into their recliner two times a day but often refuses to do this due to level of pain. Resident 18 stated staff will administer an as needed pain medication when the resident requests it but by the time the medication takes effect it is to late to get up and into the recliner so just stays in bed.
Review of Resident 18's Medication Administration Record for the Month of August 2024 revealed the resident was monitored for pain every shift. 20 of the 37 pain ratings obtained from the resident were of a pain level of 5 or higher on a 1 to 10 scale indicating pain at a moderate to severe level of pain.
Review of Resident 18's Medication Administration Record for the Month of August 2024 revealed Resident 18 received as needed Acetaminophen (a mild pain medication) 5 times for pain ratings of 6 or greater on a 1 to 10 scale.
Review of Resident 18's Medication Administration Record for the Month of August 2024 revealed Resident 18 received as needed Oxycodone (a narcotic strong pain medication) 17 times for pain ratings of 8 or greater on a 1 to 10 scale.
In an interview conducted on 08/21/2024 at 11:00 AM with Registered Nurse E (RN-E), RN-E confirmed that Resident 18 often refused to get up out of bed due to pain. RN-E denies offering Resident 18 pain medication prior to offering to get the resident out of bed stated the medication is administered when the resident requests it. RN-E stated the resident's provider had not been notified about the frequent use of the as needed pain medication to maintain the residents comfort level for adjustments in the resident's routine pain medication for better coverage and less breakthrough pain for Resident 18.
In an interview conducted on 08/21/2024 at 12:20 PM with the Director of Nursing (DNS), the DNS confirmed that Resident 18 pain was not controlled, and the provider should be notified for a change in the resident's routine pain medication to decrease break through pain.
B.
A review of an admission Record dated 08/18/2024 revealed the facility admitted Resident 21 on 12/01/2022 with diagnoses of multiple myeloma (which is a type of bone marrow cancer), chronic gout (which is repeated episodes of pain and inflammation of joints), and neuralgia and neuritis (which is server sharp often shock like pain that follows the path of a nerve with inflammation of the nerve).
The Quarterly MDS with the ARD, of 07/18/2024 revealed Resident 21 had a BIMS score of 15 indicating the resident was cognitively intact. The resident received both routine and as needed pain medication during the last 5 days prior to the ARD. The resident stated they frequently had pain that interfered with sleep and day to day activities. The resident rated the pain on a descriptor scale as Moderate.
Review of Resident 21's Comprehensive Care plan, dated 08/19/2024, revealed a focus of Pain with a tolerable pain level stated as Mild. The goal was listed as the resident will have pain at a tolerable level for them of Mild. An intervention was listed to observe for effectiveness of pain mediation and to keep the provider informed.
In an interview conducted on 08/19/2024 at 1:30 PM with Resident 21 revealed [gender] often suffered from pain during the early morning hours and would have to request to be gotten out of bed early in the morning to be able to change position to try and alleviate some of the discomfort they were experiencing. The resident stated they received pain medication when they requested it and on a routine basis but felt like their pain was never at a tolerable level.
Review of Resident 21's Medication Administration Record for the Month of August 2024 revealed the resident was monitored for pain every shift. 30 of the 37 pain ratings obtained from the resident were of a pain level of 5 or higher on a 1 to 10 scale indicating pain at a moderate to severe level of pain.
Review of Resident 21's Medication Administration Record for the Month of August 2024 revealed Resident 21 received as needed Acetaminophen (a mild pain medication) once for pain ratings of 10 on a 1 to 10 scale.
Review of Resident 21's Medication Administration Record for the Month of August 2024 revealed Resident 21 received as needed Tramadol (a narcotic pain medication) 7 times for pain ratings of 7 or greater on a 1 to 10 scale.
In an interview conducted on 08/21/2024 at 11:15 AM with Registered Nurse E (RN-E), RN-E confirmed that Resident 21 often awoke in the early morning hours and requested as needed pain medication and to get up out of bed to alleviate pain and discomfort. RN-E confirmed that the residents last dose of scheduled analgesics was administered at bed time and the provider had not been contacted about the frequent as needed pain medication use to adjust time of dosing of medication.
In an interview conducted on 08/21/2024 at 12:25 PM with the Director of Nursing (DNS), the DNS confirmed that Resident 21's pain was not controlled, and the provider should be notified for a change in the resident's routine pain medication in efforts to decrease break through pain.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175NAC 12-006.09(H)
Based on record review and interview; the facility failed to ensure that PRN (as needed) psychotropic medications (any medication that affects behavior, ...
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Licensure Reference Number 175NAC 12-006.09(H)
Based on record review and interview; the facility failed to ensure that PRN (as needed) psychotropic medications (any medication that affects behavior, mood, thoughts, or perception) were limited to 14 days as required for 1 resident (Resident 135) of 5 residents reviewed. The facility census was 33.
Findings are:
Record review of the facility policy titled Use of Psychotropic Drugs dated 2/2020 revealed that residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition. PRN orders for psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (such as 14 days). If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN use.
Record review of the admission Record dated 8/19/24 for Resident 135 revealed that Resident 135 admitted into the facility on 8/5/24.
Record review of the Order Summary (a listing of all physician's orders for a resident) dated 8/19/24 for Resident 135 revealed that Resident 135 had an order for Lorazepam 0.5 milligrams (a psychotropic medication used to treat anxiety) every 12 hours as needed for anxiety or agitation. The Lorazepam order had a start date of 8/5/24. The order had no end date as required.
Record review of the medication administration record (MAR, a legal record of the medications administered to a patient at a facility by a health care professional) dated 8/20/24 for Resident 135 revealed that Resident 135 received the as needed Lorazepam on 8/4/24, 8/5/24, 8/12/24, 8/14/24 and 8/20/24 (the 15th day after the original order).
Record review of the Pharmacy Note for Resident 135 dated 8/17/24 at 8:25 AM revealed that the consultant pharmacist completed a medication review for Resident 135. The Consultant Pharmacist noted that Resident 135 had an order for a PRN psychotropic medication that did not have a 14 day stop date.
Interview on 8/21/24 at 8:14 AM with the facility Infection Control Coordinator (IC) confirmed that orders for psychotropic medications are limited to 14 days unless re-evaluated for necessity and re-ordered by the physician. IC revealed that IC was unaware of the note from the Consultant Pharmacist for the PRN 14 day Lorazepam for Resident 135. IC then located an email from the consultant pharmacist and printed the recommendation note.
Record review of the Note to Attending Physician/Prescriber dated 8/17/24 for Resident 135 revealed that PRN orders for psychotropic medications are limited to 14 days. If therapy is desired past a 14 day period, a patient specific rationale and duration must be documented in the resident's medical record by the attending physician or prescribing practitioner. The PRN Lorazepam 0.25 milligrams will be automatically discontinued after 14 days of the original order date; or request to continue the PRN order for less than 1 year with clinical rationale.
Interview on 8/21/824 at 8:22 AM with the facility IC confirmed that the Note to Attending Physician/Prescriber dated 8/17/24 for Resident 135's Lorazepam PRN limited to 14 days had not been sent to Resident 135's physician for review and should have been sent.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175NAC 12-006.12(D)(vi)
Based on observation, record review, and interview; the facility failed to ensure medications were labeled clearly and accurately for 2 Residents (Re...
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Licensure Reference Number 175NAC 12-006.12(D)(vi)
Based on observation, record review, and interview; the facility failed to ensure medications were labeled clearly and accurately for 2 Residents (Resident 18 and Resident 29) of 5 sampled residents. The facility census was 33.
Findings are:
Review of a facility policy titled Labeling of Medications and Biologicals dated 02/2020 revealed All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Medication labels bust be always legible. Any medication label that is soiled, incomplete, illegible, worn, or makeshift must be returned and replaced by the issuing pharmacy.
A.
Review of an admission Record dated 08/19/2024 revealed the facility admitted Resident 18 on 04/10/2024 with diagnoses of type two diabetes mellitus, (which is when the body has trouble controlling blood sugar and using it for energy).
Review of Resident 18's Treatment Administration Record for the month of August 2024 revealed Resident 18 received Humalog Insulin (which is a medication that helps to regulate blood sugar levels), injections per a sliding scale (which is a varied dose based on blood sugar levels) schedule before meals and at bedtime.
In an observation of medication administration completed on 08/20/2024 at 7:35 AM, Registered Nurse F (RN-F) was observed to prepare to administer an injection to Resident 18 using an insulin pen. The label attached to the insulin pen was observed to have black smeared ink over one side of the label making the residents name and directions for sliding scale administration illegible.
In an interview completed on 08/202/2024 at 7:35 AM with RN-F, RN-F confirmed that the label on the insulin pen was illegible and the full directions for administering Resident 18 insulin was not visible on the label.
In an interview completed on 08/21/2024 at 1:35 PM with the Director of Nursing (DNS), the DNS confirmed that the label on Resident 18 insulin pen was illegible and needed to be replaced by the pharmacy.
B.
Review of an admission Record dated 08/19/2024 revealed the facility admitted Resident 29 on 10/25/2023 with diagnoses of hypertensive heart disease (which is high blood pressure).
Review of Resident 29 Medication Administration Record for the month of August 2024 revealed Resident 29 had physician orders to receive Potassium Chloride (which is a mineral supplement) ER (Extended Release), 20 Milliequivalents (MEQ) tablet one time every day.
In an observation of medication administration completed on 08/20/2024 at 7:45 AM, RN-F was observed preparing Resident 29 medications. RN-F removed an oblong cream granular in appearance tablet from a medication card labeled with Resident 29 name and Potassium Chloride 20 MEQ tablet. RN-F placed the tablet in a clear medication cup with other medications and took the cup to Resident 29. Resident 29 using the medication cup and a drink of water swallowed all the medications in the cup. RN-F then returned to the medication cart.
In an interview with RN-F completed on 08/20/2024 at 7:50 AM, RN-F confirmed the label on the medication card read Resident 29 name and Potassium Chloride 20 MEQ and the order in Resident 29 Medication Administration Record read Potassium Chloride ER 20 MEQ. RN-F confirmed that the label on the medication package and the order in the Medication Administration Record did not match.
In an interview with the DNS completed on 08/21/2024 at 1:35 PM, the DNS confirmed that the label on Resident 29 Potassium Chloride medication and the order in the Medication Administration Record did not match. The DNS confirmed the order needed verified and clarified with the provider and the pharmacy.
CONCERN
(E)
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 175NAC 12-006.19
Based on observation and interviews; the facility failed to maintain flooring that ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.19
Based on observation and interviews; the facility failed to maintain flooring that was stain free, ceiling tiles that are stain free, lighting fixtures that are bug and/or pest free, and thresholds that are free of trip hazards for 4 (Halls 300, 400, 500, and 700) of 5 sampled hallways. The facility census was 33.
Findings are:
In an observation completed on [DATE] from 7:25 PM to 8:20 PM the following was observed:
A.
In the 300 Hall in front of the door labeled Dining the carpet in front of the door is black and shiny in color from the threshold of the doorway extending 5 to 6 inches into the hallway where it fades to a gray color and then into the brown cream coloring of the carpeting squares.
In the 300 Hall the carpeting between room [ROOM NUMBER] and 311 a large dark colored ring extending from the wall to the middle of the hallway.
In the commons area in front of the nurse's station gray black circular discolored areas.
B.
In the 400 Hall on the exit side of the fire doors the ceiling tiles stained black, red fading into brown circles with the stained discolored area protruding down from the flat surface of the other ceiling tiles. The area is 3 ceiling tiles long and 2 ceiling tiles wide.
In the 400 Hall first light fixture in the ceiling entering the hall is a black multi legged deceased bug approximately the size of a quarter.
In the 400 Hall in front of room [ROOM NUMBER] a large dark gray black colored circular area extending from the threshold of the entry to the room approximately 4 inches into the hallway.
In the 400 Hall the thresholds of Rooms 400, 402, 403, 406, 408, and 409 the carpet is loose, and the laminate flooring is loose from the underlayment beneath creating a trip hazard for residents.
C.
In the 500 Hall on the exit side of the fire doors the ceiling tiles are stained orange fading into a red brown color. The area is 2 ceiling tiles long and 4 ceiling tiles wide.
In front of room [ROOM NUMBER] the ceiling tiles are yellow brown in color extending from the entrance to the room across 3 sections of ceiling tile.
D.
In the 700 Hall rooms [ROOM NUMBERS] the flooring of the threshold is carpet going to tile. The carpet is loose in the inner corner coming up from being secured to the floor. The tile is chipped and cracked exposing the sub floor underneath creating an uneven area where black, thick brown substance has collected and built up.
In an interview on [DATE] at 9:56 AM with the Maintenance Manager (MM) the MM confirmed that the ceiling tiles were warped and stained and needed replaced. The MM stated that a water leak had been repaired but the ceiling tiles had not been replaced yet. The MM stated that the carpets are cleaned twice a year by an outside company and the facility does not perform any carpet cleaning in between these cleanings. The MM confirmed that the carpet throughout the facility had different degrees of staining present and needed cleaned more frequently. The MM confirmed the bug present in the 400-hall light fixture and that the carpeting and tile were cracked and coming loose on the thresholds of some of the doorways of the resident rooms.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Licensure Reference Number 175NAC 1-005.06(E)
Licensure Reference Number 175NAC 12-006.18(B)
Based on record review and interview the facility failed to complete and review pre-employment health histo...
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Licensure Reference Number 175NAC 1-005.06(E)
Licensure Reference Number 175NAC 12-006.18(B)
Based on record review and interview the facility failed to complete and review pre-employment health histories for 4 of 4 sampled staff. Based on observation, record review, and interview the facility failed to perform hand sanitization during medication administration to 3 or 5 sampled residents (Resident 17, 28, and 18), sanitize blood glucose glucometer after use for 1 of 1 sampled resident (Resident 18), and failed to follow Enhanced Barrier Precautions (gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multi-drug resistant organism and residents at increased risk) to prevent the potential spread of multidrug-resistant infection for 2 residents (Residents 11 and 8). The facility census was 33.
Findings are:
A.
Review of a facility supplied documents titled Employee Heath History Screen revealed the following:
-Document for Housekeeper J (HSK-J) not completed in its entirety. No primary physician past medical history or allergies listed. The form is signed by HSK-J and dated 06/18/2024. There is no signature or date of the form being reviewed by other facility staff.
-Document for Medication Aide K (MA-K) not completed in its entirety. No immunization record present. The form is signed by MA-K and dated 06/19/2024. There is no signature or date of the form being reviewed by other facility staff.
-Document for Dietary Aide L (DA-L) completed, signed by DA-L and dated 07/30/2024. There is no signature or date of the form being reviewed by other facility staff.
-Document for Maintenance Manager (MM) not completed in its entirety. No employee name listed on the form no position title emergency contact primary physician or immunization history completed. The form is signed by MM and dated 05/24/2023. There is no signature or date of the form being reviewed by other facility staff.
In an interview on 08/21/2024 at 10:35 AM with the facility Business Office Manager (BOM), the BOM confirmed they are the individual responsible for ensuring all new hire documentation is completed and present in the employees file. The BOM confirmed that the Employee Health History Screen forms for HSK-J, MA-K, and MM were not completed entirely. The BOM confirmed that the forms were not reviewed to ensure that the individuals were free of communicable diseases prior to working with or in the direct vicinity of residents.
B.
Review of a facility policy titled Hand Hygiene and dated 2021 revealed hand hygiene is indicated and will be performed under the conditions listed in but not limited to the hand hygiene table. The Hand Hygiene Table lists hand hygiene is to be performed between resident contacts, after handling contaminated objects, before applying and after removing personal protective equipment including gloves, before preparing or handling medications.
In an observation of medication administration by Registered Nurse F (RN-F), completed on 08/20/2024 from 7:20 AM to 8:20 AM the following was observed:
RN-F knocked and entered Resident 17's room. RN-F gave the medications to Resident 17 in a clear plastic cup and Resident 17 then took the medications and swallowed them, and handed the clear up back to RN-F. RN-F thanked the resident and exited the room returning to the medication cart located in the hall outside of the room. RN-F threw the clear plastic cup in the trash can on the cart and placed the syringe in a clear plastic sleeve in the medication cart. RN-F then signed out the medication administration in the computer and removed the next residents' medications from the medication cart. RN-F did not complete hand sanitization/hygiene between administering Resident 17's medications and preparing the next residents' medications. Then RN-F prepared Resident 28's medications at the medication cart in the hallway located outside of Resident 28's room. RN-F knocked and entered the resident's room and handed the resident a cup containing clear liquid and a clear medication cup containing multiple medications. The resident emptied the cup containing the medications in their mouth and handed the cup back to RN-F. RN-F then returned to the medication cart in the hall signed out the medications administered in the computer. RN-F then locked the medication cart and proceeded down the hall to the nurse's station where another medication cart was located. The RN unlocked this cart and obtained a clear blue plastic pencil box from the cart. The RN did not complete hand sanitization/hygiene after administering Resident 28's medications and going to the other medication cart to get the clear blue plastic pencil box. Next RN-F entered Resident 18's room and obtained a paper towel and placed it on the resident's bed side stand. RN-F then set down a clear blue plastic pencil box on the paper towel. RN-F then applied gloves to both hands and performed the procedure of obtaining resident 18's blood sugar. After completion of the procedure RN-F removed their gloves from their hands and placed the items used back into the clear blue plastic pencil box. RN-F then picked up the box exited the resident's room and returned the box to the medication cart located at the nurse's station. RN-F did not complete hand sanitization/hygiene after removing their gloves post procedure.
In an interview on 08/20/2024 at 8:25 AM completed with RN-F, RN-F confirmed hand sanitization/hygiene should have been completed after administering Resident 17 and Resident 28's medications. RN-F confirmed that hand sanitization/hygiene should have been completed after [gender] removed their gloves.
C.
Review of a facility policy titled Blood Glucose Monitoring dated 2021 revealed the nurse or med aide will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions.
Review of a document titled Assure Platinum Reference Manual and dated 03/2014 revealed the glucometer should be cleaned and disinfected after each use.
Review of a document titled General guidelines for use Super Sani-Cloth and dated 2021 revealed to allow the treated surface to remain wet for two minutes then let air dry.
In an observation completed on 08/20/2024 at 7:45 AM RN-F used a glucometer to obtain Resident 18's blood sugar at the bedside. RN-F then placed the glucometer into a clear blue plastic pencil box and returned to the medication cart located down the hall by the nurse's station. RN-F placed the clear blue plastic box on the medication cart and obtained a disposable wipe from a container labeled Super Sani-Cloth located on top of the medication cart. RN-F wiped the glucometer with the disposable wipe for approximately 30 seconds. RN-F disposed of the wipe in the trash can and then placed the glucometer back into the clear blue plastic pencil box and placed it into the medication cart.
In an interview on 08/20/2024 at 8:25 AM with RN-F, RN-F stated [gender] did not know the contact time or how long the surface had to remain wet for proper cleaning technique of the glucometer per the disposable wipes manufacturer recommendations. Review of the label on the container labeled Super Sani-Cloth revealed a time of 2 minutes the item being cleansed with the cloth should remain wet. RN-F confirmed this instruction was written on the label.
In an interview on 08/21/2024 at 1:35 PM with the facility Director of Nursing (DNS), the DNS confirmed that the glucometer is to remain wet for 2 minutes for proper cleaning technique when using the Super Sani-Cloth disposable wipes.
D.
Record review of the facility policy titled Enhanced Barrier Precautions dated 4/1/24 revealed that it is the policy of the facility to implement enhanced barrier precautions for the prevention of the transmission of multidrug-resistant organisms. The definition for Enhanced Barrier Precautions (EBP) revealed that EBP is an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The policy revealed that all staff receive training on enhanced barrier precautions and are expected to comply with all designated precautions. High contact resident care activities include: Dressing, Bathing, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Wound care: any skin opening requiring a dressing. Enhanced barrier precautions should be followed outside the resident's room when performing transfers and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of an indwelling medical device.
Record review of the admission Record dated 8/19/24 for Resident 11 revealed that Resident 11 admitted into the facility on 7/24/24.
Record review of the Care Plan dated 8/19/24 for Resident 11 revealed that Resident 11 had a surgery for fracture of the left elbow. Resident 11 had an incision on the left arm to be observed for signs and symptoms of infection.
Record review of the Treatment Administration Record (TAR, a legal record of the administration of scheduled treatments or performance of other scheduled medical tasks for a resident by a health care professional such as a licensed nurse) dated 8/20/24 for Resident 11 revealed that Resident 11 had an order for dry dressing with ace wrap changed daily. Monitor incision site for signs and symptoms of infection.
Observation on 8/19/24 at 8:59 AM in the room of Resident 11 revealed that Nurse Aide-A (NA-A) transferred Resident 11 into the room in a wheelchair. Resident 11 had an ace wrap around their left elbow. A sign on the wall between the bathroom door and closet in the resident's room revealed ENHANCED BARRIER PRECAUTIONS. Everyone must clean their hands, including before entering and when leaving the room. Providers and Staff must also wear gloves and a gown for the following high contact resident care activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting. Device Care or use: Central Line, Urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. A holder with gowns and gloves hung from the back of the room door. NA-A did not put on a gown or gloves. NA-A applied a gait belt (a belt device placed around a resident's abdominal area used to aid in the safe movement of a resident with mobility problems) around the abdomen of Resident 11 with the bare hands. NA-A's arms were in contact with the arms of Resident 11 as the gait belt was applied. NA-A assisted Resident 11 to stand from the wheelchair. Resident 11 held onto a walker. NA-A assisted Resident 11 to step towards the recliner as NA-A held onto the gait belt with their right hand and held onto the left arm of Resident 11 with the left hand. Resident 11 complained that NA-A was putting pressure leaning on Resident 11's left arm during the transfer. Resident 11 complained that their left arm is sore.
Observation on 8/19/24 at 9:34 AM in the room of Resident 11 revealed that Physical Therapy Assistant (PTA) entered the room of Resident 11. PTA did not put on a gown or gloves. PTA put shoes on Resident 11 with the bare hands. PTA put a gait belt around the abdomen of Resident 11 and assisted Resident 11 to stand from the recliner. PTA rubbed against Resident 11 as Resident 11 stood up with the assistance. Resident 11 held onto the walker. PTA held onto the gait belt and walked with Resident 11 from the resident room to the therapy gym.
Observation on 8/20/24 at 9:04 AM in the room of Resident 11 revealed that Nurse Aide-B (NA-B) did not put on a gown or gloves. Resident 11 sat in the wheelchair. NA-B placed a gait belt around the abdomen of Resident 11 with the bare hands. NA-B's bare arms rubbed against the arms and torso of Resident 11 as the gait belt was applied. NA-B held onto the gait belt and the resident's left arm pit as Resident 11 was assisted to stand. Resident 11 used the walker to transfer to the recliner. Resident 11 was assisted into the recliner as NA-B held onto the resident. Resident 11 tilted the recliner back and elevated their feet.
Interview on 8/20/24 at 2:35 PM with NA-B revealed that this surveyor asked NA-B what the sign Enhanced Barrier Precautions meant. NA-B reviewed the sign and stated that it was for bathing the resident and for residents with catheters that staff have to wear gown and gloves. NA-B was unaware that gown and gloves were required for any high contact care including transfers for residents on Enhanced Barrier Precautions.
Observation on 8/20/24 at 11:06 AM in the therapy gym revealed that Physical Therapist (PT) reached across the back of Resident 11 with the left hand and held onto the back of the gait belt. PT's arm was holding against the back of Resident 11. PT placed their right hand on the upper arm of Resident 11 with the right hand. PT assisted Resident 11 to sit in a chair. PT did not wear a gown or gloves.
Observation on 8/20/24 at 11:09 AM in the therapy gym revealed that PTA sat down next to Resident 11. PTA told Resident 11 that the oxygen nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside your nostrils to provide supplemental oxygen therapy to people who have lower oxygen levels) needed to be adjusted. PTA grabbed the nasal cannula on the left and right of Resident 11's nose with the bare hands and adjusted the prongs into the nostrils of Resident 11. PTA tightened the cannula to hold it in place.
Observation on 8/20/24 at 12:44 PM revealed that Nurse Aide-B (NA-B) transferred Resident 11 in the wheelchair from the dining room into the resident's room. NA-B did not put on a gown or gloves. NA-B pushed the wheelchair into the bathroom. NA-B put on gloves and placed a gait belt around the abdomen of Resident 11. NA-B assisted Resident 11 to stand up from the wheelchair using the gait belt. Resident 11 grabbed onto the grab bar on the wall to assist with standing. NA-B pulled down the pants of Resident 11 and then pulled down Resident 11's brief. NA-B assisted Resident 11 to sit down on the toilet. NA-B removed and discarded the gloves. NA-B asked Resident 11 to use the call light to let staff know when the resident was finished in the bathroom. NA-B exited the resident's room.
Observation on 8/20/24 at 12:54 PM at the room of Resident 11 revealed that Medication Aide-C (MA-C) entered the room of Resident 11. MA-C did not perform hand sanitization. MA-C did not put on a gown or gloves. MA-C entered the resident's bathroom and asked Resident 11 if they were finished. Resident 11 responded yes. MA-C put on gloves and used a wipe to wipe the bowel movement (BM) from the resident's anal area. MA-C obtained a second wipe and wiped the resident's anal area. MA-C obtained a third wipe and wiped the resident's anal area. MA-C removed and discarded the gloves. MA-C did not perform hand sanitization. MA-C used the bare hands to assist Resident 11 to a standing position in front of the toilet. MA-C used the bare hands to pull up Resident 11's brief and pants. MA-C assisted Resident 11 to sit in the wheelchair. MA-C transferred Resident 11 out of the bathroom to near the recliner. MA-C moved the recliner as requested by Resident 11. MA-C used the bare hands to move the over bed table on the left side of the recliner towards the rear of the recliner as requested by Resident 11. MA-C positioned the wheelchair in front of the recliner. MA-C used the bare right hand to hold onto the gait belt in back of Resident 11 while draping the left arm underneath the left arm of Resident 11. MA-C held onto the front of the gait belt with the bare left hand and assisted Resident 11 to stand from the wheelchair. MA-C's uniform was touching Resident 11 as MA-C pivoted Resident 11 into the recliner. MA-C placed their bare hands on their sides touching their uniform. MA-C used the bare hands to pick up the nasal cannula from the bed and placed the nasal cannula on the face of Resident 11. MA-C used the bare hands to operate the control on the recliner to elevate Resident 11's feet and tilt the back of the chair backwards. MA-C used the bare hands to place a pillow behind Resident 11. MA-C used the bare hands to place a pillow underneath the left arm of Resident 11. MA-C entered the bathroom and performed hand washing. Resident 11 stated that the pain in their left arm was a 6 on a scale of 0-10. Resident 11 stated that they were supposed to place an ice pack to help with the pain. MA-C told Resident 11 they would get an ice pack. MA-C exited the room of Resident 11.
Observation on 8/20/24 at 1:06 PM in the room of Resident 11 revealed that MA-C returned to the room with an ice pack. MA-C did not put on a gown or gloves. MA-C used the bare hands and lifted the left arm of Resident 11 and placed the ice pack under the left elbow and forearm of the resident. An ace wrap was in place on the left elbow of Resident 11. MA-C exited the resident room.
Interview on 8/20/24 at 4:30 PM with Medication Aide-C (MA-C) revealed that the Enhanced Barrier Precautions means you have to gown up and wear gloves if doing anything with a resident's wounds. MA-C was not aware that gown and gloves were required for transferring and toileting residents on Enhanced Barrier Precautions.
Observation on 8/21/24 at 9:57 AM in the room of Resident 11 revealed that Registered Nurse-E (RN-E) performed hand sanitization and entered the resident room after reviewing the order for the incision on Resident 11's left elbow. The incision along the bottom of the left elbow had 6 steri strips (strips of tape put across an incision for wound closure) over it. The area around the incision was a light brown along the length of the incision. The incision contained a scabbed area below the elbow measuring approximately 3 centimeters (cm) long and 1 cm wide and a scabbed area above the elbow measuring approximately 2 cm long and 1cm wide. Resident 11's left arm had a moderate amount of swelling into the fingers and was light reddish in color.
Interview on 8/22/24 at 7:28 AM with the facility Director of Nursing Services (DNS) confirmed that residents on Enhanced Barrier Precautions (EBP) are to have an EBP poster sign posted to identify the resident is on EBP. The DNS confirmed that staff are expected to follow the Enhanced Barrier Precautions and wear gown and gloves for resident transfers, toileting, and wound care. The DNS revealed that the facility training to ensure staff are educated needs revised.
E.
Record review of the admission Record for Resident 8 dated 8/19/24 revealed that Resident 8 admitted into the facility on 1/10/24. Resident 8 had a chronic ulcer (open wound) of the left lower leg.
Record review of the Care Plan dated 8/19/24 for Resident 8 revealed that staff are to observe open areas for signs and symptoms of infection. See Treatment Administration Record (TAR) for treatments. The care plan contained a care focus for Enhanced Barrier Precautions. The Care Plan revealed that Resident 8 has an open pressure wound (A localized wound of the skin and/or underlying tissue, usually over a bony area. A bedsore.) and vascular wounds (wounds on your skin that develop because of problems with blood circulation) receiving treatments. Put on gown and gloves for cares at all times in the resident's room. In room care: Provide EBP care during dressing, bathing, transferring, providing hygiene care, changing bed linens, changing briefs or assisting with toileting.
Observation on 8/20/24 at 2:35 PM at the room of Resident 8 revealed that a sign on the outside of the door to the room of Resident 8 read ENHANCED BARRIER PRECAUTIONS. Everyone must clean their hands, including before entering and when leaving the room. Providers and Staff must also wear gloves and a gown for the following high contact resident care activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting. Device Care or use: Central Line, Urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person.
Interview on 8/20/24 at 2:35 PM with Nurse Aide-B (NA-B) revealed that this surveyor asked NA-B what the sign Enhanced Barrier Precautions on the door of Resident 8 meant. NA-B reviewed the sign and stated that it was for bathing the resident and for residents with catheters. NA-B stated that NA-B was unsure if it was even applicable to Resident 8 anymore. NA-B revealed that Resident 8 may have had an infection at one time.
Observation on 8/21/24 at 7:37 AM in the room of Resident 8 revealed that Medication Aide-D (MA-D) and Nurse Aide-A (NA-A) were in the bathroom with Resident 8. Resident 8 was in the wheelchair. MA-D put on gloves and stood in front of the wheelchair beside the toilet. MA-D did not wear a gown. NA-A stood behind the wheelchair just inside the bathroom doorway. NA-A did not wear a gown or gloves. NA-A placed a gait belt around the lower abdomen of Resident 8. MA-D and NA-A each held onto the gait belt with one hand and supported the resident's arms with their other hand. MA-D and NA-A assisted Resident 8 to stand up from the wheelchair. MA-D removed the resident's brief. Resident 8 was assisted to sit on the toilet.
Observation on 8/21/24 at 9:22 AM at the room of Resident 8 revealed that Registered Nurse -E (RN-E) reviewed the dressing change order. RN-E performed hand sanitization and put on gown, gloves, and face shield. RN-E revealed that Resident 8 had received a bath so the wound on the top of the foot was open to air. An open wound on the top of Resident 8's left foot measured approximately 8 cm long, 5 cm wide, and 0.5 cm deep. The wound bed was bright red and approximately 70% covered with a thick dark yellow-brown exudate (wound drainage). RN-E completed the wound treatment and applied the silicone foam border dressing over the wound.
Observation on 8/21/24 at 10:25 AM in the room of Resident 8 revealed that Resident 8 was in bed lying on their left side. RN-E reviewed the dressing change order for the pressure ulcer on the resident's coccyx (the bony lower portion of the spine). RN-E performed hand sanitization and put on a gown, gloves, and face shield. RN-E pulled down the resident's pants and brief to just below the buttocks. An open wound was visible on the resident's coccyx. The wound measured approximately 3 cm long and 2.5 cm wide and was light red in color. An approximately 1 cm long, 0.5 cm wide, and 1 cm deep open area inside the wound near the top of the wound area was present. RN-E completed the wound treatment and applied a silicone foam dressing over the wound.
Interview on 8/22/24 at 7:28 AM with the facility Director of Nursing Services (DNS) confirmed that residents on Enhanced Barrier Precautions (EBP) are to have an EBP poster sign posted to identify the resident is on EBP. The DNS confirmed that staff are expected to follow the Enhanced Barrier Precautions and wear gown and gloves for resident transfers, toileting, and wound care. The DNS revealed that the facility training to ensure staff are educated needs revised.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0923
(Tag F0923)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-007.04(D)
Based on observation, and interview; the facility failed to ensure the bathroom v...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-007.04(D)
Based on observation, and interview; the facility failed to ensure the bathroom ventilation system could pull up a square of single ply tissue in 3 rooms, (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]), of 16 sampled rooms. The facility census was 33.
Findings are:
In an observation completed on 08/22/2024 at 9:30 AM it was observed that the vent located in the ceiling of the bathroom of room [ROOM NUMBER] could not pull up a single ply of tissue.
In an observation completed on 08/22/2024 at 9:31 AM it was observed that the vent located in the ceiling of the bathroom of room [ROOM NUMBER] could not pull up a single ply of tissue.
In an observation completed on 08/22/2024 at 9:32 AM it was observed that the vent located in the ceiling of the bathroom of room [ROOM NUMBER] could not pull up a single ply of tissue.
In an interview completed on 08/22/2024 at 9:56 AM with the Maintenance Manager (MM), confirmed that the vents located in the ceilings of the bathrooms in room [ROOM NUMBER], 307, and 311 could not pull up a single ply of tissue. The MM confirmed that the vents should be able to pull up a single ply of tissue and that the ventilation system was not working properly.
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)
Based on observations, record review, and interviews; the facility failed to store food under sanitary conditions as evidenced by rodent droppings in ...
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Licensure Reference Number: 175 NAC 12-006.11(E)
Based on observations, record review, and interviews; the facility failed to store food under sanitary conditions as evidenced by rodent droppings in and around the food storage areas. This had the potential to affect all facility residents. Facility census was 32.
Findings are:
Source: Nebraska Food Code, effective date 07/21/2016 revealed section:
3-305.11: Food Storage: A. Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD:
-In a clean, dry location;
-Where it is not exposed to splash, dust, or other contamination; and
-At least 15 cm (6 inches) above the floor.
A review of the facility policy titled; Dietary Sanitation Policy Statement revealed: All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects.
Observation on 08/19/2024 at 8:35 AM revelaed the Food Services Supervisor (FSS) directed surveyor towards the back of the facility where a kitchen was presented with a dry storage on the east of the kitchen, dishwashing machine, stoves, and ovens. The dry storage had items labeled, and stored off of the floor. Underneath the dry storage was a 4-inch gap between the shelving and the floor, where visible were individual food packs of cookies, condiments and 4 wooden snap mouse traps. The FSS then lead the surveyor towards the main storage area that contained a refrigerator, 5 stand alone freezers and 2 large dry food storage wire shelving units that held dry food items, and another large shelving unit that held canned food items. The floors of the area were observed to have dried pasta, corn kernels and a buildup of dark soiling. Also observed were mouse droppings littered all over the floor with a concentration of droppings in specified areas of the storage room. There is a two-door entryway for deliveries where sticky mouse traps were present by the door and a cluster of mouse droppings.
On 08/19/2024 at 2:12 PM Cook-I is observed to be retrieving food items from the food storage area of dry goods and refrigerated items. The items are placed on a rolling cart and brought to the kitchen where food is prepared. After the food is prepared, the food is kept hot in the oven. Once food is ready to be served, the food is then moved to the serving kitchen/dining room, where the food is then placed into a steam table and served to the residents.
The FSS was interviewed on 08/19/2024 at 2:26 PM. The FSS revealed they were aware of the mouse droppings and stated they did not have the live mouse traps available to the kitchen. The FSS also revealed more cleaning needs to be done.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Licensure Reference Number: 175 NAC 1-009.01(C)
Based on observations, record review and interviews, the facility failed to maintain an effective pest control program as evidenced by rodent droppings ...
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Licensure Reference Number: 175 NAC 1-009.01(C)
Based on observations, record review and interviews, the facility failed to maintain an effective pest control program as evidenced by rodent droppings in and around the food storage areas. This had the potential to affect all facility residents. Facility census was 32.
Findings are:
A review of an undated facility policy titled Pest Control, indicates the facility shall maintain an effective pest control program. The policy further implements that the facility will maintain an on-going pest control program to ensure that the building is kept free of insects and rodents.
Observation on 08/19/2024 at 8:35 AM the Food Services Supervisor (FSS) directed the surveyor towards the back of the facility towards a kitchen with a dry storage on the east side of the kitchen. Under the dry storage was a 4-inch gap, that had food items and 4 wooden snap mouse traps. The FSS then lead the suerveyor towards the main storage area that contained a refrigerator, 5 stand alone freezers, 2 large dry food storage wire shelving units that held dry food items, and another large shelving unit that held canned food items. The floors of the area were observed to have dried pasta, corn kernels and a buildup of dark soiling present. Also observed were mouse droppings littered all over the floor with a concentration of droppings in specified areas of the storage room. There is a two-door entryway for deliveries where sticky mouse traps caught with dead bugs were present by the doors and a cluster of additional mouse droppings.
The FSS was interviewed on 08/19/2024 at 2:26 PM. The FSS revealed they were aware of the mouse droppings and stated they did not have the live mouse traps available to the kitchen as they typically did in other areas of the facility. The FSS stated they cleaned it up, however more cleaning needs to be done.
An interview with the Facility Administrator (FA) on 08/19/2024 at 5:05 PM revealed they were unaware of the rodent droppings in the dry food storage area.
Aug 2023
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175NAC 12-006.02(8)
Based on record review and interview the facility failed to ensure that notification of potential abuse and neglect occurred within the required timefram...
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Licensure Reference Number 175NAC 12-006.02(8)
Based on record review and interview the facility failed to ensure that notification of potential abuse and neglect occurred within the required timeframe for 1 resident (Resident 20) of 2 residents reviewed. The facility census was 27.
Findings are:
Record review of the facility policy titled Abuse, Neglect, and Exploitation dated September 2022 revealed that an immediate investigation is warranted when suspicion of abuse, or reports of abuse occur. The facility will report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes. Reporting is made immediately, but not later than 2 hours after the allegation is made if the events that caused the allegation involve abuse.
Record review of the admission Record for Resident 20 dated 8/23/23 revealed that Resident 20 admitted into the facility on 4/20/23. Diagnoses included Parkinson's Disease, anxiety disorder, and chronic pain.
Record review of the progress note dated 7/9/23 at 11:26 AM for Resident 20 revealed that Resident 20 was noted to have a 1 centimeter by 1.5 centimeter bruise on the index finger of the right hand.
Interview on 8/24/23 at 10:17 AM with the Facility Administrator (FA) revealed that on 7/5/23 Resident 20 reported to the bath aide that a staff member was rough with the resident and threw them around. The FA revealed that the FA was notified of the allegation on 7/13/23. This was 8 days after the resident reported the abuse to facility staff. The FA confirmed that the report to adult protective services was not within the required timeframe.
CONCERN
(D)
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** Based on record review and interviews the facility failed to provide written notice to the resident or their representative rega...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide written notice to the resident or their representative regarding discharge or transfer to the hospital for 2 residents (Residents 3 and 279) of 2 residents reviewed. The facility census was 27.
Findings are:
A.
Record review of the EHR (electronic health record) progress notes dated 4/9/23 revealed that Resident 3 was admitted to the hospital from the ER (Emergency Room) due to an elevated white blood cell count and a UTI (urinary tract infection). The resident was treated with IV (intravenous) antibiotics.
Record review of Resident 3's EHR progress notes revealed no documentation that the resident or resident's representative was notified in writing regarding the hospital transfer or discharge.
Interview with FA (Facility Administrator) on 8/23/23 at 3:40 PM confirmed that the facility did not provided written notice to Resident 3 or the personal representative regarding the discharge to the hospital.
Interview with DOO (Director of Operations) on 8/23/23 at 1:30 PM confirmed that the facility should be sending a written notice of transfer or discharge to the resident and resident representatives on a transfer or discharge.
Interview with DCO (Director of Clinical Operations) on 8/23/23 at 3:56 PM confirmed that the written notice of transfer was not provided to Resident 3 or the resident's personal representative for the transfer or discharge to the hospital.B.
A review of Resident 279's admission Record revealed an initial admission date of 7/25/23 and an admitting diagnosis of Retropharyngeal and Parapharyngeal Abscess (a collection of pus within the tissues of the back wall of the throat and the tissues surrounding the throat.)
A review of Resident 279's Progress Notes revealed that the resident was admitted to the hospital on [DATE] after an MRI (Magnetic Resonance Imaging - a non-invasive technique that produces detailed images of the internal structures of the body) of the neck and an appointment with their Primary Care Provider.
Further review of the Progress Notes from 8/2/23 revealed no documentation that the resident or resident's representative was notified in writing regarding the resident's transfer to the hospital.
An interview with the FA on 8/23/23 at 3:40 confirmed that a Written Notice of Transfer had not been given to Resident 279 or their representative on transfer of the resident to the hospital.
An interview with the DCO on 8/23/23 at 3:56 PM confirmed that Written Notice of Transfer was not given on Resident 279 for the discharge/transfer to the hospital.
A review of the facility's Transfer and Discharge Policy dated September 2022 revealed the following:
The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand.
Feb 2023
5 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
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175NAC 12-006.05(5)
Based on record review and interview the facility failed to provide in writing the required notice of discharge to 1 resident (Resident 1) and provide do...
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Licensure Reference Number 175NAC 12-006.05(5)
Based on record review and interview the facility failed to provide in writing the required notice of discharge to 1 resident (Resident 1) and provide documentation of the reason for the resident discharge for 1 resident (Resident 1). The facility census was 21.
Findings are:
Record review of the facility policy titled Transfer and discharge date d September 2022 revealed it is the policy of the facility to permit each resident to remain in the facility, and not initiate discharge for the resident from the facility except in limited circumstances. Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions: The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner they can understand. Generally, the notice must be provided at least 30 days prior to a facility-initiated discharge of the resident. In exceptional cases the notice must be provided to the resident, resident's representative if appropriate, and the Long-Term Care ombudsman (a state appointed advocate for residents of nursing homes) as soon as practicable before the transfer or discharge. The section titled Non-Emergency Transfers or Discharges revealed that the facility is to document the reasons for the discharge in the resident's medical record, and in the case of necessity for the resident's welfare and the resident's needs cannot be met in the facility, document the specific resident needs that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the needs.
Record review of the admission Record dated 2/21/23 for Resident 1 revealed Resident 1 admitted into the facility on 9/8/22 and was discharged from the facility on 1/26/23.
Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 11/29/22 revealed that Resident 1 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 15 (a score of 13 to 15 suggests the resident is cognitively intact).
Record review of the progress note dated 1/13/23 for Resident 1 revealed that the nurse called Resident 1's physician to provide an update on the resident's status. The physician ordered Resident 1 transferred to the emergency room.
Record review of the progress note dated 1/13/23 for Resident 1 revealed that Resident 1 left the facility by ambulance for transfer to the emergency room.
Record review of the Skilled Nursing Facility (SNF)/Nursing Facility (NF) to Hospital Transfer Form (a form used for communicating resident information to the hospital when a resident is transferred from the facility to the hospital) for Resident 1 documented the date of transfer as 1/13/23. The form documented that Resident 1 was a long-term resident of the facility. The reason for transfer was documented as other.
Record review of the medical record for Resident 1 revealed no documented written discharge notice for Resident 1 or documentation of the reason for the facility-initiated discharge.
Interview on 2/21/23 at 3:48 PM with the facility Business Office Manager/Social Services Designee (BOM) confirmed that Resident 1 was sent to the emergency room and hospitalized . The BOM confirmed that the facility provided no notice of discharge to Resident 1.
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 175NAC 12-006.05(5)
Based on record review and interview the facility failed to provide written notic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.05(5)
Based on record review and interview the facility failed to provide written notice of discharge and failed to provide a copy of written discharge notice to the ombudsman (a state appointed advocate for residents of nursing homes) as required for 1 resident (Resident 1). The facility census was 21.
Findings are:
Record review of the facility policy titled Transfer and discharge date d September 2022 revealed that it is the policy of the facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility except in limited circumstances. The section titled Emergency Transfers/Discharges revealed that in situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send a notice of discharge to the resident and resident representative before the discharge and must also send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. The facility will maintain evidence that the notice was sent to the ombudsman.
Record review of the admission Record dated 2/21/23 for Resident 1 revealed that Resident 1 admitted into the facility on 9/8/22 and was discharged from the facility on 1/26/23.
Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 11/29/22 revealed that Resident 1 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 15 (a score of 13 to 15 suggests the resident is cognitively intact).
Record review of the progress note dated 1/13/23 for Resident 1 revealed that the nurse called Resident 1's physician to provide an update on the resident's status. The physician ordered Resident 1 transferred to the emergency room.
Record review of the progress note dated 1/13/23 for Resident 1 revealed that Resident 1 left the facility by ambulance for transfer to the emergency room.
Record review of the MDS assessment dated [DATE] for Resident 1 revealed that the assessment was completed for resident discharge from the facility with a return to the facility anticipated (the facility expected the resident to return to the facility after hospitalization).
Record review of the medical record for Resident 1 revealed no documentation of any discharge notice or verbal notification of discharge provided to Resident 1. The medical record contained no documentation of any discharge notification to the ombudsman.
Interview on 2/21/23 at 3:48 PM with the facility Business Office Manager/Social Services Designee (BOM) confirmed that Resident 1 was sent to the emergency room and hospitalized . The BOM confirmed that the facility did not provide written notification of Resident 1's discharge from the facility to the ombudsman.
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
Deficiency F0625
(Tag F0625)
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 provide notice of bed hold (notification of the resident's right to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide notice of bed hold (notification of the resident's right to hold or reserve a resident's bed while the resident is hospitalized ) as required for 1 resident (Resident 1). The facility census was 21.
Findings are:
Record review of the facility policy titled Transfer and discharge date d September 2022 revealed that it is the policy of the facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility except in limited circumstances. The section titled Emergency Transfers/Discharges revealed that the facility will provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated.
Record review of the admission Record dated 2/21/23 for Resident 1 revealed that Resident 1 admitted into the facility on 9/8/22.
Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 11/29/22 revealed that Resident 1 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 15 (a score of 13 to 15 suggests the resident is cognitively intact).
Record review of the progress note dated 1/13/23 for Resident 1 revealed that Resident 1 left the facility by ambulance for transfer to the emergency room.
Record review of the Skilled Nursing Facility (SNF)/Nursing Facility (NF) to Hospital Transfer Form (a form used for communicating resident information to the hospital when a resident is transferred from the facility to the hospital) for Resident 1 documented the date of transfer as 1/13/23. The form documented that Resident 1 was a long-term resident of the facility. The reason for transfer was documented as other.
Record review of the MDS assessment dated [DATE] for Resident 1 revealed that the assessment was completed for resident discharge from the facility with a return to the facility anticipated (the facility expected the resident to return to the facility after hospitalization).
Interview on 2/21/23 at 3:06 PM with the facility Business Office Manager/Social Services Designee (BOM) confirmed that Resident 1 was sent to the emergency room and hospitalized . The BOM confirmed that the facility did not have a notice of bed hold for Resident 1. The BOM confirmed that a notice of bed hold should have been provided to Resident 1.
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
Safe Transfer
(Tag F0626)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.05(5)
Based on record review and interview the facility failed to permit 1 resident (Re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.05(5)
Based on record review and interview the facility failed to permit 1 resident (Resident 1) to return to the facility after hospitalization as required. The facility census was 21.
Findings are:
Record review of the facility policy titled Transfer and discharge date d September 2022 revealed that it is the policy of the facility to permit each resident to remain in the facility, and not initiate discharge for the resident from the facility except in limited circumstances. The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs. Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions: The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. The section titled Emergency Transfers/Discharges revealed that the resident will be permitted to return to the facility upon discharge from the acute care (hospital) setting.
Record review of the admission Record dated 2/21/23 for Resident 1 revealed that Resident 1 admitted into the facility on 9/8/22 and was discharged from the facility on 1/26/23.
Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 11/29/22 revealed that Resident 1 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 15 (a score of 13 to 15 suggests the resident is cognitively intact). The MDS revealed that Resident 1 required extensive assistance of 2 or more staff for bed mobility, transferring (how a resident moves between surfaces such as the bed and chair), and toilet use.
Record review of the undated current care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 1 revealed that staff are to transfer Resident 1 with 2-person assist and gait belt (a belt device placed around a resident's abdominal area used to aid in the safe movement of a resident with mobility problems). Resident 1 is to use a bedside commode (a portable toilet) with 2-person pivot transfer and extensive assistance for toileting.
Record review of the progress note dated 1/13/23 for Resident 1 revealed that Resident 1 had not voided (urinated) since 6:00 AM and had not voided yet this shift. Resident 1 complained of lower abdominal pain yesterday and today.
Record review of the progress note dated 1/13/23 for Resident 1 revealed that the resident's physician responded to the facility fax notifying the physician of the resident's weight gains and not voiding. The physician noted the weight gains were most likely from recurrent ascites (a condition in which fluid collects in spaces within the abdomen that can affect the lungs, kidneys, and other organs. Ascites causes abdominal pain, swelling, nausea, vomiting, and other difficulties) secondary to cirrhosis (severe scarring of the liver) which complicated Resident 1's last hospital stay. The physician noted that the resident will hopefully stop gaining and will lose weight with the recent addition of spironolactone (a medication that is primarily used to treat fluid build-up due to heart failure, liver scarring, or kidney disease).
Record review of the progress note dated 1/13/23 for Resident 1 revealed that the nurse called Resident 1's physician to provide an update on the resident's status. Resident 1 had not voided yet. The physician ordered Resident 1 transferred to the emergency room.
Record review of the progress note dated 1/13/23 for Resident 1 revealed that Resident 1 left the facility by ambulance for transfer to the emergency room.
Record review of the Skilled Nursing Facility (SNF)/Nursing Facility (NF) to Hospital Transfer Form (a form used for communicating resident information to the hospital when a resident is transferred from the facility to the hospital) for Resident 1 documented the date of transfer as 1/13/23. The form documented that Resident 1 was a long-term resident of the facility. The reason for transfer was documented as other.
Record review of the MDS assessment dated [DATE] for Resident 1 revealed that the assessment was completed for resident discharge from the facility with a return to the facility anticipated (the facility expected the resident to return to the facility after hospitalization).
Interview on 2/21/23 at 3:48 PM with the facility Business Office Manager/Social Services Designee (BOM) confirmed that Resident 1 was sent to the emergency room and hospitalized because the resident could not void. The BOM confirmed that Resident 1 was discharged by the facility and was not permitted to come back to the facility from the hospital.
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
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175NAC 12-006.09C3
Based on record review and interview the facility failed to provide a recapitulation of resident stay (a documented discharge summary that describes the r...
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Licensure Reference Number 175NAC 12-006.09C3
Based on record review and interview the facility failed to provide a recapitulation of resident stay (a documented discharge summary that describes the resident's course of treatment while residing in the facility) for 2 discharged residents (Residents 1 and 2). The facility census was 21.
Findings are:
A.
Record review of the facility policy titled Transfer and discharge date d September 2022 revealed that a member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following:
i. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
ii. A final summary of the resident's status.
Record review of the admission Record dated 2/21/23 for Resident 1 revealed that Resident 1 admitted into the facility on 9/8/22 and was discharged from the facility on 1/26/23.
Record review of the progress note dated 1/13/23 for Resident 1 revealed that the nurse called Resident 1's physician to provide an update on the resident's status. The physician ordered Resident 1 transferred to the emergency room.
Record review of the progress note dated 1/13/23 for Resident 1 revealed that Resident 1 left the facility by ambulance for transfer to the emergency room.
Record review of the Skilled Nursing Facility (SNF)/Nursing Facility (NF) to Hospital Transfer Form (a form used for communicating resident information to the hospital when a resident is transferred from the facility to the hospital) for Resident 1 documented the date of transfer as 1/13/23. The form documented that Resident 1 was a long-term resident of the facility. The reason for transfer was documented as other.
Record review of the medical record for Resident 1 revealed no documented discharge summary for Resident 1.
Interview on 2/21/23 at 4:02 PM with the Corporate Director of Nursing Services (DNS) revealed that the correct way of documenting the resident discharge summary was to complete the interdisciplinary discharge summary assessment in the resident's electronic health record. The DNS confirmed that they could not find a completed discharge summary for Resident 1. The DNS revealed that the DNS was now working on a discharge packet to include completion of the discharge summary for future discharges.
Interview on 2/21/23 at 5:20 PM with the DNS confirmed that the facility expects to follow the facility Transfer and Discharge policy for all discharges. The DNS confirmed that the facility expects that a discharge summary including a recapitulation of the resident stay is completed for each resident discharged from the facility.
B.
Record review of the admission Record dated 2/21/23 for Resident 2 revealed that the resident admitted into the facility on 4/30/21 and was discharged from the facility on 8/29/22.
Record review of the Minimum Data Set (MDS) assessment for Resident 2 dated 6/23/22 revealed that Resident 2 had a BIMS score of 15 (a score of 13 to 15 suggests the resident is cognitively intact).
Record review of the Minimum Data Set (MDS) assessment for Resident 2 dated 8/29/22 revealed that it was a discharge assessment with the resident not expected to return to the facility.
Record review of the progress note dated 8/29/22 at 8:00 PM for Resident 2 revealed that a relative of Resident 2 came into the facility and told the charge nurse that they were here to take Resident 2 home. The nurse informed them that the resident needed to sign Against Medical Advice (AMA) forms (a form documenting resident release of responsibility when a resident leaves a health care facility against the advice of their doctor). Resident 2 signed the AMA form. The nurse walked Resident 2 to the relative's car. They drove off after some time.
Record review of the Discharge Against Medical Advice (AMA) Release of Responsibility signed 8/29/22 revealed that it contained the signature of Resident 2 and the signature of the facility Business Office Manager/Social Services Designee (BOM).
Record review of the medical record for Resident 2 revealed no documented discharge summary for Resident 2.
Interview on 2/21/23 at 4:02 PM with the Corporate Director of Nursing Services (DNS) revealed that the correct way of documenting the resident discharge summary was to complete the interdisciplinary discharge summary assessment in the resident's electronic health record. The DNS confirmed that they could not find a completed discharge summary for Resident 2. The DNS revealed that the DNS was now working on a discharge packet to include completion of the discharge summary for future discharges.
Interview on 2/21/23 at 5:20 PM with the DNS confirmed that the facility expects to follow the facility Transfer and Discharge policy for all discharges. The DNS confirmed that the facility expects that a discharge summary including a recapitulation of the resident stay is completed for each resident discharged from the facility.
Jun 2022
12 deficiencies
1 IJ (1 facility-wide)
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Safe Environment
(Tag F0584)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Observation on 6/6/22 at 8:05 AM in the facility dining room revealed that the room temperature felt hot. An oscillating fan ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Observation on 6/6/22 at 8:05 AM in the facility dining room revealed that the room temperature felt hot. An oscillating fan was running by the fire extinguisher. A floor fan was running by the east dining room entry door. Facility residents were in the dining room for the breakfast meal.
Interview on 6/6/22 at 9:39 AM with the Facility Administrator (FA) confirmed that the facility air conditioning (AC) cooling unit had been broken for awhile. The FA added that the cooling unit had been broken since the beginning of spring and that the FA had told the facility owners. The FA confirmed that the facility indoor air temperature was over the upper limit of the required safe temperature range. The FA revealed that the facility has been running fans and dehumidifiers to keep residents comfortable. The FA revealed that the FA had emailed and talked to the company Director of Operations for an estimate for repairs on the whole cooling unit. The FA revealed that a heating and air company was at the facility and said that the job was too large for their crew. The FA revealed that the heating and air company had a crew at another office that would be able to help. The FA revealed that the heating and air company was to provide an estimate to the facility this week on the repairs to the cooling unit. The FA revealed that facility interventions for residents due to no air conditioning included room fans for residents. The FA revealed that the facility Atrium has its own separate cooling unit and that the Atrium room is cooler. The FA revealed the facility had placed fans in the hallways and had been monitoring air temperatures in the facility daily. The FA revealed that the facility had a lot of grievances (complaints) on the hot temperature in the facility. The FA revealed that to assist with resident comfort the facility was getting residents out of their rooms especially for meals.
Interview on 6/6/22 at 1:37 PM with the Facility Administrator (FA) revealed that the FA provided a copy of emails sent to the corporate office on 5/18/22 and 5/24/22. The FA revealed that the facility was waiting on an estimate for the repair of the cooling unit. The FA revealed that the heating and air company that was to be providing the estimate was to send the estimate directly to the FA. The FA revealed that the facility was making sure that the residents received ice water and that the facility was making sure that the water was not getting lukewarm.
Record review of the email from the FA to the corporate office dated 5/18/22 at 12:55 PM revealed that the subject was documented as: AC unit update. The FA wrote that the FA had called the heating and air company to come and look at the AC situation and give the facility an estimate.
Record review of the email from the FA to the corporate office dated 5/24/22 at 3:09 PM revealed that the subject was documented as: RE: AC unit update. The FA wrote that the Maintenance Director (MD) had called the heating and air company to give the facility an estimate for the current AC situation. The email revealed that the heating and air company visited the facility on 5/23/22 to assess the AC situation. The email revealed that the facility was currently trying to find mechanical plans for the building. The email revealed that the heating and air company was going to send the facility an estimate for the air handler that currently needs to be replaced. The email revealed that when the air handler is turned on it currently sounds like a freight train coming through the building so it needs some parts and repairs done to it.
Interview on 6/6/22 at 3:22 PM with Registered Nurse-A (RN-A) revealed that the facility is checking resident temperatures one time per shift (every 12-hour shift). RN-A confirmed that the facility nursing staff is not checking the air temperatures in resident rooms or in the facility.
Interview on 6/6/22 at 3:23 PM with the FA revealed that the FA did not find any documentation of air temperature monitoring in the facility in 2022.
Observation on 6/6/22 at 3:34 PM in the room of Resident 8 revealed that the resident sat in the chair in the corner of the resident's room. Resident 8 had a nasal cannula in place to receive oxygen at 3 liters per minute from the oxygen concentrator. Resident 8 breathed with pursed lip breathing (a breathing technique designed to make your breaths more effective by making them slower and more intentional when you are having difficulty breathing). Resident 8 revealed that the resident was having trouble breathing and had pressure on the chest and back due to there being no cool air to breathe. Resident 8 confirmed that the high temperature in the building was causing difficulty with the resident's breathing.
Interview on 6/6/22 at 3:37 PM with the Director of Nursing (DON) confirmed that the required air temperature in the facility was to be between 71-81 degrees Fahrenheit.
Interview on 6/6/22 at 4:21 PM with Resident 18 revealed that it was too hot in the facility. Resident 18 revealed that the resident can't sleep due to it being hot in the facility. Resident 18 revealed that the heat makes Resident 18 nauseous in the dining room and made it difficult for Resident 18 to eat.
Observation in 6/6/22 at 6:03 PM in the facility room being used by the survey team revealed that the DON provided the survey team with a copy of the updated plan to correct the temperature in the facility.
Record review of the facility document titled Plan to correct Temperature in the facility on 6/6/22 at 6:03 PM revealed that it included:
1.
Assessed all resident's immediately upon notification of temperature discrepancies.
2.
Obtained temperature of all rooms to identify out of temperature areas.
3.
The facility will check the temperature in all rooms mid-morning and late afternoon daily.
4.
The facility will move any residents in a room out of temperature range to a room that is within temperature range.
5.
The facility moved the resident dining from the facility dining room to the atrium for all meals.
6.
The facility will assess residents for heat concerns especially the ones with chronic obstructive pulmonary disease or any other respiratory illness every day and evening shift.
7.
The facility will get 2 portable air conditioner units by 9:00 PM on 6/6/22 for cooling and 1 more unit on 6/7/22.
8.
The facility will continue the system purchase process.
9.
Educate staff on heat exposure signs and symptoms and appropriate room temperature ranges.
10.
If portable air coolers are in an egress area, the facility will notify the Fire Marshal.
The Immediate Jeopardy was abated at this time and the scope and severity was lowered to 'F'.
Observation on 6/7/22 at 7:30 AM in the 300 hall revealed a portable cooling unit in place blowing cool air into the hallway.
Observation on 6/7/22 at 8:10 AM at the nurse's station revealed that the ADON provided education to Medication Aide-D (MA-D) and RN-A on the signs and symptoms of heat injury. The ADON reviewed the facility form for documenting twice daily monitoring of each resident to include the air temperature in the resident's room. The ADON provided education on how to use the thermometer to determine the air temperature in the resident rooms.
Observation on 6/7/22 at 10:19 AM revealed that the temperature per the portable thermometer was 78.8 degrees outside of the room of Resident 18.
Interview on 6/7/22 at 10:47 AM with the FA revealed that the FA provided a grievance log sheet for June 2022. The FA revealed that the facility didn't have a Social Services Director for a while. The FA revealed that the Business Office Manager (BOM) took over facility grievances and that the June 2022 grievance log sheet is what the BOM had.
Record review of the June 2022 Grievance/Complaint Log revealed that the facility received 3 grievances. A grievance dated 5/28/22 from Resident 18 revealed that Resident 18 was concerned with the temperature in the dining room and bedroom. A grievance dated 5/28/22 from Resident 21 revealed that Resident 21 was too uncomfortable in the dining room to eat and could not get comfortable. A grievance dated 5/28/22 from Resident 4 revealed that Resident 4 did not understand how the resident's room is so hot. The comments, actions, and follow up section on the Grievance/Complaint Log for each of the 3 grievances documented that the BOM spoke to the administrator about the grievance and that the administrator was already working on getting bids from different companies to repair the AC unit.
Observation on 6/8/22 at 7:08 AM outside of the room of Resident 2 revealed an air temperature of 72.8 degrees per portable thermometer.
Observation on 6/8/22 at 7:09 AM outside of the room of Resident 8 revealed an air temperature of 74.2 degrees per portable thermometer.
Observation on 6/8/22 at 7:08 AM outside of the room of Resident 18 revealed an air temperature of 71.9 degrees per portable thermometer.
Interview on 6/8/22 at 7:33 AM with Resident 18 revealed that the facility temperature was much more comfortable and that you don't have to pull at your shirt because it is so hot.
Observation on 6/8/22 at 7:45 AM revealed that Resident 8 sat in the chair in the corner of the room with legs crossed on the chair. A blanket was in place covering the resident's legs and lap. Resident breathed with no pursed lip breathing or other signs of respiratory distress. Resident 8 revealed that the resident was enjoying the cooler air.
Observation on 6/9/22 at 8:27 AM outside of room [ROOM NUMBER] revealed an air temperature of 75.9 degrees.
Observation on 6/9/22 at 8:27 AM outside of room [ROOM NUMBER] revealed that the FA and ADON exited the room. At 8:29 AM the air temperature in the room was 79.3 degrees.
Interview on 6/9/22 at 8:30 AM with Licensed Practical Nurse-C (LPN-C) revealed that Resident 8 was moved to a different room during the night. LPN-C confirmed that Resident 8's room was too hot, so the resident was moved to another room temporarily.
Observation on 6/9/22 at 8:31 AM in the temporary room of Resident 8 revealed that the FA and ADON set up an oscillating stand fan in the room.
Interview on 6/9/22 at 8:32 AM with Resident 8 revealed that the resident got hot in the middle of the night and had trouble breathing. Resident 8 revealed that the staff moved the resident to this different room. The temperature in the room with Resident 8 revealed a temperature of 79.1 degrees per portable thermometer.
C. Record review of the facility admission Agreement dated 10/2019 revealed that the resident has a right to a safe, clean, comfortable homelike environment. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
Observation on 6/6/22 at 9:20 AM in the room of Resident 8 revealed that the bathroom exhaust fan vent cover was covered with fuzzy gray/white debris.
Observation on 6/6/22 at 9:26 AM in the room of Resident 126 revealed that the bathroom exhaust fan vent cover was covered with fuzzy grayish debris and a curly black hair hung from the vent cover.
Observation on 6/6/22 at 9:27 AM in the room of Resident 4 revealed that the bathroom exhaust fan vent cover was covered with gray debris.
Observation on 6/6/22 at 9:28 AM in the room of Resident 18 revealed that the toilet base was soiled with brownish black debris between the toilet base and the floor.
Observation on 6/6/22 at 9:30 AM in the room of Resident 16 revealed that the bathroom exhaust fan vent cover was covered with fuzzy white/gray debris. Spider webs were present running from the fire sprinkler pipes near the bathroom ceiling to the light fixture above the sink in the bathroom. The toilet bowl contained dried brown/black stool splotches inside of the bowl and on the stool riser. The base of the toilet was soiled with brownish black debris between the toilet base and the floor.
Observation on 6/6/22 at 9:34 AM in the room of Resident 6 revealed that the bathroom exhaust fan vent cover was covered with fuzzy gray debris and had spider webs hanging from it.
Observation on 6/9/22 at 1:02 PM in the room of Resident 8 with the Facility Administrator (FA) confirmed that the bathroom exhaust fan vent cover was covered with fuzzy gray/white debris.
Observation on 6/9/22 at 1:07 PM in the room of Resident 126 with the FA confirmed that the bathroom exhaust fan vent cover was covered with fuzzy grayish debris and a hair hung from the vent cover.
Observation on 6/9/22 at 12:52 PM outside the room of Resident 4 with the FA revealed that Resident 4 did not provide permission to enter the resident's room to confirm that the bathroom exhaust fan vent cover was covered with gray debris.
Observation on 6/9/22 at 12:55 PM in the room of Resident 18 with the FA confirmed that the toilet base was soiled with brownish black debris between the toilet base and the floor.
Observation on 6/9/22 at 12:59 PM in the room of Resident 16 with the FA confirmed that the bathroom exhaust fan vent cover was covered with fuzzy white/gray debris. The FA confirmed that spider webs were present running from the fire sprinkler pipes near the bathroom ceiling to the light fixture above the sink in the bathroom.
Observation on 6/9/22 at 12:57 PM in the room of Resident 6 with the FA confirmed that the bathroom exhaust fan vent cover was covered with fuzzy gray debris and had spider webs hanging from it.
D. Record review of the facility admission Agreement dated 10/2019 revealed that the resident has a right to a safe, clean, comfortable homelike environment. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
Observation on 6/6/22 at 7:17 AM at the door to the room of Resident 5 revealed that the carpet over the threshold was loose. The surveyor caught their foot on the carpet.
Observation on 6/6/22 at 9:14 AM in the room of Resident 2 revealed that the toilet handle was broken and the toilet would not flush.
Interview on 6/6/22 at 9:18 AM with Resident 2 revealed that the toilet in the resident's room had been broken for at least a week.
Observation on 6/6/22 at 9:21 AM in the room of Resident 3 revealed that the bathroom sink did not drain.
Observation on 6/6/22 at 9:24 AM in the room of Resident 15 revealed that the light above the sink in the resident's bathroom flickered constantly and was bright. The bathroom sink did not drain. The lower wall of the bathroom contained gouges. Drywall was torn away by the closet in the resident's room next to the hand sanitizer dispenser.
Observation on 6/6/22 at 9:34 AM in the room of Resident 6 revealed that the vinyl floor outside of the bathroom was wet and slick. Water leaked from around the base of the toilet and there were standing water puddles on the bathroom floor. The bathroom floor contained orange-yellow stains surrounding the standing water puddle edges.
Observation on 6/9/22 at 1:05 PM with the Facility Administrator (FA) in the room of Resident 2 revealed that the toilet handle had been repaired.
Interview on 6/9/22 with Resident 2 revealed that the Maintenance Director (MD) had repaired the toilet handle so that the toilet could be flushed.
Observation on 6/9/22 at 12:53 PM in the room of Resident 3 with the FA confirmed that the bathroom sink did not drain.
Observation on 6/9/22 at 12:49 PM in the room of Resident 15 with the FA confirmed that the light above the sink in the resident's bathroom flickered. The FA confirmed that the bathroom sink did not drain. The FA confirmed that the lower wall of the bathroom contained gouges. The FA confirmed that drywall was torn away by the closet in the resident's room next to the hand sanitizer dispenser.
Observation on 6/9/22 at 12:57 PM in the room of Resident 6 with the FA confirmed that water leaked from around the base of the toilet. The FA confirmed that the bathroom floor contained orange-yellow stains from standing water.
LICENSURE REFERENCE NUMBER 175 NAC 12-006.18
Licensure Reference Number 175NAC 12-006.18A
Licensure Reference Number 175NAC 12-006.18B
Based on observation, interview, and record review; the facility failed to ensure that the facility air temperatures were maintained within the regulatory temperature range of 71 F (Fahrenheit) to 81 F and comfortable levels for the residents which had the potential to affect all the facility residents. The facility failed to ensure resident areas were clean for 6 residents (Residents 8, 126, 4, 18, 16, and 6), and failed to ensure repair of sinks, toilets, or carpet for 5 residents (Residents 5, 2, 3, 15, and 6). The facility identified a census of 23 at the time of survey.
Findings are:
A. Observation of the facility on 6/06/22 at 6:55 AM revealed fans were running in the dining room and in the hallways. The air felt hot in the facility and the dining room. There was one yellow carpet drying fan in the hall on 400.
Observation of the facility dining room on 6/6/22 at 7:14 AM revealed the dining room temperature was 86.7 F.
Observation of the facility dining room on 6/6/22 at 7:17 AM revealed the thermostat on the wall in the dining room read 85 F degrees. The temperature on the 400 hall was 86.2 F. There was no ice in any of the water cups on the unit for Resident 14, Resident 3, Resident 7, Resident 5, Resident 15, and Resident 4.
Interview with RN-A (Registered Nurse) on 6/6/22 at 8:10 AM revealed the facility AC (air conditioning) was not working. RN-A revealed they did not know how long the AC had not been working. RN-A revealed the staff passed ice to the residents during the night and between 2:30 PM and 3:30 PM.
Observation of the facility dining room on 6/6/22 at 8:14 AM observed 15 residents were eating breakfast in the dining room. Observation of the temperature in the dining room revealed the temperature in the middle of the dining room was 86 F. 8 residents were seated in that area, Residents 12, 10, 19, 3, 21, 18, 7, and 11. The temperature by the north entrance to the dining room in proximity to the steam table was 88.5 F. Seven residents were seated in that area, Residents 14, 20, 22, 1, 13, 16, and 126.
Observation of the facility dining room on 6/6/22 at 8:17 AM revealed Resident 3 was sitting in the middle of the dining room. Interview with Resident 3 at this time revealed it was too warm in the facility and the dining room. Resident 3 revealed the temperature in the facility and the dining room got worse as the day went on. Resident 3 revealed they noticed that sometimes the other residents (Resident 3 pointed to the other residents seated in the dining room) did not eat because it got so hot in the dining room. Residents 12, 18, 10, 7, 11, 3, 14, 9, 22, 1, 13, 126, 19, 21, 20, and 16 were observed sitting in the dining room.
Interview with Resident 22 on 6/06/22 at 8:23 AM revealed the resident reported it's so hot in this place, the air conditioner hasn't worked since I've been here. It's terribly uncomfortable.
Interview with Resident 7 on 6/6/2022 at 8:39 AM revealed sometimes it got hot in the dining room. Resident 7 was observed sitting in their wheelchair in their room at this time. No ice was observed in their water bottle.
Observation of Resident 7's room on 6/06/22 at 8:44 AM revealed the window was open in their room. The room temperature was 80.6 F. There was no ice in the water cup in Resident 7's room.
Interview with Resident 10 on 6/6/2022 at 8:46 AM revealed it was too warm in the dining room at breakfast. Resident 10 revealed it got even hotter at times in the dining room than it was this morning. Resident 10 revealed it had been hot in the facility for a long time. Resident 10 revealed they did not get offered extra fluids. Resident 10 was observed resting in bed in their room at this time. No ice was observed in the resident's water bottle.
Observation of Resident 5 on 6/06/22 at 9:10 AM revealed Resident 5 was observed resting in bed in their room. Resident 5 was uncovered and was wearing a brief only. There was a fan running at the foot of the bed. There was no ice observed in their water bottle. Resident 5's room temperature was 84 F. Interview with Resident 5 at this time revealed it was too hot in the facility and they were uncomfortable. Resident 5 revealed yesterday and on Memorial Day it was so hot in the facility it was miserable in here. Resident 5 revealed it was ridiculous how hot it was in the facility and Resident 5 revealed they have been sweating. Resident 5 revealed they must have help to get out of bed. Resident 5 revealed the AC had never been started yet this spring. When inquired how long the AC had not been working, Resident 5 revealed the AC never had been working.
Interview with Resident 3 on 6/06/22 at 9:21 AM revealed it was excessively warm in their room.
Observation of Resident 4 on 6/06/22 at 9:27 AM revealed the thermostat on the wall by the door in their room read 82 F. The temperature in the middle of the room was 86 F. Resident 4 was resting in bed and had oxygen on at 2 ½ liters. There was a small fan running that was sitting on the stand next to Resident 4's bed. There was no ice in their water jug. Interview with Resident 4 at this time revealed it was too warm in their room. Resident 4 revealed they were hot and sweaty all the time and it was worse for them because they were diabetic. Resident 4 revealed the facility was not offering extra fluids.
Interview with the FA (Facility Administrator) on 6/06/22 at 9:39 AM confirmed the facility air conditioner was not working and it had not worked since the spring. The FA revealed they were running fans and de-humidifiers in the facility, and they had e-mailed and talked to the facility owners and director of operations. The FA revealed no repairs had been made to the AC.
Interview with Resident 8 on 6/06/22 at 11:20 AM revealed it had been hot in their room the past two months. Resident 8 revealed there was no AC (air conditioner) in their room. Resident 8 revealed they kept their door closed and used a fan. Resident 8 revealed it was difficult to breathe due to the heat. Resident 8 was observed with an oxygen concentrator and a small fan in their room.
Observation of the facility dining room on 6/6/2022 at 11:42 AM revealed the dining room temperature was 86 F on the thermostat thermometer on the wall. Residents 12, 21, 18, 10, 19, 7, 11, 3, 6, 14, 20, 9, 22, 1, 13, 126, and 16 were observed sitting in the dining room.
Observation of the facility on 6/6/22 at 11:45 AM revealed Residents 8, 5, 15, and 4 were observed eating their meals in their rooms. The room temperatures were warm.
Interview with the FA on 6/6/22 at 1:37 PM when asked what the faciliyt was doing to help with resident comfort since the AC was not working revealed the staff were supposed to be putting ice in the resident cups to keep the water from getting lukewarm.
Observation of Resident 4's room on 6/6/22 at 2:28 PM revealed the room temperature was 86 F in the middle of the room. The thermostat thermometer on the wall by the door read 84.
Observation of the 400 hall on 6/6/22 at 2:32 PM revealed the temperature was 84.9 F. 1 fan was blowing in the hall along the floor. It was a carpet drying fan. Residents 21, 14, 3, 7, 5, 15, 10, and 4 had ice in their water cups.
Observation of the facility on 6/6/22 at 3:35 PM revealed the ice was melted in the water cups for Residents 21, 14, 3, 7, 5, 15, and 10, and there was heavy condensation on the outside of the cups.
Observation of Resident 4's room on 6/6/22 at 3:25 PM revealed the ice in Resident 4's cup was melted and there was condensation on the outside of the cup. It was warm in Resident 4's room. When inquired how the heat and humidity was making Resident 4 feel, Resident 4 reported that it was hard to breathe due to the excess heat and humidity in the facility. Resident 4 revealed they just couldn't get their breath and their chest felt real heavy all the time. Resident 4 revealed the staff told Resident 4 the resident had COPD. Resident 4 stated, I have never had COPD. I didn't have any trouble breathing until I came to live in this place. Resident 4 reported when they came to the facility in March it was hot and humid in the facility, and the nurses had to call the MD and get an order for oxygen for Resident 4. Resident 4 revealed they never had to use oxygen before they came to the facility. Resident 4 revealed if they didn't have the oxygen, they would not be able to breathe at all because it was so hot and humid in the facility. Resident 4 was listless and had to stop and take a breath while conversing as they would get short of breath while talking.
Interview with Resident 15 on 6/06/22 at 4:18 PM revealed it was too warm in the room. Observation of the thermostat/thermometer on the wall revealed the room temperature was 86 F. The thermostat was set at 56.
Interview with Resident 18 on 6/06/22 at 4:21 PM revealed it was too hot in the facility. Resident 18 revealed the heat was making it difficult to sleep at night and the heat was making Resident 18 nauseous and they did not have an appetite and found it difficult to eat.
Interview with Resident 5 on 6/6/22 at 4:27 PM revealed the facility ran out of fans so they had to get someone to go downtown and buy them one with their own money as the AC was not working. The water in Resident 5's water bottle no longer had ice in it.
Interview with the DON (Director of Nursing) on 6/6/22 at 4:58 PM confirmed the temperature in the dining room was stifling. The DON revealed they moved the dining area to the atrium.
On 6/6/2022 at 6:03 PM The FA and DON presented their written plan to get the air temperatures down which included 2 air cooling units to be delivered tonight and more to follow and they will assess all the residents.
Observation of Resident 4's room on 6/07/22 at 10:00 AM revealed Resident 4 was sitting on the edge of their bed in their room. A small fan on the stand next to Resident 4's bed was running. The room curtain was open, and the sun was shining in Resident 4's room. It was hot in Resident 4's room. There was a jug of water and a jug of yellow drink that looked like lemonade or Mountain Dew soda both half full with no ice in them. The temperature in the middle of the room was 89.6 F. Interview with Resident 4 at this time revealed they liked it warm in their room but that it was a little too warm. Resident 4 revealed no one came and talked to them about getting a different fan. Resident 4 thought a bigger fan would help. Resident 4 revealed someone came in an turned the wall AC unit on, but it didn't work and there was no air coming out of it.
Interview with the FA on 6/07/22 at 10:15 AM revealed the temperature in Resident 4's room was 84 F this morning and Resident 4 told them they liked it warm in their room. When the FA was notified it was 89.6 F in Resident 4's room the FA revealed they would offer Resident 4 a larger fan.
Observation of Resident 5's room on 6/07/22 at 10:28 AM revealed they were resting in bed in their room wearing a brief only. Interview with Resident 5 at this time revealed it was still warm in their room, but the fan was helping. Observed a pedestal fan that was blowing on Resident 5. There was no ice in Resident 5's water bottle.
Interview with the DON on 6/07/22 at 10:35 AM revealed Resident 4 was comfortable with 84 degrees. When notified the temperature in Resident 4's room was now 89.6 F, the DON revealed they would offer Resident 4 a bigger fan or offer to move Resident 4 to a cooler room due to the sun shining on Resident 4's window causing the temperature in Resident 4's room to go up. Observation of the FA at this time revealed they took a pedestal fan into Resident 4's room.
Interview with the DON 6/07/22 at 1:15 PM revealed they were still working with Resident 4 on a plan for their room temperature.
Interview with the DON on 6/07/22 at 3:40 PM revealed Resident 4's room temperature was 84 now and it was 86 this AM when the DON checked it. The DON revealed they tried putting a dehumidifier in Resident 4's room and it would not stay on. The DON revealed they would get a portable air conditioner at the store, but Resident 4 reported to the DON they really did not want their window boarded up which is what they would have to do to pipe the exhaust out from a portable AC unit. The DON revealed they could get a different type of unit online, but it would not be here until Friday. The DON revealed Resident 4 preferred the unit they would have to order, however, the DON revealed they were still not getting the temperature in Resident 4's room down below 81 and the DON revealed Resident 4 told them they were okay with that.
Interview with Resident 4 on 6/07/22 at 3:50 PM revealed they did not want their window altered. Resident 4 revealed they did not want to make that much work for the facility and if it were them, they would not board the window up. Resident 4 revealed they could take quite a bit of heat. When it was discussed with Resident 4 about the temperature being over 89 degrees this AM in their room, Resident 4 revealed the sun did shine on their room due to the location of their room. Resident 4 revealed that now they had a pedestal fan, and the air circulating had helped a lot and that was the biggest thing for them. Resident 4 did agree to have staff turn the fan up and close their window curtain to keep the sun out and Resident 4 revealed they would report any concerns with breathing or sweating to the facility immediately.
Interview with the DON on 6/07/22 at 4:03 PM revealed they would order the cold ice evaporator and continue to monitor Resident 4 and increase the air in the room, close the curtain, and offer fresh icy drinks. The DON revealed they would also look at tinting the windows, getting Resident 4 a neck fan, and offering cold packs.
Observation of Resident 4 on 6/08/22 at 7:30 AM revealed Resident 4 was observed sitting up on the edge of their bed in their room. The room temperature was 78 F. Both fans were running. Interview with Resident 4 at this time revealed they were comfortable at this time, and they had slept better last night. Resident 4 also revealed they were breathing better.
Observation of Resident 4's room on 6/08/22 at 2:25 PM revealed the air temperature in their room was 78 F from thermometer on the wall. Interview with Resident 4 at this time revealed they were comfortable with the room temperature.
Observation of Resident 4's room on 6/09/22 at 8:32 AM revealed the room temperature was 80 F from wall thermometer. 2 fans were running, and the window curtains were closed. Resident 4 had a water jug in reach and yellow colored drink in another mug. Interview with Resident 4 at this time revealed they were comfortable. Resident 4 had no signs of respiratory distress. Oxygen was on at 2 ½ LPM.
Review of the Accuweather air temperatures for the community for March, April, May, and June 2022 revealed the temperatures over 70 F were listed for the following dates:
March 1- 75°, March 2-76°, March 20-78°, April 9-75°, April 12-89°, April 20-70°, April 21-72°, April 22-
92°, April 23-74°, April 26-76°, April 27-77°, April 28-82°, May 7-79°, May 8-79°, May 9-79°, May 10-78°, May 11-90°, May 12-89°, May 13-79°, May 14-74°, [TRUNCATED]
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an Advance Directive (Advance directives explain how you wan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an Advance Directive (Advance directives explain how you want medical decisions to be made when you're too ill to speak for yourself.) was documented consistent with the resident's wishes for 1 of 1 sampled residents, Resident 15. The facility identified a census of 23 at the time of survey.
Findings are:
Review of Resident 15's admission Record dated [DATE] revealed an admission date of [DATE].
Review of Resident 15's Resuscitation Designation Order dated [DATE] revealed it was marked I DO NOT desire CPR (Cardiopulmonary Resuscitation- a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest). The Resuscitation Designation Order was signed by Resident 15, the SSD (Social Services Designee), and Resident 15's physician.
Interview with MA-D (Medication Aide) on [DATE] at 10:23 AM revealed they got the information they needed to care for the residents from the NA Pocket Care Plan (a worksheet the direct care staff carried that contained the information to care for each resident).
Review of the untitled undated Nurse Aide Pocket Care Plan worksheet revealed Resident 15's code status was listed as full code (perform CPR).
Review of Resident 15's Care Plan dated [DATE] revealed the following: ADVANCED DIRECTIVE: ***CPR*** Resident 15 and their family have indicated that Resident 15 desires to have CPR initiated should their respirations or heartbeat cease.
Date Initiated: [DATE]
o a) CPR will be initiated should Resident 15's respirations and heartbeat cease.
Date Initiated: [DATE]
o Communicate to all staff Resident 15's choice to have CPR initiated should Resident 15's respirations or heartbeat cease.
Date Initiated: [DATE]
o Initiate CPR if you find Resident 15 pulseless or breathless and continue CPR until Paramedics arrive to take over.
Date Initiated: [DATE]
Review of Resident 15's Order Summary Report dated [DATE], revealed the order of Full Code with an order date of [DATE] was documented.
Interview with the DON (Director of Nursing) on [DATE] at 11:31 AM confirmed Resident 15's Advance Directive read Resident 15 wanted DNR (Do Not Resuscitate) and Resident 15's care plan did not reflect that. The DON revealed the order had been documented on Resident 15's orders as CPR but the staff were expected to follow Resident 15's Advance Directive which was DNR.
Interview with the ADON (Assistant Director of Nursing) on [DATE] at 1:18 PM confirmed Resident 15 wanted a DNR. The ADON confirmed Resident 15's EHR dashboard, Order Summary Report, NA Pocket Care Plan, and Care Plan read Resident 15 wanted CPR however, this information would need to be corrected as Resident 15 was a DNR.
Review of the facility policy Care Plan Process reviewed 1/2020 revealed the following: The plan of care must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and social well-being. Documentation includes but is not limited to-added/changes in goals and interventions/approaches initiated and dated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175NAC 12-006.02(8)
Based on record review and interview, the facility failed to complete and submit the investigation for injury of unknown origin for 2 residents (Resident...
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Licensure Reference Number 175NAC 12-006.02(8)
Based on record review and interview, the facility failed to complete and submit the investigation for injury of unknown origin for 2 residents (Residents 123 and 125). The facility census was 23.
Findings are:
A.
The facility policy titled Abuse, Neglect, Misappropriation and Exploitation dated 10/19 revealed that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including physical injury of a resident of unknown source (origin). When a suspicion of abuse, neglect or exploitation occur, an investigation is immediately warranted. Investigation of injuries of unknown origin must be immediately investigated to rule out abuse. Report the results of all investigation to the administrator or his or her designated representative and to the other official in accordance with state law, including to the State Survey Agency within 5 working days of the incident.
Record review of the admission Record dated 6/8/22 for Resident 123 revealed that Resident 123 admitted into the facility on 9/8/21.
Record review of the Minimum Data Set (MDS) Resident Assessment (a mandatory comprehensive assessment tool used for care planning) for Resident 123 dated 9/15/21 revealed that Resident 123 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 00. A score of 0 to 7 suggests severe cognitive impairment.
Record review of the progress note dated 10/27/22 at 8:48 AM for Resident 123 revealed that Resident 123 was complaining of right hip pain.
Record review of the progress note dated 10/27/22 at 10:45 AM for Resident 123 revealed that the nurse assessed Resident 123 due to the complaint of right hip pain. The nurse noted minimal outward rotation of the right foot. The resident had facial grimacing with movement of the right leg. The resident's physician was notified and an order was received to transfer Resident 123 to the emergency room for evaluation, treatment, and X-Ray of the right hip.
Record review of the Adult Protective Services Intake Worksheet dated 10/27/21 at 1:51 PM revealed that the facility reported that Resident 123 was sent to the hospital and was found to have a right hip fracture. The facility started their investigation this afternoon. It is not known what caused the hip fracture.
Interview on 6/9/22 at 9:22 AM with the DON (Director of Nursing) revealed that the facility was working to find the facility investigation for the injury of unknown origin for Resident 123 that was reported on 10/27/21.
Interview on 6/9/22 at 11:18 AM with the facility DON confirmed that the facility did not have a completed investigation report for the injury of unknown origin for Resident 123. The DON confirmed that an investigation should have been completed and submitted to the state agency.
B.
Record review of the admission Record dated 6/8/22 for Resident 125 revealed that Resident 125 admitted into the facility on 2/16/18.
Record review of the MDS for Resident 125 dated 3/10/22 revealed that Resident 125 had a BIMS score of 99. A score of 99 means that the resident had severe cognitive impairment and was unable to complete the assessment.
Record review of the progress note dated 2/1/22 at 6:22 PM for Resident 125 revealed that Resident 125 complained of left hip pain. Assessment revealed increased pain that radiated down the left leg with movement of the left leg. Some swelling was noted in the area of increased pain.
Record review of the progress note dated 2/1/22 at 11:30 PM for Resident 125 revealed that Resident 125 had imaging done in the emergency room and no fractures or dislocations were present.
Record review of the progress note dated 2/2/22 at 1:41 PM for Resident 125 revealed that Resident 125 continued to have pain in the left leg, left thigh area.
Record review of the progress note dated 2/8/22 at 5:14 AM for Resident 125 revealed that Resident 125 continued to be uncomfortable with the left lower extremity.
Record review of the progress note dated 2/10/22 at 2:17 AM for Resident 125 revealed that Resident 125 continued to experience pain to the left hip. Resident 125 was crying out during transfers and when lying in bed.
Record review of the progress note dated 2/14/22 at 7:13 AM for Resident 125 revealed that Resident 125's left leg was very swollen, especially from the knee to the ankle. The nurse also noted bruising of the lower leg. Lightly touching anyplace on the left leg causes a cry from the resident.
Record review of the progress note dated 2/14/22 at 7:13 AM for Resident 125 revealed that Resident 125 was sent to the emergency room by ambulance at 8:18 AM.
Record review of the progress note dated 2/14/22 at 1:44 PM for Resident 125 revealed that a family member reported that Resident 125's left leg was broken.
Record review of the Adult Protective Services Intake Worksheet dated 2/14/22 at 6:14 PM revealed that the facility reported that Resident 125 was sent to the hospital and was found to have a tibia (the larger of the two bones of the lower leg) fracture. The facility reporter revealed that they were reporting the information as it is an injury of unknown origin.
Interview on 6/9/22 at 9:22 AM with the DON revealed that the facility was working to find the facility investigation for injury of unknown origin for Resident 125 that was reported on 2/14/22.
Interview on 6/9/22 at 11:18 AM with the facility DON confirmed that the facility did not have a completed investigation report for the injury of unknown origin for Resident 125. The DON confirmed that an investigation should have been completed and submitted to the state agency.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure that the required Preadmission Screening and Resident Review (PASARR) Level 2 screen (a screening program mandated by the federal Ce...
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Based on record review and interview, the facility failed to ensure that the required Preadmission Screening and Resident Review (PASARR) Level 2 screen (a screening program mandated by the federal Centers for Medicare and Medicaid Services (CMS) to ensure that nursing home applicants and residents with mental illness and intellectual/developmental disabilities are appropriately placed and receive necessary services to meet their needs) was conducted for 1 resident (Resident 8). This had the potential to prevent the resident from receiving specialized services. The facility census was 23.
Findings are:
Record review of the facility policy titled Resident Assessment-Coordination with the PASARR Program dated 2021 revealed that the facility coordinates assessments with the PASARR program to ensure that individuals with a mental disorder (illness), intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. All applicants to the facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the state's Medicaid rules for screening. PASARR Level 1 is pre-screening that is completed prior to admission. A positive PASSAR Level 1 screen necessitates a PASARR Level 2 evaluation prior to admission. A PASSAR Level 2 is a comprehensive evaluation by the appropriate state-designated authority that determines whether the individual has mental disorder, intellectual disability, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. A record of the pre-screening shall be maintained in the resident's medical record.
Record review of the admission Record dated 6/8/22 for Resident 8 revealed that Resident 8 admitted into the facility on 4/30/21. Diagnoses present on admission included Major Depressive Disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts), Delusional Disorders [a type of psychotic disorder (a mental disorder) causing a belief or altered reality that is persistently held despite evidence or agreement to the contrary], and Anxiety (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).
Record review of the PASARR Level 1 dated 4/26/21 revealed that a staff member from the hospital where Resident 8 was a patient performed the PASARR Level 1 assessment screening. The PASARR Level 1 screen incorrectly documented that Resident 8 had no mental health diagnosis known or suspected. The screen documented that Resident 8 had a history of depression, anxiety, and paranoia with paranoid delusions. The screen documented that Resident 8 was transferred to a psychiatric facility on 1/28/20. The screen documented yes that Resident 8 had received recent treatment for a mental illness with an indication that the resident experienced psychiatric treatment more intensive than outpatient care. The screen incorrectly documented that a PASARR Level 2 evaluation was not required at this time due to no diagnosis of serious mental illness or intellectual disability or related condition.
Record review of the PASARR Level 1 dated 4/27/21 revealed that the same staff member from the hospital where Resident 8 was a patient performed the PASARR Level 1 assessment screening. The PASARR Level 1 screen documented that there were no signs of a serious mental illness, intellectual, disability, or a related condition found during the Level 1 screen. No further clinical review of onsite evaluation is needed. The screen incorrectly documented that Resident 8 had no mental health diagnosis known or suspected. The screen incorrectly documented that a PASARR Level 2 evaluation was not required at this time due to no diagnosis of serious mental illness or intellectual disability or related condition.
Record review of the care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 8 dated 6/6/22 revealed that Resident 8 has a history of behavior problems related to major depressive disorder, anxiety disorder, and delusional disorder and takes medications to help manage these.
Record review of the progress note dated 5/4/22 at 9:20 AM for Resident 8 revealed that Resident 8 was crying and screaming at the nurse and the charge nurse. Resident 8 reported that staff are out to make the resident crazy.
Record review of the progress note dated 5/5/22 at 1:47 PM for Resident 8 revealed that Resident 8 told the nurse that the resident wanted protection this weekend because Resident 8 did not trust the Registered Nurse that would be working. Resident 8 stated that the Registered Nurse would give the resident too much insulin and would call the doctor without telling the resident.
Record review of the progress note dated 5/5/22 at 7:25 PM revealed that Resident 8 came down the hall and was upset. Resident 8 told the staff that you need to listen up, I'm only saying this once! Resident 8 told staff that all you board members need to stop worrying about my blood sugars. You board members smoke and drink more than my blood sugars are. I don't want you talking about my blood sugars in the board room then coming and telling doctors to change my insulin.
Record review of the progress note dated 6/7/22 at 2:30 PM for Resident 8 revealed that the physician of Resident 8 saw the resident in the facility for a required physician visit. The physician discussed Resident 8's outbursts of anger and paranoia. The physician did not want to change any medication.
Interview on 6/9/22 at 2:44 PM with the Assistant Director of Nursing (ADON) confirmed that Resident 8 had diagnoses of major depression, delusions, and anxiety upon admission to the facility. The ADON confirmed that these diagnoses would be considered serious mental illness.
Interview on 6/9/22 at 2:45 PM with the Director of Nursing (DON) confirmed that the facility should have done their own PASSAR Level 1 screening and should have requested a Level 2 PASSAR screen for Resident 8. The DON revealed that PASSAR Level 1 screening performed by the hospital is not always accurate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0923
(Tag F0923)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175NAC 12-007.04D
Based on observation and record review, the facility failed to ensure that bathroom exhaust fans were operational for 2 residents (Residents 2 and 8). The ...
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Licensure Reference Number 175NAC 12-007.04D
Based on observation and record review, the facility failed to ensure that bathroom exhaust fans were operational for 2 residents (Residents 2 and 8). The facility census was 23.
Findings are:
A.
Record review of the facility admission Agreement dated 10/2019 revealed that the resident has a right to a safe, clean, comfortable homelike environment. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
Observation on 6/6/22 at 9:14 AM in the room of Resident 2 revealed that the bathroom exhaust fan did not work. The bathroom exhaust fan would not suck up a 1-ply square of toilet paper.
Observation on 6/9/22 at 1:05 PM with the Facility Administrator (FA) in the room of Resident 2 confirmed that the bathroom exhaust fan did not work.
Interview on 6/6/22 at 1:05 PM with the FA confirmed that the bathroom exhaust fan was to be maintained and kept operational.
B.
Observation on 6/6/22 at 9:20 AM in the room of Resident 8 revealed that the bathroom exhaust fan did not work. The bathroom exhaust fan would not suck up a 1-ply square of toilet paper.
Observation on 6/9/22 at 1:02 PM in the room of Resident 8 with the Facility Administrator (FA) confirmed that the bathroom exhaust fan did not work.
Interview on 6/6/22 at 1:05 PM with the FA confirmed that the bathroom exhaust fan was to be maintained and kept operational.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify 2 non-sampled residents when they were within the resource l...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify 2 non-sampled residents when they were within the resource limit (Residents 14 and 16); and the facility failed to dispense resident trust account funds to 14 non-sampled residents discharged from the facility (Residents 124, 23, 27, 28, 24, 25, 29, 26, 30, 125, 31, 32, 33, and 34). This affected 16 of 22 residents with funds in the Resident Trust Account. The facility identified a census of 23 at the time of survey.
Findings are:
A. Review of Resident 14's admission Record dated June 8, 2022, revealed an admission date of 11/3/2016. Resident 14's Primary Payer was Medicaid (Medicaid is a government-funded health care coverage program for people with limited income or disabilities). Resident 14 was widowed.
Review of the facility Trust-Current Account Balance report as of 6/7/2022 revealed Resident 14 had a current balance of 5618.07.
B. Review of Resident 16's admission Record dated June 8, 2022, revealed Resident 16 had an admission date of 1/3/2014. Resident 16's Primary Payer was Medicaid. Resident 16 was married.
Review of the facility Trust-Current Account Balance report as of 6/7/2022 revealed Resident 16 had an account balance of 35,765.73.
Review of the Department of Health and Human Services State of Nebraska website revealed the resource limits for Medicaid were:
$4,000 for one-member family
$6,000 for two-member family
https://dhhs.ne.gov/Pages/Medicaid-Eligibility.aspx
Interview with the BOM (Business Office Manager) on 6/07/22 at 1:46 PM confirmed the Resident Trust Account balances for Resident 14 and Resident 16 were over the Medicaid resource limit.
Interview with the BOM on 6/07/22 at 5:00 PM revealed they had not notified the PR (Personal Representative) or Resident 16 they were over their resource limit or when they were within 200.00 of being within the resource limit.
Interview with the BOM on 6/08/22 at 8:19 AM revealed they had not notified Resident 14's POA (Power of Attorney) that Resident 14 was over the 4000.00 limit for Medicaid. The BOM revealed Resident 14's Share of Cost was 800.00 a month which the BOM hadn't taken out of the account yet; however, the BOM revealed the Share of Cost amount would not be enough to bring the account balance down below the limit.
C. Review of the facility Trust-Current Account Balance report as of 6/7/32022 revealed the following:
Resident 124 had an account balance of 51.43.
Resident 23 had an account balance of 79.84.
Resident 27 had an account balance of 231.17.
Resident 28 had an account balance of 1642.77.
Resident 24 had an account balance of 25.05.
Resident 25 had an account balance of 130.79.
Resident 29 had an account balance of 59.58.
Resident 26 had an account balance of 157.18.
Resident 30 had an account balance of 30.03.
Resident 125 had an account balance of 154.60.
Resident 31 had an account balance of 13.08.
Resident 32 had an account balance of 25.12.
Resident 33 had an account balance of 3481.69.
Resident 34 had an account balance of 25.92.
Review of the facility Resident Listing Report dated June 6, 2022, revealed Residents 124, 23, 27, 28, 24, 25, 29, 26, 30, 125, 31, 32, 33, and 34 no longer resided in the facility.
Review of the admission Records for the residents who were discharged revealed the following:
Resident 124 admission date 5/4/2021 and discharge date [DATE].
Resident 23 admission date 8/11/2015 and discharge date [DATE].
Resident 24 admission date 7/9/2019 and discharge date [DATE].
Resident 25 admission date 3/2/2016 and discharge date [DATE].
Resident 26 admission date 3/18/2019 and discharge date [DATE].
Resident 125 admission date 2/16/2018 and discharge date [DATE].
Resident 27 admission Date 4/26/2019 and discharge date [DATE].
Resident 28 admission Date 2/5/2018 and discharge date [DATE].
Resident 29 admission Date 11/1/2018 and discharge date [DATE].
Resident 30 admission Date 9/27/2019 and discharge date [DATE].
Resident 31 admission Date 2/5/2014 and discharge date [DATE].
Resident 32 admission Date 8/24/2016 and discharge date [DATE].
Resident 33 admission Date 11/8/2016 and discharge date [DATE].
Resident 34 admission Date 10/8/2009 and discharge date [DATE].
Interview with the BOM on 6/08/22 at 10:54 AM confirmed Residents 124, 23, 27, 28, 24, 25, 29, 26, 30, 125, 31, 32, 33, and 34 no longer resided in the facility and had funds in the Resident Trust Account. The BOM confirmed the funds were not paid out to the residents or resident representatives when Residents 124, 23, 27, 28, 24, 25, 29, 26, 30, 125, 31, 32, 33, and 34 were discharged from the facility.
Review of the undated facility admission Agreement Attachment E1 Management of Resident's Personal Funds revealed the following: If the Resident receives Medicaid benefits, the Facility will notify the Resident when the amount in the Resident's account reaches $200 less than the social security income (SSP) (sic) resource limit for one person and that if the amount in the account in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI. Upon the death of a resident with personal funds deposited with the Facility, the Facility will convey within thirty (30) days the resident's funds and a final accounting of those funds to the Executor administering the Resident's estate.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected multiple residents
Licensure Reference Number 175 NAC 12-006.05(1)
Based on interview and record review, the facility failed to ensure that they provided one of the two required beneficiary notice forms to two of three ...
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Licensure Reference Number 175 NAC 12-006.05(1)
Based on interview and record review, the facility failed to ensure that they provided one of the two required beneficiary notice forms to two of three residents reviewed (Residents #1 and #19). This had the potential to prevent the resident/resident representative from having an opportunity to appeal the discontinuation of Medicare Part A benefits and make an informed decision. The facility census was 23.
Findings are:
A. Record Review revealed no documentation of the SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice is a form that provides information to the Resident to help them decide whether to continue care that may not be paid for by Medicare and their right to appeal) for Resident #1.
Review of Resident #1's NOMNC (Notice of Medicare Non-Coverage) form dated 2/15/22 revealed the Resident's Medicare start date was 12/20/21 and the end date was 2/18/22.
Review of the NOMNC form dated 2/15/22 revealed that Resident #1 remained in the facility.
B. Record Review revealed no documentation of the SNFABN for Resident #19.
Review of Resident #19's NOMNC form dated 2/2/22 revealed the Resident's Medicare start date was 12/7/21 and the end date was 2/15//22.
Review of NOMNC form dated 2/2/22 revealed that Resident #19 remained in the facility.
Interview on 06/09/22 at 10:38 AM with the Business Office Manager (BOM), revealed no SNFABN notices were given.
Interview with BOM on 6/9/22 at 1:44 PM revealed the facility didn't have a policy for the SNFABN forms.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C
Based on interview and record review; the facility failed to provide sufficient st...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C
Based on interview and record review; the facility failed to provide sufficient staff to respond to resident calls for assistance within the residents' expected time frame. This affected 6 sampled residents, Residents 8, 15, 5, 4, 2, and 7. The facility identified a census of 23 at the time of survey.
Findings are:
A. Interview with Resident 8 on 6/06/22 at 11:18 AM revealed they waited up to an hour and a half for help when they have called for help. Resident 8 revealed the night shift staff were slow with assisting them to bed at night.
B. Review of Resident 15's Quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 4/28/2022 revealed Resident 15 required extensive assistance from staff for bed mobility, transfer, walk in room and corridor, locomotion on and off unit, dressing, toilet use, and personal hygiene.
Interview with Resident 15 on 6/06/22 at 4:08 PM revealed the facility did not have enough staff. Resident 15 revealed they had to wait anywhere from 15 minutes to 1 ½ hours for help.
C. Review of Resident 5's annual MDS dated [DATE] revealed Resident 5 required extensive assistance from staff for bed mobility, walk in room, and locomotion on and off unit.
Interview with Resident 5 on 6/06/22 at 9:10 AM revealed Resident 5 required assistance from staff to get out of bed.
Interview with Resident 5 on 6/06/22 at 4:28 PM the facility did not have enough staff. Resident 5 revealed the facility often only had 1 nurse aide on staff at night. Resident 5 revealed if they needed help between 7 PM and 11 PM at night they did not receive assistance. Resident 5 revealed they have had to wait 3 hours for help. Resident 5 revealed they were incontinent and have had to sit in their own urine and excrement while waiting for assistance.
Interview with Resident 5 on 6/08/22 at 7:07 AM revealed Resident 5 expected the facility staff to respond to their calls for assistance within 15 minutes but that did not always happen as the facility did not have enough staff, especially in the evening/night.
D. Review of Resident 4's admission MDS dated [DATE] revealed Resident 4 required extensive assistance from staff for bed mobility and was dependent on staff for transfers.
Interview with Resident 4 on 6/06/22 at 4:33 PM revealed the facility did not have enough staff and Resident 4 often had to wait at least 15 minutes or more for help.
Interview with Resident 4 on 6/08/22 at 7:30 AM revealed Resident 4 revealed an expectation for the staff to respond to their calls for assistance with a 5 to 10-minute response time was reasonable. Resident 4 revealed the facility did not have enough staff and Resident 4 had to wait 15 to 30 minutes for assistance.
E. Interview with Resident 2 on 6/6/22 at 10:41 AM revealed they did not feel the facility was adequately staffed. Resident 2 revealed the staff did not come to their room unless Resident 2 called on them. Resident 2 felt the facility staff should check on Resident 2 regularly, but they did not.
Record review of the Daily Staffing and Census posting on the wall by the nurses' station dated 6/6/2022 revealed the nursing staff shifts were listed as 6 AM to 6 PM for day shift and 6 PM to 6 AM for night shift.
Review of the Facility Assessment updated 6/7/22 revealed the following: Direct Care Staff Plan listed 1 RN (Registered Nurse) or LPN (Licensed Practical Nurse) Charge Nurse (12-hour shifts) for Day shift and NOC (Night) shift; Medication Aides (8-hour shifts) 1 day shift. 0 PM shift and 0-night shift. NA (Nurse Aide) (12 hour shifts): Day shift 1 bath aide (8-hour shift); Day shift 2 nurse aides (12-hour shift); NOC shift 2 nurse aides.
Review of the Employee Schedule nursing staff schedule for June 2022 revealed the following: 1 nurse aide was scheduled on night shift (6 PM-6 AM) on June 1, June 4, June 11, June 12, and 17.
Review of Resident 8's Device Activity Report for 5/7/22 to 6/7/22 revealed the following: 70 calls for assistance. 10 calls with over a 10-minute staff response time (used the 10-minute threshold as that was the fastest expectation of the residents); the longest response time was a bathroom call for 32 minutes 8 seconds.
Review of Resident 5's Device Activity Report for 5/7/22 to 6/7/22 revealed the following: 351 calls for assistance. 99 calls with over a 10-minute staff response time. Longest response time was 79 minutes.
Review of Resident 4's Device Activity Report for 5/7/22 to 6/7/22 revealed the following: 343 calls for assistance. 96 calls with over a 10-minute staff response time. Longest response time was 106 minutes.
Review of Resident 7's Device Activity Report for 5/7/22 to 6/7/22 revealed the following: 208 calls for assistance. 43 calls with over a 10-minute staff response time. Longest response time was 108 minutes.
Review of 15's Device Activity Report for 5/7/22 to 6/7/22 revealed the following: 127 calls for assistance. 35 calls with over a 10-minute staff response time. Longest response time was 72 minutes.
Interview with the DON (Director of Nursing) on 6/07/22 at 4:27 PM revealed the facility staff were expected to answer resident calls for assistance as quickly as possible.
Interview with the DON on 6/07/22 at 4:55 PM revealed the facility did not have a policy for the time frame the staff were required to respond for resident calls for assistance. The DON revealed the staff were expected to answer calls for assistance as quickly as they could within a reasonable time frame.
Interview with NA-L on 6/09/22 at 10:52 AM revealed the staff tried to answer call lights within a minute but sometimes they got busy. They definitely were expected to get them answered within 5 minutes. NA-L revealed that was what they were trained to do in NA training.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected most or all residents
Licensure Reference Number 175NAC 12-006.04A3
Licensure Reference Number 175NAC 12-006.04A3b(4)
Based on record review, interview, and observation; the facility failed to ensure that pre-employment cr...
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Licensure Reference Number 175NAC 12-006.04A3
Licensure Reference Number 175NAC 12-006.04A3b(4)
Based on record review, interview, and observation; the facility failed to ensure that pre-employment criminal background and sex offender checks were completed for 1 staff member (Nursing Assistant-F). This placed facility residents at risk for abuse and neglect. The facility census was 23.
Findings are:
Record review of the facility policy titled Abuse, Neglect, Misappropriation and Exploitation dated 10/19 revealed that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including but not limited to: facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident. The facility must not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Background, reference, and credentials checks should be conducted on employees prior to or at the time of employment.
Record review of the facility policy titled Background Investigations dated 10/10/20 revealed that job reference checks, licensure verifications and criminal conviction record checks are conducted on all personnel making application for employment with the facility.
Record review of the undated facility provided list of staff hired in the last 4 months revealed that Nursing Assistant-F (NA-F) had a hire date of 4/13/22.
Record review of the employee file for NA-F revealed no documentation of criminal background checks or sex offender registry checks being completed on NA-F.
Observation on 6/8/22 at 8:42 AM at the room of Resident 2 revealed that NA-F carried a meal tray and knocked on the resident's room door. NA-F carried the meal into the resident's room.
Observation on 6/8/22 at 9:55 AM in the room of Resident 2 revealed that Resident 2 sat in the wheelchair. NA-F finished brushing the resident's hair and held up a mirror for the resident to see how they looked.
Interview on 6/8/22 at 3:19 PM with NA-F confirmed that NA-F began working in the facility a couple of months ago.
Interview on 6/9/22 at 11:29 AM with the facility Business Office Manager (BOM) confirmed that criminal background checks are to be completed before hiring staff. The BOM confirmed that criminal background checks and sex offender registry checks had not been completed for NA-F. The BOM revealed that the BOM was requesting background checks for NA-F at this time.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B
Based on observation, interview, and record review; the facility failed to ensure oxygen was maintained to prevent potential cross contamination for 1 of ...
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LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B
Based on observation, interview, and record review; the facility failed to ensure oxygen was maintained to prevent potential cross contamination for 1 of 1 sampled residents, Resident 4. The facility census was 23.
Findings are:
Review of Resident 4's admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 3/21/2022 revealed an admission date of 3/14/2022. Resident 4 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated Resident 4 was cognitively intact. Resident 4 required extensive assistance from staff for bed mobility and was dependent upon staff for transfer. Active diagnoses included asthma, COPD (Chronic Obstructive Pulmonary Disease), or chronic lung disease and Resident 4 had shortness of breath or trouble breathing with exertion or while sitting at rest. Oxygen was used while a resident.
Observation of Resident 4 on 6/06/22 at 2:12 PM revealed they had oxygen on through a nasal cannula connected to tubing which was connected to an oxygen concentrator. The cannula and tubing were not marked with the date they were changed, and the cannula appeared to be soiled/brownish yellow in color.
Review of Resident 4's Care Plan dated 3/30/2022 revealed the following:
The resident has altered respiratory status with dx (diagnoses) of pulmonary edema, respiratory failure, COPD and CHF (Congestive Heart Failure). Provide oxygen as ordered. Change tubing weekly or per protocol.
Review of Resident 4's MAR and TAR (Medication and Treatment Administration Records) for May and June 2022 revealed no documentation the oxygen cannula or tubing had been changed.
Review of Resident 4's Order Summary Report revealed no documentation of an order or directions to change the nasal cannula routinely or when it was soiled.
Interview with RN-A (Registered Nurse) on 6/08/22 at 8:18 AM revealed the night shift staff were expected to change the oxygen cannulas weekly. RN-A revealed the alert should have popped up on the TAR when it was due.
Interview with the ADON (Assistant Director of Nursing) on 6/08/22 at 8:20 AM confirmed the oxygen cannulas were to be changed weekly and documented on Resident 4's TAR.
Interview with the DON (Director of Nursing) on 6/08/22 at 8:30 AM revealed the order to change Resident 4's oxygen cannula routinely did not get entered into Resident 4's EHR (Electronic Health Record) orders so there was no documentation it was being done. The DON confirmed the oxygen cannulas were expected to be changed weekly and documented on the TAR.
Interview with the DON on 6/08/22 at 1:07 PM revealed the facility did not have a policy regarding changing the oxygen tubing/cannulas.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to ensure that staff not up to date for Covid-19 vaccination were tested as required to prevent the potential for Covid-19. This affected all ...
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Based on record review and interview, the facility failed to ensure that staff not up to date for Covid-19 vaccination were tested as required to prevent the potential for Covid-19. This affected all facility residents. The facility census was 23.
Findings are:
A.
Record review of the facility policy titled Covid-19 Testing dated October 2020 revealed that all staff in the facility will be offered testing for Covid-19. Staff and Residents declining testing will be treated as having a positive or unknown Covid-19 status.
Record review of the Centers for Medicare and Medicaid Services Quality and Safety Oversight Memo 20-38 Long-Term Care Facility Testing Requirements dated 3/10/22 revealed that the term vaccinated was replaced with up-to- date with all Covid-19 vaccine doses. Up-to-Date means that a person has received all recommended Covid-19 vaccines, including any booster doses when eligible. Routine testing of staff not up-to-date for Covid-19 should be based on the extent of the virus in the community. Staff who are up to date do not have to be routinely tested. Routine Testing Intervals by County COVID-19 Level of Community Transmission are: Blue (low)-testing not recommended; Yellow (Moderate)- test once per week; Orange (Substantial)-test twice per week; and Red (High)- test twice per week.
Interview on 6/8/22 at 2:37 PM with the Facility Administrator (FA) confirmed that Medication Aide-M (MA-M) was the only staff member that had been positive for Covid-19 infection in the past 90 days. The FA confirmed that staff with a positive Covid-19 infection do not test for Covid-19 during the 90 day period after testing positive. The FA confirmed that MA-M would not be tested for Covid-19 again until the 90 day period was over.
Interview on 6/9/22 at 11:20 AM with the Facility Administrator (FA) revealed that the facility is testing staff that are not up to date for Covid-19 vaccination two times per week as determined by the corporate office. The FA revealed that the corporate office told the facility to test staff that are not up to date twice weekly until the county Covid transmission rate is blue (low transmission). The FA revealed that the facility has been testing all staff two times weekly for Covid-19. The FA confirmed that the two times a week testing was being done for both the staff that are not up to date with Covid-19 vaccination and for the staff that are up to date for Covid-19 vaccination. The FA revealed that the facility has been testing all staff two times weekly for Covid-19 since the start of 2022.
Interview on 6/7/22 at 1:42 PM with Medication Aide-D (MA-D) revealed that all facility staff are currently to be tested for Covid 2 times weekly regardless of their vaccination status.
Interview on 6/7/22 at 1:53 PM with Medication Aide-H (MA-H) revealed that the facility is testing all staff- both vaccinated and unvaccinated staff.
Interview on 6/9/22 at 2:49 PM with the FA revealed that the facility was doing extra testing of staff that were not up-to-date for Covid-19 vaccination.
Record review of the undated facility List of Current Staff revealed that Medication Aide-G (MA-G) had a hire date of 6/24/19.
Record review of the undated facility Covid-19 Staff Vaccination Status for Providers revealed that MA-G had not received any vaccinations for Covid-19. MA-G was not up-to-date for Covid-19 vaccination and was required to have routine testing for Covid-19.
Record review of the undated facility Covid-19 Testing Logs revealed that MA-G was tested for Covid-19 on 2/23/22, 3/3/22 (8 days after previous test), 3/14/22 (11 days after previous test), 4/5/22 (22 days after previous test), 4/11/22 (6 days after previous test), 4/25/22 (14 days after previous test), 5/2/22 (7 days after previous test), 5/9/22 (7 days after previous test); and 5/16/22 (7 days after previous test). No testing for Covid-19 was documented for MA-G from 5/16/22 through 6/7/22.
Record review of the Time Card Report dated 6/9/22 for MA-G for hours worked between 1/1/22 and 6/9/22 revealed that MA-G worked in the facility on 1/19/22, 1/23/22, 1/27/22, 2/7/22, 2/13/22, 2/14/22, 2/18/22, 2/22/22, 2/24/22, 2/26/22, 2/27/22, 3/2/22, 3/5/22, 3/7/22, 3/10/22, 3/11/22, 3/12/22, 3/13/22, 3/14/22, 3/17/22, 3/21/22, 3/23/22, 3/24/22, 3/26/22, 3/28/22, 3/30/22, 3/31/22, 4/1/22, 4/4/22, 4/6/22, 4/7/22, 4/8/22, 4/9/22, 4/10/22, 4/14/22, 4/15/22, 4/16/22, 4/17/22, 4/19/22, 4/20/22, 4/21/22, 4/24/22, 4/25/22, 4/26/22, 4/27/22, 4/29/22, 5/1/22, 5/5/22, 5/7/22, 5/9/22, 5/12/22, 5/13/22, 5/14/22, 5/16/22, 5/19/22, 5/20/22, 5/22/22, 5/23/22, 5/24/22, 5/25/22, 5/26/22, 5/28/22, 5/29/22, 5/30/22, 5/31/22, 6/2/22, 6/3/22, and 6/6/22.
B.
Record review of the undated facility List of Current Staff revealed that Medication Aide-E (MA-E) had a hire date of 7/20/21.
Interview on 6/7/22 at 1:47 PM with MA-E confirmed that MA-E had an approved religious exemption from receiving the Covid-19 vaccination and was unvaccinated against Covid 19. MA-E confirmed that MA-E was not being tested for Covid-19.
Record review of the undated facility Covid-19 Staff Vaccination Status for Providers revealed that MA-E had not received any vaccinations for Covid-19. MA-E was not up-to-date for Covid-19 vaccination and was required to have routine testing for Covid-19.
Record review of the undated facility Covid-19 Testing Logs for testing between 2/20/22 and 6/7/22 revealed that no testing for Covid-19 occurred for MA-E.
Record review of the Time Card Report dated 6/9/22 for MA-E for hours worked between 12/1/21 and 6/9/22 revealed that MA-E worked in the facility on 12/6/21, 12/13/21, 12/20/21, 12/27/21, 12/29/21, 12/30/21, 1/1/22, 1/3/22, 1/17/22, 1/20/22, 1/22/22, 1/24/22, 2/3/22, 2/8/22, 2/17/22, 2/25/22, 5/2/22, 5/6/22, 5/20/22, 6/6/22, and 6/7/22.
C.
Record review of the undated facility List of Current Staff revealed that Maintenance Director (MD) had a hire date of 2/16/22.
Record review of the undated facility Covid-19 Staff Vaccination Status for Providers revealed that MD had received the Covid-19 vaccination but had not received the booster dose. MD was not up-to-date for Covid-19 vaccination and was required to have routine testing for Covid-19.
Record review of the undated facility Covid-19 Testing Logs for testing between 2/20/22 and 6/7/22 revealed that no testing for Covid-19 occurred for MD.
Record review of the Time Card Report dated 6/9/22 for Maintenance Director (MD) for hours worked between 1/1/22 and 6/9/22 revealed that MD worked in the facility on 2/16/22, 2/17/22, 2/18/22, 2/21/22, 2/22/22, 2/23/22, 2/24/22, 2/25/22, 2/28/22, 3/1/22, 3/2/22, 3/3/22, 3/4/22, 3/5/22, 3/7/22, 3/8/22, 3/9/22, 3/10/22, 3/11/22, 3/14/22, 3/15/22, 3/16/22, 3/17/22, 3/18/22, 3/20/22, 3/21/22, 3/22/22, 3/23/22, 3/24/22, 3/30/22, 4/1/22, 4/5/22, 4/8/22, 4/12/22, 4/13/22, 4/15/22, 4/20/22, 4/21/22, 4/22/22, 4/23/22, 4/26/22, 4/27/22, 4/29/22, 4/30/22, 5/2/22, 5/4/22, 5/6/22, 5/11/22, 5/14/22, 5/16/22, 5/18/22, 5/20/22, 5/23/22, 5/25/22, 5/31/22, 6/4/22, 6/6/22, and 6/7/22.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected most or all residents
Based on observation, record review, and interview; the facility failed to ensure that Covid-19 mitigation measures (extra protective measures to prevent the potential for the spread of Covid-19) were...
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Based on observation, record review, and interview; the facility failed to ensure that Covid-19 mitigation measures (extra protective measures to prevent the potential for the spread of Covid-19) were in place for staff with exemptions (an approved medical or religious reason freeing the individual from the obligation to be vaccinated for Covid-19) from receiving the Covid-19 vaccination to prevent Covid-19; failed to ensure that staff exemption forms contained documented facility approval of the exemption; and failed to ensure that a medical exemption form was completed for 1 staff member. This affected all facility residents. The facility census was 23.
Findings are:
A.
Record review of the facility policy titled COVID-19- Vaccine Policy dated 02/2022 revealed that it is the facility policy that all employees, contractors, and any other individuals who contracts with or provides services to our residents will take the necessary precautions and adhere to mandated guidelines established through this policy. The intent of this policy is to safeguard the health of our employees and their families, our customers and visitors, and the community at large from COVID-19 that may be reduced by vaccinations. It is required that all employees in the facility receive the designated COVID-19 vaccination or provide evidence of vaccine receipt or exemption. The policy revealed that any employee or contractor who obtains approval for a valid exemption will be required to wear Personal Protective Equipment (PPE) as an infection prevention and control measure when in the facility and may be subject to routine COVID-19 testing to reduce the risks giving rise to the vaccine mandate.
Interview on 6/9/22 at 11:20 AM with the Facility Administrator (FA) revealed that the corporate office told the facility to test staff that are not up-to-date (staff with exemption from receiving Covid-19 vaccination) twice weekly until the county Covid-19 transmission rate is blue (low transmission). The FA revealed that the facility has been testing all staff two times weekly for Covid-19. The FA confirmed that the two times a week testing was being done for both the staff that are not up-to-date with Covid-19 vaccination and for the staff that are up-to-date (fully vaccinated with all recommended Covid-19 vaccine doses including any booster doses) for Covid-19 vaccination. The FA confirmed that the facility did not require the exempt staff to test more frequently than the up-to-date staff.
Observation on 6/7/22 at 1:42 PM near the facility Medication Storage Room revealed that Medication Aide-D (MA-D) wore a light blue surgical mask and no other PPE.
Interview on 6/7/22 at 1:42 PM with MA-D confirmed that MA-D had an approved religious exemption from getting the Covid-19 vaccination. MA-D confirmed that MA-D was not vaccinated for Covid-19. MA-D confirmed that MA-D wears the same surgical mask as all staff wear. MA-D confirmed that the staff that are vaccinated for Covid-19 and the staff that are unvaccinated for Covid-19 all wear the same PPE.
Observation on 6/7/22 at 1:47 PM near the facility nurse's station revealed that Medication Aide-E (MA-E) wore a light blue surgical mask and no other PPE.
Interview on 6/7/22 at 1:47 PM with MA-E confirmed that MA-E had an approved religious exemption from getting the Covid-19 vaccination. MA-E confirmed that MA-E was unvaccinated against Covid-19. MA-E confirmed that MA-E was not being tested for Covid-19 infection.
Observation on 6/7/22 at 1:53 PM near the facility nurse's station revealed that Medication Aide-H (MA-H) wore a light blue surgical mask and no other PPE.
Interview on 6/7/22 at 1:53 PM with MA-H confirmed that MA-H was fully vaccinated for Covid-19 and that MA-H also received the booster dose (MA-H was up-to-date with all Covid-19 vaccinations). MA-H revealed that MA-H is tested 2 times weekly for Covid-19.
Interview on 6/9/22 at 2:49 PM with the FA confirmed that exempt staff from Covid-19 vaccination were not required to wear any extra or different PPE than what the up-to-date for Covid-19 vaccination staff wore. The FA revealed that the facility mitigation measures for staff exempt from Covid-19 vaccination were extra testing and following Centers for Medicare and Medicaid Services recommendations.
B.
Record review of the facility policy titled COVID-19-Vaccine Policy dated 02/2022 revealed that it is required that all employees in the facility receive the designated COVID-19 vaccination or provide evidence of vaccine receipt or exemption. The section titled Exemption Requests revealed that exemptions from the immunization mandate may be available for medical contraindications, disability, and/or sincerely held religious beliefs or practices. The approval or denial of a requested exemption will be made based on a review of the exemption request form (and supporting documentation as required) submitted by the individual in accordance with established guidelines and an interactive process. If an exemption is granted; approval will be noted on the individual's exemption form.
Record review of the undated facility Covid-19 Staff Vaccination Status for Providers revealed that 12 facility staff had a non-medical (religious) exemption from receiving the Covid-19 vaccination and 2 facility staff had a medical exemption from receiving the Covid-19 vaccination.
Record review of the facility Covid-19 Vaccine Religious Exemption Request forms provided by the facility Business Office Manager (BOM) on 6/8/22 at 12:34 PM revealed that:
-The COVID-19 Vaccine Religious Exemption Request form for Licensed Practical Nurse-N (LPN-N) contained the signature of LPN-N dated 11/18/21 and the signature of the religious leader dated 11/18/21. The form did not contain any facility signature of approval of the exemption.
-The COVID-19 Vaccine Religious Exemption Request form for Medication Aide-D (MA-D) contained the signature of MA-D dated 11/24/21 and the signature of the religious leader dated 11/24/21. The form did not contain any facility signature of approval of the exemption.
-The COVID-19 Vaccine Religious Exemption Request form for Medication Aide-E (MA-E) contained the signature of MA-E dated 12/6/21 and the signature of the religious leader dated 12/6/21. The form did not contain any facility signature of approval of the exemption.
-The COVID-19 Vaccine Religious Exemption Request form for Medication Aide-I (MA-I) contained the signature of MA-I dated 11/22/21 and the signature of the religious leader. The form did not contain any facility signature of approval of the exemption.
-The COVID-19 Vaccine Religious Exemption Request form for Activity Director (AD) contained the signature of the AD dated 11/22/21 and the signature of the religious leader dated 11/22/21. The form did not contain any facility signature of approval of the exemption.
-The COVID-19 Vaccine Religious Exemption Request for Dietary Cook-O (DC-O) contained the signature of DC-O dated 11/18/21. The form did not contain any signature of the religious leader. The form did not contain any facility signature of approval of the exemption.
- The COVID-19 Vaccine Religious Exemption Request form for the facility Business Office Manager (BOM) contained the signature of the BOM dated 11/18/21. The form did not contain any signature of the religious leader. The form did not contain any facility signature of approval of the exemption.
Record review of the facility Covid-19 Vaccine Medical Exemption Request forms provided by the facility Business Office Manager (BOM) on 6/8/22 at 12:34 PM revealed that:
-The COVID-19 Vaccine Medical Exemption Request form for the facility Assistant Director of Nursing (ADON) contained the signature of the LPN. The form did not contain any facility signature of approval of the exemption.
Interview on 6/9/22 at 2:55 PM the BOM confirmed that the employee Covid-19 Exemption Request forms for LPN-N, MA-D, MA-E, MA-I, the AD, DC-O, the BOM, and the ADON did not contain a facility approval signature.
Interview on 6/9/22 with the Facility Administrator (FA) confirmed that the employee Covid-19 Exemption Request forms for LPN-N, MA-D, MA-E, MA-I, the AD, DC-O, the BOM, and the ADON did not contain the required approval signatures.
C.
Record review of the undated facility Covid-19 Staff Vaccination Status for Providers revealed that Nursing Assistant-P (NA-P) had a granted Medical Exemption from Covid-19 vaccination.
Record review of the facility Covid-19 Vaccine Exemption Request forms provided by the facility Business Office Manager (BOM) on 6/8/22 at 12:34 PM revealed that there was no Covid-19 Vaccine Medical Exemption Request form for NA-P. Only a physician letter dated 1/28/22 for NA-P was found. The physician letter for NA-P documented that NA-P had a chronic medical condition that prevented NA-P from receiving the Covid-19 vaccine.
Interview on 6/9/22 at 2:55 PM with the BOM confirmed that the facility did not have a Covid-19 Medical Exemption Request Form for NA-P.
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
- • No fines on record. Clean compliance history, better than most Nebraska facilities.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 29 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade F (28/100). Below average facility with significant concerns.
- • 71% turnover. Very high, 23 points above average. Constant new faces learning your loved one's needs.
Bottom line: Trust Score of 28/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Arbor Care Centers - Ord, Llc's CMS Rating?
CMS assigns Arbor Care Centers - Ord, LLC an overall rating of 2 out of 5 stars, which is considered 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 Arbor Care Centers - Ord, Llc Staffed?
CMS rates Arbor Care Centers - Ord, LLC's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 71%, which is 24 percentage points above the Nebraska average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Arbor Care Centers - Ord, Llc?
State health inspectors documented 29 deficiencies at Arbor Care Centers - Ord, LLC during 2022 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 28 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 Arbor Care Centers - Ord, Llc?
Arbor Care Centers - Ord, LLC 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 ARBOR CARE CENTERS, a chain that manages multiple nursing homes. With 60 certified beds and approximately 35 residents (about 58% occupancy), it is a smaller facility located in Ord, Nebraska.
How Does Arbor Care Centers - Ord, Llc Compare to Other Nebraska Nursing Homes?
Compared to the 100 nursing homes in Nebraska, Arbor Care Centers - Ord, LLC's overall rating (2 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 (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Arbor Care Centers - Ord, Llc?
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 Arbor Care Centers - Ord, Llc Safe?
Based on CMS inspection data, Arbor Care Centers - Ord, LLC has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-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 Arbor Care Centers - Ord, Llc Stick Around?
Staff turnover at Arbor Care Centers - Ord, LLC is high. At 71%, the facility is 24 percentage points above the Nebraska average of 46%. 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 Arbor Care Centers - Ord, Llc Ever Fined?
Arbor Care Centers - Ord, LLC has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Arbor Care Centers - Ord, Llc on Any Federal Watch List?
Arbor Care Centers - Ord, LLC 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.