Chimney Rock Villa

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain a safe, sanitary, homelike bathing environment. This affected 6 (Resident 2,3,4,5,6, and 7) of 6 sampled residents. The facility identified a census of 32. LICENSURE REFERENCE NUMBER 175 NAC 12-006.19(A) A record review of Resident 2's facesheet revealed they were admitted to the facility on [DATE] and had diagnoses of type 1 diabetes mellitus, substance abuse, and respiratory failure. A record review of Resident 3's facesheet revealed they were admitted to the facility on [DATE] and had diagnoses of dementia, urinary tract infection, depression, and anxiety. A record review of Resident 4's facesheet revealed they were admitted to the facility on [DATE] and had diagnoses of dementia, back pain, and hypertension. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(D)(i)Nebraska Revised Statute 71-6018.02 Based on record review and interview, the facility failed to designate a full-time Director of Nursing (DON) from 12/24/2024 through 2/10/2024 as required. This had the potential to affect all residents who reside within the facility. The facility identified a census of 35.

Inspectors wroteLICENSURE REFERENCE NUMBER NAC 175 12-006.11(E) Based on observations, interviews, and record review, the facility failed to store, prepare, and serve food in a manner that prevented the potential for foodborne illness. The facility failed to label items for consumption with date and contents and prevent the potential for cross-contamination by storing uncooked meat above ready-to-eat food items. The facility also failed to ensure that dishes were being sanitized in a manner to prevent the potential for foodborne illness. This had the potential to affect all 35 residents that resided in the facility.

Inspectors wroteLICENSURE REFERENCE NUMBER 175-12 005.06(H0)Based on interview and record review the facility failed to designate the role and duties of the Infection Preventionist to a qualified staff member that did not function as the facility Director of Nursing (DON).

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iv)Based on record review and interview, the facility failed to follow their bowel protocol to prevent constipation for 3 (Residents 3, 5, and 7) of 5 sampled residents. The facility census was 35. Findings Are: A record review of the facility's undated Bowel Elimination guidelines revealed a goal stating, To promote resident health and comfort through proper functioning. The policy statement was, Bowel elimination patterns will be monitored every shift and timely intervention will be provided as needed to ensure resident health and comfort. The procedure section stated the facility staff was to monitor bowel elimination every shift, taking into consideration the resident's individual elimination pattern. If after 3 days there is no bowel movement administer prune juice, if after 4 days give milk of mag, if no results contact MD. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(D)Based on record review and interview, the facility failed to ensure the Minimum Data Sets (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) were coded correctly related to hypoglycemic (medication used to lower blood glucose levels in people with type 2 Diabetes Mellitus) medication usage for 1 (Resident 5) of 5 sampled residents. The facility census was 35. Findings Are:A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities) dated October 2023 revealed in the High-Risk Drug Classes: [...]

Inspectors wroteLicensure Reference Number 175 12.006.09(H)(v)Based on observations, record review, and interviews. The facility failed to identify a contracture and implement treatment to prevent potential worsening of the contracture for Resident 12. The facility identified a census of 35.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)(i)(1) Based on record reviews and interviews, the facility failed to develop and or implement appropriate interventions to prevent additional falls for 4 (Residents 2, 4, 6, and 7), which resulted in two residents (Resident 4 and 7) sustaining major injuries from subsequent falls. The facility identified a census of 24.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(2) Licensure Reference Number 175 NAC 12-006.09(H)(iii)(3) Based on record reviews and interviews, the facility failed to provide ongoing monitoring of an incision, follow physician's orders for care of the incision, and implement treatment and other interventions to promote healing and prevent infection for 1 (Resident 7) of 4 sampled residents. The facility identified a census of 24.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.07 Based on record reviews and interviews, the facility failed to ensure the Quality Assurance Performance Improvement Program [QAPIP, a facility process that identifies problems in the facility and works to correct the concerns] identified ongoing issues relevant to F689 and implement plans of action to identify and correct the deficient practice. This had the potential to affect all residents that reside within the facility. The facility identified a census of 24.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on record reviews and interview, the facility failed to report to the State Agency a fall with major injury as a potential allegation of abuse/neglect within 2 hours and submit a complete investigation within five working days of the incident as required for 1 (Resident 7) of 2 sampled residents. The facility identified a census of 24.

Inspectors wroteLicensure Reference 175 NAC 12-006.11(D) Licensure Reference 175 NAC 12-006.11(E) Licensure Reference 175 NAC 12-006.18(B) Based on observations, interviews, and record review; the facility failed to ensure food products were disposed of or used before expirations dates, failed to ensure foods were not stored on the floor of the freezer in according to manufacturer's recommendations, failed to ensure the steam table food temperatures were held at safe temperatures and implement hand hygiene after the changing of gloves in order to prevent the potential for foodborne illness. This had the potential to affect all resident who resided within the facility. The facility census was 31.

Inspectors wroteLicensure Reference 175 NAC 12-006.05(S) Based on observations, interviews, and record review; the facility failed to provide care for residents in a manner that enhanced dignity and respect during meal services by ensuring staff did not stand over residents while assisting them to eat and by conducting social conversations with other staff rather than conversing with the residents they were assisting for 8 (Residents 8, 18, 20, 22, 23, 26, 29, and 31) of 8 sampled residents. The facility census was 31.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview; facility staff failed to develop and implement a comprehensive person-centered Care Plan (CP) for 4 (Residents 7, 12, 17, and 27) of 12 sampled residents. The facility census was 31. The Findings Are: A.A record review of facility policy care plans (CP), Comprehensive Person-Centered with revision date of March 2022, revealed that the comprehensive, person-centered care plan should describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and should reflect currently recognized standards of practice for problem areas and conditions. B. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview, the facility failed to accurately assess 1 (Resident 17) of 12 sampled resident's nutritional status on their admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning). The facility census was 31. The Findings Are: A record review of facility policy Certifying Accuracy of the Resident Assessment with revision date of November 2019, revealed that the information captured on the assessment should reflect the status of the resident during the observation period for that assessment. A record review of Resident 17's admission MDS dated [DATE], revealed in Section K that the resident had had a Loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not on a prescribed weight loss program. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record review and interviews, the facility failed to review and revise Resident 19's care plan to reflect their current nutritional interventions and Resident 20's Care Plan (CP) to accurately reflect the level of assistance needed with their Activities of Daily Living (ADLs). The sample size was 12 and the facility census was 31. The Findings Are: A. A record review of facility policy Care Plans, Comprehensive Person-Centered with revision date of March 2022, revealed that the comprehensive, person-centered care plan should describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and should reflect currently recognized standards of practice for problem areas and conditions. [...]

Inspectors wroteLicensure Reference 175 NAC 12-006.09 Based on record review and interviews, the facility failed to ensure a hypertension (high blood pressure) medication was administered in accordance with the Prescribers' orders for 1 (Resident 12) of 1 sampled resident. The facility census was 31.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on observation, record review, and interviews the facility failed to ensure an order was in place for 1 (Resident 7) of 1 sampled resident's oxygen therapy, resulting in an insufficient oxygen flow rate. The facility census was 31. The Findings Are: A record review of Resident 7's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), dated 7/6/24, revealed in Section C that the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated that the resident had moderately impaired cognition. The MDS also revealed in Section I that the resident had Chronic Obstructive Pulmonary Disease (COPD) and in Section O that the resident was receiving oxygen therapy. [...]

Inspectors wroteLicensure Reference 175 NAC 12-006.09(H) Based on interviews and record reviews, the facility failed to ensure antibiotics had a stop date for 2 (Resident 1 and 19) of 5 sampled residents. The facility census was 31.

Inspectors wroteLicensure Reference 175 NAC 12-006.10 Based on observations, interviews, and record reviews; the facility failed to ensure a medication that could not be crushed was not crushed for 1 (Resident 22) of 4 sampled residents. The facility census was 31.

Inspectors wroteLicensure Reference 175 NAC 12-006.04B2c. Based on an interview and record reviews, the facility failed to employ a Dietician full-time or have a certified Food Service Director. This had the potential to affect 29 residents who ate from the kitchen. The facility census was 29.

Inspectors wroteLicensure Reference 175 NAC 12-006.10D Based on observation, interviews, and record review, the facility failed to ensure residents are free of a signification medication error for 1 (Resident 4) or 3 sampled residents. The facility census was 29.

Inspectors wroteLicensure Reference 175 NAC 12-006.17D Based on observation, interview and record review, the facility failed to perform hand hygiene, change gloves, and utilize a sanitary surface during catheter cares for 1 (Resident 1) of 1 sampled resident. The facility census was 29. The Findings Are: A record review of facility policy Handwashing/Hand Hygiene dated October 2023 revealed hand hygiene was indicated immediately before touching a resident, before performing an aseptic task, after touching a resident, after touching a resident's environment, before moving from work on a soiled body site to a clean body site on the same resident, and immediately after glove removal. The policy also stated that the use of gloves did not replace handwashing/hand hygiene. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D2a Based on record review and interviews; the facility staff 1) failed to assess residents for skin impairment, existing pressure ulcers (localized injury to the skin and/or underlying tissue over a bony prominence as a result of pressure, or pressure in a combination with shear and/or friction), or new pressure ulcers; 2) failed to implement interventions to treat and prevent the development of pressure ulcers; 3) failed to monitor residents' skin, 4) failed to follow provider orders to promote wound healing for 2 (Residents 2 and 1) of 4 sampled residents. The facility identified a facility census of 31 residents at the time of the survey.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.07C Based on record reviews and interview, the facility failed to identify, monitor, and evaluate a system for pressure ulcers as part of the Quality Assurance and Performance Improvement (QAPI) committee's performance improvement activities. This affected 2 (Residents 1 & 2) of 4 sampled residents. The facility census was 34.

Inspectors wroteLICENSURE REFERENCE NUMBER 174 NAC 12-006.11D Based on observation, record review and interview: the facility failed to ensure food temperatures were maintained to prevent the potential for food borne illness and ensure the palatability of the food. This had the potential to affect 9 (Residents 3, 4, 5, 10, 16, 17, 20, 25 and 26 ) of 9 residents who received mechanically altered diets. The facility staff identified a census of 37. A. Review of the facility policy Food Temperature (undated) revealed hot foods were to kept hot at or above 140 degrees Fahrenheit (F) and food temperatures were to be obtained and documented prior to each meal service. B. During an observation on 8/8/23 from 11:30 AM to 1:16 PM the following was observed with the Dietary [NAME] (DC): [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09B Based on record review and interview: the facility failed to ensure the Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) was coded to reflect the resident's status related to Anticoagulant (a medication used to thin the blood) medication use for 2 (Residents 1 and 9) of 19 sampled residents reviewed. The facility census was 37.

Inspectors wroteLicensure Reference Numbers 175 NAC 12-006.09D7 Based on record review and interview; the facility failed to investigate/identify causal factors and to develop and/or revise interventions for the prevention of falls for 1 (Resident 9) of 4 residents reviewed for accidents. The facility census was 37.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8 Based on observations, record review and interview; the facility failed to implement nutritional interventions and to notify the Registered Dietician (RD) of ongoing weight loss for 1 (Resident 35) of 2 sampled residents. The facility census was 37.

Inspectors wroteLicensure Reference Number: 175 NAC 12-006.17B Based on observations and interviews, the facility failed to ensure Resident 9's nebulizer machine, tubing and mask were not placed directly on the floor to reduce the risk of cross contamination. The facility census was 37 with 19 sampled residents.