Crowell Memorial Home

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview and record review the facility failed to implement interventions identified on the care plan to prevent falls for 3 (Resident 1, 2 and 4) of 4 residents sampled. The facility census was 77.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to report a significant injury to the state agency in appropriate time frames for 1(Resident 2) of 4 residents sampled. The facility census was 77.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)Based on record review and interview; the facility staff failed to implement assessed interventions to prevent falls for 1 (Resident 4) of 3 sampled residents. The facility staff identified a census of 66.

Inspectors wroteLicensure reference: 175 NAC 12-006.09(H)(iv)(5)Based on record review and interview, the facility failed to ensure monitoring of bowel function for 1 [Resident 3] of 3 sampled residents. The facility had a total census of 63 residents.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(G) Based on record reviews and interviews, the facility failed to provide a rationale for not conducting a Gradual Dose Reduction (GDR, Stepwise tapering of a dose to determine whether or not symptoms, conditions, or risks can be managed by a lower dose or whether or not the dose or medication can be discontinued) for 1 (Resident 2) of 3 residents sampled. The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to report an allegation of misappropriation within the required timeframe to Adult Protective Services [APS] and the Department of Health and Human Services [DHHS] for 1 (Resident 39) of 5 facility investigations reviewed. The facility census was 61.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to thoroughly investigate an allegation of misappropriation for 1 (Resident 39) of 5 facility investigations reviewed. The facility census was 61.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(v) Based on record reviews and interviews, the facility failed to provide services as care planned to help prevent further decrease in range of motion for 2 (Residents 40 and 8) out of 2 residents sampled. The facility census was 61.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(B) & 12-006.09(H)(vi)(3)(g) Based on observation, record review and interview; the facility failed to date oxygen tubing for 1 (Resident 11) of 1 sampled resident. The facility also failed to utilize Personal Protective Equipment (PPE, includes clothing, gloves, face shields, goggles, facemask's, respirators, and other equipment to protect front-line workers from injury, infection, or illness) for Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(G) Based on observation, interview, and record review, the facility staff failed to ensure individualize use of restraints to include identification of medical symptoms for use, duration of use, evaluation of less restrictive alternatives, review of risk and benefits, and re-evaluation of need for a restraint in accordance with facility policy for restraint use for 3 [Residents 1, 2, and 5] of 3 sampled residents. The facility had a total census of 63 residents.

Inspectors wroteLicensure Reference Number NAC 12-006.09(D) Based on record review and interview, the facility failed to accurately code MDS [Minimum Data Set; a comprehensive assessment used in care planning] related to use of restraint for 2 [Residents 1 and 2] of 3 sampled residents utilizing a Merry Walker. The facility had a total census of 63 residents.

Inspectors wroteLicensure Reference Number 175 NAC 006.09(I) Based on observation, interview, and record review, the facility failed to ensure supervision to protect residents from elopement for 3 [Residents 1, 4, and 6] of 3 sampled residents at risk for elopement. The facility had a total census of 63 residents.

Inspectors wroteLicensure reference Number 175 NAC 12-006.11E Nebraska Food Code 4-601.11(C) Based on observation, interview, and record review; the facility staff failed to ensure dietary staff wore beard restraints that fully enclosed all hair on the face during 2 meal service observations, failed to ensure scoops were stored separate from the flour and sugar, failed to ensure that the surface of plates stored in a plate warmer were not exposed to potential contaminants and failed to maintain the cleanliness and condition of floors, ventilation covers and ceiling tiles, the interior of conventional ovens and convection ovens, the exterior of the stove, stove back splash, convection ovens, shelf above the stove, floors in the walk in cooler, fans in the walk in cooler, pan storage units, electric slicer, and the large commercial mixer in the facility kitchen. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on observation, and interview, the facility failed to maintain the cleanliness and condition of walls, floors, fixtures, ceilings, and baseboards in 24 (rooms: 102, 105, 106, 113, 116, 122, 123, 125, 131, 132, 134, 144, 146, 158, 159, 162, 203, 205, 212, 215, 225, 233, 236, and 238) of 59 occupied resident rooms and the 2nd floor north hallway nurses station of the facility. The facility census was 60.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10D Based on observation, record review and interview the facility failed to maintain a medication error rate of less than 5% which affected 1(Resident 44) of 3 sampled residents. There were 26 opportunities and 2 errors observed resulting in a 7.69% medication error rate. Facility Census was 60.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17B Based on observation, interview, and record review the facility failed to handle linens and a catheter drainage bag in a manner to prevent the potential for cross contamination for 1(Resident 44) of 3 sampled residents. The facility census was 60.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04A3b Based on record review and interview the facility failed to conduct adult and child protective service (APS and CPS) registry checks upon hire for 1 (Nursing Assistant, NA G) of 5 sampled new employee files. Record Review of NA G's employee file revealed NA G was hired on 03-04-2024. Further review of NA G's employee file revealed results from registry checks with APS and CPS were not observed in the file. An interview conducted with the Administrator (Admin) on 4-16-2024 at 2:20 PM revealing APS and CPS registry checks are completed on hire and employees should not be allowed to work until the results are back. An interview conducted on 4-16-2024 at 2:40 PM with the Administrative Assistant confirmed APS and CPS registry checks were not completed for NA G. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication error for 1 (Resident 3) of 3 sampled residents. The facility had a total census of 59 residents.

Inspectors wroteLicensure reference: 175 NAC 12-006.09D1c Based on interview and record review, the facility failed to ensure baths were being offered in accordance with resident preferences for 2 (Residents 1, and 2) of 3 sampled residents. The facility had a census of 59 residents.

Inspectors wrote175 NAC 12-006.11. E Based on observation, record review and interviews, the facility staff failed to 1) ensure hair restraints were worn by staff and 2) failed to ensure food temperatures were maintained at a level to prevent potential food-borne illness. This practice had the potential to affect 55 residents. The facility staff identified a census of 55.

Inspectors wroteBased on record review and interview, the facility staff failed to provide SNFABN (Skilled Nursing Facility Advance Beneficiary Notice-a notice issued to a resident and/or their responsible party to inform them that Medicare will likely no longer pay for their services) for Resident 46 and Resident 112. This affected 2 of 3 sampled residents. The facility identified a census of 55. Findings Are: Record review of the NOMNC (Notice of Medicare Non-Coverage) for Resident 46 revealed a last covered day of Medicare part A services would be on 12/9/22. The NOMNC contained a handwritten note signed by the Director of Nursing (DON) which revealed Resident 46's representatives were contacted on 12/6/22 and Resident 46's last covered skilled day was 12/9/22. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide notice of the bed-hold policy to Resident 6 or their Representative upon transfer to the hospital. This affected 1 of 1 sampled residents for hospitalization. The facility census was 55. Findings Are: Record review of the Electronic Medical Record (EMR), per a tab of census information, revealed Resident 6 was on hospital leave from 2/11/23 and returned to the facility on 2/22/23. Interview on 04/20/23 at 2:01 PM with the DON (Director of Nursing) revealed the facility did not complete a bed hold policy for Resident 6 when hospitalized on [DATE].

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09C Based on interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) that reflected the care needs of Resident 3 and Resident 16. This affected 2 of 2 sampled residents. The facility identified a census of 55.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to provide bathing assistance for one (Resident 16) of 2 sampled residents that required assistance with activities of daily living. The facility census was 55.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D2 Based on observation, record review and interview, the facility failed to obtain treatment orders for 1 (Resident 106) of 1 sampled resident. The facility census was 55.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.12 Based on observation, record review, and interview, the facility failed to ensure the provision of services of medications and biologicals to meet the needs of 2 (Resident 10 and Resident 105) of 3 sampled residents. The facility identified a census of 55. Findings Are: Observation of medication administration on 04/18/23 at 09:06 AM revealed MA-A preparing 8:00 A.M. medications for Resident 10. The following medications were prepared and given; [...]

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, interview, and record review, the facility failed to ensure a medication error rate of 5% or less. The sample size was 3. The facility identified a census of 55.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17 Based on observation, record review and interview, the facility failed to clean and store one (Resident 106) of one sampled resident Positive Airway Pressure (PAP-a machine used to deliver pressure to the airway to keep it open during sleep) mask to prevent the potential for cross contamination. The facility census was 55.