Holdrege Memorial Homes, Inc

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(A)(iii)(3)Based on record review and interviews, the facility failed to implement the facility policy and procedure when an allegation of abuse or neglect was made. This had the potential to affect all of the residents residing in the facility. The facility census was 74.

Inspectors wroteLicensure Reference Number 175NAC 12-006.04(A)(iii)(2)(c)Licensure Reference Number 175NAC 12-006.04(A)(iii)(3)Based on record review and interview the facility failed to ensure that required registry checks (Child/adult abuse and neglect central registry checks, maintained by the Nebraska Department of Health and Human Services (DHHS), identify individuals with substantiated cases of abuse or neglect) were completed for new staff prior to working in the facility for 5 of 6 sampled staff. This had the potential for residents to be at risk of abuse and neglect. The facility census was 73.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure that the Direct Care Daily Staffing posting (a required daily posting of facility nurse staffing information) included the required actual hours worked for each staff category. The facility census was 73.

Inspectors wroteLicensure Reference Number 175NAC 1-005.06(D) Licensure Reference Number 175NAC 12-006.18(B)Licensure Reference Number 175NAC 12-006.18(C) Based on observation, record review, and interview the facility failed to ensure that pre-employment health screens were completed for 1 of 6 sampled staff to prevent the potential for communicable diseases, failed to maintain fingernails while working with exposed foods that affected all facility residents, failed to ensure oxygen delivery devices were stored in a sanitary manner for 2 of 3 sampled residents (Resident 37 and 46), and failed to ensure the required PPE (Personal Protective Equipment) was available and used during care for 2 of 2 sampled residents (Resident 2 and 85). The facility census was 73.

Inspectors wroteThe facility failed to ensure that all Minimum Data Set transmissions for each resident were submitted within 14 days after completion. This affected 7 of 7 residents (Residents 20, 53, 8, 55, 62, 68 and 70) sampled. The facility census was 73. Based on record review and interviews, the facility failed to ensure that all Minimum Data Set assessments (MDS - information which provides a comprehensive overview of a resident's functional status, diagnoses, and treatments used for resident care planning and quality monitoring in the long term care setting) was submitted within 14 days of completing the resident assessments. This affected 7 residents (Residents 20, 53, 8, 55, 62, 68 and 70) of 7 residents sampled. The facility census was 73.

Inspectors wroteLicensure Reference Number 175NAC 12-006.09(E)(ii) Licensure Reference Number 175NAC 12-006.09(E)(iii) Licensure Reference Number 175NAC 12-006.09(E)(iv) Based on Record reviews, observations, and interviews, the facility failed to ensure the comprehensive care plans had person-centered goals, measurable objectives, and interventions related to respiratory infections, nutrition, diabetes, resident choices, urinary tract infections and other infections, resident fluid restrictions, and self-directed care wishes for 4 of 18 sampled residents (Residents 68, 55, 9, and 2). The facility census was 73.

Inspectors wroteLicensure Reference Number 175NAC 12-006.05(E) Based on record review, and interview the facility failed to ensure that the risk versus benefit information for 2 of 5 sampled residents, (Resident 50 and 72), were discussed to the resident and resident representative for any psychotropic medications and prior to starting any psychotropic medications which describe in plain language the risks, benefits, options, and alternatives of the medication being prescribed. The facility census was 73.

Inspectors wroteBased on record review and interview the facility failed to notify the ombudsman (a state appointed advocate for residents of nursing homes) of resident discharge for 1 of 2 residents reviewed (Resident 82) as required. The facility census was 73.

Inspectors wroteLicensure Reference Number NAC 175 12-006.09(H)(iii)Based on interview and record review the facility failed to ensure wounds were comprehensively assessed on a routine basis and failed to ensure a wound had treatment orders for 1 resident (Resident 10) of 2 sampled residents. The facility census was 73.

Inspectors wroteBased on interview and record review the facility failed to ensure coordination of care of dialysis for 1 resident (Resident 2) of 1 sampled residents. The facility census was 73.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) as directed in the Adult Protective Services Act, Neb. Rev. Stat. § 28-372. Based on record reviews and interviews, the facility failed to report incidents resulting in serious bodily injury within 2 hours for 2 residents, Resident 2 and Resident 6, of 4 residents sampled for reporting and for 1 resident, Resident 2, of 4 residents sampled for reporting. The facility census was 71.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.18(B) Based on observations, interviews, and record reviews: the facility failed to store oxygen tubing and CPAP (Continuous Positive Airway Pressure) (a machine that is used to keep airways open while sleeping) mask/tubing in a manner to prevent the potential for cross contamination for 5 (Residents 7, 23, 59, 53, 42) of 6 sampled residents. The facility census was 71.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.4(B)(ii)(1) Based on interview and record review the facility failed to ensure 12 hours of continuing education had been completed for 3 Nursing Assistants (NA-A, NA-C and NA-D) of 5 reviewed employees that had been employed more than one year. This had the potential to affect all residents in house. The facility identified a census of 71. Findings Are: A record review of continuing education hours for NA (Nurse Aide)-A, hired on 3/21/2011, revealed a total of zero hours had been completed for the last one year, covering 3/21/23 through 3/21/24. A record review of continuing education hours for NA-C, hired on 7/6/2022, revealed a total of 11.75 hours had been completed for the last one year, covering 7/6/23 through 7/6/24. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D6 (7) Based on observation, record review, and interview, the facility failed to ensure that a Metered Dose Inhaler (Nebulizer), (a machine that turns a liquid medication into a vapor for inhalation) was cleaned after each use to prevent the potential for cross contamination for 1 (Resident 58) of 1 sampled resident. The facility census was 71.