Northfield Retirement Communities Care Center

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record review and interview, the facility failed to ensure 2 of 5 sampled Nurse Aides completed 12 hours of ongoing in-service training and at least 4 hours of dementia care training. This had the potential to affect all residents who resided within the facility. The facility identified a census of 60. Findings Are:A record review of the Facility Assessment Tool, last updated on 7/3/26 revealed that Nurse Aides (NA) must complete no less than 12 hours of in-service training per year and the training would include dementia management training. The in-service training would address areas of weakness as determined in NA's performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(D)&(E) Based on record review and interview, the facility failed to ensure residents or their representatives were informed in advance of the risks and benefits of a medication, the treatment alternatives or other options prior to the use of psychotropic medication for 7 (Residents 2, 8, 10, 24, 54, 57, and 62) of 7 sampled residents. The facility identified a census of 60.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(H) Based on record review and interview, the facility failed to protect other residents from 1 (Resident 54) of 1 sampled resident's adverse behaviors. The facility identified a census of 60. Findings Are:A record review of the facility policy Abuse, Neglect, Exploitation, and Misappropriation Prevention Program with a revision date of April 2021 revealed Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to notify Adult Protective Services (APS) of alleged resident-to-resident abuse for Resident 54. failed to notify APS within the required timeframe of an injury of unknown origin for Resident 6, and failed to submit an investigation report to the State Agency within the required timeframe for Residents 54 and 6. The sample size was 4 and the facility identified a census of 60. A record review of the facility policy Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating with a revision date of July 2026 revealed all allegations of resident abuse (including injuries of unknown source), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations). A. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)(i)(1),(3), & (4)Based on record review, interview and observation, the facility failed to identify causal factors and implement interventions to prevent falls, and ensure resident safety for 4 (Resident 1, 5, 3, and 7) out of 7 sampled residents. The facility showed a census of 55.

Inspectors wroteBased on record review and interview, the facility failed to submit a comprehensive investigative report to the State Agency for 2 (Residents 1 and 3) of 6 sampled residents who had a fall with major injury. The facility census was 55. Findings Are: A record review of facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program with revision date of April 2021 revealed the facility was to investigate and report any allegations within timeframes required by federal requirements. A.A record review of Resident 1's Facesheet dated 3/10/2026 revealed the resident was admitted to the facility on [DATE] and was discharged from the facility on 2/22/2026. A record review of Resident 1's Progress Notes dated 2/20/2026 revealed the resident had a fall on 2/19/2026 which resulted in a laceration to the left side of their head, a left wrist fracture, and a left femur fracture. [...]

Inspectors wroteNebraska Revised Statute 71-6018.02(2)(a) Based on record reviews and interviews, the facility failed to ensure the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week as required. This had the potential to affect all residents who reside within the facility. The facility identified a census of 45.

Inspectors wroteLicensure Reference Number NAC 175 12-006.11(E) Based on record review, interviews, and observations the facility failed to identify and dispose of spoiled fruits and vegetables stored in the walk-in refrigerator. This had the potential to affect all residents who resided within the facility. The facility identified a census of 45.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(B)(i) Based on record reviews and interviews, the facility failed to implement an effective initial training program to ensure new employees had completed training on topics of resident rights, emergency procedures, abuse/neglect, dementia care and medical emergency directives (for nursing staff) for 3 (Dietary Aide (DA) -G, Nurse Aide (NA) -B, and Medication Aide (MA) -D) of 5 sample employees. This had the potential to affect all residents residing within the facility. The facility identified a census of 45.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(B)(ii) Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record review and interviews, the facility failed to ensure nurse aides (NA)/ medication aides (MA) had completed ongoing training of at least 12 hours per year on topics appropriate to the employee's job duties, abuse/neglect training, and at least 4 hours of dementia training as required for 5 (MA-H, NA-A, MA-F, MA-E, and NA-I) of 5 sample employees. This had the potential to affect all residents residing within the facility. The facility identified a census of 45.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on Interview and record review, the facility failed to notify the medical provider of 1 (Resident 22) of 1 resident's elevated blood pressures. The facility identified a census of 45.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(G) Based on interview and record review, the facility failed to attempt gradual dose reductions or provide clinical rationale for not attempting a gradual dose reduction for 2 (Residents 19 and 24) of 5 sampled residents' psychotropic medications. The facility identified a census of 45.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F)(i) Based on record reviews and interviews, the facility failed to develop a baseline care plan (BCP, a resident's plan of care that includes the minimum information needed to provide effective, person-centered care immediately upon admission) within 24 hours as required for 1 (Resident 41) of 2 sample residents. The facility identified a census of 45.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12 Based on interview and record review, the facility failed to follow the physician's orders for 1 (Resident 44) of 1 sampled resident. The facility identified a census of 45.

Inspectors wroteLicensure Reference Number NAC 175-12-006.09(H)(v) Based on observations, interviews, and record review the facility failed to provide treatment and care for contractures for 1 (Resident 1) of 4 sampled residents. The facility identified a census of 45.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on record review and interviews the facility failed to provide rational or clinical indicators of continued use of an antibiotic for one (Resident 14) of one sampled resident. The facility census was 45.

Inspectors wroteBased on record review and interview, the facility failed to provide a written summary of the baseline care plan to 1 (Resident 1) of 3 sampled residents. The facility census was 51. Findings Are: A record review of a facility policy Care Plans-Baseline with a last revised date of March 2022, revealed that a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission. The policy also stated that the resident and/or representative are to be provided a written summary of the baseline care plan. A record review of Resident 1's admission Record revealed the resident was admitted to the facility on [DATE]. A record review of Resident 1's medical records revealed no evidence that a written summary of Resident 1's baseline care plan had been provided to the resident or their representative. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.01(G)&(H) Based on record review and interview, the facility failed to notify the State Agency of a change in administrator within 5 working days as required. This had the potential to affect all residents who resided within the facility. The facility census was 51. Findings Are: A record review of a facility provided document titled Change of Administrator or Director of Nursing Notification Form revealed that the facility had a change in administrator on 10/11/2024. A record review of a facility provided email exchange revealed that the facility had emailed the Change of Administrator or Director of Nursing Notification Form related to the change in administrator that occurred on 10/11/2024 to the State Agency on 11/8/2024. [...]

Inspectors wroteLicensure Reference 175 NAC 12-006.11D Based on observations, interviews, and record review; the facility failed to follow a recipe to ensure nutritive value was preserved. This had the potential to affect all 47 residents that reside and eat at the facility.

Inspectors wroteLicensure Reference 175 NAC 12-006.11E Based on observations, interviews, and record review; the facility failed to ensure foods were discarded before the expiration dates, foods were stored in a manner that prevented potential for foodborne illnesses and failed to ensure the kitchen was maintained in a sanitary conditions. This had the potential to affect all 47 residents that resident at the facility.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17 Based on observation, interviews, and record review the facility failed to utilize Enhanced Barrier Precautions as required for 1 (Resident 39) of 1 sampled resident and failed to implement a water management program that would prevent the growth and spread of Legionella and other opportunistic water borne pathogens. This had the potential to affect all residents. The facility census was 47. The Findings Are: A. A record review of undated facility policy Enhanced Barrier Precautions (EBP) Policy for Long-Term Care Facilities, revealed enhanced barrier precautions would be implemented in the facility to prevent the transmission of infectious diseases, including but not limited to, respiratory viruses (e.g., influenza, COVID-19) and multi-drug resistant organisms (MDROs). [...]

Inspectors wroteBased on record review and interview, the facility failed to provide the Centers for Medicare and Medicaid Services (CMS)-10055 form to 3 (Residents 23, 33, and 41) of 3 sampled residents as required. The facility census was 47. The Findings Are: A record review of facility policy Medicare Advance Beneficiary and Medicare Non-Coverage Notices with last revised date of September 2022, revealed in the Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) section that if the director of admissions or benefits coordinator believed that Medicare would not pay for an otherwise covered skilled service, the resident (or representative) would be notified in writing why the service may not be covered and of the resident's potential liability for payment of the non-covered service. A. [...]

Inspectors wroteLicensure Reference 175 NAC 12-006.12B Based on interviews and record reviews, the facility failed to ensure a medication regimen review was completed monthly by the pharmacist and that a physician had reviewed the pharmacist's recommendations as required for 3 (Resident 1, 21, and 39) of 5 sampled residents. The facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18E1 Based on observations, record review, and interview the facility failed to ensure an' oxygen concentrator was turned off when not in use, and failed to ensure the nasal cannula was not left on the resident's unoccupied bed when the concentrator was left on and unattended for 1 (Reskdent 32) of 1 sampled resident. The facility census was 47. The Findings Are: A record review of facility policy Oxygen Administration with last revised date of October 2010, revealed the facility would instruct the resident, their family, visitors, and roommate (if any) of the oxygen safety precautions and that the facility would provide the resident with a written copy of the Oxygen Safety handout. A record review of undated facility provided document Using Oxygen Safely, revealed instruction to Turn off your oxygen when you're not using it. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on record review and interview, the facility failed to evaluate and implement interventions to manage pain for 1(Resident 39) of 1 sampled residents. The facility census was 47. The Findings Are: A record review of facility policy Pain Assessment and Management with last revised date of October 2022, revealed pain would be assessment using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. A record review of website, wongbakerfaces.org revealed the Wong-Baker FACES Pain Rating Scale was a self-assessment tool that must be understood by the patient, so they would be able to choose the face that best illustrated the physical pain they were experiencing. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10 Based on interviews and record reviews, the facility failed to ensure PRN (as needed) antipsychotic medication use was limited to 14 days and that a rationale for continued use was documented by the provider as required for 1 (Resident 21) of 5 sampled residents. The facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10D Based on Record Review, Observations, and Interviews, the facility failed to ensure it was free of a medication error rate of 5% or greater. Observation of 36 medications administered revealed 4 errors while crushing medications resulting in a medication error rate of 11.11%. These medication errors affected 2 residents (Resident 5 and Resident 22) of 5 observed residents. Current Census at the facility was 48.

Inspectors wroteLicensure reference Number 175 NAC 12-006.04A3b Based on record review and interviews, the facility staff failed to completed background checks for 5 of 5 employees reviewed and failed to provide rational for hiring for 1 of 1 staff member who had a negative findings. This had the potential to affect all residents who resided within the facility. The facility census was 47. The Findings Are: A record review of facility policy Background Screening Investigations with revised date of March 2019, revealed the facility was to conduct background checks and criminal conviction checks on all potential direct access employees. The policy also revealed that the background and criminal checks would be initiated within two days of an offer for employment and would be completed prior to employment. [...]

Inspectors wroteLicense Reference Number 175 NAC 12-006.04D2A Based on interview and record review, the facility failed to ensure the Dietary Manager had the credentialing to meet the regulatory requirements for the position. This had the potential to affect all 47 residents in the facility.

Inspectors wroteLicense Reference Number NAC 175 12-006.11E Based on observation, interview, and record review, the facility failed to ensure food was stored in a manner to prevent food borne illness and failed to ensure staff wore hair restraints during food preparation. This had a potential to affect all 47 residents residing in the facility that received meals from the kitchen.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17 Based on interview and record review, the facility failed to employ at least a part time employee who had completed the required training as an Infection Preventionist. This had the potential to impact all 47 residents in the facility.

Inspectors wroteLicensure Reference Number: 175 NAC 12-006.09D3(6) Based on record review and interview, the facility failed to ensure that residents were free of indwelling Foley catheters (a drainage tube inserted into the bladder) without an approved clinical diagnosis for 1 resident (Resident #22). The sample size was 12. The facility census was 47.