Eventide Prairie Commons Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NA 12-006.10(D) Based on record reviews, observations and interviews, the facility failed to ensure medication error rates were not 5% or greater (27 opportunities with 10 errors resulted in an error rate of 37.04%). This affected 3 (Residents 1, 5, and 123) of 4 residents sampled. The facility census was 23. Findings are: Record review of the undated Medication Error Policy revealed it is the facility policy to ensure residents are free from significant medication errors and that the facility maintains a medication error less that 5%. Medication errors included the following errors: Wrong time Omission of a medication Record review of the undated facility medication times revealed that 6:00 AM to 11:00 AM [NAME] is called AM 6a-11a. This is the time period any of the scheduled morning medications can be given to residents except those medications that have a specific time indicated by pharmacy or a physician. A. Record review of the Electronic Medical Record for Resident 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 1-005.06(D) Based on observation, record review, and interview; the facility failed to ensure staff performed hand hygiene to prevent the potential for cross contamination while assisting residents who were eating meals in the dining room. This had the potential to affect 9 (Residents 1, 2, 3, 6, 10, 11, 12, 13, and 123) of 9 sampled residents. The facility census was 23. Findings are: A record review of the facility's Hand Hygiene policy with a review date of 10/26/2024 revealed the purpose of the policy was to prevent and control the spread of infections to the best of the facility's abilities. The procedure stated; 1. Alcohol-based hand rub is recommended in all situations except when hands are visibly soiled or when caring for a resident with certain known infections. 3. Food and Nutrition staff or staff that are handling food must wash hands with soap and water. 6. The facility strives to provide feedback regarding hand hygiene. 7. Supplies to adhere to hand hygiene practices are readily accessible within resident care areas. An observation on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice-SNFABN Form CMS 10055 ( a notice issued to a resident and/or responsible party to inform them that Medicare will no longer pay for their services) and Notice of Medicare Non-Coverage-NOMNC Form CMS 10123 (a notice required to be provided by the facility to beneficiaries (residents) that are receiving nursing services paid for by Medicare Part A explaining that skilled nursing services will no longer be paid for by Medicare and informing the residents of the right to appeal) for discharge from Medicare Part A to 2 (Residents 5 and 125) of 3 residents sampled which resulted in the potential to prevent Resident 5 and 125 from filing an appeal of the discharge from Medicare Part A covered services. The facility census was 23. Findings are: A. Record review of the undated SNF Beneficiary Notification Review for Resident 5 revealed this resident started Medicare Part A skilled services on 10/16/2024. The last date of coverage for part A services occurred…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175NAC 12-006.09(H)(iii)(2) Based on observation, record review, and interview the facility failed to ensure documentation that resident wounds were evaluated and monitored at least weekly as required for 1 of 1 residents reviewed (Resident 16). This prevented staff from determining if the wound condition was healing or worsening. The facility census was 23. Findings are: Record review of the facility Wound and Skin Care Management dated 11/11/23 revealed that the facility will provide care to promote prevention and management of skin injuries. Weekly evaluations of skin impairment, including measurements, will be completed in the EMR (electronic medical record) (the electronic health record). Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 4/14/25 for Resident 16 revealed that Resident 16 admitted into the facility on 4/8/25. The MDS revealed that Resident 16 had an unstageable pressure ulcer [a wound/bedsore where…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175NAC 12-006.09(H)(i)(3) Based on observation, record review, and interview, the facility failed to answer call lights timely for 1 (Resident 1), of 8 sampled residents and failed to ensure residents received routine bathing for 1 (Resident 1), of 8 sampled residents. The facility census was 32. Findings are: Review of the facility supplied Resident Handbook revealed documentation that residents would be assisted with a bath or shower each week or more often if necessary and assistance from the nursing staff may be obtained by pushing the button on the call light or pendent. Review of the resident demographic record revealed Resident 1 was admitted to the facility on [DATE] with diagnoses of: multiple sclerosis (which is disease that affects central nervous system causing muscle weakness and vision changes), malnutrition (which is the lack of proper nutrition), type 2 diabetes (which is when the body does not produce enough or properly use insulin resulting in elevated blood sugar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175NAC 12-006.10D Based on observation, record review, and interview, the facility failed to follow provider orders for medication administration for 1 (Resident 1) of 2 sampled residents, and failed to ensure proper labeling and priming of an insulin pen for 1 resident (Resident 1) of 1 sampled resident. The facility census was 32. Findings are: A. Review of the resident demographic record revealed Resident 1 was admitted to the facility on [DATE] with diagnoses of: hypertensive heart disease (which is high blood pressure), type 2 diabetes (which is when the body does not produce enough or properly use insulin resulting in elevated blood sugar levels), and atrial fibrillation (which is a type of irregular heartbeat). The comprehensive 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 an Assessment Reference Date (ARD) of 12/09/2024 revealed Resident 1 had a Brief Interview for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.11A1 Based on record review, observation and interviews; the facility failed to use recipes during meal preparation of all foods to ensure the nutritional adequacy of dishes served. This affected all residents that ate food prepared by the facility kitchen. Current census was 18. Findings are: Observation on 04/30/24 at 9:21 AM in the facility's main kitchen. Observed the Cook-A (C-A) preparing a substituted soup of the day; Ham and Beans. There was no recipe visible. This will be an alternative to scheduled soup of the day. Information was sent out to the satellite areas so that all residents were aware of the change. Interview on 04/30/24 at 9:25 AM with the Certified Dietary Manager (DM). When asked about the recipe C-A was using, DM states the ham and beans were substituted for the [NAME] Wedding Soup that they were to have today. DM confirms that recipes are generated from their Dining Manager (DiningRD) computer program to which the facility is subscribed (this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.11E Based on record review, observation and interviews; the facility failed to ensure that foods were maintained at the required temperatures to prevent food borne illnesses on the steam table during meal service and failed to remove and destroy foods that were in the refrigerator longer than 7 days. This had the ability to affect all 18 residents who ate food served by the facility kitchen. Current census was 18. Findings are: A. The Nebraska Food Code of 2017 states that foods must be heated to a temperature of 165 degrees Fahrenheit prior to serving and can then be held for hot holding at a temperature of 135 degrees Fahrenheit until served for up to two hours. (Nebraska Food Guide 2017) Observation on 04/29/24 at 11:50 AM in the satellite kitchen of the Long Term Care (LTC) area: Food products were transferred from the main kitchen area to the satellite kitchen in the LTC area. Once the food products were loaded onto the steam table, all foods were temped. Temperature of the turkey ham and cheese sandwich alternative had a temperature of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to obtain the advanced directive for the residents wishes in regards to code status [a resident's choice for cardiopulmonary resuscitation (a lifesaving attempt combination of rescue breathing and chest compressions when someone's heart has stopped) or do not resuscitate (DNR) (a type of advance directive in which a person states that health care providers should not perform cardiopulmonary resuscitation (restarting the heart) if his or her heart or breathing stops)] and obtain a signed physician order for DNR for 1 resident (Resident 61) and failed to obtain a signed physician order for DNR for 1 resident (Resident 68). The facility census was 18. Findings are: A. Record review of the facility Advanced Directives form dated [DATE] revealed that the facility will provide all clients (residents) with information regarding their right to formulate an Advance Directive and honor Advanced Directives as executed by the client to the extent allowed under state…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175NAC 12-006.12E5; Licensure Reference Number 175 NAC 12-006.12E1b Based on observation, interview, and record review the facility failed to store medications administered by different routes separately for 1 resident, (Resident 67) of 7 sampled residents; failed to administer eye drops following current professional standards of care for 1 resident, (Resident 63) of 7 sampled residents; and failed to ensure accountability of a controlled substance for 1 resident (Resident 7) of 7 sampled residents. The facility census was 18. Findings are: A. Medication pass observation was conducted on 04/30/2024 from 11:50 AM to 12:21 PM with Medication Aide-C (MA-C), in which the following was observed: MA-C knocked and entered Resident 67 room. MA-C used keys to unlock the cabinet located just inside the doorway to Resident 67's room and retrieved a drawer like container from the cabinet that contained unit dose cards for medications and two taller cardboard boxes. The cardboard boxes were labeled as Fluticansone Propionate which is a medication that is administered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05 (4) Based on interview and record review, the facility failed to provide bathing preferences for 1 (Resident 71) of 2 sampled residents. The facility census was 18. Record review of Resident 71's admission Record dated 05/01/2024 revealed that Resident 71 admitted to the facility on [DATE]. Record review of Resident 71's Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 04/22/2024 revealed a Brief Interview for Mental Status (BIMS-a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) of 10, which indicated the resident was mildly impaired. In an interview on 04/29/24 at 11:23 AM with Resident 71 and spouse revealed they wanted a bath twice weekly and that they have not been receiving that preference. A record review of Resident 71's bathing task report documented in Point Click Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.09D3(5) Based on interview and record review; the facility failed to ensure routine bowel movements for 1 (Resident 2), of 2 sampled residents. The facility stated census of 18. Review of a facility policy titled Maintaining Bowel and Bladder Function dated 09/21/2023 revealed the Bowel Care Medication regimen will be implemented for all patients unless otherwise directed by the patient's provider to prevent or manage constipation. Review of a facility document labeled Bowel Care Protocol and dated 04/30/2024 revealed Resident 2 had gone five days without a bowel movement. The document also stated: A. on day three of no bowel movement - Milk of Magnesia 30 milliliters by mouth one time. B. on day four of now bowel movement - Bisacodyl 10 milligram suppository one time. C. if no stool with in four hours of having Dulcolax, re-evaluate to rule out impaction and administer one of the following: Fleets enema on time, or Magnesium Citrate 4 ounces by mouth. If no results, contact the physician to update on client's bowel status. Review of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12.006.09D7b Based on observation, interview, and record review; the facility failed to update and or change interventions to prevent falls for 1 resident (Resident 2), out of 2 sampled residents. The facility census was 18. Findings are: Review of facility policy titled Fall Risk Evaluation and Post fall Procedures not dated revealed under procedure to review and update care plan if a resident falls. Review of facility supplied document labeled Post-Fall Checklist dated 02/12/2023 revealed item four, care plan which is a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident, updated post-fall with new fall in focus statement, new intervention, and goals. A review of an admission Record revealed the facility admitted Resident 2 on 05/04/2023 with diagnoses of dementia which is the impaired ability to remember, think, or make decisions that interferes with doing everyday activities, with mood disturbance which is noticeable disruptions in someone's emotions, and anxiety which is feelings of worry, anxiety,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licsensure Reference Number 175 NAC 12-006.09D Based on record review, observation and interviews, the facility failed to ensure that medications used together will not lead to adverse consequences, and that all medications had adequate indications for use with an appropriate diagnosis code. This affected 1 (Resident 3) of 5 sampled residents. Census was 18. Findings are: A. The National Capital of Poison Control posted an article entitled Trazodone: Side Effects, Interactions, and Overdose on their website accessed and read May 2024. Taking trazodone with other medications that increase serotonin levels, such as dextromethorphan, tricyclic antidepressants, tryptophan or 5-HTP, and buspirone, can cause a potentially life-threatening condition called serotonin syndrome (serotonin syndrome is a potentially life-threatening drug reaction. It causes the body to have too much serotonin, a chemical produced by some nerve cells.). Trazodone commonly causes drowsiness, which may be increased when taken with other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.