Holdrege Memorial Homes, Inc

Licensure 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. Findings are: A.Record review of the facility policy titled Abuse and Neglect Prevention Protocol dated 1/10/19 revealed that it is the facility policy to prohibit and prevent abuse, neglect, and exploitation from occurring. The section titled Screening revealed that the facility will not knowingly employ or otherwise engage individuals who have been found guilty of abuse, neglect exploitation, misappropriation of property, or mistreatment by a court of law; have a finding entered into the 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.

Based 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. Findings are:Record review of the undated facility policy titled Posting Direct Care Daily Staffing Numbers revealed that the facility will post the number of nursing personnel responsible for providing direct care to residents on a daily basis for each shift. The information recorded on the form shall include the actual time worked during that shift for each category and type of nursing staff. Observation on 7/31/25 at 8:23 AM on the wall between the facility Activity Room and Greenhouse Cafe revealed that the Report of Nursing Staff Directly Responsible for Resident Care was posted. The report was dated 7/31/25 and revealed a census of 74 residents. The report revealed day shift staff consisting of 1 Registered Nurse (RN), 3 Licensed Professional Nurses (LPN), and 10 nurse aides (NA). The report…

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 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. Findings are:A. Record review of the undated facility policy titled Employee Orientation and Training revealed that employee orientation will be provided in two stages for new hires. General Orientation will be provided to complete facility and regulatory employment information and forms. Department Orientation will be used to provide…

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.

The 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. Findings are: Record review of the undated facility policy MDS Policy (in regulation with CMS guidelines) revealed the purpose of the policy was to ensure accurate and timely completion of the MDS in compliance with federal and state regulations for all residents of the facility. The procedures were as follows; 1. Resident will be assessed per the MDS…

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(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.Findings are:A. Review of the progress notes revealed that on 12/27/2024 Resident 68 was transferred to the emergency room via ambulance and admitted on [DATE] with a diagnosis of pneumonia. Resident 68 was readmitted to the facility on [DATE]. An entry on 01/10/2025 revealed that the primary care physician had changed the current antibiotic, Bactrim, to cefdinir to treat Resident 68’s pneumonia. An entry on 01/17/2025…

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 12-006.05(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. Findings are: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), was given to the resident and resident representative for any psychotropic medications and prior to starting any psychotropic medications (medications are drugs that affect the mind, emotions, and behavior) which describe in plain language the risks, benefits, options, and alternatives of the medication being prescribed. Findings are: A. Record review 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 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. Findings are:Record review of the undated facility policy titled Transfer and Discharge from the Facility Policy revealed that each resident has the right to remain in the facility and not transfer or discharge a resident. The facility forwards a copy of all discharge notices to the Office of the State Long Term Care Ombudsman and required state agencies. The facility staff will document in the resident's record the date that a copy of the discharge notice was sent to the representative of the Office of the State Long Term Care Ombudsman and identified state agencies per requirements. Record review of the discharge Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 82 dated 6/5/25 revealed that Resident 82 admitted…

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 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.Findings are:A record review of a document titled Best Practices for Wound Assessment and Documentation dated 04/17/2025 by the Wound Care Education Institute revealed the foundational elements of wound assessment should include precise anatomical location, classification and etiology, accurate wound measurements, wound bed characteristics, wound edge and margin assessment, exudate (drainage) characteristics, peri wound (skin surrounding the wound) status, and pain and symptom reporting.A record review of facility's undated policy titled Skin Assessment and Treatment Policy revealed it is the policy of the facility to routinely monitor, assess, and manage residents' skin integrity. All assessments and treatments…

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 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.Findings are:A record review of facility's undated policy titled Policy and Procedures revealed it was the policy of the facility to ensure that residents who require dialysis are monitored and have care needs related to dialysis. Under section 3, monitoring and observation is to occur upon return for dialysis and the resident was assessed for general condition and tolerance of dialysis. Under section 5, Nurses will document date and time of transport to and from dialysis, resident condition before and after dialysis and all communication with dialysis providers and physicians will be documented in the resident's chart.A record review of an Resident Face Sheet revealed the facility admitted Resident 2 on 11/05/2024 with a diagnosis of stage 3 chronic kidney disease (a condition of moderate kidney damage and reduced kidney function 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 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. Findings are: A. A record review of the facility's Abuse and Neglect Prevention Protocol revised May 2024 revealed that the facility was required to report a reasonable suspicion of abuse or neglect to the state agency within 2 hours of forming the suspicion if there was a serious bodily injury, and within 24 hours of forming the suspicion if there was not a serious bodily injury. B. A record review of Resident 2's Continuity of Care Document created 12/12/2024 revealed Resident 2 was admitted on [DATE] and had diagnoses of a fractured right fibula (the bone on the outer side of the…

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 12.006.18(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. Findings are: A record review of the undated facility policy titled Storage of Medications and Treatment Supplies revealed: -When not in use oxygen tubing should be placed in the bag that is attached to the resident's oxygen concentrator. -No mention of CPAP supply storage was located on the policy. A. An observation on 7/9/24 at 8:53 AM revealed that Resident 7's oxygen tubing was not in use and was underneath the handle of the oxygen concentrator at the end of the bed. A bag was attached to the concentrator and was empty. A record review of Resident 7's Order summary dated 7/08/24 revealed the following…

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 12.006.4(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. A record review of continuing education hours for NA-D, hired on 4/3/2023, revealed a total of 9.25 hours had been completed for the last one year, covering 4/3/23 through 4/3/24. A record review of the undated facility policy titled Training Requirements revealed it contained the following guidelines related to training…

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 12-006.09D6 (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. Findings are. A record review of the facility's undated policy titled Administering Medications through a Metered Dose Inhaler (Nebulizer) revealed the following: - the purpose of the policy was to provide guidelines for the safe administration of inhaled medications, - the resident has the right to have their medications in the right dose, - when the dosing is complete, rinse the nebulizer equipment in warm water. A record review of Resident 58's Face Sheet dated 7/10/24 revealed the resident was admitted into the facility on 4/26/24 with a diagnosis of Asthma (a disease that causes the breathing passages to swell and /or close off). A record review of Resident 58's Order Summary dated 7/10/24…

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.