Inspection Reports for Prestige Care Center of Plattsmouth
Prestige Care Center of Plattsmouth, PLATTSMOUTH, NE, 68048
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
19.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
355% worse than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
40
30
20
10
0
Census
Latest occupancy rate
60 residents
Based on a July 2018 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Capacity: 111
Deficiencies: 0
Date: Apr 16, 2019
Visit Reason
The document is related to the licensing and transfer of operations of the skilled nursing facility Prestige Care Center of Plattsmouth due to a change of ownership and facility name change, with the effective date of the new license being April 16, 2019.
Findings
The report details the issuance of a new Skilled Nursing Facility license to Plattsmouth Operations LLC, effective April 16, 2019, following a change of ownership and name. It includes the terms of the operations transfer agreement, conditions for licensing, employee transition, and transfer of assets and contracts.
Report Facts
Total licensed capacity: 111
License effective date: Apr 16, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Tanner | Administrator | Named as facility administrator in licensing letter |
| Brooklin Zimmerman | Director of Nursing | Named as Director of Nursing in facility information |
| Ephram Mordy Lahasky | Authorized Signatory, Sole Member, 100% Owner | Named as sole member and authorized signatory of Plattsmouth Operations LLC, new licensee and operator |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 2
Date: Jul 31, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Plattsmouth Care And Rehabilitation Center, LLC from July 25, 2018 to July 31, 2018, regarding allegations including insufficient staffing, lack of supplies, failure to follow practitioners' orders, medication misappropriation, and staff training.
Complaint Details
The complaint investigation was substantiated for failure to follow practitioner's orders related to pressure sore treatment and failure to implement fall prevention interventions. Other allegations related to staffing, supplies, medication accounting, and staff training were found not to be violations.
Findings
The facility was found compliant with staffing, supplies, medication accounting, and staff training. However, the facility failed to follow practitioner's orders by not providing treatment to a pressure sore for one resident and failed to implement fall prevention interventions for another resident at risk of falls.
Deficiencies (2)
Failed to provide treatment to a pressure sore for one sampled resident with a pressure sore.
Failed to implement interventions to prevent falls for one sampled resident at risk for falls.
Report Facts
Facility census: 60
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed letter regarding complaint investigation findings |
| Chasity Coover | Administrator | Facility administrator addressed in the report |
| Dr. Horton-Brown | Medical director who ordered treatment change for pressure sore | |
| Director of Nursing | Reported on missed order for pressure sore treatment and confirmed fall alarm requirements | |
| Nurse Aide A | Reported Resident 1's fall alarm was not on | |
| Licensed Practical Nurse B | Observed treating Resident 4's pressure sore |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 111
Deficiencies: 39
Date: May 14, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Plattsmouth Care And Rehabilitation Center, Llc on May 14, 2018-May 21, 2018, by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
Complaint investigation included allegations of failure to protect residents from misappropriation, failure to ensure dental services, failure to follow medication administration rights, housekeeping and maintenance issues, failure to answer call lights promptly, failure to provide appropriate activities, insufficient staffing, failure to maintain equipment, failure to follow plan of care, and failure to notify practitioners of changes in condition.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents received dental services regularly, ineffective housekeeping and maintenance, failure to answer call notification systems promptly, failure to provide appropriate activities, failure to maintain essential equipment, failure to follow plan of care, failure to notify practitioner of changes in condition, and multiple life safety code violations.
Deficiencies (39)
Failure to ensure residents received dental services on a regular basis.
Failure to ensure an effective housekeeping and maintenance program.
Failure to answer call notification systems promptly.
Failure to provide appropriate activities to meet psychosocial needs.
Failure to maintain essential equipment (freezer with hole and insulation exposed).
Failure to follow the plan of care.
Failure to notify the practitioner of changes in condition.
Failure to provide written notice of bed hold policy within 24 hours of transfer to hospital.
Failure to provide bathing and shaving assistance as needed.
Failure to provide individualized activity program for residents with dementia.
Failure to monitor wound site and implement interventions to prevent skin tears.
Failure to ensure pressure relieving cushion was inflated.
Failure to implement Facility Maintenance Program for restorative nursing.
Failure to implement toileting program for resident with incontinence.
Failure to change tubing for oxygen and nebulizer treatments weekly.
Failure to monitor dialysis access site post treatment.
Failure to ensure residents with dementia were engaged in activities and activities in dementia care unit were not monitored by certified activities director.
Failure to conduct monthly drug regimen review including monitoring for adverse effects of antipsychotic medications.
Failure to ensure residents received routine dental services.
Failure to have an effective quality assurance program to address deficient practices.
Failure to maintain an infection prevention and control program including hand hygiene and surveillance.
Failure to implement an antibiotic stewardship program.
Failure to maintain ACU refrigerator in good repair with hole and exposed insulation.
Failure to ensure call system was functional in multiple resident rooms and bathrooms.
Failure to ensure kitchen window was in good repair.
Failure to ensure functional ventilation system in hopper rooms.
Failure to include contact information for emergency preparedness staff and agencies in emergency plan.
Failure to include primary and alternate means for communication with staff and emergency agencies in emergency plan.
Failure to include method for sharing emergency plan information with residents and families.
Failure to maintain safe walking surface on sidewalk egress path with abrupt elevation changes.
Failure to maintain delayed egress doors to activate alarm and unlock with no more than 15 pounds of force.
Failure to maintain 2-hour fire resistance rating of horizontal exit door allowing it to be pushed open without latching.
Failure to provide smoke resistant enclosure for hazardous areas with doors that latch.
Failure to have exhaust system for kitchens inspected every 6 months and fire suppression nozzles properly positioned.
Failure to conduct biannual smoke detector sensitivity test and replace corroded sprinkler heads.
Failure to ensure corridor doors resist passage of smoke with door closure devices that latch.
Failure to implement annual inspection and testing program for fire rated doors.
Failure to test diesel fuel annually, test emergency generator monthly at 30% load for 30 minutes, and provide documentation of annual load bank test.
Failure to take precautions to prevent oxygen-enriched atmosphere by shutting off oxygen concentrators when not in use.
Report Facts
Deficiencies cited: 38
Residents sampled: 7
Facility census: 62
Facility total capacity: 111
Elevated blood sugar readings: 50
Residents affected by call light system: 39
Residents affected by call light bathroom light: 11
Residents affected by ventilation failure: 14
Residents affected by freezer hole: 16
Residents affected by sidewalk elevation change: 18
Residents affected by delayed egress door: 18
Residents affected by horizontal exit door: 18
Residents affected by hazardous area door: 62
Residents affected by sprinkler system issues: 62
Residents affected by corridor door smoke passage: 11
Residents affected by fire door inspection: 62
Residents affected by oxygen concentrator left on: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed complaint investigation report and communicated plan of correction instructions. |
| Roxanne Smith | Administrator | Facility administrator receiving complaint investigation report and involved in plan of correction. |
| Maintenance Staff A | Acknowledged findings related to sidewalk elevation, delayed egress doors, horizontal exit door, sprinkler system, corridor doors, and fire door inspections. | |
| Registered Nurse E | RN | Involved in blood sugar monitoring and wound care observations. |
| Registered Nurse F | RN | Observed in blood sugar monitoring procedure. |
| Director of Nursing | DON | Provided multiple interviews regarding deficiencies and corrective actions. |
| Social Worker | Interviewed regarding complaint investigation and quality assurance. | |
| Activities Director | Interviewed regarding activities program deficiencies. | |
| Assistant Activities Director | Observed providing activities in Alzheimer's Care Unit. | |
| Dietary Director | Interviewed regarding freezer and kitchen window issues. | |
| Registered Nurse A | Staff Development RN | Interviewed regarding quality assurance and infection control logs. |
| Maintenance Director | Interviewed regarding call light system and ventilation issues. |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 6
Date: Feb 21, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Plattsmouth Care And Rehabilitation Center, LLC from February 21, 2018 to February 27, 2018 by the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint investigation included allegations of insufficient staffing, call notification system issues, failure to supervise residents, failure to follow plan of care, failure to prevent injuries, disrespectful treatment, delayed call light response, lack of call light access, and insufficient supplies. Several allegations were substantiated including staffing, plan of care, and injury prevention failures.
Findings
The investigation found multiple deficiencies including insufficient staffing with the Director of Nursing working as a charge nurse despite census over 60, failure to follow the plan of care for two residents, failure to implement interventions to prevent hot liquid burns for one resident, failure to follow bathing preferences for two residents, co-mingling of resident and facility funds, failure to investigate bruising for one resident, failure to identify and monitor bruising for one resident, and failure to ensure adequate supervision and accident prevention measures.
Deficiencies (6)
Facility failed to ensure sufficient staffing; DON worked as charge nurse with census over 60.
Facility failed to follow the plan of care for two residents regarding bathing preferences.
Facility failed to ensure resident funds were not co-mingled with facility funds.
Facility failed to investigate bruising for one resident.
Facility failed to identify and monitor bruising for one resident.
Facility failed to implement interventions to prevent potential hot liquid burns for one resident.
Report Facts
Resident census: 78
Baths missed: 13
Charge nurse shifts worked by DON: 4
Bruise size: 3
Bruise size: 2
Hot Liquid Safety Evaluation score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed complaint investigation letter |
| Tara Gabel | Administrator | Facility administrator interviewed regarding DON working as charge nurse |
| Director of Nursing | Director of Nursing (DON) | Named in findings for working as charge nurse and failure to monitor bruising |
| Secured Unit Manager | Secured Unit Manager (SUM) | Interviewed regarding bathing records for residents |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding hot liquid safety interventions |
| Nursing Assistant A | Nursing Assistant | Present during observation of bruising on Resident 21 |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 7
Date: Jun 7, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint survey at Plattsmouth Care And Rehabilitation Center, LLC from May 11, 2017 to June 7, 2017, triggered by multiple allegations including failure to protect residents from abuse, failure to provide care for bladder elimination, skin breakdown prevention, call system response, food temperature and palatability, staffing sufficiency, bathing preferences, medical appointment cancellations, restorative program effectiveness, and fall interventions.
Complaint Details
The complaint investigation was substantiated with findings of failure to protect residents from abuse, failure to provide care to prevent skin breakdown, failure to maintain an effective restorative program, medication errors, failure to serve food at proper temperatures and palatability, and failure to secure medications. Some allegations were found not to be violations.
Findings
The investigation found multiple deficiencies including failure to protect residents from abuse by not reporting neglect allegations timely and not reviewing a new hire's criminal background check; failure to provide care to prevent skin breakdown; failure to maintain an effective restorative program; medication errors with a 7.69% error rate; failure to serve food at appropriate temperatures and ensure palatability; and failure to secure medication carts and medications. Several allegations were found not to be violations, such as bladder care, call system response, staffing sufficiency, bathing preferences, medical appointment cancellations, and fall interventions.
Deficiencies (7)
Failure to protect residents from abuse by not reporting neglect allegations to APS within required 2 hours and failure to review and document new hire employee's positive criminal background check.
Failure to provide care and treatment to prevent skin breakdown for one resident; wound was not monitored or treated as ordered.
Failure to notify physician timely of skin breakdown and suicidal statements for residents.
Failure to maintain an effective restorative program for one resident.
Medication error rate of 7.69%, exceeding the 5% threshold, affecting 2 of 16 sampled residents.
Failure to serve food at appropriate temperatures and ensure food is palatable; room trays served cold and food quality poor.
Failure to secure medication carts and medications, leaving them unlocked and unattended with medications on top.
Report Facts
Facility census: 85
Medication error rate: 7.69
Number of sampled residents affected by medication errors: 2
Number of residents with medications observed unsecured: 7
Number of allegations investigated: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed letter regarding complaint investigation findings |
| Cassandra Putnam | Administrator | Facility administrator named in report |
| RN A | Registered Nurse | Observed wound care and interviewed regarding skin breakdown monitoring |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding failure to notify physician and abuse reporting |
| Social Service Director | Social Service Director (SSD) | Interviewed regarding resident suicidal statements |
| Licensed Practical Nurse D | LPN | Observed medication administration error |
| Registered Nurse E | RN | Observed medication administration error and medication cart unsecured |
| Director of Human Resources | DHR | Interviewed regarding criminal background check documentation |
| Facility Administrator | Facility Administrator (FA) | Interviewed regarding abuse reporting and background check documentation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 18, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to provide appropriate positioning/transfers and failure to change fall interventions after residents were identified at risk for falls.
Complaint Details
The complaint alleged failure to provide appropriate positioning/transfers and failure to change fall interventions after residents were identified at risk for falls. Both allegations were found to be unsubstantiated.
Findings
The investigation found no violations related to the allegations. Observations and record reviews confirmed appropriate use of gait belts for transfers and proper revision of fall interventions for at-risk residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the complaint investigation report. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 111
Deficiencies: 21
Date: Mar 13, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Plattsmouth Care And Rehabilitation Center, LLC from March 13, 2017 to March 16, 2017.
Complaint Details
The complaint investigation included allegations of abuse, failure to provide required care and treatment, failure to follow plans of care, medication errors, insufficient staffing, and failure to notify family and physicians of significant changes. Some allegations were substantiated with deficiencies found.
Findings
The facility was found to be in compliance with abuse protection, interventions for resident behaviors, family visitation, bowel elimination care, discharge planning, care according to practitioner's orders, food temperature, and therapeutic diet orders. Deficiencies were found related to failure to provide required tracheotomy cares, staff training for resident needs, failure to follow plan of care, medication administration errors, and insufficient staffing.
Deficiencies (21)
Failed to provide required tracheotomy cares.
Failed to ensure staff is trained to deal with residents needs.
Failed to implement or follow the plan of care.
Failed to provide medications per practitioner's orders.
Failed to maintain sufficient staffing.
Failed to notify physician and family of significant changes for residents 36 and 49.
Failed to evaluate and document bathing preferences for resident 127.
Failed to develop comprehensive care plans for tracheostomy care and dental care for residents 86, 104, and 58.
Failed to ensure call lights were answered timely for dependent residents 130 and 74.
Failed to evaluate and develop interventions to promote bladder continence for residents 130 and 74.
Failed to ensure tracheostomy supplies were available for emergent care and staff were trained for resident 86.
Medication error rate exceeded 5% due to crushing extended release medications and late medication administration for residents 16 and 76.
Failed to ensure resident 58 received influenza immunization for current season.
Failed to follow infection control practices during wound dressing change for resident 56.
Delayed egress doors required more than 15 pounds of force to release, risking occupant egress in emergency.
Failed to provide illumination of exit discharge so failure of any single bulb did not leave area in darkness.
Storage within 18 inches of fire sprinkler deflectors and openings in ceiling allowed heat to bypass sprinkler heads.
Failed to ensure doors opening onto corridor resist passage of smoke due to curtains preventing doors from latching.
Failed to provide remote manual stop switch for emergency generator outside generator area.
Failed to conduct all required weekly and monthly inspections of emergency generator.
Failed to conduct annual inspection/testing of fire alarm system.
Report Facts
Deficiencies cited: 20
Medication error rate: 6.6
Residents affected by delayed egress doors: 33
Residents affected by sprinkler storage issue: 26
Residents affected by corridor door smoke passage: 11
Residents affected by exit discharge lighting: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassandra Putnam | Administrator | Named as facility administrator and signer of documents. |
| Eve Lewis | RNC, Program Manager - Office of LTC Facilities - Licensure Unit | Signed complaint investigation letter. |
| Carol LPN | Licensed Practical Nurse | Observed medication administration errors. |
| Maintenance A | Acknowledged and verified delayed egress door and lighting deficiencies. | |
| LPN B | Licensed Practical Nurse | Observed tracheostomy care and supply deficiencies. |
| LPN I | Licensed Practical Nurse | Observed wound dressing change infection control deficiencies. |
| NA H | Nursing Assistant | Observed wound dressing change infection control deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 20, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility fails to protect residents from abuse.
Complaint Details
The complaint alleged the facility fails to protect residents from abuse. The investigation found no substantiated violations.
Findings
Observations, interviews, and record reviews found no violations; residents denied abuse and staff were knowledgeable about abuse policies. The facility was in compliance with regulatory requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Licensure Unit, Division of Public Health-DHHS | Signed the inspection report and represents the regulatory authority conducting the investigation. |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 2
Date: Nov 14, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to use and update fall interventions as identified on the plan of care.
Complaint Details
The complaint alleged the facility failed to use fall interventions as identified on the plan of care, failed to change fall interventions after residents were identified at risk for falls, and failed to follow the plan of care to prevent falls. The investigation substantiated these allegations.
Findings
The facility failed to implement and revise fall interventions for residents identified at risk for falls, violating Federal and State regulations. Observations, interviews, and record reviews confirmed these deficiencies.
Deficiencies (2)
Failed to review and revise fall interventions for one of four sampled residents (Resident 3).
Failed to implement a fall intervention for another resident (Resident 1).
Report Facts
Facility census: 84
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation letter |
| Cassandra Putnam | Administrator | Facility administrator addressed in the report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 4, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint at Plattsmouth Care And Rehabilitation Center, Llc on October 4-5, 2016 by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint investigation addressed multiple allegations including failure to respond promptly to calls for assistance, failure to treat pain complaints timely, failure to provide bladder elimination care, failure to treat residents with respect and dignity, failure to provide essential equipment, failure to ensure grievance filing without retribution, failure to provide privacy during care, failure to serve attractive and palatable meals, failure to assess food allergies prior to meals, failure to secure narcotic medication, and failure to administer medications according to practitioner orders. All allegations were found to have no violations.
Findings
The investigation found no violations related to the complaints including timely response to calls for assistance, treatment of pain complaints, bladder elimination care, respect and dignity for residents, provision of essential equipment, grievance filing without retribution, privacy during care, meal quality and allergy assessment, narcotic medication security, and medication administration according to practitioner orders. An error in medication transcription was found but no administration error occurred and preventative measures were in place.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Licensure Unit, Division of Public Health-DHHS | Signed the complaint investigation report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 21, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding infection control guidelines, care and treatment for bowel elimination, and care according to the plan of care at Golden Livingcenter - Plattsmouth.
Complaint Details
The complaint alleged failure to follow infection control guidelines, failure to provide care and treatment for bowel elimination, and failure to provide care according to the plan of care. All allegations were found to be unsubstantiated.
Findings
The investigation found no violations related to infection control guidelines or bowel elimination care. It was determined that the facility provided care as identified on the plan of care, with staff knowledgeable about individualized care plans and residents' rights.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 2, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint at Golden Livingcenter - Plattsmouth regarding allegations of failure to complete written investigations timely, provide care for bowel elimination, provide bathing as required, and use appropriate interventions to prevent injuries.
Complaint Details
The complaint allegations included failure to complete written investigations within five working days, failure to provide care and treatment for bowel elimination, failure to provide bathing as required, and failure to use appropriate interventions to prevent injuries. All allegations were found to be unsubstantiated or corrected.
Findings
The investigation found no violations related to timely completion of written investigations, care for bowel elimination, or injury prevention interventions. The facility was providing bathing as required and had corrected previous deficiencies cited on 5/9/16.
Report Facts
Citation date: May 9, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 6
Date: May 9, 2016
Visit Reason
An unannounced visit was conducted to investigate multiple complaints at Golden Livingcenter - Plattsmouth, including failure to provide bathing, failure to answer call lights promptly, failure to evaluate causal factors for falls, and insufficient staffing.
Complaint Details
The complaint investigation was triggered by allegations including failure to provide bathing, failure to answer call lights promptly, failure to evaluate causal factors for falls, failure to change fall interventions, insufficient staffing, failure to provide emergency care, failure to ensure food form meets resident needs, failure to provide medications per physician orders, failure to ensure residents are free from misappropriation, failure to allow residents to choose bedtime, failure to report resident death related to abuse/neglect, failure to ensure grooming, and failure to provide prompt CPR. Some allegations were substantiated with violations found; others were not.
Findings
The facility was found deficient in providing scheduled bathing to residents, timely response to call lights, evaluating and updating fall interventions, and maintaining sufficient staffing levels. Some residents experienced extended periods without baths, call light pagers were not consistently carried by staff, fall interventions were not always updated or implemented, and staffing shortages impacted care delivery. The facility also failed to ensure food consistency met individual resident needs for one resident.
Deficiencies (6)
Failure to provide bathing as required for residents.
Failure to answer call notification systems promptly.
Failure to evaluate causal factors for falls and failure to change fall interventions after residents identified at risk.
Failure to ensure sufficient staffing to care for residents.
Failure to provide food in the form to meet individual needs for one resident.
Failure to provide prompt cardio-pulmonary resuscitation (CPR) as required.
Report Facts
Census: 90
Grievances regarding call light response: 5
Baths missed: 18
Baths missed: 24
Bath aide reassignment days: 13
Bath aide partial shift assignments: 2
Medication dosage: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the cover letter for the complaint investigation report |
| Cassandra Putnam | Administrator | Facility administrator named in the report |
| Nursing Assistant G | Interviewed regarding call light pager usage and failures | |
| Nursing Assistant F | Observed and interviewed about forgetting to carry call light pager | |
| Nursing Assistant H | Interviewed about call light pager and bathing refusals | |
| Nursing Assistant I | Interviewed about missing call light pager | |
| Nursing Assistant J | Interviewed about staffing shortages impacting bathing frequency | |
| Licensed Physical Therapy Aide D | Interviewed about therapy services for Resident 1 after falls | |
| Licensed Practical Nurse C | Interviewed about toileting schedule for Resident 1 | |
| Licensed Practical Nurse L | Interviewed about Resident 8 fall causes | |
| Medication Assistant E | Interviewed about dietary food consistency issues for Resident 2 | |
| Dietary Manager | Interviewed about diet orders and waivers for Resident 2 |
Inspection Report
Renewal
Capacity: 111
Deficiencies: 0
Date: Jan 20, 2016
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related materials for Golden LivingCenter - Plattsmouth, indicating the purpose is to renew the facility's license.
Findings
The documents confirm the facility meets statutory requirements for licensure renewal as a Skilled Nursing Facility with various therapy services and an Alzheimer unit. No deficiencies or violations are noted in the materials provided.
Report Facts
Number of beds to be relicensed: 111
Renewal fee: 1950
Cost of care on the Alzheimer's Care Unit: 6802
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassandra Putnam | Administrator | Named as Administrator on the Nursing Home Licensure Renewal Application and in email signature |
| Jennifer Nichols | Director of Nursing | Named as Director of Nursing on the Nursing Home Licensure Renewal Application |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 14
Date: Jan 19, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Golden Livingcenter - Plattsmouth from January 12, 2016 to January 19, 2016.
Complaint Details
The visit was complaint-related, investigating allegations that the facility failed to report accidents with injury and failed to ensure liquids were served at appropriate temperatures. Both allegations were found to have no violations.
Findings
The facility was found deficient in multiple areas including housekeeping and maintenance, ADL care for dependent residents, accident hazard prevention, nutrition maintenance, therapeutic diet preparation, food handling, drug storage, infection control, life safety code compliance, fire safety, medical gas storage, and electrical safety.
Deficiencies (14)
Failed to ensure vent fans in resident restrooms were clean and free from dust in 5 resident rooms.
Failed to ensure a dependent resident was assisted with bathing needs on a weekly basis.
Failed to prevent potential for accidents and injury by propelling residents in wheelchairs without foot pedals and failed to ensure a grab rail was tightly secured.
Failed to maintain nutrition status by not implementing interventions to prevent weight loss for one resident.
Failed to ensure pureed foods were prepared to a smooth/pudding consistency for 9 residents.
Failed to ensure bare hand contact was not used when serving ready to eat food for 5 residents.
Failed to ensure seven medications were secured in a locked compartment.
Failed to disinfect a glucometer for the required time to prevent potential cross contamination between residents.
Failed to ensure a sign was installed on delayed egress doors instructing occupants on the use of the exit.
Failed to install an audible and visual occupant notification device for the automatic fire alarm system in the enclosed courtyard.
Failed to provide a placard for the Class K fire extinguisher stating the fire protection system shall be activated prior to use and fire extinguishers were installed more than 5 ft above the floor.
Failed to ensure all internal seams and joints of the hood and exhaust system for commercial cooking equipment were sealed and grease tight.
Failed to identify and segregate empty oxygen cylinders from full ones in the storage area.
Failed to use approved surge protectors and extension cords and failed to protect energized electrical wiring and equipment.
Report Facts
Facility census: 91
Residents affected by vent fan dust: 10
Residents affected by wheelchair foot pedal issue: 5
Residents affected by pureed diet issue: 9
Residents affected by bare hand food contact: 5
Medications unsecured: 7
Residents sharing glucometer: 7
Facility census for life safety: 97
Empty oxygen cylinders: 18
Total oxygen cylinders: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter |
| Cassandra Putnam | Administrator | Facility administrator during inspection |
| Maintenance A | Verified observations related to delayed egress signs, fire alarm system, hood sealing, oxygen storage, and electrical issues | |
| LPN G | Licensed Practical Nurse | Observed using glucometer and confirmed refrigerator was unsecured |
| Dietary Manager | Interviewed regarding food handling and diet preparation deficiencies | |
| Cook A | Observed preparing pureed food and interviewed about diet consistency | |
| Assistant Director of Nursing | ADON | Interviewed about medication storage and glucometer cleaning |
| Director of Nursing | DON | Interviewed about wheelchair safety and glucometer cleaning |
Inspection Report
Enforcement
Deficiencies: 0
Date: Jan 11, 2016
Visit Reason
The visit was a revisit survey conducted on January 11, 2016, to verify corrections made after a December 3, 2015 survey that found the facility not in substantial compliance with Federal requirements for skilled nursing facilities.
Findings
The revisit survey established that corrections had been made and the facility was now in substantial compliance, resulting in the lifting of the denial of payment for new Medicare/Medicaid admissions. A civil money penalty was imposed effective November 27, 2015, with accrued penalties detailed and a reduced total amount due.
Report Facts
Civil Money Penalty per day: 5400
Number of days: 6
Total Amount: 32400
Civil Money Penalty per day: 100
Number of days: 27
Total Amount: 2700
Total CMP due after reduction: 22815
Interest rate: 9.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Hauptman | Health Insurance Specialist | Contact person for additional comments or concerns; signed enforcement letter |
| Darla McCloskey | Branch Manager | CMS Regional Office contact for payment correspondence |
Notice
Deficiencies: 0
Date: Dec 17, 2015
Visit Reason
The notice was issued to inform the facility of disciplinary action including probation and prohibition from admitting residents due to violations of licensure regulations related to Resident Rights and failure to follow CPR directives.
Findings
The facility was found to have violated licensure regulations by failing to follow the Cardiopulmonary Resuscitation (CPR) directive for a resident, resulting in disciplinary action including probation and prohibition on admissions until compliance is achieved.
Report Facts
Probation period: 180
Date of CMS-2567 Report: December 17, 2015
Date of revisit: January 11, 2016
Date of Notice: December 17, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Recipient of reports and correspondence related to the disciplinary action |
| Courtney N. Phillips | Chief Executive Officer | Signed the Notice of Disciplinary Action |
| Becky Wisell | Administrator | Signed the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II | Certified mailing of the Notice of Disciplinary Action |
| Dan Taylor | RN, Office of LTC Facilities - Licensure Unit | Conducted the revisit and confirmed correction of violations |
| Cassandra Putnam | Administrator | Facility administrator addressed in follow-up letters |
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 1
Date: Dec 2, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding failure to notify healthcare practitioners of change in condition, failure to provide prompt cardiopulmonary resuscitation (CPR), and failure to ensure sufficient staffing at Golden Livingcenter - Plattsmouth.
Complaint Details
The complaint alleged failure to notify healthcare practitioners of change in condition, failure to provide prompt CPR, and failure to ensure sufficient staffing. The notification and staffing allegations were unsubstantiated. The CPR failure was substantiated as a violation of federal and state regulations.
Findings
The investigation found no violation related to notification of change in condition or staffing sufficiency. However, the facility failed to provide prompt CPR to one resident, violating federal and state regulations. The facility implemented education and corrective actions in response.
Deficiencies (1)
Failure to provide prompt cardiopulmonary resuscitation (CPR) to one resident as per their directive.
Report Facts
Facility census: 100
Deficiency cited: 1
Time delay: 5
Time delay: 10
Date of survey completion: Dec 3, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation letter |
| Cassandra Putnam | Administrator | Facility administrator addressed in the report |
| LPN A | Nurse involved in CPR event who reported code status and experienced delay due to lack of oxygen tank key | |
| LPN B | Nurse involved in CPR event who delayed CPR initiation due to misunderstanding of code status | |
| RN C | Nurse involved in CPR event who delayed CPR initiation and was terminated | |
| Director of Nursing | DON | Interviewed regarding CPR event and facility response |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 12, 2015
Visit Reason
An unannounced visit was conducted to investigate multiple complaints at Golden Livingcenter - Plattsmouth from November 12, 2015 to November 16, 2015, by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint investigation addressed multiple allegations including failure to change fall interventions, failure to protect residents from abuse, failure to submit investigations within five working days, failure to ensure residents are free from misappropriation, failure to protect residents from residents with adverse behaviors, failure to report allegations of abuse to state agencies, failure to protect residents' right to refuse care, and failure to identify change in condition. All allegations were found to be unsubstantiated with no violations identified.
Findings
The investigation found no violations related to the allegations including failure to change fall interventions, protect residents from abuse, timely submission of investigations, protection from misappropriation, protection from residents with adverse behaviors, reporting abuse allegations, residents' right to refuse care, and identification of change in condition.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 3
Date: Jun 10, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding inadequate staffing and inaccurate and untimely MDS assessments at Golden Livingcenter - Plattsmouth.
Complaint Details
The complaint alleged the facility failed to ensure adequate staffing and/or staff posting and failed to ensure MDS assessments were accurate and timely. The investigation confirmed these allegations.
Findings
The facility failed to post and maintain daily nurse staffing information for the required 18 months and failed to ensure accuracy and timeliness of MDS assessments, including incorrect coding of UTIs, indwelling catheter use, and antipsychotic medication use. Additionally, the facility failed to evaluate clinical indications for catheter use for one resident.
Deficiencies (3)
Failure to post and maintain daily nurse staffing information for the required 18 months.
Failure to ensure MDS assessments were accurate and timely, including incorrect coding of UTIs for 3 residents, indwelling catheter use for 1 resident, and antipsychotic medication use for 1 resident.
Failure to evaluate clinical indications for use of an indwelling catheter for 1 resident.
Report Facts
Resident census: 98
Days of nurse staffing information retained: 40
Residents with UTI coding errors: 3
Residents with indwelling catheter coding error: 1
Residents with antipsychotic medication coding error: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation letter. |
| Ron Chase | Registered Nurse | Investigator conducting the complaint investigation. |
| Carol Neneman | Social Worker | Investigator conducting the complaint investigation. |
| MDS Coordinator A | Confirmed inaccuracies in MDS coding for multiple residents. | |
| Assistant Director of Nursing | Confirmed inaccuracies in MDS coding and lack of evaluation for catheter use. | |
| Director of Admissions | Confirmed absence of posted nurse staffing information. | |
| Director of Nursing | Confirmed absence of posted nurse staffing information. | |
| Facility Administrator | Confirmed lack of retention of nurse staffing information and absence of related policies. |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 111
Deficiencies: 11
Date: Dec 9, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Golden Livingcenter - Plattsmouth from December 1, 2014 to December 9, 2014.
Complaint Details
The complaint investigation included allegations regarding odor control, hallway clearance, meal temperature and palatability, abuse prevention, call notification response, hygiene, resident protection from behaviors, fall interventions, and call notification systems. Most allegations were found to be unsubstantiated except for failure to ensure clean and groomed hair, skin, teeth, and/or nails.
Findings
The facility was found to be in compliance with many complaint allegations including odor control, hallway clearance, meal temperature and palatability, abuse prevention, call notification response, and fall interventions. However, deficiencies were found related to privacy during care, water temperature, pressure ulcer prevention and treatment, individualized toileting program, food sanitation, infection control, and privacy curtains. Life safety code deficiencies were also identified including exit signage, smoke barrier doors, sprinkler system maintenance, and electrical wiring.
Deficiencies (11)
Failed to ensure privacy for two residents during provision of cares; privacy curtains not used and residents exposed.
Failed to ensure water temperatures on the 100 and 200 hallways were warm for residents.
Failed to prevent pressure ulcer development and implement interventions to promote healing for one resident.
Failed to implement an individualized toileting program for one resident with decline in continence.
Failed to ensure foods were prepared and served under sanitary conditions; improper hand hygiene, glove use, and unclean equipment observed.
Failed to prevent cross contamination during wound care and failed to ensure hand hygiene during cares and treatments for two residents.
Failed to assure full visual privacy for residents due to unavailable or insufficient privacy curtains in resident rooms.
Failed to have all exits marked by approved exit signage; exit sign in Southeast Dining area not lit.
Failed to provide smoke barrier doors that positive latch, allowing smoke to spread between compartments.
Failed to maintain automatic sprinkler system in reliable operating condition; sprinkler heads blocked by bird nests.
Failed to have all electrical wiring and appliances in accordance with National Electrical Codes; exposed wires and improper power tap use observed.
Report Facts
Facility licensed capacity: 111
Facility census: 98
Deficiency count: 11
Residents affected by water temperature issue: 11
Residents affected by privacy curtain issue: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassandra Putnam | Administrator | Named in complaint letter and interview |
| Eve Lewis | Program Manager, Office of Long Term Care Facilities | Signed complaint investigation letter |
| Sherri Lovelace | Registered Nurse Surveyor | Conducted complaint investigation |
| Kathleen Philippi | Registered Nurse Surveyor | Conducted complaint investigation |
| Victoria Smith | Registered Nurse Surveyor | Conducted complaint investigation |
| Rebecca Young | Registered Nurse Surveyor | Conducted complaint investigation |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 2
Date: Oct 7, 2014
Visit Reason
An unannounced visit was conducted to investigate multiple complaints regarding care and treatment at Golden Livingcenter - Plattsmouth.
Complaint Details
The visit was complaint-related with allegations including failure to provide care for bladder elimination, prevent skin breakdown, sufficient staffing, adequate fluid intake, and neglect. The facility was found substantiated for failure in bladder elimination care and neglect for one resident, but no citations were issued due to corrective actions taken.
Findings
The investigation found one instance where the facility failed to provide care and treatment for bladder elimination and one instance of neglect of a resident. The facility took appropriate action by identifying and addressing staff deficiencies, resulting in no citations. Other allegations regarding skin breakdown prevention, staffing sufficiency, and adequate fluid intake were found to have no concerns.
Deficiencies (2)
Failure to ensure staff provide care and treatment for bladder elimination for one resident.
Failure to ensure one resident was not neglected due to staff not completing required duties.
Report Facts
Facility census: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Smith | Registered Nurse | Conducted the complaint investigation visit. |
| Eve Lewis | Program Manager | Signed the report as representative of the Office of Long Term Care Facilities. |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 1
Date: Jul 10, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to maintain emergency exit corridors free from obstruction.
Complaint Details
The complaint was substantiated during the survey. The allegation was that the facility failed to maintain emergency exit corridors free from obstruction.
Findings
The facility failed to maintain emergency exit corridors free from obstruction, with various equipment such as wheelchairs, lifts, food carts, and trash cans stored in hallways used as emergency exits. Staff confirmed the storage practice and lack of knowledge that it violated the Life Safety Code.
Deficiencies (1)
Facility failed to maintain exit corridors free of obstructions including wheelchairs, lifts, food carts, floor fan, ice/drink cart, and trash cans throughout the facility.
Report Facts
Facility census: 96
Number of wheelchairs stored in corridors: 7
Number of medication carts stored in corridors: 4
Number of empty food carts stored in corridors: 2
Number of patient lifts stored in corridors: 3
Trash cans stored in corridors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed letter reporting complaint investigation findings |
| Cassandra Putnam | Administrator | Confirmed facility stored items in exit corridors and acknowledged lack of storage |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Date: Jun 4, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint at Golden Livingcenter - Plattsmouth on June 4, 2014, focusing on allegations including verbal abuse, fall interventions, call light response, odors, hot water adequacy, and evaluation of fall causative factors.
Complaint Details
The complaint investigation addressed multiple allegations including verbal abuse, failure to change fall interventions, delayed call light response, odors, inadequate hot water, and failure to evaluate fall causative factors. No violations were substantiated, and corrective measures were taken for the verbal abuse allegation.
Findings
The investigation found no violations related to the allegations. Corrective measures were taken regarding verbal abuse, and all other areas including fall interventions, call light response, odors, hot water, and fall evaluations were found compliant with no concerns identified.
Report Facts
Facility census: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Philippi | Registered Nurse | Conducted the complaint investigation visit |
| Eve Lewis | Program Manager | Signed the report as Program Manager, Office of Long Term Care Facilities |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 101
Deficiencies: 2
Date: Apr 21, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Golden Livingcenter - Plattsmouth on November 20, 2013-December 3, 2013, focusing on multiple allegations including failure to implement fall interventions, protect residents from misappropriation, timely reporting and investigation of abuse allegations, supervision of residents with condition changes, confidentiality breaches, discharge planning involvement, medication administration, nutritional needs, and staffing sufficiency.
Complaint Details
The complaint investigation addressed multiple allegations including failure to implement fall interventions, protect residents from misappropriation, timely reporting and investigation of abuse allegations, supervision of residents with condition changes, confidentiality breaches, discharge planning involvement, medication administration, nutritional needs, and staffing sufficiency. The facility was found compliant on all except bathing assistance and staffing sufficiency.
Findings
The facility was found to be in compliance with all allegations investigated, except for failure to assist two residents with bathing and insufficient staffing to meet residents' needs, which affected care such as call light response and bathing assistance. Resident complaints and staff interviews confirmed these deficiencies. The facility census was 94 and total capacity was 101.
Deficiencies (2)
Facility failed to assist two residents with bathing, resulting in one resident not receiving a bath for almost one month and another resident not bathed for two weeks.
Facility failed to ensure sufficient 24-hour nursing staff to meet residents' needs, leading to delayed call light responses and missed incontinence care or bathing assistance.
Report Facts
Facility census: 94
Total capacity: 101
Resident bath frequency: 1
Staffing openings: 1
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Date: Jan 13, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint at Golden LivingCenter - Plattsmouth regarding allegations of failure to provide care and treatment to promote healing of skin breakdown, failure to notify healthcare practitioners of changes in condition, failure to complete laboratory work or testing according to orders, and failure to send residents for evaluation as requested.
Complaint Details
The investigation was complaint-related and found no substantiated violations for the allegations regarding skin breakdown care, notification of condition changes, laboratory/testing compliance, and resident evaluations.
Findings
The facility was found to have provided appropriate care and treatment for skin breakdown, notified healthcare practitioners of changes in condition, completed laboratory work and testing as ordered, and ensured residents were evaluated by proper healthcare providers. Therefore, no violations were identified related to the allegations.
Report Facts
Census: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Travis Castner | Registered Nurse | Representative of the Department of Health and Human Services conducting the investigation |
| Rebecca Young | Registered Nurse | Representative of the Department of Health and Human Services conducting the investigation |
| Eve Lewis | Program Manager | Signed the report as Office of Long Term Care Facilities, Licensure Unit |
Inspection Report
Annual Inspection
Census: 94
Capacity: 96
Deficiencies: 12
Date: Dec 3, 2013
Visit Reason
Annual inspection of Golden Livingcenter - Plattsmouth to assess compliance with Nebraska Administrative Code and Life Safety Code standards.
Findings
The facility was found deficient in several areas including failure to promptly resolve resident grievances regarding call light response times, inadequate housekeeping resulting in urine odor, fire safety code violations such as improper door gaps, missing exit signage, unsealed penetrations compromising smoke barriers, lack of emergency lighting, improper fire drill scheduling, inadequate smoke detector testing, unsafe kitchen stove operation, presence of prohibited portable heaters in resident rooms, and unsafe electrical wiring practices including use of power strips as permanent wiring.
Deficiencies (12)
Failure to promptly resolve grievances about call light response times for three residents.
Failure to provide housekeeping services to maintain an environment free of odors from one room.
Double doors leading into the South-east Dining Room had a gap greater than 1/8 inch, allowing smoke to spread.
Failure to provide 'No Exit' signs at five doors leading to the courtyard.
Failure to maintain hazardous areas with smoke tight separations; unsealed penetrations and obstructed fire rated hatches.
Failure to post the code for magnetically locked doors in ACU and AACU wings.
Failure to provide emergency lighting of required 1½ hour duration in Dining Room.
Failure to conduct fire drills at unexpected times and on all shifts.
Failure to test and maintain smoke detectors throughout the facility as required.
Failure to ensure stove top in Physical Therapy was inoperable and failure to correct kitchen hood deficiencies.
Presence of prohibited portable space heaters in resident rooms.
Use of power strips as permanent wiring in resident rooms and failure to maintain clearance in front of electrical panels and cover electrical junction boxes.
Report Facts
Facility census: 94
Facility total capacity: 96
Call light wait times (minutes): 241.2
Call light wait times (minutes): 175.2
Fire drills reviewed: 17
Fire drills conducted at end of month: 14
Fire drills conducted between 11:13 am and 11:58 am: 6
Facility census: 96
Facility census: 98
Facility census: 96
Residents affected by portable heaters: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed multiple findings including door gaps, missing signage, fire drill scheduling, emergency lighting, stove top power, and smoke detector testing | |
| Maintenance A | Confirmed findings related to call light response, fire safety penetrations, fire alarm deficiencies, kitchen hood issues, and electrical safety | |
| Registered Nurse C | RN | Interviewed regarding call light response times and staff education |
| Nursing Assistant A | NA | Interviewed regarding call light response times |
| Nursing Assistant B | NA | Interviewed regarding call light response times and resident complaints |
Inspection Report
Annual Inspection
Census: 90
Deficiencies: 2
Date: Jul 10, 2013
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulations governing licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities.
Findings
The facility failed to revise interventions to prevent unplanned significant weight loss and failed to ensure sufficient fluid intake to maintain proper hydration for one resident. The resident experienced significant weight loss and dehydration leading to hospitalization.
Deficiencies (2)
Failed to revise interventions to prevent unplanned significant weight loss for one resident.
Failed to ensure daily fluid intake was monitored and documented to identify sufficient fluid intake for one resident to maintain adequate hydration.
Report Facts
Facility census: 90
Weight loss percentage: 11.6
Weight loss percentage: 9.3
Weight loss percentage: 9.4
Fluid intake offered: 2400
Fluid intake offered: 2760
Fluid intake offered: 3120
Sodium level: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krystal Hays | MSN RN RAC-CT | Reviewer of the Informal Dispute Resolution report |
| Joseph Shafer | Interim Administrator | Named in the nursing home request for informal conference |
| Heather Geis | RN Director of Nursing | Participant in the Informal Dispute Resolution |
| Michelle Anzalone | CDM, CFPP, Dietary Manager | Participant in the Informal Dispute Resolution |
| Sandi Gardner | Alzheimers Director | Participant in the Informal Dispute Resolution |
| Bernie Hillyer | MD, Medical Director | Participant in the Informal Dispute Resolution |
Inspection Report
Routine
Census: 89
Capacity: 90
Deficiencies: 15
Date: Aug 23, 2012
Visit Reason
Routine inspection of Golden Livingcenter - Plattsmouth to assess compliance with federal and state regulations including resident care, safety, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to complete discharge summaries, delayed call light responses, incomplete care plans for psychotropic medication use, inadequate bowel assessments, fire safety code violations including obstructed fire doors, lack of fire drills on night shift, fire alarm system maintenance issues, sprinkler head obstructions, unsecured fire extinguisher, malfunctioning kitchen stove burner, obstructed exit corridors, missing oxygen storage signage, and improper electrical wiring with use of extension cords and power strips.
Deficiencies (15)
Failure to complete discharge summaries for discharged residents.
Failure to promptly respond to resident call lights causing grievances.
Care plans for residents on psychotropic medications lacked target behaviors, non-pharmacological interventions, and gradual dose reduction plans.
Failure to perform bowel assessment for resident with rectal complaints and impaction.
Resident room door obstructed and failed to latch properly.
Hazardous areas used for storage lacked self-closing doors and had doors that failed to latch.
Magnetically locked exit door lacked posted unlocking code.
Fire drills were not conducted as actual drills on the night shift, only in-services were held.
Fire alarm system not maintained and heat detectors not tested or replaced as required.
Sprinkler heads obstructed by objects or missing escutcheons in multiple locations.
Portable fire extinguisher unsecured and placed on floor near nurses station.
Gas stove burner failed to ignite and kitchen staff lacked training on fire extinguisher use.
Corridor used as storage obstructing exit door and egress.
Oxygen storage room lacked required no smoking signage.
Use of extension cords and power strips in multiple offices and activity room, violating electrical code.
Report Facts
Facility census: 89
Facility total capacity: 90
Sample size: 29
Residents affected by door obstruction: 18
Residents affected by hazardous area door issues: 58
Residents affected by locked exit door code missing: 36
Residents affected by fire drill deficiencies: 90
Residents affected by fire alarm system deficiencies: 90
Residents affected by sprinkler head obstructions: 56
Residents affected by unsecured fire extinguisher: 17
Residents affected by kitchen stove burner malfunction: 47
Residents affected by obstructed corridor exit: 68
Residents affected by missing oxygen signage: 17
Residents affected by electrical code violations: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN T | Registered Nurse | Interviewed regarding missing discharge summaries and care plan deficiencies |
| NA E | Nurse Aide | Interviewed regarding resident behaviors and toileting assistance |
| LPN A | Licensed Practical Nurse | Interviewed regarding resident behaviors and care plan deficiencies |
| Maintenance A | Interviewed regarding fire alarm system and stove burner malfunction | |
| Administrator | Interviewed regarding multiple deficiencies including fire safety and signage | |
| Kitchen Staff A | Interviewed regarding fire extinguisher knowledge |
Inspection Report
Annual Inspection
Census: 90
Deficiencies: 25
Date: Sep 14, 2011
Visit Reason
Annual inspection survey to assess compliance with federal and state regulations including health, safety, and fire codes at Golden Livingcenter - Plattsmouth.
Findings
The facility was found to have multiple deficiencies including failure to notify physicians timely of resident condition changes, medication administration errors, fire safety code violations such as smoke door latching failures, obstructed egress, electrical code violations, and infection control issues including improper ice handling and lack of oxygen signage.
Deficiencies (25)
Failed to notify physician of significant resident condition changes and medication availability.
Failed to provide prompt efforts to resolve grievances related to call light response times.
Failed to conduct comprehensive assessments for residents experiencing change of condition.
Failed to revise care plan to reflect resident's current transfer status.
Failed to provide adequate ADL care using proper technique for dependent resident.
Failed to maintain environment free of accident hazards including unsecured beauty shop door, accessible stove in Alzheimer's unit, frayed bath belt, and non-functioning call light.
Failed to provide accurate pharmaceutical services including medication administration and physician notification.
Failed to maintain infection control including improper ice water handling.
Failed to maintain complete and accurate resident records including obtaining physician of record and code status within 24 hours of admission.
Failed to maintain smoke tight corridor doors and positive latching on smoke separation doors.
Failed to provide self-closing doors in hazardous areas.
Failed to maintain automatic sprinkler system penetrations and clearance.
Failed to maintain kitchen hood suppression system inspection and staff training.
Failed to maintain means of egress free of obstructions.
Failed to maintain decorations and furnishings flame retardant.
Failed to maintain flame retardant curtains or provide flame retardant rating.
Failed to store soiled linen barrels greater than 32 gallons in a hazardous area.
Failed to provide current annual boiler inspection certification.
Failed to post oxygen in use signage where oxygen was used or stored.
Failed to conduct weekly generator testing and monthly load testing.
Failed to install electrical wiring and equipment in accordance with electrical code including improper use of extension cords and power strips.
Failed to maintain fire alarm system testing within required timeframes.
Failed to maintain smoke detectors including one hanging from ceiling by wires.
Failed to maintain sprinkler system coverage and clearance.
Failed to install Alcohol Based Hand Rub dispensers away from ignition sources.
Report Facts
Facility census: 90
Residents affected by smoke door deficiency: 18
Residents affected by smoke separation door deficiency: 73
Residents affected by hazard area door deficiency: 18
Residents affected by sprinkler penetration deficiency: 18
Residents affected by obstructed egress: 6
Residents affected by electrical code violations: 57
Residents affected by fire alarm system deficiency: 90
Residents affected by kitchen hood deficiency: 48
Residents affected by obstructed egress: 6
Residents affected by flammable decorations: 31
Residents affected by flammable curtains: 18
Residents affected by soiled linen storage deficiency: 19
Residents affected by oxygen signage deficiency: 6
Residents affected by ABHR placement deficiency: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN - P | Registered Nurse | Failed to notify physician and provide care for Resident 144 during change of condition |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and call light response |
| Maintenance Director | Maintenance Director | Interviewed regarding fire safety deficiencies and maintenance issues |
| Administrator | Facility Administrator | Interviewed regarding multiple deficiencies and corrective actions |
Inspection Report
Plan of Correction
Census: 95
Deficiencies: 1
Date: Jan 26, 2011
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pest control regulations following observations and resident interviews indicating a pest problem, specifically fruit flies, in the facility.
Findings
The facility failed to maintain an effective pest control program, evidenced by the presence of fruit flies in the dining room and kitchen areas. The pest control company had not treated for fruit flies recently, and residents and staff confirmed the ongoing issue.
Deficiencies (1)
Facility failed to maintain an effective pest control program to keep the environment free of pests and rodents, specifically fruit flies.
Report Facts
Number of residents: 95
Date of inspection: Jan 26, 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jodi Harrah | Provisional Administrator | Signed the plan of correction document |
Document
Capacity: 111
Deficiencies: 0
Date: APP2017
Visit Reason
The documents pertain to the renewal of the nursing home license for Plattsmouth Care and Rehabilitation Center, LLC, including ownership disclosures, certification renewals, and Alzheimer's special care unit endorsement application.
Findings
The documents confirm the facility's licensed capacity of 111 beds, ownership structure, renewal of licensure, and detailed description of the Alzheimer's Care Unit program including philosophy, staffing, environment, activities, family support, and fees.
Report Facts
Total licensed capacity: 111
Daily rate: 217.28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassandra Putnam | Administrator | Named as facility administrator in renewal application |
| Joseph Schwartz | Authorized Representative | Signed renewal and Alzheimer's Care Unit endorsement applications |
| Rosie Schwartz | Authorized Representative | Named as 50% member in organizational chart |
| Alan Viox | Deputy State Fire Marshal | Inspected and approved occupancy permit |
| Brandie Lamberth | Contact for Alzheimer's Care Unit endorsement application |
Inspection Report
Renewal
Capacity: 111
Deficiencies: 0
Date: APP2018
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related certification materials for Plattsmouth Care and Rehabilitation Center, LLC, verifying the facility's license renewal and compliance with statutory requirements.
Findings
The documents confirm the facility meets statutory requirements for licensure renewal as a Skilled Nursing Facility with specialized services including physical therapy, occupational therapy, speech therapy, and an Alzheimer unit. No deficiencies or inspection findings are reported.
Report Facts
Total licensed beds: 111
Renewal fees: 1750
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Gabel | Administrator | Named as facility administrator on renewal application |
| Cynthia Schlotfeld | Director of Nursing | Named as Director of Nursing on renewal application |
| Joseph Schwartz | Authorized Representative | Signed renewal application and Alzheimer's unit endorsement application |
| Rosie Schwartz | Authorized Representative | Signed renewal application |
Document
Capacity: 111
Deficiencies: 0
Date: APP2020
Visit Reason
The documents serve to verify licensing status, renew the nursing home license, disclose ownership, certify occupancy capacity, and apply for Alzheimer's special care unit endorsement for Prestige Care Center of Plattsmouth.
Findings
The documents confirm that Prestige Care Center of Plattsmouth meets statutory licensing requirements, holds a valid occupancy permit for 111 beds, and is applying for renewal of its nursing home license and Alzheimer's special care unit endorsement. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 111
Number of beds to be relicensed: 108
Maximum capacity for Alzheimer's beds: 18
Daily rate: 236
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chasity J. Coover | Administrator | Named on Nursing Home Licensure Renewal Application and Alzheimer's Special Care Unit Disclosure |
| Deb Neebitt | Director of Nursing | Named on Nursing Home Licensure Renewal Application |
| Yisroel Meir Kaplan | Member of ownership entity Plattsmouth Operations LLC and contact name on Alzheimer's Special Care Unit Disclosure | |
| Ephram Lahasky | Member of ownership entity Plattsmouth Operations LLC |
Document
Capacity: 111
Deficiencies: 0
Date: APP2021
Visit Reason
The documents serve to renew the nursing home license, provide occupancy permit details, disclose Alzheimer's special care unit information, and certify ownership and facility details.
Findings
No inspection findings or deficiencies are reported. The documents confirm licensing renewal, facility capacity, ownership, and care unit disclosures.
Report Facts
Total licensed beds: 111
Maximum capacity for Alzheimer's unit: 18
Renewal application date: 2021
Daily rate: 236
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chasity J. Coover | Administrator | Named as facility administrator on renewal application and Alzheimer's disclosure forms. |
| Deb Nesbitt | Director of Nursing | Named as Director of Nursing on renewal application. |
| Yisroel Meir Kaplan | Named as member of ownership and authorized representative signing renewal application. | |
| Ephram Lahasky | Named as member of ownership and authorized representative signing renewal application. |
Notice
Capacity: 111
Deficiencies: 0
Date: APP2022
Visit Reason
The document serves as a renewal application for the nursing home license of Prestige Care Center of Plattsmouth and includes verification of licensure, ownership details, occupancy permit, and Alzheimer's care unit endorsement.
Findings
The documents confirm the facility's licensure renewal status, ownership structure, maximum bed capacity, and compliance with Alzheimer's special care unit requirements. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 111
Alzheimer's unit capacity: 18
Daily rate: 236
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephen Osborne | Administrator | Named as the facility administrator on the renewal application and Alzheimer's unit disclosure. |
| Trista Driscoll | Director of Nursing | Named as the Director of Nursing on the renewal application. |
| Yisroel Meir Kaplan | Authorized Representative | Signed the renewal application and Alzheimer's unit disclosure as authorized representative. |
| Chasity Joanne Coover | Authorized Representative / Regional Director of Operations | Signed the renewal application and listed as Regional Director of Operations in ownership/control documents. |
| Ephram Lahasky | Authorized Representative / Member | Signed the renewal application and listed as member with 40% ownership in ownership/control documents. |
| Corey Fuchs | Chief Financial Officer | Named as officer in ownership/control documents. |
Notice
Capacity: 111
Deficiencies: 0
Date: APP2023
Visit Reason
This document serves as a licensure renewal application and certification for Prestige Care Center of Plattsmouth, verifying that the facility's SNF/NF dual certification is licensed through the renewal date.
Findings
The documents include licensure renewal application details, ownership and control information, occupancy permit, and Alzheimer's Special Care Unit disclosure and endorsement application. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 111
Maximum capacity for Alzheimer's beds: 18
Daily rate: 240
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chasity Coover | Administrator / Regional Director of Operations | Named as Administrator in the renewal application and as Regional Director of Operations in ownership/control document. |
| Trista Driscoll | Director of Nursing | Named as Director of Nursing in the renewal application. |
| Yisroel Meir Kaplan | Authorized Representative / Contact Name | Signed the renewal application and Alzheimer's disclosure application as authorized representative and contact. |
| Ephram Mordy Lahasky | Authorized Representative | Signed the renewal application as authorized representative. |
Document
Capacity: 111
Deficiencies: 0
Date: APP2024
Visit Reason
The documents serve to renew the nursing home license for Prestige Care Center of Plattsmouth, provide ownership and control details, confirm occupancy permit status, and submit Alzheimer's special care unit disclosure and endorsement application.
Findings
No inspection findings or deficiencies are reported in these documents. They primarily contain administrative and licensing information, including facility capacity, ownership, and care unit endorsements.
Report Facts
Total licensed beds: 111
Maximum capacity for Alzheimer's beds: 18
Occupancy permit date: Jan 30, 2023
Renewal application signature date: Feb 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rick Prusa | Administrator | Named as facility administrator on the Nursing Home Licensure Renewal Application and Alzheimer's Special Care Unit Disclosure. |
| Trista Driscoll | Director of Nursing | Named as Director of Nursing on the Nursing Home Licensure Renewal Application. |
| Yisroel Meir Kaplan | Authorized Representative | Signed the Nursing Home Licensure Renewal Application and Alzheimer's Special Care Unit Disclosure as authorized representative. |
| Chasity J Coover | Authorized Representative | Signed the Nursing Home Licensure Renewal Application as authorized representative. |
Notice
Capacity: 111
Deficiencies: 0
Date: APP2025
Visit Reason
The document is a Nursing Home Licensure Renewal Application for Prestige Care Center of Plattsmouth, submitted to renew the facility's license.
Findings
The documents confirm the facility's licensure renewal status, ownership information, and occupancy permit details, with no inspection findings or deficiencies reported.
Report Facts
Total licensed beds: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Davis | Administrator | Named in the Nursing Home Licensure Renewal Application. |
| Trista Kuhn | Director of Nursing | Named in the Nursing Home Licensure Renewal Application. |
| Meir Kaplan | Authorized Representative | Signed the Nursing Home Licensure Renewal Application. |
| Batsheva Cherns | Authorized Representative | Signed the Nursing Home Licensure Renewal Application and listed under managerial control. |
| Chasity Coover | Managing Employee | Listed in ownership and management information. |
Document
Capacity: 111
Deficiencies: 0
Date: CHOW2016
Visit Reason
Documents include issuance and renewal of Skilled Nursing Facility license, fire marshal occupancy permit, ownership and organizational information, and description of the Alzheimer's Care Unit program.
Findings
No inspection findings or deficiencies are reported. The documents provide licensing status, ownership details, fire safety occupancy permit, and detailed program description for the Alzheimer's Care Unit including philosophy, placement criteria, staff training, physical environment, activities, family involvement, and cost of care.
Report Facts
Total licensed beds: 111
License issuance date: Oct 1, 2016
License expiration date: Mar 31, 2017
Alzheimer's Care Unit monthly rate: 6802
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassandra Putnam | Administrator | Named as facility administrator on licensure application and correspondence. |
| Courtney N. Phillips | Chief Executive Officer | Signed licensing letters and official documents from Department of Health and Human Services. |
| Joseph Schwartz | 50% owner of the facility as shown in ownership organizational chart. | |
| Rosie Schwartz | 50% owner of the facility as shown in ownership organizational chart. | |
| Eve Lewis | RN-C, Program Manager | Contact person for questions about the license. |
| Alan Viox | Deputy State Fire Marshal | Inspected the facility for fire marshal occupancy permit. |
| Cynthia Schlotfeld | Director of Nursing | Named on licensure application. |
Notice
Deficiencies: 0
Date: DAN120914
Visit Reason
The notice serves to inform Golden Livingcenter - Plattsmouth of disciplinary action placing their license on probation for 90 days starting January 7, 2015, due to violations related to skin integrity and failure to prevent pressure ulcer development.
Findings
The facility was found to have violated licensure regulations concerning skin integrity, specifically failing to prevent pressure ulcer development and implement appropriate interventions, as documented in the CMS-2567 Report dated December 23, 2014.
Report Facts
Probation period length: 90
Date of CMS-2567 Report: Dec 23, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph M. Acierno | Acting Chief Executive Officer, Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Disciplinary Action |
| Becky Wisell | Administrator, Licensure Unit | Signed the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II, Office of Long Term Care Facilities | Certified mailing of the Notice of Disciplinary Action |
| Eve Lewis | RNC, Program Manager, Office of Long Term Care Facilities | Contact for submission of reports and correspondence related to the Notice |
Document
Capacity: 111
Deficiencies: 0
Date: APP2015
Visit Reason
The document set pertains to the renewal of the nursing home license for Golden LivingCenter - Plattsmouth and includes related administrative and regulatory information such as occupancy permit and organizational details.
Findings
No inspection findings or deficiencies are reported. The documents provide certification of licensure renewal, occupancy permit approval, ownership and officer details, and a detailed description of the Alzheimer's Care Unit program and services.
Report Facts
Total licensed beds: 111
Alzheimer's Care Unit monthly rate: 6482.58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassandra Putnam | Administrator | Named in licensure renewal application |
| Jennifer Nichols | Director of Nursing | Named in licensure renewal application |
| Julianne Williams | Director and President | Named as Director and Executive Officer in Officers and Directors Report |
| Holly Rasmussen-Jones | Secretary | Named in Officers and Directors Report |
| Ann Truitt | Treasurer & Assistant Secretary | Named in Officers and Directors Report |
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