F-F880) and to ensure correction for repeat deficient practice from previous surveys (March 2023 and May 2024 for F 584 and May 2024 survey for F 812) was maintained. This had the potential to affect 69 residents that resided in the facility.
-F 880: The facility failed to use a disinfectant wipe to clean a glucometer between resident use for Residents 16 and Resident 44 and failed to ensure Resident 66's catheter bag was not in contact with the trash can or floor.
Repeat citations:
- F 584 from previous surveys 03/09/2023 and 05/02/2024: environmental concerns
-F 812: from previous survey 05/02/2025: kitchen sanitation concerns
Interview on 05/21/25 at 11:31 AM with the facility Administrator confirmed that an environmental tag had been written for the past 2 years and was written again this year and no PIP had been brought through the QAPI program related to the environment. The Administrator confirmed that the kitchen tag had been written last year, and a PIP had been started in March but had not been effective in maintaining correction related to kitchen cleanliness. The Administrator confirmed that the QAPI process had identified the kitchen issues but was not effective to avoid a tag this year.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 285238 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285238 B. Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Keystone Ridge Post Acute Nursing and Rehab 7501 Keystone Drive Omaha, NE 68134
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or 52170 potential for actual harm LICENSURE REFERENCE NUMBER 12-006.18(B) Residents Affected - Few Based on observation, interview, and record review; the facility failed to store a urinary catheter drainage bag
in a manner to prevent cross-contamination for 1 (Resident 66) of 2 sampled residents; and failed to disinfect
the glucometer during blood glucose checks. This had the potential to affect 1 (Resident 16) of 2 sampled residents. The facility staff identified a census of 69.
Findings are:
A. Record review of Resident 66's Admission Record revealed the facility admitted Resident 66 on 02/28/2025 and identified the following diagnoses: hyperosmolality (a condition where the blood is too concentrated) and hypernatremia (too much sodium in blood); severe protein-calorie malnutrition; pressure ulcer of sacral region; anoxic brain damage (a result of the brain not receiving enough oxygen, causing brain cells to die); sepsis (the body's extreme response to an infection); depression; epilepsy; and secondary pulmonary arterial hypertension (high blood pressure in the arteries of the lungs that is caused by another underlying health condition).
Record review of Resident 66's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 03/14/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 3. According to the MDS manual, a score of 3 indicated that the resident had severe cognitive impairment. Further review of the MDS identified Resident 66 utilized a urinary catheter for bladder elimination.
An observation on 05/20/2025 at 9:45 AM revealed Resident 66 sitting in a wheelchair with the urinary catheter drainage bag hung inside a red trash can.
An observation on 05/20/2025 at 11:07 AM revealed Resident 66 in a wheelchair in the resident's room watching television with the urinary catheter drainage bag directly on the floor.
An observation on 05/20/2025 at 12:11 PM revealed Resident 66 in a wheelchair in the resident's room watching television with the urinary catheter drainage bag directly on the floor.
An observation on 05/20/2025 at 12:43 PM revealed Resident 66 with a noon meal watching television with
the urinary catheter drainage bag directly on the floor.
An interview on 05/20/2025 at 12:46 PM with Nurse Aide (NA)-C confirmed that Resident 66's catheter bag was on the floor and should not be. NA-C further confirmed that the urinary catheter drainage bag should not be stored inside a trashcan.
52351
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 285238 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285238 B. Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Keystone Ridge Post Acute Nursing and Rehab 7501 Keystone Drive Omaha, NE 68134
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 B. An observation on 05/19/25 at 7:43 AM of Licensed Practical Nurse (LPN)-A completing a blood glucose check of Resident 16. LPN-A performed hand hygiene and applied gloves, completed the blood glucose Level of Harm - Minimal harm or check and returned to the treatment cart. LPN-A wiped the glucometer with an alcohol wipe and placed the potential for actual harm glucometer on a clean surface.
Residents Affected - Few An Interview was conducted on 05/19/25 8:30 AM with the Director of Nursing (DON) and DON confirmed
the glucometers should be disinfected with the Sani-Cloth Germicidal Wipes.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 285238