Omaha Nursing And Rehabilitation Center

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

The therapy may be gauze based, foam based, or peel and stick, and includes an evacuation tube and a computerized pump that applies the negative pressure) dressing change revealed a softball sized stage four pressure ulcer approximately three centimeters (cm) deep to Resident 1's sacrum. The wound bed was beefy red and tissues surrounding the wound were intact. There was no noted odor. PA-B performed a wound assessment including measurements while ADON assisted Resident 1 to remain on the left side.

PA-B cleansed the wound utilizing wound cleanser and a gauze square. PA-B informed Resident 1 that the cleanser was cold. Upon PA-B cleansing the wound, Resident 1 yelled out Ow! PA-B continued the wound treatment as ordered and placed Amchoplast (a skin substitute used in wound treatment designed to support wound healing and protection of the wound) in the base of the wound and applied drape around

the wound. PA-B cut black foam to the size of the wound and placed the black foam in the wound bed.

Resident 1 yelled out Ow! was facial grimacing and began to cry while both of Resident 1's shoulders were moving up and down. The ADON began rubbing Resident 1's back and utilized conversation to distract the resident. PA-B continued with the wound treatment and applied the top layer of drape while the ADON held

the black foam in place. Resident 1 began crying again and yelled out that hurts! and was whimpering.

PA-B and the ADON continued with the wound treatment, and Resident 1 continued crying and facial grimacing and yelling out Ouch! Oww! That Hurts! The wound dressing was completed, and the wound dressing was attached to the wound vac. The ADON powered on the wound vac device and when suction was applied, Resident 1 again yelled out Ow! That hurts! PA-B and the ADON provided verbal encouragement to Resident 1 at that time. Before leaving the room, the ADON asked Resident 1 if they felt better. Resident 1 responded A little bit.Throughout the treatment, neither PA-B nor the ADON stopped the treatment to inquire with the resident if the wound treatment should go on or if the resident's pain needed to be addressed.Interview on 10/7/25 at 10:57 AM with the ADON confirmed that the procedure can be painful and further confirmed that Resident 1 was crying out and yelling out ouch, oww, and that hurts. The ADON reported the resident received an as needed Oxycodone at 5:17 AM and scheduled acetaminophen at 6:00 AM. ADON confirmed a dose of oxycodone should have been administered prior to the treatment but was not.Interview on 10/7/2025 at 11:11 AM with Resident 1 and Licensed Practical Nurse (LPN)-A present, Resident 1 reported pain during the treatment was rated 10 out of 10. Resident 1 stated that's why I was crying. When asked if they would have liked staff to stop the treatment, Resident 1 stated they didn't give me a choice, they just kept going.During a follow-up interview on 10/7/2025 at 2:00 PM, the ADON stated Yes, we could have stopped and offered Resident 1 pain medication, but I feel like the response would have been the same.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Omaha Nursing and Rehabilitation Center

4835 South 49th Street Omaha, NE 68117

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 potential for actual harm

Licensure Reference Number 175 NAC 1-005.06(D)Based on observation, interview, and record review; the facility failed to perform hand hygiene between glove changes during the provision of wound care for 1 (Resident 2) of 3 sampled residents. The facility staff identified a census of 50.The findings are:Record

review of a facility policy entitled Hand Hygiene revised 10/2022 revealed facility staff were to perform an alcohol-based hand rub containing at least 62 percent (%) alcohol; or alternatively, soap and water before handling clean or soiled dressings, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care; after handling used dressings and contaminated equipment; and after removing gloves.Observation on 10/7/2025 from 9:54 AM through 10:05 AM of Licensed Practical Nurse (LPN)-A performing wound care treatments for Resident 2 revealed LPN-A washed hands with soap and water for 32 seconds and donned (applied) a gown and gloves. LPN-A washed the resident's right and left posterior thighs. LPN-A doffed (removed) gloves, and without performing hand hygiene donned a new pair of gloves. LPN-A washed Resident 2's right posterior heel and doffed gloves. Without performing hand hygiene, LPN-A donned new gloves and performed the wound treatment to Resident 2's right posterior heel. LPN-A doffed gloves, and without performing hygiene donned new gloves. LPN-A proceeded with the left and right posterior thigh treatment as ordered, and doffed gloves. Without performing hand hygiene, LPN-A donned new gloves and re-applied the treatment to Resident 2's right posterior heel as ordered.

LPN-A doffed gloves, performed hand hygiene, and exited the room.An interview on 10/7/2025 at 10:07 AM with LPN-A confirmed hand hygiene had not been performed between glove changes and should have been.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet