Adept Nursing & Rehab Of Sutherland

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation.

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

of the resident desiring to go outside unaccompanied dated 09/19/2025 had interventions listed that the resident would sign out when exiting the facility, for staff to educate the resident on the importance of telling them where they wished to go, and staff would safely assist the resident through the doors and to their desired location all dated 09/19/2025. A review of Resident 1's Progress Notes revealed documentation that

on 09/18/2025 at 9:39 AM Resident 1 exited the facility out of the front door without their assistive device.

Documentation stated that the resident was educated to sign out when leaving the facility.A review of Resident 1's Progress Notes revealed documentation that on 09/20/2025 at 3:59 AM the facility received a telephone call from a police officer informing the facility that Resident 1 was sitting in the road in front of the building and had been there a while. The resident was assisted into their wheelchair and then back into the facility by staff. The resident did not have their assistive device of walker or wheelchair in use. The resident did not sign out or notify facility staff that they were exiting the facility.A review of a facility supplied document titled Incidents by Incident Type on 09/23/2025 at 11:50 AM revealed and incident of Elopement occurring on 09/20/2025 for Resident 1. The document revealed no incident of Elopement for Resident 1 on 09/18/2025.In an interview completed on 09/23/2025 at 2:10 PM with the facility Director of Nursing (DON),

the DON confirmed that an incident report and investigation was not completed for elopement when Resident 1 exited the facility on 09/18/2025 with out signing out or staff knowledge. The DON confirmed that this incident met the definition of elopement and should have been completed. The DON confirmed that

the facility Administrator, Adult Protective Services, and the state regulatory agency were not notified of Resident 1's Elopement incidents on 09/18/2025 and 09/20/2025. The DON confirmed that the facility policy was not followed for these incidents.

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

09/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Birch at Sutherland

333 Maple Street Sutherland, NE 69165

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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation.

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

facility doors will be secured at all times. - Elopement risk assessment for the whole facility will be completed by end of day 9-23-25.- Elopement Training was completed for all The Leadership Team Members including the Elopement Policy, Resident Abuse prevention and Timely Reporting, and Abuse Policy reviewed 9-23-25. - Each Department Head completed 9-23-25 Elopement Training including the Elopement Policy, Resident Abuse prevention and Timely Reporting, and Abuse Policy reviewed with each staff member before they work again beginning on 9-23-35. Any staff on leave will receive education on their next scheduled workday. - Education was provided on 9-23-25 to staff currently working in the facility that the doors will be locked all the time. Facility will continue to educate all staff on each shift until all staff have been educated. Audit will be conducted by Maintenance/Nursing that doors are locked every shift for a minimum of three months or until the pattern of compliance is maintained.- The Elopement Binder was updated by DON/ADON(Assistant Director of Nursing) using elopement risks assessment completed 9-23-25. The assessments completed on 9-23-25 were placed in the Elopement Binder by DON/ADON.Social Services will audit starting 9-23-25 the elopement binder 2 x weekly through morning standup to ensure accuracy of the binder, to include all residents that are admitted , readmitted , or had a change of condition and deemed to be at risk for elopement. This will be done for a minimum of three months or until

the pattern of compliance is maintained.- Elopement care plans were reviewed and updated to ensure they reflect audit findings by MDS/Social Services. Actions to Prevent Occurrence/Recurrence: The facility took

the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 9-23-25)Elopement and wandering residents' policy was reviewed.- The DON or designee will audit new admissions for elopement risk and ensure care plans are completed, and appropriate interventions are in place.- The DON or designee will audit that Elopement Risk Assessment are completed upon Admission, Re-admission, Quarterly, Change of Condition, or as needed.- New hires will receive education on wandering, elopement, and resident safety by the DON, Director of Social Services, or designee(s). - All licensed nurses will be educated and trained on accurate completion of elopement risk assessment. Audit will be done by DON/ADON for a minimum of three months or until the pattern of compliance is maintained for accuracy beginning on 9-23-25 until all staff have been educated.- All staff will be educated on Independent Out on Pass Policy starting on 9-23-25 until all staff have been educated. This policy defines who can go out on pass without an escort or responsible party. A competency assessment progress note will be documented by clinical staff to determine the resident's ability to leave the facility safely. The residents will be educated on the sign out/sign in process. Approval is based on the resident's ability to make sound decisions regarding their safety, manage their medications, if applicable, and physically navigate their surroundings without significant fall risk. It will be care planned and noted on special instructions on PCC if the resident is assessed to be safe to go out on pass independently.- Performance Improvement Project (PIP) was implemented and presented to all Department Heads on 9-23-25. The incident was reviewed, and all audit findings were discussed. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained for accuracy.At the time of the survey, the violation was determined to be at the immediate jeopardy level J.

Based on observation and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the immediacy of the IJ violation at 6:50 PM on [DATE REDACTED]. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to D Level.

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

09/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Birch at Sutherland

333 Maple Street Sutherland, NE 69165

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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Licensure Reference Number 175 NAC 12-006.04Based on record review and interview, the facility failed to complete competencies to ensure proficiency for 8 of 9 sampled staff which had the potential to affect all of

the residents residing in the facility. The facility census was 41.Findings are:In an interview completed on 09/23/2024 at 12:50 PM with Medication Aide A(MA-A), MA-A stated that a competency had not been completed on the services they provide to residents in the last year.Record review of MA-A facility supplied documents revealed a date of hire of 10/20/2023. There were no competencies for MA-A supplied in the documents.Record review of Medication Aide B (MA-B) facility supplied documents revealed a date of hire of 06/09/2025. There were no competencies for MA-B supplied in the documents.Record review of Nurse Aide D (NA-D) facility supplied documents revealed a date of hire of 06/24/2025. There were no competencies for NA-D supplied in the documents.Record review of Nurse Aide E (NA-E) facility supplied documents revealed a date of hire of 01/05/2025. There were no competencies for NA-E supplied in the documents.Record review of Registered Nurse F (RN-F) facility supplied documents revealed a date of hire of 01/02/2025. There were no competencies for RN-F supplied in the documents.Record review of Licensed Practical Nurse G (LPN-G) facility supplied documents revealed a date of hire of 07/28/2025. There were no competencies for LPN-G supplied in the documents.Record review of Registered Nurse H (RN-H) facility supplied documents revealed a date of hire of 03/12/2025. There were no competencies for RN-H supplied

in the documents.Record review of Licensed Practical Nurse I (LPN-I) facility supplied documents revealed

a date of hire of 07/28/2025. There were no competencies for LPN-I supplied in the documents.In an

interview completed on 09/24/2025 at 1:15 PM with the Director of Nursing (DON), the DON confirmed that MA-A, MA-B, NA-D, NA-E, RN-F, LPN-G, RN-H, and LPN-I had not completed competencies ensuring proficiency of skills and services the individuals were providing to residents who reside in the facility. The DON confirmed that staff should complete competencies on hire and annually there after on these skills and services and this was not completed.

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Facility ID:

If continuation sheet