Blue Valley Lutheran Nursing Home

In the surveyor’s words

From the most serious findings on record at Blue Valley Lutheran Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF801May 25, 2023

  Licensure Reference Number 175NAC 12-006.04D2 Based on record review and interview the facility failed to ensure that it had a Dietary Manager (DM) that held the required credentials for the position. This affected 29 residents that received meals from the facility kitchen. The facility census was 31. Findings are: Record review of the undated facility Resident Handbook revealed that the Dietary Supervisor (Dietary Manager) and Registered Dietitian are responsible for selecting nutritious meals and that they manage all special diets and offer recommendations for the use of nutritional supplements. Food consumed by residents must be prepared in a licensed kitchen. […]

• No harm, potential for more than minimal, widespreadF812Mar 17, 2022

  Licensure Reference Number 175 NAC 12-006.11E Based on observations, interviews, and record reviews; the facility failed to ensure that foods stored in the kitchen walk in freezer were covered without getting air to the food, and food was discarded after the expiration dates. This affected 35 of 39 residents at the facility. The facility census was 41. Findings are: Observation in the kitchen walk in freezer on 3/14/21 at 8:59 AM revealed chicken pieces found in a plastic bag without any date on the package, a box of chicken chunks with breading. The plastic bag was open to the air and was in an open box. Biscuits were setting by some bread had an outdate of 3/8. Residents' refrigerators in the 200 hallway had food and fluids that had been opened and no outdates were written on the items. […]

• No harm, potential for more than minimal, widespreadF880Mar 17, 2022

  Licensure Reference 175 NAC 12-006.18C1; 175 NAC 12-006.17D Based on observation, record review, and interviews; the facility failed to ensure infection control measures were followed to prevent cross contamination related to the delivery of resident clothing, which had the potential to affect all residents. The facility census was 41. Findings are: An observation on 3/16/22 at 10:11 AM of laundry staff passing clean resident clothing revealed the following: -Laundry Aide (LA) J carried resident clothing into rooms [ROOM NUMBER] by holding the clothing against (gender) own clothing. -LA K carried resident clothing into rooms [ROOM NUMBERS] by holding the clothing against (gender) own clothing. […]

• No harm, potential for more than minimal, patternF584May 25, 2023

  Licensure Reference Number 175NAC 12-006.18B Based on observation, record review, and interview the facility failed to ensure that it maintained the cleanliness of facility lighting fixtures. This affected 24 residents that resided on the 200 hallway. The facility census was 31. Findings are: Record review of the facility Admission Packet Nursing Home Accommodation Rates for 2022-2023 revealed that the facility daily rate includes laundry and housekeeping services. Record review of the undated facility Resident Handbook revealed that the maintenance staff is responsible for the general care and maintenance of the nursing home. Record review of the facility Resident Rights dated 2016 revealed that the resident has the right to a safe, clean, comfortable, and homelike environment. […]

• No harm, potential for more than minimal, patternF655May 25, 2023

  LICENSURE REFERENCE NUMBER 175NAC 12-006.09C1a Based on record review and interview, the facility failed to ensure that a review of the baseline (interim) care plan (a written plan required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) was reviewed with the resident/resident representative and failed to ensure that the resident/resident representative was provided a written summary of the baseline care plan as required for 3 of 3 sampled residents (Residents 30, 33, and 34). This prevented the resident/resident representative from identifying additional areas of care required by the resident. The facility census was 31. Findings are: A. […]