SIDNEY CARE AND REHABILITATION CENTER, LLC

Nursing Home Inspector

1435 TOLEDO STREET
SIDNEY, NE 69162
Cheyenne County
Phone: 308-254-4756
Provider Number: 285113
Last Inspection: 04/19/2017

About the Nursing Home

Number of Beds: 41
Number of Residents: 24
Beds Available: 17
Percent Occupancy: 59%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

53

Facility
31

County
20

NE
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

53

2017
80

2016
75

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

4/19/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 5/12/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 5/12/2017
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 5/12/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 5/12/2017
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 5/12/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 5/12/2017
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Minimal 4 5/12/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 5/12/2017
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 5/12/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 5/12/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 5/12/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 5/12/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 5/12/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 5/12/2017
 

5/11/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Pattern : Minimal 4 6/23/2016
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 6/23/2016
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 6/23/2016
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 6/23/2016
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 6/23/2016
 
Failed To: Maintain comfortable sound levels. Pattern : Minimal 4 6/23/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 6/23/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Pattern : Minimal 4 6/23/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 6/23/2016
 
Failed To: Develop a post-discharge plan with the resident and family for the resident's care after leaving the nursing home. Pattern : Minimal 4 6/23/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 6/23/2016
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 6/23/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 6/23/2016
 
Failed To: Give each resident enough fluids to keep them healthy and prevent dehydration. Isolated : Minimal 3 6/23/2016
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 6/23/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 6/23/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 6/23/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 6/23/2016
 
Failed To: Have enough outside ventilation via a window or mechanical ventilation, or both. Pattern : Minimal 4 6/23/2016
 
Failed To: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Isolated : Minimal 3 6/23/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 6/23/2016
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 6/23/2016
 

5/6/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Pattern : Minimal 4 6/20/2015
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Minimal 4 6/20/2015
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 6/20/2015
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated : Minimal 3 6/20/2015
 
Failed To: Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. Pattern : Minimal 4 6/20/2015
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Isolated : Minimal 3 6/20/2015
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 6/20/2015
 
Failed To: Maintain comfortable sound levels. Pattern : Minimal 4 6/20/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 6/20/2015
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 6/20/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 6/20/2015
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 6/20/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 6/20/2015
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Isolated : Minimal 3 6/20/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 6/20/2015
 
Failed To: Provide or obtain dental services for each resident. Isolated : Minimal 3 6/20/2015
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 6/20/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 6/20/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 6/20/2015
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Isolated : Minimal 3 6/20/2015
 
Failed To: Have enough outside ventilation via a window or mechanical ventilation, or both. Pattern : Minimal 4 6/20/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 6/20/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

6/14/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 7/14/2017
 

2/22/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Try to resolve each resident's complaints quickly. Isolated : Minimal 3 4/7/2017
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 4/7/2017
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 4/7/2017
 
Failed To: Employ staff that are licensed, certified, or registered in accordance with state laws. Widespread : Minimal 5 4/7/2017
 

12/6/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 12/20/2016
 

10/11/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents talk to and get information from agencies acting on their behalf. Pattern : Minimal 4 12/15/2016
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 12/15/2016
 

8/31/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 10/1/2016
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 10/1/2016
 
Failed To: Develop a post-discharge plan with the resident and family for the resident's care after leaving the nursing home. Isolated : Immediate 5 10/1/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 10/1/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 10/1/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 10/1/2016
 

1/13/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 2/16/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NE State Avg
Number of Residents 24 34.00 53.60
Registered Nurses 1.21 1.00 0.76
Licensed Practical / Vocational Nurses 0.50 0.47 0.68
Certified Nursing Assistants 2.76 3.19 2.49
Total Staff Hours 4.47 4.67 3.93

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NE State Avg%
of high risk long-stay residents with pressure ulcers 5 6 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 90 94 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 95 97 96
of long-stay residents experiencing one or more falls with major injury 11 8 4
of long-stay residents who have depressive symptoms 1 6 5
of long-stay residents who lose too much weight 12 9 7
of long-stay residents who received an antianxiety or hypnotic medication 15 14 21
of long-stay residents who received an antipsychotic medication 12 13 18
of long-stay residents who self-report moderate to severe pain 14 10 9
of long-stay residents who were physically restrained 0 1 0
of long-stay residents whose ability to move independently worsened 32 20 19
of long-stay residents whose need for help with daily activities has increased 36 21 15
of long-stay residents with a catheter inserted and left in their bladder 4 7 2
of long-stay residents with a urinary tract infection 2 2 5
of low risk long-stay residents who lose control of their bowels or bladder 22 30 46
of short-stay residents assessed and appropriately given the pneumococcal vaccine 54 74 83
of short-stay residents who had an outpatient emergency department visit 23 17 8
of short-stay residents who newly received an antipsychotic medication 3 74 75
of short-stay residents who self-report moderate to severe pain 44 3 2
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 33 32 19
of short-stay residents who were rehospitalized after a nursing home admission 41 61 80
of short-stay residents with pressure ulcers that are new or worsened 3 29 17