Inspection Reports for Arbor Care Center-Valhaven, LLC
300 West Meigs Street, NE, 68064
Back to Facility ProfileDeficiencies (last 12 years)
Deficiencies (over 12 years)
9.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
129% worse than Nebraska average
Nebraska average: 4.2 deficiencies/year
Deficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
65% occupied
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 43
Capacity: 66
Deficiencies: 0
Mar 19, 2025
Visit Reason
This document is related to the renewal of the nursing home license for Arbor Care Center-Valhaven, LLC, including submission of the Nursing Home Licensure Renewal Application and verification of licensed capacity and census.
Findings
The documents confirm that Arbor Care Center-Valhaven, LLC meets statutory requirements for licensure renewal as a skilled nursing facility with a licensed capacity of 66 beds and a census of 43 residents at the time of the renewal. The renewal application was signed and dated in March 2025.
Report Facts
Licensed Capacity: 66
Census: 43
Renewal Application Date: Mar 13, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Todd Muckey | Administrator | Named on Nursing Home Licensure Renewal Application |
| Roger Bayliff | Director of Nursing | Named on Nursing Home Licensure Renewal Application |
Inspection Report
Renewal
Capacity: 66
Deficiencies: 0
Mar 13, 2024
Visit Reason
The document is a Nursing Home Licensure Renewal Application and renewal certification for Arbor Care Center-Valhaven, LLC, indicating the facility is renewing its license to operate as a skilled nursing facility.
Findings
The document certifies that Arbor Care Center-Valhaven, LLC meets statutory requirements for SNF/NF dual certification and is licensed through the renewal date. No deficiencies or inspection findings are reported in this document.
Report Facts
Licensed beds: 66
Renewal license fees: 1750
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Todd Muckey | Administrator | Named in Nursing Home Licensure Renewal Application |
| Sara Forsberg | Director of Nursing | Named in Nursing Home Licensure Renewal Application |
| Aaron Klaasmeyer | Authorized Representative | Signed Nursing Home Licensure Renewal Application |
| Kenneth Klaasmeyer | Authorized Representative | Signed Nursing Home Licensure Renewal Application |
Inspection Report
Renewal
Capacity: 66
Deficiencies: 0
Mar 31, 2022
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related renewal certification and occupancy permit for Arbor Care Center-Valhaven, LLC, indicating the facility's license renewal and compliance with state requirements.
Findings
The documents certify that Arbor Care Center-Valhaven meets statutory requirements for licensure renewal as a Skilled Nursing Facility with 66 beds, including certifications for Medicare and Medicaid. A temporary occupancy permit was also issued with an expiration date of 12/31/2022.
Report Facts
Total licensed beds: 66
License expiration date: Mar 31, 2023
Occupancy permit expiration date: Dec 31, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Todd Muckey | Administrator | Named on Nursing Home Licensure Renewal Application |
| Denise Kass | Director of Nursing | Named on Nursing Home Licensure Renewal Application |
Notice
Capacity: 66
Deficiencies: 0
Mar 25, 2021
Visit Reason
The document is a Nursing Home Licensure Renewal Application for Arbor Care Center-Valhaven, LLC, indicating the facility is applying to renew its license for 66 beds.
Findings
The documents certify that Arbor Care Center-Valhaven, LLC meets statutory requirements for licensure renewal and includes an occupancy permit issued by the Nebraska State Fire Marshal with a maximum occupancy of 66 beds.
Report Facts
Total licensed beds: 66
Renewal license fee: 1550
Inspection Report
Original Licensing
Capacity: 66
Deficiencies: 0
Jul 1, 2019
Visit Reason
The document is related to the issuance of a new Skilled Nursing Facility license due to a change of ownership and a DBA facility name change from Valhaven Care and Rehabilitation Center LLC to Arbor Care Centers-Valhaven, LLC, effective July 1, 2019.
Findings
The document details the transfer of operations of the facility from the Receiver to the new operator, Arbor Care Centers-Valhaven, LLC, including terms of the transfer agreement, licensing, employee transition, assets, liabilities, and regulatory compliance. The facility is licensed for 66 beds and the transfer includes all necessary approvals and certifications.
Report Facts
Total licensed beds: 66
License issuance date: 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Klaasmeyer | Administrator | Named as Administrator of Arbor Care Centers-Valhaven, LLC in licensing documents. |
| Roger Bayliss | Director of Nursing | Named as Director of Nursing in licensing application. |
| Ken Klaasmeyer | President | Named as authorized representative and signatory for Arbor Care Centers-Valhaven, LLC in the Operations Transfer Agreement. |
Inspection Report
Annual Inspection
Census: 45
Capacity: 66
Deficiencies: 16
Feb 25, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Valhaven Care And Rehabilitation Center from February 19, 2019 to February 25, 2019 by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility was found to be in compliance with noise control regulations. Deficiencies were identified in multiple areas including failure to notify physicians of elevated blood sugars, failure to provide privacy during personal cares, environmental cleanliness issues, failure to provide restorative nursing care, failure to monitor wandering devices, catheter care deficiencies, hand hygiene lapses, ventilation system issues, emergency preparedness plan deficiencies, fire safety system issues including fire alarm and sprinkler system policies, corridor door smoke resistance, and smoke barrier integrity.
Complaint Details
The visit was complaint-related due to an allegation that the facility failed to ensure adequate noise control. The complaint was found to be unsubstantiated as the facility was in compliance with noise level regulations.
Severity Breakdown
SS=F: 6
SS=D: 5
SS=E: 3
SS=C: 2
Deficiencies (16)
| Description | Severity |
|---|---|
| Failure to notify physician of blood sugars greater than 350 as ordered for one resident. | SS=D |
| Failure to provide privacy during personal cares for two residents. | SS=D |
| Failure to maintain cleanliness and condition of ventilation system and non skid gripper strips in resident bathrooms. | SS=E |
| Failure to provide restorative nursing care to maintain resident's ability to ambulate. | SS=D |
| Failure to monitor a wandering device for one resident at high risk for elopement. | SS=D |
| Failure to provide proper suprapubic catheter care per facility policy. | SS=D |
| Failure to ensure hand hygiene was completed during personal cares, catheter care, and glucometer checks for multiple residents. | SS=E |
| Failure to maintain operational ventilation system in 10 resident bathrooms. | SS=E |
| Emergency Preparedness Communication Plan did not include names and contact information for resident physicians and volunteers. | SS=C |
| Failure to conduct required emergency preparedness exercises and maintain documentation. | SS=C |
| Fire alarm system out of service policy incomplete; failed to include notification of State Fire Marshal. | SS=F |
| Accumulation of dust and lint on fire sprinklers in laundry room and kitchen. | SS=F |
| Fire sprinkler system out of service policy incomplete; failed to include notification of State Fire Marshal. | SS=F |
| No placard posted by Class K fire extinguisher explaining sequence of operation in relation to kitchen hood fire extinguishing system. | SS=F |
| Corridor room doors in 2 of 5 smoke compartments failed to resist passage of smoke. | SS=D |
| Smoke barrier separating 100 Hall from Dining Room had a 2-inch hole around wire penetrations above smoke barrier doors. | SS=F |
Report Facts
Deficiencies cited: 16
Resident census: 45
Licensed capacity: 66
Blood sugar readings: 363
Blood sugar readings: 378
Elopement risk score: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Tanner | Administrator | Named as facility administrator in multiple documents. |
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter. |
Inspection Report
Annual Inspection
Census: 53
Capacity: 66
Deficiencies: 14
Dec 14, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Valhaven Care And Rehabilitation Center, Llc on December 11, 2017-December 14, 2017, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility was found to have multiple deficiencies including failure to provide adequate activities for residents, failure to assess and monitor wounds and skin conditions, medication errors, failure to follow therapeutic diet orders, failure to ensure dental care recommendations were followed, and multiple life safety code violations including means of egress obstructions, delayed egress door malfunctions, fire alarm system documentation deficiencies, obstructed fire extinguishers, corridor door issues, fire drill deficiencies, improper use of power strips, and unsafe oxygen concentrator use.
Complaint Details
The complaint allegations were that the facility failed to complete discharge planning and failed to protect residents from residents with behaviors. The facility was found to be in compliance with the regulatory requirements for both allegations after investigation.
Severity Breakdown
SS-D: 6
SS-E: 5
SS-F: 4
Deficiencies (14)
| Description | Severity |
|---|---|
| Facility failed to ensure 3 residents were given the opportunity to participate in activities of interest. | SS-D |
| Facility failed to assess and monitor a surgical wound for Resident 150 and failed to monitor skin tears and bruises for Resident 5. | SS-D |
| Facility failed to ensure one resident did not receive foods prohibited on a therapeutic diet. | SS-D |
| Facility failed to ensure a medication error rate of less than 5% related to insulin administration and gastric tube medication. | SS-D |
| Facility failed to ensure recommendations for dentist evaluation of dentures was followed for one resident. | SS-D |
| Facility allowed decorations to hang from the ceiling in corridors that encroached into the minimum headroom requirements. | SS-F |
| Facility allowed abrupt changes in the elevation of the walking surfaces in a path of egress that exceeded 1/2 inch. | SS-E |
| Facility allowed delayed egress doors to require more than 15 pounds of force to unlock and failed to activate alarms properly. | SS-E |
| Facility failed to provide smoke resistant enclosure for hazardous areas due to unsealed penetrations. | SS-D |
| Facility allowed access to fire extinguishers to be obstructed. | SS-E |
| Facility failed to ensure corridor doors resist passage of smoke and had excessive gaps and doors that did not latch. | SS-F |
| Facility failed to activate fire alarm system within 24 hours of 3rd shift fire drills and during a 2nd shift fire drill. | SS-F |
| Facility allowed use of power strip cord in lieu of permanent wiring in patient care vicinity. | SS-F |
| Facility failed to take precautions to prevent creation of oxygen-enriched atmosphere due to unattended oxygen concentrator. | SS-E |
Report Facts
Residents present: 53
Licensed capacity: 66
Medication observations: 26
Medication error rate: 7.69
Fire drills not activating alarm: 3
Minimum headroom: 80
Observed headroom: 72
Abrupt elevation change: 1
Force to open door: 35
Allowed force: 15
Door gap: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter |
| Annie Paul Allen | Administrator | Named in multiple findings and plan of correction |
| Maintenance A | Acknowledged and verified multiple facility deficiencies related to life safety and maintenance | |
| Director of Nursing (DON) | Interviewed regarding wound care, medication administration, and oxygen concentrator use | |
| Activities Director (AD) | Interviewed regarding resident activities and documentation | |
| Dietary Manager | Interviewed regarding therapeutic diet compliance |
Notice
Deficiencies: 0
Apr 19, 2017
Visit Reason
The notice was issued to impose disciplinary action on Valhaven Care And Rehabilitation Center for violations of licensure regulations related to care and treatment, specifically failure to implement interventions to prevent and heal pressure sores.
Findings
The facility failed to implement interventions to prevent the development and aid in healing of pressure sores, resulting in a probation period with required corrective actions and reporting.
Report Facts
Probation period length: 90
Report submission frequency: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Contact person for submission of required reports and correspondence |
| Thomas L. Williams | MD, Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II | Certified mailing of the Notice of Disciplinary Action |
| Becky Wistell | Administrator, Licensure Unit | Mentioned in relation to the Notice of Disciplinary Action |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Mar 21, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding failure to notify family/POA of change in condition and failure to provide care and treatment to prevent skin breakdown at Valhaven Care And Rehabilitation Center.
Findings
The facility was found compliant with notification of change in condition but failed to consistently implement interventions to prevent skin breakdown, resulting in a pressure ulcer worsening for one resident. Staff were unaware of necessary interventions, leading to non-compliance with federal and state regulations.
Complaint Details
The complaint alleged failure to notify family/POA of change in condition and failure to provide care to prevent skin breakdown. The notification allegation was substantiated as compliant; the skin breakdown allegation was substantiated as non-compliant.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement interventions to prevent development and aid healing of a pressure sore for one resident. | SS=G |
Report Facts
Facility census: 46
Pressure ulcer size increase: 1.3
Pressure ulcer size increase: 3.9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed letter from Office of LTC Facilities - Licensure Unit |
| NA-A | Nurse Aide | Interviewed regarding use of Prevalon boots |
| Assistant Director of Nursing | Interviewed regarding pressure ulcer care and use of Prevalon boots |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 66
Deficiencies: 10
Sep 12, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Golden Livingcenter - Valhaven on September 12-14, 2016, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility was found to be in compliance with regulations related to call light response times, resident dignity, and advance directives. Deficiencies were identified related to bathing preferences documentation, housekeeping and maintenance issues, unsafe resident transfers, drug regimen monitoring, infection control practices, and life safety code violations including fire safety and electrical hazards.
Complaint Details
The complaint allegations included failure to answer call notification systems promptly, failure to ensure residents are treated with respect and dignity, and failure to have accessible/accurate advance directives available for staff to follow. The facility was found in compliance with the first two allegations and self-corrected the third.
Severity Breakdown
SS=F: 4
SS=D: 5
SS=E: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure bathing preferences were evaluated and documented for 2 of 3 sampled residents. | SS=D |
| Failed to maintain walls, equipment and ventilation covers in a clean manner and good condition in 7 of 32 occupied resident rooms. | SS=E |
| Failed to ensure residents were transferred safely using mechanical lift requiring two staff for 1 of 2 sampled residents. | SS=D |
| Failed to ensure drug regimen was free from unnecessary drugs including inadequate monitoring of diuretics and insulin, and failure to identify Black Box Warning medications for 3 residents. | SS=D |
| Failed to ensure gloves were worn while checking blood sugars for 2 of 27 sampled residents to prevent cross contamination. | SS=D |
| Failed to maintain positive latching for hazard room doors in 2 of 4 smoke compartments. | SS=F |
| Failed to provide all required documentation for the annual fire alarm system inspection. | SS=F |
| Allowed foreign matter to accumulate on one automatic fire sprinkler head in the Dishwasher Room. | SS=D |
| Allowed emergency generator to have 'common fault' trouble which could prevent operation during power outage. | SS=F |
| Failed to provide an approved cover for one opening in the main electrical panel in the Transfer Switch Room. | SS=D |
Report Facts
Facility census: 56
Total licensed capacity: 66
Deficiencies cited: 10
Residents sampled for bathing preference deficiency: 3
Residents affected by bathing preference deficiency: 2
Residents sampled for safe transfer deficiency: 2
Residents affected by safe transfer deficiency: 1
Residents sampled for infection control deficiency: 27
Residents affected by infection control deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Loretta Paul Allen | Administrator | Named as facility administrator and interviewed regarding bathing preferences and other findings |
| Eve Lewis | RNC, Program Manager - Office of LTC Facilities - Licensure Unit | Signed the initial complaint investigation letter |
| Interim Director of Nursing | Interim DON | Interviewed regarding safe transfer, drug regimen monitoring, infection control, and other deficiencies |
| LPN B | Licensed Practical Nurse | Observed not wearing gloves during blood sugar monitoring |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 3
Mar 28, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint at Golden Livingcenter - Valhaven on March 28-29, 2016, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The investigation found the facility was generally in compliance with regulatory guidelines for safety, pain management, bladder elimination, resident dignity, food provision, positioning, and grooming. However, deficiencies were found in housekeeping and maintenance related to cleanliness of wheelchairs, hallways, and resident rooms, and in narcotics accountability, specifically failure to maintain individual controlled substance count sheets and failure to account for destruction or disposition of narcotics for a resident.
Complaint Details
The complaint investigation included allegations that the facility failed to provide a safe environment, assist with pain management, maintain housekeeping and maintenance, provide care for bladder elimination, submit investigations timely, ensure narcotics accountability, treat residents with dignity and respect, provide enough food, ensure proper positioning, provide appropriate transfer services, and ensure cleanliness and grooming. The facility was found non-compliant only in housekeeping and narcotics accountability.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to maintain cleanliness of Resident 8 and 9's wheelchairs, 100 hall, and resident rooms 105, 106, 107, and 117, with visible soil and debris. | SS=E |
| Facility failed to ensure accurate individual narcotic count sheets signed by two persons for each resident's controlled substances. | — |
| Facility failed to account for destruction or disposition of narcotics for Resident 4, with missing required documentation. | SS=D |
Report Facts
Facility census: 54
Deficiency completion dates: 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter |
| Loretta Paul Allen | Administrator | Facility administrator addressed in complaint investigation |
| Director of Nursing (DON) | Interviewed regarding controlled substance count process and narcotics accountability deficiencies | |
| Housekeeping Supervisor | Interviewed regarding housekeeping deficiencies and cleaning schedules | |
| Executive Director (ED) | Involved in narcotics accountability and housekeeping corrective actions |
Inspection Report
Renewal
Capacity: 66
Deficiencies: 0
Feb 22, 2016
Visit Reason
The document is a Nursing Home Licensure Renewal Application for Golden LivingCenter - Valhaven, submitted to renew the facility's license.
Findings
The document certifies that the facility meets statutory requirements for licensure renewal and includes information about services provided and ownership.
Report Facts
Number of beds to be relicensed: 66
Renewal fees: 1550
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Loretta Paul Allen | Administrator | Named in the Nursing Home Licensure Renewal Application |
| Kathy Daniels | Director of Nursing | Named in the Nursing Home Licensure Renewal Application |
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 12
Sep 17, 2015
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements including medication management, food safety, life safety code, and equipment maintenance.
Findings
The facility was found deficient in multiple areas including failure to monitor lab values for anticoagulant medication, unsanitary food preparation conditions, unsafe equipment, pest control issues, obstructed and uneven exit access, non-functional emergency lighting, fire alarm system maintenance deficiencies, sprinkler system obstructions, inaccessible fire extinguishers, improper oxygen cylinder storage, missing oxygen precautionary signage, and use of unapproved electrical wiring and equipment.
Severity Breakdown
SS=D: 1
SS=F: 5
SS=E: 5
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to monitor lab values for Resident 27 related to anticoagulant medication. | SS=D |
| Failure to ensure sanitary food procurement, storage, preparation, and serving conditions including hair/beard restraints and cleanliness of kitchen equipment. | SS=F |
| Failure to maintain essential equipment in safe operating condition related to a knicked meat slicer blade. | SS=F |
| Failure to maintain an effective pest control program; presence of live cockroach and bugs under floor tiles. | SS=F |
| Failure to ensure exit access is unobstructed and walking surfaces are level, including pallets blocking hospice exit and uneven sidewalk. | SS=E |
| Failure to maintain emergency lighting in transfer switch room. | SS=F |
| Failure to maintain fire alarm system with proper sensitivity testing. | SS=F |
| Obstruction of sprinkler head by stored items in therapy room closet. | SS=F |
| Fire extinguisher access obstructed by cart in 200 hall. | SS=E |
| Oxygen cylinders not segregated between full and empty in storage room. | SS=E |
| Oxygen use rooms lacked precautionary no smoking signs. | SS=E |
| Use of unapproved electrical wiring and equipment including multi-plug and extension cords, and uncovered electrical box. | SS=E |
Report Facts
Facility census: 57
Deficiencies cited: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Verified observations related to exit access, emergency lighting, fire alarm system, sprinkler obstruction, fire extinguisher obstruction, oxygen storage, oxygen signage, and electrical wiring deficiencies. | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding failure to monitor lab values for Resident 27 and medication management. |
| Dietary Manager (DM) | Dietary Manager | Interviewed and observed regarding food sanitation, equipment condition, pest control, and oxygen use signage. |
Notice
Deficiencies: 0
Jun 30, 2015
Visit Reason
This Notice of Disciplinary Action was issued to impose probation on the facility's license for 90 days beginning July 15, 2015, due to violations related to accidents and failure to assess causal factors and implement interventions to prevent falls.
Findings
The facility was found in violation of licensure regulations related to accidents and failure to assess causal factors and implement interventions to prevent falls, as specified in the CMS-2567 Report dated June 29, 2015.
Report Facts
Probation period: 90
Report submission deadline: 25
Response timeframe: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Contact for submission of required descriptions and reports |
| Courtney N. Phillips | Chief Executive Officer | Signed the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II | Certified mailing of the Notice of Disciplinary Action |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Jun 11, 2015
Visit Reason
An unannounced visit was conducted to investigate complaints regarding failure to implement interventions to prevent falls and failure to protect residents from aggressive behaviors.
Findings
The facility failed to assess and implement interventions to prevent falls for Resident 1 and failed to protect residents from aggressive behaviors of Resident 2. Multiple falls and injuries were documented without appropriate new interventions or root cause analysis.
Complaint Details
The complaint investigation found the facility failed to implement interventions to prevent falls and failed to protect residents from aggressive behaviors. Observations, record reviews, and interviews confirmed these failures. The facility census was 55.
Severity Breakdown
SS=D: 1
SS=G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to evaluate and put interventions in place to protect residents from aggressive behaviors of Resident 2. | SS=D |
| Failure to assess for causal factors and put interventions in place to prevent repeated falls for Resident 1. | SS=G |
Report Facts
Facility census: 55
Number of falls: 10
Bruises: 3
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Apr 27, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging multiple deficiencies at Golden Livingcenter - Valhaven from April 27 to April 30, 2015.
Findings
The investigation found the facility in compliance with all regulatory requirements related to abuse prevention, resident rights, care plans, medication administration, environment, staffing, and other allegations. No violations were identified.
Complaint Details
The complaint alleged failures including abuse prevention, access to phone communication, appropriate notice of involuntary discharge, fall precautions, food service compliance, staffing sufficiency, environment comfort, housekeeping, plan of care implementation, notification of healthcare practitioners, respect and dignity, pressure sore prevention, bowel/bladder care, fluid intake, medication administration, and medication storage. All allegations were found to be unsubstantiated.
Report Facts
Facility census: 56
Medications administered: 31
New hires background checks: 5
Residents reviewed: 3
Discharged resident charts reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Schmidt | Registered Nurse | Investigator conducting complaint investigation |
| Lori Frodsham | Registered Nurse | Investigator conducting complaint investigation |
| Carol Neneman | Social Worker | Investigator conducting complaint investigation |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Report signatory and program manager |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 4
Oct 8, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Golden Livingcenter - Valhaven on October 8, 2014-October 16, 2014.
Findings
The facility failed to ensure appropriate housekeeping and infection control procedures, failed to utilize assessed fall prevention interventions, had insufficient dietary support personnel causing delayed meal service, and failed to prevent bare hand contact with medications and cross-contamination of blood glucose monitors.
Complaint Details
The complaint alleged failure to protect residents from missing money/personal items, failure to ensure clean and groomed hair, skin, teeth and nails, failure to ensure residents are free from abuse, failure to ensure appropriate housekeeping, and failure to ensure infection control procedures are followed. The facility was found to have no violations related to missing money, grooming, or abuse but failed housekeeping and infection control.
Severity Breakdown
SS=E: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure no odors and maintain cleanliness and condition of nurse call systems, bathroom fixtures and walls in multiple resident rooms and hallways. | SS=E |
| Facility failed to utilize assessed fall prevention interventions and failed to secure chemicals, affecting residents with poor safety awareness. | SS=E |
| Facility failed to employ sufficient dietary support personnel to ensure timely meal service. | SS=F |
| Facility failed to prevent bare hand contact with medications and failed to clean accucheck machine to prevent cross-contamination. | SS=E |
Report Facts
Facility census: 60
Resident rooms with deficiencies: 11
Residents affected by fall prevention failure: 5
Residents potentially affected by dietary staffing: 59
Residents affected by medication and infection control deficiencies: 29
Residents affected by accucheck machine deficiency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martin Brown | Administrator | Named in complaint investigation letter |
| Connie Kincaid | Registered Nurse | Surveyor and complaint investigation representative |
| Kelly Schmidt | Registered Nurse | Surveyor and complaint investigation representative |
| Lori Frodsham | Registered Nurse | Surveyor and complaint investigation representative |
| Carol Neneman | Social Worker | Surveyor and complaint investigation representative |
| Eve Lewis | Program Manager | Signed complaint investigation letter |
| LPN F | Licensed Practical Nurse | Named in fall prevention deficiency observation |
| MA H | Medication Aide | Named in fall prevention deficiency observation |
| Director of Nursing | Director of Nursing | Interviewed regarding fall prevention and dietary staffing deficiencies |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Jun 16, 2014
Visit Reason
An unannounced visit was conducted to investigate multiple complaints at Golden Livingcenter - Valhaven on June 16-17, 2014, including allegations of misappropriation of resident property, abuse, insufficient staffing, failure to assist with activities of daily living, incomplete treatments, delayed call system response, and failure to provide therapeutic diets.
Findings
The investigation found no violations related to any of the allegations. The facility ensured resident property was accounted for, protected residents from abuse, maintained sufficient staffing, assisted residents with daily living activities, completed treatments as ordered, responded promptly to call notifications, and provided therapeutic diets according to physician orders.
Complaint Details
The visit was complaint-related, investigating allegations of misappropriation of resident property, abuse, insufficient staffing, failure to assist with activities of daily living, incomplete treatments, delayed call system response, and failure to provide therapeutic diets. All allegations were found to be unsubstantiated with no violations.
Report Facts
Facility census: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Connie Kincaid | Registered Nurse | Representative of the Department of Health and Human Services who conducted the investigation |
| Carol Neneman | Social Worker | Representative of the Department of Health and Human Services who conducted the investigation |
| Eve Lewis | Program Manager | Signed correspondence from the Office of Long Term Care Facilities |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 3
Mar 19, 2014
Visit Reason
An unannounced visit was conducted to investigate multiple complaints at Golden Livingcenter - Valhaven on March 18-19, 2014, including allegations of staff chemical impairment, dishwashing standards, resident property misappropriation, fall intervention changes, resident abuse, treatment completion, and staffing sufficiency.
Findings
The facility was found compliant with staff chemical impairment, dishwashing standards, fall interventions, abuse protection, and staffing sufficiency. Deficiencies were found related to failure to ensure resident property was free from misappropriation, failure to notify physicians to discontinue or implement treatments for wounds for two residents, incomplete treatments according to physician orders, and failure to develop and implement abuse/neglect policies regarding registry checks for two staff members.
Complaint Details
The complaint investigation included allegations that staff provided care while chemically impaired, failure to follow dishwashing standards, misappropriation of resident property, failure to change fall interventions, failure to protect residents from abuse, failure to complete treatments as ordered, and insufficient staffing. The facility was found compliant with most allegations except for misappropriation of resident property, treatment completion, and registry check policies.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify physician to discontinue treatment orders for wounds for Resident 5 and to implement treatment for Resident 7. | SS=D |
| Failure to develop and implement policies to ensure reference and APS/CPS registry checks were reviewed for negative findings on two nursing staff members. | SS=D |
| Failure to complete treatments as ordered for Resident 7 and failure to implement bowel interventions for Resident 4. | SS=D |
Report Facts
Facility census: 61
Number of grievances regarding staffing: 3
Number of employee files reviewed for drug/substance abuse policy: 5
Number of employees and supervisors interviewed regarding abuse protocols: 8
Number of residents interviewed regarding abuse: 5
Number of employee files missing state registry checks: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| D. Kirk Sweeney | Administrator | Facility administrator receiving the report |
| Kelly Schmidt | Registered Nurse | Investigator for complaint |
| Ron Chase | Registered Nurse | Investigator for complaint |
| Kay Reeves | Nutrition/dietitian | Investigator for complaint |
| Eve Lewis | Program Manager | Signed the report letter |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 15
Jul 11, 2013
Visit Reason
The inspection was an annual survey to assess compliance with state and federal regulations governing skilled nursing facilities, including resident rights, care planning, pressure ulcer treatment, infection control, medication management, food safety, and life safety code compliance.
Findings
The facility was found deficient in multiple areas including failure to evaluate and follow resident bathing preferences, inadequate care planning and treatment for pressure ulcers, insufficient incontinence care, lack of monitoring of behaviors related to psychotropic medication use, food safety and sanitation issues in the kitchen, and life safety code violations including smoke barrier construction, exit accessibility, fire alarm maintenance, sprinkler system installation, and flame retardancy of window coverings.
Severity Breakdown
SS=D: 3
SS=G: 2
SS=E: 5
SS=F: 4
Deficiencies (15)
| Description | Severity |
|---|---|
| Facility staff failed to evaluate and follow bathing practices for 3 residents (Residents 20, 46, and 69). | SS=D |
| Facility failed to review and revise the comprehensive care plan related to the development of a pressure ulcer for Resident 50. | SS=D |
| Facility failed to evaluate, monitor, and provide treatment for a pressure ulcer for Resident 50 and failed to evaluate and implement interventions for Resident 46. | SS=G |
| Facility failed to provide routine incontinence care to Resident 79. | SS=D |
| Facility failed to identify and monitor target behaviors for Residents 23, 75, 87, 88, and 90 who were on psychotropic medications. | SS=E |
| Facility staff failed to ensure unpasteurized eggs were fully cooked for 3 residents, failed to ensure correct portion sizes, and failed to ensure palatability of foods served to 7 residents on a pureed diet. | SS=E |
| Facility staff failed to maintain kitchen equipment and food storage areas in a clean and sanitary manner, risking food contamination. | SS=F |
| Facility failed to maintain kitchen equipment and storage areas in a clean manner including convection oven, steam table, freezer vent, dish storage rack, baking pans, and metal shelving. | SS=F |
| Facility Quality Assurance committee failed to correct ongoing issues related to resident care and kitchen sanitation and failed to implement effective plans of action. | SS=G |
| Facility failed to provide a smoke barrier with at least ½ hour fire resistance rating constructed in accordance with NFPA 101 for 1 of 3 smoke barriers. | SS=E |
| Facility failed to maintain 1 of 8 exits so that the exit was readily available at all times; delayed egress signage was obstructed. | SS=F |
| Facility failed to maintain the fire alarm system in accordance with NFPA 72; semiannual inspection reports were incomplete. | SS=F |
| Facility failed to install the automatic sprinkler system in accordance with NFPA 13; antifreeze loop expansion tank was not rated for sprinkler system pressure. | SS=E |
| Privacy curtains in resident rooms overlapped blocking sprinkler spray pattern, failing to maintain 70% open mesh. | SS=E |
| Facility failed to provide documentation that window coverings (plastic mini-blinds) were flame retardant. | SS=E |
Report Facts
Residents affected: 3
Facility census: 60
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 5
Residents affected: 7
Residents affected: 13
Residents affected: 58
Residents affected: 30
Residents affected: 30
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 15
Jul 11, 2013
Visit Reason
Annual inspection of Golden Livingcenter - Valhaven to assess compliance with Nebraska regulations and federal requirements for skilled nursing facilities.
Findings
The facility was found deficient in multiple areas including residents' rights to make choices, care planning and treatment of pressure ulcers, incontinence care, drug regimen monitoring, food preparation and sanitation, environmental safety, and quality assurance processes.
Severity Breakdown
SS=D: 3
SS=G: 2
SS=E: 6
SS=F: 4
Deficiencies (15)
| Description | Severity |
|---|---|
| Facility staff failed to evaluate and follow bathing practices for 3 residents, violating residents' right to make choices. | SS=D |
| Facility failed to review and revise comprehensive care plan related to pressure ulcer development for Resident 50. | SS=D |
| Facility failed to evaluate, monitor, and provide treatment for pressure ulcers for Residents 50 and 46. | SS=G |
| Facility failed to provide routine incontinence care to Resident 79. | SS=D |
| Facility failed to identify and monitor target behaviors for Residents 23, 75, 87, 88, and 90 receiving psychotropic medications. | SS=E |
| Facility failed to ensure unpasteurized eggs were fully cooked, correct portion sizes, and palatability of pureed foods for residents. | SS=E |
| Facility failed to maintain kitchen equipment and food storage areas in a clean and sanitary manner. | SS=F |
| Facility failed to maintain a safe, functional, sanitary, and comfortable environment in the kitchen. | SS=F |
| Facility Quality Assurance committee failed to correct ongoing issues and implement effective plans of action for multiple deficiencies. | SS=G |
| Facility failed to provide a smoke barrier with at least ½ hour fire resistance rating in accordance with NFPA 101. | SS=E |
| Facility failed to maintain exit doors readily accessible and failed to provide required signage for magnetically locked doors. | SS=F |
| Facility failed to maintain fire alarm system inspection documentation as required. | SS=F |
| Facility failed to install automatic sprinkler system components in accordance with NFPA 13, risking sprinkler system failure. | SS=E |
| Privacy curtains overlapped obstructing sprinkler coverage in resident rooms. | SS=E |
| Facility failed to provide documentation that window coverings were flame retardant. | SS=E |
Report Facts
Facility census: 60
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 5
Residents affected: 3
Residents affected: 7
Residents affected: 13
Residents affected: 30
Residents affected: 58
Residents affected: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kirk Sweeney | Administrator | Named in informal dispute resolution and plan of correction |
| Krystal Hays | MSN RN RAC-CT | Reviewer of informal dispute resolution report |
| Jill A. Garner | Director of Nursing | Named in informal dispute resolution report |
| Brenda Knutson | Clinical Director | Named in informal dispute resolution report |
| Maintenance A | Interviewed regarding fire safety and environmental deficiencies | |
| Cook G | Interviewed regarding food preparation and sanitation deficiencies | |
| Dietary Manager | Interviewed regarding food service and QA committee | |
| Director of Nursing | Interviewed regarding QA committee and care deficiencies |
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 15
Apr 12, 2012
Visit Reason
The inspection was the annual survey to assess compliance with state and federal regulations governing skilled nursing facilities, including investigation of allegations, catheter care, medication management, food service, and life safety code compliance.
Findings
The facility was found deficient in timely reporting of abuse investigations, catheter care procedures, medication regimen management including duplicate medications and monitoring, food temperature and palatability, expired medications, and multiple life safety code violations including smoke barrier doors, fire drills, flammable decorations, emergency lighting, and electrical safety.
Severity Breakdown
SS=D: 2
SS=E: 7
SS=F: 5
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to submit investigations to the required state agency within the required 5 working day time frame for 2 residents. | SS=D |
| Failed to complete catheter care for 2 residents with indwelling catheters. | SS=D |
| Medication regimen included duplicate antidepressants, medications without clinical rationale, and lack of monitoring for 6 residents. | SS=E |
| Failed to provide meals that were palatable and at the proper temperature for 4 residents. | SS=F |
| Pharmacist failed to identify and report medication irregularities for 4 residents. | SS=E |
| Expired insulin and undated acetaminophen available for use. | SS=E |
| Therapy smoke separation door failed to latch, allowing passage of smoke. | SS=E |
| South door to Housekeeping Storage failed to engage frame, allowing fire and smoke migration. | SS=F |
| Emergency lighting in medication room did not operate automatically during power failure. | SS=F |
| Fire drills were not conducted at unexpected times as required. | SS=F |
| Decorations hanging on resident doors and corridors were not flame retardant. | SS=F |
| Fabric curtains and valances throughout the facility were not verified as flame retardant. | SS=F |
| Crushed dryer duct in laundry room increased fire risk. | SS=F |
| Oxygen in use sign missing on resident room where oxygen was used. | SS=E |
| Extension cord used in resident room for multiple devices. | SS=E |
Report Facts
Facility census: 62
Sample size: 38
Residents affected: 2
Residents affected: 2
Residents affected: 6
Residents affected: 4
Residents affected: 4
Residents affected: 33
Residents affected: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance A | Confirmed door latch failures and extension cord use | |
| Director of Nursing | DON | Interviewed regarding medication and reporting deficiencies |
| Nurse Consultant D | Interviewed regarding medication irregularities | |
| Registered Nurse B | RN | Confirmed expired insulin |
| LPN Unit Manager E | LPN | Interviewed regarding medication monitoring and lab results |
| Consultant Pharmacist | Failed to identify medication irregularities | |
| Dietary Director | Reported food quality issues and corrective actions |
Inspection Report
Plan of Correction
Census: 63
Deficiencies: 5
Jan 5, 2011
Visit Reason
The document is a Plan of Correction submitted by Golden Livingcenter - Valhaven in response to deficiencies identified during a survey conducted on 01/05/2011.
Findings
The facility was found deficient in multiple areas including failure to revise comprehensive care plans, failure to provide services by qualified persons, failure to ensure free of accident hazards, failure to provide therapeutic diets as prescribed, and failure to maintain a safe, functional, sanitary, and comfortable environment. The plan of correction outlines specific corrective actions, responsible persons, and completion dates for each deficiency.
Severity Breakdown
SS=D: 4
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to review and revise a Comprehensive Care Plan (CCP) for planned weight loss for one resident. | SS=D |
| Failure to provide services by qualified persons per care plan. | SS=D |
| Failure to ensure resident environment remains free of accident hazards and provide adequate supervision and assistance devices. | SS=D |
| Failure to provide therapeutic diets prescribed by physician. | SS=D |
| Failure to provide a safe, functional, sanitary, and comfortable environment; kitchen floor was soiled with dust and debris. | SS=F |
Report Facts
Census: 63
Sampled residents: 15
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RNAC | Responsible Person | Named as responsible for correction of care plan revision for resident #8 |
| DNS | Director of Nursing Services | Named as responsible person for multiple corrections including OT evaluation, wheelchair brake audits, and therapeutic diet compliance |
| Executive Director | Executive Director | Signed the plan of correction document |
| DSM | Dietary Services Manager | Named as responsible for kitchen floor cleaning correction |
| ED | Executive Director | Named as responsible for kitchen floor cleaning correction |
Notice
Capacity: 66
Deficiencies: 0
APP2015
Visit Reason
This document serves as the nursing home licensure renewal application and includes the occupancy permit for Golden LivingCenter - Valhaven.
Findings
The documents confirm the facility's licensure renewal status, ownership information, and fire marshal occupancy permit with a maximum capacity of 66 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 66
Notice
Capacity: 66
Deficiencies: 0
APP2017
Visit Reason
This document serves to verify the renewal of the Skilled Nursing Facility/Nursing Facility dual certification license for Valhaven Care and Rehabilitation Center, LLC, and includes the renewal application and related ownership and occupancy information.
Findings
The documents confirm that the facility is licensed through the renewal date, with no deficiencies or inspection findings reported. The occupancy permit issued by the Nebraska State Fire Marshal authorizes a maximum occupancy of 66 beds.
Report Facts
Total licensed capacity: 66
Renewal fees: 1750
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Loretta Paul-Allen | Administrator | Named in renewal application |
| Kathy Daniels | Director of Nursing | Named in renewal application |
| Joseph Schwartz | Authorized Representative | Signed renewal application and ownership disclosure |
| Rosie Schwartz | Authorized Representative | Signed renewal application and ownership disclosure |
| Brandon Augustyniak | CFO of Highlite Healthcare Management, LLC | Named in ownership and control disclosure |
Inspection Report
Renewal
Capacity: 66
Deficiencies: 0
APP2018
Visit Reason
This document serves as a licensure renewal application and certification for Valhaven Care and Rehabilitation Center, LLC, verifying that the facility's SNF/NF dual certification is licensed through the indicated renewal date.
Findings
The document confirms the facility meets statutory requirements for licensure renewal as a Skilled Nursing Facility and Nursing Facility, with no deficiencies or inspection findings noted.
Report Facts
Total licensed beds: 66
Renewal fee: 1750
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Loretta Paul Allen | Administrator | Named in the licensure renewal application |
| Jason Keenan | Director of Nursing | Named in the licensure renewal application |
| Joseph Schwartz | Authorized Representative | Signed the licensure renewal application |
| Rosie Schwartz | Authorized Representative | Signed the licensure renewal application |
Notice
Capacity: 66
Deficiencies: 0
APP2020
Visit Reason
This document serves as a licensure renewal application and verification of licensure for Arbor Care Center-Valhaven, LLC, including renewal of the Skilled Nursing Facility/Nursing Facility dual certification and occupancy permit.
Findings
The documents confirm that Arbor Care Center-Valhaven, LLC meets statutory requirements for licensure renewal as a Skilled Nursing Facility/Nursing Facility dual certified center, with a licensed bed capacity of 66 beds as per the occupancy permit.
Report Facts
Licensed beds: 42
Maximum occupancy: 66
Renewal license expiration date: Mar 31, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joe Kezar | Administrator | Named in Nursing Home Licensure Renewal Application (page 2) |
| Roger Bayliff | Director of Nursing | Named in Nursing Home Licensure Renewal Application (page 2) |
| Kenneth Klaasmeyer | Authorized Representative | Signed Nursing Home Licensure Renewal Application (page 2) |
| Linda Klaasmeyer | Authorized Representative | Signed Nursing Home Licensure Renewal Application (page 2) |
Document
Capacity: 66
Deficiencies: 0
APP2023
Visit Reason
The document serves as a renewal application for nursing home licensure and includes verification of licensure status and occupancy permit information.
Findings
The documents confirm that Arbor Care Center-Valhaven, LLC meets statutory requirements for licensure renewal and occupancy with a maximum capacity of 66 beds.
Report Facts
Total licensed beds: 66
Renewal license fees: 1750
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Todd Muckley | Administrator | Named on the Nursing Home Licensure Renewal Application. |
| Denise Kass | Director of Nursing | Named on the Nursing Home Licensure Renewal Application. |
Notice
Capacity: 66
Deficiencies: 0
CHOW2016
Visit Reason
Issuance of a Skilled Nursing Facility license due to change of ownership and facility name change, along with renewal verification and occupancy permit issuance.
Findings
The document confirms the facility meets statutory requirements for SNF/NF dual certification, issues a new license effective October 1, 2016, and provides an occupancy permit for 66 beds. Ownership and administrator information are also detailed.
Report Facts
Number of beds licensed: 66
License expiration date: 2017
Occupancy permit date: 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Annie Paul Allen | Administrator | Named as facility administrator in licensure application |
| Kathy Daniels | Director of Nursing | Named as Director of Nursing in licensure application |
| Courtney N. Phillips | Chief Executive Officer | Signed license issuance and renewal notices |
| Susen Lindner | Deputy State Fire Marshal | Approved occupancy permit |
Notice
Deficiencies: 0
DAN071113
Visit Reason
The document serves as a Notice of Disciplinary Action issued to Golden LivingCenter - Valhaven for violations related to failure to evaluate, monitor, and implement interventions to prevent pressure ulcers.
Findings
The Department of Health and Human Services determined that the facility violated licensure regulations by failing to properly assess and manage residents at risk for pressure sores, resulting in probation for 90 days with required submission of corrective action plans and reports.
Report Facts
Probation period length: 90
Probation start date: Aug 8, 2013
Report due date: Aug 18, 2013
Notice date: Jul 24, 2013
Notice finalization date: Aug 8, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph M. Acierno | Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Disciplinary Action |
| Helen K. Meeks | Administrator, Licensure Unit | Signed the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II, Office of Long Term Care Facilities | Certified mailing of the Notice of Disciplinary Action |
| Eve Lewis | RNC, Administrator, Program Manager, Office of Long Term Care Facilities | Recipient of required reports and author of letter terminating probation |
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