Inspection Reports for Arbor Care Centers-Countryside LLC
703 North Main Street, NE, 68748
Back to Facility ProfileDeficiencies (last 11 years)
Deficiencies (over 11 years)
4.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% better than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
66 residents
Based on a October 2018 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Capacity: 70
Deficiencies: 0
Mar 13, 2024
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related certification and occupancy permits for Arbor Care Centers-Countryside LLC, indicating the facility is renewing its license to operate as a skilled nursing facility.
Findings
The documents certify that Arbor Care Centers-Countryside LLC meets statutory requirements for licensure renewal, with no deficiencies or violations noted in the materials provided.
Report Facts
Number of beds to be relicensed: 70
Maximum occupancy: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heather DeBolt | Administrator | Named in Nursing Home Licensure Renewal Application |
| Sam Relgle | 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 |
| Robert Stoess | Deputy State Fire Marshal | Inspected and issued Nebraska State Fire Marshal Occupancy Permit |
Inspection Report
Renewal
Capacity: 70
Deficiencies: 0
May 8, 2023
Visit Reason
The document is a Nursing Home Licensure Renewal Application for Arbor Care Centers-Countryside LLC, indicating the facility is renewing its license to operate as a skilled nursing facility.
Findings
The document certifies that the facility meets statutory requirements for licensure renewal and includes information about the facility's services, capacity, and certifications. No deficiencies or violations are noted.
Report Facts
Number of beds: 70
Maximum capacity for Alzheimer's beds: 17
Renewal application date: May 8, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joe Kezar | Administrator | Named on renewal application |
| Kathy Baumert | Director of Nursing | Named on renewal application |
| Aaron Klaasmeyer | Authorized representative signing renewal application and Alzheimer's Special Care Unit Disclosure |
Notice
Capacity: 70
Deficiencies: 0
Mar 17, 2022
Visit Reason
This document serves as a renewal application for the nursing home license of Arbor Care Centers-Countryside LLC, including certification and occupancy permits.
Findings
The documents confirm that Arbor Care Centers-Countryside LLC meets statutory requirements for licensure renewal, with no inspection findings or deficiencies reported.
Report Facts
Total licensed beds: 70
Maximum capacity for Alzheimer's beds: 17
Renewal Licensure Fees: 1550
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsay Hutchinson | Administrator | Named on the Nursing Home Licensure Renewal Application. |
| Erin Petersen | Director of Nursing | Named on the Nursing Home Licensure Renewal Application. |
| Lisa McDermed | Administrator | Named on the Alzheimer's Special Care Unit Disclosure form. |
Notice
Capacity: 70
Deficiencies: 0
Oct 2, 2020
Visit Reason
Issuance of a new Skilled Nursing Facility license due to a change of ownership and a DBA name change from Countryside Homes to Arbor Care Centers-Countryside LLC.
Findings
The Department of Health and Human Services issued a Skilled Nursing Facility License #524002 to Arbor Care Centers-Countryside LLC effective October 1, 2020, replacing the previous license. The license is for the premises and persons named on the application and is not transferable.
Report Facts
Total licensed beds: 70
Inspection Report
Renewal
Capacity: 70
Deficiencies: 0
Mar 18, 2020
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related licensing and certification documents for Countryside Home, indicating the renewal of the facility's license and certifications.
Findings
The documents confirm that Countryside Home meets statutory requirements for licensure as a Skilled Nursing Facility with a Special Care Unit for Alzheimer's and memory care. The facility is licensed for 70 beds, all Medicare and Medicaid certified, and includes detailed disclosures about care philosophy, staffing, environment, and fees.
Report Facts
Total licensed beds: 70
License expiration date: Mar 31, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristi Jarecki-Vering | Administrator | Named as Administrator and authorized representative signing renewal and endorsement applications. |
| Al Brandl | Mayor | Named as authorized representative signing renewal application. |
Notice
Deficiencies: 0
Nov 8, 2018
Visit Reason
The facility was placed on probation for 90 days beginning November 8, 2018, due to violations of licensure regulations related to accident hazards and other deficiencies. The notice outlines the terms of probation, including submission of a Plan of Correction and periodic reports on residents with accidents.
Findings
The facility was found to have violated regulations by failing to ensure residents were free of accident hazards, as evidenced by the CMS-2567 Report dated October 24, 2018. Additional violations included inability to self-perform, food preparation, and infection control deficiencies.
Report Facts
Probation period: 90
Report submission frequency: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | RN, BSN, Program Manager | Named as contact for submission of reports and correspondence related to the disciplinary action |
| Bo Botelho | Interim Chief Executive Officer | Signed the Notice of Disciplinary Action |
| Becky Wisell | Administrator, Licensure Unit | Signed the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II | Certified service of the Notice of Disciplinary Action |
| Linda Anderson | Administrator | Facility administrator addressed in the termination letter of probation |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 5
Oct 1, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Countryside Home from October 1, 2018 to October 9, 2018 by the Department of Health and Human Services Division of Public Health.
Findings
The facility was found non-compliant in evaluating causal factors for falls, infection control guidelines, and ensuring residents' competence to operate motorized equipment. The facility was compliant in ensuring the Minimum Data Set reflected residents' needs, residents had access to communication in a language they understand, care plans addressed identified needs, and staff background checks were completed. Additional deficiencies were found related to ADL care, fall prevention, meal temperature and palatability, and infection control related to catheter care.
Complaint Details
The complaint investigation included allegations that the facility failed to ensure the minimal data set reflected residents' needs, failed to evaluate causal factors for falls, failed to ensure residents had access to communication in a language they understand, failed to follow infection control guidelines, failed to develop a plan of care to address identified needs, failed to ensure residents were competent to operate motorized equipment, and failed to complete staff background checks. The investigation found non-compliance in fall evaluation, infection control, and motorized equipment competence.
Severity Breakdown
SS=G: 2
SS=D: 2
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to evaluate causal factors for falls and develop interventions to prevent further falls. | SS=G |
| Failed to ensure residents were competent to operate motorized recliners, resulting in a major injury fall. | SS=G |
| Failed to follow infection control guidelines; urinary catheter drainage bag was allowed to drag on the floor and mechanical lift foot rest, risking cross contamination. | SS=D |
| Failed to provide toileting assistance every 2 hours as required, resulting in resident being soiled for over 4 hours. | SS=D |
| Failed to ensure meals served in the Special Care Unit were palatable and served at proper temperature. | SS=E |
Report Facts
Residents reviewed for falls: 4
Residents reviewed for MDS compliance: 17
Facility census: 66
Temperature of hot cereal served: 115
Temperature of eggs served: 109
Required meal serving temperature: 150
Residents reviewed for catheter cross contamination audit: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Anderson | Administrator | Facility administrator addressed in the report. |
| Connie Vogt | RN, BSN, Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation letter. |
| NA-M | Nursing Assistant | Confirmed Resident 42 had not been toileted for over 4 hours. |
| NA-L | Nursing Assistant | Confirmed Resident 42 had not received incontinent care or toileting since 6:00 AM. |
| LPN-J | Licensed Practical Nurse | Indicated Resident 66 activated call light and required 1 person assist with ambulation. |
| Dietary Cook-D | Dietary Cook | Checked meal temperatures during breakfast service. |
| Dietary Manager | Dietary Manager | Confirmed meals were served below proper temperature. |
| NA-E | Certified Nursing Assistant | In-serviced on proper handling of urinary catheter drainage bags after cross contamination observation. |
| NA-F | Certified Nursing Assistant | In-serviced on proper handling of urinary catheter drainage bags after cross contamination observation. |
| Director of Nursing | Director of Nursing | Confirmed urinary catheter drainage bag and tubing should not contact the floor. |
Inspection Report
Renewal
Capacity: 70
Deficiencies: 0
Mar 5, 2018
Visit Reason
This document is a Nursing Home Licensure Renewal Application and related certification materials for Countryside Home, verifying the renewal of the SNF/NF dual certification and license through March 31, 2019.
Findings
The facility is licensed for 70 beds, all Medicare and Medicaid certified. The application includes detailed information on services provided, staffing patterns, care philosophy, and room rates. No deficiencies or violations are noted in the renewal application.
Report Facts
Total licensed beds: 70
Renewal license expiration date: Mar 31, 2019
Renewal application approval date: Mar 5, 2018
Room rates - Semi-Private Rooms: 176
Room rates - Special Care Unit: 188
Room rates - Private Rooms: 191
Room rates - Special Care Unit Private Rooms: 193
Staff training hours: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Anderson | Administrator | Named as Administrator and authorized representative signing the renewal application. |
| Mindy Buckendahl | Director of Nursing | Named as Director of Nursing on renewal application. |
| Paula Biehle | Treasurer | Contact name for legal owning entity, City of Madison. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 28, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Countryside Home regarding failure to identify a change of condition and failure to answer call lights promptly.
Findings
The facility was found to be in compliance with relevant regulatory requirements for both allegations. The facility identified changes of condition appropriately and answered call lights promptly, with response times varying from three to five minutes and no complaints found in grievances or resident interviews.
Complaint Details
The investigation addressed two allegations: failure to identify a change of condition and failure to answer call lights promptly. Both were found to be unsubstantiated with the facility in compliance.
Report Facts
Call light response time: 3
Call light response time: 5
Resident Council meetings reviewed: 6
Resident interviews: 3
Staff interviews: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed the report as Training Coordinator, Office of LTC Facilities - Licensure Unit |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 70
Deficiencies: 7
Jul 12, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Countryside Home from July 6, 2017 to July 17, 2017, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility was found non-compliant for failing to complete written investigations within five working days for resident to resident abuse allegations and failing to report a resident fall requiring emergency treatment. Additional deficiencies included failure to maintain fire safety standards such as maintaining 2-hour fire separation, posting delayed egress lock instructions, maintaining sprinkler clearance, ensuring corridor doors latch properly, and conducting fire drills under varied conditions.
Complaint Details
The complaint investigation focused on allegations that the facility failed to ensure staff had appropriate credentials and failed to complete written investigations within five working days. The facility was found compliant with staff credentials but non-compliant with timely investigations and reporting of incidents including a resident fall and resident to resident abuse allegations.
Severity Breakdown
SS=E: 5
SS=F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to complete written investigations within five working days for resident to resident abuse allegations and failed to report a resident fall requiring emergency treatment. | SS=E |
| Failed to maintain 2-hour fire separation between Nursing Home and Assisted Living allowing smoke and fire migration. | SS=E |
| Failed to post instructions for operation of delayed egress lock on exterior exit door in Activities room. | SS=E |
| Failed to maintain required minimum clearance around sprinkler heads in closets, potentially obstructing sprinkler function. | SS=E |
| Failed to ensure corridor doors positively latched within door frames in 2 smoke compartments. | SS=E |
| Failed to ensure smoke separation doors were capable of resisting passage of smoke in 2 smoke compartments. | SS=F |
| Failed to hold fire drills under varied conditions on all shifts and failed to conduct an actual fire drill for one of four 3rd shift drills. | SS=F |
Report Facts
Facility census: 69
Total licensed capacity: 70
Resident sample size: 29
Resident affected by fire safety deficiencies: 41
Residents affected by fire separation deficiency: 15
Residents affected by corridor door latch deficiency: 31
Residents affected by smoke door deficiency: 15
Residents affected by delayed egress signage deficiency: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Anderson | Administrator | Named in complaint investigation and interview regarding findings |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit | Signed complaint investigation letter |
| Social Services Director | Interviewed regarding complaint investigation findings | |
| Director of Nursing | Interviewed regarding complaint investigation findings and fire drill compliance | |
| Maintenance Staff A | Interviewed regarding fire safety deficiencies | |
| Maintenance Staff B | Interviewed regarding fire safety deficiencies |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 70
Deficiencies: 3
Apr 11, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Countryside Home from April 11, 2016 to April 14, 2016 by the Department of Health and Human Services Division of Public Health.
Findings
The facility failed to have a certified Dietary Manager but was actively seeking one and no deficiency was written for this. Life safety code deficiencies were found related to resident room doors not fitting tightly to resist smoke passage and unsealed penetrations in smoke barriers compromising fire resistance. These deficiencies affected multiple residents and smoke zones.
Complaint Details
The complaint alleged the facility failed to have a qualified Dietary Manager. Investigation confirmed the facility did not have a certified Dietary Manager but was actively seeking one and providing dietary management via interim staff and a Registered Dietician. No deficiency was cited for this allegation.
Severity Breakdown
SS=E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to have a certified Dietary Manager but was actively seeking one; no deficiency written. | — |
| Resident room doors did not fit tightly within doorframes to resist passage of smoke, affecting 14 residents in 100 wing and 15 residents in 400 wing. | SS=E |
| Smoke barriers had unsealed penetrations compromising fire resistance, affecting 14 residents in 100 wing and 13 residents in 300 wing. | SS=E |
Report Facts
Residents affected by door deficiency: 29
Residents affected by smoke barrier deficiency: 27
Facility capacity: 70
Facility census: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator - Office of LTC Facilities - Licensure Unit - Division of Public Health | Author of the complaint investigation letter |
| Linda Anderson | Administrator | Facility administrator named in the report |
| Maintenance Staff A | Verified observations of door and smoke barrier deficiencies |
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 5
May 7, 2015
Visit Reason
Annual survey conducted to assess compliance with licensure regulations and life safety codes for Countryside Home nursing facility.
Findings
The facility failed to maintain safe water temperatures to prevent scalds affecting 16 residents using the whirlpool tub and 5 residents using hand sinks, and failed to implement interventions related to suicidal ideations for one resident. Additionally, the facility failed to maintain smoke barriers, properly install fire safety doors, ensure proper electrical wiring, and correctly install alcohol-based hand rub dispensers according to life safety codes.
Severity Breakdown
SS=E: 4
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Water temperatures exceeded safe levels, risking scalds to residents using whirlpool tub and hand sinks; failure to implement interventions for resident with suicidal ideations. | SS=E |
| Failure to maintain one of six smoke barriers in the facility, risking smoke spread during fire. | SS=E |
| Failure to maintain smoke resistance in a hazard area due to missing automatic door closing device. | SS=E |
| Improper electrical wiring: use of relocatable power strip with refrigerator in Director of Nursing office. | SS=E |
| Alcohol-based hand rub dispensers installed too close to electrical night lights, an ignition source. | SS=F |
Report Facts
Facility census: 57
Residents affected by water temperature deficiency: 16
Residents affected by water temperature deficiency: 5
Residents at risk due to smoke barrier deficiency: 10
Facility census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding water temperature monitoring and fire safety deficiencies | |
| Administrator | Interviewed regarding water temperature risks and fire safety deficiencies | |
| Director of Nursing | Director of Nursing | Interviewed regarding suicidal ideations interventions and water temperature risks |
| Social Services Director | Interviewed regarding assessment and documentation of suicidal comments | |
| Maintenance A | Interviewed regarding smoke barrier and electrical wiring deficiencies | |
| Administrative A | Interviewed regarding alcohol-based hand rub dispenser installation |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 70
Deficiencies: 12
Apr 8, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Countryside Home on April 1, 2014-April 8, 2014.
Findings
The facility failed to submit investigations within 5 working days for an alleged abuse incident, failed to notify family of significant weight loss for two residents, failed to ensure effective handwashing and glove use, failed to maintain equipment cleanliness, failed to implement fall prevention interventions, and failed to prepare pureed meals according to recipes. Life safety code deficiencies were also identified including unsealed penetrations in smoke compartments, doors not positively latching, unmaintained emergency lighting and exit signs, and kitchen fire safety issues.
Complaint Details
The complaint investigation found the facility failed to submit investigations within 5 working days for an alleged abuse incident involving Resident 73, failed to notify family of significant weight loss for Residents 20 and 52, failed to ensure effective handwashing and glove use, failed to maintain equipment cleanliness, and failed to implement fall prevention interventions.
Severity Breakdown
SS=D: 5
SS=E: 5
SS=F: 3
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to notify family/responsible party of significant changes in condition related to weight loss for Residents 20 and 52. | SS=D |
| Failed to investigate and report an allegation of abuse for Resident 73. | SS=D |
| Failed to implement identified fall interventions to protect Resident 20 from injury related to falls. | SS=D |
| Failed to prepare pureed meals for 5 residents in accordance with planned menus as recipes were not used. | SS=E |
| Failed to assure staff washed hands and changed gloves at appropriate intervals and failed to disinfect glucometer and oximeter between residents. | SS=E |
| Failed to separate use areas from corridors by walls with at least ½ hour fire resistance rating in sprinklered building. | SS=E |
| Failed to ensure doors to resident rooms positively latched. | SS=E |
| Failed to maintain separation resistant to passage of smoke between hazardous areas and adjacent spaces. | SS=F |
| Failed to maintain emergency lighting in accordance with NFPA 101, 7.9. | SS=F |
| Failed to maintain internally illuminated exit sign. | SS=E |
| Failed to maintain exhaust hood and fire suppression system in compliance with NFPA 96. | SS=F |
| Failed to prohibit improper use of UL listed electrical appliances which may cause a fire. | SS=D |
Report Facts
Facility census: 54
Facility capacity: 70
Residents affected by smoke compartment deficiencies: 21
Residents affected by door latch deficiencies: 31
Residents affected by exit sign deficiency: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Anderson | Administrator | Named in complaint investigation letter |
| Dan Taylor | RN, Training Coordinator | Signed complaint investigation letter |
| Krista Roeber | Social Worker | Surveyor in complaint investigation |
| Brenda Orlowski | Registered Nurse | Surveyor in complaint investigation |
| Patricia Wolfe | Registered Nurse | Surveyor in complaint investigation |
| Janice Hake | Registered Nurse | Surveyor in complaint investigation |
| Maintenance A | Confirmed multiple life safety deficiencies during interview |
Inspection Report
Routine
Census: 60
Capacity: 70
Deficiencies: 4
Mar 4, 2013
Visit Reason
Routine inspection of Countryside Home to assess compliance with regulations governing skilled nursing facilities and life safety codes.
Findings
The facility was found deficient in infection control practices related to handling soiled linens in the Special Care Unit, life safety code violations including unsealed penetrations in smoke barriers, lack of illuminated exit signs, and failure to maintain and test the automatic sprinkler system quarterly.
Severity Breakdown
SS=E: 2
SS=F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to handle linens in a manner to prevent cross contamination during provision of care in the Special Care Unit, including soiled linens placed on the floor and overflowing laundry barrels. | SS=E |
| Failure to separate use areas from corridors by walls with at least ½ hour fire resistance rating, allowing passage of smoke and fire between smoke zones. | SS=E |
| Lack of illuminated directional exit signs in four patient corridors near the nurse's station. | SS=F |
| Failure to maintain and test the automatic sprinkler system quarterly as required. | SS=F |
Report Facts
Residents in Special Care Unit: 17
Sample size: 35
Facility census: 60
Facility capacity: 70
Residents affected by smoke barrier deficiency: 35
Residents census: 61
Inspection Report
Annual Inspection
Census: 61
Capacity: 70
Deficiencies: 9
Nov 17, 2011
Visit Reason
Annual inspection of Countryside Home to assess compliance with licensure regulations and life safety codes.
Findings
The facility failed to develop comprehensive care plans addressing risks such as hot liquid spills and dehydration for several residents. Care plans were not consistently implemented, including failure to use fall mats and protective clothing. Life safety code violations included unsealed penetrations in smoke compartment walls, unprotected hazardous areas, improperly maintained fire alarm and sprinkler systems, and electrical wiring issues.
Severity Breakdown
SS=E: 7
SS=D: 1
SS=F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to develop comprehensive care plans identifying Resident 18's risk for hot liquid spills and Residents 32, 62, and 66's risk for dehydration. | SS=E |
| Failed to provide services by qualified persons per care plan, including failure to implement fall mat use and hot liquid spill prevention interventions. | SS=D |
| Failed to ensure resident environment free of accident hazards; interventions for hot liquid spill prevention and fall mat use were not consistently implemented. | SS=E |
| Failed to separate use areas from corridors by construction of at least ½ hour fire resistance rating walls in smoke compartments. | SS=E |
| Failed to provide one-hour fire rated construction or approved automatic sprinkler system with self-closing doors for hazardous areas; unsealed penetrations in boiler room. | SS=F |
| Fire alarm system not properly tested and maintained; fire alarm control panel not electronically supervised by a smoke detector. | SS=F |
| Smoke detectors improperly located near air supply vents, impeding operation. | SS=E |
| Sprinkler system heads corroded, obstructed, or improperly maintained, including corroded head near dishwasher and obstructed head in boiler room. | SS=E |
| Electrical wiring not in accordance with NFPA 70; junction box without approved cover in corridor. | SS=E |
Report Facts
Facility census: 61
Total capacity: 70
Notice
Capacity: 70
Deficiencies: 0
app2019
Visit Reason
This document serves as a licensure renewal application and certification for Countryside Home, verifying that the facility meets statutory requirements for skilled nursing and nursing facility dual certification, including renewal of Alzheimer's Special Care Unit endorsement.
Findings
The documents confirm the facility's licensure renewal status, maximum licensed capacity of 70 beds, and include details on services offered such as physical therapy, occupational therapy, speech therapy, and Alzheimer's care. An occupancy permit for 70 beds is also included.
Report Facts
Maximum licensed capacity: 70
License expiration date: 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Anderson | Administrator | Named as facility administrator on renewal application and Alzheimer's Special Care Unit Disclosure. |
| Bo Botelho | Interim CEO, Interim Director of Public Health | Signed certification of licensure renewal. |
| Paula Biehle | Treasurer | Contact name for legal owning entity City of Madison. |
Notice
Capacity: 70
Deficiencies: 0
APP2016
Visit Reason
This document serves as a licensure renewal application and verification for the Countryside Home skilled nursing facility, confirming its licensed status and capacity.
Findings
The documents confirm the facility's licensure renewal status, ownership, accreditation, and licensed bed capacity. No inspection findings or deficiencies are reported.
Report Facts
Licensed beds: 70
Renewal fees: 1550
Renewal fees: 1750
Renewal fees: 1950
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Anderson | Administrator | Named as the facility administrator on the renewal application. |
| Stephanie Wehrle | Director of Nursing | Named as the director of nursing on the renewal application. |
Inspection Report
Renewal
Capacity: 70
Deficiencies: 0
APP2017
Visit Reason
The document is a renewal application and certification for the Countryside Home nursing facility license, verifying continued licensure and compliance with statutory requirements.
Findings
The facility is licensed as a Skilled Nursing Facility/Nursing Facility dual certification with a maximum capacity of 70 beds. The renewal application confirms the facility's services including physical therapy, occupational therapy, speech therapy, and an Alzheimer's special care unit. The facility meets statutory requirements and holds an occupancy permit for 70 beds issued by the Nebraska State Fire Marshal.
Report Facts
Licensed bed capacity: 70
Renewal license number: 524002
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Anderson | Administrator | Named as Administrator in the renewal application and Alzheimer's special care unit endorsement. |
| Mindy Buckendahl | Director of Nursing | Named as Director of Nursing in the renewal application. |
| Paula Biehle | Treasurer | Named as contact person for the legal owning entity City of Madison in the Alzheimer's special care unit endorsement application. |
| James Sloup | Deputy State Fire Marshal | Inspected and approved the occupancy permit for 70 beds. |
Document
Capacity: 70
Deficiencies: 0
APP2021
Visit Reason
The documents pertain to the renewal of the nursing home license for Arbor Care Centers-Countryside LLC, including verification of licensure, occupancy permit, and Alzheimer's special care unit endorsement.
Findings
No inspection findings or deficiencies are reported. The documents confirm licensure renewal, facility capacity, and special care unit endorsement details.
Report Facts
Total licensed beds: 70
Maximum capacity for Alzheimer's beds: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa McDermed | Administrator | Named as the facility administrator on the Nursing Home Licensure Renewal Application and Alzheimer's Special Care Unit Disclosure. |
| Erin Petersen | Director of Nursing | Named as Director of Nursing on the Nursing Home Licensure Renewal Application. |
| Aaron Klaasmeyer | Authorized representative and contact name on the Nursing Home Licensure Renewal Application and Alzheimer's Special Care Unit Disclosure. |
Notice
Capacity: 70
Deficiencies: 0
APP2025
Visit Reason
The document serves as a renewal application for the nursing home license of Arbor Care Centers-Countryside LLC and includes related licensing and occupancy permits.
Findings
The documents certify that Arbor Care Centers-Countryside LLC meets statutory requirements for licensure and includes an occupancy permit with a maximum capacity of 70 beds.
Report Facts
Total licensed beds: 70
Renewal license fee: 1750
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tristian McNeill | Administrator | Named on the Nursing Home Licensure Renewal Application |
| Leslie Eisenmann | Director of Nursing | Named on the Nursing Home Licensure Renewal Application |
| Aaron Klaasmeyer | Authorized Representative | Signed the Nursing Home Licensure Renewal Application |
| Linda Klaasmeyer | Authorized Representative | Signed the Nursing Home Licensure Renewal Application |
| Robert Stoess | Deputy State Fire Marshal | Inspected and approved the Occupancy Permit |
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