Inspection Reports for Bailey Pointe Assisted Living at Miracle Hills
11909 Miracle Hills Dr, Omaha, NE 68154, United States, NE, 68154
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 26, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint that the facility fails to have a plan in place to remove residents in case of emergency.
Findings
The facility was found to have a plan in place to remove residents in case of emergency, including marked fire exits, knowledgeable staff, established fire procedures, documentation of fire drills, and completion of a fire inspection. The facility was determined to be in compliance with related regulatory requirements.
Complaint Details
The complaint alleged the facility fails to have a plan in place to remove residents in case of emergency. The complaint was not substantiated as the facility was found compliant.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed the report and identified as representative of the Office of LTC Facilities - Licensure Unit - Division of Public Health |
Notice
Capacity: 70
Deficiencies: 0
Mar 20, 2017
Visit Reason
This document serves as a licensure renewal application and verification for the assisted-living facility The Waterford at Miracle Hills, including a certificate of occupancy confirming maximum occupancy.
Findings
The facility is licensed as an assisted-living facility with a total licensed capacity of 70 beds. The Nebraska State Fire Marshal issued a certificate of occupancy confirming the maximum occupancy of 70 persons/beds.
Report Facts
Total licensed beds: 70
Maximum occupancy: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheri Teut | Administrator | Named as facility administrator in the licensure renewal application (page 2) |
| David Mausbach | Inspector | Inspected the facility for the Nebraska State Fire Marshal Certificate of Occupancy (page 6) |
Inspection Report
Complaint Investigation
Census: 5
Deficiencies: 7
May 31, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at An Angel's Touch on May 31, 2016-June 1, 2016, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility was found compliant with allegations related to misappropriation of resident property, resident stability, chemical restraints, and assistance with food/fluid intake. However, deficiencies were found related to failure to complete required background and registry checks on direct care staff, failure to obtain annual medication lists for residents, failure to follow up on unexplained weight loss in residents, and environmental safety issues including unsecured hazardous materials and unsafe outdoor areas.
Complaint Details
The complaint investigation included allegations that the facility failed to protect residents from misappropriation, failed to investigate and report misappropriation, failed to complete background checks on direct care staff, failed to ensure residents are stable and predictable to retain, failed to ensure residents are free from chemical restraints, and failed to provide assistance to enable adequate food/fluid intake.
Deficiencies (7)
| Description |
|---|
| Failure to complete criminal background checks on one direct care staff member and failure to document decision to hire a person with a criminal background for another staff member. |
| Failure to complete nurse aide registry checks and APS/CPS registry checks for four direct care staff members. |
| Failure to establish and implement a procedure for obtaining an annual list of drugs, devices, biologicals and supplements taken by residents for 4 residents. |
| Failure to follow up on unplanned weight losses for 3 residents. |
| Failure to maintain environment in good repair related to missing register covers, missing trim around patio door, and missing ceiling light fixture cover. |
| Failure to secure hazardous materials in kitchen cabinet accessible to residents. |
| Failure to ensure a safe outdoor area including an unlocked gate, uncovered electrical outlet, protruding electrical wires, pipe stored in walking area, and unsecured propane tank. |
Report Facts
Direct care staff total: 9
Residents total census: 5
Residents with missing annual medication list: 4
Residents with unaddressed weight loss: 3
Direct care staff without completed nurse aide and APS/CPS registry checks: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS. |
| Kay Reeves | Nutrition/dietitian Surveyor | Conducted the inspection. |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 3
Apr 26, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint at The Waterford At Miracle Hills on April 26-27, 2016, by representatives of the Department of Health and Human Services Division of Public Health. The investigation included review of resident records, observation of care and services, and interviews with residents, family members, and staff.
Findings
The facility was found compliant with providing appropriate notice of involuntary discharge and ensuring meals met dietary requirements. However, deficiencies were found related to failure to protect residents from misappropriation, failure to provide services as agreed upon in the Service Agreement (including night wellness checks), failure to ensure the call system was operational, and failure to complete required criminal background and nurse aide registry checks for some staff.
Complaint Details
The complaint investigation was triggered by allegations that the facility failed to provide appropriate notice of involuntary discharge, failed to protect residents from misappropriation, failed to ensure meals met dietary requirements, failed to provide services as agreed upon, failed to have sufficient staff, and failed to ensure the call system was operational. Some allegations were substantiated (misappropriation, service provision, call system), others were not (notice of discharge, meals, staffing).
Deficiencies (3)
| Description |
|---|
| Failure to implement procedures to protect residents from misappropriation, including missing criminal background and nurse aide registry checks for some direct care staff. |
| Failure to provide services agreed upon in the Service Agreement, specifically night wellness checks not routinely completed for residents who requested them. |
| Failure to ensure the call system was operational; one resident's call pendant was not functional when found on the floor and no incident report was located. |
Report Facts
Census: 57
Missing criminal background checks: 1
Missing nurse aide registry checks: 4
Residents requesting night wellness checks: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation report |
| Kay Reeves | Nutrition/dietitian Surveyor | Conducted the complaint investigation |
| Sheri Teut | Administrator | Facility administrator interviewed regarding findings |
Inspection Report
Renewal
Capacity: 70
Deficiencies: 0
Apr 19, 2016
Visit Reason
The document is related to the renewal of the assisted-living facility license for The Waterford at Miracle Hills.
Findings
The facility meets statutory requirements as an assisted-living facility, and the renewal application and related documentation confirm compliance with licensing standards.
Report Facts
Total licensed beds: 70
Renewal expiration date: Apr 30, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Brickman | Authorized Representative | Signed the renewal application. |
| Sheri Teut | Administrator | Named as facility administrator in renewal application. |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 5
Mar 2, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint and perform an annual survey at The Waterford At Miracle Hills from March 2 to March 4, 2015.
Findings
The facility was found to be in compliance with most regulatory requirements including protection from misappropriation, pest control, emergency care, disaster preparedness, and discharge notice. However, the facility failed to protect residents from abuse due to incomplete background checks for four direct care staff members, failed to ensure ongoing training requirements for four staff members, failed to update medication administration policies to reflect electronic records, failed to document admission/readmission weights for two residents, and failed to ensure medication aides washed hands or used sanitizer after care provision.
Complaint Details
The complaint investigation included allegations of failure to protect residents from misappropriation, failure to provide direction and monitoring by a licensed health care provider, failure to be free from pests, failure to ensure residents are stable before being moved, failure to follow disaster preparedness plan for tornados, failure to protect residents from abuse, and failure to give appropriate notice for discharge. The facility was found noncompliant only for failure to protect residents from abuse due to incomplete background checks for staff.
Deficiencies (5)
| Description |
|---|
| Failed to ensure nurse aide registry, Adult Protective Services, Child Protective Services, and Nebraska Sex Offender Registry checks were completed for four sampled direct care staff members. |
| Failed to ensure 12 hours of ongoing training was completed for four sampled direct care staff members employed over one year. |
| Failed to ensure Registered Nurse approved medication administration policies and procedures were current with use of electronic medication administration records and medication bubble packs. |
| Failed to have admission or readmission weights documented for two sampled residents. |
| Failed to ensure medication aides washed hands or used sanitizer after blood sugar checks and/or provision of care for two sampled residents. |
Report Facts
Census: 63
Direct Care Staff Members: 16
Number of sampled Direct Care Staff Members without completed background checks: 4
Number of sampled Direct Care Staff Members without required ongoing training: 4
Number of residents without admission/readmission weights: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kay Reeves | Nutrition/dietitian | Surveyor conducting the complaint investigation and annual survey. |
| Sheri Teut | Administrator | Facility Administrator interviewed regarding policies and findings. |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Author of the inspection report and correspondence. |
| Director of Resident Care | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration, emergency care, and training. |
Inspection Report
Plan of Correction
Census: 58
Deficiencies: 1
Dec 1, 2010
Visit Reason
The document is a Plan of Correction submitted in response to a compliance inspection and complaint investigation conducted on December 1, 2010, regarding medication storage at The Waterford at Miracle Hills assisted living facility.
Findings
The inspection found that medications were not properly stored in residents' rooms for 2 residents out of a sample of 7, with specific observations of unlocked medications on kitchen counters and unlocked apartment doors. The facility census was 58 at the time. The facility was found to be in compliance with other complaint allegations but had an unrelated violation regarding medication storage.
Complaint Details
The inspection was triggered by a complaint investigation. The facility was found to be in compliance with the complaint allegations related to medication administration, unlicensed staff, services provided, complex nursing care, and protection from misappropriation. However, an unrelated violation regarding medication storage was identified.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure proper storage of medications in residents' rooms for 2 residents; medications were found unlocked on kitchen counters and apartment doors were not always locked. |
Report Facts
Facility census: 58
Sample size: 7
Residents with medication storage issues: 2
Inspection date: Dec 1, 2010
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Harrison | Registered Nurse | Surveyor who conducted the compliance inspection and complaint investigation |
| Eve Lewis | RN-C, Administrator | Facility administrator addressed in the Plan of Correction and correspondence |
| Chelsey Tate | Resident Care Director | Responsible for weekly monitoring to assure resident compliance with medication storage |
| Sheri Teut | Executive Director | Signed the Plan of Correction letter |
Notice
Capacity: 70
Deficiencies: 0
APP2024
Visit Reason
This document package serves as a renewal application and license renewal verification for the assisted-living facility Bailey Pointe at Miracle Hills.
Findings
The documents confirm the facility meets statutory requirements for licensing as an assisted-living facility with a total licensed capacity of 70 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 70
Maximum occupancy: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Glover | Administrator | Named as facility administrator on the renewal application (page 2). |
| Sharon Makowsky | Authorized Signer | Authorized representative signing the renewal application and ownership documents (pages 2 and 3). |
Notice
Capacity: 70
Deficiencies: 0
APP2025
Visit Reason
This document serves as a renewal application and verification of licensure for the assisted-living facility Bailey Pointe at Miracle Hills.
Findings
The documents confirm the facility's licensure status, ownership structure, and maximum occupancy as approved by the Nebraska State Fire Marshal.
Report Facts
Total licensed beds: 70
Maximum occupancy: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Glover | Administrator | Named as facility administrator in renewal application (page 2). |
| Sharon Makowsky | Authorized Representative | Signed renewal application and ownership documents (pages 2 and 3). |
| Donald Davis | Inspected by Nebraska State Fire Marshal (page 4). |
Notice
Capacity: 70
Deficiencies: 0
APP2018
Visit Reason
This document serves as a licensure renewal application and verification for the assisted-living facility The Waterford at Miracle Hills, including certification of occupancy and ownership information.
Findings
The documents confirm that The Waterford at Miracle Hills is licensed as an assisted-living facility with a total licensed capacity of 70 beds. The Nebraska State Fire Marshal issued a certificate of occupancy for 70 persons/beds on March 20, 2017. Ownership and corporate officer information is provided, but no inspection findings or deficiencies are included.
Report Facts
Total licensed capacity: 70
Renewal expiration date: License expiration date is April 30, 2019
Notice
Census: 65
Capacity: 70
Deficiencies: 0
APP2019
Visit Reason
This document serves as a licensure renewal application and verification that The Waterford at Miracle Hills is licensed as an assisted-living facility through the indicated renewal date. It also includes a certificate of occupancy confirming the maximum licensed capacity.
Findings
The facility is licensed as an assisted-living facility with a total licensed capacity of 70 beds. The certificate of occupancy confirms the maximum occupancy as 70 persons/beds. The renewal application was submitted with no noted deficiencies or inspection findings.
Report Facts
Total licensed capacity: 70
Current census: 65
Renewal fee: 1450
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Fester | Administrator | Named as facility administrator on renewal application |
| David W. Beathard | Interim CEO / Interim Director of Public Health | Signed renewal verification and listed as Interim CEO on license |
| David Mausbach | Inspector | Inspected facility for certificate of occupancy |
Notice
Capacity: 70
Deficiencies: 0
APP2020
Visit Reason
The document serves as a renewal application and license renewal notice for The Waterford at Miracle Hills Assisted-Living Facility, verifying licensure through the expiration date and providing renewal fee information.
Findings
The document confirms that The Waterford at Miracle Hills meets statutory requirements as an assisted-living facility and is licensed through April 30, 2021. It includes ownership information, licensing details, and a certificate of occupancy with a maximum capacity of 70 beds.
Report Facts
Total licensed beds: 70
Renewal license expiration date: License expires on 2021-04-30 as shown on the renewal card
Maximum occupancy: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Fester | Administrator | Named as facility administrator in the renewal application |
| Liz Bartels | Authorized Representative | Signed the renewal application on 2020-04-08 |
| Gloria Holland | Authorized Representative | Signed the renewal application on 2020-04-08 and listed as Vice President - Finances in ownership information |
| Donald Davis | Inspected the facility for the Certificate of Occupancy |
Notice
Capacity: 70
Deficiencies: 0
APP2021
Visit Reason
This document serves as a renewal application and certification for the assisted-living facility license of The Waterford at Miracle Hills.
Findings
The documents certify that The Waterford at Miracle Hills meets statutory requirements as an assisted-living facility and includes ownership and licensing information.
Report Facts
Total licensed beds: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon M. Ribar | President | Listed as President and Executive Vice President and Chief Operating Officer in ownership and officers information |
| Liz Bartels | Vice President | Listed as Vice President in ownership and officers information |
Notice
Capacity: 70
Deficiencies: 0
APP2022
Visit Reason
The document serves as a renewal application for the assisted-living facility license and includes certification of occupancy and ownership information.
Findings
The documents confirm that The Waterford at Miracle Hills meets statutory requirements as an assisted-living facility and is licensed through the indicated renewal date. The maximum occupancy is certified at 70 beds.
Report Facts
Total licensed beds: 70
Maximum occupancy: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassandra Gardner | Administrator | Named as the facility administrator on the renewal application on page 2. |
| Brandon M Ribar | President | Listed as President and Chief Operating Officer in ownership and officer information on pages 3 and 4. |
| David R Brickman | Vice President and Secretary | Listed as Vice President and Secretary in ownership and officer information on pages 3 and 4. |
| Michael Fryar | Vice President and Chief Revenue Officer | Listed as Vice President and Chief Revenue Officer in ownership and officer information on pages 3 and 4. |
| Liz Bartels | Vice President | Listed as Vice President and authorized representative signing the renewal application on page 2. |
| Kimberly S. Lody | President and Chief Executive Officer | Listed as President and Chief Executive Officer in ownership and officer information on pages 3 and 4. |
Notice
Capacity: 70
Deficiencies: 0
APP2023
Visit Reason
This document serves as a renewal application and license renewal notice for the assisted-living facility Bailey Point at Miracle Hills.
Findings
The document certifies that the facility meets statutory requirements as an assisted-living facility and includes ownership information, license number, and maximum licensed capacity.
Report Facts
Total licensed capacity: 70
Renewal license fee: 1650
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Ellen Pisanelli | Senior Vice President | Authorized representative signing the renewal application and ownership documentation (pages 2 and 3). |
| Tara Gabel | Administrator | Named as facility administrator on the renewal application (page 2). |
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