Inspection Reports for Brookestone Acres
4715 38th Street, COLUMBUS, NE, 68601
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
79% occupied
Based on a March 2018 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Capacity: 80
Deficiencies: 0
Mar 10, 2025
Visit Reason
This document set includes a nursing home licensure renewal application for Brookestone Acres, along with a renewal card and occupancy permit, indicating the facility's license renewal and capacity status.
Findings
The documents certify that Brookestone Acres meets statutory requirements for licensure renewal and confirm the facility's licensed capacity of 80 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 80
Renewal application date: Mar 10, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raven Schmid | Administrator | Named on the renewal application form. |
| Sarah Dankart | Director of Nursing | Named on the renewal application form. |
| Brian Stuhr | Treasurer | Named as officer in related corporate documents. |
| Glenn Van Ekeren | President | Named as officer in related corporate documents and signed renewal application. |
Inspection Report
Renewal
Capacity: 80
Deficiencies: 0
Feb 28, 2024
Visit Reason
The document is a Nursing Home Licensure Renewal Application for Brookestone Acres, indicating the facility is applying to renew its skilled nursing facility license.
Findings
The document certifies that Brookestone Acres meets statutory requirements for SNF/NF dual certification and includes renewal application details, ownership information, and licensing fees. No inspection findings or deficiencies are reported.
Report Facts
Number of beds to be relicensed: 80
Renewal license fees: 1750
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raven Schmid | Administrator | Named on Nursing Home Licensure Renewal Application |
| Sarah Danikart | Director of Nursing | Named on Nursing Home Licensure Renewal Application |
| Brian Stuhr | Authorized Representative | Signed Nursing Home Licensure Renewal Application |
| Glenn Van Ekeren | Authorized Representative | Signed Nursing Home Licensure Renewal Application |
Notice
Capacity: 80
Deficiencies: 0
Jan 27, 2020
Visit Reason
This document serves as a renewal application and verification of licensure for the Brookestone Acres skilled nursing facility.
Findings
The document confirms that Brookestone Acres meets statutory requirements for licensure renewal as a skilled nursing facility with physical, occupational, and speech therapy services.
Report Facts
Number of beds to be relicensed: 80
Renewal license expiration date: License expires on 3/31/2021 as shown on the renewal card.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Woznick | Administrator | Named in the renewal application form. |
| Mindy Buckendahl | Director of Nursing | Named in the renewal application form. |
| Jack D. Vetter | Authorized Representative | Signed renewal application and listed as Chairman of the Board and CEO of parent corporation. |
| Glenn Van Ekeren | Authorized Representative | Signed renewal application and listed as President of parent corporation. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 30, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Brookestone Acres regarding the facility's failure to identify change in condition.
Findings
The facility was found to identify changes in condition appropriately. Resident records, interviews, and grievance files showed no failure to identify or report changes in resident conditions, resulting in no violation related to the allegation.
Complaint Details
The complaint alleged the facility failed to identify change in condition. The investigation found the allegation unsubstantiated.
Report Facts
Resident records reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed the report as Training Coordinator, Office of LTC Facilities - Licensure Unit - Division of Public Health |
Inspection Report
Annual Inspection
Census: 63
Capacity: 80
Deficiencies: 6
Mar 20, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Brookestone Acres from March 14, 2018 to March 20, 2018 by the Department of Health and Human Services Division of Public Health.
Findings
The facility was found to be in compliance with emergency preparedness regulations but had deficiencies related to failure to immediately report alleged abuse, infection prevention and control issues related to catheter care, and life safety code violations including hazardous door obstructions, missing ceiling tiles affecting sprinkler function, suspended heating units installed within reach, and improper storage of oxygen cylinders.
Complaint Details
The complaint allegation was that the facility fails to assist residents with pain management. The investigation found no violation related to pain management.
Severity Breakdown
SS=F: 2
SS=D: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to immediately report potential abuse/neglect for 4 residents. | SS=D |
| Failure to maintain infection control practices during catheter care for Resident 15. | SS=D |
| Use of unapproved device (wooden wedge) to hold open hazardous area door and obstruction of fire-rated door by bussing cart. | SS=F |
| Failure to maintain intact ceiling tile in sprinkler protected area allowing potential delayed sprinkler activation. | SS=F |
| Suspended heating unit installed within reach of people without safety shutoff. | SS=D |
| Failure to separate empty oxygen cylinders from full cylinders in storage. | SS=D |
Report Facts
Facility census: 63
Total licensed capacity: 80
Sample size: 28
Deficiency completion dates: Apr 2, 2018
Deficiency completion dates: Apr 27, 2018
Deficiency completion dates: Mar 23, 2018
Deficiency completion dates: Mar 22, 2018
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 |
| Tanya Babel | Administrator | Facility administrator named in complaint and inspection documents |
| NA-M | Nursing Assistant | Named in abuse/neglect investigation for resident interactions |
| NA-J | Nursing Assistant | Interviewed regarding abuse concerns |
| RN-A | Registered Nurse | Interviewed regarding nursing assistant performance |
| NA-N | Nursing Assistant | Interviewed regarding abuse concerns |
| MA-D | Medication Aide | Observed providing catheter care with infection control deficiencies |
| MA-B | Medication Aide | Observed providing catheter care with infection control deficiencies |
| MA-J | Medication Aide | Observed providing catheter care with infection control deficiencies |
| RN-O | Registered Nurse | Observed catheter care and confirmed infection control deficiencies |
| Administration Staff A | Confirmed hazardous door obstructions and heating unit issues | |
| Maintenance Staff A | Confirmed hazardous door obstructions, missing ceiling tile, and heating unit issues | |
| Maintenance Manager A | Confirmed oxygen cylinder storage deficiencies |
Inspection Report
Renewal
Capacity: 80
Deficiencies: 0
Jul 1, 2017
Visit Reason
The document is related to the renewal of the Skilled Nursing Facility license for Brookestone Acres due to a change of ownership, effective July 1, 2017.
Findings
The documents include the issuance of a new Skilled Nursing Facility license, a lease agreement between Columbus Health Care, Inc. and VSL Columbus, LLC, and related certifications and approvals. The facility is licensed for 80 beds and complies with state regulations.
Report Facts
Total licensed beds: 80
License effective date: Jul 1, 2017
License expiration date: Mar 31, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tanya Babel | Administrator | Administrator of Brookestone Acres mentioned in licensing documents |
| Dan Smith | Director of Nursing | Director of Nursing mentioned in licensing application |
| Thomas L. Williams | Chief Medical Officer, Director, Division of Public Health | Signed licensing and renewal documents |
| Shari Terry | Chief Operations Officer | Signed letter regarding change of ownership and licensing packet |
| Jack D. Vetter | President, Chairman of the Board and CEO | Signatory on lease agreement and listed as officer of parent company |
| Glenn Van Ekeren | President | Signatory on lease agreement and listed as officer of parent company |
Inspection Report
Routine
Census: 60
Capacity: 80
Deficiencies: 19
Dec 6, 2016
Visit Reason
Routine Life Safety Code survey of Brookestone Acres nursing facility to assess compliance with NFPA 101 and related regulations.
Findings
The facility had multiple deficiencies related to Life Safety Code including unsecured furniture in corridors, obstructed delayed egress signage, malfunctioning emergency exit doors, inadequate egress lighting, lack of fire door inspections, missing self-closing devices on hazardous area doors, improper kitchen hood maintenance, use of non-flame retardant materials, sprinkler system impairment policy deficiencies, corridor door gaps and roller latches, inaccurate electrical panel directories, suspended heater installation, fire drill scheduling, lack of remote manual stop for emergency generator, improper essential electrical system wiring, incomplete emergency generator testing, and improper oxygen cylinder storage.
Severity Breakdown
SS=F: 13
SS=E: 4
SS=D: 2
Deficiencies (19)
| Description | Severity |
|---|---|
| Furniture in corridors was not secured to walls or floors, potentially obstructing means of egress. | SS=F |
| Delayed egress door signage was obstructed by window coverings. | SS=F |
| Manual emergency operation of front entry doors failed to provide required clear opening width. | SS=F |
| Egress lighting to public way from Therapy exterior exit was inadequate. | SS=E |
| Emergency light in Mechanical Room failed to operate during test. | SS=D |
| Missing 'No Exit' signage on doors leading to enclosed courtyards. | SS=F |
| Facility failed to implement and document annual inspections and testing of all fire rated doors. | SS=F |
| Self-closing device missing on Med Records room door; door to Main Kitchen held open by trash can. | SS=E |
| Facility failed to ensure biannual inspection and cleaning of kitchen hood suppression systems and ductwork. | SS=F |
| Facility failed to provide documentation of flame spread rating for wood panel in Electrical/Storage room. | SS=E |
| Facility failed to provide and maintain self-closing doors to hazardous areas. | SS=E |
| Facility failed to ensure exit corridor doors resist passage of smoke; gaps and roller latches present. | SS=F |
| Inaccurate electrical panel box directory could lead to incorrect breaker operation. | SS=E |
| Suspended heating unit installed within reach in Mechanical Room. | SS=D |
| Fire drills were not conducted under varied conditions on all shifts. | SS=F |
| Facility failed to provide remote manual stop switch for emergency generator. | SS=F |
| Essential electrical system wiring mixed Life Safety and Equipment branches improperly. | SS=F |
| Emergency generator was not tested under full load for required 30 minutes monthly. | SS=F |
| Oxygen cylinders were not segregated or labeled as full or empty in storage rooms. | SS=E |
Report Facts
Deficiencies cited: 19
Facility census: 60
Total licensed beds: 80
Emergency generator monthly test duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tanya Babel | Administrator | Named in relation to facility operations and plan of correction |
| Doug Hohbein | Chief Plans Examiner | Conducted Informal Dispute Resolution |
| Eve Lewis | Program Manager | Reviewed and approved Informal Dispute Resolution report |
| Mitchell Elliott | Participant in Informal Dispute Resolution | |
| Joel Wichman | Participant in Informal Dispute Resolution | |
| Jim Morrissey | Provided electrical system analysis for Informal Dispute Resolution |
Inspection Report
Renewal
Capacity: 80
Deficiencies: 0
Feb 16, 2016
Visit Reason
This document serves as a licensure renewal application and verification for Brookestone Acres Skilled Nursing Facility, confirming the facility's SNF/NF dual certification and license renewal through the indicated date.
Findings
The documents confirm the facility's licensure renewal status, including certification for physical, occupational, and speech therapy services, and an occupancy permit for 80 beds issued by the Nebraska State Fire Marshal.
Report Facts
Number of beds to be relicensed: 80
Maximum Occupancy: 80
Renewal Fees: 1750
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tanya Babel | Administrator | Named on Nursing Home Licensure Renewal Application |
| Dan Smith | Director of Nursing | Named on Nursing Home Licensure Renewal Application |
Notice
Deficiencies: 0
Oct 7, 2015
Visit Reason
The notice was issued to inform Brookestone Acres Skilled Nursing Facility of disciplinary action placing their license on probation for 90 days starting October 7, 2015, due to violations related to resident rights and failure to protect a resident from abuse.
Findings
The facility was found to have violated licensure regulations, specifically failing to intervene to protect a resident from abuse, with violations documented in the CMS-2567 report dated September 22, 2015. The facility must submit a Plan of Correction and ongoing reports during the probation period.
Report Facts
Probation period: 90
Report due date: 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Courtney N. Phillips | Chief Executive Officer | Signed the Notice of Disciplinary Action |
| Becky Wisell | Administrator | Listed in Licensure Unit and signed the Notice |
| Linda Stenvers | Staff Assistant II | Certified mailing of the Notice |
| Eve Lewis | Program Manager | Contact for submission of reports and responses |
Inspection Report
Annual Inspection
Census: 39
Capacity: 80
Deficiencies: 7
Aug 25, 2015
Visit Reason
The annual survey was conducted to assess compliance with federal regulations governing skilled nursing facilities, including resident care, abuse prevention, and life safety code adherence.
Findings
The facility was found deficient in several areas including failure to protect a resident from abuse, failure to report incidents of abuse, failure to implement care interventions to prevent skin injuries, and multiple life safety code violations including unsealed hazardous area penetrations, incomplete fire drills on all shifts, obstructed fire alarm strobes, and lack of quarterly sprinkler system inspections.
Severity Breakdown
Level G: 1
Level D: 2
Level E: 3
Level F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to protect Resident 56 from abuse/involuntary seclusion. | Level G |
| Failure to develop and implement abuse/neglect policies ensuring staff report incidents to administration. | Level D |
| Failure to implement interventions to prevent skin injuries for Resident 64, including failure to ensure use of protective geri sleeves. | Level D |
| Unsealed gas pipe penetration in laundry area compromising hazardous area separation. | Level E |
| Failure to conduct fire drills quarterly on each shift, missing drills on second, third, and fourth quarter for third shift. | Level F |
| Fire alarm strobes obstructed by curtains in multiple wings, reducing visibility. | Level E |
| Failure to have fire sprinkler system inspected quarterly by licensed contractor. | Level E |
Report Facts
Facility census: 39
Facility capacity: 80
Skin tear measurement: 2.1
Skin tear measurement: 1.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tanya Babel | Administrator | Named in informal conference and correspondence related to inspection findings and plan of correction |
| Dan Smith | RN Director of Nurses | Participant in informal dispute resolution conference |
| Kimberly A. Divis | RN NSSC | Person conducting informal dispute resolution conference and report author |
Inspection Report
Deficiencies: 0
Jul 29, 2014
Visit Reason
The inspection was conducted to assess compliance with regulations at a skilled nursing facility as part of a regulatory oversight visit.
Findings
The facility was found to be in compliance with the regulations at Title 175, Chapter 12: Skilled Nursing Facilities, Nursing Facilities, and Intermediate Care Facilities. No deficiencies were cited.
Inspection Report
Renewal
Capacity: 80
Deficiencies: 0
APP2017
Visit Reason
This document serves as a renewal application and certification for the Skilled Nursing Facility/Nursing Facility dual certification of Brookestone Acres, verifying licensure through the indicated renewal date.
Findings
The document confirms that Brookestone Acres meets statutory requirements for licensure renewal as a Skilled Nursing Facility/Nursing Facility dual certified facility. It includes occupancy permit details and ownership information without reporting any deficiencies or inspection findings.
Report Facts
Total licensed beds: 80
Renewal fees: 1750
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tanya Babel | Administrator | Named in Nursing Home Licensure Renewal Application |
| Dan Smith | Director of Nursing | Named in Nursing Home Licensure Renewal Application |
| Jack D. Vetter | Chair of the Board & CEO | Named in corporate ownership and related corporations listing |
| Eldora D. Vetter | Vice President and other officer roles | Named in corporate ownership and related corporations listing |
| Glenn Van Ekeren | President | Named in Vetter Health Services, Inc. officers |
| Shari Terry | Chief Operations Officer | Named in Vetter Health Services, Inc. officers |
| Rhonda Flanigan | Chief People Officer | Named in Vetter Health Services, Inc. officers |
| Todd D. Vetter | Assistant Secretary and other officer roles | Named in corporate ownership and related corporations listing |
Notice
Capacity: 80
Deficiencies: 0
APP2018
Visit Reason
This document serves to verify that Brookestone Acres SNF/NF dual certification license is renewed through the indicated expiration date and includes an occupancy permit for 80 beds.
Findings
The document confirms the facility meets statutory requirements for licensure and includes an occupancy permit issued by the Nebraska State Fire Marshal for 80 beds.
Report Facts
Total licensed beds: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tanya A Babel | Administrator | Listed as facility administrator on relicensing application. |
| Dan Smith | Director of Nursing | Listed as Director of Nursing on relicensing application. |
| Jack D. Vetter | CEO and Chairman of the Board | Named as CEO and Chairman of the Board of Vetter Senior Living, parent entity. |
| Glenn Van Ekeren | President | Named as President of Vetter Senior Living and subsidiaries. |
Notice
Capacity: 80
Deficiencies: 0
APP2019
Visit Reason
This document serves to verify that Brookestone Acres SNF/NF DUAL CERT is licensed through the date indicated on the renewal card and includes an occupancy permit issued by the Nebraska State Fire Marshal.
Findings
The document confirms the facility meets statutory requirements for licensure renewal and has an occupancy permit for 80 beds issued on 3/21/2018 by the Deputy State Fire Marshal.
Report Facts
Total licensed beds: 80
Occupancy permit issue date: Mar 21, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tanya Babel | Administrator | Named on the relicensing application. |
| Minday Stricklandall | Director of Nursing | Named on the relicensing application. |
| Jack D. Vetter | Chairman of the Board and CEO | Listed as officer of Vetter Senior Living, parent entity. |
| Eldora D. Vetter | Secretary | Listed as officer of Vetter Senior Living, parent entity. |
| Glenn Van Ekeren | President | Listed as officer of Vetter Senior Living, parent entity. |
| Brian Stuhr | Treasurer | Listed as officer of Vetter Senior Living, parent entity. |
Notice
Capacity: 80
Deficiencies: 0
APP2021
Visit Reason
This document serves as a renewal application for the nursing home license of Brookestone Acres and includes verification of licensure and occupancy permit information.
Findings
The documents confirm that Brookestone Acres meets statutory requirements for licensure renewal as a Skilled Nursing Facility and Nursing Facility dual certification, with a licensed capacity of 80 beds and an occupancy permit issued by the Nebraska State Fire Marshal.
Report Facts
Licensed beds: 80
Renewal license fees: 1750
Occupancy permit date issued: Feb 18, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Woznick | Administrator | Named in the Nursing Home Licensure Renewal Application. |
| Cathy Galla | Director of Nursing | Named in the Nursing Home Licensure Renewal Application. |
| Jim Kenney | Deputy State Fire Marshal | Inspected the facility for the occupancy permit. |
Notice
Capacity: 80
Deficiencies: 0
APP2022
Visit Reason
This document serves as a renewal application for the nursing home license of Brookestone Acres, including certification of licensure and occupancy permit details.
Findings
The documents confirm the facility's licensure renewal status, certification of services offered, and occupancy permit with a maximum capacity of 80 beds.
Report Facts
Number of beds to be relicensed: 80
Maximum occupancy: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kaitlin Clegg | Administrator | Named in Nursing Home Licensure Renewal Application |
| Cathy Gall | Director of Nursing, RN | Named in Nursing Home Licensure Renewal Application |
| Brian Stuhr | Authorized Representative | Signed Nursing Home Licensure Renewal Application and listed as Treasurer in Directors and Officers document |
| Glenn Van Ekeren | Authorized Representative and President | Signed Nursing Home Licensure Renewal Application and listed as President in Directors and Officers document |
Notice
Capacity: 80
Deficiencies: 0
APP2023
Visit Reason
This document serves as a renewal application for the nursing home license of Brookestone Acres and includes related licensing and occupancy permit information.
Findings
The documents verify that Brookestone Acres meets statutory requirements for licensure as a Skilled Nursing Facility and include certification of services, ownership information, and occupancy permit details.
Report Facts
Total licensed beds: 80
Renewal Licensure Fees: 1550
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raven Schmid | Administrator | Named in the Nursing Home Licensure Renewal Application. |
| Sarah Dankart | Director of Nursing | Named in the Nursing Home Licensure Renewal Application. |
| Brian Stuhr | Authorized Representative | Signed the Nursing Home Licensure Renewal Application. |
| Glenn Van Ekeren | Authorized Representative | Signed the Nursing Home Licensure Renewal Application. |
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