Deficiencies (last 11 years)
Deficiencies (over 11 years)
9.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
124% worse than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
123% occupied
Based on a September 2018 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Jul 21, 2025
Visit Reason
The notice was issued to inform the facility of disciplinary action due to violations related to failure to implement interventions to protect residents from elopement, as evidenced by a survey conducted on July 21, 2025.
Findings
The facility was found to have violated regulations by failing to implement necessary interventions to protect residents from elopement, resulting in a prohibition on admitting new residents until compliance is demonstrated and a fine of $1,000 per violation.
Report Facts
Fine amount: 1000
Notice finalization date: Aug 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Tesmer | Chief Medical Officer | Signed the Notice of Disciplinary Action |
| Dan Taylor | Administrator | Named in the notice as Health Facilities Licensure Unit Administrator |
Inspection Report
Renewal
Capacity: 30
Deficiencies: 0
Date: Apr 17, 2020
Visit Reason
The document is related to the renewal of the assisted-living facility license for Chrisoma West Assisted Living.
Findings
The facility meets statutory requirements as an assisted-living facility, and the renewal application was completed and signed. An occupancy permit was issued confirming a maximum occupancy of 30 beds.
Report Facts
Total licensed beds: 30
Maximum occupancy: 30
Notice
Capacity: 30
Deficiencies: 0
Date: Apr 30, 2019
Visit Reason
This document serves as a licensure renewal application and verification for Chrisoma West Assisted Living, confirming the facility's license renewal through April 30, 2020, and includes an occupancy permit issued by the Nebraska State Fire Marshal.
Findings
The documents confirm that Chrisoma West Assisted Living meets statutory requirements for licensure renewal as an assisted-living facility with a total licensed capacity of 30 beds. The occupancy permit issued on 2018-05-10 authorizes a maximum occupancy of 30 beds.
Report Facts
Total licensed beds: 30
Occupancy permit beds: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kendra Norton | Administrator | Named as facility administrator in the licensure renewal application |
| Charles Reeser | Board Member | Named in the Board of Directors list |
| Marlys Anderson | Board Member | Named in the Board of Directors list |
| Ron Haflich | Board Member | Named in the Board of Directors list |
| Doug Gustafson | Board Member | Named in the Board of Directors list |
| Craig Hadley | Board Member | Named in the Board of Directors list |
| Erika Hunt | Board Member | Named in the Board of Directors list |
| Jeff Moon | Board Member | Named in the Board of Directors list |
| Matt Samuelson | Board Member | Named in the Board of Directors list |
| Louis Strydom | Board Member | Named in the Board of Directors list |
| Troy Urbom | Board Member | Named in the Board of Directors list |
| Tom Thompson | Board Member | Named in the Board of Directors list |
| Cherlyn Hunt | Board Member | Named in the Board of Directors list |
| Noah Palmer | Board Member | Named in the Board of Directors list |
| Russ Gaar | Board Member | Named in the Board of Directors list |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 19, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint at Chrisoma West Assisted Living on March 19, 2019, by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint alleged the facility failed to protect residents from misappropriation, failed to ensure residents met retention criteria, and failed to have sufficient staff to meet residents' needs. All allegations were found to be unsubstantiated with the facility in compliance.
Findings
The investigation found the facility was in compliance with regulatory requirements regarding protection from misappropriation, retention criteria for residents, and sufficiency of staff to meet residents' needs.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health | Signed the report and identified as Program Manager |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 1
Date: Sep 11, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Christian Homes Health Care Center regarding allegations that the facility failed to ensure residents were treated with respect and dignity and failed to investigate causative factors in falls.
Complaint Details
The complaint investigation was triggered by allegations that the facility failed to treat residents with respect and dignity and failed to investigate causative factors in falls. The allegation regarding respect and dignity was not substantiated. The allegation regarding failure to report a fall with significant injury was substantiated.
Findings
The facility was found to be in compliance with respect and dignity requirements, but was found in violation for failing to report a fall with significant injury to the State Agency within the required time frame affecting one resident. The facility failed to report Resident 3's fall with rib fractures to the State Agency as required.
Deficiencies (1)
Failure to report a fall with significant injury to the State Agency within the required time frame.
Report Facts
Resident census: 74
Number of sampled residents for fall investigations: 4
Number of residents affected by deficiency: 1
Size of abrasion: 10
Size of abrasion: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cherlyn Hunt | Administrator | Facility Administrator who confirmed failure to report fall |
| Dan Taylor | RN, Training Coordinator | Signed letter regarding complaint investigation |
| Kimberly A. Divis | RN, NSSC | Conducted Informal Conference/Informal Dispute Resolution |
| Cindy Peterson | DON | Participant in Informal Conference |
| Connie Vogt | RN, BSN, Program Manager | Sent letter confirming Informal Conference scheduling and final decision |
| Becky Wisell | Administrator, Licensure Unit | Sent notification affirming Informal Dispute Resolution decision |
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 19
Date: Jun 28, 2018
Visit Reason
Annual state survey and complaint investigation to assess compliance with licensure regulations and federal requirements for nursing facilities.
Complaint Details
Complaint investigation included allegations of abuse and neglect involving resident to resident altercations, medication errors, and failure to report incidents to the State Agency. Some allegations were dismissed based on facility investigations and subsequent evidence.
Findings
The facility was cited for multiple deficiencies including failure to timely report abuse allegations, incomplete investigations, failure to notify legal representatives of bed hold policies, incomplete comprehensive assessments, inaccurate MDS coding, failure to develop comprehensive care plans, bedrail safety issues, labeling and storage of drugs, laboratory service deficiencies, quality assurance program failures, fire safety code violations, electrical system maintenance failures, and clinical record confidentiality breaches.
Deficiencies (19)
Failure to submit investigations into allegations of abuse and neglect to the state agency within required timeframes for 7 sampled residents.
Failure to document investigation of resident to resident altercation.
Failure to notify legal representative of bed hold policy in writing for one resident.
Failure to complete timely and accurate comprehensive assessments for 2 sampled residents.
Failure to accurately assess and code MDS including medications and behavioral symptoms for 2 sampled residents.
Failure to complete PASRR assessment for one resident with newly evident serious mental disorder.
Failure to develop and implement comprehensive care plans addressing behavioral-emotional, dementia, pressure ulcer/injury, unnecessary medications/psychotropic medications and clinical conditions for 2 sampled residents.
Failure to update care plans timely to reflect current resident status including medical procedures, resident altercations, skin impairments, and psychotropic medication side effects.
Failure to notify family/legal representatives of residents' rights and safeguard clinical records from unauthorized access.
Failure to maintain 3-hour fire barrier between assisted living and nursing home including unsealed penetrations and holes.
Failure to ensure side rails assessments to prevent entrapment and monthly maintenance inspections.
Failure to ensure corridor doors positively latch and fully close to resist smoke passage in 2 smoke compartments.
Failure to label opened insulin vials and medication syringes properly.
Failure to annually test electrical receptacles at patient bed locations.
Failure to maintain emergency generator including fuel testing, circuit breaker inspection, and load testing.
Failure to use electrical wiring and equipment safely including improper use of power strips and cords.
Failure to restrain oxygen cylinders to prevent tipping and potential hazards.
Failure to conduct fire drills quarterly on all shifts.
Failure to develop and implement effective quality assurance plans to maintain correction of cited deficiencies.
Report Facts
Residents affected: 7
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 4
Residents affected: 2
Residents affected: 3
Residents affected: 69
Fire drills missing: 1
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 20
Residents affected: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cherlyn Hunt | Administrator | Named in plan of correction and interviews |
| Cindy Peterson | Director of Nursing | Named in plan of correction and interviews |
| Dan Taylor | Program Manager | Signed Informal Dispute Resolution report |
| Dain Weiss | Licensure Unit Administrator | Signed Informal Dispute Resolution report |
| RN-K | Registered Nurse | Interviewed about medication labeling |
| LPN-J | Licensed Practical Nurse | Interviewed about abuse reporting and skin care |
| MDS-A | MDS Coordinator | Interviewed about care planning and assessments |
| MDS-B | MDS Coordinator | Interviewed about care planning and assessments |
| ADM | Administrator | Interviewed about fire safety and maintenance |
| Maintenance Director | Named in plan of correction for fire safety and maintenance | |
| OT-I | Occupational Therapist | Interviewed about side rail assessments |
| RN-K | Registered Nurse | Interviewed about medication labeling and storage |
| LPN-J | Licensed Practical Nurse | Interviewed about oxygen concentrator use |
| MA-L | Medication Aide | Interviewed about resident behaviors and interventions |
| SSD-C | Social Services Director | Interviewed about care planning and PASRR |
| HIM | Health Information Management | Interviewed about clinical record security |
Notice
Capacity: 30
Deficiencies: 0
Date: Mar 28, 2018
Visit Reason
This document serves as a licensure renewal verification for Chrisoma West Assisted Living and includes the occupancy permit issued by the Nebraska State Fire Marshal.
Findings
The facility is licensed as an assisted-living facility with a total licensed capacity of 30 beds. The occupancy permit was issued on 2017-04-26 by the Deputy State Fire Marshal.
Report Facts
Total licensed beds: 30
Renewal expiration date: Apr 30, 2019
Inspection Report
Routine
Census: 75
Capacity: 86
Deficiencies: 7
Date: Jun 6, 2017
Visit Reason
Routine inspection of Christian Homes Health Care Center to assess compliance with regulatory requirements including care plans, food safety, sanitary conditions, and life safety code.
Findings
The facility was found deficient in updating a resident's care plan to reflect a fluid restriction order, maintaining sanitary conditions in food preparation areas including ice machines and glove use, and ensuring safe and sanitary environmental conditions such as cleaning overhead light fixtures. Life safety deficiencies included missing exit signage on courtyard gates, missing kitchen range hood suppression system nozzle seals and inspections, improperly mounted fire extinguishers, and electrical hazards including daisy chained power strips and uncovered fire alarm junction boxes.
Deficiencies (7)
Failed to ensure fluid restriction order was included in Resident 89's comprehensive care plan.
Failed to ensure ice machines were free from brown and white substances and failed to ensure gloves were changed appropriately during food handling.
Failed to ensure no dead bugs and debris in overhead light fixtures in food preparation areas.
Failed to mark courtyard gates with exit signage for 2 of 4 exterior courtyards.
Missing kitchen range hood suppression system nozzle protective seals and failure to perform monthly inspections.
Fire extinguishers installed exceeding 5 feet above floor in 2 of 6 smoke compartments.
Failed to use electrical wiring and equipment safely; daisy chained power strip and uncovered fire alarm wire junction box.
Report Facts
Facility census: 75
Total licensed capacity: 86
Number of residents affected by exit signage deficiency: 23
Number of smoke compartments with fire extinguisher height deficiency: 2
Number of smoke compartments affected by electrical hazard: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance A | Confirmed missing exit signage, missing kitchen suppression system seals, fire extinguisher height issues, and electrical hazards | |
| RN-1 | Registered Nurse | Confirmed fluid restriction order should have been added to care plan |
| MDS/Care Plan Coordinator | Confirmed fluid restriction order was not on care plan | |
| Kitchen PM Supervisor | Confirmed ice machine contamination and glove use deficiencies | |
| Kitchen AM Supervisor | Confirmed glove use deficiency and overhead light fixture contamination | |
| Administrator | Confirmed glove use deficiency and overhead light fixture contamination |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 28, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Christian Homes Health Care Center regarding multiple allegations including misappropriation of personal property, failure to notify changes in care, medication administration errors, inappropriate resident admission evaluations, ineffective infection control, and failure to change care plans for fall risk residents.
Complaint Details
The complaint investigation addressed six allegations concerning personal property accounting, notification of care changes, medication administration, admission evaluations, infection control for scabies, and care plan changes for fall risk residents. All allegations were found to be unsubstantiated with no violations.
Findings
The investigation found no violations related to any of the six allegations. The facility was determined to be in compliance with all related regulatory requirements after review of records, observations, and interviews with staff and residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 18, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint at Chrisoma West Assisted Living regarding failure to protect residents from residents with adverse behaviors and failure to complete written investigations within five working days.
Complaint Details
The complaint alleged failure to protect residents from residents with adverse behaviors and failure to complete written investigations within five working days. Both allegations were investigated and found to be unsubstantiated with the facility in compliance.
Findings
The investigation found no evidence of resident-to-resident adverse behaviors and confirmed the facility had measures in place to protect residents. The facility was also found to be in compliance with requirements for timely completion of written investigations.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 12
Date: Mar 1, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Christian Homes Health Care Center from February 29, 2016 to March 7, 2016 by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The visit was complaint-related, investigating allegations that the facility failed to administer medications according to practitioner's orders and failed to investigate injuries of unknown origin. Both allegations were found to be in compliance.
Findings
The investigation found the facility was in compliance regarding medication administration and investigation of injuries of unknown origin. However, deficiencies were found related to care plan documentation, pressure ulcer prevention and treatment, side rail safety, food sanitation and hand hygiene, and life safety code violations including fire safety and smoke barrier issues.
Deficiencies (12)
Facility staff failed to address the use of side rails on Resident 40's care plan and Personal Care Sheet.
Facility failed to provide care and services to prevent an avoidable Stage 4 pressure ulcer for Resident 18 caused by improper toileting technique.
Facility failed to maintain a side rail on Resident 40's bed to prevent a potential entrapment hazard.
Facility staff failed to perform proper hand hygiene and failed to ensure dishwasher water temperatures met guidelines.
Chapel doors failed to positively latch when self-closed, allowing smoke migration.
Unsealed smoke barrier penetrations in North Unit, Peony, and MM/RP smoke barriers.
DD Storage Room lacked self-closure and DD Soiled Linen Room door failed to positively latch and had unsealed holes.
Fire drills were not conducted quarterly on each shift under varying conditions with at least one hour difference between drills.
Range hood suppression system nozzles obstructed by shelf above range cook top.
Chapel exit corridor obstructed by furniture.
Empty oxygen cylinders were not segregated or labeled from full cylinders in oxygen storage room.
Fire alarm wiring splices above ceiling were exposed and not enclosed in listed fittings or boxes.
Report Facts
Facility census: 75
Pressure ulcer size: 3.4
Pressure ulcer size: 4
Dishwasher temperature records: 23
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 24, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to provide prompt cardio-pulmonary resuscitation (CPR).
Complaint Details
The complaint alleged failure to provide prompt cardio-pulmonary resuscitation. The allegation was investigated and substantiated in part, but no citation was issued due to staff training and policy adherence.
Findings
The investigation found that one facility staff member failed to provide prompt CPR to a resident who had requested it, although staff were trained on CPR and the facility's CPR policy. No related citations were issued as other residents' CPR information was accessible and staff were aware of the policy.
Deficiencies (1)
Failure of one facility staff member to provide prompt cardio-pulmonary resuscitation to a resident who requested CPR.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 12
Date: Feb 18, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Christian Homes Health Care Center from February 18, 2015 to February 25, 2015.
Complaint Details
The complaint alleged the facility failed to protect residents from abuse. Investigation revealed a resident bit two other residents causing bruises. The facility was found in violation of Federal tag F224 and State Licensure tag 175 NAC 12-006.05(9).
Findings
The facility failed to protect residents from abuse by an abusive resident who bit two other residents causing bruises. The facility also had deficiencies in comprehensive assessments, care planning, medication error rates, nurse staffing postings, food storage, medication storage, infection control, quality assurance, and life safety code compliance including fire alarm testing and sprinkler clearance.
Deficiencies (12)
Failed to protect 2 residents from an abusive resident who bit them causing bruises.
Failed to perform comprehensive assessments for residents with potential restraints and weight loss.
Failed to develop comprehensive care plans including for a pressure ulcer.
Medication error rate of 24% due to improper insulin and gastrostomy tube medication administration.
Failed to post nurse staffing information at the start of each shift.
Food items stored directly on the floor in the kitchen.
Failed to dispose of expired medications and supplies and stock outdated items.
Failed to prevent cross contamination and improper glove use and hand hygiene during resident care.
Failed to maintain smoke barrier wall between janitor's closet and resident room.
Failed to have fire alarm tested and inspected every 6 months as required.
Failed to maintain 18 inch clearance from sprinkler head to nearby obstructions in kitchen storage.
Failed to document monthly generator load test for 1 month and weekly inspections for 5 weeks in 2014.
Report Facts
Residents present: 81
Medication error rate: 24
Deficiency counts: 12
Bruise size: 2
Bruise size: 1.5
Weight loss percentage: 12.58
Sprinkler clearance: 18
Generator load test months missed: 1
Generator weekly inspections missed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vicki Lepant | Registered Nurse | Surveyor and complaint investigation representative |
| Ronda Gunther | Registered Nurse | Surveyor and complaint investigation representative |
| Carmen Blake | Registered Nurse | Surveyor and complaint investigation representative |
| Betty Smith | Registered Nurse | Surveyor and complaint investigation representative |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit | Signed complaint investigation letter |
| Don Bakke | Administrator | Facility administrator named in complaint letter |
| Maintenance A | Confirmed deficiencies related to smoke barrier, fire alarm testing, sprinkler clearance, and generator testing | |
| LPN-A | Licensed Practical Nurse | Named in medication administration errors and infection control deficiencies |
| RN-I | Registered Nurse | Interviewed regarding care plans and medication errors |
| DON | Director of Nursing | Interviewed regarding biting incidents, medication errors, infection control, and QA committee |
| Dietary Manager | Interviewed regarding food storage and weight loss | |
| SSD-C | Social Service Designee | Interviewed regarding nurse staffing posting |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 2
Date: Nov 3, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding failure to provide care and treatment to promote healing of pressure sores and failure to notify family or responsible party of change in condition.
Complaint Details
The complaint alleged failure to provide care and treatment to promote healing of pressure sores and failure to notify family or responsible party of change in condition. Investigation confirmed these allegations for Resident 63.
Findings
The facility was found in violation for failing to notify family of a resident's change in condition and failing to provide care to promote healing of a pressure sore, which deteriorated to osteomyelitis. The facility was found compliant regarding notification of healthcare practitioner.
Deficiencies (2)
Failure to notify family or responsible party of change in condition for Resident 63.
Failure to provide care and treatment to promote healing of pressure sores for Resident 63, resulting in deterioration to osteomyelitis.
Report Facts
Census: 82
Pressure ulcer measurements: 4
Pressure ulcer measurements: 2
Pressure ulcer measurements: 3
Braden scale score: 11
Pressure ulcer measurements: 1.7
Pressure ulcer measurements: 1
Pressure ulcer depth: 0.6
Pressure ulcer measurements: 1.4
Pressure ulcer measurements: 1
Pressure ulcer depth: 0.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Don Bakke | Administrator | Named as facility administrator in multiple documents |
| Betty Smith | Registered Nurse | Conducted complaint investigation visit |
| Eve Lewis | Program Manager | Signed correspondence related to inspection and informal dispute resolution |
| Kimberly A. Divis | RN, NSSC II | Conducted informal conference |
| Cindy Peterson | RN Director of Nurses | Participant in informal conference |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 17, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint at Christian Homes Health Care Center regarding allegations of failure to protect residents from injury, failure to monitor blood work according to standards, and failure to change fall interventions after residents were identified at risk for falls.
Complaint Details
The complaint investigation addressed three allegations: failure to protect residents from injury, failure to monitor blood work in accordance with standards, and failure to change fall interventions after residents were identified at risk. The first allegation was substantiated with corrective actions taken; the other two were found to be in compliance.
Findings
The investigation found the facility failed to protect a resident from injury related to not following a resident's care plan for transfer, but corrective actions were implemented and no deficient practice was cited. The facility was found to be in compliance with monitoring blood work and changing fall interventions for residents at risk of falls.
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 10
Date: Mar 18, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Christian Homes Health Care Center on March 10, 2014-March 18, 2014. The investigation included review of resident records, observation of care and services, and interviews with residents, family members and staff.
Complaint Details
The complaint investigation included allegations that the facility failed to ensure family/Power of attorney/resident involvement in care planning, failed to provide services to meet residents' needs, failed to coordinate care, failed to identify changes in condition, failed to provide care for bladder/bowel elimination, failed to protect residents from abuse and misappropriation. The facility was found in violation for failure to involve families in care planning and failure to protect residents from misappropriation. Other allegations were found to be in compliance.
Findings
The facility was found to have multiple deficiencies including failure to resolve grievances related to misappropriation of resident property, failure to complete thorough investigations, failure to maintain dignity and respect for residents, failure to provide notice before room changes, failure to revise care plans and involve families in care planning, failure to implement non-pharmacological interventions prior to psychoactive medication use, failure to administer insulin properly before meals, and failure to maintain proper fire safety door closers.
Deficiencies (10)
Failure to ensure grievances were resolved and to prevent loss of personal property for multiple residents.
Failure to develop and implement policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property.
Failure to enhance and maintain residents' dignity and respect by not giving residents the opportunity to invite staff to enter their rooms and by not ensuring catheter bags were covered.
Failure to provide notice before room or roommate changes for residents.
Failure to revise care plan interventions for prevention of falls and failure to provide documentation that families were invited to care planning meetings.
Failure to implement non-pharmacological interventions prior to use of psychoactive medications and lack of documentation of behaviors and medication effectiveness.
Failure to administer insulin before meals to ensure therapeutic benefit.
Failure to date multi-dose insulin vials when opened and failure to replace outdated insulin vials.
Failure to ensure proper closing and latching of fire rated doors in Rose Peony hall.
Failure to install or maintain door closers on two hazardous rooms to ensure fire and smoke separation.
Report Facts
Facility census: 79
Number of falls: 16
Ativan administrations: 12
Ativan administrations: 5
Insulin units: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Don Bakke | Administrator | Named in complaint investigation letter |
| Nancy Harms | Registered Nurse | Surveyor and complaint investigator |
| Dixie Jackson | Social Worker | Surveyor and complaint investigator |
| Betty Smith | Registered Nurse | Surveyor and complaint investigator |
| Eve Lewis | Program Manager | Signed complaint investigation letter and plan of correction |
Inspection Report
Routine
Census: 72
Deficiencies: 13
Date: Dec 4, 2012
Visit Reason
The facility was surveyed for compliance with regulations governing licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities.
Findings
The facility failed to complete investigations for 3 reported incidents of missing resident property, maintain a comfortable environment due to marred doors and gouged walls, establish non-pharmacological interventions before administering antipsychotic medications for one resident, maintain medication error rates below 5%, follow the pre-planned menu portions, offer milk or substitutes to residents, and ensure proper labeling and storage of drugs and biologicals. Life safety code violations were also identified including inadequate exit signage, smoke door gaps, fire-rated door issues, and generator maintenance deficiencies.
Deficiencies (13)
Failed to complete investigations for 3 reported incidents of missing resident property affecting 3 residents.
Failed to maintain a comfortable environment due to marred doors and gouged walls affecting 5 residents.
Failed to establish and implement non-pharmacological interventions before administering antipsychotic medications for one resident with aggressive behaviors.
Medication error rate of 6% due to improper timing and dosing of medications affecting 3 residents.
Failed to follow pre-planned menu portions and failed to serve milk or milk substitutes to residents.
Failed to offer substitutes of similar nutritive value for residents who refused milk.
Failed to ensure expired laboratory hemoccult slides, skin prep swabs, and outdated medication were not available for use.
Failed to mark the means of egress with visible exit signs in one smoke compartment.
Failed to provide smoke compartment doors that resisted passage of smoke due to excessive gaps.
Failed to provide smoke resistive and one hour fire-rated partitions from hazardous areas in 3 smoke compartments.
Failed to maintain doors in a two-hour fire barrier to latch properly.
Failed to separate oxygen storage room by smoke resisting partitions and failed to install automatic door closure.
Failed to maintain emergency generator in accordance with NFPA 110 including non-functioning annunciator panel and lack of load bank testing.
Report Facts
Facility census: 72
Survey sample size: 56
Medication error rate: 6
Residents affected by missing milk: 17
Residents affected by marred doors and gouged walls: 5
Residents affected by exit sign deficiency: 10
Residents affected by smoke door gaps: 8
Residents affected by hazardous area fire rating deficiency: 10
Residents affected by fire door latch deficiency: 13
Residents affected by oxygen storage deficiency: 12
Facility census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance A | Confirmed exit sign visibility issues, door gap issues, fire door latch issues, oxygen storage door closure issues, generator maintenance deficiencies | |
| MA T | Medication Aide | Administered medication improperly and unaware of timing requirements |
| RN F | Registered Nurse | Administered insulin improperly and confirmed facility practices |
| Social Service Director | Social Service Director | Interviewed regarding missing resident property investigations |
| Dietary Aide DA-A | Dietary Aide | Failed to offer milk or milk substitutes during meals |
| Dietary Manager | Dietary Manager | Confirmed menu and milk serving deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding antipsychotic medication use and generator maintenance |
| LPN K | Licensed Practical Nurse | Confirmed expired hemoccult slides and skin prep swabs |
Inspection Report
Routine
Census: 21
Deficiencies: 1
Date: Nov 16, 2011
Visit Reason
An onsite inspection was conducted to determine compliance with regulatory requirements for an assisted living facility.
Findings
The facility was found to have committed a violation related to food safety, specifically failure to ensure dietary staff washed hands when soiled, increasing risk of food contamination and potential foodborne illness.
Deficiencies (1)
Failure to ensure dietary staff washed hands when soiled, increasing risk of food contamination and potential foodborne illness.
Report Facts
Facility census: 21
Survey sample size: 4
Correction period: 90
Compliance statement submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dixie Jackson | Social Worker | Surveyor who conducted the inspection |
| Linda Amstuz | Director of Resident Services | Reviewed surveyor's findings with dietary staff and signed plan of correction |
| Terra Meyer | Dietary Manager | Responsible for monitoring dietary staff for proper hand washing and food handling techniques |
| Kendra Norton | Director of Resident Care | Observed dietary staff demonstrating proper hand washing techniques during re-education |
Inspection Report
Annual Inspection
Census: 66
Capacity: 89
Deficiencies: 16
Date: Nov 7, 2011
Visit Reason
Annual inspection of Christian Homes Health Care Center to assess compliance with regulatory requirements including resident records, care plans, medication management, food service, and life safety code standards.
Findings
The facility had multiple deficiencies including failure to maintain accurate resident personal property inventories, failure to notify residents or representatives of room changes, incomplete care plans addressing weight loss and fall prevention, medication regimen issues with duplicate therapies, food temperature concerns, medication administration errors, and life safety code violations including fire safety and emergency lighting.
Deficiencies (16)
Failed to maintain accurate and updated personal inventory records for residents 76 and 49.
Failed to notify residents 59 and 49 or their legal representatives of room changes prior to the move.
Failed to identify and plan interventions for resident 89's significant weight loss.
Failed to revise comprehensive care plans to address fall prevention for residents 89 and 59.
Failed to assess causal factors and implement new interventions to prevent falls for residents 89 and 59.
Failed to assure drug regimen was free of duplicate drugs for residents 48 and 66.
Failed to act upon pharmacist recommendations regarding duplicate drug therapy for residents 48, 66, and 68.
Failed to ensure food temperature was acceptable to residents at time of meal service, potentially impacting meal satisfaction.
Medication administration error: Omeprazole given after meal instead of 30-60 minutes before meal for resident 60.
Failed to maintain rated ceiling assemblies and fire safety measures including attic hatches and smoke dampers in multiple locations.
Failed to maintain corridor walls as smoke resistive partitions allowing potential smoke migration into exit corridors.
Failed to provide one hour fire separation from hazardous areas in partially sprinklered facility.
Failed to provide slip resistant walking surface outside of M and M Dining Room Exit with abrupt elevation change creating fall hazard.
Failed to maintain 3 of 4 battery backup emergency lights, risking darkness during power loss.
Allowed use of microwaves in 3 resident rooms, contrary to fire safety code.
Failed to ensure electrical outlet in resident room Rose 8 was securely anchored and free of mechanical damage.
Report Facts
Facility census: 66
Facility total capacity: 89
Survey sample size: 32
Weight loss: 13
Weight loss: 16
Medication administration opportunities observed: 56
Medication errors observed: 1
Residents affected by microwaves in rooms: 3
Residents affected by corridor smoke migration risk: 16
Residents affected by hazardous area fire separation risk: 24
Residents affected by slip hazard: 12
Battery backup lights failed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-C | Licensed Practical Nurse | Confirmed medication regimen issues and pharmacy review failures |
| LPN-S | Licensed Practical Nurse | Observed medication administration error for Resident 60 |
| RN J | Registered Nurse | Interviewed about falls and resident care |
| Maintenance A | Acknowledged fire safety and emergency lighting deficiencies | |
| General Contractor A | Acknowledged fire safety deficiencies during renovation | |
| DON | Director of Nursing | Interviewed about care plans, medication follow-up, and fall prevention |
| Social Service Director | Interviewed about resident notification and inventory procedures |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 9
Date: Aug 5, 2010
Visit Reason
The inspection was conducted to investigate complaints related to dignity and respect of individuality, safe and comfortable environment, housekeeping and maintenance, nurse call light response, catheter care, drug regimen, food safety, medication storage, and clinical record keeping at Christian Homes Health Care Center.
Complaint Details
The visit was complaint-related focusing on issues such as dignity and respect, environmental safety, housekeeping, nurse call response, catheter care, medication management, food safety, and clinical record accuracy. The complaints were substantiated as deficiencies were found in these areas.
Findings
Multiple deficiencies were identified including failure to address residents by preferred names, ammonia odor in resident rooms, gaps in exit doors allowing hot air and bugs, inadequate nurse call light response, catheter bags resting on the floor, lack of monitoring for psychotropic drug use, uncovered food items, medication stored at excessive temperatures, and incomplete clinical documentation.
Deficiencies (9)
Facility staff failed to address residents by their preferred names, affecting dignity and respect of individuality.
Ammonia odor was noted in Resident 63's room on multiple days.
Facility failed to maintain exit doors for a well-maintained environment; gaps allowed hot air and bugs to enter.
Nurse call lights were not answered timely, affecting resident satisfaction.
Catheter bags and tubing were found resting on the floor, risking urinary tract infections.
Facility failed to monitor psychotropic and sedative/hypnotic medication use adequately.
Food items were not properly covered during storage and transport, risking contamination.
Medication room temperatures were not maintained within required limits; medications stored at excessive temperatures.
Clinical records were incomplete and not properly documented for multiple residents.
Report Facts
Facility census: 78
Sample size: 16
Residents affected: 60
Residents sampled: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donald Bakke | Signed letter submitting amended responses | |
| Director of Nursing | Director of Nursing | Named in findings related to nurse call light response, catheter care, medication monitoring, and quality assurance processes |
| Housekeeping Supervisor | Housekeeping Supervisor | Named in findings related to ammonia odor and housekeeping services |
| Maintenance Director | Maintenance Director | Named in findings related to exit door maintenance and temperature control |
| Food Services Supervisor | Food Services Supervisor | Named in findings related to food safety and storage |
| Social Service Director | Social Service Director | Named in findings related to resident name preferences and monitoring resident comments |
Document
Capacity: 86
Deficiencies: 0
Visit Reason
The document serves as a renewal application for the nursing home license of Christian Homes Health Care Center, including certification of licensure, occupancy permit, and Alzheimer's special care unit endorsement.
Findings
No inspection findings or deficiencies are reported in this document; it contains administrative and licensing information, facility capacity, and care unit disclosures.
Report Facts
Total licensed beds: 86
Maximum capacity for Alzheimer's beds: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cherlyn Hunt | Administrator / Executive Director | Named as Administrator on the renewal application and Alzheimer's unit disclosure (pages 2, 8). |
| Michelle Thaden-Gydesen | Director of Nursing | Named as Director of Nursing on the renewal application (page 2). |
Document
Capacity: 86
Deficiencies: 0
Visit Reason
The document serves as a licensure renewal application for Christian Homes Health Care Center, verifying the facility's license status and providing administrative and operational information.
Findings
The document includes the facility's licensure renewal details, occupancy permit with maximum bed capacity, board of directors, evacuation routes, and admission agreement terms including room rates and services.
Report Facts
Licensed beds: 86
Renewal fees: 1750
Room rates: 189
Care point rate: 3.85
Document
Capacity: 86
Deficiencies: 0
Visit Reason
This document package serves to verify and renew the license for Christian Homes Health Care Center as a skilled nursing facility with dual certification for Medicare and Medicaid, including occupancy permit and ownership information.
Findings
No inspection findings or deficiencies are reported; the documents confirm licensure status, renewal application details, occupancy permit with maximum capacity, and facility ownership and board information.
Report Facts
Licensed beds: 86
Renewal fees: 1750
Notice
Capacity: 86
Deficiencies: 0
Visit Reason
This document serves to verify the renewal of the SNF/NF dual certification license for Christian Homes Health Care Center and includes the occupancy permit issued by the Nebraska State Fire Marshal.
Findings
The facility is licensed for 86 beds and meets statutory requirements for skilled nursing and nursing facility dual certification. The occupancy permit confirms compliance with fire marshal codes as of the issuance date.
Report Facts
Licensed beds: 86
Renewal fee: 1750
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cherlyn Hunt | Administrator | Named as the facility administrator in the renewal application. |
| Cindy Peterson | Director of Nursing | Named as the director of nursing in the renewal application. |
Document
Capacity: 86
Deficiencies: 0
Visit Reason
The document serves to verify the renewal of the SNF/NF dual certification license, provide occupancy permit details, list licensed bed counts, and present administrative information such as board members and evacuation routes.
Findings
The document confirms the facility's licensure renewal through March 31, 2020, an occupancy permit issued on June 26, 2018, with a maximum occupancy of 86 beds, and includes detailed licensed bed distribution and administrative data.
Report Facts
Licensed beds: 86
Document
Capacity: 86
Deficiencies: 0
Visit Reason
The document serves as a renewal application for the nursing home license of Christian Homes Health Care Center and includes related licensing and occupancy permit information.
Findings
No inspection findings or deficiencies are reported in this document; it primarily contains administrative and licensing information.
Report Facts
Total licensed beds: 86
Document
Capacity: 86
Deficiencies: 0
Visit Reason
The document set serves to renew the nursing home license for Christian Homes Health Care Center, verify occupancy permit, and provide administrative information such as board of directors and evacuation routes.
Findings
No inspection findings or deficiencies are reported in these documents. They primarily consist of licensing renewal application, occupancy permit certification, and facility administrative details.
Report Facts
Total licensed beds: 86
Renewal licensure fee: 1550
Number of beds to be relicensed: 86
Notice
Capacity: 86
Deficiencies: 0
Visit Reason
This document serves as a renewal application for the nursing home license of Christian Homes Health Care Center and includes verification of licensure and occupancy permits.
Findings
The documents confirm that Christian Homes Health Care Center is licensed and meets statutory requirements for skilled nursing and nursing facility services, with an approved occupancy permit for 86 beds.
Report Facts
Total licensed beds: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cherlyn Hunt | Administrator | Named on the Nursing Home Licensure Renewal Application |
| Cindy Peterson | Director of Nursing | Named on the Nursing Home Licensure Renewal Application |
| Thomas Thomas | Authorized Representative | Signed the Nursing Home Licensure Renewal Application |
| Ivy Uhling | Authorized Representative | Signed the Nursing Home Licensure Renewal Application |
Notice
Capacity: 60
Deficiencies: 0
Date: APP2025
Visit Reason
The document serves as a renewal application and licensing documentation for Chrisoma West Assisted Living, including bed capacity and special population endorsements.
Findings
The documents certify that Chrisoma West Assisted Living meets statutory requirements for licensing and includes information on bed capacity, ownership, facility features, and memory care endorsement.
Report Facts
Total licensed beds: 60
Maximum occupancy: 60
Alzheimer's beds capacity: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kendra Norton | Administrator | Named as facility administrator on renewal application and Alzheimer's endorsement application (pages 2 and 10). |
| Cherlyn Hunt | Executive Director | Named as contact person and legal entity contact on Alzheimer's endorsement application (page 10). |
Notice
Capacity: 30
Deficiencies: 0
Date: APP2016
Visit Reason
This document serves to verify that Chrisoma West Assisted Living is licensed through the date indicated on the renewal card and includes the assisted-living facility license renewal application and occupancy permit.
Findings
The documents confirm the facility's licensure renewal and occupancy permit with a maximum capacity of 30 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 30
Renewal expiration date: License renewal expiration date is 04/30/2017 as shown on the renewal card
Inspection Report
Renewal
Capacity: 30
Deficiencies: 0
Date: APP2017
Visit Reason
The document is a licensure renewal application and certification for Chrisoma West Assisted Living facility, verifying that the facility is licensed through the indicated renewal date.
Findings
The documents confirm that Chrisoma West Assisted Living meets statutory requirements for licensure renewal and includes an occupancy permit certifying a maximum occupancy of 30 beds.
Report Facts
Total licensed beds: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Amstuz | Administrator | Named as the administrator of Chrisoma West Assisted Living in the renewal application. |
Notice
Capacity: 30
Deficiencies: 0
Date: APP2021
Visit Reason
This document serves as a renewal application and verification of licensure for Chrisoma West Assisted Living facility.
Findings
The document confirms that Chrisoma West Assisted Living meets statutory requirements for licensure and includes renewal application details, ownership information, and occupancy permit.
Report Facts
Total licensed beds: 30
Renewal license fees: 1950
Occupancy maximum: 30
Occupancy permit date issued: 2020
Notice
Capacity: 30
Deficiencies: 0
Date: APP2022
Visit Reason
This document serves to verify the assisted-living facility license renewal and includes the renewal application, occupancy permit, and related facility information.
Findings
No inspection findings or deficiencies are reported; the documents confirm licensing status and facility capacity.
Report Facts
Total licensed beds: 30
Notice
Capacity: 30
Deficiencies: 0
Date: APP2023
Visit Reason
This document serves to verify that Chrisoma West Assisted Living is licensed through the date indicated on the renewal card and includes the renewal application and occupancy permit.
Findings
The documents confirm the facility meets statutory requirements for licensure as an assisted-living facility, with no inspection findings or deficiencies noted.
Report Facts
Total licensed beds: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kendra Norton | Administrator | Listed as the facility administrator on the renewal application. |
| Tom Thompson | Authorized Representative | Signed the renewal application on 2023-01-26. |
| Troy Urbom | Authorized Representative | Signed the renewal application on 2023-01-26. |
Notice
Capacity: 30
Deficiencies: 0
Date: APP2024
Visit Reason
This document serves as a licensure renewal application and verification for Chrisoma West Assisted Living facility, confirming the facility's license status and capacity.
Findings
The documents include licensing renewal confirmation, facility capacity details, floor plans, Alzheimer's Memory Care endorsement application, and detailed facility policies and procedures related to assisted living and memory care services.
Report Facts
Total licensed capacity: 30
Renewal license fees: 1650
Date: Mar 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kendra Norton | Administrator | Named as facility administrator on renewal application and Alzheimer's Memory Care endorsement application. |
| Cherlyn Hunt | Executive Director | Named as contact person on Alzheimer's Memory Care endorsement application. |
Document
Capacity: 86
Deficiencies: 0
Visit Reason
The document set serves to renew the nursing home license for Christian Homes Health Care Center and includes related administrative and certification information.
Findings
No inspection findings or deficiencies are reported in these documents; they primarily consist of licensing, certification, and occupancy permit information.
Report Facts
Total licensed beds: 86
Renewal license fees: 1550
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cherlyn Hunt | Administrator | Named on the Nursing Home Licensure Renewal Application |
| Erika Muthart | Director of Nursing | Named on the Nursing Home Licensure Renewal Application |
Notice
Capacity: 86
Deficiencies: 0
Visit Reason
This document serves as a Nursing Home Licensure Renewal Application for Christian Homes Health Care Center, including verification of licensure and occupancy permit details.
Findings
The documents confirm the facility's licensure renewal status, licensed bed capacity of 86, and compliance with state fire marshal occupancy requirements.
Report Facts
Licensed bed capacity: 86
Renewal licensure fee: 1750
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryln Hunt | Administrator | Named in Nursing Home Licensure Renewal Application |
| Erika Muthart | Director of Nursing | Named in Nursing Home Licensure Renewal Application |
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