Inspection Reports for Emerald Nursing & Rehab Cozad
318 West 18th Street, COZAD, NE, 69130
Back to Facility ProfileDeficiencies (last 12 years)
Deficiencies (over 12 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% worse than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
84% occupied
Based on a September 2018 inspection.
Census over time
Inspection Report
Renewal
Capacity: 67
Deficiencies: 0
Date: Jan 18, 2024
Visit Reason
This document is a Nursing Home Licensure Renewal Application and related licensing and certification documents for Emerald Nursing & Rehab Cozad, indicating the renewal of the facility's license and certification.
Findings
The documents confirm that Emerald Nursing & Rehab Cozad meets statutory requirements for licensure renewal as a Skilled Nursing Facility with specialized care services including Alzheimer's/Special Care Unit, Physical Therapy, Speech Therapy, and Occupational Therapy. The facility has a licensed capacity of 67 beds.
Report Facts
Number of beds to be relicensed: 67
Renewal Licensure Fees: 1550
Renewal Licensure Fees: 1750
Renewal Licensure Fees: 1950
Cost/Fees of care: 265
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kiley Goff | Administrator | Named in Nursing Home Licensure Renewal Application and Alzheimer's Special Care Unit Disclosure |
| Kristin Henggeler | Director of Nursing | Named in Nursing Home Licensure Renewal Application |
| Yisroel I Chafetz | Authorized Representative | Signed Nursing Home Licensure Renewal Application and Alzheimer's Special Care Unit Disclosure |
| Jacob I Walden | Authorized Representative | Named in Nursing Home Licensure Renewal Application |
| Michael Hoeft | Deputy State Fire Marshal | Inspected facility for Nebraska State Fire Marshal Occupancy Permit |
Document
Capacity: 67
Deficiencies: 0
Date: Dec 1, 2023
Visit Reason
The document serves to issue a new Skilled Nursing Facility license to Emerald Nursing & Rehab Cozad due to a change of ownership, and includes related licensing and ownership disclosure information.
Findings
The documents confirm the facility's licensure status, ownership information, and occupancy permit with a maximum capacity of 67 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kiley Goff | Administrator | Named as facility administrator on licensure application and license issuance letter |
| Kristin Henggeler | Director of Nursing | Named as Director of Nursing on licensure application |
| Timothy Tesmer | Chief Medical Officer | Signed the license issuance letter |
| Dan Taylor | Administrator | Contact person for license questions and signed on behalf of Chief Medical Officer |
| Yisroel I. Chafetz | Authorized Representative / Managing Member | Signed ownership disclosure and licensure application |
| Michael Hoeft | Deputy State Fire Marshal | Inspected the facility for occupancy permit |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 13, 2020
Visit Reason
An unannounced visit was conducted to investigate a complaint at Emerald Nursing & Rehab Cozad on January 13, 2020, 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.
Complaint Details
The complaint included allegations of failure to provide care and services for diabetes management, medication administration errors, insufficient staffing, lack of privacy during cares, delayed response to calls, disrespectful treatment of residents, inadequate bowel/bladder care, and denial of residents' right to choose medical providers. All allegations were found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found to be in compliance with regulatory requirements for all allegations investigated, including management of diabetes, medication administration, staffing sufficiency, privacy during cares, timely response to calls, respectful treatment of residents, bowel/bladder care, and residents' right to choose a medical provider.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Renewal
Capacity: 67
Deficiencies: 0
Date: May 1, 2019
Visit Reason
The document is a regulatory licensing and transfer of operations report related to the renewal and transfer of ownership of Emerald Nursing & Rehab Cozad, a skilled nursing facility, effective May 1, 2019.
Findings
The report documents the transfer of operations from Klaasmeyer and Associates, Inc. to Cozad Operations LLC, including licensing, regulatory approvals, employee transfer, and asset transfer. The facility is licensed and certified for Medicare and Medicaid participation, with no outstanding regulatory or legal issues noted.
Report Facts
Total licensed capacity: 67
Maximum endorsed capacity: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kiley Goff | Administrator | Named as facility administrator in licensing and transfer documents |
| Loretta Smith | Director of Nursing | Named as Director of Nursing in licensing application |
| Ephram (Mordy) Lahasky | Sole Member, Authorized Representative | Named as contact and authorized representative for Cozad Operations LLC, new operator |
Inspection Report
Annual Inspection
Census: 56
Capacity: 67
Deficiencies: 19
Date: Sep 12, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Cozad Care And Rehabilitation Center, Llc on September 10-17, 2018 by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The visit was complaint-related and annual survey combined. Allegations included failure to ensure accurate MDS, failure to protect residents from abuse, failure to ensure residents are free from misappropriation, failure to complete investigations timely, and failure to provide appropriate transfer services. Some allegations were substantiated with deficiencies cited.
Findings
The facility was found to have multiple deficiencies including failure to ensure accurate resident assessments, failure to report alleged violations timely, improper use of restraints, failure to notify legal representatives of bed hold policy, medication administration errors, inadequate staff competencies, food safety violations, infection control lapses, and fire safety code violations.
Deficiencies (19)
Failure to ensure the Minimal Data Set reflects residents overall care.
Failure to complete written investigations within five working days.
Failure to recognize use of physical restraints without medical justification for 2 residents.
Failure to report alleged violations involving abuse and neglect timely and submit final written investigations within 5 working days.
Failure to notify resident's legal representative of bed hold policy within 24 hours of transfer to hospital.
Failure to ensure accuracy of resident assessments, specifically missing diagnosis on MDS.
Failure to ensure PASARR screening for residents with serious mental illness or intellectual disability was completed.
Failure to update care plans timely and revise after assessments.
Failure to provide appropriate catheter securement device for resident with suprapubic catheter and tape allergy.
Failure to ensure nursing staff competency in mechanical lifts and handwashing.
Failure to provide nurse aides with required 12 hours of in-service education annually and performance reviews.
Failure to ensure resident was free from significant medication errors related to timing of insulin administration.
Failure to ensure food safety in Alzheimer's Care Unit kitchenette including unsecured food, undated opened food containers, improper hair net use, and contamination of cereal container.
Failure to maintain infection prevention and control practices including hand hygiene and glove use during resident care and sanitation of equipment.
Failure to ensure hazardous areas are separated by smoke resisting partitions and doors that latch properly.
Failure to maintain fire alarm system with non-functioning smoke and heat detectors.
Failure to inspect, test, and maintain fire sprinkler system as required.
Failure to ensure corridor doors latch properly to resist passage of smoke.
Failure to prohibit combustible decorations such as candles in resident rooms.
Report Facts
Facility census: 56
Total licensed capacity: 67
Deficiencies cited: 16
Residents affected by restraint deficiency: 2
Residents affected by reporting deficiency: 2
Residents affected by PASARR deficiency: 2
Residents affected by care plan deficiency: 2
Nurse Aides lacking required education: 4
Nurse Aides lacking performance review: 5
Residents affected by medication error: 1
Residents affected by infection control deficiency: 2
Residents affected by fire safety door deficiency: 30
Residents affected by combustible decoration deficiency: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Named as author of complaint investigation letter |
| Kiley Goff | Administrator | Named as facility administrator in multiple documents |
| Rayla Cooper | Presented education on abuse reporting to staff |
Notice
Capacity: 67
Deficiencies: 0
Date: Mar 19, 2018
Visit Reason
This document serves as a licensure renewal application and certification for Cozad Care and Rehabilitation Center, LLC, verifying the facility's SNF/NF dual certification and renewal of licensure through the indicated expiration date.
Findings
The documents confirm the facility meets statutory requirements for licensure renewal, including certifications for physical therapy, occupational therapy, speech therapy, and Alzheimer's/special care. The maximum licensed capacity is 67 beds.
Report Facts
Licensed beds: 67
Renewal fees: 1550
Renewal fees: 1750
Renewal fees: 1950
Staffing pattern: 3
Daily rate: 235
Daily rate: 227
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barry Emerson | Administrator | Named as facility administrator on renewal application and Alzheimer's Special Care Unit Disclosure |
| Loretta Smith | Director of Nursing | Named as Director of Nursing on renewal application |
| Joseph Schwartz | Authorized Representative | Signed certification and Alzheimer's Special Care Unit Disclosure |
| Rosie Schwartz | Authorized Representative | Signed certification on renewal application |
| Brandie Lamberth | Contact Person | Named contact on Alzheimer's Special Care Unit Disclosure |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Date: Feb 7, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Cozad Care And Rehabilitation Center, Llc on February 7, 2018, regarding allegations including failure to ensure room square footage meets regulatory requirements, over medication of residents, unresolved grievances, inadequate staff training, and failure to give appropriate notice of involuntary discharge.
Complaint Details
The complaint investigation was triggered by allegations that the facility failed to meet regulatory requirements related to room size, medication management, grievance resolution, staff training, and discharge notice. The investigation substantiated the allegation regarding failure to provide appropriate notice of involuntary discharge and failure to notify of Bed Hold policy.
Findings
The facility was found to be in compliance with regulatory requirements for room size, medication management, grievance resolution, and staff training. However, the facility was found to be in violation for failing to provide appropriate written notice of involuntary discharge to residents or their representatives, specifically for Resident 1. Additionally, the facility failed to notify legal representatives of the Bed Hold policy at the time of discharge for Residents 1 and 3.
Deficiencies (2)
Failure to provide Resident 1 with 30 days written notice of involuntary discharge.
Failure to notify legal representatives of Residents 1 and 3 of the facility Bed Hold policy at the time of discharge.
Report Facts
Census: 58
Number of sampled residents affected: 3
Number of residents affected by discharge notice deficiency: 1
Number of residents affected by Bed Hold notice deficiency: 2
Date of inspection/visit: Feb 7, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed complaint investigation letter |
| Barry Emerson | Administrator | Facility administrator interviewed regarding Resident 1 discharge |
| Director of Nursing | DON | Interviewed regarding discharge notice and Bed Hold policy |
| interim SSD | Social Services Director | Interviewed regarding Bed Hold policy notification |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 18, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to ensure appropriate measures to maintain safe body temperatures.
Complaint Details
The complaint alleged failure to maintain safe body temperatures. The allegation was investigated and found to be unsubstantiated as the facility was in compliance.
Findings
The investigation found that the facility maintained adequate temperature in the transport vehicle, residents reported comfortable temperatures, and documentation showed staff monitored resident conditions to maintain safe body temperatures. The facility was found to be in compliance with related regulatory requirements.
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 - DHHS |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 2
Date: Oct 10, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Cozad Care And Rehabilitation Center, LLC regarding allegations of verbal abuse, uncomfortable sound levels, and failure to resolve grievances to the satisfaction of residents.
Complaint Details
The complaint investigation was triggered by allegations that the facility failed to protect residents from verbal abuse, maintain comfortable sound levels, and resolve grievances satisfactorily. The verbal abuse allegation was not substantiated. The noise level allegation was found to be in compliance. The grievance resolution allegation was substantiated with a citation issued, but later modified after an Informal Dispute Resolution.
Findings
The investigation found no evidence of verbal abuse but cited a deficiency for failure to check the Nurse Aide Registry for certain employees. The facility was found in compliance regarding sound levels after observations, but failed to resolve grievances related to noise complaints, resulting in a citation. An Informal Dispute Resolution later modified the citation related to grievance resolution.
Deficiencies (2)
Failure to ensure that the Nurse Aide Registry was checked for three dietary employees hired in the past four months.
Failure to resolve grievances related to noise complaints to the satisfaction of the resident.
Report Facts
Facility census: 62
Number of dietary employees without Nurse Aide Registry check: 3
Number of residents interviewed for verbal abuse allegation: 5
Number of staff interviewed for verbal abuse allegation: 8
Number of employee files reviewed for verbal abuse allegation: 5
Number of residents interviewed for noise allegation: 4
Number of staff interviewed for noise allegation: 4
Number of days of noise observation: 2
Number of unresolved grievances in September 2017 log: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barry Emerson | Administrator | Named as facility administrator during interviews and correspondence. |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation letter and involved in communication regarding noise grievance. |
| Daniel Taylor | Program Manager - Office of Long Term Care Facilities Licensure Unit | Sent letter confirming Informal Dispute Resolution meeting and later communicated modification of deficiency. |
| Dain Weiss | RN, Reviewer - Nebraska Department of Health and Human Services | Conducted Informal Conference and authored the Informal Dispute Resolution report. |
| Tammy Deemer | Regional Director | Participant in the Informal Conference. |
Inspection Report
Annual Inspection
Census: 57
Capacity: 67
Deficiencies: 19
Date: Aug 17, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Cozad Care And Rehabilitation Center, LLC from August 13 to August 17, 2017.
Complaint Details
Complaint investigation included allegations that the facility failed to complete discharge planning and failed to protect residents from abuse. The facility was found in compliance with discharge planning but was cited for failure to screen employees for potential abuse.
Findings
The facility was found in violation for failing to complete required employee abuse screening, maintain resident privacy, uphold resident dignity, address resident grievances, provide individualized activities, maintain housekeeping and maintenance standards, maintain comfortable sound levels, provide accurate medication administration, maintain infection control, ensure fire safety compliance, and other regulatory requirements.
Deficiencies (19)
Failed to complete required registry checks and screening for new employees for potential abuse.
Failed to maintain resident privacy by posting care instructions in areas visible to the public.
Failed to maintain resident dignity including knocking before entering rooms, not leaving incontinent pads on beds in view, asking permission before applying clothing protectors, and sitting while assisting with feeding.
Failed to address and resolve resident grievances related to noise complaints.
Failed to provide individualized activities for residents in the Alzheimer's Care Unit.
Failed to maintain housekeeping and maintenance standards including stained floors, marred walls, stained curtains, rusty sinks, cracked tiles, bathroom odors, and unsecured toilet risers.
Failed to maintain comfortable sound levels for residents, resulting in noise complaints.
Failed to provide necessary services to maintain good nutrition, grooming, and personal hygiene including providing eyeglasses as needed.
Failed to ensure resident environment was free from accident hazards and provide adequate supervision to prevent accidents, including securing hazardous chemicals from wandering residents.
Failed to ensure adequate ventilation in resident bathrooms.
Failed to maintain fire alarm system to continuously monitor and transmit system trouble signals.
Failed to ensure corridor doors were provided with a means suitable for keeping the doors closed.
Failed to conduct required quarterly fire drills on all shifts under varied conditions.
Failed to provide approved covers for exposed live electrical components in an electrical panel.
Failed to minimize fire risk by storing combustible materials on a stove and not ensuring power to the stove was turned off when not in use.
Failed to perform hand hygiene to prevent cross contamination during dining and medication administration, and failed to handle linens properly to prevent cross contamination.
Failed to observe resident taking medication.
Failed to maintain infection prevention and control program including hand hygiene, glove use, and linen handling.
Failed to ensure electrical power strips used in resident rooms met UL requirements.
Report Facts
Deficiencies cited: 18
Facility census: 57
Total capacity: 67
Number of residents affected by noise complaint: 2
Number of residents affected by dignity issues: 10
Number of residents affected by housekeeping issues: 18
Number of residents affected by electrical panel issue: 24
Number of residents affected by locked egress door issue: 14
Number of residents affected by power strip issue: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barry Emerson | Administrator | Named in complaint investigation and informal conference |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed letters and correspondence |
| Kimberly Divis | RN, NCCSII | Conducted Informal Conference |
| LPN-A | Licensed Practical Nurse | Named in medication administration and infection control deficiencies |
| NA-G | Nurse Aide | Named in dignity and feeding deficiencies |
| MA-E | Medication Aide | Named in employee screening deficiency |
| MA-F | Medication Aide | Named in employee screening deficiency |
| RN-C | Registered Nurse | Named in employee screening deficiency |
| SSD | Social Services Director | Named in grievance and privacy deficiencies |
| DON | Director of Nursing | Named in multiple deficiencies including privacy, dignity, medication, infection control |
| Administrator Staff A | Named in locked egress door deficiency | |
| Maintenance Staff A | Named in locked egress door, fire alarm, sprinkler system, electrical panel deficiencies |
Notice
Capacity: 67
Deficiencies: 0
Date: Apr 6, 2017
Visit Reason
The document serves as a renewal application and certification for the nursing home license of Cozad Care and Rehabilitation Center, LLC, including Alzheimer's Special Care Unit endorsement and occupancy permit.
Findings
The documents confirm the facility's licensure renewal, ownership, organizational structure, and certification status. The Alzheimer's Special Care Unit disclosure outlines the philosophy, admission criteria, care planning, staffing, environment, activities, family support, and fees.
Report Facts
Total licensed capacity: 67
Daily rate - Private Room: 223.2
Daily rate - Semi-Private Room: 216.09
Direct Care Nurse Staffing: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barry Emerson | Administrator | Named as facility administrator in renewal application. |
| Loretta Smith | Director of Nursing | Named as director of nursing in renewal application. |
| Joseph Schwartz | Authorized Representative | Signed renewal application and Alzheimer's Special Care Unit disclosure. |
| Rosie Schwartz | Authorized Representative | Named as 50% member of ownership and authorized representative. |
| Brandie Lamberth | Contact for Alzheimer's Care Unit | Contact person for Alzheimer's Care Unit endorsement application. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 28, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Cozad Care And Rehabilitation Center, Llc on March 28, 2017. The investigation focused on allegations related to resident fall evaluations, implementation of fall interventions, response to fall alarms, and protection of residents' skin integrity.
Complaint Details
The complaint investigation addressed four allegations: failure to properly evaluate residents after a fall, failure to implement care planned fall interventions, failure to ensure prompt response to fall alarms, and failure to protect residents' skin integrity. All allegations were found to be unsubstantiated with the facility in compliance.
Findings
The investigation found the facility to be in compliance with regulatory requirements for all allegations. Documentation, observations, and interviews confirmed proper evaluation after falls, implementation of fall interventions, prompt response to fall alarms, and interventions to protect residents' skin integrity.
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: Dec 20, 2016
Visit Reason
The inspection was conducted as a compliance inspection and complaint investigation at the assisted-living facility to assess compliance with licensure regulations.
Complaint Details
The inspection was complaint-related and included a complaint investigation. The violations found did not create imminent danger or serious harm and no direct or immediate adverse effect on residents was noted.
Findings
The facility was found in compliance with the regulations governing licensure of assisted-living facilities, with no imminent danger or immediate adverse effects on residents. The results were commendable.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ronda Gunther | Registered Nurse | Conducted the compliance inspection and complaint investigation. |
| Betty Smith | Registered Nurse | Conducted the compliance inspection and complaint investigation. |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 2
Date: Dec 15, 2016
Visit Reason
An unannounced visit was conducted to investigate multiple complaints at Cozad Care And Rehabilitation Center, LLC, including allegations related to food form, fall interventions, grooming, staffing, misappropriation, and resident transport.
Complaint Details
The complaint investigation was substantiated for violations related to grooming and staffing. The facility was found in violation of Federal tags F312 and F353 and corresponding Nebraska state licensure regulations.
Findings
The investigation found the facility in compliance with food form, fall interventions, misappropriation, and transport security allegations. However, the facility was found in violation for failing to ensure residents were clean and groomed and for insufficient staffing, impacting resident care and hygiene.
Deficiencies (2)
Facility failed to provide bathing per facility requirements for 2 of 3 sampled residents, resulting in residents not being clean and groomed.
Facility failed to provide sufficient nursing staff to meet residents' needs, resulting in inadequate care and grooming.
Report Facts
Census: 59
Residents on Alzheimer's Care Unit: 17
Complaints: 5
Staffing levels: 3
Staffing levels: 2
Staffing levels: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation letter |
| Barry Emerson | Administrator | Facility administrator addressed in the report |
| RN-B | Alzheimer's Care Unit Director | Interviewed regarding bathing documentation and facility practices |
| DON | Director of Nursing | Interviewed regarding bathing policies and staffing issues |
| RN-A | Consultant Registered Nurse | Interviewed regarding bathing and staffing policies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 26, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to investigate causative factors in falls and failure to protect residents from residents with behaviors.
Complaint Details
The complaint alleged failure to investigate causative factors in falls and failure to protect residents from residents with behaviors. Both allegations were found to be unsubstantiated as the facility was in compliance.
Findings
The investigation found that the facility had investigated causative factors in falls and implemented interventions to prevent them, and staff were aware of these measures. Additionally, no behaviors affecting other residents were observed, and interventions were in place to protect residents from others with behaviors. The facility was found to be in compliance with related regulatory requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Licensure Unit, Division of Public Health-DHHS | Signed the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 67
Deficiencies: 6
Date: Sep 7, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Golden Livingcenter - Cozad from September 7, 2016 to September 13, 2016 by the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint investigation included allegations regarding failure to implement or follow care plans, grooming, staffing, protection from misappropriation, housekeeping, supervision, and response to alarms. The facility was found in compliance with most allegations except housekeeping and other cited deficiencies.
Findings
The complaint investigation found the facility in compliance with several allegations including implementation of care plans, grooming, staffing, supervision, and protection from misappropriation. However, the facility was found deficient in maintaining an effective housekeeping program, dignity and respect of residents, honoring resident bathing preferences, sanitary food preparation and service, and complete documentation of resident bathing choices. Additionally, a life safety code inspection found improper use of electrical equipment and extension cords.
Deficiencies (6)
Failed to maintain an effective housekeeping program; windows not clean, doors and walls marred, sinks with cracked caulking and slow drainage.
Failed to treat residents with dignity; administering injections in dining room in view of others and entering rooms without invitation.
Failed to honor resident bathing preferences for Residents 4 and 30.
Failed to ensure sanitary food preparation and service; dietary staff failed to cover hair fully and failed to perform hand hygiene, resulting in potential cross contamination.
Failed to document resident bathing choices in clinical records for Residents 4 and 60.
Failed to use electrical equipment in accordance with regulations; use of power strips and extension cords not permitted by CMS waiver, creating potential fire hazard.
Report Facts
Facility census: 58
Facility total capacity: 67
Deficiency count: 6
Residents affected by housekeeping deficiency: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barry Emerson | Administrator | Named as facility administrator in report |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter |
| LPN-A | Licensed Practical Nurse | Observed administering injections in dining room and improper glove use during food service |
| RN-D | Registered Nurse | Confirmed injections should be administered in private |
| MA-F | Medication Aide | Observed entering resident room without invitation |
| RN-E | Registered Nurse | Entered resident room without knocking or invitation |
| DON | Director of Nursing | Interviewed regarding bathing preferences and dignity expectations |
| SSD | Social Service Director | Interviewed regarding resident bathing preferences and dignity |
| MA-C | Medication Aide | Observed improper glove use and potential cross contamination during meal service |
| FSS | Food Service Supervisor | Confirmed dietary staff glove and hair covering expectations |
| Cook-B | Cook | Observed with hair exposed during food preparation |
| Maintenance Man | Confirmed use of extension cords and power strips not permitted | |
| Administration A | Confirmed use of extension cords and power strips not permitted |
Inspection Report
Renewal
Capacity: 67
Deficiencies: 0
Date: Sep 23, 2015
Visit Reason
The document is a nursing home licensure renewal application and related certification and occupancy permit for Golden LivingCenter - Cozad, verifying the facility's license renewal and compliance with statutory requirements.
Findings
The documents confirm the facility's licensure renewal status, accreditation certifications, and occupancy permit with a maximum capacity of 67 beds. No deficiencies or violations are noted in the provided materials.
Report Facts
Number of beds to be relicensed: 67
Renewal fees: 1750
Occupancy permit date: Sep 23, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barry Emerson | Administrator | Named in the licensure renewal application |
| Carolyn Griese | Director of Nursing | Named in the licensure renewal application |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 67
Deficiencies: 10
Date: Sep 23, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Golden Livingcenter - Cozad from September 23, 2015 to September 29, 2015.
Complaint Details
The complaint alleged the facility failed to offer alternative ways to keep personal items/money safe. The investigation found the facility did not complete a thorough investigation related to missing money for Resident 59, failing to interview staff or other residents. The allegation was unsubstantiated after investigation and police involvement.
Findings
The facility failed to ensure a complete investigation related to missing money for one resident, including interviewing staff and other residents. Additional deficiencies were found related to resident rights, bathing preferences, temperature control, care planning participation, food sanitation, and life safety code violations.
Deficiencies (10)
Failed to ensure that an investigation was completed related to missing money for one resident that included interviews with staff or other residents.
Failed to determine and honor bathing preference for one resident.
Failed to maintain comfortable and safe temperature levels for three residents.
Failed to include two residents in care planning decisions and failed to review and revise one resident's care plan to reflect current condition.
Dietary staff failed to perform hand hygiene during food service preparation.
Failed to provide corridor doors that securely latched within the door frames, allowing potential spread of smoke.
Failed to provide unobstructed corridor that provides a clear path of egress due to storage of linen carts.
Failed to hold fire drills under varied conditions at different times of the day for all shifts and failed to include transmission of fire alarm signal during drills.
Failed to store oxygen cylinders in an approved location according to NFPA 99, exceeding allowable cubic feet in corridor storage.
Failed to prohibit use of extension cords and power strips as substitute for permanent wiring, allowing motor driven appliances to be powered by power strips.
Report Facts
Facility census: 63
Facility capacity: 67
Missing money amount: 80
Oxygen cylinders stored: 31
Oxygen cubic feet stored: 744
Fire drills conducted: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barry Emerson | Administrator | Named in complaint letter and informal dispute resolution |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit | Signed complaint investigation letter and decision letter |
| Kimberly A. Divis | RN NSSC | Conducted informal conference/informal dispute resolution |
| Becky Wisell | Administrator Licensure Unit | Signed notification of department decision following informal conference |
| Lee Marshall | Registered Nurse | Investigator for complaint and annual survey |
| Vicki Lepant | Registered Nurse | Investigator for complaint and annual survey |
| Ronda Gunther | Registered Nurse | Investigator for complaint and annual survey |
| Betty Smith | Registered Nurse | Investigator for complaint and annual survey |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 67
Deficiencies: 2
Date: Sep 11, 2014
Visit Reason
The inspection was conducted to investigate allegations related to compliance with 42 CFR Part 483 Subpart B-Requirements for Long Term Care, excluding fire protection.
Complaint Details
The visit was complaint-related, investigating allegations under 42 CFR Part 483 Subpart B. The facility was found non-compliant with fire safety standards due to the painted heat detector and unauthorized power tap use.
Findings
The facility was found to be in compliance with most regulations except for fire protection. Deficiencies included a painted heat detector in the laundry room that could impair fire detection and the use of an unauthorized multi-plugged power tap in the activities room.
Deficiencies (2)
The heat detector located in the laundry room had been painted, which may damage the detector and render it inoperable, affecting fire safety in one of four smoke compartments.
The facility failed to maintain the use of relocatable power taps, which are not permitted in patient care areas. A multi-plugged outlet was found behind the piano in the activities room.
Report Facts
Facility capacity: 67
Census: 57
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Mentioned in relation to the painted heat detector and power tap findings; responsible for corrective actions and monitoring |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Jun 25, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint survey at Golden Livingcenter - Cozad on June 25, 2014, regarding allegations that the facility failed to ensure residents were not restrained and failed to ensure fall interventions were being followed in accordance with the plan of care.
Complaint Details
The complaint investigation included allegations that the facility failed to ensure residents were not restrained and failed to ensure fall interventions were followed. The restraint allegation was not substantiated. The fall intervention allegation was substantiated with violation of Federal tag F323 and State Licensure tag 175NAC 12-006.18B1.
Findings
The facility was found to be in compliance with restraint-related regulatory requirements. However, the facility failed to have identified interventions in place to prevent falls for one sampled resident, violating Federal tag F323 and State Licensure tag 175NAC 12-006.18B1. Specifically, fall interventions such as bed and chair alarms were not in place or functioning, and the bed was elevated due to a broken motor.
Deficiencies (1)
Facility staff failed to have identified interventions in place to prevent falls for one sampled resident, including lack of bed alarm and elevated bed due to broken motor.
Report Facts
Facility census: 55
Admission date: May 7, 2013
Plan of correction completion dates: Multiple dates including 06/25/2014, 07/16/2014, 07/18/2014, 07/25/2014 for corrective actions
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dixie Jackson | Social Worker | Investigator in complaint survey |
| Betty Smith | Registered Nurse | Investigator in complaint survey |
| Eve Lewis | Program Manager | Signed complaint investigation letter |
| Barry Emerson | Administrator | Facility administrator interviewed regarding bed replacement expectation |
Inspection Report
Annual Inspection
Census: 61
Capacity: 67
Deficiencies: 2
Date: Jul 16, 2013
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident transfer/discharge notice requirements and life safety code standards.
Findings
The facility failed to provide a written notice of discharge for Resident 71 prior to transfer to a hospital, violating transfer/discharge notice requirements. Additionally, the facility did not conduct fire drills at least quarterly on each shift as required by the Life Safety Code, affecting all occupants' safety preparedness.
Deficiencies (2)
Failed to provide written notice of discharge for Resident 71 prior to transfer.
Facility did not conduct fire drills at least quarterly on each shift.
Report Facts
Resident census: 61
Facility capacity: 67
Fire drills conducted: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Don Messamuth | Surveyor | Named as surveyor conducting the inspection |
| Don Fritz | Approved plan of correction on 08/06/2013 |
Inspection Report
Routine
Census: 58
Capacity: 67
Deficiencies: 6
Date: May 10, 2012
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory requirements including discharge planning, housekeeping and maintenance, care planning, pharmaceutical services, and life safety code standards.
Findings
The facility failed to provide adequate discharge planning for Resident 74, maintain clean and functional bathroom surfaces and vents, develop comprehensive care plans, and properly administer medications. Additionally, the fire alarm system was not properly tested and maintained, and improper use of power strips was observed.
Deficiencies (6)
Failed to provide discharge planning for Resident 74 to ensure safe and orderly discharge.
Resident bathrooms had uncleanable surfaces and non-functioning exhaust vents in multiple rooms.
Failed to develop a comprehensive care plan for Resident 74 addressing discharge needs.
Failed to observe Resident 3 actually take and swallow medications as per facility policy.
Failed to provide a properly tested and maintained fire alarm system.
Improper use of relocatable power taps in patient care areas.
Report Facts
Facility census: 58
Total capacity: 67
Survey sample size: 29
Medications left unattended: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident 74 | Resident | Subject of discharge planning deficiencies |
| Resident 3 | Resident | Subject of medication administration deficiency |
| MA-T | Medication Aide | Observed leaving medications unattended for Resident 3 |
| SSD | Social Services Director | Interviewed regarding discharge planning for Resident 74 |
| RN-L | Registered Nurse | Interviewed regarding discharge planning for Resident 74 |
| RN-M | Registered Nurse | Interviewed regarding discharge planning for Resident 74 |
| Maintenance Director | Interviewed regarding bathroom maintenance and fire alarm system | |
| DON | Director of Nursing | Observed medication administration for Resident 3 |
Inspection Report
Annual Inspection
Census: 61
Capacity: 67
Deficiencies: 4
Date: Mar 22, 2011
Visit Reason
Annual inspection survey conducted to assess compliance with state and federal regulations for skilled nursing facilities, including resident care, safety, and facility conditions.
Findings
The facility was found deficient in notifying physicians of changes in resident oxygen orders for 2 residents, ensuring call lights were accessible to residents, maintaining unobstructed exit corridors, and proper use of electrical equipment. Deficiencies were documented with corrective plans.
Deficiencies (4)
Failed to notify physician of need to adjust oxygen orders for 2 of 15 sampled residents.
Failed to ensure call lights were accessible to residents 21, 22, 37, and 44.
Corridor obstructed with wheelchairs and bed stands restricting exit access.
Use of relocatable power taps in patient care areas not permitted.
Report Facts
Sample size: 15
Facility census: 61
Facility capacity: 67
Number of residents affected: 4
Number of residents affected: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses (DON) | Confirmed oxygen orders and practices during interview | |
| Registered Nurse (RN) - P | Interviewed regarding call light placement | |
| Maintenance Staff | Acknowledged corridor obstruction and power tap observations | |
| Jim Heinz | State Fire Marshal | Consulted regarding surge protector requirements |
Notice
Capacity: 67
Deficiencies: 0
Date: APP2015
Visit Reason
This document serves as a nursing home licensure renewal application and related administrative documentation for Golden LivingCenter - Cozad, including verification of license renewal, occupancy permit, ownership details, and facility mission and training policies.
Findings
The documents confirm the facility's licensure renewal status, occupancy permit for 67 beds, ownership and organizational structure, mission and philosophy for Alzheimer's care, and detailed training policies for staff working in the dementia care unit. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 67
Renewal fees: 1550
Renewal fees: 2250
Renewal fees: 1950
Alzheimer's Care Unit semi-private rate: 6572.72
Alzheimer's Care Unit private rate: 6789.07
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barry Emerson | Administrator | Named on renewal application |
| Carolyn Griese | Director of Nursing | Named on renewal application |
| Julianne Williams | Director and Executive Officer | Named in Officers and Directors report |
| Nicholas R Finn | Senior Vice President | Named in Officers and Directors report |
| Michael Karicher | Senior Vice President, Human Resources | Named in Officers and Directors report |
| Kathleen K Vardell | Senior Vice President | Named in Officers and Directors report |
| Tina C Chavis | Vice President | Named in Officers and Directors report |
| Paul M Helm | Vice President | Named in Officers and Directors report |
| Larry N Joseph | Vice President | Named in Officers and Directors report |
| Salvatore F Salamone | Vice President | Named in Officers and Directors report |
| Holly Rasmussen-Jones | Secretary | Named in Officers and Directors report |
| Ann Truitt | Treasurer & Assistant Secretary | Named in Officers and Directors report |
| Greg D Swartz | Assistant Secretary | Named in Officers and Directors report |
| Roberta G Williams | Assistant Secretary | Named in Officers and Directors report |
Document
Capacity: 67
Deficiencies: 0
Date: CHOW2025
Visit Reason
The documents serve to issue and confirm licensure and certification for Emerald Nursing & Rehab Cozad, including a new license due to change of ownership, occupancy permit, and Alzheimer's special care unit endorsement.
Findings
No inspection findings or deficiencies are reported. The documents confirm licensure status, ownership details, facility capacity, and special care unit information.
Report Facts
Total licensed beds: 67
Alzheimer's unit capacity: 29
License effective date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kiley Goff | Administrator | Named as facility administrator on multiple documents including license issuance letter, nursing home licensure application, and ownership confirmation letter. |
| Brittney Douglas | Director of Nursing | Named as Director of Nursing on the nursing home licensure application (page 4). |
| Yisroel Chafetz | Manager | Named as Manager and authorized representative of ownership entity Cozad Holdco LLC on the nursing home licensure application and ownership confirmation letter (pages 4 and 5). |
| Timothy Tesmer, MD | Chief Medical Officer | Signed the license issuance letter from the Department of Health and Human Services (page 1). |
| Lisa Osborne | Administrator, Health Facilities Licensure Unit | Signed the license issuance letter from the Department of Health and Human Services (page 1). |
Notice
Capacity: 67
Deficiencies: 0
Date: APP2020
Visit Reason
This document serves as a renewal application for the nursing home license of Emerald Nursing & Rehab Cozad, including certification of licensure, occupancy permit, and Alzheimer's Special Care Unit endorsement.
Findings
The documents confirm that Emerald Nursing & Rehab Cozad meets statutory requirements for licensure renewal, has a maximum licensed capacity of 67 beds, and includes an Alzheimer's/Special Care Unit with a maximum endorsed capacity of 29. The occupancy permit was issued on 2020-03-17.
Report Facts
Maximum licensed capacity: 67
Maximum endorsed capacity: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kiley Goff | Administrator | Named in Nursing Home Licensure Renewal Application. |
| Kristin Henggeler | Director of Nursing | Named in Nursing Home Licensure Renewal Application. |
| Ephram Mordy Lahasky | Sole Member / Authorized Representative | Signed Alzheimer's Special Care Unit Disclosure and Nursing Home Licensure Renewal Application. |
| Jacob Walden | Authorized Representative | Named in Nursing Home Licensure Renewal Application and ownership information. |
| Todd Wright | Deputy State Fire Marshal | Inspected and issued the occupancy permit. |
Notice
Capacity: 67
Deficiencies: 0
Date: APP2021
Visit Reason
This document serves as a renewal application and certification for the nursing home license of Emerald Nursing & Rehab Cozad, verifying licensure through the indicated renewal date.
Findings
The documents confirm the facility meets statutory requirements for licensure renewal, including certification for Alzheimer's/Special Care Unit and other therapy services. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 67
Renewal license expiration date: 2022
Occupancy permit issue date: Mar 17, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Walden | Authorized Representative | Signed the renewal application and Alzheimer's Special Care Unit Disclosure. |
| Yisroel Chafetz | Authorized Representative | Signed the renewal application. |
| Kiley Goff | Administrator | Listed as facility administrator on renewal application and Alzheimer's Special Care Unit Disclosure. |
| Todd Wright | Deputy State Fire Marshal | Inspected the facility for the occupancy permit. |
Notice
Capacity: 67
Deficiencies: 0
Date: APP2022
Visit Reason
This document serves as a nursing home licensure renewal application and includes certification of license validity, occupancy permit, and Alzheimer's Special Care Unit disclosure for Emerald Nursing & Rehab Cozad.
Findings
The documents confirm the facility's licensure renewal status, maximum licensed capacity of 67 beds, and provide details on special care services including Alzheimer's care. No inspection findings or deficiencies are reported.
Report Facts
Number of beds to be relicensed: 67
Renewal license fees: 1550
Renewal license fees: 1750
Renewal license fees: 1950
Cost per day: 240
Date issued: Nov 13, 2022
Application signature date: Jan 13, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kiley Goff | Administrator | Named as facility administrator in renewal application and Alzheimer's Special Care Unit disclosure. |
| Jacob Walden | Authorized Representative | Signed renewal application and Alzheimer's Special Care Unit disclosure as legal owning entity representative. |
| Nicole Zook | Director of Nursing | Named as Director of Nursing in renewal application. |
| Gary J. Anthone, MD | Chief Medical Officer, Director, Division of Public Health | Named on license certification card. |
| Michael Hoeft | Deputy State Fire Marshal | Inspected and approved occupancy permit. |
| Yisroel Chafetz | Authorized Representative | Signed renewal application. |
| Ephram M Lahasky | Named in ownership information on renewal application. |
Document
Capacity: 67
Deficiencies: 0
Date: APP2023
Visit Reason
The documents serve to renew the nursing home license, verify occupancy permit, and provide disclosure and endorsement information for the Alzheimer's Special Care Unit at Emerald Nursing & Rehab Cozad.
Findings
No inspection findings or deficiencies are reported. The documents confirm licensure renewal, facility capacity, and Alzheimer's unit disclosure details including staffing and care philosophy.
Report Facts
Number of beds to be relicensed: 67
Maximum Occupancy: 67
Maximum Capacity for Alzheimer's Beds: 17
Cost/Fees of care: 265
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kiley Goff | Administrator | Named in Nursing Home Licensure Renewal Application and Alzheimer's Special Care Unit Disclosure |
| Nicole Zook | Director of Nursing | Named in Nursing Home Licensure Renewal Application |
| Jacob I Walden | Authorized Representative | Signed Nursing Home Licensure Renewal Application and Alzheimer's Special Care Unit Disclosure |
| Yisroel I Chafetz | Authorized Representative | Signed Nursing Home Licensure Renewal Application |
| Michael Hoeft | Deputy State Fire Marshal | Inspected Nebraska State Fire Marshal Occupancy Permit |
Notice
Capacity: 67
Deficiencies: 0
Date: APP2025
Visit Reason
The document serves as a renewal application for the nursing home license of Emerald Nursing & Rehab Cozad and includes certification of licensure and occupancy permit information.
Findings
The documents verify that Emerald Nursing & Rehab Cozad meets statutory requirements for licensure renewal, with no inspection findings or deficiencies reported.
Report Facts
Total licensed beds: 67
Expiration date: License expiration date is 03/31/2025 as stated on the renewal application.
Maximum capacity for Alzheimer's beds: 17
Cost/Fees of care: 315
Cost/Fees of care: 320
Cost/Fees of care: 325
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kiley Goff | Administrator | Named as Administrator on the renewal application and Alzheimer's Special Care Unit Disclosure. |
| Natasha Friedrichsen | Director of Nursing | Named as Director of Nursing on the renewal application. |
| David Fleischmann | Contact name | Contact name for the legal owning entity on the Alzheimer's Special Care Unit Disclosure. |
| Michael Hoeft | Deputy State Fire Marshal | Inspected the facility for the Nebraska State Fire Marshal Occupancy Permit. |
Notice
Capacity: 67
Deficiencies: 0
Date: CHOW2016
Visit Reason
Issuance and renewal of Skilled Nursing Facility license for Cozad Care and Rehabilitation Center, LLC due to change of ownership and facility name change.
Findings
The documents certify that the facility meets statutory requirements for licensure as a Skilled Nursing Facility with a licensed capacity of 67 beds. The facility includes a specialized Alzheimer's Care Unit with detailed program philosophy, admission criteria, staff training, physical environment, and family involvement.
Report Facts
Licensed beds: 67
License effective date: 2016
License expiration date: 2017
Alzheimer's Care Unit semi-private rate: 6572.72
Alzheimer's Care Unit private rate: 6789.87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barry Emerson | Administrator | Named as facility administrator in licensure application. |
| Patti Herndon | Director of Nursing (Interim) | Named as interim Director of Nursing in licensure application. |
| Courtney N. Phillips | Chief Executive Officer | Signed license issuance and renewal letters. |
| Eve Lewis | RN-C, Program Manager | Contact person for questions about the license. |
| Becky Wisell | Administrator, Licensure Unit | Signed licensure correspondence. |
| Joseph Schwartz | 50% Owner | Named as 50% owner in ownership organizational chart. |
| Rosie Schwartz | 50% Owner | Named as 50% owner in ownership organizational chart. |
| Mike Hoeft | Deputy State Fire Marshal | Inspected and approved fire marshal occupancy permit. |
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