Inspection Reports for Emerald Nursing & Rehab Legacy Pointe llc
3110 Scott Circle, OMAHA, NE, 68112
Back to Facility ProfileDeficiencies (last 13 years)
Deficiencies (over 13 years)
9.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
119% worse than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
60 residents
Based on a January 2018 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Original Licensing
Capacity: 108
Deficiencies: 0
Date: Jun 16, 2025
Visit Reason
The document is related to the issuance of a Skilled Nursing Facility/Nursing Facility License #NH0093 to Emerald Nursing & Rehab Legacy Pointe due to a change of ownership, with an effective date of June 16, 2025.
Findings
The documents certify that Emerald Nursing & Rehab Legacy Pointe meets statutory requirements as a Skilled Nursing Facility with services including Occupational Therapy, Speech Therapy, Physical Therapy, and an Alzheimer's Unit. The license is issued for the premises and persons named and is not transferable.
Report Facts
Total licensed beds: 108
Maximum occupancy: 108
Alzheimer's beds capacity: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephen M. Osborne | Administrator | Named as Administrator on the Nursing Home Licensure Application and Alzheimer's Special Care Unit Disclosure |
| Melissa Neiger | Director of Nursing | Named as Director of Nursing on the Nursing Home Licensure Application |
| Yisroel Chafetz | Manager | Named as Manager of Legacy Pointe Opco Holdings, LLC and authorized representative on the Nursing Home Licensure Application and related documents |
| Ty Hernes | Deputy State Fire Marshal | Inspected the facility for the Nebraska State Fire Marshal Occupancy Permit |
| Larisa Mulroney | RN | Contact person for questions about the license as stated in the licensing letter |
Inspection Report
Renewal
Capacity: 108
Deficiencies: 0
Date: Apr 6, 2022
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related renewal certification for Legacy Pointe Rehabilitation Center, verifying the facility's license renewal and compliance with statutory requirements.
Findings
The documents confirm the facility's licensure renewal, ownership information, and certification of compliance with applicable rules and regulations. No inspection deficiencies or findings are reported.
Report Facts
Total licensed beds: 108
Renewal Licensure Fee: 1750
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Rudman | Administrator | Named as facility administrator on renewal application and Alzheimer's endorsement |
| Marguerite Walton | Director of Nursing | Named as Director of Nursing on renewal application |
| Eric Spiro | Contact Name / Authorized Representative | Contact and authorized representative for Alzheimer's Special Care Unit Disclosure and Memory Care Endorsement Application |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 7, 2020
Visit Reason
An offsite investigation was conducted to investigate a complaint that the facility failed to implement CMS directives related to COVID-19.
Complaint Details
The complaint alleged failure to implement CMS directives related to COVID-19. The investigation found the allegation unsubstantiated as the facility complied with the directives.
Findings
The facility did implement CMS directives related to COVID-19 and was found to be in compliance with relevant regulatory requirements after review of records and staff interviews.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the report and communicated findings |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 21, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint at Ridgecrest Rehabilitation Center on May 21-22, 2019, by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The investigation addressed nine allegations including failure to provide assistance for safe transfers, pressure sore prevention, bladder elimination, dehydration prevention, bowel and bladder elimination, adequate fluids for hydration, freedom from misappropriation, adequate oral care, and resident choice in leisure activities. All allegations were found to be unsubstantiated with no violations.
Findings
The facility was found to be in compliance with relevant regulatory requirements for all nine allegations investigated, including assistance for safe transfers, pressure sore prevention, bladder and bowel elimination, hydration, freedom from misappropriation, oral care, and resident choice in leisure activities.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the report and identified as Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 23, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint at Ridgecrest Rehabilitation Center on April 23-24, 2019. The investigation included review of resident records, observation of care and services, and interviews with residents, family members, and staff.
Complaint Details
The complaint allegations included failure to allow resident choice in leisure activities, inadequate oral care, inadequate hydration, disrespectful treatment of residents, failure to follow the plan of care, inadequate housekeeping and maintenance, and failure to notify responsible parties of changes in condition. All allegations were found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found to be in compliance with all relevant regulations regarding the allegations of failure to allow resident choice in leisure activities, provide adequate oral care and fluids, ensure respectful treatment, follow the plan of care, maintain housekeeping and maintenance programs, and notify responsible parties of changes in condition. No concerns were identified in any of these areas.
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 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 8, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint at Ridgecrest Rehabilitation Center on April 8-9, 2019, regarding allegations of failure to provide care to prevent pressure sores and failure to provide appropriate catheter care to prevent infections.
Complaint Details
The complaint alleged failure to provide care and treatment to prevent pressure sores and failure to provide appropriate catheter care to prevent infections. The investigation found the facility compliant with these allegations.
Findings
The facility was found compliant with regulatory guidelines for both allegations. Observations, record reviews, and staff interviews confirmed that care and treatment to prevent pressure sores and appropriate catheter care to prevent infections were provided according to standards.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the report letter |
Inspection Report
Renewal
Capacity: 108
Deficiencies: 0
Date: Feb 20, 2019
Visit Reason
This document is related to the renewal of the nursing home license for Ridgecrest Rehabilitation Center, LLC, including certification and endorsement applications for Alzheimer's Special Care Unit and Memory Care.
Findings
The facility is licensed for 108 beds, all dually certified. The renewal application confirms compliance with statutory requirements and includes detailed information about special care services, staffing, and facility features.
Report Facts
Licensed beds: 108
Renewal approval date: Feb 20, 2019
License expiration date: Mar 31, 2020
Cost per semi-private room: 180
Cost per private room: 220
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephen Osborne | Administrator | Named as administrator in the renewal application and Alzheimer's Special Care Unit application. |
| Victoria Zarate | Director of Nursing | Named as Director of Nursing in the renewal application. |
| William Rothner | Authorized Representative | Signed renewal application as authorized representative. |
| Steven Miretzky | Authorized Representative | Signed renewal application as authorized representative. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 2, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint and revisit survey at Ridgecrest Rehabilitation Center on April 2-3, 2018, focusing on allegations related to grievance responses, medication administration, and notification of changes in condition.
Complaint Details
The complaint investigation addressed allegations of inadequate grievance response, medication administration errors, and failure to notify responsible parties of changes in condition. Only the medication administration allegation was substantiated.
Findings
The facility was found to adequately respond to grievances and notify responsible parties of changes in condition, with no violations in these areas. However, the facility failed to provide medications according to the five rights, with 6 medication errors out of 30 observed, constituting a violation.
Deficiencies (1)
Failure to provide medications according to the five rights, with 6 errors out of 30 medications administered.
Report Facts
Medication errors: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed the letter as Training Coordinator for the Office of LTC Facilities - Licensure Unit. |
Inspection Report
Enforcement
Deficiencies: 1
Date: Jan 23, 2018
Visit Reason
A survey was conducted by the Nebraska Department of Health and Human Services to determine compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs. The facility was found not in substantial compliance, leading to enforcement actions including civil money penalties and denial of payment for new admissions.
Findings
The survey identified deficiencies constituting a level of actual harm or above, specifically related to Nutrition/Hydration Status Maintenance (Federal citation F0692). As a result, a civil money penalty was imposed, and a denial of payment for new Medicare and Medicaid admissions was enforced until substantial compliance was achieved.
Deficiencies (1)
Deficiency described at Federal citation F0692 - Nutrition/Hydration Status Maintenance
Report Facts
Civil Money Penalty (CMP) amount: 1255
CMP reduction percentage: 35
Denial of payment effective date: Feb 20, 2018
Substantial compliance date: May 22, 2018
Termination effective date: Jul 23, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator - Office of LTC Facilities - Licensure Unit | Signed letter confirming removal of denial of payment after substantial compliance |
| LCDR Marsophia R. Powers | Long Term Care Branch Manager | Signed enforcement notice letter |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 14
Date: Jan 8, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Ridgecrest Rehabilitation Center from January 8, 2018 to January 23, 2018. 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 was triggered by allegations that the facility failed to protect residents from abuse and failed to implement interventions to prevent weight loss. The investigation confirmed these allegations and identified multiple deficiencies related to resident care, staff qualifications, and infection control.
Findings
The facility failed to protect residents from abuse due to incomplete reference checks on employee files and failed to implement interventions to prevent weight loss in several residents. Additional findings included failure to maintain resident dignity during meal services, failure to notify physicians of significant weight loss, improper use of restraints, incomplete admission physician orders, inadequate physician visit frequency, insufficient nurse aide education, lack of resident-centered activities for dementia patients, improper food handling and infection control practices, and administrative deficiencies in quality assurance and staff qualifications.
Deficiencies (14)
Facility failed to protect residents from abuse due to incomplete reference checks on employee files.
Facility failed to implement interventions to prevent weight loss for several residents.
Facility staff failed to maintain resident dignity during meal services.
Facility failed to notify physician and responsible party of significant weight loss for residents.
Facility failed to ensure resident was free from physical restraints in wheelchair.
Facility failed to ensure admission physician orders were signed upon admission.
Facility failed to ensure physician visits occurred at required frequency.
Facility failed to ensure nurse aides received required 12 hours of in-service education annually.
Facility failed to provide specific resident-centered activities for residents with dementia in Memory Support Unit.
Facility failed to ensure food service staff changed gloves between assisting residents to prevent foodborne illness.
Facility failed to ensure infection prevention and control program was followed, including hand hygiene during blood sugar testing and insulin administration.
Facility failed to ensure staff qualifications including valid nursing licenses and dementia training for Memory Support Unit staff.
Facility failed to develop and implement a plan of action to correct and maintain compliance for multiple deficiencies.
Facility failed to maintain medication error rate below 5%, with insulin administration errors observed.
Report Facts
Medication errors: 6
Residents affected by dignity issues: 4
Residents with weight loss not notified: 2
Nursing assistants without required in-service hours: 24
Residents with dementia lacking activities: 4
Residents affected by infection control issues: 3
Staff with expired license: 1
Staff without dementia training: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed letters and coordinated informal conferences related to the complaint investigation. |
| Courtney Ruhland | Administrator | Facility administrator named in multiple findings and correspondence. |
| Dan Taylor | Program Manager | Signed informal dispute resolution reports and correspondence. |
| LPN A | Licensed Practical Nurse | Observed administering insulin with errors and improper hand hygiene. |
| LPN G | Licensed Practical Nurse | Had expired nursing license but continued to work. |
| NA B | Nursing Assistant | Mentioned in relation to incomplete reference checks and lack of dementia training. |
| NA E | Nursing Assistant | Mentioned in relation to incomplete reference checks and lack of dementia training. |
| NA F | Nursing Assistant | Mentioned in relation to incomplete reference checks and lack of dementia training. |
| NA O | Nursing Assistant | Mentioned in relation to lack of dementia training. |
| NA P | Nursing Assistant | Mentioned in relation to lack of dementia training. |
| NA Q | Nursing Assistant | Mentioned in relation to lack of dementia training. |
| NA R | Nursing Assistant | Mentioned in relation to lack of dementia training. |
| NA S | Nursing Assistant | Mentioned in relation to lack of dementia training. |
| NA T | Nursing Assistant | Mentioned in relation to lack of dementia training. |
| Dan Taylor | Program Manager | Signed final decision letters on informal dispute resolutions. |
Inspection Report
Renewal
Census: 65
Capacity: 108
Deficiencies: 0
Date: Oct 10, 2017
Visit Reason
The document is related to the renewal of the nursing home license for Ridgecrest Rehabilitation Center, LLC, including verification of licensure, bed capacity, and special care unit endorsements.
Findings
The facility is licensed for 108 beds with a current census of 65 residents. The renewal application includes details on ownership, special care units, staffing, and policies related to Alzheimer's and memory care. No deficiencies or enforcement actions are noted.
Report Facts
Licensed Capacity: 108
Current Census: 65
Renewal Fees: 1750
Staffing Goal: 2.8
Recreational Programming Hours: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Courtney Ruhland | Administrator | Named as facility administrator on renewal application and Alzheimer's Special Care Unit Disclosure. |
| William Rothner | Authorized Representative | Signed renewal application and Alzheimer's Special Care Unit Disclosure as authorized representative. |
| Steven Miretzky | Authorized Representative | Named as authorized representative on renewal application. |
| Alan Vox | Deputy State Fire Marshal | Inspected facility and approved occupancy permit on 2017-10-10. |
| Victoria Zarate | Director of Nursing | Named on renewal application. |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 108
Deficiencies: 18
Date: Oct 4, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Ridgecrest Rehabilitation Center from October 4, 2017 to October 11, 2017.
Complaint Details
The complaint investigation included allegations that the facility failed to provide care according to practitioner's orders, failed to ensure residents were treated with respect and dignity, failed to have adequate pest control, housekeeping and maintenance, failed to address food preferences, and failed to have sufficient staff. The facility was found to be out of compliance with care provision and dignity allegations, housekeeping and maintenance, and medication administration. Other allegations were not substantiated.
Findings
The facility was found to be out of compliance with several federal and state regulations including failure to provide care according to practitioner's orders, failure to ensure residents were treated with respect and dignity, failure to maintain appropriate housekeeping and maintenance, medication error rate greater than 5%, failure to provide timely notice of Medicare non-coverage, failure to investigate and report allegations of abuse and misappropriation, failure to honor bathing preferences, failure to maintain facility environment, failure to develop comprehensive care plans, failure to ensure medication carts were locked, failure to maintain food safety standards, failure to label medications properly, failure to follow up on pharmacy recommendations, failure to maintain fire safety standards including hazardous area enclosures, sprinkler system maintenance, disaster plan availability, fire drills, and electrical receptacle safety.
Deficiencies (18)
Failure to provide care and services according to practitioner's orders with medication error rate greater than 5%.
Failure to ensure residents are treated with respect and dignity.
Failure to maintain appropriate housekeeping and maintenance program with issues in resident rooms.
Failure to provide timely notice of Medicare non-coverage to residents or representatives.
Failure to investigate and report allegations of abuse and misappropriation of resident property.
Failure to honor bathing preferences for a resident.
Failure to maintain toilet caulking, flooring, and paint in multiple resident rooms.
Failure to correctly code resident safety on MDS assessments for residents on secure dementia unit.
Failure to develop comprehensive care plan related to falls for a resident.
Failure to ensure medication cart was locked when unattended on secured dementia unit.
Failure to ensure medication labels included special procedures such as 'Do Not Crush' for extended release tablets.
Failure to ensure ready to eat foods were handled and served at safe temperatures.
Failure to follow up and address monthly pharmacy consult recommendations for residents.
Failure to ensure hazardous areas were properly enclosed with fire barriers and doors connected to fire alarm system.
Failure to maintain ceiling tiles in dining hall to prevent smoke and fire migration.
Failure to ensure disaster plan was readily available to supervisory staff.
Failure to conduct fire drills under varied conditions on all shifts quarterly.
Failure to ensure electrical receptacles in wet areas were equipped with GFCI protection.
Report Facts
Medication error rate: 7.7
Residents present during inspection: 65
Total licensed beds: 108
Residents with missing Medicare non-coverage notice: 3
Resident rooms with toilet caulking issues: 6
Resident rooms with flooring issues: 3
Resident rooms with paint issues: 3
Residents affected by unlocked medication cart: 14
Residents affected by lack of GFCI receptacles: 25
Fire drills missing varied shift times: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Courtney Ruhland | Administrator | Named as facility administrator receiving the inspection report. |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the inspection report letter. |
| Social Services Director | Social Services Director | Interviewed regarding Medicare non-coverage notices and abuse allegations. |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse allegations, medication cart security, and medication errors. |
| Medication Aide C | Medication Aide | Observed administering medications and leaving medication cart unlocked. |
| Cook A | Cook | Observed handling food improperly and serving food at unsafe temperatures. |
| Facility Pharmacist | Pharmacist | Interviewed regarding medication labeling and crushing. |
| Maintenance Director | Maintenance Director | Interviewed regarding fire safety deficiencies and electrical receptacles. |
| Administrator A | Administrator | Interviewed regarding disaster plan availability and fire safety. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 28, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that the facility fails to protect residents from abuse.
Complaint Details
The complaint alleged failure to protect residents from abuse. The investigation found the facility in compliance with abuse prohibition policies and procedures.
Findings
The facility was found to ensure that residents were protected from abuse based on review of incident reports, grievance reports, policies, hiring practices, trainings, and interviews with residents, family members, and staff.
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
Annual Inspection
Census: 62
Deficiencies: 11
Date: Jun 23, 2016
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with state and federal regulations governing skilled nursing facilities, including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of critical blood sugar levels, failure to assess resident bathing preferences, incomplete comprehensive care plans for several residents, failure to ensure an arm sling was in place for a resident, inadequate supervision of a resident while smoking, and improper cleaning of glucose monitors. Additionally, life safety code deficiencies were identified related to fire safety doors, fire drills, fire alarm system documentation, oxygen cylinder storage, and emergency generator controls.
Deficiencies (11)
Failed to notify physician of blood sugars outside specified parameters and failed to notify physician of blood glucose monitoring as ordered for Resident 7.
Failed to assess resident choice related to bathing frequency for Resident 13.
Failed to develop comprehensive care plans for risk of elopement (Resident 88), Coumadin therapy (Resident 29), psychoactive medication use (Resident 58), and diabetes management (Resident 7).
Failed to ensure an arm sling was in place for Resident 11 as ordered.
Failed to evaluate and implement safety interventions for Resident 23 while smoking, including failure to provide and enforce use of smoking apron.
Failed to maintain cleanliness of glucose monitor according to manufacturer's recommendations, risking infection transmission to 20 residents.
Failed to ensure fire doors to hazardous areas closed and latched properly, allowing potential smoke and fire migration affecting 50 residents.
Failed to include transmission of fire alarm signal for all fire drills, affecting all residents.
Failed to provide all required documentation for annual fire alarm system inspection and smoke detector sensitivity test, affecting all residents.
Failed to label oxygen cylinders as empty or full and segregate empty cylinders from full ones in storage, risking confusion and improper use affecting 32 residents.
Failed to provide a remote manual stop for the emergency generator, risking damage in event of malfunction affecting all residents.
Report Facts
Facility census: 62
Residents affected by glucose monitor cleaning deficiency: 20
Residents affected by fire door deficiency: 50
Facility census: 64
Residents affected by oxygen cylinder storage deficiency: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance A | Verified fire door deficiencies and oxygen cylinder storage issues | |
| Administrator A | Acknowledged fire drill documentation deficiencies | |
| Licensed Practical Nurse B | LPN | Confirmed signing off on arm sling MAR for Resident 11 |
| Director of Nursing | DON | Confirmed care plan deficiencies and medication side effect monitoring |
| Assistant Director of Nursing | ADON | Interviewed regarding physician notification and faxing blood sugar results |
| Medication Aide G | Responsible for taking Resident 23 to smoking area and observing |
Inspection Report
Renewal
Capacity: 108
Deficiencies: 0
Date: Mar 3, 2016
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related materials for Ridgecrest Rehabilitation Center, LLC, indicating the facility is applying for renewal of its skilled nursing facility license.
Findings
The documents include licensure renewal application details, ownership information, occupancy permit, facility bed layout, special care unit policies, and an observation report related to resident care and assessments. No deficiencies or violations are explicitly stated.
Report Facts
Total licensed beds: 108
Renewal fee: 1750
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Kezar | Administrator | Named on Nursing Home Licensure Renewal Application |
| Kandi Stull | Director of Nursing | Named on Nursing Home Licensure Renewal Application |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Date: Dec 9, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that the facility fails to protect residents from injury.
Complaint Details
The complaint alleged the facility fails to protect residents from injury. The investigation found the allegation unsubstantiated and the facility in compliance.
Findings
The facility was found to protect residents from injury based on observations, staff interviews, resident record reviews, and resident interviews. The facility was determined to be in compliance with all related regulatory requirements.
Report Facts
Facility census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Licensure Unit, Division of Public Health-DHHS | Author of the inspection report |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 6
Date: Aug 5, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Ridgecrest Rehabilitation Center from July 29, 2015 to August 5, 2015. The investigation included review of resident records, observation of care, and interviews with residents, family members, and staff.
Complaint Details
The complaint alleged the facility failed to protect residents from residents with adverse behaviors and failed to submit investigations within 5 working days. The facility was found compliant with protection from adverse behaviors. One investigation was submitted late but corrective action was taken, so no deficiency was cited for that.
Findings
The facility was found to be in compliance regarding protection from residents with adverse behaviors. One investigation was submitted late but corrective action was taken. Deficiencies were cited related to criminal background checks, comprehensive care plans, infection control, and life safety code violations including corridor door latching and use of extension cords.
Deficiencies (6)
Failed to ensure staff did not have negative findings on adult and child protective services registries for 4 of 5 employee files reviewed.
Failed to develop a comprehensive care plan for an indwelling Foley catheter for Resident 48.
Failed to revise comprehensive care plans related to significant weight loss for Resident 71 and behaviors for Resident 60.
Failed to ensure staff were free of communicable disease as evidenced by no documentation of health screening on hire for 5 of 5 employee files reviewed.
Failed to ensure corridors are separated to resist passage of smoke due to doors failing to latch properly in multiple locations.
Failed to use electrical wiring and equipment in accordance with NFPA 70; unapproved extension cord found in environmental services room.
Report Facts
Facility census: 66
Number of staff employed: 81
Weight loss: 28
Weight loss percentage: 7.7
Weight loss: 9.6
Nutritional supplement volume: 60
Nutritional supplement volume: 90
Facility census: 64
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Date: Jun 15, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's care and treatment standards for feeding tubes.
Complaint Details
The complaint alleged failure to provide care and treatment according to standards of practice for feeding tubes. The allegation was not substantiated.
Findings
The facility provided care and services according to standards of practice for feeding tubes with no violations found. Observations, record reviews, and staff interviews confirmed compliance with policies, procedures, and physician orders.
Report Facts
Residents observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Neneman | Social Worker | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Date: Mar 18, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint at Ridgecrest Rehabilitation Center regarding allegations of failure to notify family of change in condition, failure to administer medications according to practitioner's orders, and failure to provide adequate fluid intake to prevent dehydration.
Complaint Details
The complaint investigation addressed three allegations: failure to notify family of change in condition, failure to administer medications according to practitioner's orders, and failure to provide adequate fluid intake to prevent dehydration. All allegations were found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found to be in compliance with all related regulatory requirements for all allegations. Family notification of changes in condition was documented, medications were administered correctly with no errors observed, and adequate fluid intake was provided to prevent dehydration.
Report Facts
Facility census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Schmidt | Registered Nurse | Conducted the complaint investigation visit |
| Eve Lewis | Program Manager | Signed the inspection report |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Date: Feb 23, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint at Ridgecrest Rehabilitation Center from February 23, 2015 to February 25, 2015. The investigation included review of resident records, observation of care and services, and interviews with residents, family members, and staff.
Complaint Details
The complaint alleged failures in ensuring personal property accounting, bladder elimination care, personal hygiene, clean/odor free environment, appropriate equipment, operational call light system, timely submission of investigations, and protective interventions against aggressive behavior. All allegations were found to be unsubstantiated with the facility in compliance.
Findings
The facility was found to be in compliance with all regulatory guidelines related to the allegations investigated, including personal property accounting, bladder elimination care, personal hygiene, clean and odor-free environment, appropriate equipment, operational call light system, timely submission of investigations, and interventions to protect residents from aggressive behavior.
Report Facts
Facility census: 66
Investigation dates: 3
Previous investigations reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Kincaid | Registered Nurse | Conducted the complaint investigation |
| 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: 62
Deficiencies: 13
Date: Sep 9, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Ridgecrest Rehabilitation Center on September 3-9, 2014. The complaint alleged the facility failed to have appropriate reason for involuntary discharge.
Complaint Details
The complaint alleged the facility failed to have appropriate reason for involuntary discharge. The investigation found the facility issued a 30-day notice to a resident without significant reason. The resident appealed and remained in the facility. No citation was issued for this issue, but two related citations were found.
Findings
The facility failed to have an appropriate reason for involuntary discharge for one resident. The resident remained in the facility after appealing a 30-day notice. The facility had two related citations. The facility also had deficiencies in housekeeping and maintenance, care planning, behavior management, toileting, fall prevention, chemical security, psychotropic drug use, and life safety code compliance.
Deficiencies (13)
Failed to maintain cleanliness and condition related to carpets, walls, bathroom fixtures, ventilation covers, baseboards, and furniture in multiple rooms.
Failed to review and revise a Comprehensive Care Plan for interventions to manage behaviors for one resident.
Failed to evaluate behaviors and implement individualized interventions to manage behaviors for one resident.
Failed to provide toileting as identified in the plan of care for one resident.
Failed to implement interventions to prevent falls for two residents and failed to maintain security of chemicals.
Failed to ensure drug regimen was free from unnecessary drugs; failed to identify specific target behaviors for continued use of antipsychotic medication for one resident.
Failed to maintain Beauty Shop door protecting corridor opening by allowing a trash can to block door closure.
Failed to maintain Kitchen door so that it would close and latch within the door-frame.
Failed to provide emergency illumination in the East Dining Room of the required 5 foot-candles.
Failed to provide exit signs above newly installed doors and in required locations in the East Dining Room and corridors.
Failed to conduct fire drills at unexpected times under varying conditions on each shift.
Failed to follow guidelines for microwave use in resident room and failed to assure coffee maker was used as instructed.
Failed to assure generator was run monthly under a 30% load or that an annual load bank test had been conducted.
Report Facts
Deficiencies cited: 12
Resident census: 62
Facility census: 63
Fire drills times: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Kezar | Administrator | Named as facility administrator in complaint investigation letter. |
| Eve Lewis | Program Manager | Signed complaint investigation letter from Department of Health and Human Services. |
| Khristy Long | Registered Nurse | Surveyor involved in complaint and annual survey investigation. |
| Connie Kincaid | Registered Nurse | Surveyor involved in complaint and annual survey investigation. |
| Ron Chase | Registered Nurse | Surveyor involved in complaint and annual survey investigation. |
| Carol Neneman | Social Worker | Surveyor involved in complaint and annual survey investigation. |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Date: Jun 30, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint survey at Ridgecrest Rehabilitation Center on June 30, 2014, triggered by allegations that the facility failed to provide medications as ordered by Health Care Practitioner and failed to notify the health care practitioner of a need to change the plan of care.
Complaint Details
The complaint investigation found that the facility failed to provide medications as ordered by Health Care Practitioner with a medication pass error rate of less than 5%. The facility failed to evaluate bowel function and provide constipation medications for two residents. The facility did notify health care practitioners of needed changes in the plan of care and was found in compliance with that allegation.
Findings
The facility failed to evaluate bowel function and provide constipation medications in accordance with physician orders for two sampled residents, resulting in a violation of Federal requirement F 309 and licensure regulations. The facility was found to be in compliance with notifying health care practitioners of changes in the plan of care.
Deficiencies (1)
Facility failed to evaluate bowel function and provide ordered interventions for 2 residents, including failure to document administration of bowel medications and lack of a bowel management policy.
Report Facts
Census: 58
Medication error rate: 5
Days without bowel movement: 10
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Kezar | Administrator | Named as facility administrator in complaint letter |
| Eve Lewis | Program Manager | Signed complaint investigation letter from Department of Health and Human Services |
| Khristy Long | Registered Nurse | Surveyor conducting complaint investigation |
| Kay Reeves | Nutrition/dietitian | Surveyor conducting complaint investigation |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Date: Jan 29, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint at Ridgecrest Rehabilitation Center on January 28-29, 2014, regarding failure to identify change of condition, notify health care practitioner of need to change plan of care, provide pain medication as requested, provide prompt emergency care, provide medications according to the Five Rights, and ensure residents are aware of medications given.
Complaint Details
The complaint investigation included allegations that the facility failed to identify a change of condition, notify the health care practitioner of a need to change the plan of care, provide pain medication as requested, provide prompt emergency care, provide medications in accordance with the Five Rights, and ensure residents are aware of medications. The facility was found deficient only in notifying the practitioner and medication administration.
Findings
The facility failed to notify the health care practitioner of a need to change the plan of care and failed to provide medications in accordance with the Five Rights, resulting in a medication error rate of 14.81%. Other allegations such as failure to identify change of condition, provide pain medication, provide prompt emergency care, and ensure residents were aware of medications were not substantiated.
Deficiencies (2)
Facility failed to notify the health care practitioner of a need to change the plan of care related to Resident 5's change in condition and medication administration.
Facility failed to provide medications in accordance with the Five Rights, with 4 errors out of 27 medications observed.
Report Facts
Medication errors observed: 4
Resident census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ron Chase | Registered Nurse | Conducted the complaint investigation. |
| Eve Lewis | Program Manager | Signed the complaint investigation letter. |
| Joseph Kezar | Administrator | Facility administrator named in the report. |
| RN A | Registered Nurse | Involved in medication administration errors. |
| RN B | Registered Nurse | Confirmed medication delivery issues. |
| Nurse Consultant | Interviewed regarding notification and medication errors. |
Inspection Report
Routine
Census: 34
Deficiencies: 14
Date: May 20, 2013
Visit Reason
Routine inspection of Hidden Hills Health and Rehabilitation Center to assess compliance with regulations governing licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities.
Findings
The facility failed to maintain housekeeping and maintenance services, failed to ensure drug regimens were free from unnecessary drugs, failed to maintain essential equipment in safe operating condition, and failed to maintain complete and accurate clinical records. Additional deficiencies were found in life safety code compliance including fire safety and electrical safety.
Deficiencies (14)
Failed to maintain fixtures and carpets in a clean condition in 9 resident rooms and hallways.
Failed to evaluate an anti-convulsant medication for mood stabilization and failed to identify target behaviors for antipsychotic medication use.
Pharmacist failed to identify need for laboratory monitoring for an anticonvulsant medication and failed to identify duplicate medications.
Failed to maintain a washing machine in good working condition.
Failed to maintain complete and accurate documentation for a resident.
Two unattended clean linen carts stored in front of resident room door preventing door from closing.
Laundry room door failed to close and latch properly; no self-closing door on resident room used as clean linen storage.
Fire drills were not conducted at varied times and shifts; 8 of 17 drills were at month end or within last few days.
Failed to test fire alarm equipment biannually and maintain documentation of testing.
Two sprinkler heads installed below ceiling tile level in resident room.
Failed to conduct required hood suppression inspections within six months.
Portable space heating device found in business office.
Remote annunciator panel in East Nurses Station obstructed by resident charting binders.
Electrical power cord for electric wheelchair run through resident restroom door opening.
Report Facts
Deficient resident rooms: 9
Facility census: 34
Residents affected by fire safety deficiencies: 35
Fire drills reviewed: 17
Fire drills conducted at month end or last few days: 8
Residents affected by blocked door deficiency: 17
Residents affected by laundry room door deficiency: 27
Residents affected by portable heater deficiency: 17
Residents affected by electrical cord deficiency: 10
Inspection Report
Routine
Census: 43
Deficiencies: 6
Date: Feb 1, 2012
Visit Reason
Routine inspection of Hidden Hills Health and Rehabilitation Center to assess compliance with state and federal regulations including resident care and life safety code standards.
Findings
The facility was found deficient in notifying physicians of residents' depression scores, failure to submit Medicare demand bill for one resident, and life safety code violations including blocked corridor doors, malfunctioning laundry room doors, inadequate fire drills, and untested fire alarm batteries.
Deficiencies (6)
Failed to notify physicians of increased depression scores for Residents 4 and 5.
Failed to submit Medicare demand bill for Resident 12.
Unattended medication cart blocked dining room door preventing proper closing.
Laundry room double doors failed to latch properly allowing potential smoke migration.
Fire drills not consistently conducted at end of month or tested after third shift drills.
Fire alarm batteries not replaced as required, system testing deficient.
Report Facts
Census: 43
Sample size: 11
Residents affected: 43
Residents affected: 17
Fire drills reviewed: 18
Fire drills conducted at month end: 13
Facility census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN | Accepted plan of correction |
| Jim Heine | Approved plan of correction |
Notice
Deficiencies: 0
Date: Jun 29, 2011
Visit Reason
This document serves as a Notice of Modification of Disciplinary Action against Hidden Hills Health And Rehabilitation Center due to repeated violations found during a survey conducted on June 29, 2011. The probation period was extended and additional conditions were imposed.
Findings
The Department of Health and Human Services determined that repeated violations were found at the facility during the June 29, 2011 survey, leading to an extension of probation and requirements for an outside consultant to oversee quality assessment and assurance.
Report Facts
Probation period extension: 365
Report submission frequency: 30
Original survey date: Jun 29, 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Administrator | Recipient of reports and correspondence related to disciplinary action |
| Joann Schaefer | M.D., Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Modification of Disciplinary Action |
| Helen L. Meeks | Administrator, Licensure Unit | Signed the Notice of Modification of Disciplinary Action |
| Linda Stenvers | Staff Assistant, Office of Long Term Care Facilities | Certified mailing of the Notice of Disciplinary Action |
| Floyd Adams | Administrator | Recipient of letter terminating probation and restoring license |
Inspection Report
Routine
Census: 52
Deficiencies: 17
Date: Jun 29, 2011
Visit Reason
The facility underwent a routine semi-annual inspection to assess compliance with state and federal regulations including licensure, life safety, infection control, and quality of care.
Findings
The inspection identified multiple deficiencies including failure to document criminal background checks for new hires, delayed reporting of significant injury, inadequate resident positioning during meals, poor housekeeping and maintenance, unsafe transfer practices, medication errors related to insulin administration timing, improper food preparation and sanitation, infection control lapses, and fire safety code violations including blocked doors and inadequate fire drills.
Deficiencies (17)
Failed to ensure documentation of positive findings on criminal background reports for 4 of 5 sampled newly hired employees.
Failed to investigate and report a significant injury of unknown origin to required state agencies within required timeframes for 1 resident.
Failed to evaluate and provide proper wheelchair positioning to facilitate ease with eating for 3 residents.
Failed to maintain housekeeping and maintenance services to ensure cleanliness and condition of walls, floors, baseboards, doors, fall mats, call cords, privacy curtains, fixtures, and resident wheelchairs in 27 of 38 occupied resident rooms.
Failed to ensure resident transfers were performed safely, including locking wheelchair brakes and proper transfer techniques for 2 residents.
Medication error rate of 7.1% due to insulin administration timing not aligned with meal times for multiple residents.
Failed to prepare pureed food according to established recipe to conserve nutritive value and ensure palatability.
Failed to maintain sanitary food preparation and storage practices including handwashing, avoiding bare hand contact, maintaining cold food temperatures, and cleanliness of equipment.
Failed to perform proper handwashing and gloving techniques to prevent infection and cross-contamination for multiple residents.
Failed to maintain corridor door capable of resisting passage of smoke due to door blocked by plastic basin.
Failed to provide smoke separation and protection for hazardous areas by not providing doors which latch or self-close on storage and resident rooms.
Failed to provide posted code which was easily understood for release of magnetically locked exit doors.
Failed to document and maintain emergency battery powered lighting fixture tests.
Failed to conduct fire drills at varied days throughout the month during all shifts.
Failed to maintain means of egress free of obstructions including clean linen carts stored in corridors.
Failed to maintain facility free from highly flammable curtains or provide flame retardant rating for newly installed curtains.
Failed to store soiled linen barrels with capacities greater than 32 gallons in a room protected as a hazardous area with self-closing door.
Report Facts
Medication error rate: 7.1
Number of residents affected by positioning deficiency: 3
Number of resident rooms with housekeeping deficiencies: 27
Number of residents affected by transfer safety deficiency: 2
Number of residents affected by infection control deficiencies: 4
Number of residents affected by fire safety door deficiency: 13
Number of residents affected by hazardous area door deficiency: 19
Number of residents affected by flammable curtain deficiency: 38
Number of residents affected by soiled linen storage deficiency: 13
Facility census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Human Relations Staffer I | Human Relations Staff | Confirmed no documentation was made regarding how misdemeanors of new hires do not pose threat to patient safety. |
| Licensed Practical Nurse J | LPN | Performed medication pass with insulin timing errors and blood sugar checks. |
| Licensed Practical Nurse L | LPN | Performed medication pass with insulin timing errors and blood sugar checks. |
| Cook E | Cook | Observed preparing pureed food inconsistently with recipe and poor sanitation. |
| Director of Nursing | DON | Confirmed multiple deficiencies including delayed injury reporting, improper resident positioning, transfer safety issues, infection control lapses, and sanitation concerns. |
| Maintenance A | Maintenance Supervisor | Confirmed door deficiencies, fire safety issues, and maintenance lapses. |
| Dietary Manager | Dietary Manager | Confirmed sanitation deficiencies and food preparation issues. |
| Registered Dietician | RD | Provided input on food preparation and sanitation deficiencies. |
Notice
Deficiencies: 3
Date: Feb 23, 2011
Visit Reason
The notice modifies a previously imposed disciplinary action against Hidden Hills Health And Rehabilitation Center following a revisit on February 23, 2011, to determine correction of previously cited deficiencies.
Findings
The facility was found to have repeated violations including failure to provide oxygen as ordered, failure to clean glucometers between residents, and failure to perform handwashing and glove changes according to standards.
Deficiencies (3)
Failure to provide oxygen to a resident in accordance with physician order
Failure to clean glucometers between usage from one resident to another
Failure to perform handwashing and glove changes in accordance with prevailing and acceptable standards
Report Facts
Probation extension days: 180
Probation original days: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joann Schaefer | M.D., Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Modification of Disciplinary Action |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 2
Date: Feb 23, 2011
Visit Reason
The inspection was conducted due to a complaint investigation regarding deficient practices related to oxygen therapy and infection control at Hidden Hills Health and Rehabilitation Center.
Complaint Details
The complaint investigation found deficiencies related to oxygen therapy and infection control. The findings were substantiated as evidenced by observations, record reviews, and interviews conducted on 02/23/2011.
Findings
The facility failed to provide oxygen therapy in accordance with physician's orders for sampled residents and failed to utilize proper hand-washing techniques and clean glucometers between residents, leading to potential cross contamination.
Deficiencies (2)
Facility failed to provide oxygen therapy in accordance with physician's orders for Residents 30 and 31.
Facility failed to utilize hand-washing techniques to prevent cross contamination during treatments and failed to clean glucometers between residents.
Report Facts
Census: 60
Sample size: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Reviewed oxygen orders and confirmed oxygen concentrator settings for Residents 30 and 31 |
| Charge Nurse LPN | Licensed Practical Nurse | Provided information on oxygen saturation level checks and hand-washing practices |
| LPN-A | Licensed Practical Nurse | Observed performing blood sugar readings and insulin administration without proper sanitizing |
| LPN-B | Licensed Practical Nurse | Observed performing dressing change with improper hand hygiene |
Notice
Deficiencies: 0
Date: Jan 27, 2011
Visit Reason
The Department of Health and Human Services placed Hidden Hills Health And Rehabilitation Center on probation for 90 days beginning January 27, 2011, due to numerous and repeated failures to maintain a safe environment, prevent medication errors, comply with food safety, maintain infection control, and keep accurate medical records.
Findings
The facility was found to have multiple regulatory violations including failure to maintain a safe, clean, and homelike environment, failure to minimize accidents, medication errors, noncompliance with food code, inadequate infection control, and incomplete medical records.
Report Facts
Length of probation: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joann Schaefer | Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Disciplinary Action |
| Helen L. Meeks | Administrator, Licensure Unit | Signed the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II, Office of Long Term Care Facilities | Certified service of the Notice and completed HIPDB Reporting Worksheet |
| Eve Lewis | RNC, Administrator, Office of Long Term Care Facilities | Recipient of reports and involved in HIPDB Reporting Worksheet |
| Karlene Greenleaf | Registered Nurse | Listed staff member at the facility |
| Vicki Clements | Registered Nurse | Listed staff member at the facility |
| Ron Chase | Registered Nurse | Listed staff member at the facility |
| Carol Neneman | Social Worker | Listed staff member at the facility |
| Kay Reeves | Nutrition/dietitian | Listed staff member at the facility |
Inspection Report
Annual Inspection
Census: 61
Capacity: 61
Deficiencies: 8
Date: Dec 15, 2010
Visit Reason
The inspection was conducted as an annual survey to assess compliance with state and federal regulations governing skilled nursing facilities, including life safety code standards and quality of care.
Findings
The facility was found deficient in multiple areas including resident rights and services, notification of changes, abuse/neglect policies, housekeeping, medication error rates, infection control, and life safety code compliance. Several residents had pressure ulcers and documentation deficiencies. The facility failed to ensure staff knowledge of policies and timely notifications to physicians. Plans of correction were submitted with compliance dates mostly by January 29, 2011.
Deficiencies (8)
Facility failed to ensure staff knowledge of advanced directives and timely notification of bill notices to responsible parties for residents with full code status.
Facility failed to notify physician of development of pressure ulcers and changes in resident condition in a timely manner.
Facility failed to notify facility administration of injury of unknown origin and failed to report to Adult Protective Services as required.
Facility failed to maintain cleanliness and condition of floors, ceilings, equipment, and fixtures in resident rooms and common areas.
Facility failed to maintain medication error rates below 5%, with observed error rate of 12%.
Facility failed to maintain clinical records accurately and completely, including documentation of pressure ulcers and dialysis site monitoring.
Facility failed to maintain infection control program and failed to ensure staff compliance with hand washing and glove use.
Facility failed to maintain life safety code standards including smoke door closures, fire safety signage, and heating device safety.
Report Facts
Facility census: 61
Deficiency sample size: 15
Medication error rate: 12
Medication error sample size: 50
Compliance date: Jan 29, 2011
Inspection Report
Enforcement
Deficiencies: 1
Date: Dec 15, 2010
Visit Reason
A survey was conducted on December 15, 2010 by the Nebraska Department of Health and Human Services to determine compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs. The facility was found not in substantial compliance, leading to enforcement actions.
Findings
The facility was designated as a Special Focus Facility since February 2005 and had a change of ownership in October 2008. Eight deficiencies cited in the current survey were also cited in previous surveys between February 2009 and December 2010. As a result, a denial of payment for new Medicare and Medicaid admissions was imposed effective January 26, 2011. A revisit on April 20, 2011 confirmed substantial compliance and the denial was removed effective that date.
Deficiencies (1)
Deficiencies cited on the current survey that were also cited on previous surveys and revisits during the period February 2009 and December 2010 (F156, F226, F323, F332, F371, F441, F465, F514).
Report Facts
Deficiencies cited: 8
Fine amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gary Hemphill | Administrator | Named as facility administrator in relation to the inspection and enforcement |
| Jennifer King | Branch Manager, Survey, Certification and Enforcement Branch II | Signed enforcement letter and contact for the case |
| Jane Weiler | Health Quality Review Specialist | Contact person for additional comments or concerns |
Inspection Report
Plan of Correction
Census: 61
Deficiencies: 1
Date: Oct 19, 2010
Visit Reason
The visit was conducted to address deficiencies related to the facility's failure to follow a physician's order for lab work for one resident, as part of regulatory compliance under Nebraska Administrative Code, Chapter 12.
Findings
The facility failed to complete a PT/INR lab test for Resident 2 as ordered by the physician. The Director of Nursing confirmed the lab test was not completed and the lab requisition could not be located. The facility implemented corrective actions including audits, staff training, and monitoring to ensure compliance.
Deficiencies (1)
Failure to follow physician's order for lab work for Resident 2.
Report Facts
Resident census: 61
Number of sampled residents: 5
Lab test due date: Aug 24, 2010
Date of survey completion: Oct 19, 2010
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Confirmed lab test was not completed and lab requisition could not be located |
Notice
Capacity: 108
Deficiencies: 0
Date: APP2017
Visit Reason
The document serves as a license renewal application and certification for Ridgecrest Rehabilitation Center, LLC, including verification of licensure, occupancy permit, and disclosure related to the Alzheimer's Special Care Unit.
Findings
The documents confirm the facility's licensure renewal, occupancy permit for 108 beds, and provide detailed information about the Alzheimer's Special Care Unit including admission criteria, staffing, environment, and care philosophy.
Report Facts
Total licensed beds: 108
Special Care Unit licensed beds: 20
Staffing ratio: 2.8
Training hours: 4
License renewal fee: 1750
Cost of care: 180
Cost of care: 220
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Kezar | Administrator | Named as facility administrator and contact for application |
| Kandi Stull | Director of Nursing | Named as Director of Nursing on renewal application |
| William Rothner | Authorized Representative | Signed Alzheimer's Special Care Unit disclosure application |
| Alan Viox | Deputy State Fire Marshal | Signed occupancy permit inspection |
Inspection Report
Renewal
Capacity: 108
Deficiencies: 0
Date: APP2020
Visit Reason
This document serves as a Nursing Home Licensure Renewal Application and certification that Ridgecrest Rehabilitation Center, LLC is licensed through the indicated renewal date.
Findings
The facility is licensed for 108 beds, all dually certified. The renewal application confirms compliance with statutory requirements for continued licensure.
Report Facts
Licensed beds: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Zarate | Director of Nursing | Named in the renewal application form |
| Erin Dye | Administrator | Named in the renewal application form |
Notice
Capacity: 108
Deficiencies: 0
Date: APP2021
Visit Reason
This document serves as a renewal application for the nursing home license of Legacy Pointe Rehabilitation Center and includes related licensing and occupancy permit information.
Findings
The documents verify the facility's licensure renewal status, ownership information, maximum occupancy, and fire marshal occupancy permit. No inspection findings or deficiencies are reported.
Report Facts
Maximum licensed capacity: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chadd Russell | Administrator | Named as administrator on the renewal application and Alzheimer's special care unit disclosure. |
| Debra Swiers | Director of Nursing | Named as Director of Nursing on the renewal application. |
Notice
Capacity: 108
Deficiencies: 0
Date: APP2023
Visit Reason
The document serves as a renewal application for the nursing home license of Emerald Nursing & Rehab Legacy Pointe and includes verification of licensure, occupancy permit, and Alzheimer's special care unit endorsement application.
Findings
The documents confirm that Emerald Nursing & Rehab Legacy Pointe meets statutory requirements for licensure renewal, with no inspection findings or deficiencies noted. The occupancy permit certifies a maximum capacity of 108 beds.
Report Facts
Total licensed capacity: 108
Renewal licensure fee: 1950
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brinton Strohmeyer | Administrator | Named as administrator and contact person on renewal and Alzheimer's special care unit application. |
| Melissa Neiger | Director of Nursing | Named as Director of Nursing on renewal application. |
| Jacob I Walden | Authorized Representative | Signed the renewal application and Alzheimer's special care unit endorsement application. |
| Yisroel I Chafetz | Authorized Representative | Signed the renewal application. |
| Susen Lindner | Deputy State Fire Marshal | Inspected the facility and approved the occupancy permit. |
Document
Capacity: 108
Deficiencies: 0
Date: APP2024
Visit Reason
The documents pertain to the renewal of the nursing home license for Emerald Nursing & Rehab Legacy Pointe LLC, including submission of renewal application and verification of licensure through the renewal date.
Findings
No inspection findings or deficiencies are reported. The documents certify licensure renewal, occupancy permit with maximum capacity, and Alzheimer's special care unit disclosure information.
Report Facts
Total licensed capacity: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chadd Russell | Administrator | Named as facility administrator on renewal application and Alzheimer's special care unit disclosure. |
| Melissa Neiger | Director of Nursing | Named as Director of Nursing on renewal application. |
| Jacob I Walden | Authorized Representative | Signed renewal application and Alzheimer's special care unit disclosure. |
| Yisroel I Chafetz | Authorized Representative | Named as authorized representative on renewal application. |
Notice
Capacity: 108
Deficiencies: 0
Date: APP2025
Visit Reason
The documents pertain to the renewal of the nursing home license for Emerald Nursing & Rehab Legacy Pointe llc, including verification of licensure, renewal application, and Alzheimer's special care unit disclosure.
Findings
No inspection findings or deficiencies are reported. The documents certify licensure renewal, occupancy permit, and provide disclosure information for the Alzheimer's special care unit.
Report Facts
Total licensed beds: 108
Renewal license expiration date: Expires 03/31/2026 as shown on the renewal card.
Renewal license expiration date: Expiration date 03/31/2025 on renewal application form.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephen M Osborne | Administrator | Named as administrator on renewal application and Alzheimer's special care unit disclosure. |
| Melissa Nelger | Director of Nursing | Named as Director of Nursing on renewal application. |
| Yisroel I Chafetz | Authorized Representative | Signed renewal application and Alzheimer's special care unit disclosure. |
| Jay Walden | Name printed on renewal application dated 3/19/2025. |
Notice
Deficiencies: 0
Date: DAN012318
Visit Reason
The document serves as a Notice of Disciplinary Action against Ridgecrest Rehabilitation Center for violations related to failure to identify and intervene in cases of weight loss and pressure ulcers, followed by a modification of the disciplinary action and subsequent notices regarding the termination of admission prohibition and probation.
Findings
The facility was found in violation for failing to identify significant weight loss and pressure ulcers and to implement appropriate interventions for four residents. The disciplinary action included prohibition from admitting residents and probation with required corrective actions and reporting. Subsequent reviews found the violations corrected, leading to termination of admission prohibition and probation.
Report Facts
Probation period: 180
Number of residents with weight loss and pressure ulcers: 4
Dates for reports: First report due March 2, 2018 and every other week thereafter during probation
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Program Manager / Interim Program Manager / Training Coordinator | Recipient of reports, author of termination and probation continuation letters |
| Thomas L. Williams | MD, Chief Medical Officer, Director, Division of Public Health | Signed Notice of Disciplinary Action and Modification |
| Becky Wisell | Administrator, Licensure Unit | Signed Notice of Disciplinary Action and Modification |
| Linda Stenvers | Staff Assistant II | Certified mailing of notices |
Notice
Deficiencies: 0
Date: DAN012914
Visit Reason
This document is a Notice of Disciplinary Action issued by the Nebraska Department of Health and Human Services against Ridgecrest Rehabilitation Center for violations related to medication errors and failure to obtain necessary laboratory testing and medication for pain management.
Findings
The facility was placed on probation due to failure to administer medications as ordered by the physician and failure to obtain laboratory testing and medication for pain management. The probation period was initially 90 days starting February 19, 2014, and later extended to 180 days ending August 18, 2014. The probation was terminated on September 25, 2014, after requirements were met.
Report Facts
Probation period: 90
Probation period: 180
Probation termination date: Sep 25, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Recipient of reports and signer of termination letter |
| Joseph M. Acierno | Chief Medical Officer, Director, Division of Public Health | Signer of the Notice of Disciplinary Action |
| Helen L. Meeks | Administrator, Licensure Unit | Signer of the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II, Office of Long Term Care Facilities | Certified mailing of the Notice of Disciplinary Action |
| Joseph Kezar | Administrator | Facility administrator addressed in the probation termination letter |
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