Deficiencies (last 12 years)
Deficiencies (over 12 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
186% worse than Nebraska average
Nebraska average: 4.2 deficiencies/year
Deficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
66 residents
Based on a January 2019 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
The notice was issued to inform the facility of disciplinary action placing its license on probation for 90 days beginning October 17, 2024, due to violations related to failure to provide treatment for skin breakdown as evidenced by a CMS-2567 survey dated September 24, 2024.
Findings
The facility failed to provide adequate treatment for residents with skin breakdown, leading to disciplinary action including probation and requirements to submit plans of correction and periodic reports on residents with skin breakdown.
Report Facts
Probation period: 90
Report due date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Tesmer | Chief Medical Officer | Signed the notice as Chief Medical Officer of the Division of Public Health |
| Dan Taylor | Administrator | Named as Health Facilities Licensure Unit Administrator |
| Linda Stenvers | Administrative Specialist | Certified service of the notice |
Inspection Report
Original Licensing
Capacity: 155
Deficiencies: 0
Date: Nov 1, 2023
Visit Reason
The document is related to the issuance of a new Skilled Nursing Facility License for Emerald Nursing & Rehab Omaha due to a change of ownership.
Findings
The Department of Health and Human Services issued a Skilled Nursing Facility License to Emerald Nursing & Rehab Omaha, confirming the facility meets statutory requirements for operation as a skilled nursing facility with dual certification.
Report Facts
Total licensed beds: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Pilege | Administrator | Named as the facility administrator in the licensing documents. |
| LeAndrea Haynees-Bowman | Director of Nursing | Named as the Director of Nursing in the licensure application. |
| Jacob Walden | Authorized Representative / Managing Member | Signed ownership and controlling interest disclosure and licensure application. |
| Timothy Tesmer | Chief Medical Officer | Signed the licensing letter from the Department of Health and Human Services. |
Inspection Report
Renewal
Capacity: 155
Deficiencies: 0
Date: Jul 12, 2023
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related occupancy permit for Emerald Nursing & Rehab Omaha, indicating the renewal of the facility's license and certification.
Findings
The documents confirm that Emerald Nursing & Rehab Omaha meets statutory requirements for licensure renewal as a Skilled Nursing Facility with various therapy services. The occupancy permit certifies a maximum capacity of 155 beds.
Report Facts
Total licensed beds: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LeAndrea Haynees-Bowman | Director of Nursing | Named in the Nursing Home Licensure Renewal Application. |
| Kelley Seitz | Administrator | Named in the Nursing Home Licensure Renewal Application. |
| Jacob I Walden | Authorized Representative | Signed the Nursing Home Licensure Renewal Application. |
| Yisroel I Chafetz | Authorized Representative | Signed the Nursing Home Licensure Renewal Application. |
| Susen Lindner | Deputy State Fire Marshal | Inspected the facility and approved the occupancy permit. |
Inspection Report
Renewal
Capacity: 155
Deficiencies: 0
Date: Jan 13, 2022
Visit Reason
This document is a Nursing Home Licensure Renewal Application for Emerald Nursing & Rehab Omaha, submitted to renew the facility's license.
Findings
The document certifies that Emerald Nursing & Rehab Omaha meets statutory requirements for licensure renewal as a Skilled Nursing Facility with dual certification for Medicare and Medicaid. It includes facility details, ownership information, and services provided.
Report Facts
Total licensed beds: 155
Renewal application date: Jan 13, 2022
Occupancy permit date issued: Feb 22, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelley Seitz | Administrator | Named as the facility administrator in the renewal application. |
| LeAndrea Hayness-Bowman | Director of Nursing | Named as the director of nursing in the renewal application. |
| Jacob Walden | Authorized Representative | Signed the renewal application as an authorized representative. |
| Yisroel Chafetz | Authorized Representative | Printed name on the renewal application as an authorized representative. |
Inspection Report
Renewal
Capacity: 155
Deficiencies: 0
Date: Apr 16, 2019
Visit Reason
The document is a licensing and renewal inspection report related to the Skilled Nursing Facility license issuance and transfer of operations for Emerald Nursing & Rehab Omaha due to a change of ownership.
Findings
The report details the transfer of operations of the facility from the Receiver to a new operator, Omaha Operations LLC, effective April 16, 2019. It includes licensing, regulatory compliance, employee transition, and financial/accounting arrangements. No deficiencies or violations are explicitly stated.
Report Facts
Total licensed beds: 155
License issuance date: Apr 16, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Clifton | Administrator | Named as facility administrator in licensing documents |
| Melissa Neiger | Director of Nursing | Named as Director of Nursing in licensing documents |
| Ephram (Mordy) Lahasky | Authorized Signatory | Authorized representative of Omaha Operations LLC, new operator |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 6
Date: Jan 24, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint at Omaha Metro Care And Rehabilitation Center, LLC from January 24, 2019 to January 28, 2019 by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint included allegations that the facility failed to follow practitioner's orders, answer call notification systems promptly, ensure residents had access to communication devices and call lights, maintain sufficient staffing, address grievances, maintain essential equipment, ensure adequate supervision, and provide required discharge planning. The investigation found substantiated deficiencies related to practitioner's orders, supervision, and discharge planning.
Findings
The facility failed to follow practitioner's orders, ensure adequate supervision during resident transfers, and provide required discharge planning. The facility was compliant with call light response, communication device access, staffing sufficiency, grievance handling, and equipment maintenance. Specific deficiencies included failure to implement treatment orders, failure to conduct thorough fall evaluations, and failure to obtain daily weights as ordered.
Deficiencies (6)
Failure to follow practitioner's orders for residents.
Failure to ensure residents had adequate supervision according to their plan of care during a transfer.
Failure to provide required discharge planning for residents.
Failure to implement treatment orders for a resident, including missed treatments and repositioning.
Failure to thoroughly evaluate causal factors for a fall during use of a mechanical lift.
Failure to obtain daily weights as ordered for a resident.
Report Facts
Census: 66
Deficiencies cited: 6
Missed treatment dates: 3
Missed weight dates: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | RN, BSN, Program Manager | Signed the complaint investigation letter and report. |
| Stephanie Clifton | Administrator | Facility administrator addressed in the report. |
| Director of Nursing | Interviewed regarding treatment and supervision deficiencies; confirmed failures. | |
| Medical Records Director | Interviewed regarding lack of discharge planning for residents. |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 155
Deficiencies: 15
Date: Sep 5, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Omaha Metro Care And Rehabilitation Center from September 5 to September 11, 2018.
Complaint Details
The complaint investigation included allegations of failure to ensure eligibility for admissions, prompt response to calls, property accounting, fall reporting, documentation accuracy, resident dignity, housekeeping, care planning, staffing, supplies, supervision, and change in condition identification. Most allegations were found to be in compliance except for dignity issues related to lift slings visible in the dining area.
Findings
The facility was found to be in compliance with most allegations except for failure to treat residents with respect and dignity related to visible lift slings in the dining area. Multiple deficiencies were cited related to resident dignity, competent nursing staff, food safety, life safety code violations including means of egress, fire door maintenance, electrical safety, and emergency preparedness.
Deficiencies (15)
Facility failed to ensure resident dignity in the dining area due to visible lift slings under residents in wheelchairs.
Facility failed to ensure medication aides received training and competencies for performing Accu checks.
Facility failed to ensure food safety by improper hand hygiene during food service and uncovered food items during transport to resident rooms.
Facility allowed signage and attachments in an egress corridor creating confusion and obstruction.
Facility failed to maintain corridors free of obstructions due to unattended housekeeping cart.
Facility failed to ensure magnetically locked delayed egress exit door unlocked within required time.
Facility failed to ensure hazardous area doors closed, latched, and were smoke tight.
Facility failed to have kitchen range hood fire-extinguishing system inspected every 6 months.
Facility failed to ensure fire extinguishers were not obstructed.
Facility failed to ensure corridor doors resisted passage of smoke and latched properly.
Facility failed to secure oxygen cylinders and separate empty from full cylinders in storage.
Facility failed to provide a complete evacuation and relocation plan addressing relocation of items in corridors.
Facility failed to prohibit use of power strips and extension cords and allowed daisy chaining of power strips.
Facility failed to have diesel fuel tested annually for quality for emergency generator.
Facility failed to have a fire door assembly inspection program and failed to perform or document annual inspection, testing and maintenance of fire rated doors.
Report Facts
Deficiencies cited: 14
Facility census: 53
Total licensed capacity: 155
Residents potentially affected: 68
Residents potentially affected: 40
Residents potentially affected: 29
Residents potentially affected: 28
Residents potentially affected: 22
Residents potentially affected: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed the complaint investigation report. |
| Stephanie Clifton | Administrator | Facility administrator named in the report and complaint investigation. |
| Maintenance Staff A | Interviewed multiple times regarding facility deficiencies and maintenance issues. | |
| Director of Nursing | Interviewed regarding dignity issues with lift slings. | |
| Director of Environmental Services | Responsible for corrective actions and inspections related to multiple deficiencies. | |
| Occupational Therapist | Interviewed regarding dignity concerns with lift slings. |
Inspection Report
Renewal
Capacity: 155
Deficiencies: 0
Date: Mar 2, 2018
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related renewal certification for Omaha Metro Care and Rehabilitation Center, LLC, verifying the facility's license renewal and compliance with statutory requirements.
Findings
The documents confirm the facility's licensure renewal for a Skilled Nursing Facility with a total licensed capacity of 155 beds. The renewal application includes ownership and management information, certification of compliance with regulations, and an occupancy permit issued by the Nebraska State Fire Marshal.
Report Facts
Total licensed beds: 155
Renewal fees: 1950
Occupancy permit date: Jun 22, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Sealer | Administrator | Named in the Nursing Home Licensure Renewal Application |
| Kalinda Thiede | Director of Nursing | Named in the Nursing Home Licensure Renewal Application |
| Joseph Schwartz | Authorized Representative | Signed the Nursing Home Licensure Renewal Application |
| Rosie Schwartz | Authorized Representative | Signed the Nursing Home Licensure Renewal Application |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Date: Feb 6, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Omaha Metro Care And Rehabilitation Center, LLC regarding allegations of failure to provide care to prevent pressure sores, insufficient staffing, misappropriation of residents' property, inadequate pain management, and failure to notify responsible parties of changes in condition.
Complaint Details
The complaint investigation was substantiated with a finding that the facility failed to notify the resident representative of a change of condition and treatment for one resident (Resident 5) out of four reviewed. The facility census was 70. The failure involved lack of notification regarding a wound infection and antibiotic treatment.
Findings
The facility was found compliant with care to prevent pressure sores, staffing sufficiency, property accountability, and pain management. However, the facility failed to notify the responsible party of changes in condition for one resident, resulting in non-compliance with federal and state regulations.
Deficiencies (1)
Failure to notify the responsible party of changes in condition for one resident.
Report Facts
Facility census: 70
Residents reviewed: 4
Deficiency completion date: Apr 16, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation report |
| ADON | Interviewed regarding notification practices for resident representative |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 2
Date: Jan 24, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Omaha Metro Care And Rehabilitation Center, LLC on January 24, 2018, regarding allegations including failure to protect residents from abuse, evaluate causal factors for falls, follow medication administration protocols, serve requested foods, prevent skin breakdown, and resolve grievances.
Complaint Details
The complaint investigation addressed allegations of abuse, fall evaluations, medication administration errors, food service issues, skin breakdown care, and grievance resolution. The facility was found compliant in most areas except for medication timing errors (below threshold), hair restraint violations, and respiratory equipment maintenance issues.
Findings
The facility was found compliant with abuse protection, fall evaluations, skin breakdown prevention, grievance resolution, and food requests. A medication administration error was observed but was below the regulatory error rate, so no deficiency was cited. Deficiencies were found related to improper hair restraints worn by kitchen staff and failure to maintain respiratory treatment equipment properly for two residents.
Deficiencies (2)
Failure to maintain oxygen and respiratory treatment tubing in a manner to prevent cross-contamination for 2 residents.
Failure to ensure kitchen staff wore hair restraints to contain all head and facial hair to prevent potential food borne illness for 68 of 72 residents.
Report Facts
Facility census: 72
Residents reviewed for respiratory care: 4
Residents affected by respiratory deficiency: 2
Residents affected by hair restraint deficiency: 68
Medication error rate: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed complaint investigation letter |
| Judy Sealer | Administrator | Facility administrator addressed in report |
| Licensed Practical Nurse (LPN)-B | Interviewed regarding nebulizer mask rinsing | |
| Medication Aide (MA)-A | Observed removing nebulizer mask | |
| Dietary Aide (DA)-D | Observed not properly wearing hair restraints | |
| Dietary Manager (DM) | Interviewed regarding hair restraint policy | |
| Dietary cook-C | Observed not properly wearing hair restraints | |
| DA-E | Observed not properly wearing hair restraints | |
| Director of Nursing (DON) | Interviewed regarding respiratory equipment maintenance |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 20, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Omaha Metro Care And Rehabilitation Center, LLC on December 20-21, 2017, focusing on multiple allegations including medication administration, meal provision, care according to practitioner's orders, hygiene, staff training, abuse prevention, and other resident care concerns.
Complaint Details
The complaint included 11 allegations related to medication errors, meal provision, care services, hygiene, staff training, elimination assistance, dining assistance, staff respect, tracheostomy care, wheelchair safety, and abuse protection. All allegations were found to be in compliance with regulations.
Findings
The investigation found the facility in compliance with all cited allegations, including medication administration, meal provision, care services, hygiene, staff training, assistance with elimination and dining, respect and dignity, tracheostomy care, power wheelchair safety, and abuse prevention.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed as Training Coordinator for the Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 27, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Omaha Metro Care And Rehabilitation Center, Llc on September 27, 2017, by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint alleged failure to ensure residents are free from abuse, failure to provide assistance with transfers, and failure to ensure meals are served at proper temperatures. All allegations were found to be unsubstantiated.
Findings
The investigation found the facility was in compliance with regulatory guidelines regarding abuse prevention, assistance with transfers, and meal temperature standards. No deficiencies were identified in these areas.
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 |
Notice
Deficiencies: 0
Date: Jul 6, 2017
Visit Reason
The document serves as a Notice of Disciplinary Action against Omaha Metro Care And Rehabilitation Center, LLC, placing the facility's license on probation for 90 days starting July 21, 2017, due to violations of licensure regulations including failure to ensure a resident was free from involuntary seclusion.
Findings
The facility was found in violation of multiple regulations related to resident rights, care and treatment, housekeeping, medication integrity, infection control, and other areas. The violations were evidenced by failure to prevent involuntary seclusion of a resident and other deficiencies as detailed in the CMS-2567 report dated July 6, 2017.
Report Facts
Probation period: 90
Probation start date: Jul 21, 2017
Report submission frequency: 14
Notice finalization date: Jul 21, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Recipient of reports and contact for compliance communication |
| Thomas L. Williams | Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Disciplinary Action |
| Becky Wisell | Administrator, Licensure Unit | Signed the Notice of Disciplinary Action |
Inspection Report
Annual Inspection
Census: 85
Capacity: 155
Deficiencies: 16
Date: Jun 21, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Omaha Metro Care And Rehabilitation Center, Llc on June 21, 2017-June 28, 2017, by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint investigation included allegations related to staff credentials, hygiene, pest control, misappropriation, staffing, adverse event notification, emergency transfer paperwork, fall prevention, meal quality, communication access, investigation submission, and plan of care development. Some allegations were substantiated with deficiencies cited.
Findings
The facility was found to be in compliance with staff credentialing, pest control, protection from misappropriation, staffing sufficiency, notification of adverse events, emergency transfer paperwork, resident choice on personal care, submission of investigations, and development of plans of care. Deficiencies were found related to hygiene care, fall prevention interventions, meal quality, individualized activity programming, housekeeping maintenance, PASRR recommendations, antibiotic re-evaluation, oral care, pressure ulcer treatment, bladder and bowel continence programs, fall prevention interventions post-fall, food temperature and handling, infection control including isolation procedures, medication label accuracy, and quality assurance committee effectiveness. A fire safety deficiency was also cited related to hazardous area door self-closing devices.
Deficiencies (16)
Failed to ensure clean and groomed hair, skin, teeth, and/or nails for one resident.
Failed to ensure implementation of new fall prevention interventions for one resident after a fall.
Failed to ensure meals were served hot, palatable, and with appropriate texture.
Failed to ensure floors and walls were clean and in good repair in Room 509.
Failed to implement PASRR recommendations for one resident.
Failed to re-evaluate antibiotic effectiveness leading to rehospitalization of one resident.
Failed to provide oral care and facial/hand hygiene for one resident.
Failed to evaluate and treat pressure ulcer and complete treatments as ordered for one resident.
Failed to develop and implement bladder and bowel continence programs for multiple residents.
Failed to ensure resident environment free from accident hazards and failed to implement fall prevention interventions post-fall for one resident.
Failed to ensure medication label matched current physician order for one medication.
Failed to have defined indicators for isolation procedures and failed to provide education and demonstration of hand hygiene for one resident in isolation.
Failed to maintain effective quality assurance committee that identifies and corrects ongoing issues and implements effective plans of action.
Failed to provide smoke resistant enclosure for hazardous areas; door to Old Smoke Hut used as storage was not self-closing.
Failed to provide placard for Class K fire extinguisher stating fire protection system must be activated prior to use.
Failed to maintain food temperatures, serve pasteurized eggs, ensure hand hygiene and proper handling of drinking glasses in kitchen.
Report Facts
Deficiencies cited: 14
Facility census: 85
Licensed capacity: 155
Temperature of pureed taco: 136
Temperature of pureed rice: 126
Temperature of pureed corn: 129
Temperature of regular rice: 134
Temperature of regular taco: 101
Temperature of milk: 45
Temperature of apple juice: 58
Number of residents affected by food temperature: 17
Number of residents in facility: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Signed complaint investigation letter |
| Judy Sealer | Administrator | Facility administrator named in report |
| LPN H | Licensed Practical Nurse | Interviewed regarding isolation procedures for Resident 133 |
| LPN I | Licensed Practical Nurse | Interviewed regarding isolation procedures for Resident 133 |
| LPN E | Licensed Practical Nurse | Administered insulin with label discrepancy |
| RN G | Registered Nurse | Evaluated pressure ulcer for Resident 55 |
| NA J | Nursing Assistant | Reported on toileting assistance for Resident 6 |
| RN F | Registered Nurse | Interviewed about Resident 91 toileting program |
| Cook Q | Cook | Observed serving cold food and touching food with bare hands |
| Cook R | Cook | Observed handling food with soiled gloves |
| Dietary Manager | Interviewed about food temperatures and handling | |
| NA D | Nursing Assistant | Observed improper handling of drinking glasses |
| Maintenance Director | Interviewed about QA committee awareness and fire safety | |
| RN N | Registered Nurse | Interviewed about QA committee awareness |
| LPN P | Licensed Practical Nurse | Interviewed about repositioning documentation |
| NA O | Nursing Assistant | Interviewed about QA committee awareness |
Notice
Deficiencies: 2
Date: Feb 28, 2017
Visit Reason
The notice was issued to impose disciplinary action placing the facility's license on probation for 90 days due to violations related to failure to prevent pressure sores and accidents.
Findings
The facility failed to implement interventions to prevent the development of pressure sores and burns from hot liquid spills, violating licensure regulations.
Deficiencies (2)
Failure to implement interventions to prevent pressure sores
Failure to implement interventions to prevent accidents (burns from hot liquid spills)
Report Facts
Probation period length: 90
Report submission frequency: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Contact person for submission of reports and correspondence |
| Thomas L. Williams | MD, Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Disciplinary Action |
| Becky Wisell | Administrator, Licensure Unit | Signed the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II | Certified mailing of the Notice of Disciplinary Action |
| Judy Sealer | Administrator | Facility administrator receiving the notice and probation termination letter |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 3
Date: Feb 2, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Omaha Metro Care And Rehabilitation Center, LLC from January 31, 2017 to February 2, 2017 by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint investigation found multiple allegations substantiated including failure to supervise residents to prevent injuries, failure to protect residents from injury, and failure to provide care and treatment to prevent and promote healing of skin breakdown. Specific incidents involved residents sustaining injuries in the dining room without supervision and pressure ulcers not properly managed.
Findings
The facility failed to ensure residents were supervised to prevent injuries, failed to protect residents from injury, and failed to provide care and treatment to prevent and promote healing of skin breakdown. Two residents sustained injuries from hot liquids due to lack of supervision in the dining room. The facility also failed to evaluate causal factors and implement interventions for pressure ulcers in one resident.
Deficiencies (3)
Failure to ensure residents are supervised to prevent injuries, resulting in injuries in the dining room.
Failure to protect residents from injury, including hot liquid burns due to lack of supervision.
Failure to provide care and treatment to prevent skin breakdown and promote healing, including failure to evaluate causal factors and implement interventions for pressure ulcers.
Report Facts
Census: 79
Pressure ulcer measurements: 2.3
Pressure ulcer measurements: 5
Burn measurements: 17
Burn measurements: 2
Hot liquid temperature: 150
Deficiency completion date: 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Sealer | Administrator | Facility administrator addressed in the report |
| Eve Lewis | Program Manager | Signed letter from Office of LTC Facilities - Licensure Unit |
| DA A | Dietary Assistant | Reported incident of Resident 3 dropping hot coffee |
| RN H | Registered Nurse | Observed Resident 4's buttocks and unaware of open areas |
| NA C | Nursing Assistant | Assisted Resident 4 to dining room and reported spill incident |
| LPN B | Licensed Practical Nurse | Reported Resident 4's burn to Director of Nursing |
| LPN D | Licensed Practical Nurse | Removed dressing and observed burn area on Resident 4 |
| CMA F | Certified Medication Assistant | Reported no nurse supervision in dining room during Resident 4's spill |
| LPN G | Licensed Practical Nurse | Reported nurse was to be in dining room at meal times |
Notice
Deficiencies: 0
Date: Jan 11, 2017
Visit Reason
The notice serves to inform Omaha Metro Care And Rehabilitation Center, LLC that their facility license is placed on probation for 90 days starting January 26, 2017, due to violations of licensure regulations related to care and treatment, specifically failure to implement interventions to prevent or relieve episodic significant pain.
Findings
The facility was found in violation of several regulations including resolution of complaints and grievances, administrator responsibilities, medication errors, and sanitary conditions. The violations were evidenced by failure to implement interventions to prevent and/or relieve episodic significant pain.
Report Facts
Probation period: 90
Report submission frequency: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Contact person for submission of reports and correspondence related to the disciplinary action |
| Thomas L. Williams | Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Disciplinary Action |
| Becky Wisell | Administrator, Licensure Unit | Signed the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II | Certified mailing of the Notice of Disciplinary Action |
| Judy Sealer | Administrator | Facility administrator addressed in the May 3, 2017 letter terminating probation |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 5
Date: Jan 3, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Omaha Metro Care And Rehabilitation Center, LLC from December 29, 2016 to January 3, 2017, by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint investigation was triggered by allegations including failure to submit timely investigations, misappropriation, staffing sufficiency, discharge planning, medication administration errors, food temperature violations, grievance resolution, nutritional needs, food preferences, and fall interventions. The investigation substantiated failures in timely abuse investigation reporting, grievance resolution, medication administration, food safety, and pain management.
Findings
The investigation found multiple deficiencies including failure to submit a timely written investigation of abuse allegations, unresolved resident grievances, medication administration errors with a 13.33% error rate, failure to maintain food at appropriate temperatures, and inadequate pain management for a resident. Some allegations such as misappropriation, sufficient staffing, discharge planning, nutritional needs, food preferences, and fall interventions were found to be compliant.
Deficiencies (5)
Failure to submit a written investigation within five working days to the State agency regarding an abuse allegation.
Failure to resolve a resident grievance related to staff conduct and care.
Failure to ensure medication error rates below 5%, with a 13.33% error rate observed during medication administration.
Failure to maintain food temperatures to prevent potential food borne illness; cold foods such as salads, cottage cheese, and yogurt were found at unsafe temperatures.
Failure to provide adequate pain management for a resident with documented pain and injury.
Report Facts
Medication error rate: 13.33
Residents affected by medication errors: 3
Resident census: 88
Temperature of ham and egg salad: 62.5
Temperature of cottage cheese: 57
Temperature of yogurt on medication cart: 70
Temperature of yogurt on medication cart (Hall B): 48.3
Temperature of yogurt on medication cart (Hall B): 51.2
Temperature of yogurt used for medication pass: 63.2
Resident pain level: 9
Resident pain level: 8
Resident pain level: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Sealer | Administrator | Named as facility administrator in the complaint investigation letter. |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit | Signed the complaint investigation letter. |
| Director of Nursing | Interviewed regarding unresolved grievance and failure to report abuse. | |
| Licensed Practical Nurse A | LPN | Observed administering incorrect medication dosage to Resident 15. |
| Registered Nurse B | RN | Interviewed about medication errors and food temperature issues. |
| Licensed Practical Nurse D | LPN | Observed administering incorrect medication dosage to Resident 19. |
| Certified Medication Assistant I | CMA | Observed administering incorrect medication dosage to Resident 20. |
| Licensed Practical Nurse H | LPN | Observed stirring medication into yogurt at unsafe temperature. |
| Dietary Service Manager | DSM | Observed and measured unsafe food temperatures during meal service. |
| Cook K | Cook | Reported no cold food temperatures had been taken in 4 years. |
| Director of Staff Development | DSD | Observed resident transfer and confirmed pain management issues. |
| Nursing Assistant E | NA | Observed transferring resident in pain without notifying nurse. |
Notice
Deficiencies: 0
Date: Aug 16, 2016
Visit Reason
The notice was issued to inform the facility of disciplinary action placing its license on probation for 90 days beginning August 31, 2016, due to violations related to failure to implement assessed interventions and evaluate causal factors to prevent falls and implement additional interventions after falls occurred.
Findings
The facility was found in violation of licensure regulations related to accidents, specifically failing to implement assessed interventions and evaluate causal factors to prevent falls. The CMS-2567 Report dated August 16, 2016, documents these violations.
Report Facts
Probation period length: 90
Report submission frequency: 7
Report due date: 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Recipient of required reports and responses |
| Courtney N. Phillips | Chief Executive Officer | Signed the Notice of Disciplinary Action |
| Becky Wisell | Administrator | Licensure Unit, signed the Notice |
| Linda Stenvers | Staff Assistant II | Certified mailing of the Notice |
| Dan Taylor | RN, Training Coordinator | Signed letter terminating probation on December 28, 2016 |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 2
Date: Aug 3, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to investigate causative factors in resident falls.
Complaint Details
The complaint alleged the facility failed to investigate causative factors in falls. The investigation confirmed the facility did not evaluate or implement new interventions after falls and did not follow the plan of care for transfers.
Findings
The facility failed to investigate causative factors for falls and did not follow the plan of care for transfers. Interventions to prevent additional falls were not always evaluated or implemented. Specific deficiencies were found related to toileting programs and fall prevention interventions for two residents.
Deficiencies (2)
Failure to implement a toileting program for Resident 1.
Failure to implement assessed interventions and evaluate causal factors to prevent falls for Resident 1 and failure to implement additional interventions after a fall for Resident 2.
Report Facts
Census: 89
Deficiency completion date: Sep 16, 2016
Plan of correction completion date: Aug 29, 2016
Plan of correction completion date: Aug 31, 2016
Plan of correction completion date: Aug 5, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the complaint investigation letter. |
| Judy Sealer | Administrator | Facility administrator addressed in the complaint investigation letter. |
| Director of Nursing | Director of Nursing | Interviewed and confirmed failure to implement toileting program and fall prevention interventions. |
| LPN A | Licensed Practical Nurse | Interviewed regarding Resident 1's care and transfer practices. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding Resident 1's supervision and fall incident. |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Date: May 2, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding allegations of abuse, verbal abuse, and inadequate care for bowel elimination at Golden Livingcenter - Omaha.
Complaint Details
The complaint alleged failure to protect residents from abuse, failure to ensure residents were free from verbal abuse, and failure to provide care and treatment for bowel elimination. All allegations were found unsubstantiated.
Findings
The investigation found no violations related to abuse or verbal abuse, as residents and staff reported no indications of such issues. The facility provided appropriate care and treatment for bowel elimination with no violations identified.
Report Facts
Census: 90
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 21
Date: Feb 29, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Golden Livingcenter - Omaha on February 29, 2016-March 8, 2016, by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint investigation included allegations of failure to resolve complaints/grievances, failure to provide staff assistance with food/fluid intake, failure to ensure proper temperatures of food, failure to administer medications according to orders, failure to provide appropriate housekeeping/maintenance, failure to provide a safe environment for residents at risk for elopement, failure to ensure clean grooming, failure to ensure sufficient staffing, failure to ensure accurate documentation, failure to ensure proper equipment for resident transfer, failure to notify POA prior to discharge, failure to prevent resident injury, failure to notify family of change in condition, and failure to provide care to prevent pressure sores.
Findings
The investigation found multiple deficiencies including failure to provide staff assistance with food/fluid intake, insufficient staffing, failure to notify POA prior to discharge, failure to prevent pressure sores, failure to ensure accurate documentation, failure to report abuse and injuries timely, failure to maintain sanitary environment, failure to provide appropriate activities, and multiple medication and treatment errors.
Deficiencies (21)
Failure to provide staff assistance to enable food/fluid intake.
Failure to provide appropriate housekeeping/maintenance in the facility.
Failure to ensure sufficient staffing; Director of Nursing assigned as charge nurse.
Failure to notify and/or obtain POA consent prior to discharge.
Failure to provide care and treatment to prevent pressure sores.
Failure to ensure accurate documentation of resident status and treatments.
Failure to report allegations of abuse and injuries of unknown origin timely.
Failure to provide activities to meet resident interests and needs.
Failure to maintain housekeeping and maintenance services to keep facility sanitary and orderly.
Failure to provide necessary care and services to maintain or improve resident abilities.
Failure to ensure a skin assessment was completed for one resident.
Failure to provide sufficient fluid intake to maintain proper hydration.
Failure to ensure medication and treatment carts were secured when not in use.
Failure to ensure drug regimen is free from unnecessary drugs and non-pharmacological interventions were not implemented prior to psychoactive medication use.
Failure to maintain a full-time Director of Nursing not serving as charge nurse when census exceeds 60.
Failure to ensure exit access doors are readily accessible; one door dragged on frame.
Failure to maintain fire sprinkler heads free of dirt and corrosion.
Failure to segregate empty oxygen cylinders from full ones in storage area.
Failure to provide or arrange routine and emergency dental services to meet resident needs.
Failure to maintain infection control practices including handwashing, gloving, and cleanliness of bedpans, urinals, and graduates.
Failure to maintain kitchen and dining room environment in a safe, functional, sanitary, and comfortable manner.
Report Facts
Deficiencies cited: 22
Facility census: 88
Average daily census: 84
Medication carts audit frequency: 3
Medication carts audit frequency: 3
Sprinkler heads audit frequency: 5
Sprinkler heads audit frequency: 1
Oxygen room audit frequency: 3
Oxygen room audit frequency: 1
QAA meeting frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Signed the complaint investigation report |
| Judy Sealer | Administrator | Named in report as facility administrator |
| NA B | Nursing Assistant | Observed failing to change gloves during catheter care |
| LPN A | Licensed Practical Nurse | Observed failing to provide feeding assistance and incorrect feeding/fluid administration |
| Director of Nursing | Interviewed regarding multiple deficiencies including staffing and documentation | |
| Maintenance Director | Interviewed regarding door and sprinkler deficiencies | |
| Social Services Director | Interviewed regarding failure to notify POA and dental services | |
| Registered Dietitian | Interviewed regarding dietary and infection control deficiencies | |
| ADON | Assistant Director of Nursing | Interviewed regarding medication cart security and infection control |
Inspection Report
Renewal
Capacity: 155
Deficiencies: 0
Date: Feb 22, 2016
Visit Reason
This document is a Nursing Home Licensure Renewal Application for Golden LivingCenter - Omaha, submitted to renew the facility's license.
Findings
The document certifies that the facility meets statutory requirements for licensure renewal and includes ownership and accreditation information.
Report Facts
Total licensed beds: 155
Renewal fees: 1950
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Sealer | Administrator | Named in the licensure renewal application |
| Dottie Rice | Director of Nursing | Named in the licensure renewal application |
| Holly Rasmussen-Jones | Authorized Representative | Signed the renewal application |
| Ann Truitt | Authorized Representative | Signed the renewal application |
Inspection Report
Routine
Census: 85
Deficiencies: 2
Date: Jan 26, 2016
Visit Reason
The inspection was conducted to assess compliance with state and federal regulations governing licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities, including accuracy of resident assessments and nurse staffing postings.
Findings
The facility failed to accurately record one resident's indwelling catheter status on the Quarterly MDS and failed to maintain accurate daily posted nurse staffing information. Corrective actions and staff education were implemented, and ongoing audits were planned.
Deficiencies (2)
Failed to record one resident's indwelling catheter on the Quarterly MDS.
Failed to ensure posted nurse staffing information was updated daily and accurately reflected staff working and resident census.
Report Facts
Facility census: 85
Deficiencies cited: 2
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 2
Date: Jan 13, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint survey at Golden Livingcenter - Omaha from January 13, 2016 to January 19, 2016, triggered by allegations that the facility failed to protect residents from injury and failed to submit investigations within 5 working days.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to protect residents from injury and failed to submit investigations within the required timeframe. The facility was cited for violations at F323 and F225 related to these issues.
Findings
The facility failed to protect residents from injury by not implementing identified interventions to prevent falls and elopement. Additionally, the facility failed to submit investigations of alleged neglect to the required state agency within 5 working days for two residents. Immediate corrective actions and staff education were implemented.
Deficiencies (2)
Failure to protect residents from injury by not implementing interventions to prevent falls and elopement.
Failure to submit investigations to the required state agency within 5 working days for two residents.
Report Facts
Census: 86
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Sealer | Administrator | Facility administrator addressed in the report |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Author of the letter and contact person for the investigation |
| Director of Nursing | Interviewed and confirmed failures in submitting investigations and implementing interventions | |
| Registered Nurse A | RN | Confirmed bed positioning issues for Resident 1 |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 1
Date: May 26, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint at Golden Livingcenter - Omaha regarding failure to provide care and services according to practitioner's orders, medication administration, staff training, call notification system access, and oxygen administration standards.
Complaint Details
The complaint investigation found that the facility failed to provide care and services according to practitioner's orders, specifically oxygen administration not following physician orders for two residents. The facility was compliant with staff training and call notification system access.
Findings
The facility failed to provide care and services according to practitioner's orders, specifically failing to administer oxygen treatments as ordered for Residents 2 and 4. The facility was found compliant with staff training and call notification system access. The oxygen administration did not follow standards of practice, with oxygen levels set below physician orders.
Deficiencies (1)
Facility staff failed to administer oxygen according to physician orders for Residents 2 and 4.
Report Facts
Facility census: 92
Oxygen liter flow order for Resident 2: 5
Observed oxygen liter flow for Resident 2: 4.5
Oxygen liter flow order for Resident 4: 10
Observed oxygen liter flow for Resident 4: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Schmidt | Registered Nurse | Investigator conducting complaint investigation |
| Lori Frodsham | Registered Nurse | Investigator conducting complaint investigation |
| Carol Neneman | Social Worker | Investigator conducting complaint investigation |
| Judy Sealer | Administrator | Facility administrator addressed in report |
| Eve Lewis | RNC, Program Manager - Office of LTC Facilities - Licensure Unit | Author of the complaint investigation letter |
| LPN A | Licensed Practical Nurse | Staff interviewed regarding oxygen administration for Residents 2 and 4 |
| Director of Nursing | Interviewed confirming oxygen administration standards and orders | |
| Medication Aide B | Medication Aide | Observed administering oxygen to Resident 2 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 11, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint at Golden Livingcenter - Omaha on May 11, 2015, by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint alleged the facility failed to protect residents from injuries, failed to submit investigations within 5 working days, and failed to give residents appropriate notice of involuntary discharge. All allegations were found to be unsubstantiated as the facility was in compliance.
Findings
The investigation reviewed resident records, observations, and interviews related to three allegations: failure to protect residents from injuries, failure to submit investigations in 5 working days, and failure to give appropriate notice of involuntary discharge. The facility was found to be in compliance with regulatory guidelines for all allegations.
Report Facts
Resident records reviewed: 3
Facility investigations reviewed: 3
Discharge records reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Frodsham | Registered Nurse | Conducted the complaint investigation visit |
| Eve Lewis | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit |
Inspection Report
Routine
Census: 88
Deficiencies: 4
Date: Apr 1, 2015
Visit Reason
Routine inspection conducted to assess compliance with state and federal regulations including criminal background checks, life safety code standards, fire drills, and means of egress.
Findings
The facility failed to complete criminal background and sex offender registry checks for several direct care staff. Life safety code violations included doors that did not latch properly, fire drills not conducted at random times on all shifts, and obstructions in means of egress corridors. Corrective actions and monitoring plans were implemented to address these deficiencies.
Deficiencies (4)
Failed to ensure criminal background and sex offender registry checks were completed for 5 direct care staff.
Therapy door and resident room door failed to latch properly, obstructing smoke passage resistance.
Fire drills were not conducted at random times during 1st and 2nd shifts as required.
Means of egress corridors obstructed by furniture and equipment, delaying egress.
Report Facts
Number of direct care staff missing background checks: 5
Facility census: 88
Number of residents affected by door latching issue: 28
Number of residents affected by means of egress obstruction: 60
Number of fire drills reviewed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nurse Aide | Missing criminal background and sex offender registry checks |
| NA B | Nurse Aide | Missing criminal background and sex offender registry checks |
| NA C | Nurse Aide | Missing criminal background and sex offender registry checks |
| NA D | Nurse Aide | Missing sex offender registry checks |
| NA E | Nurse Aide | Missing sex offender registry checks |
| Maintenance Director | Confirmed findings related to door latching and fire drill timing | |
| Human Resources Generalist | Confirmed missing background and registry checks in employee files |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 4
Date: Dec 31, 2014
Visit Reason
An unannounced visit was conducted to investigate multiple complaints at Golden Livingcenter - Omaha from December 29, 2014 to December 31, 2014, including allegations about supplies, call system response, emergency care, supervision, dignity and respect, laundry, documentation, medication administration, meals, cleanliness, pain management, hydration, bowel care, nutrition, feeding tube care, plan of care implementation, administrator presence, pressure sore prevention, equipment maintenance, discharge planning, and physical therapy.
Complaint Details
The complaint investigation addressed multiple allegations including insufficient supplies, call system delays, emergency care delays, supervision failures, dignity and respect issues, laundry delays, documentation failures, medication errors, meal quality, cleanliness, pain management, hydration, bowel care, nutrition, feeding tube care, plan of care adherence, administrator absence, pressure sore prevention, equipment maintenance, discharge planning, and physical therapy provision. The facility was found out of compliance on dignity and respect, housekeeping and maintenance, infection control related to feeding tube care, and administrator presence.
Findings
The facility was found compliant with most allegations including supplies, call system response, emergency care, supervision, laundry, documentation, medication administration, meals, pain management, hydration, bowel care, nutrition, plan of care, pressure sore prevention, equipment maintenance, discharge planning, and physical therapy. Deficiencies were found related to dignity and respect due to compression stockings hanging in sight of visitors, failure to maintain a clean and sanitary environment with dirty floors, walls with blood stains, and infection control issues related to improper storage of feeding tube supplies. The facility also failed to ensure the administrator or a qualified designee was present during an extended administrator absence.
Deficiencies (4)
Residents' compression stockings were hanging in sight of visitors, violating dignity and respect.
Facility failed to maintain floors and walls in a clean and sanitary condition, including dirty beauty shop floor and blood on walls.
Tube feeding supplies were stored improperly, with feeding tube adapters uncapped and placed near a urinal, risking cross contamination.
Facility failed to designate a qualified person to monitor day-to-day operations during extended absence of the administrator.
Report Facts
Facility census: 88
Number of residents affected by feeding tube infection control issue: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Smith | Administrator | Named in relation to administrator absence and facility management |
| Connie Kincaid | Registered Nurse | Investigator for complaint visit |
| Lori Frodsham | Registered Nurse | Investigator for complaint visit |
| Eve Lewis | RNC, Program Manager - Office of LTC Facilities - Licensure Unit | Author of complaint investigation letter |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 2, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint at Golden Livingcenter - Omaha from October 2, 2014 to October 6, 2014. The investigation was triggered by multiple allegations regarding the facility's care and services.
Complaint Details
The complaint investigation addressed multiple allegations including failure to answer call lights promptly, failure to provide a clean environment, failure to ensure residents are clean and groomed, failure to provide medications according to the Five Rights, failure to treat residents with respect and dignity, failure to identify change of condition, failure to protect residents from abuse and misappropriation, failure to notify healthcare practitioners of changes, failure to provide care according to orders, failure to ensure meals are attractive, failure to provide prompt emergency care, failure to implement interventions to prevent bruising, failure to provide appropriate discharge planning, and failure to protect residents from injury. All allegations were found to be unsubstantiated.
Findings
The investigation found that the facility met all regulatory requirements related to the allegations. The facility promptly answered call lights, maintained a clean environment, ensured residents were clean and groomed, provided medications according to the Five Rights, treated residents with respect and dignity, identified changes in condition, protected residents from abuse and misappropriation, notified healthcare practitioners of changes, provided care according to orders, ensured meals were attractive, provided prompt emergency care, implemented interventions to prevent bruising, provided appropriate discharge planning, and protected residents from injury.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Kincaid | Registered Nurse | Representative of the Department of Health and Human Services who conducted the complaint investigation. |
| Lori Frodsham | Registered Nurse | Representative of the Department of Health and Human Services who conducted the complaint investigation. |
| Rebecca Smith | Administrator | Administrator of Golden Livingcenter - Omaha, recipient of the report. |
| Eve Lewis | Program Manager | Program Manager, Office of Long Term Care Facilities, Licensure Unit, Division of Public Health, Department of Health and Human Services, signed the report. |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 10
Date: Feb 27, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Golden Livingcenter - Omaha on February 24-27, 2014.
Complaint Details
The complaint investigation included allegations related to access to communication, treatment completion, medication administration, timely submission of investigations, plan of care adherence, laboratory work completion, pain medication provision, family notification of condition changes, pressure sore care, staffing adequacy, physician visits, medication administration accuracy, and skin breakdown prevention. The facility was found compliant on most allegations except for dignity and respect, social services, odor control, unnecessary drug use, food temperature and sanitation, infection control, ventilation, and life safety code compliance.
Findings
The facility was found to be in compliance with many complaint allegations including access to communication, treatment completion, medication administration, injury prevention, family notification, and staffing. Deficiencies were noted related to dignity and respect of individuality for one resident, failure to provide medically-related social services for one resident with increased depression and behaviors, odor issues in hallways, unnecessary antipsychotic drug use without proper orders or target behaviors, food temperature and sanitation issues in food service, infection control breaches, and inadequate ventilation in resident bathrooms. Life safety code deficiencies were also identified related to smoke compartment doors and smoking area safety.
Deficiencies (10)
Facility failed to provide care in a manner that maintained and enhanced dignity for 1 resident who was dressed in a hospital gown and not assisted to dress appropriately.
Facility failed to provide medically-related social services for 1 resident with increased symptoms of depression and behaviors.
Facility failed to maintain odor free environment in 2 of 4 resident living hallways affecting 16 residents.
Facility failed to ensure drug regimen free from unnecessary drugs; failed to have order and target behaviors for antipsychotic medications for 2 residents.
Facility failed to provide food at temperatures palatable to residents affecting 75 residents.
Facility failed to maintain non-food contact surfaces and kitchen floor in a clean and sanitary manner affecting 75 residents.
Facility failed to implement infection control procedures including isolation, handwashing, gloving, and cleaning of equipment for 2 residents.
Facility failed to maintain working ventilation system in 8 resident rooms affecting 16 residents.
Facility failed to ensure smoke compartment doors had no impediments to closing in 6 smoke compartments.
Facility failed to ensure all used cigarettes were discarded in approved ashtrays.
Report Facts
Facility census: 79
Medication error rate: 5
Number of residents affected by odor issue: 16
Number of residents affected by ventilation issue: 16
Number of residents affected by smoke door issue: 86
Number of residents affected by cigarette disposal issue: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Smith | Administrator | Named in complaint investigation letter |
| Eve Lewis | Program Manager, Office of Long Term Care Facilities | Signed complaint investigation letter |
| Connie Kincaid | Registered Nurse Surveyor | Complaint investigation team member |
| Ron Chase | Registered Nurse Surveyor | Complaint investigation team member |
| Carol Neneman | Social Worker Surveyor | Complaint investigation team member |
| Kay Reeves | Nutrition/Dietitian Surveyor | Complaint investigation team member |
| Janice Hake | Registered Nurse Surveyor | Complaint investigation team member |
| Rebecca Smith | Executive Director | Signed plan of correction documents |
| Maintenance A | Maintenance Staff | Acknowledged smoke door and cigarette disposal deficiencies |
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 14
Date: Dec 11, 2012
Visit Reason
Annual inspection of Golden Livingcenter - Omaha to assess compliance with federal and state regulations including life safety code standards.
Findings
The facility was found deficient in multiple areas including failure to provide flame spread rating for air-conditioning unit covers, malfunctioning resident room doors, inadequate smoke separation doors, lack of emergency lighting and egress lighting, improper storage of oxygen cylinders, missing oxygen warning signage, use of power strips and extension cords, and failure to conduct fire drills as required. Several fire safety code violations were noted including obstructed egress paths, combustible decorations, and failure to maintain kitchen hood systems.
Deficiencies (14)
Interior finish of cloth and styrofoam covering air-conditioning units lacked required flame spread rating.
Resident room 314 door failed to latch properly due to tape covering latch receiver.
Smoke separation door into A Hall corridor failed to close and latch.
Self-closing device on Beauty Shop door failed to close and latch.
Exit discharge lighting failed to provide illumination so that failure of any single bulb would not leave area in darkness.
Fire drills were not conducted once per shift per quarter during 2011 and 2012.
Smoking areas lacked safe design ashtrays.
Kitchen hood exhaust system lacked grease seals and gas stove burners failed to ignite.
Means of egress obstructed by food tray warming carts, lifts, wheelchairs, linen and medication carts in corridors.
Combustible decorations (fabric Christmas stockings) hung on resident door 306 without flame retardant treatment.
Highly flammable curtains present on stairwell window and activity room window without flame retardant rating.
Oxygen cylinders in resident room 511 were not restrained.
Oxygen in use signs missing on resident rooms 312, 206, 515, 413, and 405.
Use of power strips and extension cords as substitute for fixed wiring in resident rooms 305, 314, and 514.
Report Facts
Facility census: 79
Number of residents affected by flame spread deficiency: 7
Number of residents affected by door latch deficiency: 38
Number of residents affected by smoke separation door deficiency: 24
Number of residents affected by emergency lighting deficiency: 72
Number of residents affected by fire drill deficiency: 79
Number of residents affected by smoking ashtray deficiency: 79
Number of residents affected by kitchen hood and stove deficiency: 72
Number of residents affected by egress obstruction: 79
Number of residents affected by combustible decoration deficiency: 28
Number of residents affected by flammable curtains deficiency: 7
Number of residents affected by unrestrained oxygen cylinders: 32
Number of residents affected by missing oxygen signage: 79
Number of residents affected by electrical wiring deficiencies: 60
Inspection Report
Annual Inspection
Census: 90
Deficiencies: 5
Date: Feb 6, 2012
Visit Reason
The inspection was conducted as an annual survey to assess compliance with state and federal regulations governing licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities.
Findings
The facility was found deficient in multiple areas including failure to notify residents' legal representatives and physicians of significant changes, failure to update comprehensive care plans and implement appropriate interventions for pressure ulcers, failure to maintain medication error rates below 5%, and failure to complete required pre-employment criminal background and registry checks for direct care staff.
Deficiencies (5)
Failure to notify resident's legal representative and physician of condition changes, hospital transfers, and development of pressure sores for multiple residents.
Failure to review and revise comprehensive care plans related to pressure ulcer interventions for multiple residents.
Failure to provide necessary treatment and services to prevent and heal pressure sores for multiple residents.
Failure to maintain medication error rates below 5%, with observed error rate of 15.21% involving 3 residents.
Failure to complete pre-employment criminal background and registry checks for unlicensed direct care staff members.
Report Facts
Census: 90
Medication error rate: 15.21
Number of medication errors: 7
Number of residents sampled: 18
Number of non-sampled residents: 1
Number of nurse aides with incomplete background checks: 4
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 26
Date: Aug 2, 2011
Visit Reason
Annual inspection of Golden Livingcenter - Omaha to assess compliance with state and federal regulations including resident care, safety, and facility conditions.
Findings
The facility was found deficient in multiple areas including medication documentation, resident privacy, personal care, complaint investigations, dignity and respect, housekeeping and maintenance, care planning, infection control, medication errors, food safety, drug storage, and life safety code compliance. Several residents had issues with care plans, pressure ulcers, medication administration, and environmental safety concerns.
Deficiencies (26)
Failed to properly document medication administration for 3 residents; medication signed off prior to administration.
Failed to ensure resident privacy during personal care; residents left exposed during care.
Failed to report injuries of unknown origin and potential neglect to state agencies timely for 3 residents.
Failed to maintain resident dignity related to choice of clothing which partially exposed chest area of a resident.
Failed to maintain housekeeping and maintenance services to ensure cleanliness and condition of walls, floors, doors, mats, call cords, fixtures, handrails, carpets, and wheelchairs in multiple resident rooms and areas.
Failed to review, revise, and implement comprehensive care plans for multiple residents including depression, falls, medication management, and pressure ulcers.
Failed to provide necessary care and services to evaluate and implement interventions for depression and monitor dialysis fistula site for infection.
Failed to provide care and services to monitor and prevent development of pressure ulcers for 2 residents.
Failed to ensure resident environment free of accident hazards; resident at risk for injury from hot liquids due to inadequate assessment and interventions.
Medication error rate of 5% due to insulin administration errors for a resident.
Failed to ensure residents free of significant medication errors; resident received incorrect doses of Coumadin and Janumet.
Failed to maintain food temperatures to prevent growth of microorganisms during meal service.
Failed to maintain drug records, label/store drugs and biologicals properly; medication cart unsecured and improper disposal of controlled substances.
Failed to maintain infection control; staff failed to sanitize hands between resident medication administration to prevent cross-contamination.
Failed to maintain complete, accurate, and accessible clinical records; care plans lacked dates on changes and medication administration documentation incomplete.
Failed to ensure smoke separation doors in sprinklered building close and latch properly to resist passage of smoke.
Failed to provide smoke separation and protection for hazardous areas by providing doors that close and latch within the door frame.
Failed to post delayed egress signage on magnetically locked main entrance doors.
Failed to provide automatic sprinkler protection coverage for all portions of the building including newly remodeled areas.
Failed to maintain latching device on soiled linen chute door and intake door in corridor allowing fire spread.
Failed to maintain facility free from highly flammable curtains or provide flame retardant rating for curtains in therapy area.
Failed to secure oxygen bottles in resident rooms and failed to prevent oxygen-enriched atmosphere.
Failed to provide current inspection certification for boilers.
Failed to post 'oxygen in use' signs in areas where oxygen is used or stored.
Failed to provide remote audible annunciator for emergency generator at a work site readily observable by staff at all times.
Failed to ensure electrical wiring and equipment installed in accordance with NFPA 70; presence of damaged electrical outlets and unauthorized power strips.
Report Facts
Residents sampled: 23
Non-sampled residents: 4
Facility census: 96
Medication administration observed: 40
Medication errors observed: 2
Residents affected by smoke door issue: 45
Residents affected by smoke separation door issue: 54
Residents affected by flammable curtains: 13
Residents affected by unsecured oxygen: 30
Residents affected by lack of oxygen signage: 20
Residents affected by electrical issues: 61
Residents affected by hand hygiene deficiency: 17
Residents affected by housekeeping deficiencies: 47
Residents affected by dignity clothing issue: 1
Residents affected by complaint investigation deficiencies: 3
Residents affected by pressure ulcer care deficiencies: 2
Residents affected by medication documentation deficiencies: 3
Residents affected by medication error rate: 1
Residents affected by significant medication errors: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-E | Licensed Practical Nurse | Named in medication documentation and medication disposal findings |
| LPN-R | Licensed Practical Nurse | Named in medication error finding |
| LPN-H | Licensed Practical Nurse | Named in medication cart security and medication administration findings |
| DON | Director of Nursing | Named in multiple findings including medication documentation, complaint investigations, care planning, infection control, and medication disposal |
| MD | Maintenance Director | Named in housekeeping and maintenance findings |
| ADM | Administrator | Named in housekeeping and maintenance findings and life safety interviews |
| HRN Q | Hospice Registered Nurse | Named in hospice care and depression findings |
| LPN-A | Licensed Practical Nurse | Named in pressure ulcer assessment findings |
| NA-C | Nursing Assistant | Named in skin care and infection control findings |
| NA-D | Nursing Assistant | Named in skin care and infection control findings |
Inspection Report
Plan of Correction
Census: 109
Deficiencies: 3
Date: Oct 22, 2010
Visit Reason
The document is a plan of correction submitted by Golden Livingcenter - Omaha in response to deficiencies cited during a survey conducted on 10/22/2010.
Findings
The facility was found deficient in several areas including failure to follow physician orders for residents, medication administration errors with an 11.5% error rate, and nurse aide competency related to gait belt use. Specific residents were cited for medication and care deficiencies.
Deficiencies (3)
Failure to ensure physician orders were followed for Resident 3 regarding lactulose administration.
Medication error rate exceeded 5%, with 3 errors out of 26 medications observed, resulting in an 11.5% error rate.
Failure to ensure nurse aides demonstrated competency in skills and techniques necessary for resident care, specifically regarding gait belt use.
Report Facts
Total census: 109
Medication error rate: 11.5
Medications observed: 26
Medication errors: 3
Notice
Capacity: 155
Deficiencies: 0
Date: APP2015
Visit Reason
This document serves as a license renewal confirmation for Golden LivingCenter - Omaha and includes an occupancy permit issued by the Nebraska State Fire Marshal.
Findings
The facility is licensed as a Skilled Nursing Facility with a total licensed capacity of 155 beds. The occupancy permit was issued on 2014-03-18 by the State Fire Marshal.
Report Facts
Licensed capacity: 155
Renewal fees: 1750
Notice
Capacity: 155
Deficiencies: 0
Date: APP2017
Visit Reason
The document serves as a renewal application and verification of licensure for Omaha Metro Care and Rehabilitation Center, LLC, including confirmation of licensed beds and occupancy permit.
Findings
The documents confirm that Omaha Metro Care and Rehabilitation Center, LLC is licensed as a Skilled Nursing Facility with 155 beds, dual certified for Medicare and Medicaid, and holds a valid occupancy permit issued by the Nebraska State Fire Marshal.
Report Facts
Total licensed beds: 155
Occupancy permit maximum beds: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Sealer | Administrator | Named in the renewal application as facility administrator |
| Kalinda Thiede | Director of Nursing | Named in the renewal application as director of nursing |
| Joseph Schwartz | Authorized Representative | Signed renewal application and listed as 50% member of the facility |
| Rosie Schwartz | Authorized Representative | Signed renewal application and listed as 50% member of the facility |
| Brandon Augustyniak | CFO | Named as CFO of Highlite Healthcare Management, LLC, the management company for the facility |
Document
Capacity: 155
Deficiencies: 0
Date: APP2020
Visit Reason
The document set is related to the renewal of the nursing home license for Emerald Nursing & Rehab Omaha and includes occupancy permit details and ownership information.
Findings
The documents verify that the facility meets statutory requirements for licensure renewal and has an approved occupancy permit for a maximum of 155 beds. No inspection findings or deficiencies are reported.
Report Facts
Maximum Occupancy: 155
Renewal License Expiration Date: License expiration date is 2021-03-31 as shown on renewal card
Notice
Capacity: 155
Deficiencies: 0
Date: APP2021
Visit Reason
The document serves to verify the renewal of the SNF/NF Dual Certification license for Emerald Nursing & Rehab Omaha and includes the nursing home licensure renewal application.
Findings
The documents confirm that Emerald Nursing & Rehab Omaha meets statutory requirements for licensure renewal and provide details on ownership, services offered, and occupancy permit.
Report Facts
Total licensed capacity: 155
Renewal license fees: 1950
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Walden | Authorized Representative | Signed nursing home licensure renewal application |
| Yisroel Chafetz | Authorized Representative | Signed nursing home licensure renewal application |
| Jim Kenney | Deputy State Fire Marshal | Inspected facility for occupancy permit |
Notice
Capacity: 155
Deficiencies: 0
Date: APP2024
Visit Reason
This document package serves as a nursing home licensure renewal application and includes certification of license renewal, ownership information, and occupancy permit details for Emerald Nursing & Rehab Omaha.
Findings
The documents confirm the facility's licensure renewal status, ownership details, and maximum licensed bed capacity. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 155
Renewal license expiration date: Expires 03/31/2024 as stated on renewal application.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristina Pledge | Administrator | Named in renewal application as facility administrator. |
| LeAndrea Haynes-Bowman | Director of Nursing | Named in renewal application as director of nursing. |
| Jacob I Walden | Authorized Representative | Signed renewal application as authorized representative. |
| Yisroel I Chafetz | Authorized Representative | Signed renewal application as authorized representative and listed as managing partner. |
| Susen Lindner | Deputy State Fire Marshal | Inspected facility for occupancy permit. |
Notice
Capacity: 155
Deficiencies: 0
Date: APP2025
Visit Reason
This document serves as a renewal application for the nursing home license of Emerald Nursing & Rehab Omaha, including verification of licensure and occupancy permit details.
Findings
The documents confirm that Emerald Nursing & Rehab Omaha meets statutory requirements for licensure renewal and holds an occupancy permit for 155 beds.
Report Facts
Total licensed beds: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristina Piledge | Administrator | Named as Administrator on the Nursing Home Licensure Renewal Application. |
| Liberty Annette Knudsen | Director of Nursing | Named as Director of Nursing on the Nursing Home Licensure Renewal Application. |
| Ty Hernes | Deputy State Fire Marshal | Inspected the facility and approved the occupancy permit. |
Document
Capacity: 155
Deficiencies: 0
Date: CHOW2016
Visit Reason
The documents serve to issue and verify the Skilled Nursing Facility license for Omaha Metro Care and Rehabilitation Center, LLC, including renewal verification and occupancy permit issuance.
Findings
The documents confirm the facility's licensure status, ownership, and compliance with occupancy regulations, including a fire marshal occupancy permit for 155 beds.
Report Facts
Number of beds licensed: 155
Occupancy permit date: Mar 14, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Sealer | Administrator | Named as facility administrator in licensure application |
| Kalinda Thiede | Director of Nursing | Named as director of nursing in licensure application |
| Courtney N. Phillips | Chief Executive Officer | Signed licensing documents as CEO of Department of Health and Human Services |
| Becky Wisell | Administrator, Licensure Unit | Signed licensing correspondence |
| Alan Viox | Deputy State Fire Marshal | Inspected and approved occupancy permit |
Document
Capacity: 174
Deficiencies: 0
Date: CHOW2025
Visit Reason
The documents pertain to the issuance of a new Skilled Nursing Facility license due to a change of ownership and include licensure application and certification materials for Emerald Nursing & Rehab Omaha.
Findings
No inspection findings or deficiencies are reported. The documents confirm licensure, ownership, and facility capacity information.
Report Facts
Total licensed beds: 174
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chris Sobrilsky | Administrator | Named as Administrator on the Nursing Home Licensure Application and in ownership confirmation letter. |
| Kelli Gregerson | Director of Nursing | Named as Director of Nursing on the Nursing Home Licensure Application. |
| Timothy Tesmer | Chief Medical Officer | Signed the license issuance letter from the Department of Health and Human Services. |
| Lisa Osborne | Administrator | Listed as Administrator of Health Facilities Licensure Unit on license issuance letter. |
| Yisroel Chafetz | Manager | Signed the Nursing Home Licensure Application as authorized representative and mentioned in ownership confirmation letter. |
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