Inspection Reports for Gold Crest Retirement Center
200 LEVI LANE, ADAMS, NE, 68301
Back to Facility ProfileDeficiencies (last 14 years)
Deficiencies (over 14 years)
6.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% worse than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
67% occupied
Based on a February 2019 inspection.
Census over time
Inspection Report
Renewal
Capacity: 52
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related certification and licensing documents for Gold Crest Retirement Center, indicating the purpose is to renew the facility's license and certifications.
Findings
The documents confirm that Gold Crest Retirement Center meets statutory requirements for licensure renewal as a Skilled Nursing Facility with specialized care units including Alzheimer's/Special Care. The renewal application includes facility details, ownership, certifications, and staffing plans.
Report Facts
Total licensed beds: 52
Maximum capacity for Alzheimer's beds: 8
Renewal license fees: 1750
Staff-to-resident ratio: 8
Medication aide hours: 40
Shift hours: 8
Daily flat rate: 276
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer D. Graff | Administrator | Named as administrator on the renewal application and Alzheimer's unit disclosure. |
| Kili Krauter | Director of Nursing | Named as Director of Nursing on the renewal application. |
| Henry "Chris" Gramann | President | Named as President of the Board of Directors. |
| Julie Kealy | Secretary/Treasurer | Named as Secretary/Treasurer of the Board of Directors. |
Inspection Report
Renewal
Capacity: 35
Deficiencies: 0
Date: May 18, 2023
Visit Reason
The document is a renewal application and related licensing documentation for Gold Crest Retirement Center's assisted-living facility license renewal.
Findings
The documents confirm that Gold Crest Retirement Center meets statutory requirements for an assisted-living facility license renewal with a maximum capacity of 35 beds. The renewal application was completed and signed by authorized representatives.
Report Facts
Total number of beds: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Graff | Administrator | Named as administrator on the renewal application |
| Henry Gramann | Authorized Representative | Signed the renewal application |
| Julie Kealy | Authorized Representative | Signed the renewal application and listed as Secretary/Treasurer on Board of Directors |
Inspection Report
Renewal
Capacity: 35
Deficiencies: 0
Date: Mar 30, 2021
Visit Reason
The document is a renewal licensure application and verification for Gold Crest Retirement Center, an assisted-living facility, to confirm the facility's license renewal and compliance with statutory requirements.
Findings
The facility is licensed as an assisted-living facility with a total licensed capacity of 35 beds. The renewal application was completed and signed on 2021-03-30, and the occupancy permit was issued on 2020-09-11 with no deficiencies or violations noted in the provided documents.
Report Facts
Total licensed beds: 35
Renewal application date: Mar 30, 2021
Occupancy permit date: Sep 11, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Fritzen | Administrator | Named in renewal licensure application |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 6, 2020
Visit Reason
An unannounced visit was conducted to investigate a complaint that the facility fails to protect residents from infection.
Complaint Details
The complaint alleged failure to protect residents from infection. The complaint was not substantiated as the facility was found compliant.
Findings
The facility was found to protect residents from infection. Interviews and record reviews confirmed that recommended interventions were implemented, staff training and competencies were completed, and the facility was in compliance with related regulatory requirements.
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
Annual Inspection
Census: 35
Capacity: 52
Deficiencies: 18
Date: Feb 27, 2019
Visit Reason
An unannounced visit was conducted to investigate an annual survey at Gold Crest Retirement Center from February 27, 2019 to March 5, 2019 by the Department of Health and Human Services Division of Public Health.
Findings
The facility was found to be in compliance with protecting residents from adverse behaviors. However, multiple deficiencies were identified including failure to include advance directives in care plans, unclean restroom vents, inaccurate assessments, unsecured chemicals, unsafe hot equipment, bedrail issues, drug regimen irregularities, food safety concerns, infection control lapses, emergency preparedness deficiencies, and fire safety code violations.
Deficiencies (18)
Failed to ensure residents' advance directives were included in the Comprehensive Care Plan.
Restroom vent fans were covered with dust and brown fuzzy substance.
MDS assessment inaccurately coded swallowing/nutritional status for weight loss.
Chemicals were not secured, and hot equipment was accessible to residents with cognitive impairment.
Bedrail assessment and consent were not completed; mattress holder missing causing entrapment risk.
Drug allergies for one resident did not match between electronic and paper records.
Glucose test strips were not labeled with the date opened, risking use of expired strips.
Food service equipment and ventilation system covers were dirty; hair restraints did not fully contain hair.
Infection control lapses including improper hand hygiene, glove use, and linen storage below required height.
Emergency generator diesel fuel was not tested annually for quality.
Snow and ice were not removed from sidewalks, impeding emergency egress.
Magnetically locked doors in Memory Care Unit lacked posted exit codes.
Hazardous area doors failed to close and latch properly; unsealed sprinkler penetration present.
Sprinkler heads were covered with dust.
Corridor doors failed to latch properly and were obstructed.
Electrical disconnect panels were obstructed by stored items.
Fire doors were not inspected and tested annually as required.
Essential electrical system diesel fuel was not tested annually for quality.
Report Facts
Facility census: 35
Total licensed capacity: 52
Weight loss percentage: 11.33
Weight loss percentage: 13
BIMS score: 11
BIMS score: 4
Number of residents affected by unclean restroom vents: 4
Number of residents affected by unsecured chemicals: 7
Number of residents affected by unsafe hot equipment: 7
Number of residents affected by infection control lapses: 3
Number of residents affected by drug allergy discrepancy: 1
Number of residents affected by expired glucose strips: 3
Number of residents affected by hair restraint issues: 34
Number of residents affected by snow and ice on sidewalks: 50
Number of beds: 53
Number of beds: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Fritzen | Administrator | Named in cover letter and civil rights compliance form |
| Connie Vogt | RN, BSN, Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed cover letter |
| Maintenance Staff A | Maintenance Supervisor | Interviewed regarding generator fuel testing, snow removal, door issues, electrical panel obstructions, sprinkler maintenance |
| RN-E | Registered Nurse | Observed performing wound care and glucose testing with infection control lapses |
| LPN-J | Licensed Practical Nurse | Interviewed about glucose meter cleaning and allergy documentation |
| MDS Coordinator | Interviewed about advance directives, allergy documentation, and infection control | |
| Dietary Manager | Interviewed about food safety and hair restraint issues | |
| NA-A and NA-B | Nursing Assistants | Observed performing peri care with glove and hand hygiene lapses |
| MA-F | Medication Aide | Observed leaving steam table unattended |
| Administrator | Interviewed about chemical storage and snow removal policy |
Inspection Report
Renewal
Capacity: 52
Deficiencies: 0
Date: Feb 11, 2019
Visit Reason
This document is related to the renewal of the nursing home license for Gold Crest Retirement Center, verifying licensure and compliance with state regulations.
Findings
The document confirms that Gold Crest Retirement Center meets statutory requirements for licensure renewal as a Skilled Nursing Facility/Nursing Facility with a licensed capacity of 52 beds. It includes certification of occupancy and detailed information about the Alzheimer's/Special Care Unit and memory care services.
Report Facts
Licensed capacity: 52
Maximum endorsed capacity: 8
Rug Rate surcharge: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Fritzen | Administrator | Named as facility administrator and authorized representative on renewal application and Alzheimer's disclosure |
| Michelle Denker | Director of Nursing | Named as Director of Nursing on renewal application |
Inspection Report
Renewal
Capacity: 52
Deficiencies: 0
Date: Feb 15, 2018
Visit Reason
This document is a Nursing Home Licensure Renewal Application and related certification and occupancy permit for Gold Crest Retirement Center, verifying licensure renewal and certification status.
Findings
The facility is licensed as a Skilled Nursing Facility with a total licensed capacity of 52 beds. The renewal application confirms the facility's services including physical therapy, occupational therapy, speech therapy, and Alzheimer's/Special Care Unit. The occupancy permit confirms compliance with fire safety codes.
Report Facts
Licensed beds: 52
Maximum endorsed capacity: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Fritzen | Administrator | Named as Administrator on renewal application and Alzheimer's Special Care Unit Disclosure |
| Michelle Denker | Director of Nursing | Named as Director of Nursing on renewal application |
| Susen Lindner | Deputy State Fire Marshal | Inspected the facility for occupancy permit |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 26, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Gold Crest Retirement Center regarding allegations that the facility fails to ensure residents are free from abuse.
Complaint Details
The complaint allegation was that the facility fails to ensure residents are free from abuse. The investigation found this to be true but no tag was written due to the facility's corrective plan.
Findings
The facility failed to ensure residents are free from abuse. Records were reviewed and staff interviews conducted related to the allegations. The facility recognized the problem and implemented a plan to prevent reoccurrence.
Deficiencies (1)
Failure to ensure residents are free from abuse.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed the report and is the author of the findings letter. |
Inspection Report
Life Safety
Census: 37
Capacity: 52
Deficiencies: 9
Date: Nov 16, 2017
Visit Reason
The facility underwent a Life Safety Code inspection to assess compliance with fire safety regulations and related National Fire Protection Association standards.
Findings
The facility was found not in compliance with several fire safety requirements including maintenance of fire doors, egress door locking devices, hazardous area door enclosures, sprinkler system maintenance, corridor door integrity, smoke barrier door gaps, electrical junction box covers, and oxygen cylinder storage. Multiple deficiencies were identified that could affect resident safety.
Deficiencies (9)
Failed to maintain fire doors in a two-hour fire barrier separating Long Term Care and Assisted Living; west fire door failed to close and latch.
Use of unapproved locking device on egress door in Memory Care Living Room; manual thumb turn lock did not release upon fire alarm activation.
Doors to hazardous areas were not smoke tight; unsealed penetrations in fire rated door to 300 File Room.
Sprinkler heads in kitchen covered in corrosion, risking failure to activate during fire.
Incomplete fire watch policy regarding sprinkler system impairment notifications and procedures.
Corridor room doors failed to resist passage of smoke and were obstructed; doors to LTC and AL dining rooms failed to latch and were blocked by drink carts.
Smoke barrier doors had gaps greater than 1/8 inch allowing smoke passage between compartments.
Electrical junction box in attic above kitchen suppression system lacked approved cover.
Oxygen cylinders in storage room were not labeled as full or empty and empty cylinders were not segregated from full cylinders.
Report Facts
Facility census: 37
Total licensed capacity: 52
Number of sprinkler heads corroded: 8
Number of smoke compartments: 6
Number of residents affected by egress door locking deficiency: 8
Number of residents affected by oxygen cylinder storage deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Staff A | Confirmed multiple fire safety deficiencies including fire door maintenance, egress door locking, sprinkler corrosion, open junction box, and oxygen storage issues. | |
| Maintenance Supervisor | Responsible for corrective actions including inspections, adjustments, and monitoring of fire doors, sprinkler heads, junction boxes, and oxygen storage. |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Nov 9, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint at Gold Crest Retirement Center regarding fall interventions and evaluation of causal factors for falls.
Complaint Details
The complaint alleged failure to change fall interventions after residents were identified at risk, failure to ensure interventions were in place for residents at risk, and failure to evaluate causal factors for falls. The facility was found non-compliant only for failure to ensure interventions were in place.
Findings
The facility failed to ensure interventions were in place for residents at risk for falls, resulting in a violation of Federal and State regulations. However, the facility did change fall interventions after residents were identified at risk and did evaluate causal factors for falls, with no violations found in those areas.
Deficiencies (1)
Facility failed to implement interventions to prevent the potential for falls for one of three sampled residents (Resident 1).
Report Facts
Facility census: 40
Sampled residents: 3
Fall date: Oct 20, 2016
Intervention date: Dec 21, 2015
Correction date: Nov 14, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed letter regarding complaint investigation findings |
| Jeff Fritzen | Administrator | Administrator of Gold Crest Retirement Center addressed in the letter |
| Nursing Assistant A | Interviewed regarding Resident 1's fall interventions | |
| Director of Nursing | Interviewed confirming care plan interventions for Resident 1 |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 1
Date: Oct 5, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Gold Crest Retirement Center from October 5, 2016 to October 13, 2016. The investigation focused on the facility's failure to complete written investigations within five working days and failure to report significant injuries as potential instances of abuse/neglect within 24 hours.
Complaint Details
The complaint alleged that the facility fails to complete written investigations within five working days. The investigation confirmed failure to report significant injuries as potential abuse/neglect within 24 hours, violating federal regulations.
Findings
The facility failed to report fractures as potential instances of abuse/neglect for two residents and did not comply with reporting requirements. The facility was not found in compliance at the time of the investigation.
Deficiencies (1)
The facility failed to report fractures as potential instances of abuse/neglect for two residents (Residents 8 and 35).
Report Facts
Facility census: 39
Deficiency completion date: Nov 4, 2016
Fire drill documentation missing quarters: 2
Facility census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Fritzen | Administrator | Named as facility administrator in the report |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit | Signed the complaint investigation letter |
| Social Services Director | Interviewed about reporting requirements related to abuse/neglect | |
| Maintenance A | Interviewed and verified findings related to fire drill documentation and fire extinguisher maintenance |
Inspection Report
Routine
Deficiencies: 0
Date: Aug 2, 2016
Visit Reason
The inspection was conducted as a Compliance Inspection to assess the facility's adherence to the regulations governing licensure of Assisted-Living Facilities.
Findings
The facility was found in compliance with the regulations, and the results of the Compliance Inspection were commendable.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Wehrs | Registered Nurse | Conducted the Compliance Inspection |
| Victoria Smith | Registered Nurse | Conducted the Compliance Inspection |
| Rebecca Young | Registered Nurse | Conducted the Compliance Inspection |
Inspection Report
Routine
Deficiencies: 0
Date: Aug 2, 2016
Visit Reason
The inspection was conducted as a Compliance Inspection to assess the facility's adherence to the Regulations Governing Licensure of Assisted-Living Facilities.
Findings
The facility was found in compliance with the applicable regulations, and the results of the Compliance Inspection were commendable.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Wehrs | Registered Nurse | Conducted the Compliance Inspection |
| Victoria Smith | Registered Nurse | Conducted the Compliance Inspection |
| Rebecca Young | Registered Nurse | Conducted the Compliance Inspection |
Inspection Report
Routine
Census: 43
Deficiencies: 17
Date: Oct 13, 2015
Visit Reason
Routine inspection of Gold Crest Retirement Center to assess compliance with state and federal regulations including resident care and life safety code standards.
Findings
The facility was found deficient in multiple areas including failure to notify physician of resident's abnormal bleeding, failure to protect resident dignity by posting care instructions without permission, life safety code violations such as improper interior finish materials, fire door latching issues, inadequate emergency lighting, fire alarm system deficiencies, and oxygen safety concerns.
Deficiencies (17)
Failed to notify physician of abnormal bleeding for one resident using anticoagulants.
Failed to protect dignity and privacy of residents by posting individualized care instructions in public view without permission.
Failed to provide documentation for flame spread rating of wooden wall divider and fabric quilt in chapel area.
Failed to assure that corridor doors latch properly to contain fire and smoke.
Failed to ensure smoke separation doors resist passage of smoke and properly latch.
Failed to maintain doors to hazardous areas so they latch within door frame.
Failed to maintain exit doors so delayed egress hardware releases with required force and failed to provide signage.
Failed to provide and verify illumination of exit discharge so failure of any single bulb does not leave area in darkness.
Failed to provide emergency lighting of at least 1.5 hour duration and failed to conduct annual test of emergency lights.
Failed to provide exit sign for second required exit in exit corridor.
Failed to hold fire drills at unexpected times under varying conditions at least quarterly on each shift.
Failed to provide fire alarm notification devices in interior courtyard, N Zone room, and AL entrance corridor.
Failed to ensure 100% of fire alarm heat detectors were tested annually or replaced after 15 years and contractor used incomplete inspection forms.
Failed to maintain sprinkler heads free from obstructions and failed to assure sprinkler heads were installed within openings provided.
Failed to assure hood suppression system was inspected every six months as required.
Failed to provide manual shutdown button for generator in remote area from generator.
Failed to protect against creation of oxygen enriched atmosphere by leaving oxygen concentrator running in unoccupied resident room.
Report Facts
Facility census: 43
Resident census: 43
Bruise size: 7
Bruise size increased: 11
Occupant load: 92
Occupant load: 54
Occupant load: 93
Fire drills: 4
Heat detectors: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Interviewed regarding monitoring residents on anticoagulants |
| RN B | Registered Nurse | Interviewed regarding monitoring residents on anticoagulants |
| DON | Director of Nursing | Interviewed regarding notification of physician and care plan documentation |
| DOR | Director of Rehabilitation | Interviewed regarding posting of care instruction signs |
| Administrator A | Interviewed regarding fire door issues, fire alarm, emergency lighting, and other deficiencies | |
| Maintenance A | Interviewed regarding fire door issues, fire alarm, emergency lighting, and other deficiencies |
Inspection Report
Life Safety
Census: 44
Deficiencies: 2
Date: Dec 22, 2014
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, specifically focusing on cooking facilities and emergency generator maintenance.
Findings
The facility failed to seal range hood penetrations allowing grease accumulation, which did not affect residents but was a code violation. Additionally, the emergency generator was not maintained according to NFPA 110 standards, with missing documentation for weekly inspections, increasing the risk of failure during power loss.
Deficiencies (2)
Facility failed to seal range hood penetrations allowing grease accumulation.
Facility failed to maintain emergency generator with required weekly inspections and documentation.
Report Facts
Facility census: 44
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance A | Confirmed findings related to range hood penetrations and generator testing documentation |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 13
Date: Nov 10, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Gold Crest Retirement Center on November 4, 2014-November 10, 2014, including allegations related to misappropriation and resident care.
Complaint Details
The complaint investigation focused on allegations that the facility failed to protect residents from misappropriation and failed to educate residents or family on preventing misappropriation. The investigation found no concerns related to misappropriation or education on prevention.
Findings
The facility was found to protect residents from misappropriation and educate residents and families on preventing misappropriation. Deficiencies were identified related to dignity and respect of individuality, housekeeping and maintenance, urinary incontinence care, range of motion services, fall prevention, food safety, infection control, laboratory services, and life safety code violations.
Deficiencies (13)
Failed to ensure the dignity of two residents related to positioning and hygiene.
Failed to keep the caulking around the base of the toilets clean and in good repair in 8 resident rooms.
Failed to assess causal factors and implement interventions to minimize urinary incontinence for one resident.
Failed to identify the need for and implement range of motion for one resident with contractures and failed to ensure range of motion was implemented as needed for another resident.
Failed to ensure the resident environment remains free of accident hazards and provide adequate supervision and assistance devices to prevent accidents for one resident.
Failed to ensure food was prepared and served in a sanitary manner, including improper thermometer use and utensil handling.
Failed to ensure the arm bike and mechanical lifts were sanitized between resident use.
Failed to provide or obtain laboratory services only when ordered by the attending physician; missed PT/INR testing for one resident.
Failed to separate hazardous areas from the exit corridor in 1 of 6 smoke compartments.
Failed to maintain a horizontal exit free of penetrations allowing smoke and fire migration.
Failed to seal range hood penetrations allowing grease accumulation.
Failed to maintain emergency generator inspection and testing documentation weekly as required.
Failed to use electrical equipment in accordance with National Electrical Code; power strip not plugged directly into wall outlet.
Report Facts
Facility census: 43
Deficiencies cited: 12
Residents affected by dignity deficiency: 2
Resident affected by urinary incontinence deficiency: 1
Residents affected by range of motion deficiency: 2
Resident affected by fall prevention deficiency: 1
Residents affected by infection control deficiency: 3
Residents requiring mechanical lift: 14
Facility census for fire safety inspection: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed complaint investigation letter |
| Gerald Nevins | Registered Nurse | Complaint investigation team member |
| Sherri Lovelace | Registered Nurse | Complaint investigation team member |
| Kathleen Philippi | Registered Nurse | Complaint investigation team member |
| Victoria Smith | Registered Nurse | Complaint investigation team member |
| Rebecca Young | Registered Nurse | Complaint investigation team member |
| LPN M | Licensed Practical Nurse | Interviewed regarding dignity and urinary incontinence findings |
| Maintenance A | Interviewed regarding fire safety and generator maintenance findings | |
| Restorative Aide E | Interviewed regarding range of motion and infection control findings | |
| Nursing Assistant F | Observed and interviewed regarding mechanical lift sanitation | |
| Nursing Assistant G | Observed and interviewed regarding mechanical lift sanitation | |
| Nursing Assistant H | Observed transferring resident with mechanical lift | |
| Nursing Assistant I | Observed transferring resident with mechanical lift | |
| MA-A | Medication Aide | Observed providing perineal care to Resident 53 |
| NA-B | Nurse Aide | Observed providing perineal care to Resident 53 |
| MA-C | Medication Aide | Interviewed regarding toileting of Resident 53 |
| NA-D | Nurse Aide | Observed providing perineal care to Resident 53 |
| Charge Nurse | Responsible for assessing fall causal factors and updating care plans | |
| CDM | Responsible for dietary inservice and QA on thermometer and utensil use | |
| DON | Director of Nursing | Interviewed regarding multiple findings and responsible for monitoring corrections |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 8
Date: Jan 14, 2014
Visit Reason
The facility underwent an annual inspection to assess compliance with licensure regulations, life safety code standards, and resident care requirements.
Findings
The inspection identified multiple deficiencies including failure to ensure direct care staff registry and background checks, inadequate range of motion treatment for a resident, unsafe water temperatures in resident sinks, fall hazards related to unsecured benches, and several life safety code violations such as unsealed smoke barriers, improperly installed smoke doors, hazardous storage room door without automatic closure, obstructed sprinkler heads, and unsafe electrical wiring.
Deficiencies (8)
Failed to ensure direct care staff were screened for registry and background checks for 3 of 5 personnel files reviewed.
Failed to provide appropriate treatment to prevent decrease in range of motion for a resident with limited range of motion.
Failed to protect residents from potential accidents related to high water temperatures in 5 resident room sinks and falls related to unsecured benches.
Failed to provide smoke barriers with at least ½ hour fire resistance rating for 2 of 7 smoke barriers.
Failed to provide smoke compartment doors that resist passage of smoke for 2 of 7 sets of smoke compartment doors.
Failed to separate a hazardous area from the exit corridor with an automatic closure on the door.
Failed to maintain sprinkler heads properly; one sprinkler head was obstructed by a light fixture and one sprinkler escutcheon was missing.
Failed to use electrical wiring in accordance with NFPA 70; damaged power cord, improper use of power strips, and daisy chaining of power strips.
Report Facts
Facility census: 41
Facility census: 42
Number of personnel files reviewed: 5
Number of smoke barriers inspected: 7
Number of smoke compartment doors inspected: 7
Number of smoke compartments inspected: 6
Number of resident room sinks with high water temperature: 5
Water temperature: 121
Water temperature: 128.6
Water temperature: 127.9
Water temperature: 129.2
Water temperature: 127.6
Resident fall assessment score: 12
Resident cognitive status score: 6
Inspection Report
Routine
Census: 40
Deficiencies: 1
Date: May 28, 2013
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in a skilled nursing facility, specifically related to the assessment of a resident after an unwitnessed fall with potential head injury.
Findings
The facility failed to assess Resident 4 for a change in condition after an unwitnessed fall, despite the resident being at risk for bleeding due to anticoagulant use and having a history of multiple falls. Neurological assessments were not initiated as required by facility policy.
Deficiencies (1)
Failed to assess one resident for a change in condition after an unwitnessed fall with potential head injury.
Report Facts
Facility census: 40
Falls: 6
Date of fall: May 7, 2013
Plan of correction completion date: Jun 21, 2013
Inspection Report
Annual Inspection
Census: 40
Capacity: 52
Deficiencies: 9
Date: Sep 27, 2012
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulations governing licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities, including medication administration and life safety code standards.
Findings
The facility failed to maintain medication error rates below 5%, with an observed error rate of 11.53% affecting three residents. Additionally, multiple life safety code deficiencies were identified, including unsealed penetrations in mechanical rooms, improper door closures and seals on smoke barriers, lack of proper signage on exit doors, failure to maintain emergency lighting testing, and inadequate smoke detector sensitivity testing.
Deficiencies (9)
Medication error rate of 11.53% due to medications given before breakfast contrary to physician orders for Residents 39, 36, and 64.
Unsealed holes around pipes and conduits in the 500 Hall Mechanical room.
Exit doors from Memory Care Wing and Commons area had delayed egress locking devices without required signage.
Smoke separation doors by Skilled Dining rooms failed to close completely and seal properly.
Failed to maintain doors in smoke barriers to be rated and automatic closing affecting two of four smoke compartments.
Emergency lighting testing and documentation were not conducted monthly or annually as required.
Failed to maintain and test smoke detectors for sensitivity as required.
Failed to maintain sprinkler coverage in one of four smoke compartments due to missing ceiling tiles.
Double fire doors in Memory Care wing failed to resist passage of smoke due to gaps and lack of astragal.
Report Facts
Medication observations: 52
Medication errors: 6
Resident sample size: 30
Facility census: 40
Facility total capacity: 52
Facility census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Acknowledged medication errors during interview on 9/29/12 | |
| Maintenance Staff A | Confirmed failure of sealing penetrations and verified observations related to fire safety | |
| Jim Heine | Approved plan of correction on 10/31/2012 |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Feb 28, 2012
Visit Reason
The inspection was conducted to investigate allegations of abuse, neglect, or mistreatment involving a resident with an injury of unknown origin.
Complaint Details
The complaint investigation found that the facility did not report an injury of unknown origin for Resident 1 and failed to conduct a complete written investigation of the incident. The injury was a 15 cm x 10 cm bruise and an acute humerus fracture. The facility did not notify the state health agency as required.
Findings
The facility failed to report an injury of unknown origin for one sampled resident and did not document a full investigation of the incident. The resident had a severe arm bruise and fracture, but the facility did not report the injury to the state health agency or complete a written investigation.
Deficiencies (1)
Failure to report an injury of unknown origin for one resident and failure to document a full investigation of the incident.
Report Facts
Facility census: 38
Sample size: 4
Bruise size: 15
Bruise size: 10
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 5
Date: Aug 24, 2011
Visit Reason
The inspection was conducted to investigate allegations related to missing money reported by Resident 55 and to assess the facility's compliance with reporting and investigation procedures for lost or stolen resident property.
Complaint Details
The complaint investigation was substantiated. Resident 55 reported missing $60 that was not properly investigated or reported by the facility. The facility census was 39 at the time of the investigation.
Findings
Surveyors found that Resident 55 reported missing $60 which was not properly investigated or reported to the State Agency or APS. The facility failed to investigate and report the allegation of missing money and lacked proper procedures for reporting missing resident property. Additionally, the facility failed to ensure hazardous chemicals and sharps were secured, posing safety risks to residents.
Deficiencies (5)
Failed to investigate and report an allegation of missing money for Resident 55.
Failed to ensure hazardous chemicals, disposable razors, scissors, and a blanket warming unit were not accessible to confused and independently mobile residents.
Failed to provide separation of hazardous areas from other compartments by not providing self-closing doors and allowing unsealed penetrations in separation walls.
Failed to maintain the sprinkler system in reliable operating condition and free of foreign material.
Failed to ensure electrical wiring and equipment were installed and used in accordance with National Electric Code by allowing use of unapproved power taps.
Report Facts
Resident sample size: 28
Facility census: 39
Missing money amount: 60
Number of confused and independently mobile residents: 6
Number of smoke compartments affected: 1
Facility census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Fritzen | Executive Director | Signed plan of correction and addendum |
| Michelle Denker | Director of Nursing | Responsible for weekly audits to ensure bath house door is locked and hazardous items secured |
Inspection Report
Plan of Correction
Census: 41
Deficiencies: 1
Date: Aug 9, 2010
Visit Reason
The inspection was conducted to assess the accuracy and coordination of Minimum Data Set (MDS) assessments and nursing restorative programs as part of regulatory compliance for Gold Crest Retirement Center.
Findings
The facility failed to ensure that MDS assessments were coded accurately and that residents were correctly placed on nursing restorative programs for eating, swallowing, communication, dressing, grooming, and splint/brace assistance. Documentation and program minutes were missing or inaccurate for several residents.
Deficiencies (1)
The assessment must accurately reflect the resident's status; a registered nurse must conduct, coordinate, sign, and certify each assessment. The facility failed to ensure MDS assessments were coded accurately for residents and that restorative programs were properly documented.
Report Facts
Facility census: 41
Sample size: 11
Corrective action completion date: Sep 23, 2010
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS coordinator | Named in relation to re-education of restorative nursing staff and review of MDS sections for accuracy | |
| Restorative Aide (RA) A | Interviewed regarding restorative program services and documentation |
Document
Capacity: 52
Deficiencies: 0
Visit Reason
The documents pertain to the renewal of the nursing home license for Gold Crest Retirement Center, including certification of licensure, renewal application, occupancy permit, and Alzheimer's special care unit disclosure.
Findings
The documents certify that Gold Crest Retirement Center meets statutory requirements for licensure renewal, confirm the facility's licensed bed capacity of 52, and provide detailed information about the Alzheimer's special care unit including staffing, care philosophy, and discharge criteria.
Report Facts
Total licensed beds: 52
Maximum endorsed capacity for Alzheimer's unit: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Fritzen | Administrator | Named as administrator on the renewal application and Alzheimer's Special Care Unit Disclosure. |
| Michelle Denker | Director of Nursing | Named as Director of Nursing on the renewal application. |
| Gary J. Amihone, MD | Chief Medical Officer, Director, Division of Public Health | Signed the licensure certification. |
Document
Capacity: 52
Deficiencies: 0
Visit Reason
The documents pertain to the renewal of the nursing home license for Gold Crest Retirement Center and related administrative information including occupancy permit and Alzheimer's special care unit disclosure.
Findings
No inspection findings or deficiencies are reported. The documents include licensing renewal application details, facility capacity, ownership information, occupancy permit, floor plan, and Alzheimer's care unit disclosure.
Report Facts
Total licensed beds: 52
Maximum capacity for Alzheimer's beds: 8
Occupancy permit date: 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Graff | Administrator | Named as administrator on renewal application and Alzheimer's special care unit disclosure. |
| Kili Krauter | Director of Nursing | Named as director of nursing on renewal application. |
Notice
Capacity: 52
Deficiencies: 0
Visit Reason
The document serves as a renewal application and certification for the licensure of Gold Crest Retirement Center as a skilled nursing facility with Alzheimer's/special care services.
Findings
The documents confirm the facility meets statutory requirements for licensure renewal, including certifications for special care services and occupancy permits. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 52
Maximum capacity for Alzheimer's beds: 8
Renewal license fees: 1550
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer D. Graff | Administrator | Named as facility administrator on renewal application and Alzheimer's special care application. |
| Kili Krauter | Director of Nursing | Named as Director of Nursing on renewal application. |
| Henry C. Gramann | President | Named as President of Board of Directors. |
| Julie Kealy | Secretary/Treasurer | Named as Secretary/Treasurer of Board of Directors. |
Notice
Capacity: 52
Deficiencies: 0
Visit Reason
The documents serve to verify the licensure renewal and certification status of Gold Crest Retirement Center, including renewal of SNF/NF dual certification, occupancy permit issuance, and Alzheimer's special care unit endorsement application.
Findings
The documents confirm that Gold Crest Retirement Center meets statutory requirements for licensure renewal and certification, holds an occupancy permit for 52 beds, and has applied for renewal of Alzheimer's special care unit endorsement with a maximum endorsed capacity of 8 beds.
Report Facts
Total licensed beds: 52
Maximum endorsed capacity: 8
Renewal license expiration date: 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Fritzen | Administrator | Named as administrator and contact person on renewal application and Alzheimer's special care unit endorsement application. |
| Gary J. Anthone, MD | Chief Medical Officer, Director, Division of Public Health | Named on licensure renewal card. |
Document
Capacity: 52
Deficiencies: 0
Visit Reason
The document serves as a licensure renewal application for Gold Crest Retirement Center, including verification of license status, facility information, and supporting documentation for renewal.
Findings
The document contains no inspection findings or deficiencies; it provides administrative and operational information about the facility, including ownership, accreditation, occupancy, care philosophy, staff training, and activity schedules.
Report Facts
Total licensed beds: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Fritzen | Administrator | Named on the Nursing Home Licensure Renewal Application. |
| Michelle Denker | Director of Nursing | Named on the Nursing Home Licensure Renewal Application. |
Notice
Capacity: 52
Deficiencies: 0
Date: APP2017
Visit Reason
This document serves as a license renewal verification for Gold Crest Retirement Center and includes the Alzheimer's Special Care Unit Disclosure and Memory Care Endorsement renewal application.
Findings
The document confirms the facility's license renewal through 03/31/2018, details the Alzheimer's memory care program philosophy, criteria for placement and discharge, staffing patterns, training, physical environment, resident activities, family support, and cost of care.
Report Facts
Total licensed beds: 52
Maximum endorsed capacity: 8
Staff to resident ratio: 8
Memory care room price premium: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Fritzen | Administrator | Named as facility administrator and contact person on renewal and Alzheimer's disclosure forms |
| Michelle Denker | Director of Nursing | Named as Director of Nursing on renewal application |
| Julie Kealy | Secretary | Listed as Secretary of Coffman-Levi Charitable Trust, Inc. |
| Wes Siefkes | Board Member | Listed as Board Member of Coffman-Levi Charitable Trust, Inc. |
| Ron Sutter | Board Member | Listed as Board Member of Coffman-Levi Charitable Trust, Inc. |
| Chris Gramann | Board Member | Listed as Board Member of Coffman-Levi Charitable Trust, Inc. |
| Max Gramann | President | Listed as President of Coffman-Levi Charitable Trust, Inc. |
Notice
Capacity: 52
Deficiencies: 0
Visit Reason
This document package serves as a licensure renewal application for Gold Crest Retirement Center, including certification of licensure, occupancy permit, and Alzheimer's Special Care Unit endorsement application.
Findings
The documents verify that Gold Crest Retirement Center is licensed as a Skilled Nursing Facility with a total licensed capacity of 52 beds, all Medicare/Medicaid certified, and includes an Alzheimer's/Special Care Unit. The facility has submitted renewal paperwork and maintains compliance with state requirements.
Report Facts
Total licensed beds: 52
Maximum endorsed capacity for Alzheimer's unit: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Fritzen | Administrator | Named as administrator on licensure renewal application and Alzheimer's unit endorsement application. |
| Michelle Denker | Director of Nursing | Named as Director of Nursing on licensure renewal application. |
| Gary J. Anthone, MD | Chief Medical Officer, Director, Division of Public Health | Signed licensure certification. |
| Susan Lindner | Deputy State Fire Marshal | Inspected and approved occupancy permit. |
Notice
Capacity: 35
Deficiencies: 0
Date: APP2020
Visit Reason
This document serves to verify that Gold Crest Retirement Center is licensed as an assisted-living facility through the expiration date on the renewal card and includes the renewal application, occupancy permit, and floor plan.
Findings
The documents confirm the facility meets statutory requirements for licensure as an assisted-living facility with a licensed capacity of 35 beds and includes approval by the State Fire Marshal.
Report Facts
Total licensed beds: 35
Renewal expiration date: 2021
Notice
Capacity: 35
Deficiencies: 0
Date: APP2022
Visit Reason
This document serves as a renewal application for the assisted-living facility license of Gold Crest Retirement Center and includes the current licensure and occupancy permit information.
Findings
The document certifies that Gold Crest Retirement Center meets statutory requirements as an assisted-living facility and is licensed through the renewal date. It also includes the occupancy permit with maximum occupancy of 35 beds.
Report Facts
Total licensed beds: 35
Notice
Capacity: 35
Deficiencies: 0
Date: APP2023
Visit Reason
This document serves as a renewal application and verification that the Gold Crest Retirement Center is licensed as an assisted-living facility through the indicated renewal date.
Findings
The document confirms the facility meets statutory requirements for licensure renewal as an assisted-living facility with a licensed capacity of 35 beds.
Report Facts
Total licensed beds: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Graff | Administrator | Listed as facility administrator on renewal application |
| Henry Max Gramann | Authorized Representative | Signed renewal application as authorized representative |
| Julie E. Kealy | Authorized Representative | Signed renewal application as authorized representative |
Notice
Capacity: 35
Deficiencies: 0
Date: APP2025
Visit Reason
The document serves to verify that Gold Crest Retirement Center is licensed as an assisted-living facility through the date indicated on the renewal card and includes a renewal application for the facility license.
Findings
No inspection findings are reported; the document confirms licensure status and includes occupancy permit and facility information.
Report Facts
Total licensed beds: 35
Document
Capacity: 35
Deficiencies: 0
Date: APP2016
Visit Reason
The document serves as a licensure renewal application for the Gold Crest Retirement Center assisted-living facility, including verification of licensure and occupancy permit details.
Findings
No inspection findings or deficiencies are reported; the document confirms licensure renewal and occupancy capacity.
Report Facts
Total licensed beds: 35
Licensure renewal fee: 1650
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Fritzen | Administrator | Named as the facility administrator on the licensure renewal application. |
| Julie E. Kealy | Authorized Representative | Signed the licensure renewal application as an authorized representative. |
| Max Gramann | Authorized Representative | Signed the licensure renewal application as an authorized representative. |
Notice
Capacity: 35
Deficiencies: 0
Date: APP2018
Visit Reason
This document serves as a licensure renewal application and verification for the Gold Crest Retirement Center assisted-living facility, confirming compliance with statutory requirements and renewal of the facility license.
Findings
The documents confirm that Gold Crest Retirement Center meets statutory requirements as an assisted-living facility and is licensed for 35 beds. An occupancy permit issued by the Nebraska State Fire Marshal also authorizes a maximum occupancy of 35 beds.
Report Facts
Total licensed beds: 35
Renewal fees: 1650
Occupancy permit beds: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Fritzen | Administrator | Named as facility administrator on the renewal application |
| Julie Kealy | Secretary | Listed as Secretary on facility board member list |
| Wes Siefkes | Board Member | Listed as Board Member on facility board member list |
| Ron Sutter | Board Member | Listed as Board Member on facility board member list |
| Chris Gramann | Board Member | Listed as Board Member on facility board member list |
| Max Gramann | President | Listed as President on facility board member list |
Document
Capacity: 35
Deficiencies: 0
Date: APP2019
Visit Reason
This document serves as a licensure renewal verification and occupancy permit for Gold Crest Retirement Center, confirming the facility meets statutory requirements as an assisted-living facility and is licensed through the indicated expiration date.
Findings
The documents confirm the facility's licensure renewal status and maximum occupancy of 35 beds, with no inspection findings or deficiencies reported.
Report Facts
Total licensed beds: 35
Renewal expiration date: Licensure expiration dates noted as 4/30/2019 and 4/30/2020 on different documents.
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