Inspection Reports for Mid-Nebraska Lutheran Home
109 North 2nd Street, NEWMAN GROVE, NE, 68758
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
64% occupied
Based on a June 2018 inspection.
Census over time
Notice
Capacity: 45
Deficiencies: 0
Date: Aug 1, 2019
Visit Reason
The document serves as an official amendment to the Health Insurance Benefits Agreement to update the certified bed assignments and counts at the facility as requested by the facility.
Findings
The letter confirms changes in the certified bed locations and maintains the total number of 45 Medicare certified beds, reflecting updated room assignments effective August 8, 2019.
Report Facts
Certified beds: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager | Signed the letter as representative of the Office of Long Term Care Facilities |
Inspection Report
Renewal
Capacity: 45
Deficiencies: 0
Date: Feb 21, 2019
Visit Reason
The document is a nursing home licensure renewal application and related certification for Mid-Nebraska Lutheran Home, verifying the facility's license renewal and compliance with statutory requirements.
Findings
The facility meets statutory requirements for licensure as a Skilled Nursing Facility/Nursing Facility dual certification. The documents include detailed disclosures about Alzheimer's special care unit services, staffing, physical environment, security features, family support programs, and fee schedules.
Report Facts
Number of beds to be relicensed: 45
Maximum occupancy: 45
Daily room rates: 158
Daily room rates: 163
Daily care level rates: 20
Daily care level rates: 30
Daily care level rates: 40
Daily care level rates: 50
Daily care level rates: 60
Daily care level rates: 70
Daily care level rates: 80
Transportation attendant fee: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Caubarrus | Administrator | Named as contact and authorized representative in renewal application and Alzheimer's special care unit disclosure |
| Carol Metz | Business Office Manager | Named in room and care level rate documentation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 6, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's handling of residents at risk for falls and timeliness of investigations.
Complaint Details
The complaint alleged failure to follow and change plans of care for residents at risk for falls and failure to submit investigations within 5 working days. The investigation found the facility compliant with all allegations.
Findings
The facility was found to be in compliance with relevant regulatory requirements regarding following and changing fall prevention plans and submitting investigations within 5 working days.
Report Facts
Working days for investigation submission: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the report and is the contact person for questions. |
| Angela Caubarrus | Administrator | Facility administrator addressed in the report. |
Inspection Report
Annual Inspection
Census: 29
Capacity: 45
Deficiencies: 17
Date: Jun 4, 2018
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements including life safety, medication management, and facility maintenance.
Findings
The facility was found deficient in multiple areas including pain management, medication administration, life safety code compliance, fire safety, emergency generator maintenance, and oxygen cylinder storage. Several fire safety and electrical system deficiencies were identified, with plans of correction and waivers requested.
Deficiencies (17)
Failed to ensure pain management interventions were utilized to control Resident 2's pain.
Failed to ensure parameters were set for Resident 2's Acetaminophen and failed to ensure self-administered medications were documented per facility policy.
Allowed abrupt changes in elevation of walking surfaces in a path of egress exceeding 1/2 inch.
Failed to assure lettering for delayed egress signage was at least 1 inch and failed to provide keys for all staff for two locked exterior exit gates.
Failed to provide required emergency lighting in the Dining Room.
Failed to assure doors to hazardous areas close and latch properly, were smoke tight, and not equipped with kick downs.
Failed to assure fire alarm heat detector was maintained, found corroded.
Failed to provide sprinkler protection for fabric awning and separate Post Indicator Valve (PIV) for Long Term Care.
Failed to assure fire sprinkler installation and missing escutcheon on sprinkler head.
Failed to ensure corridor doors resist passage of smoke and were not equipped with roller latches.
Failed to ensure corridor separation doors close and latch properly and were smoke tight.
Failed to have a preventative maintenance plan to inspect and test fire doors annually.
Failed to provide a remote manual stop switch for the emergency generator outside the generator room.
Failed to conduct all required weekly inspections of the emergency generator and document all required information.
Failed to assure that an indicating light on the emergency power system annunciator panel was not lit and failed to provide an audible alarm.
Failed to verify code compliance of the fuel tank for the emergency generator; tank not listed, no containment or venting provided.
Failed to separate empty oxygen cylinders from full ones in storage.
Report Facts
Facility census: 29
Total licensed capacity: 45
Resident sample size: 19
Pain level ratings above acceptable: 38
PRN Acetaminophen doses given: 13
Facility census: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Metz | Interim Administrator | Named in waiver request documents |
| RN-I | Registered Nurse | Interviewed regarding pain management and medication administration |
| RN-E | Registered Nurse | Interviewed regarding pain management and medication administration |
| Director of Nursing | Director of Nursing | Interviewed regarding pain management and medication administration |
| Maintenance Staff A | Interviewed regarding life safety, fire safety, and electrical system deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 21, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility fails to protect residents from abuse.
Complaint Details
The complaint alleged failure to protect residents from abuse. The investigation found the allegation unsubstantiated and the facility compliant.
Findings
The facility was found to have protected residents from abuse. Reviews of records, observations, and interviews revealed no concerns, and the facility was in compliance with relevant regulatory requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed the report and identified as representative of the Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Renewal
Capacity: 45
Deficiencies: 0
Date: Feb 12, 2018
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related materials for Mid-Nebraska Lutheran Home, submitted to renew the facility's license.
Findings
The documents confirm that Mid-Nebraska Lutheran Home meets statutory requirements for licensure renewal as a Skilled Nursing Facility with a licensed capacity of 45 beds. The Nebraska State Fire Marshal occupancy permit indicates compliance with fire safety codes for the licensed capacity.
Report Facts
Licensed beds: 45
Renewal fee: 1550
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lindsi Lueken | Administrator | Named as facility administrator on the renewal application |
| Sue Stevenson | Director of Nursing | Named as director of nursing on the renewal application |
| James Sloup | Deputy State Fire Marshal | Inspected the facility for the occupancy permit |
| Becky Beckmann | President (Clergy) | Authorized representative signing the renewal application |
| Larry Kurtenbach | Authorized Representative | Authorized representative signing the renewal application |
Inspection Report
Routine
Census: 35
Capacity: 45
Deficiencies: 4
Date: Mar 22, 2017
Visit Reason
Routine inspection of Mid-Nebraska Lutheran Home to assess compliance with regulatory standards including quality of care, pain management, and life safety code.
Findings
The facility failed to monitor a resident for potential side effects and complications from a pain pump, and failed to provide non-medication interventions prior to administering pain medications for other residents. Life safety deficiencies included a delayed egress lock that did not release under required force and corridor doors that did not latch properly to resist smoke passage. The facility also lacked a complete fire watch policy for sprinkler system outages over 10 hours.
Deficiencies (4)
Failure to monitor Resident 9 for potential side effects or complications from use of a pain pump and failure to provide non-medication interventions prior to pain medication for Residents 1 and 11.
Delayed egress lock on east exit door of 400 wing did not release when pressure was applied, affecting 14 residents.
Facility failed to provide a complete fire watch policy describing procedures when sprinkler system is out of service for more than 10 hours.
Corridor door to resident room 412 did not positively latch within the door frame, allowing potential smoke passage.
Report Facts
Facility census: 35
Total licensed capacity: 45
Pain pump medication dosage: 799.7
Pain pump medication dosage: 59.97
Number of residents affected by delayed egress lock: 14
Number of occasions Resident 1 had pain level >5: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-A | Licensed Practical Nurse | Identified protocol for notifying Charge Nurse and providing non-medication interventions for Resident 1 |
| RN-F | Registered Nurse | Reported Resident 9 transfer to hospital and medication details |
| Director of Nurses | Director of Nursing | Interviewed regarding lack of pain pump monitoring policy and care plan requirements |
| Maintenance Staff | Confirmed delayed egress lock malfunction and corridor door latch issues |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 45
Deficiencies: 10
Date: Feb 23, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Mid-Nebraska Lutheran Home on February 17, 2016-February 23, 2016, 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 injury. The investigation found the facility failed to protect residents from injury, failed to evaluate causal factors for falls, and failed to implement interventions to prevent future falls. The facility was found non-compliant with Federal tag F323 and 175 NAC 12-006.09D7.
Findings
The facility failed to protect residents from injury, failed to notify physicians of significant changes in residents' conditions, failed to assess residents for self-administration of medications, failed to develop interventions for bowel and bladder incontinence, failed to implement fall prevention interventions, failed to maintain residents' nutritional status, failed to serve food at proper temperatures, failed to ensure expired medications were not available, and failed to prevent cross contamination during blood sugar testing.
Deficiencies (10)
Failed to notify physician regarding Resident 14's elevated blood sugar levels.
Failed to assess Resident 10 for self-administration of medications.
Failed to develop and implement interventions to manage bowel and bladder incontinence for Resident 41.
Failed to assess causal factors and implement interventions for prevention of falls for Resident 26 who sustained falls with injury.
Failed to implement nutritional interventions to address significant weight loss for Resident 26 and to provide supervision with eating for Resident 28.
Failed to ensure hot food items were served at palatable temperatures for residents.
Failed to ensure expired medications were not available for administration for Residents 33, 3, and 22.
Failed to prevent possible cross contamination when completing Accu-checks for Residents 20 and 22.
Resident room doors did not fit tightly within the doorframe to resist the passage of smoke.
Failed to notify physician of significant change in condition for Resident 31, failed to follow practitioner's orders for low pulse rates for Resident 7.
Report Facts
Facility census: 36
Facility total capacity: 45
Blood sugar levels above 350: 8
Weight loss percentage: 11.3
Pulse rates below 55: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lindsi Lueken | Administrator | Named in complaint letter |
| Eve Lewis | RNC, Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint letter |
| Medication Aide MA-F | Observed during Accu-check procedure with cross contamination risk | |
| Licensed Practical Nurse LPN-J | Observed during Accu-check procedure with cross contamination risk and interview about medication expiration | |
| Director of Nursing | Interviewed regarding multiple findings including notification failures and fall prevention |
Inspection Report
Renewal
Capacity: 45
Deficiencies: 0
Date: Feb 8, 2016
Visit Reason
This document is a Nursing Home Licensure Renewal Application for Mid-Nebraska Lutheran Home, submitted to renew the facility's license and certify compliance with state regulations.
Findings
The document certifies that Mid-Nebraska Lutheran Home meets statutory requirements for licensure renewal as a skilled nursing facility with Medicare and Medicaid certification. It includes ownership information, services provided, and confirms the licensed bed capacity.
Report Facts
Licensed beds: 45
Renewal fees: 1550
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lindsi Lueken | Administrator | Named as the facility administrator on the renewal application and ownership disclosure |
| Sue Stevenson | Director of Nursing | Named as Director of Nursing on the renewal application |
| David Lapka | President | Named as President of the Board of Directors |
| Thomas L. Barnes | Authorized Representative | Signed the renewal application as authorized representative |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 13, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility fails to protect residents from injury.
Complaint Details
The complaint alleged the facility fails to protect residents from injury. The complaint was investigated and found to be unsubstantiated.
Findings
The facility protected residents from injury. Reviews of three residents at risk for falls showed that Fall Risk Assessments and Post Fall Assessments were completed routinely, interventions were developed and revised, and staff interviews verified these interventions were followed. No violation was found related to the allegation.
Report Facts
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 8
Date: Feb 9, 2015
Visit Reason
Annual inspection survey conducted to assess compliance with Nebraska Administrative Code and federal regulations for skilled nursing facilities, including care planning, skin care, medication use, infection control, and life safety code compliance.
Findings
The facility failed to revise care plans for residents with skin issues and behaviors, failed to provide adequate care to prevent skin tears and bruising, and failed to ensure residents were free from unnecessary medications including duplicate psychoactive drugs. Infection control surveillance was not conducted consistently, and life safety code violations were noted including smoke resistance issues, incomplete smoke detector sensitivity testing, inadequate generator testing, and improper installation of alcohol-based hand rub dispensers.
Deficiencies (8)
Failed to revise care plans to address skin issues and behaviors for multiple residents.
Failed to provide care and treatment to prevent bruising, skin tears, and abrasions.
Failed to ensure residents were free from unnecessary psychoactive medications, including lack of non-pharmacological interventions and duplicate therapy.
Failed to complete ongoing infection surveillance and investigation to prevent spread of infection.
Failed to maintain smoke resistance for hazardous areas; laundry room doors did not close tightly.
Failed to maintain complete documentation of smoke detector sensitivity testing every two years.
Failed to maintain emergency generator testing monthly at 30% load for 30 minutes or conduct annual load bank test.
Alcohol-based hand rub dispenser installed too close to ignition source (night light).
Report Facts
Facility census: 39
Skin assessment frequency: 1
Medication administration: 6
Behavior shifts: 93
Behavior shifts: 118
Medication doses: 6
Smoke zones affected: 4
Residents affected by smoke zone deficiency: 1
Residents affected by alcohol hand rub dispenser deficiency: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Staff A | Confirmed smoke door deficiency, lack of smoke detector sensitivity testing, generator testing deficiency, and alcohol hand rub dispenser installation issue | |
| Director of Nursing | Provided information on care plan deficiencies, infection control surveillance, medication management, and monitoring processes | |
| Medication Aide G | Verified Resident 4's skin condition and medication application | |
| Licensed Practical Nurse C | Verified Resident 16's anxiety and non-pharmacological interventions | |
| Licensed Practical Nurse G | Verified Resident 21's bruising and use of protective sleeves | |
| Nursing Assistant H | Verified Resident 16's anxiety and calming interventions |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Date: Sep 24, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint survey regarding failure to provide care and treatment to prevent pressure ulcers at Mid-Nebraska Lutheran Home.
Complaint Details
The complaint alleged the facility failed to provide care and treatment to prevent pressure ulcers, failed to ensure adequate staffing, and failed to answer call notification systems promptly. The investigation substantiated the failure to prevent pressure ulcers but found the facility compliant with staffing and call light response.
Findings
The facility failed to provide ongoing assessments and revise interventions to promote healing of one resident's pressure ulcer and failed to complete ongoing skin assessments and preventative treatments for two other residents at risk for pressure sores. The facility was found non-compliant with regulatory requirements related to pressure ulcer care. However, the facility was found to have adequate staffing and timely call light responses.
Deficiencies (2)
Failure to provide ongoing assessments and revise interventions to promote healing of Resident 1's pressure sore.
Failure to complete ongoing skin assessments and/or provide preventative treatments for Residents 2 and 4 who were identified at risk for pressure sores.
Report Facts
Facility census: 40
Pressure sore measurements: 6
Dates of omitted treatments: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lindsi Lueken | Administrator | Named as facility administrator in the complaint investigation letter. |
| Krista Roeber | Social Worker | Investigator conducting the complaint survey. |
| Brenda Orlowski | Registered Nurse | Investigator conducting the complaint survey. |
| Patricia Wolfe | Registered Nurse | Investigator conducting the complaint survey. |
| Janice Hake | Registered Nurse | Investigator conducting the complaint survey. |
| RN-B | Registered Nurse | Observed performing improper wound care and hand hygiene during dressing change on Resident 1. |
| Eve Lewis | Program Manager | Signed the complaint investigation letter. |
| Director of Nursing | Verified improper wound care practices and lack of policy for pressure ulcer prevention. |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 1
Date: Mar 31, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding staffing sufficiency, presence of a Registered Nurse as Director of Nurses, and protection of residents from abuse at Mid-Nebraska Lutheran Home.
Complaint Details
The complaint alleged insufficient staffing, lack of a Registered Nurse as Director of Nurses, and failure to protect residents from abuse. The facility was found compliant with staffing and Director of Nurses requirements but was cited for failure to complete CPS/APS checks for a newly hired staff member.
Findings
The facility was found to have sufficient staffing and a Registered Nurse as Director of Nurses at the time of survey. However, the facility failed to protect residents from abuse by not completing required Child Protective Services and Adult Protective Services checks for one of five newly hired staff.
Deficiencies (1)
The facility failed to ensure Child Protective Services and Adult Protective Services (CPS/APS) checks were completed for 1 of 5 newly hired staff.
Report Facts
Facility census: 39
Number of newly hired staff reviewed: 5
Number of staff without CPS/APS check: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lindsi Lueken | Administrator | Named as facility administrator in report |
| Eve Lewis | Program Manager | Signed complaint investigation letter |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 45
Deficiencies: 6
Date: Jan 13, 2014
Visit Reason
Unannounced visit conducted to investigate a complaint and annual survey at Mid-Nebraska Lutheran Home from January 6 to January 13, 2014.
Complaint Details
Complaint investigation found failures in acting upon resident grievances, ensuring resident access to communication, protecting resident rights, providing a safe environment, changing fall interventions after risk identification, and investigating causal factors in falls.
Findings
The facility failed to develop and implement timely fall prevention care plans for residents identified at high risk for falls, failed to assess and manage pain adequately for a resident with a fractured hip, and failed to identify causal factors and develop interventions to prevent falls. The facility was found to be non-compliant with regulatory requirements related to fall prevention and pain management.
Deficiencies (6)
Failed to develop comprehensive care plans addressing prevention of falls for Residents 48 and 9 in a timely manner.
Failed to assess, treat, and manage pain for Resident 49 with a fractured hip adequately.
Failed to ensure resident environment remains free of accident hazards and provide adequate supervision and assistance devices to prevent accidents, specifically related to fall prevention interventions and causal factor identification.
Doors protecting corridor openings did not stay latched tightly within the doorframes, potentially allowing smoke to spread.
Unsealed PVC pipe and gas line penetrations in the ceiling above the furnace in the laundry furnace closet were not sealed to resist passage of smoke.
Combustible decorations were present on resident room doors without documentation of flame-retardant treatment.
Report Facts
Facility census: 37
Facility capacity: 45
Number of residents affected by door latch deficiency: 17
Number of residents affected by combustible decorations: 5
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 3
Date: Jun 25, 2013
Visit Reason
The inspection was conducted as a complaint investigation related to failure to notify family/POA of a resident's fall and failure to investigate and report the fall to the State Agency within required timeframes.
Complaint Details
The complaint investigation focused on Resident 1's fall on 6/7/13, failure to notify family/POA timely, failure to investigate and report the fall to the State Agency within 5 days, and failure to protect Residents 1 and 3 from falls.
Findings
The facility failed to notify Resident 1's family/POA promptly after a fall on 6/7/13, resulting in delayed family notification until 6/11/13. The facility also failed to complete and report a timely investigation of the fall to the State Agency within 5 working days. Additionally, the facility failed to protect Residents 1 and 3 from potential accidents by inconsistent implementation of fall prevention interventions and inadequate supervision.
Deficiencies (3)
Failure to notify resident's family/POA of a fall and related injuries in a timely manner.
Failure to complete and report investigation of a fall resulting in change of condition to the State Agency within 5 working days.
Failure to ensure resident environment is free of accident hazards and provide adequate supervision to prevent accidents for Residents 1 and 3 at risk for falls.
Report Facts
Facility census: 35
Fall date: Jun 7, 2013
Investigation reporting timeframe: 5
Fall risk assessment score: 15
Fall risk assessment score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA-F | Nursing Assistant | Observed failing to provide supervision to Resident 3 in Solarium |
| NA-C | Nursing Assistant | Observed not lowering Resident 1's bed to low position |
| NA-A | Nursing Assistant | Verified Resident 1 fall risk and nursing interventions |
| MA-G | Medication Aide | Verified Resident 3 fall risk and nursing interventions |
| LPN-H | Licensed Practical Nurse | Verified Resident 3 fall risk and nursing interventions |
| Director of Nursing | DON | Confirmed failure to notify family/POA timely and failure to report fall investigation |
Inspection Report
Annual Inspection
Census: 31
Capacity: 41
Deficiencies: 11
Date: Oct 9, 2012
Visit Reason
Annual inspection to assess compliance with federal and state regulations including resident care, safety, infection control, medication management, and life safety code.
Findings
The facility was found deficient in multiple areas including failure to report and investigate abuse allegations, incomplete care plans for residents at risk of elopement and those on psychoactive medications, inadequate fall prevention interventions, lack of medication monitoring, failure to provide vaccine education and documentation, improper infection control practices, and life safety code violations including fire door maintenance, hazardous area separation, fire alarm monitoring, and sprinkler system maintenance.
Deficiencies (11)
Failure to report and investigate alleged incidents of abuse and neglect.
Failure to develop comprehensive care plans addressing elopement risk and psychoactive medication management.
Failure to revise comprehensive care plans for residents related to elopement risk and diet orders.
Failure to implement interventions to prevent falls and elopement.
Failure to monitor medications (Digoxin and thyroid medications) for safety and effectiveness.
Failure to provide education and documentation regarding influenza and pneumococcal immunizations.
Failure to follow infection control practices including hand hygiene and use of protective barriers during nursing care and medication administration.
Failure to maintain smoke barrier doors to automatic close.
Failure to provide separation of hazardous areas from other compartments due to unsealed pipe penetrations.
Failure to ensure fire alarm system is continuously monitored by an approved central station.
Failure to maintain sprinkler system air compressor with a reliable power source.
Report Facts
Facility census: 31
Facility capacity: 41
Residents affected: 10
Inspection Report
Annual Inspection
Census: 30
Capacity: 41
Deficiencies: 10
Date: Jul 13, 2011
Visit Reason
Annual inspection survey conducted to assess compliance with state and federal regulations governing skilled nursing facilities, including life safety code, social services, resident care, medication management, infection control, and fire safety.
Findings
The facility was found deficient in multiple areas including failure to employ qualified social services and activities directors, failure to report and investigate resident incidents, inadequate wheelchair positioning and care interventions, failure to monitor medication regimens, improper infection control practices, and fire safety code violations such as doors not latching properly, lack of self-closing devices on storage room doors, missing fire alarm system maintenance documentation, and missing semiannual kitchen hood inspections.
Deficiencies (10)
Facility failed to employ a qualified social services director who completed required training.
Facility failed to employ a qualified resident activities director who completed required training.
Facility failed to report and investigate a resident fall with significant injury and a resident altercation resulting in bruising.
Facility failed to provide interventions to meet individualized needs of a resident with poor wheelchair positioning.
Facility failed to routinely monitor effectiveness and necessity of certain medications for a resident as ordered by physician.
Facility failed to utilize proper infection control techniques including hand washing before and after resident care.
Resident room door did not close and positively latch, compromising smoke barrier.
Storage room doors lacked self-closing devices and one door did not positively latch.
Facility failed to provide and maintain documentation of semiannual fire alarm system testing and maintenance.
Facility failed to have kitchen hood and duct system inspected for grease deposits on a semiannual basis.
Report Facts
Facility census: 30
Total licensed capacity: 41
Deficiency count: 10
Notice
Deficiencies: 0
Date: DAN091224
Visit Reason
The notice serves to inform the facility of disciplinary action placing its license on probation for 90 days starting October 8, 2024, due to violations related to failure to evaluate causal factors and implement interventions to prevent falls.
Findings
The facility was found to have violated licensure regulations by failing to evaluate causal factors and implement interventions to prevent resident falls, as documented in the CMS-2567 report dated September 12, 2024.
Report Facts
Probation period length: 90
Date of CMS-2567 Report: Sep 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Tesmer | Chief Medical Officer | Signed the Notice of Disciplinary Action |
| Dan Taylor | Administrator | Health Facilities Licensure Unit contact |
| Kolby Venger | Administrative Specialist | Office of Long Term Care Facilities, signed Certificate of Service |
Notice
Capacity: 45
Deficiencies: 0
Date: APP2017
Visit Reason
This document serves as a license renewal application and certification for Mid-Nebraska Lutheran Home, including ownership and controlling interest disclosures, and an occupancy permit.
Findings
The documents confirm the facility's license renewal status, ownership information, and fire marshal occupancy permit approval for 45 beds. No inspection findings or deficiencies are reported.
Report Facts
Number of beds: 45
License expiration date: License expiration date stated as 03/31/2018 on renewal card.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lindsi Lueken | Administrator | Named as administrator in ownership disclosure and renewal application. |
| Sue Stevenson | Director of Nursing | Named as director of nursing in renewal application. |
Notice
Capacity: 45
Deficiencies: 0
Date: APP2020
Visit Reason
This document serves to verify the renewal of the SNF/NF dual certification license for Mid-Nebraska Lutheran Home and includes the Alzheimer's Special Care Unit Disclosure and Memory Care Endorsement renewal application.
Findings
The documents confirm the facility's licensure renewal through 3/31/2021, specify a total licensed bed capacity of 45, and provide detailed information about the Alzheimer's Special Care Unit including staffing, care philosophy, and physical environment.
Report Facts
Total licensed beds: 45
Maximum capacity for Alzheimer's beds: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Caubarrus | Administrator | Named as facility administrator on licensure renewal application and Alzheimer's unit application. |
| Becky Beckmann | Authorized Representative | Signed licensure renewal application as authorized representative. |
| Connie Rankin | Authorized Representative | Signed licensure renewal application as authorized representative. |
Notice
Capacity: 45
Deficiencies: 0
Date: APP2021
Visit Reason
This document package serves as a licensure renewal application and includes verification of licensure, renewal application, fire marshal occupancy permit, and Alzheimer's Special Care Unit disclosure for Mid-Nebraska Lutheran Home.
Findings
The documents confirm that Mid-Nebraska Lutheran Home meets statutory requirements for licensure renewal, with a licensed capacity of 45 beds and an Alzheimer's Special Care Unit with a maximum capacity of 15 beds. The fire marshal issued a temporary occupancy permit for 45 beds, valid through 03/31/2022.
Report Facts
Total licensed beds: 45
Maximum capacity for Alzheimer's beds: 15
Renewal licensure fees: 1550
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Caubarrus | Administrator | Named as administrator on the renewal application and Alzheimer's Special Care Unit Disclosure. |
| Becky Beckmann | Authorized Representative | Signed the renewal application as authorized representative. |
| Connie Rankin | Authorized Representative | Signed the renewal application as authorized representative and listed as Treasurer on Board of Directors. |
| Gary J. Anthone, MD | Chief Medical Officer, Director, Division of Public Health | Named on licensure verification certificate. |
| Robert Folck | Deputy State Fire Marshal | Inspected the facility for the temporary occupancy permit. |
Document
Capacity: 45
Deficiencies: 0
Date: APP2022
Visit Reason
The document set serves primarily as a licensure renewal application and related administrative documentation for Mid-Nebraska Lutheran Home, including certification of licensure, occupancy permit, and Alzheimer's special care unit endorsement.
Findings
No inspection findings or deficiencies are reported in these documents. They mainly provide facility information, licensing renewal details, occupancy capacity, and Alzheimer's care program disclosures.
Report Facts
Total licensed beds: 45
Maximum capacity for Alzheimer's beds: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chad Thompson | Administrator | Named as facility administrator on multiple pages including the Nursing Home Licensure Renewal Application and Alzheimer's Special Care Unit Disclosure. |
| Shalynne Hohnholt | Director of Nursing | Named as Director of Nursing on the Nursing Home Licensure Renewal Application (page 2). |
Notice
Capacity: 45
Deficiencies: 0
Date: APP2023
Visit Reason
The document serves as a nursing home licensure renewal application and includes a renewal license card and occupancy permit for Mid-Nebraska Lutheran Home.
Findings
The documents certify that the facility meets statutory requirements for licensure renewal and confirm the licensed bed capacity and occupancy permit status.
Report Facts
Number of beds to be relicensed: 45
Renewal Licensure Fees: 1550
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chad Thompson | Administrator | Named in the licensure renewal application. |
| Alicia Kraft | Director of Nursing | Named in the licensure renewal application. |
| Becky Beckmann | Authorized Representative | Signed the licensure renewal application. |
| Larry Kurtenbach | Authorized Representative | Signed the licensure renewal application. |
Notice
Capacity: 45
Deficiencies: 0
Date: APP2024
Visit Reason
The document serves as a renewal application for the nursing home license of Mid-Nebraska Lutheran Home and includes certification of licensure, occupancy permit, and Alzheimer's Special Care Unit disclosure.
Findings
The documents confirm the facility's licensure renewal status, maximum bed capacity of 45, and certification for Alzheimer's/Special Care Unit services. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 45
Alzheimer's unit capacity: 17
Renewal licensure fees: 1550
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chad Thompson | Administrator | Named as administrator and contact person on multiple documents including renewal application and Alzheimer's unit disclosure. |
| Dora Miller | Director of Nursing | Named as Director of Nursing on the renewal application. |
Notice
Capacity: 45
Deficiencies: 0
Date: APP2025
Visit Reason
This document serves as a renewal application for the nursing home license of Mid-Nebraska Lutheran Home and includes certification of licensure, occupancy permit, and Alzheimer's Special Care Unit endorsement application.
Findings
The documents confirm that Mid-Nebraska Lutheran Home is licensed and certified to provide skilled nursing and special care services, with a total licensed capacity of 45 beds and a maximum of 17 beds for Alzheimer's care. The occupancy permit is valid and approved by the State Fire Marshal.
Report Facts
Total licensed beds: 45
Maximum Alzheimer's beds: 17
Renewal license expiration date: 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eugene Sarniak | Administrator | Named as administrator on the renewal application and Alzheimer's Special Care Unit Disclosure. |
| Linda Chao | Director of Nursing | Named as Director of Nursing on the renewal application. |
Notice
Deficiencies: 0
Date: DAN022316
Visit Reason
The document serves as a Notice of Disciplinary Action against Mid-Nebraska Lutheran Home for violations related to failure to assess causal factors and implement interventions to prevent falls and weight loss, resulting in probation for 90 days starting March 22, 2016.
Findings
The facility was found to have violated licensure regulations concerning accidents and unplanned weight loss by failing to assess risk factors and implement effective interventions. The disciplinary action includes probation and requirements for submitting plans of correction and periodic reports.
Report Facts
Probation period length: 90
Report submission due date: 2016
Notice finalization date: 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Recipient of reports and contact for response regarding disciplinary action |
| Courtney N. Phillips | Chief Executive Officer | Signed the Notice of Disciplinary Action |
| Becky Wisell | Administrator | Licensure Unit Administrator signing the Notice |
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