Inspection Reports for Saunders Medical Center
1760 County Rd J, WAHOO, NE, 68066
Back to Facility ProfileDeficiencies (last 12 years)
Deficiencies (over 12 years)
6.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% worse than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
98% occupied
Based on a October 2025 inspection.
Census over time
Inspection Report
Renewal
Census: 59
Capacity: 60
Deficiencies: 0
Date: Oct 2, 2025
Visit Reason
This document is a hospital license renewal application and related documentation for Saunders Medical Center for the period 1/1/2026 to 12/31/2026, including verification of bed count and occupancy permit.
Findings
The facility is licensed as a Long Term Care Hospital with a total licensed bed capacity of 60 beds. The occupancy permit issued by the Nebraska State Fire Marshal confirms a maximum occupancy of 60 beds. The bed count forms dated 10/2/2025 show 59 beds occupied out of 60 licensed beds.
Report Facts
Total licensed beds: 60
Beds occupied: 59
Renewal fee: 1850
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Rezac | Chief Executive Officer | Named as Administrator/CEO in the renewal application and managing staff. |
| Ty Hernes | Deputy State Fire Marshal | Inspected the facility and issued the occupancy permit. |
Inspection Report
Renewal
Census: 57
Capacity: 60
Deficiencies: 0
Date: Oct 17, 2024
Visit Reason
This document is a hospital license renewal application and related certification and occupancy permit for Saunders Medical Center for the period 1/1/2025 to 12/31/2025.
Findings
The documents certify that Saunders Medical Center meets statutory requirements for long term care hospital/dual licensing and includes a renewal application, occupancy permit, and bed count forms showing licensed beds and current occupancy.
Report Facts
Total licensed beds: 60
Beds occupied: 57
Inspection Report
Renewal
Census: 59
Capacity: 60
Deficiencies: 0
Date: Oct 24, 2022
Visit Reason
The document is a hospital license renewal application and related materials for Saunders Medical Center for the renewal period 1/1/2023 - 12/31/2023.
Findings
The documents verify that Saunders Medical Center meets statutory requirements for licensing as a Long Term Care Hospital/Dual facility with a licensed capacity of 60 beds. The occupancy permit was issued on 10/5/2022 with a maximum occupancy of 60 beds. Bed count forms dated 10/24/2022 show 59 beds occupied during the inspection.
Report Facts
Licensed beds: 60
Beds occupied: 59
Renewal period: 1/1/2023 - 12/31/2023
Occupancy permit date: 10/5/2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Rezac | CEO | Administrator named in renewal application |
| David N Lutton | Authorized person | Signed renewal application |
| Mark Manchester | Deputy State Fire Marshal | Inspected facility for occupancy permit |
Inspection Report
Renewal
Census: 48
Capacity: 60
Deficiencies: 0
Date: Oct 19, 2021
Visit Reason
The document is a licensure renewal application and related materials for Saunders Medical Center's Long Term Care Hospital (LTCH) and Critical Access Hospital (CAH) for the renewal period 1/1/2022 - 12/31/2022.
Findings
The documents confirm that Saunders Medical Center meets statutory requirements for licensure renewal as a Long Term Care Hospital/Dual facility. The renewal application includes bed counts, board of trustees and county supervisors rosters, managing staff list, and occupancy permits with no deficiencies or violations noted.
Report Facts
Licensed Capacity: 60
Beds Occupied: 48
Renewal Fees: 2025
Renewal Fees: 1850
Inspection Report
Renewal
Capacity: 60
Deficiencies: 0
Date: Nov 13, 2018
Visit Reason
This document is a hospital license renewal application for Saunders Medical Center for the renewal period January 1, 2019 to December 31, 2019.
Findings
The document contains information related to the renewal of the hospital license, including facility and ownership details, renewal fees, signatures, and occupancy permit. No inspection findings or deficiencies are reported.
Report Facts
Number of licensed beds: 60
Renewal license fee: 1850
Date of signature: Nov 13, 2018
Occupancy maximum: 60
Occupancy permit issue date: Apr 12, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doris Karloff | Chairperson | Named as Chairperson of Saunders County Board of Supervisors and signatory on renewal application |
| Sam Prokopec | Administrator | Named as facility administrator on renewal application |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 24, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Saunders Medical Center on May 24, 2018, regarding allegations that the facility fails to protect residents from residents with adverse behaviors and fails to put interventions in place to prevent injuries.
Complaint Details
The complaint involved two allegations: failure to protect residents from residents with adverse behaviors and failure to implement interventions to prevent injuries. Both allegations were investigated and found to be unsubstantiated with no citations.
Findings
The investigation included reviews of policies, resident records, interviews with staff, residents, and family members, and observations. The facility was found to be in compliance with regulations for both allegations and was not cited.
Report Facts
Number of residents interviewed: 3
Number of family members interviewed: 3
Number of resident care plans reviewed: 5
Timeframe for incident reports reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed the report as Training Coordinator, Office of LTC Facilities - Licensure Unit |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 60
Deficiencies: 10
Date: Apr 10, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Saunders Medical Center from April 3, 2018 to April 10, 2018 by the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint investigation focused on allegations that the facility failed to protect residents from residents with adverse behaviors, failed to immediately report allegations of abuse, failed to protect residents from abuse, failed to submit investigations within 5 working days, and failed to ensure reports were complete and accurate. The investigation found substantiated failures related to protection from adverse behaviors and report accuracy.
Findings
The facility failed to protect residents from residents with adverse behaviors, failed to ensure reports were complete and accurate, failed to provide required Medicaid liability notices, failed to prevent verbal abuse by a nurse, failed to follow handwashing policies in the kitchen, failed to properly disinfect glucometers between uses, and had fire safety and electrical code deficiencies.
Deficiencies (10)
Failed to protect residents from residents with adverse behaviors.
Failed to ensure reports are complete and accurate related to abuse investigations.
Failed to provide required CMS 10055 Medicaid liability notices to residents discharged from Medicare Part A services.
Failed to prevent verbal abuse by a nurse and failed to update care plans for residents with adverse behaviors.
Failed to ensure staff followed handwashing standards in the kitchen.
Failed to properly disinfect glucometers between resident uses.
Failed to maintain 2-hour fire resistance rating of a wall used as a horizontal exit.
Allowed foreign material buildup on fire sprinkler deflectors.
Failed to conduct fire drills quarterly on each shift.
Allowed use of an extension cord in lieu of permanent wiring in the chapel.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 42
Residents affected: 10
Facility census: 52
Facility census: 54
Facility capacity: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter. |
| Samuel Prokopec | Administrator | Named in facility information and staffing forms. |
| LPN C | Licensed Practical Nurse | Named in glucometer disinfection deficiency. |
| Maintenance A | Acknowledged fire safety deficiencies and electrical extension cord use. | |
| Social Services Director | Interviewed regarding CMS 10055 notices and care plan updates. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 7, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Saunders Medical Center regarding allegations that the facility failed to protect residents from abuse and failed to protect residents with adverse behaviors.
Complaint Details
The complaint alleged failure to protect residents from abuse and failure to protect residents with adverse behaviors. Both allegations were found to be unsubstantiated with no violations issued.
Findings
The investigation found that the facility did protect residents from abuse and from adverse behaviors, resulting in no violations related to these issues. Reviews included resident records, observations, interviews, and policy assessments.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed the report as Training Coordinator, Office of LTC Facilities - Licensure Unit - Division of Public Health |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 60
Deficiencies: 5
Date: Feb 8, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Saunders Medical Center from February 8, 2017 to February 14, 2017 by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint investigation focused on allegations that the facility failed to protect residents from residents with adverse behaviors, failed to report incidents within 24 hours, failed to protect residents from misappropriation, and failed to protect residents from injuries of unknown origin. The facility was found non-compliant with Federal regulation F225 for failure to report incidents within the regulatory timeframe.
Findings
The facility was found to be in compliance with regulatory guidelines for protecting residents from adverse behaviors, misappropriation, and injuries of unknown origin. However, the facility failed to report incidents of potential abuse within the regulatory timeframe for 3 of 7 incidents reviewed, affecting 4 residents. The facility census was 51.
Deficiencies (5)
Facility failed to report incidents of potential abuse within the regulatory timeframe for 3 of 7 incidents reviewed.
Facility failed to maintain emergency lights in resident restrooms in 3 of 3 smoke compartments.
Facility failed to minimize fire risk by not assuring stove top in 100 Hall was inoperable and not available for use by unsupervised residents.
Facility failed to prohibit use of power taps plugged into each other, increasing electrical fire risk.
Facility failed to follow plan of correction to ensure doors to corridors were capable of resisting passage of smoke and allowed doors to be held open by unapproved means.
Report Facts
Facility census: 51
Total licensed capacity: 60
Number of incidents not reported timely: 3
Residents potentially affected: 4
Facility census: 50
Skilled certified beds: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Toline | Administrator | Named in introductory letter of complaint investigation |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter |
| Don Fritz | Assistant State Fire Marshal | Signed approval of life safety code waiver and plan of correction |
| Steve Sladky | Support Services Director | Contact person for life safety code waiver request |
Notice
Capacity: 60
Deficiencies: 0
Date: Oct 11, 2016
Visit Reason
Notification of acceptance of Saunders Medical Center as a skilled nursing facility participating in the Medicare Health Insurance Benefits Program for the Aged, effective September 8, 2016, covering 60 Medicare certified beds.
Findings
The letter outlines the facility's participation conditions, including compliance with Civil Rights requirements and ongoing unannounced surveys to monitor deficiencies and regulatory compliance.
Report Facts
Medicare certified beds: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the letter notifying the facility of Medicare participation acceptance. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 21, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint at Saunders Medical Center on June 21, 2016, regarding failure to transfer residents in a manner to prevent injury.
Complaint Details
The complaint alleged that the facility failed to transfer residents in a manner to prevent injury. The investigation substantiated this allegation with findings of staff not being fully educated on mechanical lift transfers, leading to injury of Resident 1.
Findings
The facility failed to transfer residents safely using mechanical lifts, as not all staff had been educated on their proper use, resulting in injury to one resident. The deficiency was cited as a violation of F498 and state regulations 12-006.04.
Deficiencies (1)
Failure to educate staff regarding the use of mechanical lifts resulting in injury to a resident.
Report Facts
Deficiencies cited: 1
Reviewer fee: 1200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed initial complaint investigation letter and plan of correction correspondence |
| Tyler Toline | Administrator | Facility administrator named in multiple letters and correspondence |
| Kimberly A. Divis | RN, NSSC | Person conducting Informal Dispute Resolution conference |
| Julie Rezac | RN, COO | Participant in Informal Dispute Resolution conference |
| Nichola Kugel | RN, DON | Participant in Informal Dispute Resolution conference |
| Jordan Spencer | CNA | Participant in Informal Dispute Resolution conference |
| Eve Lewis | Program Manager | Sent letters regarding Informal Dispute Resolution and refund form |
| Janet Endorf-Olson | BSN, RN, CPHQ, LSSGB, Quality Improvement Director | Sent letter declining to perform Informal Dispute Resolution for Saunders Medical Center |
| Cheryl Points | Executive Assistant | Sent letter regarding scheduling of Informal Dispute Resolution meeting |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 5, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint that the facility fails to identify causal factors for falls.
Complaint Details
The complaint alleged the facility fails to identify causal factors for falls. The investigation found no concerns and no violation related to this issue.
Findings
The facility does assess and identify causal factors for falls, and no violation was found related to this issue after review of resident records, observations, and staff interviews.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 9, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint at Saunders Medical Center on March 9, 2016. The investigation included review of resident records, observation of care and services, and interviews with residents, family members, and staff.
Complaint Details
The complaint investigation addressed allegations regarding infection control guidelines for supplies in residents' rooms, infection control isolation procedures, staff checking with nursing before residents receive alcoholic drinks, and implementation of interventions to prevent further behaviors. All allegations were found to be unsubstantiated with no violations.
Findings
The facility was found to be in compliance with infection control guidelines for supplies in residents' rooms, appropriate infection control isolation procedures, proper checks before residents receive alcoholic beverages, and implementation of interventions to prevent further behaviors. No violations were identified related to the allegations.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the report and is the contact person for questions. |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 8
Date: Nov 19, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Saunders Medical Center from November 19, 2015 to November 30, 2015 by the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint investigation focused on allegations that the facility failed to evaluate causal factors for falls and failed to protect residents from injury. The investigation found the facility did evaluate causal factors for falls but failed to protect residents from injury related to bruising.
Findings
The facility was found to have failed to protect residents from injury related to bruising and failed to maintain beds in a clean and safe condition. Additional deficiencies included failure to ensure safety of repositioning bars on beds, improper food handling practices risking cross-contamination, inadequate medical gas cylinder storage, smoke separation door issues, lack of generator load testing documentation, and improper use of extension cords.
Deficiencies (8)
Failed to maintain hard surfaces of beds in a cleaned manner in resident rooms 303, 308, 312 and 225 with splintered veneer and missing pieces.
Failed to identify bruising and put preventative interventions in place for one resident (Resident 35) with bruising on fingers.
Failed to ensure safety and secure repositioning bars on beds for Residents 38 and 27, creating potential injury hazard.
Failed to ensure staff changed gloves and sanitized hands properly to prevent cross contamination during meal service in kitchen and dining room.
Failed to have medical gas cylinders adequately secured and failed to separate empty and full tanks to prevent confusion.
Smoke separation door next to resident room 102 failed to close and latch properly to resist passage of smoke.
Failed to verify that the emergency generator had been run monthly under a 30 percent load or that an annual load bank test had been conducted.
Did not prohibit the use of extension cords as a substitute for adequate wiring; extension cord found powering hair dryer in beauty shop.
Report Facts
Facility census: 55
Number of residents affected by smoke door deficiency: 40
Facility census: 64
Number of residents affected by medical gas cylinder deficiency: 21
Date range of inspection: 2015-11-19 to 2015-11-30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed letter regarding complaint investigation findings |
| Tyler Toline | Administrator | Facility administrator addressed in the report |
| RN C | Registered Nurse | Interviewed regarding unawareness of bruising on Resident 35 |
| LPN D | Licensed Practical Nurse | Interviewed regarding unawareness of bruising on Resident 35 and observed during meal service with glove issues |
| Director of Maintenance | Interviewed regarding smoke separation door and generator testing deficiencies | |
| Administration A | Interviewed regarding medical gas cylinder storage and extension cord use |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 8
Date: Aug 25, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint at Saunders Medical Center on August 24-25, 2015, focusing on dementia care and related allegations.
Complaint Details
Complaint investigation focused on dementia care and related allegations including choking incidents and medication use.
Findings
The facility was found in violation of multiple regulations including failure to notify physician and family of a choking incident, failure to develop comprehensive care plans addressing resident behaviors, failure to provide necessary care to maintain highest well-being, failure to ensure resident safety during bathing and chemical storage, failure to secure medications, failure to maintain infection control during medication administration, and failure of the Quality Assurance Committee to address antipsychotic medication use without approved diagnoses.
Deficiencies (8)
Failure to notify physician and family of a choking incident for Resident 32.
Failure to develop comprehensive care plans addressing behaviors for Residents 30, 31, 32, and 34.
Failure to provide necessary care and services to maintain highest physical and psychosocial well-being for Residents 31 and 32.
Failure to ensure Resident 30 was free from potential injury during bathing and failure to secure chemicals in resident living units.
Failure to secure medications on Unit Two.
Failure to maintain infection control procedures during medication administration for Resident 32.
Failure to address use of antipsychotic medications without approved FDA diagnoses by Quality Assurance Committee.
Failure to ensure residents' drug regimens were free from unnecessary drugs; Residents 31, 32, and 34 received antipsychotic medications without adequate indication.
Report Facts
Facility census: 56
Antipsychotic medication days: 7
Vital signs: 165
Vital signs: 81
Vital signs: 80
Vital signs: 97.6
Vital signs: 18
Vital signs: 93.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter |
| Tyler Toline | Administrator | Facility administrator addressed in complaint letter |
| Medication Aide 3 | Performed abdominal thrusts on Resident 32 during choking incident; involved in medication administration with infection control violation | |
| Director of Nursing | Director of Nursing | Verified failures related to notification, care plans, and policy adherence |
| Medication Aide 6 | Confirmed lack of care plans for resident behaviors | |
| Social Service Worker 6 | Responsible for behavioral care plans; confirmed lack of care plans for certain residents | |
| Consultant Psychiatrist 2 | Consultant Psychiatrist | Provided psychiatric consultation; confirmed lack of appropriate diagnosis for antipsychotic use |
| Licensed Practical Nurse 1 | LPN | Confirmed unsecured medication supplies on Unit Two |
| Nurse Aide 4 | Nurse Aide | Provided information on resident behaviors and bathing observations |
| Nurse Aide 7 | Nurse Aide | Observed resident behaviors during cares |
| Medication Aide 1 | Observed resident behaviors during cares | |
| Medical Director | Medical Director | Aware of antipsychotic medication use without approved diagnosis but had not addressed issue with physicians |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Date: Apr 16, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility fails to ensure residents are free from abuse.
Complaint Details
The complaint alleged the facility fails to ensure residents are free from abuse. The complaint was not substantiated based on the onsite investigation.
Findings
The investigation found that the facility does ensure residents are free from abuse. Staff, residents, and administration were interviewed, and no concerns were noted regarding abuse or suspected abuse.
Report Facts
Facility census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Smith | Registered Nurse | Conducted the complaint investigation visit |
| Eve Lewis | Program Manager | Signed the inspection report letter |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Date: Mar 24, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint at Saunders Medical Center regarding allegations of failure to serve food at appropriate temperatures, failure to treat residents with dignity and respect, failure to provide comfortable and safe temperature levels, and failure to implement interventions to prevent falls.
Complaint Details
The complaint allegations were not substantiated as the facility met all regulatory requirements related to food temperatures, resident dignity and respect, environmental temperature safety, and fall prevention interventions.
Findings
The investigation found that the facility served food at appropriate temperatures, treated residents with dignity and respect, provided comfortable and safe temperature levels, and implemented interventions to prevent falls. No concerns were noted in any of the areas investigated.
Report Facts
Facility census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Smith | Registered Nurse | Conducted the complaint investigation |
| Eve Lewis | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 17
Date: Nov 3, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Saunders Medical Center on October 27, 2014-November 3, 2014.
Complaint Details
The complaint investigation included allegations that the facility failed to ensure residents are free from abuse, failed to ensure resident privacy/confidentiality, failed to investigate injuries of unknown origin, failed to ensure resident narcotic medication is free from misappropriation, and failed to protect residents from abuse. The facility was found to be in compliance with all these allegations except for failure to allow Resident 59 a choice regarding toileting options.
Findings
The facility was found to be in compliance with abuse prevention, privacy/confidentiality, and narcotic medication misappropriation allegations. However, a complaint was substantiated regarding failure to allow Resident 59 a choice regarding toileting options. The facility census was 56.
Deficiencies (17)
Facility failed to allow Resident 59 a choice regarding toileting options.
Facility failed to ensure resident rooms were free from scratches and gouges, and wheelchairs were in good repair.
Facility failed to develop a comprehensive care plan regarding the potential for fluid volume imbalance for Resident 50.
Facility failed to identify the underlying cause of agitation for Resident 54 resulting in use of PRN psychotropic medications.
Facility failed to ensure staff checked for placement of gastrostomy tube prior to medication administration for Resident 20.
Facility failed to ensure pre-packaged condiments did not contaminate prepared food when served to residents.
Facility failed to assure Resident Room 122 was free of storage of personal items without providing a self-closure on the door; failed to maintain door to soiled linen room to latch; failed to provide self-closing device on an office used as storage.
Facility failed to assure the key code for the locked exit door in the 300 hall was visible.
Facility did not conduct fire drills at unexpected times during all three shifts.
Facility failed to maintain sprinklers as designed and provide documentation for quarterly inspection.
Facility failed to provide documentation that kitchen hood had been cleaned.
Facility failed to provide maintained egress path free from snow and ice at 4 of 5 sampled exits.
Facility failed to provide flame retardant fabric curtains, sheets, pillow case used as curtains, and decoration on Resident 122 door.
Facility failed to provide current inspection certification of 3 of 3 facility boilers.
Facility failed to store gas motor equipment outside of the facility.
Facility failed to post 'oxygen in use' sign in areas where oxygen is used.
Facility failed to assure Resident in room 122 did not use Christmas lights as an extension cord.
Report Facts
Facility census: 56
Deficiency count: 16
Residents affected by fire safety deficiencies: 58
Residents affected by storage door deficiency: 23
Residents affected by locked exit door code visibility: 12
Residents affected by oxygen signage deficiency: 23
Residents affected by electrical fire hazard: 23
Inspection Report
Life Safety
Census: 50
Deficiencies: 6
Date: Aug 8, 2013
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations for a skilled nursing facility.
Findings
The facility was found deficient in several life safety code areas including door latching failures on resident and hazardous area doors, inadequate fire drill timing, lack of monthly fire extinguisher inspections, improper oxygen cylinder storage, and electrical safety violations such as use of power strips as permanent wiring and blocked electrical panels.
Deficiencies (6)
Resident Room 225 door failed to latch within the door frame, not resisting fire for at least 20 minutes.
Linen Room door self-closing device failed to close and latch within the door frame.
Fire drills were not conducted at unexpected times under varied conditions as required.
Fire extinguishers throughout the facility lacked current monthly inspections.
Oxygen cylinders stored in the Resident Exam room lacked required five feet separation from combustibles.
Power strip used as permanent wiring for refrigerator in Resident Room 201 and wheelchairs stored in front of electrical panel boxes in 200 Hall storage room.
Report Facts
Facility census: 50
Resident living compartments affected: 3
Residents potentially affected: 18
Oxygen storage volume: 525
Fire drills reviewed: 13
Fire drills conducted at month end: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed door latch failures, fire drill timing, fire extinguisher inspection status, oxygen cylinder storage, and electrical safety issues | |
| Plant Operations Manager | Responsible for monitoring corrective actions and system changes | |
| Long-term care D.O.N. | Responsible for monitoring compliance with oxygen cylinder storage and electrical panel clearance |
Inspection Report
Routine
Census: 60
Deficiencies: 1
Date: Oct 29, 2012
Visit Reason
The inspection was conducted to assess compliance with regulations governing licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities, focusing on accident hazards, supervision, and devices to prevent accidents.
Findings
The facility failed to ensure that residents were free from accident hazards and did not adequately assess causal factors or implement new interventions after falls for 2 of 5 sampled residents. Specifically, no new interventions were added to the care plans of residents who experienced falls, contrary to facility policy.
Deficiencies (1)
Failure to assess causal factors and implement new interventions to prevent accidents for 2 residents who experienced falls.
Report Facts
Facility census: 60
Sampled residents: 5
Residents with deficient care: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding expectations for new interventions after falls |
Inspection Report
Routine
Census: 58
Deficiencies: 11
Date: May 9, 2012
Visit Reason
The inspection was a routine survey to assess compliance with federal Medicare and Medicaid requirements, including resident care, food service, and life safety code standards.
Findings
The facility failed to accommodate residents' needs during meal times, including inadequate feeding assistance for dependent residents and improper food handling practices. Life safety deficiencies included failure to post exit codes, untested emergency lighting, obstructed means of egress, improper electrical wiring, and alcohol-based hand rub dispensers placed near ignition sources.
Deficiencies (11)
Failed to accommodate residents' needs during meal times, including moving residents and seating arrangements.
Failed to provide adequate feeding assistance to dependent residents requiring total assistance.
Failed to assure all foods were protected from contamination; employees used bare hands when handling food.
Failed to post the code for the locked door on the east exit in the 300 Hall, delaying egress during emergency.
Failed to test newly installed emergency lighting in resident restrooms.
Failed to conduct fire drills at unexpected times during the month.
Failed to ensure smoke detectors had bi-annual sensitivity testing.
Failed to maintain sprinkler head clearance in restroom of Resident 202.
Means of egress obstructed by dining table and chairs in Main Dining Room.
Power strips used as permanent wiring in Resident TV lounge area.
Alcohol Based Hand Rub dispenser installed adjacent to an ignition source in 100 Hall Dining Room.
Report Facts
Facility census: 58
Sampled residents: 17
Residents affected by keypad code deficiency: 14
Residents affected by sprinkler head deficiency: 22
Residents affected by ABHR dispenser deficiency: 22
Fire drills reviewed: 16
Fire drills conducted at end of month: 11
Inspection Report
Census: 55
Deficiencies: 12
Date: Apr 7, 2011
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations including food safety, life safety code, and fire safety standards.
Findings
The facility was found deficient in food storage and temperature control practices, life safety code compliance including fire door hardware, exit access, emergency lighting, fire alarm system maintenance, electrical safety, flame retardant treatment of curtains, oxygen concentrator policies, and placement of alcohol-based hand rub dispensers.
Deficiencies (12)
Failed to ensure uncooked raw meats were stored away from potential contamination of cooked meats and other raw foods; failed to maintain pureed hot food items in temperature control during meal service.
Failed to provide latching hardware on a storage room door in the 100 hall, preventing containment of fire and smoke.
Allowed exiting through a storage area and failed to assure front entry controlled access door was operational after 8:00 pm, delaying emergency exit.
Failed to provide illumination of exit discharge so that failure of any single lighting fixture would not leave area in darkness for 2 of 5 exit discharges.
Failed to provide smoke detection to activate doors with magnetic hold-opens to the chapel.
Failed to test and maintain sensitivity of smoke detectors throughout the facility.
Failed to maintain sprinkler system by ensuring Post Indicator Valve was installed at required height.
Failed to maintain flame retardant treatment or provide flame retardant rating for resident curtains throughout the building.
Failed to have a policy for shutting off oxygen concentrators when not in use, increasing fire risk.
Failed to maintain and test emergency generator power supply as required, delaying emergency lighting during electrical outage.
Failed to ensure electrical wiring and equipment were installed in accordance with NFPA 70; prohibited use of electrical adaptors and storage in front of electrical panel boxes.
Failed to install Alcohol Based Hand Rub dispensers so they are not above or immediately adjacent to ignition sources.
Report Facts
Facility census: 55
Residents receiving pureed meals: 6
Temperature of pureed hot food items: 136
Post Indicator Valve height: 29
Emergency generator transfer times: 0
Emergency generator transfer times: 2
Emergency generator transfer times: 5
Emergency generator transfer times: 7
Notice
Capacity: 60
Deficiencies: 0
Date: APP2024
Visit Reason
This document serves as the hospital license renewal application and renewal notice for Saunders Medical Center for the period 1/1/2024 to 12/31/2024.
Findings
The documents verify that Saunders Medical Center meets statutory requirements as a Long Term Care Hospital and is licensed through 12/31/2024. The renewal application includes provider information, ownership details, renewal fees, and required signatures.
Report Facts
Licensed beds: 60
Renewal period: From 1/1/2024 to 12/31/2024 as stated in renewal application.
Renewal fee: 1850
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Yosick | Administrator | Named in provider information section of renewal application. |
| Cheryl Points | Provider Enrollment Contact | Named as preferred contact for official notices in renewal application. |
| David Lutton | Chairman | Signed renewal application as authorized person. |
| Mark Manchester | Deputy State Fire Marshal | Inspected the facility as noted on the occupancy permit. |
Notice
Capacity: 60
Deficiencies: 0
Date: APP2016
Visit Reason
This document serves to verify the licensure renewal of Saunders Medical Center as a Long Term Care Hospital/Nursing Facility and includes related administrative information such as occupancy permit, ownership, and management details.
Findings
The documents confirm that Saunders Medical Center meets statutory requirements for licensure renewal with a total licensed bed capacity of 60. There are no inspection findings or deficiencies reported.
Report Facts
Total licensed beds: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Toline | Administrator | Named as administrator on licensure renewal application and correspondence. |
| Diana Meyer | Program Manager | Signed correspondence regarding compliance with state licensure regulations. |
| Julie Rezac | Chief Operations Officer/Interim LTC DON | Listed as managing staff on management organization page. |
Document
Capacity: 60
Deficiencies: 0
Date: APP2017
Visit Reason
This document set includes a license renewal application, occupancy permit, and organizational details for Saunders Medical Center, verifying licensure and capacity for the long term care hospital and nursing home.
Findings
No inspection findings or deficiencies are reported. The documents certify licensure status, ownership, and facility capacity with no noted deficiencies or complaints.
Report Facts
Total licensed beds: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Toline | Administrator / CEO | Named as facility administrator and CEO in license renewal application and management staff list. |
| Carol Friesen | VP Rural Health Systems | Listed as managing staff. |
| Julie Rezac | Chief Operations Officer | Listed as managing staff. |
| Chase Manstedt | CFO | Listed as managing staff. |
Notice
Capacity: 60
Deficiencies: 0
Date: APP2018
Visit Reason
This document serves as a license renewal verification for Saunders Medical Center's long-term care hospital license and includes an occupancy permit for the nursing home facility.
Findings
The document confirms that Saunders Medical Center is licensed through the indicated renewal date and has a maximum occupancy of 60 beds as per the occupancy permit issued by the Nebraska State Fire Marshal.
Report Facts
Total licensed beds: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Toline | Administrator and CEO | Named as Administrator on the renewal application and CEO in the management staff list. |
| Susen Lindner | Deputy State Fire Marshal | Inspected the facility for the occupancy permit. |
Notice
Capacity: 60
Deficiencies: 0
Date: APP2020
Visit Reason
The document serves as a hospital license renewal for Saunders Medical Center for the period 1/1/2020 to 12/31/2020.
Findings
The documents verify that Saunders Medical Center meets statutory requirements for licensing as a Long Term Care Hospital/Dual facility and includes the renewal application, occupancy permit, and organizational information.
Report Facts
Licensed beds: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sam Prokopec | Administrator | Named as facility administrator in the license renewal application. |
| Doris Karloff | Chairperson | Signed the renewal application as authorized person and listed as Chairperson on the Saunders Medical Center Board Roster. |
| Curt Bromm | Member | Listed as a member on the Saunders Medical Center Board Roster. |
| Greg Hohl | Treasurer | Listed as Treasurer on the Saunders Medical Center Board Roster. |
| Theresa Klein | Vice Chairperson | Listed as Vice Chairperson on the Saunders Medical Center Board Roster. |
| Jason Libal | Member | Listed as a member on the Saunders Medical Center Board Roster. |
| George Robertson | Member | Listed as a member on the Saunders Medical Center Board Roster. |
| Marsha Rogers | Chairperson | Listed as Chairperson on the Saunders Medical Center Board Roster. |
| John Woodrich | COO | Named as Chief Operating Officer in the management organization. |
| Tyler Toline | CEO | Named as Chief Executive Officer in the management organization. |
| Julie Rezac | Chief Operating Officer | Named as Chief Operating Officer in the management organization. |
| Chase Manstedt | CFO | Named as Chief Financial Officer in the management organization. |
Notice
Capacity: 60
Deficiencies: 0
Date: APP2021
Visit Reason
This document package serves as the hospital license renewal application for Saunders Medical Center for the period 1/1/2021 - 12/31/2021, including supporting documents such as board rosters, managing staff lists, occupancy permits, and bed count forms.
Findings
The documents confirm the renewal of the hospital license for Saunders Medical Center with a licensed capacity of 60 beds. Supporting documentation includes lists of board members, managing staff, occupancy permits from the State Fire Marshal, and detailed bed count forms for various hospital wings.
Report Facts
Licensed Capacity: 60
Renewal Fees: 2025
Renewal Fees: 1850
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sam Prokopec | Administrator | Named as facility administrator on renewal application. |
| Cheryl Points | Executive Assistant | Contact person for questions regarding the renewal application. |
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