Inspection Reports for Skyview Care and Rehab at Bridgeport
505 O Street., Bridgeport, NE 69336, NE, 69336
Back to Facility ProfileDeficiencies (last 12 years)
Deficiencies (over 12 years)
7.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
88% worse than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
91% occupied
Based on a March 2019 inspection.
Census over time
Notice
Deficiencies: 0
Nov 17, 2025
Visit Reason
This Notice of Disciplinary Action was issued due to violations related to failure to ensure residents were free from neglect by not having adequate supplies to meet residents' needs, including prevention and treatment of pressure sores.
Findings
The facility is prohibited from admitting new residents until compliance is demonstrated. Probation is extended through July 12, 2027, with requirements including submission of a Plan of Correction, regular reporting on residents with pain and pressure sores, and employment of an outside licensed registered nurse consultant.
Report Facts
Probation end date: 2027
First report due date: 2025
Consultant hours per week: 20
Disciplinary Action final date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Tesmer | Chief Medical Officer | Signed the Notice of Disciplinary Action |
| Dan Taylor | Administrator | Named as Administrator in the Notice |
| Kolby Venger | Administrative Specialist | Certified mailing of the Notice |
Notice
Deficiencies: 0
Aug 18, 2025
Visit Reason
This Notice of Disciplinary Action was issued due to violations found during a survey dated August 18, 2025, related to failure to prevent and properly manage pressure sores in residents.
Findings
The facility failed to accurately identify residents at risk for pressure ulcers, promptly detect ulcer development, and implement preventative care for two residents. Additionally, the facility did not follow physician orders or consistently assess and document pressure ulcer wound characteristics and healing progress.
Report Facts
Probation extension duration: 365
Number of residents with pressure ulcers involved: 2
Date of survey: Aug 18, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Tesmer | Chief Medical Officer | Signed the Notice of Disciplinary Action |
| Dan Taylor | RN Administrator | Mentioned as part of Health Facilities Licensure Unit |
| Kolby Venger | Administrative Specialist | Certified the Notice of Disciplinary Action |
Notice
Deficiencies: 0
Jun 27, 2025
Visit Reason
This Notice of Disciplinary Action was issued due to violations related to failure to ensure sufficient staff to meet resident needs for mechanical lift transfers and assistance with resident ADLs, resulting in probation and prohibition from admitting new residents until compliance is demonstrated.
Findings
The facility was found to have violated licensure regulations concerning staff requirements for resident care, specifically mechanical lift transfers and assistance with activities of daily living. The Department imposed probation for 180 days and required submission of a Plan of Correction and weekly reports during the probation period.
Report Facts
Probation period length: 180
Report due date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Tesmer | Chief Medical Officer | Signed the Notice of Disciplinary Action |
| Dan Taylor | Administrator | Mentioned as part of Health Facilities Licensure Unit |
| Kolby Venger | Administrative Specialist | Certified service of the Notice |
Notice
Deficiencies: 0
Jun 11, 2025
Visit Reason
This Notice of Disciplinary Action was issued due to violations identified in an informal conference and the CMS-2567 Report dated June 11, 2025, related to insufficient staffing to meet resident needs for mechanical lift transfers and assistance with activities of daily living.
Findings
The facility was found to have violated provisions of the Health Care Facility Licensure Act by failing to ensure sufficient staff to meet resident needs, resulting in disciplinary action including prohibition from admitting residents and placing the license on probation for 180 days starting September 23, 2025.
Report Facts
Probation period days: 180
Days until disciplinary action becomes final: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Tesmer | Chief Medical Officer | Signed the Notice of Disciplinary Action |
| Dan Taylor | Administrator | Named in the Notice of Disciplinary Action |
| Kolby Venger | Administrative Specialist | Certified mailing of the Notice of Disciplinary Action |
Notice
Capacity: 48
Deficiencies: 0
Mar 31, 2025
Visit Reason
The document serves as a licensure renewal application and certification for Skyview Care and Rehab at Bridgeport, verifying the facility's license renewal through the indicated date.
Findings
The documents confirm the facility meets statutory requirements for licensure renewal and include ownership information, facility capacity, and an occupancy permit.
Report Facts
Total licensed beds: 48
Renewal license expiration date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kim Burry | Administrator | Named on the Nursing Home Licensure Renewal Application. |
| Brandi Wright | Director of Nursing | Named on the Nursing Home Licensure Renewal Application. |
| Mitchell Friedman | Authorized Representative | Signed the renewal application on 2/19/2025. |
| Dana Reece | Deputy State Fire Marshal | Inspected the facility and approved the occupancy permit. |
Inspection Report
Renewal
Capacity: 48
Deficiencies: 0
Mar 8, 2023
Visit Reason
This document is a Nursing Home Licensure Renewal Application for Skyview Care and Rehab at Bridgeport, submitted to renew the facility's license for 48 beds.
Findings
The application certifies compliance with Nebraska Department of Health and Human Services rules and regulations for license renewal. The facility is licensed for skilled nursing and nursing care with special care and treatment for physical therapy, speech therapy, and occupational therapy.
Report Facts
Number of beds to be relicensed: 48
Renewal license fees: 1550
Expiration date: Mar 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mitch Friedman | Authorized Representative | Signed the Nursing Home Licensure Renewal Application |
| Lora Sullivan | Administrator | Named as facility administrator on renewal application |
| Niki Hill | Director of Nursing | Named as director of nursing on renewal application |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 12, 2020
Visit Reason
An unannounced visit was conducted to investigate a complaint at Skyview Care And Rehab At Bridgeport on February 12, 2020, regarding allegations of inaccurate documentation, medication administration, bathing equipment functionality, and resident dignity.
Findings
The facility was found to be in compliance with relevant regulatory requirements for all allegations, including documentation accuracy, medication provision, bathing equipment functionality, and treatment of residents with respect and dignity.
Complaint Details
The complaint included four allegations: failure to ensure documentation is accurate and complete; failure to provide medications as ordered; failure to ensure bathing equipment is functioning properly; and failure to ensure residents are treated with respect and dignity. All allegations were found to be unsubstantiated with no negative findings.
Report Facts
Water temperature checks: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 44
Deficiencies: 11
Mar 18, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's response to calls for assistance.
Findings
The facility was found to be in compliance with related regulatory requirements regarding prompt response to calls for assistance. However, multiple deficiencies were identified including issues with advance directives documentation, hot water temperature, transfer/discharge notices, PASARR coordination, psychotropic medication use, medication labeling and storage, food safety, resident record completeness, hazardous area enclosure, and electrical equipment use.
Complaint Details
The complaint alleged the facility failed to ensure prompt response to calls for assistance. The investigation found the facility was in compliance with this allegation.
Severity Breakdown
SS=D: 2
SS=E: 5
SS=F: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure one sampled resident's signed Advanced Directive matched the visual card, face sheet, and care plan. | SS=D |
| Failed to provide 3 residents with hot comfortable water for hand washing. | SS=E |
| Failed to notify resident, resident representative, and Ombudsman in writing of facility initiated transfer for 3 residents. | SS=E |
| Failed to notify resident and legal representative of the bed hold policy within 24 hours of transfer to hospital for 3 residents. | SS=E |
| Failed to ensure a level 2 PASARR had been requested after newly evident diagnosis of serious mental disorder for 3 residents. | SS=E |
| Failed to ensure PRN psychotropic medications were not extended beyond 14 days without medical practitioner evaluation for 2 residents. | SS=D |
| Failed to ensure no discontinued, outdated, or deteriorated drugs were available for use for 9 residents. | SS=E |
| Failed to prevent buildup of ice and condensation in freezer and failed to keep a can of green beans off pantry floor. | SS=F |
| Failed to ensure medical records were complete by ensuring SNF Determination of Continued Stay forms were properly completed for 3 residents. | SS=E |
| Failed to provide proper separation at a hazardous area (Main Boiler Room ceiling penetration) allowing potential smoke and fire spread. | SS=F |
| Failed to restrict use of an extension cord as permanent wiring, creating potential fire hazard. | SS=F |
Report Facts
Sample size: 18
Facility census: 40
Facility capacity: 44
Deficiency count: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ronald Stavely | Administrator | Named in complaint letter and facility correspondence |
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter |
Inspection Report
Renewal
Capacity: 44
Deficiencies: 0
Jan 30, 2019
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related certification verifying that Skyview Care and Rehab at Bridgeport is licensed through the renewal date.
Findings
The documents confirm the facility meets statutory requirements for licensure renewal as a Skilled Nursing Facility with a total licensed capacity of 44 beds. No deficiencies or inspection findings are reported.
Report Facts
Total licensed beds: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ronald Stavely | Administrator | Named on the Nursing Home Licensure Renewal Application |
| Jama Oenning | Director of Nursing | Named on the Nursing Home Licensure Renewal Application |
| Mitch Friedman | Listed as 100% owner of Senex Foundation of Nebraska, Inc, the facility owner | |
| Bo Botelho | Interim CEO, Interim Director of Public Health | Signed certification on licensure verification |
| Dana Reece | Deputy State Fire Marshal | Inspected the facility for the Nebraska State Fire Marshal Occupancy Permit |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 4
Oct 1, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Skyview Care And Rehab At Bridgeport on October 1, 2018, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The investigation confirmed deficiencies related to failure to act upon resident grievances, failure to provide bathing as scheduled, failure to develop care plans addressing residents' needs, and failure to complete follow-up assessments for changes in condition. The facility was found in compliance regarding maintenance of essential equipment and including family/POA in care planning.
Complaint Details
The complaint investigation included allegations that the facility failed to act upon resident grievances, maintain essential equipment, provide bathing as required, identify change in condition, and include family/POA in care planning. The investigation confirmed deficiencies in grievances, bathing, care planning, and follow-up assessments. The facility was found in compliance with equipment maintenance and family/POA inclusion.
Severity Breakdown
SS=D: 2
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to follow facility policies and procedures for grievances, including lack of investigation and notification/signature from complainants. | SS=D |
| Failure to provide bathing as scheduled for residents. | SS=E |
| Failure to develop care plans to address recurrent urinary tract infections, loose stools, decreased energy, and ongoing itching for sampled residents. | SS=E |
| Failure to complete and document follow-up assessments for residents with changes in condition including ongoing loose stools, complaints of lack of energy, and refusal of routine medications due to lethargy. | SS=D |
Report Facts
Facility census: 38
Sampled residents: 6
Deficiency citations: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | RN, BSN, Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation letter |
| Lora Sullivan | Administrator | Facility administrator addressed in the report |
| Director of Nursing | Interviewed regarding care plans and bathing deficiencies |
Notice
Capacity: 44
Deficiencies: 0
Sep 28, 2018
Visit Reason
The document serves to acknowledge and authorize the increase in the number of licensed beds at Skyview Care And Rehab At Bridgeport from 40 to 44 beds, effective October 1, 2018.
Findings
The letter confirms the approval of the bed increase as requested by the facility, in accordance with Nebraska state regulations allowing an increase of no more than ten beds or ten percent of total bed capacity over two years.
Report Facts
Licensed beds increase: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | RN, Program Manager | Signed letter authorizing bed increase. |
Inspection Report
Renewal
Capacity: 40
Deficiencies: 0
Sep 1, 2018
Visit Reason
The document is a renewal license issued to Skyview Care and Rehab at Bridgeport due to a change of ownership and a DBA facility name change, effective September 1, 2018.
Findings
The facility was licensed as a Skilled Nursing Facility with 40 beds. The renewal license confirms compliance with statutory requirements and authorizes continued operation under the new ownership and name.
Report Facts
Licensed beds: 40
Assignment fee: 18000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dean Dragon | Administrator | Named as facility administrator in license application |
| Jama Oenning | Director of Nursing | Named as Director of Nursing in license application |
| Mitchell Friedman | President | Named as individual in control of the facility |
Inspection Report
Annual Inspection
Census: 31
Capacity: 40
Deficiencies: 12
Mar 29, 2018
Visit Reason
Annual survey conducted to assess compliance with federal and state regulations for skilled nursing facilities.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity, unsafe environment conditions, unresolved grievances, incomplete care plan updates, inadequate activities programming, failure to assist with hearing aids, improper oxygen administration, food safety violations, infection control issues, ventilation problems, and life safety code violations related to corridor doors and electrical equipment.
Severity Breakdown
SS=F: 1
SS=E: 4
SS=D: 5
SS=S: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Urinary catheter drainage bag was not placed in a privacy cover for resident dignity. | SS=D |
| Failed to clean dead bugs and repair broken light covers in the main dining room. | SS=E |
| Failed to address and resolve grievances filed by a resident regarding cold bath water. | SS=E |
| Care plans were not revised timely to reflect medication changes for two residents. | SS=D |
| Activities did not meet the needs of a resident who required flexible timing due to sleep patterns. | SS=S |
| Failed to assist resident in repairing or replacing hearing aids. | SS=D |
| Failed to administer oxygen as ordered by physician for a resident. | SS=D |
| Food safety violations including unlabeled food, improper hand hygiene, and peeling paint in kitchen ceiling. | SS=F |
| Urinary catheter bag was stored on the floor and towel bars were not labeled to prevent cross contamination. | SS=D |
| Bathroom ventilation was not working for a resident's restroom. | SS=D |
| Corridor doors did not completely close and latch, risking smoke spread in fire. | SS=E |
| Power strips were used improperly in patient care vicinity for non-medical devices. | SS=E |
Report Facts
Facility census: 31
Total licensed capacity: 40
Deficiency severity counts: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dean Dragon | Administrator | Named in waiver request and plan of correction signatures |
| Katharine Achor | Health Quality Review/LSC Specialist | Named in waiver approval documentation |
| Don Fritz | Chief Deputy State Fire Marshal | Named in waiver approval documentation |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 40
Deficiencies: 7
May 1, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Skyview At Bridgeport from May 1, 2017 to May 3, 2017 by the Department of Health and Human Services Division of Public Health.
Findings
The complaint regarding failure to ensure resident's personal property safety was investigated and found to be in compliance with no violations. The annual survey identified deficiencies related to care plan updates for pain management, oxygen concentrator safety, medication administration timing and availability, infection control practices, and life safety code violations including emergency lighting and smoke barrier integrity.
Complaint Details
The complaint alleged the facility failed to ensure resident's personal property was safe. The investigation included resident interviews, record reviews, and policy assessments. The facility was found in compliance with regulatory requirements and no violation was cited.
Severity Breakdown
SS=D: 3
SS=E: 1
SS=F: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to update care plan for resident's pain management despite daily medication. | SS=D |
| Oxygen concentrators were left on when residents were not in rooms, increasing fire risk. | SS=E |
| Medications not administered according to manufacturer's recommendations and medication not available for administration. | SS=D |
| Failure to wear disposable gloves and perform hand washing before and after injections, risking cross contamination. | SS=D |
| Emergency lighting failed to provide minimum illumination in dining and recreation areas. | SS=F |
| Smoke barriers incomplete and not providing required subdivision into smoke compartments. | SS=F |
| Smoke barriers not constructed to required 1/2-hour fire resistance rating. | SS=F |
Report Facts
Sample size: 30
Resident interviews: 23
Family interviews: 3
Facility census: 33
Facility capacity: 40
Deficiency count: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gerald Dragon | Administrator | Named in complaint investigation and correspondence |
| Eve Lewis | Program Manager | Signed complaint investigation letter |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan, oxygen concentrator use, medication administration, and infection control deficiencies |
| RN B | Registered Nurse | Observed administering medications and injections |
| RN A | Registered Nurse | Observed administering insulin injections without gloves or hand washing |
| Maintenance Personnel A | Interviewed regarding emergency lighting and smoke barrier deficiencies |
Inspection Report
Annual Inspection
Census: 25
Capacity: 40
Deficiencies: 8
Jun 22, 2016
Visit Reason
Annual inspection survey conducted to assess compliance with state and federal regulations governing skilled nursing facilities, including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to address resident grievances about noise, inadequate care plan updates for aspiration risk, unsanitary food preparation areas, improper medication labeling and administration, and failure to properly manage and destroy discontinued and controlled medications. Life safety code violations included unsealed ceiling penetrations compromising fire resistance and obstructions to fire sprinkler heads.
Severity Breakdown
SS=E: 4
SS=D: 3
SS=F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to act on repeated resident grievances related to excessive noise from doors slamming and loud staff conversations. | SS=E |
| Failure to maintain comfortable sound levels disturbing residents' sleep due to noisy doors. | SS=E |
| Failure to update care plan for a resident at risk of aspiration to include elevating the head of the bed after meals. | SS=D |
| Failure to maintain sanitary conditions in the kitchen including unclean steam table, storage shelves, and food bins. | SS=F |
| Failure to verify physician orders prior to administering sliding scale insulin doses for two residents. | SS=D |
| Failure to prevent overflow of discontinued medications and failure to destroy narcotic medications timely per facility policy. | SS=F |
| Failure to maintain one-hour fire-rated separation between attic and occupied area due to unsealed ceiling penetrations. | SS=D |
| Failure to maintain required clearance around fire sprinkler heads due to storage of items within 18 inches of sprinkler heads. | SS=E |
Report Facts
Facility census: 25
Total licensed capacity: 40
Residents affected by medication overflow: 22
Residents affected by medication overflow: 16
Date of survey completion: Jun 22, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Named in findings related to medication administration and storage |
| Maintenance Director | Named in findings related to noise control and fire safety corrections | |
| Director of Nursing | Named in findings related to care plan updates and medication destruction | |
| LPN A | Licensed Practical Nurse | Named in findings related to insulin administration |
| Medication Aide E | Named in findings related to medication storage and destruction | |
| Dietary Manager in training | Named in findings related to kitchen sanitation |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 2
Mar 31, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to protect residents from injuries and failure to report allegations of neglect.
Findings
The investigation found no issues with the use of lifts or protection from injuries, but identified violations related to failure to report an incident with a significant injury within the required timeframe and failure to revise care plans following an accident. No violations were found regarding protection from injuries, but deficiencies were cited for reporting and care plan revisions.
Complaint Details
The complaint alleged the facility failed to protect residents from injuries and failed to report allegations of neglect. The investigation substantiated failure to report a significant injury incident and failure to revise care plans after falls. The resident involved in the deficiencies was deceased at the time of the report.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report an allegation of neglect/abuse to the State Agency within 5 working days for a resident with a fall and significant injury. | SS=D |
| Failure to revise care plan interventions after falls to prevent further reoccurrences for a resident. | SS=D |
Report Facts
Facility census: 27
Date of fall incident: Jan 1, 2016
Date of survey completion: Mar 31, 2016
Deficiency tags cited: 2
Reporting timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gerald Dragon | Administrator | Interviewed regarding resident fall and reporting |
| Eve Lewis | Program Manager | Signed letter regarding complaint investigation |
| Director of Nursing | Interviewed regarding resident fall, reporting, and care plan revisions |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 0
Feb 8, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint that the facility fails to ensure equipment is working/maintained.
Findings
The investigation found that the facility maintained and monitored alarming systems for the sampled residents, with all alarms tested and functioning. Staff responded appropriately to resident falls, and the facility maintenance program regularly tested and repaired alarm systems. No violation or citation was issued regarding the allegation.
Complaint Details
The complaint alleged failure to ensure equipment is working/maintained. The investigation was conducted on-site with record reviews, observations, and interviews. The allegation was not substantiated and no violations were found.
Report Facts
Facility census: 26
Sample size: 4
Investigation period: 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
Routine
Census: 33
Capacity: 40
Deficiencies: 17
Jul 15, 2015
Visit Reason
The inspection was a routine regulatory survey to assess compliance with state and federal regulations governing skilled nursing facilities, including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident privacy during medication administration, dignity and respect related to mechanical lift sling visibility, failure to maintain the courtyard as requested by residents, inaccurate resident assessments, incomplete care plans, unsafe medication administration practices, unsecured oxygen storage, unsanitary kitchen conditions, unsecured medication carts, and infection control issues.
Severity Breakdown
SS=F: 3
SS=E: 5
SS=D: 8
Deficiencies (17)
| Description | Severity |
|---|---|
| Failed to provide privacy to two residents in semi-private rooms during medication administration. | SS=D |
| Failed to assure mechanical lift sling was not in full view of others for two residents. | SS=D |
| Failed to maintain courtyard as requested by Resident Council. | SS=E |
| Failed to accurately identify terminal illness and hospice care on resident assessment. | SS=D |
| Failed to develop comprehensive care plans addressing footwear concerns and positioning bolsters for residents. | SS=D |
| Failed to update care plan to reflect current interventions for safe transfers and nutritional supplements. | SS=D |
| Failed to develop non-contradictory approaches and assess rationale for footwear discomfort and positioning devices. | SS=D |
| Failed to ensure therapy storage room containing oxygen cylinders was secured and properly labeled. | SS=E |
| Failed to label and date food items properly in kitchen, risking foodborne illness. | SS=F |
| Failed to maintain sanitary conditions in kitchen including clean freezers, rust-free backsplash, clean floor mats, clean utensils, and proper hand hygiene by serving staff. | SS=F |
| Failed to ensure accurate medication administration including observation of resident consuming medication and proper medication checks. | SS=D |
| Failed to secure medication carts while unattended in a facility with confused/wandering residents. | SS=E |
| Failed to maintain body positioning device free of cracks and fraying to ensure cleanability. | SS=D |
| Failed to maintain overhead lights free of debris and dead insects in resident areas. | SS=E |
| Failed to document amount of nutritional supplement not consumed by resident. | SS=D |
| Failed to conduct fire drills at varied times on all shifts quarterly. | SS=F |
| Failed to prohibit use of extension cords as substitute for adequate wiring. | SS=E |
Report Facts
Facility census: 33
Facility capacity: 40
Fire drill times: 2
Fire drill times: 2
Medication administration observation period: 60
Food item monitoring frequency: 3
Food item monitoring duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MA D | Medication Aide | Named in privacy and medication administration deficiencies |
| RN A | Registered Nurse | Named in medication administration deficiencies |
| DON | Director of Nursing | Interviewed and verified multiple deficiencies and corrective actions |
| Administrator | Interviewed and verified multiple deficiencies and corrective actions | |
| NA F | Nursing Assistant | Interviewed regarding resident transfer assistance |
| NA H | Nursing Assistant | Interviewed regarding resident footwear care |
| Maintenance Personnel A | Interviewed regarding fire drills and extension cord use | |
| Dietary Manager | Interviewed regarding food labeling and kitchen sanitation |
Inspection Report
Annual Inspection
Census: 37
Capacity: 40
Deficiencies: 3
May 1, 2014
Visit Reason
Annual inspection to assess compliance with Nebraska Administrative Code and Life Safety Code standards for a skilled nursing facility.
Findings
The facility was found deficient in infection control practices related to labeling and covering urinary collection devices, and life safety code violations including lack of one-hour rated ceilings in the laundry area and failure to provide self-closing doors on a storage room. The facility census was 37 with a capacity of 40 at the time of inspection.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to label and cover urinary collection devices in bathrooms shared by multiple residents, risking cross-contamination. | SS=E |
| Facility not providing a one-hour rated ceiling in the laundry area, allowing potential passage of smoke or fire. | SS=E |
| Failure to provide self-closing devices on the doors to a storage room, risking passage of smoke and fire. | SS=E |
Report Facts
Facility census: 37
Facility capacity: 40
Date survey completed: May 1, 2014
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 11
Jun 26, 2013
Visit Reason
Annual inspection of Skyview at Bridgeport to assess compliance with federal and state regulations including resident rights, housekeeping, assessment accuracy, care planning, nutrition, medication management, staffing, and life safety code.
Findings
The facility was found deficient in multiple areas including failure to provide resident bathing choices, inadequate housekeeping and maintenance of bathroom ventilation fans, inaccurate medication coding on assessments, incomplete care plans for dehydration risk and palliative care, failure to update care plans after falls, significant weight loss in a resident due to inadequate feeding assistance, unnecessary use of anxiolytic medication without proper monitoring, failure to post daily nurse staffing information, improper medication administration of crushed enteric coated aspirin, loose corridor handrails, incomplete sprinkler system, and improper clearance around electrical panels.
Severity Breakdown
SS=E: 3
SS=D: 5
SS=C: 1
SS=F: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to provide resident choices regarding bathing schedules for three sampled residents. | SS=E |
| Failure to clean and remove dust and debris from bathroom ventilation fans and repair noisy fan. | SS=E |
| Failure to accurately code medications on Minimum Data Set for one resident. | SS=D |
| Failure to develop comprehensive care plans including dehydration risk, palliative care, and fall interventions. | SS=D |
| Failure to maintain nutrition status and prevent significant weight loss for one dependent resident. | SS=D |
| Failure to ensure drug regimen free from unnecessary drugs and lack of monitoring for one resident. | SS=D |
| Failure to post daily nurse staffing information accessible to residents and visitors. | SS=C |
| Failure to provide enteric coated medication as recommended; crushed enteric coated aspirin administered. | SS=D |
| Failure to have firmly secured handrails in corridors on 300 and 400 wings. | SS=E |
| Failure to provide a complete automatic supervised sprinkler system throughout the facility. | SS=F |
| Failure to provide proper clearance around electrical panels; supplies stored within 36 inch clearance. | SS=F |
Report Facts
Facility census: 36
Residents affected by sprinkler deficiency: 29
Weight loss percentage: 12.2
Medication dose: 81
Medication dose frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Personnel A | Interviewed regarding sprinkler system and electrical panel clearance | |
| LPN-C | Licensed Practical Nurse | Observed crushing medications including enteric coated aspirin for Resident 13 |
| RN A | Registered Nurse | Interviewed regarding medication coding and care plan updates |
| Director of Nursing | Interviewed regarding care plan deficiencies, staffing posting, medication administration, and environmental issues | |
| NA E | Nursing Assistant | Observed feeding Resident 13 and interviewed about feeding practices |
| NA G | Nursing Assistant | Interviewed about feeding Resident 13 and snack policies |
| Dietary Manager | Interviewed about resident nutrition and snack policies | |
| Dietary Aide H | Interviewed about dietary intake records and snack policies |
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 9
Jun 13, 2012
Visit Reason
Annual survey inspection conducted to assess compliance with Nebraska Administrative Code and Life Safety Code standards for Heritage of Bridgeport skilled nursing facility.
Findings
The facility was found deficient in housekeeping and maintenance services, assessment accuracy, care planning, accident hazard prevention, infection control, resident records documentation, and life safety code compliance including incomplete sprinkler system, emergency lighting failure, and use of multi-plug outlets.
Severity Breakdown
SS=E: 6
SS=D: 2
SS=F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Vinyl door covers were cracked and broken creating sharp edges; heating unit cover was broken and dirty; bathroom vent not working; bathroom door had a hole. | SS=E |
| Failed to accurately code Minimum Data Set (MDS) items including diuretic use, therapy minutes, fall history, and bladder incontinence for sampled residents. | SS=E |
| Care plan failed to include use of hand splint and removal of discontinued protective helmet for a resident. | SS=D |
| Bed grab bars were not routinely assessed for safety and continued need for five residents; spaces within grab bars and between mattress and grab bars posed potential safety risks. | SS=E |
| Whirlpool bath seatbelt was worn and frayed, risking cross contamination for nine residents. | SS=E |
| Restorative nursing interventions for use of hand splint, range of motion, and stretching reminders were not documented as ordered for one resident. | SS=D |
| Facility failed to provide a complete automatic supervised sprinkler system throughout the facility (Type III construction). | SS=F |
| Emergency lighting in generator transfer switch room did not operate when tested. | SS=F |
| Use of multi-plug outlets as a substitute for adequate wiring found in resident rooms 108 and 104. | SS=E |
Report Facts
Facility census: 29
Stage 2 sample size: 11
Deficiency count: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Clarke | Administrator | Signed inspection report and plan of correction |
| Maintenance Personnel A | Interviewed regarding sprinkler system and emergency lighting deficiencies | |
| RN-D | MDS Coordinator | Interviewed regarding inaccurate MDS coding |
| LPN-C | Licensed Practical Nurse | Interviewed regarding inaccurate MDS bladder incontinence coding |
| LPN-B | Licensed Practical Nurse | Interviewed regarding resident contracture and restorative care |
| NA-A | Nurse Aide | Interviewed regarding restorative nursing interventions |
| Director of Nursing | Interviewed regarding care plan and restorative documentation deficiencies |
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 1
Dec 15, 2011
Visit Reason
The inspection was conducted as an annual survey to assess compliance with Nebraska regulations governing licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities.
Findings
The facility failed to ensure Resident 1 had clothing appropriate for the weather when leaving the facility for appointments. Observations, interviews, and record reviews revealed the resident was inadequately dressed for cold weather during an appointment on 12/7/11, despite having appropriate clothing brought in later.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide Resident 1 with clothing appropriate for the weather when leaving the facility for appointments. | SS=D |
Report Facts
Facility census: 29
Sample size: 4
BIMS score: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided information about Resident 1's clothing brought in by spouse | |
| Social Services Director | Reported Resident 1 returned from appointment inadequately dressed | |
| NA-A (Nurse Aide) | Observed Resident 1's clothing situation during transport to appointment | |
| Charge Nurse | Advised Nurse Aide to use the heaviest item available for Resident 1 |
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 10
Jul 25, 2011
Visit Reason
The facility underwent an annual inspection to assess compliance with state and federal regulations including care planning, discharge summaries, catheter use, medication management, infection control, and life safety code standards.
Findings
The inspection identified multiple deficiencies including failure to update care plans for significant weight loss, incomplete discharge summaries, lack of physician diagnosis for catheter use, inadequate monitoring of medications, unsanitary kitchen equipment, unlabeled medications, expired insulin, improper linen handling, incomplete wound care technique, incomplete medication documentation, incomplete sprinkler system, and lack of documentation for kitchen hood cleaning.
Severity Breakdown
SS=E: 2
SS=D: 5
SS=F: 3
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to update care plan to address significant weight loss for Resident 7. | SS=D |
| Failure to complete discharge summaries for two residents (Resident 8 and Resident 20). | SS=D |
| Failure to ensure physician diagnosis supports ongoing use of indwelling catheters for Residents 41 and 16. | SS=D |
| Failure to ensure drug regimen is free from unnecessary drugs; inadequate monitoring of benzodiazepines and antihistamine for Resident 39. | SS=D |
| Two kitchen mixers had paint chips and peeling paint, risking food contamination. | SS=F |
| Failure to ensure medication syringes were labeled and expired insulin was discarded. | SS=E |
| Failure to maintain infection control: improper linen handling and wound care technique. | SS=D |
| Failure to maintain complete and accurate clinical records including medication administration and resident response documentation. | SS=E |
| Failure to provide a complete automatic supervised sprinkler system throughout the facility. | SS=F |
| Failure to provide documentation of semi-annual cleaning of kitchen hood and related equipment. | SS=F |
Report Facts
Facility census: 30
Stage 2 sample size: 9
Medication administration days: 29
Medication administration days: 30
Medication administration days: 30
Medication administration days: 30
Medication administration days: 30
Insulin vial open date: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Beth Mann | Administrator | Signed plan of correction |
| Maintenance Personnel A | Interviewed regarding sprinkler system and kitchen hood cleaning | |
| Director of Nursing | DON | Interviewed regarding care plan updates, discharge summaries, catheter use, medication monitoring, wound care, and medication documentation |
| Cook - A | Interviewed regarding kitchen mixers | |
| Dietary Manager | DM | Interviewed regarding kitchen mixers |
| Laundry Aide-C | Observed and interviewed regarding linen handling | |
| Consulting Pharmacist | Interviewed regarding medication regimen review | |
| Med Aide MA-B | Interviewed regarding medication labeling and insulin storage | |
| LPN-D | Observed applying wound care ointment |
Notice
Capacity: 44
Deficiencies: 0
APP2020
Visit Reason
This document serves as the licensure renewal application and verification of licensure for Skyview Care and Rehab at Bridgeport, including occupancy permit and ownership information.
Findings
The documents confirm the facility meets statutory requirements for licensure renewal, with a licensed capacity of 44 beds, and include ownership details and fire marshal occupancy approval.
Report Facts
Licensed capacity: 44
Renewal license expiration date: Mar 31, 2021
Renewal license fees: 1550
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ronald Stavely | Administrator | Named in licensure renewal application |
| Lauren Esquivel | Director of Nursing | Named in licensure renewal application |
| Mitch Friedman | President | Authorized representative signing renewal application and listed as owner |
Notice
Capacity: 48
Deficiencies: 0
APP2021
Visit Reason
This document serves as a renewal application for the nursing home license of Skyview Care and Rehab at Bridgeport, confirming licensure through the renewal date and providing related ownership and occupancy information.
Findings
The documents confirm the facility meets statutory requirements for licensure renewal, with a licensed capacity of 48 beds and certification for Medicare and Medicaid. An occupancy permit was issued with a maximum occupancy of 48 beds.
Report Facts
Licensed capacity: 48
Renewal license expiration date: Expires 3/31/2022 as shown on renewal card
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Esquivel | Director of Nursing | Named on the Nursing Home Licensure Renewal Application |
| Ronald Stavely | Administrator | Named on the Nursing Home Licensure Renewal Application |
| Mitch Friedman | Authorized Representative | Signed the Nursing Home Licensure Renewal Application |
Notice
Capacity: 48
Deficiencies: 0
APP2022
Visit Reason
This document serves as a renewal application for the nursing home license of Skyview Care and Rehab at Bridgeport and includes related licensing and occupancy permit information.
Findings
The documents verify the facility's licensure renewal status, ownership information, and occupancy permit with a maximum capacity of 48 beds.
Report Facts
Total licensed beds: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lora Sullivan | Administrator | Named in the Nursing Home Licensure Renewal Application. |
| Niki Hill | Director of Nursing | Named in the Nursing Home Licensure Renewal Application. |
| Mitch Friedman | Authorized Representative | Signed the Nursing Home Licensure Renewal Application and listed as owner. |
| Dana Reece | Deputy State Fire Marshal | Inspected the facility and approved the occupancy permit. |
Notice
Capacity: 48
Deficiencies: 0
APP2024
Visit Reason
The document serves as a renewal application for the nursing home license of Skyview Care and Rehab at Bridgeport, including verification of licensure and occupancy permit.
Findings
The documents confirm the facility meets statutory requirements for licensure renewal and has an approved occupancy permit for 48 beds.
Report Facts
Total licensed beds: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lora Sullivan | Administrator | Named on the renewal application. |
| Niki Hill | Director of Nursing | Named on the renewal application. |
| Mitchell Friedman | Authorized Representative | Signed the renewal application. |
| Dana Reece | Deputy State Fire Marshal | Inspected and approved the occupancy permit. |
Notice
Capacity: 40
Deficiencies: 0
APP2016
Visit Reason
This document serves as a licensure renewal application and verification for the Skyview at Bridgeport skilled nursing facility, including occupancy permit and ownership information.
Findings
The documents confirm the facility's licensure renewal status, total licensed bed capacity of 40, and ownership details. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 40
Notice
Capacity: 40
Deficiencies: 0
APP2017
Visit Reason
The document serves as a renewal application and certification for the nursing home license of Skyview at Bridgeport.
Findings
The documents verify that Skyview at Bridgeport meets statutory requirements for SNF/NF dual certification and includes ownership information, occupancy permit, and renewal application details.
Report Facts
Total licensed beds: 40
Renewal fee: 1550
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gerald Dragon | Administrator | Named in the renewal application and ownership information. |
| Jama Penning | Director of Nursing | Named in the renewal application. |
| Boni Golden | Business Office Manager | Named in email correspondence related to license renewal. |
| John Berg | Officer | Named in ownership information. |
Notice
Capacity: 40
Deficiencies: 0
APP2018
Visit Reason
This document serves as a renewal application and verification of licensure for the Skyview at Bridgeport nursing home, confirming the facility's license renewal and occupancy capacity.
Findings
The documents confirm that Skyview at Bridgeport is licensed as a Skilled Nursing Facility with a total capacity of 40 beds. The renewal application was signed and submitted, and the facility holds a valid occupancy permit issued by the Nebraska State Fire Marshal.
Report Facts
Total licensed beds: 40
Renewal expiration date: 2018
Occupancy maximum: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gerald Dragon | Administrator | Named as Administrator on the renewal application on page 2 and as Managing Employee on page 3. |
| Jama Oenning | Director of Nursing | Named as Director of Nursing on the renewal application on page 2. |
| John Berg | Officer | Named as Officer on the Medicare ownership information on page 3. |
| Boni Golden | Business Office Manager | Mentioned in email correspondence regarding renewal application on page 4. |
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