Inspection Reports for Southlake Village Rehabilitation & Care Center, Inc.
9401 Andermatt Dr, Lincoln, NE 68526, USA, NE, 68526
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Renewal
Capacity: 126
Deficiencies: 0
Mar 10, 2025
Visit Reason
This document is a Nursing Home Licensure Renewal Application and related licensing and occupancy permit documents for Southlake Village Rehabilitation & Care Center.
Findings
The documents verify that Southlake Village Rehabilitation & Care Center meets statutory requirements for licensure renewal and includes certification of occupancy with a maximum capacity of 126 beds.
Report Facts
Number of beds to be relicensed: 126
Maximum Occupancy: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Bergmann | Administrator | Named in Nursing Home Licensure Renewal Application |
| Jacque McCall | Director of Nursing | Named in Nursing Home Licensure Renewal Application |
| Glenn Van Ekeren | Authorized Representative | Signed Nursing Home Licensure Renewal Application |
| Brian Stuhr | Authorized Representative | Signed Nursing Home Licensure Renewal Application |
| Susen Lindner | Deputy State Fire Marshal | Inspected Nebraska State Fire Marshal Occupancy Permit |
Inspection Report
Renewal
Capacity: 126
Deficiencies: 0
Feb 28, 2024
Visit Reason
The document is a Nursing Home Licensure Renewal Application for Southlake Village Rehabilitation & Care Center to renew its skilled nursing facility license.
Findings
The document certifies that the facility meets statutory requirements for licensure renewal and includes information about services offered, ownership, and accreditation status.
Report Facts
Number of beds to be relicensed: 126
Renewal license fees: 1750
License expiration date: License expires on 2025-03-31 as shown on the renewal card
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Bergmann | Administrator | Named in the Nursing Home Licensure Renewal Application |
| Jacque McCall | Director of Nursing | Named in the Nursing Home Licensure Renewal Application |
| Brian Stuhr | Authorized Representative | Signed the Nursing Home Licensure Renewal Application |
| Glenn Van Ekeren | Authorized Representative | Signed the Nursing Home Licensure Renewal Application |
Inspection Report
Renewal
Capacity: 126
Deficiencies: 0
Mar 1, 2021
Visit Reason
This document is a Nursing Home Licensure Renewal Application and related certification and occupancy permit documents for Southlake Village Rehabilitation & Care Center, indicating the renewal of the facility's license.
Findings
The documents verify that Southlake Village Rehabilitation & Care Center meets statutory requirements for licensure renewal as a Skilled Nursing Facility with a licensed capacity of 126 beds. The renewal application was signed and dated March 1, 2021.
Report Facts
Number of beds to be relicensed: 126
Maximum Occupancy: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jack D Vetter | Authorized Representative | Signed the Nursing Home Licensure Renewal Application on 03.01.2021 |
| Glenn Van Ekeren | Authorized Representative | Signed the Nursing Home Licensure Renewal Application on 03.01.2021 |
| Jacque McCall | Director of Nursing | Listed on the Nursing Home Licensure Renewal Application |
| David Bergmann | Administrator | Listed on the Nursing Home Licensure Renewal Application |
Notice
Capacity: 126
Deficiencies: 0
Mar 16, 2020
Visit Reason
This document serves as the renewal application for the nursing home license of Southlake Village Rehabilitation & Care Center and includes verification of licensure and occupancy permit information.
Findings
The documents confirm that Southlake Village Rehabilitation & Care Center is licensed as a Skilled Nursing Facility with a total capacity of 126 beds and holds a valid occupancy permit issued on 2019-05-31. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 126
License expiration date: License expires on 2021-03-31 as per renewal card
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Bergmann | Administrator | Named in licensure renewal application |
| Jacque McCall | Director of Nursing | Named in licensure renewal application |
| Jack D. Vetter | Authorized Representative | Signed renewal application and listed as Chairman of the Board and CEO of parent corporation |
| Glenn Van Ekeren | Authorized Representative | Signed renewal application and listed as President of parent corporation |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 28, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility failed to provide care and services for safe transfers.
Findings
The facility was found to provide care and services for safe transfers in accordance with the plan of care. Residents reported satisfaction with transfer assistance, staff were knowledgeable, and residents were evaluated for transfer assistance needs. The facility was determined to be in compliance with related regulatory requirements.
Complaint Details
The complaint alleged failure to provide care and services for safe transfers. The allegation was not substantiated as the facility was found compliant.
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 - DHHS |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 126
Deficiencies: 10
Mar 21, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Southlake Village Rehabilitation & Care Center from March 21, 2019 to March 27, 2019 by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility was found compliant with most allegations except for failure to provide appropriate care and treatment of indwelling catheters, failure to revise comprehensive care plans to include specific restorative services, failure to complete discharge summaries, failure to maintain sanitary food preparation areas, and failure to follow infection prevention and control practices including hand hygiene and catheter care. Additionally, several life safety code deficiencies were identified including unsafe stovetop use, corridor doors not latching properly, incomplete fire drills, combustible decorations, and use of unapproved power strips.
Complaint Details
The complaint investigation included allegations of medication administration errors, failure to allow resident choice, accessibility of items and assistive devices, catheter care, call light response, investigation submission timeliness, resident protection from behaviors, notification of charge changes, care planning, and injury prevention. Only the catheter care allegation was substantiated as deficient.
Deficiencies (10)
| Description |
|---|
| Failure to provide appropriate care and treatment of indwelling catheters. |
| Failure to revise comprehensive care plans to include specific restorative services for residents. |
| Failure to complete discharge summaries for discharged residents. |
| Failure to ensure hair restraints fully enclosed hair and maintain cleanliness of kitchen equipment. |
| Failure to perform proper hand hygiene and catheter care including preventing catheter tubing from touching the floor and keeping catheter bag below bladder level. |
| Failure to ensure stovetop in physical therapy area had safety device to prevent unauthorized use. |
| Corridor door to Town Hall failed to close and latch properly. |
| Failure to conduct fire drills at random times on all shifts each quarter. |
| Use of combustible latch hook rug on resident room door without flame retardant treatment. |
| Use of unapproved power strip in resident care area. |
Report Facts
Deficiencies cited: 11
Facility census: 112
Total licensed capacity: 126
Number of beds: 126
Number of smoke compartments: 7
Number of residents reviewed for care planning: 15
Number of closed records reviewed for discharge: 1
Number of residents reviewed for infection control: 6
Number of fire drills reviewed: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter |
| David Bergmann | Administrator | Facility administrator named in documents |
| LPN-A | Nurse observed failing to perform hand hygiene between glove changes during catheter and tube feeding care | |
| Assistant Director of Nursing L | Assistant Director of Nursing | Confirmed restorative services provided but care plan not updated |
| Restorative Aides J and K | Restorative Aides | Observed providing restorative exercises |
| Social Services Director | Social Services Director | Confirmed discharge summary not completed |
| Dietician | Facility Dietician | Confirmed hair restraint and kitchen cleanliness issues |
| Chef B | Chef | Confirmed kitchen hair restraint and cleanliness issues |
| Maintenance Staff A | Maintenance Staff | Confirmed stovetop power not turned off and door latch issues |
| NA E, NA F, NA G | Nursing Assistants | Observed providing catheter care with improper technique |
| Education Coordinator/Infection Control Coordinator | Education Coordinator/Infection Control Coordinator | Confirmed catheter care and hand hygiene deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 26, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Southlake Village Rehabilitation & Care Center regarding failure to use appropriate interventions to prevent injuries and failure to ensure residents are free from misappropriation.
Findings
The facility was found to be in compliance with regulatory requirements for both allegations. Appropriate interventions to prevent injuries were in place and implemented, and the facility ensured residents were free from misappropriation with secured safe areas and no reports of missing items.
Complaint Details
The investigation addressed two allegations: 1) failure to use appropriate interventions to prevent injuries, and 2) failure to ensure residents are free from misappropriation. Both allegations were found to have no violations.
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
Renewal
Capacity: 126
Deficiencies: 0
Feb 28, 2018
Visit Reason
The document is a renewal application and licensing verification for Southlake Village Rehabilitation & Care Center, confirming the facility's SNF/NF dual certification and license renewal through March 31, 2019.
Findings
The document confirms the facility meets statutory requirements for licensing renewal as a skilled nursing facility/nursing facility dual certified center with a licensed capacity of 126 beds. It includes ownership information, facility services, and detailed floor plans but does not report any deficiencies or inspection findings.
Report Facts
Total licensed beds: 126
Maximum endorsed capacity: 12
Base rate: 242
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Revonna White | Administrator | Named as facility administrator on page 2 and page 11 |
| Michelle Thompson | Director of Nursing, R.N. | Named on page 2 |
| Jack D. Vetter | CEO | Authorized representative signing renewal application on page 2 and 14; Chairman of the Board and CEO of parent company on page 3 |
| Glenn Van Ekeren | President | Officer of parent company listed on page 3 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 6, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Southlake Village Rehabilitation & Care Center regarding allegations of failure to provide care and services according to practitioner's orders, failure to promote healing of skin breakdown, and failure to prevent pressure sores.
Findings
The investigation found the facility was in compliance with relevant regulatory requirements for all allegations, including providing care according to practitioner's orders, promoting healing of skin breakdown, and preventing pressure sores.
Complaint Details
The complaint allegations were not substantiated; the facility was found to be in compliance with all relevant regulatory requirements after review of records, observations, and interviews.
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: 109
Capacity: 126
Deficiencies: 12
Dec 11, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Southlake Village Rehabilitation & Care Center from December 11, 2017 to December 14, 2017.
Findings
The investigation found no violations related to call light notification systems, reporting allegations of abuse, or submission of investigations. The facility was found to be in compliance with regulations related to these allegations.
Complaint Details
The complaint allegations included failure to answer call notification systems promptly, failure to immediately report allegations of abuse, and failure to submit investigations within 5 working days. All allegations were found to have no violations.
Severity Breakdown
SS=F: 8
SS=E: 3
SS=D: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| The facility failed to protect residents from injury by not providing a policy or procedure related to the operation, care or maintenance of 6 gas fireplaces, which had the potential to affect 22 residents. | — |
| The fire alarm system's circuit breaker was not equipped with a lock out device, which could allow the fire alarm panel to be inadvertently disconnected from its power supply. | SS=F |
| The facility failed to correct deficiencies identified during the inspection of the fire alarm system, including a non-operational beam detector in the Main Street corridor. | SS=F |
| The facility failed to maintain the required clearance to the sprinkler head in the Chapel Closet and failed to conduct required sprinkler inspections. | SS=F |
| The facility failed to ensure corridor room doors would resist the passage of smoke and were not obstructed in 2 of 7 smoke compartments. | SS=F |
| The facility failed to install suspended heating units so that they were out of reach, increasing potential for harm to staff. | SS=D |
| The facility failed to ensure the controls to operate the direct-vent gas fireplaces were locked or kept in a secure area, allowing unattended residents to access the controls. | SS=F |
| The facility failed to prohibit the use of combustible decorations in the Chapel, specifically a Christmas tree without documentation of flame retardant treatment. | SS=F |
| The facility failed to provide a remote annunciator panel for the emergency generator in an attended location. | SS=F |
| The facility failed to provide documentation for the annual testing of the emergency generator. | SS=F |
| The facility allowed the use of non-hospital grade power strips and extension cords in patient care areas. | SS=E |
| The facility failed to separate empty oxygen cylinders from full ones and failed to secure oxygen cylinders in storage in 2 of 7 smoke compartments. | SS=E |
Report Facts
Facility census: 109
Total capacity: 126
Residents potentially affected by fireplace deficiency: 22
Facility census: 108
Residents potentially affected by oxygen cylinder storage deficiency: 10
Smoke compartments affected: 7
Deficiency counts: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Revonna White | Administrator | Named in complaint investigation and facility staffing |
| Dan Taylor | RN, Training Coordinator, Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter |
| Maintenance Staff A | Confirmed multiple deficiencies including fire alarm breaker lockout, fireplace controls unsecured, sprinkler obstructions, and extension cord use | |
| Maintenance Manager A | Confirmed oxygen cylinder storage deficiencies | |
| Administration Staff A | Confirmed unsecured fireplace controls | |
| Nurse Staff A | Confirmed oxygen cylinder storage practices |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 1, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Southlake Village Rehabilitation & Care Center from November 1, 2017 to November 7, 2017 by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility failed to ensure residents are free from abuse, failed to ensure residents are treated with respect and dignity, and failed to complete thorough investigations of resident complaints. However, the facility had identified these concerns and provided staff re-training prior to the onsite survey, so no deficiencies were written. The facility met requirements related to meal service, dining assistance, and pleasant dining experience.
Complaint Details
The complaint investigation addressed allegations including failure to ensure residents are free from abuse, failure to provide meals and dining assistance as required, failure to ensure a pleasant dining experience, failure to treat residents with respect and dignity, and failure to complete thorough investigations of resident complaints. Some concerns had potential to affect multiple residents, but no deficiencies were cited due to corrective actions taken prior to the survey.
Report Facts
Residents sampled: 6
Residents affected by abuse concern: 5
Residents affected by dignity concern: 5
Residents affected by incomplete investigations: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed the report and identified as Training Coordinator, Office of LTC Facilities - Licensure Unit |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 1
Jul 6, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint that the facility fails to protect residents from injury.
Findings
The investigation found that the facility failed to protect residents from injury by not initiating interventions based on all possible root causes for one resident out of three sampled. Specifically, improper use of a gait belt during transfer caused injury to Resident 300, and the facility did not provide adequate staff education or documentation regarding the incident.
Complaint Details
The complaint alleged the facility fails to protect residents from injury. The investigation substantiated this allegation with findings related to improper use of gait belt causing injury to Resident 300.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure resident environment was free from accident hazards and failed to provide adequate supervision and assistance devices to prevent accidents, specifically improper use of gait belt leading to injury. | SS=D |
Report Facts
Facility census: 101
Resident bruise size: 18
Resident bruise size: 16
Residents sampled: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the complaint investigation letter |
| Dennis Wheeler | Administrator | Facility administrator addressed in the report |
| Director of Nursing | Director of Nursing | Interviewed regarding the investigation and staff education |
Inspection Report
Renewal
Capacity: 126
Deficiencies: 0
Jul 1, 2017
Visit Reason
The document packet and related materials pertain to the renewal and change of ownership of the Skilled Nursing Facility license for Southlake Village Rehabilitation & Care Center, effective July 1, 2017.
Findings
The documents include licensing applications, ownership information, facility descriptions, memory support household philosophy and operations, facility floor plans, occupancy permits, and lease agreements. The facility is licensed for 126 beds and includes a specialized memory support household for residents with dementia.
Report Facts
Total licensed beds: 126
Memory support household capacity: 12
Daily room rates: 232
Daily room rates: 242
Daily room rates: 257
Daily room rates: 272
Level of care rates: 25
Level of care rates: 34
Level of care rates: 46
Level of care rates: 54
Level of care rates: 64
Level of care rates: 73
Memory support daily rate: 10
Premium room additional daily rate: 3
Premium room additional daily rate: 6
Medicare co-payment: 164.5
Transportation local area: 20
Transportation attendant fee: 20
Transportation mileage charge: 0.55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Wheeler | Administrator | Named as facility administrator in licensure application and contact |
| Michelle Thompson | Director of Nursing | Named as Director of Nursing in licensure application |
| Julie Knobbe | Contact | Contact person for legal owning entity VSL Lincoln Southlake, LLC |
| Jack D. Vetter | Chairman of the Board and CEO | Board of Directors and Officers of Vetter Senior Living and subsidiaries |
| Eldora D. Vetter | Secretary | Board of Directors and Officers of Vetter Senior Living and subsidiaries |
| Glenn Van Ekeren | President | Board of Directors and Officers of Vetter Senior Living and subsidiaries |
| Brian Stuhr | Treasurer | Board of Directors and Officers of Vetter Senior Living and subsidiaries |
| Shari Terry | Chief Operations Officer | Signed letter submitting Change of Ownership packet to Nebraska Department of Health and Human Services |
Notice
Capacity: 126
Deficiencies: 0
Mar 31, 2017
Visit Reason
This document serves as a licensure renewal application for Southlake Village Rehabilitation & Care Center, including an Alzheimer's/Special Care Unit Disclosure and Memory Care Endorsement application.
Findings
The document certifies that Southlake Village Rehabilitation & Care Center meets statutory requirements for SNF/NF dual certification and includes detailed descriptions of the memory care philosophy, staffing, training, physical environment, resident activities, family support, and care plans.
Report Facts
Total licensed capacity: 126
Memory support household capacity: 12
Renewal expiration date: 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aimee Middleton | Administrator | Named in the Nursing Home Licensure Renewal Application |
| Michelle Rawtin Van | Director of Nursing | Named in the Nursing Home Licensure Renewal Application |
| Dennis Wheeler | Administrator | Named in the Memory Care Endorsement Application |
| Jack D. Vetter | Authorized Representative | Signed the Memory Care Endorsement Application |
Notice
Deficiencies: 0
Mar 21, 2017
Visit Reason
The notice was issued to inform Southlake Village Rehabilitation & Care Center of disciplinary action placing their license on probation for 90 days starting March 21, 2017, due to violations related to failure to implement interventions to prevent accidents resulting in injury.
Findings
The facility violated licensure regulations by failing to implement adequate interventions to prevent accidents, resulting in resident injuries. The probation requires submission of a Plan of Correction and biweekly reports on residents with accidents.
Report Facts
Probation period: 90
Report submission frequency: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Contact person for submission of reports and correspondence |
| Thomas L. Williams | Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Disciplinary Action |
| Becky Wisel | Administrator, Licensure Unit | Mentioned in relation to the Notice of Disciplinary Action |
| Dennis Wheeler | Administrator | Facility administrator addressed in the notice |
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 4
Jan 25, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Southlake Village Rehabilitation & Care Center regarding multiple allegations including insufficient staffing, failure to protect residents from abuse, failure to provide services to maintain mobility, failure to assist with toileting requests, failure to change fall interventions, failure to investigate causative factors in falls, failure to report accidents with injury, and failure to ensure prompt response to calls for assistance.
Findings
The investigation found no violations related to staffing, abuse protection, mobility services, toileting assistance, or accident reporting. However, violations were found related to failure to have appropriate fall interventions to prevent injuries, failure to investigate causative factors in falls, and failure to ensure prompt response to call lights for dependent residents. Specific deficiencies involved two residents (Resident 5 and Resident 235) with inadequate fall prevention measures and delayed call light responses, contributing to falls and injuries, including Resident 235's death.
Complaint Details
The complaint investigation was substantiated with findings of violations related to fall prevention and response to call lights. The facility was found in violation of Federal regulations F312 and F323 and corresponding state regulations. The investigation included review of resident records, observations, and interviews with residents, family, and staff. Resident 235 experienced delayed call light response leading to a fall and subsequent death. Resident 5 had multiple falls with inadequate fall interventions.
Severity Breakdown
SS=D: 2
SS=G: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure call lights were answered as quickly as requested for one dependent resident (Resident 235). | SS=D |
| Failure to have appropriate fall interventions in place to prevent injuries for two residents (Residents 5 and 235). | SS=G |
| Failure to investigate causative factors in falls for one resident (Resident 235). | SS=G |
| Failure to ensure prompt response to calls for assistance, resulting in violation of Federal tag F312 and State Licensure Number 175 NAC 12-006.09D1c. | SS=D |
Report Facts
Facility census: 114
Deficiency completion date: 2017
Resident 235 BIMS score: 15
Call light response time: 39
Call light response time: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation letter |
| Dennis Wheeler | Administrator | Facility administrator named in the report |
Notice
Deficiencies: 5
Nov 2, 2016
Visit Reason
The document serves as a Notice of Disciplinary Action placing the facility's license on probation for 90 days starting November 17, 2016, due to violations related to medication errors and failure to comply with licensure regulations.
Findings
The facility was found to have significant medication errors resulting in emergency treatment for residents, violating licensure regulations including resident assessment, review and revision, skin integrity, and handwashing requirements.
Deficiencies (5)
| Description |
|---|
| Violation of licensure regulation 175 NAC 12-006.10D pertaining to medication errors. |
| Violations of 175 NAC 12-006.09B Resident Assessment. |
| Violations of 175 NAC 12-006.09C1c Review and Revision. |
| Violations of 175 NAC 12-006.09D2 Skin Integrity. |
| Violations of 175 NAC 12-006.17D Handwashing Requirement. |
Report Facts
Probation period length: 90
Report submission frequency: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Contact person for submission of reports and correspondence related to disciplinary action. |
| Thomas L Williams | Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Disciplinary Action. |
| Becky Wisell | Administrator, Licensure Unit | Mentioned in relation to the Notice of Disciplinary Action. |
| Linda Stenvers | Staff Assistant II, Office of Long Term Care Facilities | Certified service of the Notice of Disciplinary Action. |
| Dennis Wheeler | Administrator | Facility administrator addressed in the termination of probation letter. |
Inspection Report
Annual Inspection
Census: 107
Deficiencies: 11
Oct 17, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Southlake Village Rehabilitation & Care Center from October 5, 2016 to October 17, 2016 by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility was found to be in compliance with many regulatory requirements including interventions for residents at risk for falls, plan of care implementation, call light response, housekeeping, staffing, nutrition, change of condition identification, food safety, and resident protection from injury. However, deficiencies were cited related to comprehensive assessments, care plan revisions, monitoring of bruises, medication errors, immunizations, infection control, life safety code violations, emergency lighting, oxygen safety, generator maintenance, and electrical safety.
Complaint Details
The complaint investigation included allegations related to failure to ensure interventions for residents at risk for falls, failure to implement or follow the plan of care, failure to answer call notification systems promptly, failure to ensure appropriate housekeeping and maintenance, failure to provide sufficient staff, failure to provide adequate intake of calories or nutrients, failure to identify change of condition, failure to ensure foods are labeled and stored properly, and failure to protect residents from injury. The investigation found the facility in compliance with no violations for these allegations.
Severity Breakdown
SS=D: 3
SS=E: 3
SS=F: 3
SS=G: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to complete an assessment reflecting Resident 235's dysphagia disorder. | SS=D |
| Failed to update the Care Plan for Resident 235 to reflect nutritional interventions. | SS=D |
| Failed to monitor and assess bruises on 2 residents (Residents 92 and 147). | SS=E |
| Failed to ensure residents were free from significant medication errors on Resident 213. | SS=G |
| Failed to ensure documentation of influenza immunization for Resident 57. | SS=D |
| Failed to ensure staff changed gloves and washed hands between dirty and clean procedures during resident care. | SS=E |
| Failed to maintain corridor doors to be smoke tight and not blocked open in 5 of 7 smoke compartments. | SS=E |
| Failed to provide and verify emergency lighting of at least 5 foot-candles in Neighborhood Dining Rooms, Activity Areas, and Town Hall. | SS=F |
| Failed to take precautions to prevent oxygen-enriched atmosphere in Resident Room 308. | SS=E |
| Failed to conduct all required weekly inspections of the emergency generator. | SS=F |
| Failed to prohibit use of extension cords and power strips beyond temporary installation and failed to ensure medical equipment was plugged into hospital grade receptacles. | SS=F |
Report Facts
Residents reviewed: 27
Facility census: 107
Deficiency severity counts: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aimee Middleton | Administrator | Named as facility administrator in multiple documents. |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit | Signed report and correspondence related to inspection and enforcement. |
| Dain Weiss | RN, Reviewer | Conducted Informal Dispute Resolution conference. |
| Michelle Thompson | Director of Nursing | Interviewed regarding medication error and other findings. |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 0
Sep 7, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility fails to investigate for causative factors in falls.
Findings
The investigation found that the facility assessed four residents at risk for falls, identified causal factors, and implemented interventions. Staff were knowledgeable about fall risks and precautions, and observations confirmed use of multiple fall prevention measures. The facility was found to be in compliance with all related regulatory requirements.
Complaint Details
The complaint alleged the facility fails to investigate for causative factors in falls. The investigation found the allegation unsubstantiated as the facility conducted appropriate investigations and interventions.
Report Facts
Residents sampled: 4
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: 1
May 4, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint at Southlake Village Rehabilitation & Care Center regarding multiple allegations including failure to prevent injuries, complete investigations timely, ensure residents are free from abuse, serve meals at appropriate temperatures, prevent skin breakdown, respect residents' choice of wake-up time, respond promptly to calls for assistance, maintain infection control, and follow health practitioner's orders.
Findings
The facility was found to be in compliance with relevant regulatory requirements for all allegations except for failure to complete written investigations within five working days, which was substantiated but did not constitute a regulatory violation. The facility had identified this deficiency and implemented a system to prevent recurrence.
Complaint Details
The complaint investigation substantiated the allegation that the facility failed to complete written investigations within five working days. Other allegations were found to be unsubstantiated or in compliance.
Deficiencies (1)
| Description |
|---|
| Failure to complete written investigations within five working days |
Report Facts
Facility self-report investigations reviewed: 13
Investigations submitted to department: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the report and responsible for the investigation |
Inspection Report
Renewal
Capacity: 126
Deficiencies: 0
Feb 22, 2016
Visit Reason
The document is a nursing home licensure renewal application and related materials for Southlake Village Rehabilitation & Care Center, including certification of licensure and facility information for renewal of the SNF/NF dual certification.
Findings
The documents primarily confirm the facility's licensure renewal status, ownership, services offered including specialized memory support care, and detailed facility information including room rates and floor plans. No deficiencies or inspection findings are reported.
Report Facts
Total licensed beds: 126
Memory Support Daily Rate: 10
Daily Room Rates - Companion Standard Room: 217
Daily Room Rates - Companion Deluxe Room: 227
Daily Room Rates - Private Standard Room: 242
Daily Room Rates - Private Deluxe Room: 257
Level of Care Rates - Level I: 25
Level of Care Rates - Level II: 34
Level of Care Rates - Level III: 46
Level of Care Rates - Level IV: 54
Level of Care Rates - Level V: 64
Level of Care Rates - Level VI: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aimee Middleton | Administrator | Named in the licensure renewal application as facility administrator. |
| Michelle Santistevan | Director of Nursing | Named in the licensure renewal application as director of nursing. |
| Jack D. Vetter | President and Chair of the Board & CEO | Named as President and Chair of the Board & CEO of Vetter Health Services and related entities owning the facility. |
| Eldora D. Vetter | Vice President, Treasurer, Secretary | Named as Vice President, Treasurer, and Secretary of Vetter Health Services and related entities. |
| Todd D. Vetter | Assistant Secretary, Secretary | Named as Assistant Secretary and Secretary of Vetter Health Services and related entities. |
| Joani Schelm | Chief Financial Officer | Named as Chief Financial Officer of Vetter Health Services and related entities. |
| Glenn Van Ekeren | President | Named as President of Vetter Health Services, Inc. |
| Mitchell S. Elliott | Chief Development Officer | Named as Chief Development Officer of Vetter Health Services, Inc. |
| Patrick Fairbanks | Chief Operations Officer | Named as Chief Operations Officer of Vetter Health Services, Inc. |
| Rhonda Flanigan | Chief People Officer | Named as Chief People Officer of Vetter Health Services, Inc. |
| Shari Terry | Chief Quality Officer | Named as Chief Quality Officer of Vetter Health Services, Inc. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 4, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to identify causal factors for a resident with a change in condition.
Findings
The facility was found to have a process in place for identifying causal factors for residents with changes in condition, supported by review of six residents' medical records and staff interviews. The facility was determined to be in compliance with relevant regulatory requirements.
Complaint Details
The complaint alleged the facility failed to identify causal factors for a resident with a change in condition. The complaint was not substantiated as the facility demonstrated compliance.
Report Facts
Residents' medical records reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Notice
Capacity: 126
Deficiencies: 0
Feb 3, 2016
Visit Reason
Notification of Medicaid room changes scheduled to occur effective March 1, 2016, specifically converting all 126 beds to dually-certified beds.
Findings
The Medicaid certified beds for Papillion Manor have been amended to reflect 126 dually-certified beds effective March 1, 2016.
Report Facts
Total licensed beds: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danny Vanourney | Program Specialist, MDS/OASIS Automation Coordinator | Author of the letter regarding Medicaid bed certification changes |
| Eve Lewis | Program Manager | CC recipient of the letter |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 2
Sep 15, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Southlake Village Rehabilitation & Care Center from September 9, 2015 to September 15, 2015.
Findings
The facility was found to have changed interventions to prevent ongoing aggressive behaviors toward others, with no violation related to this issue. Observations and interviews regarding respect and dignity found no violations, although some staff were perceived as rushed. The facility was in compliance with regulations except for fire safety code deficiencies related to fire drills and electrical wiring.
Complaint Details
The complaint alleged the facility failed to change interventions to prevent ongoing aggressive behaviors toward others and failed to ensure residents were treated with respect and dignity. The investigation found no violations related to these allegations.
Severity Breakdown
SS=F: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Fire drills failed to have at least one hour difference between each quarter for the past year on the 1st and 2nd shifts, not meeting NFPA 101 requirements. | SS=F |
| Electrical wiring and equipment were not used in accordance with NFPA 70; decorative lights and a phone charger were improperly plugged into extension cords in resident rooms 603 and 514. | SS=D |
Report Facts
Facility census: 99
Fire drills: 5
Fire drills: 5
Facility census: 101
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jean Obermier | Registered Nurse | Conducted the investigation and annual survey |
| Susan Griepenstroh | Registered Nurse | Conducted the investigation and annual survey |
| Nancy Hauschild | Nutrition/dietitian | Conducted the investigation and annual survey |
| Maintenance A | Acknowledged findings related to fire drills and electrical wiring deficiencies |
Inspection Report
Life Safety
Census: 106
Deficiencies: 4
Nov 5, 2014
Visit Reason
The inspection was conducted to assess compliance with the 2000 Edition of the Life Safety Code of the National Fire Protection Association, specifically for fire safety and life safety standards in the facility.
Findings
The facility failed to seal smoke barrier penetrations in 2 of 10 smoke barriers, failed to separate 6 gas fireplaces from patient sleeping areas, failed to maintain corridors free of obstructions in 4 of 7 smoke compartments, and failed to use electrical equipment in accordance with NFPA 70 in 2 resident rooms. These deficiencies had the potential to affect multiple residents and posed fire and safety risks.
Severity Breakdown
SS=E: 2
SS=F: 1
SS=D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to seal smoke barrier penetrations in 2 of 10 smoke barriers allowing potential smoke migration affecting 72 residents. | SS=E |
| Failed to separate 6 gas fireplaces from patient sleeping areas, posing fire spread risk affecting all residents. | SS=F |
| Failed to maintain corridors free of obstructions in 4 of 7 smoke compartments, slowing evacuation affecting approximately 72 residents. | SS=E |
| Failed to use electrical equipment in accordance with NFPA 70 in 2 resident rooms, posing electrical fire risk affecting 2 residents. | SS=D |
Report Facts
Facility census: 106
Smoke barriers inspected: 10
Smoke barriers failed: 2
Gas fireplaces inspected: 6
Smoke compartments inspected: 7
Smoke compartments with obstructions: 4
Resident rooms inspected: 108
Resident rooms with electrical issues: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance A | Confirmed findings related to smoke barrier penetrations, gas fireplaces, corridor obstructions, and electrical equipment issues during interviews |
Inspection Report
Routine
Census: 96
Deficiencies: 2
Jul 24, 2013
Visit Reason
Routine inspection conducted to assess compliance with regulations governing licensure of skilled nursing facilities, including food procurement, sanitary food handling, infection control, and life safety code compliance.
Findings
The facility failed to ensure proper glove changing, hand washing, and prevention of bare hand contact with ready-to-eat foods during meal service, potentially affecting 36 residents. Infection control deficiencies included inadequate handwashing during resident care, improper Foley catheter drainage bag handling, and failure to follow isolation precautions for a resident with C. difficile infection. The facility was found to be in compliance with the Life Safety Code.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure glove changing, hand washing, and no bare hand contact with ready-to-eat foods during meal service. | SS=E |
| Failure to establish and maintain an infection control program including handwashing, Foley catheter care, and isolation precautions. | SS=D |
Report Facts
Facility census: 96
Residents potentially affected: 36
Inspection Report
Life Safety
Census: 98
Deficiencies: 7
Aug 23, 2012
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations, including door latching, hazardous area protection, emergency lighting, fire alarm system testing, oxygen storage safety, and emergency generator maintenance.
Findings
The facility was found deficient in maintaining corridor and fire doors to close and latch properly, protecting hazardous storage areas with appropriate fire-rated barriers, maintaining emergency lighting and fire alarm testing records, securing oxygen cylinders, and performing required emergency generator testing. Several doors failed to resist smoke passage or latch properly, hazardous storage areas lacked proper fire-rated separation, emergency lighting and fire alarm testing documentation was incomplete, oxygen cylinders were unsecured, and the emergency generator was not tested monthly at required load levels.
Severity Breakdown
SS=F: 5
SS=E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to maintain all corridor doors to close and latch within the doorframe and to resist the passage of smoke, affecting all 98 residents. | SS=F |
| Failure to maintain all hazardous storage areas with a 1 hour fire rating for storage rooms greater than 100 sq. ft and failure to maintain doors to storage areas to close and latch within the door frames and resist smoke passage. | SS=F |
| Failure to maintain all smoke/fire doors to be self-closing and to resist the passage of smoke in two of seven smoke compartments affecting approximately 47 residents. | SS=E |
| Failure to maintain testing records for emergency battery powered back-up lighting fixtures affecting all residents and staff. | SS=F |
| Failure to ensure fire alarm system was tested as per NFPA 72, including incomplete function testing of smoke detectors and lack of calibration dates. | SS=F |
| Failure to maintain all oxygen cylinders in storage to be secured or in provided stands to prevent falling. | SS=E |
| Failure to maintain emergency generator by monthly testing to at least 30% of nameplate rating or conducting an annual load bank test, and failure to meet less than 10 second transfer time requirement. | SS=F |
Report Facts
Facility census: 98
Number of smoke compartments: 7
Number of residents affected by door latching deficiency: 98
Number of residents affected by smoke/fire door deficiency: 47
Emergency generator nameplate rating: 600
Emergency generator monthly test load: 30
Emergency generator transfer time: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Staff A | Confirmed door deficiencies, fire alarm testing issues, emergency generator testing deficiencies | |
| Maintenance Staff B | Confirmed fire door deficiencies | |
| Maintenance Staff C | Confirmed emergency generator transfer time deficiencies | |
| CNA Staff A | Certified Nursing Assistant | Observed unsecured oxygen cylinder and secured it upon request |
| PTA Staff A | Physical Therapy Assistant | Confirmed use of pulley obstructing rehab storage door latch |
| Surveyor 04583 | Conducted life safety code survey and documented deficiencies |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 2
Jul 2, 2012
Visit Reason
The inspection was conducted based on a complaint investigation regarding failure to protect a resident from sexual abuse and failure to revise a resident's comprehensive care plan for management of sexual behavior.
Findings
The facility failed to protect one resident (Resident 5) from sexual abuse by another resident (Resident 1) exhibiting sexually inappropriate behaviors. Additionally, the facility failed to review and revise Resident 1's comprehensive care plan to address these behaviors despite multiple documented incidents.
Complaint Details
The complaint investigation substantiated that Resident 5 was subjected to sexual abuse by Resident 1, who exhibited sexually inappropriate behaviors including touching and attempting to undo Resident 5's briefs. The facility implemented 15-minute checks for Resident 1 after the incidents were reported.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to protect one Resident (Resident 5) from behavior that meets the definition of sexual abuse. | SS=E |
| Failure to review and revise one Resident's (Resident 1) Comprehensive Care Plan for management of sexual behavior. | SS=D |
Report Facts
Unit census: 21
Resident 1 BIMS score: 4
Resident 5 BIMS score: 3
Dates of documented incidents: 5
Inspection Report
Routine
Census: 63
Deficiencies: 7
Aug 25, 2011
Visit Reason
Routine inspection of Southlake Village Rehabilitation & Care Center to assess compliance with licensure regulations and life safety codes.
Findings
The facility failed to develop comprehensive care plans addressing dialysis care for one resident and had multiple life safety code deficiencies including doors that did not latch properly, smoke barrier doors not self-closing, delayed egress doors lacking proper signage, lack of emergency lighting at medication preparation areas, fire alarm system lacking visual alarms in courtyards, and kitchen staff not trained on hood extinguishing systems.
Severity Breakdown
Level D: 1
Level E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to develop comprehensive care plan goals and interventions regarding dialysis care and services for one resident. | Level D |
| Doors protecting corridor openings failed to stay latched tightly, risking smoke spread. | Level E |
| Smoke barrier doors failed to be rated and self-closing, affecting two smoke compartments. | Level E |
| Exit doors had delayed egress locking devices without required signage explaining operation. | — |
| Emergency lighting of at least 1½ hour duration was not provided at nurse's medication preparation areas. | — |
| Fire alarm system lacked visual alarms in all courtyards. | — |
| Kitchen staff in four kitchens were not trained on use of kitchen hood extinguishing systems and fire procedures; hood manual pulls and fire extinguishers were obstructed. | — |
Report Facts
Facility census: 63
Sampled residents: 39
Facility census: 65
Notice
Capacity: 126
Deficiencies: 0
APP2019
Visit Reason
This document serves to verify that Southlake Village Rehabilitation & Care Center's SNF/NF dual certification license is renewed through the date indicated on the renewal card and includes the occupancy permit issued by the Nebraska State Fire Marshal.
Findings
The document confirms that the facility meets statutory requirements for SNF/NF dual certification and holds an occupancy permit for 126 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 126
Base rate: 242
Maximum endorsed capacity: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Bergmann | Administrator | Named in license renewal application |
| Michelle Thompson | Director of Nursing, R.N. | Named in license renewal application |
| Jack D. Vetter | Chairman of the Board and CEO | Named as authorized representative and board chairman |
| Julie Knobbe | Contact name for legal owning entity |
Document
Capacity: 126
Deficiencies: 0
APP2022
Visit Reason
The document serves as a renewal application for the nursing home license of Southlake Village Rehabilitation & Care Center and includes related certification and occupancy permit information.
Findings
No inspection findings or deficiencies are reported in this document; it primarily contains administrative and licensing information.
Report Facts
Total licensed beds: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Bergmann | Administrator | Named as the facility administrator in the renewal application on page 2. |
| Jacque McCall | Director of Nursing | Named as the Director of Nursing in the renewal application on page 2. |
| Brian Stuhr | Authorized Representative | Signed the renewal application as an authorized representative on page 2. |
| Glenn Van Ekeren | Authorized Representative | Signed the renewal application as an authorized representative on page 2. |
Document
Capacity: 126
Deficiencies: 0
APP2023
Visit Reason
The documents serve to renew the nursing home license for Southlake Village Rehabilitation & Care Center and provide related administrative information including occupancy permit and corporate officers.
Findings
No inspection findings or deficiencies are reported in these documents. They primarily confirm licensure renewal, facility capacity, and administrative details.
Report Facts
Total licensed capacity: 126
Renewal license fees: 1550
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Bergmann | Administrator | Named on the Nursing Home Licensure Renewal Application |
| Jacque McCall | Director of Nursing, R.N. | Named on the Nursing Home Licensure Renewal Application |
| Brian Stuhr | Treasurer | Named as Treasurer on the Directors and Officers list |
| Glenn Van Ekeren | President | Named as President on the Directors and Officers list |
| Jack D. Vetter | Chairman of the Board and CEO | Named as Chairman and CEO on the Directors and Officers list |
| Eldora D. Vetter | Secretary | Named as Secretary on the Directors and Officers list |
Loading inspection reports...
