Inspection Reports for The Cypress at Midtown
910 South 40th Street, OMAHA, NE, 68105
Back to Facility ProfileDeficiencies (last 10 years)
Deficiencies (over 10 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
181% worse than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
53 residents
Based on a May 2019 inspection.
Census over time
Notice
Capacity: 65
Deficiencies: 0
Mar 1, 2024
Visit Reason
Issuance of a new Skilled Nursing Facility license for The Cypress At Midtown due to a change of ownership, effective March 1, 2024.
Findings
The document confirms the facility meets statutory requirements for licensure and provides the new license and renewal card. It includes ownership details and licensing fees but does not report inspection findings or deficiencies.
Report Facts
Total licensed beds: 65
Initial licensure fee: 1550
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephen Shell | Administrator | Named as facility administrator on licensure application and ownership documents. |
| Raquel Kolker | Director of Nursing | Named as Director of Nursing on licensure application. |
| Timothy Tesmer | Chief Medical Officer | Signed the license issuance letter. |
| Dan Taylor | Administrator | Signed the license issuance letter from Health Facilities Licensure Unit. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 8, 2020
Visit Reason
A desktop investigation was conducted to investigate a complaint at Azria Health Midtown on April 8-9, 2020, regarding the facility's failure to put interventions in place to prevent injuries and failure to investigate causative factors in injury.
Findings
The facility was found to be in compliance with regulatory guidelines as it did put interventions in place to prevent injuries and conducted complete investigations into causative factors of injuries, with staff education and timely submission of investigations to the state agency.
Complaint Details
The complaint alleged that the facility failed to put interventions into place to prevent injuries and failed to investigate causative factors in injury. Both allegations were found to be unsubstantiated as the facility was 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 |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
May 6, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to use fall interventions to prevent injuries and failure to complete written investigations within five working days.
Findings
The facility failed to evaluate potential causal factors for falls, specifically the resident's blood pressure, and failed to submit written investigation results to the state survey agency within five working days for a resident with a significant injury.
Complaint Details
The complaint alleged the facility failed to use fall interventions to prevent injuries and failed to complete written investigations within five working days. The complaint was substantiated with findings of failure to evaluate blood pressure as a causal factor for falls and failure to timely submit investigation reports.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to evaluate potential causal factors for falls, including blood pressure related to falls. | SS=D |
| Failure to submit results of investigation to state survey agency within 5 working days for residents with significant injury. | SS=D |
Report Facts
Resident census: 53
Deficiency count: 2
Dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Isaac Smith | Administrator | Reported the investigation report was sent by email but not received due to misspelled email address. |
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation letter. |
| Director of Nursing | Confirmed no evidence of evaluation of Resident 1's blood pressure. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 27, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint at Azria Health Midtown regarding allegations of inadequate resident supervision and failure to use fall interventions to prevent injuries.
Findings
The facility was found to be in compliance with relevant regulations, ensuring adequate supervision according to residents' plans of care and using fall interventions to prevent injuries. No concerns were identified during the inspection.
Complaint Details
The complaint alleged failure to ensure adequate supervision and failure to use fall interventions. Both allegations were found to be unsubstantiated as the facility complied with regulations.
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
Deficiencies: 0
Oct 31, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Azria Health Midtown on October 31, 2018, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The investigation found the facility to be in compliance with all allegations including staff background checks, prompt response to calls for assistance, housekeeping program, and meal quality. No violations were identified related to the complaint.
Complaint Details
The complaint alleged failure to complete staff background checks, ensure prompt response to calls for assistance, maintain an effective housekeeping program, and ensure meals are attractive and palatable. All allegations were found to be unsubstantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Isaac Smith | Administrator | Named as facility administrator in relation to the complaint investigation. |
| 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: 51
Deficiencies: 4
Jul 16, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Azria Health Midtown on July 16-17, 2018, regarding multiple allegations including failure to identify change in condition, prompt response to calls, medication administration errors, and housekeeping.
Findings
The investigation found no violations for change in condition, bathing, hand washing, respect, meal temperature, plan of care, and housekeeping. However, medication errors were identified with a medication error rate of 32.14%, including failure to follow the five rights and practitioners' orders. The facility also lacked a qualified dietary manager and had food safety violations related to improper food handling.
Complaint Details
The complaint investigation was triggered by allegations including failure to identify change in condition, prompt response to calls, medication errors, and housekeeping issues. The investigation substantiated medication errors and food safety violations.
Severity Breakdown
Level E: 1
Level D: 1
Level F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide medications according to the five rights with a medication error rate of 32.14%. | Level E |
| Failed to ensure residents are free of significant medication errors. | Level D |
| Failed to employ a qualified dietary manager. | Level F |
| Failed to serve ready to eat foods in a manner to prevent potential food borne illness. | Level F |
Report Facts
Medication error rate: 32.14
Number of medication errors: 9
Census: 51
Medication administrations observed: 28
Food temperature recordings missed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Isaac Smith | Administrator | Facility administrator addressed in the report. |
| Dan Taylor | RN, Training Coordinator | Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS representative who signed the complaint investigation letter. |
| LPN A | Involved in multiple medication administration errors related to insulin. | |
| LPN B | Involved in medication administration errors related to insulin pen priming. | |
| Certified Medication Assistant (CMA) C | Administered medications without food as ordered, contributing to medication errors. | |
| Certified Medication Assistant (CMA) D | Administered medications without food and did not follow timing instructions. | |
| Dietary Manager (DM) | Facility dietary manager not certified and lacked knowledge of food temperature requirements and food safety. | |
| Dietary Aid F | Observed touching ready to eat foods with bare hands. | |
| Cook E | Observed touching ready to eat foods with bare hands and improper food handling. |
Inspection Report
Annual Inspection
Census: 48
Capacity: 65
Deficiencies: 19
Jun 12, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Azria Health Midtown on June 5, 2018-June 12, 2018, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility was found out of compliance for failure to ensure the plan of care reflected resident needs and failure to maintain an effective housekeeping program. Other areas such as hygiene, medication administration, abuse protection, staffing, and call light response were found in compliance. Multiple life safety and fire safety deficiencies were also cited.
Complaint Details
The visit was complaint-related with multiple allegations including failure to ensure clean and groomed residents, failure to follow plan of care, failure to protect residents from abuse and misappropriation, and failure to maintain an effective housekeeping program. Some allegations were substantiated such as failure to maintain housekeeping and plan of care deficiencies.
Severity Breakdown
Level E: 8
Level D: 2
Level F: 5
Deficiencies (19)
| Description | Severity |
|---|---|
| Failure to ensure the plan of care reflected resident's needs including anticoagulant and antipsychotic medication use and fall interventions. | — |
| Failure to maintain an effective housekeeping program with damaged walls, floors, door frames, stained call light cords, and missing toilet paper holders in multiple resident rooms. | Level E |
| Failure to provide notice of bed hold policy at time of transfer to hospital for 2 residents. | Level D |
| Failure to monitor for adverse effects of antipsychotic medications for one resident. | Level D |
| Failure to ensure ventilation system was operational in 3 resident rooms. | Level E |
| Failure to document decision to hire employee with adverse registry finding. | — |
| Failure to ensure door in means of egress would open easily. | Level E |
| Failure to post correct code required to unlock a door in means of egress. | Level E |
| Failure to conduct monthly tests of emergency lighting for 6 smoke compartments. | Level F |
| Use of unapproved expandable foam for penetrations in hazardous area walls. | Level E |
| Failure to train kitchen staff on procedures to extinguish grease fires. | Level E |
| Failure to have fire watch policy in disaster plan for fire alarm system out of service for more than 4 hours. | Level F |
| Failure to inspect all portable fire extinguishers annually. | Level F |
| Failure to ensure corridor doors resist passage of smoke with proper sealing. | Level F |
| Failure to ensure smoke separation doors resist passage of smoke in 2 smoke compartments. | Level E |
| Failure to include smoke compartment evacuation plan in disaster plan. | Level F |
| Failure to provide letter from natural gas company confirming uninterrupted supply for emergency generator. | Level E |
| Failure to provide approved covers for electrical receptacles and use of unapproved adapter for refrigerator. | Level E |
| Use of unapproved power strip for medical equipment in patient care area. | Level E |
Report Facts
Medication error rate: 3.7
Call light average response time: 368
Number of residents observed with housekeeping deficiencies: 9
Number of residents affected by ventilation system failure: 3
Number of residents affected by fire extinguisher inspection failure: 30
Number of residents affected by electrical receptacle deficiencies: 29
Number of residents affected by unapproved power strip use: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Isaac Smith | Administrator | Named as facility administrator in multiple findings and correspondence |
| Dan Taylor | RN, Training Coordinator | Signed correspondence and reports related to the inspection |
| Kimberly A. Divis | RN, NSSC | Conducted Informal Dispute Resolution |
| Maintenance A | Interviewed regarding maintenance and safety deficiencies | |
| Dietary Manager | Responsible for dietary staff training on fire safety |
Inspection Report
Renewal
Capacity: 65
Deficiencies: 0
Feb 23, 2018
Visit Reason
This document is a nursing home licensure renewal application and certification for Azria Health Midtown, verifying the facility's license renewal and compliance with statutory requirements.
Findings
The document confirms that Azria Health Midtown meets statutory requirements for licensure renewal as a Skilled Nursing Facility/Nursing Facility dual certification. It includes ownership information, bed capacity, and fire marshal occupancy permit details.
Report Facts
Number of beds to be relicensed: 65
Facility Total Licensed Beds: 65
Total Facility Certified Beds: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Spencer Bartlett | Administrator | Named in Nursing Home Licensure Renewal Application |
| Heavenlee Brown | Director of Nursing | Named in Nursing Home Licensure Renewal Application |
| Alan Viox | Deputy State Fire Marshal | Inspected and approved occupancy permit |
Inspection Report
Annual Inspection
Census: 46
Capacity: 65
Deficiencies: 7
Apr 6, 2017
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for skilled nursing facilities, including care planning, accident prevention, medical record accuracy, and life safety code adherence.
Findings
The facility was found deficient in developing comprehensive care plans related to side rail use for one resident, evaluating and documenting side rail use and risks, documenting wound treatment as ordered for another resident, maintaining fire safety features including stairwell door closures, fire alarm system testing and documentation, sprinkler system maintenance, and oxygen equipment safety.
Severity Breakdown
SS=D: 3
SS=F: 3
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan for side rail use for Resident 46. | SS=D |
| Failed to evaluate and document the use and risks of side rails for Resident 46. | SS=D |
| Failed to document wound treatment as ordered for Resident 69. | SS=D |
| Failed to maintain stairwell exit door to close and latch properly, compromising fire resistance rating. | SS=F |
| Failed to provide complete documentation for annual fire alarm system inspection. | SS=F |
| Failed to complete 5-year calibration test of gauges and internal pipe examination of fire sprinkler system. | SS=F |
| Failed to take precautions to prevent oxygen-enriched atmosphere by leaving oxygen concentrator running unattended. | SS=E |
Report Facts
Facility census: 46
Total licensed capacity: 65
Deficiencies cited: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Spencer K. Bartlett | Person Completing Form CMS-671 | Signed staffing form on page 13 |
| Brenda Hutchison | Surveyor | Signed Civil Rights Compliance Form on page 14 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 23, 2016
Visit Reason
An unannounced visit was conducted to investigate multiple complaints at The Rehabilitation Center Of Omaha Llc from November 23, 2016 to December 6, 2016 by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The investigation found the facility in compliance with all related regulatory requirements for the allegations investigated, including prompt emergency services, monitoring of blood work, administration of eye drops, safe resident transport, and sufficient staffing to meet residents' needs.
Complaint Details
The complaint investigation addressed allegations that the facility failed to provide prompt emergency services, failed to monitor blood work as ordered, failed to give eye drops according to standards, failed to ensure residents were transported safely, and failed to provide sufficient staff. All allegations were found to be unsubstantiated with the facility in compliance.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the report and identified as Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 3, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint at The Rehabilitation Center Of Omaha Llc regarding multiple allegations including failure to prevent falls, protect residents from abuse, provide medications as ordered, ensure grooming, prevent injuries, and maintain sufficient staffing.
Findings
The facility was found to be in compliance with regulatory requirements for all allegations investigated, including fall prevention, abuse protection, medication administration, grooming, injury prevention, and staffing sufficiency.
Complaint Details
The complaint investigation addressed allegations of failure to prevent falls, protect residents from abuse, provide medications as ordered, ensure clean and groomed hair, skin, teeth and/or nails, failure to put interventions in place to prevent injuries, and insufficient staffing. All allegations were found to be unsubstantiated with the facility in compliance.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Licensure Unit | Signed the report and identified as Training Coordinator for the Licensure Unit, Division of Public Health-DHHS |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Jun 13, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to submit investigations within 5 working days and failure to evaluate causal factors for falls.
Findings
The facility failed to submit investigations related to allegations of abuse within 5 working days, violating federal and state regulations. However, the facility was found to be in compliance with evaluating causal factors for falls.
Complaint Details
The complaint alleged the facility failed to submit investigations within 5 working days and failed to evaluate causal factors for falls. The investigation substantiated the failure to submit investigations timely but found compliance with fall evaluations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit investigations within 5 working days as required by facility policy and regulatory standards. | SS=D |
Report Facts
Facility census: 59
Deficiency completion date: Jul 2, 2016
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 |
| Spencer Bartlett | Administrator | Facility administrator named in the report |
Inspection Report
Routine
Census: 45
Deficiencies: 10
Feb 23, 2016
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with licensure and safety regulations for The Rehabilitation Center of Omaha LLC.
Findings
The facility was found deficient in providing a homelike environment for residents, maintaining housekeeping and maintenance services, ensuring sanitary food preparation and storage, and compliance with life safety codes including fire safety, emergency lighting, fire alarm system maintenance, and electrical wiring standards.
Severity Breakdown
SS=D: 1
SS=E: 4
SS=F: 5
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure a homelike environment by supplying room decorations for two resident rooms, Residents 55 and 47. | SS=D |
| Failed to maintain walls in good condition as evidenced by scrapes and scuffs in multiple rooms and elevator trim. | SS=E |
| Failed to ensure hair restraints fully covered hair during meal service and maintain cleanliness of kitchen equipment and storage areas. | SS=F |
| Allowed a wooden block to obstruct the closing of a door leading into a hazardous area, compromising fire safety. | SS=E |
| Failed to maintain delayed egress door hardware within required pressure limits, delaying evacuation. | SS=F |
| Failed to ensure emergency lighting near the emergency generator. | SS=F |
| Failed to provide complete documentation for the annual fire alarm system inspection. | SS=F |
| Allowed unapproved items to hang from fire sprinkler pipes and failed to replace missing escutcheon ring around sprinkler head. | SS=E |
| Allowed alarm annunciator for emergency generator to be installed in an area not readily observed by operating personnel. | SS=F |
| Allowed use of an extension cord as a substitute for permanent wiring. | SS=E |
Report Facts
Facility census: 45
Residents affected by fire door obstruction: 5
Residents affected by delayed egress door issue: 54
Residents affected by emergency lighting deficiency: 54
Residents affected by fire alarm documentation deficiency: 54
Residents affected by sprinkler system deficiencies: 5
Residents affected by alarm annunciator placement: 54
Residents affected by extension cord use: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance A | Verified multiple deficiencies including fire door obstruction, delayed egress door pressure, emergency lighting absence, fire alarm documentation, sprinkler system issues, alarm annunciator placement, and extension cord use. | |
| Administrator | Participated in environmental tours and interviews regarding homelike environment deficiencies. | |
| Social Services Director | Provided information on resident preferences related to homelike environment. | |
| Director of Nursing | Agreed on deficiencies related to homelike environment and participated in interviews. | |
| Dietary Manager | Confirmed hair restraint and kitchen sanitation deficiencies. |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Dec 23, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint at The Rehabilitation Center Of Omaha Llc from December 23, 2015 to December 29, 2015 by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility was found to be in compliance with regulatory guidelines regarding implementation and following of the plan of care, protection of residents from abuse, and use of appropriate interventions to prevent injuries. Observations, record reviews, and interviews supported these findings.
Complaint Details
The complaint alleged failure to implement or follow the plan of care, failure to protect residents from abuse, and failure to use appropriate interventions to prevent injuries. The facility was found compliant in all these areas.
Report Facts
Facility census: 47
Number of employee files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Licensure Unit | Signed the report as Training Coordinator for the Licensure Unit, Division of Public Health-DHHS |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 16
Apr 6, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at The Rehabilitation Center Of Omaha LLC on April 6, 2015-April 9, 2015.
Findings
The facility did protect residents from abuse so the allegation was unsubstantiated. However, the facility staff did not follow the facility policy related to immediate reporting of abuse to the administrative staff, resulting in a related deficiency. Additional deficiencies were found related to employee background checks, housekeeping, care planning, medication errors, infection control, and quality assurance.
Complaint Details
The complaint alleged the facility failed to protect residents from abuse. The allegation was unsubstantiated but related deficiencies were cited including failure to immediately report abuse incidents to administration.
Severity Breakdown
SS=E: 11
SS=F: 4
SS=D: 2
Deficiencies (16)
| Description | Severity |
|---|---|
| Facility staff failed to ensure criminal background check specific information, APS/CPS checks and Sex Offender Registry checks were included in 5 employee files. | SS=E |
| Facility staff failed to follow and implement the facility policy related to reporting of sexual contact between residents immediately to the facility administrative staff. | SS=E |
| Facility failed to maintain odor control and sanitary conditions in multiple resident bathrooms and rooms. | SS=E |
| Facility failed to develop a comprehensive care plan for a resident related to dental care and services. | SS=D |
| Facility staff failed to monitor a dialysis access port site used in dialysis treatments for a resident. | SS=D |
| Facility staff failed to ensure medication error rate was less than 5%, with 3 medication errors out of 28 opportunities. | SS=E |
| Facility staff failed to ensure residents were free of significant medication errors related to Coumadin therapy. | SS=D |
| Facility staff failed to ensure medications were secure related to an unlocked and unattended medication cart. | SS=E |
| Facility staff failed to ensure infection control practices were followed to prevent cross contamination related to bare hand contact with medications and administration of medications through a gastric tube without gloves. | SS=E |
| Facility failed to have a Quality Assessment and Assurance committee that identified potential repeat citations and additional citations and failed to develop and implement plans of action to maintain correction of repeat citations. | SS=E |
| Facility failed to assure that Medical Records door could be left open with the use of holder, allowing smoke, fire and gasses to migrate into exit corridors. | SS=E |
| Facility failed to assure that fire drills were conducted at random times during the 1st, 2nd and 3rd shifts. | SS=F |
| Facility failed to maintain the single station smoke detector in the break room to be replaced within manufacturer's requirements. | SS=E |
| Facility failed to maintain and test a complete automatic sprinkler system with quarterly inspections and testing. | SS=F |
| Facility failed to assure the generator had been run monthly under a 30 percent load. | SS=F |
| Facility failed to use electrical wiring and equipment in accordance with NFPA 70 by failing to install Ground Fault protected outlets in resident restrooms, failed to provide cover plate on electrical outlet in Resident Room 213 and allowed use of an extension cord in the break room. | SS=E |
Report Facts
Facility census: 43
Medication error rate: 10.71
Number of residents affected by unlocked medication cart: 24
Number of resident rooms without GFCI outlets: 27
Number of residents affected by electrical deficiencies: 38
Number of residents affected by smoke detector deficiency: 4
Number of residents affected by sprinkler system deficiency: 45
Number of residents affected by generator testing deficiency: 45
Number of residents affected by fire drill deficiency: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| D. Kirk Sweeney | Administrator | Named in complaint investigation and plan of correction correspondence |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit | Named in complaint investigation correspondence |
| George Voigtlander | Physician Reviewer/Medical Director | Named in Informal Dispute Resolution correspondence |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 0
Feb 22, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint survey regarding allegations that the facility failed to ensure proper staffing to meet residents' needs and failed to have enough supplies to meet residents' needs.
Findings
The investigation found that the facility ensured proper staffing to meet resident needs and had enough supplies to meet resident needs, resulting in no violations related to the allegations.
Complaint Details
The complaint alleged insufficient staffing and supplies. The investigation found no violations; staffing was adequate and supplies were sufficient.
Report Facts
Resident census: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Neneman | Social Worker | Conducted the complaint investigation |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the inspection report letter |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 30, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint at The Rehabilitation Center Of Omaha Llc on September 30, 2014-October 1, 2014, regarding multiple allegations including hygiene, catheter equipment cleanliness, food handling, misappropriation of resident items, staffing levels, dignity, medication administration, pain management, food preferences, nutritional needs, and protection from abuse.
Findings
The facility was found to be in compliance with all allegations investigated, including ensuring residents were clean and groomed, catheter equipment was maintained to reduce odors, food handling procedures prevented food borne illness, resident items were free from misappropriation, staffing was adequate, residents' dignity was maintained, medications were administered as ordered, pain management was provided, food preferences and nutritional needs were addressed, and residents were protected from abuse.
Complaint Details
The investigation was complaint-related and included multiple allegations as listed. All allegations were found to be unsubstantiated based on observations, interviews, and record reviews.
Report Facts
Residents observed for hygiene: 3
Residents with catheters observed: 3
Meals observed: 1
Days of menus reviewed: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Frodsham | Registered Nurse | Conducted the complaint investigation visit |
| Eve Lewis | Program Manager | Signed the report correspondence |
Notice
Deficiencies: 0
Jul 15, 2014
Visit Reason
The notice was issued to inform The Rehabilitation Center Of Omaha LLC of disciplinary action placing their Skilled Nursing Facility license on probation for 90 days starting July 30, 2014, due to violations of licensure regulations related to accident prevention and quality assurance/performance improvement.
Findings
The facility failed to establish and implement an effective process to prevent accidents and a Quality Assurance/Performance Improvement process to identify issues, analyze causes, and develop corrective action plans. The notice requires submission of a Plan of Correction and ongoing reports during the probation period.
Report Facts
Probation period length: 90
Probation start date: Jul 30, 2014
Notice date: Jul 15, 2014
Response due date: Aug 9, 2014
Monthly report due date: Aug 30, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Contact for submission of reports and response to the Notice |
| Joseph M. Acierno | MD, JD, Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Disciplinary Action |
| Helen L. Meeks | Administrator, Licensure Unit | Signed the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II | Certified mailing of the Notice |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 6
Jul 1, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at The Rehabilitation Center Of Omaha LLC on July 1-2, 2014.
Findings
The facility failed to ensure residents received the proper consistency of diet, failed to administer medications as ordered, and failed to provide privacy during personal cares. Other findings included failure to prevent medication errors, and failure to assist residents with incontinent care. Some residents were exposed during personal cares and received incorrect diet consistencies, putting them at risk for aspiration and choking.
Complaint Details
Complaint investigation included allegations of failure to ensure residents handle hot fluids safely, receive proper diet consistency, receive medications as ordered, and receive assistance with incontinent care. The facility was found non-compliant in diet consistency, medication administration, privacy during personal cares, and incontinent care assistance.
Severity Breakdown
SS=D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure privacy during personal cares for 2 residents (Resident 1 and 45). | SS=D |
| Failed to ensure bathing preferences were followed for 2 residents (Resident 46 and 17). | SS=D |
| Failed to ensure residents received the proper consistency of diet to prevent aspiration for Resident 43 and failed to implement fall prevention interventions for Resident 45. | SS=D |
| Failed to ensure residents received medications as ordered for Resident 81. | SS=D |
| Failed to assist residents with incontinent care using proper cleansing techniques for 2 residents (Resident 1 and 45). | SS=D |
| Failed to have an effective Quality Assurance program with repeat citations and additional citations. | SS=D |
Report Facts
Facility census: 48
Medication administration errors: 6
Bathing frequency: 2
Bathing frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nursing Assistant | Involved in providing personal care without privacy and improper cleansing technique |
| NA B | Nursing Assistant | Involved in providing personal care without privacy and improper cleansing technique |
| RN E | Registered Nurse | Confirmed Resident 45 was left unattended in wheelchair |
| DON | Director of Nursing | Confirmed medication error and diet order discrepancies |
| ADON | Assistant Director of Nursing | Reported staff are taught to clean residents from front to back |
| DM | Dietary Manager | Confirmed diet orders and food consistencies for Resident 43 |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 1
Jan 2, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to provide a safe environment for residents identified at risk for elopement.
Findings
The facility failed to provide a safe environment for one resident at risk for elopement who was able to exit the building independently by entering codes into door key pads. Observations and interviews confirmed the resident was off the building grounds unsupervised, violating federal requirements.
Complaint Details
The complaint alleged the facility failed to provide a safe environment for residents identified as a risk for elopement. The investigation confirmed the allegation as substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to provide a safe environment for residents at risk for elopement, allowing a resident to exit the building independently by entering door codes. | SS=D |
Report Facts
Census: 53
Deficiency severity level: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Schultz | Administrator | Named in plan of correction and interviews related to the elopement deficiency |
| Kelly Schmidt | Registered Nurse | Investigator representing Department of Health and Human Services |
| Kay Reeves | Nutrition/dietitian | Investigator representing Department of Health and Human Services |
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 3
Jul 1, 2013
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with licensure regulations for skilled nursing facilities.
Findings
The facility was found deficient in investigating and reporting an allegation of potential neglect for one resident, failure to evaluate and implement interventions for a pressure ulcer for another resident, and medication errors resulting in an error rate of 7.4%.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to investigate and report an allegation of potential neglect for Resident 3. | SS=D |
| Failure to evaluate causal factors and implement assessed interventions for the development of a pressure ulcer for Resident 4. | SS=D |
| Medication error rate of 7.4% exceeding the allowed 5%, including errors in administration timing and medication instructions. | SS=D |
Report Facts
Census: 49
Medication error rate: 7.4
Medications observed: 27
Medication errors: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding failure to investigate and report neglect allegation | |
| Licensed Practical Nurse C | Observed dressing change and interviewed about pressure ulcer care | |
| Licensed Practical Nurse B | Interviewed about evaluation of pressure ulcer and medication administration | |
| Certified Occupational Therapy Assistant D | Interviewed about pressure relief cushion | |
| Registered Nurse B | Observed medication administration and interviewed about medication errors |
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 27
Jan 17, 2013
Visit Reason
The facility underwent an annual inspection to assess compliance with federal and state regulations including resident rights, personal funds management, privacy, abuse prevention, infection control, and life safety code standards.
Findings
The inspection identified multiple deficiencies including failure to timely issue liability notices, inadequate management of resident personal funds, lack of privacy practices such as knocking before entering rooms, verbal abuse incidents, incomplete investigations and reporting of abuse and misappropriation, failure to follow up on dental care, lack of comprehensive dental assessments and care plans, improper catheter and personal care, failure to post nurse staffing information, poor food preparation and sanitation, infection control lapses, and multiple life safety code violations including obstructed doors, unsecured oxygen cylinders, and inadequate fire safety equipment maintenance.
Severity Breakdown
SS=E: 9
SS=D: 6
SS=F: 3
Deficiencies (27)
| Description | Severity |
|---|---|
| Failure to issue liability notices timely and inform residents of potential payment liability. | SS=E |
| Failure to ensure resident personal funds were available at all times, especially after hours and weekends. | SS=E |
| Failure to ensure privacy by knocking before entering resident rooms. | SS=D |
| Failure to ensure residents were free from verbal abuse. | SS=D |
| Failure to investigate and report allegations of abuse, misappropriation, and significant injury. | SS=D |
| Failure to provide medically-related social services including follow-up for dental treatment. | SS=D |
| Failure to complete comprehensive dental evaluation and update care plans accordingly. | SS=D |
| Failure to ensure complete cleansing during catheter and personal cares. | SS=D |
| Failure to maintain a safe, clean, comfortable, and homelike environment in resident rooms and dining areas. | SS=E |
| Failure to post daily nurse staffing information in a prominent and accessible location. | SS=D |
| Failure to prepare food to conserve nutritive value, flavor, and appearance. | SS=D |
| Failure to maintain kitchen and dietary areas in a clean and sanitary manner. | SS=D |
| Failure to implement isolation procedures, handwashing, gloving, and proper linen handling to prevent infection spread. | SS=E |
| Failure to maintain a quality assessment and assurance committee that effectively identifies and corrects quality issues, resulting in repeat deficiencies. | SS=F |
| Bed obstructing door, doors failing to close and latch, and medical records office door lacking proper latching hardware. | — |
| Smoke barrier doors failing to resist passage of smoke due to failure to close within frame. | — |
| Doors to hazardous areas failing to close and latch, obstructed doors, missing self-closing devices, and unsealed penetrations around sprinkler pipes. | — |
| Delayed egress hardware deficiencies including missing signage and access codes on exit doors. | — |
| Exit discharge lighting not verified or documented. | — |
| Sprinkler system deficiencies including obstructed sprinkler heads, unsealed penetrations, missing ceiling tiles, and lack of spare sprinkler heads and wrench. | — |
| Non-compliant kitchen hood suppression system not replaced after being red-tagged. | — |
| Means of egress obstructed by stored equipment and furniture. | — |
| Oxygen cylinders not properly secured, increasing risk of injury. | — |
| Lack of address posted on exterior of building, delaying emergency response. | — |
| Oxygen in use signs not posted in resident rooms where oxygen is used. | — |
| Emergency generator testing documentation incomplete and generator not run at required load. | — |
| Electrical wiring and equipment deficiencies including open junction boxes, obstructed panel boxes, and exposed wiring. | — |
Report Facts
Sample size: 52
Facility census: 50
Deficiency count: 36
Deficiency count: 22
Deficiency count: 42
Deficiency count: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Don Fritz | Administrator | Approved plan of correction documents |
| Patsy Curtis | Administrator | Named in waiver request documents |
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 22
Aug 10, 2011
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with federal and state regulations governing skilled nursing facilities, including life safety code compliance.
Findings
The facility was found deficient in multiple areas including failure to prevent misappropriation of resident property, failure to investigate and report allegations, inadequate housekeeping and maintenance, failure to revise care plans, infection control issues, non-functioning call lights, unsafe environment conditions, inadequate emergency water supply procedures, ventilation system failures, ineffective administration, and failure to maintain an effective quality assurance program. Life safety code deficiencies included malfunctioning smoke doors, inadequate fire-rated doors, failure to notify central station during fire drills, kitchen hood suppression system issues, presence of flammable decorations, missing oxygen warning signs, generator testing deficiencies, unsecured gas shut-off valve, and electrical safety violations.
Severity Breakdown
SS=F: 9
SS=E: 8
SS=D: 5
Deficiencies (22)
| Description | Severity |
|---|---|
| Failed to prevent misappropriation of resident property. | SS=D |
| Failed to investigate and report allegations of missing property and elopement. | SS=D |
| Failed to maintain cleanliness and repair of environmental items. | SS=E |
| Failed to review and revise comprehensive care plans for bowel management. | SS=D |
| Failed to re-evaluate and implement bowel protocols. | SS=D |
| Failed to maintain cleanliness and maintenance of kitchen equipment and handwashing to prevent cross contamination. | SS=D |
| Failed to ensure handwashing and gloving techniques during personal care and proper linen handling. | SS=D |
| Failed to maintain functioning call light in a bathroom accessible to residents. | SS=E |
| Failed to maintain cleanliness and repair of items in non-resident use areas. | SS=E |
| Failed to establish written procedure to assure adequate emergency water supply. | SS=F |
| Failed to ensure ventilation system was functioning properly. | SS=E |
| Failed to ensure effective administration and management of facility resources. | SS=F |
| Failed to maintain an effective Quality Assessment and Assurance program. | SS=F |
| Smoke separation doors failed to close properly and resist passage of smoke. | SS=E |
| Failed to provide fire rated protection for hazardous areas including door closures and ceiling penetrations. | SS=E |
| Failed to notify central receiving station of night time fire drills within 24 hours. | SS=F |
| Failed to maintain kitchen hood suppression system inspection schedule and staff training. | SS=E |
| Decorations on resident door were not flame retardant. | SS=E |
| Failed to post oxygen in use signs on resident rooms with oxygen. | SS=E |
| Failed to test newly installed natural gas generator under required load and notify authority having jurisdiction. | SS=F |
| Failed to secure shut-off valve for natural gas supply to emergency generator and failed to identify valve properly. | SS=F |
| Failed to use electrical wiring and equipment in accordance with NFPA 70 including missing GFCI outlets and exposed wiring. | SS=F |
Report Facts
Facility census: 52
Deficiency counts: 22
Inspection Report
Enforcement
Deficiencies: 0
Aug 10, 2011
Visit Reason
The inspection was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs. The facility was found not in substantial compliance, leading to enforcement actions including denial of payment for new admissions.
Findings
The facility was found not in substantial compliance with Federal participation requirements during the August 10, 2011 survey and the subsequent Life Safety Code revisit on September 15, 2011. Payment for new Medicare and Medicaid admissions was denied effective October 8, 2011. A later revisit on September 29, 2011 established that corrections had been made and the facility was then in substantial compliance, so the denial of payment was not effectuated.
Report Facts
Denial of payment effective date: Oct 8, 2011
Survey date: Aug 10, 2011
Life Safety Code revisit date: Sep 15, 2011
Second revisit date: Sep 29, 2011
Compliance termination date: Feb 10, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Shumate | Branch Manager | Signed enforcement letter from Survey, Certification & Enforcement Branch |
| Jane Weiler | Health Quality Review Specialist | Contact person for additional comments or concerns |
Document
Capacity: 65
Deficiencies: 0
APP2020
Visit Reason
The documents pertain to the renewal of the nursing home license for Azria Health Midtown and include the occupancy permit issued by the Nebraska State Fire Marshal.
Findings
The documents certify that Azria Health Midtown meets statutory requirements for licensure as a skilled nursing facility with a licensed capacity of 65 beds. The occupancy permit confirms the maximum occupancy of 65 beds.
Report Facts
Licensed capacity: 65
Number of beds to be relicensed: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Brewer | Administrator | Named in nursing home licensure renewal application. |
| Savannah Gomez | Director of Nursing | Named in nursing home licensure renewal application. |
| Steve Hornung | Owner | Listed in ownership control list and nursing home licensure renewal application. |
| Noah Kaminer | Owner | Listed in ownership control list and nursing home licensure renewal application. |
| Jim Kenney | Deputy State Fire Marshal | Inspected the facility for occupancy permit. |
Notice
Capacity: 65
Deficiencies: 0
APP2021
Visit Reason
The document serves as a Nursing Home Licensure Renewal Application for Azria Health Midtown, verifying the facility's license renewal and occupancy permit status.
Findings
The documents confirm the facility's licensure renewal through the specified expiration date and the maximum occupancy of 65 beds as per the Nebraska State Fire Marshal occupancy permit.
Report Facts
Total licensed beds: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steve Hornung | Authorized Representative | Signed the Nursing Home Licensure Renewal Application. |
| Noah Kaminer | Authorized Representative | Signed the Nursing Home Licensure Renewal Application. |
Notice
Capacity: 65
Deficiencies: 0
APP2022
Visit Reason
This document serves as a nursing home licensure renewal application and includes verification of licensure, renewal fees, ownership information, and occupancy permit details for Azria Health Midtown.
Findings
The documents confirm the facility's licensure status, ownership, and maximum licensed bed capacity of 65 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 65
Renewal application date: Feb 22, 2022
Document
Capacity: 65
Deficiencies: 0
APP2023
Visit Reason
The document serves as a renewal application for nursing home licensure for Azria Health Midtown and includes verification of ownership and licensure details.
Findings
The documents confirm the facility's licensure renewal status, ownership information, and licensed bed capacity. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Gault | Administrator | Named in the renewal application and ownership verification. |
| Raquel Kolker | Director of Nursing | Named in the renewal application. |
| Steve Hornung | Named in ownership verification letter and as authorized representative on renewal application. | |
| Aaron Kaminer | Named in ownership verification letter and as authorized representative on renewal application. |
Notice
Capacity: 65
Deficiencies: 0
APP2024
Visit Reason
The document serves as a renewal application for the nursing home license of The Cypress at Midtown and includes related licensing and occupancy permit information.
Findings
The documents confirm the facility's licensure renewal status, ownership details, and occupancy permit with a maximum capacity of 65 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Curtis Nielsen | Administrator | Named in the Nursing Home Licensure Renewal Application. |
| Andrea Mills | Director of Nursing | Named in the Nursing Home Licensure Renewal Application. |
| Ari Silberstein | Authorized Representative | Signed the Nursing Home Licensure Renewal Application. |
Document
Capacity: 65
Deficiencies: 0
APP2025
Visit Reason
The documents pertain to the renewal of the nursing home license for The Cypress at Midtown facility, including submission of the renewal application and related authorizations.
Findings
No inspection findings or deficiencies are reported in these documents; they focus on licensure renewal and facility information.
Report Facts
Total licensed beds: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beth Block | Administrator | Named on the Nursing Home Licensure Renewal Application. |
| Cassandra Crapser | Director of Nursing | Named on the Nursing Home Licensure Renewal Application. |
| Devora Kirschner | Authorized Representative | Signed the Nursing Home Licensure Renewal Application. |
| Ari Silberstein | Authorized Representative | Signed the Nursing Home Licensure Renewal Application. |
| David Weisz | Authorized representatives to sign renewal applications in a letter dated February 17, 2025. | |
| Ty Hermes | Deputy State Fire Marshal | Inspected the facility and approved the occupancy permit. |
Document
Capacity: 65
Deficiencies: 0
CHOW2017
Visit Reason
The documents relate to the licensing and ownership change of Azria Health Midtown, including issuance of a new Skilled Nursing Facility license due to change of ownership and DBA name change, and related administrative notices and applications.
Findings
No inspection findings or deficiencies are reported. The documents confirm licensure issuance, ownership structure, and occupancy permit details for the facility.
Report Facts
Total licensed beds: 65
Initial licensing fee: 1950
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Spencer Bartlett | Administrator | Named as facility administrator in licensure application. |
| Heavenlee Brown | Director of Nursing | Named as Director of Nursing in licensure application. |
| Noah Kaminer | Authorized Representative and LLC Manager | Named as authorized representative and indirect owner in ownership documents. |
| Steven Hornung | Authorized Representative and LLC Manager | Named as authorized representative and indirect owner in ownership documents. |
| Judy Dunaway | Sr. Director of Disbursements | Signed notice of facility termination letter from Genesis HealthCare. |
| Teresa L. Salamon | VP and Deputy General Counsel | Signed letter regarding change of ownership notification. |
Document
Capacity: 65
Deficiencies: 0
APP2016
Visit Reason
The document serves as a licensure renewal application for The Rehabilitation Center of Omaha, verifying the facility's license and providing ownership and certification details.
Findings
No inspection findings or deficiencies are reported in this document; it primarily contains administrative and licensing information.
Report Facts
Total licensed beds: 65
Certified dual beds: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kirk Sweeney | Administrator | Named as the facility administrator on the renewal application. |
| Heavenlee Brown | Director of Nursing | Named as the Director of Nursing on the renewal application. |
Notice
Capacity: 65
Deficiencies: 0
APP2019
Visit Reason
The document serves as a licensure renewal application for Azria Health Midtown nursing home and includes certification of licensure and occupancy permit information.
Findings
The documents confirm that Azria Health Midtown meets statutory requirements for licensure renewal as a skilled nursing and nursing facility with a licensed capacity of 65 beds. No inspection findings or deficiencies are reported.
Report Facts
Licensed beds: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Isaac Smith | Administrator | Named on the Nursing Home Licensure Renewal Application |
| Jennifer Beisheim | Director of Nursing | Named on the Nursing Home Licensure Renewal Application |
| Noah Kaminer | Authorized Representative | Signed the Nursing Home Licensure Renewal Application |
| Steven Hornung | Authorized Representative | Signed the Nursing Home Licensure Renewal Application and listed as owner |
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